Digitized by the Internet Archive in 2016 with funding from Duke University Libraries https://archive.org/details/dictionaryofmedi01quai A DICTIONARY OF MEDICINE EXCLUDING GENERAL PATHOLOGY, GENERAL THERAPEUTICS, HYGIENE, AND THE DISEASES PECULIAR TO WOMEN AND CHILDREN BY VARIOUS WRITERS EDITED BY RICHARD QUAIN, M.D., F.R.S. FEXLCW AND LATE SENIOR CENSOR OF THE ROYAL COLLEGE OF PHYSICIANS; MEMBER OF THE SENATE CF THE UNIVERSITY OF LONDON; MEMBER OF THE GENERAL COUNCIL OF MEDICAL EDUCATION AND REGISTRATION; CONSULTING PHYSICIAN TO THE HOSPITAL FOR CON- SUMPTION AND DISEASES OF THE CHEST AT CROMPTON, ETC. TWELFTH EDITION. NEW YORK D. APPLETON AND COMPANY 1, 3 and 5 BOND STEEET 1890 T-V~- ' l3 =0 . . *5 i : -i PREFACE The vast number of facts and observations, by which the recent progress of scientific and practical medicine has been marked, is dif- fusely recorded in the Transactions of learned societies, in journals, in monographs, and in systematic treatises. With progress so rapid, and information so diffused, it is extremely difficult alike for the practitioner, the teacher, and the student to keep pace. It was the perception of this difficulty which induced the Editor-, when invited to undertake the production of a new Medical Dictionary, to engage in a task which, he was fully conscious, must be one of great labour and of great responsibility. He felt, however, that he would be rendering useful service to his profession if he could bring together the latest and most complete information in a form which would allow of ready and easy reference. Accordingly, he invited the co-operation of certain of his colleagues and professional friends, both in this country and abroad ; and evidence of the readiness with which this invitation has been accepted, is afforded by the list of contributors. Each contributor volunteered or was invited to write on a subject with which he was specially familial - . The present work, which is the result of these combined efforts, may therefore be regarded not only as a dictionary, but also as a treatise on systematic medicine, in which the articles on the more important subjects constitute monographs in themselves, whilst definitions and descriptions of matters having less claim to extended notice are given as fully as is required. Thus an endeavour has been made to supply, in a clear, condensed, and readily accessible form, all the information that is at present available for the use of the practitioner of medicine. As indicated on the title-page, the work is primarily a dictionary of Medicine, in which the several diseases are fully discussed in alphabetical order. The description of each includes an account of its n PREFACE. aetiology and anatomical characters ; its symptoms, course, duration, and terminations ; its diagnosis, prognosis, and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and nature of disease, and the many considerations which these topics suggest. General Therapeutics will be found to include articles on the several classes of remedies — medicinal or otherwise — which are avail- able for the purpose of treatment ; on the modes of action of such remedies ; and on the methods of their use. The articles devoted to the subject of Hygiene will be found to treat of the causes of disease, of its prevention, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of the nursing the sick. Lastly, the diseases peculiar to Women and Children are discussed under their respective headings, both in aggregate and in detail. It may be well to explain that, although it has been found neces- sary to include some notice of diseases which fall more generally under the care of the surgeon, the work does not pretend to be a dictionary of Surgery ; and also that, although certain drugs are enumerated in discussing subjects of general therapeutics, and of poisons and their actions, there has been no intention to invade the domain of Materia Medica. It is right to observe that all the articles have been edited and revised with great care, so as to ensure a completeness and unity in the work, which it is not always possible to obtain in books composed by a number of writers. The Editor desires also to state that, although the work has occu- pied several years in preparation, arrangements were made with the printers which have enabled him to revise every article which required revision, up to the time of going to press. Further, by the addition of an Appendix it has been possible to incorporate the latest contributions to medical knowledge. Having thus set forth the aims and objects of his undertaking, and how far they have been carried out, the Editor has the great satis- faction of offering his thanks to his friends and colleagues, for the valuable assistance which he has received from them. He is fully conscious of the trouble which must often have been necessary in order PREFACE. vii to condense extended knowledge of a familiar subject within the limited space which the nature of this work could afford. The Editor has further the pleasing duty of offering his special thanks to Dr. Frederick T. Eoberts and to Dr. J. Mitchell Bruce, who from the first have been his Assistant-editors and fellow-labourers. Without the help which they have afforded him, it would have been impossible for him to have fulfilled the duties which he undertook. He is well aware of the time and labour which their assistance has involved ; and he appreciates most fully the marked ability by which i t has been characterised. The Editor cannot conclude without a reference to some of those who were his friends and colleagues when this work was commenced, but who have since been taken away by death. He would specially mention the names of Edmund Parkes, Charles Murchison, G-eorge Callender, Thomas Bevill Peacock, John Eose Cormack, Lockhart Clarke, Tilbury Fox, Thomas Hayden, Harry Leach, Alexander Silver. The loss of these eminent men, many of them dear and valued friends, and all of them taken too soon from their unfinished labours, is to him a source of personal sorrow. The articles written by them for these pages were in most instances their last contributions to medical literature, and will be valued accordingly. Lostdon : September 1832 . * LIST OF ILLUSTRATIONS na. PAG3 1. OXdium albicans . . 2. Bilharzia hcematobia, male and female . 3. Bilharziali eematobia, ovum of, 'with contained embryo and free sarcode- granules 4. Cardiogram 5. Renal casts — blood 6. hyaline . 7. , epithelial . 8. fatty . . . 9. granular 10. enclosing crystal smaller cast ; also cast of seminal tubule with spermatozoa 11. Filaria sanguinis-liominis . 12. Side view of the left hemisphere of the monkey, illustrating localisation of the cerebral centres .... 13. Side view of the left hemisphere of man, illustrating localisation of the cerebral centres 71 107 107 210 213 213 213 213 213 213 252 297 297 14. Cgsticercus (tela) celluloses, removed from the human eye 323 15. Cysticerci in a portion of measled pork 323 16. Bistoma conjunctum 401 17. B racunculus medincnsis .... 403 18. Filaria sanguinis-liominis, anterior end of the mature ...... 512 19. Filaria sanguinis-hominis, a portion of the mature, showing uterine tubules, &c. . 512 20. Filaria sanguinis-liominis, ova and em- bryos of 513 21. Fungoid filaments and capsules from fungus disease of India . . . 522 22. Fatty degeneration of the heart . . 594 23. Fatty growth in the substance of the heart 697 24. Hydatids cf four weeks’ growth, showing ectocyst and endocyst .... 654 25. Group of Echinococci, with their hook- crowns inverted 654 26 The so-called ‘ Echinococcus head,’ show- ing hooks, suckers, cilia, and corpuscles 654 FIG. 27. Micrococci, different forms of . 28. Red blood-corpuscles — human . 29. Scaly epithelial cells 30. Leucocytes ; pus, mucous, or white blood-corpuscles . 31. Ciliated epithelial cells . 32. Cotton fibres, showing character- istic twist .... 33. Milk, showing colostrum corpuscles and oil-globules . o face » 11 34. Particles of vomited matter . 35. Epithelium from urinary tracts 36. Spermatozoa — human 37. Fragments of hair . 38. Sarcina ventriculi . 39. Hooklets of echinococcus 40. From phthisical sputum, showing elastic fibres of lung-tissue and leucocytes .... 41. Hamlin crystals from old blood-clo 42. Cubes of chloride of sodium 43. Leucin 44. Tyrosin ... 45. Uric acid, various forms . . 46. Cholesteric plates . . . 47. Cystin 48. Oxalate of lime : dumb-bells and octahedra .... V >» n n » 49. Triple phosphate of ammonia and magnesia .... 50. Torula cerevisia : yeast fungus 51. Sputum of early pneumonia, showing red blood- corpuscles and leucocytes 52. Shreds of elastic tissue in sputum cf phthisis .... 53. Oldium albicans ; thrush . 54. Fenicillium glaucum . . 55. Pulse-trace — typical 56. „ of high ten si< a . 1 PAG2 974 982 982 982 982 982 982 982 982 982 982 982 982 982 982 982 9S2 982 982 982 982 982 98S 982 982 982 982 982 1295 1295 LIST OF ILLUSTRATIONS. PIG. PAGE 57. Pulse-trace — of low tension . . . 1295 58. „ hard, frequent, sudden, and small pulse . . . 1297 59. „ hard, slow, gradual, and large pulse . . . 1297 GO. „ hard, large, gradual pulse . 1298 61. „ hard, sudden, large, and vibratory pulse . . 1298 62. „ soft, frequent pulse . . 1298 G3. „ soft, frequent, and large pulse .... 1298 E4. „ soft, small, frequent, and sudden pulse . . . 1298 65. „ soft, frequent, and small pulse 1298 66. The spleen in anthrax .... 1303 67. The spleen in anthrax under a high power 1303 68. Forms of Bacillus antliracis . . . 1303 69. From a cultivation of Bacillus antliracis, after forty- eight hours . . . 1304 70. Bacilli from the fluid exuded from the lung in a case of internal anthrax . 1305 71. Ascaris lumbricoid.es ; male, with exserted spicules 1379 72. Ascaris mystax, male and female . . 1380 73. Sclerostoma duodenale, male and female . 1398 74. Spliygmographic tracing, showing ob- structed peripheral circulation . . 1452 75. Spliygmographic tracing, showing easy and quick capillary circulation . . 1452 76. Sphygmographie tracing, showing hyper- dichrotism 1452 77. Sphygmographie tracing, showing con- traction of muscular coat of artery . 1452 78. Sphygmographie tracing, showing ri- gidity of arterial walls . . . 1452 79. Sphygmographie tracing of right radial artery in aneurism of the aorta . . 1453 80. Sphygmographie tracing of left radial artery in aneurism of the aorta . . 1453 81. Sphygmographie tracing in aortic regur- gitation 1453 82. Sphygmographie tracing in aortic sten- osis 1453 83. Sphygmographie tracing in njitral regur- gitation ...... 1454 84. Sphygmographie tracing in mitral sten- osis ....... 1454 85. Transverse sections of the normal spinal cord 1456 86. Transverse sections of the spinal cord, showing areas of descending degene- ration 1461 87. Transverse sections of the spinal cord, showing areas of ascending degene- ration 1461 88. Spirillum Obermeieri , amengst red blood- corpuscles ...... 1508 89. Taenia echinococcus . . . . ,1585 90 Taenia mediocanellata, unarmed head of . 1585 9 . Taenia solium, armed head of . . 1585 FIG. PAG 11 92. Taenia mediocanellata, proglottis of. . 1585 93. Taenia solium, proglottis of . , • 1585 94. Taenia mediocanellata, head and several segments of 1586 95. Oxyuris vermicularis, female . 1624 96. Oxyuris vermicularis, eggs of . 1624 97. Trichina spiralis, male and female . 165 98. Trichina, a single capsuled, in a portion of human muscle 1657 99. Trichocephalus, male and female 1653 100. Tubercle in a lymphatic gland 1663 101. Fibroma (neuroma) . . to face 1672 102. Polypus of nose 99 1672 103. Myxoma . . . 99 1672 104. Ossifying chondroma . 99 1672 105. Enchondroma (of jaw) . 99 1672 106. Enchondroma (of orbit) J> 1672 107. Myeloid of jaw .... 99 1672 108. Large round-celled sarcoma . 99 1672 109. Small round-celled sarcoma . 99 1672 110. Oval-celled sarcoma 99 1672 111. Lymphoma 99 1672 112. Small spindle-celled sarcoma 99 1672 113. Alveolar sarcoma .... 99 1672 114. Mixed sarcoma 99 1672 115. Melanotic sarcoma 99 1672 116. Large spindle-celled sarcoma 99 1672 117. Papilloma of soft palate 99 201 118. Epithelioma of lip 201 119. Edge of rodent ulcer . 99 204 120. Simple polypus of rectum 99 204 121. Columnar epithelioma of intes- tine 99 204 122. Colloid of breast .... 99 204 123. Cancer of liver (scirrho-encepha- loid 99 204 124. Encephaloid cancer „ 204 125. Scirrhus infiltrating fat 99 204 126. Cicatrizing cancer „ 204 127. Scirrhus of mamma 99 204 128. Adenoid of upper jaw (benign) . 99 204 129. Ulcerated adenoid of parotid (malignant) .... 99 204 130. Adenoid of breast (common type) . 99 204 131. Adenoid of breast (epithelial ele- ment in excess) 99 204 132. Adenoid of breast (adeno-sar- coma) 99 204 133. Urinary flocculi .... . 1710 134. Vaginal speculum — Cusco’s bi-valve • 1777 135. „ Fergusson’s . . 1777 136. „ the duck-bill . • 1777 137. Uterine sound .... . 1778 138. Uterine probes .... • 178* BIST of contributors ADAMS, WILLIAM, Surgeon to the Great Northern Hospital, AITKEN, WILLIAM, M.D., F.R.S., Professor of Pathology in the Army Medical School Netley. ALLBUTT, T. CLIFFORD, M.A., M.D., F.R.S., Senior Physician to the Leeds General Infirmary, and Lecturer on Practice of Physic, Leeds School of Medicine. ALLCHIN, W. H., M.B., F.R.S.E., Physician to, and Lecturer on Physiology and Pathology at, the Westminster Hospital ; Physician to the Victoria Hospital for Children. ANDREW, JAMES, M.D., Physician to, and Joint Lecturer on Physic at, St. Bartholomew's Hospital ; Consulting Physician to the City of London Hospital for Diseases of the Chest. BALFOUR, GEORGE W., M.D., F.R.S.E., Physician to the Royal Infirmary, and Con- sulting Physician to the Royal Hospital for Children, Edinburgh. BANHAM, G. A., late Veterinary Assistant at the Brown Institution. BARNES, ROBERT, M.D., Obstetric Physician to, and Lecturer on Midwifery and Diseases of Women at, St. George’s Hospital ; Consulting Physician to the Royal Maternity Charity. BASTLAN, H. CHARLTON, M.A., M.D., F.R.S., Physician to, and Professor of Clinic?.! Medicine at, University College Hospital ; Professor of Pathological Anatomy, University College ; and Physician to the National Hospital for the Paralysed and Epileptic. BAUMLER, C. G. H., M.D., Professor of Clinical Medicine, and Director of the Medicai Clinic, University of Freiburg in Baden. BECK, MARCUS, M.B., M.S., Assistant Surgeon to, and Assistant Professor of Clinical Surgery at, University College Hospital. BEDDOE, JOHN, B. A., M. D., F. R. S., late Physician to the Bristol Royal Infirmary. BELLAMY, EDWARD, Surgeon to, and Lecturer on Anatomy at, the Charing Cron; Hospital. BENNET, J. HENRY, M.D , late Physician-Accoucheur, Royal Free Hospital. BENNETT, SIR J. RISDON, M.D., LL.D., F.R.S., late President of the Royal College of Physicians ; Consulting Physician to St. Thomas’s Hospital, and to the City of London Hospital for Diseases of the Chest. BEVERIDGE, ROBERT, M.B., Physician to, and Lecturer on Clinical Medicine at, tin Aberdeen Royal Infirmary. BINZ. CARL M.D., Professor of Pharmacology in the University of Eonn. LIST OF CONTRIBUTORS. BIRKETT, JOHN, Consulting Surgeon to Guy's Hospital. BISHOP, JOHN, M.D., C.M., Assistant Surgeon to the Royal Infirmary, Edinburgh. BLANDFORD, G. F., M.D., Lecturer on Psychological Medicine at St. George’s Hospital. BOWLES, R. L., M.D., Physician to St. Andrew’s Convalescent Hospital, Folkestone. BRISTOWE, J. STER, M.D., F.R.S., Physician to, and Joint Lecturer on Medicine at, St Thomas’s Hospital. BROADBENT, W. IL, M.D., Physician to, and Lecturer on Medicine at, St. Mary’s Hos- pital; Consulting Physician to the London Fever Hospital. BROWN-SEQUARD, C. E., M.D., LL.D., F.R.S., Professor of Medicine, College de France BRUCE, J. MITCHELL, M.A., M.D., Physician to, and Lecturer on Materia Medica and Therapeutics at, the Charing Cross Hospital; Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. BRUCE, WILLIAM, M.A., M.D., Physician to the Ross Memorial Hospital, Dingwall. BRUNTON, T. LAUDER, M.D., D.Se., F.R.S., Assistant Physician to, and Lecturer on Materia Medica and Therapeutics at, St. Bartholomew’s Hospital. BUCHANAN, GEORGE, B.A., M.D., F.R.S., Medical Officer, H.M. Local Government Board; Consulting Physician to the London Fever Hospital. BUTLIN, H. T., Assistant Surgeon to, and Demonstrator of Surgerv at. St Bartholomew’s Hospital; Surgeon to the Metropolitan Free Hospital. BUZZARD, THOMAS, M.D., Physician to the National Hospital for the Paralysed and Epileptic. CADGE, WILLIAM, Surgeon to the Norfolk and Norwich Hospital. CALLENDER, The late G. W., F.R.S., Surgeon to, and Lecturer on Surgery at, St. Bar- tholomew’s Hospital. CANTL1E, JAMES, M.A., M.B., C.M., Senior Assistant Surgoon to, and Demonstrator of Anatomy at, the Charing Cross Hospital. CARPENTER, W. B., C.B., M.D., LL.D., F.R.S. CARTER, R. BRUDENELL, Ophthalmic Surgeon to, and Lecturer on Ophthalmic Surgery at, St. George’s Hospital. CAYLEY, WILLIAM, M.D., Physician to, and Lecturer on Medicine at, the Middlesex Hospital; Physician to the London Fever Hospital. CLARKE, The late J. LOCKHART, M.D., F.R.S., Physician to the Hospital for Diseases of the Nervous System. CLARKE, W. FAIRLIE, M.A., M.D., late Assistant Surgeon to the Charing Cross Hospital. CLOVER, The late J. T., Lecturer on Anaesthetics at University College Hospital. COBBOLD, CHARLES S. W., M.B., Senior Assistant Medical Officer, Colney Hatch Asylum. COBBOLD, T. SPENCER, M.D., F.R.S., Professor of Botany and Helminthology at the ltoyal Veterinary College. COLLIE, ALEXANDER, M.D., Medical Officer, Fever Hospital, Homerton. LIST OF CONTRIBUTORS. xiil COOPER, ARTHUR, M.R.C.S., late House Surgeon to the Male Lock Hospital. CORMACK, The late SIR JOHN ROSE, KB., M.D., F.R.S.E., Physician to the Hertford British Hospital, Paris. CUNNINGHAM, D. DOUGLAS, M.D., Surgeon-Major H.M. Bengal Army. CURLING, T. B., F.R.S., Consulting Surgeon to the London Hospital. CURNOW, JOHN, M.D., Assistant Physician to King's College Hospital; Professor of Anatomy at King’s College ; Senior Visiting Physician to the Seamen’s Hospital. DALBY, W. B., B.A., M.B., Aural Surgeon to, and Lecturer on Aural Surgery at, St, George’s Hospital. DAVIDSON, ALEXANDER, M.A., M.D., Physician to the Royal Infirmary, Liverpool, and Lecturer on Pathology at the Liverpool Medical School. DE ZOUCHE, ISAIAH, M.D., Honorary Physician to the Dunedin Hospital, New Zealand, DOWN, J. LANGDON, M.D., Physician to, and Locturer on Clinical Medicine at, the London Hospital. DUNCAN, J. MATTHEWS, M.A., M.D., LL.D., F.R.S.E., Physician-Accoucheur to, and Lecturer on Midwifery at, St. Bartholomew’s Hospital. DURHAM, ARTHUR E., Surgeon to, and Lecturer on Surgery at, Guy’s Hospital. ECHEVERRIA, M. G., M.D., late Physician-in- Chief to the Hospital for Epileptics and Paralytics, and to the City Asylum for the Insane, New York. EWAlRT, JOSEPH, M.D., Retired Deputy Surgeon-General, H.M. Bengal Army; late Professor of Medicine, Principal, and Senior Physician, Calcutta Medical College. EWART, WILLIAM, B.A., M.D., Assistant Physician to St. Georgo’e Hospital ; late Assistant Physician and Pathologist to the Hospital for Consumption and Diseases of the Chest, Brompton. FARQUHARSON, ROBERT, M.D., M.P., late Physician to the Belgrave Hospital for Children, and late Assistant Physician to, and Lecturer on Materia Medica at, St. Mary’s Hospital. FAYRER, SIR JOSEPH, K.C.S.I., M.D., LL.D., F.R.S., Honorary Physician to H.M. the Queen, and to H.R.H. the Prince of Wales ; President of the Medical Board, India Office ; Consulting Physician to the Charing Cross Hospital. FENWICK, SAMUEL, M.D., Physician to, and late Lecturer on Medicine at, the London Hospital ; Assistant Physician to the City of London Hospital for Diseases of the Chest. PERRIER, DAVID, M.A., M.D., LL.D., F.R.S., Assistant Physician to King’s College Hos- pital ; Professor of Forensic Medicine at King’s College ; Physician to the National Hospital for the Paralysed and Epileptic. FINNEY, J. M., B.A., M.D., Physician to the City of Dublin Hospital; King’s Professor of the Practice of Medicine at the School of Physic in Ireland, and Professor of Clinical Medicine in Sir Patrick Dun's Hospital. FOSTER, BALTHAZAR W., M.D., Physician to the General Hospital, and Professur of the Principles and Practice of Physic at Queen’s College, Birmingham. FOX, E. LONG, M.D., Consulting Physician to the Bristol Royal Infirmary, and late Lecturer on the Principles and Practice of Medicine at the Bristol School of Medicine. FOX, T. COLCOTT, B.A., M.B., Physician to the St. George’s and St. James’s Dispensary Assistant Physician to the Victoria Hospital for Children. or LIST OF CONTRIBUTORS. FOX, The late TILBURY, M.D., Physician to the Skin Department, University College Hospital. GALTON, CAPTAIN DOUGLAS, R.E. (retired), C.B., D.C.L., F.R.S. C3ASCOYEN, The late GEORGE G., Surgeon to the Lock Hospital ; and Assistant Surgeon to, and Lecturer on Surgery at, St. Mary’s Hospital. GEE, SAMUEL, M.D., Physician to St. Bartholomew’s Hospital, and to the Hospital for Sick Children ; Joint-Lecturer on Practice of Physic at St. Bartholomew’s Hospital. (JODLEE, RICKMAN J., B.A., M.B., M.S., Assistant Surgeon to University College Hos- pital ; Demonstrator of Anatomy at University College ; Assistant Surgeon to the North- East Hospital for Children. GODSON, CLEMENT, M.D., Consulting Physician to the City of London Lying-in Hospital ; Assistant Physician-Accoucheur to St. Bartholomew’s Hospital. GOWERS, W. R., M.D., Assistant Physician to, and Assistant Professor of Clinical Medicine at, University College Hospital ; Physician to the National Hospital for the Paralysed and Epileptic. GREEN, T. HENRY, M.D., Physician to, and Lecturer on Pathology at, the Charing Cross Hospital ; Assistant Physician to tho Hospital for Consumption and Diseases of the Chest, Brompton. GREENFIELD, W. S., M.D., Professor of General Pathology and Clinical Medicine in the University of Edinburgh. GRIMSKAW, T. W„ M.A., M.D., Registrar-General for Ireland ; Consulting Physician to the Fever Hospital, and to Steeven’s Hospital, Dublin. ILAWARD. J. WARRINGTON, Surgeon to St. George’s Hospital ; late Assistant Surgeon to the Hospital for Sick Children. UAYDEN, The late THOMAS, Physician to the Mater Misericordise Hospital, Dublin ; Professor of Anatomy and Physiology, Catholic University, Dublin. GERMAN, G. ERNEST, M.B., Assistant Obstetric Physician to the London Hospital; Physician to the Royal Maternity Charity. SICKS, J. BRAXTON, M.D., F.R.S. , Physician-Accoucheur to, and Lecturer on Midwifery and Diseases of Women and Children at, Guy’s Hospital. HILL, BERKELEY, M.B., Surgeon to, and Professor of Clinical Surgery at, University College Hospital ; Teacher of Practical Surgery at University College ; Surgeon to the Lock Hospital. HOLMES, TIMOTHY', M.A., Surgeon to, and Lecturer on Surgory at, St. George's Hospital. HORSLEY, V. A. II., B.S., M.B., Assistant to the Professor of Pathological Anatcmy, University College ; Surgical Registrar, University College Hospital. HOWARD, BENJAMIN, M.D., late Professor of Medicine, and Lecturer on Medicine, in the University of New York. HUTCHINSON, JONATHAN, F.R.S., Senior Surgeon to the London Hospital, and to the Hospital for Diseases of the Skin ; Consulting Surgeon to the Royal London Ophthalmic Hospital. LIST OF CONTRIBUTORS. xv IRVINE, The late J. PEARSON, B.A., B.Sc., M.D., Assistant Physiciar to, and Lecturer on Forensic Medicine at, the Charing Cross Hospital ; Physician to the Victoria Hospital for Children. JENNER, SIR WILLIAM, Bart., K.C.B., M.D., D.C.L., LL.D., F.R.S., Physician-in-Ordinary toH.M. the Queen, and to H.R.H. the Prince of Wales ; President of the Royal College of Physicians ; Consulting Physician to University College Hospital. JONES, JOSEPH, M.D., President Board of Health, State of Louisiana, New Orleans. LATHAM, P. W., A.M., M.D., Physician to Addenbrooke’s Hospital; Downing Professor of Medicine in the University of Cambridge. LEACH, The late HARRY, Medical Officer of Health for the Port of London, and Phy- sician to the Seamen's Hospital, Greenwich. LEGG, J., WICKHAM, M.D., Assistant Physician to, and Lecturer on Pathological Anatom v at, St. Bartholomew’s Hospital. LEWIS, TIMOTHY, M.D., Surgeon-Major, H.M. Army. LITTLE, JAMES, M.D., Physician to the Adelaide Hospital, Dublin ; Professor of Practice of Physic in the Royal College of Surgeons in Ireland ; Consulting Physician to the Rotunda Lying-in Hospital. LIVEING, ROBERT, M. A., M.D., Physician for Diseases of the Skin to, and Lecturer on Diseases of the Skin at, the Middlesex Hospital. McCARTHY, JEREMIAH, M.A., M.B., Surgeon to, and Lecturer on Physiology at, the London Hospital. MAC CORMAC, SIR WILLIAM, M.A., M.Ch., Surgeon to, and Lecturer on Surgery at, St. Thomas’s Hospital. McKENDRICK, J. GRAY, M.D., F.R.S.E., Professor of the Institutes of Medicine in the University of Glasgow. MACKENZIE, STEPHEN, M.D., Physician to, and Lecturer on the Principles and Practice of Medicine at, the London Hospital. MACLEAN, W. C., C.B., M.D., Inspector-General of Hospitals ; Professor of Military Medicine in the Army Medical School, Netley. MACNAMARA, CHARLES, Surgeon to the Westminster Hospital, and to the Westminstei Ophthalmic Hospital; Joint-Lecturer on Surgery at the Westminster Hospital. MACPHERSON, JOHN, M.A., M.D., Inspector-General of Hospitals, H.M. Bengal Army (retired) ; Physician to the Scottish Hospital. MADDEN, T. MORE, Obstetric Physician to the Mater Misericordiae Hospital, Dublin. MANSON, PATRICK, M.D., Amoy. MEREDITH, W. A., M.B., C.M., Surgeon to the Samaritan Free Hospital for Women and Children. MERYON, The late EDWARD, M.D., Physician to the Hospital for Epilepsy and Paralysis. MUIRHEAD, CLAUD, M.D., Physician to, and Lecturer on Clinical Medicine at, the Royal Infirmary, Edinburgh. MURCHISON, The late CHARLES, M.D., LL.D., F.R.S., Physician to, and Special Pro- fessor of Clinical Medicine at, St. Thomas's Hospital ; Consulting Physician to the London Fever Hospital. LIST OF CONTRIBUTORS. MYERS, A. B. R., Surgeon, Coldstream Guards. NETTLESHIP, EDWARD, Ophthalmic Surgeon to St. Thomas’s Hospital, and to the Hospital for Sick Children ; Lecturer on Ophthalmic Surgery at St. Thomas’s Hospital. NIGHTINGALE, FLORENCE. OLIVER, GEORGE, M.D., Harrogate. ORD, W. M., M.D., Physician to, and Lecturer on Medicine at, St. Thomas's Hospital. PAGET, SIR JAMBS, Bart., D.C.L., LL.D., F.R.S., Sergeant-Surgeon to H.M. the Queen, Surgeon to H.R.H. the Prince of Wales; Consulting Surgeon to St. Bartholomew’s Hospital. PARKE3, The late EDMUND A., M.D., F.R.S., Professor of Hygiene in the Army Medical School, Netley. PAVY, F. W., M.D., F.R.S., Physician to, and Lecturer on Medicine at, Guy’s Hospital PAYNE, J. FRANK, B.A., B.Sc., M.D., Senior Assistant Physician to, and Lecturer on General Pathology at, St. Thomas’s Hospital. PEACOCK, The late T. BEVILL, M.D., Honorary Consulting Physician to St. Thomas’s Hospital ; and Consulting Physician to the City of London Hospital for Diseases of the Chest. PLAYFAIR, W. S„ M.D., Physician-Accoucheur to H.I. and R.H. the Duchess of Edinburgh ; Physician for Diseases of Women and Children to King’s College Hospital, and Con- sulting Physician to the General Lying-in Hospital; Professor of Obstetric Medicine at King’s College. POORE, G. VIVIAN, M.D., Assistant Physician to University College Hospital; Professor of Medical Jurisprudence, University College. POWELL, R. DOUGLAS, M.D., Physician to the Middlesex Hospital, and to the Hospital for Consumption and Diseases of the Chest, Brompton. QUAIN, RICHARD, M.D., F.R.S., Consulting Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. RADCLIFFE, J. NETTEN, Assistant Medical Officer, Local Government Board. REDWOOD, THEOPHILUS, Ph.D., Professor of Chemistry and Pharmacy, Pharmaceutical Society of Great Britain. ROBERTS, FREDERICK T., M.D., B.Sc., Physician to, and Professor of Clinical Medi- cine at, University College Hospital ; Professor of Materia Medica at University College; Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. ROBERTS, WILLIAM, B.A., M.D., F.R.S., Physician to the Manchester Royal Infirmary; Professor of Clinical Medicine, Owens College School of Medicine. ROSE, WILLIAM, B.S., M.B., Assistant Surgeon to King’s College Hospital ; Surgeon to the Royal Free Hospital. ROY, C. S., M.D., Professor Superintendent cf the Brown Institution, London. RUSSELL, JAMES A., M.A., M.B., CM., Inspector of Anatomy for Scotland; Lecturer on Sanitation, Watt’s Institution, Edinburgh. SALTER, S. J ., M.B., F.R.S., F.L.S., Late Dental Surgeon to Guy's Hospital. SA.NGSTER, ALFRED, B.A., M.B., Physician for Diseases of the Skin to, and Lecturer oc Skin Diseases at, th* Charing Cross Hospital. LIST OF CONTRIBUTORS. srvu 8AUNDBY, R., M.D., Assistant Physician to the General Hospital, Birmingham. SEATON, The late EDWARD C., M.D., Medical Officer, Local Government Board. SHAPTER, THOMAS, M.D., LL.D., Consulting Physician to the Devon and Exetei Hospital. SIBBALD, JOHN, M.D., F.R.S.E., Commissioner in Lunacy for Scotland. SILVER, The late ALEXANDER, M.A., M.D., Physician to, and Lecturer on Physiology at, the Charing Cross Hospital. SIMON, JOHN, C.B., D.C.L., LL.D., F.R.S., Consulting Surgeon to St. Thomas’s Hospital ; late Medical Officer to Her Majesty’s Privy Council, and to the Local Government Board. SIMPSON, ALEXANDER R., M.D., Physician to the University Clinical Ward for Diseases of Women, Royal Infirmary, Edinburgh ; Professor of Midwifery and Diseases of Women and Children in the University of Edinburgh. SMITH, EUSTACE, M.D., Physician to H.M. the King of the Belgians ; Physician to the City of London Hospital for Diseases of the Chest, and to the East London Hospital for Children. SMITH, W. JOHNSON, Surgeon to the Seamen’s Hospital, Greenwich. SOUTHEY, ROBERT, M.D., Physician to, and Lecturer on Forensic Medicine and Hygiene at, St. Bartholomew’s Hospital. SPARKS, The late EDWARD I., M.A., M.B., Physician for Diseases of the Skin to the Charing Cross Hospital, and Physician to the Royal Infirmary for Women and Children. SQUIRE, WILLIAM, M.D., Physician to the North London Hospital for Diseases of the Chest, and to St. George’s Dispensary. STEVENSON, THOMAS, M.D., Lecturer on Chemistry and Medical Jurisprudence at Guy’s Hospital ; Analyst to St. Pancras, &c. STEWART, T. GRAINGER, M.D., F.R.S.E., Ordinary Physician to H.M. the Queen in Scotland ; Professor of Practice of Physic in the University of Edinburgh. STREATFEILD, J. F., Surgeon to the Royal London Ophthalmic Hospital; Professor of Clinical Ophthalmic Surgery at, and Ophthalmic Surgeon to, University College Hospital. THIN, GEORGE, M.D., London. THOMPSON, E. SYMES, M.D., Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. THOMPSON, SIR HENRY, Surgeon Extraordinary to H.M. the King of the Belgians ; Consulting Surgeon to University College Hospital ; Emeritus Professor of Clinical Surgery at University College. THORNTON, W. PUGIN, Surgeon to the St. Marylebone General Dispensary. THOROWGOOD, J. C., M.D., Physician to the City of London Hospital for Diseases of the Chest, and to the West London Hospital ; Lecturer on Materia Medica at the Middlesex Hospital. TUKE, J. BATTY, M.D., F.R.S.E., formerly Lecturer on Mental Diseases at the Royal College of Surgeons, Edinburgh. WALKER, T. J., M.D., Surgeon to the Peterborough Infirmary and Dispensary. sviii LIST OF CONTRIBUTORS. WARD, The late STEPHEN H., M.D., Consulting Physician to the Seamen's Hospital Greenwich ; and Physician to the City of London Hospital for Diseases of the Chest. WARDELL, J. R., M.D., Consulting Physician to the Tunbridge Wells Infirmary. WATERS, A. T. H., M.D., Physician to the Royal Infirmary, Liverpool Loctarcr on Principles and Practice of Medicine at the Liverpool School of Medicine. WEBER, HERMANN, M.D., Physician to the German Hospital. WELLS, T. SPENCER, President of the Royal College of Surgeons ; Surgeon to the Queen’s Household ; Consulting Surgeon to the Samaritan Hospital fcr Women and Children. WILLIAMS, C. THEODORE, M.A., MX., Physician to the Hospital fcr Consumption and Diseases of the Chest, Brompton. WILSON, SIR ERASMUS, LL.D., F.R.S., late President of the Royal College of Surgeons ; Professor of Dermatology, Royal College of Surgeons, WILTSHIRE, ALFRED, M.D., Physician-Accoucheur to, and Joint Lecturer on Obstetric Medicine at, St. Mary’s Hospital; Physician for Diseases of Women to the West London Hospital. WOOD, JOHN, F. R. S., Surgeon to Bang’s College Hospital, and Professor of Clinical Sur- gery at King’s College. A DICTIONARY OR MEDICINE, A ABDOMEN, Diseases of the. — Before entering upon the study of the particular diseases -which are liable to be met with in con- nexion with each of the principal regions of the body, it is expedient to regard them from a ge- neral point of view, as such a course helps mate- rially in clearing the way for their clinical investigation. This general survey is particularly advantageous in the case of abdominal diseases, which are necessarily very numerous and varied, both as regards the structure affected and the na- ture of the morbid change they present; they are consequently difficult to recognise with certainty in many instances, and are occasionally involved in much obscurity. Excluding a few peculiar affections, the dis- eases of the abdomen may be arranged under the following groups : — I. Diseases of the anterior abdominal walls. II. Diseases of the peritoneum and its folds. III. Diseases of the organs contained within the abdominal cavity, namely: — 1. Stomach and Intestines; 2, Hepatic organs, including the liver, gall-bladder, and gall-ducts ; 3, Spleen ; 4, Pan- creas; 5, Supra-renal capsules ; 6, Urinsiry appa- ratus, viz., the kidneys and their ducts, and the bladder ; 7, Female generative organs, including the uterus and its broad ligament, the Fallopian tubes, and the ovaries ; 8, Absorbent glands. IV. Diseases of the abdominal vessels, espe- cially the aorta and the iliac arteries. V. Diseases of the sympathetic or other nerves contained within the abdomen. VI. Diseases originating in connexion with the cellular tissue, such as inflammation or abscess. VII. Diseases springing from the posterior boundary of the abdomen; from the pelvis or the structures lining it; or from the diaphragm, and invading the abdominal cavity. VIII. Diseases encroaching upon the abdomen ; from other parts, especially from the thorax. It must be borne in mind that the groups of diseases above-mentioned may be presented in va- rious combinations, two or more structures being not uncommonly implicated at the same time. The special nature and mode of origin of the diseases thus summarised will be discussed under 1 their appropriate headings, but a few general observations on this subject may prove service- able. Several of the abdominal organs are very liable to so-called functional disorders, being much exposed to the repeated action of various disturbing influences, and these disorders often give rise to prominent and troublesome symptoms, which are urgently complained of by the patient. Definite organic diseases are also of common occurrence, many of them being of a very serious character. Some of the organs contained within the abdomen are subject to malposition or displacement, as well as to malformations, these being either congenital or acquired ; while the hollow viscera may be the seat of obstruction or accumulations of different kinds ; and each of these conditions may become clinically important. Abdominal lesions are frequently purely local in their origin, but several of them are but local manifestations of some general condition, being either associated with certain acute febrile diseases, e.g., typhoid fever ; or with some consti- tutional cachexia, such as cancer. Again, symp- toms connected with the abdomen may depend upon disease in some remote part of the body, oi some of its organs may become the seat of morbid changes as a consequence of disease in other structures. For instance, vomiting is frequently associated with cerebral disorders ; while affections of the heart are liable to lead to troublesoms symptoms, as well as to serious lesions in con- nexion with many of the abdominal viscera Lastly, a morbid condition of one organ within the abdomen may be the direct means of originat- ing secondary mischief in other structures. Clinical Investigation. — The clinical exami- nation of cases in which the symptoms point to the abdomen as the seat of mischief should always be conducted with particular care and thoroughness, as well as in a systematic manner, otherwise serious mistakes are liable to be made. It is also very desirable to avoid forming any de- finite conclusion as to the nature of the complaint hastily or on insufficient data, but rather to wait and observe the course of events in ary doubtful case, repeating the investigation from time to I ABDOMEN, DISEASES OF THE. tune, when any obscurity which, may exist will olien be cleared away. The past and. family his- tory of the patient, with the course and progress of the symptoms, are often of material assistance in diagnosis, and demand due attention in every instance. The chief clinical phenomena which may be associated with abdominal affections, and with reference to which it is requisite to inquire, may be thus indicated. First, there are usually symptoms directly connected with the structure implicated, such as pain and other morbid sen- sations, disorders of secretory or other functions, or excited action. Secondly, several of the organs mutually affect each other, either from being anatomically or physiologically related, or from a morbid condition of one part causing pressure upon or irritation of some neighbouring structure. In this way numerous symptoms are liable to arise, sometimes in remote parts, and often of material significance. Thirdly, sympa- thetic or reflex phenomena in connexion with organs in other regions of the body are frequently excited by many abdominal disorders, such as palpitation of the heart, convulsions, and other nervous disturbances. Fourthly, the general system often suffers seriously, and in various ■ways. For instance, pyrexia may be excited ; the blood may become impoverished or impregnated with noxious materials ; or more or less general wasting and debility may be induced. Where an abdominal disease is but a local manifestation of some constitutional condition, it commonly ag- gravates materially the general symptoms; while in connexion with lesions of certain of the ab- dominal viscera these general symptoms consti- tute in many cases the most prominent clinical features. Fifthly, morbid conditions within the abdomen not unfrequently interfere directly with the diaphragm and the thoracic organs ; occa- sionally also they invade upon the chest, or actually make their way into this cavity through the diaphragm. In rare instances morbid pro- ducts, such as pus, may find their way to distant parts of the body. In these different ways a variety of symptoms may be. caused, sometimes of a curious nature and difficult to explain. Lastly, abdominal diseases are frequently at- tended with abnormal physical or objective signs, which are revealed on physical examina- tion, and these are of such importance that they demand separate consideration. Physical Examination-. — The neglect of submitting patients to a satisfactory physical examination is a frequent source of error in diagnosis in cases of abdominal disease, "and there ought to be no hesitation or delay in resorting to this method of clinical investigation -whenever it seems called for. The precise course to be pursued must vary according to cir- cumstances, butthe following outline will serve to indicate the plan of procedure ordinarily required. First, there are certain modes of examination which are applied to the abdomen externally, including Inspection-, Palpation or Manipula- tion-, Mensuration on Measurement-, Percussion-, and Auscultation ( see Physical Examina- tion). Of these, inspection, palpation, and porcussion are by far the most important, and have,. in the large majority of cases, to be relied upon for the information required. In ex- ceptional instances Succussion or shaking the patient proves serviceable, by bringing out cer- Laiu sensations or sounds. In order to carry out these methods properly, it is necessary to expose the abdomen sufficiently, due regard being paid to decency in the examination of females ; to place the patient in a suitable posi- tion ; and to see that the muscles of the abdo- minal walls are duly relaxed. The best posi- tion usually is for the patient to lie on the back, in a half-reclining attitude, with .the head and shoulders well raised, and the thighs and knees more or less flexed. This posture serves to relax the abdominal muscles, which may bo further aided by taking off tho patient's atten- tion by conversation or in other ways, as well as by directing him to breathe deeply. The posi- tion, however, has often to he varied in the investigation of particular cases, and mucli information is frequently gained by noticing the effects of altering the posture. The objective conditions which may be revealed by the modes of examination thus far con- sidered are as follows: — 1. The state of the superficial structures. 2. The size and shape of the abdomen, generally and locally, as indi- cating an alteration in the volume of the ordinary contents of the abdomen, or the presence of some new or fresh element, such as dropsical fluid or a tumour. 3. The characters of the abdominal respiratory movements ; and the pre- sence of any unusual sensations during the act of breathing, such as friction-fremitus. 4. The sensations experienced on palpation and percussion over the abdomen, either as a whole, or in any particular part of it, such as its mobility, degree of resistance, regularity, con- sistence, &c. ; as well as the presence of cer- tain peculiar sensations, c.g., fluctuation, r hydatid-fremitus. 5. Tho presence and cha- racters of any pulsation. 6. The occurrence of abnormal movements within the abdomen, as ■those of a foetus. 7. The sounds elicited, gene- rally and locally, on percussion. 8. The pre- sence of certain sounds within the abdomen, heard on auscultation, such as friction-sounds ; murmurs connected with aneurism or due to pressure on an artery ; or murmurs and sounds associated with the pregnant uterus. Secondly, it not uncommonly happens that special modes of examination have to be applied to particular organs within the abdomen, in order to arrive at a diagnosis with any cer- tainty. And here it may he remarked that it is highly important in all cases to see that no accumulation of faeces exists within the bowels, and that the bladder is properly emptied, other- wise very serious mistakes are liable to be made. Purgatives and enemata are needed in order to remove any faecal collection. The urine should also be properly tested in every instance ; and much information may often be gained in the in- vestigation of affections of the alimentary canal, from a personal inspection or more complete examination of faces or vomited matters. The abdominal organs to which special modes of examination are chiefly applicable are the female generative organs, which are investigated per vaginam (see Womb, Diseases of i : the bladder, by means of the catheter, the sound, and other ABDOMEN, DISEASES OF THE. surgical instruments ; the stomach, by the use of the stomach-pump, probang, & c. ; and the in- testines, by examining -with the finger, hand, or surgical instruments per rectum, or by injecting water or air through the anus into the bowels. The ordinary modes of examination already men- tioned may afford assistance when employed along with some of the special methods just indicated. Thirdly, occasionally it is requisite to hare recourse to exceptional modes of investigation, such as the use of the exploring trochar or aspi- rator ; or to the administration of chloroform. The latter may afford direct information in certain abdominal conditions, and it may also materially assist in carrying out other methods jf exploration. The abnormal conditions discoverable by physical examination may involvo the entire abdomen, giving rise, for instance, to general enlargement or retraction ; or they may be limited to some particular region, e.g., enlarged organs, tumours, or abscesses. This part of the body has been artificially divided by anatomists nto regions, and the seat of any local morbid mndition can thus be defined and described. The diseases peculiar to the several regions will l e considered under their respective headings. Frederick T. Roberts. ABDOMINAL ANEURISM includes aneurism of the aorta, and of any of its branches within the abdomen. Aneurism of the Abdominal Aorta is essen- tially a disease of middle age. Of fifty-nine cases collected by Dr. Crisp, thirty-three were under t he age cf forty. It is more common in the male than in the femalo sex in the proportion of about 8:1; and is usually traceable to strain, or to a blow upon the abdomen or back. The aneu- rism is most frequently located in that portion of the vessel included between the aortic open- ing in the diaphragm and the origin of the superior mesenteric artery. In this situation the tumour is deeply seated; liable to tension from the crura of the diaphragm ; and likely to involve the great splanchnic nerves, the semilunar gan- glia, and the solar plexus. Hence the occasional difficulty of diagnosis ; and the frequency of boring pain in the hack from erosion of the vertebrae, and of paroxysms of radiating pain in the abdominal viscera from stretching of the adjacent nerves. When situated lower down in the course of the aorta, the disease is less obscure, and the symptoms are less urgent. Aneurism of the abdominal aorta is usually of tli & false variety; and, as contrasted with thoracic aneurism, it is less often associated with extensive atheroma of the aorta, and with fatty or other structural disease of the heart. The symptoms referable to excentric pressure are also fewer, and, with the exception of pain, are less urgent. Symptoms and Signs. — Of the symptoms, is the most characteristic and the most urgent ; it is of two kinds, which are not, however, neces- sarily associated. In its usual form the pain of abdominal aneurism is essentially neuralgic; it is intermittent and paroxysmal, — radiating through the abdomen, back, pelvis, and base of the thorax, and not unfrequently into either groin or testicle. The accession is sudden, and usually attributable ABDOMINAL ANEURISM. 3 to some definite cause of vascular excitement. The duration extends over a period varying from one to three hours, rarely longer; and the cessation is equally abrupt, leaving the patient in a state of exhaustion, but quite free from actual suffering. The second kind of pain referred to is continuous and boring ; fixed at a particular point of the vertebral column ; aggravated by pressure at this point, by active movement or stamping, and by gently turning the patient half round upon his axis in the standing posture ; but relieved by anti-recumbency or leaning forward. Pain so characterised is pathognomonic of erosion of the vertebrae. Pressure of an aneurism may affect tho functions of several organs within the abdo- men. Thus jaundice may result from pressure upon the hepatic or common biliary duct: it is, however, more frequently due to an aneurism of the hepatic or of the superior mesenteric artery. Interference with the urinary secretion, and the consequences thereof, from pressure upon the renal vessels ; dysphagia from pressure upon the oesophagus ; vomiting from obstruction of the pylorus; displacement of the liver forwards, or of the heart upwards — though rare symptoms — may he likewise due to the same cause. The radial pulse is not often affected. Symptoms of constitutional irritation and impaired nutrition are rarely exhibited, and appear only at the ter- mination of protracted and. painful cases, asso- sociated with great suffering and want of sleep. The physical signs are those discoverable by palpation, percussion, and auscultation. The tumour usually projects to the left of the mesial line, and tends to descend ; it is smooth and elastic ; communicating to the hand alternate movements of lifting and expansion with increas- ing tension, and of subsidence with relaxation. Tho pulsation is all hut invariably single, and synchronous with the radial pulse ; it is limited to the tumour, and occasionally accompanied by thrill. Pressure upon the aorta below the tumour will increase the force of impulse, diminish or abolish the thrill, and arrest the collapse. In a few recorded examples the tumour was hard and uneven on the surface, and non-expansile ; and in a still smaller number no pulsation was per- ceptible, the aperture of communication with the u.rtery having been blocked, or the vessel com- pressed on the proximal side by the growth of the aneurism itself. Owing to tho position of tho hollow viscera in front, and the mass of lumbar muscles behind, the evidence from percus- sion is less conclusive in regard to abdominal than thoracic aneurism. If, however, the ab- dominal muscles he relaxed, and the stomach and bowels free from flatus, absolute dulness to the extent of the tumour may be detected. A sound, single or double, as distinguished from murmur, is rarely heard in front in connexion with abdominal aneurism ; whereas the existence of sound without murmur, and usually double, at a point of the posterior wall of the abdomen corresponding to the tumour, is the rule, and. when detected, is of the utmost diagnostic value. Murmur in the recumbent posture is rarely absent in front ; it is single, blowing, prolonged post-systolic, and not transmitted into the vessel beyond. It may, however, he musical, .or it may present both these characters, hut at dif ABDOMINAL ANEURISM. ferent points of the tumour ; in one instance it was of a buzzing quality. Should the aneu- rism have taken an exclusively backward course, which is the exception, a single murmur, not audible in front, may be heard in ihe back. In a few recorded cases a double murmur has been heard over the aneurism in front. In the erect posture the murmur is usually suspended ; but in a few published cases it was audible in both the erect and the recumbent posture, and in one at least in the erect posture only. These peculiari- ties depend upon the various conditions of the sac, its orifice, and its contents. A small aneurism engaging the posterior wall of the vessel only, and eroding the vertebrae, may be latent as to physical signs, though attended with severe fixed pain in the back. Diagnosis.- — The diagnosis of abdominal aneu- rism has reference mainly to its physical signs. Strong pulsation of the aorta, simulating that of aneurism, may exist in connexion with hys- teria, uterine or intestinal irritation, dyspep- sia, or copious haemorrhage. But in all these cases, irrespectively of the positive and specific evidence presented by each, throbbing exists throughout the aorta, and is propagated into the main arteries of the lower limbs, whereas it is localised in aneurism ; and a careful exploration of the aorta, if necessary under the influence of chloroform, will show that its dimensions are at all points normal. In these cases, too, although a murmur may he produced by strong pressure with the stethoscope, it does not exist when pressure is withdrawn. A cancerous or other tumour pressing upon the aorta may like- wise produce murmur, and may exhibit pulsation communicated from the aorta ; but in most cases both these phenomena are promptly arrested by placing the body in the prone position ; the tumour, in that position, gravitating from the vessel. The fixed local pain in the hack, aggra- vated by pressure and motion, may he simulated by spinal rheumatism ; and the paroxysmal vis- ceral pain by biliary colic. The differential diagnosis must rest upon the specific evidence in each case, and upon the absence of the signs of aneurism. Aneurism of the Branches of the Ab- dominal Aorta. — The branches most liable to aneurism are the common iliacs and their divisions; the cosliac axis and its branches; . the renal and the superior mesenteric. Aneurism of the Iliac Arteries belongs to the domain of sur- gery, and will not be further referred to here. Aneurism of the Cceliac Arts and of its branches of division, and of the Superior Mesenteric Artery , are, in addition to the ordinary signs, equally characterized by mobility ; and the first two varieties by jaundice, haematemesis, and melaena, from pressure. Renal aneurism may cause ob- struction in the kidney or renal colic by pressure on the structures in the hilus. Duration and Terminations. — The duration of life in cases of abdominal aneurism has, in the writer’s experience, varied from fifteen days to eleven years. Death occurs usually (1) by rup- ture of the sac into ( a ) the retro-peritoneal tissue ; ( b ) the cavity of the peritoneum ; (c) the left pleura or lung ; (c?) the intestinal canal ; (e) the inferior cava ; (f) the psoas muscle ; (g) the pelvis of the kidney ; ( h ) the spinal canal ; 01 (i) the ureter, biliary passages, or oesophagus : and in the order of relative frequency just given ; or (2) by exhaustion or syncope. The duration of life after the rupture of the aneurism has ranged from a few minutes to several weeks. A consecutive false aneurism of the retro-perito- neum is specially characterised by feeble pulsa- tion of the tumour, and diminished or arrested cir- culation in the femoral artery of one or both sides. Treatment. — The Curative treatment of abdo- minal aneurism may be considered under three heads — Mechanical , Postural and Dietetic, und Medicinal. Mechanical treatment consists in pressure applied to the aorta on the proximal side of the sac, or simultaneously on its proximal and distal sides, by means of tourniquets, so as com- pletely to stop the circulation. The bowels should be first well moved and freed from flatus ; and during the continuance of pressure the patient should he kept under the influence of chloroform or ether. Five cases, if not more, in which a cure was effected by these means have been reported. The object sought to he attained being that of effecting rapid coagulation in the sac, the period during which pressure needs to be continued in these cases varies from three quarters of an hour to ten hours and a half. Where space for the application of proximal pressure does not exist, distal pressure alone may he tried. Under all circumstances, pressure must he used with cir- cumspection, as inflammation of tiie peritoneum or of tiie bowels may result from it. Bellingham introduced the plan of treatment by posture and restricted diet. Under this plan perfect repose of mind and body is, as far as practicable, to be maintained; the bowels being kept moderately free, and the dietary restric'.td to 10 oz. of solids and G oz. of liquids daily. According to the method of Mr. Tufuell, which is based upon the same principle, but is more rigid, the patient is strictly confined to the horizontal posture for a period varying from eight to thirteen weeks, as determined by the effect upon the aneurism, movement in bed being effected with caution ; whilst, by a special arrangement, the bowels and the bladder may be evacuated without disturbance of the body. For breakfast, 2 oz. of white bread and butter, with 2 oz. of cocoa or milk, are allowed ; for dinner, 3 oz. of meat, with 3 oz. of potatoes or bread, and 4 oz. of water or claret ; and for supper, 2 oz. of bread and butter, and 2 oz. of milk or tea. The total amount in the twenty- four hours would be, solids 1 0 oz., liquids S oz. This system might be in some degree relaxed if the patient prove restive. Mild laxatives and opiates as required are the only medicines used. Ten cases of the successful treatment of aortic aneurism by this method have been re- ported by Mr. Tufnell. Abdominal aneurism was solidified in two instances, after treatment extending over thirty-seven and twenty-one days respectively. Of tiie various medicinal agents used with a view to favouring or effecting a deposit of laminated fibrin in the sac. acetate of lead, iodide of potassium, aconite, and ergotin ( hypo- dermically), alone claim attention. Iodide of potassium maybe given with advantage in doses ABDOMINAL ANEURISM, of 10 to 20 grs. thrice daily, with a view to reducing vascular tension, and thereby relieving pain and promoting deposition in the sac, whilst perfect rest in the recumbent posture and a re- stricted dietary are observed. The latter are, however, the more important factors in the treatment. Dr. G. W. Balfour has reported several cases successfully treated by means of iodide of potassium ; and recently an example of a similar kind has been published by Dr. Dyce Duckworth. Dr. Grimshaw has lately had an example of cure mainly through the use of aconite. At the same time the allowance of liquids must be reduced to the lowest possible standard, whilst excretion is promoted. Alco- holic stimulants may be given in small quantity and at long intervals, if the pulse exhibit debility and the patient complain of a sen- sation of sinking ; otherwise they should be prohibited. The Palliative treatment as applied to Ab- dominal Aneurism will be found described in the article Aorta, Diseases of (Aneurism). The application of a few leeches, followed by a warm poultice, is very efficacious in relieving pain. The hypodermic use of morphia is still more rapidly effective. Thomas Hayden. ABDOMINAL TYPHUS. — A synonym for Typhoid Fever. See Typhoid Fever. ABDOMINAL "WALLS, Diseases of. But little more will be needed in this ar- ticle than to give a brief outline of the nature of the affections to which the abdominal walls ire liable, as most of these are but local forms of diseases which are fully described in other parts of this work. The parietal peritoneum will be excluded from consideration, as its morbid conditions are treated of separately". 1. Superficial Affections. — a. The skin covering the abdomen may be the seat of various eruptions. The rash of typhoid fever is chiefly observed over this region, b. "When the abdo- men is greatly enlarged, its cutaneous covering becomes stretched and thinned, often presenting a shining appearance : this may even give way", so that it exhibits superficial cracks or fissures. If it has been distended for a considerable time or on several occasions, as after repeated preg- nancies, the skin becomes impaired in its structure, and is often the seat of permanent white lines or furrows — lines aVAcantes. In this connection al- lusion may be made to the umbilicus, which, in certain forms of distension of the abdomen, may become pouched out, everted, or actually obliter- ated. c . The veins of the skin frequently become enlarged and tortuous, when the return of the blood which is normally conveyed through them is in any way impeded. The particular vessels which are distended will necessarily depend upon the seat of the obstruction, d. The cu- taneous sensibility over the abdomen is some- times materially altered. In certain nervous diseases it may become more or less impaired or lost ; tut the most important deviation is a marked increase of sensibility — hyperesthesia— which is occasionally observed in hysterical females, and which may simulate more serious affections, particularly peritonitis, especially if it is accompanied with symptoms of much depres- ABDOMINAL WALLS. 6 sion. This condition is characterised by ex- treme superficial sensibility or tenderness of the abdomen, the slightest touch being resented; but if the patient’s attention can be taken off, and deep pressure be then made, this is borne with little or no indication of distress. The aspect of the patient, the presence of other symptoms indicative cf hysteria, and the ab sence of pyrexia, usually' serve to distinguish this affection from others of a graver nature. The surface of the abdomen may also be af- fected with neuralgia, which is sometimes very severe. 2. Subcutaneous Accumulations. — a . The chief morbid condition coming under this head is oedema or dropsy of the subcutaneous tissue. This generally follows anasarca of the legs, and may be associated with ascites. The fluid tends to collect especially in the lower part of the ab- dominal walls and towards the flanks. The skin often presents a white pasty aspect ; the abdo- men maybe more or less enlarged ; the umbilicus appears depressed and sunken, if the cedema ex- tends up to this level ; the superficial structures pit on pressure, and yield the peculiar sensa- tion of dropsical tissues ; and the percussion note is frequently muffled, b. The abdominal subcutaneous tissue is, in many persons, the seat of an abundant collection of fat, which may be important from its causing general enlarge- ment, and simulating or obscuring other more serious morbid conditions which enlarge the abdomen. 3. Affections of the Muscles and Aponeu- roses. — a . The abdominal walls maybe the seat of muscular rheumatism, which is particulaily likely to follow undue straining, such as that caused by violent coughing or vomiting. It is characterised by pain, sometimes severe, evidently located in the muscular and tendinous structures, accompanied with much soreness and tenderness. The affected parts are kept as much at rest as pos- sible, and any action which disturbs them materi- ally" aggravates the pain. b. As the result of violent strain, the muscular or aponeurotic tissues maybe more or less torn or ruptured. As a consequence a protrusion of some internal structure may take place, forming a hernia, c . The abdominal mus- cles are liable to be the seatef spasmodic con- tractions, cramp, or rigidity. These are not un- commonly excited in sympathy with grave dis- turbance of the alimentary canal, as in cholera. In certain painful internal affections also some of the abdominal muscles are occasionally kept in a state of more or less rigid tension, as if they were involuntarily contracted in order to protect the diseased parts underneath from injury. The spasmodic contractions in tetanus not unfre- quently cause great suffering over the abdomen. d . On the other hand, the abdominal muscles are occasionallyparalysed, as the result of centric nervous disease. The movements of respiration are then altered in character ; while the expulsive acts in which the abdominal muscles naturally take part are much interfered with. 4. Relaxed Abdominal Walls. — All ihe structures forming the walls of the abdomen are often in a relaxed and flabby state, yielding to any pressure from within, so that the abdomtx becomes enlarged and prominent, especially if. 3 ABDOMINAL WALLS, as is frequently the case, this condition is as- sociated with much flatulence. It materially weakens the act of defaecation, and promotes constipation. 5. Inflammation and Abscess. — Local inflam- mation may be set up in any of the abdominal structures, and this may terminate in suppura- tion and the formation of an abscess. Purulent accumulations from within, as in cases of pelvic abscess, aa well as certain abscesses originating in diseases of bones or joints, may likewise extend among the tissues of the abdominal walls, causing thickening and induration, or may make their way outwards, directly or through a sinus. Subse- quently permanent sinuses or fistulce may be left. 6. The abdominal wall may be the seat of extravasation of blood ; and various kinds of tumour or new growth may form in its structures. Frederick. T. Roberts. ABERRATION. — A divergence or wander- . ing from the usual course or condition ; applied in medicine chiefly to certain disorders of the mental faculties. See Insanity. ABORTION. — The act of abortion signi- fies the expulsion of the contents of the preg- nant uterus before the seventh month of gesta- tion. An abortion is a designation given to a fetus prematurely expelled. See Miscarriage. ABSCESS (abscedo, I depart). Synon. : Pr. abces ; Ger. Eiterbeule ; Geschwur. Definition. — -A collection of purulent matter, one of the results of inflammation. See Pus and Inflammation. Pathology. — If the material which collects in a tissue as the consequence of inflammation softens and becomes liquid (suppuration), it does so either rapidly or slowly : if the former, the result is an acute abscess ; if the latter, the abscess is termed chronic or cold. If the material thus softened and forming pus, often mingled with fragments of dead tissue, is limited by condensation of the parts around, which are usually consolidated by the products of inflammation, the abscess is said to be circumscribed ; but if the surrounding parts in their turn soften, so as practically to offer no barrier to the pus, then the abscess spreads and is said to be diffused. In an acute circumscribed abscess the lymph which collects around it as the result of inflammation becomes organised and forms a sae (pyogenic membrane) ; and this, with the compressed tissue about it, is the wall of the abscess, consisting therefore of contents (pus), of a limiting sac, and of con- densed tissue around. The resistance offered to the extension of the suppuration is greatest when the parts adjacent are dense and tough, such as bone and fascia ; yet, as the pus in an abscess in- creases in quantity, probably by breaking down of the pyogenic layer, sufficient pressure is ex- erted to cause the most dense structures to yield, and an abscess will thus make its way even through osseous tissue. As might be ex- pected, an abscess always advances in the direc- tion of least resistance, and this extension is spoken of as its pointing. This pointing may he towards the surface of the body, but an abscess may direct itself towards a serous cavity, such as the peritoneum, or along a track of cellular tissue, ABSCESS. as when pus beneath thedeep cervical fascia- poin.s into the mediastinum. On the side at which th - abscess is pointing, its wall, as the resistance lessens, projects ; and by ulcerative absorption the parts covering it become quickly thinner, until they and the abscess-wall give way and the pus escapes. In by far the greater number of cases this absorption of tissue before the pointing abscess is towards the surface, aDd it is by ulcer- ation of the skin that the opening for the dis- charge of the matter is effected. The wall of the abscess then contracts, pus continuing for a time to be discharged; and in the end, aided bv the resilience of the tissues around, the sac of tin- abscess is obliterated, and the orifice through which its contents were discharged heals by gra- nulation process. To ensure this result the walls must be left at rest, or the granulations which cover them will fail to unite, and the obliteration of the sac will not then take place, as happens for example in the case of an abscess situated between the moveable rectum on the one tide and the ischium on the other, where the opposite abscess-walls are prevented from joining by mus- cular movements on the side of the bowel, and will only unite after such movements have been stopped by cutting across the muscular fibres which occasion them. The track which results from such failure of the healing of an abscess is called a sinus or fistula. In a diffused abscess the inflammation of the parts around does not limit the suppuration by organisation of the efiused lymph, but such lymph, itself degenerating, forms more pus. and so the abscess extends rapidly and widely, unless checked by some barrier of dense tissue. In this way matter often spreads along tracks of cellular tissue, as along the course of veins, and iu the subcutaneous structures. An abscess when formed between bone and periosteum, oi otherwise hindered from reaching the surface by pointing, also tends to diffuse itself by following the course of least resistance. In most of these cases by direct pressure upon the resisting tissue or by cutting off the blood supply (as of the skin when its subcutaneous tissue is infil- trated with pus), sloughing of the parts covering in the abscess ensues, oftentimes to a consider- able extent, and so the pus eventually makes its way to the surface. It is these abscesses, spreading along tracks of tissue before they can reach the surface, which are apt, however, when involving certain parts, such as the course of some of the lumbar nerves, to burst into a serous cavity with fatal consequences. A chronic abscess begins in some local inflam- mation without active symptoms, such as resu.rs in the deposit of aplastic lymph and subsequent ulcerative changes, as caries of bone, the irrita- tion leading to suppuration. The formation of matter proceeds in a languid manner, so that it is only by slow degrees that it collects in any considerable quantity, although eventually these chronic abscesses may acquire great size. They slowly point, and in their tardy advance occa- sionally traverse even serous cavities, which have been first obliterated in the line of transit by ad- hesive inflammation of their opposed surfaces : ia this way an abscess formed in the liver (andtliii. holds good also for those of a more acute eliarsc. ABSCESS. ter) may travel through the layers of the perito- neum, and may point through the anterior wall of the abdomen. When an abscess discharges, its contents are seen to be either a thick yellow ( laudable ) pus, or pus stained with blood, or otherwise coloured, such as black or bluish-green ; or the pus may be thin, almost watery 7 , mingled with flakes of lymph; it may he inodorous or foetid, or irritating to the touch (ichorous). Abscesses may also con- tain sloughs of tissue, or foreign bodies, or masses of inspissated pus, as hard occasionally as calculi, or fragments of dead bone, or calculi of various kinds. Sometimes a chronic abscess ceases to enlarge and if the irritation which occasioned it comes to an end, it may diminish by absorption of the fluid part of its contents, the solid drying up into a shrunken putty-like mass. It may re- main in this state without giving rise to trouble, or it may become again the seat of suppuration by the formation of what under such circum- stances has been termed by Sir James Paget a residual abscess. The progress of any abscess is largely influ- enced by the state of the general health. In persons otherwise robust an abscess commonly runs an acute course; in those weakened by acute illness, such as scarlet fever or typhus, they form quickly, but are slowly recovered from, and severely tax by an exhausting discharge the powers of the patient. Persons in feeble health, hereditary or acquired, usually suffer from the chronic and diffused forms ; and chronic affections of internal organs, as of the liver or kidneys, are not unfrequently associated with the develop- ment of such abscesses. yEtioeogy. — The cause of an acute abscess may be an injury, such as a blow or pressure, as often happens in persons weakened by continued fever ; exposure ; or the irritation of a foreign body, or that of a poison introduced from without. In the last case the abscess is often diffused. Abscess running an acute course may also he due to a foreign body or to an irritant from within, as when it follows necrosis of a portion of bone, or the escape of urine into the tissues of the perineum. It also arises in connection with blood-poisoning, as in various fevers, and affec- tions distinguished as septic. The cause of a chronic abscess is usually found in changes which go with deposits of a tuberculous character ; or it is found in the changes which slowly occur around an irritating body, such as a renal cal- culus ; or chronic inflammatory changes may culminate in one of these collections of matter. They may also form in parts which are long congested in connection with obstructed vein cir- culation ( varix ) ; and they may follow, or con- ditions closely allied may follow, the occlusion of a main artery and the consequent cutting off of the supply of blood to a particular region. Symptoms. — The symptoms of an acute abscess are those of a local inflammation, with constitu- tional disturbance if the abscess is of any size ; followed by a sense of cold or actual shivering, with increase of pain and swelling, tenderness, and throbbing. The tenderness can he recog- nised in the case of most abscesses ; and, if pus is formed anywhere near the surface, the presence of the fluid is detected by its fluctua- ' 7 tion. The severity of the pain is much influ- enced by the site of the abscess, as when the pus is held down and hindered from pointing bj dense structures; such as fascine. Special symp- toms may also arise in connection with the situa- tion of the suppuration, as when urgent dyspnoea is caused by the pressure on the larynx of an abscess deeply seated at the base of the tongue A diffused abscess, if subcutaneous, is recog- nised by its rapid spreading, and may be sus- pected if other signs point to a part as the site of the abscess in which diffusion is the rule, as, for instance, by the side of the rectum in the isehio-rectal fossa. Of chronic abscess there is seldom in its early stage any evidence. The symptoms, if any, are those of failing health, and for the rest are marked by those of other changes from which the abscess is an outcome. Thus in disease of the hip joint or of the spine, unless an attack of shivering chances to attract attention, an abscess is not as a rule suspected until it has broken through its first limits, and has attained considerable size. It is not worth while to attempt to distinguish between chronic abscess and other swellings, such as extravasated blood or soft tumours, especially malignant tumours ; for if a doubt in anj- case arises, it can be at once solved by the introduction of a grooved needle or of a fine trochar into the swelling. The true pulsation in an aneurism sufficiently tells its nature, and is not easily mis- taken for the impulse sometimes given to an abscess by an adjacent artery. Varieties. — The chief local varieties of ab- scesses which are likely to he met with in medical practice may be thus arranged : — 1, Subcutaneous or more deeply seated abscesses in the limbs, in connection with low fevers, ery- sipelas, pyaemia, &c. 2. Abscesses of local origin in the walls of the abdomen or chest. 3. Abscesses originating in serous membranes. 4. Certain special abscesses associated with dis- eased hone, e.g., psoas and lumbar abscess. 5. Abscesses formed in the cellular tissue around organs, e.g., peri-nephritic, peri-csecal, &c. 6. Abscesses originating, in inflammation of or- gans, the chief of which include hepatic, renal, pyelitic, pulmonary, mammary, cerebral, splenic, pancreatic. 7. Obscure abscesses formed in the deep cellular tissue, e.g., retro-pharyngeal, is- ehio-rectal, mediastinal. 8. Glandular abscesses, which are usually chronic and of a scrofulous nature. Treatment. — The treatment of an acute ab- scess consists in rest, soothing local applica- tions, and the use of remedies to allay pain and constitutional disturbance, if the latter exists. As soon as the presence of pus is re- cognised the abscess must he opened, if possible where the matter is most dependent; and as soon as its contents have escaped ail troublesome symptoms will usually disappear. The opening is needed to relieve pain, and to prevent in some cases diffusion, and sometimes to relieve urgent distress, as when dyspnoea is caused by the pres- sure of an abscess upon the air-passages. It is also desirable to open an abscess to avoid the considerable scar which must result if the matter is left to escape by ulceration and sloughing of the superficial tissues. If it is important to 8 ABSCESS, avoid the sear of an incised -wound, an abscess may be punctured in several places -with, a grooved needle, -when the punctures, if kept open, will effectually drain off the pus, and the marks left will in the end bo scarcely discernible. In most cases, however, it is necessary to open an abscess by an incision : a narrow double-edged knife should be used ; and if the matter is deeply seated, the superficial parts only need be cut, the deeper being torn through, as Mr. Hilton re- commends, by dressing forceps : the risk of dividing important structures, as in the neck, is thus avoided. After the pus has escaped, the wound should be kept open by means of a drainage tube (unless the abscess is of in- significant size), which is conveniently made by introducing a twisted slip of thin gutta-percha tissue or of oiled silk, and should be covered with carbolised oil on lint, or with a poultice of linseed and ferralum. Some surgeons pro- tect the wound whilst operating by means of the carbolic spray or by a piece of linen steeped in carbolic lotion (1 in 20), or take other anti- septic precautions. Tho drainage tube should be withdrawn after the first day if the abscess is superficial, but if the pus has been deeply seated it should be only gradually withdrawn, portions being cut off as tho abscess contracts. If a foreign body has caused the formation of the abscess, it must be sought for and removed before the suppuration can be expected to cease. Occasionally the vascular wall of an abscess bleeds freely, or a vessel is opened in the pro- gress of the affection : the hsemorrhage usually ceases on laying the abscess freely open ; but if this does not suffice it may be permanently con- trolled by pressure, and the cases are rare in which further operative interference is called for. Inflammation of the sac used not infrequently to follow the discharge of its contents, but under the treatment now employed such an occurrence is unknown. During the healing of any consi- derable abscess the general health should be attended to, and tonics and change of air may be useful to expedite recovery. Diffused abscesses, whether subcutaneous or more deeply seated, require free incisions as soon as suppuration is even suspected, so as to avoid the damage which results from their spreading and from the sloughing of tissue, as of the skin, which will otherwise occur, especi- ally with those due to poison introduced into the system or those caused by infiltration of urine. These abscesses sometimes lead to fatal results. A chronic abscess may have its contents drawn off by the aspirator ; or it may, when it has come near the surface, be opened, drained, and dressed with carbolised oil on lint, without any risk of constitutional disturbance, but its ultimate closing will depend upon the removal of the cause ; if, for example, it is due to disease of a joint, it cannot be cured until the disease in which it has originated has in some way ended. Sinus. — An abscess .after being opened may contract until it forms a narrow track, sinus or fistula , leading to the site of primary irritation. Such a track has a dense fibrous wall from which muco-purulent fluid escapes : it may also convey secretions, as from the liver (hepatic fistula) or ACARUS. stomach (. gastric fistula), or excretion, as from the kidneys ; or it may simply carry out the pua which forms around some irritant at the deep extremity, such as a foreign body, a portion of carious or of necrosed bone. Some such fistulse are due to the movements of adjacent muscles preventing union of the abscess walls. Unless the cause of the sinus can be removed, as by ex- tracting necrosed bone, these fistulous tracks are difficult to manage, requiring especial treatment according to their situation. Other fistula are those forming communications between mucous canals ( recto-vesical , vesico - vaginal fistula), and these need special treatment, such as plastic operations and operations diverting the course of excreta escaping through unnatural channels. The tissue about healed abscesses, scar-tissue generally, and tissue spoiled by inflammation, are apt on slight provocation to inflame and suppurate, and to those collections of matter the term ‘ residual ’ has been applied. The treat- ment of such abscesses in no way differs from that of others, and they usually heal in the or- dinary manner. G. W. Callender. AB SIN THIS M. — Definition. — The condi- tion induced by the undue imbibition of ab- sinthe. From the mode in which absinthe is taken, we should expect that the symptoms in- duced by its excessive consumption would bo generally obscured by, and intermixed with those of alcohol (see Alcoholism). That it has a special effect on the organism, and that this may be diagnosed from alcoholism, has been pointed out by Motet, Magnan, and other French physicians ; and the writer last-mentioned has clearly exemplified its action by numerous ex- periments on dogs. In persistent absinthe- drinkers vertigo and epileptiform convulsions are marked symptoms, and come on much earlier than when alcohol in other forms is habitually drunk. Hallucinations occur also without auv other symptom of delirium tremens ; and, when tremors coexist, these are limited more par- ticularly to the muscles of tho arms, hands, and upper extremities. Absinthe acts chiefly on the cervical portion of the spinal cord, and this readily explains the special symptoms arising from its regular use. John Curnow. ABSORBENT AGENTS. — Definition. — In Surgery, absorbents are substances used to absorb fluids, as sponges, charpie, or tow : in Medicine, drugs which neutralize excessive acidity in the stomach — a synonym for alkalis (see Al- kalis). The term is sometimes also made use of to designate remedies, such as the preparations of mercury and iodine, which are believed to pos- sess the property of promoting the absorption of morbid products. ABSORBENT VESSELS and GLANDS, Diseases of. S:e Lymphatic System, Diseases of ; also Bronchial, and MIesexteric Glands, Diseases of. ACARUS. — Acari or Mites constitute an order of the class Aracknida, several species ol which are parasitic. The Acarus scabiei or Sar- coptes hominis, aud the Acarus foil ic u lorn m, oi ACARUS. more properly the Steatozoon folliculorum, are the only human parasites belonging to this family. Description. — 1. The Acarus scabiei is a small roundish animal, just visible to the naked eye. Examined under the microscope it is seen to be flattened and to resemble a tortoise in shape ; when fully developed it has eight legs, and on its under surface are scattered filaments and short spines, which are for the most part directed backwards. The female is larger than the male, and is provided with terminal suckers on the four anterior legs, while filaments occupy a similar position on the posterior ones ; in the male, how- ever, the two extreme hind legs have suckers like those on its fore limbs. The young Acarus has only six legs, the two hindmost ones, which are distinctive of the sex, being wanting ; it acquires these after shedding its first skin. The male Acarus lives near the surface of the skin, while the female burrows -within the cuticle, and deposits from ten to fifteen eggs in the cuni- eulus or burrow ; these eggs hatch in about a fort- night. The young Acari escape from the bur- row, but the parent does not leave it, and dies when she has finished laying eggs. The Acarus scabiei is the cause of the skin-affection termed Scabies or Itch (see Scabies). 2. The Acaros folliculorum is a very mi- nute parasite commonly found in the sebaceous and hair follicles of the face, but its presence can hardly be regarded as indicating disease. In this animal the head is continuous with the thorax, and to the latter are attached eight very short legs, each armed with three strong claws. On each side of the head are short jointed palpi. The abdomen varies in length from twice to three or four times that of the thorax: it is pointed at its distal extremity. The presence of this parasite in the follicles of the skin is quite unimportant. Robert Liveing. ACCOMMODATION", Disorders of. — See Vision, Disorders of. ACEPHALOCYST (d, priv. ; icecpaK-) J, a head ; and kvctis, a bladder). — A headless cyst or hydatid. — This term was formerly much em- ployed to distinguish the true hydatid from all those bladderworms that are furnished with a head visible to the naked eye. The expression is a misnomer and should be abandoned, since it is only fairly applicable to such hydatids as have failed to develop the so-called heads internally. The Acepkalocystis endogena of John Hunter and the A. exogena of Kuhl are merely varieties of the true hydatid ( Echinococcus veterinorum, or E. hominis). See Hydatids, Echinococcus, and Bladderworms. T. S. Cobbold. ACHOLIA (a, priv., andx a gland, and 6\yos, pain). — Pain in a gland. ADENITIS. — Inflammation of a gland. See the several glands. ADEIfOCELE ( oSV , a gland, and kt]\v, a tumour). — A tumour connected with a gland. ADENODMNIA (aSjjp, a gland, and oSovti, pain).— Pain in a gland. ADENOID (cl3t]v, a gland, and efSor, form). — Glandular : resembling the structure of a gland, whether secreting or lymphatic. ADENOMA (ctSV, a gland, and 6/ubs, like). — A morbid growth, the structure of which is of glandular nature. See Tumours. iSHESI^S. } “Structures are said to be adherent when they become abnormally united together, the morbid formations by which this union is effected being termed adhesions. These are most frequently met with in connection -with serous surfaces, being usually the result of an inflammatory process, but they may be observed in other structures. The adhesions vary con- siderably in extent, number, mode of arrange- ment, firmness, and other characters ; they may merely consist of a few loose, slender, and deli- cate bands, or these bands may be thick an-! strong, or the contiguous surfaces may be blended and matted together to a greater or less extent, so that they cannot be separated without tearing or cutting them asunder, this last condi- tion constituting agglutination. In structure adhesions consist mainly of connective or fibrous tissue, more or less perfectly developed, with a few new vessels. Effects. — Adhesions are often found at post- mortem examinations, which have been of little or no consequence during life, as, for instance, many of thosewhich form in connection with the pleural surfaces. If, however, they are extensive and firm, or if they occupy certain regions of the body, they may prove of serious moment. The principal evils which are liable to result from adhesions may be thus indicated : — 1 . They often bind parts together, and interfere with the movements of important organs, such as the lungs, heart, stomach, or intestines ; in this way preventing the due performance of their functions. 2. When an organ is displaced in any way. as, for example, the heart by pleuritic effusion, it may become fixed in its new position by the formation of adhesions, its functions being thus disturbed. 3. It is highly probable that agglutination may lead to hypertrophy of an organ, e.g., the heart, by embarrassing its move- ments, and hence affecting its action. 4. On the other hand, atrophy or degeneration of structure may ensue, in consequence of the adhesions in- terfering with the due supply of blood by pressing upon the vessels, so that the nutrition of the tissues becomes impaired. In the young, also, If. ADHESIONS, the development of structures may be checked. 5. Adhesions may involve important structures, such as nerves or vessels, pressing upon or de- stroying them, thus giving rise to symptoms of a serious nature. 6. Tubes or canals for the pas- sage of secretions or other materials are some- times narrowed or obliterated by adhesions. 7. When formed within the abdominal cavity, espe- cially when they take the form of bands, adhe- sions may prove highly dangerous by com- pressing, constricting, exerting traction upon, or strangulating some portion of the intestine, in either of these ways leading to intestinal ob- struction. It is frequently difficult or impossible to deter- mine the existence of adhesions by clinical inves- tigation during life ; but the history of some past illness during which they were likely to be formed, the results of physical examination, espe- cially in connection with the heart and lungs, and the symptoms present, not uncommonly enable them to be discovered. Frederick T. Eoberts. ADIPOCERE ( adeps , fat, and cera, wax). — Synon. : Er. Adipocire; Gcr . Fettwachs. Definition. — A substance formed by a spon- taneous change in the dead tissues of animals. Description. — As seen generally in a dried state in museums, adipocere somewhat resembles spermaceti in consistence, but it is less crystalline in fracture, and is of a dull white or buff colour, the surface being marked by the outlines of blood- vessels or other textures. Adipocere in the earli er stages of its formation, or when formed in a damp situation, is soft, and if rubbed between the fingers communicates a greasy feeling. The odour is peculiar and rather disagreeable. Chemical Composition. — Adipocere dissolves in ether, leaving a delicate filamentous web; it burns with a blue flame, yielding a white ash. It is properly described as a soap composed of mar- garic and oleic acids in combination with ammo- nia, the fixed alkalies, and alkaline earths ; the relative proportion of the latter ingredients vary- ing with the age of the specimen (the ammonia disappearing), and with the composition of the fluids in contact with which the adipocere had been formed. It is said that oleic acid predo- minates in adipocere formed from dead fish. Microscopic Appearances. — When the flesh of animals in which this transformation has recently commenced is examined with the microscope, it is found to be composed of broken-down or dis- integrated tissues, fatty granules or particles, together with a few acieular scales or crystals. The granules may be seen in what w'as muscular tissue to assume somewhat the arrangement of the muscular filaments, thus presenting an ap- pearance resembling an early stage of fatty degeneration. In old and dry specimens of adipocere the crystalline scales form the great portion of the mass, and they may be observed preserving the outlines of the muscular fibres. Origin. — Adipocere has long been known. It is formed readily from the flesh of animals ex- posed to moisture, or placed in running water, in very dilute nitric acid, or in alcohol and water in the proportion of 1 to 6. It is often taet with in inconvenient abundance in the ADLPOCEEE. specimen jars of the anatomist. The bodies of men and other animals buried in peat moss have frequently been found completely converted into adipocere. Lord Bacon mentions it in the Sylva Sylvarum, and so also does Sir Thomas Brown in the Hydriotaphia ; but attention was es- pecially called to its presence when a vast number of bodies were removed (in 1786-87) from the Oimetiere des Innocents at Paris to the Cata- combs. Fourcroy found many of these bodies converted into what he named adipocire, a name since retained. Gibbes (as did others) suggested the possibility of applying adipocere formed from the waste flesh of animals to some useful pur- poses, but the tenacity of the disagreeable odour and the presence of other difficulties have prevented these suggestions from being carried out. With re- spect to the immediate changes which give origin to adipocere chemists have differed in opinion. One class believes with Gay-Lussac and Berzelius that the compound results from the fat originally present in the tissues, and that the other compo- nents are completely destroyed by putrefaction. The other class, which includes the names of Thomas Thomson and Brande, maintains ‘that the fatty matter is an actual product of the decay, and not merely an educt or residue.’ These opinions may, the present writer thinks, be reconciled by the better knowledge we now possess of the elementary composition of tissues. We know that the combination of fat and albu- min constituting one of the earliest steps in the process of nutrition is traceable in the further de- velopment and formation of nearly every texture. When that combination is destroyed by a ces- sation of the process of life, the tissues are as it were resolved into their primary elements. We may thus have adipocere derived not only from free fat, but from the elements of fat existing in and obtained from the decomposition of other tissues. Adipocere may thus be described as both an educt and a product. This opinion is confirmed by the researches of Bauer and Voit, who showed that fatty matter was derived from the meta- morphosis of albumin in starved animals, to which phosphorus had been administered. 1 The interest concerning this substance is not confined to the chemist. The medical jurist lms studied it with the view of determining the time and progress of its formation, and of thus ascer- taining the probable period at which death oc- curred. But hitherto no decided or satisfactory information has been obtained, owing to the varied circumstances which influence the progress of the change, in connexion not only with the condition of the body itself, bnt also with the character of its surroundings. The formation of adipocere has a further and a special interest for the pathologist. It was the study of this process which led the present writer to point out the analogy which exists between it and fatty degeneration in the living body, and thus to es- tablish the pathological doctrine that fatty dege- neration is the result of a retrograde metamor- 1 The writer would desire to refer here to the analogy which seems to exist between the change of animal matter into adipocere, and that which occurs in vegetable matter by its conversion into peat and coal. This, h js- ever, is not the place in which to examine further such an analogy. AMPOCERE. phosis, clue to defective nutrition. ( See Medical and Chirurgical Transactions, vol. xxxiii.) Richard Quatn, M.D. ADIPOSIS. — A term which properly signi- fies either general corpulency, or accumulation of adipose tissue in or upon an organ. See Fatty Growth ; and Obesity. and Siva /us, ADYNAMIA \ ( , ADYNAMIC J *• ’ p ’ power). — Terms indicating serious depression of the vital powers, and employed as synonymous with the 'typhoid condition' The adjective is applied to diseases in which the phenomena of this condition are prominent. See Typhoid Condition. JEGOPHONY (at£, a goat, andcpapr;, voice). —A peculiar alteration of the resonance of the voice, as heard on auscultation of the chest, compared to the bleating of a goat. See Physicai. Examination. AETIOLOGY (atria, cause, and Xiyos, word). — That branch of pathological science which deals with the causation of disease. See Disease, Causes of. AFFINITY. — This term is the designation of a property by which elementary and com- pound substances unite with one another and form new compounds. It is, therefore, a pro- perty with which chemists are principally con- cerned. But the ideas suggested to the chemist by the term affinity are also, though less explicitly, excited in the mind of the pathologist and of the therapeutist by certain classes of facts frequently falling under their observation. The pathologist, for instance, knows that saline or earthy matter is very prone to accumulate in the midst of degenerated tissue in the walls of an artery or of a cardiac valve, so as to give rise to a patch of ‘ calcification ’ ; he knows that in a gouty patient urate of soda is most apt to accumu- late and form ‘chalk stones ’ in the tissues around affected joints ; he knows that, however it may be administered, arsenic in poisonous doses tends to produce inflammation of the alimentary canal, that strychnia acts with preference upon the ner- vous system, and that in ordinary cases of lead- poisoning this metal interferes especially with the nutrition of the extensor muscles of the fore- arm. Applications of the same notion in the department of therapeutics are equally familiar in respect to the action of many drugs. It may be regarded as an ascertained fact that iodide of potassium tends especially to influence the nutrition of the fibrous structures in the body, and that bromide of potassium has a no less certain action in modifying the nutrition of the nervous centres in many unhealthy states. Again, there is a whole class of substances which when taken into the system have, whatever their other actions may be, an undoubted effect in modifying the functional activity of the kidney. We have in nitrite of amyl a remedy possess- ing a remarkable influence over the unstriped muscular fibres of the arteries and bronchi, or else over the nerve-centres by which they are controlled. We have in woorara an agent which acts especially upon the motor side of the ner- 2 AGORAPHOBIA. 17 vous system ; and we have in digitalis an im portant remedy which, amidst its other effects, seems to have a decided power of improving the nutrition of the cardiac ganglia. The recent progress of therapeutics encourages us to hope that more and more of these specific effects of drugs will be accurately determined, so that the notion implied by the term affinity may, after a time, have a deeper meaning than at present for the practitioner of medicine. See Anta gonism. H. Charlton Bastian. AFFUSION. — A method of treatment which consists in pouring a fluid, usually water, either cold or warm, upon the patient. See Water. Therapeutics of ; and Baths. AFRICA, South. — See Appendix. AGEUSTIA (a, priv., and 7euy comparison with which a faint cloud in tlio heated part may be more readily detected. Fallacies of the test by boiling. — The first fallacy is that albumin may be present, and yet no cloud or coagulum be produced on boiling. This may occur if the urine be alkaline or very strongly acid, because alkali-albumin or acid- albumin, which are soluble in water, may’ be formed. It is to prevent the formation of alkali-albumin that acetic or nitric acid should be added to alkaline urine before boiling. This addition of acid also causes the coagulum to separate more readily ; and it should therefore be made when the urine is neutral. On the other hand, urine rarely or never contains sufficient acid to form acid-albumin, unless the patient has been taking mineral acids ; and therefore til- addition of liquor potassse is not necessary except under these circumstances. The second fallacy of the test by boiling is, that a cloud resembling that of albumin may be produced, although the urine is free from this substance. This occurs when the acidity of the urine is too slight to hold the earthy phosphates in solution, without the aid of the carbonic acid which it usually contains. When such urine is boiled, the car- bonic acid is driven off, and the phosphates are precipitated, forming a cloud like that of albumin. The two clouds are readily distinguished by the addition of a drop or two of nitric or acetic acid, when if due to phosphates it will disappear ALBUMINURIA. 23 by solution ; but if caused by albumin it will remain. If an excessive quantity of nitric acid be added, an albuminous cloud may also clear up; for albumin coagulated by heat is soluble in strong acid, though only to a slight extent. Application of the nitric-acid test. — Pour some urine into a test-tube, and then allow about one-fourth of its bulk of strong colourless nitric acid to trickle slowly down the side of the tube, so as to form a layer below the urine without mixing. Or the acid may be put in the test-tube first, and the urine poured on it. Both processes give the same result. If albumin be present, a haze or cloud will form close to the line where the liquids meet. Fallacies of the nitric-acid test. — 1. Albumin may be present and yet escape detection, if the nitric acid is simply poured into the urine and mixed with it, as is sometimes done. For if there bo too much or too little acid, acid-albumin is formed and dissolved ; whereas, if the liquids form two distinct layers, as in the process already described, the acid gradually mixes with and shades off into the urine, so .that, at a greater or less distance from the line where they join, it is certain to he of the proper strength to precipitate the albumin. 2. Albumin may be supposed to be present when it is not, from the formation of a cloud by the precipitation of acid urates or uric acid. This cloud disappears on the applica- tion of heat : and another specimen of tho urine tested by boiling gives no cloud. To avoid this fallacy, it is common to employ the test by boiling, in addition to that by nitric acid. 3. The third fallacy is not of common occur- rence. It is due to the presence of fat or saponi- fied fats in the urine. Urine containing these when simply boiled gives no cloud ; but if nitric acid is added to it in the cold, or acetic acid when it is hot, the fatty acids are precipitated and form a cloud resembling albumin. This is distinguished by not being formed if along with dilute acetic acid some ether is added to the urine before boiling; the ether retaining the fatty acids in solution. If the precipitate pro- duced by nitric acid be collected on a filter, and treated with ether, it will be dissolved, while an albuminous precipitate will not. Copaiba, which can be recognised by its smell, sometimes causes an opalescence in the urine, which is increased by nitric acid, but is removed by heat. Additional tests for albumin. — "When urine contains mucus, which would render the presence of an albuminous cloud obscure, a solution of ferrocyanide of potassium followed by acetic acid should be added : this will produce a cloud if albumin be present, while it rather clears up a tur- bidity due to mucus. A solution of pyrophosphate of soda also precipitates albumin. If a drop of albuminous urine be poured into a test-tube containing one or two drachms of a saturated solution of picric acid, a precipitate is formed. These tests are sometimes useful in determining the presence of albumin in the urine in doubtful cases. Quantitative Estimation of Albumin. — There are three methods in common use for this pur- pose. The first is easy but inexact. It consists in boiling the urine with dilute acetic, acid in a test-tube, allowing the coagulum to subside for a definite number of hours, and then estimating the proportion it bears to the quantity of urine boiled, for example, a fourth, a third, &c. The second is the most exact, but is troublesome. It is like the first ; but the urine is carefully measured before boiling, and the amount of coagulum is ascertained by collecting it on a weighed filter, washing, drying, and again weigh- ing it. The third method is easy and tolerably exact. A tube of known length is filled with urine and placed in a polarizing apparatus. From the amount of rotation which the polarized ra_' undergoes in passing through the urine, the amount of albumin it contains may be calcu- ated. A fourth method has recently been re- commended by Dr. W. Roberts. It consists in diluting the urine with water until it gives a haze on the addition of nitric acid, which does not become visible until between one-half and three-quarters of a minute after the acid has been added. This dilute urine contains 0'0034 per cent., or 0’01-lS grain of albumin per fluid ounce ; and from the degree of dilution required the amount contained in the urine may be calculated. Pathologt. — Albuminuria has been said to occur in consequence of various conditions ; c.g., changes in the blood, changes in the circulation, changes in the kidneys. Thus abstinence from salt, or a diet of eggs alone, is said to produce albuminuria by altering the constitution of tht blood ; and an alteration in this fluid is sup posed to be partly the cause of the albuminuria observed in high fevers, scarlatina, diphtheria, and osteo-malacia. The albuminuria of heart- disease depends on changes in the circulation, and that of nephritis on alterations in the kidney. In order to distinguish more clearly between the different kinds of albuminuria we may divide them into — 1st, true albuminuria, in which serum- albumin appears in the urine ; 2ndl j, false albu- minuria, in which some other albuminous body, but not serum-albumin, is present. In true albuminuria there is always some change either in the circulation through the kidney, or in the structure of the kidney itself. In false albumi- nuria the albuminous body passes out through the kidney, without there being any alteration either in its circulation or structure. The chief albuminous bodies occurring in false albuminuria are htemoglobin, egg-albumin, and Bence-Jones’s albumin. Haemoglobin occurs in the urine whenever blood is present in it ( see Hjematcria), in which case it is contained in the corpuscles ; or it may occur free {see H-aaiA- tinuria), the blood-corpuscles, while still circu- lating in the vessels, having undergone solution. This may result from the inhalation of arse- niuretted hydrogen, or from the introduction of bile-acids or of a large quantity of water intc the veins. Haemoglobin is also found in the urine in paroxysmal hpematinuria, but the cause of the solution of blood-corpuscles in this disease is unknown. Egg-albumin is excreted by the kidneys, and appears in the urine, whenever it is injected directly into the circulation or under the skin, or when it is absorbed unchanged from the stomach or rectum. "When taken into the sto- mach it is usually completely digested before it undergoes absorption ; but when taken in such «1 ALBUMINURIA. largo quantities that the whole of it cannot be digested, part of it is absorbed unchanged and is excreted in the urine. Thus a diet consisting exclusively of eggs, especially when continued for several days, produces false albuminuria, and large enemata of eggs have a similar effect in animals and probably also in man. Bence-Jones’s albumin is of very rare occurrence. It is found in osteo-malacia. Like egg-albumin, it is ex- creted by the kidneys when it is injected into the circulation or in large quantities into the intestine. It is almost if not quite identical with the hemialbumose, which Kiihne finds to be one of the products of imperfect digestion. It seems probable that those cases of albuminuria which appear to depend on imperfect digestion are due to the passage into the systemic circulation of albuminous bodies, which have not undergone the proper transformation in the alimentary canal or liver. In true albuminuria there must be some change, either in the circulation or structure of the kidney, for serum-albumin differs from the other albuminous bodies just mentioned, in not being excreted by the healthy kidney. Some re- gard the alterations in circulation which produce albuminuria as of two kinds : — (a) increased pres- sure of blood in the renal arteries ; (b) increased pressure in the renal veins. Increased pressure in the arteries may depend either on general high arterial tension, or upon an increased local supply of blood to the kidney, owing to dilatation of the renal arteries, such as follows division of their vaso-motor nerves. Experiments seem to show, however, that increased tension in the renal arteries does not produce albuminuria, and that the only change in circulation which will cause it is increased pressure in the renal veins. Con- gestion of the renal veins may be produced by ligature of the renal arteries, and. when the flow of blood through the kidney is temporarily arrested by ligature of the artery, the urine secreted after the removal of the ligature is albuminous. Venous congestion of the kidney also occurs whenever the onward flow of venous blood is obstructed, either by a ligature on the renal veins ; by the pressure of a tumour or of the pregnant uterus upon them or the vena cava ; by disease of the liver obstructing the vena cava; or by disease of the heart or lungs, such as tricus- pid or mitral regurgitation, or chronic bronchitis and emphysema. The temporary albuminuria sometimes observed after cold bathing may also be due to venous congestion ; and it is probable that albuminuria consequent upon lesions of the nervous system is due rather to the changes which these produce in the circulation than to any direct action of the nerves upon the tissues of the kidney itself. The albuminuria observed after varnishing the skin is probably due to the retention of some substance which acts as a poison. The structural changes in the kidney which cause albuminuria are acute and chronic inflammation, waxy degeneration, and cirrhosis. See Beight’s Disease. Treatment. — In false albuminuria where hae- moglobin appears in the urine, the treatment in- dicated is to counteract the solution of blood-cor- puscles ; and for this purpose quinine is very ofleu useful. When other kinds of albumin ap- ALCOHOL. pear in the urine, and are probably due to im- perfect digestion, the treatment is to give some artificial digestive fluid. Arsenic is aLso useful. Regarding those cases of osteo-malacia in which Bence-Jones’s albumin occurs, we unfortunately know very little. In true albuminuria, depending on venous congestion, the obstacle to free circulation should be removed, if possible ; and conges- tion lessened, both by drawing the blood from the interior to the surface of the body, and by causing contraction of the renal vessels. The blood may be drawn from the interior to the surface by means of warm baths, hut in some cases they prove injurious rather than useful, and the employment of a wet pack, which has a similar effect on the distribution of blood without exciting the heart, is to be preferred. Cupping over the kidneys is serviceable : it pro- bably acts by causing reflex contraction of the renal •vessels rather than by actually draining blood away from them. The tone of the renal vessels may he increased by the employment of digitalis (see Diuretics) ; and this drug is useful even when no cardiac disease is present, although its good effects are still more marked when the con- gestion is dependent on disease of the heart . The constant drain of albumin from the body occa- sions anaemia, whicb not only produces many unpleasant symptoms, but tends to cause fatty degeneration of various organs, from which there is no reason to believe that the kidneys are exempt. The administration of iron, therefore, is the chief remedy in structural disease of the kidneys, and it is useful by diminishing or re- moving the symptoms of anaemia and the ten- dency to fatty degeneration consequent thereon, and also by increasing the tone of the vessels, thus diminishing the loss of albumin. T. Lauder Bruxtox. ALCOHOL. Synon. : Ethyl-Alcohol ; Vitiic Alcohol ; Spirit of Wine (C H, ; 6). — Alcohol is the product of a process of fermentation induced by the action of a microscopic fuDgus, Yeast, upon certain kinds of sugar, especially grape sugar, but also upon that derived from starch of any description, and, in the same manner, upon milk sugar. In this process a peculiar meta- morphosis takes place, by which alcohol and car- bonic acid are produced in considerable amount, together with very minute quantities of succinic acid, glycerine, and other bodies. Alcohol may also he produced synthetically from its elements, carbon, hydrogen, and oxygen. As alcohol is very volatile, boiling at 172° Fahr. (78° G.), it may readily be separated by distillation from the water with which it is at first combined. Other means must be resorted to, however, in order to separate the very ulti- mate particles of this water, as a strong attrac- tion exists between the two liquids. Alcohol, diluted with about 95 per cent, of water, and subjected to the action of another microscopic fungus, is oxidised into aldehyd and acetic acid. Piiysioj.ogical Effects. — Applied to the skin, alcohol produces a sensation of coolness, due to its rapid evaporation ; hut, if the appli- cation be continued sufficiently long, irritation ALCOHOL. 'js ex sited. This latter effect ensues imme- diately if alcohol is brought into contact with a mucous membrane. Its strong attraction for water seems to be the chief cause of this action. Alcohol is a powerful antiseptic, probably from the fact that it is capable, even when diluted, of preventing the development of septic germs, such as vibrios and bacteria, as well as of paralysing the activity of those already formed. There is scarcely any other therapeutical agent the internal action of which varies so much ac- cording to the dose given. In small quantity, and slightly diluted with water, alcohol promotes the functional activity of the stomach, the heart, and the brain ; whilst a like quantity, largely diluted, exerts but a limited influence upon these organs : if, however, the dose of alcohol be often repeated, it is readily assimilated ; and, becoming diffused throughout the system, undergoes com- bustion within the tissues of the body, imparts warmth to them, and yields vital force for the performance of their various functions. Simul- taneously with this consumption of alcohol, the .body of the consumer is often observed to gain in fat — a circumstance due to simple accumulation, the fat furnished by the food remaining unburned in the tissues, because the more combustible alcohol furnishes the warmth required, leaving uo necessity for the adipose hydrocarbon to be used for that purpose. A quantity of 100 cubic centimetres of alcohol per diem (about three and a-kalf fluid ounces) — equivalent to about ono litre of Ehine wine of medium strength — is sufficient to supply between one-third and one-quarter the whole amount of warmth requisite for the human body during the twenty-four hours. The warmth so supplied cannot be measured by a thermometer, however, any more than can that furnished by the internal combustion of other hydrocarbons, such as the oils or sugars. The subjective im- pression of increased warmth usually experienced after taking a dose of any alcoholic liquid is deceptive, and is only due to an irritation of the ■nerves of the stomach, and to the increased cir- culation of blood through the cutaneous vessels, particularly those of the head. Doses somewhat larger, but still sufficiently moderate not to cause intoxication, act, for the most part, in the same way ; but, as an additional effect, they produce a distinct decrease of tem- perature in the blood, lasting half-an-hour or more. As far as the matter has hitherto been ex- plained, this latter effect depends upon a directly depressing influence exerted by alcohol upon the working cells of the body, and upon a temporary paralysis of the vaso-motor nerves. The latter is followed, of course, by dilatation of the super- ficial vessels, particularly those of the head, in consequence of which a larger surface of blood is exposed, and the loss of heat by irradiation into the air is increased, the temperature of the circulating fluid being thus lowered ; whilst, the combustion curried on by the cells being re- tarded, the generation of heat from this source is diminished. The quantity of carbonic acid eliminated is thus diminished, as is also the amount of urea excreted. After the organism has become inured to the action of alcohol, these effects upon the temperature of the blood are ies3 distinctly, or not at all, marked. 2d The agreeable excitement at first caused bv such doses of alcohol is succeeded by a reaction, characterised by lassitude and drowsiness, the latter condition usually lasting longer than the previous one of exhilaration. The symptoms of intoxication produced by large doses of alcohol are sufficiently well known. "When the abnormal condition of excite- ment in the brain induced by this stimulant has been kept up, almost without intermission, for a length of time; or when it is suddenly withdrawn after the organ has been long subjected to it ; the disturbance brought about is so great and persistent as to result in a complete overthrow of the reasoning faculties, "and the condition known as delirium, tremens ensues. At the same time that this pernicious influence is being exerted upon the cells of the brain, fatty accumulations may take place in other organs, particularly in the liver, heart, and connective tissues ; the biood-vcssels become diseased ; and, in many instances, cirrhosis of the liver, kidneys, and meninges makes its appearance, as part of the general disorder of nutrition. The shrinking of connective tissue, characteristic of this last-mentioned complica- tion, seems to depend upon the direct irritation caused by the presence of un-oxidised alcohol. Under ordinary circumstances, and after the consumption of moderate quantities of alcohol, only slight traces of it are to be detected in the urine, and none whatever in the breath. Pure alcohol imparts no taint to the exhalations of the body; the ethers and fusel oils, on tho other hand, do so by reason of their being less readily combustible. It is very likely that alcohol is completely oxidised into carbonic acid and water during the process of assimila- tion ; at least, no other secondary products resulting from its disintegration have as yet been detected. Therapeutical Applications. — There can be no doubt but that a healthy organism, supplied with sufficient food, is capable of performing all its regular functions without requiring any specially combustible material for the generation of heat and the development of vital force. But the case assumes a different aspect when, in sickness, it transpires that, while the metamor- phosis of tissue goes on with its usual activity, or with increased energy, as happens in many diseases, the stomach, refusing to accept or digest ordinary food, fails to supply material to com- pensate for this waste. Here it is, then, that a material which can be most readily assimilated by the system, and which, by its superior com- bustibility, spares the sacrifice of animal tissue, is especially called for ; and such a material we have in alcohol. Small but oft-repeated doses of alcohol, largely diluted with water, are gene- rally well tolerated by the weakest stomach ; and, thus given, the absorption and oxidation of the spirit goes on without difficulty or effort on the part of the patient’s system. According to the experiments of Dr. Frank- land and others, the burning of l’O gramme of alcohol yields sufficient heat to raise the tem- perature of seven litres of water 1°C. ; and the burning of DO gramme of cod-liver oil suffice-! for nine litres. Now, in taking three table- ALCOHOL. <2t> spoonfuls of the oil daily, we yield about the same amount of warmth to the body as is given by four table-spoonfuls of absolute alcohol — the quantity contained in a bottle of light claret or hock. The oil, however, is digested and oxidised by the organs of the body with difficulty, while, for the assimilation of the alcohol, scarcely any exertion of the working cells is required. Thus, it can be demonstrated by calculation, as above- mentioned, that heat-producing material, suffi- cient to supply nearly one-third the whole amount of warmth required by the body within twenty-four hours, is offered in a quantity of 100 grammes (about three and a-half fluid ounces) of alcohol. In this sense alcohol is a. food ; for we must regard as food not only the building material, but all substances which, by their combustion in its tissues, afford warmth to the animal organism, and, by so doing, con- tribute towards the production of vital force, and keep up the powers of endurance. Alcohcl, therefore, diluted with at least 90 per cent, of water (in any convenient form of beverage), may be given with advantage, in small but oft-re- peated doses, in most of the acute and chronic diseases where it is desired to sustain the strength of the patient, hut where at the same time the digestive organs, from any cause, refuse to tolerate a more substantial form of nourish- ment, at least in quantities that would answer the necessities of the case. In such cases it is certainly not sufficient to call alcohol merely a stimulant. If alcohol served here only in the quality of a stimulant, its effect would soon pass away, leaving the patient more ex- hausted than ever ; for the human organism is so constituted that it cannot he driven to per- form its functions by the application of mea- sures that simply stimulate, without supplying some new force to take the place of that put forth by the organs of the body under the im- pulse of excitemont. To take a familiar illus- tration, alcohol thus given stimulates no more than does the easily burning coal which we put in small quantities upon a languid fire, to pre- vent its going entirely out. Medium doses act powerfully upon the brain and heart, and are therefore serviceable as real etimulants in cases where it is desirable to excite the cerebral and circulatory systems to greater activity. We must not forget, however, that, while exciting this increased activity, such doses do not elevate the temperature of the body ; on the contrary, where the effect can he measured, it is found that they depress it a little. By con- tinuing to exhibit such doses, we can sometimes (in erysipelas, puerperal peritonitis, and similar diseases) lower febrile heat by alcohol where even quinine proves ineffectual. The consequences of this decline of fever-heat are an immediate re- storation to consciousness, if delirium or stupor has been present ; and, in any case, a general improve- ment in the feelings of the patient. Todd and his school, before the application of the thermometer, called this the effect of stimulus , while in reality the improvement is due almost entirely to the withdrawal or diminution of febrile disturbance. As fever patients can tolerate large quantities of alcohol without showing any sign of intoxica- tion. it is allowable, and sometimes even neces- sary, to rise in the scale of doses beyond the limits ordinarily prescribed. Of late years alcohol has been given during the night to hectic phthisical patients as a preventive against copious and exhausting at- tacks of sweating, and with a gratifying amount of success. Such patients certainly tolerate the remedy much better than has hitherto been generally supposed. It need hardly be said that, in cases of cardiac excitement, not resulting from fever, alcohol is at least to be used with caution. Mode of Administration. — One of the most important, but at the same time most difficult, points for decision is the exact nature and quality of the alcoholic drink to be prescribed or allowed to a patient, who may require alcohol in some form. For general use, a pure Claret, Hock, or Mosel wine are the preparations most to he recommended. Cognac, Champagne, old Gin or Whisky, and the heavier Southern wines, may also be used according to circumstances. But whatever drink may be selected, it must at least be free from fusel oil to such an extent that a healthy man, even after imbibing a consider- able quantity, will not feel any other effects than those of a pure stimulus ; that is to say, an agreeable exhilaration of spirits, neither accom- panied by a sense of weight in the head, nor followed by that persistent overfilling of the cerebral vessels and dulness of ideas charac- teristic of the physiological effects of fusel oil. The Fusel O/ls (so-called from their oily quali- ties) consist chiefly of propyl, butyl, and amyl alcohol, of which the last-named forms the largest proportion. In order to examine any specimen of alcohol with reference to its purity from theso objectionable constituents, it is only neces- sary to rub a few drops between the palms of the hands for half a minute, by which rapid evaporation is caused, and then to smell the moist spot left on either palm. If the alcohol be pure no odour whatever should remain, as ethyl alcohol evaporates very quickly; amyl alcohol, on the contrary, is much less volatile, and, if present in the liquid, will not have evaporated, so that its peculiar and unmistake- able odour will remain to attest its presence as an impurity in the specimen examined. This test is not applicable to the more com- plicated liqueurs and wines, as these all contain certain odoriferous organic principles of their own that might disguise the smell of the fusel oil. The inoffensive quality of any given pre- paration, as a wine or spirit, can only be relied upon when one knows by experience that it is pure ; and then it should always be obtained, if possible, from the same source, so as to ensure uniform purity. By far the most pernicious of all the ordinary drinks in use is the spirit obtained from potatoes, as this contains the largest proportion of fusel oil. Even after being redistilled, this liquor is still tainted with the poison to a fearful extent Of course, wines mixed with such spirit possess tlio same objectionable qualities ; whilst wines made from must to which potato-sugar has been added are likewise tainted, though to a less degree. It can easily be demonstrated by experiments upon animals, that amyl alcohol is the ageDt to the presence of which the extremely poisonous ALCOHOL. action of many drinks upon our nerves and other organs is due. All distilled drinks ma.de from other sources than from grapes contain it to a greater or less extent. To facilitate the process of estimating the quantity of any particular beverage necessary to 1)9 administered in order to produce a given effort, a table is subjoined showing the per- centage of absolute alcohol contained in average specimens of the different kinds of wine, beer, &c.. in common use. Absolute Alcohol contained in — Kumiss (a fermented liquor made from whey) is from 1 to 3 vol. per cent. German Beer 1 is from 3 to 5 vol. per cent. Hock or Claret is from 8 to 11 vol. per cent. Champagne is from 10 to 13 vol. per cent. Southern Wines (Port, Sherry, Madeira, &c.) is from 14 to 17 vol. per cent. Brandy and the stronger liqueurs is from 30 to 50 vol. per cent. For antipyretic purposes one will need to give an adult daily not less than the equivalent of fifty cubie centimetres (about two fluid ounces) of absolute alcohol, in divided doses within an hour or two. Taking this as a starting-point, the dose suitable for each individual case can be estimated accordingly. The great quantity of carbonic acid contained in certain 1 sparkling ’ wines acts upon the tem- perature of a fever patient much in the same favourable manner as the alcohol itself, and when alcohol is to be taken as a food, it would seem that the impregnation with carbonic acid facilitates its absorption. All that has been stated thus far with regard to the use of alcohol in sickness applies to children as well as to adults. Of course no reasonable person would accustom healthy chil- dren to the use of alcoholic beverages ; hut, in cases of disease, really good and pure wine or brandy can be advantageously employed, even for infants, either as a stimulant , an antipyretic, or as an article of food, according to circum- stances. For external use, alcohol has been superseded by various more modern agents, of which car- bolic and salicylic acids may be mentioned as the most important. In this connection the author cannot omit to notice one method of applying alcohol, suggested by Dr. Richardson, namely, the treatment of diphtheria affecting the throat, by means of the inhaler, which projects the al- cohol-spray with considerable force upon the infected mucous membrane, causing it to pene- trate more deeply than any other caustic would te likely to do. C. Binz (Bonn). ALCOHOLIC INSANITY. See Alcohol- ism, and Insanity. ALCOHOLISM. — Definition. — This term is applied to the diverse pathological processes and attendant symptoms caused by the excessive ingestion of alcoholic beverages. These are very different if a large quantity is consumed at once or at short intervals ; or if smaller quanti- ties are taken habitually: and hence they are 1 English beer will contain a little more, but the writer has made no personal examination as to exactly how much. ALCOHOLISM. 27 subdivided into those due to (a) acute, and (6) chronic alcoholism. To the acute forms of alco- holic poisoning belong the acute catarrh of the alimentary mucous membrane, rapid coma, some cases of delirium tremens, and certain special forms of acute insanity ; whilst to the chronic class are referred the prolonged congestions, the fatty and connective-tissue degenerations of the various organs and tissues, most cases of deli- rium tremens, nervous affections of slow onset and course, and the cachexiae, which, in varying combinations, attend a continuously immoderate consumption of alcohol. .Etiology. — That ordinary vinic or ethyl al- cohol, in any and every shape, is a sufficient ex- citing cause of such chronic affections is beyond a doubt ; moreover, we find that the more con- centrated the form in which it is taken, the more surely and rapidly are they induced, and that, although some beverages give a greater liability to certain forms of disease than to others, yet the ultimate tissue-changes produced by all are practically similar, and of a markedly degenerative character, The purest alcoholic fluids will also induce the acute forms ; but some of the phenomena observed in the worst cases of alcoholic poisoning have been referred, with some probability, to admixture with fusel oil, essential oil of wormwood, coeculus indicus, and other substances, more deleterious even than ordinary alcohol itself. See Alcohol, and Absinthism. The predisposing causes of a sudden debauch, such as festive gatherings, example of com- panions, desire of relief from anxiety and melan- choly, &e., scarcely require mention. Acute alcoholic coma is generally due to the rapid consumption of a large quantity, but occasionally it is caused by taking a smaller quantity in the presence of some special condition, such as starvation, prolonged exposure to cold, or de- bilitating disease. Chronic habitual drinking is undoubtedly hereditary in many cases ; not that the ancestors have necessarily been drunkards, but that the family is of unstable nervous organisation, and that the neurotic taint which shows itself in other members in such affections as epilepsy, hysteria, insanity, is manifested in these cases by an intense craving for alcohol. Sometimes a pernicious education, by festering habits of indulgence in early youth, has led to subsequent excess ; and the prescribing of stimulants has occasionally been productive of similar harm. In the experience of the writer, the exhibition of large doses in fevers and acute affections has never done this — indeed, in several instances, a great dislike to stimulants has been pro- duced — hut the custom of recommending small quantities to young people and women as a remedy in hysteria, hypochondriasis, neuralgia, and allied disorders, or to relieve the fatigues incident to their daily life, cannot he too strongly protested against. The effect of occu- pation is very marked. Brewers, publicans, pot- men, and others who trade in alcohol are, as a class, very intemperate, and so frequently are commercial travellers (Thackrah). Sedentary employments, being moro monotonous, are more baneful than out-door occupations. Mechanics ALCOHOLISM. 28 drink more freely than agricultural labourers ; whilst night-labourers, cabmen, sailors when on shore, brewers’ draymen, navvies, pitmen, and puddiers consume an enormous amount of alco- holic fluids. Social influences, such as domestic unhappiness, rate of wages, unhealthy dwellings, bad drinking water, or an intermittent supply, are important factors in the causation of drunken- ness. Under some circumstances, alcoholic ex- cesses do less injury than usual, for example, in persons whose employment leads to copious sweating, or necessitates abundant exercise in a keen air ; and some constitutions resist their baneful influence to a remarkable extent. Pathology. — A large amount of ardent spirits nets on the nerve-centres as a narcotic poison, and causes rapid death by coma. Smaller quan- tities produce intoxication, accompanied with or followed by an acute congestion and catarrh of the alimentary canal, especially of the stomach and duodenum. Habitual dram-drinking, by altering the chemical composition of the blood, and checking the normal changes of its cor- puscles, exerts an injurious influence on the nutrition of the tissues. This is increased by the lessened consumption of food, and by the alterations in the calibre of the blood-vessels, set up at first by a special action on their vaso- motor nerves, and afterwards maintained by de- generation of their coats, as well as frequently of the heart itself. Moreover, alcohol probably in- terferes directly with the nutrition of the cell- elements of the various organs as it circulates through them ; and it retards the elimination of effete materials — carbonic acid, uric acid, and urea. Anatomical Characters. — ( a) Acute Alcohol- ism. — Dr. Beaumont thus describes the appear- ances which he observed in the stomach of Alexis St. Martin, after an excess of alcoholic stimulants : — ‘ Inner membrane morbid ; con- siderable erythema, and some aphthous patches on the exposed surface ; secretions vitiated.’ On another occasion, ‘ Small drops of grumous blood exuded from the surface, the mucous covering was thicker than common, and the gastric juices were mixed with a large propor- tion of thick ropy mucus and muco-purulent matter slightly tinged with blood.’ The post- mortem appearances in a case of rapid coma in a patient at King’s College Hospital, after taking three pints of raw whiskey, were : — in- tense injection of the vessels of the pyloric end of the stomach and duodenum, with a peculiar blanching of the mucous membrane between them, giving rise to a vivid scarlet arborescent appearance on a white ground ; two ounces of bloody serum in the pericardial sac, and about sixteen ounces in the right pleural cavity (the left being obliterated by old' adhesions) ; double pneumonia of the lower lobes ; extreme congestion of the kidneys ; and engorgement of the large veins over the posterior part of the brain. Contrary to the usual statements, no alcoholic odour could be detected in the brain, and there was no increase of fluid in the ven- tricles. The heart, liver, and kidneys were fatty ; but these changes were probably of older date. In similar cases Deverjie has noticed a bright rod colouring of the pulmonary tissue ; whilst Tar- dieu found pulmonary apoplexies in two cases. and meningeal haemorrhages in five others. Death from acute delirium tremens leaves no marked characters ; meningitis and coarse brain- lesions are extremely rare, whilst pneumonia is much more common. After repeated attacks, as well as in old drunkards, fatty degeneration of the viscera, and various other chronic changes are found. (6) Chronic Alcoholism. — The amount of fat in the blood is increased, cr it becomes more visible. Chronic congestion and catarrh of the stomach, leading to atrophy of the gland-cells and an increase m the submucous connective- tissue, is very constant, but chronic ulcer is not frequent. Tho liver is at first enlarged from congestion, and may continue so from a sub- sequent infiltration with fat ; but more frequently it shrinks owing to cirrhosis. Lobar emphysema, chronic bronchitis, and hypostatic pneumonia are common. The heart is flabby, dilated, and presents fatty infiltration or even degeneration of its muscular tissue ; but it may be hypertrophied, probably as a result of coexistent disease of the kidneys. The arteries and endocardium are studded with atheromatous deposits ; the capil- laries are congested ; and the veins varicose. The kidneys exhibit the fatty, or, more com- monly, the granular form of Bright's disease. The muscles are pale and flabby, and even in the bones formation of fat takes place at the expense of the bony texture. The nervous centres are atrophied and tough ; the convolutions are shrunken ; the nerve-cells and nerve-fibres are wasted ; and an increased amount of serous fluid exists in the ventricles and subarachnoid space. The abnormal adhesion of the dura mater to the cranium, the large Pacchionian bodies, the opaque arachnoid, and the thickened pia mater, all testify to an exaggerated develop- ment of fibrous tissue. Occasionally haemor- rhage into, or softening of, the br ain, consequent on the diseased state of its blood-vessels, is met with. The increase of connective-tissue is es- pecially marked in spirit-drinkers , and explains the emaciated appearance, prematurely aged look, sunken cheeks, and wrinkled countenance which they generally present. The beer- and wine- drinkers, on the contrary, are loaded with fat. not only in the viscera, but in the subcutaneous tissue and the omenta ; and hence these subjects arc corpulent, with oily skins and prominent ab- domens, even when the face and extremities are wasted. Gouty deposits are also frequent. These differences, however, are not nearly so absolute as is maintained by many writers. The presence of a variable amount of dropsy, a congested pharynx, chronically-inflamed con- junctivas, turgid capillaries, and occasionally papules of acne rosacea on the face, complete the morbid anatomy of the confirmed toper. The autopsy in alcoholic insanity discloses no specific characters. Symptoms. — 1 . Acute Intoxication. — In this state the successive and varying mental pheno- mena, the disorders of common and special sense, and of the motor apparatus, are well know:;. These are followed by uneasy sensations and tenderness in the epigastrium, vomiting or retching, headache and vertigo, with dimness and occasionally yellowness of vision on stooping ALCOHOLISM. end rising again. The tongue is furred, the appetite is lost, and there is a constant feeling of thirst. The urine is copious and pale, but afterwards becomes scanty and loaded with iithates. The countenance is sallow, and the general lassitude and depression are very marked. 2. Acute Alcoholic Coma. — In slight cases of this condition prolonged drowsiness is the chief symptom : but in the more severe forms the patient is quite insensible ; the power of motion is in complete abeyance; the breathing is ster- torous ; the face is usually pale, the features re- maining symmetrical; the pupils are generally dilated, though thoy may be contracted or even unequal ; the pulse is slow and laboured ; the skin feels cold and clammy ; and the temperature is low — in one case it fell to 92° Fahr. There may bo albuminuria ; and occasionally the urine and feces are passed involuntarily. o. Chronic Alcoholism. — The earliest symptoms of this form are muscular tremors, especially on waking; disturbed sleep; noises in the ears; dull headache ; occasional vertigo ; and disorders of vision. If there be also a foul breath, slightly- jaundiced conjunctiva, watery eyes, and dabby features, with or without papules of acne rosacea around the nose and mouth, the combination is very characteristic. Irritative dyspeptic symptoms — the vomitus matutinus of Hufelami — and the signs of commencing or actual cirrhosis, of Bright’s disease, or of fatty heart, frequently co- exist. As the affection advances, the insomnia and tremors increase; the mental condition be- comes impaired ; a striking deficiency of will and uncertainty of purpose are noticeable ; the gait becomes ataxic ; and the patient has a constant feeling of dread and anxiety. 4. Delirium Tremens. — This form of alco- holism occasionally supervenes on a single de- bauch, but it much more frequently affects the chronic drinker. It generally comes on during a drinking-bout, but this may have terminated before the attack commences. In some cases it is undoubtedly determined by prolonged ab- stinence from food, mental distress, surgical in- jury, or the onset of an acute disease, along with the ingestion of alcohol; but in others no cause but the last can be traced. The first stage is indicated by inability to take food ; marked anxiety and restlessness ; tremor of the voluntary muscles ; furred and tremulous tongue; cool skin, which is frequently bathed in perspira- tion; cold hands and feet; and a soft weak pulse. There is complete insomnia, or short periods of sleep are interrupted by terrifying dreams, and the patient’s nights are tormented with visions of horrid insects, reptiles, and other ob- jects pursuing him and eluding his attempts to escape from them or to seize them. Illusions of hearing are not uncommonly added ; but the sense of smell is much more rarely involved. If there is no improvement, these not only haunt his nights, but persist in the day-time ; he becomes moro incoherent, his mental alienation increases, and attempts at suicide are com- mon. The pupils are now minutely contracted, but there is no intolerance of light. The pulse quickens, and is very feeble or even dicrotic ; and the general symptoms become more marked. 20 A prolonged sleep may occur in this stage, and the disease thus terminate. If it continues, the strength fails : the pulse becomes small, weak, and thready ; the tremor increases ; the tongue gets dry and brown in the centre ; persistent coma-vigil and subsultus tendinum come on ; the patient talks incessantly, and picks at the bed- clothes ; and death is ushered in by a delusive calm, or takes place in a paroxysm of violence. The writer has known cases in which the attack of delirium tremens always began by several severe epileptic fits. 5. Alcoholic Insanity. — The forms of insanity caused by alcoholism are acute mania and melan- cholia, chronic dementia, and oinomania. In the first homicidal impulses, and in the second strong suicidal tendencies, due to actual delusions and, not to mere passive terrors, are added to the other signs of delirium tremens. Oinomania is a peculiar form of insanity, in which the patient breaks out into paroxysms of alcoholic excess, attended with violent, strange, or even indecent acts, due to apparently uncontrollable impulses. The attack lasts a few days, and is succeeded by a long interval of sobriety and chastity. These patients have generally some hereditary taint ; and not unfrequently evidences, though often slight, of a morbid mental state may bo detected in the intervals, if very carefully looked for. See Insanity. Complications. — Most of these have been pointed out, but chronic drinkers are especially liable to pneumonia of a low type, and to rapid phthisis. Delirium tremens is very rarely com- plicated with meningitis; acute alcoholic gastric catarrh may be followed by jaundice ; and cere- bral haemorrhage may come on in a drunken fit. Temporary albuminuria is occasionally caused by the ingestion of large quantities of spirits, and even of beer. Diagnosis. — The diagnosis of acute alcoholic gastric catarrh, of insanity from alcohol, and of oinomania depends on obtaining a true history. Acute alcoholic coma can only be diagnosed with certainty by emptying tho stomach and examining its contents. Mere odour of the breath is quite fallacious ; and the writer attaches but little importance to the state of the pupils, or to the general features of the coma. Convul- sions sometimes usher in the condition ; and apoplexy may arise from the accidental rupture of a blood-vessel whilst a person is drunk. Opium-poisoning can cnly be satisfactorily elimi- nated by examining the contents of the stomach. Urtemic poisoning may be diagnosed by testing the urine, though hero an element of uncer- tainty is introduced by the occasional occurrence of albuminuria in alcoholic cases ; the pre- sence of hypertrophy of tho heart, of dropsy, of easts in the urine, or other changes typical of Bright’s disease, must decide the question. De- lirium tremens is occasionally separated with difficulty from some forms of insanity not caused by drink; but in these cases delusions, not mere terrors or hallucinations, are of primary im- portance. The delirium of acute fevers and pneumonia may be mistaken for delirium tremens ; but the pyrexia, history of the case, and physical condition of the patient will guide to a correct diagnosis if the possibility of error i» ALCOHOLISM, is remembered. Chronic alcoholism has been mistaken for other chronic nervous affections, such as locomotor ataxy, chronic softening and multiple sclerosis of the nerve-centres, para- lysis agitans, chronic tremors from metallic poisons, senile dementia, and commencing general paralysis. In all these maladies, special symp- toms are present, besides those common to them and to chronic alcoholism. Prognosis. — In the acute forms of alcoholism I he prognosis is favourable so far as the imme- diate attack is in question. In acute coma, the patient generally, but by no means invariably, rallies from the state of insensibility ; but he may die from the supervention of a very rapid pneu- monia. The prognosis in delirium tremens is favourable in young subjects ; but its gravity increases •with every attack, and with the co- existence of disease of the viscera, especially of the heart, liver, or kidneys. Patients with marked symptoms of fatty heart, or in whom pneumonia sets in, but rarely recover. Chronic alcoholism may be temporarily arrested ; but the ultimate issue is unfortunately as a rule only too certain, for the habit is in most cases too strong to be broken off, or even to be checked for any lengthened period. Mental impairment, persistent tremors, ataxy, and signs of coarse brain-lesions, are especially significant of a speedy termination. Treatment. — The acute gastric catarrh is most rapidly subdued by washing out the stomach with copious draughts of tepid water, and then giving a saline purge. All forms of alcohol should be rigidly abstained from; and the diet must bo simple, and taken in a fluid form for a day or two. Passive exercise in the open air, or, if the patient be vigorous, a brisk ride on horseback, is very beneficial. In cases of acute coma the stomach should be at once emptied by means of the stomach-pump. Cold affusion, followed by energetic friction and the application of bottles filled with warm water, so as to keep up the temperature, will generally revive the patient. Galvanism, in the form of the interrupted current, may often be employed with advantage. If the patient be strong, a smart purge, or, if weak, a milder one, will be all the after-treatment that is necessary. Delirium tremens must be treated differently in the young and in the old. In first attacks in young subjects, complete abstention from al- cohol, light and easily assimilated food (milk diet), moderate purgation, and occasionally antimony in doses of one-eighth of a grain, carefully watched, have been most efficacious in the writer’s hands. If the patient has two or three restless nights in succession, bromide of potassium (thirty grains), or chloral hydrate (twenty grains), may he given at intervals of four hours, until sleep is pro- cured ; hut as the disease is spontaneously curable, sedatives must not be pushed. An ex- perienced attendant should be always present, but no form of mechanical restraint j s permissible. In older cases, a mild purge should begin the treatment; and light but very nourishing food should be administered at short intervals. Milk, beef-tea, raw eggs beaten up with milk, strong soups, and such articles are to be given freely ; when, by careful management and good nursing, ALEPPO EVIL. a very severe attack may be tided over, and natural sleep will return in from three to fivo days. The early administration of sedatives is to be deprecated, but should the restlessness persist, in spite of careful and assiduous feed- ing, a full dose of laudanum (in xxx. — xl.) at bed-time is of great value. In the absence of albuminuria, lung-complications, or any sign of failure of the heart’s action, the writer prefers this drug to other sedatives. If the opium alone fail, its combination with an alcoholic stimulant (brandy, whisky, or stout ) often suc- ceeds. If there be any tendency to syncope, or if pneumonia should come on, as well as in cases complicated with shock, as in surgical injuries, a free use of stimulants is imperative. Hypo- dermic injections of morphia, and large doses of digitalis, are recommended by many autho- rities; but the writer has seen great harm attend their free exhibition. The cautious inhalation of chloroform vapour has occasionally cut short an attack by irducing sleep, but it much more frequently fails. Mechanical restraint is seldom, if ever, necessary, if the patient be properly nursed and attended to. All methods of self- destruction must be carefully guarded against; and a padded room, when available, is of the utmost benefit. The great desideratum in chronic alcoholism is to substitute an easily-digested and nourishing diet for the alcoholic stimulants, which can then be safely dispensed with altogether. The prac- titioner's judgment, and his knowledge of the cuisine, are very important in the management of these cases. Strong meat-soups and good speci- mens of the concentrated preparations of meat are of great value. The strictly medicinal treatment will consist in the administration of hitter toDies, such as nux vomica, quinine in small doses, calumba, or gentian ; with car- minatives, such as spirit of chloroform, ar- moraeia, and capsicum. Alkalis, effervescent mixtures, and hydrocyanic acid are peculiarly useful if the stomach is irritable. The condi- tion of the liver and bowels should be carefully regulated. Bromide of potassium is in general the best sedative to employ against the insomnia, though chloral hydrate is more certain ; but tho latter should only be given occasionally, lest the patient fall into the habit of frequently resort- ing to it. In long-standing cases, cod-liver oil, arsenic in small doses, and oxide of zinc have all done good, but they require a long and pro- tracted administration. Phosphorus has been of no use whatever in the cases in which the writer has tried it ; but small doses of tho more easily assimilable preparations of iron are occasionally well borne, and are then most useful. The craving for drink, if urgent, may be cheeked by small doses of opium, but this drug must be exhibited with extreme caution. Ju- dicious supervision, and. in inveterate cases, a residence in a proper asylum, are the only means from which any permanent benefit can be ex- pected. The treatment of insanity induced by alcoholism will not differ from that recommended in other forms, except in an enforced abstinence from its cause. John Curnow. ALEPPO EVIL. See Delhi Boil. ALGID. ALGID {algidus, cold). — A word implying extreme coldness of the body, used only when it urises in connection with an internal morbid state, such as cholera, or a special form of malignant remittent fever. ALGIERS. — Warm winter climate. Mean winter'temperature59° F., liable to rapid changes. Heavy rains not infrequent. See Climate. ALIMENT. — Food or aliment furnishes the elements required for the growth and main- tenance of the organism ; and, through its action with the other life factor — air, forms the source of the power manifested. The aliment of organisms belonging to the ve- getable class is derived from the inorganic king- dom. Under the influence of the sun’s rays the inorganic principles are applied to growth, and constructed into organic compounds. This con- stitutes the main operation of vegetable life, and in it we have the source of the aliment of animals, which can only appropriate organic compounds, and which either directly or indirectly derive these compounds from the vegetable kingdom. As the solar force employed in the construction of organic compounds, through the agency of the ve- getable organism, becomes locked up in the com- pound formed, such compound represents matter combined with a definite amount of latent force. In the employment, therefore, of organic matter as aliment by animals, we have to look upon it not only as yielding the material required for the construction and maintenance of the body, but as containing and supplying the force which is evolved under various forms by the operations of animal life. Aliment constituting the source from which the several elements belonging to the body are derived, it follows that to satisfy the require- ments of life it must contain all the elements that are encountered. It is not, however, with the elements in a separate state that we have to deal, but with the products of nature in which they are variously combined. The alimentary products as supplied by na- ture are resolvable by analysis into a variety of definite chemical compounds. These constitute the alimentary principles. Some are common to both animal and vegetable food, as for instance albumen, caseine, fats, &c. ; others are peculiar to either the animal or vegetable kingdom. Starch, for example, is met with only in vegetable, and gelatine only in animal products. With reference to the alimentary principles, it must be understood that in no case do they exist in natural products in an isolated form, and no single alimentary principle is capable of sup- porting life. Although, however, it is with the alimentary products as a whole that we are prac- tically concerned, yet, regarded from a scientific point of view, a knowledge of these constituent principles is required, to enable us to assign to them their proper value as alimentary articles ; and for the purpose of systematic consideration some kind of classification is needed. Classification.— Prout classified the consti- tuent principles of food into four groups, which lie named (1) the aqueous-, (2) the saccharine-, (3) the oleaginous-, and (4) the albuminous. This classification is defective, inasmuch as it ALIMENT. 31 omits from consideration saline matter, which is equally as essential to nutrition as any other part of an alimentary product. The saccharine and oleaginous groups also stand as primary and independent divisions, whilst physiologically they are related, and may be conveniently con- sidered under a combined heading. Liebig proposed a classification based on phy- siological principles ; and, taking into account only the organic constituents of food, grouped them under the heads of (1) plastic elements o f nutrition-, and (2) elements of respiration. Ilis plastic elements of nutrition comprise the nitro- genous principles ; and to these he assigned the office of administering not only to the growth and renovation of the tissues, but also to the produc- tion of muscular and nervous power. Believing that the source of these powers issued from the oxidation of the respective tissues, he held that the exercise of muscular and nervous action created a corresponding demand for nitrogenous alimentary matter, which thus became invested with an importance that led it to be regarded as affording a measure of the value of an alimen- tary article. By recent experimental research this view has been found to be untenable. The nervo-muscular organs are now looked upon as holding the position of instruments, by whose agency the force liberated by chemical action is made to manifest itself under certain other forms ; and what is wanted for the purpose is simply oxidisable organic material, which may be de- rived from non-nitrogenous as well as nitro- genous food. The dements of respiration or, as they were afterwards more appropriately styled, the calorifacient principles, represent the organic non-nitrogenous constituents of foed. Their destination, according to Liebig, was heat- production. It is now maintained, however, as stated above, that they play a part in connection with nervo-muscular action ; and it may be also said that they are to some extent concerned in tissue-development. From the considerations set forth, Liebig’s classification loses the scientific value it was at one time supposed to possess. The following grouping of the alimentary principles based on chemistry furnishes a classi- fication which involves no theoretical proposi- tion, and is practically convenient : — Food is primarily divisible into Inorganic and Organic principles. The Inorganic principles consist of water, and the various saline matters required by the sys- tem. They are as much needed for the support of life as the organic portion of food. The Organic principles are sub-divisible into nitrogenous and Non-nitrogenous ; and the Non- nitrogenous are again further sub-divisible into Hydro- carbons and Carbo-hydrates. The Nitrogenous principles contribute to tho growth and nutrition of the various bodily textures, and furnish the active agents of the se- cretions. They also undergo resolution in the system into urea, which is excreted ; and a com- plementary hydro-carbonaceous portion, which is susceptible of application to force-production. They are thus capable of administering to all the purposes fulfilled by the organic portion of an aliment. The Hydro-carbons or Fats are applied to the 32 ALIMENT, production of heat and other forms of force, they seem also to be essential to tissue-de- velopment generally, besides yielding the basis of the adipose tissue. The Carbo-hydrates (starch, sugar, gum, &c.) contribute to the formation of fat, and are also applied indirectly if not directly to force-produc- tion. There are a few principles, such as alcohol, the vegetable acids, and pectin or vegetable jelly, which do not strictly fall within either of the preceding groups. Alcohol occupies a chemical position intermediate between the fats and carbo- hydrates; whilst the others mentioned are more highly oxidised compounds than the carbo- hydrates. All alimentary products in the form supplied by nature contain organic and inorganic prin- ciples, and the organic principles comprise more or less of the nitrogenous and non-nitrogenous kinds ; but the non-nitrogenous do not neces- sarily, and indeed do not generally, include both hydro-carbons and carbo-hydrates. In milk, however, which may be regarded, from the posi- tion it holds in nature, as furnishing a typical representation of an alimentary article, principles exist belonging to each of the groups enumerated in the above classification. See Diet. F. W. Pavy. ALIMENTARY CANAL, Diseases of. See Digestive Organs, Diseases of ; and tho several organs. ALKALINITY. — The reaction of human blood is always alkaline; and, though the normal degree of alkalescence has not yet been deter- mined, it is probable that, like the temperature of the body, it is tolerably constant. In dis- ease considerable variation, no doubt, occurs, but still the blood is always found alkaline. Pettenkofer and Voit found the serum of blood acid in a case of leukaemia some few hours after death, but not during life ; and Dr. Gurrod states that in chronic gout the serum may become some- what neutralized, but never acid. F. Hoffman has also found that the blood retains its alka- linity with great obstinacy ; he fed pigeons for a considerable length of time on food yielding only acid ash, but the animals suffered from blood-poisoning before the alkalinity of the serum was neutralized. The alkalinity of the blood is maintained by the constant passage into it cf the alkaline salts of the food, and of alkaline carbonates derived from the oxidation of the lactic, oxalic, and uric acids furnished by the disintegration of the tissues. The blood is pro- bably prevented from becoming too alkaline by the withdrawal of its alkaline salts by the alka- line secretions, namely, the saliva, the bile, and the pancreatic fluid ; whilst the acid salts, which, if accumulated, would tend to depress its normal alkalinity, are removed by tho acid secretions, namely, the sweat, the gastric juice, and the urine, and by the exhalation of carbonic acid from the lungs. It has been shown that the withdrawal of acid by one secretion has a decided effect on tho reaction of other secretions ; thus the saliva becomes more alkaline during digestion, when the stomach is pouring out the acid gastric iuioe; and Dr. Bence Jones has shown that ALKALIS. during digestion the acidity of the urine is lessened. A similar relationship is also shown to exist between the elimination of carbonic acid by the lungs and the acidity of the urine, the latter falling as the former is increased, and vice versa. The importance of a proper degree of alkalescence for the blood is ob- vious, when we consider that this condition increases the absorption-power of its serum fc r gases, and is necessary to maintain its albu- min in the liquid state, whilst oxidation is always more perfectly performed in alkaline solutions. ALKALIS. — Definition. — Inorganic sub- stances, which turn syrup of violets green, and turmeric brown ; and restore the blue colour to litmus which has been reddened by acids. They combine with acids to form salts, and their car- bonates are soluble in water. Enumeration.— The only substances which correspond with the above definition are — Potash. Soda, Lithia, and Ammonia. The alkaline earths —Lime, Magnesia, Baryta, and Strontia, and the organic alkaloids, have a similar action on vege- table blues and yellows ; but the carbonates of the former group are almost insoluble in water ; whilst the latter contain carbon, and are there- fore classed with organic substances. Properties. — Ammonia is distinguished from the other alkalis by its volatility. The non- volatile alkalis are readily recognised by thoir spectra; and by the colour they impart to tho blowpipe flame, potash giving it a violet, soda a yellow, and lithia a carmine colour. Potash and soda are present as constituents of the body in considerable quantities ; ammonia exists to a smaller amount; and lithia probably in traces. Soda is found chiefly in the blood, potash in the muscles. Action. — When applied to the skin dilute alkalis and their carbonates act as rubefacients. Pure ammonia is a vesicant, and potash and soda have a caustic action. Both caustic potash and soda absorb water from the tissues, and form a corrosive fluid, which destroys the parts around, as well as that to which the caustic has actually been applied. To prevent this effect they are sometimes mixed with lime, which absorbs the wafer. A mixture of potash and lime forms tho Vienna Paste. When inhaled, ammonia causes irritation of the respiratory passages, and in- creased secretion of mucus. This irritation ex- cites reflex contraction of the blood-vessels and consequent rise of blood-pressure. When swal- lowed in quantity, the caustic alkalis and their carbonates produce symptoms of irritant poison- ing. In the case of ammonia these symptoms may be accompanied by those of inflammation of the air-passages, caused by the irritant vapour. The best antidote is dilute acid, such as vinegar. In small quantities and diluted, alkalis increase the secretion of gastric juice. After absorption into tho blood the} 7 render this fluid more alka- line; whilst potash appears especially to accele- rate tissue-change, and is accordingly classed among the alteratives. When injected directly into the blood, potash acts specially on the mus- cles, which it paralyses. Ammonia stimulates the motor centres in the brain and spinal cord, the ALKALIS. respiratory centre in the medulla oblongata, and the accelerating nerves of the heart. When injected into the veins it therefore causes con- vulsions like those of strychnia, and quickening of the respiration and pulse. Alkalis are chiefly excreted by the urine; and potash, soda, and iithia lessen its acidity, or render it alkaline. Ammonia is partly excreted unchanged, but a portion passes out in the form of urea; and it does not render the urine alkaline like the others. Potash and Iithia act as diuretics ; soda to a less extent ; and ammonia least of all. The diuretic action does not depend on any change in the blood-pressure. Potash and ammonia are diapho- retic. Potash lessens the tenacity of mucus. Uses. — -Dilute solutions of potash and soda relieve itching in skin diseases. Caustic potash or soda is used to destroy warts ; to cauterizo poisoned wounds and ulcers; to open hydatid cysts in the liver; and to establish issues. Am- monia neutralizes the formic acid which renders venomous the stings of bees, ants, and mosquitos, and is therefore applied to relieve the pain which they cause. The intravenous injection of am- monia has been recommended as an antidote in snake-poisoning; but the value of the remedy is not established. Mixed with oil, so as to form a liniment, ammonia is used as a rubefacient in sore throats, bronchitis, rheumatic pains, and neu- ralgia. It is inhaled to relieve headache ; as a restorative in syncope and shock, when it raises the blood-pressure ; and to facilitate expectora- tion in chronic bronchitis. Alkalis administered after meals act as antacids, and relieve heartburn. When given before meals they increase the secre- tion of gastric juice, quicken digestion, and relieve w eight at the epigastrium, pain between the shoulders, and flatulence. Bicarbonate of soda is usually given for this purpose, but when the stomach is very irritable liquor potassse is pre- ferred, as it is considered to have a sedative action on the mucous membrane. Alkalis appear to lessen tho transformation of glycogen into sugar, and they are used on this account in dia- betes. Liquor potassae sometimes helps to reduce obesity. Alkalis are used in the treatment of scrofula, rheumatism, gout, and lithiasis ; but in the two last-mentioned Iithia is considered the most valuable, whilst potash is preferred to soda, as the urate of Iithia is most soluble, and the urate of soda least so. The salts of certain organic acids, such as the acetate or citrate, may be employed as remote antacids to render the urine alkaline, as they undergo combustion and are converted into carbonates in the blood. Alkalis are given to lessen the acidity of the urine in inflammation of the bladder or urethra, and potash is employed as a diuretic in dropsies. On account of its stimulating action on the heart and respiration, ammonia is administered in adynamic conditions and in chronic bronchitis. T. Lauder Brunton. ALKALOIDS and other ACTIVE PRINCIPLES. — Definition. — An alkaloid is a substance formed in the tissues of a pilant or of an animal, having a definite composition as re- gards tho proportions of the chemical elements of which it is composed, and capable of combining, liko an alkali, with acids to form salts. 3 ALKALOIDS. 35 Besides alkaloids there are other active priD ciples found in plants, which have also a power ful influence on the animal economy but do not possess all the chemical properties jus' stated. Chemical Composition and Relations. — These are briefly expressed in the above defini tion. Thus morphia, one of the alkaloids ot opium, has always the chemical composition represented by the formula C 1; H„K0 3 , and it may unite with acetic acid to form acetate of morphia, just as potash may unite with the same acid to produce acetate of potash. But tho em- pirical formula CpH^NOj represents only the percentage composition of the substance in tho simplest numbers, and does not express how the atoms of the different elements are related to each other. For, just as etliylic alcohol, with the composition CTPO, is believed by the chemist, from its behaviour towards other bodies, to contain a ‘ radicle,’ or group of atoms, CUP, having certain chemical properties resembling those of a base, such as potassium, K ; and just as this radicle, C 2 H 5 may replace one of tho elements of water, so as to form alcohol (C 2 H 5 + H 2 0 = 0 + H) ; so chemists have good reason for believing that alkaloids belong to the group known as amines or amides , which are really ammonia, Nil 3 , iu which one or more of the atoms of hydrogen are replaced by a radicle or radicles. It is impossible, however, in the present state of knowledge, to represent the true chemical composition of alkaloids, the exact con- stitution of the radicles being still unknown. It is obvious that two or more alkaloids may resemble each other in percentage composition, and still be very different, both in their chemical structure and, necessarily, in their physiological action. Thus strychnia, C 21 H 22 N 2 0 2 , quinia, C 20 H 24 N 2 O 2 , and cinchonia, C 20 H 2 ,N 2 O, differ only in a few atoms of carbon or of oxygen, more or less ; but they have different physiological ac- tions, showing that their chemical structure, which is not indicated in these formulae, must also be different. Tho physiological action of an alkaloid may also be modified by combining it with another substance. Thus, as was pointed out by Crum-Brown and Fraser, compounds of strychnia with methyl, ethyl, and amyl, do not present the well-known physiological action of that substance, but one analogous to that of woorara. Enumeration. — The alkaloids and other ac- tive principles most familiar to the physician are Morphia, Apomorphia, Narceia, Codeia, Thebaia, Narcotin. Papaverin ; Atropia, Hyos- cyamia, Daturia ; Nicotin ; Conia; Physostigmia ; Strychnia, Brucia ; Quinia, Cinchonia, Beberia ; Caffein ; Aconitia, Veratria ; Digitalin ; Curarin ; Muscarin; Santonin ; and Ergotin. Sources. — The majority of alkaloids are formed by plants. The function which they subserve in the economy of the plant is not known. Some plants produce only one alkaloid, while in others two or more may be formed. A few of the alkaloids have been produced syn- thetically by the chemist. Physiological Action. — Alkaloids have various degrees of physiological activity when ALKALOIDS 14 introduced into the animal body. Manyare slow in their action, and a large dose is required to produce any observable effect ; while others act more rapidly, and are so potent that even a minut e dose may destroy life. Compare, for example, narcotin, one of the alkaloids of opium, with nicotin, the alkaloid of tobacco. Twenty to thirty grains of the former have been taken by the human subject without producing any marked symptoms, while the twentieth part of a grain of the latter may induce symptoms so severe as to threaten death. It is also well known that alkaloids may have a different kind of action on different animals. Thus one-fourth of a grain of atropia will produce serious symptoms of a com- plex character in a dog, while three or even four grains may be given to a rabbit without causing any more marked effect than dilatation of the pupil. In considering the physiological ac- tions of these substances the following general- izations may, in the present state of science, be made tentatively: — 1. As a general rule, the more complex the organic molecule, and the greater the sum of the atomic weight, the more intense will be the action of the substance. This has been shown in experiments on the action of the chinoline and pyridine series of bases by McKendrick and Dewar. 2. Substances which split up quickly into simpler bodies, produce rapid but transient physiological effects, whereas substances which resist decomposition in the blood or tissues may produce no appreciable results for a time, but when they do begin to break up. the effects are sudden and violent, and usually last fora considerable time. 3. Al- kaloids have frequently a double action on dif- ferent parts of a great physiological system, and their action in a particular group of animals rill depend on the relative degree of develop- ment of the parts of the system in that group. Thus most of the alkaloids of opium have such a double action — a convulsive action resembling that of strychnia, due to their influence on the spinal cord or on the motor centres in the brain ; and a narcotic or soporific action resembling that of anaesthetics, due to their influence on sensory centres in the brain. Hence, in animals where the spinal system predominates, as in frogs, these alkaloids act as convulsants ; while in the higher mammals their principal action is ap- parent'y on the encephalic centres, which have now become largely developed. Passing to the consideration of the action of the individual substances, we cannot do more than give, by way of example, a brief resume of our knowledge regarding a few of them. 1. Morphia — C 17 H ls ,N0 3 — an alkaloid of opium. In the frog this substance has an action resembling that of strychnia. At first there is a state of agitation, followed by tetanic spasms : finally, all reflex actions, including those cf the heart and of respiration, are paralysed. Pigeons have been found to possess a remarkable power of withstanding the influence of this drug — an ordinary-sized bird requiring about two grains to kill it. Babbits become partially somnolent, show a tendency to reflex spasms, and tolerate a large dose — say about one-lialf to one grain per pound weight of the animal. In the dog the intravenous injection of even one-tenth of a grain (for a small animal) causes agitation fol- lowed by sleep; the pulse and respiratory move- ments are slowed ; the smaller arteries become (at least during one stage) contracted, so as to cause an augmentation of general blood-pressure; the pupil is contracted ; and, if the dose he large, death may be preceded by convulsions. In the higher mammals morphia acts chiefly on the sensory apparatus, both peripheral and central. 2. Other alkaloids of opium have also been investigated. — (a.) Nareeia, C._, 3 H.„,N0 3 , is a pure hypnotic, causing profound sleep. Even in large doses it does not produce convulsions. (b.) Codeia, C^H.^NOj. has an action like that of morphia, (c.) Thebaia, C^H-jNOj, causes tetanic convulsions, thus resembling strychnia. ( d .) Narcotin, C 23 H. rj N 0 7 , is slightly narcotic, but strongly convulsant. (c.) Papaverin, causes a somniferous action like that of narceia. Apomorphia, C,-H 1; X0 2 , a deri- vative of morphia, has none of the characteristic actions of that substance, but acts chiefly as a vas- cular depressant and as an emetic. It is evident, therefore, that opium, which may contain more or less of all of these substances, must have an action on the body of a very complicated cha- racter. 3. Strychnia, C. J ,II_v J K. J 0. J , — the alkaloid of Strychnos mix vomica. In the frog very mi- nute doses cause convulsions of all "the volun- tary muscles, excited by peripheral irrita- tion. These convulsions are due to the action of the poison on the spinal cord, as they persist after decapitation. In warm-blooded animals the reflex character of the convulsions is less evident ; they have more of a tonic character, and chiefly affect the extensors. The exact modus operandi of the poison on the cord is un- known, but in some way or otlmr it heighten* its reflex sensibility. Death is usually the result of asphyxia from arrest in spasm of the respira- tory mechanism, but it may. result from exhaus- tion. Brucia, C 23 IL, 6 N.D 4 , another substance found in nux vomica, appears to have an action like that of strychnia, but more feeble. 4. Atropia, C 17 H., 3 'N0 3 , — the alkaloid of Atropa belladonna. In the frog it causes tetanic reflex spasms. Herbivorous animals, as a rule, have a tolerance of this poison, so that its effects are best studied in carnivora. Even in these the action is somewhat uncertain. .Respiration may be paralysed without general convulsions : the pulse is quickened by paralysis of the inhibitory action of the pneumogastric nerve on the heart ; and the arterial pressure is increased. After very large doses the arterial pressure may be dimin- ished with paralysis of all parts containing in- voluntary muscular fibre. Secretion is dimin- ished. The pupil is dilated apparently by a direct influence of the poisou on the centres or nervous arrangements in the iris itself, as the effect may be observed even in an eye removed from the head. Hyoscyamia, the alkaloid of Hyoscyamus niger, and Daturia, the alkaloid of Datura stramonium, have an action like that of atropia. o. Digitalin, C 27 H,_,0,., — the active principle of Digitalis purpurea. A large dose causes slow- ing of the heart’s action, and if the dose bo in- creased the heart will be arrested in diastole ALKALOIDS. and will not respond to direct excitation. With medium doses there is a period of acceleration of the heart’s action, but this period may rapidly pass into that of slowness just mentioned. This action on the heart has not yet been clearly accounted for, and it remains to be de- cided whether it be due to the influence of the drug on the terminations of the pneumogastric, or of the sympathetic, or on the intracardiac ganglia themselves. Coincident with the action on the heart, the smaller arteries are contracted and the arterial tension is increased. Digitalis would appear to have little effect on involuntary muscle, but it exerts a potent action on voluntary muscle, which, after small doses, becomes feeble in con- tractile power, while large doses may abolish contractility altogether. 6. Physostigmia, C 15 H 21 N 3 0 2 , — the active substance of Physostigma venenosum, or Calabar bean. As has been pointed out by Professor Fraser, this alkaloid has an action antagonistic to that of atropia. Sensibility and conscious- ness remain until death ; the voluntary muscles are paralysed ; involuntary muscles are said to show tetanic contractions ; respiration is at first accelerated, and afterwards slowed ; the vessels become alternately dilated and contracted ; secre- tion, especially that from the lachrymal and sali- vary glands, is increased ; and the pupil is con- tracted. It appears to paralyse the extremities of the motor nerves, in this respect resembling curare. 7. Curare is a resinous substance, containing an alkaloid, Curarin, of the composition C, 0 H,jN, obtained from certain parts of South America, and used by the natives of these regions as an arrow-poison. It is probably obtained from cer- tain plants belonging to the genera Strychnos and Paullinia. Its distinctive physiological action is abolition of the power of all voluntary movement, in consequence of its action, as was proved by Claude Bernard, upon the peripheral terminations of motor nerves — the “ terminal plates ” of muscle. Respiratory movements are arrested in consequence of paralysis of the muscles of respiration, but the heart may con- tinue to beat for a considerable time. If arti- ficial respiration be established, the circulation may be maintained for several hours while the animal is completely under the influence of the substance. All the secretions are increased, and the mean temperature falls. 8. Muscarin. the alkaloid of Agaricus mus- carius, causes arrest of the heart’s action in dia- stole, an effect which may be removed by the influence of atropia, thus affording an instance of physiological antagonism. In warm-blooded animals muscarin slows the heart's action ; the blood-pressure falls ; respiration is first embar- rassed, and may be completely arrested ; parts containing involuntary muscle are in a state of tetanic spasm ; the pupil is contracted ; and secre- tion is increased. 9. Santonin, C, 3 H ls 0 3 , the alkaloid of Arte- mesia santonica, may cause in man nausea, vomiting, hallucinations, vertigo, and a peculiar state of visual sensation — the field of vision usually appearing yellow, but sometimes violet. It is said that the stage of violet rapidly passes into that of yellow, and therefore it is probable ALTERATIVES. 30 that santonin may first excite the retinal fibres sensitive to violet (according to Thomas Young's theory of colour-perception), and afterwards para lyse them. In large doses, santonin causes loss of consciousness, tetanic convulsions, and death. 10. Ergotin, the active principle of Secale eornutum, causes contraction of the smaller blood-vessels, contractions of the uterus, and slowing of the pulse; and the animal may die in consequence of arrest of the action of the heart. 1 1 . Quinia, C 20 H,,jN 2 O 2 , one of the alkaloids of Cinchona, in small doses accelerates the heart’s action in the warm-blooded animal ; in moderate doses it slows it ; and in large doses it may ar- rest it, and cause convulsions and death. Research shows that its action is essentially upon the cen- tral nervous system. It destroys all microscopic animal organisms, apparently killing vibrios, bacteria, and amoebae ; but it seems to be with- out action on humble organisms belonging to the vegetable kingdom. It arrests the movements of all kinds of protoplasm, including those cf the colourless corpuscles of the blood. It arrests fermentive processes which depend on the pre- sence of animal or vegetable organisms, but it does not interfere with the action of digestive fluids. 12. Cinchonia, C 20 H 24 N 2 O, is said to have an action similar to quinia, but much more feeble. Further research is needed on this point. John G. McKendrick. ALOPECIA. See Baldness. ALPHOS and ALPHOIDES (a\bs, white). — "Whiteness, or the process of turning white. See Achroma. ALTERATIVES. — Definition. — Medicines which gradually restore the nutrition of the body to a healthy condition, without producing evacua- tions, or immediately exerting any very evident action upon the nervous system. Enumeration.— The principal alteratives are — Nitric and Nitro-hydrochloric acids ; Chlo- rine and Chlorides ; Iodine and Iodides ; Sulphur and Sulphides; Potash and its salts; Mercury and its salts ; Phosphorus ; Hypo- phosphites ; Antimony ; Arsenic ; Taraxacum ; Sarsaparilla ; Hemidesmus and Guaiacum ; Me- zereon and Dulcamara. Action. — Healthy nutrition depends on the digestion of the food, its assimilation by the tissues, the decomposition of the tissues during the exercise of their functions, and the removal of their waste products being performed in a proper manner — in due proportion one to another. If the food is not properly digested, as in dyspepsia ; or is not properly assimilated, as in diabetes ; if the tissues break up too rapidly, as in fever : or if the waste products are not properly removed, as in some cases of kidney-disease, nutrition suffers. Digestion and excretion may be improved by tonics, purgatives, and diuretics ; but alteratives seem to exert their action upon assimilation and tissue-change. The digestion of food is effected by means of ferments, such as 86 ALTERATIVES, those of the salivary glands, stomach, pancreas, etc. Some also of the changes, such as the con- version of glycogen into sugar, -which the food undergoes after absorption in the liver, and even certain so-called vital actions — such as the coagulation of the blood — are produced by a similar agency. It is not improbable that the histolytic changes in the tissues are tdso effected by ferments. They do not de- pend upon oxidation, for although during health the products of tissue-decomposition are oxidised as fast as they are formed, yet under cer- tain circumstances the tissues are split up so rapidly that the products which they yield are only partially oxidized. This is seen in poisoning by antimony, arsenic, and still more markedly by phosphorus, where such tissues as the muscles become decomposed, yielding nitrogenous sub- stances, such as leucin, tyrosin, or urea, and fat. The former are excreted in the urine ; while the last, instead of undergoing combustion, accumu- lates in the place formerly occupied by the mus- cular tissue, which is accordingly said to be in a state of fatty degeneration. It is possible then, although by no means certain, that alteratives influence nutrition, either by modifying the ac- tivity of ferments, or by altering the susceptibility of the tissues to their action. Mercurials in purgative doses, taraxacum, nitric and nitro-hydrochloric acids, probably act by modifying the digestion of the food in the upper part of the small intestine, or by affecting the changes which it undergoes in the liver after ab- sorption. Potash has probably an action on the muscles. Antimony, arsenic, and phosphorus especially affect the nervous and cutaneous sys- tems. Mercury has a peculiar power of breaking up newly-formed fibrinous, and particularly syphilitic deposits. Iodine, iodides, and pro- bably chlorides, act upon the lymphatic system and promote absorption. Uses. — Purgative doses of mercurials, taraxa- cum, nitric and nitro-hydrochloric acid are useful in cases of frontal headache, general malaise, and depression of spirits, associated with symptoms of so-called biliousness, or with the appearance of urates or of oxalates in the urine. Potash and colchicum are employed in the treatment of gout. Phosphorus and arsenic are used in cases of nervous debility, as well as in nervous diseases, such as neuralgia and chorea, in which antimony is also serviceable. Arsenic is also given in diseases of the skin ; and antimony in inflammation of the mucous membrane of the bronchi. Mercury in alterative, that is, in small doses, which are absorbed into the cir- culation without purging, is used to break up newly-deposited fibrinous masses, as in iritis, pericarditis, etc., and to counteract the effect of syphilitic virus upon the soft tissues in the secondary stage of this disease. Iodine and iodides act on the lymphatic system, and are useful in removing glandular swellings. By stimulating the absorbent system they may also assist in the removal of the fibrinous deposits and syphilitic growths disintegrated by the mer- cury. The iodides are sometimes given in the secondary, but are still more valuable in the tertiary stage of syphilis. T. Lauder Biiunton. AMAUROSIS. ALVEOLAR. — A word used in pathology aB descriptive of any morbid growth which consists of small cavities or spaces {alveoli), usually occupied by contents, and bounded by walls formed of cells or fibres. Alveolar Cancer is the most familiar application of the term, being a synonym for Colloid Cancer. See Cancer. AMAUROSIS {a/xavpbs, dark). — Definition. — This term cannot be strictly defined. Liter- ally, it means an obscurity of vision, a state of blindness, in the popular sense of the term, whereby nothing more is learnt than that the patient cannot see well enough for practical pur- poses, and is thereby unfitted for the usual occu- pations of life. Besides this, it is always tacitly understood that an external observation of the organ of vision, during the life of the patient, does not reveal any ostensible cause of blindness. It is further understood that th6 use of glasses is no remedy in amaurotic cases. It is rather the kind, than the degree, of blindness that is called amaurotic ; but it must be observed that lesser degrees of blindness, of the amaurotic type, are generally, vaguely and indefinitely, called amblyopic. To add to the obscurity of the subject, some writers call some cases of moderate blindness, of the amaurotic kind, amaurotic amblyopia ; others speak of partial or incomplete amaurosis. IV e now estimate any defect of vision with more accuracy, and record its area on a map, and its degree in figures, in comparison with a standard of ordinary normal vision. JEtiology. — The causes of amaurosis have been more recently specifically attributed to morbid conditions of the percipient nervous apparatus of the eye or of vision. All cases are excluded in which, in the present state of science, and using the ophthalmoscope, we can sec any morbid condition. But very few cases are now, in the statistical tables of tho chief eye-hospitals, included under the head amau- rosis. Some few cases seem likely, at least for some time to come, to be called by this term of reproach. The ophthalmoscope has enabled ns more accurately to classify a large majority of the cases formerly called amaurotic. Many new names are thus introduced to our systematic treatises on eyo diseases, whereby we gain more definite information, if only, as in some of them, e.g. ‘ white atrophy,' we have substituted the name of a particular ophthalmoscopic sign for an indefinite symptom. At least we can speak more accurately of the part that is or has been diseased — of the retina, or of the ocular end of the optic nerve. And, indeed, before the invention of the ophthalmoscope, the ancients, whilst professing to include only cases of disease of the percipient nervous apparatus of vision, included all kinds of obscure visual disorders. Mackenzie (1854) includes, besides retinitis, etc., choroiditis, and dislocated lenses! Of the first named he says, ‘ It would he superfluous to consider these states separately, because we are at present ignorant of any diagnostic signs by which, during life, the one can be discriminated from the other.’ Even now, whenever the term amaurosis is had recourse to, it expresses more particularly that of which we are ignerant, and it may mean any one of so many different states that AMAUROSIS. ao anatomical characteristics can be assigned to it. In a large majority of the cases commonly classed as those of amaurosis, it is found ophthalmoscopically that there is ‘white atro- phy ’ of the optic nerves. The ‘ disks ’ are nearly or quite bloodless; white, not pinky- white ; and the nerve-fibres going to the retin®, being more or less wasted, there is some exca- vation of the disks, perhaps so much that the lamina cribrosa, in one or both, is exposed to view, while the retinal vessels are somewhat diminished in size. The causes of this condition are, most commonly, intracranial tumours or other diseases which induce pressure upon the optic nerve, or lead to an extension of inflam- mation, followed by oedema or double optic neuritis (descending), these terminating in the atrophy and amaurosis. The nerve-disease is often due to syphilis. But some cases of white atrophy occur, in which there has been no pre- cedent neuritis. Of such ‘tobacco amaurosis ’ is an example, in which, unless smokiDg be given up, by an idiosyncrasy of the patient, he soon becomes blind. But nerve-atrophy or inflam- mation should be no longer called amaurosis — they have obtained a better nomenclature. The preceding stages of the diseases causing them, if, as is rarely the case, unaccompanied by any definite ophthalmoscopic signs, and yet producing i considerable amount of blindness, may, for vant of better knowledge, at present be called amaurotic. Other such cases are those reported is snow-blindness ; or in which blindness has oecn produced by a lightning-flash near the eye ; a blow on tho eye without other mischief re- sulting; disuse of an eye in children, as in some neglected squint cases ; irritation from some branches of the fifth nerve (dental caries, etc.) ; anmmia after excessive losses of blood ; suppres- sion of menses ; blood-poisoning by tobacco, lead, quinine ; urmmia; and some cases of cerebral apoplexy. Embolism of the central artery of the retina occurs, but it is easy of diagnosis with the ophthalmoscope, and therefore should not be called amaurotic. The writer does not think there are any cases of longstanding blindness that show no ophthalmoscopic changes. Symptoms and Diagnosis. — There is one symptom of amaurotic blindness, affecting both eyes, which is noteworthy, as constituting, primd facie, a general distinction between it and the other cases of blindness not of nervous origin : the gait and general aspect of the patient is peculiar — he is hesitating and hope- less-looking. He no more tries to see objects. He holds up his head ; the eyes are open and turned upwards, as eyes not in use (in sleep) always are, or because the patient has felt the heat of the sun from overhead, and has last enjoyed sensation of light, whence he knows it ' comes, from above. He feels his way with his feet, and his hands are extended before him. He does not look towards you, or at anything in particular. But amaurosis does not by any means imply a similar state of vision in both eyes, nor that the blindness is to be taken in the ophthalmological sense, i.e. wanting perception of light. It would be well if any less degree of Imperfection of vision, without evident cause, AMBLYOPIA. 87 might be called amblyopic, but the two eyes must be considered separately. To diagnose tho absence or presence of a power of perception of light, certain important precautions must be taken, as almost all patients who are abso- lutely blind will declare, and probably be- lieve, that they still can see light, i.e. objective light. The patient should be placed opposite to a bright light, such as a gas-lamp, and near to it, but not so near that he can feel the heat of it ; the light is then turned up and down, and it is fully exposed and obscured, and the patient is asked many times, in quick succession, if he sees light or not. The light should be left burning and exposed, or not, during several of the suc- cessive queries, so as to do away with any doubt. The word of the patient untested is quite inad- missible. Any ether blindness than this of abso- lute amaurosis, or originating in any other diseases than those of the percipient nervous apparatus of the eye, is never so great as to prevent the perception of light. If the patient can see light from darkness, test whether he can see shadows of some small object — of the hand, or of ono finger only, passed between him and tho burning light, or the light of the window only. If he can see to count fingers, his blind- ness is insufficient to indicato what is called amaurosis. Another point in the diagnosis of amaurosis is that, ophthalmoscopically, the appearance of the fundus of the eye is normal, or such as, independent of errors of refrac- tion, wo find in other cases compatible with standard vision, or at least with a fair amount of useful vision. This will allow of aconsiderable latitude, and will not include any slight or imagi- nary hyperremia or anmmia of the optic disk, any physiological excavations of the same, or congenital opacities of the retina, etc. The pupil of the affected eye is, if the other be perfectly ex- cluded from light or vision, nearly always dilated, to almost the greatest extent, though atropine dilates it yet more fully, and it is fixed, being insensible to light. Prognosis. — After a due consideration ol the cases thus classed together — and they are very unlike in fact, and often very obscure — wo may say generally, that if the blindness be of one eye only, sudden and recent, the prognosis is hopeful ; but if both eyes are affected, and the disease, whatever it may be, is of steady progress and of long standing, it is very serious. Tho cases of amaurosis are very rare indeed in which vision is perfectly restored ; most of them end fatally to vision, or would so end but that tho disease is sooner fatal to life. Treatment. — This must necessarily be varied according to the cause of the amaurotic condi- tion. For instance, if there is intra-cranial disease, treatment directed thereto must be fol- lowed out ; and should there be indications of syphilis, iodide of potassium and small doses of mercury must be given for some time. When amaurosis depends on any injurious habit, sueh- as smoking, this must be relinquished. Large doses of strychnine and iron are useful in ad- vanced white atrophy. J. P. Streatfeild. AMBLYOPIA (ap&Xus, blunt,’ and Snit, sight). — Obscurity of vision. See Amaurosis. 33 AMBULATORY. AMBULATORY ( ambulare , to -walk).— A term applied to latent typhoid fever, signifying that the patient is able to walk about during the attack. See Typhoid Fever. AMENOHBHCEA (a, priv. ; /ur/v, a month; and I flow). — Absence of the menstrual flow during any portion of the period of life when it tight to be present. See Menstruation, Dis- orders of. AMENORRHCEAL INSANITY. See Insanity. AMENTIA (a, priv., and pevos, the mind). -An obsolete term for Dementia. See De- mentia. AMNESIA (a, priv., and nrijim, memory). See Aphasia. AMPHORIC.— A peculiar hollow metallic sound, elicited occasionally by percussion, but more commonly heard in auscultation. Am- phoric breath-sound resembles that produced by blowing into a large empty glass or metallic vessel (amphora). See Physical Examination. AMYGDALITIS ( amygdala , the tonsils). — A synonym for inflammation of the tonsils. See Tonsils, Diseases of. AMYLOID DISEASE (&pv\ov, starch). - The name given by Virchow to Albuminoid Disease, from the belief that the material charac- teristic of this morbid condition is of the nature of starch or cellulose. See Albuminoid Disease. ANAEMIA (a, priv., and alp a, blood).— iiYNON. : Spancemia ; Hydrcemia ; Oligamia ; A- glohulism . Fr. Anemie. Ger. Anamie ; Blutar- muth. Definition. — Deficiency of blood in quantity, either general or local ; also, deficiency of the most important constituents of blood, particu- larly albuminous substances and red corpuscles. This definition is purely pathological, and the condition thus expressed presents many varieties, Anaemia in the widest senso of the term including Oligaemia, Oligocythaemia, Hydraemia, and Spanae- uiia, as well as Chlorosis. (See Chlorosis, Hydre- mia, SpANiEMiA, Oligocythemia, and Blood, Morbid Conditions of.) From the clinical point of view, Anaemia is a condition of system in which impoverishment of the blood, whether from want or from waste, is associated with symptoms of imperfect discharge of the vital functions. AEtiology. — The causes of anaemia are gene- rally multiple and complex. First, the supply of blood to the body may be insufficient, and that from a variety of causes, of which the chief are : — derangements of alimentation, including in- sufficient food, and morbid states of the lymphat ic and blood-glands ; such defective hygienic con- ditions affecting the formation and nutrition of the blood as want of light, air, and muscular exercise ; prolonged exposure to the influence of certain poisons, as lead, mercury, and malaria ; and, lastly, interference with the free circulation of the blood by cardiac or vascular disease, such as valvular disease or dilatation of the heart and aneurism of the aorta. Secondly, the con- sumption of blood may be increased by haemor- rhage ; by profuse discharges, such as suppura- ANAEMIA. tion, catarrh, and albuminuria; by rapid growth and development ; by frequent pregnancy and superlactation ; by excessive muscular exertion , and by the presence of pyrexia, or of new growths, which rob the system of nutritive material. In a third group of cases of anaemia both the supply and the consumption are at fault. Thus derangement of the organs and of the whole process of sanguification is frequently associated with profuse discharges from various parts ; and in malignant diseases and the ‘ chronic constitu- tional diseases,’ such as syphilis, tuberculosis, Bright’s disease, albuminoid disease, Addison’s disease, and others, the cause of the anaemia is extremely complex. But the majority of the cases of anaemia that aro regarded and treated as such fall into the class to which the name of idiopathic has been applied. In such cases the anaemic condition is due, not to any disease so- called, but to disturbance of nutrition generally, that is of the healthy relation between the demands of the system and the supply of nu- trient material This condition occurs chiefly in children and young women, at the period of bodily growth and of the development and early activity of the sexual functions ; and when, as so frequently and unfortunately happens, the air, light, food, occupation, and moral rela- tions of the individual are all more or less un- healthy. Anatomical Characters. — The blood suffers three principal changes in declared anaemia, namely, (1) deficiency in amount (Oligaemia) ; (2) deficiency in red corpuscles or haemoglobin (Oli- gocythsemia, Aglobulism) ; and (3) deficiency in albuminous constituents (Hypalbuminosis). Of these Oligaemia is the simplest, and perhaps never occurs alone ; it is speedily complicated with Aglobulism, which is a very early and common, as well as the most obstinate, change in tbc blood. Hypalbuminosis is the most advanced and perhaps the most serious alteration of the throi. ( See Blood, Morbid Conditions of.) The blood is scanty and pale, and has a diminished specific gravity; and coagulates slowly and loosely, or in aggravated cases not at all, settling into three layers — consisting respectively of red corpuscles, white corpuscles, and plasma. The body pre- sents certain changes directly due to the state of the blood. Whether the anaemia be local or general, the corresponding parts are blanched and ‘ bloodless.’ The cells of the tissues become atrophied and degenerate, in consequence of, and in proportion to, the interference with their plastic and functional activity respectively ; and the so-called ‘amende’ form of fatty heart, liver, kidneys, and other organs, is the result. If death occur suddenly from acute anaemia the heart is found empty and contracted. Pathology. — W'hcn the volume of blood in the body has been reduced by repeated small hae- morrhages, the phenomena that supervene, while they express the want of blood as a whole, and of its several constituents, are chiefly referable tb the loss of two of these constituents — the albuminous substances and the red corpuscles or haemoglobin — that is, of the oxidisable and the oxidising materials. The pathology of hypalbu- minosis and aglobulism is fully discussed in the article on diseases of the blood, and need not 1* AN. 4': .•opeated here. The same effects will be pro- duced by a drain of the liquid part only of the blood, or by poverty of the blood from. aDy of the causes enumerated above, whether of the uature of waste or of want ; inasmuch as loss of plasma speedily affects the nutrition of the red corpuscles. These phenomena constitute the symptoms of the anaemic condition whatever may be its cause ; their relative prominence naturally varying according to an immense number of cir- cumstances. Symptoms. — The subjects ofanaemia are usually girls and young women. Their general appear- »nce, which is striking, is one of pallor, debility, and variable loss of feminine fulness. The visible parts of the surface are pallid, often with a tinge of dusky brown on the eyelids and the backs of the hands; the clearness of the complexion varies with the normal pig- mentation of the body • the skin is soft, satiny, and rather loose. The mucous surfaces also are blanched ; the sclerotic is pearly blue. The loss of flesh maybe moderate, or it may be considerable. The extremities are cold, and the legs and lower eyelids are often cedematous. Bodily strength is reduced ; muscular force is diminished, while myalgia is common ; an air of languor and want of vigour pervades the whole demeanour ; and the patient is sleepy, dull, and depressed. The subject of anaemia generally complains of weakness, va- rious pains about the body and head, and marked shortness of breath on the least exertion. The last symptom is unaccompanied by other evi- dence of respiratory derangement; in character the breathing is regular, and short or even pant- ing. The symptoms referable to the circulation consist chiefly of palpitation on exertion; a tendency to faint ; and pain or even distress over the cardiac region. The impulse is variable ; the first sound is either hollow or murmurish, or con- verted into a murmur at the base, and frequently even over the whole praecordium ; the diastolic sound is sharp generally. Over the manu- brium and in the cervical vessels a murmur followed by a sharp sound is commonly audible, and therewith a venous hum. The cervical vessels may throb ; the radial pulse is small, soft, weak, and of variable but usually increased fre- quency and suddenness. There is a tendency to haemorrhages, especially epistaxis ; and petechiae are occasionally observed. The digestive system is markedly affected, as shown by loss or perversion of appetite ; an anaemic, often bare, but variable tongue ; dyspepsia, nausea, and sick- ness after meals or on rising; and constipation, which is present in the majority of cases and is frequently prolonged and severe. The menstrual functions are almost always deranged ; amenor- rhoea is common in some form ; menorrhagia is rare (except as a cause of anaemia) ; dysmenor- rhoea is frequently associated ; and leueorrhoea is the rule. The urine is usually abundant and pale, but varies greatly. Headache and other cerebral symptoms are common. Blood drawn from the finger presents aglobulism. (S'eeHjEMACYTOMETEB. The leading phenomena of acute anaemia are those of syncope, or suspended animation from failure of the circulation, and are described under that title. Course and Terminations. — The course of MIA. 31' anaemia in this form is essentially slow and pro- gressive, unless it is checked ; the duration is perfectly indefinite. The course of the symp- tomatic form will naturally vary with its cause, idiopathic anaemia rarely terminates fatally : and, when it does so, the event may be referred with few exceptions to some complication. Occa- sionally, however, it proceeds steadily to death (see Progressive Pernicious An.emia, below). Intercurrent diseases may be expected to he severe in an anaemic condition, in proportion to its degree. Diagnosis. — Anaemia is generally recognised with the greatest ease, and the chief question of diagnosis relates to its cause. The first point to be determined, therefore, is whether it is not symptomatic of some more grave state, such as tuberculosis, syphilis, albuminoid disease, or some other of the many possible causes of poverty of blood. Having settled that the anaemia if idiopathic, we must next exclude two diseases with which it may be confounded, namely, chlorosis and leukaemia. Chlorosis, in which the plasma is not considered to be altered, and which possesses otherwise a special pathology, is ex pressed by the yellow tint of skin, by the absence of wasting and of dropsy, as well as by other features ( see Chlorosis.) Leukaemia is recog- nised by examination of the blood, spleen, and lymphatic glands. The starting-point of the blood-change in cases of idiopathic anaemia, can only be discovered by careful investigation of all the facts of the case. Prognosis. — The prognosis of anaemia is favourable as regards life. In simple anaemia from loss of blood, the patient may be assured of speedy and complete recovery. In idiopathic anaemia, however, this promise can be given only when the cause can be removed or avoided. Under favourable circumstances and sound treat- ment, improvement will begin almost immedi- ately ; and. health should be restored after a few weeks or months. Treatment. — The treatment of anaemia, when it is symptomatic of some more grave con- dition, such as Bright’s disease or phthisis, does not require notice here. When blood has been lost in serious quantity, without other injury of consequence, it will be naturally restored if suffi- cient time but be given and interference other- wise avoided. Attention to the ordinary rules of health, abundance of food and air, and moderate exercise, will surely, if slowly, restore the patient, without the administration of a single drug. Even in this case, however, treatment may be of great service, by arresting, if necessary, the cause of the anaemia, such as menorrhagia or epistaxis ; and by assisting nature, if the condition should threaten at any time to become intensified by its own effects. But before the blood can be restored in the large and ill-defined group of cases known as idiopathic anaemia, the unhealthy influences under which the patient is placed, and the functional and other derangements, which are usually accountable for the imperfect sanguification, must be dis- covered and corrected. Where the aetiology is complex, treatment must be equally general, and the whole system of life will have to be reformed. On the other hand, in the rapidly growing child 10 AN2EMIA. iud youth, and still more in girls at puberty, the great demand for nutritive material must be duly considered and every obstacle to its supply re- moved. When other than direct discharges are draining the blood they must be cheeked. Lac- tation may have to be forbidden ; and leucorrhoea and spermatorrhoea 'will sometimes demand local treatment. The removal of the cause being thus made the first element in treatment, means must next be adopted for the restoration of the blood. But before this can be accomplished, it will be neces- sary to bring the alimentary tract and the organs of sanguification into a healthy state. Dyspepsia and constipation require immediate treatment; and for this purpose simple alkaline and bitter stomachics with rhubarb, and free purgation by ordinary means, followed by a course of aloes and iron pill at night, are the best. The food must be carefully ordered, so that it shall not only supply the albuminous elements that are specially deficient in the blood, but be retained and ab- sorbed ; it must therefore be at once nourishing and digestible, and be taken in small quantities at frequent intervals. The patient must not be allowed to yield to the disgust that she may have for meat. The process of sanguification may be success- fully assisted by means of drugs. Iron is the sovereign remedy for aglobulism ; and, practically speaking, it speedily becomes a question in the treatment of a case of anaemia in what form iron is to be given. The compound iron mixture of the pharmacopoeia answers more frequently than any other ; but, on the one hand, when there is much constipation, the protosulphate with pur- gative saline sulphates will be more suitable for a time ; and, on the other hand, when there is a tendency to discharges, the per-salts with bitters will better answer the purpose. The combinations of iron with quinia or strychnia, should be given in cases where less marked anaemia occurs in older subjects with nervous depression and general want of vigour. In special cases the ferrum redactum, saccharated carbonate, vinum ferri, or the French dragees fer- ruginenses at meal timesmaybeordered. Cod-liver 011 may sometimes be prescribed with success. Other symptoms must be treated on ordinary principles. Uterine complaints demand special attention ; and bromides, ergot, opium, and other sedatives and astringents are indicated where excitement and excessive discharge are present. While these dietetic and medicinal measures are being carried out, it is impossible to insist too strongly upon attention to bodily and mental hygiene. In a large number of cases change of air fulfils all the necessary conditions, and it is generally to be recommended. Above all, time is an essential element in the cure ; and rest is scarcely less so. A frequent charge in the form of the medicinal remedies is also advisable. Progressive Pernicious Anaemia. — A peculiar form of anaemia has long been known, but has lately attracted special attention, and is variously designated as pernicious, malig- nant, idiopathic, and progressive, on account of the intensity of the symptoms, the ob- scurity of its pathology, and the frequency with ANAESTHETICS. which it advances to a fatal termination. Thib disease may occur in both sexes, but has beenmost frequently observed in middle-aged, pregnant wo- men ; it presents no special post-mortem appear- ances ; and it cannot be referred to any reasonable cause. The symptoms are those of excessive anae mia, as described above ; but gastric disturbance and general haemorrhages are relatively promi- nent, and, in some cases, irrpgular attacks of pyrexia occur. The blood during life is said to differ from that found in ordinary anasmia, by con- taining an unusual amount of ill-shaped red cor- puscles and granular matter. The course of the disease is steadily towards death, in which it gene- rally terminates. The pathology of progressive pernicious anaemia is obscure. It is believed by some to be but the advanced stage of or- dinary anaemia, which attracts attention by its resistance to treatment, and its fatal ter- mination. The appearance of the blood would seem to indicate excessive destruction, rather than insufficient supply of the important elements, as the essential cause of the morbid condition; but there is probably derangement in both directions. The prognosis is as unfavourable as possible. Treatment must be ordered on general principles : transfusion has been frequently tried, but with- out success. J. Mitchell Bruce, ANEMIA LYMPHATICA.-A form of Anaemia which is associated with a peculiar af- fection of the Lymphatic System. See Hodg- kin's Disease. ANESTHESIA (a, priv., and aurdavo/xai, I feel). — Anaesthesia literally means absence or loss of sensation, which may be general or local. The word is, however, more especially employed to signify loss of tactile sensibility, as distin- guished from insensibility to pain or Analgesia. It is further used to indicate the condition in- duced by the action of Anwsthetics upon the system. See Sensation, Disorders of. ANESTHETICS. — Definition. The name given to a series of agents which are employed for the prevention of pain, but more especially applied to those used in surgical practice. History. — The idea of annulling pain in sur- gical operations is a very old one. Compression of the nerves and blood-vessels, and the inhala- tion of the vapour of mixtures containing car- bonic anhydride were practised at an early date. In the sixteenth century ether was probably the active ingredient of a volatilo anaesthetic de- scribed by Porta. The use of anaesthetics was, however, but little understood and rarely prac- tised. Even the suggestion of Sir Humphry Davy, that nitrous oxide should be used in minor operations not attended with loss of blood, was of little practical value, on account of the inefficient apparatus then available. In 1 815 Horace Wells inhaled laughing gas so successfully that he may be said to have introduced the practice ; but he appears to have so often failed to produce the desired effect that this agent fell into disuse on the introduction of ether in 1816 by Morton, after some communication on its properties from a chemist named Jackson. In 1847 chloroform was used by Simpson, and quickly superseded ether almost all over Europe. At the presen' ANESTHETICS. time the comparative safety of ether has caused this anaesthetic again to be preferred by many surgeons in this country. Enumeration. — The three agents just men- tioned, namely, nitrous oxide, ether, and chloro- form, are those chiefly in use, and they have each advantages in particular cases. Experiments made vith other agents, such as amylene, tetrachloride of carbon, ethidenedichloride, and bichloride of methylene, have not shown that they possess sufficient advantages to counterbalance the defect of requiring special management in their ad- ministration. This list of anaesthetics might be still further increased, for in order to produce insensibility it is only necessary to reduce the supply of arterialised blood to the nervous centres, or to introduce into the blood a sub- stance which deprives it of its power of oxygen- ating the tissues. Modes of Use. — Anaesthesia may be produced for surgical purposes: — 1. by benumbing the part to be operated on by means of cold ; 2. by intercepting its nervous communication; 3. by arresting the activity of the nervous centres concerned in sensation. Thus anaesthetics may be local or general in their action. Local Anaesthesia may be induced by cold. The most convenient plan is to blow a jet of anhydrous ether spray upon the part, as sug- gested by Dr. Kichardson, and thus to freeze it. The surface to be frozen should be dry, and hence the difficulty of freezing the gum of the lower jaw, on account of the saliva. A mixture of equal parts of pounded ice and common salt contained in a bag of muslin is effective, but less easily applied. This plan is adapted for opening ab- scesses and boils, and for the extraction of a few teeth ; but the process both of congelation and of thaw is painful. Chloroform applied locally is said to cause numbness, but it is very little used except inside the mouth, and then it owes its soothing effects to the quantity of chloroform vapour which is inhaled. Compression of nerve trunks for inducing anaesthesia is never prac- tised at the present day. General Anaesthesia is at present rarely obtained in any other way than by inhalation, although successful attempts have been made to induce the condition by subcutaneous and in- travenous injection of chloral or morphia. Subjects for Anesthetics. — We may say generally' that any person fit for a severe ope- ration is a fit subject for an anaesthetic, but no one is so free from danger that care in watching its effects can be dispensed with. The cases requiring the greatest vigilance are not the young and deli- cate, forwhom a small dose suffices, butthestrong, who inhale deeply and struggle much. Ether is probably better for those suspected of fatty de- generation of the heart, although as a rule such cases aro eminently satisfactory under chloro- form. Many of the deaths under chloroform have occurred in intemperate drinkers, and the presence of alcohol in the system undoubtedly intensifies its effect. Precautions. — Before commencing inhalation file following particulars should be attended to. The patient must not have recently taken a full meal ; he should lie comfortably, in a horizontal position if possible, unless when gas or ether is 41 given for a short operation ; and the dress should not be tight. When the administration is begun, he should be encouraged to breathe regularly and freely. The pulse as well as the respiration must be watched. If the vapour excites either swal- lowing or coughing, it is more pungent than is requisite, and its strength should be diminished. Most patients are at first afraid of breathing, and some hold their breath for half a minute. The vapour should not be removed on this account, but care should be taken, by holding the inhaling apparatus farther off, to prevent the vapour becoming too strong in the interval. After volition has been abolished, any pause in the breathing should be noted, and more or less fresh air given. Further directions will be given in describing the anaesthetics specially. Special Anesthetics. — Protoxide of Nitrogen , Nitrous Oxide, or Laughing Gas. This agent is now prepared wholesale, and sold condensed into a liquid in strong iron bottles. The gas, whether supplied thus or from a gasometer, should be inhaled from a bag having such a free com- munication with the face that it will readily be supplied even in panting respiration. A long tube, however large, is objectionable, as the gas is less mobile than common air. The special aim in giving gas should at first be to exclude air, and to exchange the atmosphere within the air-passages and lungs for one of pure gas. The patient should not merely be told to breathe slowly and deeply, but be shown how to do so, about fifteen times in a minute. The in- spiration should not be jerking, and the expira- tion should be complete. It is a special merit of laughing gas that no harm can come of inhal ing too freely at first. The gas-bag must be kept filled either by pressure on the gasometer, or by turning the screw tap of the gas bottle. This may be done by the hand of an assistant, or more conveniently with the foot of the admi- nistrator, by means of a contrivance invented by Mr. Braine, in which the gas-bottle is placed hori- zontally upon rollers and moved by the foot whilst the head of the screw is fixed. The writer’s plan is to fix the bottle vertically and turn the screw by pressing the foot against an iron plate with spikes on its upper surface, and a square hole fitting the tap on its lower surface. It is imperative that the face-piece or mouth- piece should fit accurately, and the air-pad is almost essential to effect this in a great many cases. It should be warmed if the indiarubber is stiff. After five or six good respirations there is no need of supplying fresh gas with each in- spiration. The expiring valve should be kept closed, and the inspiring valve opened. Care must always be taken that the supply’ of gas is suffi- cient to replace any that is lost by absorption into the blood or by leakage. This is more easily effected if the gas-bag is made of thin indiarub- ber, so as to distend easily and contract gently with the movement of breathing. It should be sufficiently filled, so that if the mouth-piece does not fit, the gas would escape instead of air entering and becoming mixed with it. Lividity of the skin will not help us to know when the patient is fully under the influence of the gas, neither will insensitiveness of the eyelids, nor yet the state of the pupils. The breathing Vi AN^ESl should become stertorous or interrupted, or the pulse very feeble, or convulsive twi tellings should occur, before the face-piece is removed. A little air may be admitted by raising the face-piece, if the operation is not upon the face, and by doing so every fourth or fifth respiration anaesthesia may be kept up for several minutes. The effect of a single full inspiration may he to bring the patient into a state of excitement, and the continuance of the gas without air brings on convulsive move- ments, so that it is not well adapted for any operation lasting as much as five minutes, and requiring steadiness. Patients are sometimes so unsteady that it is found to be almost impossible to make the face-piece fit. In such cases the best plan is to cover the patient's eyes and let him breathe air, merely preventing him from rising from the chair or bed, and not speaking till he is conscious, and as soon as he becomes so to recommence the inhaling as if nothing had happened. A violent patient often becomes perfectly rational in less than two minutes. Sickness and headache ought not to result from the inhalation of gas, but if the use of it is prolonged, or if the patient is kept for several minutes in a semi-conscious state, breathing a little air with the gas, both these symptoms may occur. The recumbent posture, quiet, and warmth to the feet, constitute all that is likely to be required in the way of treatment. Ether, Sulphuric Ether, Ethylic Ether, Vinic Ether, or Oxide of Ethyl, was first used for anaes- thetic purposes in 1816. Before its use was well understood in England chloroform was brought forward as a more convenient agent, and much less unpleasant to the patient. Ether is less liable to become dangerous to life, as it does not under ordinary circumstances depress the action of the heart. If ether be given from a towel or hollowsponge, ihe best kind is the JEther Purus of the Pharma- copoeia, of sp.gr. '720 ; hut the ether of sp. gr. '735, which contains a little water, answers very well if the towel or napkin is arranged so as to form a large cone, thus lessening the access of fresh air. 'i he disadvantage of using the latter kind is that the moisture of the patient’s breath condenses upon the surface made cold by the evaporating ei.her, and diminishes its volatility. When pure ether is used, a certain amount of condensed aqueous vapour is taken up before it reaches the density '735. In all inhalers where an arrangement is made for preventing the ether from becoming too cold, the washed ether '735 may be used, and will be found cheaper. Not only is it sold at a lower price, but it is much easier to keep from escaping through cork or stopper. Although it is not difficult to destroy dogs sud- denly with ether, it is believed by many writers on the subject that in man it can only prove fatal by causing asphyxia, and that the signs of this condition are so easily seen and remedied that practically this anaesthetic is quite safe. The writer is not of this opinion, believing that some- times when narcosis is far advanced, the glottis will allow ether vapour to pass of sufficient strength to stop the heart. Such cases, however, are very rare indeed. Ether is extensively adminis- tered by pouring an ounce at a time upon a very large cup-shaped sponge, which, if cold from previous use, is dipped into hot water and squeezed as dry as possible. It is to be expected that the patient will resist breathing when this is held over his face, but after a minute’s struggling he becomes unconscious, and easy to manage. Compared with giving ether timidly, so as to let the patient remain delirious for several minutes, this may be a good plan ; but there is no necessity for giving the ether so strongly if we diminish the access of fresh air. The ad- ministration of nitrous oxide from which air is at first excluded, and afterwards admitted very sparingly, has taught us how slight the after- effects are from the asphyxiaso induced. Cones of leather or pasteboard lined with felt, and having a small opening at the apex, are better than sponges ; but they should be larger. They may be made more effective and economical by placing a thin india-rubber bag over the apex of the cone, so that more of the expired atmosphere may be breathed again. Morgan’s inhaler is very efficient. The ether is poured into a tin chamber as large as a hat, con- taining sponge. This is covered by a sort of diaphragm, which rises and falls with respiration as the patient breathes into and out of it by means of a tube and face-piece. Thero are no valves. Anaesthesia results partly from asphyxia, and partly from the action of the ether. The amount breathed depends on its temperature, and on the freedom of respiration. If the respiratory movements are slight, as in young children, or in persons suffering from emphysema, the amount of ether supplied is apt to be too small. Ormsby’s inhaler is an improvement upon it. The sponge for ether is contained in a cage near the face-piece. An excellent inhaler for hospital purposes and for prolonged operations is sold by Mr. Hawkes- ley. The ether -vessel is kept in a water-bath. There are valves which allow air to pass over the ether, but prevent its return, and the ap- paratus has an arrangement for lessening the odour of ether in the room, consisting of a tube leading to the floor, which carries off the expired air and ether. With the view of regulatiug the strength of the ether vapour, the writer has contrived the following apparatus, which is made by Mayer and Meltzer. It consists of an oval india-rubber bag fifteen inches loDg, at one end connected with the face-piece, at the other with the ether-vessel Within the hag is a flexible tube also leading from the face-piece to the ether vessel. By turning a regulator the patient is made to breathe into the bag either directly or indirectly through the tube and ether vessel, or partly one way and partly the other. The more the regulator is turned towards the letter E, the more ether vapour he tikes. By turning it back again the amount of vapour is diminished. The ether- vessel contains a reservoir of water, which prevents the ether becoming too cold from evaporation. It is filled with ether up to a mark on the vessel. A thermo- meter in connection shows the temperature of the ether. The vessel should be just dippec. into a basin of warm water and gently rotated till the thermometer reaches from 65° to 70 °. ANAESTHETICS. When used this vessel should be suspended by a strap from the neck of the administrator. At first the regulator allows the passage from the face-piece into the bag to remain open, and the bag should be filled by pressing the face-piece more firmly against, the face during expiration than inspiration. By degrees the regulator is turned towards letter E, and thus the way to the inner tube is opened, and the air breathed through it carries ether vapour from the vessel into the dis- tal end of the bag. When the regulator allows half the inspired air to pass through the ether, the vapour is strong enough to induce sleep in two mi-nutes, usually without exciting cough. As the act of swallowing is excited by a smaller quantity of ether than that of coughing, it should be watched for, and the regulator very slightly turned back should it occur. This same apparatus may be used for giving laughing-gas, all communication with the ether- vessel being cut off by turning a stopcock, and by attaching the tube leading from the gas- bottle to a mount near the bag. By far the least unpleasant and the quickest way of preparing a patient for a surgical operation is to use gas and ether combined ; the change from gas to ether being made by turning the regulator above described as soon as the patient is sufficiently under the influence of gas to disregard the flavour of ether. The supply of gas should be stopped as soon as the ether is introduced ; but i ( subsequently the patient is allowed to become conscious, the gas may be given freely as at first, in order to make him sleep again. The writer tiuds less sickness and more rapid recovery from the unpleasant taste of ether than when the latter is given alone. The chief difficulty is to prevent the unsteadiness of the patient, resulting from the panting character of the breathing. To lessen this the ether must be given as strong as possible without producing initation of the throat, and the operator should wait until the influence of the ether has increased to the production of deep stertor. Air being then admitted with every fourth or fifth inspiration, the breathing soon be- comes as regular as it is under ether when given in any other way. On recovering from the inhalation of ether patients are often in a state of intoxication for a period corresponding to the time and extent of l he etherization. The eyes should be covered, but the mouth and nose left free ; and the room should bo kept quiet, with a brisk fire, and the window more or less open. See Appendix. Chloro form was introduced by Simpson in 1847. It should not be made from methylated spirit, and, when a drachm is poured upon blotting paper, it should evaporate without leaving an unpleasant odour. It is the most convenient of all anaesthetics, and the most easy to admi- nister. Unfortunately, when given beyond a certain strength, it has a tendency to produce cardiac syncope, and it is not improbable that 6om9 persons are particularly liable to be so affected. Some authorities think it desirable to give alcoholic stimulants before administering chloro- form ; others partially narcotize the patient with morphia or chloral. No doubt these agents assist the action of the chloroform, but if from any 4a accident an excess of chloroform should be given, they interfere with the means of recovery, and for this reason are not to be recommended. There is less objection to the inhalation of a mix- ture of chloroform and ether, or of these agents with alcohol ; but such mixtures, if kept for some length of time, alter their relative proportions, owing to the escape of the more volatile in- gredients. Even the change from the adminis tration of chloroform to that of ether, if made suddenly, is not free from danger, for, w r hen a person is partially under the influence of chloro- form, the glottis allows a high percentage ot ether to pass ; and, if the lung-circulation be slow, as is likely to be the case, the blood may be so highly charged with ether as to depress rather than stimulate the heart. Chloroform, therefore, should be given gradu- ally. The object should be to keep down the proportion of chloroform-vapour rather than to give abundance of fresh air. In preparing for an operation requiring perfect stillness, six to eight minutes should be allowed for the process. Sponges or lint saturated with chloroform, and held close to the mouth, are dangerous, from the possibility of liquid chloroform falling on the lips or into the mouth. In midwifery practice a piece of linen or blotting paper sprinkled with chloroform and placed at the bottom of a tumbler is a convenient plan of administration, care being taken to prevent any liquid chloro- form from settling at the bottom. In general surgery a handkerchief or towel may be folded into a small cone, open at the apex, into which not more than a drachm should be poured at first, and fifteen minims at a time afterwards. A better plan is to roll and tie a piece of lint into a compress the size of a walnut. A drachm to a drachm and a-half of chlo roform should be poured upon this, which is to be held about an inch in front of the patient's upper lip, the hand and compress being covered with a towel, which should gradually be drawn over the patient's face. This plan gives considerable com- mand over the supply of chloroform, for, when the chloroform, having cooled by evaporatiou, is given off too slowly, the vapour can be increased by warming the compress in the palm of the hand. When it is becoming dry it ceases to feel cold, and warning is thus given that fresh chloroform is needed. This should be supplied half a drachm at a time. In doing this the towel should still be left over the face of the patient in order to keep him breathing a slightly chloroformed atmosphere. The movement of swallowing should be looked for, and regarded as evidence that the vapour is stronger than is necessary. If any sound like hiccough indicates laryngeal obstruction, the chloroform and towel should be removed, and, if the sound continue, the chin should be raised as much as possible from the sternum. Laryngeal obstruction arises from two main causes, viz., spasm of the glottis, and falling down of the epiglottis. The first is excited by the pungency of the vapour, and also by reflex action when certain nerves are injured, notably when a ligature is tightened upon a pile. The epiglottis covers the larynx every time we swallow, but the muscles coming from the chin raise it again directly. In deef> ANAESTHETICS. 44 narcosis these muscles are sluggish, and cannot act thus if the position of the chin places them at a disadvantage. If raising the chin fail to open the air-passage, the tongue must be pulled forward. In doing this the head should be kept back. Depressing the chin renders a partial obstruction complete. A laryngeal sound in- dicating obstruction is of little consequence if the pulse is good, since, although the breathing be imperfect, sufficient fresh air continues to be breathed; but if the pulse flags, or if it appears that the amount of chloroform in the air-pas- sages is excessive, not a moment should be lost in seizing the tongue with forceps. When a patient is delirious and struggling, extra care must be taken that the chloroform be not too strong, because he inhales deeply, carry- ing the vapour almost to the air-cells of the lungs, and, when he next closes the glottis and strains, l he pressure of the air and vapour within the lungs is increased, and the chloroform enters the blood very quickly. The compress should be held at least two inches off the mouth, although the towel may still cover the face. Directly any stertorous noise is heard, a breath or two of fresh air should be allowed, and no more chloroform given till the pulse beats well and the respiration is free. Skinner’s apparatus -—a capof ‘domette’ flannel stretched over a fram9 — is a much better appa- ratus than a towel ; but its virtue is simplicity, and it has little pretension to exactitude. Snow’s apparatus is very efficient, portable, and econo- mical. The addition of a water-jacket to equal- ize the temperature was a great improvement; but it should be provided with a thermo- meter. The safest and least unpleasant mode of giving chloroform is by means of the apparatus fitted with a large bag of air containing not more than thirty-three minims of chloroform in a thousand inches of air. The apparatus is, how- ever, too complex to bo generally adopted, and the writer hopes shortly to be able to introduce a modification of it which will be more easily used. The advantage of more precise measure- ment of the strength of chloroform-vapour than is afforded by towels or napkins will appear when we consider the Several circumstances that alter it when so given. The strength of vapour given off from a known quantity of chloroform is influenced by : — 1. The extent of surface of chloroform. 2. The temperature of the chloroform, which is constantly changing. 3. The temperature of the air of the room, of the patient's face, and of the administrator's hand. 4. The distance at which the chloroform is held from the patient’s face. 5. The rapidity of the current of air. 6. The height of the barometer. Moreover, when the chloroform-mixture is of Known strength, its effect is increased by high barometrical pressure; by low temperature of the blood ; by deep or quick respiration, and especially by muscular efforts when the glottis is closed ; and by slow movement of the blood through the lungs. On the other hand, it is lessened by low baro- metrical pressure ; by high temperature of blood ; by superficial or slow respiration ; and by rapid circulation through the lungs. Under ordinary circumstances danger from these causes is easily averted with moderate care, for they do not often concur to produce the same effect ; but if a patient, fatigued with struggling, takes a very deep breath just as fresh chloroform has been poured upon the towel, and then closes his glottis and makes another struggle — the barometer being high at the same time — it is evident that blood unduly charged with chloroform will gain access into tho coronary arteries, and depress the cardiac ganglia. Death has occurred so rapidly under these cir- cumstances, that it has been thought to bo tho result of shock from the operation. Chloroform lessens, if it does not entirely prevent, the shock of an operation, but it is to be feared that if chloroform be given freely for this purpose, a dangerous amount of it will be administered. If a severe operation is about to be performed, the chloroform should bo given in the same gradual manner as in a slighter one, but con- tinued to the point of fixing tho pupils and pro- ducing stertorous breathing ; and, when the chief shock is expected, two or three breaths of pure air should be admitted, so that, if the pulse fail, there may not be an excessive amount of chloro- form-vapour in the lungs. Compounds of Chloroform . — Under this head comes Bichloride of Methylene , which contains a variable quantity of chloroform. Its che- mical characters and physiological effects are very similar to those of a mixture of chloroform, ether, and alcohol. It narcotizes quickly', but not safely ; and, as the amount of chloroform in it is not always uniform, it is better to inix, in small quantities at a time, one part of alcohol, two of chloroform, and three of ether, and to keep the bottle so well corked that the ether is not likely to evaporate and leave chloroform in excess. The word ACE fixes the proportions in one’s memory. A mixture of one part of chloroform with four of ether is convenient for a brief operation, as this produces much less excitement than ether alone. On the whole the writer objects to keeping mixtures of this kind ready-made ; and it is probable that the plan of giving at the out- set sufficient chloroform to abolish conscious- ness, and subsequently administering ether, will be found safer than mixing them together in the liquid state. Ethidcnc, 8>c. See Appendix. Afte r-tiie atm ent. — Quietude or conversation of an encouraging or soothing character is de- sirable during the half-minute of recovery from gas. The eyes should be covered, unless the view is tranquil as well as pleasant. If gas be given until there are intermissions in tho breathing, or its administration continued for several minutes with a small allowance of air. there may be headache and even vomiting : still no other treatment than repose is needed. After the inhalation of ether a taste will re- main, varying with the strength of the vapour, and the duration of the administration. This may be got rid of by washing out the mouth, and gargling with warm fluids ; while tho vapour re- maining about the patient and in the room may ANAESTHETICS. be removed by beating the surface by means of hot bottles, and making a bright fire. When the system has been long or pro- foundly under the influence of chloroform or ether, nausea and vomiting are likely to ensue. The writer has not found any remedies more efficient in relieving these symptoms than warmth, fresh air, and abstinence from food. Hot tea and coffee, taken from a feeder without raising the head, and afterwards beef-tea and jelly, are sufficient for twenty-four hours, unless the patient wishes for something solid. The rule then should be to give as little as, or less than, is asked for. Ice has been recommended, and, if it does nothing else, it relieves thirst, and serves to postpone the necessity for giving solids which might prove hurtful. Treatment of Dangerous Symptoms. — An- aesthetics in excess destroy life by stopping the action of the heart, or the respiration ; generally both are affected. When laughing-gas is given to animals till the breathing has ceased, the heart continues to beat long afterwards, and artificial respiration rapidly restores them. Ether-vapour, given almost pure through a tracheal tube, will arrest the action of a dog’s heart in sixteen se- conds; but if administered as rapidly as possible with a cloth, without opening the trachea, the breathing fails before the heart, and the lisema- dynamometer shows adequate pressure in the vessels whilst the breath is gasping, and for several seconds after it has ceased. With chloroform the hsemadynamometer indi- cates diminished pressure directly the animal ceases to struggle, and the heart sometimes stops before the breathing. In case alarming symptoms should arise, the first effort should bo directed to lessening the amount of tho anaesthetic in the lungs, by pressing the trunk with both hands, and squeezing out as much air as possible with- out causing a shock. If, after this has been done two or three times, the air does not readily re-enter the chest, tho obstruction is to be over- come either by lifting the chin or drawing out the tongue, and other artificial movements of the chest must bo carried on. ( See Artificial Respiration.) If pallor be noticed whilst breathing is going on, the recumbent posture and elevation of the feet are immediately re- quired. (See Resuscitation.) Nelaton’s plan of inverting the body has often been followed by recovery, but, considering the impediment to inspiration from the weight of the abdominal viscera, the writer is of opinion that the pelvis should never be many inches higher than the head. Nitrite of amyl — by reason of its effect in dilating the vessels of the skin — has been recommended, but without careful physiological inquiry, and upon very small clinical experience. Electricity might be expected to prove the best agent to assist the action of a feeble heart. The writer's experimental observation has not been favourable to its employment; and cer- tainly artificial respiration should not be delayed one moment in order to apply electricity. Insufflation is not to be depended on. The condition would be rendered worse by distending the stomach, which cannot always be prevented by pressing the larynx against the spine. Larvngotomy may be required in cases where in ANAPHEODISIACS. 4S spite of throwing the head backward, and re moving the chin away from the sternum, air can- not be made to enter the chest. Hot-water injections may be of use, but the o can be no necessity for brandy whilst artificial breathing is being carried on. Afterwards, if swallowing is difficult, brandy may be added to the enema. Friction of the limbs in the direction of the heart is unnecessary, provided the feet are slightly raised. Where there has been great loss oi blood, the limbs should be bandaged firmly from the fingers and toes upward, as in Esmarch’s plan for saving the blood of a limb about to be amputated. In warm weather, or if the body is warm, a towel dipped in cold water may be flap- ped against the chest, but harm would result from cooling the body generally. Bottles of hot water and hot blankets should be applied as soon as the breathing is restored, and a brisk fire should be kept up, in order to favour the venti- lation cf the chamber. J. T. Clover. ANALGESIA (A priv., and iiA/yos, pain). — Absence of sensibility to painful impressions. See Sensation, Disorders of. ANAPHRODISIA (a, priv., and ’A(J>po5iT7j, Venus). — Absence of sexual appetite. Some- times used to express Impotence. See Sexual Functions, Disorders of. ANAPHEODISIACS— Definition— Me- dicines which diminish the sexual passion. Enumeration. — The agents employed as ana- phrodisiacs are : — Ice, Ccld Baths — local and general ; Bromide of Potassium and Ammonium ; Iodide of Potassium ; Conium ; Camphor ; Digi- talis ; Purgatives ; Nauseants ; and Bleeding. Action. — The erection which occurs in th< genital organs during functional activity is due to dilatation of the arteries in their erectile tissues, and is regulated by a nervous centre situated in the lumbar portion of the spinal cord. From this centre vaso-inliibitory nerves pass to these arteries, and cause them to dilate whenever it is called into action. It may bo excited either reflexly by stimulation of the sensory nerves of the genital organs and ad- joining parts; or by psychical stimuli passing to it from the brain. Anaphrodisiacs may act by lessening the excitability of the nerves of the genital organs, as the continuous application of cold, and probably, also, bromide of potassium ; by diminishing the excitability of the genital cen- tres in the spinal cord and brain, as bromide and iodide of potassium and conium ; or by influencing the circulation, as digitalis. There are also ad- juvant measures, of a hygienic and moral charac- ter, which greatly assist and may even replace anaphrodisiac medicines, such as a meagre diet, especially of a vegetable nature, the avoidance of stimulants, and the pursuit of active mental and bodily exercise. Everything tend ing to stimulate the genital organs, or to in- crease the flow of blood to them or to the lumbar portion of the spinal cord, should be avoided, such as warm and heavy clothing, or pads about the hips or loins ; and a hard mattress should be used in place of a feather-bed. Everything likely to arouse the passions, such as certain 10 ANAPHRODISIACS. novels, pictures, theatrical representations, &c. should also be shunned. Uses. — Anaphrodisiacs are employed to lessen the sexual passions when these are abnormally excited in satyriasis, nymphomania, and allied conditions. As such excitement may some- times depend on local irritation of the genitals, in consequence of prurigo of the external organs, excoriations of the os uteri, or balanitis ; or on the presence of worms in the rectum or vagina ; these sources of excitement should be locked, for, and, if present, should be subjected to appro- priate treatment. T. Lauder Brunton. ANASARCA (ava, through, and ad.pl, the flesh). — An efi'usion of serous fluid into the subcutaneous connective tissues, not limited to a particular locality, but becoming more or less diffused. See Dropsy. ANCHYLOSIS (ay K i\os, crooked).— Marked stiffness or absolute fixation of a joint, which may be due to various morbid conditions of the structures entering into its formation. See Joints, Diseases of. ANCHYLOSTOMA (ayuvAos, crooked, and aviga, a mouth). — A genus of nematoid worms. See Sci.erostoma. ANEURISM (avevpvvw, I dilate.) — Defi- nition. — Aneurism is a local dilatation of an artery, leading to the formation of a tumour which contains blood, and the walls of which are composed either of the tissues of the vessel, or those which form its sheath or immediately sur- round it. Therefore every aneurism, properly so called, consists of two parts — a sac and its con- tents. Classification. — Aneurisms are usually divi- ded, according to the varying composition of the sac, into the following varieties : — 1. True aneurism, in which all the three coats of the artery form the sac or a portion of the sac. This variety is rare : at least it is so rarely possible to trace all tho coats of the artery over any part of the sac beyond its orifice, that some patho- logists deny the existence of this so-called ‘ true ’ form of aneurism, and most admit its existence in the aorta only . 2. False aneurism, in which the sac is formed by one only of the coats of the artery. This is almost always the external coat; but a sub- variety has been proved to exist as a consequence of wound of the outer part of the vessel, and is believed by some to take place spontaneously, in which the inner coat, or the inner and part of the middle coat, is dilated, pushed through the outer coat, and forms the sac. This is called hernial false aneurism. 3. Diffused or Consecutive aneurism. Here the sac is formed of the sheath, cellular tissue, or other structures around the artery, which are matted together into the form of a membrane. The name ‘ difiused ' is applied to this form of aneurism to express the fact that the blood is at first diffused amongst the tissues in consequence of the rupture or division, whether from injury or disease, of all the coats of the vessel, either in a part or the whole of its circumference ; but it is not a good term, since, as soon as the aneu- rismalsaeis formed, the blood is diffused no longer, ANEURISM. but, on the contrary, is encysted in the newly formed sac. So that the other term, ‘ consecutive,’ seems a better one, expressing, as it does, the important fact that the formation of such aneu- risms is always consecutive on a rupture, partial or entire, of the artery. 4. Dissecting aneurism is seen only within the trunk of the body, and always involving tho aorta — although it may spread from the main artery down to its branches. In this form the internal and middle coats have given way, or cracked ; and the blood has forced its way, usually into the substance of the middle coat, sometimes perhaps between the middle and outer coats, dis- tending the external portion of the vessel into a kind of aneurism. This is the nomenclature still in common use ; but as the first and second varieties are practi- cally indistinguishable during life, and the first, though called the ‘true’ form of aneurism, is very rare, it would be better to include both under the common name ‘ true ’ aneurism, and apply the term ‘ false ’ to the third or ‘ consecu- tive ’ form. 5. Besides these, which are all forms of pure arterial aneurism, there are aneurisms in which the vein and artery are simultaneously involved, and which are therefore called Arterio-venous, which will be afterwards spoken of ; and tumours having a certain analogy to aneurism, which are formed of dilated and tortuous arteries — Cirsoid and Anastomotic aneurisms. Other classifications of great importance are, according to the cause of the disease, into Spontaneous and Traumatic-, or, according to tho shape of the tumour, into Fusiform and Sacculated. In fusiform aneurism there is a dilated tract of artery, often of considerable length, from either end of which springs the vessel of its natural calibre. Sacculated aneurism springs like a bud from one side of the vessel, and the artery is often buried for some distance in the wall of the aneu- rism ; but there are many sacculated aneurisms which approach in shape to the fusiform, tho vessel being dilated for some part of its extent, so that its two openings lie at different parts, and sometimes on different aspects of the sac. ^Etiology and Pathology. — The proximate cause of spontaneous aneurism appears to be usually a loss of the elasticity of the wall of the artery, whereby it loses its power of resilience after having been dilated by the force of the cir- culation. This loss of elasticity is commonly caused by atheroma or else by partial calcifica- tion of the wall of the artery. In the latter case the blood often forces its way through the entire arterial wall, and an aneurism of the consecutive variety forms, 1 or the external part of the artery is dissected off, and a dissecting aneurism results. Inflammatory softening of the artery, without the presence of any definite atheromatous deposit is looked upon by many writers of credit, such as Wilks and Moxon, as a common cause of aneu- rism. Such low inflammation may have its origin possibly in rheumatism — and, as a matter of fact aneurism is often preceded by acute rheumatism ; more certainly in violent strain, or 1 Sometimes, however, the bleeding will go on without the formation of any aneurismal eac, and lead to thf loss of life or limb. ANEURISM. in mechanical violence. Anything else which weakens the arterial wall, such as the exposure of the vessel in an abscess, is looked on as a cause of aneurism. The yielding of a weakened arterial wall is doubtless accelerated by irre- gularities of the circulation. The influence of syphilis and of intemperance in causing aneurism is widely believed, though perhaps as yet neither fact is absolutely established : the latter, at any rate, is rendered very probable from the consideration that chronic alcoholism tends to impair the nutrition of all the tissues, including the arteries, and is accompanied by a constantly irritable condition of the circulation. That syphilis may cause a fibroid degeneration of the vessels must also be allowed to be at least possible, and that it does so is the opinion of many eminent pathologists. If so, the tran- sition to aneurism is natural, if not inevitable. Another proved cause of aneurism is embolism, or the obstruction of a diseased artery by a fibrinous plug, which has been known to be followed by the dilatation of the artery immedi- ately above the plug, just as in very rare cases the ligature of a healthy vessel has given rise to the formation of aneurism above the tied part. 1 Violence is a very frequent cause of aneurism, even in cases which are not technically denomi- nated ‘ traumatic.’ The latter term is generally restricted to cases in which the vessel is wounded by a cut, or is known to be ruptured, and the aneurism makes its appearance at once ; and in these cases the aneurism is of the ‘ diffused ’ or ‘consecutive’ variety. But there are, no doubt, many cases in which the artery is partially torn, and the walls, being thus weakened, afterwards slowly yield at the injured spot. This fact is illustrated by the well-known experiment of Richerand, designed to explain the frequency of popliteal aneurism. The experiment consists in hyperextension of the knee in the dead subject. If this be carried on forcibly till the ligaments are heard to crack, it will usually be found that the two inner coats of the popliteal artery are torn. All these causes of aneurism act much more powerfully in later life than in childhood, and many are unknown in early years. Aneurism, therefore, is very rare in children. In cases where the arterial system is extensively affected with atheroma, a great number of aneurisms may be found in the same person, or another may form after the cure of the first. To such cases the term ‘ aneurismal diathesis ’ has been applied. This fact shows the great importance, in all cases of spontaneous aneurism, of examin- ing the whole body to detect disease of the heart or any second aneurism which may exist. Almost all aneurisms contain more or less clof, and much of this clot is usually of the laminated variety, consisting almost entirely of fibrine mixed with more or less of the blood-corpuscles. These laminated coagula adhere very firmly to the interior of the sac ; they are arranged con- centrically like the coats of an onion ; and usually lose their colour in proportion to their remote- ness from the blood which still circulates through the sac. Their deposition depends in a great 1 For case* of this nature s« System of Surgery, 2nd «dit ml. iii. p. 422. 47 measure on the presence of rough projections from the wall or mouth of the sac, and on the shape of the aneurism. "When the latter is purely cylindrical, much less coagulum, possibly none, will be found in it. VTien the tumour stands well away from the artery, so that the force of the circulation is much broken, the formation of coagula is greatly favoured. Tim deposition of such firm coagula must be looked on as the commencement of spontaneous cure, and at any rate defends the patient from the risks of rupture, or of renewed growth of the tumour at the parts which are so lined. Symptoms. — The symptoms of arterial aneu- rism are as follows : — There is a pulsating tumour, which is situated in the course of one of the arteries, and which cannot bo drawn away from the vessel. The pulsation is equable and ex- pansile, that is, it not only causes an up-and-down movement of the tumour, for such a movement may be communicated to any tumour by a large vessel lying in contact with it, but also expands the tumour laterally and in all other directions. The pulsation is in most cases accompanied by a bruit or blowing sound, heard on auscultation, which can be tolerably well imitated by the lipa, and which is synchronous with the pulsation. Pres- sure on the artery above suspends both the pulsation and the bruit. Sometimes it may be noticed that the pulse below is retarded, that is, that it reaches the finger later than in the corresponding vessel on the other side. Besides these, which are the main signs of aneurism, there are others, which are of less constant occurrence or of subordinate impor- tance. Thus, on compression of the artery above, the tumour will empty itself more or less com- pletely, and the greater or less change of size under these conditions is a useful test of the proportion of fluid and solid in the sac. Some- times pressure on the artery beyond the tumour may cause an increase in its size. The pulse below the tumour is often found to differ strik- ingly from that on the sound side. There are many and various symptoms due to the pressure of the aneurism on neighbouring veins, nerves, bones, and viscera — symptoms which are of subordinate importance in a diagnostic point of view in the case of external aneurism, but are often of the greatest value in thoracic and abdominal aneurisms. Thus dyspncea and ring- ing cough from pressure on the trachea, spasm or paralysis of the vocal cords from pressure on the recurrent laryngeal nerve, pain in the back from pressure on the vertebrae, or neuralgic pains from pressure on the nerves at the root of the neck, are well-known symptoms of aortic aneu- rism; and, similarly, pain in the leg from pres- sure on the popliteal nerve, and (edema from com- pression of the vein are frequent symptoms of popliteal aneurism. Diagnosis. — The affections which are usually confounded with aneurism are tumours of various kinds lying upon arteries, abscesses, and can- cerous tumours which have large vascular spaces in their interior, and therefore pulsate. The tumours which receive pulsation from arteries against which they lie are of various kinds; cysts and enlarged glands in the popliteal space, and enlargements ot the thyroid body pressing ANEURISM. 48 on the carotid or innominate artery, are the most familiar examples. The diagnosis is usually easy. They have commonly little or no bruit, though in some cases a dull thud is produced by their pressure on the artery; they have not the expansile pulsation of aneurism ; they present no change in size or form when the circulation is stopped ; and they can usually be drawn away from the artery sufficiently far to lose their pul- sation. An abscess has been often mistaken for aneurism, but the mistake has generally pro- ceeded from a neglect of auscultation . 1 There are a very few cases in which aneurisms have lost their pulsation in consequence of the rupture of the sac, and in which no bruit may be audible , 2 and such tumours can hardly be diagnosed from abscess except by an exploratory puncture, which under these circumstances is justifiable ; these cases are, however, extremely rare. The disease most commonly mistaken for aneurism is pul- sating cancer, and the resemblance has been sometimes so striking as to deceive the best sur- geons, even after the fullest possible investi- gation of the case. These pulsating cancers almost always grow from the bones ; 3 and the neighbouring bone can generally be felt to be en- larged, which is rare in aneurism. They have not usually the well-marked bruit of an aneurism, nor is the bruit universal ; the pulsation also is more indistinct, and not so expansile as in aneurism ; and the growth of the tumour is more rapid. Course and Terminations. — ’Aneurism is generally a fatal disease if left to itself. The sac enlarges ; parts of it give way, either by a pro- cess of inflammatory softening or by rupture ; or it produces fatal pressure on the surrounding parts ; or the whole tumour suppurates, and the patient dies of fever, of pyaemia, or of hiemor- rhage. But to this general statement, inde- pendent altogether of what the effects of any special treatment may be, there are numerous exceptions. In some cases, and especially in the fusiform kind of aneurism, the tumour, after hav- ing attained a certain size, remains stationary, and this stationary condition is sometimes produced by a deposit of eoagulum lining the sac, and leaving a canal through which the blood-stream passes, as through the normal artery. In these cases, however, the symptoms persist, but there are others in which a complete spontaneous cure is obtained, and this may happen in various ways. Spontaneous Cure . — The first, and probably the most usual method of spontaneous cure is by the gradual diminution of the circulation through the tumour, and the gradual filling of the sac by successive layers of fibrinous eoagulum. The second is by impaction of clot in the mouth of the aneurism, whereby in some cases possibly the sac of the aneurism is cut off from the blood- stream, and its contents brought to coagulate. In other cases, where more than one artery opens out of the sac, the impaction of clot in one of the distal arteries leads to consolidation of all that 1 See a paper by the author in St. George’s Hospital Reports, vol. vii. pp. 17.j et seg. 3 See a case under the care of the writer, reported in the same paper, p. 190. 3 In one case under the care of the writer the disease was unconnected with the hones, and affected the kidney only. — Pathological Transactions, vol. xxiv. p. 149. part of the tumour through which the circula- tion used to pass into the obstructed vessel, and thus a practical cure is sometimes effected , 1 i.e. the symptoms are cured and the disease arrested, though the whole sac is not consolidated. The third method of spontaneous cure is by inflam- mation of the tumour. This is usually accom- panied by suppuration of the sac and evacuation of all the contents of the aneurism, the accom- panying inflammation closing the mouths of the arteries which open out of it. If the arteries are not so closed, death from haemorrhage will occur. It seems possible that inflammation of the sac and the cellular membrane around it may sometimes produce coagulation within the aneu- rism without any suppuration. A fourth way in which coagulation of an aneurism has been known to be caused is by retardation of the circulation or impaction of clot, caused by another aneurism above; and there is an old idea, which can hardly yet be said to be exploded, that an aneurismal sac may by its growth compress the artery, and so lead to its own coagulation. This, however, it it ever happens, is purely excep- tional. Rupture. — The rupture of an aneurism may take place either through the skin, in which ease the haemorrhage is usually, but not always, fatal at once ; 2 or into one of the cavities of the body, when death generally occurs immediately, if the rupture is into a serous cavity, and after one or two attacks of haemorrhage if a mucous mem- brane has been involved ; or lastly into the cellular tissue of a part. This event is marked by the cessation of the pulsation ; the sudden swelling, accompanied with ecchymosis if tho blood is effused subcutaneously; and the abrupt fall of temperature below the aneurism. A sensation of pain, or of ‘something giving way,’ is often experienced. Stethoscopic ex- amination will probably detect a bruit. Treatment— a. Medical.— The methods of treatment of aneurism are very numerous, and it would be impossible in a summary of this kind to discuss fully all the indications for each. In the first place, those aneurisms which are inacces- sible to any local treatment, or in which local treatment would involve great danger, are treated medically, that is by regimen, diet, and medicine, by which it is hoped that gradual coagulation will be promoted in the contents of the tumour, and thus a complete or a partial cure will be brought about, as in the natural process above spoken of. The method of Valsalva, of which the main features were starving and excessive bleeding, and which therefore produced consider- able and often dangerous irregularity of t!ie hearts action, is now given up in favour of the opposite plan introduced by Bellingham and modified by Mr. Jolliffo Tufnell , 3 in which, by complete rest and restricted but nutritious diet, the absolute regularity of the heart’s action is secured, and at a rate below that of health, both 1 See a case of innominate aneurism with remarks in the Lancet, June 15, 1872, p. 818. Instances of successful ligature of the artcrv above after bleeding from ruptured aneurism are on reconi. See a case in the Lancet, 1851, vol. ii. p. 30, in which the femoral artery was successfully tied after the bursting of a femoral aneurism through the skin. S j he Successful Treatment of Internal Aneurism, 2nd edit. lS7o. ANEURISM. as to rapidity and force. Mr. Tufntll lias given some interesting and conclusive examples of the complete cure of abdominal aneurisms thus ac- complished, verified by dissection; and one, at least, in which an aneurism of the arch of the aorta was in all probability entirely consolidated, though this fact was not verified by dissection. At any rate the patient was permanently restored t i health. In this method of treatment drugs are duly employed when necessary (as narcotics, laxatives, and tonics often are) to ensure the regu- larity of the functions, to control irritability, or to support the general health. The drugs which have been recommended as producing a direct effect on aneurism by promoting the coagulation of blood in the sac, such as acetate of lead and iodide of potassium, do not, in the writer's opinion, produce any such effect, nor in fact any specific effect on the disease whatever. He has often seen a certain amount of improvement under the use of these drugs, but not, he thinks, more than the regimen and diet used at the same time would account for. Other drugs, as aconite and digitalis, are recommended in order to steady and reduce the heart’s action, and the latter especially is sometimes a useful adjuvant, if employed with caution, to the treatment by restricted diet and rest. The rest is total, the patient never leaving his bed, nor ever rising from it, or changing his position more than by occasionally turning on his side ; the bowels are so regulated as to avoid both constipation and looseness; and the diet is restricted to about 10 oz. of solid food, of which one half is meat or fish, and 8 oz. of fluid (comprising 2 or 3 oz. of light wine if necessary), per diem. The period may be extended indefinitely, so long as improve- ment continues ; but in all cases the patient and his friends should be prepared for a confinement of not less than three months. See Abdominal Aneurism ; and Aorta, Diseases of {Aneurism). b. Surgical. — Most aneurisms which occupy an external position, and are therefore amenable to surgical treatment, are curable, when the degeneration of the vascular system is not too extensive, by mechanical means. Of these the chief and by far the most successful are either the ligature of the artery, whether in the sac, above it, or in some special cases below ; or compression, applied either to the artery above the aneurism, or to the tumour itself, or simultaneously in both situations, and either by the pressure of an instrument, of the fingers, or of Esmarch’s bandage. But as these methods of treatment belong exclusively to the province of surgery, it is thought better in a work of this kind merely to name them, and to refer the reader to the standard works on surgery for their de- scription. The other methods of surgical treatment are far less successful than the above, and have the great drawback of being addressed exclusively to the contents of the sac ; while in the treatment by the ligature and by compression the resilient power of the sac, and its consequent reaction on the blood which it contains, no doubt play a creat part in the cure. The methods now to be mentioned, on the contrary, as far as they act on the sac at all, rather tend to contuse or to inflame it. Galvanopuncture. — The first is galvanopunc- ture, in which a currentof electricity of low ten- sion, long continued, is passed through the blood in the sac, decomposing it, and causing its coa- gulation. Needles are plunged into the sac, and are then connected with the battery, and the action is continued until the reduction in the pulsatic n and the flattening of the tumour show that the blood has been partly coagulated. Au- thorities differ as to the details of the method. Some apply first the positive and then the nega- tive pole to each needle, others the negative pole only, the positive being brought in contact with the neighbouring skin, while some on the con- trary use the positive pole only. It. will be found on experiment that a certain amount of coagulation takes place around both poles, the clot round the positive pole being smaller but firmer than that round the negative. The ob- ject of the operation is to fill the sac as much as possible with eoagulum which shall gradually harden, and shall attract to itself fresh coagula. The dangers of the proceeding are those of inflammation of the sac, or of the cellular tissue around it; of suppuration within the tumour; or of sloughing of the punctures and haemor- rhage ; and it must be allowed that the effects of galvanopuneture are very uncertain, both as to the amount and firmness cf the eoagulum produced. Still there is satisfactory evidence of benefit i n many cases, and of a cure i n a few. The danger of inflaming or cauterising the sac or the tissues around may be in some measure obviated by coating the needles with vulcanite, as recom- mended by Dr. John Duncan of Edinburgh. For a very clear exposition of the details of this method, as well as for statements regarding the success which has attended electrolysis hit herto, the reader is referred to a lecture by this gentleman, reported in the British Medical Journal, May 20, 1S7G. The writer thinks himself justified in adding that electrolysis should be restricted to cases of thoracic, subclavian, or abdominal aneurism, which cannot he cured by medical means, and in which rupture seems to be imminent, while the situation of the tumour forbids the application of pressure. Coagulating Injections. — Another method of producing coagulation of the blood in tlie sac is by the use of coagulating injections. Other fluids have been employed, but the only one in general use now is the perehloride of iron. The circulation is to be suspended by pressure on the artery above, before the injection is made and for some- time afterwards. The method is a very danger- ous one for large aneurisms, on account of the risks of embolism, sloughing, and inflammation, but it may be used with success in small cirsoid and anastomotic aneurisms, and also in varicose aneurism. Introduction of foreign bodies. — Aneurisms have also been treated by the introduction of foreign bodies into the sac, with the view of pro- ducing coagulation of the blood upon the foreign substance, such as fine wire, carbolised catgut, and horsehair ; but no case of cure has hitherto been reported. Manipulation. — Finally, aneurisms may 1 -i- treated by manipulation. The object of tins treatment is either to detach a portion of coagu 4 50 ANEURISM, lum from tlie wall of the aneurism, which may 1>8 carried into the mouth of the sac or the distal artery, and so effect a cure as in our second mode of spontaneous cure, or at any rate so to disturb and break up the clot, that its detached laminae may form nuclei for further coagula- tion. With this view the aneurismal tumour is grasped between the two hands to squeeze all the fluid blood out of it, and one wall rubbed against the other till ‘ a friction of surfaces is felt within the flattened mass.’ 1 The proceeding is obviously a very dangerous and uncertain one, but some indubitable cures have been thus effected. Arteriovenous Aneurisms. — A few words must be added with respect to the rarer forms of aneurism. Arteriovenous aneurisms are generally, but not always, traumatic, and are divided into two chief forms : — 1 . Varicose aneurism, in which there is a small aneurismal tumour communicat- ing both with the artery and with a vein which is always varicose ; and 2. Aneurismal varix, in which the opening between the two vessels is direct without any tumour interposed ; 1 he vein pulsates as well as being varicose, and the tempe- rature of the limb and nutrition of the skin and hair are increased. In all forms of arterio- venous aneurism the artery after a time becomes thin and much dilated. The signs of arterio- venous differ from those of arterial aneurism mainly in this — that besides the intermittent blowing murmur caused by the arterial current, there is a continuous purring or rasping bruit due to the venous current ; and that besides the intermittent pulsation there is a continuous thrill. Varicose aneurism may he cured by digital pres- sure applied directly to the venous orifice, and indiroctly to the artery above at the same time; or the old operation may be performed, the clots being turned out of the sac and the artery tied above and below, the vein, being of course laid open and secured either by ligature or pressure ; or the artery may be tied above and below without opening the sac. Electropuncture and coagulating injections have also been used with success. Aneurismal varix does not usually require or admit of surgical treatment. If it does, the ligature of both parts of the artery is the only measure that can he adopted, on the failure of compression. Cirsoid, and Anastomotic Aneurisms. — Cirsoid aneurism, or arterial varix, is a tumour formed by the coils of a single dilated and elon- gated artery ; - while aneurism by anastomosis is a tumour formed by the coils of numerous di- lated and elongated arteries, with the dilated capillaries and veins which communicate with those arteries. It is often difficult to distinguish these two forms of arterial disease from each other. Aneurism by anastomosis frequently origi- nates congenitally as one of the forms of ntevus. The usual situation of these tumours is on the scalp. They have often a peculiar continuous buzzing or rushing murmur, which is propagated over the whole head, and much disturbs the patient’s rest ; while they are liable to ulcerate and to become the source of serious and even fatal bsemorrhage. Some cases of spontaneous cure ' Sir W. Fergnsson, Med. Ctlir. Trans. xU 8. 3 See the figure on p. 534, vol. iii. of the System of Surgery, 2nd edition. ANGUS A PECTORIS. are on record. Verv numerous methods of treat- ment have been employed, of which the writer can only mention those which are most generally use- ful. When feasible, the total removal of the tumour with the knife is certain to effect a radical cure, but this operation is often too dangerous to he attempted. The entire removal by ligature is still more rarely practicable. The galvanic cautery is often successful ; the incandescent wire being drawn through the mass in various directions divides it into portions, and obliterates the vessels by producing cicatrices at the parts cauterised. Setons have also been used with success, when combined with the ligature of the trunk-artery ; and the ligature of the artery alone has been said to he followed by success, but certainly is generally unsuccessful. Finally, coagulating injections and galvanopuncture have both effected a certain number of cures. T. Holmes. ANGEIECTASIA [txyyriov, a vessel, and eKTams, extension). — Extension or hypertrophy of the capillaries and minute vessels of the sur- faces of the body, especially the skin ; hence angeiectasia capillaris, a term applicable to several forms of vascular naevus. ANGEIOLEUCITIS (b.yyeiuv, a vessel, and \evnbs, white). — Inflammation of lymphatic vessels. See Lymphatic System, Diseases of. ANGINA (&yx“> I seize by the throat, strangle, or choke). — Syxox. : — Fr. angine ; Ger. die Briiune. The term angina was originally applied bj Latin writers on Physic, and is still much used oo the Continent, to indicate a condition in which dif- ficulty of breathing and of swallowing exist either together or separately, caused by disease situ- ated between the mouth and the lungs, or between the mouth and the stomach. By a special affix to the original term, significative of the seat or the nature of the disease, several varieties of morbid states are known and described, for example : — angina parotidca, or mumps : angina tonsiUari ! , or quinsy ; angina laryngca, or laryngitis ; an- gina pectoris, or breast-pang ; angina maligna, or malignant sore throat ; angina membranosa , or croup. These and numerous other diseases, differing essentially in their nature and pathological rela- tions, and having nothing in common but certain difficulties in breathing or swallowing, are thus classed under the word angina. Such a classifi- cation is open to several objections, and has nothing to recommend it. With the exception, therefore, of angina s pectoris, which has a special and familiar signification, the various diseases occasionally recognised by the term angina will be found described under the names by which they are generally known in this country. See also Cynanche. R. Quain, M.D. ANGINA PECTORIS .— Sykon. : Syncope Anginosa ; Angor Pectoris ; Suffocative Breast- pang. Fr. Angine de poilrine ; Ger. Brust- brdune. Defdtition. — An affection of the chest, cha- racterised by severe pain, faintness, and anxiety, occurring in paroxysms : connected with disorders of the pneumogastric and sympathetic nerves and ANGINA their branches ; and frequently associated ■with organic disease of the heart. Descbiption. — An attack of angina pectoris commences suddenly with pain in the region of the heart, generally on a level with the lower end of the sternum. The pain is severe, and of a grasping, crushing, or stabbing character ; it extends sometimes across the chest, but more frequently backwards to the scapula, and up- wards to the left shoulder and arm. The pain is accompanied by a distressing sense of sink- ing, of faintness, or of impending death. The action of the heart is generally irregular. The pulse at the wrist corresponds ; but in some well-marked cases it is regular, tense, and resist- ing. A fear of aggravating the pain prevents the patient from breathing, though the respiratory lunetion may not be really interfered with. The expression is anxious, the face is pallid, and the lips are more or less livid. The whole surface of the body is pale, cold, and covered with a clammy sweat. Flatulence is often present ; urine in some cases is passed at short intervals, and generally in abundance. The sense of faintness causes the patient to seek support, and he rests on any object by which this maybe obtained. The attack having lasted for a variable time — from u few minutes to one or two hours — comes to an end, either by a sudden cessation of the more urgent symptoms, or by their gradual disappearance. The pallor and coldness of the surface are replaced by a uniform glow — the face may even flush, the pulse becoming soft and full, and there is a general feeling of relief; a sense of numbness or tingling along the course of the nerves derived from the brachial and cervical plexuses of the affected side occasionally remains. An attack of angina pectoris frequently comes on during sleep ; but it may be induced by emotion or by physical exertion, especially by walking up an ascent, or by exposure to cold air or wind. An attack of this kind may occur but once and end fatally ; or it may recur after an interval^f hours, days, or weeks, and be thus continued ; or there may be an interval even of years. These and other modifications of the disease will be again referred to. Pathology. — The nature of the aggregate of the symptoms or phenomena comprised under the name angina pectoris , cannot be understood with- out a clear apprehension of the relations of the nerve-elements of the organs and regions that seem to be involved in the affection. It will be well briefly to summarise them. The nerves chiefly involved are the pneumo- gastric and the sympathetic, and their branches, which nerves, it should here be stated, are con- nected with each other at their origin in the medulla oblongata, in their course, and in their distribution to the ganglia and structures of the heart. They also communicate with certain of the cerebral nerves, and with the cervical and brachial plexuses, which supply part of the head and neck, the arms, the diaphragm, and the chest-walls. Their connections with the heart are very extensive. This organ is supplied by the cardiac ganglia and the branches derived from them, which are in relation with, and, in fact, constitute part of the cardiac plexus formed by the interlacement of branches from PECTORIS. 61 the pneumogastric and the sympathetic nerves, The pneumogastric supplies the superior cardiac nerve and apparently the inferior cardiac nerve (which, however, is derived from the spinal accessory, and is merely distributed with the pneumogastric) ; the sympathetic contributes several branches through the cervical ganglia. Branches of both pneumogastric and sympathetic nerves are distributed to the respiratory pas- sages, the lungs, stomach, intestines, liver, and other abdominal viscera. The connection of the pneumogastric and sympathetic nerves in the medulla, to which allusion has been made, occurs at the cardiac and vaso-motor centres ; and consequently these nerves, and the heart (which they supply) are thus brought into relation with the vaso-motor nerves throughout the body, and with all the systemic blood-vessels; they are also in relation with the other important centres in the neigh- bourhood ; and with the cerebrum itseif, more especially that part of it associated with the emotions. Such being the distribution and the relation of the nerves connected with the heart and sur- rounding parts, we learn, in reference to their functions, that the movements of the heart are maintained by its ganglia, but that these move- ments may be accelerated by the action of the sympathetic, whilst they are controlled and may be even arrested by that of the inferior cardiac branch from the pneumogastric. The superior cardiac branch of the pneumo- gastric has to do with the specific function, of conveying impressions contripetally from the heart to the medulla, whence these impressions may be reflected through the inferior cardiac nerve to the heart, controlling for a time its movements ; and also reflected through the vaso- motor centre and vaso-motor nerves, to the general circulation. By means of this latter functional relation, relaxation of the arteries, especially those of the abdomen through the splanchnic nerves is accomplished, and the heart is relieved of pressure. With regard to other functions of the cardiac nerves, it is believed that such common sensi- bility as the heart possesses is more especially connected with the superior cardiac branch of the pneumogastric. Numerous communications exist between this nerve and the ordinary spinal nerves; and it must also be remembered in reference to the sites of pain in angina, that nerves may be rendered sensitive by disease which are not sensitive in health. Lastly, it is to be noted that the pnenmogas- tric and sympathetic nerves, as well as the heart and blood-vessels, whose functions they regulate, possess the extensive connections above mentioned with the abdominal and thoracic viscera, and thus they not only influence but are influenced by the conditions of the lungs, liver, stomach, kidneys, and other organs. Keeping in mind this distribution of nerves and their functions, we can recogniso how the movements of the heart may be affected, whether in the direction of acceleration, retardation, or even arrest. We can further understand how painful impressions originating in the cardiac nerves may be propagated so as to be referred ANGINA PECTORIS. 52 to the associated sensory nerves and their branches; and how relations may be established with the raso-motor system and the circula- tion generally. Thus the vessels throughout the body may be acted upon, producing cold- ness and pallor of surface from the abnormal filling of the abdominal at the expense of the superficial vessels, a condition which seems to be the cause of the diminished arterial ten- sion noticed in these cases. We can also com- prehend how morbid impressions mads either on these nerves, in their distribution to the abdominal viscera or the heart, or on the peripheral distribution of the vaso-motor nerves at the surface of the body, may, passing cen- tripetally, admit of reflex impressions and re- flex actions, which in some cases may be pro- vocative of the symptoms of this disease : also how direct impressions made on the nerves themselves in their course, or at the vaso-motor centre, or through the cerebral emotive centres, may each give rise to the phenomena which represent the symptoms constituting angina pec- toris. Pathology of Uncomplicated Angina Pectoris . — That this disease is dependent on an affection of nerves may be held to be demonstrated by the paroxysmal character of the attack ; by its sudden access and sudden departure ; by the nature of the causes that promote it, whether they be mental emotion or direct or reflected irritation ; by the course and character of the pain, and by the fact that in severe — even fatal — in- stances of angina, there is often an absence of any tangible or evident organic local disease. The morbid state affecting the nerves may be situated in the medulla ; or it may be in the course of these nerves, or in their branches ; or in the cardiac ganglia themselves. It may be the result of congestion or inflammation of the nerve, such as occurs in the litliic acid or gouty diathesis ; or of other textural changes, such as connective-tissue growth, involving the nerve-fibres and ganglia. It may be produced by emotions acting centrifugally ; or by irritation acting centripetally, reflected, as we have just said, from impressions made on the peripheral extremities of nerves. Thus acidity of the stomach distended by flatus, the result of indiges- tion, often gives rise to symptoms which very closely resemble, if they do not constitute, an attack of angina. The like effect has been pro- duced by irritation reflected from the fifth nerve, as, for example, in pivoting teeth ; by such irrita- tion of the surface of the skin as results from severe herpes ; by cold, or by exposure to wind. But the most frequent source of the symptoms of angina caused by reflex action is to be found in those organic affections of the heart which will be described in the next section. Whatever the nature of the irritation or of the exciting cause, the symptoms will, in some measure, bear a relation to the nerves affected. Thus, if the sensory branches connected with i he spinal nerves suffer, we shall probably have pain more severe and more diffused : whereas if the branches more immediately supplying the heart are affected, we shall have the action of that organ more or less disturbed, accelerated or depressed. And so with the branches of other nerves, more especially of those connected with the vaso-motor system, or wi;h the lungs and abdominal viscera, modifications of symptoms are produced which it is needless to describe at this point in detail. Pathology of Angina Pectoris complicated uitr Organic Disease of the Heart and Vessels.— The striking character of the symptoms of angina pectoris has led pathologists to connect the heart with the disease, and to investigate its condition accordingly. Such researches have established the fact already mentioned, that angina may exist without any discoverable disease in the heart or its appendages. On the other hand, in the grear majority of cases various forms of structural disease of the heart and aorta have been ob- served ; for example atheromatous or calcareous degeneration in the coronary arteries, in the valves, or in the aorta; dilatation of the cavities of the heart, or of the aorta ; accumulation of fat in the cardiac walls ; and lastly, and probably the most important change of all, fatty degeneration of the muscular tissue. A knowledge of this lesion is of comparatively recent date ; it is constantly associated with the calcareous and atheromatous diseases described above, and which alone at- tracted the notice of older observers. Nay more, this lesion of the walls of the heart is in itself a frequent and sufficient cause of one of the most prominent symptoms of angina pectoris — faint- ness. This conditiorf has been elsewhere described by the present writer ( Medical and Chirurgical Society's Transactions, vol. xxxiii.) under the name of Syncope _ Lcthalis or fatal- faintness — a designation analogous to that given by Parry to angina pectoris, which he called Syncope Anginosa. /Etiology. — When treating of the pathology of angina pectoris we have already discussed the conditions under which it occurs. We have endeavoured to show that the disease consists in a lesion of certain nerves, associated with various morbid conditions. In seeking to in- dicate the predisposing causes of the^ condi- tions, we have to point out (1) the existence of a peculiar state of the nervous system, which may be described as an undue susceptibility to impressions. What that state is we know not. It would seem to be often hereditary-, and to be found in those temperaments in which there is a high development of the nervous element, associated with certain habits of life, such as sedentary employments, high living, and so on. Thus it is that this disease has been the cause of the death of many men who, by their intel- lectual parts, have left their mark on history. It is merely necessary to mention, as instances, Lord Clarendon, John Hunter, Dr. Arnold. (2) The influence of age is conspicuous ; the disease is rare before puberty ; and the writer's researches show that quite eighty per cent, ot cases occur after forty years of age. (3) Sex also displays a marked influence on the dis- ease ; it is comparatively rare amongst women, a statement by the late Sir John Forbes show- ing that out of 49 fatal cases, only 2 occurred in females ; and 4 out of 15 non-fatal cases — facts entirely corresponding with the writer's expe- rience. (4) The peculiar diathesis which gives rise to neuralgia of various p;irts, and that i'J ANGINA PECTOEIS. which lithic acid, predominates in the system, would seem to he in many cases an efficient cause of the symptoms of angina. The exciting causes of angina pectoris are (1) Those that affect the nerve- textures themselves. (2) The condition to which we have referred, in which organic disease of the heart exists. (3) Mental emotion, especially anger or nervous shock. (4) Irritation propagated centripetally from the surface, as by the brandies of the fifth nerve ; through the brachial plexus ; through the sympathetic and pneumogastric nerves distributed to the abdominal viscera. (5) Cold applied to the surface, and especially cold winds. (6) Physical exertion, or any other agency by which the circulation is quickened. ( 7 ) Depressing agents, such as excessive tobacco-smoking, malaria, &c. Anatomical Characters. — Beyond the con- ditions indicated under the head of Pathology, there is little to be said on the morbid anatomy of angina pectoris. These several conditions, and the symptoms of angina as above described have been found to exist independently of each other. There must therefore be something in the state of the nervous tissues that acts as the pre- disposing or exciting cause of this aggregate of phenomena. Inflammatory changes and tumours, involving the vagus or the cardiac plexus, have been observed and described. With reference to the state of the heart itself, its cavities have been found dilated and containing blood ; or con- tracted and empty ; and theories have been founded thereupon, as to whether death occurred by spasm or by paralysis. It is more than probable that either one or the other of these conditions may occur in angina, and lead to fatal results, accord- ing to the particular nerves controlling the func- tions of the hoart which are affected. See Pnec- hogastric Nerve, Disease of. Clinical Varieties. — All the phenomena of an anginal seizure as above described may be more or less modified. The attack, though gene- rally induced by exertion, may come on when the patient is at rest, and not unfrequently it sets in during sleep. The pain may be comparatively’ alight, and as such may’ recur occasionally, it may be, for months or years. On the other hand, it maybe so severe as to mark a first, a single, and a fatal attack. In its character the pain may be stabbing or burning; but it is more fre- quently described as grasping, crushing, or op- pressive. It may be limited almost to the region of the heart, or the lower part of the sternum ; it may extend all over the chest to both arms, or spread to the side of the head and neck and down one or both legs ; and it may in some cases apparently involve the diaphragm. The action of the heart, may be slow, weak, and fluttering ; or excited and bounding — constituting palpita- tion ; and it may be regular or irregular. The pulse corresponds with the heart’s action ; in the earlystage of a genuine attack itsometimes yields a sphygmographic tracing indicative of extremely high tension. The breathing is sometimes dis- tressing ; and although the patient can take a deep breath when asked to do so, he generally avoids this through fear of aggravating the pain. There may be laryngeal spasm. The mental functions are generally undisturbed ; yet there 53 is sometimes slight wandering as the attack passes off, and unconsciousness is said to be occasionally observed. The sense of danger of impending death is a characteristic symptom of angina, and one not often absent; whilst a sensation of gasping or choking with difficulty in swallowing is occasionally present. The position of the patient varies ; sometimes ho sits, sometimes he stands, resting his arms on any convenient object to obtain support ; sometimes he sits and stoops, or leans forward. As a rule the attack passes off as abruptly as it commenced, leaving the sufferer free from discomfort ; in other cases its disappearance is more slow. The varieties in the symptoms of angina pectoris are thus seen to be remarkably numerous, constituting a form of disease which may be comparatively mild and of long duration, or one of intense suffering, hastening to a fatal termination. 1 Complications. — Amongst the diseases with which angina pectoris may be said to be asso- ciated, rather than complicated, are disorders of the liver and digestive functions, gout, albu- minuria, diabetes, and certain diseases of the nervous system. Indeed, so marked is the latter connexion, that Trousseau dwelt on the relation between epilepsy and angina — a relation which seems to depend on the susceptibility to nervous maladies which some individuals present, rather than on any special identity between these two diseases. More than one striking example of the connexion has fallen under the writer's notice ; he might mention an instance recently met with in which this susceptibility was such, that an oppressive meal of indigestible food brought on a first and distressing anginal attack, followed by others. In this case brain disease with epilepsy was subsequently developed on the disappearance of the angina. Progress, Duration, and Terminations. — The progress and duration of this disease will depend wholly upon the nature of its cause. Cases have been recorded in which the first attack proved fatal. The writer has seen several ; in three of these cases a post-mortem examination revealed the fact that there was slight partial hemorrhage into the walls of the heart, which had been the seat of fatty degeneration, con- nected with calcification of the coronary arteries. The symptoms in these cases perfectly resembled those of the most severe examples of angina pectoris. It is highly probable, therefore, that ‘ A case has recently come under the writer’s notice in which a gentleman accustomed to pass lithic acid, and who for several years has had pains over the right side of the chest as low as the hypochondrium, was seized at night with a severe aggravation of these pains, coldness of the surface, irregular action of the heart, depression, and other symptoms, which, had the attack commenced on the left side of the chest, would have been really called angina pectoris. Similar attacks recurred at intervals for some weeks ; they were easily brought on even by walking on a level surface for a few hundred yards. The most careful examination failed to elicit any evidence of organic disease in the organs of circulation or respiration. The patient was recommended to try a course of Homburg waters, and a short residence in Switzerland ; from which he returned greatly improved, and almost free from pain. It should be mentioned that an interesting case has recently been recorded by Dr. Morison in which disease of the right side of the heart was accompanied by symptoms of angina affecting th* corresponding side of the chest and arm. 54 ANGINA PECTORIS. some of the cases proving fatal in a first attack of the disease are rather examplos of partial rupture of the heart than of what is usually called angina. On the other hand, cases of the disease may continue with interruptions for years ; the difference being entirely due to the nature of the cause on which the disease depends. Thus in many instances individuals present all the symptoms of marked angina, accompanied by most of its distressing pheno- mena, and by the anxieties and fears that they beget ; yet these cases, having more a neurotic or gouty origin, yield to treatment, the sufferers being restored to health, and continuing for years to enjoy comparative comfort. On the contrary, in the cases in which angina is con- nected with organic disease of the heart or of the nerves intimately connected with cardiac action, the symptoms progress in frequency and severity; and the attacks tend, with more or less certainty, to a fatal termination — it may be within a few days or weeks, or it may be, in milder eases, not for years. Diagnosis. — A typical case of angina pectoris, such as has been described at the commencement of this article, can hardly be mistaken. But when the several symptoms constituting an attack are variously modified, some being lessened in severity and others exaggerated ; or when these symptoms depend on, so to speak, remote and Removable causes ; it is often difficult to say how far the disease is what may be regarded as a passing neuralgia, or an attack of what is com- monly recognised as angina pectoris. So also it may be difficult to say, in cases of angina, whether the seizure is dependent on organic lesions which admit of no improvement, or on some con- dition that is amenable to treatment. It is, therefore, with this, as with most other affec- tions, more difficult to determine the cause on which the symptoms depend, than to recognise the presence of the disease itself. With re- ference to the diagnosis of the organic dis- eases of the heart above alluded to, it is un- necessary to repeat here what will be found described under other heads. It remains but to say that in every case the closest scrutiny must be made into the condition of the heart and great blood-vessels, with a view to determine t he presence or absence of organic disease. The investigation must further extend to the other viscera, such as the liver, stomach, and the diges - tive organs generally, as well as to the several other sources from which symptoms of angina may be excited by reflected irritation. Certain symp- toms resulting from the presence of other diseases should not be confounded with angina — such, for example, as the pain and dyspnoea caused by pressure of aneurisms or of tumours within the chest ; by rheumatic or gouty neuralgia of the chest- walls ; by pleurodynia, or acute pleurisy ; or by indigestion. Each and all of these conditions must be considered by way of exclusion in de- termining the nature and origin of the disease. Pkognosis. — In anticipating the future of an attack of angina pectoris, one must be guided chiefly by a knowledge of its cause ; in some respects also by its severity ; and by the previous history of the case. Thus, if we can ascertain that tho attack has been brought ANGINA PECTORIS. on by some clearly established and remov- able cause, a favourable prognosis may be fairly entertained. On the other hand, if the history of the case tells that there have been several previous attacks, increasing in severity and connected with heart-disease, one can scarcely avoid being led to the conclusion that the disease will tend, with more or less rapidity, to a fatal termination. Between these two classes of cases exist a large majority of the examples of the disease in which the symptoms of angina, of greater or less severity, depend on neurosis, on gouty diathesis, or on other sources of nerve disorder, amenable to treatment ; and in which, therefore, a favourable prognosis may to some extent be given. But in all cases great caution should be exercised ; for many instances occur in which, from slight and obscure beginnings, severe and even fatal examples of the disease have been developed. Treatment. — The treatment of angina pec- toris must first have reference to relief of the attack itself; and, secondly, during the inter- val to the removal of the causes on which the attacks may depend. During the attach , it is necessary first, if pos- sible, to inspire confidence, atid remove appre- hension. The patient should be allowed to retain tho position in which he feels most comfort. Secondly, if the exciting cause is one that can be removed, this should bo done ; for example, if the stomach be full of undigested food, an emetic of mustard might be given with ad- vantage ; or if flatulence he present, peppermint, ether, and other anti-spasmodics will bo useful. If cold have produced the seizure, the feet and hands should he immersed in hot water, hot bottles applied to the surface of the body, and poultices of linseed or mustard, or embrocations of chloroform or laudanum, should be placed on the chest. The administration of chloroform internally had better be avoided. The nitrite of amyl, as recommended by Dr. Lauder Brunton, has been found one of the most efficient remedies employed hitherto. Five or six minims of this drug (preserved in a glass capsule) should be in- haled from a handkerchief, and, if necessary, the inhalation may be repeated. Nitro-glyeerine is useful (yij of a minim dose), and hypodermic injection of morphia may be tried with advan- tage. In cases where debility and exhaustion exist, the ordinary stimulants will be required; and various antispasmcdics, such as ether, ammonia, &c., may be given with more or less benefit. During the intervals . — It is of course desi- rable to avoid all causes likely to bring on an attack of angina, such as mental excitement, bodily exertion, exposure to cold, and the use of indigestible food or heavy meals. The leading principle in treatment should, however, be to endeavour to determine and to remove, if pos- sible, the cause of the disease. "Whether it de- pend on organic disease of the heart, whether on simple neuralgia, whether on gout or dys- pepsia, whether on debility, or on fulness of habit — to each of such conditions mustappropriate treatment be directed. A variety of specific remedies have been recommended: such as arsenic, phosphorus, steel, zinc, and the different ANGINA PECTORIS. 4 iiti-spasmoiiies. Galvanism, in the form of the continuous current from thirty cells, has proved successful in some uncomplicated cases, the positive pole being placed on the sternum, and the negative on the lower cervical vertebrae. Ex- cellent, however, as each of the remedies named may be under special and suitable circum- stances, the result of treatment must entirely de- pend on the cause of the disease, and how far it is within reach of remedy. Some cases of ap- parently severe angina will be found to yield to treatment ; whilst, as might be expected from the nature of the disease, others unhappily pro- ceed to a fatal termination in spite of every effort directed to their relief. R. Quain, M.D. ANIDROSIS (a, priv., and iSpas, sweat). — Absence or want of perspiration. See Perspi- ration, Disorders of. ANILINE POISON. — The aniline dyes, which are a modern discovery, present the most brilliant hues of yellow, blue, and red; as such they have been used for dyeing stockings, gloves, &e. These articles when worn are apt to pro- duce an intense form of inflammation and vesi- cation of the skin, which is rebellious against treatment, and liable to relapse for many months after the original attack has subsided. See Dermatitis. ANIMAL POISONS. See Poisons. ANODYNES (a, priv., and otivvr], pain). — Definition. — Medicines which relieve pain by lessening the excitability of nerves or of nerve-centres. Enumeration. — Anodyne medicines include Opium and its alkaloids — Morphia and Codeia ; Bromide of Potassium ; Cannabis Indica ; Bella- donna and its alkaloid — Atropia ; Hyoscyamus and Hyoscyamin ; Stramonium; Aconite and Aconitia ; Veratrum and Veratria ; Conium and Conia ; Lupulus and Lupulin ; Gelseminum ; Chloroform, Ether, and their allies ; Chloral- hydrate ; Butyl-chloral-hydrate ; and Camphor. Action. — Pain is due to a violent stimulation of a sensory nerve being conveyed to some of the encephalic nerve-centres (probably the cerebral hemispheres), and perceived there. The impres- sion produced on all sensory nerves, except the cephalic nerves, is conveyed for a piart of its course to the head along the spinal cord. The primary impression which is felt as pain, is usually made upon the peripheral ends of the seDsory nerves ; but it may also be made upon their trunks, upon the spinal cord, or possibly upon the en- cephalic centres directly, without any affection of the nerves themselves, as, for example, in hysteria. Pain may therefore be relieved, while the source of irritation still remains, by lessening the ex- citability of the ends of the sensory nerves which receive the painful impression ; of their trunks ; of the spinal cord along which the impression travels ; or of the encephalic centre in which it is perceived. Opium acts by lessening the excitability of the sensory nerves, the spinal cord, and the encephalic ganglia ; bromide of potassium is also believed to act on all three, although to a much less degree than opium ; belladonna and atropia affect the sensory nerves, as probably does hyoscyamus; ANTACIDS. 56 stramonium, aconite and aconitia, veratria, chloral and butyl-chloral, lupulus and lupulin, and gelseminum probably act on the encephalic centres. Uses. — As opium and morphia act upon all the nervous structures concerned in the production of pain, they may be used to relieve pain what ■ ever its cause. Cannabis indica and bromide of potassium may be employed under the same circumstances as opium, but they have very much less power. Chloral seems to relieve pain only by inducing sleep, and does not produce as anaesthetic effect unless it is given in dangerous doses. Butyl-chloral also induces sleep, but seems to have a special sedative action on the fifth nerve ; so likewise has gelseminum — and henca both these agents are used in the treatment of facial neuralgia. As the action of belladonna is exerted chiefly on the peripheral ends of the sen- sory nerves, this remedy is usually applied directly to the painful part in the form of plaster, liniment, or ointment. Aconite, veratria, and opium are also used as local applications in several forms, for the relief of pain. The various anodynes may be administered not only by the mouth, but by other channels, such as by inhala- tion, by enema or suppository, by hypodermic injection, or by endermic application. Several therapeutic measures are employed as Anodynes, such as the application of Dry cr Moist Heat ; Cold ; Electricity ; various forms of Counter-Irritation ; Acupuncture; or the Ab- ANOEEXIA (a, priv., and ope(is, appe- tite). — Want or deficiency of appetite, not ac- companied with disgust for food. See Appetite Morbid conditions of. ANOSMIA (a, priv., and bayr], smell). — Loss of the sense of smell. See Smell, Disorders of. ANTACIDS. — Definition. — Medicines used to counteract acidity of the secretions. Enumeration. — The antacids include Potash, Soda, Lithia, Ammonia, Lime, Magnesia, and their carbonates ; as well as the salts which th« alkalis form with vegetable acids, such as Ace tales, Citrates*, and Tartrates. Action.— Antacids are divided into (1) thosr which act directly, lessening acidity in thv stomach ; and (2) those which act remotely . diminishing acidity of the urine. The alkalis and alkaline earths and their carbonates, with the exception of ammonia, have both a direct and a remote influence ; for when swallowed they act on the stomach, and being absorbed from the intes- tinal canal, they are excreted by the kidneys, thus lessening the acidity of the urine. Ammonia and its carbonate are direct but not remote antacids ; for, although they neutralize acidity in the stomach, they are partly excreted in the form of urea, and do not diminish the acidity of the urine. The acetates, citrates, and tartrates of the alkalis and alkaline earths, on the other hand, have no antacid effect in the stomach, but undergo combustion in the blood, being converted into carbonates, in which form theyars excreted in the urine, and diminish its acidity. Uses. — Excessive acidity of the contents of the stomach gives rise to acid erccviUons and 56 ANTACIDS, heartburn. It may sometimes depend on tko secretion of a too acid juice by the stomach, but probably is generally caused by the forma- tion of acid, from the decomposition of food when tho process of digestion is slow and im- perfect. Antacids are given after meals to lessen acidity in the stomach, and afford imme- diate relief to its attendant symptoms. They may prove even more efficacious by preventing acidity when given before meals ( see Alkalis). If the action of the bowels be regular, soda is preferable ; but'iime should be used if they are relaxed, and magnesia if there is a tendency to constipation. Remote antacids are given to lessen the acidity and irritating qualities of the urine in cystitis and gonorrhoea ; and to prevent the deposition of uric acid gravel or calculus in gouty persons. For this purpose potash and lithia are preferable, as their urates are more soluble than those of the other bases. T. Lauder Bjsunton. ANTAGONISM. —This term is employed to express the fact that the physiological action of certain substances may be affected, even to the extent of neutralisation, by the presence in the body, at the same time, of other substances having an action of an opposite character. It is important to distinguish between antidotal action and physiological antagonism. By an antidote is meant a substance which so affects the chemical or physical characters of a poison, as to prevent its having any injurious action on living animal tissues. Thus acids and alkalies neutralise each other, so as to form innocuous salts ; tannin may render tartar-emetic and many vegetable alkaloids insoluble ; and the hydrated sesquioxide of iron may be used to precipitate arsenious acid. In these cases, the action is limited chiefly to the alimentary canal ; and the object of administering the antidote is to form insoluble salts, or compounds which will be physiologically inert. But the physiolo- gical antagonism of certain substances is pre- sumed to take place in the blood or in the tissues. When such a substance as strychnia, for example, is introduced into the alimentary canal, it. is quickly absorbed, and carried by the blood throughout the body. It does not, so far as observation has discovered, influence all the tis- sues ; but it so affects the spinal cord, and pos- sibly the brain, as to give rise to severe tetanic convulsions, chiefly of a reflex character. This cffectis, no doubt, due either to some interference in the nutritional changes between the blood and the tissues composing the nerve-centres ; or to some specific action of the poison on the nerve-centres themselves (see Affinity). These changes, which are termed physiological, and on which the normal action of the nerve-centres depends, are probably of a molecular or chemical nature ; and it is possible to conceive that they may be modified in different ways by different substances. Thus has arisen the idea of phy- siological antagonism ; and experiment has shown that, within certain limits, which will no doubt vary in each case, such an antagonism is possible. Antagonism maybe either local, affect- ing one organ, as is seen in the opposite effects u^ion the pupil of opium or morphia upon the ANTAGONISM. one hand, and stramonium, hyoscyamus, or bel- ladonna upon the other; or it may extend apparently to more important organs or groups of organs, as in the case of the antagonism between strychnia and the hydrate of chloral. The most important investigations upon the subject of physiological antagonism are the fol- lowing ; — (1) Physostigma and Atropia, by Professor Fraser — an inquiry which showed that the fatal effect of three and a half times the mini- mum fatal dose of physostigma may be prevented by atropia. (2) Atropia and Prussic Acid , a research byPreyer of Jena — of a more doubtful character as regards the point to bo proved, but still sufficient to show that, within certain limits not yet indicated, it is possible to prevent the fatal action of prussic acid by atropia. (3) Atropia and Muscarin (the active principle of Agaricus muscarius) : — which were found by Schmiedeberg and Koppe to have entirely antagonistic actions ontheganglia of theheart — muscarinexcitingths intra-cardiac inhibitory centres, and stopping the heart in diastole, while atropia has the contrary effect. (4) Chloral and Strychnia, — an anta- gonism first pointed out by Oscar Liebreich, who showed that minute doses of strychnia might so rouse an animal from the effects of an overdose of chloral as even to save its life. And (5) Strychnia and Chloral — with respect to which Hughes Bennett demonstrated the converse of the last-mentioned observation, namely, that in the rabbit a fatal dose of strychnia might be so antagonised by a dose of chloral as to save life. Conclusions. — It has unfortunately to be admitted that the practical results of the pre- ceding researches have not been very encouraging. In all of these investigations it was quite ap- parent that the limits of physiological antagonism were very narrow. Three elements affect the chances of success in the way of saving life ; — (1) the ago and strength of the animal; (2) the amount of the doses of the two active substances — so that if either the one or the other active substance be given slightly in excess, death will probably take place ; and (3) the time between the administration of the two active substances. If the stronger be introduced first, and be allowed to manifest distinctly its physiological action, it is almost impossible to counteract this by that of another substance ; but if the two substances be introduced simultaneously, or if the supposed antagonist to the more active substance be introduced first, the chances of success are much greater. It is apparent, there- fore, that the facts relating to physiological anta- gonism at present known in science do not hold out much hope of good results from their application in practice ; but still the physiolo- gical facts are so definite as to indicate a precise mode of treatment. For example, no one ac- quainted with the investigations mentioned above would hesitate in attempting to relievo the tetanie spasms of a case of poisoning by strychnia by repeated doses of hydrate of chloral, or by the administration of chloroform. A practical result of such researches is that the principle of physiological antagonism may serve as a guide to the application of re ANTAGONISM. medies in disease. Thus excessive secretion, say from mucous membranes or from sali- vary glands, may be modified or arrested by the use of sulphate of atropia, a striking ex- perimental demonstration of -which may be seen in the antagonism between bromal hydrate and sulphate of atropia in the rabbit. John G. McKendrick. ANTEFLEXION. — A bending forwards of any organ. The term is specially used in rela- tion to the uterus, when this organ is bent for- wards at the line of junction of its body and cervix. See AVomb, Diseases of. ANTEVERSION. — A displacement for- wards of any organ. The term is particularly applied to a change of position of the uterus, in which this organ is bodily displaced in the pelvic cavity, so that the fundus is directed against the bladder, and the cervix towards the sacrum. See AVomb, Diseases of. ANTHELMINTICS (ar-rl, against, and eAfuvs, a worm). — Definition. — Medicines which kill or expel intestinal worms. Enumeration. — -The principal anthelmintics are : — Oil of Male Fern ; Kamala ; Kousso ; Oil of Turpentine ; Pomegranate Root ; AVorm-seed audits active principle, Santonin; Areca ; Mu- cuna ; Eue ; and drastic purgatives. As purga- tives only expel the worms, they are termed Vermifuges ; while the other anthelmintics which kill the worms are called Vermicides. Action. — The oil of male fern, kamala, kousso, oil of turpentine, and bark of pomegranate root, act as poisons to tape-worms ; worm-seed and santonin kill round-worms.and also thread-worms. Castor oil, jalap, scammony, and other purgatives do not kill the worms, but dislodge and expel them, by the increased peristaltic action which they occasion. Uses. — Drastic purgatives may be used for worms of any sort ; areca for both tape- and round- worms ; and the other agents for the worms on which they severally act as poisons. Vermicides are generally given after the patient has fasted for several hours, in order that, the intestines being empty, the drugs may act more readily on the worms. A purgative is usually given some hours afterwards, in order to expel the dead worms. As thread-worms chiefly inhabit the rectum, they are most effectually killed by enemata, which may consist of a strong infusion of quassia ; salt and water ; vinegar and water ; solution of sulphate, or of perchloride of iron ; oil of turpentine ; castor oil ; decoction of aloes ; or infusion of senna. As abundance of mucus in the intestines forms a convenient nidus for the growth of worms, anything that diminishes this tends to prevent their occurrence ; and for this purpose preparations of iron and bitter tonics are useful. T. Lauder BnuNTON. ANTHRAX (Svflpaf, a coal). — A synonym for carbuncle, and for malignant pustule. See Carbuncle ; and Pustule, Malignant. ANTIDOTE (avrl, against, and SISu/xi, I give.) — Definition.— -An antidote is any remedy which, by its physical or its chemical effect upon a poison, or in both ways, is capable of AN TIPERIODICS. 57 preventing or counteracting the physiological effects of that substance. (See Antagonism.) Sometimes, however, the term is used in a more comprehensive sense, so as to include the gene- ral treatment of a person affected by a particular poison. Thus, in poisoning by opium, the use of the stomach-pump, enforced exertion, chafing the limbs, and artificial respiration may be in- cluded in the general antidotal treatment. Modes of Action, and Application. — Most antidotal substances form with the poison insol- uble or innocuous compounds. Without at- tempting to give a complete list, the following are examples of the more common poisons and their respective antidotes: — -(1) Ar&>nious acid: hydrated peroxide of iron, or light magnesia; (2) hydrocyanic acid: newly precipitated oxide of iron with an alkaline carbonate; (3) oxalic acid: chalk, common whiting, or magnesia sus- pended in water; (-1) tartar emetic: tannin, catechu, or other vegetable astringents ; (5) ace- tate of lead : sulphate of magnesia, or the phos- phates of soda and magnesia ; (6) caustic potash : dilute acetic acid, fixed oils, lemon juice ; (7) corrosive sublimate : albumen, white of egg, flour, or milk ; (8) mineral acids : chalk, common whiting, plaster from the walls or ceiling, or carbonate of magnesia; (9) chloride of zinc: albumen, milk, or carbonate of soda. A r egetable poisons cannot thus be counter- acted. If they have been taken in the form of seeds, leaves, or roots, the proper course is to remove them from the stomach or bowels as soon as possible by emetics and purgatives, and at the same time to sustain the flagging strength of the patient by the administration of stimulants. On the other hand, if the alka- loid has been taken, it is so soon absorbed that emetics and purgatives are of little avail, or may even be injurious. In these circum- stances we must rely on the administration of the physiological antagonist of the poison (such as chloral hydrate in the case of strychnia- poisoning), and on supporting the strength of the patient. The following are the best antidotes to the vegetable poisons most frequently met with: — (1) aconite root: emetic of sulphate of zinc and stimulants ; (2) belladonna leaves or root : emetic of sulphate of zinc, ammonia, stimulants, and after some time an active pur- gative; (3) digitalis : emetics, stimulants, and the maintenance of the recumbent position ; (-1) hyos- cyamus leaves : emetics and stimulants; (5) hydro- chlorate or meconate of morphia , or any of the preparations of opium: emeticof sulphate of zinc, external stimulation by warmth, turpentine or camphor liniments, enforced exertion, artificial respiration, and small repeated doses of sulphate of atropia ; (6) chloral-hydrate : the same as for opium; (7) strychnia or mix vomica: animal charcoal suspended in water, repeated large doses of chloral-hydrate, or chloroform. See Poisons. John G. M‘Kendeick. ANTIMONY, Poisoning by. Nee Tartar Emetic, Poisoning by. AN TIPERIODICS. — Definition. — M edi- cines which prevent or relieve the paroxysms of certain diseases which exhibit a periodic character. 58 ANTI PERI0DIC3. Enumeration. — The chief antiperiodics are : — Cinchona-bark and its alkaloids — Quinine, Cinchonine, Quinidine, and Cinchoni dine ; Be- beera-bark and its active principle, Bebeerin; Salicin, Salicylic Acid and its salts ; Eucalyptus globulus ; and Arsenic. Action. — The mode of action of antiperiodics is at present unknown. Uses. — Cinchona, and still more quinine, is almost a specific in the treatment of intermit- tent fevers, periodic head-aches, neuralgias, and other affections caused by malaria. Though loss certain in its action than in intermittent fevers, quinine is also the best remedy in the remittent fevers of the tropics, in which, however, it must be given in very large doses. The other alkaloids of cinchona have a similar action to that of quinine, but they are not so powerful. Bebeerin is only about one-third as powerful, and is by no means so certain ; and the same remark applies to the other remedies enumerated. In some cases of ague and other intermittent affections arsenic proves successful when qui- nine fails. Emetics and purgatives are useful auxiliaries to quinine in the treatment of ague, and are employed alone for the cure of this disease in some parts of the world where quinine is not available. T. Lauder Brunton. ANTIPHLOGISTIC (dvrl, against, and fAi-yu, I burn). — A term for any method of treatment that is intended to counteract inflam- mation and its accompanying constitutional disturbance. ANTIPYRETICS (avrl, against, and nvperbs, a fever). — Definition. — Medicines which reduce the temperature in fever. Enumeration. — The principal agents used as antipyretics are — Cold Baths, Cold Applications, Tee; Diaphoretics; Alcohol; Chloral; Quinine; Salicylic Acid and its salts ; Eucalyptol ; Essen- tial Oils; Aconite; Digitalis; Veratria; Pur- gatives; and Venesection. Action. — The temperature of the body may be reduced, either by increasing the abstraction of heat, or by lessening its production. The direct application of cold, by means of baths, affusion, or sponging, or by enveloping the body in sheets wrung out of cold water, is the most powerful and rapid means of abstracting heat. But the loss of heat w'hich constantly occurs, even in health, by evaporation of the sweat, and the radiation and conduction of heat from the skin, may be increased by the use of diapho- retics, such as salts of potash, preparations of antimony, or acetate of ammonia ; or by such medicines as dilate the cutaneous vessels, so as to allow the heated blood to circulate freely through them, and to become cooled by the ex- ternal media surrounding the skin. Alcohol, in the form either of wine or spirits, and chloral, have an action of this sort, though alcohol also influences the production of heat. Alcohol, quinine, salicylic acid and its salts, eucalyptol, and essential oils lessen the production of heat within the body, probably by diminishing oxida- tion of the tissues. (See Alcohol.) Aconite, digitalis, and veratria reduce the temperature, ANTISEPTICS. but their mode of action is not precisely Ascer- tained. Uses. — Antipyretics act much more powerfully in reducing the temperature of the body in fever than they do in health. They may he used when the temperature has risen either from ex- posure to a high external temperature, as in thermal fever ; in consequence of inflammation, as in pneumonia, or pericarditis ; or in specific fevers, as acute rheumatism, typhus, and scarla- tina. The most rapid and powerful antipyretic remedies are cold baths ; next probably come large doses of salicylic acid and quinine. The latter seems to act very efficiently in thormic fever when injected subcutaneously. T. Lattder Brunton. ANTISEPTICS. — Antiputrescents (a^Tl, against, and o-qirTiKbs, putrefying). Definition. — An antiseptic is a substance which prevents or retards putrefaction, that is, the decomposition of animal or vegetable bodies accompanied by the evolution of offensive gases. The putrefactive change occurs only in dead matter, and requires the presence of water, heat, and a ferment. That there is no putrefac- tion in the absence of water is obvious, for bodies, such as albumin and blood, which in the moist state are highly susceptible of putrefaction, may be kept for an indefinite time without change if they he perfectly dry. Heat also has an im- portant influence on putrefaction. At very low temperatures the putrefactive change ceases, while elevated temperatures, such as prevail in tropical climates, are favourable to it. An addi- tional element besides heat and moisture is, how- ever, required, and the opinion generally accepted at present is, that this consists of minute vital organisms, which in some way excite putrefac- tive decomposition. Mode of Action. — The substances used as antiseptics act either directly on the bodies in which putrefaction is occurring or might occur, forming with them combinations that are not susceptible of the decomposing action of a fer- ment ; or they act indirectly, by destroying the vitality or otherwise preventing the develop- ment and propagation of the organisms of which the ferment is composed. In this respect anti- septics are distinguished from disinfectants, the action of the latter being directed only towards the excitiDg causes and offensive or deleterious products of a class of changes which are them- selves more comprehensive than those implied by the term putrefaction. Enumeration. — There are numerous chemical agents possessing antiseptic properties, the chief of these including Chlorine, Sulphurous Acid. Nitric Oxide, and Peroxide of Nitrogen, as gases : Carbolic Acid, Creasote, Benzol, Sulphites and Hyposulphites, and the Hypochlorites, which emit vapours at common temperatures ; Chromic, Boric, Tannic, and Salicylic acids, Permanganate of Potash, Sulphoearbolates, Chlorate of Potash Chloride of Zinc, and Charcoal, from which no vapour is emitted. Uses. — 1. In therapeutic practice antiseptics are chiefly employed in the treatment of surgical operations and open wounds, to prevent the occur- rence of putrefactive decomposition. Those antisep- ANTISEPTICS. tics are best suited for this purpose -which, acting efficiently on the ferment, have little action, and no injurious effect, on the parts in which the healing process is going on. Gases, except in solution, cannot be readily used, as it would be necessary to enclose the substance to be preserved in an air-tight vessel containing the gas. The volatile antiseptics which slowly emit a vapour have been preferred to those which emit no vapour, although among the latter salicylic and boric acids, being devoid of any irritating pro- perties when applied to inflamed surfaces, would on this account present a marked advantage. Carbolic acid has been used with success, a solution in water containing one part of the crystallised acid in from forty to one hundred parts of water being applied as a lotion, and also in the form of spray, diffused through the atmosphere during a surgical operation or the dressing of a wound. The carbolic acid solution may also be used on lint or cotton-wool for covering the affected part. Antiseptic gauze for a similar purpose may be made by adding one part of crystallised carbolic acid to five parts of common resin and seven parts of paraffin melted together, and applying the compound to coarse muslin, so as to form a thin coating of the plaster over the gauze, which, when it has hardened, is used for covering the parts to be protected. Professor Lister has also re- commended a boric acid dressing for rodent ulcers, which is composed of boric acid and white wax, each one part, paraffin and almond oil each two parts. The boric acid and oil are added to the melted wax and paraffin, and the whole stirred in a mortar until it thickens, then set aside to cool and harden, after which it is to be rubbed in the mortar until it acquires tho consistence of an ointment. This is thinly spread on fine rag and applied to the wound. The oil separates, and is absorbed by lint or rag placed over the dressing, while a firm plaster remains attached to the skin, which is easily removed when necessary. Salicylic acid may be substituted in this dressing for the boric acid. In some cases salicylic acid is applied alone, by merely sprinkling it in fine powder over the part affected. Its very slight solubility in water presents an obstacle to its use in solution, un- less something be added to render it more solu- ble ; and borax, which is itself a good antiseptic, may be used for that purpose. One drachm of salicylic acid, two drachms of borax, and half an ounce of glycerine, with three ounces of water, form, if aided with a little heat, a clear solution which may be used as an antiseptic lotion. 2. In medical practice antiseptics are also em- ployed, either as local applications or as internal remedies. Those which are chiefly available include creasote, carbolic acid, the snlphocarbo- lates, sulphurous acid, the sulphites or hypo- sulphites, chlorine water, permanganate of potash, borax or boric acid, chlorate of potash, charcoal, salicylic acid, and thymol. They are principally used for the prevention and treat- ment of infectious fevers ; and in low forms of ulceration of the throat. 3. In using antiseptics for the preservation oi anatomical specimens, a wider range of chemical agents may be taken, and a selection made of ANTISEPTIC TREATMENT. 59 substances that would be inapplicable in the treatment of the living subject. Arsenious acid, corrosive sublimate, or chloride of zinc in solution are of service for this purpose, and chromic acid, even when diluted with from five hundred to one thousand parts of water, possesses the pro- perty of preserving animal matter from decom- position, as also does a solution of one part of borax in forty parts of water. Besides the more powerful antiseptics noticed, others of a milder nature, such as common salt, nitre, and sugar, are used for preserving articles of food ; while alcohol and glycerine are employed for the preservation of animal and vegetable sub- stances as specimens. T. Redwood. ANTISEPTIC TREATMENT is treat- ment directed against putrefaction, or rather, as now generally understood, against the develop- ment of fermentative organisms. 1. Ik Suegeky, the employment of the anti- septic method is based upon the theory which attri- butes putrefaction and its consequences to minute organisms (bacteria, &c.) derived from without. The treatment yields tho most satisfactory re- sults when it is so employed as to prevent, rather than to attempt to correct putrefaction. To ob- tain these results the surgeon must have unbroken skin to operate upon, or the wound must have been so recently inflicted that there has not been time or opportunity for the septic organisms to get beyond the reach of the antiseptic whicli he employs. Hence there must always be a per- centage of failures in the treatment of compound fractures and large lacerated and contused wounds, owing to the amount of septic air and dirt carried into tho recesses of the wounds between the time of the injury and the commencement of the treat- ment. In the event of putrefaction occurring in such a case, antiseptic dressings should be con- tinued, but the question of operative interference must be determined according to the ordinary principles of surgery. Putrid ulcers and super- ficial wounds may certainly he rendered aseptic by suitable means, and so probably may cavities laid open during excision or amputation ; but the attempt to correct putrefaction in deep sinuses, such as those connected with caries of vertebrae, is hopeless, though by appropriate dressings the putrid emanations may be rendered less noxious to the patient and those about him. The antiseptics which have been found most suitable are carbolic acid, boric acid, chloride of zinc, and salicylic acid. Carbolic acid is the antiseptic most generally useful. A solution of one part to twenty ot water is employed to purify tlie skin of the parL to be operated upon, the sponges, instruments, &c. A solution of one part to forty is used for washing sponges during an operation, for the hands of the surgeon and assistants, and for the changing of dressings. The volatility of carbolic acid renders it invaluable for dressing hollow wounds and abscesses. It is the active constituent of the ordinary dressing — antiseptic gauze, which is applied in eight layers, of size proportioned to the expected quantity of dis- charge, a piece of reliable thin mackintosh cloth (hat lining) being interposed beneath the outer layer of gauze; this serves to prevent the dia SO ANTISEPTIC charge from soaking directly through the central part of the dressing, thereby washing out the stored up acid, and allowing the direct access of putrefactive organisms to the cavity. Disastrous consequences have followed from a defect in the mackintosh. A small portion of gauze wrung out of the one-to-forty carbolic acid solution 'e applied over the wound before the ordinary eight-fold dressing, so as to prevent possible mischief from putrefactive organisms accident- ally adherent to the inner layer of the gauze, which might not otherwise be destroyed, owing to the slight volatility, at the ordinary tempera- ture of the atmosphere, of the acid stored in the gauze. The gauze is also useful, on account of its antiseptic properties, as a bandage in retrac- tion of the soft parts in stumps, and in any case in which free discharge is expected. In addition to other measures, there must be an antiseptic atmosphere provided, so that the air which gains access to the wound or abscess may be innocuous. This is secured by means of a spray of one-to-forty carbolic acid solution, for the production of which Lister’s portable steam apparatus may be used. When the spray is suspended during an operation or the changing of a dressing, the wound is covered with a piece of sound calico moistened with the same solution. Of course superficial sores and wounds require neither spray nor guard. Cicatrisation is promoted by interposing between the healing parts and the antiseptic agent an impervious, unirritating protective layer, composed of thin oil-sill;; varnished with copal and then coated with a layer of dextrine, which allows the oil-silk to be uniformly wetted by the antiseptic solution into which it is dipped at the moment of application. The antiseptic dressing proper must extend a considerable dis- tance beyond the protective layer, so as to prevent the access of putrefactive organisms beneath it. Lint soaked in a one-to-ten solution of car- bolic acid in olive oil is used as a dressing for abscesses near the anus, and occasionally as a stuffing for cavities. A one-to-twenty oily solu- tion is smeared upon urethral instruments to pre- vent putridity of urine and its consequent evils . 1 Boric acid is a powerful antiseptic, but its non-volatility prevents its being used for the dressing of hollow wounds and in the form of spray. It is bland and unirritating as compared with carbolic aeid, and is therefore particularly serviceable as a dressing for superficial wounds and sores. It is employed in the form of a satu- rated watery solution ; as an ointment, in the proportion of one to six; and as boric, lint, which contains about half its weight of the acid. Chloride of zinc has the remarkable property of producing such an effect upon the tissues of a recent wound, that when applied once as a watery solution of about forty grains to the ounce, the cut surface, though not presenting any visible slough, is rendered incapable of putrefaction for two or three days, even when exposed to the * Cystitis, thus complicated with putridity of the urine, due to infection by catheters, may often be benefited by washing out the bladder with solution of boric acid. This complication of course never arises when the instru- ments have been carbolised from the commencement of the treatment. TREATMENT. influence of septic material. The patient is thus tided over the dangerous period preceding sup- puration, during which the divided tissues are most prone to inflammation and the absorption of septic products. Hence this agent, though not adapted for general use, is of the highest value when it is impossible to exclude septic organisms in the after-treatment, as, for ex- ample, after the removal of tumours of the jaws, in operations about the anus, and in ampu- tations or excisions in parts affected with putrid sinuses, which should first be scraped out with the sharp spoon. Sometimes a peculiar, disagreeable odour is observed on removing an antiseptic gauze dress- ing which has been applied for several days, especially to regions which have naturally a powerful odour, as the axilla or groin ; and occa- sionally the odorous material is so irritating as to produce actual eczema around the wound. This seems to depend upon a reaction between the discharge or excretion and some ingredient of the gauze. Salicylic acid has the power of pre- venting this reaction, or, at any rate, of obviating or remedying its bad effects, if a little of the acid is smeared upon the protective or upon the inner layer of gauze. Salicylic acid has been introduced as an independent dressing by Prof. Thiersch, but has been found by Prof. Lister to be inferior to carbolic acid for the destruction of bacteria, though very efficient in preventing fermentations. Chloral, thymol, and Euculyptol are used as anti- septics. Mr. Lister recommends gauze containing oil of Eucalyptus when symptoms of poisoning follow the use of the ordinary gauze dressing. Prepared antiseptic catgut is employed for arresting arterial htemorrhage. Chassaignac’s drainage-tubing is introduced to prevent tension after the opening of an abscess, or after the application of antiseptics to the raw surface of a hollow wound. Carbolised silk sutures are used, as they are not liable to catch in the dressings. 2. In Medicine, antiseptic treatment is based on the hypothesis that infectious and contagious diseases are caused by the presence and multipli- cation in the human organism of minute para- sites, termed mierozymes, microphytes, micro- cocci, &c. On this assumption, special remedies are administered for the purpose of destroying these minute organisms, or of rendering the blood and other tissues incapable of sustaining them. The treatment further aims at preventing the spread of these diseases by the prophylactic administration of antiseptic remedies to persons who are compelled to remain in infected places. At present a definite relation would seem to have been made out between specific microphytes and cow-pox, sheep-pox, splenic fever, and re- lapsing fever respectively ; whilst a similar con- nection has been so far supported by observations in the case of measles, scarlatina, diphtheria, enteric fever, and erysipelas ; but much remains to be done before the true relation between microphytes and infectious diseases can be est i- blished. Seeing that antiseptic therapeutics depends on an unestablished aetiology, it cannot, he expected to be in a very advanced condition ; accordingly there is at present but little that is settled or satisfactory to be said. The sulphite* . ANTISEPTIC treatment. f.r.d hyposulphites, introduced by Professor Polli in 1857, have been freely givon in zymotic diseases in twenty-grain doses every three or four hours, end with apparently good effect. Carbolic acid is also said to have been success- fully used in diphtheria and in intermittent and eruptive fevers, in doses of from one tc five minims or more. The sulphocarbnlates, introduced by Dr. San- som in 1867, have been used with success in many diseases. They produce very little phy- siological effect, and seem to deserve increased attention. Dr. Brakenridge believed that he found sulphocarbolate of soda remarkably bene- ficial in an epidemic of scarlatina in 1875. Patients under ten years were given five grains, and those above that age twenty grains, every two hours. Also, according to this authority, the prophylactic effect of ten-grain doses three times a day was very striking. Thymol and salicylic acid have also risen into favour, owing to their powerful antiseptic effects being associated with comparative physiological inertness. Sarcinous dyspepsia is greatly relieved and sometimes cured by Kussmaul’s method of wash- ing out the stomach with solution of perman- ganate of potash, or some other antiseptic. Reference must be made to solution of per- manganate of potash, solution of carbolic acid, glycerine of borax or a preparation of boric acid of the same strength, sulphurous acid, and chlorate of potash, as applications to the throat in such diseases as diphtheria and scarlatinal tonsillitis, or in any form of sloughy ulceration of this part. To these may be added a five- grain solution of sulphate of quinine. John Bishop. ANTISPASMODICS (avrl, against, and airdafj.a, a spasm). — Definition. — Medicines which prevent or allay spasm. Enumeration.— Antispasmodics may be ar- ranged in groups as follows : — Valerian, Vale- rianic Acid and its salts; Musk, Castor, Assafoetida, Sumbul and Galbannm, Camphor, Brominated Camphor, Oil of Amber ; Ammonia and its Carbonate ; Alcohol, Ether, Acetic Ether, Chloroform, Nitrite of Amyl ; Bromide of Po- tassium, Bromide of Ammonium ; Conium, Lobe- lia, Opium, Gelseminum, Indian Hemp, Bella- donna, Stramonium ; and the Essential Oils. As adjuvants may be mentioned — Cold Baths, moderato Exercise, Friction, Heat, and Mois- ture ; and also Quinine, Arsenic, Zinc, and Silver. Action. — Certain nerves and nerve-centres, when excited, produce contraction of volun- tary or involuntary muscular fibres; other nerves and centres arrest movements ; and by the combined action of these two systems the motions of the various contractile structures in the body are regulated, and subordinated to the require- ments of the organism as a whole. Excessive contraction or spasm of one part of the body may therefore arise either from excessive action of the motor, or deficient action of the inhibitory centres. Spasm may affect the involuntary mus- cular fibres of the intestines — as in colic ; of the vessels— as in some forms of headache, and in vaso-motor neurcses of the ulerus and bladder : ANUS, DISEASES OF. Cl single voluntary muscles, or groups of muscles — as in various forms of cramp : or the muscular system generally — as in tetanus, epilepsy, and hysteria. Antispasmodics may act by lessening the irritability of motor centres, as, for example, bromide of potassium and conium ; or by stimu- lating those portions of the nervous system which restrain and co-ordinate movements, as alcohol probably does. There are no direct experiments to show the action of antispasmodics on the in- hibitory centres ; but it seems probable that they have such an action, although it may rot be con- fined to these parts alone. Thus small doses of alcohol and ether, which stimulate the nervous system generally, and usually increase motor activity, will restrain and co-ordinate excessive muscular action, as in colic, nervous agitation, trembling, and hysteria. It is at present im- possible to localize the part of the nervous system affected by valerian, assafeetida, and other drugs of this class. As spasms occur when the nervous system is deficient in power, nervine and general tonics, such as quinine, zinc, and iron, are often found to be useful adjuvants. Uses. — In such convulsive diseases as epi- lepsy, laryngismus stridulus, and infantile con- vulsions, bromide of potassium is the most powerful antispasmodic ; in hysteria — valerian, assafeetida, and the bromides ; in chorea — arse- nic, conium, copper, and zinc ; in spasmodic asthma — lobelia and stramonium ; in spasm of the blood-vessels — nitrite of amyl. In all spasmodic affections, cold baths or sponging, exposure to sunlight, moderate exercise, and a plain but nutritious diet should be employed ; and late hours, a close atmosphere, exhausting emotions, or excessive bodily or mental work should be avoided. T. Lauder Brunton, ANURIA. — Absence of urination, whether from suppression or retention of urine. See Micturition, Disorders of. AHUS, Diseases of. — The principal affec- tions of this part are Congenital Abnormalities ; Epithelioma; Irritable Sphincter Ani; Irritable Ulcer; Prolapsus; Prurigo; Tumours and Ex- crescences. 1 . Congenital Abnormalities ( Atresia ) may be classed as follows: — 1. Imperforate anus without deficiency of the rectum. 2. Imperforate anus, the rectum being partially or wholly deficient. 3. Anus opening into a cul-de-sac, the rectum being partially deficient. 4. Imperforate anus in the male, the rectum being partially deficient, and communicating with the urethra or neck of the bladder. 5. Imperforate anus in the female, the rectum being partially deficient, and communi- cating with the vagina or uterus. 6. Imperforate anus, the rectum being partially deficient and opening externally in an abnormal situation by a narrow outlet. 7. Narrowness of the anus. These imperfections can be remedied, if at all, only by operation. 2. Epithelioma.— The anus, like other parts, where a junction takes place between the skin and mucous membrane, is liable to epithelioma. It is easily recognised by the ordinary characters of the sore. Warty growths and flaps of skin at this part are subject to this form of degenera- tion. The treatment applicable to this disease W ANUS, DISEASES OF. is to destroy or remove the growth by caustics or excision. 3. Irritable Sphincter Ani. — In this com- plaint the anus is strongly contracted and drawn in by the action of the sphincter. Any attempt to examine the part produces spasm, and the finger passed through it is tightly grasped as if girt by a cord. In cases of old standing the muscle be- comes hypertrophied, and forms a mass encircling the finger like a thick unyielding ring. This state is the source of serious trouble in defecation, owing to the expulsive power of the bowel being insufficient to overcome the impediment caused by the muscle to the passage of the faeces. Irritability of the sphincter occurs generally in hysterical females, and is relieved by mild laxatives, the local application of an opiate or belladonna ointment, and the occasional passage of a bougie coated with a sedative ointmert. 4. Irritable Ulcer. — This is a small super- ficial sore, situated just within the circle of the sphincter, usually at the back part, commonly known as fissure, from its appearance in the con- tracted state of the part. The fseces passing over the sore excite spasm of the muscle, and cause a sharp burning pain which lasts for two or three hours. The distress often does not come on till an interval of ten minutes or more has elapsed after defecation. The pain is sometimes so acute that patients resist an action of the bowels, and allow them to become costive. The irri- table nicer occurs usually in middle life, and is more frequent in women than in men. It sel- dom gets well under the influence of local appli- cations, but an incision through the centre of the sore sets the muscle at rest, and allows the part to heal. The French surgeons use forcible dila- tation, so as to rupture the sphincter — a rough mode of treatment not to be commended. When the suffering is moderate, a cure may be at- tempted by giving a laxative to ensure soft evacuations ; by enjoining rest in the recumbent position; and by the application of mercurial oint- ment with morphia, belladonna, or chloroform. 5. Prolapsus. See Rectum, Diseases of. 6. Prurigo. — Itching, though a common symp- tom in disorders of the lower bowel, may occur as a distinct affection, a neurosis liable to parox- ysms. It is caused by worms in the rectum, and by congestion of the hemorrhoidal veins. Patients suffer more after taking stimulating drinks and when heated in bed. The itching is extremely teasing and annoying, especially at night, keep- ing the sufferer awake for hours. Friction ag- gravates the mischief, excoriates the skin at the margin of the anus, and causes it to become dry, harsh, and leathery. As regards treatment, stimulants and condiments are to be avoided. The bowels should be regulated, and the part should be washed with soap and water after each evacuation. Every effort should be made to avoid friction. A piece of cotton wool soaked in oxide of zinc lotion should be kept applied to the anus, or the part may be smeared with some mercurial ointmeut, such as the dilute citrine, or one containing the grey oxide of mercury. Lotions of carbonate of "bis- muth aud glycerine, of borax and morphia, or of carbolic acid, are often efficacious. In weak l*rKene quinine ond arsenic help the cure. AORTA, DISEASES OF. 7. Tumours and Excrescences. — Besides the flaps and folds of integument consequent on external piles, tumours of a fibrous texture some- times form in the sub-cutaneous areolar tissue, which as they increase become pedunculated. They are usually small in size, lobulated, and have a firm feel. These growths may be easily and safely removed by excision. IVarts are liable to be developed around the anus, and sometimes grow so abundantly as to constitute a large cauliflower-looking excrescence. They then form projecting processes of various sizes, densely grouped together, with their summits isolated, expanded, and elevated on narrow peduncles. They give rise to a thin offensive discharge. They originate in want of cleanliness. In some persons there is so strong a disposition to tho formation of warts that it is difficult to. prevent their growth. If few in number and small in size, they may be destroyed with strong escbar- oties. They usually require, however, to be removed by excision, the quickest and most effectual mode of treatment. Astringent lotions must afterwards be used to prevent the reproduc- tion of the warts. Flattened growths from the skin, commonly called mucous tubercles, a secon- dary result of syphilis, are liable to occur around the anus. They yield readily to the local appli- cation of mercury and specific general treatment. T. B. CURLING. ANXIETAS. — Anxiety or distress, whether subjectively felt, or expressed in the features, attitude, or general behaviour. The term is also specially associated with a peculiar sensa- tion experienced in the region of the heart. See PliJECORDIAX AXXIETT. AOETA, Diseases of. — The diseases to which the aorta is liable may be thus considered ; — 1. Aortitis, Acute and Chronic; 2. Atheroma; 3. Primary Fatty Degeneration ; 4. Primary Calcification ; 5. Coarctation ; 6. Simple Dila- tation ; and 7. Aneurism. 1. Aortitis. — Acute aortitis is exceedingly rare. It may result from the direct irritation of an atheromatous aorta by a thrombus or an embolus, in persons of gouty diathesis ; but has never been observed as an extension of acut e endocarditis. The morbid changes consist in hypersemia, with thickening and softening of the coats of the vessel, and deposit of fibrin upon its internal surface. The ascending portion of the arch is the part most frequently affected. The symptoms are acute substernal pain with oppression, palpitation, quick and feeble pulse, and elevated temperature. 'With these symptoms may be associated a harsh systolic murmur, originating at the seat of inflammation, and transmitted to a distant point of the aorta. Sub-acute and Chronic Aortitis. — These are the usual forms of inflammation of the aorta. The disease may be general, arising from a blocd- dyserasia such as gout, from pyaemia, or from the various septic agents ; but it is usually limited to a definite portion of the vascular sur- face, being the result of local irritation. 2Eiiology. — E xcessive and continued strain cf the vascular walls is, according to its degree, the most frequent cause of sub-acute and chronic aor- i titis. Hence, the portion of the arterial system AORTA, DISEASES OF. most directly affected by the impulse of the left ventricle, namely, the arch of the aorta, is that in which inflammatory irritation is first, and often exclusively, exhibited. Labour of any kind re- quiring great and repeated muscular effort whilst the breath is held, must necessarily subject the aorta to extreme tension, partly through the ob- struction arising from the pressure of the con- tracted muscles upon the subjacent arteries, and partly from the back-pressure of the distended veins. Hence, sledgers, rammers, ship-porters, &c., are those who most frequently suffer from the effects of aortitis. As a necessary result of such efforts the left ventricle soon becomes hy- pertrophied, and the evils arising from vascular tension are thereby proportionately increased. Furthermore, the free use of alcoholic stimulants, in which such labourers habitually indulge, con- tributes to the same result by imparting irritant properties to the blood. The British soldier has been especially liable to the evils above sketched, owing to a vicious system of forced drill with a' breathing-capacity diminished by faulty con- struction of his dress and accoutrements. 1 Anatomical Characters. — Sub-acute aortitis occurs in disseminated patches, and involves all the coats of the vessel. These are infiltrated with exudation-cells at an early period; become soft and tumid, assuming a bluish-white tint; and, owing to loss of normal elasticity, project outwards, thus causing unevenness or pitting of the internal surface. In the aorta the inflammation is usually primary ; but exceptionally it may be produced by the mechanical irritation of an embolus derived from an inflamed focus. In- flammatory softening is a frequent cause of aneurism at all periods of life ; and in the young it is the ordinary precursor of that disease. In chronic aortitis, which is the most common form of the disease, the internal coat is alone in- volved. The outer portion of the intima exhibits the result of irritation in the abundant production of new cells. These cells occupy the fusiform spaces between its lamellae, and, gradually distend- ing them, ultimately project the internal and un- affected portion of the tunic into the lumen of the vessel. The prominence so caused is com- paratively solid, presents a faint bluish tint, and constitutes the condition described as ‘ fibroid or semi-cartilaginous thickening.’ The inflamma- tory product is prone to undergo fatty de- generation, and the consecutive change called atheroma. 2. Atheroma. — This morbid condition is most common in the first portion of the aorta. Anatomical Characters. — Atheroma com- mences with inflammatory overgrowth by multi- plication of the cells of the outer portion of the intima, as described in a preceding paragraph. The neoplasts, from their situation, readily un- dergo fatty change and caseation ; the septa of unaltered tissue intervening between them soon lose their vitality and are absorbed ; and the disease thus spreads, whilst it advances through the same agency towards the internal surface of the vessel. Examined microscopically, athe- 1 Also by the constrained and fixed position in which the walls of the chest are placed when the shoulders are forced backwards, with the view of producing the ap- pearance of an expanded chest. — E d. 63 romatous matter is found to consist cf fut granules, crystals of cholesterine, and tissue- debris. At an early stage collections of this matter may undergo liquefaction, and, projecting into the vessel, covered only by a thin layer of the unaltered intima, constitute a so-called athero- matous abscess. Should this establish a com- munication with the artery, an athcromatotis ulcer will be the result, and, consecutively, a false aneurism. In the most advanced stage of atheromatous change many patches undergo calcification by deposit of lime-salts in the altered cells. The calcareous lamellae so formed, being concentric with the vessel, and contracting by loss of their liquid constituents, may erode the intima by their sharp edges. FTom the injury thus inflicted aneurism may arise, or interstitial thrombosis, by which the vessel may be entirely blocked and gangrene of the extremities produced. In con sequence of the foregoing changes the vessel loses its elasticity and becomes dilated; its in- ternal surface is mottled with yellow or fawn- coloured patches of various sizes, being also rough, spiculated, and fissured; and thus the condition described by Virchow under the name of Endarteritis Chronica Deformans is established. The uric-acid and oxalic-acicl diatheses favour these changes, not only by stimulating the minute arteries to contract, and so raising the blood-pres- sure in the larger vessels, but likewise by fur- nishing material for cretification. The subjects of constitutional syphilis are liable to ‘ulcerated steatomatous ’ (atheromatous) changes of the intima. 3. Primary Patty Degeneration. — Tin how has described, under the name of fatty ■ erosion , a form of fatty degeneration of tho cells of the internal coat, unpreceded by inflammation, com- mencing on the free surface, and gradually ex- tending outwards. The internal surface of the vessel is marbled with minute yellow dots, which are groups of fatty cells ; these undergo lique- faction ; and disintegration of the internal coat, followed by aneurism, is the usual result. 4. Primary Calcification. — Exceptionally, in the distant portions of the aorta the muscular fibro-eells of the middle coat are liable to calcifi- cation, as a remote result of endarteritis. Owing to the transverse arrangement of the calcified cells, Assuring of the middle coat under the pressure of the blood-current, and dissecting aneurism, are ordinary results of this change. Finally, the entire middle coat, and even all three coats of the artery, may be infiltrated with lime-salts as a primary change. This is most probably due to precipitation of these salts from the congested vasa vasorum, in consequence of the escape of their ordinary solvent, carbonic acid. 5. Coarctation or Stenosis. — This condition may be either ccmgenital or acquired. Congenital stenosis of the aorta is most fre- quently located at the point of junction of the ductus arteriosus, and is of very limited extent ; in many cases presenting the appearance of a linear constriction, or of a perforated diaphragm. In a few examples, the vessel, at the seat of contraction, has been entirely closed and con- verted into a ligamentous cord. On the cardiac side of the constriction the aorta is dilated, and AORTA, DISEASES OF. 64 often thickened and atheromatous, whilst on the distal side it is reduced in calibre as far as the junction of the collateral vessels. Congenital stenosis of the aorta is compatible with life of moderate duration. In twenty-four out of thirty- eight cases analysed by Dr. Peacock the age at- tained varied from twenty-one to fifty years. The diagnosis of the condition rests mainly on dispro- portionate pulsation of the arteries arising from the aorta on the cardiac, as contrasted with those on the peripheral side of the obstruction; and on the enlargement of the collateral vessels, namely, the transverse cervical, internal mammary, and in- tercostals. The ordinary consequences are ex- hibited in dilated hypertrophy of the left ventricle, and inadequacy of the aortic valves. Death usually occurs from progressive debility and failure of the left ventricle ; from pulmonary congestion ; or from dissecting aneurism of the ascending por- tion of the arch. Congenital stenosis of the entire arch may result from imperfection of the inter-ventricular septum or patency of the fora- men ovale allowing the blood to take an ex- ceptional course. In the acquired form, stenosis of the aorta at any portion of its course may result from in- flammatory thickening or calcareous change of the coats of the vessel, followed by thrombosis ; or it may follow the natural cure of an aneurism. The aorta may be much reduced in calibre without being disproportionately narrowed. Such will be its condition in connection with mitral in- adequacy in early childhood, should the patient survive a few years. In such cases the left ventricle will have become dilated and hyper- trophied, and a marked disproportion will be observed between the force of cardiac and that of radial pulsation. This circumstance, taken in conjunction with the age of the patient, the existence of disease at the mitral orifice, and hypertrophy of the left ventricle, would warrant the positive diagnosis of narrowing of the aorta. C. Simple Dilatation of the aorta consists in a uniform enlargement of the vessel or of a por- tion of it, from impairment or loss of its normal elasticity ; and depends primarily upon arterial obstruction or resistance beyond its seat, and directly upon consecutive hypertrophy of the left ventricle. The continued tension, to which the walls of the aorta are subjected between these two opposing forces, necessarily leads to progressive impairment of nutrition and loss of elasticity in its middle coat. The immediate consequence of this change is exhibited in fur- ther hypertrophy of the left ventricle; and its remote effects in still further impairment of nutrition and deterioration of tissue in the vas- cular tunics, through the increased tension to which they are now exposed. No elementary change of structure is, however, discoverable. Simple dilatation of the aorta commences in the ascending portion of the arch, and to this it is usually limited ; but it occasionally extends into the transverse portion. The other portions of the vessel are never dilated, except in association with atheromatous change. The condition under notice is manifestly in close relationship with inflammatory irritation of the vessel. It has, however, a distinct pathological existence, ana- logous to that of the early stage of vesicular em- physema of the lung. No morbid results, with a single exception, arc directly traceable to simple dilatation of the aorta. But, should the dilatation extend into the trans- verse portion of the arch, and eDgage especially its superior wall, the primary branches may become tortuous, and exhibit abnormal pulsation in the neck, simulating aneurism. In a note- worthy example observed by the writer the existence of this pulsation on both sides of the neck, and the facility with which it was arrested by forcibly extending the neck and shoulders, and so unbending the vessels, sufficed to establish the diagnosis. Tortuosity of the cervical arteries, dependent upon a local dilata- tion of the aorta, may be confined to one side of the neck. Simple dilatation of the aorta most frequently occurs in connection with the contracted or gran- ular form of chronic renal disease. It may, Jiowever, likewise arise from simple functional hypertrophy of the left ventricle dependent upon habitual vascular excitement ; or from di- lated hypertrophy consecutive to inadequacy of the aortic valves. 7. Aneurism. — /Etiology and Pathot.ogy. — Aneurism of the aorta is essenlially a disease of the middle period of life. Of ninety-two cases ob- served or analysed by the writer, sixty occurred between the ages of thirty and fifty years ; twelve over fifty ; and five under thirty years. Thus, whilst deterioration of the arterial coats as typified in atheroma is most common after the age'of sixty, one of its ordinary consequences, aneurism, belongs to an earlier period of life. The apparent discrepancy may be explained by the more frequent employment of men under fifty in severe labour, and their greater capacity for extreme muscular effort then than later in life, the condition of the arterial wall which fa- vours aneurism having been already established. Aortic aneurism is more common amongst males than females in the proportion of about 8 : 1 — a difference no doubt due to the more active and laborious habits of the male sex. Soldiers, me- chanics, and porters suffer from it in larger proportion than those of other callings ; and in most instances the first symptoms of aneurism of the aorta may be traced to a great muscular effort involving vascular strain, or to a severe shock or blow, causing a direct contusion. Aneurism of the aorta is always consecutive to disease of its coats. Inflammatory softening, atheroma, and calcification are the usual ante- cedent conditions, and in exceptional instances primary fatty or calcific transformation of the internal and middle coats ; whilst a definite over- strain or a direct contusion of the vessel is fre- quently the immediate cause of the disease. Anatomical Characters. — Aortic aneurism may be presented under the following forms, viz., (a) true ; (b) false ( circumscribed , and dif- fused or consecutive ) ; (c) dissecting ; and [d] varicose. a. True aneurism of the aorta is rare; it may be either fusiform or saccular. It is es- sentially transitional, leading to the false variety of the disease ; and differs from simple dilatation of the aorta only by its sharp limitation, and by AORTA, DISEASES OF. the existence of inflammatory products in its walls. True aneurism never contains clots, save by incidental thrombosis ; and rarely, as such, attains dimensions capable of producing extrinsic symptoms or signs. It may, however, unlike simple dilatation, be the cause of valvular in- adequacy, and so give rise to a murmur of reflux at the orifice of the aorta. h. False aneurism is either circumscribed or diffused. Circumscribed false aneurism (or, as it is also termed, false aneurism') is the most common form of the disease in connection with the aorta. It is necessarily confined to a portion of the circumference of the vessel, the yielding of which relieves the remainder from extra ten- sion. Hence, it is usually saccular in general outline ; but, owing to unequal resistance at dif- ferent points of its surface, it may, and commonly does, present one or more secondary prominences The internal and middle coats are usually broken ; — the adventitia supplemented by the surrounding structures more or less condensed, forming the sac. Disintegration of the inner coat, already in a state of atheromatous change by mechanical strain or vascular tension, is ordinarily the im- mediate cause of false aneurism. The irruption of an 1 atheromatous abscess ’ may also give rise to it ; so likewise may ulceration of the intima from fatty erosion. Rupture of the coats of the vessel by mechanical strain is usually an- nounced by definite symptoms of the utmost significance, namely, a feeling of something having given way within the chest or abdomen ; followed by faintness often amounting to syncope, dyspncea, palpitation, and occasionally haemopty- sis. These symptoms of shock usually subside within a period of one to two hours, but the patient is thenceforward incapable of his ac- customed exertion, being easily put out of breath, and distressed by excitement or rapid movement, especially that of ascent ; there is likewise a fixed pain at some point of the chest, back, or abdomen. A fusiform false aneurism may become ‘ invaginating ’ by abruptly expand- ing and ensheathing the artery at its proximal or distal side, or in both these situations. Diffused false aneurism (or, as it is otherwise called, Diffused aneurism, or Consecutive aneurism) is produced by escape of blood from ihe artery, and its diffusion to a greater or less extent amongst the surrounding structures, according to their previous condition or anatomical arrange- ment. It may be the result of mechanical violence by strain or shock to the artery in a previously diseased condition ; or of progressive disintegra- tion of the sac of a circumscribed aneurism. In the latter case the diffusion of the extravasated blood is usually limited by antecedent adhesive inflammation of the surrounding parts, where, as in the transverse portion of the arch of the aorta, the position of the aneurism is favourable to that process. A case of this description recently ca mo under the writer's notice. Under ordinary circumstances diffused false aneurism of the aorta cannot occur within the pericar- dium, owing to the isolation of that portion of the vessel, and the fragile structure of its serous investment. Hence, a yielding of the sac proper in this situation is, in most instances, followed 5 65 by instant death from htemorrhage into the peri- cardium and paralysis of the heart. In a few recorded eases, owing to previous adhesion cf the pericardium, the patients survived rupture of the sac in this situation for several days. Diffused false aneurism of the abdominal aorta is frequently formed by irruption of blood into the retro-peritoneal tissue, between the layers of the transverse meso-colon or the mesentery, or into the fibrous envelope of the psoas muscle. When the aneurism grows back- wards the sac is quickly eroded by pressure against the vertebra, the naked and carious surface of which then forms its posterior boundary. Diffu- sion in such cases rarely occurs until the vertebra are entirely absorbed ; the blood may then escape into the spinal canal, causing general paralysis and immediate death. Diffusion may also occur amongst the muscles and areolar tissue of theloins, or behind the diaphragm into either pleural cavity, usually the left. Any portion of the aorta outs de the pericardium may he the seat of diffused false aneurism, but the transverse portion of the arch and the abdominal aorta are tho parts most frequently affected. Consecutive false aneurism, consisting in a primary bulging of all the coats of the artery, the internal and middle coats having subset; lentty given way, constitutes the ordinary form in which false aneurism originates : it therefore demands no further notice here. c. Dissecting aneurism consists in a breach of the internal and middle coats, and a subsequent detachment of these from the external tunic, by the force of the blood-current, to a variable extent over the length and circumference of the vessel ; or in a splitting of the middle coat by the same agency. This form of aneurism is of two kinds — that with a single aperture through which the blood enters theabuormal channel and return* to the artery ; and that which exhibits two open ings, one by which the blood escapes from, and another through which it re-enters the vessel. The former is tho more usual variety of dissecting aneurism; and it is likewise the more grave, because liable at any moment to terminate fatally by rupture of the external coat. Any portion of the aorta may he the seat of dissecting aneurism ; the asceuding part of the arch is most frequently affected, and next in the order cf frequency comes the abdominal aorta. The primary lesion consists in a transverse rent of the internal and middle coats ; when this is close to the heart, the outer or the anterior wall of the vessel is its usual site, and detachment of the tu- nics rarely extends beyond the ascending portion of the arch, and seldom engages more than a limi- ted area of its circumference. In this situation, too, an aperture of re-entranee is rarely formed, the disease usually terminating by rupture of the external coat within the pericardium. When, on the contrary, the second curve of the arch, or any portion of the aorta beyond this point, is the seat of primary lesion, separation of the eoatsis usually found to extend along the remainder of the length of the vessel, and over the whole or greater part of its circumference, whilst the blood has re-entered through an opening in one or both common iliac arteries. The establishment of a second aperture o f AORTA, DISEASES OF. 30 communication -with the artery is an attempt at •'natural cure;’ and when this happens the patient may survive for many years. Amongst the eccentricities of dissecting aneurism may be mentioned detachment of the laminated clot from the walls of the sac proper, and subsequent es- cape of blood by rupture of the latter ; and sepa- ration of the mucous from the muscular coat of the oesophagus, with irruption of blood into the stomach. Dissecting and ordinary false aneu- rism may coexist, the former being usually a consecutive lesion, and the immediate cause of death. d. Varicose or Anastomosing aneurism consists in a direct communication between an aneurism of the aorta and (a) one of the chambers of the heart ; ( b ) the pulmonary artery or one of its branches ; or ( c ) one of the venae cava; or innomi- nate veins. This form of the diseaseis necessarily consecutive, and usually late as to the period of its development. In the greatmajority of recorded examples the primary aneurism was connected with the ascending portion of the arch, and in a Iqrge number it arose from one of the sinuses of Valsalva. The communication, witli few ex- ceptions, is formed with one of the chambers of the heart, the pulmonary artery, or the descend- ing vena cava. Of the cavities of the heart, the right ventricle is most often implicated ; next in order is the right auricle; then the left ven- tricle; and lastly the left auricle. The pulmonary artery and the descending cava have been fre- quently involved, as might have been inferred from their close relationship to the ascending aorta ; the innominate veins in fewer instances, and only when the aneurism engaged the upper portion of the arch. An aneurism of the ab- dominal aorta has communicated with the in- ferior vena cava in a few cases. In the pro- cess of formation of a varicose aneurism of the aorta, the apposed surfaces are agglutinated by adhesive inflammation ; and the composite septum is subsequently eroded by progressive absorption, or suddenly rent by the force of the arterial cur- rent. The immediate effects of communication are engorgement and increased tension of the recei rung chamber or vessel; diminished blood-current and vascular tension in the aorta and its branches; and admixture of arterial with venous blood when the right side of the heart or one of the great veins is the seat of discharge. The special symptoms and signs by which tho diseaso is characterised have direct reference to these re- sults. Death has followed most rapidly in those cases in which the aneurism had established a communication with the pulmonary artery or the left auricle. Effects upon the Left Ventricle. — Hypertrophy of the left ventricle cannot be regarded as a consequence of aneurism of tho aorta. The association, when it exists, is accidental ; hyper- trophy depending upon antecedent or consecutive disease or inadequacy of the aortic or the mitral valves, chronic atheroma of the aorta, granular degeneration of the kidneys, or excessive func- tional activity. Simptoms. — T he symptoms of aortic aneu- rism may be discussed under the three heads of (a) Pain; ( b ) Excentric Pressure; and (c) Tumour. Pain.— The pain of aneurism is cf two kinds, intrinsic and extrinsic. The former is due to subacute inflammation and tension of the sac, and varies with intra-vascular pressure. It is dull, aching, and localised, and promptly allevi- ated by measures which depress the circulation or reduce local tension. Extrinsic pain usually arises from pressure upon adjacent nerves, and may be direct or reflex. This kind of pain has the characters of a diffused and aggravated neuralgia, being paroxysmal, and wandering to a greater or less extent over the back, chest, shoulders, arms, abdomen, and thighs. In the ab- domen, when due to pressure upon the splanchnic nerves or tension of the solar plexus, it is of the most excruciating character. The extrinsic pain of aneurism may be fixed and boring. When of this character, it is usually located in the back, and arises from progressive absorption of the ver- tebrae. Excentric Pressure. — The parts affected by the pressure of an aneurism, and the symptoms thereby developed, vary according to its situation and the direction of its growth. Parts which are exposed to counter-pressure, or are other- wise fixed, suffer most ; whilst those which are flexible or moveable are less injuriously affected. The symptoms have reference to the respective functions of the organs or structures pressed upon ; whilst their severity is in direct proportion to the importance of those functions, and the degree of pressure exercised. Structures sub- jected to the remittent pressure of an aneurism are slowly removed by absorption, but between the sac and the resisting surface union has been previously established by adhesive inflammation. Hence the sac itself is at the same time absorbed, and escape of blood will inevitably occur where further resistance is not presented. When serous cavities are laid open by this process, entrance is effected by a rent ; and if the cavity be large, e.g. the pleura or the peritoneum, death by haemorrhage, almost instantaneous, is the result; in case of irruption into the pericardium or the spinal canal, death occurs with equal rapidity from compression and paralysis of the contained organ. Communication with a mucous canal or with the cutaneous surface is effected by a pro- cess of sloughing, and bleeding occurs by • leak- age,’ in variable quantity and at uncertain inter- vals, till the slough is finally detached, when death by copious haemorrhage immediately ensues. The irruption of an aneurism into a gland-duct, such as the ureter or one of the biliary passages, is fatal by obstruction and suspended secretion, the duct and its tributaries having been blocked by eoagulum. Communication with the thoracic duct proves slowly fatal by inanition ; and when an opening is effected into a vein, a varicose aneurism, characterised by special symptoms and signs, and of greater or less gravity according to its situation, will be the result. The symptoms of nerve-pressure vary accord- ing to the nerves affected. Thus, pressure upon the roots or branches of sentient nerves is attended with neuralgic twinges or paroxysms referred to the seat of their peripheral distribu- tion, and, when the pressure is extreme, with numbness in the same situation. Irritation of motor nerves is indicated by spasm or paralysis AORTA, DISEASES OF. 67 according to the degree of pressure, of the muscles supplied by them. Irritation of the cer- vical sympathetic, or of its cilio-motor roots, is repealed by dilatation of the pupil on the corres- ponding side : or, if the pressure be such as to cause paresis, by contraction of the pupil ■with, ptosis, hyperaemia, hyperaesthesia, and elevation of tem- perature in the eye and corresponding side of the face. The effects of pressure upon the pulmonic and cardiac plexuses have been less precisely determined, owing to the difficulty of distinguish- ing the symptoms due to this cause from those which arise from direct pressure upon the trachea or bronchi, the great vessels, or the heart, or from structural disease of the heart or the coronary arteries : but that the paroxysms of bronchial spasm and of angina, so often -witnessed in connection with aneurism of the arch of the torta, are in some degree dependent upon pressure on the pulmonary and cardiac nerves, and occasionally are due to it exclusively, the writer entertains no doubt. The symptoms arising from the pressure of an aneurism upon the pneumo- gastric or recurrent nerve of either side have reference to the larynx, and are eminently characteristic. They are of two kinds, according to the degree of pressure ; namely, those due to spasm, and those to paralysis, of the laryngeal muscles on one or both sides. They are presented under the several forms of dysphonia, aphonia, stridor, metallic cough, and paroxysmal dyspncea. The latter is frequently of the most urgent charac- ter, and sometimes is the immediate cause of death. Adjacent organs, such as the heart, lungs, liver, and kidneys, are occasionally displaced by an aneurism, the direction being determined by that of the pressure, and in part also by the di- rection in which the organ is moveable. Obstruc- tion or occlusion of adjacent arteries, as indicated by diminished or suppressed pulsation, may like- wise result from the pressure of an aneurism. Pressure on a vein is evidenced by venous stasis distal to the seat of obstruction ; upon the pul- monary artery, by engorgement of the right chambers of the heart and general venous con- gestion. Obstruction or occlusion of either bron- chus or of one of its primary branches is evi- denced by distress in breathing or shortness of breath ; and by diminution or suppression of respiratory sound in the corresponding portion of the lung. Inasmuch as the symptoms of excentric pressure may be produced by a tumour of any kind, they possess, in regard to aneu- rism, a diagnostic value only correlative to other and more positive evidence of that dis- ease. Tumour. — The tumour formed by an aneurism of the aorta is fixed, smooth, and compressible. It is alternately tense and soft in unison with cardiac pulsation, and is especially characterised by a movement of general and equal expansion, synchronous with the impulse of the heart. It is further distinguished by a remarkable liability to vary in the rate and direction of its growth, retrocession at one point coinciding with enlargement at another ; a new set of symptoms being at the same time developed by its en- croachment upon fresh territory. In the pro- gress of cure the tumour may become solid, incom- pressible, and uneven, by deposition of laminated fibrin within the sac. Physical Signs. — The physical signs of aneu- rism of the aorta are those which may be elicited by palpation, percussion, and auscultation. They supply the most valuable, and, indeed, the only positive evidence of the disease. Tactile signs. — The tactile signs of aneurism, impulse, fremitus, and remittent tension, are con- tingent on perceptible tumour. The impulse maj be single or double. It is most frequently single, and is then always systolic in rhythm, coinciding approximately with the impulse of the heart. In character the systolic impulse is heaving and expansile ; and it is diffused, in most in- stances equally, over the entire tumour. It is due to sudden expansion of the sac from active influx of blood during ventricular systole : hence, iu those portions of the aorta which are close to the heart, it is synchronous with the apex- pulsation ; but in the descending-thoracic and abdominal aorta perceptibly post-systolic in time. The force of systolic impulse and the expansion of the sac will be directly as the con- tractile power of the left ventricle, and inversely as the deposit of coagulum within the sac. A second and more feeble impulse of diastolic rhythm is occasionally, but much less frequently, exhibited by an aortic aneurism. This is the ‘ back-stroke,’ or ‘ impulse of arrest ’ of authors. It coincides with the first period of ventricular diastole and the second sound of the heart, and is due to asynchronism of re- action between the aorta and the sac — that of the latter being notably later, owing to its defective elasticity. The consequence is a sudden arrest to the recoil of the sac by influx from the aorta. Diastolic impulse is therefore emi- nently characteristic of aneurism. Fremitus or thrill is of more frequent occur- rence than diastolic impulse, and. when not communicated from the heart, no less distinc- tive of aneurism. It accompanies the systolic impulse, and is due to the vibration of a thin sac from an eddy in the current of influx, pro- duced either by a spiculated condition of the orifice, or by a pendent flake of fibrin. Percussion-sound. — The intrinsic percussion- sound of aortic aneurism is absolutely dull to the extent of the tumour. Posteriorly the dulness is not sufficiently distinguishable from that of the vertebral column and muscles to be of positive diagnostic value ; whilst laterally and in front, when the tumour is not in actual contact with the walls of the thorax or abdo- men, it is modified or masked by the interven- tion of the lung or the intestinal canal. Under any circumstances, dulness per se cannot afford positive evidence of aneurism, inasmuch as it may be due to a tumour of any kind, solid or liquid, in the same situation ; but, the presence of a tumour having been determined, the shift- ing of percussion-dulness from one point to another, or its cessation where it had been pre- viously detected, would be in the highest degree suggestive of aneurism. Acoustic signs. — These are tone or sound, and murmur. Sound without murmur is of frequent occurrence in aneurisms of the arch, but com- paratively rare in those of the descending- 38 AORTA. DISEASES OF. thoracic and abdominal aorta. It is usually double, corresponding in time to the sounds of the heart, but exaggerated, the second aneu- rismal sound being especially intensified. The first sound is occasionally ‘ splashing,’ and both are not unfrequently of a ‘ booming ’ quality, — characters no doubt due to the density, rigidity, and great capacity of the sac. The murmur of aneurism is most frequently single, systolic, and blowing; it is occasionally double (systolic and diastolic) ; and still more rarely single and diastolic. As to quality, the systolic murmur may be accompanied by a musical note, ‘cooing,’ or shrill, and audible over the whole or only a portion of the tumour. Lastly, it may be, and usually is, of a ‘buzzing’ character in cases of varicose aneurism. The essential cause of the murmur of aneurism consists in friction of the blood against the orifice, and the production of an eddy or a ‘ fluid vein ’ within the sac. A certain force of ventri- cular contraction is, however, likewise necessary. Hence the not unfrequent coincidence of cessa- tion of murmur with failure of the left ventricle for some time before death. A strongly con- tracting ventricle, a relatively small orifice, a capacious sac, and a liquid state of its contents, supply the most favourable conditions for the production of murmur. The orifice of entrance need not be absolutely narrow ; a large fusiform aneurism, even of the true kind, with rough walls, and containing liquid blood, may yield a loud systolic murmur, as the writer has fre- quently witnessed. A murmur may be absent in an aneurism lined by thick laminae of fibrin through which there is a smooth channel, or in a lateral aneurism communicating by a small orifice with the vessel. Diagnosis. — The positive diagnosis of aneu- rism of the aorta may be made from the exist- ence of a tumour, forming a second centre of pulsation and of sound ; the pulsation being systolic, expansile, and equally diffused over the tumour, accompanied by thrill, and succeeded by a minor pulsation of diastolic rhythm ; whilst the Sound, single or double, and accompanied or not by murmur, is always sharp and ringing, and occasionally of a ‘ booming ’ quality. The foregoing signs are rarely all associated in the sam’e ease. Various other groupings of rational symptoms and signs would be scarcely less con- clusive as to the existence of aneurism of the aorta. General systolic expansion, thrill, dia- stolic impulse, and exaggerated sound, at a point more or less distant from the heart, constitute the most positive signs of the disease. The existence of aneurism of the aorta may be inferred with greater or less confidence from certain symptoms and signs, according to their individual or correlative value. Even negative signs, if associated with others in themselves of minor significance, may be scarcely less con- clusive than the most positive evidence would be. Thus, for example, suppressed respiration with percussion-resonance on the left side of the chest, dyspnoea, haemoptysis, fixed pain in the I Kick, and left intercostal neuralgia — the entrance >f a foreign body into the left bronchus and the existence of cancer of the posterior mediastinum having been excluded — would be all but con- clusive as to the existence of aneurism. A foreign body in the bronchus might be diag- nosed from the history of a misadventure in swallowing, followed immediately by dyspncea, hsemoptysis, and the special signs of bronchial obstruction, which, in nine cases out of ten, would be on the right side: whilst the diagnosis of mediastinal cancer would rest upon evidence eminently suggestive, namely, the presence of cancerous enlargements in the neck and axilla, and of extreme dulness over the root of the lung, without corresponding pulsation or sound. Finally, aneurism of the aorta may be, though it very rarely is, strictly latent in regard to both symptoms and signs. Prognosis, Duration, and Terminations. — The prognosis of aortic aneurism is in the highest degree unfavourable. Recovery is, how- ever, under favourable circumstances and ap- propriate treatment, quite within the range of medicine. Numerous examples of cure of aortic aneurism, both thoracic and abdominal, have been lately recorded. The duration of life, in connection with aneu- rism of the aorta, has varied, according to the experience of the writer, from ten days to eleven years ; but it may be much longer. The situa- tion and relations of the aneurism ; its complica- tions ; the constitution of the sac, and the state of its contents ; the previous health and present habits of the patient; and the advantages enjoyed in regard to rest and treatment — will all ma- terially influence the prognosis, whether as to duration of life or prospect of recover} - . Death in aneurism of the aorta may result from — (a) ruptureof the sac; (b) exhaustion from pain, loss of sleep, or leakage of blood ; (c) asphyxia : (if) syncope; ( e ) inanition; or (/) intercurrcnt disease. The foregoing represents the order of relative frequency of the several causes men- tioned. Rupture of the sac is not, of necessity, immediately fatal. Hemorrhage may be stayed, and life thus protracted for several days, by ob- struction from the extravasated blood, itself ar- rested and coagulated in the surrounding tissues, or by its pressure upon the aorta on the proximal side of the sac. Rupture into one of the cham- bers of the heart, the pulmonary artery, either vena cava or the innominate vein, the portal vein, or the biliary passages, is usually fatal within a very brief period ; whilst rupture into one of the serous cavities in the absence of previous adhe- sion, into the trachea or bronchi, or into the ali- mentary or the spinal canal, is instantaneouslv fatal. Treatment. — The treatment of aneurism of the aorta is palliative and curative. Pain from nerve-pressure is most effectually relieved by hypodermic injections of morphia, one quarter to half a grain in solution, repeated and increased in quantity according to necessity. The pain and oppression due to congestion of the sac and the surrounding structures is best treated by local or general abstraction of blood, combined with the use of cardiac and vascular depressants, especially iodide of potassium (20 to 30 grains every fourth hour), chloral hydrate (20 grains \ andveratrum viride or aconite (5 to 10 minims of the tincture every thirdhour). Mechanical support by means of a well-constructed shield is likewise AORTA, DISEASES OF. useful "when the tumour projects externally. Fixed pain in the back, due to erosion of the vertebrae, is most effectually relieved by a seton or issue in the vicinity of its seat. The curative treatment of aneurism of the aorta may be classi- fied under the heads of — (a) compression of the artery, proximal or distal ; ( b ) distal ligature ; ( c ) absolute rest with regulated diet; and ( d ) the use of medicinal agents promotive of coagu- lation within the sac. For the details of these several modes of treatment the reader is referred to the articles in this volume respectively entitled Aneurism, Abdominal Aneurism, and Thoracic Aneurism. Thomas Hayden. AORTIC VALVES, Diseases of. See Heart, Valvular Diseases of. APEPSIA (a, priv., and irinTcc, I digest). — Indigestion. See Digestion, Disorders of. APERIENTS ( aperio , I open). — Medicines which produce a gentle action of the bowels. See Purgatives. APHAGIA (a, priv., and , I eat).— In- ability to swallow. See Deglutition, Disorders :f. APHASIA (a, priv., and , I breathe), lite- rally signifying breathlessness, is used by some medical writers as synonymous with asphyxia (see Asphyxia), the condition which supervenes on suspension or obstruction of the respiratory function. By physiologists, and with more justice, the term is employed to signify the cessation of respiratory movements which is brought about by hyperoxygenation of the blood, as when an animal is made to breathe oxygen, or to breathe more rapidly than the needs of the economy re- quire. APOLLIIvT APIS, "Waters of.— Acidulous alkaline table-waters. See Mineral Waters. APOPLEXY. — Definition. — The word apoplexy means-, by its etymology, a striking from (curb, from, and -irAp^is, a striking), and was at first and is still chiefly used to signify sudden abolition of consciousness and power of motion, which, in common English, is also called a stroke. Cere- bral haemorrhage being the most frequent cause ‘ APOPLEXY, CEREBRAL. of this condition, ‘haemorrhage into the bruin' and ‘apoplexy’ came to bo used as synonymous expressions. Subsequently the effusion of blood itself was spoken of as the apoplexy, the word being used to designate the pathological condition causing the symptoms which it at first epitomised. Ultimately it was applied to a similar patho- logical state elsewhere, and thus haemorrhages into the substance of the lung, the spleen, or the retina were, and still are termed respectively pulmonary, splenic, or retinal ‘ apoplexies.’ The term cerebral apoplexy is sometimes used to particularise haemorrhage into the brain, but it is more commonly employed to denote an apoplectic condition depending on any cerebral lesion, and in that sense it will be here employed. W. R. Gowers. APOPLEXY, CEREBRAL. — SrxoN. : A Stroke ; Fr. Apoplexie ; Ger. Schlag. Definition. — Loss of consciousness, of sen- sation, and of voluntary motion, coming on more or less suddenly, and due to a morbid state of the brain. This condition of coma is termed ‘apoplectic when of sudden or rapid onset. Loss of con- sciousness may be due to other causes acting directly on the brain, 6uch as defective or exces- sive supply or altered condition of blood; but it is customary to include among the forms of apoplexy only that sudden loss of consciousness which is due to cerebral congestion, and to con- sider as apoplectic states only those which result from distinct toxaemia. ^Etiology. — The apoplectic condition may be due (1) to the influence upon the brain of a poison circulating in the blood ; (2) to a sudden cerebral lesion, such as haemorrhage or vascular obstruction; or (3) to a sudden shock or other impression arresting the cerebral functions, but causing no visible alteration in the brain. 1. The toxaemic states in which apoplectic symptoms occur are thoso of uraemia, drunken- ness, and poisoning by narcotics, as opium, &c. These are described elsewhere, and need be referred to in this article only in respect to the diagnosis. 2. The great cause of apoplexy is a sudden cere- bral lesion, which may be traumatic or may occur without external injury. Injury may lead to apoplexy by simple concussion, by laceration of brain, or by rupture of vessels and haemorrhage. Apoplexy, not due to injury, may be caused by congestion ; by thrombosis or embolism ; but especially by haemorrhage. The latter is its most common and most efficient cause. Profound ccma is rarely due to any other spontaneous cerebral lesion. A very small haemorrhage may cause apoplexy. 3. Lastly, apoplectic symptoms may occur with- out obvious lesion of the brain. Thecoma which results from concussion, that which succeeds an epileptic fit, and that which, in the absence of any recognisable cause, has been called ‘ simple apoplexy,’ furnish examples. Pathology. — In all these eases the apoplexy is in relation chiefly to the extent and suddenness of the lesion. Roughly speaking, its occurrence may he said to depend on the suddenness, its degree on the extent of the cerebral mischief. Butthe occurrence of apoplexy depends sometimes APOPLEXY, in the size of the lesion, and the degree varies not only directly with the extent of the mischief, but with the extent of brain-tissue which is exposed in- directly to the irritative influence of the primary lesion. Hence position of lesion has an important influence in determiningthe apoplectic symptoms. For these several reasons apoplexy is especially profound when the hsemorrhage affects both hemispheres, either by simultaneous extrava- sation on each side, or as the result of hsemor- rhage into the lateral ventricles. The precise condition on which the apoplexy is immediately dependent has been a matter of dispute. It was formerly ascribed to the pres- sure exerted by the clot on the rest of the brain, either influencing directly the cerebral tissue, or pressing on and emptying its capillaries (Niemey- er). That such pressure is exerted by a large haemorrhage is unquestionable. The convolu- tions on the side of the extravasation are flat- tened, and the falx is bulged to the opposite side (Hutchinson, Jackson). It cannot be doubted that the intensity of the apoplexy in these cases is due in part to this cause. But this will not explain the occurrence of the symptom in small haemorrhages, by which no general pressure is ex- erted, or not more than is at once relieved by the displacement of the mobile fluid which sur- rounds the vessels. It will not explain its occur- rence in laceration of the brain, or the early loss of consciousness in severe hsemorrhage, in which, as Jaccoud insists, it should, if merely due to pressure, be a late rather than an early symptom. There can be little doubt from these considera- tions, and from the cases in which there is no recognisable brain-lesion, that shock is an im- portant element in the causation of apoplexy. Thus in cerebral hsemorrhage the apoplectic symptoms are due in part to the influence on the rest of the brain of the irritation of the nerve- elements by laceration. W e can thus understand why vascular occlusion causes a slighter degree of apoplexy, since the immediate irritation of the local ansemia is less than that of laceration ; and also why lesions of the pons produce as they do such deep and long-continued coma, since the irritated fibres are connected with, and thus influence indirectly a large part of the cerebrum. Simple Apoplexy was a term given by Aber- crombie to the cases, once thought to be frequent, in which apoplexy occurs without recognisable brain-mischief or blood-poisoning. Some of these cases were probably instances of uraemic poisoning, and others may have been due, as Dr. Bastian suggests, to capillary embolism. But cases are not infrequent to which neither of these explanations applies, in which death occurs in an apoplectiform attack, all organs being found healthy, and the brain only exhibiting, in common with the other organs, that passive con- gestion which results from an asphj'xial mode of death. The nature of these cases is still mysterious, but they may be grouped with those in which fatal coma follows an epileptic attack, and is apparently duo to the brain-shock pro- d uced. Serous Apoplexy is a term applied sometimes to cases of fatal apoplexy in which no lesion is discoverable except excess of serum on the surface of the brain. It is now understood that CEREBRAL. 7-3 such serous effusion is met with constantly in atrophy of the convolutions, rarely in Bright’s disease, and under no other circumstances. There is no reason for associating its presence with the apoplectic symptoms. The cases de- scribed under this term were probably instances of uraemia, or of ‘simple apoplexy’ in old persons with atrophied brains. Symptoms. — The prominent feature of apoplexy is loss of consciousness without obvious failure of the heart’s action. The onset is often instanta- neous, so that the sufferer falls to the ground. The face may be flushed or pale — it is rarely very pale. The heart and arteries beat, often with undue force and lessened frequency. Re- spiration continues, but is laboured and stertorous, with flapping cheeks. The limbs are motionless. In severe cases no reflex action can at first be excited. The pupils may bo dilated, contracted, or unchanged ; in profound coma they are usually dilated ; and they often vary in size spontaneously, being sluggish in their action to light. The patient can usually swallow, although often with difficulty. The sphincters permit the escape of urine and faeces, or the urine may be retained. In a case of moderate severity the reflex action soon returns, the conjunctiva become sensitive, and the patient can be roused to exhibit some sign of consciousness, shows returning power of voluntary motion, opens his eyes when spoken to, and tries, when told to do so, to pro- trude his tongue. On the other hand, the apo- plexy may continue or may deepen in intensity, the patient dying at the end of a few hours or a few days. Death rarely occurs in a shorter time than two or three hours. In very rare instances an extensive hsemorrhage into the pons or medulla may stop the respiration and kill the patient in a few minutes. It is not often, however, that there is this simple loss of cerebral function, uniformly dis- tributed, and gradually deepening or passing away. Much more commonly the symptoms of a local cerebral lesion are added to those of apo- plexy. Frequently such symptoms precede the loss of consciousness — unilateral weakness, deviation of the mouth, convulsion. They may be recog- nised during the attack: the limbs on one side exhibit more complete muscular relaxation than those on the other ; they fall more helplessly when raised ; or there is unilateral rigidity or clonic spasm, unvaried in its seat ; or inequality of pupils is observed, or rotation of the head and conjugate deviation of the eyes. As the patient recovers, these local symptoms become more and more distinct, the tongue deviates on protrusion, speech and swallowing are difficult, or the patient may have lost the use of language. In ingravescent apoplexy the commencement of the cerebral mischief is marked by symptoms of general shock, without any, or with merely transient, loss of consciousness. There is com- monly pain in the head, and there may be other localising symptoms. After some hours, during which the patient may continue his occupation, coma gradually comes on and deepens into death. This form of apoplexy, first described by Aber- crombie, is usually due to a slowly increasing cerebral hsemorrhage. The temperature in cerebral apoplezy is at first APOPLEXY. CEREBRAL. always lowered, but usually the fall is small, and is succeeded, after twelve to twenty-four hours, by a rise. Diagnosis. — Prom the unconsciousness due to cardiac syncope, apoplexy is easily distinguished. In the former the heart’s action fails, the pulse is weak and imperceptible, the face is very pale, the respiration is sighiDg and irregular, reflex action is rarely abolished, and the sphincters are seldom relaxed. Promtheseveral formsof toxmmia thediagnosis is often easy, sometimes extremely difficult. It is easy when, on the one hand, the symptoms of apoplexy are preceded or accompanied by those of a local cerebral lesion ; or when, on the other hand, the direct or circumstantial evidence of poisoning is clear, or the symptoms of toxaemia unmistakable. Where there are no local symp- toms, and where no guiding history is to be obtained, the diagnosis is difficult, but a correct opinion may commonly be formed by an attentive comparison of the symptoms present. There may be, as just observed, indirect evi- dence of toxiemia: the breath may smell of opium or alcohol; the urine may contain albu- min. But albuminuria or a smell of spirits may mislead. Cerebral haemorrhage often occurs after drinking ; spirit is constantly given to a person in a fit. A smell of spirit must therefore only be allowed weight in the absence of any evidence of cerebral mischief. So, too, albumin is always present in the urine in uraemia, but it is also very frequently present in eases of cerebral haemor- rhage. Alone, this evidence of Bright’s disease is of little value, except there be general cedema and the patient be young ; then uraemia is more probable than vascular degeneration and cerebral haemorrhage. But with other symptoms which indicate uraemic poisoning, albuminuria is con- clusive. The age of the patient should be considered. Late life is in favour of brain-diseaso. The history of a fall or blow on the head adds weight to other symptoms of cerebral mischief. The character of the coma will sometimes guide. In uraemia, and commonlyin alcoholism, it is less profound than in cerebral mischief. The patient can readily be roused. In apoplexy, in opium-poisoning, and in the most intense alcoholic poisoning, the coma may be profound. On the other hand, in cerebral haemorrhage the patient, as Dr. Hughlings Jackson remarks, may sometimes be roused to answer questions. Violent struggling is strongly in favour of drink. The mode of onset of the coma is important. In apoplexy it is sudden ; in uraemia slow. The uraemic patient becomes first drowsy, then coma- tose. But with convulsions uraemic coma may come on suddenly. The onset of the coma of opium- and alcohol-poisoning is also slow. In- gravescent apoplexy is of deliberate onset, but a profound degree of coma is quickly reached. General convulsions at the onset exclude drunk- enness, and usually opium-poisoning, while they favour uraemia. Cerebral mischief sometimes commences with a convulsion, but the convulsion is then commonly unilateral, and one-sided symptoms are almost always afterwards to be recognised. Rigidity of limbs or local muscular twitching during the coma is, if constantin seat, in favour of cerebral mischief ; if variable ir position, it is in favour of uraemia (Reynolds) Post-epileptic coma is of course preceded by a convulsion, and should be borne in mind. The state of the pupils is alone of little im portance. Great contraction occurs in and suggests opium-poisoning, but it is present in hemorrhage into the pons Yarolii. The pupils may be normal or dilated in uremia, in alcoholic or opium-poisoning, and in apoplexy. Inequality of pupils, an unilateral symptom, points to brain-mischief. The retina should be examined, since the presence of albuminuric retinitis points, in the absence of the signs of a localised cerebral lesion, strongly to uraemia. Lastly, the temperature should bo noted. In uraemia there is persistent uniform depression ; in cerebral lesions the initial depression is suc- ceeded by a rise to a point above the normal. The diagnosis of the cause of cerebral apoplexy will be described more fully under the heads of cerebral congest on, haemorrhage, and softening. It may bo here pointed out that slight and transient apoplexy, without local symptoms, with flushed face, and coming on during effort, points to cerebral congestion ; slight and transient apo- plexy with marked local symptoms points to soften- ing ; early and profound loss of consciousness to cerebral haemorrhage. Post-epileptic coma may be distinguished by the history of epileptic attacks ; or, if this be not forthcoming, it may be suspected if symptoms of local cerebral lesion or indications of toxaemia are absent, if the patient bo under 40, and exhibits indications of speedy recovery. ‘ Simple apoplexy ’ cannot be diagnosed during life, since freedom from the symptoms of a local lesion does not afford ground for inferring that there is no such lesion. Prognosis. — The prognosis in cerebral apo- plexy depends in part upon the intensity of the attack. As long as unconsciousness is complete, and reflex action abolished, the patient is in danger of speedy death. The longer the apoplectic con- dition lasts without improvement, the less pro- spect is there of recovery. Persistent depression of temperature, or a rise of several degrees above the normal after an initial fall, are both of grave significance : such cases rarely recover ■; Charcot, Bourneville). The nature, extent, and position of the cere- bral lesion, when they can be inferred, furnish other prognostic indications. In haemorrhage the prognosis is more serious than in softening. A sudden occurrence or increase of apoplectic symptoms, a few hours or days after a slighter attack, is always grave, indicating a fresh ex- travasation. If such apoplectic symptoms become profound and uniform, the prognosis is fatal, rupture into the ventricles or on the surface of the brain having probably occurred. If the localising symptoms point to a lesion of the medulla or pons, the prognosis is almost as un- favourable. Early return of consciousness anil slight alteration in temperature are favourable signs. Previous cerebral disease renders the prognosis worse. Lastly, the prognosis must be influenced unfavourably by any impairment of the organic functions of circulation and respir.v tion, whether independent of or due to tko cere bral lesion. APOPLEXY, CEREBRAL. Treatment. — The treatment of cerebral apo- plexy must be guided by the indications of its cause. Where none can be obtained, it should be treated as cerebral haemorrhage. Still- ness is the most important condition. The patient should be moved as little as possible, but placed in the recumbent posture -with the head slightly raised. The neck should be freed from constriction. If tho extremi ties are cold, warmth may be applied to them ; and cold to the head if there is local heat or flushing. Sinapisms to the neck and ex- tremities sometimes seem to hasten the return of consciousness. The administration of stimulants should be regulated by the state of the heart. In thrombosis or embolism the heart should be kept up to the normal by very careful administration of alcohol, ether, or ammonia. In haemorrhage it may be allowed to fall a little below the nor- mal, but indications of failing power should be watched for and counteracted. Where no causal indication exists, the latter is the wiser plan. Venesection and purgation are remedies of similar effect, but different in degree, and are indicated by high arterial tension and cephalic conges- tion, shown by incompressibility of the pulse and flushing of the face. Venesection is useful where the heart acts strongly, and the pulse is full as well as incompressible. Its effect is proportioned to the rapidity with which the blood is taken, rather than to the quantity removed. Purgatives remove serum from the blood, and lessen the amount of blood within the skull by causing an afflux to the capacious intestinal vessels. The best purgative is croton oil. With a failing heart and pale surface they should be avoided. Diuretics may then be used to relieve the vascular tension. As the apoplexy clears, the nature of the case becomes evident, and the treatment of the several conditions is described elsewhere. {See Brain, Haemorrhage and Soften- ing of.) For treatment of the other causes of the apoplectic state, see Axcoholism, Poisons, and Uremia. W. E. Gowers. APPENDIX VEEMIPOEMIS, Inflam- mation, Ulceration, and Perforation of. Definition. — Inflammation of the appendix vermiformis from lodgment of hardened, fasces or a foreign body, leading to ulceration, frequently ending in perforation of the coats ; to inflamma- tion and suppuration of adjacent tissues (peri- typhlitis) ; and to peritonitis, local or general. ^Etiology. — The usual cause of this affection is a foreign body {e.g., fruit-pips or -stones, a small bone, shot, pins, &c.); or a faecal concretion imprisoned within the cavity of the vermiform appendix. Perforation has been recorded in ty- phoid fever and tuberculous disease. Anatomical Characters.. — Before perfora- tion takes place the appendix may be found distended with pus ; a foreign body or concretion lodged within it ; and the mucous membrane ulcerated. The concretion or concretions vary in size from a small pea to a bean ; are usually brown and hard ; and consist of layers of con- densed faeces, secretions, and phosphates, depo- sited around a small nucleus, which may prove to be a seed or other foreign body, or a piece of u tmsually inspissated faeces. These concretions greatly resemble, and are often mistaken for, APPENDIX VERMIFORMIS. 76 fruit-stones. Ulceration and perforation may oc- cur at any part of the appendix, usually, however, at the extremity or the lower third. There may be a circumscribed peritoneal abscess ; or the perforated part of the appendix may be found ad- herent to the surrounding parts, for example the caecum or the abdominal wall. Symptoms. — Pain, generally ill-defined, in the right iliac region, may be the only symptom to attract attention, and, as a rule, it is not until local peritonitis or perityphlitis is set up that we may suspect the nature of the disorder ; the ab- sence of premonitory symptoms, of the character- istic tumour of typhlitis, and of intestinal ob- struction, excluding inflammation of the caecum. Often, however, the course from the first is latent, and the mischief is suddenly revealed by perfor- ation into the peritoneum, followed by general and rapidly fatal peritonitis. Adhesions formed in front of the slowly advancing ulceration may localise the consecutive inflammation. The substance imprisoned within the appendix may be dislodged by (a) inflammation and sup- puration of the tissues around the caecum (peri- typhlitis, pericaecal abscess); or ( b ) the appendix, at the point of perforation, having become adhe- rent to the caecum, a communication is estab- lished with this part. Diagnosis. — Inflammatory affections of the caecum and of the appendix can rarely be clearly distinguished from each other. Inflammation of the appendix is apt to persist, continuing to be acute and severe ; while caecitis may be subdued by free relief of the bowels. Caecitis with ulce- ration is apt to follow intestinal inertia ; while the alarmingly acute and rapidly fatal symptoms of inflammation with ulceration and perforation of the appendix often arise during perfect health, Inflammation of the cellular tissue surrounding the caecum (perityphlitis) is more commonly the result of ulcerative inflammation of the caecum than of the appendix. The complete investment of the appendix by'peritoneum contributes to perforation and fatal general peritonitis. Prognosis.— General peritonitis from sudden perforation into the cavity of the peritoneum is the great danger, recovery from which is extremely rare. Inasmuch as this may occur at any time during the course of ulcerative inflam- mation of the appendix, a guarded opinion should always be given when there is suspicion of the existence of this affection. Continued uneasiness in the right iliac region without indications of fecal accumulation, or of inflammation in or around the ctecum, should not be regarded lightly. Though this serious accident is less apt to occur after the formation of adhesions around the advancing ulceration, we must not forget that well-marked local inflammation of the peritoneum, or of the cellular tissue around the caecum, does not always prevent it, inas- much as the adhesion which may thus form may not be sufficiently strong to withstand the pres- sure of pus in the appendix. Treatment. — -The patient must be kept at rest in bed, hot poultices applied, and an uairritating fluid diet allowed. Opiates, for the purpose of relieving pain and subduing the peristaltic con- traction of the intestines, should be freely and continuously administered ; and if irritability of 70 APPENDIX VERMIFORMI8. the stomach exist, they should be introduced by enema or by subcutaneous injection. Peritonitis or other complications must be treated as they arise. George Oliver. APPETITE. — In disease th6 desire for food may be either lessened or increased ; or the appe- tite may be per verted , and a longing for various substances unfitted for or incapable of digestion may be displayed. Loss of appetite — Anorexia accompanies almost all forms of acute or chronic gastritis ; and as these affections constantly coexist 'with other diseases, great variety as regards the desire for food is manifested in various complaints. In acute gastritis there is often not merely a loss of desire for, but a positive aversion to food, and the patient resolutely resists any attempt at obliging him to take either solid or liquid nourishment. In the more chronic forms of gas- tritis the distaste for food may be only slight ; in some cases the appetite is increased, but is quickly satisfied as soon as a small quantity of food is taken. In chronic ulcer of the stomach the appetite, as a rule, remains good, and the patient is only prevented from indulging it by the fear of the pain that will result from his so doing. Whenever the secreting structure of the organ is extensively diseased the appetite fails. Thus, in atrophy of the stomach the desire for food generally lessens along with the diminish- ing strength of the invalid. In cancer of the stomach there is always an extensive destruction of the glandular structure, and loss of the appe- tite is a constant and prominent symptom. It must be remembered that a loss of appe- tite may be more apparent than real, The phy- sician is constantly consulted on account of this Bymptom, when a little inquiry will show that !he patient is really digesting as much as his system requires, but that by a habit of eating without allowing a proper interval between his meals, or by indulging in food of too nutritious a nature, or in an undue amount of alcoholic stimulants, the sensation of hunger is prevented. Increase of appetite — Bulimia usually occurs where there is a necessity for an increased supply of food. Thus it is common after all febrile diseases, where the stomach has been long inac- tive. Again, in diabetes, where a large portion of the food is passed off in the form of sugar instead of being converted into the material required to keep up the nutrition of the body, there is an unusually large appetite. A craving sensation is a common symptom in chronic catar- rhal gastritis. It probably arises from the ir- ritation set up by the mucus and fermenting substances long retained in the stomach, and is temporarily relieved by eating. The best treat- ment for such cases is to give alkalis about half an hour before the craving usually occurs, at the same time that the affection of the mucous mem- brane is combated by appropriate diet and reme- dies. In some persons the sensation of extreme hunger appears to arise from an irritable condi- tion of the stomach, by which the food is passed into the duodenum before digestion is completed. The sensation is mostly complained of at night, and the writer has found it a good plan to let the patient have some beef-tea or meat lozenges, ARCUS SENILIS. for example, either just before retiring to rest or during the night. In children a craving for food is a frequent symptom, and arises either from the irritation of worms, or from chronic catarrh of the mucous membrane of the small intestines. Perversion of appetite — Pica is most common in pregnant or hysterical females. Curious articles, such as chalk, cinders, and slate-pencil, are some- times swallowed. In the insane and in idiots articles of an indigestible nature are not unfre- quently introduced into the stomach, such as string, paper, cocoa-nut fibre, &c. It is a matter of great importance that all persons, but especially dyspeptics, should ac- custom themselves to control their appetite. Whenever a larger amount of food is taken than the stomach is capable of digesting, the residue is apt to ferment and thereby to produce gastric catarrh. This is more especially the case where the digestive powers have been enfeebled by previous attacks of gastric inflammation. S. Fenwick. AFYRETICS. See Antipyretics. APTEEXIA (h, priv., and irvpiaau, I am feverish). — This word literally means absence of fever : it is also used to denote the interval between paroxysms of intermittent fever. ARACHNITIS. — Inflammation of the arachnoid membrane. See Meningitis. ARCACHON, "West coast of France.— Summer and autumn resort. Sheltered by pine woods. Calm in winter. See Climate, Treat- ment of Disease by. ARCUS SENILIS is a crescentic opacity of the cornea, within its margin, often seen in old people. Thearcus is usuallyfirst observed in the upper part, and soon afterwards a smaller opaque crescent, opposite to this, appears below. In the course of years the two crescentic marks become slightly wider and more opaque, their points having at the same time extended much more con- siderably in proportion, so that an annulus or ring is formed. It probably is always widest and most opaque above, and wider and more opaque below than at the sides. An arcus is grey when it first appears, but it may attain at last to an ivory whiteness. It is especially noteworthy that arcus, besides being regular in shape, of an evenly-graduated degree of opacity, and well-de- fined at its inner margin, is never continuous with the opaque sclerotic external to it, but is always separated from this membrane by T an extremely narrow line of demarcation of unaffected corneal tissue, which, as it is normally almost transparent here at its margin, is the more conspicuous by force of contrast with the new opacity. At the same time it must be observed that the well-defined opacity is most opaque in the centre or slightly external to the centre of its width, at any part ; so that, although it is everywhere well-defined, it is shaded off somewhat abruptly towards its outer circum- ference, and more gradually at its inner margin. The arcus is much more prone to increase in opa- city than in width. It rarely attains a width, even at the upper part of the cornea, of more than ^-in. It is very conspicuous when backed by a dark iris. The cornea within the regular boundaries of the arcus senilis remains perfectly transparent, and vision is in no degree impaired by it- Wounds arcus senilis. in me part of the cornea thus affected heal well, and no surgeon is led by it to operate in any other part of the cornea, rather than divide the arcus itself in the part in which the corneal opening is made in almost all operations on the eye. Pathology and ^Etiology. — Arcus senilis is essentially a fatty degeneration of the proper substance of the cornea. It is not fully explained why it should appear just where it does, so near to the source of nutrition of the cornea; the fatty substitute for the natural tissues seeming to occupy only the circumference, and first and chiefly under the upper and lower lid, where also the conjunctiva and sclerotic overlap the cornea more particularly — a situation in which the lids exercise a certain amount of pressure, which has been regarded by Dr. C. J. B. Williams as the immediate cause of the degeneration. If an eye suffers from chronic deep-seated disease an arcus will develop more rapidly ; as, for example, in a case of old recurrent iritis of one eye only, in which there was a well-marked arcus, while in the other there was hardly a trace of it. An anomalous case is that in which the upper and lower arcus are opposite as usual, but in an inclined meridian. Arcus senilis is as capricious in its appearance as other senile changes ; it is no clear indication of the age, certainly not of the number of years of life of a patient, as it may appear even in youth, and may never appear even in extreme old age; but when it occurs before forty years of age it is taken, by some life-insurance medical officers, to be an indication of concomitant fatty disease of the heart and degeneration of the arteries. But fatty heart is often found without arcus, and ar- cus without fatty heart. If, together with other evidence of weakened heart-power, there be an arcus, it is probable that fatty degeneration of the heart exists. Treatment. — Arcus senilis is incurable, and no one endeavours expressly to cheek its increase, which, no doubt, is sometimes possible, as the writer is acquainted with a case in which the successful treatment of Bright’s disease has, for ten ytars, completely arrested its advance. J. F. Streatfeild. ARDOR {ardor, heat). — A sensation of heat, burning, or scalding, which may be felt along the urethra during the passage of urine {Ardor Urines) ; or in connection with the stomach {Ardor Ventriculi). ARGYEIA {Hpyvpos, silver). — The slate- coloured stain of the skin produced by the inter- nal use of the salts of silver. See Pigmentary Affections. ARSENIC, Poisoning by. -Arsenic is classed as a metallic irritant poison, though its action is by no means limited to that of an irritant. It acts specifically on the gastro-intestinal mucous membrane, whatever be the channel bv which the poison gains access to the system. The most usual source of acute arsenical poisoning is the administration of white arsenic or arsenious acid ; but the sulphides, various arsenides, and impure commercial articles, such as dyes, wall-papers, and pigments, may be fertile sources of arsenical poisoning. Poisoning by arsenic, may be either acute or chronic. ARSENIC, POISONING BY. 77 A. Acute Arsenical Poisoning. — This is the usual form of poisoning ensuing on the nefarious administration of any preparation of arsenic, but usually the oxide {arsenious acid) is employed. Symptoms. — The symptoms do not, as in the case of corrosive poisoning, come on immediately after the administration of the poison. There is most commonly an interval of half an heur or an hour between the swallowing of the agent and the onset of prominent symptoms. The quantity of the noxious agent, and its state as regards solubility, have also an obvious relation to the commencement of symptoms. Most commonly, after a sense of faintness and depression, intense burning pain is felt in the epigastric region, accompanied by tenderness on pressure. Nausea and vomiting quickly supervene, increased by every act of swallowing. Unlike what occurs in an ordinary bilious attack, with which arsenical poisoning may be at first confounded, the pain and sickness are not relieved by the act of vomiting. The vomited matters are extremely varied, and present no characteristic appearances. At first they usually consist of the ordinary con- tents of the stomach, but at a later stage are largely charged with bile which has regurgitated into the stomach in consequence of the violence of prolonged emesis ; and they may be tinged with blood. Ordinarily vomiting is speedily followed by violent purging, and great straining at stool, the motions being often streaked with blood. Purging may, however, be entirely ab- sent. Other prominent symptoms are great thirst, a feeble irregular pulse, and cold clammy skin. The patient as a rule dies within eighteen to seventy-two hours in a state of collapse ; but tetanic convulsions are not uncommon, and even coma and paralysis may close the scene. Diagnosis. — From an ordinary bilious attack, induced by improper diet or by decomposing food, arsenical poisoning is diagnosed by the persist- ence of the symptoms after the removal of ths apparent cause ; and not infrequently by the symptoms remitting and again supervening on the administration of food or drink of a parti- cular kind, or given by a particular hand. Prom choleraic diarrhoea it is distinguished by the sudden onset of symptoms, thirty to sixty minutes after food or drink has been taken ; by the absence of rice-water stools, or of lividity of the skin ; and by the symptoms not yielding to treatment. Moreover, in poisoning by arsenic there is usually greater tenderness over the epigastrium ; the diarrhoea is less passive, and accompanied with more tenesmus than in choleraic diarrhoea ; the stools are more often bloody' ; and nervous symptoms may be more pronounced. The diag- nosis is, however, often very difficult, except when aided by a chemical analysis of the matters ejected from the stomach or of the excreta which should always be made in doubtful cases. Prognosis. — This must always be uncertain, since it is rarely possible to ascertain the quan- tity taken, or to ensure its entire evacuation from the stomach. Treatment. — Emetics, diluents, and demul- cents are the appropriate remedies. The stomach- pump may also be usefully employed. In ad- ministering emetics, tartar emetic should be avoided, as it increases the depression, and its !8 ARSENIC, POISONING BY. presence complicates a chemical analysis. More- over, tartar emetic frequently contains traces of arsenic, and, in the event of an analysis being made, an unfounded suspicion may be raised. No confidence can be placed in the so-called antidotes, ferric hydrate and magnesia, except where a solution of arsenic has been taken. B. Chronic Arsenical Poisoning. — This form of poisoning is not uncommon, and is, unlike the acute form, generally accidental. The inhalation of arsenical vapours in factories, or of arsenical dust, as from green and other wall-papers, and in the process of manufacturing artificial flowers, is a common source of chronic arsenical poisoning. Those who are chiefly exposed to this form of poisoning are persons employed in the manufac- ture of pigments, especially green pigments ; paperhangers and decorators ; artificial-flower manufacturers; milliners; persons exposed to the fumes of heated metals, particularly zinc and brass ; manufacturers of dyes ; and leather- dressers. In the process of depilating sheep-skins, previous to the tanning or the tawing process, a mixture of lime and orpiment (sulphide of arsenic) is used ; and serious ulceration of the hands, scrotum, nose, and cheeks not infrequently results. Persons living in rooms the walls of which are covered with arsenical paper, especi- ally bright-green papers containing arsenite of copper, are liable to suffer from chronic arseni- cal poisoning. It is uncertain whether this is entirely caused by the mechanical transfer of pigmentary dust to the air-passages, or is partly due to volatilisation of the arsenic, probably in the form of arseniurctted hydrogen. Many brown wall-papers also contain arsenic, and arsenious acid is sometimes added to the size ; such papers have been known to produce the specific symp- toms of arsenical poisoning. That some persons can take arsenious acid internally with impunity in relatively large doses (arsenic-eating) is now a well-established fact. Symptoms. — The first symptoms of chronic arsenical poisoning are usually loss of appetite, prsecordial pains, irritability of the bowels, and occasionally headache. Suffusion of the eyes, a peculiar and characteristic appearance of the conjunctiva, often amounting to actual conjunctivitis, and intolerance of light are early manifested. The muscular power of the limbs is impaired pretty constantly, and actual paralysis extending upwards from the lower extremities is occasionally observed. A characteristic vesicular eruption on the skin ( eczema arsenicale) is fre- quent, as well as irritation of the skin, especially over the neck, scalp, hands, and armpits. Males who handle arsenical preparations are liable to ulcerations of the scrotum and penis, obviously due to a mechanical transference of the poison to the genitals when these are touched. If the source of the disease be not removed, progressive emacia- tion, exfoliation of the cuticle, and nervous pros- tration supervene; and convulsions may precede the fatal termination. The effects of green arsenical pigments are sometimes manifested by bleeding from the nose. Diagnosis. — When a patient suffers more or less from the symptoms above described, and is als i known to be exposed to any of the sources ARTERIES, DISEASES OF. of danger from arsenical poisoning enumerated under the setiology, the diagnosis is not difficult. Treatment. — The source of poisoning should invariably be removed. It is found that those who suffer from working in arsenic make no progress towards recovery until they are removed from contact with the poison. Wall-papers which contain arsenic, and are suspected to be the cause of symptoms, should be taken away. Quinine, or other tonics, iron, and attention to the digestive organs will be needed. Removal to fresh country air is often productive of marked benefit. Soothing lotions to the skin, and careful attention to eroding ulcers, especially of the cheek, may be necessary. Shampooing and warm baths form the best treatment for paralytic lesions. Morbid Appearances. — These are the same by whatever channel the poison has gained access to the system. As a rule there is marked inflammation of the stomach and duodenum, usually of the small and large intestines also ; but not uncommonly the inflammation is limited to the stomach, duodenum, and rectum, the intervening alimentary tract having escaped. If the poison has been administered in a solid form, white patches of the arsenical compound may be foundimbeddedinthickbloody mucus andinflam- matory exudation. Portions of the white arsenic are also sometimes converted by the sulphuretted hydrogen evolved during decomposition into the yellow sulphide. Ulceration of the stomach is rare, and perforation almost unknown. An ecchy- mosed condition of the heart is often observed ; and fatty degeneration of the liver, as in poison- ing by phosphorus, has been described. T. Stevenson. ARTERIES, Diseases of. — It is important to keep in mind the following anatomical facts in studying the morbid processes to which arteries are subject: — In immediate contact with the blood-stream in arteries lies the endothelium — a layer of flattened cells ; outside this is the tunica intima, composed of elastic tissue in longitudinal arrangement : together the endothe- lium and tunica intima constitute the internal coat of the older writers. Still more external we find the middle coat , made up of muscular fibre arranged transversely, in the larger arteries mixed with elastic tissue ; and, most external of all, the external coat, consisting of longitudinally fibril lated connective tissue. 1. Acute Arteritis, affecting a very limited portion of a vessel, and leading to ulceration, occasionally occurs. In some cases this lias arisen from the irritation caused by an embolus, which, becoming detached from a cardiac valve, has blocked a distant artery’ ; and Dr. Moxon has specially drawn attention to its occurrence in the aorta, when the ascending portion of the vessel has been exposed to the impact of a hard, freely movi ng vegetation on one of the segments of the aortic valve. Dr. Moxon has also described, under the designation inflammatory mollif ies, the occur- rence of softening and swelling of the arterial tunics in circumscribed spots ; which become flabby and inelastic, and ultimately bulge out- wards and form aneurisms. He believes that this condition depends on a peculiar general state, and is the great cause of aneurism in young, hard- ARTERIES, DISEASES OF. 79 working men. Except in these circumscribed inflammatory lesions, we do not meet with any condition of the arterial tunics to which the de- signation acute arteritis can be applied. Such a change has, indeed, been described, and the writer has seen the lining membrano of the ascending and transverse portions of the aorta of a blight vermilion hue, strongly suggestive of acute inflammatory change ; but the best ob- servers are now agreed in believing that this appearance arises from staining by haematin. 2. Chronic Arteritis has been described as pursuing a course different from the endarteritis deformans, which will immediately be noticed ; and as causing thickening of the coats of the vessels, narrowing of their calibre, and absence of pulsation during life. As such, chronic ar- teritis appears to be a disease of extreme rarity. But, on the other hand, if it be considered as the first stage of atheromatous disease, it may be said to be of frequent occurrence. 3. Periarteritis is the term applied by Charcot and Bouchard to the morbid change which, in their opinion, eventuates in cerebral haemorrhage. According to these physicians, cerebral haemorrhage is not usually due to itheromatous decay of the vessels of the brain ; but, in the vast majority of cases, to the rupture if miliary aneurisms, which in their turn have been produced by a morbid process beginning in the perivascular sheath surrounding the cerebral vessels ; and which, proceeding from without in- wards, ultimately involves all the coats of the vessels {see Brain, Haemorrhage into). 4. Atheromatous Disease, the Endarteritis deformans of Virchow, is the arterial disease which is most frequently met with, and the one whose consequences are most serious. It presents three tolerably well-defined stages, (n) In the first stage we notice, when the vessel is slit open, greyish patches, by which the lining membrane is irregularly thickened ; these patches seem to lie on the surface of the membrane, but this appearance is deceptive; the endothelium lies between them and the blood-stream, and is, at least at the begin- ning of the morbid process, unaffected. The ma- terial of which the patches are formed is really situated between the tunica intima and tunica media ; it is semi-cartilaginous in consistence, and is formed by an abnormally rapid multiplication of the deeper cells of the tunica intima, — the new growth pushing up this tunic with its super-im- posed endothelium, and so causing a bulging into the interior of the vessel. The process is of the nature of an inflammatory change ; that is, it con- sists in the proliferation of cellular elements, in consequence of some influence which has excited them to unnatural growth. (A) In the second stage the cellular elements of which the new growth is composed undergo a process of fatty degeneration ; and in consequence it becomes yellowish in colour and pasty in consistence : it was the paste-like appearance of the mass in this stage which originally gained for the process the designation Atheroma (atbjpi) = meal). It not un- frequently happens that the whole of the internal coat with its endothelium is involved in the softening, and gives way under the pressure of the blood, leaving an excavation, the floor of which is formed by the middle and external coats of the artery, (c) In other instances, how- ever, the pasty mass, instead of being washed away, becomes the seat of calcific deposit. This is the third stage in the process. The appearance of a vessel in which atheromatous disease has reached this stage is very striking : plates which present to the naked eye the appearance, but do not show the minute structure of bone, are observed at intervals in the walls of the ves- sel, and their sharp spicula project into its interior ; in the aorta it is not uncommon to find such plates an inch long and half an inch broad, and in the smaller arteries the calcific matter sometimes forms a ring round the vessel. In the latter the calcareous particles appear to be deposited in the patch while it is still firm, so that the second stage of the process is wanting. Atheromatous disease sometimes invades both the aorta and the small vessels, but the aorta may be extensively diseased and the small arteries unaffected; or, on the other hand, the cerebral, temporal, and coronary arteries may be the seat of calcific change while the great vessels are healthy ; occasionally the disease is limited tc afew vessels. Next to the aorta, the cerebral, coron- ary, and splenic vessels, and the arteries of the lower extremities, are prone to this form of arteritis. Effects. — The dangers to which an athero- matous state of vessels exposes the person in whom it exists are varied. The stream of blood is retarded by the projection of the new growth into the vessel, and still more by the destruction of the elasticity of its coats ; and hence ensues a failure in the nutrition of the organ which de- pends for its supply of blood on the diseased vessel ; — this is said to be a cause of cerebral softening. When the paste-like mass is washed away it sometimes happens that the blood in- sinuates itself between the coats of the vessel, producing a dissecting aneurism ; or the portion of the vessel, which has been weakened by the removal of the internal coat, yields to the pressure of the current, and a sacculated aneurism is originated; sometimes the diseased vessel bursts. Cerebral vessels, probably on account of the thinness of their walls, are specially liable to rupture when they are the seat of atheromatous change ; and occasionally a diseased coronary artery has given way, filling the pericardium with blood. Arteries have been completely occluded by the deposition of fibrin on the spiculated edges of calcareous plates : this is one of the causes of senile gangrene ; and embolic plugging of distant vessels at times results from the detachment of such fibrinous clots, and the washing away of atheromatous debris. Rigidity of the larger arteries from atheromatous change is likewise one of the most frequent causes of hypertrophy of the left ventricle of the heart, on which increased work is imposed iu consequence of the destruction of the elasti- city of the vessels. Anasarca has not, so far as the writer is aware, been mentioned by any author among the consequences of diseased ar- teries ; but some cases which have come under his observation have led him to the conclusion that persistent anasarca, especially of the lower ex- tremities in elderly men, is sometimes mainly due to a diseased condition of the arterial tunics. In the cases which he has observed there ■was ARTERIES, DISEASES OF. SO likewise present dilatation with hypertrophy and commencing fatty change of the left ventri- cle, itself a consequence of the arterial disease ; but this seemed insufficient to account for the persistent cedema of the lower extremities. Etiology. — T he cause of endarteritis de- formans is now generally admitted to be over- strain of the vessel. It was formerly thought that syphilitic impregnation of the system was a power- ful favouring condition ; but this opinion rested chic-fly on observations made among soldiers, who, in addition to the syphilitic taint, were subject to other influences now known to be adequate in themselves to develop the disease: and the writer has himself seen the most extensive atheromatous disease in men in whom there was no trace of the ey^philitic taint. Intemperate habits and gout appear to be powerfully predisposing causes ; they probably render the blood impure, and its pas- sage through the capillary vessels being thereby retarded, the tension of the arterial system is increased. Besides violent exertion, which im- poses a strain on the entire arterial tree, there are other influences which act upon certain vessels. Thus the renal arteries are kept over-full in the cirrhotic form of Bright’s disease, owing to the destruction of the capillary tufts, and hence athe- roma of these vessels is almost constantly present in that form of renal mischief. The writer has on two occasions found extensive calcareous formations in the cerebral vessels of persons in whom cerebral degeneration had followed ex- cessive anxiety and mental effort. The pul- monary artery is very rarely i nvaded by atheroma ; and only in cases in which it has been kept in a state of tension by hypertrophy of the right ventricle or disease of the mitral orifice. Diagnosis. — The diagnosis of atheromatous inflammation of the aorta will be discussed in a separate article. The existence of the disease in the arteries of particular organs can only be a matter of reasonable presumption when the patient is past middle life; when the ascertained causes of atheroma have been in operation ; when symptoms of impaired nutrition of the organ are present ; and when the organ (the brain or heart) is one the arteries of which are known to be prone to the disease. Calcification of the super- ficial arteries renders these vessels rigid and tortuous ; the temporals when so affected attract the eye by their prominence, and may be felt hard and rigid beneath the finger ; the brachial may equally be made the subject of examination ; and, although the presence or absence of athero- matous change in such superficial vessels does not necessarily prove that the other arteries of the body are in a similar condition, it renders it more than probable that they are. Those who are not familiar with the resisting feel of the radial artery, when it is the seat of the change now under consideration, are liable to form a very erroneous estimate of the strength of the pulse : this may convey to the inexperienced finger an impression of a force which it does not possess. The error also is sometimes committed of inferring the existence of aortic regurgitation in these cases in consequence of the tortuous course and visible pulsation of the superficial vessels ; but they do not collapse suddenly under the finger, as do the vessels during the receding wave in I aortic patency. The sphygmographic tracing, moreover, is essentially different: in atheromatous disease of the artery the upstroke is vertical, and the summit of the tracing extended. The existence of such evidences of vascular mischief affords a fair subject for consideration to those who are called upon to form an opinion as to the eligibility of a life for assurance. Treatment. — The treatment of endarteritis deformans is mainly preventive. It consists in the avoidance of all those influences to which we have adverted as causes of the disease, namely, indulgence in alcohol ; causes originating a gouty state of the blood ; excessive muscular efforts, especially in constrained positions ; pos- tures which involve the long-continued con- traction of muscles which surround arteries ; and, as far as the brain and heart are concerned, all those states which favour overfulness of their respective arteries : — in the case of the brain, excessive mental application, deficient sleep, and, the writer believes, prolonged periods of sexual excitement; in the case of the heart, inter alia , efforts which involve holding the breath, thus leading to distension of its right cavities, and imposing an obstacle to the return of blood from its walls. 5. Fatty Degeneration, unconnected with the atheromatous process, is sometimes, though rarely, found to affect arteries. Circumscribed opaque and velvety spots appear on the surface of the intima, and erosion ultimately occurs. Once this has taken place, the muscular coat, unable to bear the pressure of the blood-stream, fissures transversely ; and the blood either rup- tures the external coat, or, insinuating itself be- tween the middle and external coat, produces a dissecting aneurism. This change has been found in the arteries of persons who seemed otherwise quite healthy ; it is ‘ a morbid change which is simply degenerative from the first, and of whose immediate cause we know nothing’ (Rindfleisch). Fatty degeneration of the external coat of the smallest arteries has also been no- ticed : it appears to be a senile change, and to play a part in the production of cardiac and cerebral degeneration. 6. Calcification of the arterhd tunics also occurs unconnected with endarteritis, but more rarely than fatty degeneration. "When this is the case, it is the middle coat of the smaller vessels that is the seat of the deposit, which consists of carbonate and phosphate of lime and magnesia. The process is usually limited to the vessels in which muscular fibre is abundant ; but these it may affect extensively, the super- ficial vessels and the arteries of tho brain and of the extremities being the favourite seat : it is eminently a senile change. 7. Gummatous Disease of the cerebral arteries in syphilitic patients has been described by Dr. Hughlings Jackson, Dr. Wilks, and others. The vessels present nodose swellings, and are thick- ened sometimes to three times their normal size by gummatous material infiltrating the outer coat ; the calibre of the vessels is thereby nar- rowed, the formation of thrombi favoured, and cerebral softening produced. ‘ A random suc- cession of nervous symptoms,’ to use the words of Dr. Jackson, affords strong grounds for sus- ARTERIES, DISEASES OF. pecting syphilitic disease within the cranium ; and the writer has himself seen three cases in which such symptoms disappeared under the use of perchloride of mercury and iodide of potassium, and in which it seemed to him that the supposi- tion of arterial disease was much more probable than that of any other form of intracranial syphilis. 8 . Albuminoid Disease, when it attacks the spleen or kidneys, appears first in the walls of tlie small arteries of these organs, but is not found in the larger arteries of the body. 9. Contraction and final impermeability of an artery from atheromatous calcification, from the accumulation of fibrine in its rough inner surface, from pressure, or from other causes, occasionally occurs, leading to gangrene of the extremity which it supplied. 10. Dilatation of arteries is in the ma- jority of cases due to previous disease of their coats ; but sometimes in the aged the arteries are found dilated without any degeneration of their tunics being present, — a state of affairs which Rindfleisch suggests may depend on atony of the muscular coat, and in some cases may pos- sibly be connected with deficient innervation. 11. Aneurism receives full consideration in a separate article. Here it is merely necessary to point out the ways in which atheromatous inflammation and the other morbid processes which have been described contribute to the pro- duction of dilatation and aneurism. In some cases the course of events consists in the wash- ing away of the diseased patch of the intima ; when the middle coat either dilates, or, by separation of its muscular bundles, undergoes rupture, and the external coat yields before the pressure of the blood-stream. In other cases the dilatation occurs, not at the point where the endarteritis has invaded the vessel, but nearer to the heart. At the affected point there is narrowing of the canal of the vessel, and loss of elasticity in its coats ; and as a consequence we have slowing of the circulation and deficiency in the supply of blood beyond, and increased ar- terial tension on the proximal side of the affected spot. The effect of this tension is more serious than would at first sight appear ; in health the blood, propelled by each ventricular sysf ole, enters contracted vessels, which, yielding before it, are uninjured by its sudden impact; but a vessel in a state of tension is exposed to the full violence of the column of blood discharged by the heart, and must gradually dilate before it. 12. Arterial Disease in Insanity. — Accord- ing to Dr. J. Batty Take, and other physicians who have specially investigated the morbid changes in the brains of the insane, arterial dis- ease is almost invariably present. It consists in such alterations as would result from obstruc- tion in the ultimate ramifications of the vessels ; — thickening of the proper coats of the arteries, and of the sheath of connective tissue which surrounds the. cerebral vessels ; the deposition of fine molecular matter and crystals of hEematoidin between the adventitia and the sheath ; and ex- treme tortuosity of the vessels. 13. Arterio-Capillary Fibrosis is the term applied by Sir William Gull and Dr. Sutton to the hypertrophy of the walls of the small arteries 6 ARTIFICIAL RESPIRATION. 81 found in the subjects of the cirrhotic form of Bright’s disease. It is admitted by all observers of repute that the walls of tho blood-vessels of the kidney are greatly thickened in this malady : but it is by no means so universally admitted that the small arteries throughout the whole body are in all such cases similarly hvpei'tro- phied. That they are hypertrophied in a certain proportion of the cases admits of no doubt ; bui the nature of the thickening remains to be do cidod. Dr. George Johnson, who early called attention to this condition, considers that there is present an hypertrophy of all tho tunics of the small arteries, especially of the muscular coat- a consequence of the obstruction which impure blood invariably meets within the capillaries. Sir William Gull and Dr. Sutton, on the other hand, assert that the thickening is due to a fibroid growth, especially seated in the external coat of the vessel; and they believe that the coexisting disease of the kidney is not the cause of the arterial change, but that both are parts of a general diseased process. James Little. ARTERIES, Examination of. See Phy- sical Examination ; and Pulse. ARTHRALGIA ( apdpov , a joint ; and &A . 70 s, pain). — Pain in a joint. Tho term is more par- ticularly applied to articular pain in the absence of objective disease. ARTHRITIS (cipSpou, a joint). — A term generically used to signify any disease whatever involving a joint, but more correctly confined to articular inflammation. It is also employed to designate inflammation of all the structures forming a joint, as distinguished from mere syno- vitis. See Joints, Diseases of. ARTHBODYNIA ( ap9pou , a joint; and oSvvq, pain). — See Arthralgia. ARTICULAR RHEUMATISM.— Rheu- matism affecting joints. See Rheumatism. ARTIFICIAL RESPIRATION, or the method of exciting and keeping up the move- ments of the chest, so as to supply air to the lungs, is a subject of tho highest importance, since the hopes of recovery depend on its due performance in many cases of narcotic poisoning, in the apparently drowned or asphyxiated, and in the collapse of tho advanced stage of the condition induced by anaesthetics. For its effective employment it is essential to see that no foreign body obstructs the air-passages. Children and old people are liable to swallow large pieces of meat or crust, which become impacted in the pharynx or oesophagus. These should, if pos- sible, be dragged away with the finger or a spoon-handle, but they may require the use of a probang. Tracheotomy is rarely necessary. A knife-handle held between the molar teeth is a ready and useful gag to keep the mouth open. A button-hook, in the absence of pharyngeal forceps, is sometimes very serviceable. Vomited matter should be quickly removed with a sponge or cloth twisted round a piece of wood. In treating the half-drowned the body should be inverted for a few minutes to favour the escape of water from the air-passages, but artificial ■>'> ARTIFICIAL RESPIRATION, breathing should be commenced even whilst the tody is in this position. Methods. — In most cases the best method of commencing artificial respiration is to compress the chest and abdomen simultaneously, then remove pressure so as to allow air to enter the chest, and again repeat the pressure every two or three seconds. If the sound indicates that air is passing into and out of the lungs, this method may be continued for half a minute ; but if we are not sure that the air is exchanged, and in all cases if the patient's condition is not decidedly improved in half a minute, we should resort to : — ■ 1 . Sylvester's method ,. — Place the patient on his back on the floor, with a block or pillow under his shoulders, and raise the arms upwards above his head, by grasping them above the elbow, and pulling firmly and steadily as long as there is any sound of air entering the chest. Some arrangement is needed to prevent the body from being dragged towards the operator. For this purpose the plan of raising the chest on a high cushion or box has been adopted, but as a condition of cardiac anaemia is often present, this is objectionable. It is better to effect the object by placing a book in front of the thighs while kneeling at the head of the patient. It may be needful to draw forth the tongue, but generally if the head falls back over a cushion placed behind the neck, this is not required. An artery forceps, or a noose of string, or a handkerchief will enable an assistant to keep the tongue well forward. As soon as the sound produced by the entrance of air into the chest ceases, the arms should be brought down a little towards the front of the chest, and pressed firmly and steadily against it for about one second after air is heard escaping. In cases of drowning it is enough to repeat this operation every four seconds, but in the collapse resulting from chloroform or other anaesthetics, the necessity for getting the vapour quickly out of the chest justifies a more rapid performance of the movements during the first five minutes. After this time the movements should be carried on more slowly, but they should bo continued for half an hour at least, and even longer if the warmth of the surface and diminution of lividity gives any reason to hope that the heart has not entirely ceased to act. 2. Marshall Hall’s ready method is performed by placing the body on one side, and alternately rolling it on its face to compress the chest, and on its back to allow the elasticity of the ribs free movement to draw air into the lungs. The plan is not nearly so effective as Sylvester's, but if no assistant is at hand it is the best mode of artificial breathing that can be adopted. 3. Howard’s method. See Resuscitation. 4. Moutk-to-moutk insufflation is not to be depended upon, on account of the difficulty both of keeping the larynx open, and also of prevent- ing the air going down the gullet. Of the instruments introduced for the purpose ot carrying on artificial respiration, mention should be made of those invented by Dr. Marcet and Dr. Richardson ; but except in the hands of the inventors or of those who had gained much experiencein theiruse by practising upon animals, the writer thinks they would do as much harm us good. The objection to them all is that they ASCITES. interfere with the prompt imitation of the move- ments of respiration just described. The administration of oxygen is indicated in most cases of artificial respiration, but the results of its use have not been satisfactory hitherto. Now that the gas can be had in a compressed state, and can be given by means of the laughing- gas inhaler, it is worthy of a further trial; but it is certain that in all cases of impending asphyxia time is of so much importance that anything which would delay the supply of oxygen would not be compensated for by giving it pure, in- stead of in the form of common air. Tracheo- tomy is not to be thought of in the first instance in any case in which air can be made to pass, even in very small quantity, through the trachea. Eor supplemental and after-treatment, see Resuscitation. J. T. Clover. ASCARIDES (aCKapls, a kind of worm).- Tliis term, by long usage, is often employed to designate the very common intestinal parasites popularly known as Thread-worms or Scat-worms. Strictly speaking, these do not belong to the genus Ascaris, but to the genus Oxyuris. The fuller consideration, therefore, of their characters and clinical importance will bo found under the Article Thread-worms. Although the term as employed in the sense referred to is altogether erroneous, there are two true species of the genus Ascaris found infesting man. These are, respectively, the common round- worm or Lumbricus ( Ascaris lumbricoides ) ; and the moustached or margined round-worm(AscaWs my stax ). Full particulars respecting the former will bo found under Round-worms, whilst the consideration of tho latter need only occupy a few words in this place. Since the discovery and description of the Ascaris mystax as a genuine human parasite by the writer in 1868, six instances of its occurrence have been noticed at home and abroad, and there can be little doubt that the parasite is much more frequent in man, especially in children, than is commonly supposed. The writer has also shown that this parasite is identical with the Ascaris mystax in the cat, which, according to most helminthologists, is only a variety of the Ascaris marginata in the dog. The males are usually from 2 to 21 inches in length ; the fe- males sometimes acquiring a length of 4 inches or more. Treatment. — Like its congener, the falsely so-called Lumbricus, the margined round-worm readily yields to treatment by santonine. Two or three grains of this drug, followed by castor oil or a saline purgative, should be administered twice or thrice daily fora few days in succession. T. S. CoBBOLD. ASCITES (daubs, a leathern sac; a large belly). — Synon. : Dropsy of the peritoneum ; Hydrops peritonei vcl abdominis; Hydroperi- toneum. Fr. Ascite ; Ger. Die Bauch wasscrsuch t . Definition. — An accumulation of fluid within the cavity of the peritoneum, more or less serous in character, the accumulation being of the nature of a local dropsy, and not originating in inflammation. The amount of fluid varies much in different cases. .Etiology and Pathology. — The chief mattai ASCITES. relating to the causation of ascites is to point out the morbid conditions by which it may be produced, as it almost always follows, and is a consequence of certain pre-existing organic diseases, of which it becomes a most important symptom and pathological phenomenon. The causes to which it has been attributed may be discussed according to the following arrange- ment: — - I. Direct mechanical obstruction affecting the portal circulation. 1. Obstruction of the trunk of the portal vein before it enters the liver, either from external pressure or internal obstruction. 2. Pressure upon or obliteration of the branches of the vein within the liver. 3. Pressure upon the trunk of the hepatic vein, or upon the inferior vena cava after it receives this vein. II. Cardiac or pulmonary diseases obstructing .he general venous circulation. III. Disease of the kidneys. IV. Morbid conditions of the peritoneum. V. Miscellaneous. I. Any direct obstruction interfering with the portal circulation must necessarily lead to congestion and over-distension of its tributaries, one of the consequences of which is exces- sive transudation of the fluid portion of the blood into the peritoneal cavity, while absorption s checked. The ascites is, under such circum- stances, in short, merely a localised dropsy, resulting from mechanical congestion. The impediment may affect either the portal trunk before it enters the liver ; its branches in the substance of this organ ; or the hepatic vein or inferior vena cava near its termination. 1. The portal trunk may be pressed upon as it lies in the fissure, by prominences from the liver itself, enlarged absorbent glands in its vicinity, a neighbouring tumour (as cancer of the pancreas or a growth in the small omentum), a hepatic aneurism, or inflammatory thickening resulting from peri-hepatitis. The pressure may absolutely close up the vessel, but it more com- monly causes a local clot to form, and thus its channel is blocked up. A thrombus is also in exceptional instances produced in connexion with a diseased condition of the portal vein, such as inflammation or calcification ; obstruction to the circulation within the liver ; or feebleness of the circulation, with an abnormal tendency to coagulation of the blood. 2. Pressure upon, or obliteration of the branches of the portal vein within the liver, can only arise as a consequence of some morbid condition involving the actual substance of this organ. The hepatic disease which by far most commonly leads to this result, and which is one of the most frequent causes of ascites, is cirrhosis. Occasionally it accompanies syphi- litic and other forms of contracted and indurated liver, or it may be associated with infiltrated cancer. The extent of the obstruction thus set up will necessarily vary with that of the morbid changes in the organ. Occasionally a mass within the liver obstructs a considerable branch of the portal vein. 3. Obstruction of the hepatic vein or inferior vena cava is a rare event, but may arise from S3 the pressure of a growth connected with the liver itself, or of some neighbouring tumour. II. Diseases of the lungs or heart which impede the general venous circulation musi necessarily exercise a speedy and direct in- fluence upon the hepatic circulation, and may thus lead to ascites. Usually, however, in cases of this kind the legs are the seat of considerable anasarca before peritoneal dropsy is observed. In course of time the continued congestion ori- ginates serious organic changes in the liver, its vessels being more or less obliterated, and consequently it is at this period that ascites is particularly liable to set in. III. Ascites may constitute a part of the dropsy which so often accompanies renal diseases. It is, however, of comparatively infrequent occurrence to any great extent under these circumstances, the amount of fluid being not considerable as a rule, and the ascites being but a subsidiary part of a general dropsy. IV. More or less serous effusion into the peritoneal cavity is a pathological result of peritonitis ; but, in accordance with the defini- tion of ascites given above, this does not come strictly within the present article. In excep- tional instances, however, true ascites is observed as a sequel of peritonitis, in consequence ol the morbid conditions which it leaves behind. Chronic peritonitis may also occasion a simple local dropsy ; but this is particularly liable to be set up in connexion with morbid formations in the peritoneum, such as cancer or tubercle, of which the writer has seen striking examples. The immediate causes of ascites associated with diseases of the peritoneum may be : — active congestion ; implication of the capillaries or minute veins, or even of the larger veins, lead- ing to mechanical congestion ; obstruction of the lymphatic orifices, and consequent impaired absorption; or undue activity of the secreting structures. V. Among the chief miscellaneous causes to which ascites has been attributed may be men- tioned exposure to cold or wet ; the sudden sup- pression of habitual discharges, or the rapid cure of chronic cutaneous affections ; and extreme anaemia and debility. These causes are supposed to originate this symptom either by inducing active internal congestion ; or by disturbing the renal functions ; or in consequence of the abnormal state of the blood and tissues ; butitis very doubt- ful whether either of them can actually of itself occasion ascites. Fluid may collect within the peritoneum as the result of the rupture of a cyst within the abdomen, especially an ovarian cyst. It must be remembered that ascites may be due to a combination of two or more of the causes which have been indicated in the pre- ceding remarks. For instance, there may be obstruction affecting the portal circulation within the liver and outside this organ at the same time; or the different organs maybe in- volved simultaneously. Predisposing causes . — Whatever tends to set up either of the morbid conditions which originate ascites, may be regarded as a pre- disposing cause. It may be met with at an> age, but is most common during middle life | The hepatic form is much more frequent ASCITES. 34 males than females. An anaemic condition of the Llood and weakness of the tissues predis- pose to peritoneal dropsy, as they do to dropsy in other parts. Anatomical Characters. — The essential ana- tomical character of ascites is the accumulation of a serous fluid within the peritoneal sac. Its amount may range from a few ounces to some gallons. As regards physical characters, the fluid is generally thin, limpid, and watery in consist- ence ; colourless or slightly yellow ; clear and transparent ; and of alkaline reaction. In ex- ceptional instances, however, it maybe coloured by blood or bile ; or more or less turbid and dirty-looking ; or of thicker and somewhat gelatinous consistence. Soft fibrinous masses occasionally float in the fluid, or these may form spontaneously when it is allowed to stand. Very rarely the reaction is neutral or acid. The specific gravity varies considerably. Chemically the fluid consists of water holding in solution al- bumin and the usual salts which are found in drop- sical fluids ; but their proportion is very variable, though the albumin is generally in good quantity, which is evidenced by the degree of coagulation which takes place when the fluid is boiled. Occasionally it contains fibrin, cholesterine, bile- elements, or, in cases of renal dropsy, urea. The effects of the accumulation upon surround- ing structures are to distend and macerate them mere or less, or to compress them. Of course along with the ascites there will be the signs of any morbid condition upon which it depends ; and there may also be indications of anatomical changes resulting from long-continued pressure of the fluid upon certain structures. Symptoms and Sions. — Ascites usually sets in very gradually, being chronic in its progress, but advancing steadily. Occasionally, however, the fluid collects with considerable rapidity. The clinical phenomena associated with this patholo- gical condition differ in different cases, both in their exact nature and their degree, according to its cause, the amount of the fluid, and other circumstances, but they may conveniently be considered under the following heads, namely : — 1 . Physical signs. 2. Mechanical effects of the dropsical accumulation. 3. General symptoms. 1 . Physical Signs .— Physical examination con- stitutes a most important part of the clinical investigation of cases of ascites, and it will be requisite to discuss the signs in some detail. (a) If fluid collects in the peritoneum in any quantity, the abdomen presents more or less general enlargement. This is often the first change which attracts the patient's attention, and it may also have been noticed that the increase in size commenced below. The degree of en- largement depends upon the amount of fluid, but it may become extreme, so that the skin is tightly stretched and thin, presenting a smooth and shining appearance, or sometimes white lines are visible, due to laceration of its deeper layers. The umbilicus becomes affected in a character- istic manner, being more or less stretched and everted, and finally becoming obliterated, or in some cases more or less pouched out, and it may form a considerable prominence. Should there happen to be a weak portion of the abdominal walls, such as a hernial sac, this will be unduly pro- truded. The important characters of abdominal enlargement due to uncomplicated ascites are that it is of a rounded form, though tending to he more prominent or to bulge towards the lower part or in the flanks, according to the posture of the patient; that it is quite symmetrical in shape, when the patient stands or lies on his back, but that the form alters considerably with a change of position, the abdomen becoming then more prominent in the dependent region, in con- sequence of the gravitation of the fluid in this direction, and it may actually he seen to move as the posture is changed. In contrast with the enlarged abdomen, the chest often looks small and depressed, and the fluid may cause its margin to become everted, or it may push for- wards the xiphoid cartilage. (b) The abdomen feels perfectly smooth and even over its entire surface. It usually gives a sensation of tension of the walls, without any hardness underneath. In some instances an obscure feeling of fluctuation is experienced on palpation with the fingers. (c) The tendency of ascites is to interfere with the abdominal respiratory movements , if it is at all considerable, by preventing the diaphragm from acting properly. At the same time the writer has not uncommonly observed that, even in cases where the accumulation of fluid has been very considerable, abdominal respiration did not seein to he much diminished. (i d ) Percussion affords some of the most im- portant signs of peritoneal dropsy ; and when the fluid is present only in small quantity, this is the only mode of examination that can lead to its detection. In tho first place marked dulness is elicited over the seat of the fluid ; while a tympanitic sound, which is often abnormally clear and distinct, is heard over the intestines. When there is but little fluid, it may be im- possible to detect any abnormal dulness as the patient lies in the recumbent posture, but on placing him on his hands and knees, the fluid gravitates towards the front of the abdomen, and dulness may then he noticed in the um- bilical region. In most cases, however, there is no difficulty in making out the dulness, and this sign is observed in those regions towards which the fluid naturally gravitates. Hence, when the patient lies on his back, the lower part and sides of the abdomen are dull, while its upper and front part is tympanitic. As more and more fluid collects, so the dulness increases in extent, gathering in, as it were, from below and from the sides, until finally the entire abdomen may be dull, except the umbilical region, which remains longest tympanitic. The boundary line between tho dulness and tympanitic sound is usually well-dofined. As the posture is changed, so will the site of the dulness vary, the part which is undermost presenting this sign, while that which becomes highest is tympanitic ; and thus the relative situation of these two sounds, as well as tho shape of the dulness, can be altered in a variety of ways. When the patient sits up, the prominence between the recti muscles gives a tympanitic sound on percussion. In exceptional instances a distended colon gives rise to a tym- panitic sound along each side of the abdomen even when there is abundant fluid present. ASCITES. Another important sign brought out by a kind of percussion is the sensation specially termed fluctuation , -which is the peculiar ware-like move- ment realised on placing the fingers of one hand over one side of the abdomen, and fillipping or tapping the opposite side with the fingers of the other hand. This sensation is very easily brought out if there is much fluid present, pro- vided it is free to move, and sometimes the motion is actually visible. Change of posture will modify the seat over which fluctuation can be produced. (e) Auscultation yields negative results in cases of ascites, there being no sound of any kind heard over the abdomen. ( f) In the large majority of cases ascites is clearly revealed by the physical signs already described. In exceptional instances, however, when the diagnosis is obscure, it is requisite to resort to a digital examination through the rectum , and in females through the vagina. The fluid collects in the recto-vesical pouch, and on examination per rectum, the finger detects the sensation of this fluid through its anterior wall. The vagina is usually felt to be shortened, while the uterus is pushed down and flexed. In ex- treme cases of ascites the posterior wall of the vagina, or even the uterus itself, may protrude through the vulva. (g) Now and then it is requisite to make use of the aspirator or a small trochar, by the aid of which not only can it be determined whether fluid is present in the abdominal cavity, but its nature can also be ascertained. This method of examination is further useful when ascites is associated with some other morbid condition within the abdomen, which frequently cannot be made out so long as the fluid remains in the peritoneum. It must be borne in mind that the ordinary physical signs of ascites will be materially modi- fied or obscured under certain circumstances. For example, the quantity of fluid may be so small that most careful examination is required in order to detect its presence; on the other hand, it may be so abundant that dulness is observed over the entire abdomen, and fluctua- tion may be very indistinct. The existence of peritoneal adhesions — for instance, those which may be formed as the result of repeated para- centesis — also renders some of the most charac- teristic signs of ascites very ill-defined. Again, the association of peritoneal dropsy with some other abdominal morbid condition, such as a new growth, an enlarged liver or spleen, or an ovarian tumour, will also modify the signs elicited. The mesentery may be abnormally short, or the in- testines may be adherent, thus being prevented from floating forwards, so that the usual relative positions of dulness and tympanitic sound are not observed. 2. Mechanical effects of the dropsical accumu- lation . — The clinical phenomena resulting from the mechanical effects of ascites are both sub- jective and objective. The patient often expe- riences a feeling of uneasiness and discomfort in the abdomen, as well as more or less tension and fulness, if there is much fluid present; while there may be a sense of fatigue and aching about the loins or abdominal walls. As a role no 86 particular pain is felt, but colicky pains are liable to occur from time to time, and extreme distension of the structures constituting the abdo- minal wall may also cause painful sensations. In exceptional instances peritonitis is set up. When the fluid is abundant, the patient expe- riences its weight when he walks, and, during this act, he throws the head and shoulders back, at the same time keeping the legs apart. Symptoms connected with the alimentary canal are of com- mon occurrence, but these are often to a great extent due to the same cause which originates the ascites, though the fluid must necessarily tend to interfere with the functions of the stomach and intestines. The bowels are usually constipated, but in some instances diarrhoea or dysenteric symptoms may arise. Flatu- lence is very commonly complained of, even a small amount of gaseous accumulation in the intestines b'feing felt unduly, producing much discomfort, and increasing the enlargement of the abdomen temporarily. Occasionally vomit- ing occurs, in consequence of interference with the stomach. When considerable fluid has re- mained in the peritoneum for some time, it presses upon the inferior vena cava and prevents the return of blood through this vessel, and may thus lead to anasarca of both lower extremities, with enlargement of the superficial abdominal veins. Exceptionally the anasarca attracts atten- tion at an early period. The flow of blood through the renal veins may also be obstructed, inducing mechanical congestion of the kidneys, with consequent diminution in the quantity of urine and albuminuria. In rare instances the fluid has been known to accumulate to such an extent as to rupture some part of the abdominal walls. Ascites also frequently interferes with the thoracic organs. The bases of the lungs are more or less collapsed, and the breathing becomes chiefly upper-costal, while a sense of dyspnoea is experienced, especially in the recumbent posture and after taking food, the breath is short on exertion, and the respirations are often hurried and shallow. The heart is likewise liable to be disturbed in its action, as evidenced by palpitation, irregularity, or a tendency to faintness. This organ may also be displaced, so that its apex-beat is raised and too far towards the left, and in rare instances a basic systolic murmur has been originated as a result of this displacement. 3. General symptoms . — The general system is frequently seriously affected in cases in which ascites is a prominent symptom, but this usually depends upon the cause or causes which have originated the dropsy, though it may itself in- duce more or less debility, wasting, anaemia, and other general effects. The loss of fluid in this way has also been supposed to lead to deficient perspiration, and consequent dryness of the skin; as well as to diminution in the quantity of urine. Diagnosis. — The first matter bearing upon the diagnosis of ascites is to determine whether this morbid condition actually exists. The presence of fluid in the peritoneum, as well as its amount, can only be positively made out by physical examination, and in the great majority of cases the signs thus elicited are quite charac- ASCITES. *6 teristic. When the fluid is small in quantity, as •well as under other circumstances in which the physical signs are obscured or modified, the diagnosis may be difficult and uncertain, but it may then be aided by a knowledge of the ex- istence of some disease likely to give rise to ascites. That the accumulation of fluid is of a dropsical nature, and not due to acute or chronic peritonitis, is usually sufficiently obvious from the history of the case, and the collateral symp- toms, while the local signs are also of a different character ( see Peritoneum, Inflammation of). The remaining abdominal enlargements from which ascites has to be most commonly distin- guished are those due to flabby relaxation of the walls of the abdomen, combined with flatulence ; accumulation of fat in the subcutaneous tissue and omentum ; abundant subcutaneous oedema, which may be associated with and obscure ascites ; an ovarian tumour ; or a pregnant uterus. Among the rarer conditions with which ascites is liable to be confounded may be men- tioned colloid disease of the omentum ; a greatly dilated stomach ; distension of the uterus with fluid; great accumulation of urine in the blad- der ; a very large hydatid tumour, usually con- nected with the liver; extreme cystic enlarge- ment of the kidney ; and the so-called ‘ phantom tumour.’ Most of these conditions are described in other parts of this work, and the limits of this article forbid any discussion of their several diagnostic characters; but a consideration of the history and existing symptoms of the case, com- bined with the results of a proper physical exami- nation, constitute the data upon which the diag- nosis is founded. It roust be remembered that ascites may coexist with other morbid con- ditions in the abdomen, their physical signs being combined. Should there be an enlarged organ or other solid mass, it may often be recognised by making sudden firm pressure with the fingers over the abdomen, when the fluid is pushed aside, and the underlying resistance can be felt ; or paracentesis may be performed, and further examination carried out after the evacuation of the fluid. Another most important point in the diagnosis of ascites is to make out its cause. Por this purpose all the facts bearing upon the case must be taken into account and carefully weighed, special attention being paid to the liver and the structures in its vicinity, to the heart, and to the kidneys. The amount of the ascites, and its relation to other forms of dropsy, afford consider- able aid in the diagnosis. If it results from cardiac or renal disease, ascites always follows dropsy in other parts of the body, to which it is also generally subordinate; when it is due to hepatic or some neighbouring disease, the peri- toneal dropsy appears first, and is throughout most prominent. Should the vena cava inferior be obstructed at its upper part, anasarca of the legs will be observed simultaneously with, or even before the ascites. Prognosis. — The prognosis of ascites will mainly depend upon its cause ; the amount of fluid present; the state of the patient; the condition of the main organs ; and the results of treatment. In some cases this symptom is in it- Bolf attended with immediate danger, on account of the mechanical effects of the dropsical accumu lation, especially upon the thoracic organs, and still more if these organs are in a diseased condi- tion. In other instances it aids in reducing the patient, and in thus bringing about a fatal ter- mination. When ascites is due to local inter- ference with the portal circulation, great relief can unquestionably be afforded in a considerable number of cases, and life may be prolonged by appropriate treatment ; while, if the local causo is not such as in itself to lead to a fatal issue, the ascites may not infrequently be permanently cured. Treatment. — The principles of treatment ap- plicable to cases of ascites are (a), to attend to the condition upon which the dropsy depends, and thus endeavour to get rid of its cause ; (6) to promote the absorption of the fluid ; (c) to im- prove the constitutional condition and the state of the blood, if necessary ; (d) to remove the fluid by operation, if absorption cannot be ac- complished ; and ( e ) to treat any symptoms need- ing special attention. («) As an important, part of the treatment directed to the cause of ascites, particular atten- tion must be paid to those organs which are most commonly accountable for this symptom, though unfortunately in a large proportion of cases but little effect can be produced upon the dropsy in this way. ( b ) Absorption of the fluid is chiefly promoted by acting freely upon the bowels, skin, or kidneys. The class of remedies indicated will vary in different cases, and must be adapted to the state of the different organs, but as a rule active pur- gatives are most efficient in relieving ascites, especially when due to local causes, of which the most useful are compound jalap powder, cream of tartar, elaterium, calomel, gamboge, podo- phyllin, and croton oil. These remedies must, however be used with due caution. In some instances balsam or resin of copaiba has proved useful in the treatment of peritoneal dropsy. Assistance may be derived in certain forms of ascites from acting upon the skin by means of various diaphoretic baths. Digitalis and squills may be of service as diuretics ; or the application of poultices of digitalis leaves over the abdomen is occasionally attended with benefit. The administration of iodide of potas- sium also seems to aid absorption in some cases. (c) Treatment directed to the general condition of the patient, and to the state of the blood, is undoubtedly valuable in many cases of ascites. Tonics are often of decided service, and prepara- tions of iron are specially indicated for im- proving the quality of the blood, if there is any tendency to anaemia. Not only do these remedies sustain the patient, but they may also have an influence in promoting the process of absorption. The diet must bo adapted to the circumstances of the case, but usually needs to be of a nutri- tious character. ( d ) In a considerable proportion of cases, however, no effect is produced upon the dropsical accumulation by any of the measures thus far considered. Then it becomes necessary to de- termine whether it is desirable to remove the fluid by operation. The fluid may be taken away either by means of the aspirator, or by the trochar and canula. The advisability of ASCITES. having recourse to this plan of treatment must depend upon circumstances. The ascites is fre- quently not sufficiently abundant to justify paracentesis, and when the condition is of cardiac or renal origin, the operation can only afford temporary relief, so that there is no object in resorting to it unless the mechanical effects of the accumulation are such as to cause trouble- some or dangerous symptoms, and it had better be delayed as long as possible. When ascites is a local dropsy, the fluid is often so considerable in amount as to necessitate its removal for the mere purpose of giving relief for the time. In cases of ascites associated with malignant disease, for instance, this is all that can be hoped for, as the fluid will certainly collect again. When, however, the condition is due to some local disease which is not in itself fatal, and especially to cirrhosis of the liver, the writer has found signal benefit result from the repeated performance of paracentesis, and has advocated this plan of treatment as a curative measure, so far as the ascites is concerned. Barely does the operation give rise to any immediate ill-effects, and it is frequently found that remedies will act much more efficiently after the removal of the fluid than they did previously. In the writer's experience paracentesis repeated as often as the fluid re-accumulated has ultimately led to a complete cure in several instances; in others the cure was partial, a certain quantity of fluid remaining in the peritoneum, limited by ad- hesions; while in others still, life has been greatly prolonged, and much comfort afforded. The repeated accumulation does not seem to affect the system materially by reason of the drain upon it, and frequently not at all. Of course due care must be exercised in the per- formance of the operation, and in the subsequent treatment. In a few days after the removal of the fluid, the application of a bandage firmly round the abdomen, so as to exert even pressure, may prove of service in aiding the absorption of what remains, and preventing the recurrence of the ascites ; and this measure may also be useful when a certain amount of fluid continues after the repeated performance of paracentesis. (e) The symptoms resulting from ascites which are likely to require attention are those con- nected with the alimentary canal ; dyspnoea ; and cardiac disturbance, or a syncopal tendency. These should be treated on ordinary principles ; but it must be observed that marked dyspnoea, if evidently due to the fluid, is an indication for the immediate performance of paracentesis. FREDERICK T. BoBERTS. ASIATIC CHOLERA. Sec Cholera, ASPHYXIA (a, priv., and o- order). — Terms which originally meant any irregularity or disorder, but are now specially applied to ir- regularity of associated or co-ordinated muscular movements. The noun is frequently used as synonymous with the disease known as Loco- motor Ataxy. See Locomotor Ataxy. ATELECTASIS (are\i;s, imperfect, and eKTatrts, expansion). — Absence or imperfection of the expansion of the pulmonary alveoli which normally takes place at birth, the lungs thus remaining more or less in their fcetal condition See Lungs, Collapse of. ATHEROMA. See Arteries, Diseases of. ATHETOSIS (fideToy, without fixed po- sition). — Definition. — A name given by Dr. Hammond of New York to a condition in which the hand and foot are in continual slow irregular movement, and cannot be retained in any position in which they may be placed. Description. — The special character of the movements in athetosis is that they are slow and deliberate. They usually affect the arm and leg on one side only. Voluntary power is retained, bntis interfered with by the slow spasm. The fingers areirregularlyflexedandextended: at onemomeDt they spread wide apart, the thumb being over- stretched; thereafter first one, then another isbent in to the palm, and again extended. The move- ment can be arrested for a moment in certain positions by the will, but is renewed with in- creased force. The foot is usually inverted; the toes being flexed or extended, but in less constant movement. The spasm may cause pain. The muscles sometimes become hypertrophied. The movements in some cases cease during sleep, in others they do not. Sensation is often, but not always impaired. The onset of this condition is usually sudden, and in some cases with a con- vulsion. The subjects bave been generally in middle life. Athetosis differs from tho spastic contrac- ture so common after hemiplegia in children in the slowness and spontaneity of the move- ments ; but the two conditions are probably very closely allied. It cannot be regarded as a distinct disease. Typical athetosis may suc- ceed hemiplegia. Pathology. — It is probable that, as Dr. ATHETOSIS. Hammond suggests, the seat of the mischief in athetosis is the corpus striatum or optic thala- mus. The sudden onset of the disease, and the slight affection of sensation, render it pro- bable that a lesion damaging, but not destroy- ing, a portion of one of these nuclei, leads to a perverted action of the nerve-cells, so that abnormal motor impulses are originated, and those transmitted from above disturbed — 1 irra- diated’ (Nothnagel). Charcot believes that all post-hemiplegic chorecrd movements depend on the implication of fibres outside the optic thalamus. In a case of simple ataxy after hemi- plegia — an analogous condition, — the writer has found a cicatricial sclerosis extending across the optic thalamus, and probably left by a patch of softening. Prognosis. — This is unfavourable, hut the slighter cases improve and may even approxi- mately recover. Treatment. — Nervine tonics and sedatives are the remedies chiefly indicated. Of the former arsenic, and of the latter Indian hemp, do most good ; bromides are also useful. The continuous current is perhaps the agent which affords most distinct relief. In one well-marked case under the writer’s care the spontaneous movements ceased entirely after some months’ galvanisation. The positive pole may be placed on the spine or brachial plexus, the negative on the muscles involved. The action of the continuous current is probably in part direct, in part reflex, lessening by the peripheral impression the over-action of the centre, as do some other peripheral Impressions. W. R. Gowers. ATONY* } P rir ” and ' rivo ' s ' tone )-— Terms implying want of tone, power, or vigour, and associated either with such a condition of the system generally, or of particular organs, espe- cially those which are contractile. ATRESIA (a, priv., and rlrpri/xi, I pierce).— Absence of a natural opening or passage, whether congenital or caused by disease. ATROPHY, GENERAL.— Synon. : Ma- rasmus. Definition. — Atrophy means, etymologically, simply want of nourishment (a, priv., and rpoepr), nourishment), but the term is commonly applied to the condition resulting from want of nourish- ment, namely, wasting or diminution in bulk and substance, even though this may have bpen pro- duced by some other cause, and even though the supply of nutritive material may have been abundant. General atrophy is used to denote wasting in which the whole body participates. All acute diseases, if severe, are accompanied by emaciation, for at such times nutrition is tem- porarily interfered with. The use of the word ‘ atrophy ’ is, however, confined, as a rule, to cases where the interference with nutrition has been gradual, and the loss of flesh consequently slow. ^Etiology. — Atrophy is common enough at all periods of life. In infants and children it is duo. in the majority of cases, to chronic functional derangements which interfere with the digestion and elaboration of food. Less frequently it is a ATROPHY, GENERAL. 9o consequence of organic disease. In adults general atrophy seldom results from any other cause than organic disease, and functional disorder as a cause of serious wasting is the exception. In old age atrophy is a common consequence of the degenerations of tissue which accompany the decline of life. The interference with nutrition may, however, be aggravated by the presence of disease. In infants under twelve months old there are four principal causes to which chronic wasting can usually be referred, namely, unsuitable food ; chronic vomiting (gastric catarrh) ; chronic diarrhcea (intestinal catarrh) ; and inherited syphilis. Bad feeding, by setting 'up a chronic catarrhal condition of the stomach and bowels, is a frequent cause of both vomiting and diarrhoea, but it may produce atrophy without either of these symptoms. AVhen an infant, is fed, for instance, with large quantities of farinaceous matter — a form of food which is alike indiges- tible and innutritious — a very small part only can enter as nutriment into the system. The remainder passes down the alimentary canal, and is ejected at rare intervals in an offensive putty- like mass or in hard roundish lumps. The child, therefore, although overloaded with food, is really under-nourished, and loses flesh as long as such a diet is persisted in. If, as often happens, diarrhoea or vomiting be set u p by the irritation to which the digestive organs are subjected, wasting is more rapid and the danger of the case is increased. Any form of bad feeding, and not only excess of farinaceous matter, will produce this result. Wasting, indeed, will he found in every case where the food selected is unfitted for the child, and thus it is not unfrequently seen in infants who are fed upon milk and water alone. The casein of cow’s milk is difficult of digestion by many infants on account of its tendency to coagulate into a large firm clot like a lump of cheese. In this respect it differs from the curd of human milk, which forms light small floccu- lent coagula, and is digested without difficulty. Special preparation is therefore generally' re- quired to render cow’s milk a suitable diet for a young child. It is not only, however, unsuitable food which is a cause of atrophy in infants. Catarrh of the stomach and bowels may be present, although the feeding is in all respects satisfactory. In- fants are excessively sensitive to chills, ami catarrh of their delicate digestive organs is easily excited. Now, catarrh of a mucous mem- brane is always accompanied by an increased flow of mucus, and this alkaline secretion in excess acts as a ferment and sets up decom- position of food. A sub-acute gastric catarrh from this cause is not rarely seen in new-born infants, who thus are rendered for the timo incapable of digesting even their mother's milk. In such cases the fault is usually attributed to the milk, which is said to be unsuited to the child; and the mother is compelled, much against, her will, to wean her baby and feed it in a different way. So long as the catarrh continues, however, no food appears to agree, and the child often after a time dies exhausted. Between one and three years atrophy is • com- monly associated with rickets. In theso cases 9(j ATROPHY, GENERAL, the wasting is noted chiefly about the chest and limbs, for the belly is large and swollen from flatulent accumulation. At this age children are still liable to waste from catarrh of the stomach and bowels: indeed, rickets is itself often com- plicated by such derangements. Cancer of the internal organs is also sometimes found at this time of life, and is attended with extreme emaciation. AJ'ter the age of three years caseous enlarge- ment of the mesenteric glands becomes a cause I of wasting. After the fifth or sixth year chronic pulmonary phthisis begins to appear. Cases of heart- disease as a result of acute rheumatism are also more frequently seen. Diabetes, too, is sometimes met with. All these diseases may pro- duce much interference with nutrition. From the time that the child begins to take other food than that furnished by his mother's breast, he is liable to worms in the alimentary canal. The presence of worms is frequently accompanied by loss of flesh, not, perhaps, so much on account of the parasites themselves, as on account of the derangement of the digestive organs which is associated with them. Emacia- tion due to this cause may sometimes be extreme. In the adult atrophy is rarely the result of mere functional derangement, but is almost in- variably a sign of serious organic disease. All chronic ailments are not, however, accompanied by marked wasting. Purely local diseases lead to little loss of flesh unless they affect some part of the digestive apparatus, or of the glandular system which is concerned in the elaboration of nutritive material ; or otherwise directly influence the processes of nutrition. Thus, emaciation quickly results from gastric ulcer or chronic dysentery, but chronic pneumonic phthisis may produce little diminution in weight if there is no pyrexia, and if the case is not complicated by diarrhoea or profuse ex- pectoration. The most marked atrophy is pro- duced by the so-called constitutional diseases, such as cancer and syphilis in the third stage ; by those which set up a persistent drain upon the system, such as severe albuminuria, chronic haemorrhages, and long-continued suppurations ; or by those which directly impede the passage of nutritive material into the blood: and in the latter class of diseases, influences which act directly upon the thoracic duct, such as obstruction to its passage from pressure by aneurism and other tumours, must not be over- looked. There is a form of atrophy sometimes seen in hysterical females, depending upon dis- ordered innervation, in which the most extreme emaciation may be reached. Such cases are marked by a dislike to food which may amount to absolute loathing. Symptoms. — The symptoms of general atrophy are loss of flesh, loss of colour, and loss of strength, combined with other special phenomena arising from the particular disorder to which the impair- ment of nutrition is due. Anatomical Chakactehs. — The most marked post-mortem appearance in this condition is diminution or loss of fat, especially of the sub- cutaneous adipose tissue ; and this is accom- panied by wasting of the tissues and organs ATROPHY, LOCAL. generally. The histological elements are reduced in size without undergoing, as a rule, actual numerical diminution. With the atrophy ia often associated a certain amount of fatty degeneration. Treatment. — The treatment of general atro- phy consists in removing, if possible, the impedi- ment to efficient nutrition. In the case of a child the diet must be selected with care. Excess of farinaceous food is to be avoided, and cow's milk can be diluted, if necessary, by admixture with thin barley water. Any gastric or intestinal derangement must be at once remedied, plenty of fresh air should be obtained, and perfect cleanli- ness strictly enjoined. In an adult the disease which is the cause of the malnutrition must be sought for and submitted to treatment. Efforts should be made on the one hand to arrest any drain upon the system ; and, on the other hand, by a judicious arrangement of the dietary, and by attention to the eliminatory organs, to remove all obstacles to the entrance of nourishment. Even in cases of organic and incurable disease much benefit may often be derived from due observance of physiological laws. Eustace Smith. ATROPHY, LOCAL. — This condition sig- nifies atrophy of a part of the body, which may be apparently congenital, or may be produced by various causes acting during life. It will be convenient to consider local atrophy according to the several forms which are met with. Congenital Atrophy is that condition in which some part of the body never reaches its full standard of size. It is more correctly den’o minated arrested growth or congenital smallness. When the whole of one side of the body is thus affected, a marked and permanent dispro- portion between the two sides results. This hemiatrophy is, in theory, difficult to distinguish from hypertrophy of the opposito side, but mostly the paralytic or enfeebled state of the atrophic side shows it to be abnormal. The limbs are most strikingly implicated, while the corresponding side of the face and head is some- times similarly, sometimes conversely affected. In many cases atrophy of the opposite half of the cerebrum was found on post-mortem examina- tion. The same condition may be partial — hemiatrophia partialis — and it then chiefly affects the face, or some part of the territory of the fifth cranial nerve. These conditions must be ascribed to some perversion of innervation occurring during development. Other congeni- tal atrophies, local but not /jc/m'-atrophic, an more probably referred to obstruction of blood- vessels during the same process. The defective development of the brain in cretinism has been attributed to the pressure of an enlarged thyroid upon the carotid arteries. Physiological Atrophies. — These form a distinct class, where atrophy of a part of the body takes place in the ordinary course of development. Such are the wasting of the thymus gland in early life, of the niammte and sexual organs after middle age. Most commonly the atrophy is here closely connected either with the involution or perhaps the development of some correlated organ ; but it is not possible ATROPH Y, LOCAL. to say what the nature of this connection is, whether one of nutrition or of innervation. Acquired Atrophies. — The conditions thus distinguished possess most interest for the practical physician. Wasting of any part of the body during life, when not physiological, usually depends either upon some interference with the blood-supply, or some disturbance of innervation ; but to these must be added, in the case of organs which have an active and con- tinuous function, disuse or over-stimulation. Deficient blood-supply, which causes atrophy, may be produced by the obstruction of a nutrient artery, especially if it be gradual, since sudden blocking will produce more complicated pheno- mena. Constant pressure is a cause of atrophy, because it interferes both with the blood- supply, and with the vital actions of the tissue- elements. Intermittent pressure, on the other hand, by causing hypertemia, is more likely to lead to hypertrophy. Moreover, inadequate renewal of blood, that is, filling of the vessels, even to excess, with venous blood, or venous en- gorgement, though at first it may cause enlarge- men’ mostly leads to atrophy in the end ; as is seen n the granular induration of liver and kid- neys aused by disease of the heart obstructing the circulation. Many forms of atrophy in old age are clearly dependent upon senile obstruction of the arteries, for example, that of the skin, spleen, and kidneys. The instances of atrophy from disturbed innervation are less easy to discriminate, except where there is actual paralysis. In two distinct dis- eases, however, progressive muscular atrophy and infantile or essential paralysis, loss of power in the muscles is followed by a remarkable wasting, far more rapid than that which results from dis- use alone. Division of the nerve of a limb produces rapid wasting of the muscles no longer used, and this is accompanied in the end by some diminu- tion in the size of the bones and accessory parts. Local atrophy of the skin is sometimes seen in regions limited by the distribution of a nerve, especially some branch of the fifth ; and more ex- tensive atrophy of one side of the face or head, equally marked out by nervous distribution, and resembling some cases of congenital atrophy, has also been, though very rarely, observed. These facts raise the interesting question whether there are ‘ trophic nerves.’ Without discussing this question, it may be pointed out that the nerves which delineate an atrophic region are always motor or mixed branches, never solely sensory. Disuse produces atrophy only in organs whose functions are active and constant, such as nerves and muscles. Nervous tissue wastes constantly, and sometimes rapidly when currents cease to traverse it. This is seen not only in the nerves of paralyzed limbs, but even in the nerve-centres, where any interruption of the nervous channels, either above in the cerebrum, or below in the nerve-trunks, is followed by degeneration, ending in atrophy, of the whole nervous tract leading from the cerebral cortex to the peripheral termination — so called secondary degeneration of the cord. In muscu- lar tissue the wasting is almost as constant, but hysterical paralyses make an exception, the helpless limbs preserving their nutrition in a surprising manner. In organs whose functions 7 97 are intermittent or periodic, disuse does not appear necessarily to produce atrophy, as is seen in the ovaries, testicles, and mammae. That excessive stimulation or over- work may produce atrophy is seen in degenerative diseases of the nerve-centres arising from undue mental activity; and of the sexual organs from exces- sive indulgence. Unexplained Atrophies. — Cases of local atrophv occur of which it is impossible to give any satisfactory explanation. Such are the con- ditions known as linear atrophy of the skin ; some remarkable cases of atrophy of bone, especially of the skull ( fragilitas ossium), and of some parts of the cerebrum. We may have to attribute to changes of the latter class just men- tioned, certain peripheral atrophies, without being able to account for the original lesion. It is possible that deficiency of special kinds of food may lead to atrophy of special organs — thus deficiency of lime may make the bones soft, and deficiency of iron arrest the development of blood-corpuscles ; but even these familiar in- stances must be accepted with a little reserve. In the same way it is still doubtful whether any special drugs, such as iodine, can produce atrophy of special glands. Pathology.- — Wasting may occur simply, or as a consequence of change of substance, or from the intrusion of some new material; in other words, there may be simple atrophy, atrophv frorn degeneration, or atrophy by substitution. Tho first is probably rare ; generally some change of substance occurs. The most frequect degenerative process is fatty degeneration ; the albuminous substance being converted into or replaced by fat, which, if afterwards absorbed, leaves a void. Organs thus affected may be apparently enlarged, though the original sub- stance is wasted. Atrophy from substitution is seen when the connective tissue of an oraan, for instance, increases, compressing and destroying the other tissue-elements, and these not being renewed when the newly-formed'connective-tissue is absorbed, the whole organ is diminishea in bulk. This is seen in all the changes called cirrhosis or fibroid degeneration, as in cirrhosis of the liver and kidneys. 'Treatment. — No general rules can he laid down for treating all cases of local atrophy. Where the blood-supply is deficient, we have rarely any means of supplementing it; where innervation is at fault, it is seldom under our control. In general, harm rather than good results from anv attempt to attract blood by artificial irritation. In the case, however, of atrophy from disuse of the nervo-nmscular system, a line of treatment, and more especially of prophylaxis, is very clearly indicated ; that is, to keep the muscles in exercise by artificial means, particularly by electricity, or by the processes of friction and kneading, known as passive motion. In this way so much of the atrophy as is due simply to disuse may be cheeked for the future, and. even the past loss reinstated. We shall, moreover, never do harm by attempting to supply some special kind of food which appears to he deficient, as iron for the blood and phosphorus for the hones or nervous system. J. F. Paynu. 38 AUDITORY NERVE. AUDITORY NERVE, Diseases of. See Eah, Diseases of ; and Hearing, Disorders of. AURA ( ailpa , a breeze). — A peculiar sensa- tion, subjective in origix, immediately preceding an epileptic or hysterical convulsion, and named respectively Aura Epileptica and Aura Hysterica. The word was originally adopted because the sensation is often described as that of the pas- sage of cold air or light vapour from the trunk or extremities to the head; but it has been ex- tended so as to include any phenomenon, whether sensory or motor, that ushers in a fit of epilepsy or of hysteria. AURAL DISEASES. See Ear, Diseases of. AUSCULTATION ( ausculto , I listen).— A method of physical examination, which consists in listening over various parts of the body, either by the direct application of the ear ( immediate auscultation), or by the aid of special instru- ments ( mediate auscultation), for the purpose of studying certain sounds produced in health and disease. See Physical Examination. BACTERIA. AUSCULTATORY PERCUSSION.— A metho of physical examination in which the sounds elicited by percussion are studied by means of auscultation. See Physical Examina- tion. AUSTRALIA. See Appendix. AUTOPEONIA (ainls, itself, and tpuA), the voice). — A physical sign obtained by study- ing the modifications of the resonance of the observer's own voice during auscultation. See Physical Examination. AUTOPSY. See Necropsy. AZORES, St. Michael's. — "Warm, very moist, equable climate. Mean winter tempera- ture 58° F. Prevailing winds N. and E. See Climate, Treatment of Disease by. AZOTURIA. — A condition of the urine in which there exists an absolute and relative ex- cess of urea, without accompanying pyrexia. See Urine, Morbid Conditions of. B BACILLUS (from bacillum, a little staff) is the name now given to certain filiform Bacteria which have assumed much importance of late, principally because of their constant presence in the blood and tissues in splenic fever and malig- nant pustule. See Leptothrix, auu. Bacteria ; also Pustule, Malignant ; and Bacilli in Appendix. BACTERIA ( fiaicTTipiov , a rod) are some of the lowest known forms of life. They most fre- quently exist as minute rod-like bodies, about inch in length, with a slight median con- striction. They may be larger or smaller than this, and may present minor variations in form. They swarm in all putrefying solutions and mix- tures of organic matter, and in many fermenting fluids in which the chemical changes are not ac- companied by an emission of stinking gases. In fluids belonging to the latter category, the typical Torula or yeast-cell may be met with, as well as organic forms strictly intermediate between it and the typical Bacterium. From a chemical point of view, it is admitted that no absolute line of demarcation can be drawn between the intimately related processes of putrefaction and fermentation ; whilst from a biological point of view we are similarly unable to erect any impass- able barriers between the organic forms which are found as part of the products of change in putrefying and fermenting fluids respectively. It is unquestionably true that typical Bacteria are most frequently met with in putrefying fluids ; whilst, on the other hand, typical Torulae are only present in some fermenting fluids. But the rather long rod-like bodies, which have been hitherto named Vibriones, and the still longer filaments mostly known as Leptothrix (see Lep- roTHRix), are unquestionably capable of being derived from ordinary Bacteria in certain media. In the most highly putrescent fluids Bacteria are usually found to he very small, because, though the total bulk of living things rapidly augments in such fluids, the individual units (in consequence of the frequency with which a process of fission takes place) do not increase in size. In less putrescent fiuids, however, where the chemical changes constituting the putrefactive process take place more slowly, the living forms also appear and grow with less rapidity ; and owing to the co-existence of a lower frequency of fission or spontaneous division amongst such individual living units, they often attain a larger size. They then appear, according to their length, either as Vibriones or as Leptothrix fila- ments. These are plain, jointed, or monilated, according as partial segmentation is absent, has taken place rarely, or has occurred so rapidly as to give what would have been a plain fila- ment the appearance of a string of beads. Concerning the question of the precise rela- tion of organisms to the processes of putrefac- tion and fermentation, opposite opinions are at present held. Believers in Pasteur's germ-theory maintain that they are invariably the initiators of these chemical processes ; whilst those who reject this theory, as being too exclusive, con- tend that putrefaction and fermentation may be initiated in the absence of Bacteria and their germs. Those holding the former view believe that Bacteria are only capable of being derived from pre-existing organisms of like kinds; whilst those who reject it contend that particles of living matter, which develop into Bacteria, may be generated from the organic compounds dissolved in fermentable fluids, and that such particles of living matter are, in fact, just as much products of the fermentative process and of the fluid in which it occurs, as are the gases simultaneously generated therefrom. According to this view, these lowest living units bridge the gap hitherto held to exist between living BACTERIA. and so-called dead matter, and afford an illus- tration of the natural independent origin of chemical compounds so complex and endowed with such attributes as to win for them the name of ‘vital’ compounds. (See Proceed- ings of the Royal Society, No. 172, 1876, pp. 149-156.) Pasteur’s ‘Vital theory’ of fermentation is one of great importance both to chemists and biologists, and it also forces itself upon the attention of medical men, as the parent of another doctrine which has of late assumed great prominence in relation to the science of medicine — the doctrine, namely, that lower or- ganisms allied to those met with in putrefying and fermenting media are causally related to cer- tain morbid processes with which they either do, ->r are said to coexist. Bacteria and their allies are as uniformly coexistent with a few general diseases and certain local morbid processes as they are with putrefactions and fermentations, so that the same general question as to the precise significance of this coexistence again presses for solution. Are the organic forms associated with such morbid processes the sole causes or inciters of these processes ? or are they consequences (i.e. concomitant products) of pathological processes which have been initiated in their absence? The former view is warmly supported by many who regard Bacteria and allied organic forms as the contagious elements of such communicable diseases ; and many of these same pathologists, resting upon analogy, wish to extend their theory, so as to make it applicable to many other communicable diseases with which organic forms have not as yet been shown to be correlative. Thus, just ascertain chemists hold that Bac- teria and allied forms are the causes of all fermentations and putrefactions, so certain pathologists either do actually, or are inclined to maintain that Bacteria and allied organisms of common or of special kinds are the causes of all communicable or contagious diseases. Accord- ing to such chemists all ferments are living organisms ; and according to such pathologists all contagia are allied living organisms. The coexistence of organisms is one which ob- tains for almost all fermentations, but only for a few of the communicable diseases, so that any argument deducible from such mere coexistence in favour of the causal relationship of the or- ganisms, is much stronger in the case of fer- mentations than as regards diseases. Yet, in spite of the almost universal coexistence of organisms with fermentations, it is still necessary for us to ask whether they appear as causes or as ^effects of these phenomena. From this it may be judged how little the more limited ‘facts of coexistence’ should be allowed to influence our opinion on the derivative ques- tion of the relation of the lower organisms to disease. At least one of the reputed instances in which this coexistence of organisms has been dwelt upon, as showing that they are the causes of the morbid phenomena with which they are associated, has of late been dissipated, since in the case of the small-pox of sheep ( variola ovina) the allegod organisms are now admitted to havo no existence — certain appearances pro- BADEN. 99 duced in tne tissues by preservative media having been mistaken for organisms which have been elaborately describedand figured. (SeePro- ceedings of the Royal Society, No. 172, 1876,p.l40.) But even if all the alleged cases of coexistence of organisms with morbid processes were real, and if future investigations should show that such facts are more numerous than are at pre- sent imagined, still the multiplication of this evidence to any extent will never help us (any more than it has dene in the case of fermenta- tions) to solve the real question — whether such morbid processes are only caused and propa- gated by organisms, or whether they may at times como into existence independently? The vital or germ-theory of fermentation would bo broken down and become untenable whenever it is shown that fermentation can originate independently of the Bacteria and their germs which appear as part of the process. Similarly, the germ-theory of disease would be refuted, if it could be shown that some of the morbid processes in question could originate in the absence of the living organisms which sub- sequently appear as part of the pathological products. The latter refutation, however, could never be made directly, since no living being could in any circumstance whatsoever be proved —in an experimental sense — to be beyond the possible reach of some of the alleged disease germs. But inasmuch as this problem is, from its very nature, one which does not admit of experimental proof or disproof in the strictest 6 ense of the term, and because this germ-theory of disease is clearly a derivative doctrine from the germ theory of fermentation, it must stand or fall with the germ-theory of fermentation, which, fortunately, is capable of experimental proof or disproof. The question of ‘spontaneous generation’ comes, therefore, to be inextricably mixed up with the question of the truth or falsity of the germ-theory of disease, so that the study of the latter to the neglect of the former can only end in the propagation of vagueness and uncertainty’. The real question is not as to the extent or frequency of the co- existence of organisms with local or general diseases, but the much more important one as to the nature of their relation to such pro- cesses. If they act as invariable and sole causes, then their presence is a matter of the deepest interest and importance. If, on the other hand, the organisms are not causes but rather concomitant products, their presence from a purely medical point of view is of trifling im- portance. The study of their growth and development would in that case be important only as adding to our knowledge of the struc- tural changes pertaining to the diseases in ques- tion. See Transactions of the Pathological Society, vol. xxvi., and Journal of the Linncean Society, vol. xiv. See also the articles Micrococci; Pus- tule, Malignant ; and Zyme. H. Charlton Bastlax. BADEN-BADEN' in Germany. Thermal saline waters. See Mineral AVaters. BADEN in Austria. Thermal sulphur waters. See Mineral AVaters. 100 BADEN. BADEN In Switzerland. Thermal sulphur waters. See Mineral Waters. BADENWEILER in Germany. Simple thermal waters. See Mineral Waters. BAONEBES-DE-BIGOEEE in France. Simple thermal and earthy waters. See Mineral Waters. BAGNERES-DE-LTTCHON in Prance. Thermal sulphur waters. See Mineral Waters. BALANITIS — BALANOPOSTHITIS (/3d\a,vos, an acorn, and iroaQn), the foreskin). — - Synon.: Bastard Clap; Blennorrhagia Balani; Inflammatory Phimosis. Definition. — Inflammation of the opposing surfaces of the glans and prepuce ; sometimes acute — even gangrenous, and sometimes chronic. A purely local affection ; frequently, but not necessarily, of venereal origin. JEtiology. — Balanitis is mneh less common than urethritis, being met with at the Lock Hos- pital in the proportion of one to twenty-four of the latter. It may be either primary; or con- secutive to chancres, syphilitic eruptions, warts, accumulated smegma, variolous pustules, or gonorrhoea. When primary, the common pre- disposing co,nse is a long, narrow foreskin. Pour- nier attributes two-thirds of the cases of balanitis to a long prepuce with insufficient cleansing; about one-third to irritation by chancres and gonorrhoeal pus ; and a very few to other causes. Symptoms. — The symptoms of balanitis de- pend on the intensity and extent of the inflam- mation. In the simplest form there is heat and itching of the furrow, slight redness of that part, with a milky or yellowish secretion. When the inflammation is more severe and extended, swelling and pain are added, the other sym- ptoms are more marked, and characteristic excoriations appear. They are irregular, shal- low, never extending more deeply than the epithelium, but often coalescing into large raw chafings. An abundant yellowish-green matter of offensive odour bathes the surface. When the urine trickles over these excoriatious there is severe smarting pain. If still further irritated, the foreskin swells enormously, is divided at the free border by deep creases, and can no longer be turned back. Aching, smart- ing, great tenderness, and painful erection, often accompanied by constitutional disturbance and fever, are present. Complications. — The cellular tissue and the lymphatic ducts of the foreskin and sheath, or thelymphatic glands, may inflame to suppuration, to ulceration, and, in persons enfeebled by any cause, even to gangrene. Sloughing begins on the inner surface of the foreskin at the upper part ; seldom to much extent, though the whole prepuce, except the frser.mn, maybe lost, and when cicatrisation sets in the organ appears circum- cised. Paraphimosis is caused by imprudent retraction of a swollen foreskin. Warts keep up chronic posthitis of the furrow. Adhesions, usually at the corona and the furrow, may attach the prepuce completely to the glans. Thickening and phimosis are not uncommon after repeated attacks. Course. — The duration of balanitis depends BALDNESS. on the anatomical condition of the parts. When remedies can be easily applied, it is not more than three or four days. With phimosis, the course is severe, and the duration is indefinite ; even when limited to the furrow, posthitis is often obstinate. Diagnosis. — This is easy when the parts can be exposed. Herpes is distinguished from balanitis by small grouped round ulcers, limited to one or two points of the mucous surface, without general congestion. Simple chancre has well-defined undermined edges and a spongy surface. The syphilitic sore has the indurated base and en- larged lymphatic glands. When there is phi- mosis, the discharge may come from the urethra or from a chancre. If from the urethra, it can be usually seen escaping thence, and there is pain along the penis, with other signs of urethritis. A chancre under the foreskin is betrayed by a hard and tender point, and after a few days consecutive sores usually appear at the orifice of the prepuce. Prognosis in the primary form is always good. If the complaint is secondary or symptomatic, gangrene may result. Treatment. — The chief indication is to keep the inflamed surfaces separate. After washing and thoroughly drying, the excoriations should be touched with a 10-grain solution of nitrate of silver, and a bit of dry lint laid on the glans before the foreskin is drawn forward. If there is phimosis, frequent injections of tepid water, and twice daily of a 5-grain solution of nitrate of silver must be thrown to the farthest part of the foreskin with a long-nozzled syringe. Leeches to the groins, and opium internally, as well as in injections, relieve pain. Acupunctures give vent to simple oedoma, but tend to accelerate gangrene with brawny tension and erysipelatous redness. Incisions, if needed, should be free : one on each side, carried quite back to the fur- row. The upper half of the foreskin can then be easily turned back, and the subsequent de- formity is less than if the foreskin is divided at the dorsum. In paraphimosis, before replacing the swollen foreskin, the tension should be re- lieved by acupuncture and astringent lotions, or by incisions if needed. Berkeley Hill. BALDNESS. — Synon. : Alopecia. Description.— -Baldness or loss of hair pre- sents an extensive range of variation in degree, from moderate thinness of the hair, such as occurs in Dejluvium capillomm, to compleie baldness — Alopecia calva or Calcif ies, the latter not limited to the scalp alone, but involving eyebrows, eyelashes, beard, and every hair of the body. Instead, however, of being general, bald- ness may be partial, affecting more or less of the surface of the scalp for example, the summit and forehead in men, and the summit and occiput in women. One remarkable form of partial baldness has been denominated Alopecia areata, or simply Area, and as this was described by Celsus, it has likewise been called Area Cclsi. Area occurs suddenly, and is a mere falling-off of the hair over a space of circular figure ; there may be one or more of such Arese, and sometimes Area is only the beginning of Calvities. Area is likewise occasionally met with in the whisker.? and beard. BALDNESS. Pathology. — The pathology of Alopecia is a loss of nutritive power of the skin, sometimes progressive and consequent on advancing age, as in general baldness ; and sometimes limited to a nerve-district of small extent, as in Area. This fact is very evident in the latter form, inasmuch as, conjoined with the sudden drop- ping-out of the hair, the integument is pale and thin, poorly nourished, somewhat anaesthetic, and thinner in the centre than at the circumference ; while the hairs which remain at the periphery are altered in structure, clubbed and broken off. IEtiology. — The causes of Alopecia are ex- hausted nutritive power of the skin ; nerve paresis in the case of Area; syphilis; and local injury. The Alopecia of syphilis follows the plan of distribution of its exanthem. Partial Alopecia may result from a blow ; from the accidental tearing out of a lock of hair ; from the sting of a bee; from nervous shock; or from other causes. Treatment. — This consists in the restoration of nerve-power and nutritive power ; and in local stimulation. The best applications for the latter purpose are the stimulating liniments of the British Pharmacopoeia ; e.g. liniment of ammonia, compound camphor liniment, and the jniments of chloroform and mustard ; or the acetum cantharidis properly diluted for general Alopecia, or applied with a brush in its concen- trated form for Area. In the treatment of the latter, ammonia, turpentine, and the compound tincture of iodine are likewise useful ; while for syphilitic Alopecia the white precipitate ointment with camphor is the best local application, con- joined with an anti-syphilitic constitutional .reatment. Erasmus Wilson. BALHEOLOGT (fiaKavdiov, a bath, and \iycs, a word). A scientific exposition of all that relates to baths and bathing. See Baths and Hydrotherapeutics. BALNEOTHEEAPEUTICS (fraXavdiov, a bath, and Sepaireva, I heal). That department of therapeutics which deals with the application of baths in the treatment of disease. See Baths and Hydropathy. BABBADOES LEG. A synonym for Ele- phantiasis. See Elephantiasis. BABBIERS. A synonym for Beriberi. See Beriberi. BAREGES in Prance. Thermal sulphur waters. See Mineral Waters. BASEDOW’S DISEASE. A synonym for Exophthalmic Goitre. See Exophthalmic Goitre. BATH in Somersetshire. Simple thermal and earthy waters. See Mineral Waters. BATHS. — Baths may be regarded as simple ; and composite, medicated, or artificial. They may be used in the form of liquid, vapour, or air. We shall consider them under these heads in the following description : — - A. Simple Baths. — 1. Simple Liquid Baths. 1. The Cold Bath.—Tiy a cold bath is meant the immersion of the body in water below the temperature of 70°. Anything below 50° is considered a very cold bath. The first effect of BATHS. 101 the bath is a sensation of cold amounting almost to shivering, with slight gasping for breath. If the hath is continued for more than two or three minutes, the temperature of the skin is dimi- nished; and if it is protracted, the blood and the subjacent tissues lose a little heat, but this does not generally occur till after quitting the bath. If the cold is intense and prolonged, there is a certain degree of numbness of the skin ; while the pulse becomes small, and may fall from ten to twenty beats in the minute. After a short time (the colder the water the shorter), reaction takes place, bringing redness to the skin and increase of temperature, with a certain amount of excitement ; but if the bath be continued, the depression returns. The immediate action of the cold bath is to cause the capillaries to contract and repel the blood from the surface, while by its operation on the peri- pheral extremities of the nerves, it acts upon the central nervous system. In its more remote effects, the cold bath accelerates the transmutation of tissues, augmenting the excretion of carbonic acid and of urea from the system, and, as a con- sequence, increasing the appetite. The body is usually immersed at once in cold water, but the shock of this may be diminished by first using tepid water, and then gradually adding cold to it. The effect of a cold bath depends much on its duration. Brief immersion, that is for three or four minutes, makes both the depressing and the exciting action less ; a longer duration, say of ten to fifteen minutes, increases both actions; but if the bath he very protracted, the continued abstraction of heat produces depression only. The effects of a cold bath are less intense, if the bather is able to keep himself in motion, and es- pecially if he swims. 2. The Warm Bath . — A warm bath of 96° to 104° produces no shock to the system; it causes a moderately increased flow of the circulating fluids to the surface, augmenting the frequency of the pulse; and scarcely affects the respiration. There is not the depression or the excitement of a cold bath. It rather retards the transmutation of tissues. With a hot or very hot bath — from 104° to 114°, the central nervous and circulatory systems are more affected. The frequency of the pulse increases greatly. The respiration becomes anxious and quickened. The skin is in a hypersemic condition, and a free perspiration breaks out. 3. The Tepid Bath . — Tepid baths of the temperature of 85° to 95°, are intermediate be- tween cold and warm. Their effects seem to be confined to the peripheral extremities of the nerves, and they do not excite the nervous centres or the circulatory sj^stem. Neither the pulse nor the excretions and secretions are affected. As no heat is confined in the system or taken from it, there is no reaction, and the animal temperature is unaltered. It need scarcely be said that drying and rub- bing after a bath materially assist its action or the skin ; or that, according to circumstances, it may be convenient to order a whole bath, a hip- bath, or a slipper-bath. The foot-bath is a very useful and convenient one, especially when some stimulant substance is added to the simple water, 102 BATHS. Wet packing and the various processes of hydro- pathy, and those powerful agents hot and cold affusion, whether as shower-baths or as douches, are described in the article on Hydropathy. The duration of a bath must depend on a variety of circumstances, for instance, on the age and constitution of the patient, on the nature of his malady, and on the temperature of the bath. It may vary from a few minutes to many hours. A very hot or a very cold bath can be supported for a much shorter time than a tepid one. Action and Uses. — Cold baths are indicated for the strong, for youth, and for manhood; warm baths for the delicate, for women, for early childhood, and for old age. Tepid baths are suitable for almost all constitutions, sexes, and ages. Cold baths may in a general way be considered tonic and bracing ; they are useful when judiciously employed in many nervous affections, as in chorea and hysteria, and they are the best of all for general hygienic purposes. Of late years they have been specially employed in the treatment of fever {see article Tempera- ture). The great value of warm baths, besides their hygienic employment, as better detergents than cold ones, is in soothing and reducing excitement; in relieving spasms, such as colic and retention of urine ; in the convulsions of children, combined with the affusion of cold water on the head ; in cases of gout and rheuma- tism ; and generally when action on the skin is desired. Where prolonged immersion is wanted, tepid baths are indicated, as in calming many chronic nervous disturbances, and in many cuta- neous affections. As to contra-indications, all baths, and es- pecially prolonged and even tepid baths are not suited for the asthenic. Both hot and cold baths are to be avoided where there is a weak, fatty heart, or any tendency to apoplexy. No one should ever enter a cold bath when ex- hausted, and such baths are also contra-indicated when there is a tendency to congestion of inter- nal organs. Under such circumstances a warm bath is usually both safer and more refreshing. The too long and too frequent use of hot baths is debilitating. II. The Simple Vapour-Bath. — A vapour- bath is one in which the skin is exposed to the action of hot water presented in the form of vapour. The vapour-bath may be taken in a box with the head included or not ; or in the more common form of the Turkish or Russian baths, where a large room is filled with vapour, and where therefore the vapour is inhaled ; or by vapour obtained from a small and suitably constructed apparatus, which vapour may be diffused over the whole body or directed to a particular part. A very simple apparatus for the vapour-bath may be prepared by placing under a chair a shallow earthenware or metallic pan, containing boiling water to the depth of three or four inches, and from which abundant vapour can be obtained by placing in it one or two red- hot bricks. The patient sitting on the chair, surrounded by blankets and other suitable cover- ing, will receive the full benefit of a vapour-bath. Vapour-baths produce profuse perspiration, and act in cleansing the skin much as hot-water baths do, only more. powerfully. Vapour being a slow conductor, does not act so fast on the bodj as water. Vapour-baths can be borne hotter than warm-water baths, but their use cannot be con- tinued so long, as vapour interferes with radiation of heat from the body. In such baths a heat of more than 122° is not borne comfortably. The vapour-bath, though falling considerably short in temperature of the air-bath, raises the heat of the blood somewhat more. The great virtue of these baths is in their sweat-producing proper- ties. The average loss of perspiration by the use of a Russian bath has been set down at from § lb. to 3 lbs. In the Russian bath a slight degree of stimulation of the skin is caused by switching it with twigs of birch, and the alter- nation of depression and excitement of the cold bath is obtained by placing the patient, when in a state of profuse perspiration, under a douche of cold water. III. The Simple Hot-Air Bath. — There are two forms in which the hot-air bath is adminis- tered : according as the patient does not or does breathe the heated air. The action of the latter closely resembles that of a vapour-bath, but differs from it in not impeding the respiration, as the latter does by depositing moisture in the bronchial tubes. The lungs, instead of requiring to heat up the inspired air, are subjected to a temperature above their own. Hot-air baths favour the highest degree of perspiration, while the moisture of vapour baths somewhat retards it. If they are very hot, they raise the tempe- rature of the body by several degrees. As the arrangements for vapour- and hot-air baths are practically the same (except that in the latter it is attempted to exclude all vapour from the calidarium or sudatorium, the hottest room), the following description of an ordinary hot-air bath, the arrangements of which are closely copied from the Romans, will answer for both. The patient after unclothing first goes into the iepidarium, which has a temperature of 113° to 117°, in which ho remains until the perspira- tion bursts forth, which happens in from twenty- five to forty minutes. He next proceeds to the hottest room or calidarium (in which the air is heated by hot-air pipes which are inserted in the walls), of a temperature of 133° to 140°, and remains there until the perspiration runs down his skin, in twelve to eighteen minutes. An attendant then rubs off the per- spiration with a woollen glove, and kneads all the muscles for four or five minutes. The patient next betakes himself to the lavacrum, where he has water poured over him of the temperature of 81° to 86° ; next, the whole body is soaped over, the suds are rubbed off, and the patient goes to the frigidarium, where he lays himself on a couch and waits till his skin is completely dry. This may occupy twenty-five to thirty minutes, when the patient dresses and leaves the bath greatly refreshed. Such is a brief account of these baths, the revived use of which is at present so general. The arrangements vary in detail. For ordinary purposes it is easy to furnish either vapour- or hot-air baths. A great variety of apparatus have been invented for this purpose, which re- solve themselves into this, that the patient should lie in bed or on a seat, and have the bed- BATHS. slothes or other covering secured from contact with him by the employment of a framework or cradle. Beneath this hot air or vapour is introduced, either directly or indirectly, from a suitable apparatus. The Sand-Bath. — We may here mention baths of sand, which are a very old remedy. Of late years establishments for supplying them have sprung up in various towns. They are a con- venient way of applying dry heat either locally or generally, and are employed in chronic rheumatism. Bags filled with heated sand are useful in hospital and in domestic practice. Uses. — Both hot-air and vapour-baths are indicated when increased action of the skin is desired. They are used most for the cure of catarrhs, of neuralgic and rheumatic pains, and sciatica. They have also been much employed for reducing obesity. They are useful for general hygienic purposes, but are apt to be given too indiscriminately. Hot-air and vapour-baths are often locally applied with great advantage to a hand, or leg, or arm, iu rheumatism or thickened joints. B. Composite, Medicated, ok Artificial Baths. — A great variety of substances have been used in baths at different periods. We must confine ourselves to such as are at present in use and appear to be of some real value, omitting even seme that are employed, such as baths of iodine, of iodide of potassium, of iron, of fermented grapes, and of rvfiey. I. Composite Liquid Baths. 1. The Sea- Water Bath. — The average amount of salts in sea-water may be set down at 3 per cent. ; this may therefore be considered a suitable strength for ordinary salt baths. The quantity commonly used in London hospitals is about 9 lbs. of salt to 30 gallons of water. Some use bay salt, others Tidman’s. Owing to the high price of sea-salt in inland continental places, various natural salts, some of them containing a comparatively small amount of chloride of sodium, have been suggested as substitutes ; and also, for economy’s sake, 22 to 25 gallons have been set down as a minimum amount of water for the bath of an adult. The value of these substitutes can only bo determined by observing the degree in which they stimulate the skin. Apparently it does not matter much what particular salt is employed to produce the stimulation. A salt-bath can of course be in- creased to any strength by the addition of salt, or of the mother lye as it is termed. The chief uses of salt-water baths are as tonic remedies, especially for the young, when there is any tendency to scrofula or chlorosis ; also in convalescence from many diseases. 2. Alkaline Bathe. — Alkaline baths may be made by adding 6 ounces of crystallised car- bonate of soda, or 3 ounces of carbonate of potash, to 25 or 30 gallons of water. Alkaline baths are of use in a great variety of cutaneous affections. 3. The Corrosive Sublimate Bath. — Baths of corrosive sublimate are occasionally employed. They are commonly made by adding 3 drachms of corrosive sublimate and 1 drachm of hydro- chloric acid to 30 gallons of water. They are employed in some skin-affections, and in secon- dary syphilis. 103 4. Sulphuret of Potassium Bath. — Baths of sulphuret of potassium are made by dissolving from 4 to 8 ounces of that salt in 25 to 30 gal- lons of water. A little dilute sulphuric acid is sometimes added. These baths have long been extensively employed in the treatment of cases of skin-disease in which the sulphur that they contain is indicated. 5. The Nitro-Muriatic Acid Bath. — The nitric or rather the nitro-muriatic acid bath is made by adding nitro-muriatic acid to water. The ordinary proportion is one ounce of acid to one gallon of water. The discolouring action or. clothing makes a full bath of this kind incon- venient for domestic use, and it is best to take it in a bathing establishment. For the ordinary purposes of a foot-bath at home the old directions of Dr. Helenus Scott, who introduced the use of the acid, are sufficient. The vessel must of course be of wood or earthenware. Dr. Scott added four to six ounces of the acid to three gallons of water. This made a rather strong foot-bath. The pa- tient was to keep his feet immersed for thirty minutes : and the bath was to be repeated every other day for two or three weeks. The axillaj, the groin, and the region of the liver were to he sponged with the acid solution. The bath causes slight tingling of the skin and a taste in the mouth, and is believed occasionally to pro- duce salivation. This bath has been used very extensively in India and in England in liver affections. There is difference of opinion as to its value ; many have great confidence in it. 6. The Bran Bath.—T\\6 bran bath is made by boiling four pounds of bran in one gallon of water, straining, and adding the liquor to a quantity of water sufficient for a bath. Such a bath is useful in allaying the irritability of the skin, and also in diminishing the stimulating effect of other baths. 7. The Fucus Bath. — This is made by add- ing a decoction of sea-weed, or the sea-weed chopped up, to an ordinary bath ; it will become more or less gelatinous if enough be added. Such baths go popularly by the name of Ozone baths; and they contain a certain amount of chloride of sodium and a minute proportion of iodine. They aro useful in the same cases as sea-baths. 8. The Mustard Bath. — An extremely useful stimulating bath is the well-known mustard hath, which is made by adding a handful or two of mustard to the ordinary hot bath. The pedi- luvium is its most useful form. 9. Pine Baths. — Baths of the balsam of pine-leaves may be prepared extempore by 7 making decoctions of the fresh leaflets at certain seasons ; but the usual way is to add about one pound of the extract which is prepared from the leaves, and is everywhere for sale — at least in Germany. The extract dissolves in the bath, which is then ready for use ; but of late it has been usual to add a small amount of an essence which is also prepared from the leaflets. It floats to the surface of the water, and attaches itself to the person on leaving the bath, and its aroma is grateful. Of course the quantify of the extract to be employed depends on its strength. These baths are at present largely employed. They are slightly stimulant, and are much used in hysterical, rheumatic, and gouty 104 BATHS. affections, and also as an adjunct to the internal use of mineral waters. 10. Baths of Conium, Lavender , Spc. — Aro- matic or sedative baths are prepared by adding a decoction of lavender, hyssop, or conium to an ordinary bath. It is scarcely necessary to add that, as a rule, all composite liquid baths should be of a temperature a little above the tepid ; and that their strength, and the time that the patient is to remain in them, must be determined by the special circumstances of the case. 11. Composite Vapour- Baths. — Vapour- baths impregnated with fir balsam are popular, and are considered to be more powerful in their operation than pine-baths. The vapour which rises in making the decoction of pine leaves is conveyed to a box in which the patient is en- closed. Aromatic vapour-baths may be given by making the steam of hot water pass through bunches of fresh aromatics ( conium , lavender, &c.) before reaching the box in which the patient is placed. Such baths may be useful in hysteria. III. Composite Air-Baths. 1. Sulphurous Acid Bath. — A valuable mode of applying sulphur in the form of a bath is by using its fumes — in other words, sulphurous acid. The patient is seated on a cane-bottomed chair, and his body is encircled with a cradle, over which oil-cloth is thrown, the head remaining uncovered. Sulphur is placed on a metallic plate, to the lower surface of which the flame of a lamp is applied, when sulphurous acid is dis- engaged. This bath is less used in cutaneous affections than formerly. 2. The Mercurial Vapour-Bath.— -Very similar is the mode of applying the fumes of mercury. Under the chair are placed a copper bath con- taining water, and a metallic plate on which are put from 60 to 180 grains of the bisulphuret or of the grey or red oxide of mercury. Spirit lamps are lighted under the bath and under the plate. The patient thus experiences the effects both of aqueous and of mercurial vapour. At the end of five or ten minutes perspiration commences, which becomes excessive in ten minutes or a quarter of an hour. The lamps are then to be extinguished, and when the patient becomes moderately cool, he is to be rubbed dry. He should then drink some warm liquid and remain quiet for a time. This has often been a favourite mode of treating secondary syphilis with some practitioners. Calomel, in quantities of from 20 to 30 grains, is adminis- tered in a similar manner, under the name of the Calomel Bath. It may be given locally by a suitable apparatus. John Macphebsox. BATHS, Natural. See Mineral Waters. BED-SORE. See Ulcer and Ulceration. BELL-SOUND. A peculiar physical sign associated with pneumothorax. See- Physical Examination. BELL’S PARALYSIS, (Named after Sir Charles Bell.) A synonym for paralysis of the facial nerve. See Facial Paralysis. BERIBERI. BERIBERI. — Synon. : Barbicrs; and nume- rous other local names. Definition. — A disease characterised by anaemia, anasarca, degeneration of muscular tissue, effusion into the serous cavities, debility; numbness, pain, and paralysis of the extremities, especially the lower; prsecordial anxiety, pain, and dyspnoea ; scanty and high-coloured urine ; and in some cases drowsiness or sleepiness. Beriberi occurs in a chronic and an acute form ; in the latter often proving rapidly fatal from exhaustion, syncope, or the formation of cardiac or pulmonary eoagula. Etymology. — The etymology' of the word Beri- beri is obscure. Herklotts suggests the Hindi word, Bheree — a sheep — from the fancied resem- blance of the gait of persons affected to that of sheep. Soond-bheree comes from the words numbness and sheep. Soond-ke-baiee signifies numbness and rheumatism. Bher-bheri , a Hindi word, signifies a sore, a swelling. Mason Good says thatBontius introduced the word Beriberia, and tells us that it is of Oriental origin. Carter suggests Bhari, sailor, from Bahr, the sea ; and Bkayr, shortness of breath. As the disease is seen among African and Arab sailors, this is probable. Some think it is derived from a Cingalese word meaning weakness, first applied to a variety oi conditions, the result of scorbutic, malarious, rheumatic, and ansemic cachexice, on the Malabar Coast. Geographical Distribution. — Beriberi pre- vails endemically in Ceylon ; and in India, on the Malabar Coast, and in the Northern Circars, between 13° and 20° N. latitude, extending in- land from forty to sixty miles. It is known in other parts of India, probably occasionally all over the peninsula ; in Burmah and the Malayan peninsula ; amongst the crews of ships trading to ports in the Persian Gulf, Red Sea, coast of Africa, Bay of Bengal, Singapore, Siam, and the islands of the Indian Archipelago ; and in the Australian seas. On the West Coast and other parts of Africa beriberi also occurs, and is known as the sleeping sickness. In Europe pernicious aneemia is possibly the same disease. Beriberi is also met with in South America, and probably wherever certain conditions of food, water, soil, climate, and mode of life coexist. .'Etiology. — All observation tends to show that beriberi occurs where causes cf debility have for some time operated, especially in the cli- mates and localities previously’ mentioned, such as certain conditions of soil, air, and water; exposure to great alternations of temperature, especially when accompanied bv wet, fatigue, mental and physical depression; food deficient in quantity and quality or variety : previous ex- hausting diseases ; malaria, and other undefined atmospheric and telluric influences — all, in fact, that tends to depress the vital energies, im- poverish the blood, and starve the nerve-centres. The symptoms, it is said, seldom begin to appear within ten months or a year after first exposure to these causes. Beriberi has been ascribed by Ranking to disease of the kidney, but there is no evidence to prove that it is due to this cause, or indeed to structural changes of any of the vis- cera. Morehead refers it rather to a scorbutic origin, and in some respects it does resemble BERIBERI. scurvy ; it may probably, also, be a consequence of the cachexia that so often results from long residence in a malarious climate, especially when that has been accompanied by exposure, pri- vation, and excessive exhaustion of the vital powers. In such, the most complete ansemia, with debility, may occur, independently of the existence of organic visceral disease, though naturally they will be intensified where such disease is present. Amatomical Charactees. — Serous fluid is effused generally — in the areolar tissue, in the lungs, brain, heart, and abdominal viscera. The cavities are, like the tissues, soaked with watery efiusion. The tissties are soft and degenerate. Muscular fibre is fatty, especially that of the heart, which is often enlarged and dilated. The kidneys are enlarged, anaemic, and softened. Pathology. — The recent discovery by Mr. T. Lewis in India, of the embryo of a nematode worm in the blood of persons suffering from chyluria (see Chyltjeia), lymphorrhoea, and elephantiasis, of which diseases it appears to be to some extent the cause, suggests inquiry whether a similar haematozoon may not also be in some way con- cerned in inducing beriberi. Fonsagrives and Leroy de Mericourt describe beriberi as general dropsy with a rapid course, no albuminuria, and weakness and loss of sensibility in the lower limbs. Dropsy commences as anasarca, and extends to the serous cavities. Though hepatic, splenic, or renal complications may exist, and intensify the severity and hasten the progress of the general symptoms, they are not essen- tial concomitants of the disease, but appear to originate in a spansemic state of the blood, and to be kept up by its progressive imperfect elaboration. The resulting partial starvation of the cerebro-spinal nerve-centres, and the serous effusion into and amongst them, sufficiently account for the paralysis which, in severe cases, characterises this disease. Symptoms. — Beriberi presents itself under a chronic and an acute aspect ; rarely, it is said, ever occurring in either form, until after an ex- posure of some months to the exciting causes. The general symptoms may be said to be those of anaemia and anasarca. (Edema pervades the limbs and body generally, accompanied with numbness, pain, heaviness, and loss of power, amounting in some cases to paralysis. Along with these symptoms there occur prsecordial anxiety, dyspnoea, irregularity and palpitation of the heart, pain at the ensiform cartilage, anaemic murmurs, debility, and a small quick pulse, which at the outset may be rather hard and full, ac- companied by dryness and heat of skin. The appetite is at first not impaired. Later there is coldness of the extremities ; torpor of the bowels ; scanty, high-coloured urine, of sp. gr. 1020 to 1040, bub no albuminuria as a rule. According to Horton and others, excessive drowsiness and stupor attend some stages of certain cases of the disease ; also pale, flabby tongue and blanched mucous membranes ; occasionally hsemorrhage from the stomach and bowels ; with petechial eruptions ; an anxious look ; a puffy, swollen, and sometimes livid face ; and a peculiar tottering gait. Death results rapidly in some of the acute cases, with symptoms of effusion BERIBERI. 105 into the thoracic and abdominal cavities, or with- in the skull, by exhaustion, syncope, or the for- mation of coagula, either in the systemic or in the pulmonic circulation. Beriberi frequently assumes a slight and modified form, indicated by anaemia, numbness, and a certain amount of pain in the limbs ; an anxious expression ; dis- ordered bowels ; scanty urine ; cold skin ; a low, feeble, and irregular pulse ; praecordiai pain or uneasiness, with palpitation ; nervous depression; an unsteady, almost tottering gait ; and a puffy face and neck. Dr. Paul says ; ‘ I have met with a numerous class of cases that are not so serious (as the acute) or so often fatal, where the chief symptom complained of was burning of the feet.’ Malcolmson describes this remarkable condition in connection with beriberi, to which, he says, it is allied — it is found to affect the soles and calves of the legs, the back, and occasionally the muscles of the legs.’ It occurs in recent aud slight examples of beriberi, and was first observed in the troops after the first Burmese war — some- times in men who had not had beriberi ; on the whole, Malcolmson thinks it is neither rheuma- tism nor beriberi, and may accompany or follow other diseases, as an indication of nervous de- bility. In the acute forms of beriberi the symptoms are very severe and often rapid; and the mor- tality would indicate it to be second only to cholera in fatality. The chief symptoms are : — Rapid general ansemia and dropsy of the cavities ; scanty, almost suppressed urine ; constipation ; weak, irregular pulse ; intense prsecordial pain ; hurried, irregular, and painful breathing; occasional vomiting — sometimes of blood ; swell- ing of the limbs, with numbness, pain, and paralysis, preceded by a feeble, tottering gait ; all the symptoms of pleuritic and pericardial efiusion ; failing heart ; and death either from syncope, or perhaps almost suddenly from em- bolism — in the most acute cases within a few days. In this acute form the affection is very fatal, but in the milder and more chronic form recovery is frequent. Acute cases often super- vene in those who have suffered from the milder disease, or in those who are exhausted and anae- mic from other causes. Treatment. — Attention to diet, suitable clothing, and protection against vicissitudes of temperature, wet, and cold, are the best 'pre- ventive measures. Bad hygiene and exhausting habits of life tend to promote the development of the constitutional condition in which the disease commences. "When beriberi is established these precautions are still necessary, and attention must be paid to the symptoms as they occur. Diuretics and diaphoretics relieve the oedema and dropsical effusions. Tonics and stimulants give vigour to the weakened muscular fibre ; while appro- priate remedies and diet may improve the con- dition of the blood. Acetate of potash, digitalis, and squill, and occasionally calomel, are said to favour the re- moval of the fluid. It is needless to say that the physiological action of mercury is to be avoided. Salines, hot-air baths, diaphoretics, and turpentine may at various stages be found useful. The object being to remove the fluid and 106 BERIBERI, strengthen muscular fibre, quinine, iron, and other tonics are an important element in the treatment. No remedies, however, -will be of much avail unless the patient be placed in favourable hygienic conditions. Malcolmson speaks highly of two remedies — treak farook, and oleum nigrum , -which are considered to be very effective in the treatment of the disease, especially in relieving the. dyspnoea and cedema, which proved very fatal until these drugs were introduced. The composition of the treak is appa- rently generally unknown — it seems to be diuretic and stimulating, and probably not aperient unless combined with rhubarb, in doses of four to fifteen grains. The oleum nigrum is a stimu- lant and diaphoretic, given thrice daily, and has been found by Indian physicians to be very beneficial in some cases of beriberi. Dr. Aitken says that turpentine is a useful remedy. Ergotin, iron, and belladonna with zinc in the form of pill, accompanied with sea-bathing, were useful in this disease, as seen at Bahia. Nux vomica has often been found serviceable in cer- tain cases, as might be expected, and opium may be needed to allay pain and irritability. Hepatic and splenic complications need their appropriate remedies. Obviously the chief indications are to promote removal of the oedema ; to regulate the functions of the abdominal viscera ; to increase the action of the skin ; and to give tone and vigour to the muscular fibre. By such measures can we alone hope to deal successfully with this profound form of cachexia. Joseph Fayeee. BIARRITZ in Prance, on the Bay of Biscay. A fashionable sea-side resort. The climate is considered to be bracing. See Climate, Treatment of Disease by. BILE, Disorders of. — Disorders of the bile held a large place in the medicine of antiquity, with the exception of the theories of Van Helmont and Paracelsus ; the latter looking upon the bile as the balsam of life, and therefore incapablo of begetting disease ; the former regarding it as a mere excrementitial fluid, and therefore equally incapable of begetting disease. Disorders of the bile have, nevertheless, held their own quite into our time. It is common enough to hear persons speak of a ‘ bilious attack,’ or ‘ being troubled with the bile,’ expressions the survivals of the humoral pathology. The liver was for- merly credited with most of the dyspeptic dis- orders of the stomach. As Sir Thomas Watson says, it is an organ often blamed most gratui- tously and unjustly, but no educated or scientific physician would now think of attributing a gas- tric catarrh, or constipation, to an ‘attack of the bile,’ or to a ' sluggish liver.’ Physicians have arranged disorders affecting the bile under three heads — (1) diminished secre- tion of bile ; (2) increased secretion of bile ; and (3) secretion of morbid or altered bile. This divi- sion may very well be accepted as a convenient basis for the further discussion of biliary disor- ders, but it is nothing more than an hypothesis. It is likely enough that the bile, in certain dis- eases, changes its character as regards both its amount and constituent parts : but it cannot be denied that the means by which physicians are able to ascertain these changes can scarcely be BILHARZIA. said to exist in ordinary cases. A common saying is that the patient must be making plenty of bile because the stools are high in colour. No reasoning can be more fallacious. The colour of tho stools may be high if the fseces be quickly swept through the intestinal canal, because thero has been no time for the bile-pigment to be absorbed into the blood. Or the fseces may be pale if they lie long in the bowel aDd the coloured matter absorbed. So that the colour of the stools is no sure sign of the poveityor abun- dance of the secretion of bile. In cases of pale- coloured faeces purgatives often do good, not because they have any special tendency to in- crease the flow of bile, but because they hurry the fseces out of the intestine, and thus give no time for the absorption of the bile, which, if it lay long in the bowel, would be absorbed, carried to the liver, and again excreted into the gall- ducts — the vicious circle of Schiff. Nor is the analysis of the bile found after death in the gall-bladder of much value. Frerichs announced the presence of albumen in the bile in cases of congestion of the liver ; but it is now generally thought that this appearance is due solely to a post-mortem transudation. Bitter also has described a colourless bile in which all the constituents of bile are present except the pig- ments. Most of his analyses were made on bile taken from tho gall-bladder after death ; but if the cystic duct be obstructed for any time, it is well known that the bile contained in tho gall- bladder may become colourless without any real secretion of colourless bile having taken place in the first instance. It is impossible to be certain that the changes, which are found in tho bile taken from tho gall-bladder after death, have taken place during life. The only source of what may be called know- ledge of the disorders of the bile is observation of men or animals in whom biliary fistulm have been formed either by disease or by art. Unfor- tunate^, the majority of such observations have been physiological or pharmacological ; and but few are recorded of the changes which the bile undergoes in disease. Altogether contradictory experiments are recorded of the influence of the nerves and of the diabetic puncture of the fourth ventricle upon the secretion of bile. It is an admirable field for further research, but it will be seen that our present knowledge very closely approaches to complete ignorance. It is disputed still whether the presence of bile in the stomach puts an end to the process of digestion. By many it is thought that the bile- acids throw down the albumen of tho food, and with the albumen the pepsin. It is well known that in some disorders there is an inverted action of the duodenum, and bile is poured into the stomach, as in long-continued vomiting, for instance ; thus the dispute has a practical bear- ing. The best treatment of this state would seem to be by saline purgatives. Bile may also be taken up into the blood, and when this occurs, jaundice results (sre Jaijndicb). J. Wickham Lego. BILHARZIA. — This name was given by the writer to a genus of flukes discovered by Dr. Bilharz, of Cairo, in the portal system of human BILHARZIA. BILIARY FISTULA. 107 blood-vessels, and the worm was subsequently found by the writer in the portal rein of a monkey. This trsematode hsematozoon was first described as a Distoma, but the species is now more generally known as the Bilharzia hcematobia. It was ori- ginally found in the portal system, and Bilharz, Griesinger.Lautner,and others afterwards showed that this parasite also infests the veins of the mesentery, bladder, and other parts, producing a formidable disease which is endemic in Egypt, at the Cape, at Natal, and probably in other parts of the African continent, as well as in the Mauritius. The discovery that the endemic hsematuria of the Cape of Good Hope is occasioned by the presence of Bilharzia, is due to Dr. John Harley, who de- tected the ova in the urine of a patient who had previously resided in Southern Africa. Dr. Har- ley’s impression that he had to deal with a new species of Bilharzia has not gained general acceptance, but he furnished proof of the wide geographical distribution of this parasite, and he also added largely to our knowledge of its ravages. Description. — This parasite, unlike nearly all the other known species of fluke, has the sexes separate, the females being comparatively slen- der worms, resembling filariform nematoids. During copulation the female is lodged in a long slit-like groove, or gyncecophoric canal, with which the abdomen of the male is furnished. fid. 2. — Bilharzia hcema- tobia, male and female sexually combined. Mag- nified. After Kiichen- meister. Fig. 3. — Ovum of Bil- harzia hcematobia with contained em- bryo and free snr- code-granules : x 234 diameters. Original. The eggs, measuring from yY" to Afa" in length, are peculiar, being either sharply pointed at one end, or furnished with a projecting spine, placed at a little distance from the hinder pole. This spine gives a point of resistance to the egg during the struggles of the embryo to effect its escape. Those who are interested in the organi- zation of the ciliated embryos, and in the re- markable behaviour of the larvse during their earliest stages of growth, will find the subject fully discussed in the writer's paper ‘On the development of B. hcematobia,’ together with remarks on the ova of another urinary parasite, occurring in a case of haematuria from Natal, Brit. Med. Joum., 1872. Treatment. — The writer has pointed to the danger of treating cases of Bilharzia as if they were comparable to ordinary helminthiases. It is neither desirable to employ active drugs for the expulsion of the parasite and its eggs from the bladder, nor is it prudent to attempt the employ- ment of vermicides with the view of destroying the worms. As in Trichinosis, so in the Bilhar- zia disease, it is essential to support the sys- tem. Thus tonics, cold bathing, aud a highly nourishing diet, combined with the bicarbonate of potash and infusion of buchu, constitute our best resources when dealing with cases of endemic hsematuria. The pathological facts clearly show that in order to effect a cure we must imitate nature herself as closely as we can. IVe must seek to erect artificial barriers, and thus check the hiemorrhage as much as possible. For this purpose the writer has found the astringent properties of Arctostaphylos uva ursi eminently' serviceable ; small quantities of hyoscyamus being usefully combined. Dr. Harley advises ‘a perse- vering use of belladonna and henbane,’ under the impression that treatment with these drugs ‘ will retard the development of the parasite, even if they do not effect its destruction.’ The writer entirely disagrees in this view of the case, and he also objects to the employment of medicated injections. He thinks that the employment of diu- retics is likewise clearly' contra-indicated. Every- thing that will contribute towards allaying the vesical irritation, is certain to assist the natural process of cure ; and, in this view, the adminis- tration of buchu-infusion, the enforcing of a liberal diet, and the taking of gentle exercise, will be found amongst the most important cura- tive aids. In bad cases a thorough cure is not likely to be completed until after the lapse of several years. Prophydactically it is essential to remove patients from the localities in which there is every reason to believe they have con- tracted the disease. In view, also, of preventing infection on the part of others, it is necessary that the water employed for domestic purposes throughout the infected districts, be rendered thoroughly pure by efficient filtration. For fur- ther particulars the reader is recommended to consult the general works of Kuchenmeister and Leuckart ; the writer’s introductory treatise on Entozoa (p. 197 et scq .) ; Dr. Harley’s three separate memoirs (in the Transactions of the Royal Med. and Chir. Soc., 1864, &c.) ; and also especially the recent memoir by Dr. Sonsino, entitled 1 Researches concerning Bilharzia hcema- tobia in relation to the endemic hsematuria of Egypt, with a note on a nematoid found in human blood’ {Rend, della R. Accad. delle Scienzc, §-c., 1871). See also Hjematozoa. T. S. CoBBOLD. BILIARY CALCULUS. See Gall-stones. BILIARY FISTULA. — There are tv.o kinds of biliary fistula: — one, in which a commu- nication exists between the gall-bladder and the surface of the body; the other, in which there is a communication between the gall-bladder and other internal organs. Neither kind is common, but the first is less rare than the other. In the first variety a tumour forms, sometimes in the place of the gall-bladder, at other times near the umbilicus, in the linea alba or to the left of this line, or in the groin. The tumour, if opened spon- taneously' or by the surgeon, discharges a quantity of pus, bile, and gall-sdones. D’ the cystic duct 103 BILIARY FISTULA, be obliterated, no bile need escape. A suppura- tion of the gall-bladder, caused by the presence of gall-stones, is the common cause of these fistulse. The prognosis is good. The diagnosis, before the tumour opens, is very difficult. In a case ■which came under the writer's notice, it was mistaken for an abscess of the liver. In the second kind of biliary fistula, the gall- bladder may communicate with the duodenum or colon ; with an abscess of the liver; with the portal or other abdominal vein, though it must be owned that cases of this kind seem somewhat dubious ; or with the urinary bladder, or at least with some part of the urinary tract. Gall-stones are in nearly every case the cause of the fistulous opening. J. Wickham Legg. BILIOUS. — This term is used with much vagueness, and in popular language is often em- ployed very incorrectly, though the idea is to associate it with conditions in which an excessive formation of bile is supposed to occur. The chief uses of the word are as follows : — In the first place it is employed to designate a peculiar temperament — the bilious temperament. Again, individuals are often said to be bilious when they present a sallow or more or less yellowish tint of skin, but especially if they are distinctly jaundiced. Bilious vomiting and diarrhoea signify respectively the discharge of a quantity of bile, mixed with vomited matters or with loose stools. Certain febrile diseases, attended with yellow- ness of the skin, are sometimes designated bilious fever, and under like circumstances pneumonia has been described as bilious pneumonia. Lastly, one of the most frequent applications of the term is to certain so-called bilious attacks or biliousness, which, however, are commonly merely attacks of acute dyspepsia or migraine. The most prominent symptoms of a supposed bilious attack are anorexia, furred tongue, a bitter taste, sickness, constipation, and headache, with a feeling of marked depression and general malaise. Such attacks are most effectually pre- vented by careful regulation of diet, and the avoidance of exposure to cold, fatigue, and undue mental exertion or anxiety ; when they come on, abstinence from food is desirable, with rest in the recumbent posture, and perfect quiet. Altera- tive aperients and saline effervescents may be given, alcoholic stimulants being avoided as far as possible. Frederick T. Roberts. BILIOUS TEMPERAMENT. See Tem- Eeeament. BITTER ALMONDS, Poisoning by. See Prussic Acid, Poisoning by. BLACK VOMIT. — Vomited matters may te more or less black in different diseases, but die peculiar black vomit is that which occurs in yellow fever ( see Yellow Fever).— The rejected matters are acid in reaction, and a sediment is deposited of coagulated albumen and dis- integrated blood-corpuscles. Ammonia is also present. The black colour of the vomit has been attributed by some writers to altered bile, but there can be no doubt that it is due to its ad- mixture with blood which has undergone certain changes. BLADDER, Disea ses of. — The bladder may BLADDER, DISEASES OF. be the seat of the following morbid conditions: — Inflammation, acute or chronic ; Abscess ; Neu- ralgia ; Atrophy or Hypertrophy ; Mechanical Distension, with chronic engorgement and reten- tion of urine, commonly, but erroneously, termed ‘ Paralysis Sacculation ; Displacements, such as hernia in the male, or, very rarely, inversion and protrusion in the female ; Tumours or Growths, including fibrous, villous, or vascular growths ; Tpithelioma and Carcinoma; Tubercular Dis- ease ; Ulceration, either simple or malignant ; and Vesico-vaginal or Vesico-intestinal fistula. The bladder may also be the subject of true paralysis, partial or complete, as the result of injury to the brain or spinal cord, or following disease of those organs. Only a brief statement respecting the most im- portant of this class of affections need be pre- sented here, in order to facilitate an acquaintance with their diagnosis, since the treatment of almost all of them belongs to the province of the surgeon, and so far only as it consists of medicinal reme- dies will the subject be considered. 1. Acute Inflammation— Acute Cystitis- — The mucous lining of the bladder is the part affected by inflammation — and although after long and severe attacks some morbid action oc- curs by extension to the muscular coat, or even to the peritoneal covering, these structures are very rarely affected. An acute inflammation of a very severe kind occurs from injuries; from the presence of instruments, foreign bodies, or calculi ; and from unrelieved retention of urine. A less severe, somewhat evanescent, but very painful form of cystitis arises from irritants taken internally, as cantharides. A still less severe, but often troublesome form originates by extension from gonorrhoea. In the first class of cases there are not only severe local symptoms referable to the bladder, but the general system may be gravely affected. In the second class, of which cantharides- poisoning is the type, the phenomena of very frequent, painful, and spasmodic attempts to eject small quantities of urine which is often bloody, occur within a very short time after absorption of the poison. A common blister is said to produce the affection in some persons. In two cases — the only two the writer has seen — it has followed the application of a blister to a surface already partially denuded of the scarf skin. In one of these a blister wras applied to a knee which had been frequently painted with tincture of iodine, and was still slightly sore. In three hours after the application the patient was attacked with exceedingly painful efforts to micturate, which were at times intense. The attack lasted six hours, gradually diminish- ing in force, and leaving no ill-effects behind. In less than twenty- four hours no trace of the symptoms remained. In the third form of cystitis, which is the most common, and of which that arising by extension from gonorrhoea may be taken as the type, the usual symptoms are undue frequency of mictu- rition ; a necessity to perform the act imme- diately the want has declared itself, a condition conveniently expressed by the single word ‘urgency;’ a desire to pass more, accompanied by pain, when all the urine has been voided ; and BLADDER, DISEASES OF. some dull aching over the pubes ; together with a general febrile state of the system, often very slight, but corresponding for the most part with the degree of local inflammation. The urine itself is cloudy, and deposits some lignt mucus on standing, but is not otherwise apparently altered. Under the microscope abundance of epithelium is visible, as well as some pus-cells, and if the affection is severe, a few blood-cor- puscles are also present. It may be remarked here that the presence of a few pus-cells in ihe urine, a fact to which so many practitioners attribute considerable importance, by no means necessarily deserves to be so regarded. The very slightest attack either of this or of the pre- ceding form of cystitis is certain to be attended by the formation of some quantity, however small, of fully-developed pus-cells. Very rarely a false membrane may be produced on the surface of the mucous membrane of the bladder, and may be thrown off almost entire, leading to the belief that the inner coat has itself been exfoliated. In women this membrane has been voided per urethram in a condition for ex- amination ; in men this cannot occur, because the urethra is too small to admit of it. Now and then examples of the former have been shown at the Pathological Society of London ; and one of the latter may be seen, discovered by operation, in the museum of the Royal College of Surgeons of London. Treatment. — In the first form of cystitis, the removal of the exciting cause, if possible, is the chief indication. The treatment of the second form should consist of very hot bidets or hip-baths, the former being probably preferable as capable of being used at higher temperatures than the latter ; together with large doses of the tincture of henbane, say a drachm, with 10 or 15 drops of liquor opii every two hours while pain is severe; 20 minims of liquor potass® may be given either simultane- ously or alternately, in water or in any bland diluent. The treatment of a well-marked case of the third class consists in absolute rest in the recum- bent posture, mild diet, abstinence from all al- coholic stimuli, gentle laxative action of the bowels, and the administration of small doses of alkali. The writer prefers liquor potass® to all others, frequently repeated ; and this may be combined with henbane, or, if micturition is very frequent and painful, with opium or morphia, or with chlorodyne in small doses. Hot hip-baths or bidets, followed by hot linseed-meal poultices or fomentations, give great relief. The patient may drink freely of decoction of triticum repens, linseed tea, barley water, or similar demulcents. Relief rapidly follows, but care is requisite to avoid relapse, which easily occurs if exercise be taken too soon, if injections for the gonor- rhoea be resumed too readily, or if alcoholic stimulants are freely taken. 2. Chronic Inflammation — Chronic Cys- titis. — Chronic inflammation of the bladder is separated from the acute form by very distinct characters. It is mostly the result of retained urine from stricture or enlarged prostate ; but it may arise from the presence of calculi, or of growths in the bladder ; from over-distension, or atony of 109 its coats ; from paralysis after injury or disease affecting a nervous centre; from disease of neigh- bouring organs ; and sometimes from altered urine : it is also met with in certain affections of the kidney. Sometimes this condition is marked by the presence of a large quantity of viscous mucus, often called ‘ catarrh ’ ; but more com- monly this symptom is absent, and the urine contains merely ordinary mucus or muco-pus, rendering the secretion more or less cloudy and opaque. Perhaps there are some cases in which the inflammation is mainly due to the presence of gout. SrapTOMis. — The symptoms of chronic cystitis are increased frequency of micturition and pain, but the latter is by no means necessarily present. The urine is always cloudy, and contains some pus-cells. There is often, but not always, some suprapubic uneasiness. The general health does not suffer unless the affection is prolonged or severe. If important causes, as the presence of stricture, calculus, &c., occasion the chronic cysti- tis, their specific symptoms will predominate. It is not common to find chronic cystitis as an idiopa- thic disease, although undoubtedly it occasionally is so ; so that the writer has alwaj’s regarded it as a useful maxim, ‘ When chronic cystitis is declared to be idiopathic, we may be sure that we have only not yet discovered the real cause.’ As a general rule we may be sure that there is inability to empty the bladder, or calculus, stric- ture, or organic disease of some kind in some part of the urinary tract, when the group of symptoms are present which we denote by the term ‘ chronic cystitis.’ Respecting the well- known glairy mucus, which is deposited so abundantly from the urine in some cases, in elderly people almost invariably, it should be said that it appears only in those whose urine is abnormally retained, through atony of the vesical walls, or in consequence of enlarged pro- state, or as the result of sacculation of the blad- der, and that medicine has little or no effect upon it. Treatment. — The regular and habitual use of the catheter, and perhaps also injections into the bladder, form the essential mechanical treatment of chronic cystitis in the cases just mentioned. In the few cases in which chronic cystitis is pre- sent, and no organic cause, such as those named above, can be discovered — and also as adjuncts to mechanical treatment when these causes dc exist — certain medicinal agents are undoubtedly useful : these are buchu, triticum repens, uva ursi, alchemilla arvensis, pareira brava, and the alkalis potash and soda. Buchu is more useful in subacute and recent chronic cystitis than in cases already of long duration. The patient should take not less than ten ounces of the in- fusion daily. After this, in similar cases, the decoction of triticum repens, made by boiling two to four ounces of the prepared underground stem in a pint or a pint and a half of water, of which six ounces should be taken three or four times in the twenty-four hours, is highly useful. For more chronic cases, where the urine is alkaline and deposits much mucus, and perhaps the triple phosphates also, alchemilla, uva ursi, and pareira brava may be very valuable. The alchemilla is administered in infusion, one ounce of the 110 BLADDER, DISEASES OF. herb in one pint of boiling water, of which the dose is four to six ounces three times daily ; the others according to the directions of the pharmacopoeia. These may be taken alone or combined with potash, whicn in moderate quanti- ties diminishes the natural acidity of the urine before it enters the bladder; the mucous membrane of which, although accustomed to that condition in health, is perhaps some- times, when inflamed, irritated by urine cf even the ordinary acidity. Whether this be so or not, there is no doubt that alkalis do fre- quently tranquilliae an irritable bladder. They are often given in the form of Vichy water, Vais water, or that of Evian, all strong solu- tions of soda ; but on many grounds the salts of potash are preferable. On the other hand, the mineral acids have been largely administered in cases where the urine is alkaline ; although there is no reason to believe that the acid has any direct action through the kidneys, or that it is eliminated by those organs. Alkalinity of the urine in chronic cystitis is almost always due to inability of the bladder to empty itself, and the remedy wanted is not medicine but a cathe- ter, at all events to ascertain whether this be the cause or not. A very small quantity of urine retained in the bladder, say one or two ounces, after every act of micturition, suffices in some cases to maintain an alkaline and otherwise un- healthy state of the secretion: while it is equally true that some patients may habitually, aDd during long periods of time do fail to empty the bladder, always leaving behind from half a pint to a pint, without losing the acidity of the urine. Of course other signs, and notably great frequency of micturition, are present when such is the case. 3. Neuralgia. — It is impossible to deny that the bladder may be, like other parts of the body, subject to symptoms which are described ns neuralgia, although the occurrence is an ex- tremely rare one. All the writer can say is, that he has occasionally met with cases in which he has not been able to account, by the existence of any lesion, for pain and frequency in micturi- tion, or for difficulty in performing that act, and where these symptoms have been more or less periodic in their appearance. In such instances he has given quinine, and has occasionally found great relief to follow a few doses ; more frequently tills has not been the case. But now and then the value of the drug has been so marked as to corroborate a belief in the existence of vesical neuralgia. It mustbe repeated, however, that examples of such phenomena are extremely rare. The writer has also employed arsenic on the same ground. It is invariably necessary fx> investigate the general health, as well as the habits and diet of the patient. This, porhaps, may be the place for stating that in all chronic and slight deviations from natural and healthy function in the urinary organs, it is essentially necessary to inquire into the state of the diges- tive organs, to correct by diet and by medicine when necessary any imperfect action on their part, if possible. Constipation alone, when habitual, may produce considerable irritability of the bladder, so also may the unnecessary use of purgativos. A geutle, easy, and daily action of BLADDER, DISEASES OF. the bowels, a healthy condition of the primary digestion, the absence of flatulence and distension after food, should bo ensured as far as possible in all patients complaining of frequent, difficult, or uneasy micturition; and many such may be com- pletely cured of so-called urinary affections by strict attention to these matters. The writer’s strong convictions relative to this fact, grounded on innumerable experiences of its value as an aid ; n practice, led him nearly twenty years ago to ascertain the great value, for such patients, of Friedrichshall water, now so extensively used; and more than ever he insists on the use of a mild and laxative regimen and diet in their manage- ment. 4 . "Where obstruction to the outflow of urine exists (stricture of the urethra, most forms of enlarged prostate, other tumours, &c.), tho muscular walls of the bladder become the seat of Hypertrophy, which is a condition of compen- sation, therefore, and not of disease in or by itself. But such changes in the interlacing mus- cular fibres existing, Sacculation readily occurs, by protrusion of the lining membrane between the bands so produced. On the other hand, most commonly when the prostate is hypertrophied, the bladder becomes gradually distended, its coats become expanded, thinned and weakened, and a certain degree of Atrophy takes place. The power of the organ to expel urine is lost or diminished ; and micturition being a function of simply mechanical nature, the circumstances of the case demand only a mechanical remedy, viz. the catheter. No medicine can restore power and exercise of function under these circumstances. But atrophy and loss of power may occur from complete or partial loss of nervous influence to the bladder, as in those who are the subjects of paralytic states commencing in the spinal cord or brain. When the paralytic state follows accident causing injury to a nervous centre, the nature of the case is obvious enough. But sometimes the onset and progress of chronic disease in these organs are very slow and insidious ; theurinary troubles, as manifested by slowness or difficulty in passing urine, or by urine clouded through inability of the bladder to empty itself, may he the earliest signs of the nervous lesion. On the other hand, impaired gait, and other evidences of central mischief, may be and mostly are earlier phenomena, the derangement in the urinary function appearing at a later stage. For such patients, the habitual use of the catheter is often necessary [always of course when unable to empty the bladder by the natural efforts] ; while such constitutional treatment as is indicated by the cerebral or cerebro-spinal lesion present will comprohend that which the bladder demands. It is therefore unnecessary to allude further to that subject in this article. The same remark also applies to those few examples of Tubercular disease of the urinary organs, which is always a local expression of a general constitutional state sufficiently considered under its proper head in this work. All other treatment of this malady is local and surgical. 5. Relative to Tumours, the varieties of which have already been enumerated, no medical treat- ment other than that of chronic cystitis is to b« thought of. BLADDER, DISEASES OF. With almost all affections of the bladder, simple or malignant, ulcerative or associated with fistula, cystitis to some extent and in some form co-exists. It is this which gives rise to the presence of an undue quantity of mucus in the urino ; it is often the source of pus, sometimes of blood in small quantity. Thus in all the above- mentioned diseases, some degree of cystitis ap- pears sooner or later. Henry Thompson. BLADDEB-WOEMS. — Entozoa having the character of cysts or vesicles, and being at the same time more or less transparent. This general term embraces a variety of parasitic forms, such as Echinococci , Ccenuri, and Cysti- cerci, all of which are the larvae of different species of tapeworm. Practically, it is impor- tant to know the origin of every kind of human bladder- worm, since the adoption of appropriate hygienic measures may prevent infection by each of the various species. See Echinococcus, Cys- ticercus, Hydatids, Measle, Taenia, and Tapeworm. T. S. Cobboi.d. BLAIN. — A blister, as in the case of chil- blain. According to Mason Good, blains are ‘ orbicular elevations of the cuticle, containing a watery fluid.’ BLEB. — A large vesicle or bulla, containing for the most part a serous fluid, as in pemphigus, erysipelas, or burns and scalds. See Blister. BLENOKB.HCEA, BLEW OEEHAGIA (f}\4vva, phlegm, and [>eai, I flow ; f}\ ivva, phlegm, and piiyvO/i i, I burst out). These terms are most correctly used to express excessive flow of mucus from any mucous surface. By means of an affix, tho locality or nature of the discharge is ex- pressed: e.g., blenorrhoea oculi, nasalis,urcthralis. More commonly, however, and less accurately, bienorrhcea is employed as synonymous wilh gonorrhoea in tho male or female. BLEPHAB.ITIS ((SAetpapor, an eyelid). In- flammation cf the eyelids. See Eye and its Appendages, Diseases of. BLEPHAROSPASM (/3Ae\ paouv, an eye- lid, and 24 BOILS. shorten the duration of the inflammation. They give relief to pain, however, and check the spread of diffused boils. When made, incisions should be free, crucial, or even star-like, and carried beyond the boil. In the rapidly extend- ing boil of the face local treatment is of little avail ; the free use of the actual cautery may be beneficial if employed at an early period. Berkeley Hill. BONE, Diseases of. — Under this head are included : — Acute and Chronic Inflammation of bone and its membranes, with the consequences thereof, such as Caries, Necrosis, and Abscess ; New Growths which arise both within and upon the bone ; Malformations ; and certain Disorders of Nutrition, namely. Hypertrophy and Atrophy. Bone-tissue should be regarded as being simi- lar to other connective tissues, but some dis- eases affecting it are rendered obscure, while others are materiall}' modified, by reason of its meshes being filled with lime-salts. 1. Inflammation. — As a matter of clinical convenience, it is usual to consider separately in- flammations of the periosteum, of the bone proper, and of the medulla ; but it should not be forgotten that these structures are throughout continuous and interdependent, and that disease is rarely exclusively confined to any one of them — it may originate or be chiefly developed in one, but it cannot long exist without involving the others to a greater or less degree. A. Periostitis — Inflammation of the invest- ing membrane of bone ( die Knochenhaut). By periosteum is usually meant the thin fibrous en- velope of the bone in which the vessels for the supply of blood subdivide. But between it and the bone is a layer of osteogenetic cells like the cambium-layer of a growing plant, and immedi- ately external is a layer of cellular tissue, con- tinuous with that of the adjacent parts ; these are integral portions of the periosteum, and take an active share in all its diseased processes. Periostitis may be either acute or chronic. (a) Acute periostitis, osteoperiostitis, acute pe- riosteal abscess, or acute necrosis. — This is a for- midable, but fortunately comparatively rare, disease, at least in the adult. It attacks the long bones almost exclusively, usually those of delicate children or young adults, in whom active bone- growth is still going on, and the periosteum is highly vascular. Acute periostitis probably never occurs without coincident inflammation of bone, and it is by far the most common cause of ne- crosis. It will be best to regard it as an acute ostitis and periostitis combined, and to call it osteoperiostitis, just as we call inflammation of the bone and of the endosteum osteomyelitis. The extent to which the bone and the perios- teum are in the first instance respectively in- volved is always difficult, and sometimes im- possible, to determine — it may be inferred from the extent of the necrosis. There are two ways in which the disease may begin — - either in the fibrous investing sheath of the bone and the cellular laj'ers beneath and superficial to it, from whence it spreads inwards to the cortical bone-substance, or even to the medulla; or in the bone-tissue — the inflammation spreading outwards to the periosteum. It is impossible BONE, DISEASES OF. in the living subject to distinguish acute osteomyelitis and osteoperiostitis arising from idiopathic causes. The disease is usuallv at- tributed to an injury, often slight, or to ex- posure to extremes of cold or heat. Frequently no cause is assignable. Pathology. — Rapid exudation takes place in the layers of the periosteum, and in the Haversian spaces and canals of the bone, to such an extent as to obstruct the circulation, and probably to cause by pressure the severe pain complained of at the outset. The exudation beneath the fibrous layer of periosteum is copious, and soon becomes purulent ; the periosteum is detached ; the vascular supply of the bone is cut off ; and necrosis results. The extent of the necrosis depends upon the extent to which the periosteum is engaged, while the thickness of the dead bone depends mainly on the depth to which the inflammation in the osseous tissue extends. Large accumulations of pus are often rapidly formed in these cases, the pus escaping through openings in the fibrous envelope into the circumjacent cellular tissue. The shafts of the tibia and femur are the part3 most frequently affected ; the disease occurs more rarely in the bones of the upper extremities and other parts of the skeleton. Symptoms. — One of the earliest symptoms of acute periostitis is sudden and severe pain in the affected bone, which is soon followed by intense fever. On the second or third day deep-seated swelling sets in, somewhat obscarc at first. After an interval varying from five to ten days, the inflammatory signs approach the surface, the skin becomes cedematous. pits on pressure, and finally reddens and inflames. The length of interval depends on the thickness of muscles and soft parts covering the affected bone. Other things being alike in respect of pain and amount of fever, the longer the delay in the appearance of external swelling, the greater the probability that the bone is the first and chief tissue engaged, the inflammation having reached the periosteum secondarily, while the early appearance of swelling and fluctuation externally suggest that the inflammation is chiefly periosteal. Blood-poisoning, either sep- ticaemic or pyaemic, is a common consequence of acute inflammation of bone and periosteum. Diagnosis. — This disease may be obscure at the commencement, and its nature overlooked ; it has often been mistaken for acute rheumatism on account of the swollen joints, for phleg- monous erysipelas, for acute cellulitis, or for typhoid fever. The only malady with which acute periostitis need be confounded is an idiopathic inflammation of the deep-seated cellular tissue in a limb. This disease is rare. When we observe the chain of symptoms above described in a young person, we mav safely assume the presence of an acute osteoperiostitis. The disease almost invariably terminates in suppuration and necrosis ; resolution happens rarely, but necrosis is not inevitable, even after suppuration. In a few cases, especially in young children, if the matter be speedily evacuated, tLe abscess collapses, the periosteum reunites wilh the bone, and no necrosis takes place. This result is unfortunately quite exceptional. Prognosis. — This must be founded on the BONE, DISEASES OF. latent of the necrosis ; whether blood-poison- ing has taken place ; and whether the adjacent joints are implicated in the disease. Cure cannot take place until the dead hone is cast off or removed, and this is often long delayed. The usefulness of a limb may be permanently impaired by the disease, or it may require amputation, or the patient may lose his life altogether. On the other hand, the use of the limb, and the health of the patient, may become completely re- established. Treatment. — Early and energetic treatment is of the greatest importance, as it affords the best prospect of averting the disastrous consequences of acute periostitis, but in hospital practice the cases are rarely seen sufficiently early. In the first stage the limb should be elevated, and ice applied ; painting the limb with a strong solution of iodine is advisable. As soon as the nature of the affec- tion is manifest, incisions down to the bone, so as to divide the periosteum, are indicated even before pus is formed. They relieve pain and tension, and, by permitting the timely escape of pus as soon as it does form, the amount of perios- teal separation, and consequently of necrosis, is limited. It is the more important to make an early incision, because evidence of fluctuation is at first by no means clear or easy to make out, and this should, therefore, be done in all cases of doubt. Antiseptic precautions should always be taken. Sometimes the abscess-cavity does not readily collapse, owing to its walls being stiff and infiltrated, and its contents may become putrid, thus greatly increasing the patient’s risks. If there be synovial effusion into a neighbouring joint, the limb should be kept at rest by means of a splint or a fixed bandage. When the acute symptoms subside, the abscess- cavity contracts, one or more sinuses remain, and the dead bone begins to separate ( see Necrosis). Where the epiphysis is engaged in the disease the case is more urgent ; the fever runs higher, the suppuration is greater, and the degree of joint-implication more intense, proceeding in ex- treme cases to suppurative inflammation and destruction of the articulation. The oedema of the limb often indicates a deep-seated phlebitis, the precursor of septic poisoning. Under these circumstances, amputation of the limb is often the only resource. It is imperative to amputate where there is extensive bone-destruction, and the symptoms indicate commencing pyaemia ; or where, with the death of a large portion of the shaft, one or both of the neighbouring joints has become gravely implicated, and great suffering and loss of strength forbid us to temporise. It is precisely in these cases, however, where the diaphvsis has become necrosed up to the epiphy- sal junction, that good results are attainable by the immediate extraction of tho dead hone. The shaft where it joins the epiphysis becomes ra- pidly detached and loose, and may easily he separated, while the bone can he divided with a chain saw beyond the limit of the necrosis in the other direction, and removed. It is difficult, however, in the early stages to diagnose the extent of the necrosis. Where the joints both above and below are involved, amputation is usually necessary. A periostitis of a very acute form, almost 125 invariably suppurating, and accompanied by necrosis, is very common in the fingers, where it chiefly affects the ungual phalanges! The pain is very great, hut may be relieved by an earlv and free incision down to the bone, which, never- theless, does not usually avert either suppuratioi or necrosis. ( b ) Chronic 'periostitis is usually due to some diathetic cause, but may result from injury, or from some continuous pressure. It is most fre- quent on the superficial parts of the skeleton, as the tibia, clavicle, skull, and ribs, but may affect any bone ; and it is often observed at the origin or insertion of muscles. When the disease arises from a general cause, such as syphilis, many parts of the skeleton are affected ; when from a local cause, usually only one. Symptoms. — Chronic periostitis generally takes tho form of what is called a node — a tender, more or less painful, rounded or oval swelling ; at first tense and hard, afterwards softer, or even fluctuating. The pain is much greater at the outset, from the tension of the parts involved, and is general^ worse at night. Subsequently the swelling becomes in- dolent, and painless, unless pressed upon. Nodes are due to a localised inflammation. The cambium- layer of the periosteum and its external layer proliferate and become filled with leucocytes, thus forming a well-marked projection on the hone, which may undergo resolution, suppurate, or ossify, according to circumstances. Prognosis. — In chronic periostitis this is usu- ally favourable. Under the influence of early and suitable treatment, the inflammatory products are completely absorbed, and the hone resumes its natural shape. If the chronic inflammation of the periosteum he permitted to proceed un- checked, a deposit of new osseous lamellae usually takes place on the surface of the affected bone, giving rise to permanent thickenings, or even to osteophytic growths. These are composed of light porous bone, with a rough surface. The skeleton of a syphilitic subject will often present numerous thickenings of this nature. On making a section of the hone, it is easy to see that the new hone is superimposed upon the old, and is formed by the periosteum. Treatment — When due to a local cause, the swelling will often spontaneously subside with rest to the part, hut in obstinate cases iodide of potassium internally, and iodine ointment or blistering externally, may be required. If the subject be unhealthy, or if the original injurvbe considerable, suppuration may take place, t&en the treatment will be that of an inflammatory abscess. Syphilitic nodes, which are a very common expression of chronic periostitis, yield rapidly to the influence of iodide of potassium, which in some cases may usefully be combined with a mercurial course. Blistering or friction externally is hurtful in such cases. Syphilitic nodes are not at first prone to suppuration, and even when they become soft and fluctuating, and the skin reddens over them, they should not he mistaken for abscesses, as they readily become absorbed under suitable treatment. (c) Periostitis after typhoid fever. — A peculiar form of chronic periostitis is occasionally observed as a sequel to typhoid fever. It occurs during BONE, DISEASES OF. 125 convalescence, and without general symptoms. It takes the form of hot, painful, and tender nodes, frequently symmetrical, and often placed on the Libia ; the disease is also found on the ribs and other bones. It may be associated with necrosis, but if so the extent of the dead bone is small in proportion to the inflamed area of periosteum. The general health is not seriously affected, and the disease is very amenable to treatment by iodide of potassium, combined with iodide of iron. B. Osteitis is an inflammation chiefly affect- ing the bone-substance; this form may also be acute or chronic. (a) Acute osteitis is neither clinically nor patho- logically to be distinguished from acute osteo- myelitis or endostitis {see Osteomyelitis). (b) Chronic osteitis is a disease beginning in the bone, in which the chief changes from first to last occur, the periosteum being secondarily engaged. This affection may result from injury, or be ex- cited by exposure to cold ; but it often depends on constitutional predisposition, such as the syphilitic, the strumous, the gouty, or the rheu- matic diathesis, the first being the most frequent cause. It may occur in any part of the skeleton ; the chief changes, when produced by syphilis, ocetir -in the shafts of the long bones. They con- sist mainly of hypertrophy, and the bone is ulti- mately increased in thickness, in length, and generally in density : its interior is often trans- formed into dense bone-tissue, and the medullary cavity is obliterated. Another form, associated with the strumous diathesis, is generally seated iii the joint-ends of the long bones, and in the spongy bones. It is prone to end in suppura- tion, accompanied by either caries or necrosis. The gouty and rheumatic forms are associated with evidence of the presence of either of these diatheses. Pathology. — Increased vascularity first takes place, the Haversian canals enlarge, the canali- euli disappear, the cancelli enlarge to con- tain the inflammation-products, and the earthy matter diminishes ; hence the inflamed bone softens, and, if macerated at this stage, will be found comparatively light and porous. When the inflammation affects the superficial laminae of the bone, the periosteum becomes thick and vascular ; if the deeper parts are involved, simi- lar changes will occur in the endosteum. The porous condition of the bone may become permanent, when the condition is called osteoporosis, the result of so-called rarefying ostitis ; or the granulations become transformed into new bone, and the cancellated structure is filled with osseous deposit, so that the whole of the inflamed area becomes very dense, and is then said to be sclerosed ; or the inflammation- process may terminate in suppuration, followed by caries, necrosis, or an abscess of the bone, which last may be either diffused or circum- scribed. Symptoms. — These are insidious, very obscure at the outset, and may be mistaken for those of chronic rheumatism, or mere periostitis. They consist chiefly in aching, gnawing pain in the affected bone, with characteristic remissions and nocturnal exacerbations. The bone is tender on pressure, and feels increased in bulk at first, from the infiltration of the immediately sur- rounding soft tissues ; subsequently the bone itself enlarges. There is often increase of heat in the limb. The progress is very chronic, and if unchecked by treatment may give rise to con- siderable deformity. Treatment. — This should be directed to the cause of the disease. If this be syphilis, an antisyphilitic treatment will be followed by good results ; even in chronic bone-inflammation, not dependent on syphilis, iodide of potas- sium is often of great service. Local counter- irritation may also be employed. Often the cause cannot be made out, and if iodide of potassium fail in producing an effect, we must fall back on general treatment. In the early subacute stage, rest, with elevation of the affected part, is very desirable. Warm fomentations, fol- lowed by iced compresses, relieve the suffering. If there be much pain and tension, leeches should be applied. Puncturing the tissues down to the inflamed bone with a tenotomy knife or fine bistoury, relieves the tense periosteum, and allows extravasation beneath it to escape, so that the pain is promptly abated. (c) Osteitis deformans . — A peculiar form of chronic inflammation cf bone has been described by Sir James Paget under this title, from the changes it produces, both in the form and density of the affected bones. It is a chronic osteitis of the most extreme type. It begins in middle age, and may continue for an indefinite time without influence upon the general health, which distinguishes it clinically from other bone-inflammations. It is usually symmetrical, and affects chiefly the long bones of the lower extremity and the skull. At first the bones enlarge and soften, from excessive produc- tion of imperfectly-developed structure and in- creased blood-supply, and, yielding to the weight of the body, become curved and misshapen, but the limbs, although deformed, remain strong and fitted to support the body. In its early period, and sometimes throughout its course, the disease is attended with pains in the affected bones, which vary widely in severity, and are not especially nocturnal or periodic. It is not at- tended by fever, nor associated with any consti- tutional disease. It differs from the chronic osteitis dependent on simple inflammation of bone or that produced by gout or syphilis, in affecting the whole length of the bone. Hyperostosis and osteoporosis dependent on these latter causes rarely affect the entire bone. No treatment appears to produce any effect upon this disease. C. Osteo-myelitis is an inflammation chiefly affecting the interior structure of the bone. Like the former, it may be acute or chronic. (a) Acute osteomyelitis or endostitis is a sup- purative inflammation of the medulla and bone, which very frequently ends in septic poisoning and necrosis. It is nearly always associated with bone-injury, and most frequently happens after amputation, or gunshot fractures, in which the cancellated structure is injured ; a severe contu- sion of the bone, an injury to the periosteum, or exposure to sudden extremes of heat and cold is capable, under some circumstances, of produc- ing the disease. Symptoms. — The symptoms are obscure, more especially if there be no opportunity of examining BONE, DISEASES OF. 127 the affected hot e, as the changes in the bone are often masked by inflammation of the superficial parts. They usually make their appearance from five to ten days after the injury to the bone. The pain may not be excessive ; there is fever and perhaps rigor. If there be a -wound the secretion from it diminishes in quantity’, and be- comes less healthy; the medulla protrudes from its central cavity ; the parts soon become surrounded by putrescent fluid ; and the symptoms become those of more or less intense septiesmia. The periosteum sometimes, but not always, separates from the bone. In young persons the disease is sometimes arrested at the epiphysis ; but in the adult the whole length of the bone is liable to be affected. The risk of septic poisoning is infinitely greater in osteomyelitis that in osteo- periostitis. Thrombosis of the bone-veins is especially prone to happen, and by the breaking down of the clot septic emboli are carried into the circulation, and deposited in the liver, lungs, and elsewhere. It is in this disease, too, that fatty embolism takes place— a condition associ- ated with a very acute and fatal form of blood- poisoning. The prognosis is generally bad. It is impossible to distinguish acute osteomyelitis from acute osteo-periostitis, arising from non- traumatic causes. In military hospitals, in war time, acute osteo-myelitis is often epidemic. Treatment. — Where the symptoms lead us to suspect osteomyelitis, although the medullary cavity of the bone may not have been exposed, it may be desirable to trephine the bone, and if suppuration in its interior be discovered, it will be necessary to amputate, and as soon as the nature of the disease is recognised, this affords the best chance of saving the patient's life. The chief difficulty consists in arriving at a correct diagnosis and deciding when it becomes necessary to interfere. This may best be done by observing the general progress of the case ; and locally by the introduction of a probe into the medullary cavity when this is exposed. If it reach healthy bleeding medulla near the surface, we may temporise, if the constitutional symptoms admit of this; but it is rare for the disease once commenced to be limited — it has an extreme tendency to become diffused. Ex- perience shows that nothing short of amputa- tion at, or even above, the next joint is sufficient to arrest the consequences of the malady, and this must be done before the systemic poisoning has become marked. Amputation in the con- tinuity of tile affected bone is worse than use- less. (6) Chronic osteomyelitis is an obscure affec- tion, not to be distinguished, either clinically or pathologically, from chronic ostitis. It may ter- minate in sclerosis, or in the formation of an abscess. See Chronic Osteitis. 2. Abscess. — This is a term applied usually to a limited suppuration in the bone, unattended by necrosis. Young adults are most prone to the disease, or boys about the age of puberty ; it is very rare in women. It is the result of a chronic inflammation of bone, which maybe asso- ciated with some injury. This affection is most frequently met with in the upper or lower ex- tremities of the tibia, just external to the epi- physal cartilage, less frequently in the ends of the femur, only occasionally in other bones, and very seldom in the compact tissue anywhere. Symptoms. — A circumscribed, slightly elevated, very tender and painful swelling may’ be dis- covered. This is due to a local periostitis with new bone-deposit, and the bone itself is often half an inch or an inch longer than its fellow, by reason of increased activity of growth at the epiphysis. The skin and superficial parts are un- changed at first, or there maybe but trifling sub- cutaneous cedema. There is often slight local in- crease of temperature. The pain, on deep pressure at the central point, is often intolerable. It is intermittent at first, but generally worse at night. After a time it becomes continuous, and deprives the patient of all rest, owing to its severity’. The abscess may persist with little change for months or years. The symptoms generally resemble those of osteitis, from which at the outset it is difficult to distinguish this affection. When the abscess tends to reach the periosteal surface, the soft parts become engaged, and there will be slight redness and oedema of the skin. Barely the pus makes its way into the adjacent articulation, in which it sets up destruc- tive inflammation ; but usually the joints are free from implication. The subjects of the disorder have often suffered from antecedent bone-disease. Evidence of this should be looked for, as giving a clue to the diagnosis. Treatment. — Spontaneous cure cannot occur — even if the abscess discharge itself, a perma- nent fistula will usually remain. It is necessary freely to lay open the abscess-cavity. A crucial incision must be made through the soft parts, down to the bone, at the most tender and pro- minent point, and a disc of bone removed by the bone- trephine — an instrument without a shoul- der, about half-an-inch in diameter. The sudden loss of resistance indicates the piercing of the abscess-cavity. The lay’er of granulation-tissue lining its interior should not be interfered with, but the cavity simply washed out. The pus is often foul, and greenish in colour. The wound should be dressed antiseptically ; granulations presently fill it. which are subsequently trans- formed into a fibrous cicatrix. Immediate and permanent relief follows the operation. If the abscess is missed, the trephine may be re-ap- plied, or drill punctures made in the most likely directions in the adjacent bone, in order to discover the pus. Somet imes an error of diagnosis is committed, and the symptoms are found to arise from chronic osteitis, without suppuration. The operation, however, affords relief in these cases also. Where there is doubt, a preliminary course of iodide of potassium will often re- solve it. 3. Caries is a form of chronic inflammation of bone, which has been likened to the process of ul- ceration in the soft tissues. It is generally found in the spongy bones, in any part of the skeleton, the vertebrae and tarsus being the parts most commonly affected. There are two forms of the disease — one, simple caries, resembles an indo- lent ulcer of the soft parts, is most common in the fat or short bones, but is sometimes met with in the compact tissue of long bones ; the other, fungating caries, is often met with in the articular ends of the long bones, and usually BONE, DISEASES OF. 128 terminates in joint-disorganisation. It has been called subarticular caries-, and is part of the dis- order known as tumor dibus (see Joists, Diseases of). The non-articular form of simple caries often originates in a localised periostitis, and is gene- rally due either to syphilis or struma — the latter is most frequent in young persons, the former in adults. Pathology. — In caries the bone gradually dis- integrates as the result of a chronic inflammation of its cancellated tissue. The trabeculae become in- filtrated with leucocytes, and granulations form, which prove the source of purulent discharge, just as in a granulating surface of the soft parts ; but the process is interfered with and delayed by the act of getting rid of the osseous struc- ture, in the trabeculae of which the cells remain shut up until the dead bone finally breaks down, and comes away in the discharges, being often distinguished in the form of gritty par- ticles. Until this process is completed the dead bone is soaked in pus, which often becomes putrid, and until it is got rid of a healthy granu- lation-surface is impossible. Symptoms. — Caries is very chronic in its pro- gress, and often causes extensive loss of bone, destruction of a joint, or loss of a limb. It is almost always associated with an impaired con- dition of general health : the adjacent soft parts are involved in the inflammation ; abscesses form in them, generally connected with the diseased bone ; these burst or are opened, and sinuses lined with gelatiniform granulations, and discharging a thin pus, persist for an indefinite time. On examination with the probe the surface of the bone is felt bare, rough, and much softened; and outside the area of carious bone periosteal deposits of newly-formed osseous tissue are often found. The diagnosis and prognosis depend upon the age, constitutional condition, and history of the patient, as much as on the local signs. Treatment, — This must be directed to relieve the constitutional taint, as well as the local disease. Merely to excise or destroy the diseased portion of bone is not sufficient to cure the patient. Local means prove efficient only when the general condition has been sufficiently ame- liorated, especially in the unhealthy chronie in- flammation of bone frequently called strumous. Good air, good food, and tonics are, therefore, of great importance. If syphilis be present, an anti-syphilitic treatment must be pursued. The principle by which the local moans act is to facilitate the formation of a healthy granulating surface — to transform, in fact, an indolent into a healing ulcer. The disintegration of the dead and diseased trabeculae must be assisted. For this purpose the application of strong sulphuric acid diluted by two or three parts of water, or some other mineral acid, often piroves useful. Partial gouging out of the diseased bone seldom succeeds, because of the injury done by the in- strument to the adjacent bone, weakened as it is by inflammatory changes, and therefore prone to set up fresh disease. The complete evidemcnt of the bone, leaving nothing but its thin outer shell, is more successful ; but when the disease begins to invade adjacent joints, as in the tarsus, excision of the entire bone is best ; or when several bones are involved, amputation becomes necessary. In children operations of this kind art not so often required; general treatment usually proves sufficient. In the early stages the actual cautery, applied over the most painful spot, is a valuable counter-irritant. It is undesirable to make early incisions into strumous abscesses in connection with diseased bone. It is better to empty them by a small trochar, and to preserve the diseased area as long as possible from atmo- spheric influence. When the carious action is arrested, the cavity fills with healthy granulations, the sinuses close, the parts cicatrise, and the gap in the osseous tissue is filled by fibrous, or some- times by osseous material. 4. Necrosis. — The complete arrest of nutri- tion in a portion of bone from any cause is fol- lowed by the death or necrosis of the bone, and by a series of inflammatory changes in the ad- jacent parts, which result in the complete separa- tion of the dead from the living tissue. /Etiology. — Necrosis is most frequently tho resultof acutebone-inflammation or severe injury, as after amputation, fracture, or contusion. It is especially prone to happen in the compact tissue, but it also occurs in the spongy structure, as the joint-ends of long bones, or the tarsus and car- pus, where it is usually associated with more chronic forms of inflammation, and is more limited. Tho peculiar nature of the blood-supply to bone, and the facility with which it may be interfered with or arrested under the pressure of inflammatory changes, go far to explain the frequency of necrosis as a result of bone-inflam- mation. Acute suppurative osteoperiostitis or osteomyelitis rarely terminates without necrosis. Whether the dead bone will be in the superficial or the deep lamellae depends on the seat of the in- flammation, and on the extent to which the perios- teum and endosteum are respectively implicated. The long-continued action of phosphorus, a3 observed in match-makers, and also of mercury, may induce necrosis. Syphilis is a frequent cause of necrosis, through its tendency to produce chronic osteoperiostitis, the sclerosed bone thus originated being afterwads prone to necrose. It is not an uncommon sequel during convalescence from some eruptive and continued fevers. After scarlatina, osteoperiostitis, followed by necrosis, is by no means rare, although affections of the joints are more common. It is probable that many cases of necrosis occurring in childhood are connected with an antecedent attack of scarlet fever. The nasal bones may necrose as the result of severe coryza, the vertebrae after pharyngitis, or the petrous portion of the tem poral bone as a consequence of otitis. Arterial thrombosis and embolism are occasional sequelae of typhus, and may produce a local gangrene, not only of the soft parts, but of bone. This is, however, more frequent in connection with typhoid fever. In endocarditis the nutrient artery of a bone has been observed to be obliterated by an embolus, thus producing necrosis. Pathology —After the death of a piortion of bone, the living tissue, in immediate contact with the dead, becomes inflamed. The Haversian canals and canaliculi become distended with migratory cells ; loops of capillaries form from the pre- existing vessels ; a granulating surface, in fact, surrounds the dead bone in a manner precisely BONE, DISEASES OF. similar to -what takes place in the soft parts when ! a slough is being thrown off. The periosteum separates from the bone, becomes thick and vascular, while the osseous surface beneath is smooth and white, like macerated bone. In cases of syphilitic necrosis, as well as in that result- ing from phosphorus, the surface is rough from antecedent periosteal deposit. How the osseous t rabeculse are dissolved or disintegrated over the surface of separation, so as to loosen the dead bone, is not certain. Probably the granu- 1 ition-tissue that forms from the living bone possesses amoeboid properties, and thus disposes of some of the bone-particles. The pus that is formed has a mechanical influence, while accord- ing to one theory lactic acid is produced, which transforms the insoluble into soluble salts of lime. Whilo this loosening process is going on new bone, formed chiefly from the periosteum, is being deposited, constantly becoming thicker, and with one or more openings in it for the escape of pus, called cloaca, so that eventually the dead piece becomes completely invaginated, and is named, from its position, a sequestrum. This sequestration of the dead bone is not invariable, as for instance in the spongy bones, the bones of the skull, and the upper jaw, or where from any cause the periosteum has been destroyed, no sheath of new bone will be formed. Necrosis very rarely takes placewithout suppuration ; when this does happen the nature of the case is very obscure. Occasionally nearly the whole shaft of a long bone has been found necrosed, and after an interval of months or even years no suppu- ration may have taken place. Such forms of necrosis closely simulate malignant disease, and often they cannot be relieved or even recognised save after amputation. A chronic ostitis, fol- lowed by hypertrophy and sclerosis of tho bone, is the most common antecedent condition of this form of necrosis. Treatment. — The changes already described, which separate the dead bone from the living, do not cause its expulsion from the body. On the contrary, they shut it up, like a kernel within its shell, and nothing so imperatively demands surgical interference as the presence of necrosed bone. It acts as a foreign body, is a constant source of risk to the patient, and should be re- moved as soon as practicable. Its presence ex- cites the periosteum to further formation of bone, so that the invaginating sheath becomes of great thickness in old-standiug cases. The period at which an operation is usually undertaken is when the sequestrum has become loose, and the time required for this purpose varies with the extent and. thickness of the necrosed bone. In the actively growing bones of tho young tho process of separation is accomplished more quickly than in tho adult, especially when the sequestrum in- volves the epiphysal junction. Roughly esti- mated, a period of from three to six months might be named as that within which loosening of the eequestrum usually occurs. Beyond the latter term an effort to extract the dead bone should not be delayed, even if it cannot be felt to be loose. Among other risks involved in doing so may be that of amyloid degeneration of the viscera, principally the liver, kidneys, and spleen, which are subject to this change as the conse- 9 12D I quenceof long- continued discharge from bone- disease. In order to remove a sequestrum, a director should first be introduced through a cloaca as a guide, and the soft parts sufficiently divided. An adequately large opening must now be made in the encasing sheath of new bone with the chisel, trephine, small saw, or cutting for- ceps, and the dead bone extracted, either in one or several pieces, as may be the more convenient The operation may prove difficult on account of great thickness of the soft parts or of theseques- tral envelope, or because the sequestrum itself ix extensive. After the removal of the dead bone the cavity fills with granulations, which subse- quently ossify, and the softpartscicatrise. Finally the sequestral envelope of new bone is partly absorbed, partly consolidated, just as the redun- dant callus is after fracture, and the bone tends more or less to resume its normal size and shape. 5. Tubercle. — An examination of some cases of chronic bone-disease in scrofulous subjects seems to prove their connection with the forma- tion of tubercle in the bone. The medullary tissue in the joint-ends of the long bones, and cancel- lated bone generally, are chiefly affected. The ex- ternal appearances are those of fungating caries ; but microscopical examination discloses multi- tudes of round cells like lymph-corpuscles, with protoplasmic matter, filling up the interspaces. The cells are found surrounding thesoft, gray, non- vascular patches, which are often seen on section of an inflamed cancellated bone instrumous indivi- duals, the central part of which maybe the sub- ject of calcareous, fatty, or suppurative changes. The bone when so affected is never sclerosed ; hence these are not simply cases of chronic inflam- mation. There is, however, some difference of opinion as to whother, in strictness, .they should be called tubercular in their nature, and the inference that they are so rests rather on the general condition of the patient than on any purely local characteristic. Treatment. — In cases of this kind general tonic treatment becomes of the greatest importance. Rest must be given to the affected part, and exer- cise to the body generally, combined with fresh air both day and night, and simple nourishing food. Where the bone is extensively diseased, it must either be excised, or the part amputated. The presence of the tubercular diathesis does not. forbid an operation, the local source of irritation and drain upon the system being thus removed, and a healthy traumatic surface substituted for one infiltrated with inflammation-products. The removal of the local disorder often proves a comfort to the patient, and increases his chance of regaining health and strength. 6. New Growths. — The bones are liablo to most of the new growths forming tumours found elsewhere in the body, such as cancerous, vas- cular, and other tumours. The most important are the following: — a. Some tumours are peculiar to bone, as, for instance, the Myeloid, so called from the many nucleated corpuscles contained in it, analogous to those found, in foetal marrow ; it is of en- dosteal origin, causing an expansion of the bone in which it grows. It is most common in tho maxillary bones, and near the epiphysal ends of the long bones. It is generally observed ir? BONE, DISEASES OF. 130 young persona, requires removal, and extir- pation, if complete, is not, as a rule, followed by a return of the disease. b. Periosteal or Fasciculated Sarcoma, springing from the periosteum of a long bone, such as the femur, is not uncommon. The shaft of the bone may be seen on section passing through the centre of the tumour. Numerous bands of fibrous tissue, often ossified, radiate from the periosteum through the growth, like an out- spread fan. The best treatment is amputation of the limb at the joint above, which does not, how- ever, ensure against recurrence of the disease. c. Exostosis. — This is a bony outgrowth de- veloped on any part of the skeleton. It is diffi- cult to distinguish cartilaginous from osseous outgrowths. The two structures are often mixed, and a lumonr originally cartilaginous is often transformed into bone. Cartilaginous out- growths, called Enchondroses are met with on the costal cartilages of old persons, also on the intervertebral discs, near the synchondroses, and arise also from the articular cartilages iu rheumatic arthritis. Cartilaginous tumours, growing either from the periosteum or the medulla, have tbeir favourite seat upon the phalanges ; they are usually multiple, and from the deformity and inconvenience they produce often demand either enucleation of the tumour or, in extreme cases, amputation of the finger. The more special forms of exostosis are of two kinds, the spongy and the ivory-like. Spongy exos- tosis is often developed near the articular ends of the long bones, where it forms a nodulated out- growth of cancellated hone of variable size, en- crusted with a thin layer of cartilage, and having generally a bursa superimposed. This kind of exostosis is often connected with the epiphysal cartilage, and ceases to grow when the bone is fully developed. This fact, as well as the prox- imity of the neighbouring joint, renders surgical interference generally unnecessary, and often hazardous. Another form of spongy exostosis, sometimes called osteophyte, depends on a local excessive periosteal growth of bone. At first this outgrowth is porous, and but slightly con- nected with the bone on which it is developed. Afterwards it may become dense and hard from interstitial deposit, or it may always remain spongy. Such exostoses often depend on some local exciting cause, such as a blow ; or they may be found at the insertion or origin of a muscle, as iu the so-called rider’s bone, at the origin of the adductor longus muscle, or the exos- tosis frequently found at the insertion of the adductor magnus, or the 1 exercise bone ’ of the German soldier. They may he regarded as morbid exaggerations of the normal tuberosities of the skeleton. Ivory exostosis, so called from its dense, eburnated character, is more rare. It varies much in size, and maybe pedunculated or sessile. Hereditary influence appears to exist in some cases, in others a predisposition to chronic peri- ostitis, but there may be no apparent cause. The development is slow and painless. Treatment. — Interference is seldom required m the spongy exostoses, except on account of pain or loss of function. When pedunculated they can be broken off or divided subcutaneously ; and although they may reunite, it will probably be in a more convenient and painless relation to adjacent parts. Otherwise they should be ex- cised. Except on account of deformity, or of pressing on important structures, an ivory exostosis need not be meddled with. It can often, however, when necessary, he enucleated; and where only a partial removal is possible, the low vitality of the tumour often causes necrosis and su > sequent exfoliation of the remainder. Sponta neous necrosis also occasionally occurs. d. Osteo-aneurism.— Certain sarcomata and myeloid tumours, when very vascular, pulsate, and have been mistaken for aneurism. There are, however, undoubted cases of aneurismal tumours, dilating the hone, which have been cured by ligature of the main vessel of the limb. When the tumour is small it may be excised, or the actual cautery applied. Sometimes amputation is required. The causes and pathology of the disease are obscure. It is probably in some cases of a nsevoid character. e. Bone-cysts are tumours distending and thinning the bone, and filled with serum or bloody fluid. In some rare cases they contain hydatids. The origin of bone-cysts is obscure ; some originate in the dentigerous cavities of the maxillae, in which hone-cysts are most fre- quent, but they are sometimes found elsewhere. Avery slow, painless increase in size takes place. Tho hone becomes gradually very thin, and often affords on pressure a peculiar and characteristic parchment-like crackling. In obscure cases an exploratory puncture should he. made. Treatment consists in freely laying open the cyst-cavity, and providing for subsequent drainage. The cavity gradually contracts and becomes obliterated. f. Hydatids. — The formation of echinococ cus-eysts in bone is exceedingly rare, compared with ether parts of the body. The causes arc unknown, and the symptoms very obscure, re- sembling those of an ordinary cyst. A cavity is formed, usually in the spongy extremities of the long bones, to contain the mother cyst. But it is also found iu the medullary canal. The af- fection is grave. Serious inflammation often follows interference with these entozoa. It is sometimes difficult to remove the whole disease : and unless this be effectually done a relapse will occur ; while in such parts as the pelvis art is unavailing. The cavity should, if possible, be freely laid open, and all the cysts carefully re- -moved or destroyed. The actual cautery may be sometimes employed with advantage, or the surface of the adjacent bone removed, as it may be invaded by the cysts. An exploratory punc- ture can alone resolve the diagnosis, by finding the hooks of the acephalocyst iu the fluid. 7. Malformations. — These consist in any departure from the normal type of the skeleton, by reason of excess, deficiency, or irregularity, either congenital or acquired. It is not neces- sary more than to allude to the fact, that tho skeleton is often defective in parts ; that senile changes occur, especially in certain hones ; and that supplementary bones and processes are met with. Various deformities occur in bones from fractures, both intra-uterine and subsequent to birth, and from curvatures due to rickets or BONE, DISEASES OF. fcoftcni ng. Treatment, ofeurvature consists in gra- dual s ; Heightening by splints or other apparatus, or immediate straightening under chloroform, methods which, in the soft growing bones of the young, prove successful in abating many defor- mities. The curvatures of adult bones do not yield in this way. When there is loss or impair- ment of function from deformity, the bone may be safely divided subcutaneously with the chisel or saw, and the limb straightened — often with admirable results. Forcible fracture is a clumsy md somewhat dangerous method, as the force employed cannot be regulated. 8. Hypertrophy means an excessive growth of bone-tissue. Apart from inflammation this is rare, but in museums specimens of excessive growth are met with, especially of the bones of :he face and skull. The causes are unknown, and no treatment appears applicable. 9. Atrophy consists in a diminution of the size or compactness of a bone. It may be the result of inflammatory changes, of senile degeneration, of disuse of a limb, or of an injur}’, such as a fracture followed by non-union. The bone-tis- sue gradually wastes away, the cortical portion often becoming a thin parchment-like layer of bone, filled with soft medulla. This has been called excentric atrophy. The external appear- ance and size of the bone remain unchanged. Concentric atrophy, where the size of the bone diminishes in all its dimensions, may occur in bones which have been disused for lengthened periods, as from paralysis of a limb, disease of a joint, or un-united fractures. Spontaneous frac- tures, or fractures due to trifling causes, are very common under these circumstances. The term Fragilitas Ossium has been applied to this condition of bone-tissue, which also frequently occurs in cases of cancerous cachexia. 10. Softening. — This change occurs in Rickets and Mollities Ossium. See Rickets; and Moxxi- ties Ossrcir. Wuium MacCormac. BOHBOETGMI (fSop&opvfa, I grumble). — Rumbling sounds produced in the abdomen by the movements of gas within the bowels or stomach. BORDIGHEB.A in Italy, on the Riviera. A suitable winter residence for patients suffering from some forms of chest-disease. The climate is warm and dry. See Cxtmate, Treatment of Disease by. BOTEEIOCEPHALTJS (060ptov, a pit, and KeipaX^], the head). — A genus of cestode entozoa, characterised by the possession of two pits or depressions, one on either side of the head, in place of the four sucking disks usually present in tapeworms. The reproductive open- ings, instead of being placed along the margin of the so-called joints or segments of the body, occur at the ventral surface along the mesial line. Three species of Bothriocephalus are known to infest the human body. These are the broad tapeworm ( B . latus), the Greenland tapeworm ( B . cordatus ), and the crested tape- worm [B. cristatus) recently described by Da- vaine. From a clinical point of view little need be said concerning them. The broad tapeworm is rarely seen out of Europe, and then only, it would seem, in persons who have travelled on the Continent. It is most common in Switzer- BRAIDISM. lot land and nor:h-western Russia; but cases alsi. occur in Poland, Sweden, Holland, Belgium, the south-western provinces of France, and some- times in Ireland. In reference to treatment, the parasite readily yields to the remedies em- ployed in ordinary cases of tapeworm. In English practice we have generally resorted to male fern, but Dr. Arthur Reared has found kamela equally efficacious. See Tape-worm: ; and T.isu. T. S. Cobboxd. BOTS. — A term employed to designate the larval of certain dipterous insects called gadflies. They more rarely infest man than animals. See (Estrtjs. BOULIMIA. See Bulimia. BOUEBONNE-LES-BAINS in France. Common salt waters. See Minerax Waters. BOTTRBOT7LE, LA, in France. Thermal al- kaline and arsenical waters. S&Hieerax Waters. BOUEHEMOUTH in Hampshire. Re- garded as a suitable winter residence for patients suffering from certain forms of chest-disease. The climate is mild and slightly humid. See Climate, Treatment of Disease by. BOWELS, Diseases of. See Intestxves, Diseases of. BBAIDISM. — Synojt. : Hypnotism. — Braid ism is the name which, after its inventor, James Braid, has been applied to a therapeutic method destined to utilise the undoubted powers cl mind over body for the cure of various diseases. In essence it consists of a species of Mesmerism, the patient being reduced to a partial or com- plete trance-like condition, by being made to look fixedly for a few seconds at a bright object held by the operator at ‘ about eight to fifteen inches above the eyes, at such a distance above the fore- head as may be necessary to produce the greatest possible strain upon the eyes and eyelids, and enable the patient to maintain a steady fixed stare at the object.’ The patient must be made to understand that he is to keep his eyes steadily fixed on this object, and his mind riveted upon the image of it. After so short a time as ten or fifteen seconds some patients may be intensely affected, and if so, it will he found, on gently elevating the arms and legs, that the patient has a disposition to retain them in the situation in which they have been placed. ‘ 11 this is not the case,’ Mr. Braid writes, ‘ in a soft tone of voice desire him to retain the limbs in the extended position, and thus the pulse will speedily become greatly accelerated, and his limbs in process of time will become quite rigid and involuntarily fixed.’ By slightly prolonging this process a condition of profound ‘nervous sleep ’ may be induced, in which operations may he performed as easily and in as painless a manner as if the patient had been under the influence of chloroform. All this has been abundantly proved by Esdaile and others who performed numerous operations upon Hindoos, with absence of all pain, whilst they were in the hypnotic state. In his attempts to cure morl id conditions, however, Braid only rarely pro- ceeded so far as to induce actual unconscious ness. Whilst in a scmi-cataleptic condition the patient's attention is strongly directed to the 132 BRAIDISM. Biorbid part, and some rery marvellous instances of relief are recorded by him, said to have been effected under the influence of this faculty only, without the aid of imagination, since some of the patients operated upon were quite incredu- lous as to any good being likely to result. In a recent work on ‘ The Influence of the Body upon the Mind,’ Dr. Daniel II. Tuke remarks : ‘ Braidism possesses this great advantage, that while the Imagination, Faith or Expectation of the patient may be beneficially appealed to, this is not essential; the mere concentra- tion of the attention having a remarkable influence, when skilfully directed, in exciting the action of some parts, and lowering that of others. The short period of time required, also, compares favourably with that consumed in some other forms of mental therapeutics. . . . The great principle which appears to be involved in all is the remarkable influence which the mind exerts upon any organ or tissue to which the Attention is directed, to the exclusion of other ideas, the mind gradually passing into a State in which, at the desire of the operator, portions of the nervous system can be exalted in ' a remarkable degree, and others proportionately depressed ; and thus the vascularity, innervation, and function of an organ or tissue can be regulated and modified according to the locality and nature of the disorder.’ Braidism certainly deserves more attention than it has received, though it is a method very difficult of adoption in ordinary practice, and which, however legiti- mate may be its foundations, would, unless the greatest care and vigilance were exercised, be apt to descend perilously near to the level of quackery. Still, if only half the results which have been attributed to Braidism would follow the systematic adoption of this method for the alleviation of many diseases, it is one which should commend itself to the earnest attention of future enquirers who may be able to place the practice upon a broader and firmer foundation than that on which it now rests. See Mesmerism. H. Charlton Bastian. BEAIN, Diseases of. — General Obser- vations. — The range of unnatural phenomena which manifest themselves as the result of dis- turbed actions of the brain, whether from func- tional perturbations or structural disease, is wide and varied. This result is due to the fact that the brain, though spoken of as a single organ, is really a congeries of many distinct but functionally re- lated parts ; and further to the fact that this con- geries of parts is continuous with the spinal cord and intimately related to a scattered network of ganglia — entering into the formation of the nervous sj'stem of organic life ; whilst these several centres within and without the cranium are brought into connexion, through the interven- tion of nerves, with all other structures in the body, whether entering intothecompositionof the organs of relation, or into That of the visceral system. The action of particular parts of the brain may be stimulated, depressed, or suppressed, and either of such altered modes of activity may entail a stimulation, depression, or suppression in the functions of one, two, or more distant parts of the nervous system. The first class of BRAIN, DISEASES OF. effects are spoken of as direct , and tho second as indirect symptoms. It is often extremely difficult, if not impossible, for us to say which of the symptoms presented by a patient suffering from organic disease of the brain should bs ranged under the one head and which under the other. Our ability to make such distinctions is at present hindered by our still incomplete know- ledge concerning the anatomical details of the brain, the proper functions of its several parts, and tho precise modes in which they co-operate with each other. The effects of a shock, whether produced by injury or disease, falling on such an extensive assemblage of sensitive and mutually related organs are, as may be well imagined, subject to much variation ; and as a matter of fact it happens that in different cases of structural brain disease, the symptoms produced are de- pendent upon three factors, viz., the situation, the extent , and the suddenness of the lesion. Except in so far as the nature of the lesion tends to entail variations in one or other of the above-mentioned respects, it is not of much significance from a clinical point of view ( i.e . it does not lead to much difference in the sets of symptoms produced) whether we have to do with a case of haemorrhage into, or with a case of softening of the brain. Thus the ‘locality’ and extent of the lesion in the case of a local disease of the brain has always to be enquired into as a problem altogether apart from that as to the more or less distinct nature of the pathological change in tho part affected. In other words, the problem of diagnosis in brain disease is twofold ; it must have reference to the region affected (Regional Diagnosis) and tn the pathological cause (Pathological Diagnosis). The causes interfering with the progress of our knowledge in the former direction are both numerous and baffling, so that, as yet, compara- tively little progress has been made. Symptoms. — The most frequent effects or symptoms of functional or structural brain-dis- ease may be thus classified : — 1. Perverted Sensation and Perception. — The special senses of smell, sight, hearing, touch (fifth nerve), or taste may be interfered with by diseases of their respective nerves or primary ganglia within the cranium. Owing to the decussation of the optic nerves, disease of the optic tract gives rise (most frequently) to an affection of the sight of the opposite eye. The sense of taste pertains to different nerves. Thus the glosso-pharvngeal has to do with this special sensation in the back part of the tongue, the palate and fauces ; whilst the taste- nerves for the front part of the tongue, though they pass from these parts with the lingual branch of the. fifth, seem to leave it by the chorda tympani and then proceed to the brain with the facial or the fifth nerve. Disease of the intracranial portion of the fifth nerve may not affect the sense of taste, though it impairs the common sensibility of the tongue. Disease of the primary ganglia of these nerves, whether they are separate (first and fifth) or lodged in the brain-substance at its point of connection with the nerve, will produce decided impairment of the several special senses. But BRAIN, DISEASES OF. disease of portions of the brain above these regions on one side only, even though very extensive, often exists -without disturbing the exercise of the special senses on either side. There may, however, be Illusions, Hallucinations, or Delusions in connection with either of these senses in many functional and structural diseases of the brain, where the morbid condition is situa- ted in parts higher up than the primary ganglia, or where there is a functional exaltation of the ganglia themselves. This latter functional ex- altation seems sometimes to be favoured by morbid states of some of the viscera — especially of the stomach, or of the uterus and ovaries. Disease in the brain may also impair the com- mon sensibility of the body, and in some of the most marked cases, this impairment is strictly limited to ono lateral half of the body (Hemi- anaesthesia). It may be very marked and last for a long time ; or it maybe slighter and present only for a few days. There are several modes of impressibility comprised under the term ‘ com- mon sensibility.’ The principal varieties are tactile impressions, impressions produced by differences of pressure and of temperature, im- pressions yielding pain, and lastly those of the so-called ‘ muscular sense.’ There is, moreover, a general sensibility pertaining to the muscles and joint-textures, and the last may be pro- foundly impaired in some eases. The writer be- lieves that what there is of conscious impression pertaining to that endowment known as the ‘ muscular sense,’ is compounded of the ordinary sense of touch and pressure pertaining to the skin, plus sensations in joints and muscles ac- cruing from the contraction of the latter. Besides diminutions of sensibility, we often have to do with disagreeable sensations of numb- ness tingling, or actual neuralgic pains in parts. The two former may be widely distributed, though neuralgia from brain-disease is princi- pally limited to the territory of the fifth nerves. 2. Perverted Emotion and Ideation. — These manifestations vary, from the mere in- ireased tendency to emotional displays seen in a hysterical person or in persons suffering from hemiplegia, to those more complex aberrations met with in the various forms of delirium and insanity (see Insanity). 3. Perversions of Consciousness. — Under this head may be included the comparatively rare states known as somnambulism, ecstasy, and catalepsy ; as well as the exceedingly common conditions of drowsiness, stupor, and coma. The former may be said in almost all cases to be associated with functional rather than with structural disease of the brain ; at least, this is most in accordance with our present knowledge. Drowsiness, stupor, and coma are, however, amongst the commonest results of organic dis- ease of the brain ( see Consciousness, Disorders of), though they are also common conditions in blood-poisoning — whether arising from fevers, uraemia, or from poisonous doses of opium or of other narcotic or narcotico-irritant poisons. ■f. Perversions of Motility. — These mani- fest themselves in many forms, which, however distinct they may appear to be, are, neverthe- less, closely linked to one another. Tremors may be general or local, and in the 133 latter case they may be most marked in the tongue and facial muscles — principally those about the corners of the mouth or the orbicularis palpebrarum. General tremors may arise from debility, over-exertion, nervousness ; or they may be due to alcoholic or mercurial poison- ing, or to degenerative disease about the pons and medulla, as in Paralysis Agitans. Twitchings may be characteristic of a highly nervous habit of body, and are especially fre- quent in some epileptics in the intervals between their fits, either in some of the facial muscles or in those of the neck or limbs. They may also occur in acute febrile affections, in which the functions of the cerebrum are involved, as shown by coexisting delirium, &c., and also in the course of many organic diseases of the brain. In chorea the irregular movements of different parts of the body are often of this nature ; they may affect both sides of the body, or only one (hemichorea). Spasms of a continuous or ‘tonic’ character are encountered in various diseases of the nervous system, such as laryngismus stridulus, trismus, hydrophobia, tetanus, hysteria, and some forms of hemiplegia and paraplegia. Such tonic spasms produce muscular rigidity, which has to be distinguished from that due to chronic changes apt to occur in paralysed limbs. Clonic Spasms or Convulsions maybe either unilateral or general, and may be induced by the most varied causes. "When well-marked they are mostly attended by loss of conscious- ness, as in epilepsy and the majority of epilepti- form attacks. Co-ordinated, Spasms, or movements of a strug- gling type, are met with in many epileptiform and hysterical paroxysms. Spasms of this type may be also limited to particular groups of muscles, as in the conjugated deviation of the eyes and neck occurring in hemiplegia, in wry- neck, in writer’s cramp, and other allied affections. Paralysis may be local and limited in seat to some of the ocular muscles, the muscles of mas- tication, the facial muscles, those of the tongue, or to parts supplied by the spinal accessory and pneumogastric nerve, in those cases in which there is merely an implication of the intra- cranial portion of one or more of the motor- cranial nerves ; or it may take an incomplete or a complete hemiplegic type, with lesions limited to one half of the encephalon ; or it may be general, and involve both sides of the body, if a large lesion exists in the pons Varolii, or if the functions of both cerebral hemispheres or their peduncles are gravely interfered with. In some of these cases, and especially with right-sided paralysis, various difficulties exist in giving expression to thoughts by means of speech or writing • (see Aphasia). Deficient action of the will (without obvious structural change of the cerebrum) may cause paralysis in hysteria and allied states. Defective Co-ordination of muscular acts is met with, as in stammering and in some hemiplegic defects of speech ; also in the body generally in some cases of cerebellar disease, producing a peculiar and unsteady gait (titubation) closely resembling that which may be met with in alcoholic intoxication. Similar motor distil: l> BRAIN, DISEASES OF. 134 ances may bo induced by vertigo of 'well-marked extent. Vomiting, again, is a reflex motor act due to impaired co-ordination, which occurs in many forms of brain-disease. More rarely the sphinc- ter ani and the sphincter vesicse become relaxed, or the bladder may be paralysed. But incon- tinence of faeces or of urine, or inability to void the urine, are comparatively rarely met with as a result of brain-disease, except in the comatose state, or in patients who are more or less demented. 5. Nutritive or Trophic Changes. — With lesions in the motor tract of the brain in or below the corpus striatum a band of degenera- tion is produced, occupying part of the crus cerebri, the pons, and the medulla on the same side, and (below the decussation of the pyramids) the opposite lateral column of the spinal cord. This is one of the most important of the trophic changes occasioned by brain-disease, because the degeneration in the lateral column of the cord is apt to spread to the contiguous grey matter, and thus to give rise to some of tho trophic changes prone to ensue in paralysed limbs. Trophic changes in other organs occasioned by some severe lesions in the brain appear as low inflammations and congestions of the lungs, or as haemorrhages into these organs ; also as haemorrhages beneath the pleura or endocardium, or even into the substance of the suprarenal capsules or kidneys. Again, we may have acute sloughing of the integument in the gluteal region on the para- lysed side, dropsy of paralysed limbs, inflamma- tions of joints and of the main nerves of paralysed limbs, and, though more rarely, marked atrophy of paralysed muscles. Retard- ation or arrest of growth is also apt to occur in paralysed limbs, when we have to do with infants or young children, suffering from severe organic brain-disease. Blanching of the hair, or altered pigmentation of the skin, also occurs not unfrequently in con- nection with brain-disease or violent mental emotions ; whilst in the insane the nutrition of tho bones and of the pinna of the ear is apt to be interfered with. 6. Perverted Visceral Actions. — Exalted activity of the uterus, bladder, intestine, stomach, or heart, may bo occasioned by functional brain- disturbance more especially; whilst tho same brain-conditions may give riso to depressed or exalted activity of the liver or kidneys. With other functionally disturbed or emotional brain- states there may be a lowered functional activity' of the salivary glands, of the heart, of the respira- tory organs, of the organs of deglutition, of the organs of digestion, or of the sexual organs. These are only to be taken as mere indications of the kinds of modification that may be pro- duced in visceral activity by brain-disease. Much doubtless remains to be learned in this direction. It seems fitting here also to mention those contractions and dilatations of vessels which are apt vo take place in different parts of the surface of the body, or in internal organs, from stimu- lation or contraction of vaso-motor nerves, oc- casioned either by direct or indirect influence exerted upon the principal vaso-motor centres in the region of the pons Varolii. These contrac- tions or dilatations produce correlated alterations in the temperature, sensibility, and functional activity of the parts or organs affected. The temperaturo of paralysed parts, as well as the general body temperature, in the apoplectic state is subject to great variations, and these are new beginning to be studied more attentively. They are capable of yielding diagnostic indications of great value. Remarks. — Some general remarks on tho subject of structural and functional diseases of the nervous system, showing how intimately these two classes of disease are related to one another, will be found in the article Nervous System. Most of what is said there is applic- able to diseases of the brain in particular ; here, however, it is necessary to call attention to cer- tain points specially related to brain-disease. When paralysis occurs from brain-disease affect- ing one cerebral hemisphere, in the great majority of cases it is situated on the opposite side of the body, owing to the fact that the fibres conveying the volitional impulses to the muscles decussate in the medulla oblongata. It is true that many cases are on record in which the paralysis either lias, or has been said to have existed on the same side as the brain-lesion. A certain number of these cases are probably due to errors either in the clinical or in the post-mortem records of the case. Others, however, still remain unexplained. The characters of the various forms of paralysis due to brain-disease are briefly set forth in the article on Paralysis. Lesions of the left hemisphere much more fre- quently than those of the right, are associated ■with aphasie defects of speech ; whilst, accord- ing to Brown-S4quard, lesions of the right hemi- sphere are more frequently and rapidly fatal than otherwise similar lesions of the left hemi- sphere. They are also more apt to be associated with acute sloughs of the skin on the paralysed side. Convulsions at the onset, and subsequent tonic spasms of the paralysed limbs, are also said to be more frequently associated with left- than with right-sided paralysis. Congenital atrophy of one hemisphere, or atrophy occurring in early infancy, is mostly associated with an arrest of growth and develop- ment in the limbs on the opposite or paralysed side of the body. Very little is positively known concerning the diseases of tho cerebellum. Of its functional affections we may be said to know absolutely nothing. That is, of the various functional dis- eases of tho nervous system with whose clinical characters we are familiar we are unable to name even one which we can positively say is a func- tional disease of the cerebellum. Whatever tho precise mode of activity of the cerebellum may be, there is a general consensus of opinion that it is principally, if not exclusively, concerned with motility, and that it has more especially to do with the higher co-ordination of muscular acts. Atrophy of one hemisphere of the cerebrum is followed by atrophy of the opposite half of the cerebellum, so that there is a strong presumption that the functional relationship of either half is with muscles on the same side of the body. Clinically we know that disease of the cerebel- lum is not unfrequently associated with innr. UK AIN, DISEASES OE. or less marked paralysis on the opposite side of the body ; but this effect is now generally attributed to the pressure which structural dis- eases of the cerebellum are apt to occasion on the pons and medulla of the same side. ^Etiology. — The principal modes of causa- tion of diseases of the brain may be thus sum- marised : — 1. Defective Nutrition operates by modifjdng the proper constitution of nerve-tissues as well as the constitution of the blood, and thereby in- terfering with the normal functional relations of the several parts of the brain. Anaemia, chlorosis, syphilis, ague, and all lowered states of health, howsoever induced, and w'hether acquired or in- herited, become predisposing or actual causes of brain-disease. To these states, favourable to the manifestation of brain-disease, should be added the various acute specific diseases, uraemia, metallic poisoning, poisoning by the narcotic and narcotico-irritant poisons generally, and also by the occasional qualities of certain articles of food, such as mackerel, mussels, mushrooms, &c. 2. Emotional Shocks cause cerebral disorder, especially in children, or prolonged overwork in those who are older — particularly when com- bined with worry and anxiety, with sexual ex- cesses, or with protracted lactation. Beligious excitement, again, not unfrequently leads to in- sanity. 3. Physiological Crises, such as the period of the first dentition, the period of puberty, preg- nancy, and the climacteric period, all favour the manifestations of various nervous diseases. 4. Visceral Diseases or surface-irritations (especially in children or in persons having a very sensitive and mobile nervous system) may give rise to varied nervous diseases. Thus we may havo convulsions or delirium in children from the presenco of worms or other irritants in the intestines, or convulsions in adults during the passage of a renal calculus. Again we may have the phenomena classed as hysteria, or we may have nymphomania, in consequence of certain states of the sexual organs. Cases of paralysis are said also to have a reflex origin occasionally, though this must be a very rare event. With much greater frequency we find surface-irrita- tions of various kinds leading, as in Dr. Brown- Sequard’s guinea-pigs, to epileptiform attacks. 5. Structural lesions of the brain itself give rise to a ver}' large proportion of its diseases. The various kinds of change will be found enu- merated under another heading {see Nervous System). Haemorrhage and softening are tho most common and, therefore, the most im- portant of these morbid conditions. 6. Brain-disease may be determined by the action of Heat {insolatio), especially when com- bined with fatigue and deficient aeration of blood. A somewhat similar brain-affection, however, is occasionally developed in the course of rheu- matic fever or in that of one of the specific fevers, in which the body-temperature rapidly rises to a lethal extent (109°-111° F.). 7. Concttssions (whether from blows or falls) may give rise to brain-disease, even where no traumatic injuries or lacerations of the brain are produced. Treatment. — The treatment of brain-disense BBAIN, ABSCE.' S OF. l;sn will be discussed under the articles Nervous System, Paralysis, Convulsions, and those on the several special diseases which will now be described in alphabetical order. H. Charlton Bastian. BBAIN, Abscess of. — This term is applic- able whenever a circumscribed collection of pus is formed in any part of the cerebral mass. .ZEtiology and Pathology. — Amongst the most frequent causes of cerebral abscess are severe injuries to thoBskull, disease of the temporal bone in connection with the ear, ligature or obstruc tion of a main artery, and pyaemia. Under th«. three first-named conditions the abscess is usually solitary, but from pyaemia multiple abscesses often result. For practical purposes we may per- haps conveniently discard the latter — since the symptoms will usually be those of general ence- phalitis — and confine ourselves to those cases in which single large-sized collections of pus are met with. With this limitation, abscess in the brain is by no means of frequent occurrence. The best marked, and also the more common examples of largo brain-abscess are met with in connexion with compound fractures of the skull, and by far the most definite symptom which de- notes them is the formation of a fungus cerebri. Unless in a compound fracture the brain be directly injured and the dura mater torn, it is very rare indeed for any suppuration in its sub- stance to occur. It is not to be denied, however, that now and then, after severe concussion or laceration without external wound, abscess may follow. In such cases we may conjecture that, usually some slight laceration or extravasation occurred in the first instance, which constituted a focus for the inflammation. Abscess after simple concussion without lesion is probably a most rare event. In the article Brain, Inflammation of, wr shall have to define Encephalitis as a diffuse change of a large part of the cerebral mass, per- haps of a whole hemisphere, attended by the infiltration of cells and fluid. It is obvious that the term abscess in the brain is applicable tc one of the results of encephalitis, but it seems clinically probable that the two classes of eases are for the most part distinct, and that diffuse encephalitis has but little tendency to result in abscess, and that abscess is rarely preceded by a stage of encephalitis. Both are usually tho con- sequences of local injury to the brain, or of ex- tension from local disease of its coverings ; but whilst encephalitis probably resembles the ery- sipelatous type of inflammatory action, in loca- lised abscess this tendency is not present. Having distinguished brain-abscess from ence- phalitis, we must next say a word as to the risk of confusing it with intra-cranial but extra- cerebral collections of pus. Encysted collections of matter may be met with either between the dura mater and bone ; or within the arachnoid cavity; and perhaps it ought to be added, though with some hesitation, beneath the arachnoid, in the pia mater. Not unfrequently inflammation of the membranes precedes and attends the for- mation of an intra-cerebral abscess, and in these cases the symptoms will be mixed. In dealing with published cases it is also necessary to be on our guard as to certain errors which have crept 136 BRAIN, ABSCESS OF. in — cases of meningeal abscess being spoken of as brain-abscess. Mr. Prescott Hewett has ex- pressed his opinion that the celebrated case of De la PeyroniAs was an example only of extra- eerebral abscess. It is absolutely necessary to make these restrictions if we would judge cor- rectly as to the symptoms which attend local collections of matter in the brain and the usual terminations of such cases. Symptoms. — The symptoms of local suppura- tion in the brain will vary with the stage, the size of the collection, its precise situation, and, above all, with the presence or otherwise of a fistula of relief. In many of the cases which come under surgical care a fistula exists from a very early period, though not unfrequently it is liable to occlusion. Under the latter conditions the symp- toms of a closed and an open cerebral abscess may be alternately studied in the same case. It will usually be observed that when the exit is closed and the abscess fills, the patient complains more or less of headache, becomes heavy and drowsy, experiences twitehings or spasms in the opposite side of the face and limbs, with some ten- dency to hemiplegia. Of this group the tendency to spasms is probably by far the most significant. The headache may be but trifling, and the pa- tient may even be well enough to leave his bed, when the occurrence of spasm followed by pare- sis alone gives warning of what is going on. The cases now alluded to are chiefly those in which abscess results from compound fracture of the skull with laceration of the brain-sub- stance. In these the abscess often gives way spontaneously, and a fistula forms, around the orifice of which a mass of pouting brain-granu- lations, known as fungus cerebri, usually forms. In these cases the canal of communication may be very tortuous, and the liability to blocking considerable. Now and then the same result may be met with after syphilitic disease of the skull and meninges. The writer had some years ago a man under his care in whom he had opened a cerebral abscess beneath a hole in one parietal bone. The patient was able to walk about, and ailed but little so long as the fistula was freely open ; but spasms of the face, or even convulsions of the limbs (on the opposite side) always fol- lowed its occlusion. The softening gradually extended, and he at length died in consequence, perhaps, of the impossibility of making a counter- opening in a depending situation. Unless the abscess be in the anterior lobe, there will almost invariably be present some degree of hemiplegia, but this will of course vary with the size of the collection and the extent of destruction of tissue. The formation of an abscess after injury is some- times very insidious, the symptoms being very slight. The cases in which violent headache and pain, vomiting, delirium, and dry tongue, are said to have been present in the early stages are, the writer suspects, usually instances of suppuration between the bone and dura mater. These symptoms occur especially when brain- abscess follows disease of the internal ear, and in these there nearly always is the complication of inflammation around the petrous bone. Such symptoms are very rarely present in traumatic abscesses, which often develop very quietly autil they attain a considerable size. It is pro- BRAIN, ANAEMIA OF. bable that some degree of rigor, attended by rise of temperature, usually occurs in the begin- ning of cerebral abscess, but no very precise data are extant on these points. The contents of a brain-abscess usually con- sist to some extent of broken-up cerebral tissue, and in some cases there are but very few pus- cells. Especially is this likely to occur when the so-called abscess follows on ligature of the carotid or occlusion of a cerebral artery. In these cases, it is in the first instance at least the result of a process of softening rather than of true suppuration. If a large abscess be permitted to develop without relief, the symptoms of compression will in time ensue : first spasm, then hemiplegia then hebetude and coma, preceded possibly by violent convulsions. Diagnosis. — The diagnosis between cerebral abscess and meningeal abscess is exceedingly diffi- cult, and often a guess is all that can be made The almost invariable occurrence of spasm or con- vulsions in the former, and their frequent a n- sence, with the greater degree of pain and head- ache in the latter, are the most reliable signs Sometimes — as, for instance, when trephining has been practised, and no inflammatory products are found between the bone and dura mater or under the latter — the diagnosis maybe helped by this negative knowledge. In such cases, if hemi- plegia, preceded by spasm, have been gradually developed, the surgeon will be well justified in making an incision or puncture into the hemi- sphere. Optic neuritis may equally be present in both, and its presence or absence will scarcely help the diagnosis. Prognosis. — In addition to the danger of death by compression, there is the risk that the abscess may break into the ventricles or into the subarachnoid space. Some cases are on record in which spontaneous openings into the nose or into the ear occurred, and profuse discharge followed, the patient in the end recovering. It may be doubted whether these were not instances of meningeal abscess. Treatment. — It is needless to say that if ab- scess be diagnosed with any degree of confidence a-n opening is essential. There is little or no room for medical treatment. For the prevention of abscess, in all cases in which injuries likely to produce it have occurred, the utmost precautions should be enforced. Mercury in small doses, fre- qently repeated, should be given from the first ; the injured region should be covered with lint soaked in a strong spirit-of-wine lotion, frequently re-wetted ; purgatives should be administered ; and the patient should be kept very quiet until long after the healing of the wound. Jonathan Hutchinson. BRAIN, Anaemia of.— Definition. — A con- dition in which the blood contained within the capillaries of the brain is deficient in quantity, or defective in quality. The blood within the brain is contained in arteries, capillaries, and veins. The functional condition of the brain depends on the quantity and quality of the blood circulating in its capil- laries, and it is to these that the special symptoms are related. Deficiency in the quality of th» BRA IX, AN2EMIA OF. J37 blood supplied to the brain is always of gradual occurrence, andaffeets the whole brain ; deficiency in quantity of blood may affect the whole brain or part only, and it may be sudden or gradual in its production. Aetiology. — General cerebral anemia may be due to the following causes: — (1) It may be a part of systemic amentia — defect in quantity or quality of the whole blood, and due to causes which are considered elsewhere. This is often seen in cases of htemorrhage, of exhausting discharges, or of defective blood-nutrition, as in chlorosis, (2) The supply of blood to the brain may be deficient, the quantity of blood in tho body being normal. This may be due to cardiac weakness, or to causes acting through the nervous system on the heart, as in swooning. In systemic anaemia, the lessened cardiac power increases the cerebral deficiency. Whatever lessens the amount of blood discharged from the heart at each systole, such as aortic or mitral disease, may be a cause of cerebral anaemia. Pressure on the vessels conveying the blood to the head, as by an aortic aneurism, has a similar effect. Unequal distribution of the systemic blood is another cause. The intestinal vessels, if dilated, are capable of containing a large part of the blood, of the body, and the effect of their engorgement is often seen after paracentesis abdominis. One theory of shock ascribes its mechanism to vaso-motor dilatation of these vessels, and consequent anaemia of the rest of the system. The effect of each cause is increased by the action of gravitation in the erect posture. Some causes act only in that position. (3) The capacity of the cerebral vessels may be diminished by pressure on the brain, exerted by effusions of fluid (hydrocephalus), of blood (in cerebral and meningeal haemorrhage), or by growths within the skull. Partial cerebral anemia is due to some ob- struction to the passage of the blood through tho vessels. To be permanently efficient such obstruction must be situated beyond the circle of Willis. Ligature of one carotid causes immediate symptoms of cerebral anaemia, but permanent symptoms are not frequent. Pressure on, or disease of one carotid, for the same reason rarely gives rise to symptoms. Obstruction in certain arteries of the brain may cause local ansemia, sudden or gradual, temporary or permanent, according to its cause. Such obstruction may be due to narrowing of the calibre of the vessel by atheromatous changes in its wall, or by spasm of its muscular coat, or may be due to actual occlusion by embolism or thrombosis. The pressure-effects of an intruding substance within the skull (tumour, or clot) act most intensely in, and may influence only one region of the brain. It is obvious that of these causes some act suddenly, others gradually, and the symptoms produced will differ accordingly. Anatomical Characters. — The principal ana- tomical character of cerebral anaemia is pallor of the brain, observable chiefly in the paler tint of the cortical substance, and the diminished number of red spots in the white centre. The pallor may bo partial or general. The mem- branes are usually pale, but in some cases of partial anaemia they are hyperaemic. Effusion of serum in the meshes of the pia mater and between the convolutions, may be found in general anaemia. Symptoms. — The symptoms of this condition vary according as the an®mia is suddenly or slowly produced, and as it is general or partial. (1) In sadden general ansemia of the brain the sufferer feels drowsy; the special senses are dulled ; noises in the ears and vertigo are com- plained of; the pupils are at first contracted; sight may fail; muscular power is weakened; respiration is sighing; the skin is pale, cold, and moist ; nausea is common ; and headache is rare. If the anaemia is more intense, consciousness is lost ; there is universal paralysis ; and general convulsions may occur, epileptiform in character, these being especially frequent in sudden exten- sive losses of blood in strong subjects. The pupils dilate, and the coma may deepen to death. The loss of sight in cases which recover may persist as permanent amaurosis. (2) When general ansemia of the brain is slowly produced, the state of the cerebral func- tions is usually that of ‘irritable weakness.’ Their action is imperfect in degree, and excited with undue facility. There is mental dulness and drowsiness ; sometimes, however, insomnia is troublesome. Delirium is common in severe cases, and is conspicuous in some forms of im- perfect blood-nutrition, as in the so-called ‘ inanition delirium.’ Headache, usually general, is a common symptom. Sensory hypermsthesi®, tinnitus, muse® volitantes, and vertigo are fre- quent. Convulsions are rare, but muscular power is generally deficient. All these phenomena are more marked in the erect than in the recumbent posture, especially when the erect posture is suddenly assumed. It has been remarked that some an®mie persons can think well only when lying down. In young children, after exhausting discharges, as diarrhoea, symptoms referable to cerebral an®mia are common, namely, somnolence and pallor, with depressed fontanelle and con- tracted pupils. The somnolence may deepen to coma with insensitive conjunctiva, and the coma increase to death. Such symptoms have been called hydrocephalcid, from some resemblance to those of acute hydrocephalus. (3) Partial cerebral an®mia causes, if complete, loss of function in the affected area ; and if it be permanent, as in obstruction of a vessel beyond the circle of "Willis, necrosis of the cerebral tissue results (see Brain, Softening of). Ifincomplete and sudden, there is temporary arrest of function. Ligature of one carotid, for instance, causes transient weakness and numbness in the opposite half of the body. There may be at first an over- action of grey matter, causing, in certain regions, unilateral convulsions. If slowly developed, as in atheroma of arteries, pain and vertigo are common, with recurring local symptoms, such as numbness, tingling, and weakness. In all cases of long-continued cerebral ansmia, permanent damage to the nutrition of the brain may result. In the child the development of the brain may be arrested; in the adult, loss of memory and of general mental power indicate the deterioration of structure. Pathology. — The symptoms are, as already stated, dependent mainly on the defective quantity 1S8 BRAIN, ANAEMIA OF. and quality of the blood circulating in the brain. Some influence may probably be ascribed to the diminution in the blood-pressure to which the nerve-elements are ordinarily exposed (Burrows). Nothnagel has pointed out that the symptoms indicate an early affection of the respiratory centre in the medulla, and of the cortical grey matter. Kussmaul and Tenner ascribe the con- vulsions in acute anaemia to the irritation of the medulla ; Nothnagel, to that of the pons Varolii. Diagnosis. — The diagnosis is not difficult. It rests on the recognition, in a given case, of the causes of cerebral anaemia ; and on the exclusion of graver maladies, as organic cerebral disease. With the latter, it should be remembered, anaemia of the brain, local or general, often co-exists. Some symptoms of hyperaemia of the brain closely resemble those of ansemia. A common patho- logical state of imperfect blood-renewal probably exists in both conditions. Pbognosis. — The extent to which the cause of the anaemia is amenable to treatment, and is of transient character, must influence the prognosis. As a rule this is favourable when there is no or- ganic disease of heart, vessels, or brain. In the so-called ‘pernicious amemia,’ the prognosis is, of course, unfavourable. Hydrocephaloid symptoms in infants, if met by prompt and suitable treat- ment, are usually recovered from. Treatment. — The treatment necessarily varies in the several forms of the affection, but it is in the main causal. The beneficial effect of the recumbent posture in affording immediate relief to the symptoms, and obviating permanent damage to the cerebral nutrition, must be always remembered. In acute aniemia from loss of blood, the head must be kept continuously low, stimulants freely administered, and as a penulti- mate resort bandages applied to the limbs from below upwards may increase the proportionate supply of blood to the brain. If this fails trans- fusion must be had recourse to. In chronic ansemia sudden change of posture should be carefully avoided, and ferruginous tonics are needed. In spasm of the cerebral vessels, bro- mides are useful. In the cerebral ansemia of syncope, the recumbent posture, stimulants to the skin, cold water, faradisation, sinapisms, and ammonia to the nasal mucous membrane, assist the recovery of cardiac action and the return of consciousness. In all cases, carefully regulated food and stimulants are needed ; beef-tea should be given iu small quantities, at frequent inter- vals. The group of symptoms called hydrocepha- loid require similar treatment. W. R. Gowers. BRAIN", Aneurism of. See Brain, Vessels of, Diseases of. BRAIN", Atrophy of. — Atrophy of the brain may be congenital, due to arrest of development in very early fetal life ; or the constituents of the brain may have been perfectly developed, and may subsequently disappear from one of several causes. This morbid state is regarded as ; primary when tlieere has been no pre-existing disease of the brain or its membranes ; secondary, either when there has been such pre-existing disease, and the atrophy has occurred from absorption of the part broken down by in- flammation. softening, haemorrhage, &c. ; when BRAIN, ATROPHY OF. atrophy of some special cerebral organ follow! upon destruction of the particular nerve thal arises from it; or when localised atrophy ha: taken place in a very gradual manner from pres- sure of a tumour, of ventricular effusion, &c To take these forms in order: — 1. Congenital atrophy. — This is usually asso- ciated with weakness of intellect, even to the extent of idiocy : there is atrophy of the body op- posite to the side of the cerebral lesion, and this atrophy involves all structures, even the bones. Paralyses of various intensity supervene, often with contraction of the paralysed parts ; there being no particular sensitiveness of the special senses, possibly because of the mental hebetude. Epileptic attacks are common; vitality is low; and the patient easily succumbs to other diseases. 2. Primary atrophy. — In this variety there is general diminution both of volume and of weight, affecting most usually the cerebral hemispheres, and that in pretty equal degree. It is most common as a condition of old age — senile marasmus, atrophia cerebri senilis. It some- times in earlier life follows exhausting diseases ; and may also be caused by deficient or impure blood-supply to the brain. In close connexion with this mode of causation it is seen after re- peated attacks of intoxication, especially after delirium tremens. In this last condition the cerebral atrophy may be acute and rapid. .3. Secondary atrophy. — This may be general or partial. When general, the convolutions have a shrunken appearance, and there is always an increase of the subarachnoid fluid. This condition follows various lesions of the brain, especially oi the convex surface, such as haemorrhage of the convexity, encephalitis, or more accurately that form of encephalitis that attacks only the grey matter or perhaps only one layer of the grev matter, as in some mental diseases. When the atrophy is partial, there are found depressions in an otherwise normal hemisphere, at which point a localised haemorrhage or patch of softening, inflammatory or depending on thrombosis or embolism of vessels, bas been absorbed, leaving only a cavity of greater or less extent, filled with fluid and sometimes lined with a thin membrane. A certain portion also of the brain may become atrophied by the gradual pressure of a tumour or any foreign body. Even the little sieve-like depressions seen in various situations after con- stantly repeated congestion of vessels may be the result of atrophy from compression by the distended vessels. Functional inactivity and atrophy of the optic nerves has led to a similar abnormality of the corpora quadrigemina. Anatomical Characters. — The atrophied brain or portion of brain will vary in appear- ance on minute examination, according as the lesion has or has not been preceded by inflam mation. When the atrophy is primary and due to gradual interference with blood-supply, thero is seen a shrunken condition of the nerve-tissue, especially of the calibre of the nerve-tubes. Tho cells are smaller than usual and pigmented, the arteries being decreased in size or themselves diseased. If the lesion has had an inflammatory origin, the process in order of sequence is, first, inflammation, then softening with fatty degene- ration then partial absorption, and so atrophy : BEAIN, ATEOPHY OP. the appearances differing according to the stage of the lesion. Traces of fatty degeneration of all the tissues, — vessels, nerve-tubes, and cells, — may be found, -with the neuroglia either -want- ing or sclerosed. Dr. Budolph Arndt has lately thrown doubt on the possibility of determining atrophy of the ganglionic bodies or nerve-tubes by their size. The size of these bodies varies so greatly, within the limits of health, that he considers this test a very uncertain one. Almost the only trustworthy sign of atrophy, in his opinion, is the appearance in the substance of the ganglionic bodies and in the medullary sheath of nerve-bundles, of black shining globules, somewhat fatty-looking. In process of time these globules increase in number, and at last the whole of the bodies appear per- meated by them. These globules are not fatty, they are certainly more or less pigmental. Exactly similar bodies appear at post-mortem examinations, and are a sign of simple decom- position. The duration of this condition, irre- spective of pre-existing lesions, is protracted. Symptoms. — The symptoms of atrophy of the brain necessarily vary according to the seat, ex- tent. and aetiology of the lesion. Primary atrophy of the cerebral hemispheres and the first form of secondary atrophy will most usually induce imbecility, or some lesser degree of mental in- sufficiency, loss of memory, slowness of thought, and other mental diseases. Headache, giddiness, delirium, and stupor are seldom met with. In- terference with speech is more common. Affec- tions of sight, and of the motor condition of the eye, do not depend on general atrophy of the brain ; they own a more local cause. Convulsions, paralysis, stiffness of muscles, or contractions are often met with in connexion with this general lesion, as well as various irregu- larities of locomotion : but it must be remembered that general atrophy of brain is not seldom as- sociated with atrophic or sclerotic lesions of the spinal cord, and even where this is not so, several of the morbid phenomena, and particu- larly convulsion and paralysis, may derive their origin, not from the atrophy, but from the con- dition pre-existent to the atrophy, such as haemorrhage of the convexity, meningitis, or peri-encephalitis. In secondary atrophy of a more limited extent, the symptoms are apt to be more strictly local- ised, such as partial loss of power in a single limb, slight imperfections of speech, or strabis- mus ; but here again the positive diagnosis of atrophy is hindered by the complication of pre- existent disease, the local congestions, haemor- rhages, softenings, tumours, or other conditions of which the atrophy is only the sequence. Still less characteristic are the phenomena attending general or partial atrophy of the cerebellum, the pons, and the medulla oblongata. Treatment.— Treatment is useless as to the atrophy of the brain : it must be directed to supporting the powers of the patient. E. Long Eox. BEAIN, Carcinoma of. See Brain, Tu- mours of. BEAIN, Compression of.— The brain is cum; rc>svd in the pathological sense whenever its BEAIN, COMPBESSION OF. .30 | structure is so squeezed that its functions are in any degree interfered with. This squeezing may be effected either by the effusion of blood within the skull, the growth of a tumour, the accumula- tion of pus or serum, or lastly by the depression of some large portion of the bony parietes. The general belief that depressed fractures are fre- quently the cause of compression is probably quite a mistake. In such cases the fragment displaced is rarely of sufficient size to cause serious com- pression of the contents of the skull, and thc- symptoms usually supposed to indicate that state are really due in most cases to laceration and contusion, or to subsequent inflammation. This point is of great importance in practice, for upon its recognition depends much of the validity of the reasoning by which the operation of primary trephining in compound fractures is defended or condemned. It also offers a most serious fallacy as regards the interpretation of the symptoms due to compression. By far the best examples of uncomplicated compression of brain are supplied to us by the not very' infrequent cases in which a middle meningeal artery is injured, and a large blood- clot is effused between the dura mater and bone. It is from observation of cases of this kind that the assertion is justified, that a very considerable intrusion into the skuil is permitted without the production of any symptoms. No doubt the suddenness or otherwise has much to do with the results, but there seems good reason to believe that, as a rule, the brain will easily accommodate itself to quantities not exceeding an ounce or two, and that usually so large a quantity as four or five ounces is required to cause death. It is very rarely indeed that a depression of bone in the least approaches such an extent of intrusion as this, and the majority of such cases are, as regards the amount of possible squeezing, quite trivial. The manner in which the accommodation is effected is by the removal of the fluid contents of the skull, first the subarachnoid fluid, and secondly' the blood. Of the blood-vessels the veins and venous sinuses are probably emptied first, and lastly the arteries and capillaries. A brain in a state of strong compression is an ex- sanguine! brain. In this respect, the brain in the last stage of compression differs very much from that in cases of insensibility from con- cussion or contusion. It by no means follows that because the brain is pale, the face should be pale also ; but it is perhaps usually the case that extreme compression so much enfeebles the heart’s action that the pulse is weak or flickering, the respiration shallow and irregular, and the skin pale and cold. That stertorous breathing, a laboured pulse, and a suffused and dusky countenance, are (as according to the clas- sical description) symptoms of compression, is probably for the majority of cases a mistake. Such a group much more frequently denotes laceration, contusion, or central extravasation. Nor is it true that hemiplegia, exceptirg of the most transitory kind, is often due to compression. A clot of blood poured out over one hemisphere may, if rapidly effused, produce for a while weakness of the opposite limbs, but the brain mass is soft enough to allow of considerable yielding, and in the course of a few hours the BRAIN, COMPRESSION OF. 140 efforts of the displacement will hare become general, and not local. In a ease recorded by the writer in which a post-mortem, some weeks later, proved the presence of a large blood-clot, there had been partial hemiplegia without un- 'rmsciousness at first, but on the next day all trace of it had disappeared, and it never re- turned. In many of the cases cf bleeding be- tween the dura mater and bone, from the men- ingeal artery, the haemorrhage takes place on several different occasions, with, it may be, inter- vals of a day or two, much as is often observed in wounds of arteries, such as the palmar arch. Thus the observer is able to appreciate the symptoms caused by different degrees of com- pression, and further proof is afforded that, if the intruded quantity be but moderate, the brain bears it without obvious inconvenience. Often at the autopsy it is quite easy to dis- tinguish clots of very different dates, and to feel sure that the original one was of considerable size. It is clear then that in speaking of the symptoms of compression wo must allow for differences in amount of the compressing sub- stance, and also for differences in the rapidity or suddenness of its application. When compression is produced instantaneously, as by a large fragment of bone driven down, the case is almost invariably complicated by con- tusion. If paralysis or even insensibility be present, it is usually impossible to say to which lesion they are really due. We may, however, hold it almost certain, from what we know of other cases, that the effects in such would be a temporary hemiplegia, with symptoms of shock if the depression were but moderate ; and insen- sibility, probably soon followed by death, if the depression were very great. The cases in which depression of bone has alone been sufficient to produce long-continued compression with insensi- bility are possibly somewhat apocryphal. It is possible that compression under such circum- stances might be attended by stertor and la- boured pulse, but it is possible also that the pulse might be extremely feeble, the countenance pale, and inspiratory efforts weak and irregular. The depression of bone is perhaps the only condition which can be supposed capable of producing compression suddenly. When blood is poured out from a ruptured artery, the symp- toms come on rather gradually. The patient complains perhaps of headache, and then be- comes more or less confused in manner, his gait is unsteady, and the limbs on the side opposite to the injury show special weakness. Vomit- ing may occur and the weakened limbs may twitch, and unless, as is often the case, the intracranial bleeding stops, these symptoms are soon lost in a state of complete insensibility, with pale face, feeble pulse, and symptoms of shock. Convul- sions may now occur, and death often supervenes very quickly. In such a case the whole course of the symptoms may occupy less than an hour. The surgeon ought, of course, to trephine and let out the blood, and he must be prompt, or his patient may die during his preparations. More commonly this rapid termination occurs unex- pectedly after one or more previous attacks of temporary head-symptoms, and the patient may have appeared quite well in the intervals. In cases in which tho symptoms progress without interruption, their rapidity, no doubt, depends upon the size of the vessel ruptured. Certain special symptoms will also depend upon the pre- cise position taken up by the clot which may chance to press upon special nerve-trunks as well as upon the brain-mass. In ordinary cases the clot is beneath the squamous bone and the lower part of the parietal, and passes downwards into the sphenoidal fossa. In the latter region it may press upon the nerves going to the sphenoidal fissure; and it is of importance for the surgeon to know that dilatation of the pupil on the affected side is often produced. This important symptom is probably due to pressure upon the third nerve. There is yet another class of compression- cases in which that condition is produced by the slow accummulation of the products of inflam- mation within the skull. Much will depend, as regards special symptoms, upon the position of the abscess, either within or without the brain. If in the substance of the brain, it must more cr less disorganise its structure, and thus cause symptoms due to laceration as well as compres- sion. Under such conditions some degree of hemiplegia, with, probably, preceding spasms of limbs, can scarcely fail to be present. Now and then cases occur in which an irregular sinus leads into an abscess-cavity in the brain, and this sinus being sometimes free and sometimes blocked, the surgeon has repeated opportunity of estimating the effects of filling of the cavity. In such cases, headache, stupor, unilateral twitch- ing of limbs, partial hemiplegia, with, perhaps, vomiting, and, it may be, general convulsions, are the symptoms to be expected. The position of the abscess as regards different regions of the brain is also of much importance, but its discus- sion cannot be entered upon in any detail here, and it obviously concerns rather disorganisation of structure than simple compression. When a large accumulation of pus takes place between the bone and dura mater, the symp- toms produced are much the same as those caused by blood-clot. We must make, however, much allowance for the fact that these cases are almost always attended by meningitis, and thus the symptoms of compression are masked by those due to inflammation. Chronic abscess under the bone without arachnitis may occur now and then in syphilitic and other disease of the skull-bones, but such cases are very rare. Such cases will differ from those of haemorrhage in that the symptoms are always produced verv slowly. The writer once had the opportunity of watching such a ease, in which the patient died of compression, very gradually produced, and without any complication. The chief symp- tom was constant wearing headache, which pre- vented sleep. The man was pale and feeble, but not paralysed in any part, excepting that both eyelids drooped. He was rational, but spoke slowly, as if in a state of partial stupor. During the last two or three days of life he had convul- sions, and finally, for twenty-four hours, he was in a state of increasing insensibility. Diagnosis. — It will he seen from what has been said above that the diagnosis of compression by symptoms is exceedingly difficult, and that BRAIN, COMPRESSION OP. the -utmost us6 must in each ease be made of the history of the case. In those of blood-compression after injury to a meningeal artery, there is almost always the fact that the patient between the date of the injury and the supervention of symp- toms had an interval during which there ap- Deared to be little or nothing the matter. This history is, if the symptoms have developed rapidly and without the signs of inflammation, by itself conclusive for diagnosis. Under such conditions trephining ought to be at once resorted to, or possibly it might be yet better practice to first tie the carotid artery. The diagnosis of abscess in the brain-sub- stance has already been discussed, and that of inflammatory collections from meningitis will be examined in its proper place (see Meninges, Diseases of). Treatment. — The treatment of compression of the brain is almost wholly surgical, and con- sists in the use of the trephine and knife tc elevate depressed bone, or evacuate collections of blood or pus. Jonathan Hutchinson. BRAIN, Concussion of. — We class under the head ‘ Concussion of Brain ’ all symptoms which result simply from the shaking, more or less violently, of the contents of the skull. It will he obvious, however, that most cases of severe shake of the brain are likely to he complicated by visible lesions. The skull may be broken and the brain may he contused, lacerated, or ecchymosed. It is highly probable, however, that well-marked and even serious symptoms may be produced by shaking only, and without the existence of any lesion discoverable either by the unaided eye or the microscope. We must further clearly under- stand that this element of concussion ( i.e . the re- sults of shake independent of lesion) enters into almost every case of injury to the head. Whatever be the other lesions, it is usually the fact that the brain has been more or less severely shaken. Thus it may easily happen in cases in which conspicuous lesions are present, such as fracture of the base or local contusion, that still the results of the shake are the most important. It might be convenient if we were in the habit of speaking of most eases of severe injury to the head as Concus- sion plus other lesions, with the endeavour to assign to eaeh added complication its proper share in the general result. These explanations are necessary before we put the question — Can concussion alone cause death ? Although it is highly probable that we ought to reply with a very confident affirmation, and to assert that it is very common for concussion to be the chief cause of the fatal event, yet it is very difficult to prove it, since the cases are extremely rare in which severe concussion is produced without some attending lesion. The symptoms caused by con- cussion of the brain may he studied in very nu- merous cases of very various degrees of severity, which yet recover perfectly. From what is observed in these, we may infer as to the part which concussion takes in complicated cases many of which prove fatal. The results of concussion may be divided into three stages —the first stage is that of collapse ; the second, that of reaction, or of vaso-motor paresis, or, if named from its most prominent BRAIN, CONCUSSION OF. HI symptom, the sleepy stage ; the third is that of convalescence, or recovery. The symptoms of the first stage, or stage of coflapse, vary with the severity of the case, hut if at all well- marked consist in feebleness of pulse, pallor of skin, coldness of extremities, and dilatation of pupils. They may approach a condition which threatens immediate death. There is no stertor, for the respiration is too feebly performed. Al- though the collapse may be very great, the in- sensibility is rarely quite complete. It is of greaf importance in this stage to establish the negative as regards all forms of paralysis. If any non- symmetrical symptoms are present, the ease is more than mere concussion. During this stage nothing should he done, except placing the patient in a condition of comfort, and preventing the cooling of the body. Stimulants, unless the collapse is extreme, should be avoided. After the collapse has lasted some little time (half-an- hour to two, three, or more hours), it begins to pass off. The patient moans, manifests discom- fort, turns on his side, and draws his knees up. Very often at this period sickness occurs, and it is almost invariable if the patient’s stomach was full at the time of the accident. Consciousness is now usually restored, and, by rousing, the patient may he induced to speak, and will tell his name, &c. Gradually, during a period of some hours, the case slides on into the sleepy stage. The pulse is now relaxed and full, the skin is warm or even hot, the face may be some- what flushed, and the pupils are contracted. The patient is overpowered with sleepiness, and can only be awakened with difficulty. It is, however, always within possibility to awaken him, and he usually rouses himself to the calls of nature. Very commonly the pulse is irregular, especially if the patient be young. At this stage again care must be taken to ascertain whether there are any non-symmetrical symptoms, any weakness of a limb, of one side of the face, or of any single eye- muscle. If the patient passes his urine or fjeces in bed. or if there is long-continued retention of urine, it is very probable that there is more than mere concussion — namely, laceration or contu- sion. The sleepy stage may last for a day or for a week, and it is in severe cases so well-marked that the patient's eyelids may be held open, and the pupils examined, without awaking him. During this stage the measures of treatment called for are spare diet, purgation, cold to the head, and quiet. When the sleepy stage passes off, the patient is left weary, torpid, unfit for mental effort, and often with distressing headache. These are the symptoms of the con- valescent stage, and they may last more or less for a considerable time. The patient should still be kept carefully quiet, no stimulants should be allowed, and purgatives should occasionally he used. Some of the symptoms present during the stage of convalesenee may persist bo long that they may rank rather as sequelae. Thus there may he for years nervousness, inaptitude for business, liability to headache, and peculiar sus- ceptibility to the influence of stimulants. As a rule, however, even after very severe concussions, no such ill-results are left, but the patient re- gains after a time perfect cerebral health. This remark must, however, not be held to apply to 142 BRAIN, CONCUSSION OF. auncussion when received in railway accidents; for in these cases there is a prospect of pecuniary compensation, and the sequel* are often severe, prolonged, and very peculiar. Jonathan Hutchinson. BRAIN, Congestion of. See Brain, Hypersemia of. BRAIN, Hemorrhage into. — Synon. : Cerebral Apoplexy ; Fr. Hemorrhagic cerebrate interstitielle ; Ger. Hirnschiag. Definition. — Escape of blood, by rupture of a vessel, into the substance or cavities of the brain. Haemorrhage into the meninges is separately described. Cerebral haemorrhage is commonly due to the rupture of an artery, very rarely to that of a vein. Occasionally, minute extravasations are caused by rupture of capillaries. Haemorrhage from arteries or veins may also be due to their laceration by injury. ^Etiology. — Arterial haemorrhage is usually due to the coincidence of weakened vascular wall and increased pressure within the vessel. The causes of these states may be regarded as the conditions predisposing to cerebral haemorrhage. Hereditary influence is sometimes distinctly seen, as a tendency to vascular degeneration, or to conditions which, as renal disease, produce such degeneration. Similarity of vascular distribution may also be inherited, and may de- termine the locality of strain, and, therefore, first of degeneration, and ultimately of rupture. Cerebral haemorrhage is most frequent after fifty years of age, but occurs at any age, though rare during the first half of life. It is nearly twice as common in men as in women. It is said to be more frequent in temperate than in tropical climates, in winter than in summer, and at high than at low elevations. Certain acquired con- ditions act as predisposing causes. Chronic Bright’s disease leads to early and extreme de- generation of vessels, as well as directly to hypertrophy of the heart and increased blood- pressure : hence it predisposes powerfully to cerebral haemorrhage. In purpura and scurvy, cerebral haemorrhage occasionally occurs — it is said in consequence of acute vascular degenera- tion and increased blood-tension. The state of vascular repletion known as plethora was for- merly thought to be a frequent cause of cerebral hfemorrhage. It probably does aid other causes, but rarely co-exists with the most eflieient, and so takes a very subordinate position. Chronic alcoholism and opium-eating are said to promote vascular degeneration. The proximate causes of cerebral haemorrhage are the weakened state of the wall of the vessel, and commonly some increase of blood-pressure. The vessel-wall is weakened by degeneration, and is often imperfectly supported in an atrophied brain. The increase of pressure within the ves- sels may be permanent, as in peripheral obstruc- tion, with or without hypertrophy of the heart ; or temporary, as in excited action of heart, or impeded circulation during effort. These causes are considered more fully in the article on Brain, Vessels of, Diseases of. Hfemorrhage from a vein is rare, except as the result of laceration by direct injury, or of ulcera- tion invading the vein secondarily. Varicose BRAIN, HAEMORRHAGE INTO, veins in the pia mater may sometimes rupture (Andral). Capillary haemorrhage is usually due to venous obstruction, especially to thrombosis in a vein. Anatomical Appearances. — In intracerebral haemorrhage, the blood is extravasated into the substance or into the ventricles of the brain — into the latter usually by rupture of a previous extravasation within the cerebral substance. Ie the latter situation the blood occupies a cavity formed by laceration of the brain-tissue ; rarely, when very minute and ‘capillary,’ by merely separating the fibres. In size an extravasation varies from that of a pea or even smaller, up to that of the fist. The blood is clotted, and reddish-black in colour ; and fragments of brain-tissue are mingled with it. The cavity containing it is often very irregular in shape ; its walls are uneven, present projecting shreds of lacerated brain-substance, and are blood- stained and softened — at first by imbibition of serum, and later by inflammation. Many small extravasations are often seen in the neighbour- hood of a larger clot. Usually there is only one large extravasation : sometimes, however, there are two or three. The extravasated blood exercises pressure ; the convolutions are flattened; the falx is bulged to the opposite side (Hugh- lings Jackson, Hutchinson) ; and the rest of the hemisphere is anaemic. The effused blood may tear its way into the lateral ventricle ; it then speedily distends both lateral ventricles and the third and fourth ventricles, and escapes by the openings at the lower extremity of the fourth ventricle, central and lateral, into the subarach- noid space. Or the blood may escape to the surface, infiltrate the pia mater, and tear its wav into the subarachnoid cavity, often by a vcr-, small opening. It is rarely that the artery from which the blood has escaped can be detected. Occasionally the extravasation can be traced to the rupture of an aneurism of some size. In other cases miliary aneurisms may be found on many vessels. The larger arteries ccmmonly present atheromatous changes. After a time the extravasated blood under- goes changes. The clot shrinks and gradually becomes, first chocolate, then brown, and ulti- mately a reddish-yellow ; and it then contains chiefly fat-globules, pigment and other granules, and hsematoidin crystals. The rapidity with which it undergoes this change is doubtful, and certainly varies. It is said that the distinctive blood-colour has disappeared as early as the twentieth day. Meanwhile the walls of the cavity undergo changes. The inflammation, in rare cases excessive and purulent, is usually conservative, and leads to the formation of con- nective tissue. A firm wall is thus developed, the inner surface of which becomes smooth by the softening and removal of the loose fragments of brain-substance; by this means a cyst is formed. It is said that connective tissue may extend across its cavity, and that in rare cases, the fluid being absorbed, the cyst walls may- unite, and a cicatrix result. Such cicatrices are, however, much more frequently due to softening than to hfemorrhage. It is asserted that a cyst may be developed in thirty or forty days undei favourable conditions. BRAIN, HAEMORRHAGE INTO. 143 Hsemorrhago may occur in any part of the brain, but is more frequent in some situations than in others. The most frequent seat is the corpus striatum and the region just outside it: nearly half the intra-cerebral hemorrhages are in this situation. Other primary seats, in the order of frequency, are the pons and peduncles, the cerebellum, the cortex, the optic thalamus (often affected by an extension of the haemor- chagefrom the corpus striatum), the posterior por- tion, and the anterior portion of the hemisphere. The frequent extravasation into and outside the corpus striatum, is explained by the vascular supply. ( See Brain, Vessels of, Diseases of.) Traumatic haemorrhage occurs into and from .1 lacerated portion of brain, and is most fre- quently found on the surface, occupying mainly the middle of the convex portion of each convo- lution, and some other regions much exposed to injury, as the surface of the teniporo-sphenoidal lobe, and the under surface of the frontal lobe. Ventricular haemorrhage sometimes results from traumatic rupture of a small vein on the surface of the corpus striatum (Prescott Hewett). Soft tumours (especially glioma) are some- times the seat of haemorrhage. The distinc- tion from simple hsemorrhage (sometimes diffi- cult) rests on their position being commonly one in -which cerebral haemorrhage is rare ; and on some gelatinous-looking tumour-substance being found, into -which haemorrhage has not occurred, and "which has characteristic microscopic features. Other organs may be healthy, or present t lie changes -which have been mentioned as predis- posing causes ; the lungs are usually secondarily congested, often intensely. Symptoms. — -The occurrence of cerebral haemorrhage is indicated by cerebral symptoms of two classes, the one general and more or less transient, the other local and more or less permanent. In addition to these there are ‘-ometimes premonitory symptoms ; and commonly general symptoms manifested by pulse, tempe- rature, &c., "which are secondary to the brain- lesion. Premonitory symptoms, somewhat rare, are those of altered cerebral function due to local vascular disease, headache, vertiginous feelings, local weakness or numbness, slight mental changes, and slight affection of spieech {see Brain. Vessels of, Diseases of, and Brain, Anaemia of). They are less frequent than in cases of softening, and more commonly precede cerebral hsemorrhage in the old than in the young and middle-aged. The onset of haemorrhage is usually accom- panied with apoplexy, i.e. loss of consciousness and of power of motion and of sensation, oA-en with relaxation of the sphincters and loss of reflex action {see Apoplexy, Cerebral). These symp- toms are profound and lasting according to the size of the hsemorrhage and its position : being es- pecially marked in large and double effusions, in intraventricular hsemorrhage, and in hsemorrhage into the pons. In a case of moderate severity they last only a few hours, and gradually pass away. In severer cases they may deepen until death occurs from failure of respiratory power. Death is rarely very speedy, life being usually prolonged for some hours even in the most rapidly fatal cases. In rare instances of hsemorrhage into the medulla, and also in meniDgeal hsemorrhage, death has occurred in five minutes, probably in each case from the rapid interference with the respiratory centre. The temperature is at first lowered one or two degrees, the pulse becomes less frequent, and the respiration slow. The Cheyne-Stokes respiratory rhythm often precedes death. After a few hours the temperature rises to the normal and in mild cases stops there, but in graver cases it rises above the normal two or three degrees. In some very grave cases the initial fall or sub- sequent rise may be extreme and go on until death occurs, sometimes reaching 90° in the one case, and 107° or 10S° in the other (Bourneville). In slight eases of cerebral hsemorrhage there may be no loss of consciousness. Vomiting in such cases is not unfrequent. In other rare cases of large hsemorrhage, especially between the external capsule of the corpus striatum and the island of Reil (Broadbent), the loss of con- sciousness comes on gradually, after other symptoms, as of shock, for example, have lasted for an hour or two. These cases have been termed ingravescent. Local symptoms, often permanent, and always of longer duration than the loss of consciousness, are present in all cases of circumscribed cere- bral hsemorrhage, except in the rare instances in which, by its central position in the pons and medulla, it causes directly bilateral effects only, which are added to and intensify the gene- ral symptoms caused indirectly. In a unilateral cerebral lesion, the direct symptoms are unila- teral loss of pow r er of voluntary movement and often of sensation, accompanied sometimes with convulsion or rigidity. These local sj'mptoms may commence a few minutes or longer before the loss of consciousness. They coexist with the apoplectic condition, and may often be recognised, even during coma, by the flaccidity of the paralysed limbs, which fall more helplessly than those of the opposite side ; by inequality of the mouth and of the pupils ; by conjugate deviation of the head and eyes towards the side of the brain injured ; by convulsive movements ; and, as the apoplexy clears, by the detection of unilateral defect of sensibility. The coma passing away, these signs become more distinct, and all the symptoms of hemiplegia remain, varying in intensity and extent according to the position of the lesion. The apioplectic state may recur after its disappearance— a grave symptom, usually in- dicating that a fresh hsemorrhage has occurred in the same or the other side of the brain, or more frequently that the blood has escaped into the ventricles. In the former case the unilateral symptoms, conjugate deviation of the head and eyes, &c.,' are increased on the same, or trans- ferred to the opposite side ; in the latter the uni- lateral symptoms disappear, and general power- lessness and deep coma supervene, with stertor, relaxation of the sphincters, loweredtemperature, and impeded respiration. Death always ensues. Convulsion may be a conspicuous symptom at the onset or subsequently. It is usually unilateral in its course or commencement, be- ginning on the side paralysed, rarely affecting only the non-paralysed side. Where convulsion is 144 BKAIN. HAEMORRHAGE INTO. cot met with, muscular twitching or rigidity may occur. General or widely-spread rigidity or twitching points to a bilateral lesion; if with coma, to ventricular haemorrhage. After a day or two symptoms of irritation about the cerebral lesion come on, such as head- ache, delirium, and rigidity in the paralysed limbs. During this period the temperature rises above the normal, and the pulse becomes quick. On their subsidence, these symptoms, if the lesion is slight, may be scarcely recognisable, and a stationary period ensues, at the end of which recovery of power over the paralysed limbs begins. In slight cases power maybe recovered very speedily. Its return depends upon the structural recovery of slightly damaged tissue, and on other parts taking on an increased func- tion in compensation for that which is destroyed. The electric irritability of the muscles exhibits little change. Sometimes, however, when there is great irritation at the lesion propagated downwards to the cord, a marked initial increase in irritability may precede a considerable de- pression, coincident with rapid wasting. Re- covery of power is rarely complete except in those cases in which the area of damage is very small ; and when the damage is large and affects an important motor region, there may be no recovery, loss of power persisting, commonly with more or less 1 late rigidity ’ in the paralysed limbs. Slight permanent mental change often re- mains, and as the motor power is recovered, ataxic and other disorders of movement may supervene in the limbs which were paralysed, although much less commonly than after softening. Diagnosis. — The diagnosis of cerebral haemor- rhage rests on the symptoms of a localised cere- bral lesion, occurring suddenly. The conditions from which it has most commonly to be distin- guished are — congestion of the brain ; softening of the brain, embolic and thrombic ; and, some- times, tumour. For the distinction from it of other causes of apoplectic loss of consciousness, uraemia, post-epileptic coma, &c. see Apoplexy, Cerebral. From congestion the chief dis- tinction of cerebral haemorrhage lies in the transient nature of the loss of consciousness ; and in the slightness and general character of the symptoms which characterise the former. Congestion generally, haemorrhage only some- times, comes on during effort : and the absence of history of effort is in favour of the latter. Similarly, the premonitory symptoms which are usually present in congestion, are generally absent in lnemorrhage. The loss of motor power, and the symptoms of cerebral shock, are much greater in haemorrhage than in congestion. It must be remembered that the two states fre- quently coexist. From softening consequent on embolism cerebral haemorrhage has also to be distinguished. The subjects of the latter are usually of an earlier age than those of haemor- rhage ; their vessels are healthy, but they have organic heart-disease, w'hich is often grave. There may be evidence of embolism elsewhere, in spleen, kidney, or retina. Loss of conscious- ness may be absent in embolism, and the para- lysis often comes on deliberately. An exten- sive capillary embolism, causing deep coma, cannot be distinguished from haemorrhage. From softening due to thrombosis the distinction is often difficult. Age, and the state of the vessels, no longer serve as guides. The presence of chronic Bright’s disease is in favour of haemorrhage. The occurrence of previous hemiplegic attacks points to softening. In the attack, loss of con- sciousness is much more considerable, in pro- portion to the subsequent paralysis, in haemor- rhage than in softening. But the distinction on this ground is often very difficult, since loss of consciousness may be absent in slight haemor- rhage, and considerable in an extensive softening. A deliberate onset is in favour of softening, and so are much mental change and early rigidity. Paralysis of sudden onset, in cases of tumour, may bo ascribed to haemorrhage, to which it is indeed sometimes, but not always, due. Usually, enquiry elicits a history of gradual, long-con- tinued symptoms ; intense headache and optic neuritis are strongly suggestive of tumour. Haemorrhage into the substance of the brain is distinguished from meningeal hemorrhage by the pain and mental excitement being less con spicuous, convulsion rarer, and by the presence of symptoms of a local lesion. Hamorrhagt into the ventricles, which resembles meningeal haemorrhage in the generality of its symptoms, is usually distinguished by succeeding the symp- toms of a circumscribed lesion. Prognosis. — During the attack itself the prognosis in haemorrhage into the brain must be guided by the intensity of the symptoms, and by the place of the lesion, as far as that can be ascertained. Death is probable if the coma is profound or long-continued, and if the early depression, or the subsequent rise of tem- perature and pulse-rate is great. When the symp- toms indicate ventricular haemorrhage, or haemor- rhage into the pons, the patient will certainly die. Consciousness being recovered, and the danger of immediate death over, the freedom from much secondary pyrexia, from lung-congestion, and from bedsores, are favourable indications. The chance of recovery from the paralysis is es- timated by evidence of position of the lesion, and by any indications of improvement. Early contraction of the flexors is unfavourable. The danger of recurrence is in proportion to the ex- tent of vascular disease, and the existence of irremovable causes of increased arterial tension. Hence the prognosis is rendered unfavourable by advanced age, or chronic renal disease, and by the evidence of general premature decay. Treatment. — During the attack. Best is the most important. The patient should remain, as far as possible, where he is seized; stillness must be secured : and all effort is to be avoided. The posture should be recumbent, with the head raised. Any cause of passive cerebral congestion, such as a tight collar, must be looked for and re- moved. Venesection was formerly almost always employed in such cases — certainly toouniversally ; but it is now quite discarded — perhaps too abso- lutely. Loss of blood lessens the force of the heart and vascular tension ; it thus hastens t !><- cessation of external bleeding. Doubtless it acts in the same way in internal htemorrhage. It may- be used with probable advantage if the arteri.il tension is great (that is if the pulse is inc mpr- - sible), the heart acting strongly, an : tlr re it BRAIN, HAEMORRHAGE INTO. reason to believe that the intra-eranial haemor- rhage is increasing. A small quantity of blood should be taken rapidly. In ventricular haemor- rhage, venesection is probably powerless for good. It should not be employed where there is any evidence of failing heart-power. Its indications are drawn as much from the state of the patient as from tho feet of haemorrhage. Bright’s disease is no contra-indication. If bleeding is not employed, the objects to be aimed at by other measures must be to divert the blood as far as possible from the brain, by relaxing the systemic vessels, while endeavouring to obtain contraction of the cerebral vessels. Warmth may be applied to the limbs, aided by sinapisms. Dry-cupping to the surface, and purgatives, as croton oil, will divert the.blood to the surface, or to the capacious intestinal vessels. Drugs which would cause contraction of the vessels are to be avoided, since their influence being on the smallest vessels and universal, their tendency is to increase arterial tension and haemorrhage. Contraction of encephalic vessels may be furthered by cold to the head or sinapisms to the neck, according as the head is hotter or colder than normal. The heart should be allowed to fall a little below the normal in force, but failure of power must be warded off by stimu- lants given with great care. Convulsion is more effectually checked by cold than by bromides; the latter may be given if the convulsion recurs. After the attack. — During the stage of irrita- tion, rest must be maintained, and all sources of annoyance must be avoided. The bowels should be kept gently open by laxatives or by injec- tions. Stimulants must be avoided, and the diet should be light. Pain may be relieved by cold to the head, a blister to the neck, or by Indian hemp or by bromide of potassium. During reparation the diet must be nutritious, but carefully regulated ; and constipation of the towels must be avoided. Rubbing of the limbs, and their gentle exercise, will aid their recovery, and after the symptoms of irritation have passed, faradisation will improve muscular nutrition, and is especially indicated where rapid loss of irritability indicates probable wasting. Nervine tonics are useful ; none more so than a combination of hypophosphite of soda and tinc- ture of nux vomica. In anaemia the syrup of the phosphate of iron is good. Warmth, change of scene, and cheerful mental surroundings are useful adjuncts, especially in the later stages of recovery. W. R. Gowers. BRAIN", Hypereemia of. — Synon. : Con- gestion of the brain. Definition. — Increase in the quantity of blood within the capillaries of the brain. Since neither the arteries nor the veins of the brain-substance can be over-distended with blood without capillary hyperaemia, and since it is to capillary hyperaemia that the functional disturbance of the brain is related, this may be justly taken asthe essential pathological element in cerebral congestion. The congestion may be active, when the capillaries contain, in conse- quence of arterial distension or dilatation, oxy- genated blood passing rapidly through them ; or it may be passive, when, from venous obstruc- 10 BRAIN, HYPEREMIA OE. 146 tion, the capillaries contain slowly-moving blood, becoming, and in great part already, venous. ^Etiology. — (A) Active congestion of the brain may be general or partial. Of the general form the remote causes are as follows : — Men are said to be more liable to it than women. Age in- creases its frequency (but this is more true of the passive form) ; yet children, from the sensi tiveness of their vaso-motor system, occasional ,'j suffer from active cerebral congestion. Heredil j has only an indirect influence. The plethoric condition is a powerful predisponent. The im- mediate causes of excessive flow through the arteries of the brain may be thus stated — (1) In- crease in the blood-pressure — either general, from excessive action of the heart (as in extreme hypertrophy or functional overaction); or partial, from an obstruction elsewhere, throwing an un- due proportion of the pressure upon the cerebral vessels. This is seen in contraction of the aorta beyond the origin of the vessels to the head, and in sudden contraction of a large number of the systemic arterioles, as those of the surface, in exposure to cold and in ague. (2) Active ar- terial dilatation of vaso-motor origin may result from prolonged mental work, severe moral emotion, insolation, digestive disturbances, or from the presence in the blood of various poisons, such as alcohol and amyl-nitrite. In these cases the vaso-motor disturbance may precede and cause, or may succeed and result from the overaction of the brain-tissue, which is intensified by it. In acute alcoholic poisoning the cerebral congestion is, as Niemeyer suggests, probably secondary to the disturbance of brain-tissuo ; in chronic alcoholism it may possibly be pri- mary. In pyrexia the headache and delirium have been thought to be due to congestion, but this is not certain. (3) Increased atmospheric pressure may cause congestion of the brain. (4) And, lastly, gravitation in the recumbent posture may alone cause cerebral hypersemia, or may powerfully aid other causes in produc- ing it. Partial active congestion of brain-tissue occurs chiefly along with disease of the arteries, which perverts blood-pressure ; in organic brain-dis- eases, as tumour, haemorrhage, &c. ; and after blows on the head. (B) Passive congestion of the brain, when general, is the result of impeded return of blood from the head. It may be due to pressure on the veins in the neck, as by tumours or tight collars ; pressure on the innominate veins by tumours or aneurism ; or obstruction to the circulation from violent respiratory efforts, as cough or blowing wind-instruments. It may be caused by impedi- ments within the circulation, such as tricuspid insufficiency and its causes in the lungs, or dis- ease on the left side of the heart. The recum- bent posture assists all these influences. In arterial obstruction from diseased vessels, a weak heart, insufficient to overcome the obstruction, may permit venous stasis, but the capillary con- dition is one of anaemia. Partied passive congestion may occur from thrombosis in a cerebral vein, or from pressure by a growth on one of the cerebral sinuses. Anatomical Appearances. — The capillaries are not visible to the naked eye even when over 146 BRAIN, HYPER2EMIA OF. distended, but with the microscope they are seen to be dilated, often to twice their normal calibre. Their distension is indicated by a deeper tint of the grey substance ; and the fullness of the small arteries and veins shows itself in an increase, often very great, in the number and size of the 'ed points visible on section of the white matter. In active congestion the arteries are said to be distinctly larger than normal, and their perivas- cular spaces lessened in size ; the minute vessels of the meninges are distended. In passive con- gestion the veins and sinuses are gorged with blood. It must be remembered, however, that such engorgement of the veins occurs in all cases of death from interference with respira- tion, and that the vessels of the most dependent portion are always fullest. The state of the cerebral veins must therefore be carefully com- pared with that of the veins of other organs. Active congestion may sometimes leave no visible traces. After a time blood-pigment collects out- side the vessels (Bastian), and serous effusion into the pia mater may be found ; and after long- continued congestion, the vessels may be perma- nently distended; the spaces in which they run are increased in size. Such increase is common apart from pathological congestion, but it is so great in some cases of long-continued congestion that this effect cannot (with Mcxon) be altogether denied. Symptoms. — It is probab! e that many symptoms have been erroneously ascribed 1o cerebral con- gestion, some because hypersemia, due to the mode of death, was found 'pest mortem, others because an assumed congestion was the readiest mode of explanation. Moxon lias indeed main- tained that cerebral hypersemia never causes symptoms except perhaps in death from Strangu- lation. It is doubtful whether our knowledge of the conditions of the cerebral circulation is suf- ficiently exact to justify this conclusion, which is difficult to reconcile with clinical facts. The symptoms commonly referred to cerebral congestion may be grouped in two classes — those of excitement, and those of depression. Either of these may exist alone ; those of excitement may precede those of depression ; or they may partially co-exist. They may he slight or severe ; acute or chronic. Iu all cases thoy are increased by the recumbent posture or by depressing the head, by expiration, and bjr effort; and they are usually aggravated by constipation, and by in- dulgence in alcohol. In general cerebral hypersemia, among the symptoms of excitement may be mentioned mental irritability ; headache — slight or violent, with feelings of fulness or throbbing in the head, and vertiginous or other unpleasant sensations ; increased or perverted functions of the organs of special sense, such as flashes of light and noises in the ears; contraction of the pupils; sleeplessness, restlessness, startings, twitchings or slight actual convulsions ; and mental excite- ment. The pulse is quick. There may be vomiting. The face varies, participating in the congestions of circulatory origin, and in some of vaso-motor disturbance, such as that which may occur during digestion. In other forms of sup- posed congestion of vaso-motor mechanism, as in those which result from excessive brainwork, the face may be pale, but the nature of these case* is doubtful. Among symptoms of depressed brain-function, are dullness of the special senses ; motor weakness ; mental indifference and slowness; somnolence, especially after meals ; dilatation of the pupils ; and infrequency of the heart’s action. Conscious- ness may be lost suddenly, and the loss, it is com- monly believed, may deepen into coma. As a rule there is no fever, but in children the tern perature may be raised a degree or so. In the chronic forms of cerebral congestion, these symptoms, variously grouped and moderate in degree, continue for days, weeks, or months. Their course is marked by great variability. Durand-Fardel has pointed out that in these cases there is often much viscid secretion of the conjunctiva. In the more acute forms of cerebral congestion, the symptoms of muscular spasm, of mental dis- turbance, or of loss of consciousness, may be so predominant as to give a special character to the attack : — In the convulsive form pain or uneasiness in the head commonly precedes the muscular spasm. The latter is usually slight. Consci- ousness may or may not be lost. The delirious form is seen under two aspects — (1) in old age, after emotional excitement; in this the wandering is slight, and often related distinctly to the recumbent posture ; (2; a much more violent delirium, which is apparently re lated to cerebral congestion, and is seen some- times after mental work or emotional excite- ment, or after alcoholic poisoning. Occasionally death results. The apoplectic form is marked by sudden lose of consciousness, occurring commonly during effort. The unconsciousness usually lasts only a few minutes, and incomplete general weakness remains for a day or two. In rare cases the loss of consciousness deepens into coma, with ster- torous breathing and relaxed sphincters, and death may occur from the extension of the cerebral depression to the respiratory centres. Vertiginous sensations sometimes give a cha- racter to an attack. In children congestion of the brain is a rare but occasional cause of convulsion or delirium. Headache and contracted pupils make up a group of symptoms resembling meningitis, but fever is rarely present, and if it exists it is slight, and the symptoms usually come on suddenly and pass away in a day or two. Partial hypersemia leads to localised symptoms of excitement or depression. Local convulsion or paralysis may result. Headache is often intense and localised. If nothing more than congestion is present, the symptoms usually soon pass off. 1’athoi.osy. — The pathology of cerebral con- gestion is still obscure, since we know, little of the relative part played by tho blood-vessels and the nerve-elements in determining the symp- toms and their form. An excessive supply of arterial blood is, in all organs, attended with functional activity, and it is easy to under- stand that active congestion should result in symptoms of excitement. Subsequent depres- sion of function has been accounted for by inferring compression of brain-tissue by effused BRAIN, HYPEREMIA OF. serum. The reaction of exhaustion may con- tribute. In passive congestion the nerve-tissue is imperfectly supplied "with oxygenated blood, and compressed by distended vessels, and its functions are impaired by the presence of effete products. Hence the predominance of symptoms of depression over those of irritation. Diagnosis. — The diagnosis rests on the dis- covery of circulatory and other causes of cerebral congestion ; on the circumstances of posture, effort, &c., under which the symptoms came on ; m the existence of concomitant congestion in other parts supplied by the carotids, as the face (by no means invariable); on the diffusion of the symptoms ; on their speedy disappearance ; and on the absence, in the adult at any rate, of elevation of temperature. The diagnosis of the special forms of cerebral congestion from the diseases which they most resemble is considered inder the head of those diseases. Prognosis. — The prognosis is generally imme- diately favourable, but from a severe attack death may probably occur. The apoplectic form is most dangerous, the convulsive least so. De- generated weakened vessels render the imme- diate prognosis less favourable. After many attacks, permanent nutritive changes in the brain supervene. Treatment. — The most important elements in the treatment of cerebral congestion are pos- ture, removal of blood, purgation, cold to the head, and warm and stimulating applications to the surface. Whatever be the cause, it is im- portant to raise the patient's head, so that gra- in tation may impede the flow and aid the return of the blood. By this means alone insomnia from hypersemia may often be prevented. The removal of blood is useful in extreme forms of congestion, either active or passive, especially in those forms of act ive congestion in which the face participates. Venesection or leeching may be employed according to the severity of the attack ; in active congestion the blood which is taken should be removed quickly. The relief which in such cases follows an epistaxis illustrates the value of this method of treatment. It is not advisable in those cases in which, from overac- tion of brain-tissue, or from cold to the surface, dilatation of the cerebral vessels results, while the face remains pale. In all forms of con- gestion, purgation is useful. It removes from the blood some of its serum, and it affords im- mediate relief to the cerebral circulation, by causing an afflux of blood to the capacious in- testinal vessels. In plethoric states diuresis is also most useful, and has succeeded where venesection and purgation failed (Reynolds). Cold to the head is of most value in reflex or secondary dilatation of the cerebral vessels, as after mental work, insolation, fatigue, and some tox£emic states. In the same class of cases, sti- mulation of the peripheral nerves by sinapisms, blisters, &c., applied to the neck, will, by reflex influence, assist in obtaining arterial contraction. Hot applications to the limbs act in part in a similar manner, in part by causing local afflux of blood and thus lessening the tendency to en- cephalic engorgement. They are most useful in active congestion. Alcohol and opium must be avoided in all forms of active congestion, but BRAIN, HYPERTROPHY OF. 147 in passive congestion they may be of service. Bromide of potassium is useful in those cases in which the congestion is produced by vaso- motor mechanism, excited either by stimula- tion of brain-tissue or of distant nerves. In passive corgestion from heart-disease the treat- ment is that of the cardiac condition. All per- sons liable to congestion of the brain should live regularly, avoid hot rooms, and attend care- fully to the stomach and bowels, relieving the latter by frequent moderate purgation. W. R. Gowers. BRAIN, Hypertrophy of. — Hypertrophy of brain is a misnomer. True hypertrophy would consist of increase in number or in size of the nerve-cells, nerve-tubes, connective stroma, and supplying vessels ; and there might be expected, as a result of this condition, some manifestation of a. higher intellectual development. Such a condition is never found. A so-called hypertro- phied brain is one that is larger and heavier than normal. On removing the skull-cap, the encephalon seems to expand, so as to render it difficult to a ffix the bone-covering in its place ; the membranes are dry, the sulci have nearly disappeared, and the whole organ appears pale and bloodless. On section there is a sensation of toughness, though less in degree than in a case of general sclerosis. There is no sign of pressure upon the orbital plates, such as is met with in chronic hydrocephalus. The lesion affects only the cerebral hemispheres, espe- cially . on the convex surface, and perhaps the posterior lobes in particular. The base of the brain and the cerebellum are unaffected except by pressure. On minute examination, the nerve-cells and nerve-fibres, far from being found augmented in number or in size, may even be compressed and diminished ; and there is often also some inter- ference with the normal calibre of the vessels. Gintrac, however, records a case in which the calibre of the nerve-tubes was almost double that of the normal. What increase there is affects the white matter of the brain, and this structure is very pale and of an elastic consistence. The real and sole lesion is hyperplasia of the connec- tive tissue. It differs from sclerosis in affecting the cerebral hemispheres more universally than is the case with sclerosis ; and also that in sclerosis there is not only increase of the connective tis- sue, but subsequent retraction, and, as a fre- quent consequence of this, an absolute destruction more or less of the nerve-elements of the organ. When the disease is far advanced it may pos- sibly cause absorption of the inner table of the skull, and thus produce a roughness or thinning of the bone, or, in extreme cases, even perforation. The sinuses are generally distended with blood. Hypertrophy of smaller portions of the brain is rare : still various cases are on record in which, under the name of neuromata of the nervous centres, white or grey matter has been found in certain parts of the brain over and above the normal constituents of this organ. Hyperplasia of the pineal gland is closely allied to glioma. It should be distinguished from encysted dropsi of that organ. JEtiology. — H ypertrophy of the brain has beer 148 BRAIN, HYPERTROPHY OF. said to be sometimes secondary, and caused by the irritation of morbid growths. This, however, is rare. It is generally primary, and may be a dis- ease of intra-uterine life ; but it is generally de- veloped after birth, especially in rickety children. Some forms of encephalocele, -without, hydroce- phalus, seem to be due to tho growth of com- pact masses of cerebral substance in excess of what is normal. The conditions for the produc- tion of this morbid state are infancy ; bad diet ; repeated congestion of the cerebral vessels, such as might be induced by frequent cough ; and, perhaps, lead- poisoning. Symptoms. — The symptoms of so-called general hypertrophy vary according as the sutures are closed or not. If, from insufficient occlusion of the sutures, the head expands in proportion to the increase in size of the encephalon, the symptoms may be very slight. Children thus affected show no intellectual hebetude. In them, as long as the abnormality is uncomplicated with local inflam- mation of membranes or with haemorrhages, there may be no headache, no affection of sight, no sensory or motor paralysis, and no convulsions. Convulsions, however, are common in cases in which the occlusion of the sutures has prevented expansion of the head proportionate to the in- ternal increase of tissue. In such cases also there is generally more or less motor paralysis, often some anaesthesia of the limbs, headache, vomiting, and mental hebetude — symptoms, in fact, either of marked interference with the intra-cranial circulation, or of irritation from inflammatory complications. The prognosis is always bad, but in rachitic cases the course may be chronic. Treatment. — All treatment seems to be inef- fective in diminishing cerebral hypertrophy. E. Long Fox. Bit AIN”, Inflammation of. — Synon. : En- cephalitis. — Encephalitis is a term which ought perhaps to be strictly limited to inflammatory changes in the brain-substance itself, to the exclusion of all forms of meningitis. It may be either diffuse or local, but for our present pur- pose we have chiefly to do with the diffuse form. Local encephalitis will generally result in ab- scess ( see Brain, Abscess of) and will usually be met with, if we put aside the results of inju- ries, in association either with disease of the ear, with tubercular growths, or with pyaemic deposits. It may perhaps be doubted whether the oc- currence of diffuse inflammation of the brain- substance as an acute disease has as yet been proved, excepting as a result of wounds. Even as a traumatic lesion, its special features have by no means been accurately studied. It is, how- ever, highly probable that after penetrating wounds of the brain, its substance may inflame, just as the cellular tissue of a limb may, the inflammatory processes beginning at the site of the wound and rapidly spreading through a large part of the hemisphere. It is probably in the perivascular spaces that the process chiefly spreads, and it is in these that the microscope will detect the most abundant results. Such a condition of diffuse encephalitis may exist with- out there being any visible changes in the brain. It may perhaps be a little softened or a little BRAIN, LACERATION OF. congested, but very probably there is nothing about which the most experienced pathologist could feel certain until the microscope is re- sorted to. Symptoms. — It is not possible, in the present state of our knowledge, to speak with any cer- tainty of the symptoms of diffuse encephalitis. They will vary, of course, with the region affected; and disturbance of function, followed by more or less complete loss, will be the most frequent oc- currences. Treatment. — When the symptoms of ence- phalitis are once recognised, it will usually be too late for treatment, and measures of preven- tion are those of chief importance. The early use of mercury, beginning in anticipation of, rather than waiting for symptoms, is probably the most important ; and next to it come cold to the head, purgatives, and counter-irritation. Jonathan Hutchinson. BRAIN, Laceration of. — In the more strict sense of the word, the brain is but little liable to laceration from injury. Yet, in connec- tion with injuries, such as penetrating wounds of the skull, fractures with great depression of bone, and even with violent concussions, the brain-substance is not unfrequently, to some extent, torn. In so soft a structure, however, and under the influence of modes of violence which are usually rather of the nature of blows than of anything likely to cause stretching, wo rarely meet with results comparable to laceration of any of the firmer textures of the body. Whenever the brain is ‘lacerated’ it is also contused, and the contusion often ex- tends widely around the rent, and is by far the more important lesion. In tho peripheral parts of the brain-mass this is especially true, and it is of little practical use to speak of lacerations excepting as complications ot' very severe con- tusions. In tho central parts, the crura espe- cially, we meet now and then with a laceration properly so called, and it is not very infrequent to find the trunks of single nerves torn across. The consideration of those forms of laceration which are produced by the effusion of blood from ruptured vessels of size sufficient to supply a stream forcible enough to break up the sur- rounding substance, will be found in the arti- cles Apoplexy, Cerebral ; and Brain, Hemor- rhage into. In the case of injuries to the head from falls or blows without perforation, certain definite parts are prone to suffer from contusion and laceration. Usually some slight evidence of injury is found immediately beneath the part of the skull upon which the blow was received, but by far the chief bruising will be at the opposite point. If the occiput he struck, the anterior lobes will be contused ; and if one parietal eminence, the opposite sphenoidal lobe. This law, how- ever, is greatly modified by the differing con- ditions under which different parts of the brain- mass are placed as regards their surroundings. In the posterior half of the skull the brain-mass is bulky, and between its hinder lobes and the cere- bellum is a strong flexible membrane, well calcu- lated to break vibrations gradually, and thus to prevent contusion. Nor are there in these region! BRAIN, LACEEATION OF. any strongly marked bony ridges against which the brain might be dashed. These conditions are reversed as regards the anterior lobes and the middle lobes, and the consequence is that whilst severe contusions are often seen in the latter, they are much more rare in the cerebel- lum and posterior two-thirds of the brain- mass. In cases of compound fracture, with tearing of the dura mater, and deep depression of bone, the brain-substance may, of course, be injured at any part ; but even in respect to this kind of violence the hinder regions of the skull are specially protected. Symptoms. — W e know enough of surface-lacera- tions of the brain in parts other than the anterior and middle lobes, to be able to assert that, unless the lesion extend very widely or deeply, it does not reveal itself by any special symptoms. If very extensive, weakness of the opposite limbs and side of the face is usually observed. Injury to the anterior lobes, unless extensive, cannot be diag- nosed, but it may be guessed at in a few cases where the sense of smell is lost in one or both nostrils ; for it is very common for the olfactory bulbs to be damaged at the same time. If the anterior lobes are severely lacerated, the symp- toms will be those of very severe concussion, with the difference that the insensibility is more nearly complete, and that it increases instead of diminishing as the days pass on. When a sphe- noidal lobe is contused there is usually, accord- ding to the writer’s observation, incomplete hemi- plegia of the opposite side, involving sensation as well as motion, and the face as well as the limbs. From these symptoms the patient may, in the course of months, wholly recover. It is usually the apex of the sphenoidal lobe which is lace- rated, but if the lesion extends higher, and if it occur on the left side, aphasia may be present. In connexion with recent discoveries (Dr. Ilughlings Jackson, Dr. Ferrier, and others) as to localised functions, no doubt we shall be able before long to diagnose more accurately as to the precise regions injured. It would, however, as yet be premature to attempt to do so. Treatment, and Prognosis. — In the treat- ment and prognosis of lacerations qnd contu- sions of the surface of the brain, much depends upon whether or not the case is complicated by compound fracture and the admission of air. If air have been admitted there is risk of menin- gitis or encephalitis, denoted in either case by the occurrence, within a few days of the injury, of hemiplegia of the opposite side. To prevent this must be the object of treatment. The scalp should be shaved, the wound closed with sutures as far as practicable, and lint wetted in a spirit- and-lead lotion should be laid over the part and systematically re-wetted every hour. If the case be treated in hospital it may be well, in addition to this, to wash the wound with the lotion before closing it, or to dress with Lister's antiseptic precautions. In cases of laceration without ac- cess of air death may ensue from diffuse softening around the part. If this happens the case will probably end within a week or ten days. It is probable that many cases of fractured base with more or less severe laceration of brain recover ; in some with permanent paralysis, but in others without. It must be added that many of the cases BKAIN, MALFORMATIONS OF. 149 in which death occurs within a few hours or a day or two after fracture of the base are attended by laceration. In these the symptoms are often difficult to distinguish from those of compression. Profound insensibility, a bloated face, stertorous breathing, and a full pulse, are often present , but they may be substituted by pallor and a feeble pulse in connection with great depression of the heart’s action. If any deviation from symmetry as regards the paralysis of the limbs can be proved, it is in favour of laceration and against compression, but the differential diagnosis is a matter of extreme difficulty. Laceration of Cranial Nerves. — Lacera- tions of single nerves within the cranial cavity are not by any means uncommon. This occur- rence is to be suspected whenever the parts sup- plied by a cranial nerve are completely paralysed, without accompanying symptoms indicative of severe lesion of the brain-mass. Cases of lace- ration of the brain itself may be complicated by laceration of nerve-trunks, and thus the symptoms may become difficult to interpret with confidence. Of single cranial nerves the olfactory bulbs are the most liable to suffer from contusion ; and the third, fourth, and sixth nerve-trunks are those most frequently torn through. Jonathan Hutchinson. BKAIN, Malformations of. — The malfor- mations of the cranium and its contents may be divided into two series : — A. Those which are scarcely compatible with life ; and B. Those in which life is possible, although the intellectual power may be more or less modified from a healthy condition. A. The first series will include at least seven forms, in all of which life is so rare that it is impossible to speak of more than the pathological anatomy. 1. Diccphalia — in which two heads are found upon a single body, or upon two bodies pretty extensively connected. In the first variety, one head may be attached to the vault of the palate of the other, or may be united to the convexity of the skull. In the second variety the heads may sometimes spring from a single neck. This dieephalous condition is frequently accom- panied by malformation affecting the spinal column and spinal nerves, as well as by somo incompleteness in the development of the brain. 2. Monocephalia — the union of two heads into one, on two separate bodies. The two cranial cavities are united into one. Dissection of the dura mater points to this membrane having been formed out of two, and in like manner the cranial contents are either double, or appear to be singlo from the union of double organs. 3. Acephalia — the complete absence of head. An acephalous monster is usually a twin ; and when this is not the case, it is associated with the morbid condition of the uterus of the mother known by the name of uterine hydatids. 4. Paracephalia — the head not entirely want- ing, but deprived of most of the cranium and of the face. A monster of this kind is generally a twin. 5. Anencephalia . — The absolute meaning of this term would be the absence of all cranial contents, but it is made to include certain vario- BRAIN, MALFORMATIONS OF. 150 ties, differing according to the amount of tho encephalon developed. The aspect of tho head, resembling that of a frog, the considerable pro- jection of the eyes, the flattening of the forehead, and the absence of the cranial vault, are the chief characteristics of this abnormality. In the first degree, there is absence of cere- brum, cerebellum, mesocephalo, and spinal cord. In cases of this kind the cranial vault is generally absent, and the bones at the base of the skull convex and thickened. In the second degree, tho cerebrum, cerebel- lum, and mesocephalo are absent, but a portion of the spinal cord is found. This portion of cord is most usually the lower part. In the third degree, the spinal cord is pretty complete, but there is still an absence of the cerebrum, cerebellum, and mesocephale. A few cases have been recorded of the fourth degree, in which no cerebrum or corebellum are found, but a normal spinal cord, and a pretty complete mesocephale. In the fifth degree, the cerebrum alone is entirely or almost entirely absent, whilst the rest of the nervous centres are present, though not always in a perfectly complete condition. The seat of the absent cerebrum is often filled by fluid. Lastly, one case has been recorded in which the cerebrum was present, whilst the cerebellum, mesocephale, and spinal cord were wanting. Anencephalia, like the other previously men- tioned malformations, is due to arrest of develop- ment, such arrest depending either on physical injuries to the uterus at a very early period of pregnancy, or to some mental shock experienced by the mother during tho first two months after conception. It differs from acephalia, not only by the partial formation of the head, but by the presence of tho heart, and other thoracic organs. The ganglia of the sympathetic are usually well- developed. 6. Pscudcnccphalia. In this malformation there is anencephalia plus a very considerable thickening of tho meninges, which take the place and often imitate the aspect of the brain. Its varieties exactly correspond to those of anon - cephalia. The tumour formed by the develop- ment of the mombrancs is of variable size and position. It may be frontal, fronto-parietal, or occipital. The real seat of the lesion is the pia mater. The abnormality consists in extreme hypertrophy of this structure, with complete arrest in the development of the encephalon, or of some portion of it. Several observers have recognised certain vesicles in the interior of the membranous tumour, and these have been sup- posed to be cerebral cells in process of develop- ment. It is more in accordance with observation to believe with G-intrac that they are connected with the development of the choroid plexus. 7. Cycloccphalia. In this monstrosity there is an approximation or actual fusion of two eyes in a common orbit. It is connected with certain abnormalities in the brain, that militate against viability, or at least prolongation of life. The brain itself is generally more or less deficient, especially in its anterior and central portions, and in some cases the nose and mouth are very ill-developed. B. The sctxnd series of cases owe their ab- normal conditions to injury arising in the cour.-c of fcetal life ; and some forms at least may be due to lesion occurring at a later period than in the first series. 8. Atelencephalia — incompleteness of brain or of membranes — is the chief of these forms. This incompleteness manifests itself in seven varieties according to the part of the encephelon injured by the lesion. In the first variety, the dura mater is some- what deficient, being altogether absent in certain situations at the base of the brain. The falx cerebri may be wanting, or from incomplete development it may seem perforated with holes ; or the tentorium cerebelli may be absent. There are no symptoms which allow a positive diagnosis of any of these lesions during life. In the second variety, there is general incom- pleteness of the brain, or imperfection of several portions of it at one and tho same time. Whilst the cranial vault is thrown back, and the lower jaw is short, the base of the skull is large, the cerebral convolutions almost absent, and the cerebellum large. The head is almost always small, and it may presont various irregular forms. This coincides with certain internal lesions, partial or general atrophy with conse- quent serous effusion under the membranes, in- flammatory conditions, or thickening of the cranial bones and of the meninges. The incom- pleteness of tho brain varies exceedingly, from a condition in which the whole brain is atrophied, to spots of deficiency, such as the absence of a single convolution, of the septum, or of the pineal gland. The symptoms will necessarily vary much according to the amount of cerebral incomplete- ness. Where this is general, affecting in some degree all the convolutions, the intellectual powers, as in the microcephalous Aztecs, will be very slightly developed, and their language of the very simplest form. With the brain still more imperfect, there is generally complete idiocy or a condition closely allied to it. The special senses are dulled, particularly sight and hearing. Speech is in abeyance, or is limited to monosyllables. There are various motor pheno- mena, suah as muscular debility, hemiplegia, paraplegia, contraction, convulsion, loss cf power over sphincters, dysphagia, vomiting, or feeble- ness of respiration. Tho third variety includes incompleteness of the central parts of the brain. The corpus cal- losum, the septum, the fornix, the corpora striata, and the cornua ammonis may be imperfectly developed. The cerebral hemispheres may thus be in some sort fused together, and the shape of the ventricles altered. The symptoms differ from those of the preceding variety, in that the special senses are seldom involved; and that, although complete idiocy may accompany these lesions, it is more usual for the brain to be found capable of some slight intelligence, though un- equal to the conception of abstract ideas. In the fourth variety, the lateral portions of the brain are incomplete. This lesion generally occupies one side of the brain, leaving the other hemisphere intact. Several points in the hemi- sphere may be affected, or the whole of a singlo lobe. Most usually there is a depression occupy- ing the seat of one or more convolutions. Such brain, malformations of. a lesion occasionally attacks the 'whole hemi- sphere, giving it the appearance of a large pouch filled with fluid. Sometimes also the neighbour- ing ventricle communicates with it ; or there may be much ventricular effusion, with imperfect de- velopment of the corpus striatum, the optic thalamus, the cornua ammonis, the mamillary tubercle, the crus cerebri, and the optic and olfactory nerves of one side. In a consider- able proportion of patients so affected, the lesion is accompanied by idiocy, and possibly the inability to speak is connected with this mental condition. Some few patients, how- ever, possessed with some intelligence, have yet been unable to speak ; this has been the case even when the lesion has existed on the right side. Deafness is rare ; feebleness cf sight, various forms of strabismus, and nystagmus common. Very frequently there is hemiplegia of the side opposite to the lesion, and certain other affections of the limbs, — emaciation, incom- plete development, contraction, various deformi- ties of the hands, &e. Sensation even in the paralysed limbs is normal ; convulsions are not uncommon. In the fifth variety, there is incompleteness of the anterior portion of the brain. Here both the anterior lobes are affected together. This con- dition may bo associated with some deficiency of the corpus callosum, fornix, and corpora striata. Idiocy is not uncommon ; mutism is the rule, but in some patients not idiotic a few words have been possible. Other phenomena — amaurosis, strabismus, and various motor abnormalities — have occurred so irregularly in these patients that it is probable they were symptoms not so much of this lesion as of certain further compli- rrations- Incompleteness of the cerebellum forms the sixth variety. This is sometimes associated with a similar condition of one side of the brain. Usually one lateral lobe only is affected. Gene- ral hydrocephalus is an occasional complication, and a collection of fluid under the tentorium cerebelli is very common. The symptoms are very negative. In general terms it maybe said that there is no loss of muscular co-ordination, and no loss of sexual power. In the seventh variety, there is incompleteness of the mesocephale and medulla oblongata. This is not carried very far. Certain modifications in form and volume are alone compatible with the preservation of life. It is not a common lesion, and has generally been associated with idiocy. 9. Congenital hydrocephalus. One variety of this congenital effusion of fluid is rare, viz., when the fluid is outside the dura mater, between this membrane and the pericranium, and the cranial bones are found floating in the midst of the fluid. The second variety is that in which the fluid lies outside the brain. The writer believes that serous effusion in this position is not the cause of the atrophy, flattening, or induration of the subjacent cerebral organs, but the effect ; that where fluid is found in this situation it is only the consequence of some one of the lesions al- ready mentioned, notably atrophy of brain from whatever cause, and of atelencephalia. This view is, however, opposed to that of some authors. BRAIN, (EDEMA OF. loi The third variety is congenital hydrocephalus of the ventricles. In some such cases the in- crease in the size of the head occurs before birth ; in others, not until after. The head increases rapidly in size in the first four weeks after birth. The sutures are widely separated, the cranial bones very thin, the integuments of the head injected, and the hair deficient. The muscle* are badly developed, locomotion is imperfect, the intellect is generally obtuse, but the special senses are not particularly affected, unless it be that sight is deficient. 10. Syncncephalia is merely a matter of patho- logical interest. The head of the foetus is some- times found adherent to the membranes or to the placenta, as a consequence of intra-uterine inflam- mation. At the point of adhesion the place of the cranial bone is taken by a thin vascular mem- brane. This condition is sometimes accompanied by, and indeed perhaps causes, encephalocele. 11. Exencephalia. — Here a large portion of the brain is situated outside the cavity of the cra- nium. Practically it includes all the other mal- formations of the brain that are yet to be spoken of. Thus, if only a limited portion of the brain finds its way outside the skull by an abnormal opening, the displacement is known by the name of encephalocele, or hernia, cerebri ; if this hernia coincide with a hydrocephalic condition of the ventricles, it is called hydrencephalocele ; and if the hernia is composed not of the 'brain, but of the membranes, distended with fluid it may be, the lesion is called meningocele or hyclroTneningo- cele. Exencephalia proper may be subdivided into frontal, sincipital, and occipital, according to the direction taken by the extruded brain. In encephalocele only a portion of the brain more or less limited is found outside the skull. The exit takes place most frequently at the occi- pital, and next in the frontal region ; but the temporal and parietal regions are occasionally the seat of this lesion. The symptoms may be very negative. Encephalocele unless pressed upon externally is not often attended by convul- sion or paralysis, by intellectual feebleness, or by difficulty of speech. This latter symptom is some- times found.when the hernia includes the cere- bellum. Neither is this lesion incompatible with the prolongation of life. The chief diagnostic difficulty is the possibility of the tumour being eephalhsematoma. but this is frequently situated over the parietal bones, an unusual position for encephalocele : and external pressure of the former tumour causes none of the cerebral phe- nomena — stupor, dilatation of pupils, paralysis, convulsion, so constantly seen from compression of an encephalocele. E. Long Fox. BRAIN, Malignant Diseases of. See Brain, Tumours and New Growths of. BRAIN, Membranes or Meninges of. — See Meninges, Diseases of. BRAIN, Morbid Growths of. See Brain, Tumours and New Growths of. BRAIN, (Edema of. — Definition. — In- filtration of the brain and pia mater with serum, .Etiology and Pathology. — In chronic ma- ladies attended with general oedema, especially Bright’s disease, fluid is effused around the 152 BRAIN, (EDEMA OF. brain, into the meshes of the pia mater and between the convolutions. Occasionally the cerebral substance is infiltrated, but this is uncommon. The perivascular canals afford a ready means of escape for effused serum, and in Bright's disease, at least, the substance of the brain often contrasts, by its firmness, 'with the condition of other organs. In senile atrophy of the brain the space between the shrunken con- volutions is occupied by serum, and the ven- tricles contain an excess of fluid. The brain- tissue may appear to contain more fluid than usual in consequence of the distension by serum of the enlarged perivascular canals. In hy- persemia, especially passive, such as occurs in heart-disease, serum is commonly effused from the engorged vessels. Such effusion is also com- mon in insanity, especially in acute dementia. The scrum may infiltrate the pia mater, distend the perivascular canals, and even infiltrate the brain -tissue. The effusion of fluid in these cases is usually slight. Occasionally it is more considerable, and the cerebral substance may be enlarged, the convolutions being flattened, and the tissue much lessened in consistence. The same soften- ing is seen in the neighbourhood of effusions of fluid into the ventricles ; the brain-tissue for a depth of some lines from the ependyma being softened to a pulpy consistence. The post- mortem imbibition always increases the appa- rent amount of the oedema. Symptoms. — Little is known of the symptoms of (Edema of the brain. The oedema is usually secondary to some other condition, the symptoms of which mask those of the oedema. General oedema seems attended by slow diminution of men- tal power and motor force. The effusion of serum in cases of congestion, and consequent pressure on the nerve-olemonts, has been considered as the cause of the symptoms of depression common in that condition. Cases occasionally occur in which effusion of serum into the ventricles and the pia mater is the only post-mortem condition to be found after an apoplectiform seizure, and such cases are often spoken of as instances of scrolls apoplexy. In so far as the effusion of serum is related to the apoplectic attack, it is probably merely as the consequence of a cerebral eongest.on which has left no recognis- able post-mortem hyperaemia. Treatment. — The treatment of cerebral cedema is usually secondary to the condition, commonly conspicuous enough, which is its cause, — Bright’s disease, passive cerebral con- gestion, &c. If oedema be suspected where no causal indication for treatment exists, purga- tives and diuretics, with iron if there be debility, are the remedies most likely to be of service. The effusion of fluid into the ventricles is described under Hydrocephalus. W. R. Gowers. BRAIN, Sclerosis of. See Spinal Cord, Diseases of. BRAIN, Softening of. — Definition. — A pathological state of brain-tissue, depending commonly on vascular obstruction ; attended by diminished consistence, usually local ; and indi- cated, during life, by mental, motor, and sensory BRAIN, SOFTENING OF. symptoms, which vary according to the seat of the lesion. .(Etiology. — Local softening of the brain, occurring during life, is due to one of two causes, inflammation or vascular obstruction. Most cases were formerly thought to be due to inflam- mation ; but it is now known that very few are. The vascular obstruction, which is the usual cause of softening, may be arterial or, rarely, capillary ; it may be due to a coagulum formed in situ (thrombosis), or to a plug of fibrin con- veyed into the vessels by the blood (embolism). The predisposing and exciting causes of these conditions will therefore be those of softening of the brain ( see Brain, Vessels of, Diseases of). Tlie chief concomitant conditions are — in thrombosis, vascular degeneration ; in em- bolism, valvular disease of the heart : and as predisposing conditions we usually find, in cases of thrombosis, advanced age, Bright's disease, chronic alcoholism, or syphilis ; in cases of embolism, acute rheumatism, chorea, or scarlet fever. Senile vascular degeneration is the most common cause of all of softening of the brain, and hence the disease is met with most fre- quently in the old, especially in its recurrent and chronic form. Embolism, due to valvular disease of the heart, and thrombosis due to syphilitic disease, are the most frequent causes of acute local softening in the young and middle-aged. Anatomical Characters. — The characteristic feature of cerebral softening is diminished con- sistence. This may, however, arise from ante- mortem or post-mortem changes. In each case the diminished consistence depends on the breaking-up of the myelin, of which the nerve- fibres are composed, into globules and granules, and the separation of these by an increased quantity of fluid. Thus the continuous struc- tures of which the brain consists are broken up into disconnected fragments, and the con- sistence of the tissue is accordingly dimin- ished. In post-mortem softening thero is nothing more. The globules of myelin are often large, and the separating fluid abundant. The softened tissue has the tint of the normal cerebral substance. The process is the result of the imbibition of fluid from some collection of serum, in the ventricles or elsewhere, and occurs in the greater degree in the immediate vicinity of this. In ante-mortem softening there are, in addition, certain changes in the tissue-elements. The process of segmentation of myelin results in the formation of finer granules. These are in part aggregated into 1 granule corpuscles,’ round or oval masses of globules and granules, sometimes contained within a distinct cell-wall. Some of these bodies may arise by simple aggregation, many certainly by the degeneration and distension of connective-tissue cells, and some by the de- generation of nerve cells. The wills of vessels in the softened area also present fatty degene- ration. The specific gravity of the tissue is diminished (Bastian). No further change may exist, and the area affected may present simply a diminution of consistence, its colour remaining unchanged. It is then called white or grey softening. Very frequently, however, in the part thus diseased, distension of capillaries with BRAIN, SOFTENING OF. 153 Llood occurs, most considerable in the periphery, and blood is actually effused, chiefly by rupture of capillaries, in part perhaps by migration of corpuscles. In proportion to the amount of blood extravasated, the colour is changed, and thus red softening is produced. After a time, the effused blood degenerates, its tint becomes altered to yellow or orange, and yellow softening is produced. Ultimately, it is said, the colour, if at first moderate, may be removed, and white softening result. Red softening is found chiefly in the grey sub- stance, where the vessels are numerous, especially in tho cortex and central ganglia. The tint varies ; the red colour is usually punctiform, or mingled with yellow and white. If the extra- vasations are large and numerous, ‘ capillary apoplexy ’ results. The diminution of consistence is usually moderate. According to the amount of effusion of serum and blood there is swelling, and the diseased area may project above the cut surface. Inflammatory changes result from the vascular distension, and in proportion to these, increase in the nuclei of the neuroglia is found. From this cause and from the migration of white corpuscles, pus-like cells appear. The vessels are dilated, and may present a moniliform appear- ance. Their perivascular sheaths are often dis- tended with blood. Commencing degeneration of the effused blood may cause a brown tint. Yellow softening results from red softening, by degenerative changes in the blood effused. It has a similar seat, being frequently met with in the convolutions, where it constitutes plaques jaunes of the French. Its consistence is usually slight, its aspect granular. The colour depends on the presence of minute pigment granules, diffused colouring matter, and haema- toidin crystals. White softening has the tint of the normal cerebral substance. In consistence it varies ; it may be only a little below that of the cerebral substance, or it may be diffluent. Its aspect is uniform, or white flakes are scattered through it. The limits are usually gradual. Under the microscope it presents the detritus of nerve-ele- ments, a few nuclei from the connective tissue, granule-corpuscles, and, ultimately, corpora amy- lacea. White softening is chiefly found in the white substance of the hemispheres. It occa- sionally has a gangrenous odour, and then may be found in the white or in the grey substance, probably resulting from the obstruction of ca- pillaries by septic material. Ultimate changes . — White and yellow soften- ing may remain for years unchanged. Sometimes the changes in the elements of the neuroglia and the extravasated white corpuscles result in the formation of a considerable quantity of connec- tive tissue, consisting of fine fibre-cells and fibres, most abundant in the margins of the softened area, which become firm and dense, while trabe- cul® of connective tissue cross the cavity. After a time the fluid may be absorbed, the fat removed, and a sort of cicatrix result. In other cases the walls alone are thus altered, the solid particles are removed from the softened tissue, and a cyst is formed. The outer portion of the cyst or cica- trix may be limited by a zone of dilated blood- vessels. Seats of softening . — There is no part of the brain in which softening has not been found, but its most frequent seats are the cortex, the corpus striatum, and the optic thalamus. In the cere- bellum, pons Varolii, and medulla it is also fre- quently found. Its occurrence, position, and characters depend on the distribution of the vessels. The small arteries of the corpus stria- tum and optic thalamus are ‘ terminal arteries,’ having only capillary communication with other vessels. The arteries to the surface of the brain are usually for the most part terminal, but some- times possess arteriole-anastomoses with other branches. Hence obstruction in the central arteries leads invariably to softening. Obstruc- tion in the superficial arteries also usually causes softening, which involves the grey substance of the convolutions and some of the subjacent white centre to which the vessels penetrate ; but occasionally the anastomoses of the superficial vessels are so free that softening does not result. An obstruction of a main trunk (as the middle cerebral) may lead to softening of the central region (corpus striatum), while the convolutions escape ; but usually both suffer. Symptoms. — The premonitory symptoms of softening depend upon its cause. In embolism other symptoms than those of the cardiac trou- ble are usually absent. Occasionally a slight attack of loss of cerebral function, due to a slight embolism, may precede a graver attack. In softening due to arterial disease, premonitory symptoms of local cerebral ansemia are fre- quently present. There is defective nutrition of many parts of the brain, revealing itself by symptoms of wide range — mental deterioration, numbness, pains in the limbs, pain in the head, or slight local weakness. These symptoms are of especial significance when associated with evi- dence of arterial degeneration elsewhere; with the conditions — as chronic Bright's disease, alco- holism, and senility — in which atheroma of the cerebral arteries is common ; or with constitu- tional syphilis. The symptoms of actual softening are those of loss of function in the damaged portion of the brain. The onset of the symptoms may bo sudden, as in embolism, and sometimes in throm- brosis ; or it may be gradual, as occasionally in thrombosis. In the former case the symptoms of initial shock are added to those proper to the locality. The latter are fully considered in the articles on Localisation. Hemiplegic symptoms and mental alteration are the most common. Hemiplegia especially occurs in embolism, on ac- count of the frequency with which the middle cerebral artery is obstructed, and of the im- portant motor regions (corpus striatum and motor parts of the convolutions) to which that artery is distributed. From the distribution of the artery to the lower frontal convolutions and adjacent region, aphasia is frequently present when the obstruction is on the left side. When the symptoms come on suddenly, they often follow some exertion, or occur during ex- haustion. If the area damaged be extensive, there is loss of consciousness, and there may be all the symptoms of an apoplectic seizure. The loss of consciousness is rarely profound, and the symptoms of apoplexy soon pass off. In the most BRAIN, SOFTENING OF. 154 severe cases, however, they may deepen to fatal coma. Symptoms of irritation commonly succeed those of apoplexy as the collateral hyperaemia sets in, or they may he marked at the onset. Convulsions, often unilateral, may occur and he repeated for days. The patient may pass from the apoplectic condition into one of delirium. In the old, delirium may he the chief symptom of the onset. According as these symptoms are chiefly marked at the onset three varieties have been described, the apoplectic, convulsive, or de- lirious forms. Recovery from the special symptoms of the attack is often incomplete ; permanent weakness may remain, as hemiplegia, and mental power is weakened, the patient passing into the chronic state about to be described. The persistent hemiplegia is often accompanied by rigidity, or by motile spasm, such as, in its most marked form, has been described as athetosis. Whether recovery is complete or incomplete, return or relapse is common, and is almost invariable where the arterial disease, to which the soften- ing is due, is widely spread. Chronic softening is a term applied to a group of symptoms, of wide range, indicative of failure of brain-power. These may supervene on more acute symptoms of softening, or may be gradual in their onset. There is mental dulness, defec- tive perception, drowsiness, loss of memory (especially for recent events), often slight wan- dering ; emotional manifestations are easily excited. The patient complains of headache, pains in the limbs, and feelings of ‘numbness,’ which may or may not be associated with actual loss of sensibility. Physical power is defective, usually generally, sometimes locally. The more delicate motor actions are imperfectly adjusted : articulation becomes confluent, and the hand- writing indistinct or illegible. These symptoms may progress into actual imbecility, or maybe cut short by some more profound cerebral seizure, or by some intercurrent pulmonary affection, ren- dered grave by the deficient muscular respiratory power. They depend upon degeneration of brain, commonly due to arterial disease. Spots of softening, often widely spread, may be asso- ciated with this condition, and may be, indeed, the cause of the symptoms. But the state may come on without auy local softening; and atrophy of brain, with or even without degene- rated vessels, may be the only anatomical con- dition. It often follows any grave local lesion- softening, haemorrhage, or tumour — and then depends on a direct prejudicial influence on the cerebral nutrition, or on a secondary effect through the perturbed vascular system. Diagnosis. — The acute form of softening has to be distinguished from acute congestive apo- plexy and from cerebral haemorrhage. It is distinguished from the former by the persistence of the symptoms indicative of local mischief, and by the absence of evidence of cephalic hyperaemia. From haemorrhage the diagnosis is often difficult. In softening from thrombosis, the initial apoplec- tic symptoms may be absent, or, if present, are slight and brief. They are more often preceded by symptoms of local cerebral anaemia, due to the vascular disease, than is the onset of cerebral haemorrhage. Improvement occurs earlier than in cerebral haemorrhage. The temperature rises soon after the attack, but falls in a day or two ; in haemorrhage the rise occurs Liter (Bourneville). There is more marked mental change than in haemorrhage, shown at first in excitement, sub- sequently by depression and deterioration of power. In the cases in which the onset is sudden and the apoplexy profound, a diagnosis from haemorrhage is often impossible. In soften- ing from embolism the patient is usually below middle age, heart-disease is present, and evi- dence of arterial disease is absent. The onset of the attack is commonly sudden, but the loss of consciousness is less profound than in haemor- rhage. In capillary embolism, if extensive, a distinction from haemorrhage often cannot be made: the loss of consciousness is profound and lasting. Softening may be distinguished from local cerebral anaemia, which often precedes it, by the definiteness and persistence of local symptoms ; but a small area of softening may produce symp- toms identical with those resulting from a large area of anaemia. Softening is distinguished from tumour and chronic meningitis by the slight pain and the absence of optic neuritis. From simple atrophy of the brain, chronic soften- ing differs by its less uniform course, and by the sudden occurrence and persistence of symptoms indicative of local lesions. Prognosis. — The immediate and ultimate prognosis in an attack of softening of the brain depends on its severity in degree and extent, as indicating the extent of the lesion, and on the region of the brain damaged. Both the im- mediate and the ultimate prognosis is much graver in damage to the medulla and pons Varolii than when the corpus striatum or cere- bral hemispheres are affected. Youth and general health favour the rapidity and the degree of recovery. Where actual softening has occurred, the damaged tissue probably never regains its functional power. The congested periphery recovers in proportion to the inherent vitality of the tissues, and to the freedom of the vessels from disease. The chances of a recur- rence of softening in another situation depend on the extent to which its causal condition is widely spread or can be removed. In vascular degeneration recurrence is almost certain. In embolic softening there is usually organic valvular disease in the heart, and embolism re- curs in a considerable proportion of the cases, though less frequently than senile thrombosis. The prognosis in syphilitic disease of the vessels depends upon the recognition and treatment of the syphilitic influence. Treatment. — During an acute attack the patient must be kept at perfect rest, with the head moderately raised, in a uniform tempera- ture. During the initial stage of shock, warmth, by hot-water bottles, &c., should be applied to the surface, to equalize the circulation. Tho bowels, if confined, should be made to act gently : but, unless the evidences of encephalic congestion are early and conspicuous, purgation should be avoided. Should stimulants be administered? It has been proposed by stimulation of the heart to aid the establishment of the collateral circula- tion. But it must be remembered that the imper- BRAIN, SOFTENING OF. feet collateral flow arises from the minute sizo of the arterial anastomoses. The obstruction of one vessel always increases the adjacent pressure to such an extent as to distend the vessels to their utmost strength, and any further increase would, by rupturing them, impede rather than further the objeet in view. If, therefore, the heart is acting feebly, stimulate it by small quantities of alcohol to the normal force, but not beyond. If the diagnosis from haemorrhage be in any degree doubtful, great caution should be observed in stimulation. After the stage of depression has passed, the irritation duo to collateral hypersemia, and indicated by ele- vation of temperature, may be relieved by purgatives, dry-cupping, and even, in some cases, by the application of leeches, though the latter are only necessary when the evidence of general vascular irritation is great. When con- vulsion is an early and recurrent symptom, mustard plasters to the neck and extremities, and bromide of potassium in large doses, are useful. After the attack has passed, recovery must be aided by maintaining the general health in the best possible condition. The secretions should be kept free, the digestive organs in good order, the habits strictly regulated, and nervine tonics, cod-liver oil, hypophosphite of soda, strychnine, quinine, and iron, may be given with advantage. The symptoms of chronic softening, whether occurring after an acute attack or coming on gradually, should be treated in a similar manner. Great care should be taken that the peripheral obstruction to the circulation, indicated by aug- mented arterial tension, (incompressibility of pulse), is kept at its minimum by the avoidance of excess in diet, and by prompt purgation when any increase in tension is observed. W. R. Gowees. BRAIN, Syphilitic Disease of. iSccBhain, Tumours and New Growths of. BRAIN, Tubercle of. See Brain, Tu- mours and New Growths of. BRAIN, Tumours and New Growths of. — The intimate connection of the brain with its membranes makes it impossible, except in the most general term's, to draw any marked distinc- tion between tumours of the cerebral substance, and tumours arising from its envelopes. A growth pressing inwards from a membrane must impinge upon brain-tissue : a growth originating in brain-tissue must in many situations involve the membranes. Anatomical Chakactehs. — The tissues from which tumours have their origin seem to pre- sent the best ground for a scientific classification of these lesions : and it is not devoid of interest to mark that the absolute nerve-elements of the brain are never primarily the source of a morbid growth. Cerebral tumours, then, may be roughly sepa- rated into three series : — 1. Those whose centre of origin is some one or other of the membranes, external to the brain, or dipping into the ventricles. 2, Those which spring from the blood-vessels. BRAIN, TUMOURS OF. 155 3. Those which own the neuroglia as tlieii starting-point. Taking this subdivision, which is Rindfleisch’s, the tumours which are placed in each series differ somewhat from his arrangement. In the first series five kinds of tumour are found, arising from the membranes or from the froe surface of the ventricles. These are Pacchio- nian granulations ; spindle-celled sarcoma ; myx- oma of the membranes ; psammoma ; and lipoma. The second series will include, first, aneurisms, depending upon disease of one or more of the arterial coats ; and, secondly, such tumours as have their origin in the sheaths of the vessels, comprising carcinoma cerebri simplex ; fungus of the dura mater ; cholesteoma ; epithelioma myxomatodes psammosum ; papilloma of the pia- mater and vessels ; papilloma myxomatodes ; and tubercle. In the third series may be counted glioma ; myxoma of the nerve-substance; syphilitic gumma ; and fibroma. Included under none of these headings, echi nococci and cysticerci cellulosae must be men- tioned, as they affect the braiD. Each of the growths enumerated will now be briefly described. 1. Pacchionian granulations. These are granu- lations of the arachnoid, sometimes met with in childhood, very constantly from middle age onwards, and scarcely recognised as morbid lesions. Their aetiology is unknown. They do not give rise to any symptoms. They are chiefly situated along the superior longitudinal sinus, which in rare cases is perforated by them. They form groups of papillae, consisting of striped connective tissue, poor in cells, and proceeding directly from a thin but a continually renewed layer of sub-epithelial germinal tissue. 2. Sarcoma. This sometimes has its origin in the nervous tissue itself, but more frequently arises from the dura mater, especially at the base of the skull. From their situation sarcomata are especially apt to interfere with one or more of the cerebral nerves. They may attain the size of a pigeon’s, or even of a hen’s egg. When sarcoma attacks the dura mater it ori- ginates from its internal side. The most usual situation is the membrane about the sella tur- cica and the pars petrosa. It forms a depres- sion in the brain, while the bone becomes atro- phied behind it. The growth is composed of fusiform cells, with tolerably numerous, and sometimes dilated vessels. Sarcomatous growths are not freely developed above the surface, but rather in the depths of the tissue; they distend the cerebral convolutions, form deep depressions’ on the surface, and even penetrate far into the brain. They occur under two forms — hard sar- coma with compact fibrous fundamental tissue and small cells, often called fibrous tumour ; and soft sarcoma, with a loose scanty intercellular substance, and numerous cells of comparatively large size. The cells are mostly fusiform, but sometimes round and multinuclear, and the two latter may be surrounded by the former. Sar- coma in this situation is generally single. It may attain the size of a nut or even of an applo ; and is frequently haemorrhagic. In the cerebral tissue itself the hard sarcoma 1*6 BRAIN. TUMOURS AND NEW GROWTHS Of. attains a great degree of density: it is sometimes fibrous, at other times cartilaginous, of a dense homogeneous structure, wlntish or bluish-white, with a yellow tinge here and there, and with very few vessels. It is distinguished from the brain that surrounds it by a very vascular zone. It can be easily separated from the parenchyma, and may thus be recognised after death from simple sclerosis and hard glioma of the brain. The softer form— fibro-cellular sarcoma — is generally either a myxo- or a glio-sarcoma : but pure fuso-cellular sarcoma is met with. The tumour is a clear grey, almost like the grey matter of the corpus striatum. It is often vascular, with a reddish tinge. These sarcomata are often almost spherical, and easily detached from the surrounding brain-substance. Others, however, seem to be continuous with the neigh- bouring tissue, and to be little more than simple hypertrophies of the cerebral tissue. Especially is this the caso in tumours of the corpus striatum and optic thalamus. The cells of cerebral sarcoma are frequently the seat of fatty degeneration, and the whole tumour may be haemorrhagic. Its most frequent situations in the brain are the gan- glia at the base. 3. Myxoma . — Myxoma of the membranes is rare, and generally has its origin from the con- vexity of the brain, being connected with the inner surface of the dura mater. It is a small growth, soft, fragile, having a gelatinous as- pect. Myxomata are frequently met with in the cere- bral hemispheres, and then take their origin from the neuroglia. Such growths are probably malignant, the proof of their malignancy being that thoy are often multiple locally ; that they frequently recur when removed from a peripheral nerve ; and that they not seldom affect internal crgans. Myxoma probably includes all that has beon called colloid cancer. When this lesion affects the cerebral hemispheres it may be of large size. The mticus is a constituent part of the tissue ; it is not a product of secretion, as in mucous cysts. 4. Psammoma . — Psammomata have been met with in the brain, spinal membranes, spinal cord, and nerves: they are not uncommon in the choroid plexus, but are most usually found in the pineal gland. There are two kinds of these growths. In the first, the sand occupies the interior of the meshes of the connective tissue in very varied forms, as compact cylinders, as pear-shaped masses, as spines, or as globes, surrounded by connective tissue, and connected by it with the other parts of the tumour. In the second form, the sand lies without cohesion m the parts and between them, so that the different grains of sand may be easily isolated. In this latter form, the psammoma is composed most generally of round elliptical corpuscles, and sometimes also of large complex conglomera- tions. These little tumours have usually an internal concentric arrangement. 5. Lipoma . — This is a rare form of tumour. It may be connected with the inner surface of the dura mater, or with the ependyma of the ventricles. The fatty matter is contained in cells, and the cells are surroundedby an organised membrane. Lipoma is usually single, seldom mul- tiple; of irregular shape ; and varies in size from a small nut to a hen’s egg. Small pieces of earbonato of lime have been found in these tumours. 6. Aneurisms . — The larger cerebral aneurisms have been observed from early times. More recently Liouville has called special attention to the subject of miliary aneurisms, and has shown that they are common ; that they are multiple ; that they frequently give way in the brain or in the pia mater ; and that they often co-exist with aneurisms of the larger vessels in other parts of the body. Aneurism of the middle meningeal, of the internal carotid within the cavernous sinus and at its exit from it, of the anterior cerebral, of the anterior communicating, of the arteries of the corpus callosum, of the middle cerebral, of the posterior communicating, of the vertebral, of the basilar, of the posterior cerebral, and of the arteries supplying the cerebellum, are all met with not unfrequently. The middle cerebral and the basilar, however, are the vessels most usually affected with this lesion. The minute miliary aneurisms have 1 een observed in the pia mater, at the surface of the convolutions or in their substance, in the optic thalami, tho pons, the corpora striata, cerebel- lum, crura cerebri, and medulla oblongata ; more rarely in the centrum ovale. These miliary aneurisms may be visible to the naked eye. The smallest are seen under the microscope as ampullae of the vessels, containing coagulated blood or granules of hematoidin. The arterial walls have generally undergone some form of degeneration. The vessel, dilated at some parts, is constricted at others. The lesion may be a consequence of atheroma of the vessel, but far more commonly it is the result of arterio-sclerosis of the inner coat of the vessels, either at tho seat or in the immediate neighbourhood of the aneurism. See Bralv, Vessels of, Diseases of. 7. Carcinoma cerebri simplex. Cancer, ex- cluding from this term sarcoma and glioma, may originate in the cranial bones, the dura mater, the pia mater, the cerebrum, the cerebellum, the pons, and the medulla oblongata. The medulla oblongata, the fornix, and the corpora quadrigemina, are the regions least often affected, whereas the cerebral hemispheres are the most favourite localities. All forms of cancer are met ■with, in all cases having their origin in the coats of the vessels. Epithelial cancer has been gen- erally believed to have its starting point in the peripheral layer of the arachnoid, tho tissue that lines the under surface of the dura mater. En- cephaloid cancer is, however, the most common form met with in the brain. 8. Fungus of the dura mater can scarcelv be separated from the preceding form. It arises from the outer surface of the dura mater, pene- trates with the vessel from which it springs into the compact tissue, destroys the vitreous table, and spreads out in the diploe : in its progress it may penetrate the external table and lift up tho integuments of the cranium. The internal table invariably suffers more than the external. Sometimes there is coincident passage of the tumour inwards, and the subjacent membranes become glued to tho dura mater and to the cerebral substance. There may result simply BRAIN, TUMOURS AND NEW GROWTHS OF. the depression of surface consequent upon pres- sure from above, but more commonly cell-growth similar to that of the original tumour takes place, first from the vessels of the pia mater, and afterwards from the vessels of the cerebral convolutions. 9. Closely allied to the epithelial cancer that has its origin in the dura mater is the cholesteoma, which is generally situated at the base of the brain. Rindfleisch considers it a squamous epithelioma, whose cellular cylinders are wholly converted into a mass of pearly nodules with a silky lustre. It is covered by the arachnoid, and springs either from the vessels of the pia mater, or more rarely from the perivascular sheath of the vessels in the substance of the brain. 10. Last of the cancers is a tumour that has been found in the third ventricle — epithelioma myxomatodes psammosum, consisting of globes and cylinders of epithelial cells, embedded in a very bulky stroma of mucous tissue. 11. Springing also from the vessels, two forms of papilloma are met with — papilloma of the pia mater and vessels ; and papilloma myxomatodes. The former is composed of a number of branch- ing papillae, each of which contains a blood- vessel with a small amount of connective tissue, and a double coat of epithelium, of which the outer layer is columnar. In the latter, which is probably a mere variety of the former, the struc- ture of the tumour is the same, but the columnar cells secrete a vast amount of viscid mucus. 12. Tubercle springs from the middle tunic of the small arteries of the pia mater, or of the nerve-substance. It rarely attacks the mem- branes in the form of tumour, rarely also the white matter of the brain, but prefers as its principal seat the grey matter of the convolutions and of the deeper parts. Tubercle of the dura mater is, however, sometimes met with, and it may induce obliteration of sinuses. The cere- bellum is a frequent seat of tubercle, which exists here in the form of superficial granula- tions. The pons also is frequently affected with tubercle, both in the form of small tu- mours of its substance, and as polypous tuber- cles of the fourth ventricle. Tubercle is sepa- rated from the surrounding cerebral substance by a very delicate reddish envelope. Tubercular tumours of the cerebral substance are often multiple, and not unfrequently large ; they are of very slow growth ; persist long in the caseous state; and may be found cretified. Sometimes there is cerebral softening around them. Virchow states that the increase of tu- bercles takes place by apposition or juxta- position, and that the apposition takes place not by layers primarily caseous, but by zones of new grey proliferation, usually in the form of miliary tubercle. A very delicate layer of connective tissue of new formation, a species of encysting false membrane, represents the mother-tissue for the subsequent generation of young tubercles. 13. Glioma , called by Billroth granulated sar- coma, or round-celled sarcoma, is practically a local hyperplasie development of the neuroglia. It may appear in three forms, either as a soft glioma, rich in cells — the most common kind ; as hard glioma, fibrous, and, if the vessels are much 157 developed, telangiectasic ; or, thirdly, as a rtvjxo- glioma, a complex tumour, in which part of the tumour takes the appearance of mucous tissue. The nature of the tumour is partly determined by the nature of the tissue from which it springs ; thus glioma of the brain is generally, but not always, soft ; glioma of the ependyma hard. The soft gliomata are closely allied to myxomata. The intercellular substance is found in moderate quantity. In the more mucous gliomata the net- work is regular and large, and the tissue has little cohesion. If the meshes are larger still, and the mucous element abundant, this variety passes into a myxoma. If there be a consider- able increase of cells, whilst the trabeculae become narrower, we get a medullary glioma, which may be transformed into a medullary sarcoma if the cells continue to grow and mul- tiply. These transitions are not uncommon even in the same tumour, especially in the posterior lobes of the brain. If the vessels are developed in great abundance we get ha;morrhages and a kind of fungus hsematodes. Hard glioma is closely allied to fibroma, with which indeed it may be combined to form a fibro-glioma. In hard glioma the fibres are not arranged in a network, but in parallel lines, like felt. The nervous elements, naturally contained in the neuroglia, are absent in these tumours. The walls of the vessels are frequently thickened. The glioma of the ependyma is of little im- portance ; it is seen as fine granulations on the surface of the lateral ventricles in chronic hydro- cephalus ; on the floor of the fourth ventricle it may grow to the size of a cherry. In the cerebral substance, gliomata may attain the size of a fist, or even of a child’s head ; and they are often mistaken for cancers or sarcomata of the brain. Hard glioma may be distinguished from sclerosis, in that sclerosis encloses the normal nerve ele- ments. In glioma, too, there is great prolifera- tion of neuroglia cells. There is no distinct limit between glioma and the surrounding brain-sub- stance, but the tumour on section shows greater vascularity, greater consistence, and a more trans- parent constitution, as well as often a bluish- whito appearance compared with the white brain-mat- ter. The demarcation in grey matter is imper- ceptible to the naked eye, especially if the glioma be soft. Soft glioma is generally single ; hard is often multiple. The membranes may adhere, but form no part of the tumour. Virchow thinks that glioma is not malignant ; that hard glioma has an inflammatory origin , and that the soft variety is set up by local causes, such as injury. Gintrac, on the other hand, unites gliomata and sarcomata under the head of cancers. Soft glioma is most frequently situated in the posterior lobes, less often in the upper and lateral parts of the cerebral hemispheres. It maybe con- genital. It gives rise to complications, namely, first, great congestion, causing cerebral compres- sion, irritation, pain, excitement, or apoplexy ; and, secondly, hydrocephalus of the ventricles, which in protracted cases is seldom absent. The latter occurs most rapidly in glioma of the optic thalami, or of the posterior lobe, compressing the choroid veins, the venae Galeni, or the transverse sinus. BRAIN, TUMOURS AND NEW GROWTHS OF. 158 14. Myxoma of the nerve-substance . — This is not common in the brain. It owns the same origin as glioma, having the neuroglia as its starting point. 15. Syphilitic gumma . — Gummy tumours of the brain are generaUy found at the circum- ference, and especially at the base of the brain. Their origin is either from the membranes, from tlie vessels, or from the neuroglia of tho cerebral substance. They have infective properties, or at any rate they are multiple, and may be met with at the same time affect- ing the dura mater, the pia mater, the brain, nerves, and cranial bones. They are often accompanied by inflammatory phenomena, a point which distinguishes them from large tubercles. Gumma is not tho usual form in which syphilis attacks the dura mater on its external surface. It may, however, affect the arachnoid surface of the dura mater. In this situation the gummata may vary in size from a hemp-seed to a nut. They may be formd just above the convexity of the hemispheres, or at the anterior part of the base of the brain, especially about the sella turcica, or on the ten- torium cerebelli. They have been met with in the falx cerebri. The inflammatory condition around these tumours often unites them to the pia mater, and the subjacent portion of brain is frequently softened, either by the inflammation, or by arterial obliteration. When the pia mater is united to the dura mater, gummata very small in size may form in the former membrane. The subjacent brain may be softened or sclerosed. Much larger gummata, however, from the size of a nut to that of a hen’s egg, originate from the pia mater, and are most usually situated in the region between tho optic ehiasma and the pons, or on the crura cerebelli. On the convex surface they are much smaller. Gummata of the cerebral substance occur in situa- tions most subject to traumatic influences. The chief seats are the cerebral hemispheres, the large ganglia, especially the optic thalami, and next in frequency the pons, and crura cerebri and cere- belli. The tumours attain to a good size, but are not so large as those of the pia mater. They may be multiple, but often exist singly. See Brain, Vessels of, Diseases of. 16. Fibroma. True fibromata, distinct from hard gliomata and sarcomata, probably do not exist in the brain or its membranes. Fibromata are essentially composed of connective tissue. Such increase in this tissue is sclerosis, and its arrangement is too indefinite, its amount too small, to be considered a tumour. Rindfleisch is probably wrong in stating that there are solitary tubercles of the brain which deserve rather to be called fibroid tumours ; although it may be true that in some cheesy nodules of the nervous centres the growth of fibres and the condensation predominate enormously over the corpuscular structure. Practically, however, both enchondromata and osteomata are fibrous tumours. An enchondfoma is a heterologous tumour not developed from a pre-existing car- tilage, but produced by a change in the type of formation by proceeding from a non-cartilaginous matrix. Although osteoid enchondromata may be malignant, yet true osteomata are not so. These tumours may attack the cerebral dura mater, and on the convexity are multiple. If the tumour attack the falx cerebri it is solitary. Its start- ing-point is the internal surface of the dura mater. It is distinguished from exostosis of bone by having a fibrous layer between it and the bone. It may set up irritative pachymeningitis. Such tumours also are found small in connection with the cerebral arachnoid, as simple united patches or pointed prolongations. Their favourite seat is the convex surface of the anterior lobes. The nervous centres are very rarely the seat of these tumours. Their matrix is formed by con- nective tissue, not cartilage, the product of irri- tation of the neuroglia, and so a consequence of circumscribed encephalitis. 17. Hydatids are rare within the skull, but are met with occasionally in all parts of the brain, between the membranes, in the ventricles, and lying free at the base of the brain. They are more common in children than in adults. The brain may suffer from pressure either in the way of softening from interference with the vessels, or from sclerosis. Cysticerci are also met with in various parts of the brain or its membranes. They may be surrounded by connective-tissue capsules ; or may lie free, arranged in a racemose form. They may be single, or may attack the same individual in several hundred places at once. Symptoms.- — Even in tumours of considerable size all symptoms may be latent. The more tol- erant portion of the brain will include the hemi- spheres and the white commissural regions, whilst the mesocephale, the optic thalami, and tho cor- pora striata are amongst the least tolerant por- tions. It is not unusual, moreover, to meet with decided intermissions, especially in the early period of the disease ; such intermissions de- pending on temporary lesions in the immediate neighbourhood of the tumour. Even with these intermissions the diagnosis of the presence or position of the cerebral tumours would be comparatively easy, if the symptoms invariably depended upon direct excitation. Many of the phenomena pass the limits of the immediate sphere of the tumour, and are the results of reflex action. Sometimes also the symptoms due to direct and reflex excitation may coincide, and this is particularly the case in tumours of the base. The main difficulties lie in the possible latency of all symptoms ; in their intermission ; in the distinction and com- bination of direct and reflex excitation ; and in the remissions following physical or psychical excitement. Symptoms then may depend on direct or reflex excitation, and consist of exaltation of functional activity, such as contractions, partial or general convulsions, liypenesthesia, and hyperideation. Others are produced by secondary lesions in the neighbourhood of the tumour— congestion, haemorrhage, inflammation, &c. — and these may include not only all in the previous division, but temporary or persistent paralysis, fever, and other phenomena. Then there may be symp- toms of direct compression, definite paralyses, and gradual enfeeblement of the sensorial and intellectual faculties. Taking some of the more common conditions in BRAIN. TUMOURS AND NEW GROWTHS OF. 159 order, and viewing them as dependent on direct or reflex irritation, the most frequent certainly is headache ; and except a tumour of the cere- bellum, when the headache is almost invariably occipital, there is no symptom less useful in determining the position of the lesion. It is less frequently due to direct excitation than to reflex. The pain is very severe, indeed, more so than in any other disease, excepting, perhaps, meningitis : it persists through the whole malady; and is increased by vibration of all kinds, light, sound, or movement of the head. It may be confined to a single spot, or be diffused over the whole head. Connected with headache in many cases, and often equally the effects of radiated influ- ence, are tinnitus aurium, morbid acuteness of hearing, and painful sensitiveness to sound ; dis- turbances of vision, diplopia, muscse volitant.es, and strabismus, which may bo transient ; formi- cation, and sometimes hypersesthesise of greater or less extent. In some cases there is an agitated condition of the intellectual faculties, and even delirium. Disturbances of sight are very common. The retinal lesions will be subsequently de- scribed. It is a remarkable fact, as bearing upon reflex phenomena, that the affections of sight usually implicate both eyes, even where the tumour has involved only one optic nerve, and is not situated near the optic chiasma or the corpora quadrigemina. Hearing is far less often affected than vision. Generally a slight diminu- tion only of this function is observed ; and, in the rare cases in which complete deafness is met with, it is unilateral. Taste and smell are seldom interfered with. When these special senses are morbidly affected, the tumour in the first case will probably be located in the posterior portion of the base; in the second at the anterior half of the base of the brain. The symptoms of compression maybe included in the expression ‘lowering of function,’ com- prising apathy, feebleness of memory, want of attention, confusion, and a general enfeeblement of ideas. These conditions are often accom- panied or preceded by certain diffused symptoms, such as vertigo. Vertigo is the first symptom in many cases : it is felt especially when the patient is in the upright position. It often produces uncertainty of gait, even where the tumour is not in the cerebellum. Strange sensations in the head are also complained of, a feeling of liquid in the head, or of a mobile body; or the sensation may be that of a solid body filling the head, or press- ing upon some portion of it. These phenomena often coincide with evi- dences of irritation of the mesocephale, whether clue to direct compression or to radiated irri- tation of the medulla oblongata. Chief amongst these symptoms is vomiting. It is not accom- panied by nausea or other manifestations of dyspepsia, and it will occur when the stomach is empty. It can frequently be checked only by keeping the patient in a recumbent position. Constipation also is often obstinate. Epileptiform convulsion has an important bearing on the diagnosis of these lesions. Very frequently convulsion is preceded by many of the phenomena already touched upon, such as head- ache or vertigo. Frequently, however, convul- sion precedes all other morbid phenomena, and the patient may be in perfect health in the intervals of the attacks. G iven, therefore, con- vulsion as the one factor in forming an opinion, it is necessary to consider the liability of the patient to convulsive attacks from causes other than tumours ; to realise whether the family history shows any suspicion of epilepsy; and to eliminate from the case the possibility of satur- nine, alcoholic, and uraemic poisoning. If this is done, and especially if we find early convulsion associated with headache and with vomiting, this symptom will prove an important aid in the diagnosis of tumour. The phenomena depending on the presence of tumour itself may be associated with others due to complications, such as oedema, congestion, encephalitis, or meningitis of the surrounding parts. A high temperature, for instance, will point to inflammation either of the nervous sub- stance or of the meninges near the lesion ; and meningeal inflammation seems to be accompanied by the highest temperature. Syphilitic gumma, however, may coincide with syphilitic meningitis on some other portion of the encephalon not di- rectly connected with the immedjate surround- ings of the tumour. Passing for the moment the subject of definite paralyses with the remark that the sphincters are seldom affected, even in cases in which the paralysis takes a paraplegic form, it may be mentioned that a want of equilibrium seems to be a not unusual evidence of the presence of tumour in the cerebellum. Aphasia may not only be due to the special localisation of tumour in Broca’s region of the left anterior lobe, but also to the presence of this lesion in any part, of the track (corpus striatum, optic thalamus, or crus cerebri) which unites this portion of the hemisphere to the medulla oblongata, the highway by which the centre for the production of articulate speech is connected with the co- ordinating centre for this function. Anaesthesia of the skin is seldom met with as a symptom of cerebral tumour. When present it is found only in the limbs affected with motor paralysis, and is scarcely ever complete. Symptoms of special localities. — It remains to take special regions of the encephalon separately and to endeavour to differentiate the position of the tumour by the symptoms attending its presence. Tumour in the medulla oblongata will be ac- companied by various disturbances of sensibility, especially headache, and sometimes by convul- sions. The pressure of a tumour is seldom limited to the medulla oblongata, and the symp- toms therefore are complex. In several of the cases recorded there has not only been amaurosis and deafness of one side, but interference with taste and smell. Tumour of th & fourth ventricle may manifest itself by the presence of sugar or of inosite in the urine. Tumour here, as in the medulla oblongata, frequently destroys life quickly, before there has been time, so to speak, for much local lesion to be set up. Vomiting is a frequent symptom. Tumour of the crura cercbelli and of the corpora quadrigemina cannot be diagnosed by any peculiar symptoms. In one case, in which the 100 BRAIN, TUMOURS AN corpora quadrigemina seemed -wholly transformed into a tuberculous mass, the sight remained good, but there Teas double ptosis. In tumour of the cerebellum there is little disturbance of sensibility except occipital head- ache. There are various disturbances of motility, especially convulsions and irregularity of locomo- tion, but no true paralysis. Amblyopia, amau- rosis, and convergent strabismus are common. There is no interference with the psychical functions, or with speech, as a general rule. Vomiting is very common. In 76 cases col- lected by Ladame, there was no abnormality in the genital functions, except in four instances. In tumours of the pons, the disturbances of sensibility are general or partial anaesthesia, and in some cases more or less headache. Hemiplegia of unequal degree on the two sides, and other forms of paralysis are observed, but no convulsion. Various and manifold disturb- ances of the special senses ; phenomena of de- pression of mind; frequent alteration of speech; and early disorders in swallowing occur. Tumours of the crura cerebri follow the ex- ample of the same lesion in the pons -with reference to disturbances of sensibility. Equi- lateral hemiplogia opposite to the lesion is met with, and paralysis of the oeulo-motor nerve on the same side as the tumour, often gradually ex- tending itself to both oeulo-motors. Tumours of the pituitary gland are accom- panied by intense frontal headache ; by no definite disturbances of sensation or of motion ; by double amblyopia or amaurosis, unequally developed ; and by no loss of speech. Tumours of the middle cavities of the cranium seem to affect mainly the third and the fifth nerves, anaesthesia or pains in the face and ptosis being the prominent symptoms, with some interference with the free action of the other muscles of the eyeball supplied by the third. In one case, in which a scirrhous tumour of the left side was situated on the inner surfaco of the sphenoid bone, extending laterally to the internal auditory meatus and backwards to the pons, not only were the third and fifth nerves paralysed, but colour-blindness supervened some time before death. In tumour of the corpora striata aud optic thalami , headache is less frequent than in other regions. Hemiplegia and convulsions are fre- quent, the former especially so. Hardly any disturbance of the special senses is observed. In- telligence and speech are frequently disordered. In tumour of the corpus callosum, there is frequently some mental aberration, and often convulsions. In tumour of the middle cerebral lobes , headache is frequently a prominent symptom, but other- wise the sensory disorder is mainly anaesthetic. Hemiplegia is common, as is also convulsion of an epileptiform character. These convulsive attacks are not rarely unilateral, and sometimes affect at first one limb only. In fact the position of a tumour towards the anterior portion of the middle lobe may be determined by symptoms with tolerable accuracy. Various disturbances of sight and of hearing are met with ; as well as various psychical abnormalities, ranging from mere confusion of ideas to absolute imbecility. D NEW GROWTHS OF. In tumour of the anterior lobes there in general headache, seldom of the frontal region particularly. No other sensory disturbance occurs. Sight and smell are frequently affected, speech seldom. Hemiplegia, convulsions, and psychical disturbance will occur much as in tumours of the middle lobes. In tumour of the posterior lobes, there is gen- eral headache, seldom localised in the occiput : no other sensory disturbance. Slightly marked hemiplegia occurs, and convulsive attacks are very frequent. There is no disturbance of the organs of special sense. The mental faculties are greatly altered, particularly in the tendency to depression. All three lobes may be affected with tumour coincidently, and the headache is then very intense ; the epileptiform convulsions exceed the paralytic phenomena ; the organs of special sense are little affected ; and there are various mental disturbances. In tumour of the convexity, the headache is generally limited either to the frontal regions, to one side of the head, or to the occiput. There is neither anaesthesia, nor paralysis, but intense convulsions occur. The special senses are not disturbed. The mental condition is one of irri tation, evidenced by delirium and excitement. Lastly, very various regions of the brain may be simultaneously the seat of tumour, and the morbid phenomena will be necessarily com- plex. Retinal changes . — It has seemed more con- venient to speak of retinal changes dependent on cerebral tumour separate from the other symptoms. Great variations in the lesion occur according to the position of the tumour; its direct interference -with the optic centres ; its complication with meningitis ; and its pressure on the optic nerves and chiasma. Taking choked disc, optic neuritis, and atrophy of the optic nerve as the three chief lesions, cerebral tumour may very frequently induce choked disc, by interfering with the venous ebb from the eye; optic neuritis, if meningitis is associated with the tumour ; optic atrophy, by pressure of the tumour on the optic nerve, or by this pressure of the tumour or of hydrocephalus secondarily induced by it on the optic centres or tracts, or by softening around the tumour, such softening implicating the optic centres, or. lastly, by the propagation of sclerosis. Any tumour situated far back in the encephalon may interfere with the venous flow through the venae Galeni, and so produce hydrocephalus of the ventricles, and the retinal effects of hydro- cephalus. There are no retinal changes from tumour in the corpus callosum, nor as a rule from tumour in the optic thalami. Tumours of the cerebral hemispheres all influence the optic nerve, if they interfere with the base of the brain. Tumours of the cerebellum may cause pres- sure on the lateral sinuses, the straight sinus, the venae Galeni, or the torcular Herophili: pressure in any of these situations may produce choked disc. Or the tumour may affect the corpora quadrigemina ; or softening around it may spread to these organs, and atrophy of tha optic nerve be the result. A fortiori, tumour BE AIM , TUMOURS OF. of the corpora quadrigemina themselves will lead to atrophy of nerve. Tumour of the crura cerebelli causes hydro- cephalus, and its effects on the retina. In a similar way tumours springing from the bone or the membranes at the base of the brain may produce choked disc or atrophy, according to the position of the pressure, optic neuritis by complications with meningitis, or neuro-retinitis by irritation of the connective elements of the nerves. See Opthalmoscope in Medicine. Course. — The clinical course of cerebral tu- mours is intermittent and paroxysmal. In many eases, such as those of glioma, it is very slow. Two groups of phenomena may complicate its ordinary course, namely, those associated with meningitis and apoplexy. Special Tumours. — Aneurismal tumours may sometimes be distinguished by the sense of throb- bing in the head ; by the patient being of adult age or young ; by his being attacked in the midst of perfect health ; by vomiting being rare, apo- plexy frequent, paralysis of cranial nerves early and unilateral ; and by absence of mental pheno- mena. Aneurism situatedin the cavernous sinus produces exophthalmos. See next article. The symptoms of echinococci differ very little from those of other slow tumours : headache, dizziness, vomiting, syncope, and epileptiform attacks are most frequent. Disturbances of the motor and sensory functions, and also of the mind itself, are sometimes met with, and vary according to the situation of the lesion. The prognosis is unfavourable ; the diagnosis im- possible, unless echinococci exist at the same time in the liver. Cysticerci manifest their presence in the brain by epileptic attacks, which augment in number and severity ; the health of the patient between the fits is at first good, then apathy and torpor supervene ; hemiplegia is rare, and never early ; cranial nerve paralyses are exceptional ; the symptoms are diffuse and bilateral, owing to the position of the parasite in the grey con- volutions, and in many spots at a time. The age of the patient is above 40. Perhaps there may he evidence of the presence of cysticerci elsewhere. Syphilitic tumours coincide with actual or previous syphilis. The headache attending this form of tumour is generally intensified at night. In tubercle of the brain there is often a tuber- culous family history, or the presence of tubercle elsewhere in the body. It seldom compresses cranial nerves. Its clinical evolution is often by paroxysms, and grave cases are combined with tuberculous arachnitis and hydrocephalus of the ventricles. Tubercle in the cortical sub- stance of the brain and cerebellum may, how- ever, be attended by no special symptoms. In cancer also there is frequently a family history of this malady ; and the cancerous cachexia may be present. Cancer seldom ex- ists elsewhere when it is cerebral. This growth is much less often accompanied by symptoms due to congestion and haemorrhage than glioma or sarcoma, being less vascular. Prognosis. — The prognosis of cerebral tu- mour is always bad, except in syphilitic gumma, end perhaps aneurism. 11 BRAIN, VESSELS OF. 161 Treatment. — In syphilitic gumma and in aneurism large doses of iodide of potassium may be used with more or less success. This remedy is also useful in dispersing the results of the meningitis which so often accompanies tumour of the base. Beyond this there is little to be done, except in the endeavour to relieve pain and to support the strength of the patient. E. Long Fox. BRAIN, Ventricles of, Diseases of. Scv Ventricles of Brain, Diseases of. BRAIN, Vessels of, Diseases of. 1. Aneurism. — The larger arteries of the brain, and their minute branches in the cerebral substance, are both liable to aneurismal dila- tation. («) Aneurism of the larger cerebral arteries is more common than that of vessels of a similar size elsewhere. The large vessels of the base, or their primary branches, may be affected. The basilar and middle cerebral arteries are those most frequently diseased, aneurisms of those two vessels constituting three-fourths of the cases. Next in frequency is the internal carotid. The vertebral, anterior and posterior cerebrals, an- terior and posterior communicating, and anterior cerebellar arteries are occasionally, but less fre- quently, involved. In one or two recorded cases the aneurism has been situated in the interior of the pons Varolii or cerebellum. The arteries of the two sides of the brain are affected with equal frequency, with the exception of the mid- dle cerebral, which, with its branches, suffers twice as frequently on the left side as on the right. There may he more than one aneu- rism, situated on differert arteries or on different branches of the same artery. The aneurism is usually sacculated, rarely dissecting. Its size varies from that of a pea to that of a nut. but aneurisms of the anterior or middle cere- brals have attained a much larger size. When this is the case the brain-tissue is pressed upon and softened. .(Etiology and Pathology. — These aneu- risms are rather more common in men than in -women. They occur at all ages, being more fre- quent before the ordinary degenerative period than aneurisms elsewhere. Nearly half the re- corded instances have occurred between ten and forty years, and about one-seventli between ten and twenty. The change in the arterial wall resembles that giving rise to aneurism elsewhere — a fibroid degeneration, with loss of muscular and elastic tissue. This may he part of a widely spread arterial change, or more frequently is local. When local, it is sometimes due to syphi- litic disease of the arterial -wall, but still more frequently to the consequences of embolism. Dr. Church first pointed out the frequent asso- ciation in young persons of cerebral aneurism and valvular disease of the heart, and many facts have been published which support the hypothesis that the aneurism in these cases may he the consequence of incomplete obstruction by embolism. There is often evidence of inflammatory and degenerative changes (thickening, calcification) in the artoria) i62 BRAIN, VESSELS wall after embolism, especially -when the plug comes from an inflamed endocardium. If the obstruction is incomplete, the altered 'wall may yield to the blood-pressure. In harmony with this theory are the frequent absence of degene- ration in other arteries, the frequency with which the left middle cerebral is the seat of the aneu- rism, and the occasional occurrence of several aneurisms on branches of the same arterial trunk. The efficient agent in the production of the aneurism is the high blood-pressure in the cere- bral arteries. Rupture has occurred in about three-fourths of the recorded cases of cerebral aneurism. The blood may escape rapidly or slowly, and the haemorrhage may take place into the subarach- noid space, or into the adjacent cerebral substance. In the former case, meningeal haemorrhage is the result. Rupture into the cerebral substance is not uncommon. An aneurism in the fissure of Sylvius may cause a haemorrhage into the substance of the brain, bursting into the lateral ventricle; and an aneurism on the posterior cerebral artery may burst into the substance of the pons. Two causes may determine this rupture into the substance of the brain — first, thickening of the subarachnoid tissue adjacent to the aneurism, hindering its rupture outwards; secondly, the gradual escape of the blood, producing a slow disintegration of the brain-tissue, and thus preparing a channel for the effusion. In such ^ cases only a small quantity of blood may have trickled into the ventricles or subarachnoid space. In rare cases a communication with a sinus forms, and constitutes an arterio-venous aneurism. This has occurred between an aneur- ism of the internal carotid and the cavernous sinus. Symptoms. — Symptoms of the existence of an aneurism may be entirely absent. When present they depend on the pressure which the tumour exerts on neighbouring parts. They vary wddely according to its seat, and they are rarely by themselves distinctive. Mental disturbance is uncommon. Headache is a veryuniform symptom. It is often intense, sometimes throbbing, and may be localised, as in the occiput in basilar aneurism. Convulsions occur in some cases, and are said to be more common when the disease is near the medulla. Paralyses are frequent, and depend on the pressure of the tumour : the most common are those of the cranial nerves which lie adjacent to the aneurism, as of the nerves of the orbit in aneurism of the internal carotid. Such symptoms are suggestive of an aneurism when they indicate pressure in the known situation of a vessel. In some cases a murmur can be beard by the patient, and in still rarer cases (of aneu- rism of the internal carotid) it has been audible on auscultation. Aneurism elsewhere may increase the probability that an intracranial aneurism is present, and so, in the young, ma}' valvular disease of the heart. Rupture of cerebral aneurism gives rise to symptoms which vary, as in rupture of aneurisms elsewhere, according as the blood escapes quickly or slowly. If quickly, the blood usually escapes into the meninges and causes sudden apoplexy with general paralysis, rapidly deepen- OF, DISEASES OF. ing to a fatal issue. If slowly, the symptom* are less sudden, and unilateral paralysis or con- vulsion may occur. This is especially the case when the blood escapes slowly into the cerebral substance, unilateral symptoms occurring, and gradually increasing during a few hours or days, with or without initial lo«s of consciousness, but ending in fatal coma. Treatment. — Little can be done in eases where intracranial aneurism is suspected. Even when it is of syphilitic origin, drugs can only partially restore the damaged and dilated vessel. Hypodermic injection of ergotin (£-grain) has been recommended by Langenbeck and advo- cated by Bartholow. Iodide of potassium may also be given. Rest is important. All causes of increased intravascular pressure, sucli as effort and low positions of the head, are to be avoided. The bowels should be kept regular. In rare cases where progressive paralysis of orbital nerves suggests the probability of aneurism of tile in- ternal carotid, and a murmur renders the diag- nosis certain, ligature of the common carotid may be, and has been, resorted to with success. (b) Minute ‘ miliary ’ aneurisms occur in the small arteries of the pia mater and substance of the brain (Virchow, Charcot and Bouchard). They are found at all ages, but more fre- quently in the old. They may involve vessels not more than the inch in diameter, but are most common on vessels a little larger than this; the walls suffer fibroid degeneration of the outer and middle coat, commencing, it is said, as nuclear proliferation. The muscular tissue of the middle coat disappears, and the whole wall at the spot becomes dilated into a sacculated aneurism, varying in size from the jk to the of an inch. These dilatations have been found in all parts, but most frequently in the optic thalamus, and next most frequently in the pons Varolii, the convolutions, the corpora striata, the cerebellum, the medulla oblongata, the cerebellar peduncles, and the centrum ovale (Bouchard). They often rupture and cause minute hiemorrhage. They are found fre- quently in cases of large cerebral haemorrhage ; and Charcot and Bouchard believe that such haemorrhage is frequently due to their rupture. Liouville has pointed out that, minute aneu- risms of the retinal arteries sometimes co- exist. The rupture of a minute artery into its peri- vascular sheath distends it with blood, causing what has been termed a minute dissecting aneu- rism. Such are frequently met with in cases in which the vessels are exposed to extreme pres- sure, as in death from aspkyxial conditions ; or in the increased tension in collateral vessels when vascular obstruction has occurred. No symptoms are known to be associated with the existence of theso minute aneurisms. The symptoms cf rupture are described under ‘ Brain, Haemorrhage into.’ 2. Degeneration, (a) Of Arteries. — The larger cerebral arteries are very common seats of the thickening of the inner coat, called by Virchow ' Endarteritis deformans,’ and which, when fattily degenerated, constitutes ‘atheroma.' On the cerebral vessels the fatty change occurs quickly and frequently; and opaque vellcv BRAIN. VESSELS OE. DISEASES OF. thickenings are the result. Only one or two of these may be present; or the change may in- volve the whole of the larger vessels at the base and extend for a considerable distance along the chief cerebral branches. The dis- tribution -of the degeneration may be symme- trical. It may coexist with a similar change in arteries elsewhere, or may be isolated. De- generation of the cerebral arteries is com- mon after middle life, being found in seven- tenths of the subjects examined (Bichat). It occasionally occurs much earlier, especially in eases of chronic Bright’s disease. Bright’s dis- ease and alcoholism are its chief diathetic pre- lisponeuts. The exciting cause of this disease is probably the strain to which the badly supported cerebral vessels are exposed. It is not easy to explain their occasional freedom from atheroma when this is abundant elsewhere. The degene- rated patches rarely soften and open into the vessel, so as to permit the formation of a dis- secting aneurism. More commonly they under- go calcification. The result of these nodular degenerations is to lessen the calibre of the vessel, sometimes to close it altogether, and to favour the formation of a coagulum. The les- sened area of the vessel causes local anaemia of the brain. If the vessel becomes occluded, or if coagulation takes place in it, softening occurs in the part supplied by it. Where the degeneration has led to only slight thickening of the wall, the artery may be dilated at the spot. The degene- rated vessel may burst under the pressure of the blood and haemorrhage result. The minute arteries of the cerebral substance undergo simi- lar changes, less conspicuous from their smaller size. Fatty degeneration of the cells lining the perivascular sheath is common at all ages. Under circumstances similar to those in which the larger arteries degenerate, all the coats of the small vessels suffer. Simple fatty degene- ration of the middle coat occurs also at all ages. Miliary aneurisms may be formed, or rupture occur, as a consequence of these changes. Symptoms. — Atheroma of the cerebral vessels leads to the symptoms of local anaemia of the brain, and is a common cause of the transient cerebral symptoms so frequent in the old. Treatment. — Tonics, cardiac stimulants, and substances which, as cod-liver oil, promote the nutrition of the nerve-tissue, are the most useful remedies. ( b ) Of Veins . — Degeneration of the walls of the veins is much less frequently observed than degeneration of the arteries, perhaps on ac- count of the less degree of pressure to which they are exposed. Occasionally the veins of the pia mater may be found varicose in advanced life, and in one case recorded by Andral rupture of such a dilated vein was the cause of menin- geal haemorrhage. 3. Embolism. — Definition. — - The obstruc- tion of arteries or capillaries of the brain by solid particles carried by the blood-current from some other part of the vascular system. ■ZEtiology. — The source of the embolic par- ticles is almost invariably situated between the pulmonary capillaries and the obstructed vessels, i.e. in the pulmonary veins, the left side of the heart, or the arteries. In arterial embolism it is necessarily so, since no particles large enough tu obstruct even a small artery could pass through the capillaries of the lungs. In almost all cases the heart is the source of the plugs, a particle of fibrin being washed by the blood from a deposit on a diseased valve or in some recess (as the auricular appendix). Endocarditis, or chronic valvular disease, therefore, usually coexists with the embolism. Mitral stenosis is an especially frequent source of emboli, probably because the surface is commonly much altered, and the blood- current is in part slow (in diastole, allowing deposit), and in part very rapid (in auricular systole, detaching loose fibrin). Disease of the aorta — atheroma or aneurism — is the next most frequent source, and, less frequently, disease of the carotid or vertebral arteries, and coagulation in the pulmonary veins, large or small — the latter in some rare cases of inflammation and growths. Particles obstructing capillaries may come from some softened atheromatous patch or fibri- nous deposit, from pigmentary formations, or from deposits in ulcerative endocarditis. In the last ease the obstructing material has a septic character, and the inflammation it causes may be suppurative. Anatomicat. Characters. — Almost any of the cerebral arteries may be obstructed, the internal carotids and middle cerebrals or their branches most frequently, the anterior cerebrals or the basilar less frequently, and the posterior cere- brals still less frequently. Obstruction of several vessels is sometimes found, having occurred at the same or at different times. The cerebral arteries of the two sides are plugged with nearly equal frequency ; the internal carotid much more frequently on the left side than on the right. It seems that a large fragment is influenced in its course by the more direct path through the left carotid, while smaller fragments find their way with almost equal readiness to either side. The middle cerebrals are very frequently affected, sometimes on both sides ; and, when the bilateral symmetry of the vessels is great, each may be obstructed at the same place. The plug is usually arrested at some spot at which the vessel is narrowed by a branch being given off. Here the fragment may be found, usually decolorised, and commonly closing alto- gether the lumen of the vessel. On each side of this is a secondary clot: the distal extends far into the contracted branches of the vessel, the proximal as far as the next large branch. The obstruction may lead to inflammation of the wall of the vessel at the spot, especially when the plug has been carried from a place at which inflammation is going on. The inflammation leads to change of texture and degeneration, fibroid or fatty ; the former may permit an aneiu'ism to be formed, the latter may cause a thickened patch, in which calcification may occur. The inflammation may spread to the adjacent tissue, leading to induration around the spot. The first effect of embolism is to arrest the blood-supply to the part to which the artery is distributed. It is only when the obstruction is beyond the circle of Willis that damage to cere- bral structure (softening) follows. Softening 164 BRAIN. VESSELS OF. DISEASES OF. occurs more uniformly in obstruction of the arteries of the central ganglia than in those of the convolutions. Capillary embolism also causes softening, and when the obstruction is from a septic source, ‘ metastatic abscess ’ may result. For the symptoms, diagnosis, and treatment of cerebral embolism see Brain, Softening of. 4. Rupture. — Rapture of cerebral arteries is common and is the cause of cerebral haemor- rhage, and rupture of capillaries is not unfre- quent. Rupture of veins is extremely rare, ex- cept as the result of injury. (a) Of Arteries. — The proximate causes of rupture are weakening of the arterial wall, and increased pressure within the vessel. The con- ditions which give rise to these two factors are the remote causes of rupture. The actual rupture is commonly due to a temporary sudden excess of intravascular pressure. -^Etiology. — The wall of the vessel is weak- ened, especially by degenerative disease — chronic periarteritis, or (rarely) simple fatty degene- ration. Aneurismal dilatation and thinning may have resulted from the chronic change. In some diseases attended with a tendency to extra- vasation (purpura, haemophilia, &c.) it is conjec- tured that the vascular walls have undergone rapid degeneration, or are unusually thin. De- fective external support, from atrophy of the brain, causing increased size of the perivascular canals, was formerly thought to he a potent cause, and is now perhaps underrated. The mobile perivascular fluid which surrounds the vessels must afford a less efficient support than cerebral tissue. When vessels are much weakened, they may rupture when the extra vascular pressure is at, or even below, the normal ; very commonly, however, there coexists increased pressure. Loss of arterial elasticity leads to a jerky pressure. Arterial degeneration, and still more constantly, arterial contraction, in Bright’s disease, cause increased tension by obstruction ; and the hypertrophy of the heart, which develops to overcome the obstruction, adds materially to the pressure within the arteries. Hypertrophy to overcome an obstacle near the heart has pro- bably no influence in causing rupture of cerebral vessels. The instant cause of rupture is generally some temporary increase of the blood-pressure due to effort — as in cough, straining at stool or vomit- ing ; excited action of the heart ; suddenly de- veloped heart- or lung-disease obstructing the circulation ; local obstruction to return of blood ; contraction of the arterioles, general or local; or the action of gravitation in the recumbent pos- ture. The last two causes probably acting to- gether determine the frequent occurrence of rupture during sleep. The conditions which produce these proximate causes are the remote causes of rupture. The most efficient are those which determine weaken- ing of the vascular wall, and have been already spoken of (see Degeneration). Age is an im- portant element — rupture is most common after fifty, but may occur from local vascular disease at any age. Hereditary predisposition is seen in a tendency to early degeneration. Position of degeneration is probably largely influenced by the distribution of the vessels ; and the latter may be strikingly hereditary, as the retina some- times shows. Sex tells probably by exposure to the greater pressure entailed by muscular effort (men suffer from rupture twice as frequently as women). Alcoholism leads to early degeneration. But the most efficient predisponent is Bright's disease, which leads to great intravascular pres- sure, and weakens the cerebral vessels by causing degeneration. It is probable that some acute diathetic diseases in which rupture is common act in a similar manner. Certain of the cerebral arteries give way more frequently than others, especially the arteries of the corpus striatum and pons Varolii. This seems due (1) to their origin at right angles from vessels of very considerable size (basilar and middle cerebral), and their consequent exposure to the full pressure within the parent trunk. (2) To their ‘terminal’ character, which precludes collateral relief (Duret, Heubner). One artery, which very frequently gives way, passes from the middle cerebral through the anterior perforated spot, outwards be- tween the island of Reil and the lenticular nucleus, the outer part of which it perforates, and then passes through the white ‘ internal capsule,’ between the lenticular and eaudato nuclei, to ramify in the anterior part of the latter. The arterioles supplying the con- volutions on the surface of the brain are not often ruptured, except from injury. They are exposed much less directly to the blood-pressure, and sometimes possess considerable anastomoses. Symptoms. — The consequence of rupture of an artery is cerebral haemorrhage, the symptoms and treatment of which are described elsewhere (sec Brain, Haemorrhage into). In traumatic laceration of the brain the arteries are torn, and often cause much haemorrhage. (b) Of Capillaries . — The minutest arteries and veins and the capillaries rarely rupture, except when exposed to sudden pressure by venous thrombosis, when the obstruction in the part from which the vein proceeds may determine numerous capillary haemorrhages into the cere- bral substance. In general venous congestion, as in asphyxial states, such haemorrhage may occur; but a more frequent result is rupture of a vessel within its perivascular sheath, which thus becomes distended with blood. For symptoms see Brain, Haemorrhage into. 5. Syphilitic Disease. — The arteries of the brain are occasionally diseased in the later stages of syphilis. The large arteries at the base and the minute arterioles may be both involved. The wall is thickened at circumscribed areas by a fibro-nuclear growth, which causes a nodular projection on the exterior, and diminishes also the calibre of the vessel. The structure of the growth resembles that of syphilomata elsewhere. It is said by Heubner to begin by a nuclear pro- liferation between the inner coat and the elastic lamina; and in some cases it attains its chief development in this situation, the elastic lamina being pushed outwards and the lumen of the ves- sel obliterated. The middle coat may ultimately disappear. Vessels may form in the substance of the growth, and its centre may undergo fatty degeneration. The disease is sometimes sym- BRAIN, VESSELS metrical on the arteries of the two sides. The growth or secondary thrombosis occluding the vessel, softening may result in the area of brain- tissue supplied by it. The softening resembles in its occurrence and characters that which is produced by degenerative changes in the ar- teries, but is more varied in its seat, and it affects younger persons. The diminished elas- ticity of the diseased wall, when the thickening is slight, may permit the dilatation of the vessel into an aneurism. Possibly the same result may follow the fatty degeneration of the new tissue. Symptoms. — No symptoms are produced by the arterial disease until it causes local anaemia cr softening, the symptoms of which resemble those due to other causes. Treatment. — This is that of the later stages of syphilis. It must be remembered that the removal of arterial disease may not restore the damaged cerebral tissue. 6. Thrombosis. Thrombosis, — the coagula- tion of the blood in situ , — may occur in the cere- bral arteries ; or in the cerebral veins and sinuses. (a) In the Arteries. JEtiology. — The causes of arterial tlirom- oosis are the following: — (1) An alteration in the wall of the artery, by which the blood comes in contact with an abnor- mal surface. The most common condition is athe- roma, and hence arterial thrombosis is most frequentwhen atheroma is most common — in the old. Syphilitic disease of the artery sometimes leads to it. Much more rarely it is caused by an arteritis, spontaneous, or the result of ad- jacent inflammation or traumatic damage. (2) Retardation of the blood-current. This may result from weakened action of the heart in debilitating diseases (as phthisis and cancer), and in extreme fatigue. It may be part of the effect of a convulsive fit ; or it may be caused locally by the arterial diseases mentioned al- ready, which lead to narrowing and loss of elasticity. (3) An increased tendency of the blood to coagulate. This is seen in many diseases, espe- cially in marasmic states in young and old (such as are caused by phthisis and cancer), in acute rheumatism, and in the puerperal condition. A slight cause then suffices to produce coagulation, and the weak heart, so common in many of these conditions, may cause sufficient retardation of the blood-current. (4) Lastly, thrombosis in an artery may be secondary to its complete or partial obstruction by an embolus. Anatomical Characters. — The arteries oc- cluded may be one or several, and large or small. Of large arteries the basilar, middle cerebral, and carotid are those occluded most commonly, and with nearly equal frequency. The vascular wall may present any of the local causative con- ditions, or may be healthy. After a time thickening from secondary arteritis occurs. Within this vessel is a coagulum which usually fills its interior, and is adherent to the wall. It may not fill the vessel, either because origi- nally imperfect, or because the clot has shrunk. A recent quickly-formed coagulum is red, but after a time it becomes pale and yellow. A slowly-formed coagulum is pale, and may be OF, DISEASES OF. x 6 5 laminated. A secondary clot usually forms far into the contracted distal branches, and on the proximal side as far as the nearest large branch. Ultimately the clot may, rarely, soften, the channel being sometimes re-established. More commonly it undergoes calcification, or, with the artery, contracts and becomes atrophied. The brain-tissue, in which the artery was distributed, may be at first anaemic, but quickly becomes congested. It ultimately undergoes softening — red, yellow, or white, according to the amount of vascular distension. If the collateral circu- lation is free it may remain unsoftened. Symptoms. — AYhere chronic arterial disease is the cause of thrombosis, the symptoms of local cerebral anaemia may precede {see Brain, Anaemia of). The thrombosis itself leads to the symptoms of loss of function in the part to which the artery passed. The onset of these symptoms is slow or sudden, according to the rapidity with which the coagulum forms ; and their degree depends on the size of the vessel occluded, its position, and its relation to other vessels which may supply blood to the area involved. Throm*. bosis of a small vessel in the cerebral substance usually leads to transient brain-disturbance, headache, vertigo, tingling, and temporary weak- ness in the limbs, which soon pass away if a col- lateral circulation is established ; more slowly, if softening ensues, by compensatory action else- where. The occlusion of a large vessel causes commonly more marked symptoms. Complete hemiplegia is frequent, and its onset may be marked by loss of consciousness {see Brain, Soft- ening of). Diagnosis.— Diagnosis rests on a combination of the symptoms of local cerebral disease with the causal condition — vascular mischief (indicated by probable age, degeneration elsewhere, or syphilis), and with conditions leading to relaxa- tion of the blood-current, or increased coagula- bility of the blood. The diagnosis is rendered more probable by the symptoms if slight being transient, if severe being of gradual onset, and, whether slight or severe, being preceded by the premonitory indications of local cerebral ansemia. The prognosis and treatment of thrombosis in arteries are considered under its consequence, Brain, Softening of. {h) In Cerebral Veins and Sinuses. ^Etiology. — Thrombosis in sinuses may be primary, and due to changes in the constitution or the circulation of the blood; or secondary, and due to local causes inducing coagulation directly at the spot affected. The same conditions of retarded circulation and altered blood-state which permit coagulation in arteries, favour it also in veins, and it is often seen in such condi- tions as phthisis and cancer, and especially in marasmic states in children. Local retardation of the circulation from narrowing of the sinus, or compression of the jugular vein, occasionally as- sists. Local change causing coagulation is usually the extension to the sinus of adjacent inflam- mation, or of a clot produced in a tributary vein by such inflammation. Caries of the bones of the skull, especially of the temporal bone, and meningitis are common causes. Inflammation outside the skull, in the scalp, neck, or face, has 1G6 BRAIN, VESSELS OF. led, by means of venous connections, to intra- cranial thrombosis. Lastly, injuries of the skull involving the sinuses sometimes cause coagulation in them. Anatomical Characters. — Of primary throm- bosis the superior longitudinal sinus is the most common seat, and thence the clot spreads into the veins on either side, and often also into the lateral sinuses. When secondary, the thrombosis occurs in the sinus nearest to the local mischief ; in disease of the petrous bone, the lateral sinus is usually involved. The sinus is distended by firm clot, commonly (not invariably) adherent, sometimes in concentric layers. The walls of the vessel are healthy when the thrombosis is pri- mary or secondary by extension of clot, but thickened and brittle when invaded directly by adjacent inflammation. After a timo the clot may soften and break down. .The consequence of venous thrombosis is local arrest of the blood-current, the tributary veins and capillaries becoming enormously disten- ded with blood and rupturing, and the cerebral substance being crammed with minute capillary extravasations which often coalesce. The condi- tion is frequently seen in the convolutions. Blood is also effused into the meshes of the pia mater, and into the subarachnoid space. Into the looser tissues and into the ventricles serum may escape. Thrombosis of the veins of Galen is one causa of ventricular effusion. Ultimately the brain- tissue, the seat of the ischaemic congestion, un- dergoes softening, first red, and then yellow or white. Occasionally the softening of the clot loads to pyaemia. Stmptoms. — The symptoms are at first those of mental excitement, namely, intense headache and muscular spasm, shown as contractions in the limbs, or as convulsion, often beginning locally, according to the position of the conges- tion. Those symptoms, after one or several days, are succeeded by those of depression ; with coma, and dilatation of pupils. The coma may come on suddenly, and the first stage may bo little marked. Convulsions, when present, often continue till death. When the superior longitudinal sinus is plugged, epistaxis, oedema of the forehead, and exophthalmos have some- times been observed. When the lateral sinus is obstructed, there may be painful cedema behind the ear, and the jugular vein on that side has been noticed to be less full than on the other. Diagnosis. — The diagnosis rests on the oc- currence of severe cerebral symptoms in as- sociation with a causal condition, constitutional or local. Prognosis. — This is always serious, death being, in most cases, speedy. Treatment. — The indications for treatment are mostly causal. In primary thrombosis stimu- lants and nutritious diet are necessary, and tonics if they can be taken. In secondary throm- bosis, occurring in robust individuals, leeching or cupping is recommended ; purgatives should be given ; and, in the less severe cases, a blister may be applied to the neck, and the utmost care taken to afford free exit for pent-up inflamma- tory products. Pain and convulsion are relieved unost effectually by cold to the head. W. R. Gowers. BREAST, DISEASES OF. B RAIN- FEVER. A name popularly ap plied to any kind of febrile state in which symp- toms of cerebral excitement are prominent; as well as to cases of inflammatory disease of the brain or its membranes. BREAK-BONE FEVER. A synonym for Dengue. See Dengue. BREAST, Diseases of. — This subject will be treated under the following divisions : — I. Diseases before puberty, in both sexes. II. Diseases about the age of the establishment oj puberty ; and after that period, in the female, — (A), in the active state of the gland ; (B), in the passive state. III. Diseases affecting the rudi- mentary organ in the male. IF. Diseases of the nipple. The diseases of an organ composed essen- tially of glandular structures have here to he described. The mammary gland is classed with those termed racemose ; hut it differs from every other organ in the body of a similar class, inasmuch as it only arrives at maturity when its function is to be subservient to the nourishment of the offspring. In its perfection it appears, normally, only in the female sex, and even then it does not become developed until the internal organs of generation are capable of performing their functions. Hence, to describe systematically the diseases of ‘the breast, it is requisite to treat of them not only in reference to sex, but also in relation to the different periods of life at which certain dis- eases appear. Briefly then, from a histological point of view, they occur: (a) in the rudimentary state of the gland ; ( b ) in its mature state ; (c) when it has become a secreting organ ; (d) during a state of degeneration. I. In the rudimentary period of the gland the tissues composing it are rarely liable to morbid derangement. Usually, soon afterbirth, especially in male infants, the rudimentary nipple and the skin of the region within the zone of the areola become slightly elevated and of a pink hue. In some infants a secretion, slightly milk-like., oozes from the ducts. In this state, the injudicious rubbirg practised by the attendant excites inflammation, which, if not arrested by desistance from that pernicious interference, may advance to suppuration. When that happens, the usual local application of warmth and moisture suffices to give relief. II. About that age, in both sexes, when the development of the generative organs advances with greater rapidity to maturity than in early life, the breast-gland enlarges, and may be painful, thus causing anxiety to the individual. Usually, symmetrical development takes place in the female ; but, when the gland of one side takes precedence of that on the other, the circumstance need only he regarded as a departure from the ordinary rule, for no trouble will result, and in due time both will attain their normal pro- portions. In the male, pain or uneasiness some- times occurs for a few days about this period, very often excited by the pressure of the dress. The removal of this cause is sufficient to arrest further mischief. hi the female the development of the breast having reached maturity, the gland is now assrv. BREAST, DISEASES OF. 107 ciated by sympathetic influences communicated through nervous stimuli -with the functions of the pelvic generative organs. This physiological fact should ever he remembered when investi- gating the nature of the morbid affections of this organ. In a clinical point of view, it is essential to examine the diseases of the breast under the :,vo states before mentioned, namely, (A) whilst tho gland is undergoing metamorphosis into a secreting organ, and during lactation. (B) As a mature gland, but passive as regards its function. Glancing at the various morbid states of the body of the gland as a whole, they may be di- vided, primarily, into two groups : — the Func- tional derangements ; and the Organic or histo- logical diseases. We will now proceed to discuss these affections, as they are presented at the different periods mentioned above. A. After conception the breasts soon begin to enlarge, and at their borders and surface minute pisiform indurations may be felt. Occasionally, but very rarely, this normal increase in bulk is attended with considerable pain and irritation extending throughout the nervous relations of the gland. The pain is referred to the back, neck, inside of arms, shoulders, and side of thorax, over, in fact, the area of distribution of those filaments which pass off to the skin from the same dorsal branches of the spinal nerves, the intercostals which send filaments to the breasts. It affords a good example of reflected irritation. This state usually occurs after the first conception, and in women of excitable, nervous temperament. Attention to ordinary hygienic measures during the progress of the metamor- phosis of the organ into a secreting gland, with its accomplishment, affords relief to the pain. In large, lax, pendulous breasts, the separate lobes of which each is composed may excite apprehension of the existence of a tumour. But tumours composed of new tissue are so extremely rarely developed during pregnancy, that the greatest caution must be exercised in the diagnosis of their nature. Very rarely, no change whatever in the breasts accompanies pregnancy, under which, circumstances there is an absence of the secre- tion of milk after parturition — Agalactia. Inflammation of the Breast. — Mastitis. ^Etiology. — Before lactation, inflammation of the breasts is very uncommon. Afterwards, on the contrary, it is very frequent. This morbid state is often the result of carelessness or ignorance on the part of the nurse. The slightest unusual fulness or ‘knottiness’ discovered after the infant has been sucking, and when the ducts and their terminal secreting vesicles should be empty, requires immediate attention. Conges- tion of a lobule or lobe with milk produces the nodule, and the cause of the impediment to its escape should be sought fcr. The state of the nipple is generally the cause of the difficulty. Either the orifice of a duct may be obstructed by epithelium, or a superficial ulceration around one exists. The morbid or defective states of the nipple are the most fruitful causes of in- flammation and its results in the breast. Pro- phylactic measures should always be instituted when thsre is reason to fear that a defective development of the nipple will interfere with the free flow of the milk. Even with some mothers it would be advisable to resign the duty of suckling, rather than subject themselves to the almost certain misery arising from per sistent and ineffectual attempts to do so. In- flammation, generally passing on to suppuration and abscess, either within the body of the breast or on its surface, is most frequent in primipara, and within the first month after parturition. Symptoms. — First, hardness is felt, ‘a knot, in some part of the substance of the organ ; this enlarges, and may attain to considerable dimen- sions before causing pain or even uneasiness. Next, pain is felt during suckling; this increases each time the infant sucks, and ‘ the draught ’ is produced. The integuments then become pink, and afterwards red, tense, shining ; more or less cf the breast feeling very inelastic, Srm, prominent, and heavy. Fain is now often very severe, a'nd great constitutional disturbance is excited. In the centre of the redness the skin becomes of a purplish tint, around this it is cedematous, and with the finger, at the centre of the purple zone, a slight depression and softening spot can be detected. An abscess now exists, and in pro- portion to the quantity of pus fluctuation is more or less marked. At the purple centre the cuticle has probably by this time separated from the cutis, and a vesicle containing serum, either yellow or slightly tinged with blood, indicates that ulceration of the cutis is proceeding, and that the pus will soon escape. The above is a brief description of the objective signs indica- ting the morbid processes noticeable in all cases of local inflammation advancing to and ter- minating in suppuration and abscess. It is not possible to state with any degree of exactness the period of time required for the accomplish- ment of these definite changes. It varies accord- ing to so many local and constitutional circum- stances, that it would be idle to attempt to pre- dict any certain definite period or stage for each phase. It will be more useful to describe the treatment by which the progress of the disease may be arrested or limited and its painful course mitigated. Treatment. — Great attention should always bo given to the nipple of primiparse. In many women, this important division of the gland is very small and undeveloped, perhaps only on one side, so that the infant, especially if not very strong, has great difficulty in obtaining sufficient milk to appease the appetite, and its efforts cause pain in the part. This circumstance induces the mother to prefer suckling most with that breast the nipple of which is perfect, and the infant soon appreciates the advantages of that side. Consequently the gland-tissue of that breast having the imperfect nipple becomes congested. Every time the infant sucks it becomes worse, more and more pain and irritation are excited, the orifices of one or more of the ducts in the nipple become blocked, and perhaps the infant refuses to suck the breast. But the gland becomes more and more distended, the nipple deeply buried, until at last suckling is impracticable. Probably none of tnese increas- ing troubles have been stated to the attendant surgeon ; and, when he is consulted, he finds the BREAST, DISEASES OE. 168 breast to be in the state above described. The perfect development of the nipple should be always a subject of anxious solicitude on the part of the obstetric practitioner. If that organ be imperfect, precautions should be taken to prevent the gland itself from becoming congested, and if the infant cannot draw the milk sufficiently, some mechanical means should be employed to effect this object. The nipple itself should be care- fully examined. If its end be more than usually coated with a white secretion, or the openings of the ducts seem to be obstructed with an excess of epithelium, attempts may be made to remove it. If minute abrasions, ulcers, ‘ cracks or chaps,’ are visible between the rugae, some soothing ap- plication should be used. Erequent ablution with warm water, even the contact of a little moist cotton fibre covered with tissue gutta-percha, is very preferable to the dry dress ; or, if there be much secretion from the glands on the nipple, after cleansing its surface, .some dry powder, such as carbonate of magnesia, oxide of zinc, or starch powder is beneficial. When actual congestion of the gland-tissue exists, mechanical means should be used to reduce it. Supporting the gland with strips of plaster and a bandage is sometimes very useful. W hen inflammation is excited, local applications of warmth and moisture are indicated, and the con- stitutional condition of the sufferer demands special attention. When suppuration has taken place, its relation to the adjacent parts and the exact site of the abscess when formed should be carefully examined. Great diversity in the pro- gress, duration, and sufferings of the patient depends upon the locality of the pus. It may be situated over the body of the gland, within it, and beneath it. When overlying or superficial to the body of the breast, the course of the disease is rapid, the pus soon points and escapes, and the wound heals. In those cases the constitutional disturbance is usually trifling. Water-dressing before and after the escape of the pus is pre- ferable to the heavy poultices usually employed. The entire organ may be supported with strips of adhesive plaster and a bandage during cica- trisation. But a bandage dexterously applied should be always used. Both the local and constitutional symptoms are much more severe when inflammation affects the body of the gland, and pus collects between its lobes. The progress of the disease is tedious, pointing of the pus slow, and the exact spot at which it may reach the surface is for a long time doubtful. In the majority of cases it makes its way between the ducts and reaches the surface near the areola or within its area ; usually to the sternal side of the nipple, where the gland tissue is thinnest. The surgeon should note this fact, for as soon as he can detect a softening of the cutis, by ulceration, he may, with advantage, make an incision at that spot, and thus give immediate relief by facilitating the escape of the pus. In these cases recurrent abscesses are not uncommon, and therefore the incision should be free, and its premature closure by adhesion must be avoided. All incisions should he made in a line parallel to the course of the ducts, never transversely to their axis. Manual pressure to hasten the escape of the pus is not admissible, the natural contractility of the tissues using quite sufficient for the purpose. When the abscess forms behind the breast the local appearances are quite characteristic. The gland itself seems little involved, but it is pushed prominently forwards and seems to repose upon a cushion of fluid. To the touch the elasticity of the swelling is very striking, and, without pro- ducing additional pain, a slight bulging of the walls of the abscess may sometimes be produced at the periphery of the gland when, with the palm of the hand and outspread fingers, com- pression is made from the front backwards against the thorax. The patient should bo re- cumbent. The pus in these cases often points somewhere around the borders of the body of the gland. During the time occupied in the formation of a mammary abscess and its local treatment, the constitutional powers of the patient must he well supported, and the general health maintained by every means. The sequela of suppuration in an organ com- posed of so much connective-tissue, and endowed with its peculiar function, frequently cause great trouble. They are protracted induration, sinuses, and fistulae, through which last the milk per- sistently escapes. Induration of the whole or part of the breast subsides when lactation ceases, and the organ in due time resumes its healthy state. Sinuses and fistulae may require incisions, hut the ordinary plan for their cure should be adopted before having recourse to a treatment often involving much subsequent deformity. At the time for weaning the infant inflamma- tion rarely occurs. Considerable milk-congestion of the secreting structure may sometimes produce irritation and inconvenience, to he re- lieved by mechanically drawing the milk in just sufficient quantity only to diminish the fulness. Galacticele. — An accumulation of milk, to which the above term is given, forms a tumour in the connective-tissue of the organ, and results from the Imrsting of a lactiferous tube. The swelling always appears first during lactation. It may vary in size from time to time ; sometimes enlarging rapidly as suckling goes on. Two varieties are mot with. In one form there is a single swelling near the nipple, quite superficial, and quickly recognizable by its objective signs. In the other there may be several swellings dis- tinguishable in the substance of the gland, as well as on its surface, all of comparatively small size, very firm and globular. In the same gland they vary very much in size, and in the degree of resist ance they offer to manipulation. The discrimi- nation between these tumours and others in the breast is easy, if the surgeon is able to ascertain with exactness that the swelling appeared some- what suddenly during suckling, and that its size varied conformably with that function. In cases of long standing, the contents of the cyst become solid in proportion to the quantity of the fluid constituents of the milk absorbed, and the cyst wall itself is very often rigid and 6ven may become gritty. Treatment. — The treatment of this malady consists in cutting into the cyst, removing it j contents, and allowing the wound to heal b 7 granulation. BREAST, DISEASES OF. B. The diseases affecting the mature gland, in its passive state, from the age of puberty to that period, of life when the catamenia cease, may- be grouped as follows : — the functional affections, or those which are characterised by changes in the secreting portion of the gland, accompanied by more or less induration, inconvenience, and pain; the organic, or those diseases characterised by some new-growth, formation, or tissue-struc- ture altogether a superaddition to the organ, and growing within its sphere of nutrition, often resembling, more or less, gland-structure in composition ; and others the minute elements of which are nucleated cells of various shapes, de- finitely and diversely arranged. In this state of the breast inflammation rarely occurs. Nevertheless, both the acute and chronic varieties of that morbid process ter- minating in abscess are met with, and careful discrimination is necessary to avoid mistaking such diseases for tissue-tumours, especially in patients above forty years old. The history of the case, tactile examination, and the variations occurring during the progress of the affection, commonly suffice for the detection of such cases. The treatment should be the same as for abscess in general. Functional Derangements. — The functional derangements of the breast in its passive state demand special attention. They are charac- terised by a peculiar activity of its secreting portion, which undergoes structural changes of u specific kind. When the tissues composing a mature gland, but perfectly passive, are ex- amined with a microscope, the csecal termina- tions of the ducts are scarcely perceptible, and little else than fibre-tissue is seen. Here and there, perhaps, cseci may be detected con- taining minute aggregations of epithelium. Out when, under some sympathetic excitement, with derangement of the functions of the pelvic generative organs, the secreting cells of the gland become active and are distended with epithelium, they induce more or less enlargement of the breast. But of such affections there is this important fact to be noticed. The whole breast need not be necessarily involved. On the contrary, one lobe only may be excited, and when this occurs the existence of a tumour is declared. When, after excision, such enlarged lobes are carefully examined with the micro- scope, normal gland-tissue is seen, the caecal ends of the ducts are readily recognised, and their immediate association with the excretory ducts may be observed. The former are gorged ■with epithelium ; and true gland-tissue, less its peculiar secretion, has been developed. Symptoms. — Associated with this state of the tissues ofthebreast, the patienteomplains of pain, both locally and spread over a very wide area. To express as briefly as possible the superficial regions affected and over which pain is felt, the reader must be reminded of the distribution of the nerve-filaments of the lower cervical plexus, and of the dorsal from which the second, third, fourth, and fifth middle and anterior intercostal corves pass off From these, special filaments are distributed to the breast ; and to the site of exit of one or more of them at the intercostal foramina, the course of the pain is referred by the patient. The skin of the neck, shoulder, side of thorax, and inside of arm receives filaments from the same source. Hence an explanation of the widely-diffused pain. It is of the first importance to discriminate between this state of the gland-tissue and sub- stantial new growths, especially because the latter cannot be removed by natural processes, whilst the former most probably will be. The objective signs are the following ; — to the touch the excited gland-tissue is nodular, irregular over its surface, ranch identified and mingled with the body of the organ. If the whole breast be large and relaxed, the tips of the fingers may be insinuated between the borders of the indu- rated lobe and the lobes not affected. If the entire body of the gland be morbidly firm, it feels like a disc-shaped mass lying on the thorax, under the borders of which the fingers can be pressed. Occasionally, at one or more spots along the periphery of the gland irregular nodules are perceptible, projecting into the con- nective-tissue around them. When one lobe is affected, the shape of the induration correspond- ing with that of a lobe, namely, broad at the periphery and gradually narrowing towards the areola, may be detected. Pain as a subjective indication is of great assistance in the diagno- stication of these cases ; but the source and course of the pain must be carefully traced. Generally manipulation of the induration pro- duces increased pain ; occasionally touching the induration, even however gently, is intolerable, and persistence in or repetition of the act strongly opposed by the sufferer. Light pres- sure should be made over the intercostal fora- mina, both the middle and anterior, when the pain excited thereby will correspond with the nerve-filaments of the affected lobe. Usually, pressure along the upper dorsal spinous processes excites pain also. The morbid affections above described occur in single women, married but sterile females, and young widows, at ages be- tween twenty years and forty. More or less disturbance of the catamenia co-exists, either in relation to the frequency or quantity of the discharge. The patient complains of languor, inability for bodily or mental exertion, and is desponding and often alarmed for the possible consequences of the affection suggested by sym- pathising friends. She becomes irritable, restless at night, loses appetite for food, as well as all desire for social enjoyments, and becomes highly susceptible and emotional. Diagnosis. — An exact diagnosis of these histo- logical changes maybe made if the manipulator examines the organ methodically. He should, first, gently grasp the induration between the thumb and fingers, when it will be distinctly ap- preciable. Afterwards, placing the palmar sur- face of the fingers over the surface of the breast and gently pressing backwards against the thorax, the induration cannot be detected. Should there still remain any doubt on the subject, let the patient recline on her opposite side on a sofa, and in this posture, if there exists a substantial new-growth, the integument is usually elevated by it. Treatment. — The treatment of these eases consists in attention to the general health. Every BREAST, DISEASES OF. PO hygienic direction should be enjoined, and such medicines administered as conduce to its im- provement. Local soothing applications are usually futile, and, except in those cases of ex- treme pain, are not advisable, since it is desirable to avoid manipulation of the part, and the frequent recurrence of the patient's thoughts to it. Should the gland be heavy and pendulous, a suspensory bandage, as thin as possible, may be adjusted. New Formations. — We shall next describe the diseases of the mature gland arising from the development of new formations — either of tissues constituting new-growths; or of conditions causing collections of fluid of distinct and specific kinds. All of these may be thus arranged in three groups : — first, the fluid tumours ; second, the solid: and, third, those composed of both solid and fluid. A. Cysts. — The fluid tumours, commonly termed cystic , consist of a membranous sac with its contents. Now, calling to mind the histolo- gical divisions of the breast, and dwelling on the structural differences between its parts, the secreting apparatus and the excretory, there is little difficulty in assigning to the cysts their true histological affinities. Thus there are cysts associated with the secreting apparatus ; others with the excretory, the ducts ; and some due to the extravasation of the gland's secretion, the milk, into the connective tissue. Effusions of blood also give rise to the development of cysts, either in- dependently of other diseases ox associated with them. Another variety of cyst is produced by the development of entozoa, notably of echino- coccus hominis. An ordinary examination of the fluid derived from these cysts at once es- tablishes the fact that heat and the admixture of nitric acid produce coagulation in that abstracted from some of them, whilst that from other cysts remains unaffected by the treatment. The cysts are thus divisible by the nature of their contents into two distinctly defined groups : — a. Those containing fluid without the admix- ture of any coagulable element. h. Those enclosing fluid which does contain coagulable material. Other characteristics of these two fluids are not less conspicuous. From an objective point of view all cystic tumours of this gland may be classed in two groups, thus : — first, those associated with its ducts, the evidence of which is afforded by the escape of fluid at the nipple ; and secondly, those not connected with the ducts by any such evi- dence. The following tabular arrangement will place before the reader, at a glance, all the varieties of cysts met with in the breast. I. Cysts associated with the ducts, communi- cating and connected with them. 1. Containing milk. 2. Enclosing growths ; with serum, eo- agulahle and often tinged with blood : — a. Adenoid growths. b. Granulation cell-growths. e. Cancer. Cysts not connected with the ducts. 1. Surrounding effused blood, 2. Enclosing milk. 3. Simple cysts. Fluid not coagu 4. Entozoon cysts. / lable. 5. Investing growths; with serum co- agulable, tinged with Llood and containing cholesterine : — a. Adenoid growths. b. Granulation cell-growths. c. Cancer. 1. We have described above, under the name galaciicele, a tumour observed during suckling and composed of milk. But, occasionally, the sur- geon is consulted about a swelling which, at first sight, would seem to have no reference to that function. Nevertheless the milk, or all that remains of that secretion, constitutes its entire bulk. If exact enquiry be made, the patient states that a tumour has existed, unaccompanied by pain, from the period of the last weaning, perhaps not haring been observed until the gland ceased to secrete, and that its size slowly di- minished until a certain period, since which it has remained of unvarying bulk. This decrease is due to the absorption of the serum of the milk, and the solid parts remain. The cyst should bo incised, the contents removed, and the wound allowed to heal by granulation. Cysts containing the solid parts of the milk are sometimes associated with perfectly new growths of the glandular type. 2. True scro-cysts, that is to say, a collection of serum circumscribed by a fibrous membrane, are frequently met with, and are most commonly associated with adenoid, granulation, and can- cerous growths. They occur in the breasts of middle-aged women. The fluid which these cysts contain is sometimes quite clear, and of a yellow tint ; at others it is tinged with blood- colouring matter, and is turbid. It always con- tains some constituent coagulable by heat and the admixture of nitric acid. These are the exudation-eysts of the mammary gland. After the fluid has been removed with a trocar and canula the cyst soon refills. 3. Other cysts containing a fluid like serum, until its composition is carefully examined, are developed in the breast, and are probably asso- ciated immediately with the secreting part of the gland. For the sake of identification the writer would designate them mucous cysts. The con- tained fluid is not coagulable by either heat or acid. Its colour is brown, more or less in- clining to a greenish hue ; it is opalescent, of variable specific gravity — about 1020, rather greasy when rubbed between the fingers, and exhibits an alkaline reaction. When sufficient quantity is collected in a test-tube and allowed to cool, in a few hours the lowermost stratum of the fluid becomes clearer than the upper. The uppermost always remains opalescent. If a little of this last be examined with a microscope, oil globules are seen, together with the bodies called colostrum cells. The greasy nature of the fluid can he detected by smearing a drop of it on a piece of glass. The development of these cysts is not very common. We may here remark that they seem to have escaped the observation of surgeons, as no special notice of them occurs in the most recent monographs. Yet they are so distinctly separated from all the other cysts which arc 'BREAST. DISEASES OF. formed in the breast, in respect of the composi- tion of their fluid contents, their progress, and their prognosis, that they constitute a marked, distinct, and isolated class We meet "with them in the breasts of single -women, in married but sterile females, and in widows between forty and fifty years of age. Usually they are acci- dentally discovered in any quarter of the gland when about an inch in diameter. Their shape is globular or ovoid ; to the touch elasticity is the main feature, and if sufficiently large and superficial, fluctuation may be detected. In some instances the tips of the fingers may be insinuated into a sort of furrow around them. Pain is rarely complained of. The treatment consists in emptying the cyst with a trocar and canula. After this the fluid does not again form. These cysts usually appear singly and in one breast only, but the writer has seen a patient in whom they were multiple and on both sides. 4. Cysts containing blood — hczmatomata, are very rarely formed in the breast, except in association with some new-growtk from which blood, or more often bloody serum, oozes. 5. True entozoa-cysts are developed in the breast. They- are certainly rare, and cannot be distinguished from other cysts until incised. Extirpation by excision is the speediest means of effecting a cure. B. Solid Tumours. — We have next to de- scribe the solid tumours. These are essentially new growths of tissue superadded to the normal gland. Generally, therefore, a characteristic feature of the existence of such growths is an in- creased bulk of the affected organ ; another, the firmness or resistance to pressure with the fingers when contrasted with the group of tumours be- fore described. The solid tumours have long been classed in regard to their local and constitutional effects, and their results on the life of the indi- vidual affected with them, into two groups — the innocent or harmless; and the malignant or life- destroying. 1. Adenoma . — In the first class are placed those growths more or less closely resembling in their tissues those composing the glandular structure of the breast. Various terms have been assigned to these tumours, namely, Chronic mammary tu- mours, Pancreatic Sarcoma, Tumeur adenoide, Corps fibreux, Hypertrophie partieile, Mammary glandular tumour, Fibroma, Adenocele. Their composition is chiefly fibre-tissue, the cseci or acini of secreting structures, with more or less distinctly marked traces of ducts, being inter- spersed throughout the mass. The elementary nucleated cells are those of the gland and fibre- tissues. Adenomata are developed in the breasts of young, unmarried women from the age of puberty upwards ; rarely after thirty, but very commonly before that age. They may be intraglandular, occupying the substance or body of the gland, and having the normal gland-tissue investing them. In other instances they seem to be at- tached by a kind of pedicle either to its surface or margin. In every instance they are placed within the fascial investment of the organ. When attached, as just described, their remark- able mobility, slight lobulation of surface, and firmness, coupled with the youth of the patient, are sufficient indications of the harmlessness of their nature. Usually they occur singly and in one breast; they may be multiple and in both breasts. The only means by which they can be removed is excision. However large the tumour, its removal should be always attempted without cutting away any portion of the normal breast. In most cases this can be done, especially if the patient be youthful and the growth of medium size, even should it be developed in the body of the gland aud extend through it to the pectoral muscle. After thirty-five years of ago it is expedient to remove the breast as well. IVant of space precludes a lengthened histo- logical description of these growths. It must suffice to state that a section shows a solid, uni- form surface, divided into lobes and lobules by fibrous septa, sometimes slightly broken up by fissures or clefts in which there appears a little clear tenacious fluid. The growth is often very succulent, at other times only moist ; its hue may be greyish, yellow or almost white. Its vas- cularity is scarcely perceptible. The prognosis of these cases is invariably favourable. In many instances excision is not necessary, and the surgeon must be guided in recommending an operation by the exigencies of the case spceially under observation. 2. Fatty tumour . — Lipomata or masses of adipose tissue are developed in the breast, or rather in relation with it, to speak with accuracy. They are characterised by the usual indications, and require no special mention. 3. Ncevus . — It may be questioned whether nsevus, or a growth of true trabecular vascular fibre-tissue, is ever developed in the substance of the breast, that is to say, in the gland-tissue. The integument around the mammilla may cer- tainly be so affected in early life before the de- velopment of the gland, and a subcutaneous naevus may exist at the site of the future organ ; but to describe such a growth, in a girl of six years old, as a recent writer has done, as an example in which the whole organ was like a sponge and as large as half an orange, must be regarded as an error in pathology. 4. Fibro-plastic . — Under the term ‘fibro- plastic’ we include a group of new-growths composed of elementary nucleated cells of a fusi- form or oval shape, disposed in a stroma of more or less fibre-tissue. They are developed in women of middle age, increase rapidly, and after excision are liable to grow again. 5. Colloid . — Colloid growths are very rarely met with in the breast. They appear in middle life, and are not distinguishable from other solid tumours until after excision. 6. Carcinoma. — Carcinoma, commonly called cancer, is developed in the breast in two distinct forms. The first, and most common, is that variety which is due to infiltration of the normal tissues of the gland by the elementary cells of cancer. It constitutes the scirrhous variety, the carcinoma fibrosum of the present day. The second is that kind which is produced by the development of a mass of true cancer-growth, and is termed tuberous, often medullary. Both varieties are met with in women after forty years of age, but the first much the most frs- 172 BBEAST. DISEASES OF. quently. Previously to that age the disease is rare ; from forty to fifty it is most commonly seen ; and it becomes relatively less frequent as age advances. A larger number of married women are affected by it than single, and prolific women who have suckled their children are quite as prone to the disease as the sterile or those who have not suckled. Symptoms. — Scirrhous cancer commences in any region of the mammary gland, although most frequently perhaps in the axillary segment. A small, firm nodule is usually accidentally dis- covered, without the attention of the patient having been attracted to it by pain. Barely, the whole organ is simultaneously infiltrated, but most frequently one lobe only is affected. The infiltration is often central in the body of the gland, especially when the organ is atrophied, and the reverse occurs when the ex- treme edge of a lobe is affected at its periphery. The infiltration may steadily increase until the whole breast forms a rigid, solid mass, but most frequently the larger part of the organ remains unaffected. The disease gives rise by its con- traction to much deformity of the region, to dimpling, corrugation, and irregularities of the otherwise rotund integumental surface. The nipple, just in proportion to the effect of the growth upon the ducts, becomes retracted or drawn towards the tumour. Such are the ordi- nary objective signs of infiltrating cancer in its early stage. The progress made by the disease is subject to very remarkable variations in differ- ent individuals, and the stage above described may be long delayed. In some cases many months or even years may elapse before the growth assumes any grave importance. Sooner or later, however, the integument over the growth becomes adherent to it, infiltrated, and red, and advances towards ulceration. An ulcer now forms, the edges of which are everted, ragged, and attached to the growth beneath. A hole extending into the tumour becomes deeper and deeper ; ichorous discharges, more or less profuse, continue without much pain ; and the patient becomes at last worn-out, or succumbs to the ravages of a cancerous growth in a vital organ. The tuberous variety commences in a small circumscribed, globular nodule in the body of the gland ; grows rapidly ; separates the lobes of the organ; extends equally in all directions ; and becomes adherent to the skin, which commonly sloughs and allows of a protruding, fungating mass. In both varieties the axillary lymphatic glands sooner or later become involved in the disease, which may also spread to those in the neck and within the thorax. Treatment.— Local applications exert little if any influence on the growth of cancer, but certainly those which reduce the local tempera- ture are the best. The vital powers of the patient should be supported as much as possible by hy- gienic measures, and especially by ferruginous tonics. The removal of the primary growth before the contamination of the lymphatic system is of great importance, but whether by excision with a scalpel, or by means of escharotics, space vill not admit of discussing. The writer inclines to the first method in the majority of cases. C. Mixed Tumours. — To the group of mixed tumours belong : — 1 Those composed of cysts, intracystic growths, and solid interspe'rsed masses of new tissue. 2. Granulation cysts — cysts with growths attached to their walls, the elemen- tary tissues of which resemble those of ordinary granulation-growths — whence the term applied to them. 3. Cysts, so-called, often formed upon the surface of cancers, in consequence of the slow exudation of serum from the growth itself. 1. Tumours of the first elass belong patholo- gically to the group of adenoid formations, and although they differ so remarkably in their ex- ternal objective appearances, they are, when un- alloyed with other growths, perfectly harmless. The sero-cystic disease of Brodie, and the pro- liferous cysts of Paget belong to this class. 2. The granulation-cystic growths constitute a class of themselves. It is only of late years that attention has been attracted to them. They are rarely met with, and when pure are unattended by untoward circumstances. 3. To the third class belongs a group of cases thoroughly cancerous in their nature, and differing only from the ordinary forms of that disease by the accidental formation of cysts. See Tumours. III. Diseases of the Male Breast. — The male has sometimes a well-developed mammary gland, and the part is subject to the same dis- eases as the female. But the simple enlarge- ment of the organ is harmless, and should not be interfered with. At the age of puberty the mammary region often becomes painful, owing in part to the pressure of the dress upon the mam- milla and the rudimentary organ. Inflammation followed by suppuratiou has been observed at this time. TV. Diseases of the Hippie. — A defective formation of the nipple is of grave importance, and when it exists measures should bo adopted to assist its elongation. This is to be done bv using an exhausting glass, such as those em- ployed to empty the gland of milk. Inflammation and its effects produce- much suffering, and at the period of suckling frequently excite deep-seated mischief. The small ulcers, called ‘ cracks,’ ' chaps,’ &c., which form between the rugae on the apex and sides of the nipple, may be cured with an application of water-dressing, or by powdering the part with carbonate of mag- nesia or oxide of zinc, far more readily than with ointments. Pendulous cutaneous growths occur on the nipple, and should be excised. Cystic follicular tumours are sometimes seen within the zone of the areola. See Hipple, Dis- eases of. John Birxett. BREATH, The. — The expired air, or what is familiarly termed the breath, is important both from an aetiological and a clinical point of view, and the object of the present article is to present a brief summary of the main facts relating to this subject, with which, for practical purposes, it is necessary to be acquainted. 1. The mtiological relations of the breath will be more appropriately discussed under the gene- ral subject of aetiology (see Disease. Causes of), but a few of the more striking examples of the manner in which it affects the health may b* BREATH, THE. 173 given here. It is well known that the expired air, if re-breathed by the same individual with- out having been purified by a proper admixture with atmospheric air, will produce serious effects upon the economy, and will ultimately lead to death by asphyxia. Again, the breath of a number of persons collected together in an ill-ventilated place may prove injurious tc such individuals ; the impure atmosphere thus generated tends to lower the general health, to retard the develop- ment of the young, to increase the virulence of infectious diseases, and to predispose to pul- monary affections. Indeed, some writers regard re-breathed air as one of the most prominent causes of pulmonary phthisis. Further, un- doubtedly the expired air is a most important channel by which the poison of different infective diseases — for example, that of measles, scarlatina, or diphtheria — is conveyed frcm cne individual to another. It has been affirmed that phthisis can be transmitted directly in this manner, but adequate proof of this statement is entirely wanting. 2. In a clinical point of view, the expired air may afford useful information in diagnosis ; or it may present characters giving important indi- cations for prognosis and treatment. It might be requisite in different cases to submit the breath to a more or less complete examination, and the following outline will serve to suggest the particulars to which attention should be directed in this examination, and to point out the practical uses which it may serve. a. The breath has been made use of to distin- guish between real and apparent death. For this purpose a delicate feather or a light is held before the mouth or nostrils, and it is noted whether either of these is disturbed ; or a cold mirror is placed before the mouth, when, if breathing is going on, its surface will be clouded by the moisture condensed upon it. These tests are, however, not considered very reliable. b. The temperature of the expired air may be important to notice. In some conditions it becomes exceedingly cold, and this may he readily perceptible to the hand, the breath having a chill feel, or it may be visible in con- sequence of the moisture in the expired air being condensed, even when the surrounding atmo- sphere is warm. This phenomenon is observed, for instance, in the collapse-stage of cholera. On the other hand, the temperature of the breath may he raised more or less, as in febrile diseases. c. Chemical examination of the breath may prove of service, and it is probable that this might afford useful information, if it were re- sorted to more frequently than is the custom at present. In the first place this examination may be employed to determine the proportion of car- bonic acid present. In certain affections, as during an attack of asthma, or in cases of exten- sive bronchitis, the amount of carbonic acid in the expired air is moro or less increased ; in others, such as in the collapse-stage of cholera, this ingredient may be very deficient. Again, chemi- cal examination of tho breath may reveal the presence of a poison in the system, introduced from without, for example, hydrocyanic acid. It has also been employed to show the existence of deleterious products generated within the body, especially in cases of renal disease. It is affirmed that ammonia may he detected in the breath in some eases of this kind, by holding a glass rod dipped in hydrochloric acid before the mouth, the ammonia being a product of the de- composition of urea. d. Microscopic examination of the oxpired air has been attempted, but at present no results of practical value have been obtained. c. The odour of the breath is the most impor- tant character demanding attention in a prac- tical point of view. It is easily recognised, and the practitioner should always he on the alert to notice the smell of the breath of a patient, as this often affords material aid in diagnosis, and may even reveal certain morbid conditions which otherwise are liable to be entirely overlooked. Besides, patients not uncommonly seek advice on account of ‘ foulness of breath,’ as a symptom for w'hieh they require special treatment. The following summary will indicate the principal circumstances under which this clinical phenome- non may prove of service in diagnosis, and in the course of the remarks it will be pointed out in what conditions the breath is particularly offensive. At the outset it must be observed that in some individuals the breath seems to have naturally a more or less disagreeable odour, which cannot be referred to any particular cause, and this amounts occasionally to extreme foulness. In females this may only be noticed at certain, periods, and in some instances it seems to pass off in course of time. Again, it must be borne in mind that the breath is fre- quently unpleasant, either temporarily or con- stantly, from persons eating certain articles of food, or indulging in certain habits, such as excessive smoking, chewing tobacco, &c. (i.) The odour of the expired air maj' aid in re- cognising poisons in the system. The smell of prussic acid or laudanum, for instance, may he revealed when either of these is present in the stomach. Alcohol, however, chiefiy demands at- tention in this relationship. In cases of acute al- coholic poisoning, the odour of the alcohol or of its products is at once apparent ; and in persons who are found in a state of unconsciousness, the cause of which is not known, the smell of the breath is made use of as one of the diagnostic, signs of drunkenness, though it must be taken with great caution. It is in the chronic forms of alcoholism that the breath gives the most valu- able information. In very marked cases of chronic alcoholism it has an intensely foul odour, which is quite characteristic; but it gives extremely important indications in less confirmed case«, where the other symptoms of alcoholism are not so apparent; and especially does it enable us to de- tect dram-drinkers, and to explain the symptoms of which they so frequently complain. These per- sons, if their habits are inquired into, generally give themselves an excellent character for tem- perance, and seem entirely to forget that those with whom they come into contact are endowed with organs of smell. Again, the breath may reveal the presence of certain metallic poisons in the system, of which mercury is the most impor- tant example, hut lead may also affect its odour. The expired air is said to present the odour of ammouia in exceptional instances of uraemia. 174 BREATH, THE. due to the exhalation of carbonate of ammonia derived from the decomposition of urea. (ii.) The breath has a peculiar, or more or less disagreeable odour, in connexion ■with several diseases. That which is associated with the febrile condition is well known. In various dis- orders of the digestive organs the breath is often very offensive, but it is not practicable to refer any particular odour to particular diseases of ei ther of these organs ; it may, how ever, be affirmed that an unpleasant smell is frequently associated with habitual constipation. In cases of stercora- ceous vomiting the breath mayhavea faecal odour. In this relation it may be mentioned that in some cases of phthisis the writer has noticed a sickly smell of the breath which is quite charac- teristic, and which seems to depend upon the state of the stomach. In cases of cerebral diseases also, the breath often becomes exceed- ingly offensive, on account of the condition of the alimentary canal. Local morbid conditions about the mouth, throat, or nasal cavities con- stitute a most important class of affections which influence the odour of the breath ; in many cases it becomes extremely foul, and may be quite peculiar in its characters. Among these condi- tions should be specially mentioned want of clean- liness of the mouth and teeth ; decayed teeth ; dis- eased hone in the mouth or nose ; ulceration or gangrene about the mouth, especially cancrum oris, and gangrenous ulceration along the gums ; suppuration, ulceration, or gangrene in the throat, either of local origin, or associated with syphilis, scarlatina, diphtheria, &c. ; ulceration of the nasal mucous membrane, and chronic ozcena ; and malignant disease. The smell of the breath is of special value in drawing atten- tion to some of these conditions, for they may exist without giving rise to any local symptoms whatever, and the patient may be quite uncon- scious that there is anything wrong. Several striking illustrations of this statement have come under the writer’s observation. Again, certain conditions of the respiratory organs are liable to affect the odour of the expired air, and may render it unbearably fetid. Among these may be mentioned sloughing ulceration about the larynx, pulmonary gangrene in any form, and the decomposition of retained morbid products in dilated bronchial tubes or in certain cavities. Here, again, the smell of the expired air may reveal what otherwise is liable to be entirely overlooked, and especially when the patient coughs, so as to expel some of the retained air out of the lungs. Lastly, the breath may have a peculiar odour in some special diseases, such as pyaemia and diabetes. Treatment. — It is only intended here to offer a few remarks as to the treatment of foulness of breath. The first great indication is, of course, to seek out the cause of this symptom, and endeavour to remove or remedy this, by which in a large proportion of cases a cure may be readily effected. The habits should be duly regulated ; the mouth and teeth properly cleansed ; the ali- mentary canal maintained in good order ; and any special affection requiring treatment attended to. When unpleasant breath depends on the stomach, it may often be improved by taking charcoal powder or biscuits, at the same time I BRIGHT’S DISEASE. remedies being employed suitable for the parti- cular affection present, and calculated to promote the functions of the alimentary canal, the bowels being also kept freely open. AVhen the bad smell depends on local causes, it may be dimi- nished by the use of antiseptic mouth-washes and gargles, such as solution of Cond/s fluid, carbolic acid or creasote. Antiseptic inhalations are indicated when the respiratory organs are accountable for fetor of breath. Frederick T. Roberts. BREATHING, Disorders of. See Respira- tion, Disorders of. BRIGHT’S DISEASE. — The term Bright s Disease is now universally recognised as generic, and as including at least three different dis- eases of the kidney. Each of these maladies in- volves chiefly one of the individual structural ele- ments of the organ, and only secondarily affects the others. There is thus a disease originating re- spectively in the uriniferous tubules, in the blood- vessels and particularly in the Malpighian tufts, and in the fibrous stroma. That which originates in the tubules is always inflammatory iii its cha- racter, although the inflammation may be acute or chronic ; that which commences in the vessels consists in a peculiar degenerative change, the so-called waxy, lardaceous, albuminoid, or amy- loid degeneration ; that which is proper to the stroma is an extremely chronic process, supposed by many to he inflammatory, hut as it appears to others, rather of an hypertrophic character. In the following article are described : I. The inflammatory affection, affecting the tubules, or the stroma, or both. II. The waxy or amyloid affection, originating in the vessels. III. The cirrhotic or gouty affection, originat- ing in the fibrous stroma. Definitions. — I. Inflammatory Bright's dis- ease is an acute or chronic affection of the kidneys ; caused by exposure to cold, and by scarlatinal and other blood-poisons ; consisting in inflammation of the elements, passing through various stages of transformation, viz. inflam- matory enlargement, fatty degeneration, and atrophy; characterised in the earlier stages by di- minution of urine, albuminuria, frequently haema- turia, tube-casts, and dropsy ; in the later stages by the same symptoms, in a more or less marked degree, with secondary changes in the heart, blood-vessels, and other organs ; terminating fre- quently in recovery in the early stage, rarely in the later, often in death by dropsy, uraemia, or intercurrent affections. II. Waxy Brights disease is a chronic affec- tion of the kidney, caused by phthisis, syphilis, caries, suppuration, and other exhausting condi- tions ; consisting in waxy or amyloid degenera- tion of the Malpighian bodies, small arteries, and sometimes the basement membrane, with, in many cases, transudation into the tubules ; pass- ing through various stages of transformation, viz. simple degeneration, enlargement from trans- udation, and atrophy; characterised by a large flow of albuminous urine of low specific gravity, andabsenceof dropsy; often attended by evidences of waxy disease of other organs, particularly the liver, spleen, and intestinal canal ; resulting pro BRIGHT’S DISEASE. bablyin some cases in recovery, -usually in death, by exhaustion, uraemia, or coexisting affections of the kidneys and other organs. III. Cirrhotic Brights disease is a chronic affection of the kidney, caused generally by the abuse of alcohol, sometimes by the poison of gout, occasionally by plumbism, and by unknown conditions; consisting in increase of the fibrous stroma, with thickening of the capsule, and ulti- mate atrophy of the organ ; characterised by a very insidious commencement, by the absence of the early symptoms of either of the other forms, by albuminuria, at first slight, but possibly absent, and by the ultimate appearance of en- largement of the heart, polyuria, albuminuric retinitis, oedema of the lungs, andurmmia; re- sulting ultimately in death from uraemia, oedema of the lungs, or other intercurrent affections. IEtiology. — I. Of the inflammatory form. Cold is the commonest cause in the adult. It acts especially on those who have been exposed to its influence whilst perspiring. It frequently contributes towards the production of the disease in persons otherwise predisposed. Various blood-diseases, while they induce temporary albuminuria along with their more ordinary symptoms, have renal inflammation as a common sequela. Among these scarlatina occupies the first place, diphtheria stands next in order, fol- lowed by erysipelas, measles, pyaemia, typhus, ague, acute rheumatism, and pneumonia. Many of these maladies being most common in child- hood, it follows that in the earlier years of life they are the chief causes of inflammatory Bright's disease. Pregnancy, heart-disease, gout, and malaria contribute towards its production in some cases ; and the undue use of cantharides, turpentine, or alcohol may also be reckoned as causes. II. Of the waxy form. Constitutional syphi- lis, phthisis, prolonged suppuration, caries or necrosis of bone, and other exhausting diseases, such as cancer and chronic rheumatism, induce this degeneration. There is at present no satis- factory evidence as to the precise connexion between these influences and the morbid pro- cess. III. Of the cirrhotic form. The commonest cause is the abuse of alcohol, particularly in the form of ardent spirits. After this, though at a long interval, rank gout and lead-poisoning. Congestion from cardiac disease is also by many authorities, but erroneously, held to be a cause. (See Kidneys, Congestion of.) As experience shows that the disease is often met with in people who have neither indulged in alcohol, been exposed to lead, nor suffered from gout, it is obvious that other efficient though yet un- discovered causes must exist. Anatomical Chakactebs. — I. Of the inflam- matory form. When a case of this kind is pro- longed, the renal disease passes through several conditions, which, for convenience of description, may be divided into three stages, (a) Stage of active inflammation. In this stage the kidney is enlarged; its capsule strips off readily ; its sur- face appears more or less red, sometimes of a deep purple colour ; and occasionally extrava- sations of blood are present in its substance. Ox; section the cortical substance is found to be 175 relatively increased in mlk. Its vessels, as well as those of the cones, are congested. The struc- ture appears somewhat coarser than natural, while the convoluted tubules often present a swollen opaque appearance, and occasionally contain blood. On microscopic examination the congestion of the vessels becomes very apparent, and the tubules are found to be dark and opaque, their lumen being frequently occluded. The individual epithelial cells are granular, and in a state of cloudy swelling. In some cases almost all the tubules appear affected, in others com- paratively few. The enlargement of the organ is in part due to congestion, in part to exudation into the tubules. As the exudation increases the congestion becomes less marked, so that in the later period of this stage the kidney appears paler and more opaque. Unless recovery or death takes place, this condition passes into (h) The second stage , that of fatty transformation. In this stage the organ is still enlarged. Its capsule strips off readily ; the surface often presents stellate veins, and its colour is mottled. At this time extravasations are very rarely observed, but there are alternating patches of yellowish opaque sebaceous-looking material, mingled with more natural structure. On section the cortical substance is seen to be relatively increased. There is no congestion of the vessels, and the Malpighian bodies are not prominent. The convoluted tubules are in many parts occupied by the sebum-like material, and sometimes the straight tubules present the same appearance. On microscopic examination the tubules alone are found affected. Many of them present under low powers a black appearance, due to fatty degeneration of the con- tents of the tubules. It is in the cells alone that this change occurs, and not, so far as the writer has seen, in the free exudation which binds the cells together. Many of the tubules are completely blocked up by this material ; and sometimes in making the section there is such an amount of oil set free, that it permeates the whole struc- ture of the organ, and is liable to produce the impression that the fatty degeneration is uni- versal. This condition may be developed within a week or two of the commencement of the inflammation, and it may continue for years. During the whole course of the second stage it must be understood that inflammatory action is going on, although much less acutely than at first, and less widely diffused. The disease is sometimes recovered from, and if the patient survive long enough it passes into ( c ) The third stage, that of atrophy. The organ is then reduced to or even below the natural size. Its capsule strips off with little difficulty, and without tear- ing the surface. The surface is uneven ; it rarely appears coarsely granular, as in the cir- rhotic form, but rather presents a series of de- pressions, which give it an uneven or finely granular character. Its colour is very similar to that described as occurring in the second stage, but there is less of the sebaceous-looking material. On section the cortical substance is found relatively diminished. The Malpighian bodies are not prominent. The tissue feels more dense; and many of the tubules are occupied by sebaceous-looking material. The blood-vessels. BRIGHT’S DISEASE. 176 and particularly tho small arteries, are sclerosed ; the intima and the adventitia aro frequently, the middle coat almost invariably, thickened. The fibrous stroma is relatively increased, espe- cially towards the surface of the organ, and the tubules may be traced in different stages of atrophy. On close inspection that atrophy is found to result not from pressure of the fibrous stroma, but from molecular absorption of the contents of the tubules. Besides the typical form of the inflammatory affection just described, notice should be taken of other varieties, such as the glomerulo-nephritis of Klebs, in which the glomeruli are especially affected. The ana- tomical changes met with in other organs are described along with the complications. II. Of the waxy or amyloid form. This chronic morbid process may also, for convenience of description, be dividedinto three stages. Of these the first is, (a) The stage of degeneration proper , in which the organ presents an almost normal appearance. The size is natural ; the capsule strips off readily ; and the colour is not altered. On section all appears normal, excepting that the Malpighian tufts, without being congested, are prominent, and in certain lights may be seen even by the naked eye to present dim translu- cency characteristic of waxy degeneration. On applying a little aqueous solution of iodine, the Malpighian tufts and the small arteries assume a peculiar mahogany hue. On examination with the microscope, the stroma and tubules are found to be healthy, the vascular structures being alone affected. The affection is often first seen and is most distinct in the middle coat of the arteries, the swollen transverse fibres taking on the colour, and producing what has been described as the ipecacuanha-root appear- ance. How long this condition may last without the tubules becoming affected it is impossible at present to say, for it has only been met with in patients who had died of one or other of the causal complications while the renal malady was still in an early stage. Sooner or later it passes, however into the condition most commonly met with, (5) the second stage, that of degeneration with secondary changes in the tubules. In this condition the organ is enlarged. Its capsule strips off readily, the surface is smooth and pale, presenting, in pure examples, little or no mot- tling. On section the cortical substance appears relatively increased, and looks much paler than the cones. The structure usually is denser than natural. The vessels appear prominent, and tho Malpighian tufts resemble minute grains of boiled sago. On the addition of iodine the degenerated parts become characteristically coloured, and stand out prominently from the tubular tissue, which does not exhibit the charac- teristic reaction. On microscopic examination the vessels are found altered as in the earlier stage, but the change is more advanced. The stroma is normal, but many of the tubules are altered. Some are blocked up by a dimly translu- cent, wax-like material, which however does not assume the mahogany colour on the addition of iodine. The epithelium in many of the tubules presents a finely granular appearance, and occa- sionally is somewhat fatty, but the epithelium I and the basement membrane very rarely present 1 the characteristic reaction. This change in the tubules is thus secondary to the degenera- tion proper, which is confined to the vessels, and these secondary changes consist in some alteration of the nutrition of the epithelium, with exudation or transudation of coagulable material into the lumen of the tubes. This condition may last for years, but should the patient live long enough it passes into (c) the third stage, that of atrophy. The organ is then below the normal size ; the capsule strips off readily ; the surface presents an uneven granular appearance, and is pale. On section the cortical substance is found relatively diminished. Its small arteries are prominent and thickened; its Malpighian bodies are very conspicuous, and are grouped together in consequence of the atrophy of the intervening structure. The stroma is relatively increased, and many of the tubules are destroyed, while of those which remain not a few present the cha- racters above described as being met with in the second stage. The organ may, in extreme cases, be diminished to less than half its natural size. III. Of the cirrhotic form. The course of this affection is even more chronic than that of the waxy form. It consists essentially in an increased growth of the fibrous stroma, with secondary changes in the tubules and vessels. In an early stage the organ may be found of fully the natural size. The capsule strips off less readily than in health. The surface is somewhat uneven, and may present cysts. On section the cortical substance is relatively en- larged, and this is due merely to an increase of the stroma, not to any chango in the vessels or in the tubules. But it is in the more advanced stages that the disease is commonly seen. Then the organ is reduced in bulk, it may be slightly, it may be to one-fourth of its normal size. Its capsule cannot be peeled off without tearing the gland. The surface is uneven and granular, and often of a reddish colour. On section the cortical substance is found relatively diminished, its structure being dense and fibrous. The small arteries are thickened and very prominent, all their coats, but especially the middle, being increased in volume. Many of the tubules are atrophied, but the epithelium of such as are not involved is for the most part natural. Cysts are numerous, and are found in connexion with the tubules, the Malpighian bodies, and the cells. There are two points worthy of being specially kept in' view by those who desire to attai n to clear conceptions of Bright’s disease — viz. (1) That its different forms are very frequently combined — in particular that the inflammatory affection is found associated sometimes with the waxy dis- ease, sometimes with the cirrhotic ; but that the descriptions here given are derived from pure examples of each process ; and (2) that atrophy results in all the forms if the disease lasts long enough; that is, that a small, uneven-surfaced kidney may result from either the inflammatory disease of the tubules, or the waxy disease of the vessels, as well as from the increased growth and subsequent contraction of the fibrous stroma in the cirrhotic form. Symptoms. — 1. Of the inflammatory form. The leading clinical features of this variety, in BRIGHT'S addition to the albuminuria -which exists in all the forms of Bright's disease, are diminution in the quantity of urine, and the presence of dropsy. The onset of the disease may be sudden or gradual. Sometimes it is the diminution and alteration of the urine that attracts attention, sometimes the dropsy, sometimes the gastric derangement and general uneasiness ; but "which- ever symptommay appear first, the others usually speedily follo-w. The urine is generally dimi- nished in quantity, often somewhat opaque, and smoky or even bloody. It contains much albu- men and numerous tube-casts. The casts are granular, being composed mostly of epithelium in a state of cloudy swelling ; sometimes bloody ; frequently hyaline or fibrinous. The urea is diminished, it may be, to one-half, one-fourth, or even a less proportion of the natural amount. This leads to a corresponding reduction of the specific gravity, unless there be a compensatory diminu- tionofwater, or increase of albumen. Thedropsyis generally distinct in the face, and swelling of the eyelids is well marked in the morning. Towards evening, if the patient be out of bed, the legs are chiefly affect ed. The scrotum and penis are often swollen, and sometimes the abdomen is also dropsical. There is little quickening of pulse or elevation of temperature, but a good deal of gene- ral uneasiness is experienced, with debility and pain in the loins ; and dyspeptic symptoms are often present, due to gastric catarrh. Such is .the usual condition at the commencement of the disease, and during the period which has been already described as the first stage. But some- times at this stage a much more serious condition is developed — namely, suppression of urine, fol- lowed by coma or convulsions leading to a fatal result ; or dropsy may increase to such an extent as of itself to cause death. Or, again, without or even with the mostunfavourable symptoms, under appropriate treatment the kidneys may begin to act more freely, the urine increasing in amount and improving in characters, with consequent gradual disappearance of the dropsy, and restora- tion of health. Or, as often happens, the general condition improves, but a chronic albuminuria remains, and the disease passes into the second stage. The urine is then no longer bloody ; the quantity is greater, though still below the normal ; the specific gravity is low ; there is albumen, along with tube-casts, fatty, hyaline, or mixed, partly fatty and partly hyaline. The urea is below the normal standard. The dropsy may continue, and may even gradually increase, or it may pass off and only appear when the patient is fatigued, or when he has caught cold. The general symptoms remain unchanged, except that anaemia comes on, and the patient’s debility steadily increases. This course of events may pass on to a fatal result; or there maybe complete, or, as is more common, merely partial recovery. In this condition the patient may linger for many months, occasionally suffering exacerbations, and he may succumb to one of them, or to one of the numerous complications to be presently described. If the patient passes into the third stage, he appears prematurely old. His urineisof natural amount or even somewhat increased in quantity, hut of low specific gravity. It contains albumen 12 DISEASE. 177 and a few easts, mostly hyaline, with scattered fatty cells imbedded in them. The urea is stiii diminished. There is dropsy of the feet and ankles in the evenings, and slight exposure brings on more general attacks. The face is pale and pasty, and the eyelids are often cedema tous. The pulse becomes hard and tense ; the arteries gradually become thi ckened from sclero sis and atheroma ; while the apex-beat of tin heart passes downwards to the left side, cwinj to hypertrophy, particularly of the left ventricle In this condition a fatal result may be induced by an acute exacerbation with general dropsy ; by chronic, or, more rarely, acute uraemia ; or bv intercurrent attacks of inflammatory or other affections of various organs. 2. Of the wary disease . The onset of this affection is gradual and insidious. A patient who has suffered from phthisis, syphilis, or other wasting malady passes an excessive quan- tity of urine, and finds himself obliged to rise several times during the night for micturition. The urine is pale, of low specific gravity, containing at first no albumen, subsequently only a trace, ultimately a considerable amount. The urea is little, if at all, diminished ; the tube- casts are extremely few, and mostly hyaline. There is no dropsy, but evidence of concomitant waxy affections of other organs is frequently afforded. The liver is enlarged, its margin being easily felt and sharply-defined. The spleen is also increased in size. The blood is slightly altered, the white corpuscles being somewhat increased, and the red being rather flabby and ill-defined. These conditions gradually become more distinct, and the strength of the patient diminishes, partly from the disease of the kidneys and other organs, partly from th( wasting diseases which have induced the degene- rative changes. A case of the kind has been known to go on for nearly ten years, during which time the urine continued of the characters just described, and dropsy never appeared. At length the vital powers of the patient became de- pressed, head symptoms gradually supervened, and death ensued. It is not often that such an uncom- plicated case is met with. More commonly the exhausting disease which led to the degeneration causes death before the waxy change has gone so far. Sometimes also intercurrent complications induce the fatal result. Clinical, observation renders it probable that the kidneys, as well as the liver and spleen, may recover from then- degeneration, in cases in which the causal malady has been got rid of. 3 . Of the cirrhotic disease. The onset of this affection is extremely insidious, and it may exist for a long time without distinctly manifesting itself by symptoms. Its existence is often dis- covered only when dyspepsia, uraemic convulsions, or blindness from retinitis leads the patient to consult a medical man. The earliest symptoms are occasional slight albuminuria, and frequent calls to micturition during the night, the urine however not being excessive, its specific gravity being low, and the urea somewhat diminished. But when the disease has existed for some time the complexion becomes altered ; the eye assumes a peculiar appearance from cedema of tht conjunctiva ; the patient is subject to dy T spept.ie BRIGHT’S DISEASE. i 78 attacks; the heart becomes hypertrophied, and the vessels sclerosed and degenerated ; while there is little or no dropsy. When the disease is advanced, these changes in the circulatory organs are well-marked, and the cachectic con- dition becomes distinct. The occurrence of various complications, such as severe gastric catarrh, diarrhoea, anaemia, dyspnoea, bronchitis, oedema of the lungs, headache, uraemia, and the characteristic retinal affection, render the diag- nosis easy. Frequently towards the end there is an increased flowof urine, of low specific gravity. This is in some cases a very prominent symptom. The disease is never recovered from, and the fatal result occurs from uraemia ; from some inflammatory complication, such as pleurisy, peri- carditis, bronchitis, or pneumonia ; or from some result of degenerative change, as haemorrhage from a mucous surface or into the brain. Complications — (a) Connected with, the Abdomen and Alimentary System. Gastric affections are met with in all the forms of Bright’s disease. Catarrh of the stomach — - acute, sub-acute, and chronic — is common to them all, and is characterised by an unusual tendency to nausea and vomiting. It is especially frequent during the first stage and in acute exacerbations of the inflammatory form, and is often a chief source of suffering during the most advanced stages. It is not uncommon during the whole course of the waxy form, but is most usually met with in the cirrhotic variety. So close indeed is the relation- ship between them, that in the management of cases of cirrhosis regard should constantly be had to the state of the stomach, and in no case of chronic gastric catarrh should the physician neglect .to enquire into the state of the urine. This affection, when complicating the early stage of the inflammatory form, often owes its origin to the same cause as the kidney-affection is due to. When complicating the later stages of the inflammatory, and any of the stages of the cir- rhotic disease, the catarrh is probably a result of efforts at elimination of materials retained in the blood by the failure of the action of the kidneys. When occurring in the waxy form, it is frequently due in part to the existence of waxy degeneration of the vessels of the gastric mucous membrane. In the waxy disease we sometimes find blood mingled with the vomited matters, just as we find haemorrhage occurring in other organs when this degeneration exists. Catarrh of the intestine also occasionally occurs, sometimes producing an exhausting diarrhoea, especially in advanced inflammatory and cirrhotic cases ; but it is along with the waxy disease that intestinal symptoms are most common. These are due to waxy degeneration, and consequent ulceration; or to ordinary tu- bercular disease of the intestine. Both of these affections induce diarrhoea, but there is evidence that not only may it thus occur, hut that blood may also he discharged, although there be no ulceration recognisable by the naked eye. Hepatic affections. — Functional derangements of the liver occur in the course of all the forms of Bright’s disease. The chief organic changes are fatty degeneration, waxy degeneration, cir- rhosis, and syphilitic affections. The first-named is not specially related to any of the forms. The waxy degeneration and the syphilitic affec- tions are of course commonly met with as accompaniments of tbe waxy disease ; whilst cirrhosis attends upon the cirrhotic kidney. Ascites is often seen as a manifestation of general dropsy in the inflammatory form of Bright’s disease ; and sometimes this is a pro- minent symptom in mixed forms, when waxy liver is associated with a waxy and slightly in- flammatory condition of the kidneys. Peritonitis is occasionally the cause of death in all the forms of Bright’s disease. It may result from local affections, or from the state of the blood ; and may be acute, severe, and therefore obvious, or so insidious as scarcely to attract attention. (j3) Complications connected with the Blood, or with the Lymphatic- and Blood- glands. The spleen is usually unaffected in eases of in- flammatory Bright’s disease, except such as prove fatal in the earliest stage, and in which the spleen is affected in common with the kidney In the waxy and cirrhotic forms corresponding lesion-' are frequent in this organ. The lymphatic glands are rarely altered ex- cepting in the waxy form, in which they are sometimes the subject of the waxy degeneration, sometimes of tubercular disease, or of stramors inflammation. The blood itself is altered in its chemical com- position. In the inflammatory form its density is diminished, the corpuscles and albumen being deficient, while the water is correspondingly in- creased. The quantity of urea is above the normal. In long-standing cases of waxy disease similar changes are found ; and not unfrcquently there is a slight numerical increase of the white corpuscles, and flabbiness of the red blood- discs when the spleen is affected. In the cirrhotic form like alterations also occur. Hemorrhage is apt to occur in advanced stages, especially of the cirrhotic form. It may take place from the kidneys, or from the mucous mem- branes, particularly that of the nostrils. In the inflammatory affection hasmaturia is common in the early stage ; in the waxy variety this symp- tom occasionally occurs, but rarely to a serious extent. ( y ) Complications affecting the Circula- tory system. Hypertrophy of the heart is almost always pre- sent in cases of advanced cirrhotic disease, and also in the advanced stages of the inflammatory affection. One may trace in patients the gradual development of this hypertrophy, advancing pari passu with the progress of the renal affection. It is comparatively rare in the waxy form. Hy- dropcricardium is met with in some cases, as a manifestation of general dropsy. Pericarditis occurs as an intercurrent affection in all the forms, but especially the inflammatory and the cirrhotic. It is apt to be overlooked, owing to the absence of local pain, or from the pain being referred to the abdomen. Endocarditis is also frequently associated with the various forms of Bright’s disease The arteries are sclerosed and atheromatous in the advanced stages of the inflammatorv and in the cirrhotic, but not so much in the waxy disease. In that affection the small vessels in BRIGHTS jther paits are frequently the seat of waxy de- generation. Thickening of the arteries occurs constantly in the more advanced stages of the inflammatory and cirrhotic diseases, and is due in great part to hypertrophy of their middle coat, in lesser degree to sclerosis of the tunica intima, the tunica adventitia, and perhaps the perivascular lymphatic sheath. The 'pulse be- comes tense and sustained in chronic cases, partly from the hypertrophy of the heart, partly from ihe cliauges' in the capillaries and smaller arteries. (S) Complications connected with. the Respiratory system. Acute bronchitis is common, especially in the advanced stages of Bright's disease, and tends to pass into the chronic state. Bronchitis may originate also as a sub-acute or chronic affection. (Edema of the lungs is very common in ad- vancol stages, and frequently occurs as a mani- festation of general dropsy in the early, as well as 'n the later stages of Bright's disease. It may _-e very suddenly developed in cirrhotic eases, and may rapidly prove fatal. Pneumonia occurs sometimes as a cause of inflammatory Bright’s disease, sometimes as a consequence of exposure to cold during the course of chronic cases. Phthisis in its various forms is found causally associated with these renal affections, frequently with the waxy, and more rarely with the inflam- matory form. It usually proves fatal while the renal malady is yet in its early stage. Hyclro- tkorax, acute or chronic, is often seen in dropsical cases. Pleurisy occasionally occurs with all the forms of Bright’s disease, and may be due to the state of the blood ; or, as seems more likely, to increased susceptibility to inflammatory changes, which results from the lowered vitality of the organism. Dyspnoea is frequently met with in the inflammatory and cirrhotic forms of the dis- ease, and may he independent of any local lesion, being probably a result of uraemic poison- ing. CEclema glottidis is apt to occur in inflam- matory cases, when even a slight laryngitis has from any cause been brought on. if) Complications affecting the Skin and Subcutaneous tissues. Dropsy, in the form of anasarca, is almost constantly present in the early stage, and during exacerbations of the inflammatory form. It can scarcely bo said to occur in uncomplicated waxy and cirrhotic cases. Eczema is occasionally troublesome in chronic cases. Erysipelas is met with now and then, always constituting a serious addition to the other malady. (C) Complications affecting the Urinary organs. The chief of these is scrofulous disease of the kidney, and more rarely of the bladder and prostate. They occasionally occur along with the waxy affection. (n) Complications affecting the Nervous system and Special senses. Urcemic blindness may occur, which is sudden and usually temporary, being unaccompanied by any lesion recognisable by the ophthalmoscope. It is generally met with in advanced cirrhotic and inflammatory cases. Retinitis albuminurica is a peculiar and characteristic inflammation of the connective tissue of the retina, leading to the formation of white patches and lines, with DISEASE. m fatty degeneration. With it are also frequently associated minute hjemorrhages into the sub- stance of the retina. This occurs by far the most frequently in cirrhosis. It is often also seen in the advanced stages of the inflammatory form, and is rarely recovered from except in the case of pregnant women, in whom it seems apt to occur as a passing condition. Ur&mia includes a group of the most strik- ing symptoms of Bright's disease. It may occur at the commencement of the acute inflammatory affection, or in its later stages, or in the chronic forms. The condition is, however, rare in the purely waxy disease, but common in the cirrhotic. There are several types of uraemia, of which the most important are : — (a) Sudden acute convul- sions, followed by coma and death ; ( b ) Gradually advancing torpor, passing at last into coma. The clinical features of these and minor varie- ties are described, and the hypotheses as to their origin discussed, in the article Urjemia. Headache is frequently complained of by patients suffering from Bright's disease. Apo- plexy from hemorrhage into the substance of the brain is common in the later stages of the in- flammatory and cirrhotic diseases. It is due partly to the degenerated state of the vessels, and partly to the increased pressure resulting from cardiac hypertrophy. (0) Complications affecting the Loccmo- tory system. Of these the only ones of importance are disease of bone, which has been already referred to as a causal complication in waxy cases ; and gouty affections, which have been mentioned in connexion with the cirrhotic disease. Diagnosis, (a) Of Bright’s Disease from other affections. Erom passive congestion of the kidneys due to cardiac disease these maladies are distinguished by the general condition of the patient ; the absence of cardiac disease, and of congestion in other organs ; and the characters of the urine. In heart-affections the urine is generally scanty, high-coloured, not of low speci- fic gravity. It may contain albumin, and deposits urates, but rarely blood, renal epithelium or tube- casts. Hyaline casts may be present, but never in any large quantity. The presence of epithelial and fatty easts, or marked diminution of the amount of urea in any case, proves at least the co-existence of actual inflammation of the kidney. From paroxysmal hcematinuria and albumi- nuria, Bright's diseases are distinguished.' by the abrupt commencement and brief duration of these maladies; by the marked nervous symp toms, with gastric catarrh, and sometimes slight jaundice; and by the absence of dropsy. In haematinuria also the condition of the urine is very distinctive ; the dark-red colour being due, not to blood-corpuscles, but to granular pigment, the deposit consisting mostly of this material and of hyaline casts. In paroxysmal albuminuria again the amount ot albumin is very large, and the number of tube-casts extraordinary. Hema- turia, with tendency to suppression of urine, is distinguished from Bright’s disease by the small proportion of epithelial tube-easts, and in some eases by the complete absence of easts. There may be a question whether the case is one of hsmaturia or of commencing acute inflaro L 80 BRIGHT’S uatoiy Bright’s disease; or again -whether it is one of a chronic affection, cirrhotic or cystic, in which hemorrhage has come on. The cases in which Bright’s disease simulates haematuria are generally the sequelse of scarlatina or diph- theria ; and, therefore, even when these diseases hare been overlooked, the presence of desqua- mation or of paralysis may afford a clue ; but the peculiar reddish-brown deposit rich in cells and in epithelial tube-casts, which occurs in Bright’s disease, makes the case clearer even when, as often happens, there is no dropsy, or when, as we sometimes see, the albumen is not coagulated by heat or by nitric acid. Again, when the question is between simple haema- turia and hsematuria with cirrhosis or cystic disease, the evidence afforded by the tube-casts is not important, but the hypertrophy of the heart, the thickening of the arteries, the charac- ter of the pulse, the albuminuric retinitis, the low specific gravity of the urine and the small amount of urea which it contains, as well as the tendency to haemorrhage from other sources, afford evidence of the presence of the chronic organic disease. Slight pyelitis, with or without renal calculus or gravel, may simulate Bright’s disease, but the history of pain, the presence of mucus and pus-corpuscles in the urine, of oxalate of lime or uric acid, with the full proportion of urea, and the absence of tube-casts, indicate the nature of the case. f/3) Of the different forms of Bright’s disease from each other. The discrimination presents in simple cases little or no difficulty. The points to be attended to are the history of the patient ; the amount and characters of the urine ; the presence or absence of dropsy ; and the nature of the complications. The previous occurrence of exanthematic affections, of chronic wasting disease, or of intemperance, gout, or plumbism, would afford some obvious indications. The mode of origin and progress of the malady is very important. Thus a case commencing actually with dropsy and diminution of urine is inflammatory ; one of less acute character with polyuria is waxy; and one commencing insidi- ously, with no marked symptom until perhaps con- vulsions or dimness of vision appeared, would he an example of cirrhosis. The leading symptoms of the inflammatory variety are diminution of urine ; an abundance of albumin and of epithelial tube-casts, with diminution of urea ; and mai'ked dropsy. Of the waxy kidney, the prominent fea- tures are early and persistent polyuria ; waxy degeneration of other organs ; and ^absence of dropsy. In the cirrhotic form the insidious com- mencement ; the gradual development of vascular and cardiac changes ; with in the later stages, in many cases, polyuria, are the most important phenomena. Other indications may he gathered from the complications of each form of Bright’s disease. It must he remembered that mixed forms frequently occur, and that in these careful inquiry and patient investigation are essential to the establishing of a correct diagnosis. Prognosis. — The prognosis, though always grave, varies in the different forms of Bright's disease. In the inflammatory affection it is least unfavourable, although this affection is the most DISEASE. immediately dangerous. During its first stage we may always hope for complete recovery, especi- ally in cases of post-scarlatinal origin. Of forty- one successive cases treated by the writer in the Royal Infirmary, Edinburgh, twenty-two recov- ered entirely, while twelve died, and seven passed into the second stage. If this he the proportion in hospital cases, which are generally sent there on account of their severity, and are rarely sent in the earliest stages of the disease, it is obvious that the proportion of recoveries must he much larger in private practice. "When the disease reaches the second stage, the prognosis is more grave, complete recovery being rare, and death sometimes taking place from sudden or gradual increase of the symptoms, or from intercurrent affections. But even in this condition complete recovery may he brought about, and in many cases the patient goes on for long periods, pre senting few symptoms to attract attention. - In the third stage the prognosis is entirely un- favourable, the system becoming steadily more deteriorated, and death occurring, either from the direct effects of the disease, or from compli- cations. Still, even such cases often go on fox long periods, if placed under favourable hygienic and therapeutic conditions. In the waxy form the prognosis must almost always he unfavourable, although the malady is never rapidly fatal. On the contrary, its course is always chronic, in some cases extending ever five or even ten years. The fatal result is due to complications more frequently than to the disease itself. Recovery probably sometimes takes place, hut only when the cause of the de- generation is removed, and the general sur- roundings of the patient are favourable. It is certain that the liver and spleen may to a large extent recover from waxy disease, and recovery has been witnessed in cases which presented all the symptoms pointing to implication of the kidneys. In the cirrhotic form the prognosis is very unfavourable, hut the progress of the disease is so slow that it is often unadvisable to say any- thing about it to the patient, as the fatal result may be long deferred. It must, however, be kept in view that the disease may he far ad- vanced before its existence is made out. Among the symptoms and complications which are fitted to cause special alarm when they occur in connection with any of the forms of Bright's disease, wo must recognise suppression or great diminution of urine, especially if accompanied by nervous phenomena or general dropsy ; uraemia, more particularly its chronic form ; and acute inflammations and haemorrhages. Retinitis aibu- minurica is always a verv serious symptom, ex- cept when it occurs in pregnant women. Treatment. (1) Of the inflammatory form. The objects to he kept in view are to arrest the inflammatory action; to remove the inflammatory products from the kidneys ; and to obviate the deleterious effects upon the system generally of the accumulation of effete materials. One remedy or plan of treatment may meet more than one of these indications. The most useful means of subduing the inflammatory action, or at least the congestion which attends it, are local blood letting by means of leeches or wet cups ; drv- BRIGHT'S DISEASE. 18! •npping; and the application of hot fomenta- tions, poultices, and counter-irritants. Blood- letting is only serviceable in the early stage of the disease, or when severe exacerbations with suppression of urine occur. Poultices or hot fomentations are of use in the same circum- stances. Counter-irritation is helpful in the more chronic conditions. Iodine and croton oil inunction are the best fitted for its induction, whilst cantharides must be avoided on account of its tendency to irritate the kidneys. The removal of the inflammatory products which block up the uriniferous tubules is of tli6 utmost importance, and is in the great majority of cases best effected by means of diuretics. Water and diluent drinks are the safest, and are sometimes found sufficient. The medicinal diuretics must be non-irritating, and the best of all is digitalis, which may be given safely even when the urine is bloody. It may be adminis- tered in the form of infusion, tincture, or made up into a pill. Of the infusion from a drachm to an ounce, of the tincture from five to thirty minims, of the powder from half-a-grain to two grains, should be given three times a day. The infusion or the tincture may be combined with spirit of nitrous ether, with acetate of potash, or with tincture of percliloride of iron. Its action is often favoured by the addition of squill and car- bonate of ammonia. Sometimes it happens that diuretics do not suit the case, the urine be- coming diminished and more bloody under their use ; and in other cases the symptoms become so urgent that death might take place before there would be time for diuretics to act. In either of these conditions relief must be obtained by the bowels or skin. The bowels are best acted upon by means of from twenty grains to a drachm of the compound jalap powder, or one-twentieth to half-a-grain of elaterium. The action of the skin may be excited by the use of acetate of ammonia or antimony ; but pilocarpine, hot air, vapour-baths, and the wet pack are the most efficient agents. Throughout the whole course of the disease constipation should be avoided, and the action of the skin encouraged. When the disease has become less acute, and certainly when dropsy persists during the second stage, other diuretics are of the utmost value, par- ticularly the acid tartrate of potash, the oil of juniper, and the decoction of broom. Iron must be assiduously administered, to make up for the waste of the materials of the blood. Gallic acid, ergot, and belladonna have all been praised as tending to diminish the discharge of albumin resulting from a persistent chronic inflammation of the tubules. The treatment of special symp- toms and complications will be considered after indicating the general management of the other varieties of Bright’s disease. The diet during the earliest stages should be easily assimilable, and not too rich in nitroge- nous elements. Milk is, as a rule, well borne. Some practitioners laud skimmed milk as an unfailing remedy in tho disease. It is a good diuretic, and, when it suits the stomach, a good article of diet, but possesses no other therapeu- tical virtue. In the more chronic stages the food should be of the most nourishing kind, and a moderate allowance of stimulants may be needed. (2) In the treatment of the waxy form, the most important indication is to seek to remove the cause of the degeneration, if still existing. If there be disease of bone or chronic abscess it must, if possible.be cured; constitutional syphilis must be combated by appropriate remedies. The tincture of perchloride of iron, quinine, nux vomica, and such combinations as Easton’s syrup of the phosphates, are useful. The patient must also have good food, and should lead an easy life. (3) In the cirrhotic form it is probable that no remedy we at present possess can influence ’the pathological process, although arsenic and alka- line remedies, and particularly iodide of potas- sium, enjoy a certain reputation. It is of course the duty of the skilful physician to obviate the results of the morbid process. It is obviously of great importance to avoid the causes of the disease. Lead-poisoning should be avoided ; the gouty tendency kept in check; and the abuse of alcohol forbidden. (4) In the management of the combined forms of Bright’s disease these plans of treatment must be conjoined according to circumstances, but, on the whole, treatment is much less successful than in the simple cases. In the combined waxy and inflammatory affection, for instance, it is not uncommon for dropsy to persist, although the diuretics bring the urine up to or above the natural standard. (5) With regard to the special symptoms and complications of Bright’s disease, the sick- ness and vomiting are best relieved by counter- irritation over the stomach ; and by giving ice, milk, and hydrocyanic acid internally. These symptoms are, however, often very intractable. Diarrhoea must sometimes be let alone ; at other times it must be treated by means of astringents or sedatives, either administered by the mouth or as enema or suppository. Ascites must be treated as a manifestation of dropsy, and occasionally the abdomen requires tapping. Peritonitis must be combated by hot fomentations and opium, but the latter requires great care in its adminis- tration. All through the disease in all its forms haematic tonics are demanded; iron in some form should be constantly administered. For haemor- rhages the pernitrate of iron, local astringents, ergot and ergotine, gallic acid, or acetate of lead must be tried in various combinations. The best results have followed the use of ergotine in 3- to 5-grain doses injected subcutaneously. Tho irritating effects sometimes observed after the subcutaneous injection of ergotine may often be obviated by boiling the solution, or by the addition of a minute quantity of salicylic acid. Hydropericardium and pericarditis must be treated in the usual way. The vessels and the heart are not amenable to treatment. Bronchial catarrh must be carefully attended to, by the avoidance of exposure to cold ; by the application of counter-irritation externally; and by the internal administration of expectorants, ffidema of the lungs must be treated by counter-irri- tants, and by remedies fitted to reduce the general dropsy. Pneumonia, phthisis, and pleu- risy must be treated on ordinary principles. Hydrothorax may demand paracentesis. General dropsy is one of the most important compli- cations, and should be combated by means of 182 HEIGHT’S DISEASE, diuretics, purgatives, and diaphoretics ; in many cases puncture of the cedematous parts is de- manded. When puncture has been determined upon, precautions must be taken to avoid inflam- mation. Eczema and erysipelas, when they occur, should be dealt with according to the principles of the art. Headache is relieved in different cases by iron, by hot or cold applica- tions to the head, by quinine, or by inhalation nf a few drops of nitrite of amyl. When uraemia occurs in acute inflammatory conditions, or with •suppression of urine, dry-cupping or wet-cupping over the renal regions should be tried, along with free purgation and hot-air baths and, es- pecially in puerperal cases, general blood-letting. Bromide of potassium should be given in drachm doses, and if convulsions be severe, the patient must be kept under the influence of chloroform. In the more chronic and gradually advancing form of uraemia, counter-irritation at the back of the neck and over the scalp sometimes ap- pears to be useful. But treatment is net so often of advantage in this as in the other form. In the eye-affections, iodide of potassium enjoys some reputation. Haemorrhagic apoplexy de- mands no special measures for its treatment. T. Grainger Stewart. BEOMISM. — Definition. — Bromism is the term applied to the morbid effects produced by the administration of the salts of bromine under certain circumstances. Description. — The effect of the salts of bromine, when administered in medicinal doses, is to reduce nervous activity ; and thus, with a certain amount of anaesthetic influence, to pro- mote rest and sleep. When such doses have been long continued, or in certain idiosyncrasies, or when excessive doses are administered, re- sults are produced which constitute a state of disease, and to this condition the term ‘ brom- ism’ is applied. These results are manifested on the brain and spinal cord ; on the skin ; on the mucous membranes and glandular struc- tures ; and on the organs of circulation and respi- ration. 1. On the Brain and Spinal Cord. — When the therapeutic action intended to be obtained from the use of a salt of bromine is exceeded, the quiet or sleep becomes more pronounced, and there is more or less constant somno- lence; the memory becomes impaired, words being forgotten or misplaced, whilst written and spoken language is confused, the tongue is tremu- lous, and speech is difficult. The gait becomes feeble and staggering, with inability to control movement, and somewhat resembles the condi- tion observed in locomotive ataxy. The special senses — sight, hearing, taste, and touch — are im- paired : reflex excitability is diminished, and this is especially observed in the fauces, occasionally to such an extent as to cause difficulty in swallowing. Sexual feelings are diminished or altogether suppressed. The general aspect of a case of well-marked bromism much resembles one of senile imbecility. 2. Oh the Skin. — A very frequent result of the internal use of the bromides is a follicular eruption of the skin, closely resembling acne, which is generally situated on the face, chest, EROMISM. and shoulders. When the use of the drug is con- tinued, the acne becomes aggravated, and boiis appear. A more rare form of skin-disease simi- larly caused has been described by Dr. Cholmeley, Mr. Hutchinson, and M. Voisin. This disease appears as vesicles, which become aggregated into clusters or patches. These proceed to sup- puration, and are soon followed by scabbing, their base being slightly raised, hard, sometimes ulcerated, and surrounded by a red areola. In a later stage the eruption presents the appear- ance of dusky red stains. It has been observed more especially on the limbs and head. Erup- tions having more or less the characters of ery- thema and of eczema have also been described as following the use of these agents. 3. On the Mucous Membranes and Glandular Structures. — Dryness of the mouth and tongue is often experienced in bromism ; but in some cases there is said to be an increased flow of saliva. Nausea, flatulence, eructations having a saline taste, heat and fulness at the epigas- trium, and occasionally gastric catarrh and diar- rhoea, have been observed ; it is said that acute enteritis and even a typhoid condition have oc- curred. 4. On the Organs of Circulation and Bespira- tion. — The salts of bromine are said to produce contraction of the capillaries. The skin may present a peculiar pallor, and the extremities feel cold. The action of the heart is rendered slower and weaker; and may even cease alto- gether, under the continued operation of these drugs. The action on the respiratory organs is similar to that upon the heart. It has been observed that bromine — recognised by its pe- culiar odour in the expired air— is eliminated from the respiratory mucous membrane. Bron- chial catarrh occurs, and instances are recorded in which pneumonia is said to have followed and proved fatal. It must be remembered that, although it has been thought desirable to discuss separately here the effect of these drugs on the several systems, these effects are combined in various degrees. In some cases the affection of the skin is alone noticeable ; in others, that of the nervous sys- tem ; while in a third class there is produced a combination more or less of all the phenomena, constituting what may be called a cachexia. In such cases we find loss of flesh, strength, colour, and mental power; paralysis of the muscles; loss of reflex and general sensibility and of the functions of the special senses ; com- plete apathy and general prostration, the coun- tenance having a semi-idiotic expression ; cold- ness of the extremities ; and gradual failure of the heart’s action. Pathology. — The condition just described is but the extreme effect of the ordinary physio- logical action of the salts of bromine. This condition may be due either to idiosyncrasy — that is, to undue susceptibility on the part of the individual — or to the administration of large quantities of the drug, either in medicinal doses for a long period, or in excessive doses ad- ministered within a short time. The individual susceptibility may depend upon the want of ca- pability to eliminate the drug ; on the general state of health ; or on the presence of a disease BilOMISM. which resists its action. Under these circum- stances, as well as in the presence of certain modifying influences, such as the action of other remedial agents simultaneously administered, it is difficult to fix upon the amount of a bromine salt capable of producing morbid symptoms in any given individual. The writer has seen a nightly dose of ten grains of bromide of potas- sium, continued for some weeks, produce marked somnolence during the day, and im- pairment of memory; whilst it has required the enormous doses of 200 or 300 grains a day, which scent to be administered on the Continent, to produce the extreme effects above described. The rapidity with which these effects are produced, constituting the acute and chronic forms of bromism, will depend on the amount and frequency of the dose, and on the suscepti- bility of the individual. The effect of a sudden considerable increase in the dose has been ob- served by the -writer in a case which first directed his attention to the subject of bromism in 1872. This case hesawinconsultationwithMr. Alfred Burton. Half-drachm doses of bromide of potassium had been taken twice a day for several -weeks, when by mistake the quantity of the drug was doubled ; then, after three days, symptoms closely resembling senile imbecility were rapidly developed. Diagnosis. — Recognising the value of the bromides, and the frequency with which they are used, it is extremely important that the peculiar results which tkeyare capable of producing should be borne in mind ; for if they are not recognised in time, and if the use of the drugs be persisted in, disastrous effects which might otherwise be avoided will follow. Without going into details of diagnosis, it will probably be sufficient to point out the necessity for remembering that the symptoms which have been described above can be produced by the use of bromides; and that when such a combination of symptoms does occur during their use, it is highly probable, in the absence of disease capable of accounting for them, that the symptoms have originated from the operation of those agents. Treatment. — This consists in stopping the use of the drug, and hastening its elimination by promoting the action of the kidneys and other excreting organs. It is said that arsenic in combination acts as a preventive of the eruptions. The above description refers to the effects of bromide of potassium ; but like effects are pro- duced by other salts of bromine, though to what extent by each has not yet been ascertained. R. Quain, M.D. BROMIDROSIS (Bpafios, a stench; and I^pus, sweat). A term for fetid perspiration. See Perspiration, Disorders of. BRONCHI, Diseases of. —The diseases of the bronchi may be discussed in the following order: — 1. Acute inflammation; 2. Chronic in- flammation ; 3. Plastic inflammation ; 4. Dilata- tion; o. Narrowing or obstruction ; 6. Cancer. 1. Acute Inflammation. — -Acute Bron- chitis. — Acute Bronchial Catarrh. Definition. — An acute inflammation or con- gestion, general or partial, of the bronchial tubes. BRONCHI, DISEASES OF. 183 .Etiology. — The causes of acute bronchitis may ho classed as (a) predisposing and ( h ) ex- citing. (a) Of the predisposing causes age is one of the most important. The disease is indeed confined to no period of life, but it is most frequently me* with in the young and the old, and in these sub- jects it assumes its most serious characters. The imperfect development of the infant, and the diminished vitality of the aged, seem to render them especially liable to attacks of bronchitis, and to make the disease exceptionally fatal in them. Sex appears to have no influence as a predisposing cause. The habits of life have an important influence in the causation of bron- chitis. The practice of living in heated rooms, especially where gas is largely consumed, and of breathing the vitiated atmosphere produced by the assemblage of large numbers of persons in apartments, is undoubtedly a fertile predisposing, as well as exciting, cause of the complaint ; so also is the practice of keeping children too much within doors on the one hand, or, on the other, of exposing them to inclement weather when in- sufficiently clad. Temperament can scarcely be considered a predisposing cause, but the state of the general health exercises a powerful influence. A weakly constitution, or one weakened by over- work, improper food, &c., predisposes to bron- chitis; whilst such affections as Bright’s disease, gout, and diseases of the heart, alike favour its occurrence. Again, certain occupations are favour- able to the development of bronchitis. Inde- pendently of the fact that living or working in heated and confined rooms predisposes to the disease, such occupations as lead to the inhalation of irritating particles, as those of steel, cotton, &e.. give rise to it. The climate most favourable to the production of bronchitis is probably that which is at the same time both cold and damp, and where sudden variations of temperature occur. The seasons of the year in which it pre- vails most are the late autumn, the winter, and the early spring. (b) Exciting causes . — Although undoubtedly cold directly applied to the surface of the body ic in a large number of cases the exciting cause of bronchial inflammation, still the transition from cold to heat — passing from a cold atmosphere to a heated one — is a large factor of the disease. There can he little doubt that bronchitis is often produced directly by the effects of heated and vitiated air on the bronchial membrane, and on the system at large ; and that in the latter instance, the affection is merely a local manifestation of a general influence. Bronchitis may also be caused by the direct action of irritants contained in the air — as irritant vapours, minute particles of steel, cotton, or ipecacuanha, and the emanations (pollen) from flowering plants. Again, morbid conditions of the blood, the result of specific febrile affections, act as exciting causes of the disease ; as do also the poison of syphilis, and the altered condition of the blood produced by gout. Bronchitis is, moreover, a constant ac- companiment of influenza. Anatomical Characters. — The mucous mem- brane is mainly affected in acute bronchitis, hut morbid changes may be produced in the deeper structures. The mucous membrane is red — the BRONCHI, DISEASES OF. .84 redness being arborescent, streaked, or mottled, Imt not usually spread uniformly over a largo ^rfaee. The injected condition of the membrane does not, as a rule, extend into the finer bronchial tubes, but in some cases where there have been frequent attacks of inflammation, the smallest bronchi have a red appearance. The membrane is sometimes thickened and soft, but ulceration is very rare. The tubes are generally found more or less filled with secretion, either frothy mucus, muco-pus, or even actual pus. Sometimes the secretion is very abundant, filling all the tubes. Fibrinous masses are occasionally met with, which may form casts of the tubes. Collapse of portions of lung-substance — lobulettes or whole lobules of the lungs — is not unfrequently found, as are also patches of lobular pneumonia. The venous system and the right side of the heart are overloaded, and the blood is dark. In many cases fibrinous deposits are found in the cavities and great vessels of the heart. In speaking of the pathology of bronchitis, it is necessary to refer to the distribution of the bronchial blood-vessels. The bronchial arteries when the}' have fairly entered the lungs have no accompanying veins. The so-called bronchial veins are some small vessels which return the blood supplied to the structures about the roots of the lungs. The blood which is supplied to the bronchial tubes, when they have commenced their divisions, passesinto radicles of pulmonary veins, and is returned directly to the left side of the heart. The question whether there is a com- munication between the bronchial arteries and the pulmonary artery, is still subjudice. If such communication exist, it is only slight. The blood of the bronchial arteries, after supplying the mucous membrane and other structures of the tubes, passes, either wholly or in very large part, to the left side of the heart, not having circulated through the aerating portion of the lungs. The circumstances of this anatomical arrangement are most important in a practical point of view. Anything which embarrasses the circulation on the left side of the heart — such as mitral regur- gitation — must necessarily cause a very loaded condition of the bronchial vessels; and all physi- cians are familiar with the form of bronchitis which is so common in these cardiac affections. The congested mucous membrane, and the pro- fuse bronchial secretion, are the result of the direct impediment to its circulation which the blood meets with, from passing at once into vessels which go straight to the left side of the heart. The relief often afforded in this form of bronchitis by the exhibition of digitalis, is ex- plained by the circumstance above referred to. Symptoms. — The symptoms of acute bronchitis vary according as the larger or smaller tubes are affected. The disease attacks, first, the larger and medium-sized tubes ; and, secondly, the smaller ones. To this latter form of the affec- tion the name of capillary bronchitis has been given. 1 . Acute bronchitis of the larger tubes. The attack is usually ushered in by symptoms of catarrh,— sneezing, lachrymation, a sense of ful- ness about the nose and eyes, with frontal head- ache ; the throat becomes dry and sore, and then increased secretion sets in ; the follicles at the back of the pharynx become enlarged; the upp«r part of the larynx is often involved, there being slight hoarseness ; and the affection gradually creeps down into the bronchial tubes. The disease is not ushered in by decided rigors, but chills and sometimes shiverings aro experienced ; the pulse is not much affected, but its frequency is increased in some cases ; there is a general sense of malaise, as well as a want of energy. When the disease has set in fully certain local symptoms are found. More or less pain is felt behind and above the sternum; the sensation is increased by a deep inspiration ; the pain shoots at times over the chest in the direction of the larger bronchial tubes ; and there is a tickling or unpleasant irritation felt behind the sternum, which gives rise to cough. Dyspnoea is not a marked feature of this form of bronchitis ; it exists, however, sometimes ; and in the most severe cases a sense of oppression, weight, and tightness about the chest is experienced. Cough is one of the earliest and most prominent symptoms ; it is at first dry, and there is usually at this period some hoarseness. The cough is paroxysmal, and often very violent; it becomes attended with ex- pectoration as the disease progresses. This varies at different stages of the affection ; at first watery and frothy, and almost transparent, it becomes as the disease progresses more consistent, viscid, and opaque, passing through the stages of mucus to muco-pus and pus ; it is sometimes distinctly nummulated. Small streaks of blood are occasionally seen mixed with the sputa. Examined under the microscope the sputa are found in the early stages of the disease to con- tain epithelial cells from the mucous membrane; and, later, many of the so-called exudation-cor- puscles, molecular and granular matter, pus-cells, and occasionally blood-discs. In the milder cases of this form cf bronchitis there is but little general disturbance ; and even in the more severe cases the febrile reaction is not usually very great. The pulse rises a little, but does not become very frequent ; the temperaturo rarely becomes high ; there is in many cases but little interference with the appetite. A general feeling of depression, which in some cases is very marked, is usually experienced. 2. Acute bronchitis of the smaller tubes — Ca- pillary bronchitis. This is a very formidable disease. It attacks the finer bronchial tubes, and probably extends to their smallest ramifications. Its symptoms are very grave. Some of the worst cases of capillary bronchitis are met with in connexion with emphysema of the lungs. It may be an extension of inflammation from the larger tubes ; or the capillary tubes may be attacked simultaneously with the larger ones, or alone. The early symptoms are more severe than those of ordinary bronchitis, and rigors are more co mm on. Dyspncea is marked ; it may vary from mere rapid respiration to constant or paroxysmal orthopnoea. The respirations may rise to fifty in a minute. Cough is almost con- tinuous, at times becoming very violent and most distressing. Expectoration is attended with difficulty. The sputa soon become very abundant, and rapidly assume a purulent charac- ter ; or they are very viscid and ropy. The general symptoms are very severe. The BRONCHI, DISEASES OF. i«5 fever is high. — the temperature reaching to 103° Fahr. and upwards ; and the pulse is frequent, rising to 120 or 110. The temperature rarely attains the height which characterises acute tuberculosis or pneumonia. There are often profuse perspirations, and in some cases excessive debility is lelt. If the disease progresses unfa- vourably, symptoms of very imperfect aeration of the blood come on. The face becomes turgid and bloated, the lips and ears get livid, the veins are distended, the temperature falls, cold clammy perspirations break out, the pulse becomes very small and rapid, delirium supervenes, the respi- ration is shallow and catching, and the patient dies of apncea, and from the presence of fibrinous clots in the heart and great blood-vessels. Physical Signs. — The physical signs of both forms of acute bronchitis may be referred to together. Inspection reveals little of practical value in simple bronchitis. The chest-form is not altered. In severe cases the abdominal movements are in excess. The costal movements are frequently those of elevation rather than ex- pansion. In extreme cases the lower end of the sternum and the connected cartilages sink with inspiration ; while the expiration-movements are slow, laboured, and inefficient. If the hand is ap- plied to the chest, rhonchal fremitus may be often felt, sometimes over a large area. The percussion- sound may be somewhat exaggerated from over- distension of the lungs, especially in children ; not appreciably altered ; or deficient in resonance, owing to the accumulation of secretion at the liases of the lungs, to cedema or congestion 'as in typhoid fever), or to pulmonary collapse. In young children a sound resembling the cracked-pot sound may be occasionally pro- duced, variable in site. The sounds heard, in auscultation vary according to the stage of the disease. The breath-sounds are loud when the tubes are free; when the latter are plugged by se- cretion, they often become feeble or even totally suppressed, from closure of a tube leading to a portion of the lung. The adventitious sounds of bronchitis include the various rhonchi, dry or moist: the dry rhonchi are heard in the early stages of the disease for the most part, but when once secretion has set in, the moist rhonchi or rales are more or less extensively heard, depend- ing for their character on the size of the tubes which are the seat of inflammation. Thus they are called mucous when produced in the large tubes, sub-mucous and sub-crepitant when pro- duced in the finer ones; the latter term being used to characterise the rales of capillary bron- chitis. When the large bronchial tubes are filled with a secretion which is not viscid, the sounds may have a rattling character. The various rhonchi may be heard over different parts of the lungs at the same time, according to the seat and stage of the bronchitis. In capillary bron- chitis sub-crepitant r&les, accompanying inspira- tion and expiration, are abundantly heard, towards the bases of both lungs especially. As a rule there is no displacement of organs in bronchitis, but the diaphragm is sometimes depressed from great, distension of the lungs, and the heart is occasionally displaced towards the rL hr. Diagnosis. — The diagnosis of acute bronchitis, except in a few instances, presents no great diffi- culty. In the early stages of whooping-cough it is impossible to decide whether the case is one of simple bronchit is or not, but subsequently the paroxysmal character of the cough settles the point. In some cases of bronchitis occurring in children the breathing may resemble that of croup, but here the presence of catarrh ; the wheezing nature of the respiration ; the absence of much fever ; the characters of the sputa ob- tained by wiping the back of the tongue, and its freedom from membranous shreds ; and the phy- sical examination of the chest indicating the pre- sence of rhonchi, will be sufficient to establish a diagnosis. From laryngitis the discrimination is not difficult. Pneumonia may generally be easily diagnosed from capillary bronchitis, with which form it can perhaps be alone confounded. Capillary bron- chitis is not ushered in, as pneumonia usually is by a well-marked and prolonged rigor; the gene- ral febrile disturbance is less, and the temperature not so high ; moreover the absence of dulness on percussion, and of increased vocal resonance and fremitus will aid in the differentiation. From lobular pneumonia in children the diagnosis is not always easy. In this disease there is often no dulness to be perceived on percussion; whilst, on the other hand, in bronchitis dulness may exist from pulmonary collapse. The diagnosis of capillary bronchitis from acute phthisis often presents difficulties. The main points to be relied on, independently of the family history, which may aid, are that in capil- lary bronchitis the fever is less and the tempera- ture lower ; signs of apncea soon come on ; and there is free expectoration of muco-purulent matter. In one form of acute phthisis there is evidence of pneumonic consolidation, followed by signs of the formation of cavities. In the miliary tubercular form there are in many cases scarcely any physical signs except riles, most marked at the apices of the lungs. Prognosis, Duration, Termination, and Mortality. — The prognosis in an ordinary case of bronchitis is favourable, but when the dis- ease occurs in the very young or the aged the prognosis should always be guarded. In the milder forms the affection may last only a few days, or two or three weeks. Severe cases are more protracted. The disease may terminate in perfect recovery, in death, or by passing into the chronic form. It may be the starting point of emphysema of the lungs, or of certain forms of phthisis. The mortality is much in fluenced (1), by age, being greatest in the very young and the very old ; (2), by the pre- vious state of health, which, if lowered by any circumstances, will render recovery more doubt- ful ; (3), by the extent of the inflammation, especially when the disease is of the capillary form ; (4), by the existence or non-existence of any organic disease of the heart, lungs, or kidneys ; (5), by the disease being epidemic or otherwise ; and, lastly, by the time the case has come under treatment, whether early or late. Treatment. — In the treatment of bronchitis regard must be had to the constitutional con- dition of the patient. Care must be taken to ascertain whether the disease is secondary to 186 BRONCHI, DISEASES OF some organic affection ; 5r the result of me- chanical irritation, of the presence of gout or rheumatism in the system, or of influenza ; or whether it arises idiopathically. The treatment of the disease as a primary affection will be considered first. In an ordinary case of acute bronchitis it is very desirable to keep the patient confined to his room and, if the case is at all severe, to his bed. The temperature of the apartment should bo maintained at from 60° to 65° Fahr. A higher temperature than this is generally not favourable to the progress of the case. In the early stages of the attack it is well to allow the air of the room to be more or loss saturated with steam. A free action of the skin should be promoted ; and for this purpose warm drinks, with or without some form of alcohol or some diaphoretic medicine, may be given ; or a hot-air bath may be used in bed. Great relief is often experienced from the application of a large mustard or mustard and linseed-meal poultice to the chest ; and it is well, if mustard is applied first, to apply immediately afterwards a large hot linseed-meal poultice, to he renewed every few hours. This constant application of warmth and moisture to the chest is often pro- ductive of very great relief to the symptoms. Cases of acute bronchitis do not require venesection, nor is the application of leeches often, even if ever, called for. Severe counter- irritation is moreover to be prohibited. It is generally desirable to act on the bowels, and a mercurial, followed by a saline purgative, will often he of great service. In the old and debilitated, as also in the young, all lowering treatment must, however, be avoided. In the early stages of the affection, before secretion has commenced, and when the mucous membrane is dry and the cough hard, diaphoretics with ipe- cacuanha may often he given with advantage; but as soon as secretion is fairly established, carbonate of ammonia, spirits of chloroform, ether, cascarilla, senega, or such-like drugs should be administered. Indeed in almost every stage of bronchitis carbonate of ammonia is one of the most valuable remedies we possess. Care should be exercised, especially with the aged, that nothing should he given which will so nauseate as to prevent food being taken. In the exhibition of medicines to alleviate the cough, regard must be had to the condition of the patient and the stage of the disease. Opium in all its forms should be given with caution, especially in the young and old. It no doubt often succeeds in checking cough, but in doing so it also checks expectoration, and causes an accumulation in the bronchial tubes, which sometimes becomes very dangerous to life. Chloral in small doses is often of great use for relieving cough, and it may be combined with oxymelof squills. It has also a good effect in allaying spasm of the tubes, if this exist. In some cases of bronchitis the question of procuring sleep becomes an important one. Opium in its various forms is generally inadmissible, in consequence of its tendency to increase the condition of apnoea ; but chloral may he given with safety, and the recovery of a patient may sometimes he dated from the sleep which this agent procures. In reference to the exhibition of alcoholic stimulants, except in the early stages, and in certain cases dependent on a gouty or rheu- matic condition, they should usually be given in smaller or larger quantities. They increase expectorating power, and ward off the ten- dency to apncea. In the old they are especially called for, and. together with carbonate of ammonia, should form the main therapeutic agents to be relied on. In the treatment of capillary bronchitis, ammonia and alcoholic stimulants should be exhibited from the com- mencement, and the quantity must depend on the symptoms of each case. There is one source of danger in capillary bronchitis which should always he borne in mind, viz., the for- mation of fibrinous clots in the heart and great blood-vessels. These deposits become the proxi- mate cause of death in many cases, and they are especially liable to form when there is emphysema of the lungs. Their presence may often be diagnosed during life from the respira- tion becoming very rapid, shallow, and laboured : the pulse being quick, weak, and small, although the heart may at the same time be felt beating vigorously ; the voice becoming feeble ; and the mental faculties seriously impaired. After death a large portion of the cavities of the heart may be found occupied by these deposits, the calibre of the pulmonary artery and aorta being also materially diminished by them. In many cases of bronchitis, when the acute symptoms have passed off hut the secretion con- tinues profuse, as well as in those cases called bronchorrhcea, the exhibition of iron is often of great service. It seems to give tone to the relaxed capillaries qf the mucous membrane, and to diminish the secretion. It may be given in com- bination with carbonate of ammonia, in the form of the ammonio-eitratc ; cr the tincture of the perchloride with ether or spirits of chloro- form may he employed, or the ethereal tincture of the acetate (Ph. Ger.), which is a very valuable preparation in some cases. Inhalations are useful for allaying cough in the earlier stages of the affection, or for the relief of spasm. In some cases of severe bronchitis where apnrna has been threatened, recovery has followed the exhibition of large doses — half an ounce — of turpentine. In this dose, however, it sometimes produces alarming symptoms, and it is perhaps better to exhibit it in smaller quantities tentatively. An emetic may be serviceable, especially in children, if the tubes are much loaded. Children suffering from severe attacks of bronchitis should not be allowed to sleep long, for fear of dangerous accumulation in the tubes, and care should be taken that the secretions do not collect about the back of the mouth. Patients should not be kept on a low diet even at the beginning of an attack, and as the disease progresses the quantity of food allowed may be increased according to the appetite. In the treatment of gouty bronchitis, or bronchitis associated with - a tendency to the formation of uric acid in the system, colchicum and the alkalis must he given, and the general measures used which are applicable to tlio constitutional condition. If bronchitis depend o» a gouty state. BRONCHI. DISEASES OF. it will not yield to the ordinary treatment, but when its cause is recognised and the appro- priate remedies are administered, the symptoms usually soon begin to improve. In the cases of bronchitis which are connected with heart-disease, and especially with mitral regurgitation, digitalis is often of great value. By steadying the action of the heart it relieves the overloaded pulmonary veins, and thus directly diminishes the congestion of the mucous membrane, as mentioned in the paragraph relat- ing to the pathology of the disease. it is impossible in the scope of this article to refer specially to the treatment of bronchitic attacks arising from the various kinds of me- chanical irritation. There is, however, one form of bronchitis which may be mentioned, viz., that connected with hay-fever, arising either from the inhalation of pollen, or caused by some peculiar atmospheric influence acting on a peculiar nervous system. It is very difficult of cure. In the writer’s experience no remedies seem to have any particular influence over it, and it is usually only to be relieved by removing the patient from the exciting cause of the affec- tion. In the treatment of bronchitis depending on constitutional syphilis, the appropriate mea- sures for that affection must be resorted to. 2. Chronic Inflammation — Chronic Bron- chitis — Chronic Bronchial Catarrh. Definition. — A chronic inflammation or con- gestion, more or less extensive, of the bronchial tubes. ^Etiology. — Chronic bronchitis very fre- quently results from repeated attacks of the acute disease, but it may be chronic from the begin- ning. Emphysema of the lungs, dilated bronchi, and phthisis are causes of the complaint; as are also various forms of heart-disease, and some blood-affections, such as gout. The inhalation of irritating particles gives rise to chronic bronchitis ; and it is also met with in connexion with chronic alcoholism. It is most common amongst the old. Anatomical Chahactf.rs. • — ■ The bronchial mucous membrane is discoloured, being of a dull- red tint, greyish, or brownish. The discoloration is for the most part partially, but sometimes evenly, diffused. There is swelling and increased firmness of the mucous membrane, and the sub- mucous tissue in old-standing cases becomes infiltrated and indurated. The fibrous and mus- cular tissues are hypertrophied ; the cartilages in the larger tubes are sometimes calcareous ; and there is generally more or less emphysema of the lungs. Symptoms. — The symptoms of chronic bron- chitis vary greatly in different cases. They resemble in kind those of the acute affection. There is cough, expectoration, pain, soreness or uneasiness behind the sternum, with more or less dyspnoea. The constitutional symptoms may be very slight, scarcely any effect on the general health being apparent ; or they may be very severe. Three forms of chronic bronchitis are recognised clinically : — 1. That which includes the ordinary cases of the disease, varying much in severity ; 2. that characterised by excessive secretion — bronchorrhaa ; 3. that form which is called dry catarrh. 1. In the first form of chronic bronchitis the cough is at first slight, perhaps only occurring during the winter, being altogether absent in the summer. After a time the attacks become more frequent, and at last the patient is never free from the affection, which is aggravated at times. The cough in such eases is more or less severe, but usually most so in the morning. It is often paroxysmal, and sometimes very violent. The expectoration, in some cases being scanty, viscid, and difficult to discharge, is in others, especially old-standing cases, copious and easy. The sputa vary much both in appearance and quantity. They may be yellowish-white muco-purulent matter, or more decidedly purulent, of a green- ish-yellow or bright or dark green colour ; they are but little aerated, sometimes not at all, so that they sink in water ; at times they are mira- mulated and quite opaque. In some cases the expectoration is foetid, constituting the form of the disease denominated ‘foetid bronchitis,’ the odour resulting either from sloughs of minute portions of the mucous membrane, or from chemical changes taking place in the sputa. Occasionally streaks of blood are met with. Microscopically the sputa are found to consist of epithelium, pus-cells, and granular matter, witli at times blood-corpuscles. The constitution does not suffer much in mild attacks, but when chronic bronchitis is permanent and general, the system at large sympathises more or less severely: the appetite fails, sleep is disturbed by the cough, emaciation sets in and sometimes becomes marked, but it does not proceed beyond a certain point, unlike that of phthisis, which is usually progressive. In all cases of chronic bronchitis there is great risk of an acute attack coming on, especially amongst the aged. These attacks are very dangerous, in consequence of the rapid extension of the disease throughout the lungs, and its asphyxiating cha- racter. 2. The second class of cases is characterised by excessive secretion from the bronchial tubes — Bronchorrhcea. This form is often met with in the old and feeble, and especially in cases of valvular disease of the heart. The cough is paroxysmal, and attended with the expectoration of a large quantity of thin watery glairy fl uid, or of thick ropy gluey matter, like white of egg. The quantity expectorated is sometimes very large. This form of bronchitis may cause death somewhat suddenly by apneea. During the paroxysms of cough there is dyspnoea, but at other times it is absent, except -when heart- disease exists. The constitution suffers little, and the flux seems sometimes to be beneficial in cases of obstructive cardiac disease. 3. The third variety, or Catarrhe see, is cha- racterised by very troublesome cough, oppression of breathing, tightness of the chest, and some- times severe dyspnoea. Expectoration is either absent or very scanty, the sputa consisting of small masses of tough viscid semi-transparent mucus. There is usually no febrile disturbance. The disease is met with in gouty people, and is often associated with emphysema of the lungs. Pathologically it seems to consist in a congested condition of the bronchial tubes. Physical Signs. — Inspection reveals nothing abnormal in the form or size of the chest, unlesn BRONCHI, DISEASES OE. 188 emphysema of the lungs is present. The expansion in long-standing cases is usually deficient ; the chest being raised more than in health. Expiration is often prolonged. Rhon- chal fremitus may be felt more or less, depending on the state of the bronchial tubes. There is often increased resonance, from the presence of emphysema. The breath-sounds are more or less changed ; they are harsh and loud, and the expiration is prolonged in cases that have ex- isted for a considerable period. The rhonchi vary ; they are dry, coarse, moist, or bubbling according to the condition and contents of the tubes. Vocal resonance varies ; it may be bron- chophonic, normal, or deficient. Diagnosis. — There is usually but lit'Je diffi- culty in the diagnosis of chronic bronchitis. The affection is most likely to be confounded with phthisis, but the character and degree of the wasting, and the absence of increased tempera- ture, of haemoptysis, and of the physical signs of consolidation, will generally enable the prac- titioner to decide in favour of the less important disease. The main difficulty lies in the diagnosis of cases where the bronchi are dilated ; this will 1 e referred to hereafter. Prognosis. — Although in itself not a danger- ous malady, chronic bronchitis becomes so in consequence of the liability which exists to the occurrence of acute symptoms ; when once es- tablished in middle or advanced age it is almost incurable. The complaint is further serious from its tendency to produce emphysema and dilatation of the bronchi. Per sc it can scarcely ever be said to kill. Treatment. — No case of chronic bronchitis can be successfully treated without due regard to the constitutional condition of the patient. In some cases it is impossible to cure the lisease, and all efforts should be directed to- wards preventing its extension ; alleviating the symptoms to which it gives rise ; and warding off acute attacks. Attention must be especially paid to the state of the heart and kidneys; the duration of the affection; the age of the patient; the characters of the expectoration ; the state of the lungs, as to the existence of emphysema or other morbid conditions ; and the presence of gout or rheumatism. Speaking generally, chronic oronchitis must be treated by the use of a gene- rous diet, with more or less stimulants; by the exhibition of expectorants and tonics ; and by the a voidance of all depressing measures. The func- tion of the liver must be looked to, and the administration of a few doses of blue pill with a saline aperient often gives great relief, and alters the character of the bronchial secretion. If gout, or a tendency to the formation of uric acid, is present, eolckicnm with alkalis and other remedies for gout, such as a course of Friedrichshall or Carlsbad waters, will prove of great service. If cardiac disease exist, whether in the form of valvuLir incompetence, or of weak, flabby, or dilated heart, digitalis combined with iron frequently produces marked benefit. In the treatment of ordinary cases of chronic bronchitis, not dependent on any organic disease or constitutional condition, the patient’s general health has to he looked to. The affection has a tondency to lower the health and to diminish strength, and therefore the various tonics may often be given with great benefit. Of these the most useful are quinine, the preparations of iron, and those of zinc. Cod-liver oil is also very valuable in some eases where there is much wast - ing. The eases of bronchitis marked by excessive secretion are generally best treated by tonics ; whilst those where the secretion is slight — cases of ‘dry catarrh’ — being often associated with a gouty condition of the system, are more amenable to the use of colchicum, the alkalis, iodide of potas- sium, and mineral waters. In what may be called the symptomatic treat- ment of the affection, the various expectorants are useful — carbonate of ammonia, ipecacuanha, squill, cascarilla, senega, chloroform, &c., and these may often be beneficially combined with some form of tonic. In many cases of chronic bronchitis the expectorating power is diminished, and stimulating expectorants are of great service. Great caution must be exercised in the adminis- tration of opiates and other narcotics or sedatives. When, however, the mucous membrane is very irritable, and when there is but little secretion with a troublesome cough, these remedies are in- dicated. Opium is of great value, and chloral- hydrate is also very useful, as well as, in some cases, henbane and hydrocyanic acid, cr, when- ever spasm is present, stramonium, lobelia, the others, and cannabis indica. Inhalations are sometimes very beneficial, as of the vapour of warm water, iodine, creasote, and other sub- stances. The inhalation of creasote is especially valuable if the expectoration is foetid. Counter-irritation is one of the most impor- tant means we possess of relieving chronic bronchitis. The irritation should not be exces sive, hut should he long-continued. The appli cation of iodine over a large surface of the chest, so as to keep up a constant slight inflammation of the skin, is perhaps the best that can be used; but other irritants may be tried, such as sina- pisms, or the various stimulating liniments. The general management of the patient is most important. A mild climate should, if pos- sible, be chosen in the winter. The patient should live as far as possible in an atmosphere which is mild and dry. Although some cases are benefited by a moist and warm atmosphere, the majority of cases of chronic bronchitis do better in a drier one. The skin must be carefully looked to, its action should he well maintained, and warm clothing always worn. A moderate amount of some alcoholic stimulant is generally desirable ; and the food should be nutritious and of easy digestion. Relief will often he found from wearing a respirator. 3. Plastic Bronchitis. — This is a rare form of disease, and of its particular causes nothin" is known. It is perhaps connected with some peculiar diathesis. Sir John Rose Cormack sug- gests thatitmaybeavarietyof diphtheria. It mav occur in either sex, and atanyperiod of life, but is most frequent in those who are of a strumous or phthisical constitution. It has been known, however, to attack persons of apparently healthy frame and in the enjoyment of robust health. Anatomical Characters.- — Plastic bronchitis is anatomically characterised bv the formation of concretions in the bronchial tubes. These BRONCHI, DISEASES OF. i«S loneretions consist of fibrinous exudation from the mucous membrane ; they form casts of the tubes, and are expectorated. These casts are either solid or hollow, and on examination are always found to consist of concentric laminae. They are, for the most part, poured out into the finer bron- chial tubes, sometimes, however, into the larger ones, but never into the trachea. The casts are Of a whitish colour, but they are often stained with blood. Microscopically they consist of an amorphous or fibrillar material, with exudation- corpuscles, granular matter, and oil-globules. Symptoms. — This disease is essentially chronic, but it has been met with as an acute affection in children. At the times wdien the casts of the tubes are expelled exacerbations occur, the patient being attacked with pain and a sense of constriction across the chest, dyspnoea, and an irritating cough. After a time, varying from some hours to a few days, the dyspnoea becomes very urgent, and the cough very severe ; then, after a paroxysm of coughing, it is found that the patient has expectorated some solid material, either with or without blood, usually intermixed with ordinary bronchitic sputa. The dyspnoea and cougli now subside, to recur after an interval of a few hours or longer. The disease may last for weeks, months, or even years, marked from time to time by severe accessions, and relieved by the expulsion of further concretions. The matter expelled is often in small masses, but at times casts of bronchial tubes with several rami- fications are expectorated. The disease may recur at intervals for many years ; the general health in such cases does not seem to suffer, the breathing during the intervals being unaffected. There is, in some instances, an absence of febrile symptoms during the attack, whilst in others the fever is more marked. With the general symp- toms are combined the physical signs. These are somewhat poculiar. The bronchial tubes being obstructed, portions of lung are deprived of air ; the breath-sounds are therefore faint or absent. There may be dulness more or less complete on percussion, from collapse of the lung- substance, or, as occurs in some cases, from localized pneumonia. Apncea may be threatened if a large tube is blocked up. Diagnosis. — The diagnosis of this affection turns on the peculiarity of the expectorated matters. Doubtless tire disease may be mis- taken for ordinary bronchitis or pneumonia, but when once the fibrinous casts of the tubes are observed in the sputa, the nature of the case becomes clear. Prognosis, Duration, Terminations, and IvIortaxity. — The prognosis, if the disease is uncomplicated, is favourable ; but there is great liability to recurrence. The complaint may last for many years ; and may terminate in complete recovery. A fatal result generally depends on the presence of some other organic disease, such as phthisis or pneumonia. Treatment. — But little can be advanced as to ihe value of any special treatment for this affec- tion. Iodide of potassium is said to have been employed with success. The chief object should be to maintain the general health by hygienic measures, and the exhibition of tonics, such as iron, Quinine, and cod-liver oil, especially if there be any tubercular taint. During the exacerba- tions the administration of ammonia and the use of inhalants should be resorted to, and the general principles on which ordinary bronchitis is treated should be carried out. 4. Dilatation. — Bronchiectasis. — This is a rare disease, which arises as a secondary affection. It is often associated with serious pulmonary mischief, and is at times difficult of diagnosis. There are two forms of bronchiectasis, namely general or uniform dilatation ; and saccular or ampullary dilatation. 1. The geyieral or uniform bronchiectasis con- sists in a cylindrical dilatation of one or more of the tubes throughout a considerable portion of their extent. The tubes are evenly widened for the most part, and end abruptly. 2. The saccular form of bronchiectasis con- sists of a globular dilatation of a tube at one point, or at several points. The dilatations vary in size, being from half an inch to an inch or more in diameter. On the tracheal side they usually communicate with a slightly enlarged bronchial tube, whilst on the peripheral side the continuity of the tube is almost or entirely lost from narrowing or actual obliteration. Some- times the cavities communicate with one another. The two forms of bronchiectasis ofcen coexist. The walls of the dilatations undergo chariges in the course of the disease. The mucous mem- brane becomes granular, swollen, and congested; while at a later stage it presents a velvety or villous appearance, and in some cases there is even ulceration with superficial necrosis. The muscular and elastic coats become atrophied, and coincidently with this dilatation increases. At times the wasting of these coats is partial ; some portions of the walls retaining their natural volume, and forming bands or ridges elevated above the surrounding membrane. The dilated tubes occasionally present an appearance of hypertrophy ; the walls aro thickened, but the thickening depends on changes which have taken place in the mucous membrane. The cartilages resist the destructive metamorphoses longer than the other structures, but they sometimes partake of them. The contents of the tubes may be either muco-pus, or pus ; and casts of the minute bronchi are met with. At times the contents are very fcetid. Crystals of margarin are occasionally found, and sometimes fragments of pulmonary tissue. It is said that the contents may become calcareous. Dilatation of the bronchi may be unattended with any change in the surrounding lung-tissue, but, generally speaking, condensation of the latter takes place, either as the result of pressure or of chronic pneumonia. In some instances the tissue forms an abscess, in the centre of which the walls of the bronchus are found, whilst in others the walls of the bronchi and the sur- rounding tissue are destroyed by gangrenous inflammation. It is generally not difficult to distinguish between a phthisical cavity and a dilated bronchus. The latter is not characterised by the broken irregular surface which usually exists in the former; its shape is generally more regular ; and it is usually continuous with bron- chial tubes. The surrounding lung-tissue han no tubercular infiltration. 190 BRONCHI, DISEASES OF. The mechanism of bronchiectasis has occupied much attention. It is probable that the elastic and muscular fibres lose their elasticity and con- tractility as the result of chronic inflammation, and thus yield to the distending influence of coughing. When once a dilatation is produced, accumulation of the secretions takes place, which tends further to increase the dilatation. Symptoms. — The symptoms of bronchiectasis are those of chronic bronchitis aggravated in some important respects. The cough is frequent and paroxysmal. The expectoration is Tery abundan';, very purulent, and, when the disease has lasted some time, very foetid. The breath also becomes fetid. Haemoptysis is occasionally met with, even to a considerable extent. There is more wasting than in ordinary bronchitis, and the blood is more imperfectly aerated. Night-sweats are not uncommon. In fact, the general symptoms approach those of phthisis. The digestive functions are usually not much impaired. Physical Suns. — The movement of expansion is diminished in bronchiectasis, while that of expiration is prolonged. Over the affected por- tions of the lung there may be slight retraction. Vocal fremitus is increased, and rhonchal fre- mitus is sometimes well marked. The percussion- note is altered. If a dilated tube is surrounded by condensed lung-tissue, or is full of secretion, there is dulness on percussion ; but if it is situated near the surface and empty, some degree of tu- bular resonance may exist. Cracked-pot sound may be at times elicited. The respiratory sounds are harsh, or loudly bronchial with a more or less blowing character, and they may be distinctly cavernous. Vocal resonance is often greatly increased. The pulse becomes rapid in the later stages. The temperature rarely if ever reaches the height that it does in phthisis with cavities, and the daily oscillations are not so marked. Diagnosis. — The main difficulty as regards diagnosis is in the differentiation of certain ■ases of phthisis with cavities from bronchiec- tasis with large globular dilatations. The points to be relied on are that in the latter disease the morbid physical signs are usually met with at the middle and lower parts of the lungs, whilst in ordinary phthisis they are found at the apex ; that the temperature differs in the two affections as mentioned above ; that emaciation and night- sweats are not so marked in bronchiectasis ; and that, if cases are watched, there is usually ob- served a progressive advance of symptoms in phthisis, whilst in bronchiectasis the symptoms may remain stationary. In phthisis signs of consolidation precede those of cavities, whilst they follow them in bronchiectasis. Bronchial dilatations and tuberculous cavities have been found in the same lung. The fetor of the breath and sputa in bronchiectasis may cause a sus- picion that gangrene of the lung is present ; but the general symptoms will usually enable the practitioner to differentiate between the two affections. Prognosis. — Bronchial dilatation is probably never cured. It may last for years. Treatment. — The treatment of bronchiectasis must be that of chronic bronchitis with the use of auch measures as are applicable to wasting diseases in general. The fetor of the breath is best relieved by the inhalation of creasote. 5. Harrowing or Obstruction. — Narrowing or obstruction of the bronchial tubes is by no means uncommon, and may depend on intrinsic or extrinsic causes. Complete obliteration of a tube is sometimes found in connection with bronchiectasis, immediately beyond a globular dilatation. tEtiology. — The intrinsic causes of obstruc- tion are a thickening of the mucous membrane resulting from bronchitis ; the retention of viscid secretions ; the exudation of plastic material into the interior of the tubes ; and the deposition therein of tubercle or cancer. Amongst the principal extrinsic causes are : the pressure of adjacent tuberculous or cancerous deposits ; the contraction of plastic matter exuded into the tissues surrounding the tubes ; solid formations in the pleura; enlarged bronchial glands ; and aneurismal and other thoracic rumours. Obstruction is most frequently met with in the smaller tubes, but the pressure of thoracic tumours not unfrequently causes obstruction, or even obliteration of a main bronchus, which occasionally — as in the case of aneurisms — becomes perforated. Symptoms. — If a large bronchial tube becomes suddenly and greatly' obstructed, dyspncea of an urgent character sets in, aud death from apncea may speedily result, unless the obstruction be removed. When the obstruction is on a smaller scale, being confined to the smaller tubes, or when a large tube suffers only' from slow, gradually increasing obstruction, the sy'inptoms are by no means urgent for a time, and slight dyspncea, sometimes accompanied by stridor, is the most- marked feature. Physical Signs.— Complete obstruction of a bronchial tube invariably' leads to collapse of the portions of the lung to which the tube is dis- tributed, and thus an entire lung may collapse if its main bronchus be obliterated. Where partial collapse is produced, emphysema of the neigh- bouring lung-tissue commonly follows, and if one lung become collapsed, the opposite lung becomes enlarged and emphysematous. The existence of collapsed lung gives rise to dulness on percussion over the affected part, unless this be situated away from the chest- walls, or masked by the presence of emphysema. Further, ob struction of the bronchi causes a weakness or deficiency of the respiratory sounds, with a prolonged expiratory' murmur, attended at times with sonorous and sibilant rhonchi. Over the collapsed portion of the lung, or over portions of the lung supplied by a tube which has become completely obstructed, the breath-sounds are absent. Deficiency or absence of vocal vibration is another physical sign of obstructed bronchial tubes. Treatment. — The treatment of obstruction of the bronchi must depend on the nature of its cause. The chief interest of the affection arises from the means of diagnosis of thoracic tumours which it may afford. 6. Cancer. — Cancer of the bronchial tubes occurring independently of cancer in the lungs, or mediastina, is probably never seen ; but can- BRONCHI, DISEASES OF. cerous matter has been found in the tubes : (1) in cases where the lungs have been infiltrated with a similar deposit; (2) where a cancerous tumour connected with the root of a lung has perforated a tube ; and (3) in some cases of can- cerous disease of the lung, a tumour of a similar nature being fouud connected with the mucous membrane of a tube. (4) Cancerous matter has also been found in transitu in a tube, having been detached from a cancerous mass. A. T. H. "Waters. BRONCHIAL GLANDS, Diseases of. — Synon. : Fr. Adenopathie I'rachbo-bronchique ; Ger. Krankhdten der Bronchialdrusen. Definition. — Disease of those lymphatic glands which are situated at the b ifurcation of the trachea, between the right and left bronchus, or upon these tubes and their primary divisions. General Description. — A short reference to the anatomical relation of these glands in con- nexion with their pathological and clinical history will be useful. Taking the bifurcation of the trachea as a starting point, we find in the space between the right and left bronchus a group of glands. They are from ten to fifteen in number, and they vary in size from that of a small pea to that of an almond. The glands towards the right bronchus are larger than those towards the left. Glands are also situated upon the tubes ; they are few in number and small. The vascular supply of the glands, which is free, is derived from the bron- chial arteries, and the blood is returned to the bronchial veins. Afferent lymphatics reach the glands from the lungs, from the pleura, from the neck, and other neiglibouringparts. Besides these groups of comparatively large glands, numerous minute lymphatic glands are found in connection with the primary division of the bronchi, chiefly at the back of these tubes at their bifurcations and at those of the pulmonary artery. The central group of glands is in relation in front with the pericardium, the arch of the aorta, and the pulmonary artery; behind with the pulmonary plexus of nerves, the oesophagus, the aorta, the vena azygos, &c. The ganglia on the upper, anterior, and posterior surfaces of the right bronchus are four or five in number and smaller than those of the central group. Their situation brings them into relation with the arch of the aorta, the innominate and subclavian arteries, with the brachio-cephalic vein, and with the vena azygos, the pneumogastric nerve, and its recurrent branch. The ganglia on the left bron- chus are still smaller than those of the right side. Their position gives them relations with the arch of the aorta, the origin of the left carotid and subclavian arteries, the left branch of the pulmonary arteries, with the large veins, with the left pneumogastric nerve, and especially with its recurrent branch. Lastly it should be stated, as a guide in clinical examination, that the bifurcation of the trachea takes place in front of the body of the fifth dorsal vertebra, or between the fourth and fifth, and behind the lower end of the first bone of the sternum. The glands, except when diseased, are proportionately larger in children than in adult or aged persons. Know- ing that these glands in common with other lymphatic glands, are liable to such diseases as BRONCHLAL GLANDS. 191 enlargement, abscess, morbid deposits, growths, and other textural changes, and bearing in mind, as just mentioned, their relations to surrounding organs, we can readily see that the study of their diseased conditions is important. Not only 7 is their study important in reference to the diseased glands themselves, but by reason of their modify- ing or masking the symptoms of disease in other organs, as results of the pressure which when en- larged they cause on nerves, air-passages, blood- vessels, &c. Throughout English and foreign medical literature numerous cases will be found described, in which there existed, more or less conspicuously, striking disease of the bronchial glands, little notice, however, being taken of less striking, though far more numerous, examples of disease. It is only within a comparatively recent time that the subject has received special atten- tion and been discussed as a disease per se. MM. Rilliet and Barthez, in their well- known Traite dcs Maladies dcs Enfants, have described the disease in infants, and Dr. "West, in his work on The Diseases of Infancy and Child- hood, has fully and clearly described — under the head of Bronchial Phthisis — the tubercular dis- eases of these glands in young subjects. It is, however, to M. Noel Gueneau de Mussy, follow- ing up and widely extending the investigation of his predecessors, that we are especially' in debted for our knowledge of the effects of these lesions, and to his pupil M. Barety, who has published an exhaustive memoir upon these, under the title L’ Adenopathie Tracheo-Bron- chique. The subject has attracted the present writer’s notice since (or even before) the year 1853, and the notes of nearly sixty cases which have fallen under his observation will form the bases of some of the conclusions to be subse- quently stated in this article. Morbid Anatomy and Pathology. — The bronchial glands participate in the diseases which affect lymphatic glands generally, and which will be found described in another article. (See Lymphatic System, Diseases of.) Here it will suffice to enumerate the principal morbid changes to which they are liable, referring briefly to any special circumstances in connection with these particular glands. a. The bronchial glands are liable to conges- tion with enlargement as are glands in other situations. Hypertrophy will be the result of this last condition becoming chronic. The glands in this situation become after childhood almost invariably studded with black deposits, the quan- tity of which may be so considerable as to con- stitute melanoma. b. These glands are liable to acute and chronic inflammation. Acute inflammation in this situation, terminating in abscess, is rare, but several cases of the kind have been re- corded. Chronic inflammation of the glands is by no means uncommon. It may lead to perma- nent enlargement, to contraction and induration of the glandular textures, with the presence of calcareous particles, or to abscess. The contents of the abscess may be more or less completely absorbed, leaving a partially filled sac or cyst, containing thick pus or cheesy matter. Bnt these glands, when inflamed and enlarged, may form adhesions with surrounding parts, and 192 BRONCHIAL GLANDS. DISEASES OF. the contents of an abscess, if it exist, may be discharged, by an ulcerative process, into the substance of a lung, into the mediastinum, into the trachea, or oesophagus, or even into a blood- vessel. General emphysema has occurred in such cases ; whilst the emptied sac has assumed in some instances the character of a cavity con- nected with the lungs. When the matter is dis- charged into the air-passages, purulent expectora- tion is the result. Two or three examples of such eases were noticed in the writer’s observation, and the possibility of their being mistaken for the discharge from a cavity in the lungs, or an empyema, was remarked upon at the time. The abscess may discharge into the mediastinum. A remarkable instance of the kind is recorded in the case of the late much lamented Dr. Fuller. A chronic abscess of the bronchial glands had opened into the posterior mediastinum. This led to pyaemia, the formation of abscesses in the brain, and to the loss of a valuable life. c. These glands are liable to suffer especially from tuberculous or scrofulous disease, from various forms of malignant disease, and in secondary or tertiary syphilis. Of the latter form of disease, some striking examples have fallen under the notice of the writer, in which symptoms closely resembling phthisis existed, but which yielded to treatment directed to the specific disease. /Etioxogy. — The causes which give rise to disease of the lymphatic glands being discussed in another article, reference will here be made only to the special cireumstanceswhich influence the particular glands, and thus it will be sufficient morely to allude, amongst predisposing causes , to hereditary predisposition, to general impairment of health, and the like. With regard to the in- fluence of age and sex, reference has already been made to the works of Rilliet andBarthez, of Dr. West, and of other authors who described the fre- quency of the disease in childhood. The writer’s observations made on young persons and adults show that of 58 cases (of whom 21 were males and 36 females — in one case the sex was not re- corded) 2 were under 10 years of age, 9 were between 10 and 20 years of age, 18 were between 20 and 30, and 26 were over 30 years of age. In three cases the age was not stated. If these ob- servations justify any inference, it is that females are more liable to disease of the bronchial glands than males, and that the disease occurs with increasing' frequency after the age of puberty. Amongst the exciting causes of disease in these glands we may leave to he considered elsewhere those general conditions which give rise to dis- ease in these and other glands, sueli as scrofula, tubercle, malignant disease, &e., and pass on to the consideration of the more immediately local exciting causes. Gold leads frequently to conges- tion and enlargement of the bronchial glands. But it is to local irritation or inflammatory dis- ease in organs or tissues with which these glands have a connection that the source of diseasemay be frequently traced. As we find the submaxillary or cervical lymphatic glands enlarged from irri- tation or disease in the mouth or throat, or the axillary glands or inguinal glands enlarged from irritation or inflammation about the hands and leet, so we may find the bronchial glands en- larged temporarily or permanently from inflam- matory disease in parts the lymphatics of which pass to these glands. These glands have been observed to be enlarged in the course of or after certain acute specific diseases, such as scarlet fever, measles, and typhoid fever. In whooping cough this enlargement has been so frequently observed by M. Gueneau de Mussy, that he believes this disease to be an exanthem of the bronchial mucous membrane, and that this local condition leads to enlargement of the glands, which, again, by pressure on the pneumogastric and re- current nerves, gives rise to some of the special phenomena of the disease, such as crowing cough, and even to the vomiting so frequently observed in this disease. It is right to remark here that the late Dr. Hugh Ley speaks interrogatively, in his work on Laryngismus stridulus, of en larged bronchial glands being capable of pro- ducing a cough like that of pertussis, and he further alludes to some cases of whooping cough in which the glands by the side of the trachea were enlarged. He asks, ‘May it not be that an enlargement of these glands from a speci- fic animal poison, similar to that of the parotid gland in mumps, is after all the cause of whoop- ing cough?’ (Note, p. 440.) The same author gives several beautiful illustrations of diseased bronchial glands pressing upon the pneumogastric and other nerves. The black deposit so often found in the glands is the result of the absorption of car- bonaceous or pigmentary matter from the lungs. Syjvptoms. — The symptoms which have been recorded by the writer as more or less character- istic of the presence of enlargement of the bron- chial glands are as follows : — 1. Cough, which is noted as beiug a prominent symptom in 39 cases. In 21 of these cases it was stated to have been the most troublesome of the symptoms present. In 6 cases it was de- scribed as harsh and laryngeal ; in 4 cases spas- modic, resembling whooping cough. In other cases, 5 in number, it was characterised as short and hacking, constant, incessant, and in one case the sound resembled that made by the cough of a sheep. 2. Pain is, in regard to the frequency of its occurrence, the next symptom recorded. It was mentioned as being present in 22 cases. The seat of pain was almost constantly referred to the situation of the fourth and fifth dorsal vertebra at one or both sides of the spinal column. The pain was mentioned in a few cases as existing only in front, beneath and at one or both sides of the upper end of the sternum and below the clavicles. The feeling was de- scribed in seme cases (5) as of distressing tight- ness, and in one case as a ‘ spasm.’ Tenderness on pressure over the seat of pain was very fre- quently observed. The persistence of the pain was very varied. 3. Difficulty of breathing was a noticeable symptom in several cases. In 13 it was recorded as being specially so ; in 4 it had all the charac- ters of spasmodic asthma, occurring at intervals and especially during the night. 4. Difficulty of swallowing was noticed in 10 cases ; in one of these the difficulty was remarked especially in swallowing liquids. o. Hemoptysis was present in 10 cases. The amount of blood varied in theso cases from BRONCHIAL GLANDS, DISEASES OF. marked streaks to copious expectoration, lasting two or three days. No case was recorded as presenting this symptom except on tolerably clear proof that it depended on bronchial gland enlargement, and on no other cause. (i. Congestion and puffiness of the face hare been mentioned as present in 3 cases. 7. Expectoration of mucus , such as results from bronchial catarrh, was frequently present. Expectoration of pus was present in 3 cases. In each it resembled the contents of an ordi- nary glandular abscess mixed with air. In one of these the discharge was intermittent. The frequent occurrence of cough without any ex- pectoration was remarked in many cases. Cal- careous particles are mentioned also as having been expectorated. 8. Loss of voice (4 cases) and hoarseness (2 cases) are recorded as striking symptoms. 9. Vomiting is mentioned as having been present twice. 10. Lastly, the position assumed with least discomfort by the patient when in bed was noticed in 41 cases. Of these 23 rested on that side on which the glands were mentioned as being chiefly if not wholly affected. In 15 cases an opposite condition was noticed. In 2 cases lying on the back was the most comfortable position. One patient, unable to lie down, sat when in bed, and stooped forward. One patient, a little boy, could only rest on his face and knees. This case was further remarkable in reference to the clearness with which the disease was recognised and the successful result of subse- quent treatment. It might be mentioned here incidentally that the glands of the right side were noticed as beiDg chiefly affected in 28 cases, and of the left in 22 cases — in 4 both sides seemed equally affected, and in 4 no record was made. The general or constitutional symptoms connected with the malady under notice need not bo discussed here. They are in nowise peculiar, and will be found discussed elsewhere. The symptoms described above have special reference to the bronchial glands. The cough and its peculiar character- istics are, no doubt, in a great measure depen- dent on pressure or on irritation communicated to the pneumogastric nerves and theii branches. So likewise pain and difficulty of breathing, in a great degree, through direct pressure on the air- passages, may also cause or aggravate these symptoms. Aphonia especially seems to have relation to the condition of the recurrent nerves. In one of the cases which the writer saw with Mr. Lennox Browne, paralysis of the left chorda vocalis existed. The diagnosis of glandular disease was clear, a conclusion confirmed by the results of treatment. Vomiting is mentioned in two cases. M. de Mussy says that this is a more frequent result when the left pneumogastric nerve is pressed upon. He sees a connexion between the troublesome vomiting which occurs in some cases of tubercular disease of the lungs witn like pressure upon nerves. The puffiness of the face and eyes noticed in these cases is due to the pressure on the venous trunks, a con- dition which also accounts not only for haemop- tysis, but for bleeding from the nose, occasionally present. Copious and • sometimes persistent 13 1S3 haemoptysis has been traced to the perforation of a vessel (ulceration in connexion with disease of the glands). The Physical Signs noticed in the 58 cases referred to were: 1 . Dulness. — It was present in 47 cases. It was found between the margin of the scapula and the spinal column at one or both sides, on a level with the fourth and fifth dorsal vertebrae. It varied in degree, and was more readily manifested when the muscles of the back were made tense by folding the arms across the chest, and was often strikingly distinct when one side was contrasted with the other. Dulness was present in front in 8 cases (whether coinciden- tally with dulness at the back or not is not clearly stated), beneath the top of the sternum and at each side below the sterno-clavicular junction. The dulness here was best elicited by the patient holding the head backwards whilst percussion was being made. 2. Flattening of the affected side in front was mentioned in 3 cases. Diminished mobility of the affected side, independent of flattening, was re- corded in 4 cases. Prominence in front was not recorded in any ease, though, no doubt, it occurs sometimes. 3. The respiratory sounds were variously modi • fled. Marked tubular breathing was recorded as being present over the seat of disease in 14 cases In 10 the expiratory murmur was described a: being very loud , various modifications of the in- spiratory murmur being found at the same time. Feebleness of the respiratory murmur as a whole was noticed in 14 cases. In some this deficiency extended over the whole lung; in others it ex- isted over the upper or lower portion of a lung, behind or in front. The observations made on the voice by the writer were few, but M. de Mussy and M. Lereboullet speak of a peculiar and increased reverberation of both the voice and the cough. Dr. Eustace Smith has described in the cases of children a venous hum, heard at the root of the neck when the head is thrown back, caused by the pressure of tho enlarged glands on the venous trunks. Diagnosis. — In the present article those cases are not kept in view in which the bronchial glands becoming the seat of constitutional disease- in association with other glands in the neigh- bourhood, constitute large and manifest tumours — such will be found described under another head (see Intrathobacic Tumours). Nor has it been intended to give prominent consideration to the state of the glands when they enlarge in acute disease — such as eruptive fevers ; nor in those diseases — such as typhoid — where the glands play a secondary part. The writer has been anxious to describe and to assist in recog- nising the presence of a condition in which the disease of the bronchial glands constitutes to some extent a disease per se, or gives rise to complications which it is important to dis- criminate. He believes the symptoms and signs above described will suffice for the purpose, always remembering that in the present and in all similar instances it is necessary to take means for excluding in our investigations dis- eases which may produce like phenomena. Thus-- we may find cough, pain, tenderness on pressure, and aphonia in a case of hysteria without any 194 BRONCHIAL GLANDS, DISEASES OF. trident structural disease. On the other hand a small tumour, say, a small aneurism, may pro- duce all the signs of pressure which are above given as the signs of bronchial gland-enlarge- ment. It is the duty of the physician to recog- nise these differences and distinctions, to trace them to their origin, and thus establish as far as may be the nature of the disease under inves- tigation. Prognosis will in this, as in like instances, so entirely depend on the nature of the disease, on its amount and its condition, on its relation to and effects on surrounding organs and textures, that each case must be regarded independently. It would be impossible to discuss them fully here— all that can be said is that the simple enlargements generally yield to treatment and within a reasonable period. Treatment. — In several cases of morbid gland- enlargement, treatment has proved very effective. These cases would seem to be those of simple chronic enlargement. Many such cases have yielded to the use of iodide of iron in the form of pills or syrup, and to the external application of a solution of iodine, composed of equal parts of the tincture, and the liniment of iodine, between the shoulders. The same treatment has likewise proved very effective in cases in which a syphilitic origin for the disease could bo traced. Symptoms such as cough, difficulty of breathing, pain as well as dyspnoea, loss of flesh, strength, &c., will all require more or less suitable treatment. The cough and difficulty of breathing may in some cases be relieved by simple expectorants or antispasmodics. A useful application when pain is a prominent symptom, is an embrocation composed of equal parts of chloroform, bella- donna liniment, laudanum, and spirits of cam- phor. A couple of drachms of this composition sprinkled on the surface of piline and applied on the painful part for a few ndnutes, often affords relief. Hypodermic injection of morphia may be required when pain is very severe. Under all circumstances it is necessary to improve the general health by wholesome diet, pure air, and the other conditions which will promote good digestion and elimination from the excreting organs. R. Quain, M.D. BEONCHOCELE (Pp6y X os, the throat, and kIjAtj, a tumour). A synonym for goitre. See Goitre. BRONCHOPHONY (Ppiy X os, the throat, and the voice). The resonance of the voice, as normally heard on auscultation over those parts of the chest which correspond with the main bronchi, and, in certain mordid condi- tions, beyond these situations. See Physical Examination. BRONCHO-PNEUMONIA. A synonym for catarrhal pneumonia. See Pneumonia. BRONZED SKIN. A peculiar discoloura- tion of the skin frequently associated with Addi- son’s disease. Sec Addison’s Disease. BROW-AGUE. A synonym for frontal neuralgia, or tic-douloureux. See Neuralgia ; and Tic-Douloureux. BRUIT. {Bruit, Fr., a noise.) A word, used to designate various abnormal sounds heard on BUBO. auscultation, in connexion with the heart or vascular system. See Phtsical Examination. BUBO {Povffuv, the groin). — Syxon. : Apa.i- tema inguinis ; dragoncelus ; Fr. Bubon ; Ger. Leistenbeule. Definition. — An affection mentioned in the most ancient medical writings, but not properly distinguished in its several varieties until the present century. Inflammation of any lymphatic gland, set up by irritation of the surface con- nected with the afferent ducts of that gland, has been called bubo ; but the term is almost ex- clusively confined to swelling of the glands of the groin consequent on venereal irritation of the genitals, and will be so emploj'ed here. Varieties. — Buboes are divided into: — 1. Simple bubo, known also as sympathetic bubo, due to inflammation of a gland through ordinary irritation from an inflamed surface. 2. Specific bubo, (a) The chancrous or virulent bilbo, or abscess inoculated with the pus of a chancre. (6) The syphilitic bubo, or indolent enlargement of the lymphatic glands accompanying the de- velopment of the initial sore of syphilis. The glands first affected in the sympathetic and in both kinds of specific bubo are always those in most direct communication with the sore. Further, according to Ricord, when elia'n- crous matter has reached a gland through the absorbent ducts, it never passes beyond that gland into another more remote in the series. On the other hand, the effect of syphilitic ab- sorption is general, and affects those remote from, as completely as it does the glands nearest to, the inlet of the poison. Buboes occur most frequently on the side of the body occupied by the source of irritation, still not rarely on both sides, and sometimes only on the side opposite to the position of the ex- citing sore. The crossing of the irritant is due to anastomosis or interlacing of the lymphatics at the mesial line. When bubo forms in both groins, there is usually a sore at the mesial line or on each side. Bubo, including simple and virulent, occurs in about thirty per cent, of chancres ; how often with urethritis and other lesser venereal affections is not known. 1. Simple Bubo — Adenitis {aS^v, a gland). .ZEtiology. — This variety may be caused by: — (a) Mechanical irritation of the sur- face ; such as erosions or fissures irritated by dirt or by caustic applications. (b) Urethritis, balano-posthitis, or a chancre when acting as a simple local irritant. Simple bubo is also often excited by herpes, erysipelas, boils, or other non- venereal irritants of the genitals, (c) Lastly, though nearly all buboes can be traced to a lesion of the part where their absorbents arise, there are a very few with which no lesion is present. Such are caused by excessive sexual intercourse or excitement ; they are met with generally among young lads and girls. This form has received the names of idiopathic bubo, bubon d’emblee. Symptoms. — There are two forms of simple bubo 1. Slight swelling and tenderness of one or several glands, ending in a few days by resolution. This occurs most frequently in urethritis, balano-posthitis, or simple chafings. BUBO. In genuine chancre the next and more serious form is most frequent. 2. Swelling, commonly of one, seldom of several glands ; brawny thickening of the surrounding tissues; redness of the in- teguments ; great tenderness and pain, espe- cially when walking. In a few days this con- dition terminates either by abscess, by gradual subsidence to the normal state, or by chronic induration of one or more glands. When the bubo suppurates, the matter, instead of point- ing at once, may burrow in various directions among the layers of cellular tissue before it breaks through the skin. The pus of this form 'jf bubo is always the ordinary pus of inflamma- tion. Such cases may terminate by gradual con- version into chronic fistulas, or the glands may degenerate in scrofulous persons by enlargement and suppuration, or there may be successive formation of abscesses around the glands with undermining of the skin. This is most fre- quently seen in persons who have previously had constitutional syphilis, erysipelas, and other septic inflammations. Prognosis. — This form of bubo is seldom dangerous, but serious where it terminates in burrowing; it is then often very tedious and ex- hausting to the patient. 2. Specific Buboes. — (n) Virulent bubo. This is in reality an enormous chancre, identical in all but size with the sore whence it was inocu- lated. This form is never met with in gonor- rhoea or in syphilis, being a consequence of the local sore only T . It may be generated in two ways. 1. By touching the surface of a simple open bubo with chancrous pus. 2. By absorp- tion of chancrous pus along the lymphatic duets leading from the chancre to the gland most directly connected with the sore. Two patho- logical facts prove the reality of this mode of origin. First, occasionally small circumscribed abscesses form in the course of the lymphatic duets before they reach the gland. These little abscesses when opened present the peculiar cha- racters of the chancre. Secondly, until the necros- ing action has laid open the interior of the lym- phatic gland nearest the original chancre, the abscess about the gland retains its ordinary phlegmonous character. The conditions which assist or hinder the con- veyance of chancrous pus along the lymphatic vessels are wholly unknown. The proportional frequency of virulent bubo to the number of chancres is not known. It is far less frequent than simple bubo. It is said that women suffer more rarely than men in pro- portion. When not accidentally inoculated, virulent buboes are almost wholly confined to the groin, and originate in the gland which lie3 commonly in the centre of the group over the great blood- vessels. Occasionally with chancre on the fiDger, the epitrochlear or axillary glands de- velop into virulent bubo. Hiibbenet of Kiew experimentally inoculated a soft chancre on the cheek, which was followed by virulent bubo of the gland in front of the tragus of the ear. This bubo is generally unilateral; rarely are both sides of the body affected ; in such cases the chancre is usually at the mesial line, or 195 there are two chancres. Still more raroly the bubo forms at the side of the body opposite to that of the chancre. The time for appearance is generally in the first or second week of the existence of the chancre ; but it may occur at any time while the chancre is spreading. Symptoms. — At first the symptoms of specific bubo are those of acute abscess forming rapidly round a single gland. Thus far they differ nowise from those of simple bubo. When the contagious pus reaches the abscess accidentally from without, or from within the gland by ulcera- tion or incision of its capsule, the simple suppu- rating cavity becomes a spreading ulcer, which rapidly makes itself widely open by destruction of the integuments. The skin, thin as tissue paper, gives way at several points, and lets out a large amount of matter, which is thin, yel- lowish-grey or yellowish-red, with shreds of a chocolate colour floating in it. When perforated, the skin breaks rapidly away until the cavity is widely exposed. The further progress varies. In the least severe variety the edges of the skin ulcerate irregularly for a short distance, then thicken and begin to granulate ; the floor of the ulcer loses its unevenness and rises up to the level of the skin, and cicatrisation follows. But commonly a much greater destruction of tissue is effected. The skin is eaten away into wide gaps ; the floor burrows under the skin in long channels, or dives deeply among the great vessels. In other cases serpiginous ulceration produces a large shallow sore. The contagious condition of these buboes often continues for weeks or months, so that consecutive inoculation of the s.kin is not infrequent. The characters of the fully formed virulent bubo are those of the chancre. The surface is greyish-brown, dug-out, ‘ worm-eaten ; ’ the borders at some parts are thickened, everted, and pared away, at others sharply eroded or undermined and curled in. The matter is thin, shreddy, plentiful, reddish in colour, and inoeul- able. Again like the chancre, the virulent bubo passes through periods of extension , stagnation, and repair. The last stage is often long post- poned by phagedcena, a characteristic of no other bubo, but another mark of kinship to the chancre. Phagedaena very rarely attacks a bubo if it at- tacks the original sore. The virulent as well as the simple bubo is liable to erysipelas and in- flammatory sloughing. The duration of virulent bubo for the reason stated is wholly indefinite — in a few cases end- ing in a week, in many lasting for months or even several years. Phagedena . — The form of the sloughing in pha- gedsena is most commonly serpiginous. In this way the bubo may wander over the abdominal wall, the hip, thigh, and perineum, healing here and spread- ing there, or digging deeply among the muscles. Generally proceeding at this imperceptible speed, the phagedenic action may suddenly destroy the tissues with great rapidity for a time, and then pause altogether till another rapid extension is made. In this manner years may pass before healing is complete. Diagnosis. — The virulent bubo has in its early stage no distinguishing mark from the simple acute bubo. After it has become inoculated -with BUBO. 196 the contagious matter it is distinguished from every other affection by the characters already described. The earliest signs of virulence are two ; the matter which escapes when the bubo is lanced is thin and shreddy, and the edges of the cut become in a day or two eroded and partly covered by adherent sloughs. Subse- quently other characters develops and remove all doubt. Nevertheless, in some cases the signs of virulence are so feebly marked throughout that the diagnosis remains uncertain. This diffi- culty may be increased by the primary sore having healed before the suppuration of the bubo, or by its being hidden in some unusual position (urethra, anus). Prognosis. — Thisisnotalways grave. Virulent buboes often reach cicatrisation in a few weeks, and meanwhile cause no serious inconvenience. On the other hand, they are prone to inflamma- tion, or to phagedsena, and thus may permanently cripple or even destroy life. (b) Syphilitic Bubo ( indolent multiple bubo, pleiade ganglionnaire). — This enlargement of the group of lymphatic glands in nearest connection with the initial sore is the constant, or at least almost constant, symptom of early syphilitic in- fection. In this it differs much from the bubo of chancre or gonorrhcea, in which affections the bubo is more often wanting than present. Four conditions have been noted to exist in patients in whom the enlargement of the glands could not he detected, namely, 1. Phagedsena of the sore. 2. Obesity ; in such persons the lym- phatic system as a rule is small. 3. Second infec- tion ; i.e. a primary sore on a patient who has had constitutional disease before. 4. Scantiness of the induration of the primary sore, the sore itself being ill-developed. But these exceptions are most rare, Fournier gives five instances only in 265 cases of hard sore, accompanied by well-marked general syphilis ; or 2 per cent. In 1”6 similar cases noted by the writer, three had no apparent inguinal enlargement. One of the patients was a very fat man, and in another the initial sore was only slightly hardened. The seat of this bubo is, in the great majority of eases, the groin, whither, besides the lym- phatic ducts of the external genitals, those of the anus, perinseum, buttocks, and lower part of the abdomen are directed. But the glands of other regions, epitrochlear, axillary, sub-maxil- lary, buccal, cervical, and nuchal are all occa- sionally found primarily enlarged when the syphilitic poison enters the body through the regions whence their absorbent ducts are derived. In the groin the bubo is generally double, that is, the glands are enlarged in both groins, those on the side of the sore being most affected. On the other hand, only those on the same side as the sore, in a few cases, enlarge, and in rare examples only those of the side opposite to that i of the sore. This enlargement affects the group widely, for when the deeply-placed glands can be examined they are found to be similarly en- larged along the iliac vessels and lumbar verte- brae. Indeed, in some persons all the lymphatic glands of the body are temporarily increased in size. The enlargement of the glands is first per- ceived about eleven days after the induration of the sore, though probably the affection com. mencesatthe end of the incubation of the poison. In extremely rare instances enlargement is de- layed until the third or fourth week after th* induration of the sore. Syjiptoms. — The distinguishing marks of this bubo are swelling, wholly devoid of inflamma- tory character, and rarely surpassing an almond or a hazel nut in size ; gristly hardness ; ready isolation and mobility ; insensibility to pressure ; natural hue and condition of the overlying skin ; and absence of fulness of the cellular tissue. The gland in most direct communication with the sore is most enlarged; in rare excep- tions only a single gland is enlarged. Copious enlargement of the glands does not always attend copious induration of the sore, nor is scanty in- duration of the sore always accompanied by small swelling of the glands, though commonly this is the case. So also, though absence of tenderness is the rule, the glands may be slightly painful if pressed. Again, though the glands remain dis- tinct in most cases, they have been known to coalesce into a single mass, which becomes fixed to the fascia. In many patients the dorsal lymphatic vessel of the penis becomes indurated sufficiently to he easily distinguished under the skin. This bubo reaches full development in one or two weeks, and remains without apparent change for several weeks, or even for two or three months. Then it begins to diminish slowly, hut is generally still evident in the fifth or sixth month after infection, and now and then even for years afterwards. In rare cases the enlarge- ment vanishes in two or three weeks. The long duration of enlargement renders this bubo a valuable sign of constitutional syphilis when the primary sore has disappeared. Again, the con- spicuous enlargement of a group of glands may indicate the place of entry of the syphilitic poison when that is hidden. Terminations. — In nearly all cases the glands revert to their natural state. Now and then suppuration takes place, not from the syphilitic change, but from ordinary irritation, and then produces a simple phlegmonous abscess. This is apt to occur in strumous persons. The glands enlarge still more, grow soft, and coalesce ; presently matter forms in the thickened cellular tissue around the glands, and the further pro- gress becomes that of scrofula. Diagnosis.— This is generally easily drawn from the character of the swelling, aided by the presence of other syphilitic signs (hard sore, rash on the skin, &c.) This bubo may be con- founded with chronic inflammatory enlargement, but in such cases the history and attendant symptoms remove doubt. PnoGNOsis. — Apart from its connexion with syphilis, the prognosis is good. The only un- toward termination is scrofulous degeneration. Treatment of Buboes. — 1. The syphilitic bubo hardly needs treatment. It usually causes no trouble, and gets well independently of anti- svphilitic remedies. If tenderness or aching occur, rest and a few warm baths are sufficient. If suppuration take place the abscess must be incised and poulticed. The scrofulous degene- ration is best met by anti -scrofulous remedies — BUBO. 197 iodide of ammonium, or of iron, cod-liver oil, nu- tritious food, sea-air, and other tonics. Mercury, j n i -grain doses of the bichloride, combined with the iodide of sodium or with solution of per- chloride of iron, may be added to the treatment. Locally, the abscesses and sinuses must be emptied as fast as they form, and cleared by svringing with weak astringent lotions. 2. Simple acute bubo arising from any cause demands the same treatment, namely, that of acute abscess. In the early stages, antiphlogistics 'rest in bed, the constant application of a cream made of equal parts of extract of belladonna and glycerine, warm poultices, fomentations, and baths, sometimes even leeches) are requisite. Caution must be observed in applying leeches if chancre be present. They should be used only in the early stage of congestion, lest the bites be converted by inoculation into chancres. Again, the leeches should be applied at the circum- ference of the swelling, so that they may be removed as far as possible from the centre where pointing is most probable. If suppuration arrive more speedily than was expected, and the bubo prove a virulent one, incision must be postponed as long as possible, and the leech-bites protected by collodion, carbolic lotion, iodoform, or other antiseptics. When active congestion has ceased, the sub- sidence of the glands may be aided by pressure with a pad and spica bandage. Stimulating oint- ments and plasters, iod’ne, and similar prepara- tions are of doubtful service, and may possibly re-kindlo the inflammation. When pus has formed, it should be let out by a vertical incision at once. The proper drainage of the cavity should be insured by making the incision long (jin. usually), and by placing a bit of lint or drainage tube between the edges of the incision during the first twenty-four hours. Early evacua- tion reduces undermining of the skin to a mini- mum, and prevents burrowing. When matter forms at several points, a small incision should be made at each fluctuating point. When free exit has been given to the pus, the groins should be well poulticed for two days, and then dressed with zinc ointment spread under a compress, the bandage of which, slackly applied at first, may be tightened as the swelling subsides. 3. The chancrous bubo, not being distinguish- able during the inflammatory swelling and con- sequent suppuration from ordinary sympathetic bubo, requires the same treatment — calmants and an early single incision. By early incision the cavity of the abscess, subsequently the ehan- erous ulcer, is kept as small as possible ; by a single incision the number of chancres is re- stricted. Occasionally, but only when the ab- scess has already undermined the skin, more than one incision is necessary. Caustics have no advantage over the knife for opening the abscess, while they make a larger gap. When the abscess has been opened and the chancrous nature is suspected, it should be well cleared at the time by injections of one part of carbolic acid to eighty of water, 5-10 grains to the ounce of nitrate of silver, of tartrated iron, or of some other astringent and disinfectant. This injection may be repeated three times in the first twenty- four hours; and constant drainage maintained by a drainage-tube anda compress of Lister’s antiseptic gauze or boracic lint. Should these precautions fail to prevent the conversion of the abscess into a chancro, it must then be dressed as a chancre. It must be sedulously washed by injection twice daily, dried by careful mopping with bits of cotton-wool, and well dusted and packed with iodoform in powder ; the whole cavity being loosely filled with pellets of cotton-wool, and compressed gently with a layer of lint and a bandage. Should this fail, as it sometimes will, caustic may be applied. The caustics most suit- able are the strongest and most penetrating ; such as Vienna paste, acid nitrate of mercury, Rieord's paste (powdered charcoal and the strongest oil of vitriol). To apply the caustic thoroughly the patient should be anesthetised. If the least part of the surface is left unde- stroyed, that will reinoculate the whole. Com- plete cauterisation is practically very difficult to accomplish, hence caustics should be reserved for the cases where iodoform, which is pain- less, fails. Overlapping bands of skin should be divided, that the dressing may be fairly ap- plied. Phagedena . — When the ulceration by its ob- stinacy or by its rapidity deserves this title, plan after plan of treatment must be tried till the destruction of tissue is arrested — caustics being reserved for the last. When the patient’s general health is good, the ulceration seldom fails to yield to iodoform, applied thoroughly in the manner directed. While the nocturnal gnawing pain continues, the patient should be narcotised with opium or other narcotic. The cessation of pain is a signal that the eroding action has stopped. When iodoform alone is insufficient, the continuous warm hip-bath sel- dom fails. By it pain is at once arrested and healing soon set in motion. As continual im- mersion in a bath becomes extremely irksome in many cases, the phagedsena may be arrested by keeping the patient in water for sixteen hours every day, and allowing the night to be passed in bed — in this interval the wound should be carefully packed with iodoform. When the phagedsena is stopped, the bath may be discon- tinued and iodoform alone used. If the water- bath fail (and such a result has not yet happened during a considerable employment of this method at the Male Lock Hospital), caustics may then be used. The strength of the patient, generally much exhausted, should be restored by tonics, good diet, stimulants, and other general means. Abortive treatment of bubo . — This once fa- vourite method of treating buboes has fallen into disuse as the varieties of bubo have been better understood. The chronically enlarged glands of syphilis have little or no tendency to suppurate, but subside spontaneously if let alone. Others only suppurate when freely irritated, hence the best abortive treatment for such, is to guard against the increase of irritation, and assuage that which exists by antiphlogistics. In the bubo virulent by absorption suppuration is inevitable. Thus, the sympathetic bubo is the only one which can be acted on by abortive treatment. To anti- phlogistics may be added counter-irritants, but these are uncertain in their effect. Those least 198 BUBO. open to objection are vesicants, and the form most beneficial is ropeated ‘ flying ’ blisters. By this means a series of small blisters are produced round about, not over the swelling. Any other plan is most uncertain — painting the part with tincture of iodine, or othermild irritant, is simply waste of time. To enter at length into even a narration of the multitudinous ways in which irritants, vesicants, and even caustics have been employed would occupy much space to little purpose. Compression is of great value for reducing indolent enlargement, or for removing the boggy condition of the groin where several abscesses have formed, with more or less undermining of the skin. It is useless for the syphilitic bubo and mischievous for the virulent bubo. The simplest and most effectual method of applying compression, is by a graduated compress of lint kept firmly in place by a spica bandage of calico, or of elastic tape. For abscesses, careful packing may be added to the compress. Each focus of pus must be laid open, and bridges or tunnels cut across, so that narrow strips of lint soaked in liquor plumbi subacelatis and lightly pressed between the fingers, to drive out the dripping excess of fluid, may be laid into the hollows and under overhanging borders of skin. The strips must be renewed every day at first, and the cavities well cleared by syringing with water. In a few days, when the discharge is very small, the strips may be left for three or four days un- changed. The first application is painful, but very soon an insensible crust is formed over the ulcerating surface, and fresh applications cause no discomfort. As soon as healthy granulations are formed, the plugging should be laid aside. Berkeley Hill. BULBAR PARALYSIS. A synonym for glosso-laryngeal paralysis ; derived from the pathological relation of the disease with the bulb or medulla oblongata. See Labio-Glosso- Laryngeal Paralysis. BULIMIA (0ov, a particle signifying excess ; and \ifibs, hunger). Excessive or voracious appetite. See Appetite, Disorders of. BULL2E (Bulla, a bubble). See Bleb. BURSTS. The morbid effects produced by the direct application of excessive dry heat. See Heat, Effects of. BURS-33 MUCOSAS, Diseases of. — Bursae mucosae are spaces in the connective, tissue lubri- cated with a small amount of serous fluid, and situated at points exposed to repeated pressure or friction. Structurally they are composed of a layer of condensed cellular tissue, fusing exter- nally with the areolar tissue of the part, and lined internally with an imperfect layer of flattened endothelial cells, similar to those found in the pleura or peritoneum. Some bursae, as that over the patella, that under the deltoid, those about the great trochanter, and many others, are constantly present ; but new bursas, equally perfect in their structure, may form at any part exposed to abnormal pressure and friction, as over the outer malleolus of a tailor, under an old corn, or over the head of the metacarpal bone BUTtSJE MUCOSiE, DISEASES OF. of the great toe (bunion). Like the great serous cavities, burs® are indirect communication with the lymphatics, and inflammatory products are consequently absorbed from them with great readiness, often giving rise locally to a diffuse inflammation of the surrounding cellular tissue, closely resembling phlegmonous erysipelas in appearance, and always accompanied by high fever. Bursas are liable to four forms of disease: — 1. Acute inflammation and suppuration — Acute bursitis. — This is usually the result of some more or less violent mechanical injury. It may occur in any bursa, but is most common in the bursa patellae, those about the hip and over the olecranon, and in the small false bursa formed beneath an old corn, or in a bunion. The symptoms are those of acute inflammation gener- ally, but the redness and swelling often extend a remarkable distance up and down the limb. Thus, a drop of pus beneath a corn may cause oedema and redness to the knee. The febrile dis- turbance is usually proportionately severe. About the trochanter the abscess may assume a chronic form. Treatment. — Hot fomentations, and the ap- plication of glycerine and extract of belladonna (equal parts), may be of use. It is very impor- tant that pus should be let out early, or it may burrow extensively, especially about the knee. The antiseptic treatment, as recommended by Lister, will be found especially useful in the treatment of suppurating burs®. 2. Chronic Bursitis — Dropsy of the bursa consists simply of an accumulation of serous fluid distending a bursa more or less tensely. The wall becomes somewhat thickened and opaque, but is otherwise unchanged. The fluid is clear, straw-coloured, and albuminous in character. The cause of the disease is usually repeated slight mechanical injury, but in some cases it may be due to some of those obscure conditions spoken of as ‘ rheumatism.’ The symptoms are merely those of a collection of fluid in the situa- tion of the bursa, perhaps accompanied by a feel- ing of weakness in the neighbouring joint. There is no pain or tenderness. The commonest form of this disease is the so-called housemaid’s knee, but it is not unfrequent in the bursa of the popliteal space. Treatment. — Avoidance of the mechanical in- jury, whatever it may be. which has caused the disease, is most important. The swelling may be painted with tincture of iodine twice a day for some weeks, or a series of small blisters ap- plied over it. If this fail, a seton may be passed through and left in for a few days. Or an in- cision may be made into the swelling under anti- septic precautions, and a small drainage-tube introduced for a week or ten days. But before either of these means is adopted, care must be taken to ascertain that the bursa does not communicate in any way with the neighbouring joint. In the ham it is safer never to operate in any case, except perhaps by means of the aspirator. 3. Chronic enlargement of the bursa, with fibroid thickening of its walls. — This affec- tion is most common in the bursa patell®, but may occur in that situated over the tuberosity of BUKSjE MUCOSiE, DISEASES OF. „he ischium. The bursa becomes converted into a dense fibroid mass of almost cartilaginous hard- ness. On section it is found to be composed of concentric layers of dense fibroid tissue. There is usually a small central cavity containing a little fluid. The cause of this change, as of simple dropsy, is repeated mechanical injury of a slight nature. The only treatment is removal by the knife. 4. Chronic enlargement of the bursa, with the presence in it of the so-called melon-seed bodies. — In this form of disease, CECUM, DISEASES OF. ISO in addition to some thickening of the wall and accumulation of fluid in the bursa, small oval, flattish, smooth bodies of a white colour are found floating freely in its interior. These are similar in nature to those found in some forms of ganglion (see Ganglion). This condition is recognised by the peculiar soft crackling feeling perceived on palpation, combined with the ordinary symptoms of an- enlarged bursa. Marcus Bkcx. BUXTON in Derbyshire. Simple thermal waters. See Mineral Waters. c CACHEXIA (toa/cbs, bad, and e£is, a habit or i constitution of body). Stnon. : Fr. Cachexie. Ger. Kachcxie. Definition. — A chronic state of ill-health associated with impoverished or depraved blood, arising from mal-nutrition, persistent loss of blood-elements, or the presenceof a morbific agent. In such diseases as tabes mesenterica, lympha- denoma, and the like, the patients become cachec- tic from direct depravation of the blood, in consequence of disease of organs which are impor- tantly concerned in its nutrition and elaboration. In other diseases persistent loss of blood- elements arising from chronic suppuration or from repeated haemorrhages (especially observed in some uterine conditions) i nduces a cachexia which is well described by the term secondary anaemia. Again certain poisons introduced from without or nurtured within the body may produce marked cachexia. The syphilitic and malarial poisons are good examples of the first kind. Of cacbexise produced by the presence of morbific agents which have been generated within the body we may instance those arising from defective elimination, as the uraemic and gouty cachexiae from defective functional activity of the kidneys and liver. In the latter connexion it should be noted that, as has been hinted by Sir James Paget in reference to cancer, the malignant cachexia may arise from blood-contamination with the waste products yielded by the morbid growth in the process of its nutrition ; such a growth not only abstracting material from the blood for its nutri- tion, but also contributing effete material to it. It must be further observed that in the opinion of some of the best pathologists the term cachexia implies much more than the secondary anaemia consequent upon the ravage? of a given local or general disease upon the system. It rather signi- fies the morbid constitution which is the disease, and which may precede its local manifestation. Thus we may have the cancerous cachexia, culmi- nating in scirrhus of the breast, the tubercular cachexia in pulmonary tuberculosis, and the like. It is thus evident that with many observers the terms cachexia and constitutional disease have the same significance. K. Douglas Powell. CACOPLASTIC («a/cbr, bad, and irAatro-w, I mould or form). — A term applied to products of inflammation which are more or less incapable of organisation. CADAVERIC ( cadaver , a dead body). — This word signifies ‘ belonging to the dead body ; ’ and it is applied to the aspect, colour, odour, aDd other phenomena resembling those of death which are sometimes observed in the living subject. C-33CUM, Diseases of. — The structural pecu- liarities and anatomical relations of the caecum are specially favourable to the occurrence of the diseases to which this part of the large in- testine is most liable, viz., (1 ) accumulation of the solid and gaseous contents of the alimentary canal, and (2) inflammation. I. Accumulations. — Hardened faeces, biliary and intestinal concretions, foreign bodies, stones of fruit, balls of worms, lumbrici, and gases re- sulting from decomposition, are apt to collect in the caecum, and cause varying degrees of local disturbance. Sometimes, as in elderly patients of torpid habit, the emeum is found loaded with faeces, without inducing pain or other signs of inflammation. The right iliac region may be full and hard, and in it may be felt a well- defined, almost painless, doughy mass ; the tu- mour is of the shape of the caecum. As a rule, however, sooner or later the accumulation leads to one or more of the following results : — (a) Obstruction of the bowels. This may be partial, as in the various degrees of constipation ; or complete. "When complete, it may even prove fatal without the caecum or peritoneum exhibiting signs of inflammation. On the other hand, general peritonitis supervening, obstruction in the caecum may be quickly obscured ; still, however, the chief pain and tenderness will be found in the right iliac region. ( b ) Pressure on adjacent nerves, vessels, or other structures, producing numbness and oedema of the right leg, retrac- tion of the right testicle and other symptoms. ( c ) Inflammation (typhlitis, peritonitis). It is of clinical importance to bear in mind that the caecum, when overloaded or enlarged, may occupy an unusual position, c.g. a site betweer -00 CAECUM. DISEASES OF. the right and left iliac regions, or it may descend somewhat into the pelvis and press on the urinary bladder. Tympanitic distension of the csecuni is gener- ally associated with some fecal accumulation or obstruction in the colon or other part of the large intestine {see Flatulence). II. Inflammation. — Synon. : Typhlitis; Fr. Typhlile ; Ger. Blinddarmentz undung. Definition. — Inflammation of the walls of the caecum, liable to terminate in perforative ulceration ; in peritonitis, local or general ; or in inflammation and suppuration of the cellular tissue behind the caecum (perityphlitis). Etiology. — A s predisposing causes may bo regarded the anatomical peculiarities of the caecum, favouring the accumulation of solids and gases liable to irritate ; the causes of constipation and retention of fecal matter, or of inertia of the large intestine ; the period of childhood and adolescence ; and previous attacks of typliilitis. Exciting causes. — Attacks of typhlitis have been ascribed to exposure to cold, to irritating ingesta, unripe fruit, &e. Inflammation of the caecum may form part of an attack of enterocolitis or dysentery. Anatomical Characters. — Inasmuch as ‘ there are no cases on record of acute typhlitis proving fatal, in which post-mortem examination did not show the existence of perforation of the c tecum or appendix,’ 1 we invariably find sorious pathological changes complicating the appear- ances presented by simple inflammation of the walls of the caecum. In all cases the peritoneum investing the caecum is involved, as indicated by opacity and injection; and generally adhesions exist between folds of the intestines, in the vicinity of the right iliac fossa. General peritonitis is usually found associated with perforation into the sac of the peritoneum, and the escape into it either of the contents of the caecum, of an abscess in the cellular tissue behind the caecum, or of a circumscribed peritoneal abscess. Symptoms. — Inflammation of the caecum is met with either as part of a more extensive inflammation — e.g. enterocolitis, dysentery; or alone. In the former case its symptoms are merged into those of the more general affec- tion to which it is subsidiary, while in the latter they are special and characteristic. Clinically, two classes of cases may be recognised : — (a) The inflammation is of the catarrhal type, does not end in ulceration, pursues a favourable course, and affects children more particularly. Pro- bably it is strictly confined to the mucous lining of the caecum. {/>) The inflammation is more severe, is ulcerative, and is apt to terminate in perforation of the walls of the caecum, and to induce tedious or fatal sequelae. It would seem that all the coats of the caecum are rapidly involved. This form of typhlitis is generally observed after the period of childhood. Though typhlitis usually commences somewhat suddenly, most frequently there is a preliminary history of intestinal derangement, either in the form of obstinate constipation, or of catarrhal diarrhoea alternating with constipation. The • Meigs and Tepper, Diseases of Children . characteristic symptoms are pain, and a tumour in the right iliac fossa. The pain is continuous, and is increased by pressure and by movements, such as those in- duced by deep inspiration and coughing. The right iliac region becomes exquisitely tender and tens9; and, to relieve the muscular tension over it, the patient reclines towards the right side, with the thighs drawn up. In typhlitis from retention of feces in the caecum (Typhlitis stercoralis) there is a well- defined tumour from the first, which may attain a very large size ; while in other cases there is often merely fulness in the early stage, and afterwards a distinct tumour. In all cases the tumour is of the shape of the caecum, is sharply circumscribed, the lower part specially so, while the upper is less distinct, and may bo traced into the ascending colon if this part be also inflamed. When the tumour arises from in- flammatory thickening of the walls of tho eeecum, it is less dull on percussion than when consisting of feces. The abdomen is enlarged. Fever is usually slight or absent. The walls of the caecum failing to contract, there is obstinate constipation, with tormina and vomiting. As a rule, in children vomiting does not become fe- culent. In typhlitis stercoralis intestinal ob- struction may arise from the accumulation com- pletely blocking the ileo-caecal opening; then the paroxysms of pain become very severe, and the vomiting urgent and stercoraceous. Not uncommonly inflammation, though commencing thus in the csecum with characteristic symptoms, extends all over the colon {see Colon, Diseases of); then constipation will give place to diarrhoea, and tenesmus with muco-sanguinolent evacuations will indicate a similar affection of the sigmoid flexure and the rectum. The attack, having lasted from two or three to ten or twelve days, usually subsides by resolu- tion — the bowels are copiously relieved, the vomiting ceases, and the pain, tenderness, and tumour disappear from the right iliac region. Even symptoms of intestinal obstruction which excite much anxiety may terminate thus favour- ably. Not unfrequently, however, the course becomes tedious and dangerous. The accidents most to be feared are: — (1) Phlegmonous inflammation of the cellular tissue behind the caecum ( sec Perityphlitis) ; and (2) peritonitis. As a rule, inflammation of the peritoneum is confined to that portion covering the caecum and adjacent structures; it may, however, become general from extension of this local inflammation, but more frequently from the bursting into it of tho contents of the caecum, or of an abscess. Prognosis. — Inasmuch as typhlitis without perforation almost invariably ends in recovery, the prognosis depends on the occurrence of in- flammatory complications and sequelae, and is, therefore, merged in that of perityphlitis. As a rule, perforative ulceration is less common during childhood than after the tenth or fifteenth year. If, notwithstanding the relief of constipation and the cessation of vomiting, the signs of local inflammation persist, ulceration of the csecum, or the earliest stages of perityphlitis, may bo sus- pected. CAECUM, DISEASES OF. Treatment. — The indications are, (a) to re- lieve constipation and dislodge accumulations from the caecum -with as little irritation as pos- sible, using laxatives combined ■with sedatives, e.g. calomel, colocynth, confection of senna, or saline aperients with opiates, and large warm enemata ; the latter are indicated when aperients by the mouth set up or increase vomiting, or fail to relieve the bowels, or cannot be pre- scribed because of obstinate vomiting. ( h ) To subdue inflammation by rest, poultices, blisters, and opiates. The diet throughout should be fluid, consisting of beef-tea, milk, and such articles. All strong aperients are to be condemned — they are apt to increase the inflammation and the risk of perforation, and, while aggravating the vomit- ing, may fail to move the bowels. When local inflammation is severe, as indicated by great pain and tenderness, aperients by the mouth should be avoided, enemata used, opium given freely, as in peritonitis, and leeches may be applied. III. Dilatation, Contraction, and Per- foration. — The caecum may be (1) dilated from accumulation within it of solids and gases, or from obstruction in the colon ; (2) contracted from deposits (cancer, &c.), growths (polypi), or cicatrising of ulcers (tubercular, dysenteric) ; or (3) 'perforated from ulceration (simple perforat- ing, enteric, tubercular, cancerous, dysenteric ulcer), or tearing of the wall by over-distension. Perforation may lead to different results, accord- ing to the part of the caecum selected. When in the anterior surface, which is completely in- vested by peritoneum, a rapidly fatal peritonitis is most apt to follow ; while in the posterior part, resting on the connective tissue of the iliac fossa, suppuration is usually the result. George Oliver. CALCAREOUS DEGENERATION. — A form of degeneration characterised by the de- posit of earthy salts, especially of salts of lime, in the tissues. See Degenerations. CALCULI {Calx, chalk). — Definition. — The term calculus is now applied to any kind of concretion formed in the ducts or passages of glandular organs ; though older writers limited its employment to the designation of concretions met with in the kidneys and urinary bladder. Varieties. — The following is a concise sum- mary of the principal calculous concretions met with in the human body, given according to their alphabetical order. 1. Biliary Calculi vary considerably in size, number, form, and composition. In size they range from minute grains about the size of a pin’s head to a mass as large as a hen’s egg. The smaller they are, generally the larger is their number. Their form is veryirregular — when soli- tary they are usually round or oval, when nume- rous they are generally more or less irregular in shape, their surfaces being flattened and facetted from compression. The colour is usually a blackish-green or brown, less frequently yellow or greyish-white. In consistence, some are soft like wax; others hard, dry, and friable. On section they will he found to differ widely — some being granular, and made up of sub-morphous particles without any apparent nucleus ; others- crystalline, the glistening white crystals (choles- CALCULI. 201 terine) radiating from a central nucleus, which is frequently found to consist of inspissated bile. Biliary calculi consist almost entirely of cholesterine and bile-pigments, mixed with a variable proportion of insoluble organic matter and traces of the earthy phosphates. To separate the cholesterine, finely powder the gall-stone and thoroughly exhaust with ether; the ethereal solution on evaporation yields amorphous choles- terine. To obtain it in the crystalline form, it must be redissolved in boiling alcohol, which on cooling deposits it in characteristic, glistening, rhombic plates. The pigmentary matters can be obtained by exhausting the residue of the crushed gall-stone, from which the cholesterine has been removed, successively with water, alcohol, and dilute hydrochloric acid. The dried residue is then boiled with pure chloroform for some time, and the chloroform extract is distilled to near dryness, and several volumes of alcohol are added, which throws down bilirubin. Bilirubin thus obtained is an orange-red powder insoluble in water and ether, slightly soluble in alcohol, but very freely soluble in chloroform. On passing a current of air through an alkaline solution of bilirubin the solution acquires a green colour — biliverdin. According to Stiideler biliverdin is formed from bilirubin by the addition of one atom of water in the presence of oxygen. A brown pigment, bilifuscine, can also be obtained by acting on bilirubin with strong sulphuric acid. 2. Intestinal Calculi are rare in man and carnivorous animals, but are not uncommon in herbivorous animals. They consist almost en- tirely of ammonia, magnesium phosphate, calcium phosphate, and calcium carbonate, deposited round a nucleus, generally a fragment of some undigestible material of the food, such as stones of truit, husks of grain, or portions of bone. There is a kind of intestinal calculus occasion- ally met with among Scottish and Lancashire people, who use oatmeal largely as food, which is chiefly composed of the hairs and fragments of the envelopes of the oat, encrusted with calcium phosphate and carbonate. Magnesium carbonate when taken habitually and in bulk is apt to ac- cumulate in the bowels and concrete there ; there is now less risk of that danger since the fluid forms of magnesia have come into such general use. 3. Pancreatic Calculi are the rarest of all glandular concretions. When found they are generally numerous, being met with in the main duct, the accessory duct, and even in the smaller radicles. The size varies greatly, the largest that has come under the writer’s observation being quite one inch in length. They are generally oval in shape, and their surface has frequently a worm-eaten appearance, of whitish colour, which when rubbed acquires an enamel-like lustre. When broken, the fracture often presents a white, glistening, porcelain appearance. One calculus analysed by the writer gave a percentage com- position of organic matter -24, fixed inorganic salts ’76. The bulk of the fixed inorgauic salts consisted of calcium carbonate, calcium phosphate being present in much smaller proportion. 4. Prostatic Calculi consist essentially of calcium phosphate and calcium carbonate, though 202 CALCULI, incidentally traces of uric acid, calcium oxalate, and ammonio-magnesinm phosphate maybe found. They occur in three forms, namely, (a) small, rough concretions, from the size of a pin to a hazel nut; (6) irregular masses with porcelainous ap- pearance ; and (c) large regular concretions. The quantity of earthy matter that may be deposited in the prostate gland is often enormous. When the calculi are of the small variety, fifty or sixty may be present, and a gland may feel likeabagof nuts. The museum of the College of Surgeons contains a specimen showing the enormous size these con- cretions may attain. See Prostate, Diseases of. 5. Salivary Calculi are generally rough ex- ternally, irregular in shape, and are usually found near the orifice of the duct, which they obstruct. The nucleus frequently consists of some foreign body which has accidentally found its way into the duct, as a splinter of wood ora fragment of bone. Their chief component is calcium carbonate, of which they contain more than any other kind of concretion, and traces of early phosphates. 6. Urinary Calculi vary considerably in size, form, colour, and general appearance, according to their composition. The constituents that form these stones are uric acid, urates, cystine, xanthin, calcium oxalate, calcium phosphate, magnesium phosphate, ammonio-magnesium phosphate, cal- cium carbonate, and also concretions of blood and fatty substances (urostealitli). Any of the above- named substances, combined with a varying pro- portion of organic matter, may constitute the sole ingredient ofacaleulus ; more commonly, however, two or more are associated together. To fully ascertain the composition of the mass of the cal- culus it must be sawn across, and if made up of different layers, a portion of each layer must be analysed. See Oxalic, Phosphatic, and Ukic Acid Calculi, and Urine. Pathology. — The manner in which these con- cretions are formed, especially renal and urinary calculi, has long been a matter of speculation with physicians, some regarding them as of purely local origin, others endeavouring to show that they are the result of some peculiar diathesis, wherein uric acid, the phosphates, &c. are formed in the body so profusely, and are eliminated in such quantities as to be precipitated in the passages. The researches of Ord and Carter hare thrown much light on this obscure subject. They have shown that the particles constituting the bulk of the calculus are not mere accre- tions, formed in the urinary passages by a pro- cess of chemical precipitation, in the presence of blood, mucus, &c. ; but consist of structures, designated as ‘ sub-morphous ’—granules, sphe- roids, laminae, &c. — and which require consider- able time for their formation. They have shown that this modification of form, i.e. the change from the crystalline to the sub-morphous type, can be artificially produced by allowing two saline solutions to intermix slowly through a colloid medium ; as gum, albumen, &e. ; the more slowly the mixture is effected and the denser the colloid, the more perfect is the change to the sub-morphous condition. On the other hand if the colloid medium is attenuated, and the admixt ure rapid, the crystalline form is more or less retained. The nature of this colloid medium has not been clearly made out. The CAN AKIES. fact that calculus rarely accompanies Bright’s disease shows that the ordinary effusion of blood or albumin into the renal tubules does not furnish the necessary medium. Indeed if simple effusion of fibrin, or increased secretion of mucus, furnished the colloid, calculus, instead of being comparatively a rare disease, would be extremely common. Some authors have regarded the ‘ en- tangling mucus ’ as the product of a specific catarrh. Thus Meckel speaks of a stone-form- ing catarrh ( steinbildendend Katarrh ) ; and Dr. Owen Bees has pointed out that among the many evils attendant upon gout is ‘ a tendency of mucous membranes to secrete a viscid mucus, which modifies the ordinary crystalline character of uric acid, causing it to appear in agglutinated masses, which adhere to the sides of the urinary passages.’ In speculations as to the origin of stone, too little attention has as yet been paid to the condition of the renal cells. These cells normally eliminate the urinary constituents ; and it is not difficult to imagine that under certain conditions of vital impairment these substances- may be retained and deposited, instead of being eliminated, the cell itself furnishing the colloid medium. The objection urged against this view is that recent observers have discovered no satisfactory signs of cell-structure in the matrix of calculi; but this objection can hardly be considered fatal, since the accretion of particles within the cell would gradually destroy the cell-structure. Professor Quekett, however, figured {Med. Times, vol. xxiv., p. 552. 1851) crystals of calcium oxalate and triple phosphate contained in cells taken from human tubuli uriniferi ; and though his observations have not teen confirmed by others, still the accuracy of his work has never been questioned, and it may be when the tubuli uriniferi of persons dying of calculous affections come to be more frequently examined by pathologists, cells containing cal- culous constituents at an early stage of depo- sition may be observed — that is, before the cell- wall is destroyed. It is a remarkable fact that calculous deposit commencing in the kidney tubules is rarely met with in the convoluted portion of the tubule, but invariably occurs at the apices of the mammillary processes, the extremities of the ducti papillares. Now less blood circulates through this portion of the kidney than through any other part of it, and moreover in the ducti papillares, the basement membrane (tunica propria) disappears and the wall consists of epithelium alone. May not these anatomical differences render the cells of this part of the tubule more liable to cal- culous deposit— in short, to undergo calculous degeneration ? CALIPERS. — An instrument employed for measuring diameters, more especially in medi- cine the diameters of the chest. See Physical Examination. CALVITIES (calvus, bald). Synon. : Alopecia calva. A synonym for baldness. See Baldness. CANARIES, The (Teneriffe), in North-east Atlantic Ocean. Mean temperature in winter, 64° to 85°. "Warmer, drier, but more variable, thus Madeira. East winds from Africa. CANCER. 203 CANCER ( Cancer , a crab). — Definition. — The word cancer is without histological mean- ing. We find it and its synonym, carcinoma, used as long ago as the time of Hippocrates, and the latter term was then, as is the former at the present day by the vulgar, applied to any new growth of a malignant character. The name originated in the large ramifying veins and puckered furrows which spread from a cicatriz- ing cancer that is involving the skin. When the broad distinction between the epithelial and con- nective-tissue type of tumours was established by Virchow and others, it was decided to retain the word cancer as the name for the more malig- nant or epithelial growths ; while the equally meaningless but less formidable word sarcoma has been from this time confined to those tumours winch have connective tissue for their type. See Tumours. In this sense of the word the cancers form a class which is, on the whole, easily distinguished by definite microscopical and clinical characters, but at two points, at least, the difference from simpler growths is almost imperceptible. First, as a matter of accident, one sarcoma (the alveo- lar) resembles a cancer so closely in micro- scopical structure, that it is impossible to dis- tinguish between them without reference to cliuical facts ; and, in the second place, as can- cers are essentially depraved modifications of epithelial, epidermic, or glandular structure, they may be found to differ so slightly in histological characters from simple hypertrophies, that the fact of ultimate malignancy is often all that can decide between, say, a papilloma and an epithe- lioma, a glandular cancer of the rectum and a simple polypus, or a scirrhus of the breast and a chronic mammary tumour. Histological Structure. — Histologically, cancers are distinguished by consisting partly of cells of an obviously epithelial origin and partly of connective tissue. The connective-tissue forms alveolar spaces, and may vary in structure from a loose fibro-cellular material to strong and old fibrous tissue. The alveolar spaces com- municate with each other and contain the epithe- lial cells. These vary much in shape, size, and arrangement, but are always easily separable from the surrounding connective-tissue, while thej' are never separated from one another by a stroma of any sort. Clinical Characters. — Clinically, cancers are distinguished by the structures in which they originate ; by the method of their recurrence and their mode of growth ; as well as by a few charac- teristics apparent to the eye and touch. Seat. — As their nature would have rendered almost certain a priori, cancers probably never originate except in connection with epithelial or epidermic structures — i.e., in skin, mucous membrane, or secreting glands ; but as the epidermis and epithelium, the original upper and lower layers of the embryo, are widely diffused throughout the body, and often inti- mately associated with the descendants of the cells of the middle layer, it is not surprising that primary cancers have been described as oc- curring in organs which have their origin from connective-tissue only. Such are the instances of primary cancer of bone and lymphatic glands the possibility of the occurrence of which may be at present considered undecided. Recurrence. — The first recurrence is almost without exception in the lymphatic glands, which collect their suppily of lymph from the seat of the original tumour ; when this has oc- curred the process may be repeated in the next proximal lymphatic glands, or numerous distinct tumours may appear in different parts of the body ; but if a single growth occur in another locality without previous glandular enlargement the case may probably be looked upon as a double primary development. A soft cancer may burst into the abdominal cavity, where its small particles may stick to various parts of the peritoneum and form the starting points of new growths (disseminated cancer of the peri- toneum) ; it is probable that a similar seeding may take place into the lungs when an ulcerated epithelioma projects into the trachea. Mode of growth. — Cancers increase in size by infiltration of the surrounding tissues, and this gives rise to the very important clinical facts that they are not enclosed by a capsule like many simpler growths, and that they have a great tendency to implicate the skin and cause ulceration. Naked-eye appearances. — The contraction of the connective-tissue forming the alveoli in its advance towards fibrous tissue gives rise to puckering of the surrounding skin ; and the loose- ness of the connection between the epithelial and connective-tissue elements causes a milky juice consisting of the former to escape on scraping a recent section. This characteristic was made much of by our predecessors before the word cancer had lost its inclusive meaning ; we knownow that many rapidly growing sarcomas yield a similar juice, hut in less abundance than cancers ; and thus it has come to pass that a milky juice is now more diagnostic of the malignancy than of the genetic origin of the growth. This completes the list of the signs by which cancers may be distinguished from other tu- mours. Tables have been published to show the relative frequency with which cancer attacks different organs ; tbey are not upon the whole trustworthy, and this question will be best con- sidered in discussing the subdivisions of the genus. Classification. — The subdivisions of cancers are as follows : — Hard cancer or Scirrhus. j „ Soft cancer or Encephaloid. f tandular type Cylindrical Epithelioma. Epithelial and Lobular Epithelioma. J Epidermic type. Colloid. Typical hard and soft cancers stand obviously at opposite ends of one series which is built upon the type of a secreting gland : between the two are an infinitude of intermediate stages. The two forms of epithelioma are, quite as evidently, monstrous growths of skin or mucous membrane. Colloid is probably the result of degeneration of any one of the other forms. Besides these, other varieties are often mentioned which do not justify a more complicated classification ; amongst these are tumours, which though of nearly normal glandular structure are nevertheless malignant, CANCER. 204 and those which have received the names Me- lanotic, Teliangiectasic, Ostcocanccr, & c. Diagnosis. — The diagnosis depends upon the clinical characters of the several groups. That of an advanced case of cancer is generally easy; in the early stages it is mostly impossible. Prognosis. — The prognosis is always had, especially in encephaloid cancer, but least so in epithelioma ; this suggests the much-debated question of the constitutional nature of the dis- ease. If in its origin a cancer be purely local, early removal ought to effect a permanent cure ; but if there be at tho bottom a constitutional taint., a reprieve should merely be granted until a suitable fresh irritation arise. There is pro- bably some truth on both sides. The cancerous cachexia is often spoken of ; it depends chiefly, if not altogether, on the weakening effects of the discharge after ulceration has taken place ; mental worry may have some share in causing it; but it must be remembered that cancerous patients, who, before they are attacked, are fre- quently amongst the most robust, often retain their health for a remarkably long time. Course. — The course of a cancer depends upon its seat, and the symptoms must accordingly be sought amongst the articles on diseases of special regions. If, however, life be not shortened as a result of interference with the functions of tho organ attacked, death is caused either by marasmus — the result of prolonged suppuration and pain, or by extensive or repeated haemor- rhages. The rate of progress is more slow as age advances. Treatment. — The treatment of cancer in tho early stages can only be undertaken by the surgeon, and the reader is accordingly referred for information on this head to surgical text- books ; in the later stages the physician may be called upon to treat symptoms, but up to the present time all the specifics introduced either by regular practitioners or by charlatans have proved quite inefficient, if not actually harmful. We shall now discuss the varieties of cancer. I. Scirrhus.— Scirrhus, as its name implies, is amongst the liardestof tumours, if bony growths be excepted. Its hardness, as compared with soft cancer, depends upon the larger proportion which the alveolar stroma bears to the contained cells ; and this is probably the consequence of the soil in which the tumour originates, and the rapidity of its growth, rather than of any specific difference between them. Scat. — The female breast is the most common seat for scirrhus, but it also occurs in the stomach, uterus, tongue, oesophagus, and the liver and other glands, and it has been described as primary in the prostate, testicle, skin, and other structures. Naked-eye appearances. — A section through the centre of a matured hard cancer of the breast presents to the naked eye well-marked and constant appearances, which, with the exception of such peculiarities as are due to the situation, will serve as a description of such a tumour occurring elsewhere. These are clearly explained by the microscopical arrangement, and when looked at by the light which it affords, fully account for all the clinical characters. The knife passes through it with a creaking noise, and the cut surfaces are at once hollowed in tho centre. There is not a sharp edge to the growth, and the circumference is of a greyish or pinkish white tint, projecting a little above the surround- ing tissues, into which it sends small lobular pro- longations ; the hollow centre is very hard and cf a glistening white colour. Scirrhus is evidently fibrous in structure, and receives from all quarters fibrous bands, which often pass far out into the fat of the breast or the skin, and some of which can nearly always be traced to the prin- cipal milk-ducts. Between the centre and the edge is the greater part of the tumour, on tho whole of a pinkish-yellow colour, but notably pink and soft externally, and yellow and hard internally. The surface yields a milky juice on scraping, and may show some of the following ap- pearances, which are, however, accidental: round the circumference little masses of healthy fat may be included, though this but rarely happens; cysts containing grumous grey or red fluid may have formed by the breaking down of the new growth or by haemorrhage ; or such a htemorrhage may have resulted in patches of yellow or even black pigmentation. Microscopical appearances. — Without discuss- ing the merits of the opposing theories as to the origin of cancer-cells, the following maybe taken as the undoubted microscopical appearances of scirrhus ; the grey outer layer is made up of in- definite smallish round cells, resembling white blood-corpuscles, infiltrated through the tissue into which the growth is spreading, amongst which are scattered a few which have the ap- pearance of epithelial cells. The next or pink layer represents full development and shows fibro-cellular stroma, enclosing large epithelioid cells, and containing a copious supply of vessels. In the third or yellow layer the stroma has be- come fibrous and the cells are undergoing fatty degeneration ; and in the inner white centre the cells are replaced by indefinite masses of granular debris, and the stroma consists of firm and old fibrous tissue. See figs. 125, 12V, and 126. The relation of these appearances to the clini- cal peculiarities of scirrhus is as follows : the excessive hardness is explained by the great development of fibrous tissue ; the peculiar in- definiteness of the edge, and the tendency to involve the skin and ulcerate, by the manner of growth; while the puckering, retraction of the nipple, and indirectly (from the manner in which cutaneous nerves are involved) the pricking and shooting pains, are due to the contraction or cicatrization of the stroma. To the latter is also due a very important but notgenerally recognized diagnostic character of an early scirrhus, namely, that long before the skin is involved it is seen to be dimpled when gently moved to and fro over the growth. A scirrhus which has involved the skin forms a purplish-red, flattened, and shining tumour, covered with small veins and tender to the touch ; the ulcer which results from its break- ing down is ragged, with a hard base and hard irregular undermined edges, and a dirty surface covered by knobby masses of pseudo-granulations, which have a great tendency to bleed and often slough. As it is often removed it often returns in the scar. When occurring in the liver it Lj [To face page 204. CANCER. Fig. 117. Papilloma of Soft Palate. Fig. 120. Simple Polypus of Rectum. Fig. 118. Epithelioma of Lip. Fig. 121. Columnar Epithelioma of Intestine. Fig. 119. Edge of Rodent Ulcer. Fig. 122. Colloid of Breast. Fig. 123. Cancer of Liver (Scirrho, encephaloid). Fig. 125. Soirrhus, Infiltrating Fat. Fig. 124. Encephaloid Cancer. Fig. 126, Cicatrizing Cancer. Fig. 128. Adenoid of Upper Jaw (Benign). Fig. 129. Ulcerated Adenoid of Parotid (Malignant). Fig. 130. Adenoid of Breast (common, type). Fig. 131. Adenoid of Breast (epi- thelial element in excess). Fig. 127. Scirrhus of Mamma. Fig. 132. Adenoid of Breast (Adeno-sarcoma). Drawings Illustrating a Series of Tumours of the Epithelial Type. All drawn to the same scale ( x 87 diameters). CANCER. softer than elsewhere, and the name of scirrho- encephaloid is often given to it. See fig. 96. II. Encephaloid. — Encephaloid, medullary, or soft cancer, so named from its usually brain- like appearance and consistence, is softer and grows more rapidly, and is more frequently ob- served in internal organs than scirrhns, often in- deed formingenormous intra-abdominal tumours. Seat. — It has hitherto been observed as pri- mary in the salivary and mammary glands, tes- ticle, ovary, and prostate, the thyroid body, and in the mucous membrane of the nose, the liver, and the stomach. It has -with some degree of looseness been sometimes called the cancer of childhood by those who consider scirrhus as almost peculiar to old age. Naked-eye appearances. — To the naked eye a fresh section usually presents a convex surface ; it is whitish, but generally mottled by coloured patches, the result of old or recent haemorrhages, and yields very copiously a milky juice on scraping. Microscopical appearances. — Encephaloid can- cer differs from scirrhus only in the relative pro- portions of the two chief factors. The cells are more numerous and are contained in larger spaces ; they are sometimes small, but generally much larger than in scirrhus; and the stroma is delicate and fibro-cellular and very small in amount. See fig. 124. Its method of extension is the same as that of other members of the class. It is by far the most malignant form of cancer, because of its rate of growth and recurrence, and the rapidity with which it causes general cachexia. Epithelioma — Lobular epithelioma, epi- thelial cancer, or cancroid, develops in con- nection with skin and mucous membrane, and though consisting essentially of squamous epi- thelium, may start from a part which is covered by the cylindrical variety. It occurs near the natural orifices of the mucous tracts — as, for example, on the mouth and tongue, anus, penis, or vulva ; but also at other parts of the skin — as on the acrotum (chimney-sweep’s cancer) and at the upper end of the oesophagus. The his- tory of a local irritation is often obtainable, but more frequently nothing of the kind can be discovered. Naked-eye appearances. — The first appearance is that of a pimple, which soon breaks down in the centre, forming a small sore. 'When fully developed there is an irregular ulcer with an extensive hard and nodular, generally in- flamed base and circumference; the edges are abrupt or undermined, and the floor grey or reddish, very uneven, discharging a foul pus, and with a great tendency to bleed. As a rule there is considerable pain, and the proximal lym- phatic glands are very generally enlarged. A section to the naked eye shows a number of minute cylinders of yellowish-white colour, cut sometimes longitudinally, sometimes trans- versely. fusing together into an indefinite mass superficially, but more or less discrete below, and infiltrating amongst the subjacent tissues. On squeezing the section little nodules like sebum appear on the surface. Microscopical appearances. — The cylinders or lobes of epithelioma are found to be made up c-f 205 squamous epithelium, which generally exhibits in parts a crenatedmargin (Max Schultze’s spine- cells). A s in the skin, the deeper — that is the cir- cumferential — layer of cells in each lobe, which are the youngest, are roundish or oblong, with large nuclei, and staining readily; further in, the cells are larger and flatter, and in the centre are found the well-known globes or nests. These were considered at one time as peculiar to epithelioma, but are now known to occur in warts and corns ; they consist of onion-like ar- rangements of epithelial cells, varying much in size and the number of concentric layers, and containing in the centre sometimes an amorphous mass, sometimes large and irregular cells. The tissues beneath and between the lobules are infiltrated with small cells, and often contain in sections what appear to be iso- lated masses of epithelium ; these are, however, the ends of divided divergent lobules. Opinions differ as to the exact starting-point of an epithe- lioma, the share which the sweat- and other glands take in it, and also as to the rationale of the formation of the globes. See fig. 118. Epithelioma seems to be more local in its nature than other cancers — that is, a complete and early removal has not unfrequeutly given the patient a long lease of life. It recurs, as a rule, in the lympathic glands, which inflame and suppurate, and in the scar, and generally proves fatal from the constitutional disturbance it gives rise to. Later but more rarely it may appear in the in- ternal viscera, bones, &c. Cylindrical Epithelioma. — The cylindrical epithelioma — badly named adenoid or glandular cancer — is specially the cancer of the alimen- tary mucous membrane, but may occur in the bladder and elsewhere. Naked-eye appearances. — To the naked eye it forms at first a prominent tumour in the interior of -a viscus, which has a tendency like other cancers to ulcerate and involve surround- ing tissues, so that the mass may reach an enormous size, and may even make its appear- ance through the skin. To the naked eye a section is generally whitish and has a granular appearance, which is given to it by the tubules of which it is made. It frequently causes death by obstruction of the bowel, but if it last sufficiently long, it recurs unaltered in the lymphatic glands, and then in the viscera and other parts of the body. It is not unfrequent to find recurrences in the liver with little if any implication of lymphatic glands. Microscopical appearances. — Cylindrical epi- thelioma consists essentially of irregular tubules lined with columnar epithelium in one or more layers, which are the much overgrown crypts of Lieberkiibn, and differ in microscopical structure from simple papilloma of the digestive tract only in the greater irregularity of the cells and in the larger proportion of connective-tissue stroma between the tubes. See fig. 121. Colloid. — Colloid, or alveolar cancer, named from its jelly-like appearance, has given rise to much discussion in reference to the ques- tion whether it is developed originally in its mature form, or whether it results from tho degeneration of one of the classes of cancer described above. The latter view is that most 206 CANCER, widely held, though it must be allowed that epithelioma soldom degenerates in this way, and also that the colloid change usually takes place pari passu with the growth of the tumour. Seat. — Colloid cancer is found most frequently in the abdominal -viscera and peritoneum, but may occur elsewhere, as in the breast. Its malignancy is great, but is shown chiefly by the rapidity with which it involves surrounding tissues ; it thus forms primary tumours of enor- mous size, but as a secondary growth is less common ; it does, however, occur in lymphatic glands and other parts. It causes death in most cases by interference with the functions of the organs attacked. Naked-eye appearances. — Colloid cancer con- sists to the naked eye of a mass of semi-trans- parent jelly, varying slightly in colour, but mostly pale yellow: this is intersected by deli- cate white fibrous bands, forming alveolar spaces of different sizes, visible to the naked eye. The consistence of the growth depends upon the rela/- tive proportions of these two constituents. Microscopical appearances. — The bands are found to be actually fibrous ; the contained jelly is arranged in concentric laminae between which are minute granules, and in the centre of which is a granular mass, sometimes quite indefinite, but often showing clearly that it consists of the remains of altered cells. These cells are seen in the more recent parts of the growth to be the subjects of colloid degeneration. The source of the colloid material must be considered still undecided; that some of it is formed by the cells is certain, but it is not equally clear whether the stroma takes any share in its depo- sition. See fig. 122. Conclusion. — Our knowledge of the pathology of new growths is undergoing a process of rapid evolution. While, therefore, the writer has endeavoured in this article, and in that on Tumours, to represent the opinions most widely accepted at the present day, he is conscious that in a very short time these opinions may require considerable modification. R. J. Godlee. CANCRUH ORIS ( Cancrum , a sore; and oris, of the mouth). Synon. : Gangrenous Stomatitis ; Noma ; Fr. le Nome ; Ger. Wasser- krcbs. Definition. — A phagedsenic ulceration of the cheek and lip, rapidly proceeding to sloughing. ^Etiology. — Cancrum oris is usually seen in delicate, ill-fed, ill-tended children; and in these subjects it is commonly a sequela to one of the eruptive fevers. Formerly it used some- times to be due to excessive doses of mercury. Symptoms. — The disease commences by swel- ling and tenderness near the angle of the mouth, and if at this stage the mucous membrane is exa- mined, it will usually be found that there is some superficial ulceration on the inside of the lip or cheek — that is, ulcerative stomatitis. From this slight beginning the disease rapidly advances. The soft tissues become much swollen, brawny, shining, and red. Presently a livid spot makes its appearance in the centre, and the surround- ing part becomes purplish or mottled. If the patient can open his mouth sufficiently to give a view of the gums, they will be seen to be CAPILLARIES, DISEASES OF. red, congested, spongy, and bathed with a profuse and fretid saliva. The livid tissues of the cheek rapidly slough, the disease perhaps involving the lip, or spreading to the gum, laying bare the alveolar processes, and loosening the teeth. This local affection is attended by a high degree of pyrexia, and by great prostration. The disease is very fatal. Rilliet and Bar- thez state that not more than one in twenty cases recover. Treatment. — This consists in the application of strong nitric acid to any points where the ulceration and sloughing are spreading. Poultices should be kept constantly on the cheek, and from time to time the sore should be syringed with a disinfecting lotion. The constitutional treat- ment consists in the administration of a full amount of beef-tea, milk, eggs, &c., with a moderate allowance of alcoholic stimulants, as well as bark, ammonia, and other suitable tonics. Regular and systematic administration of food and medicine is of the utmost importance ; and if the patient is unable to swallow, nutritious enemata must be used regularly. W. Faiblie Clarke. CANITIES ( canus , hoary or greyhaired). — Whiteness or greyness of the hair. See Hair, Diseases of. CANNES in Prance, on the Mediter- ranean coast. A dry, bracing, fairly mild winter climate. Exposed to N.W. Abundant accom- modation, both near and at some distance from the sea. CANTHARIDES, Poisoning by. See Appendix. CAPE OP GOOD HOPE. — A warm, generally dry climate, but very variable, and liable to sudden storms. Living dear, and loco- motion difficult. CAPILLARIES, Diseases of. — The mor- bid conditions of the capillaries may be described in the following order : — 1. Fatty Degeneration. 2. Calcareous Degeneration. 3. Albuminoid Degeneration. 4. Pigmentation. .5. Changes in Inflammation. 6. Dilatation. 7. Narrowing and Obliteration. 8. Thrombosis. S. Embolism. 10. Rupture. 11. The New Formation of Capil- laries. 12. Capillaries in New Growths and Tubercle. 13. Changes in the Perivascular Space and Sheath. 1 4. Teleangiectasis. 1. Patty Degeneration is the most common disease of the capillary-wall, and is frequently associated with fatty degeneration cf the sur- rounding tissues. The cause of this change in the protoplasm of the capillary is, as elsewhere, interference with nutrition, and especially with oxidation. It is accordingly found in morbid conditions of the blood ; in interference with the blood-supply; and in lesions of the nervous system. The microscopical characters of the early stages of fatty degeneration when it affects the capilla- ries are not peculiar; in advanced stages the diseased vessels may present the appearance of opaque granular cords ; and the 1 vmphatic sheaths of the cerebral capillaries are sometimes found, under such circumstances, filled with oil-globules and fatty cells. A frequent termination of the disease is rupture and haemorrhage. Fattv CAPILLAKIES, DISEASES OF. degeneration of the capillaries occurs most fre- quently in the nervous centres, in the kidneys, in certain tumours, and in the products of infarction and inflammation. 2. Calcareous Degeneration is rare in capillaries. 3. Albuminoid Degeneration affects the Malpighian glomeruli in the early stage of albuminoid disease of the kidneys. In other parts of the body the capillaries are less subject to albuminoid change than the small arteries. 4. Pigmentation. — Pigment ary granules may sometimes be found in the walls of capillaries, but they more frequently occupy the perivascular space. In either situation pigmentation is the result of chronic congestion or inflammation, or of haemorrhage. 5. Changes in Inflammation. — The changes of the capillaries of an inflamed part constitute an important factor of the process of inflamma- tion. See Inflammation. 6. Dilatation of capillaries, which is one of the changes in inflammation just referred to, may become permanent if the process be chronic. Changes in the nutrition of the capillary-wall, combined with disturbances of the circulation, such as increased pressure, produce local dilata- tion or Aneurism of the vessels and subsequent rupture. This is one form of miliary aneurism as it occurs in the brain. 7. Narrowing and Obliteration. — Narrow- ing of capillaries may be temporary, as in in- flammation ; or permanent, from external pres- sure, or from interference with the blood-supply. Harrowing may proceed to complete obliteration. 8. Thrombosis commonly occurs in capil- laries as a consequence of embolism or of throm- liosis in the associated arteries or veins. Less frequently the coagulation of blood is primary, and is due to one or more of the usual causes of thrombosis, namely, feebleness of the circulation and alteration of the blood. 9. Embolism. — The phenomena of ordinary embolism in a great measure affect the capillaries corresponding with the obstructed artery. But besides this change, capillaries are themselves subject to embolism, or impaction of particles within them. The products of inflammation or degeneration, pigment-particles, oil or fat drops from the marrow of fractured bones, organisms, and various substances artificially introduced into the circulation, have been discovered ob- structing the capillaries in different instances. All the possible results of embolism in large vessels may follow, according to circumstances ; and in the case of the cerebral vessels definite symptoms are believed by some to result, such as delirium and choreic movements. See Chorea. 10. Rupture. — Three circumstances specially determine the occurrence of this lesion of capil- laries, namely, disease of the vessel-wall, increase of the blood-pressure, and a ‘ terminal ’ distri- bution of the branches of the artery that supplies them. The most common diseases of the wall are fatty degeneration and aneurism. The blood-pressure rises within the capillaries of any part in ventricular hypertrophy, in increased tension of the arteries of other parts, and in ve- nous obstruction. When an artery is ‘ terminal,’ CARBONIC ACID. 207 that is, unprovided with other anastomoses than through its capillaries, no lateral relief can be afforded in sudden and excessive rises in the force of the circulation. For these several reasons, rupture of capillaries is most frequent when the vessel-walls have been weakened in the fatty degeneration of senile decay, in septic- aemia, inflammation, purpura, fever, and scurvy ; in chronic Bright’s Disease, with increased blood- pressure ; and in such organa as the corpus striatum, retina, spleen, kidney, villi, and skin. Disturbances in the pressure of the air within the chest powerfully influence the occurrence of capillary-rupture in the respiratory tract. When a capillary-wall gives way, the blood is extrava- sated either on a free surface, constituting hsemor- hago ; into the substance of the tissues around ; or along the lymphatic sheath of the ruptured vessel, where it gives rise to the appearance that has been described as dissecting capillary aneurism. 11. New Formation of Capillaries. — Capil- laries grow or develop in nearly all forms of new growth, whether inflammatory or otherwise. The young capillaries are derived either from cellular buds upon previous capillaries, which become hollowed by the blood-pressure ; from anastomosing exudation-cells, or connective- tissue corpuscles ; or, in some cases, from the parallel disposition of exudation-cells. 12. Capillaries in New Growths and Tubercle. — The capillary- walls are believed to play an important part in the production of certain forms of new growth. See Tomoues and Tubercle. 13. Changes in the Perivascular Space and Sheath. — The perivascular or lymphatic sheath, which probably envelopes all capillaries, is liable to certain morbid conditions, which are chiefly secondary to changes in the vessel within it. Thus the space may become filled with blood from escape of the corpuscles by rupture or otherwise; with leucocytes in inflammation; with oil-globules and fatty corpuscles in degene- ration of the wall; with pigment-particles; or with serum in disturbances of the circula- tion. The calibre of the perivascular canal, which varios inversely with that of the contained capillary, may thus be increased, and present, uniform or irregular dilatation. Changes in the outer sheath, or wall of the lymphatic space, have also been observed, in- cluding fatty degeneration of the lining cells and hyaline thickening. 14. Teleangiectasis. — At least one form of vascular tumour consists of a local over-growth of capillaries, which are both enlarged and multi- plied. See Tumours. J. Mitchell Bruce. CAPILLARY BRONCHITIS. — Inflam- mation involving the minute bronchial tubes. See Bronchi, Diseases of. CARBOLIC ACID, Poisoning by. See Poisons. CARBONIC ACID, Poisoning by. — The inhalation of carbonic acid causes injurious or fatal results, according to the length of time and degree of concentration. Carbonic acid accumulates in large quantities, almost undiluted, in pits, cellars, W'ells, mines (especially after 208 CARBONIC ACID. explosions, constituting what is called choke- damp), volcanic grottoes, fermenting vats, lime- kilns, &c. A continuous contamination of the atmospheric air with carbonic acid goes on from the respiration of animals and the combustion of fuel. The gradual exhaustion of oxygen and proportionate accumulation of carbonic acid in ill-ventilated apartments is one of the factors of the evil results of bad ventilation, but not the only ohe, as other animal exhalations contribute largely to the result. As a rule excess of carbonic acid means cor- responding deficiency of oxygen in the atmo- sphere, and the proportion cannot exceed 10 per cent, without rapidly fatal results ensuing ; but much less than this causes injurious, and even the like consequences if long inhaled ; and less than 2 per cent, cannot be breathed for any length of' time with impunity. If the amount of oxygen be not correspond- ingly diminished, carbonic acid if present in sufficient quantity in the atmosphere respired will still act fatally. Thus Bernard found that a bird died instantaneously in an atmosphere of equal parts of oxygen and carbonic acid, and Snow found that 20 per cent, of carbonic acid in an atmosphere containing the normal proportion of oxygen soon proved fatal to small animals, and that even 12 per cent, might cause death after a longer interval. Symptoms. — Undiluted carbonic acid is not readily inhaled, as it tends to induce spasm of the glottis, but immersion in such an atmosphere is rapidly fatal. It seems to act like a narcotic. The patient falls down prostrate and insensible, and death occurs almost immediately. This effect is seen occasionally when labourers in- cautiously descend an old well, or when miners enter a region filled with choke-damp. Not unfrequently more than one fall victims, as one goes to see what has happened to the other and meets the same fate. When the carbonic acid is more diluted the symptoms are headache, giddiness, and sense of oppression ; followed by drowsiness, and singing in the ears ; and passing into a condition of stupor and insensibility, with stertorous breath- ing and muscular prostration, death usually occurring quickly and without convulsions. If the excess of carbonic acid corresponds with deficiency of oxygen, we have in addition to the essentially narcotic effects of carbonic acid, the dyspncea and other symptoms of asphyxia (see Asphyxia). Post-mortem appearances. - — These are largely those of asphyxia, viz., a general engorge- ment of the venous system. This is generally seen in the brain, more frequently than in as- phyxia pure and simple. The blood is dark and fluid. The haemoglobin is completely reduced. Animal heat is said to be retained long after death, and rigidity is well-marked and enduring. Pathoeogy.— As has already been said, carbonic acid does not act merely as a negative asphyxiant by taking the place of oxygen, but has a dis- tinctly toxic narcotic effect. Very frequently in cases of poisoning by carbonic acid there is a combination of asphyxia, essentially due to defect of oxygen, with the narcotic symptoms due to carbonic acid. CARBONIC OXIDE. Treatment. — 1 . Prophylactic. — Caution, should be exercised in exploring wells, mines, &c., where there is likelihood of the accumula- tion of carbonic acid. The introduction of a lighted candle is a rough and ready test of con- siderable value. The mere fact of a candle continuing to burn in an atmosphere is no test of its being respirable with impunity, for a candle will burn in an atmosphere containing 10 per cent, of carbonic acid if the oxygen is present in the normal amount, and the presence of an amount of carbonic oxide sufficient to cause death will not materially affect the flame. If carbonic acid reaches the proportion of 16 per cent, the candle will be extinguished, however. If a candle is extinguished, then certainly the atmosphere cannot be breathed, and therefore the test is of sound practical value. If car- bonic acid does exist it should be expelled by creating a draught of some kind. Thus wells may be swept by some such contrivance as an inverted umbrella, and a stream of air can be directed into enclosed spaces. 2. Restorative . — Artificial respiration and its various accessories are needed to restore a person actually in a state of coma from carbonic acid. This treatment, of course, is subsequent to instant removal from the impure atmosphere. Pure oxygen should also be administered if at hand. D. I'ereier. CARBONIC OXIDE, Poisoning by.— Carbonic oxide is a much more dangerous agent than carbonic acid, and to it are due many of the effects sometimes ascribed to the latter. Pure carbonic oxide is rarely generated out of the chemical laboratory, but mixed with other gases carbonic oxide is not uncommon. This is es- pecially the case in the fumes of burning charcoal. The carbonic acid of the burning charcoal while passing over the heated embers loses an atom of oxygen, or takes up an atom of carbon, and is converted into carbonic oxide, which burns with a bluish flame at the top. The toxic action of charcoal vapours is essentially dependent on the carbonic oxide they contain. Usually charcoal fumes contain from 2 to 3 per cent, of carbonic oxide, to 25 of carbonic acid, along with some heavy carburetted hydrogen. The vapours, how- ever, are still as effective after being passed through lime-water, which fixes the carbonic acid. Poisoning by charcoal vapour is not an un- common form of suicide, more particularly abroad; and many cases have occurred accidentally in this country, from sleeping in rooms in which there was no flue for the escape of the fumes of burning charcoal, or into which there has been leakage from stove pipes, &c. Carbonic oxide also exists in coal gas, and constitutes its main danger. It is likewise found in the emanations from brick-kilns. Carbonic oxide is an extremely active poison. Letheby found that ’5 per cent, of carbonic oxide in the respiratory medium killed small birds in three minutes, and that 2 percent, killed a guinea-pig in two minutes. ATanv similar experi- ments have been performed with similar results. The animals soon become insensible, and die generally without exhibiting convulsive pheno- mena beyond a few tremors or flutterings. CARBONIC OXIDE. Symptoms.— I n man inhalation of carbonic oxide for a short time, as Sir H. Davy and others have proved on themselves, causes headache, pulsation in the temples, giddiness, nausea, and great prostration, tending to drowsiness and insensibility, death being preceded by a state of complete coma. Usually death occurs quietly, but signs of vomiting are frequently observed near those who have been poisoned by charcoal fumes. Post-mortem Appearances. — The specially characteristic appearance of death from carbonic oxide is the cherry-red colour of the blood and internal organs. The post-mortem hypostasis exhibits a similar bright red tint. Frequently in those poisoned with carbonic oxide the face retains a ruddy hue. The red tint of the blood is due to the compound which carbonic oxide forms with haemoglobin. Carbonic oxide dis- places the oxygen and forms a very stable compound with the haemoglobin, not readily broken up, and hence the oxygen-carrying power of the corpuscles is paralysed. In the spectroscope carbonic oxide blood exhibits two absorption-bands very similar to those of ordinary blood-colouring matter or oxy- hemoglobin, but a difference in the exact breadth and position of the bands can be made out by means of the microspectroscope when the two are compared together. Carbonic oxide haemo- globin resists reduction in the usual manner, and here again differs from normal blood-colour- ing matter. Hoppe-Seyler gives as an addi- tional test the action of caustic alkalies on car- bonic oxide, and on ordinary haemoglobin. ”\Vith the latter it causes a green colour when mixed with it on a porcelain plate, while in the former the colour continues red. Pathology. — Carbonic oxide acts in the manner indicated, viz., by paralysing the bloo !- corpuscles, as Bernard expresses it, and rendering them unable to take up oxygen. Hence internal respiration is prevented, and death ensues from asphyxia. Treatment. — As carbonic oxide hsemoglobin is a very stable compound, and offers consider- able resistance to displacement by oxygen, though not absolute as was at one time con- sidered , artificial respiration is not likely to be successful by itself. The best treatment is vene- section and transfusion of fresh blood. This method of treatment has proved successful in one or two instances in which it has been employed. D. Perrier. CARBUNCLE. — Synon. : Anthrax ; Fr. Anthrax ; Ger. Karhunhcl. Definition. — A specific local inflammation of the subcutaneous areolar tissue, rapidly leading to sloughing of the deeper and mere central parts, followed by destruction of the skin ; the whole of the dead tissues finally separating in the form of a slough. ^Etiology. — Carbuncle is a constitutional affection, dependent upon conditions of general debility or plethora, and often associated with gouty or diabetic tendencies. It is more com- monly seen in men than in women ; is rarely met with under the age of twenty ; and attacks all ranks of life. Symptoms. — The most usual seat of car- 14 CABBUNCLE. 20!' buncle is the back of the trunk or neck, but it may occasionally be found in other situations. The affection usually begins as a painful, hard, slightly elevated, and ill-defined swelling, which gradually increases in extent and assumes a dusky red tint. A vesicle containing bloody serum soon forms over the most prominent part, and on rupturing discloses several small apei- tures in the subjacent skin, \vhieh give exit to a glutinous purulent discharge. This sieve-liki condition of the undermined integument often persists throughout the course of the disease ; occasionally, however, owing to the destruc- tion of the intervening skin, the several aper- tures merge into a single, large, ragged opening, and thus expose the characteristic ash-grey, slimy slough, which separates slowly by suppura- tion, leaving an irregular cavity with deeply undermined edges. The cicatrix left after heal- ing is usually uneven and may be permanently discoloured. In the early stage of the disease, while the inflammatory oedema is still extending, the pa- tient generally complains of a burning, throbbing sensation in the part, which may become intensely painful; but on the full exposure of the slough, the pain diminishes, and in the later stages it may cease entirely. When the carbuncle is large, or involves a portion of the scalp, there is usually considerable constitutional disturbance of an asthenic type. Death ma} r then occur from exhaustion, which is sometimes aggravated by free haemorrhage result- ing from incisions ; hut the most frequent cause of a fatal termination is pyaemia. Diagnosis. — Carbuncle is distinguished from boil by tho sizo and extent of the swelling, and by its tendency to spread ; by the livid tint of the skin, and the early formation in it of more than one aperture ; by the character of the slough, by the severity of the pain, and the marked con- stitutional disturbance ; and finaUy, by the fact that carbuncle, unlike boil, usually occurs singly. Prognosis. — This will depend chiefly upon the age of the patient, and upon the seat and ex- tent of the disease, which proves most dangerous to life when situated or encroaching on the scalp, especially in a person over fifty. The coexistence of albuminuria or chronic saccharine diabetes is always a grave complication. Treatment. — The constitutional treatment and the management of patients with carbuncle are best conducted on general principles. In ordinary cases the diet should be of good quality and sufficient in quantity, with n moderate allow- ance of stimulants, proportionate to previous habits. Should the patient’s strength and the situation of the carbuncle allow him to move about, he need not be confined to his room, and may even be allowed exercise in the opeD r air. In the more severe forms of the disease, the frequent administration of dietetic stimulants and good nourishment in an easily assimilable form is usually necessary. The bowels, if they require it, should be cleared out by some non- irritating aperient, and the patient put on n course of quinine or bark and the mineral acids. Opium may be required in tho earlier stages to relieve the intenso sufferings of some patients : no CARBUNCLE. while in the after-course of the disease, it may be sometimes needed to procure sleep. For local treatment see Boils. For carbuncle of the face, an affection distinct from the Malignant Pustule described by Conti- nental surgeons, fee Pustule, Malignant, and the article on Boils. William A. Meredith. CARCINOMA. See Cancer. CARDIAC DISEASES. See Heart, Diseases of. CARDIALGIA (icapSia, the heart, and aAyos, pain). — A synonym for heartburn, originating in a popular impression that this painful sensa- tion, which is situated in the epigastrium, is con- nected with the heart. See Heartburn. CARDIOGRAPH, The (ndpSia, the heart, and 7 pa(Kap4u >, I flow). Synon. : Coryza ; Catarrhus (Cullen) ; Catarrhus Communis (Good) ; Eheuma ; Fr. Catarrhe, Coryza ; Ger. Katarrh, Schnupfen, Definition. — The term catarrh is applied generally to inflammations of the mucous mem- branes attended with increased secretion. Thus authors speak of catarrh of the stomach, intestines, bladder, Spc. In the present article the term is limited to the inflammatory affections of the upper part of the air-passages, resulting from cold, and attended by discharge from the nostrils, sore- ness of the throat, hoarseness, and cough. The term coryza is, however, more especially limited to the cases in which there is copious discharge from the nasal passages, while catarrh is applied to affections of the whole mucous membrane, in- cluding the fauces and larynx. Symptoms. — The attack generally commences, "hortly after exposure to cold or more particu- larly to cold and damp, with a feeling of indisposition, sense of cold down the back or general chilliness, weight in the forehead, headache, especially frontal, and dryness of the naros and throat. These symptoms are succeeded CATARRH. 219 by the discharge from the nostrils of a thin acrid fluid, watering of the eyes, pains in the face, soreness of the throat and hoarseness, with aching in all parts of the body, and disinclination to bodily and mental exertion. At first the affection is often confined to one nostril, and there is pain in the corresponding temple, eyebrow, eyeball, and side of the face, and lachrymation on that side, but it soon ap- pears in the other nostril, and involves both eyes and all parts of the face ; and there is great sense of weight and pain in the forehead and eye-brows. The discharge, also, loses the thin character and becomes mucous, and is often very profuse ; there is copious lachrymation, the throat becomes decidedly sore, the hoarseness is greater, and there is pain in speaking and sometimes almost entire loss of voice. There aro also tran- sient pains in the chest, with a sense of tightness and some wheezing. The appetite from the first is impaired, and there may be entire distaste for food, and sometimes sickness and vomiting; not unfrequently there is some sense of weight in the right hypochondrium, and sallowness of the com- plexion ; the bowels aro usually confined, but there may be diarrhoea. The tongue is generally white, the pulse may be a little quickened, the skin may . be dry, the temperature is raised, and the urine is scanty and somewhat high-coloured and deposits a little sediment. The pains in the head and face especially affect the forehead, the eyebrows, the root of the nose, the eye-balls, and the course of the dental and other nerves ; they generally increase towards night, and may be so severe as entirely to prevent sleep. Not unfrequently there is more or less deafness, and usually loss of smell and taste. Herpetic spots often appear about the mouth, and the nostrils may bocome ulcerated from the discharge ; the throat is more or less red and swollen, and often there is stiffness and pain of the neck, and tender- ness on pressure over the larynx. After these symptoms have continued for two or three days they generally gradually subside ; but the cough may continue troublesome, and the patient be able to take very little food, and may still feel weak for a week or more. In per- sons of delicate constitution also, the weakness is often very persistent; and, if care be not taken, more serious inflammation of the bronchial mu- cous membrane or of the lungs may supervene, and may lapse into phthisis. Treatment. — In the slighter forms of com- mon cold, but little treatment is required except the use of the ordinary household remedies : the feet may be placed in hot water, some warm diluent beverage may be taken, and a light diet must be had recourse to for a day or two. In the more serious cases febrifuge medicines may be given, with an anodyne to relieve tho cough, if troublesome, or to procure rest at night, if the neuralgic pains be very severe. "When the attack has continued for two or three days a more stimulating diet may be giveD, and during convalescence tonics and stimulants may be re- quired. Dr. Ferrier recommends in catarrh the local application to tho nose of the following powder in the form of a snuff — Hydrochiorate of mor- phia 2 grains, subnitrate of bismuth 6 drachms, 220 CATARRH. gum-acacia in powder 2 drachms. From one- quarter to one-half of this may be taken in the course of twenty-four hours. It not unfrequently happens that in delicate persons a cold is very difficult to get rid of, and the slightest exposure is followed by an aggrava- tion or renewal of the symptoms. When this is the caso the most effectual remedy is change c f air, and the patient after leaving home often rapidly improves and soon gets well. Thomas 13. Peacock. CATARRHAL ( Kara , down, and pea, I flow). — Pertaining to catarrh, both in its pathological and in its clinical signification — e.g., catarrhal products, catarrhal pneumonia, catarrhal fever, catarrhal attack. CATHARTICS (k adaipa, I cleanse). — This word is sometimes used as a synonym for purgatives ; but in a more limited signification it means purgatives of moderate activity. See Purgatives. CAUSES of Disease. See Disease, Causes o£ CAUSTICS (kccIw, I burn). — Definition. — Substances or measures which destroy organic tissues with which they may be brought in con- tact. Enumeration. — The caustic substances in most common use are Potash, Soda, and Lime ; Nitric, Hydrochloric, Sulphuric, and Glacial Acetic Acids ; Red Oxide, Acid Nitrate, and Per- chloride of Mercury ; Carbolic Acid ; Chromic Acid; Chloride of Zinc; Chloride of Antimony ; and Arsenic. The ordinary caustic measures are the galvano-cautery ; the red-hot iron ; and moxse. See also Poisons. Uses. — Caustics are chiefly employed to destroy unhealthy, exuberant, or malignant growths ; to establish issues for the purpose of counter-irritation (see Counter-irritation) ; and to destroy poisons when introduced into the body by breach of the external surface. T. Lauder Brunton. CAUTERETS, in the French Pyrenees. Sulphur Waters. See Mineral Waters. CAVERNOUS. — A peculiar quality of sounds heard on auscultation of the lungs, indica- tive of the presence of a cavity. See Physical Examination. CAVITY, Pulmonary. — As the result of certain morbid processes which terminate in the destruction of portions of the pulmonary tissues, abnormal spaces or excavations are frequently formed in the lungs, which are designated cavi- ties or vomicce. These are usually associated with, and are by far most important in that large class of cases which are grouped under the term Phthisis. They may, however, originate under other conditions, namely, as the result of abscess or gangrene of the lung; of the destruction of morbid growths or hydatid cysts ; of dilatation of the bronchi ; or of destruction of the pulmo- nary tissue from without, in connection with glandular disease, empysema, and other lesions. The most recent observations on this subject are given in the article Vomica. Pulmonarv cavities present wide variations in CELL. different cases as regards their number, size, shape, condition of their walls, amount and nature of their contents, and other particulars. Usually they begin to form in the upper part of one lung, but subsequently they are produced in other parts, frequently both lungs becoming more or less involved, and any portion may be exca- vated ir the first instance. A cavity frequently goes through certain stages, namely, those of formation and extension ; of arrest ; and of heal- ing or contraction, which may terminate in ulti- mate closure and obliteration of the vomica. Enlargement of cavities is effected either by progressive implication of their walls, termi- nating in their disorganisation and removal ; or by coalescence of adjacent spaces, the intervening lung-tissue becoming destroyed. During this pro- cess of destruction some of the tissues often escape more or less, especially the vessels, which may not uncommonly be seen traversing the spaces or running along their walls, their channel being obliterated. When an excavation is arrested in its progress, it becomes lined by a smooth mem- brane, and a more or less purulent fluid is se- creted within it. This cessation of active mischief may not take place until a whole lobe, or even the greater part of the lung, is involved, a huge cavity being formed, which presents no tendency to contract. In other instances the progress of destruction is stayed, the formation of purulent matter is checked and finally ceases, a fibroid tissue forms, and the space undergoes a process of contraction or cicatrization, which may end in a complete cure, but more commonly merely diminishes the size of the vomica more or less. At a post-mortem examination in cases of phthisis it is common to find numerous cavities in the various conditions and stages indicated above. Occasionally a vomica gives way into the pleura, followed by pneumothorax and its consequences. Clinically, the existence of cavities in the lungs can only be ascertained positively by physical examination of the chest, and as a rule not only their presence, but their conditions may by this means be determined with tolerable accuracy. The physical signs vary considerably in different cases, and are more conveniently described in other articles. Sec Phthisis ; Physical Examina- tion, and Yomica. Frederick T. Eobeets. CELL (cella, a closet or store-room). — The term ‘ cell ’ was for a long time applied, in anatomy, to various spaces in the body large enough to be recognised with the naked eye. In the Anatomic Generate of Bichat, for instance, it was used exclusively for the ir- regular spaces in areolar tissue (still often called cellular tissue). An entirely different sense of the word was introduced from botanical science. The microscope had shown that the structure of plants was largely made up of hollow bodies, called bladders, vesicles, or cells, in which various substances were enclosed cr stored up. Schwann was the first to show the similarity in structure of many animal tissues which were likewise made up of minute parts. These parts were assumed to be, as in plants, hollow ; and in both eases, cells were defined as composed of a cell-wall, cell-contents, and a smaller included mass called the nucleus CELL. 221 This conception of a cell still holds its ground in the anatomy of plants. It did so in animal histology till about the year 1861, when Beale, Briieke, and Max Schultze almost simultaneously showed that many so-called cells in animal tissues did not possess the typical structure of a cell, but were homogeneous masses of a sub- stance resembling the bodies of many lower animals, which substance Schultze distinguished by the name of protoplasm. This was first shown to be true of certain special cells, such as the corpuscles of blood and lymph, but afterwards extended more widely, till now it is doubtful whether any minute elements in the higher animals, with the possible exception of the fat-cells when gorged with fat, and certain peculiar forms of cell on the mucous surfaces, come under the old definition of a cell. When the conception was altered, it would probably have been better to have introduced a new name. This, however, was not done, and hence the word cell as now used involves some incon- sistency. By ‘ cell,’ we now understand a mass of con- tractile, colloid, living matter called protoplasm, containing at some period or other a smaller structure called the nucleus. It must remain uncertain whether the nucleus is or is not essen- tial to the cell, till we know more about the nature and function of tho former ; and these points, in spite of the very numerous researches on the nucleus which have lately appeared, must be regarded as still obscure. Sometimes the superficial portion of the cell-body may become hardened or otherwise altered, so as to form what is called a ‘ cell-wall,’ but this is not to be regarded as a separate structure. In cells destined for special purposes the protoplasm be- comes modified. See Nucleus in Appendix. Protoplasm is a nitrogenous, albuminous, colloid substance, having certain properties called vital, that is, the power of altering its form under the influence of stimuli, or, apparently, spontaneously. This power may be lost, under the influence of too powerful stimulation or other causes. Protoplasm does not appear to exist in the higher animals otherwise than in the form of minute masses or cells, but it would be rash to say that it cannot exist in continuous masses, as in certain forms of plants. Many of the properties of cells are the pro- perties of protoplasm. Those cells which con- sist of unmodified or undifferentiated proto- plasm possess contractility, the power of pro- truding their substance in the form of processes, of undergoing various changes of form, and even of locomotion. In these respects they resemble very simple animals — amoeba, whose bodies are composed of homogeneous protoplasmic sub- stance, and these movements are hence called amoeboid, or simply vital. Cells which possess these properties may lose them, or die from excessive heat, cold, removal from the body, or other injurious influences. Hence the amceboid movements are especially characteristic of re- cently formed or young cells. They are seen in the white cells of the blood, lymph-corpuscles, the round or unfixed cells of connective tissue, the young cells which appear in inflamed parts, fresh pus-cells, and occasionally in the young cells of new growths, but are absent as a rule in cells highly differentiated and serving some special purpose, such as nerve-cells, secreting cells, and the fixed cells of connective tissue. Amceboid cells are sometimes found in tissues to the fixed elements of which they have no relation, .and are then to be regarded as emigrant or mi- gratory cells. They are very important in some pathological processes. Cell-proliferation . — Cells increase in number by fission, and perhaps, as some think, by gem- mation and by endogenous development. These processes collectively are called cell-prolifera- tion, which is doubtless the source of many of the new cells found in pathological states. All cells are not equally capable of proliferation, which is chiefly seen in amoeboid cells, and in all the elements of connective tissue. This tissue was regarded by Virchow as the germinal tissue, from which all others originate, but the balance of opinion is now in favour of a different view, namely, that each kind of tissue, by prolifera- tion, produces only tissue of the same kind. Re- cent researches show that cell-division takes place in two distinct modes, the direct and the indirect. See Nucleus. The mode of proliferation in epi- thelial cells is still imperfectly understood. It was formerly held by Schwann and others, that cells originated spontaneously in a homogeneous blastema ; but proof is quite wanting of this mode of origin, and it is in accordance with all experience to believe that new cells are always the descendants of pre-existing cells — a con- clusion summarised by Virchow in the words omnis cellula e cclluld. It does not follow that new cells are always descended from the cells of the tissues in which they are found, since they may have emigrated from the blood-vessels. Shape of cells . — Amceboid cells have, strictly speaking, no fixed shape ; but in a state of rest, and when dead, they are nearly spherical. Some cells of similar protoplasmic composition are very irregular in shape, and contain many nuclei, namely, mj-eloid or giaDt-cells. Other cells have various shapes, of which the commonest is an elongated form, with a process at each extremity, as in fibre-cells; some, as nerve-cells or fixed connective-tissue cells, are stellate, with several processes. Some cells in certain new growths, especially tubercle, also called giant-cells, have extremely complicated processes. Wasting and Degeneration of cells . — The ac- tual duration of life in cells is not in all cases pre- cisely known ; but in the blood and in large collec- tions of amoeboid cells we always find some with signs of decay and death, so that their life is probably measured by days. Epithelial and secreting cells have also a limited duration, while fixed cells of connective tissue and nerve cells are probably more permanent. Cells are also subject to the degenerations which affect tissues generally, especially the fatty, mu- cous, and colloid. The obvious pathological changes in organs are often due to the minute changes in the cells. Newly-formed cells are more subject to degeneration and decay than the original elements ; and this is espe cially true of cells produced in inflammation. Some pathological processes consist essentially in tho rapid production, followed by rapid 122 CELL. degeneration, of new jells, for example, scrofu- lous inflammation. Cellular Pathology. — This name is giver, to the system which explains morbid processes by reference to the independent life of cells, their active properties, their proliferation, and their degenerations, while it attaches less im- portance to derangements of the circulation, or to alterations in the composition of the blood. Its foundations were laid by Remak and Goodsir, but it was first reduced to a comprehensive system by Virchow, not only in his work thus named, but in memoirs published before and since. The cellular pathology explains many facts which were before obscure, and the impor- tant steps thus made are not likely to be retraced ; but in several points modification of Virchow’s views has become necessary. As to the origin of new-growths, it is not now held that all arise or can arise from the connective tissue; and in inflammation it is agreed that the changes of the tissues, however well-established, are only of subordinate importance, as compared with those depending upon the circulation. J. E. Payne. CE LLTTLI TI S . — Definition. — Cellulitis is the term applied to inflammation of the cellular or loose connective tissue, whether the subcuta- neous areolar tissue, or that interposed between muscles and viscera, or surrounding various organs. The areolar connective tissue is so universally distributed throughout the body that it is neces- sarily concerned in most inflammations — no matter of what structure — and in it, in fact, the chief changes generally take place. To consider completely the pathology of in- flamed connective tissue would be more or less to review the whole series of the acute diseases. We must limit our consideration to cases in which the cellular tissue is the chief or only tissue involved, or where changes in other parts are secondary to those primarily affecting the cellular tissue. Beneath the skin, over the whole surface of the body, lies a layer of this tissue, containing within its meshes more or less adipose matter. It will be convenient to consider the changes which occur in it when inflamed, as they are iden- tical with those in cellular tissue elsewhere. Inflammation of the subcutaneous cellular tissue may be diffuse or circumscribed. The former is nearly always acute in type, and the latter often, but not invariably so. A chronic form of cellulitis causing thickenings is observed in various regions, or it may be a sequel to the acute disease. 1. Circumscribed Cellulitis. — .ZEtiology. — Anj injury to a part, whether of the nature of a wound or contusion ; an impacted foreign body ; or a fragment of bone, may cause cellulitis. Pyte- mia or septicaemia, any decomposing secretion in a wound, altered blood, or infiltrated urine are prone to produce marked inflammatory changes in the connective tissue in different parts of the body. The poison introduced in a dissection- or 'post-mortem wound often occasions an acute cellular inflammation. Frostbite, burns, inflammation of muscles, arteries, veins, or peri- i CELLULITIS. osteum may produce inflammation of the adjacent cellular tissue : thus, inflammation of the kidney may cause perinephritis ; inflammation of the uterus may lead to pelvic cellulitis; or some mischief in the greater bowel or rectum ma y produce inflammation and abscess in the lcose cellular tissue around them ( Perityphlitis ) ; the poison also of scarlatina causes cellulitis of the submucous areolar tissue of the throat; and Angina Ludovici is the name given to the cellulitis of the floor of the mouth and neck which is often associated with pysemic symptoms. A sympathetic bubo is an irritated lymphatic gland causing inflammation of the cellular tissue around it. Pathology. — Pathologically, connective tissue is of the greatest importance in the organism, being the most frequent seat of inflammatory and other changes. Areolar tissue mainly consists of loosely interlaced bundles of fibrous tissue, with flattened connective-tissue corpuscles ad- herent to them, and leucocytes, or amoeboid corpuscles, in the intervals. The exact role played in inflammation by the cellular elements is not quite settled. Under ordinary circumstances the leucocytes doubtless proliferate, and the fixed corpuscles probably do so also. Even under the influence of a slight irritation the flattened corpuscles in a few hours become globular, and present many nuclei in their interior — changes certainly pointing towards proliferation ; while the very rapid increase of cells which takes place points to their derivation from cells pre-existing in the part, although the immigration of leuco- cytes from the blood into the inflamed part adds considerably to their numbers. Whether the perversion of nutrition which forms the start- ing point of the disease first induces a local cell-proliferation, or an immigration of leuco- cytes, or what proportion these two processes bear to each other, is difficult to determine. The disease consists essentially in a very active cell-proliferation and increase. Whether the cel- lulitis be circumscribed or diffuse, similar changes occur; the difference between them being that in the former there is formed a limiting zone of vascular tissue resembling graDulation-material, which is absent when the inflammation is diffuse. There are otherwise no anatomical differences. When cellular tissue inflames, the part swells from the serofibrinous exudation poured out from the distended capillaries ; its meshes are filled with young round cells, partly by proliferation of the connective-tissue corpuscles, in part by the accumulation of wandering leucocytes ; the cir- culation is interfered with by the pressure of the effusion, complete stasis sometimes taking place. While the cell-increase is proceeding, the fibrillar intercellular substance gradually disappears, in part by necrosis, and in part by becoming liquefied ; and the tissue is finall y transformed into pus. When this has happened the deeper layers of the skin disintegrate; it becomes undermined and gradually thinner; necrosis in one or more places follows ; and the pus mingled with shreds of dead cellular tissue escapes, the latter resembling nothing so much as soaked washleather. The pus, at first thin and serous, subsequently becomes laudable, i There is always a great tendency to suppi> CELLULITIS. ration, the vitality of areolar tissue being very low ; but resolution sometimes takes place with- out formation of pus. The cells then develop into fibrous material and the ordinary pheno- mena of a cicatrix result. The consequences of cicatrisation differ greatly, according to the tissue or organ involved and the extent of the disease ; but essentially they are similar everywhere. A gradual contraction sots in. In external parts we can observe atrophic changes taking place, followed sometimes by deformity or loss of function, while in the viscera the condition is known as cirrhosis. The special tissue of an organ or of a muscle cannot be reproduced ; it is replaced after an injury by connective-tissue cicatrix. In such tissues as bone, tendon, and nerve, however, the cicatrix wdl be converted into the normal tissue of the part. Symptoms.— The amount of fever varies with the extent of the disease and the nature of the cause ; when the cellulitis is quite limited there may be little or none, but deep-seated or ex- tensive cellulitis produces considerable constitu- tional disturbance. Painful swelling of the inflamed part will first be observed; the skin soon becomes tense, red, and (edematous, al- though at the outset it is sometimes paler than normal. The redness is gradually lost towards the periphery of the swelling, and is darker, or of a bluish-red tint in the centre, from the ob- struction to the exit of blood; the swelling is doughy, inelastic to the touch, and pits on pressure. The inflamed region feels hard, the induration ceasing by no well-defined border. If resolution occur all these symptoms subsido. A greater or less amount of thickening of the tissue may, however, persist — often for a lengthened period — the parts gradually returning to their normal state. Suppuration is, however, the ride ; and when it occurs the pain and tension dimi- nish, fluctuation is felt, — obscure at first, — the pus by degrees approaching the surface, and escaping spontaneously, or by an artificial outlet which may be provided. AVhen the inflamma- tion is more deeply placed, especially when be- neath strong fascise, there will at first be no perceptible redness or swelling of tho skin, or only a slight pinkish hue, with some oedema, to indicate the changes taking place beneath ; and fluctuation may bo difficult or impossible to make out long after pus has formed; but the pain and fever are more considerable. This variety of the disease may also terminate in resolution — especially when early and appropriate treatment has been adopted ; or in suppuration. It may also become chronic, or relapses may take place after temporary amendment. If the cause of irritation be a slight one, but repeatedly re- newed, permanent thickenings or atrophic changes in the tissue may result ; or the circumscribed may be converted into diffuse cellulitis. A very intense irritant sometimes induces gangrene. The same thing may happen if a previously diseased tissue be attacked, as an anasarcous limb ; or pressure, associated with the cel- lulitis preceding bed-sores, may be sufficient to cause it. 2. Diffuse Cellulitis. Synon. ; Diffuse phleg- mon ; Pseudo-erysipelas ; Diphtheria of the cellu- lar tissue. This is a severe disease attended by 229 general symptoms of a marked character, fre- quently associated with septicaemia, of which il may be both a cause and an effect. ^Etiology. — The most frequent cause of diffust cellulitis perhaps is some form of septic poisoning In the extremities tho disease may originate from some trifling cause, especially in those whose constitution is impaired by age, privation, or excess ; in the hand and forearm of such persons it is especially common after wounds on the finger or an insignificant whitlow. In con- valescence from acute febrile diseases, espe- cially typhus or typhoid, a local phlegmon is sometimes transformed into a diffuse cellulitis. Symptoms. — The local symptoms of diffuse cel- lulitis resemble those of the circumscribed form, but are more intense, and accompanied by severe constitutional disturbance. A sudden chill with elevation of temperature often ushers in the attack ; the rigor may recur at intervals, but sweating is unusual, and vomiting infrequent. In the affected region the patient experiences a sense of weight and great disten- sion, with severe dragging pain. AVhen the inflammation is deep-seated the redness of the skin may not be well marked, even after a con- siderable extent of tho cellular tissue has sloughed. This character is a very dangerous one, because it leads to the nature of the affection being for a time overlooked and efficient aid postponed. AVhen the skin participates, the redness is darker in hue, less sharply defined, and less easily dis- persed by the pressure of the finger than in the cutaneous inflammation of erysipelas, while it soon becomes cedematous. The affected part feels brawny, hard, and swollen throughout, and extremely tender and painful ; sleep is impos- sible ; any movement causes great suffering; the fever is often very high ; the secretions are dimi- nished ; and the appetite is lost. Sweating and rigor presently announce the formation of matter ; the swelling becomes less prominent and more soft ; the skin is mottled, thin, and yielding in places ; and the fever and pain subside. Convales- cence may take place on the evacuation of the pus ; or the rigor may be renewed, the fever reappear or continue, and the patient sink with symptoms of blood-poisoning. The more deeply the in- flammation extends the more tedious is recovery, and the more liable is the patient to relapse ; or the muscles, tendons, and adjacent joints may become involved in the suppuration ; or perfora- tion of a dangerous character of neighbouring cavities or organs may take place. Suppuration consequent upon diffuse cellular inflammation will sometimes extend up the fore-arm to the elbow, undermine the skin, dissect the muscles, open into the finger- and wrist-joints, cause necrosis of tendons, and terminate in the loss of the limb by amputation, or perhaps in loss of life from septic poisoning ; should recovery ensue, the limb is permanently crippled from the mat- ting together of muscles and tendons, the immo- bilization of the joints, and the adhesions that take place between tissues which should freely glide over one another. Suppuration is the rule, but under favourable circumstances and with early and suitable treatment it may occasionally be prevented. Usually pus has already formed when the case comes under observation, and 221 CELLULITIS. the surgeon has only to use his bistoury to limit the spread of the disease. The irregular cavities and sinuses left after the evacuation of the dead tissue often suppurate for a long time, and may thus induce amyloid de- generation of the viscera. The thromboses which form of necessity in the smaller veins implicated in the inflamed area may break down and lead to septic embolism and pyaemia. The risk of this complication is a serious and ever-present one in these cases. Diagnosis.— Cellulitis has chiefly to be diag- nosed from erysipelas. Erysipelas may involve the subcutaneous tissues, and cause inflammation and suppuration of the connective tissue, but it always begins in the skin, which is more exten- sively affected. Inflammation of the cellular tissue begins beneath the skin, where the swell- ing and effusion first take place, the skin becom- ing involved later and usually to a less extent, while it may remain, at least for some time, almost entirely free ; the redness, too, is less bright, and more diffused, not presenting the distinct margins of erysipelas, hut fading into the surrounding parts. In the later stages the two diseases are scarcely distinguishable. At first it may be difficult to decide whether the case is one of inflammation of the subcutaneous cellular tissue, of the perimuscular areolar tissue, or of that con- nected with the periosteum, or around a vein. The greater the general swelling of the limb, the more considerable the fever and the pain, and the less the redness of the skin, the more probable is it that the inflammation affects deeply seated structures. Prognosis. — The prognosis depends on the extent of the disease and the constitution of the patient. Treatment. — The local cause should he re- moved, so far as may he practicable. If the wound he in a foul condition it should be rendered aseptic. Absolute rest to the inflamed part is of great importance. So long as sup- puration has not occurred, resolution is pos- sible. Methodical pressure, once advocated, cannot usually be tolerated. Blistering is not employed in the acute form, hut may be useful in removing more chronic changes. Cold applica- tions and ice abate pain and inflammation, and limit the disease, even if they do not prevent suppuration. In the more advanced stages, es- pecially when they tend to become chronic, they are useless or even dangerous, from their liability to cause gangrene in debilitated subjects. Local blood-letting does not prevent suppuration, and is usually contra-indicated by the weak state of the patient. When pus forms, or its presence is suspected, a sufficiently free outlet should be provided for it as soon as possible. Nothing so effectually checks the further spread of the disease. The incision should he made at the most prominent point. It is better to make a number of small incisions, from half an inch to an inch in length, than one long one, which is apt to be followed by dangerous bleeding, and does net relieve the strangulated tissues so efficiently. When suppuration is only sus- pected, incisions should nevertheless be practised without delay, without waiting for fluctuation. CEREBELLUM, LESIONS OF. Pus and shreds of dead cellular tissue should be frequently washed out of the wound with an irrigator. No force should Le used to remove portions of dead tissue : any dragging tends to rupture the small blood-vessels, and to destroy the remaining connexions of the skin with the deeper structures. Antiseptic precautions must be zealously carried out. When a joint becomes involved, or when the patient is thoroughly exhausted by the quantity of discharge, and the tissues spoiled, amputation is often necessary. Excision may be practised if the condition of the soft parts admits of it. The general treatment consists in giving nourishing food and stimulants, combined with opiates to relieve pain, and iron, quinine, andother tonic medicines. William MacCobmac. CEPHALALGIA (K«pa\ri, the head, and &\yos, pain). — Pain in the head. See Headache. CEPHALHA1MATOMA (iceQaXh , the head; ai/xa, blood; and d/xbs, like). — Definition. — An effusion of blood occurring in newly-born infants, forming a tumour upon the head ; situ- ated beneath the pericranium, upon the surface of the skull ; or more rarely beneath the skull, between it and the dura mater. Description. — This disease is of very rare occurrence, and must not be confounded with the caput succedaneum, which is an effusion of serum external to the pericranium, and is of com- mon occurrence. The blood is generally extra- vasated immediately beneath the pericranium, over one of the parietal hones, most frequently the right, hut it may occur over the frontal or occipital. Combined with this, or arising inde- pendently, hut of extreme rarity, may be an effusion beneath the cranium. The origin of cephalhsematoma has been attributed to a variety of causes, but is most probably due to the constriction of the margin of the os uteri during labour. It is generally observed some hours or a day after birth, as a circumscribed swelling, slightly tense and fluctuating : and its peculiarity consists in a bony circle surrounding and limiting it. Diagnosis. — These tumours have been mis- taken for hernia cerebri, but their situation over the bone away from the fontanelles, the absence of pulsation, and the existence of fluctuation in cephalhasmatoma should prevent confusion. Prognosis. — Generally the blood becomes ab- sorbed, but occasionally suppuration occurs, or the bone may become necrosed ; if beneath the skull, serious consequences, including idiocy, may ensue. Treatment. — As a rule, cephalhasmatoma is not to he interfered with. If suppuration take place the pus must he evacuated. Clement Godson CEHATITIS. See Keratitis. CEREBELLUM, Lesions of. — The cere- bellum is liable to the same diseases as the brain and nerve-centres generally, such as hae- morrhage, abscess, various forms of degenera- tion, tumours, &c. The nature of the patholo- gical condition is to he determined by the symptoms peculiar to each, so far as this is pos- sible. Its locality in the cerebellum is to bo diagnosticated, first, by certain symptoms which CEREBELLUM, LESIONS OF. 225 fire due to the cerebellar lesion as such, -which may be termed the direct symptoms ; and. secondly, by those symptoms which depend more on the influence exerted by the lesion on neighbouring or subjacent centres and structures. These latter may be termed the indirect symptoms. It is by no means easy to separate these symptoms from each other, and to say how much is due to interference with the functions of the cerebellum, and how much to interference with the functions of other parts. There are few diseases which have a purely local organic or functional limitation. Hence, in order to arrive at the symptoms peculiar to cerebellar lesions, it is necessary to exclude all pathological affec- tions which in their very nature affect the whole of the intracranial centres, e.g. tumours, menin- gitis, &c. The most satisfactory conclusions from a pathological point of view are to be drawn from cases of atrophy or degeneration of the cerebellum, and, from a physiological point of view, from the results of experimental lesions of this organ in the lower animals. The evidence from these two sources is mu- tually supporting. Diiiect Symptoms. — The characteristic symp- toms of cerebellar disease are disorders of equilibrium, shown, on attempts at locomotion, in a reeling or staggering gait (titubation), and a continual tendency to stumble or fall over the most trifling obstacle, or on hurried movements. These symptoms may be confounded with locomotor ataxy, but careful observation will show that in cerebellar disorders there is no true ataxy of co-ordination. The movements are quite co-ordinated with each other, and are such as would instinctively be made to prevent fall- ing, or to preserve the equilibrium ; and have none of the precipitate, irregular, and sprawling character seen in ataxy. They are not specially intensified on closure of the eyes, which is such a marked feature in ataxy. Nor are they accom- panied by any of the sensory affections of ataxy, whether in the form of pains or anaesthesia. There is no true motor paralysis in cere- bellar disease as such, and the various volitional movements of the limbs can be carried out per- fectly well in the recumbent posture. Sensation, general and special, is not directly affected in cerebellar disease. Nystagmus and strabis- mus have been observed, more particularly in connection with lesion of the cerebellar peduncles. Defects of articulation have been noticed, but it is very doubtful whether they should be regarded as direct symptoms. It is to be noticed that in some cases of slowly progressive degeneration of the cere- bellum, the disorders of equilibrium are not observed to any marked extent, an occurrence to be accounted for in all probability by compen- satory action on the part of other centres. Ixdtrect Symptoms. — Pain in the head , more particularly at the back, though not constantly situated there, is frequently associated with organic disease of the cerebellum. Vomiting is also very frequently observed, perhaps more constantly than in connection with diseases of other parts of the brain. There is, however, no reason to regard this as due to cerebellar disease as such. It is probably due 15 to indirect effects on the medulla. Asa general rule, diseases tending to encroach on the space of theposterior fossa or to increase the pressure on this region, have a similar effect. Hemiplegia is not uncommon in connection with cerebellar disease, and more particularly in cases of tumour or haemorrhage into the lateral lobe of the cerebellum. The hemiplegia is on the side opposite the lesion. This does not prove that the hemiplegia is due to tha destruction of the cerebellar lobe, or that the cerebellar lobes have cross relations with the limbs. Experimental physiology and anato- mical investigations tend to show that the cere- bellar lobes are functionally related to the motor tracts on the same side. This is also borne out by the fact that atrophy of the lateral lobe of the cerebellum follows disease and de- generation of the opposite cerebral hemisphere. The hemiplegia, from cerebellar disease is, therefore, in all probability, due to compression or some affection of the subjacent motor tracts, which decussate at the pyramids. The fact that it occurs chiefly when the disease is limited to the lateral lobe is what might be expected on anatomical grounds. Affections of sensation, common and special, have been observed in cases of cerebellar dis- ease. Diminution of tactile sensation on the opposite side of the body, when the disease is situated in the lateral lobe, is to be accounted for in the same way as the motor paralysis. As regards the special senses, affections of sight have been most frequently noted. Sight is cer- tainly not abolished by destruction of the cere- bellum in the lower animals, and when blindness occurs in man in connection with diseases of this organ, it is either due to implication of the corpora quadrigemina, functionally or or- ganically, or to secondary degeneration in the optic tracts, as the result of increased intracranial pressure or descending optic neuritis. A special feature of tumours of the cerebellum, more especially of the middle lobe, is a tonic rigidity of the muscles of the back of the neck, with retraction of the head, associated frequently with flexion of the forearms and extension of the lower extremities and pointing of the toes. In these cases also, psychical affections, more par- ticularly mental hebetude or stupor, occur as the result of secondary dropsy of the ventricles, caused by pressure on the veins of Galen. Tha symptoms then become those of hydrocephalus. Haemorrhage into the middle lobe of the cere- bellum, in addition to the ordinary symptoms of apoplexy, has been frequently found to cause vascular excitement of the genital organs — in the male marked priapism. This symptom, of which several cases were first reported'by Serres, led this observer to modify the view of Gall that the cerebellum, as a whole, was related to the sexual instinct, and to regard the middle lobe only as having any such function. The facts, however, are susceptible of a totall}- different interpretation, and one more in har- mony with other data of physiology and pa- thology. It has been fottnd experimentally by Segalas and by Eckhaid that irritation of the- posterior surface of the medulla and pons gives rise to vascular excitement of the generative 220 CEREBELLUM, LESIONS OF organs, and hence the symptoms in cases of haemorrhage into the middle lobe are to be ascribed to irritation of this region. This fact also explains the absence of the symptoms when the haemorrhage occurs into the lateral lobes. There is absolutely no evidence of the slight- est value in support of Gall’s hypothesis. The facts of clinical medicine go a considerable way in diametrical opposition to it, if they are not themselves sufficient entirely to overthrow it. Cerebellar Peduncles. — Respecting the effects of disease of the restiform tracts or in- ferior cerebellar peduncles we have no definite knowledge. Cases, however, are on record in which lesions have been found involving principally either the superior or middle cerebellar peduncles. The symptoms, in the main, agree with those observed by Magendie on section of the middle peduncle in the lower animals. The chief effect of this lesion was to cause an irresistible ten- dency to roll over towards the side of lesion. Together with this rotatory disturbance of the equilibrium, a peculiar distortion of the optic axes was observed, the eye on the side of lesion being directed downwards and inwards, the other looking upwards and outwards. In a case described by Curschmann ( Deutsch . Archiv f. Klin. Med. xii. 356), along with appearances of basilar meningitis, wnich some- what complicate the case, there was found a focus of softening, surrounded by capillary haemorrhages in the right superior cerebellar peduncle. The symptoms observed in this case were a rotatory distortion to the right side, to which position the patient invariably returned when resistance to this movement was with- drawn. There was no motor paralysis, nor was there any distortion of the optic axes. A ease has been put on record by Nonat ( Comptcs Bendus, 181) of apoplectic extrava- sation into the right middle peduncle of the cerebellum and right cerebellar hemisphere. In this case the head and trunk were twisted towards the right side, and the ocular symp- toms were also present, the eyes being immovable sa a position of skew deviation. Other cases are on record in which the cerebellar peduncles have been involved in more extensive lesions ; but the symptoms, though not opposed to those above related, are incapable of differential analysis. The special diagnostic symptoms, therefore, of lesion of the cerebellar peduncles are what are frequently termed ‘ forced move- ments ’ ( Zwangsbewegungcn ), or distortions of the normal axis of the trunk. The exact direc- tion of the distortion, in consequence of lesion specially limited to one or other peduncle on the right or left side respectively, is somewhat doubtful, though as a rule it has been found to- wards the side of lesion. ' Much, however, will depend on w hether the lesion is of an irritative or inflammatory, or of a destructive character. A lesion of an irritative nature, though occupy- ing the same position as a destructive lesion, would exactly reverse the direction of the dis- tortion of the head and trunk. D. Ferrier. CEREBRAL ABSCESS. See Brain, Ab- bess of. CEREBRO-SPINAL FEVER. CEREBRAL APOPLEXY. Afofijexv, Cerebral. CEREBRAL ARTERIES, Diseases of. See Brain, Vessels of. Diseases of. CEREBRAL HEMORRHAGE. See Brain, Haemorrhage into. CEREBRITIS. — Inflammation of the brain- substance. See Brain, Inflammation of. CEREBRO-SPINAL FEVER. — Stnon. : Epidemic Cerebro-spinal Meningitis ; The Black Sickness (popular, Dublin) ; Fr. Meningite cerehro- spinale epidemique ; Ger. Cerebral-typhus ; Epi- demische-meningitis. Definition. — An acute epidemic febrile dis- ease, characterised by sudden invasion, with extreme nervous shock, vomiting, excessive pain referred to the back of the neck and spine, spas- modic contraction of muscles, excessive sensibi- lity of the skin, and frequently delirium ; accom- panied by purpuric eruptions, either circum- scribed, raised, hard, and shotty to the feel, or extensive purpuric spots or patches, fre- quently accompanied by vesicular eruptions usu- ally of herpetic but sometimes of a pemphigoid character, and frequently purulent inflammation of the eyes. Post mortem there aro found : inflammation of the membranes of the brain and spinal cord, especially of the arachnoid, with deposit of white, yellow or greenish-yellow lymph upon the surface of the arachnoid, espe- cially at the base of the brain and anterior portion of the modulla oblongata and spinal cord, and effusion of serum into the ventricles and sub-arachnoid spaces. JEtiolog y. — Age . — The d isease usually attacks those approaching the age of puberty or in earlv adult life ; it is seldom met with after thirty-five years, and is very rare after the age of forty. It is not unfrequent in young children. Sex. — It is much more frequent in males than females ; robust males between the ages of fifteen and thirty are its favourite victims. Occupation. — It seems specially to attack young recruits in the army, as was the case in the French epidemics. In Dublin it was specially severe among the recruits of the Roval Irish Constabulary stationed in the police barracks in the Phcenix Park. There does not seem to be any other occupation which predisposes to the disease. Excessive fatigue seems to predispose to the diseaso ; it has arisen after a hard day's hunting, foot-racing, long walks, dancing, or in children exhausted from out-door play. Season and Climate. — It is widely distributed in the temperate zone. It prevails moro in cold than in hot weather ; in Iceland it has usual lv prevailed in winter and early spring. General Sanitary Conditions. — It seems to be less influenced than any other epidemic affection by general sanitary conditions. Communicability. — It is generally believed not to be contagious ; a few doubtful cases of con- tagion have been recorded ; except, however, in cases where it has appeared as an epidemic among recruits, there are few instances of more than one case arising in any particular house or circumscribed locality. Epidemic Influence. — The disease is undoubt edly epidemic. CEREBRO-SPINAL FEVER. Unwholesome Food. — It has been suggested that the disease owes its origin to tho use of breadstuff's made from diseased grain. Anatomical Charactees. — Cadaveric rigidity is well marked; large purpuric patches form after death even in cases where there were no purpuric symptoms during life; in some cases the whole body has turned black. On incision a large quantity of dark, tarry-looking blood exudes ; the muscles are darker than usual, and in prolonged cases much weakened and wasted. There is increased vascularity of tho scalp ; the cerebral sinuses are much distended with dark blood ; serum is found in the sub-arachnoid spaces and ventricles ; all the membranes of the brain may be moro or less congested, the arachnoid being always extremely vascular and opaque from deposits of lymph — this opacity varies from slight milkiness to thick and denso deposits. The most marked intracranial lesion is the white-yellowish or yellowish-green ‘ fibrino-purulent ’ deposit found at the base of tho brain. This deposit varies somewhat with the duration of the disease ; in cases which die early the deposit is usually slight, whitish, and soft ; in those which live for a week or so tho deposit is yellowish or greenish ; in prolonged eases tho deposit is more white and pure, tho effused serum greater in quantity, and the vascular fulness less. The origins of the nerves seem to be buried in and compressed by the deposit. The brain-substance itself is more vascular than normal, but not otherwise altered. In tho spinal cord tho lesions are similar to those found in the brain and its membranes. In some cases purulent infiltration of the eye- ball and effusion into the joints have been met with. The lungs, liver, and spleen have been found much congested in many cases. Symptoms. — The patient is usually attacked suddenly when in apparently vigorous health by faintness, vomiting of greenish matter, and in- tense pain referred especially to the back of the head and neck ; the extremities become cold ; the patient becomes insensible and sometimes con- vulsed; the limbs become rigid. On recovering from the collapse, the patient complains of great pain in the head, back of neck, and along the spine ; the head is drawn back, so as to be almost at a right angle with tho spine ; the whole back is sometimes arched, as in tetanus, the muscles become rigid, and the skin excessively sensitive ; neuralgic pains are also complained of in all parts of the body. In most of the severe cases erup- tions appear within the first twenty-four hours ; the eruption usually appears first on the legs, and is frequently confined to the lower extremi- ties ; the spots are usually black, raised, about a line in breadth, and feel like a grain of shot under the skin ; sometimes these raised spots are surrounded by a dark purplish areola ; in most cases large purpuric patches of many inches in extent form on various parts and, sometimes coalescing, cover the entire body. Vesicular eruptions are also common ; these usually have the character of herpes zoster, and are most frequent on the face, neck, and shoulders. The herpetic eruptions are met with »s frequently in mild as in severe eases. Pem- phigus sometimes appears in the advanced stages of the disease. When reaction sets in, the tem- 227 perature is found to have risen to from 100° to 103° or 104° Fahr. In many cases the tem- perature never rises, and the patient dies in the collapse ; the respiration becomes of a sighing character ; the pulse rises to about 120, and has a peculiar jerking character, giving a sharp up stroke to a sphygmographic tracing. The fore- going symptoms are very variable ; any one, or even a considerable number of them, may be absent throughout the whole course of the case. Complications and Sequels. — Complica- tions connected with the nervous system are tho most common ; paralysis of one or more limbs is common, of a hemiplegic character, and most frequently attacking the arm ; deafness is not very common, but has been met with in several cases, and sometimes becomes perma- nent. The eye-complications are among the most frequent and most serious. The eye is frequently attacked with a low form of inflam- mation, terminating in purulent infiltration of tho whole or part of the organ ; the cornea is more frequently attacked than any other por- tion ; and this sometimes giving way, the whole contents of the globe escape, causing perma- nent loss of sight. The sight is also often per- manently impaired by iritis, or opacity of the cornea. In many cases, however, the inflamma- tion completely subsides. It is remarkable that it is the right eyo which is usually attacked, seldom that both eyes are affected, and scarcely ever the left eye alone. Acute inflammation of the larger joints is a frequent complication in some epidemics ; this often terminates in puru - lent effusion into the joints. Haemorrhages are frequent in the more malignant forms, and are almost always present in cases where the purpuric blotches are of large extent: these haemorrhages have occurred from the nose, uterus, bowels, kidneys, and ears in about the foregoing order of frequency. Gangrene is occa- sionally met with, and the cases in which it occurs are usually fatal. In some cases toes have been lost and the patient recovered ; the purpuric patches have also sloughed without serious danger to the patient's life. Diagnosis. — The disease is liable to bo con- founded with typhus fever on account of the petechial rash, but is distinguished from typhus by the rash appearing suddenly without any previous mottling of the skin. The nervous symp- toms also distinguish it from typhus, although in a case of typhus complicated with cerebro- spinal meningitis the diagnosis is extremely difficult, and may be impossible. It is distin- guished from purpura hamorrhagica by the in- tensity of the fever and the localised nervous symptoms. The malignant cases are more likely to be mistaken for malignant scarlatina than for any other disease, and must be distinguished therefrom by the rash, sore throat, and nervous affections. In some cases it has been indistin- guishable from malignant scarlatina, especially where death occurred within twenty-four hours, and both diseases were epidemic at the time. Prognosis, Duration, Termination, and Mortality. — The prognosis, duration, etc., of tha disease depend much upon the form the affection assumes, and for convenience we may divide the disease into the following forms; — 228 CEREBRO-SPINAL FEVER. 1st. Cases of a very mild form, terminating in recovery; the duration being usually from one to three weeks. 2nd. Cases of a very severe form, setting in suddenly; the symptoms being very violent and well marked, accompanied by purpuric spots and blotches, with a tendency to haemorrhages, with deep collapse and coma ; usually terminating fatally in from a few hours to three days. 3rd. Cases of medium severity, where all the nervous symptoms set in with less suddenness than in the second class of cases, purpuric blotches not being usually present, and no hae- morrhages. These usually yield to treatment, and terminate in recovery in from two to six weeks. 4th. Cases which set-in either in a mild or in a severe form, but in which on the subsidence of the fever the strength does not return, con- valescence is retarded or ceases altogether, and the patient falls into a general atrophic condi- tion, and usually dies in from three to six months of marasmus. By deciding to which of the above classes tire case belongs, the prognosis will be to a great extent determined. The chief indication of danger is the early appearance of purpuric and haemorrhagic conditions. The mortality in cerebro-spinal fever is very high — probably on an average about 60 per cent. In some of the American epidemics it is placed as high as 75 per cent. Among the Irish con- stabulary it roached 80 per cent. Like other epidemic diseases the mortality is highest at the commencement of the epidemic. It is most fatal about the age of twenty, and less so under fifteen years. Treatment. — The treatment in the early stage must be directed to recovering the patient from the collapse. This is best done by the application of heat, the administration of small quantities of stimulants or stimulating enomata, and the appli- cation of sinapisms over chest and back. In the next stage of the disease attention must be almost altogether directed to allaying the spinal irrita- tion, and promoting the absorption of tho effused matters. The extreme irritation will be best diminished by the use of bolladonna and bromide of potassium. The pain, which is extreme, will yield best to frequent and considerable doses of opium ; indeed many physicians rely altogether on opium as the curative agent. With a view of promoting absorption of the effused matters, mercury and. iodide of potassium have been chiefly relied upon. In the more sthenic cases calomel may be employed with benefit in small and repeated doses. The disease being usually of an asthenic type, mercury will seldom he well borne, and iodide of potassium should he pre- ferred. Leeches applied to the hack of the neck, behind the ears, or to the temples, produce great relief of the excessive pain in the head and upper part of tho spine. The application of ice to tho head and spine temporarily allays pain, hut there is little evidence of permanent benefit being derived therefrom. In prolonged cases blisters applied along the spine have been favourably spoken of. The local complications must he treated as they arise, and according to general principles applicable in each case. CHANCE OF LIFE. Stimulants are required in considerable quan- tity in a very large number of the cases which present adynamic symptoms. T. W. Grim. siiaw. CHALAZION (x°-^ a C a , hail). — A small en- cysted tumour of the eyelids, colourless and transparent, and resembling a hailstone. CHALK-STONES. — This name is applied to the deposits which are formed in connexion with the gouty diathesis, especially in the joints. They are thus denominated from their appear- ance and physical characters, in which they more or less resemble chalk ; hut in their chemical composition they are entirely different, consist- ing mainly of urate of soda. See Gout. CHALYBEATE WATER S (chalybs, steel ). — Mineral waters which contain iron. See Mineral Waters. CHANCRE (Fr. chancre). — Hard chancre is the initial manifestation of syphilis. See Syphilis. Soft chancre, see Venereal Disease. CHANGE OP LIFE. — Synon.: Climacteric epoch ; Sexual involution ; Fr. Menopause. Ger. Mcnstruationscnde. Definition. — The time of life in a woman when the functions of the uterus and ovaries cease, menstruation terminating, — a period when disease of these organs is especially prone to occur, and when various constitutional disturb- ances are almost certain to arise. Anatomical Characters. — Great changes oc- cur in the sexual organs — the ovaries lose their smooth outline, and after a while become shri- velled up, occasionally only a trace of them re- maining; the Fallopian tubes diminish in size, and sometimes become obliterated ; tho walls of the uterus atrophy, its cavity becomes much smaller, and the cervix disappears altogether. Symptoms. — The term ‘change of life’ is used among women very widely to signify every- thing which affects them at this critical time. It is so rare for the transition from activity to in- activity to take place without some disturbance locally, or constitutionally, that women are apt to neglect seeking advice for symptoms which should demand careful treatment, believing as they do that it is natural to suffer in such ways at ‘ the change.’ There is no fixed period- for the climacteric epoch, though roughly it may be said to occur between the ages of forty-five and fifty. Certain causes are apt to determine the time — amongst these are parturition and lacta- tion, febrile attacks, such as typhus or acute rheumatism, profuse haemorrhages, fright, ike. The symptoms vary much. In some women the change is abrupt, menstruation ceasing all at once after perfect regularity ; in others, and more frequently, the change is prolonged, the catamenia beiug irregular for many months, and varying as to periodicity and quantity. Frequently, after a long interval, a profuse flow with clots occurs, and this is very often attri- buted to a miscarriage. This loss is frequently beneficial, and if it do not take place, or relief he derived from vicarious discharges, such as bleedings from hsemorrhoids, the excess of blood gives rise to headaches, flushes, vertigo and a host of other unpleasant symptoms. The CHANGE OF LIFE. balance between the nervous and circulatory systems is upset ; irritability of temper, hyper- sensitiveness and all sorts of fancies arise, or de- pression sometimes amounting to melancholia en- sues. If germs of disease exist, the uterus is espe- cially prone at such time to develop them, so that carcinoma, fibroid disease, and polypus frequently present their first symptoms at this epoch. The importance, therefore, of an early examination cannot be too forcibly dwelt on, or the mischief of delay from considering the abnormal condition as typical of ‘ the change of life,’ as a natural consequence, which will therefore right itself. At these times pruritus of the vulva, vascular growths at the orifice of the urethra, and cuta- neous eruptions are especially likely to occur. There is a tendency to grow fat, and become coarse; frequently hairs appear on the face. The breasts often become very large and pendulous, and this with the increase in the size of the ab- domen from flatus, and the deposition of fat in its walls, together with the cessation of menstru- ation, not infrequently gives rise to the supposi- tion of pregnancy. To this imaginary state the term Pseudocyesis has been applied, and it is often almost impossible to set aside the opinion of the woman regarding her supposed condition. The headaches, neuralgia, loss of memory and nervous symptoms appear to be due to disturb- ance in the ganglionic system of nerves, with which the uterus and ovaries are largely sup- plied. If insanity arise the most common form 't assumes is hypochondriasis or melancholia. Treatment. — This must be directed to regu- lating the secretions. Generally constipation, previously troublesome, becomes aggravated ; and portal congestion frequently occurs. Saline pur- gatives are especially beneficial, and these may be judiciously administered in the form of mine- ral waters, such as the Hunyadi Janos, or Fried- richshall. Blue pill with aloes is often very useful. The headaches and reflex nervous symp- toms may be best combated by the administration of bromide of potassium, and this drug appears to act as a direct sedative to the sexual organs, besides diminishing the amount of blood deter- mined to them. Occasionally, bleeding from the arm or cupping gives great relief. Attention must above all be paid to the diet. It should be plain and unstimulating ; beer and spirits should be prohibited, and only light wines, if anj r , allowed. Tepid baths are useful. Late hours, heated rooms, and excitement of all kinds should be avoided. If local troubles arise, they must be treated ac- cording to their indications ; as a rule, abstracting blood from the uterus does harm, but leeches to the anus are sometimes beneficial. Ic is clearly impossible to map out any empirical line of treat- ment for a condition in which the symptoms are so variable. Clement Godson. CHAPPED NIPPLES. See Breast, Dis- eases of ; and Nipple, Diseases of. CHAPS. — Svnon. ; Rhagades. — Cracks or fissures of the skin occur where the integu- ment has become hardened by infiltration, as in the erythema of the hands and wvists of cold weather, in chronic eczema, psoriasis and lepra vulgaris. The treatment for chaps consists in CHELOID. 22!> protection from the atmosphere ; careful dry- ing after the hands have been washed or wetted ; and the use of zinc ointment and glycerine soap. Diluted glycerine, vaseline, and cold cream are also popular remedies. Erasmus ‘Wilson. CHELOID a claw).— Synon. : Chc- loides, Cheloma ; Fr. Dartre de la graisse ; Ger. Keloid. Definition. — A tumour of the skin resulting from over-growth of connective tissue within the corium. ^Etiology. — Cheloma may bo idiopathic or accidental, and in both cases it is referable to a diathesis. When of accidental origin it if commonly associated with a cicatrix, and is then developed in the midst of the cicatrix-tissue. This form of the tumour has been denominated cheloides spuria or traumatica, and, as such, has been seen scattered numerously over the chest and shoulders as a sequel of acne. The cause of cheloma must be sought for in that vital source from which is derived aberra- tion of nutrition in general. It is a consequence of feeble controlling power, and may be resident in the skin alone, or be dependent on a want of vigour of the constitution of the individual. The traumatic clieloid may follow a light as well as a severe injury of the skin, such as a boil, a blister, - a leech-bite, or even the ir- ritation of a stimulating liniment ; it is some- times met with in the scars of strumous abscesses or ulcers, but is most common in the cicatrices of burns or scalds. Anatomical Characters. — At its first de- velopment cheloma occupies the fibrous portion of the corium. As it increases in bulk it pushes the vascular layer outwards and stretches the corpus papillare, obliterating the capil- lary network, more or less completely. In its aggregate form when it presents itself as a flat plate, raised for a quarter of an inch above the level of the adjoining skin and sinking to a similar extent into the corium, it has the appear- ance of being tied down by strong cords or roots at either end, and frequently overlaps the healthy skin along its borders. In this state it is seen to be composed of strong fibrous bands closely interlaced with each other and enveloped by a smooth transparent pinkish layer, in which may be detected a scanty vascular plexus converging to venules which sink between the meshes of the fibrous structure. Around the circumference of one of these larger flattened tumours, such as is commonly met with on the sternum, and measuring several inches in diameter, there will generally be observed a few scattered knots. These are developed in the fibrous sheath of the arteries at a short distance from the mass, and, being thus linked to the central growth, are subsequently drawn into the focus of the tumour. And the development of the so-called roots is explained by the propagation of the proliferating process by the coats and sheaths of the blood-vessels communicating with the central tumour. Description. — Cheloid has received its name from its habit of throwing out spurs from its circumference, these spurs having been com- pared to crab’s claws. It originates in a round Z30 CHELOID. aval, or oblong tubercle or knot in the skin, and this may be followed by a second in its imme- diate neighbourhood, or sometimes by a cluster of three or four. When two of these knots are situ- ated at a short distance apart they are apt to become connected by a cord of the same structure as themselves, and to give rise to what has been called a cylindrical , club-shaped, or dumb-bell cheioid. When three or four knots are grouped near together they are disposed to become blended by growth and produce an oval or square-shaped cheioid ; and when the growth extends from these latter into the sur- rounding integument the appearance denominated radiciformis is established. Cheloma being due to a tendency to overgrowth or hyperplasia of connective tissue within the skin, it may appear on several parts of the integument at the same time, one of the most common seats of its development being the sternum, which it generally crosses transversely. It is often solitary; is more commonly composed of five or six tumours, discrete or confluent ; but has been met with occasionally to the number of fifty or sixty tubercles or more. Course and Prosnosis. — Cheioid rarely gives rise to much inconvenience or attains any con- siderable magnitude, and when left to itself progresses very slowly or remains stationary for a number of years or for life ; and we have known it to disappear spontaneously. Its sub- jective symptoms are cf no great severity, being limited to itching, tingling, and smarting, and more or less uneasiness in moving the limbs, or from pressure when sitting or lying in bed. It has no tendency to desquamation or ulcera- tion. Treatment. — Being dependent on a diathesis, surgical manipulation has generally proved un- availing in cheloma. It might be expected to recur in the cicatrix of a wound made for its removal, or in the scars of a suture employed to hold the cut edges together, and such has proved to be the case. The most successful treatment consists in covering up the tumour with a mercu- rial or iodine plaster, or even with simple em- plastrum plumbi. The writer’s favourite treat- ment is to paint it with a spirituous solution of soap and iodide of potassium, and then cover it with an adhesive plaster spread on washleather, repeating the application as often as the plaster becomes loosened. We have seen a multiple cheloma cured in this way ; aided by mild doses of the perchloride of mercury. The combination of warmth and moisture, such as is produced by a plaster, is an important element in the cure. But Irritants, caustics, and the knife are all equally objectionable and valueless. Erasmus Wilson. CHELTENHAM, in Gloucestershire. Common salt waters. See Mineral Waters. CHEMOSIS (x^U, a hole). — A swollen con- dition of the conjunctiva, caused by effusion into its tissue around the cornea, which thus appears as if placed in a hole or hollow. See Eye and its Appendages, Diseases of. CHEST, Diseases of the. — Following the plan adopted in the general article on the Abdo- CHEST, DISEASES OF THE. men, it is proposed in the first place to give ar outline of the diseases of the chest ; and then tc indicate the principal points bearing on the: . clinical investigation. General Summary. — The diseases of the thorax and its contents may be conveniently divided into certain groups, namely : — I. Diseases of the chest-walls, or extending inwards from these walls. II. Diseases of the respiratory apparatus con- tained within, the thorax, namely: — 1. Pleurae. 2. Trachea. 3. Main Bronchi, i. Lungs. III. Diseases connected with the circulatory system, including : — 1. Pericardium. 2. Heart. 3. Great vessels within the chest, both arteries and veins. IY. Diseases originating in the mediastinal cellular tissue. Y. Diseases of the absorbent vessels or glands within the chest ; of the thoracic duct ; and of the thymus gland or its remains. VI. Diseases of the oesophagus. VII. Diseases of either of the important nerves traversing the chest. Yin. Diseases of the diaphragm. IX. Diseases encroaching upon the chest from the abdomen or from the neck. The particular diseases comprehended within most of the groups just enumerated are very numerous, and they will be described under their respective articles. Affections connected with the chest constitute a large proportion ot the cases which come under observation in prac- tice. This will be readily understood when we remember that the thorax encloses organs essen- tial to life, which are never at rest, and which are constantly more or less exposed to influences liable to injure them. They may be mevefunc- tional disorders, and to these the heart is espe- cially prone ; but serious organic diseases are also exceedingly common, and rank very high as causes of death. Moreover, they may either come under the category of -local affections, though even then they frequently depend upon some cause acting through the general system, such as exposure to cold or wet ; or they arise in the course of some general malady. For instance, pulmonary com- plications are of common occurrence in connexion with fevers and various other diseases; the heart is implicated in a large proportion of cases of rheumatic fever ; and malignant disease is not infrequently manifested by a local development of cancer in connexion with certain of the thoracic contents. The structures within the chest have an important mutual influence upon each other ; and they may also be affected, either directly or indirectly, by local diseases involving other parts of the body, such as the abdomen or the central nervous system. Clinical Investigation. — It may be confi- dently affirmed, that the means which we now possess for investigating diseases connected with the chest are so adequate and precise, that any one possessing the requisite knowledge and skill, and who carries out the clinical examination pro- perly, can, in the very large majority of cases, arrive at a diagnosis with certainty and accuracy. At the same time it must be remembered that every complaint, referred to this region, however trivial it may appear to be, does require system- CHEST, DISEASES OF THE. atic and thorough investigation, otherwise very Bei'ious mistakes are constantly liable to be made. Of course, cases also do come under observation occasionally which are obscure, and which may call for repeated examination before a correct diagnosis can be formed; and exceptional in- stances occur in which no satisfactory conclusion can be arrived at. The previous general history of the patient, the hereditary history, and the account of the origin and progress of the illness, often afford signal aid in the investigation of chest-affections, and ought never to be overlooked. The symptoms to which these affections give rise are necessarily various. Pain or other morbid sensations are veiy commonly complained of, but only in a comparatively few instances are these at all significant, and they can never be posi- tively relied upon in making a diagnosis, while they are often absent in diseases of the most serious character. The important organs, namely, the lungs and heart, usually present more or less disturbance of their functions when they are affected, but grave diseases may exist without any such disturbance. The different structures within the chest have a mutual influence upon each other, and thus other symptoms besides those connected with the structure actually diseased may be apparent. For instance, the lungs and heart are thus very intimately associated ; while aneurisms or growths often disturb these organs seriously, or interfere with the air-tubes, nerves, veins, and other structures. In consequence of more or less interference with the circulation, various symptoms in parts remote from the chest are frequently originated ; and distant organs may become the seat of organic lesions as the result of long-continued mechanical conges- tion, a new train of symptoms being thus setup. The general system may be in this manner af- fected ; whilst pyrexia, wasting, and other general symptoms are often associated with cliest-diseases. Lastly, morbid conditions within the thorax may directly affect the abdominal organs ; or may make their way through the diaphragm into the abdominal cavity. Physical Examination constitutes an essential and most important part of the clinical investiga- tion of the chest and its contents. Indeed, with- out this examination no certain and exact diag- nosis can ever be made. This subject is fully discussed in other appropriate articles, and here it need only be mentioned that the methods of examination which are usually required, and which should in every case be practised, are: — 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. Other modes which may be called for include: — 5. Measurement (not uncommonly). 6. Succession. 7- The use of special instruments, directed to the investigation of particular organs, such as the spirometer, cardiograph, sphygmo- graph, aspirateur, oesophageal bougie, &c. See Physical Examination, arid Diseases of the several organs. Frederick T. Eobeets. CHEST, Examination of. See Physical Examination. CHE ST- WALLS, Morbid Conditions of. —The walls of the chest may he the seat of Various morbid conditions, and the affections CHEST-WALLS. 231 of tills portion of the framework of the body de- mand more attention than they are accustomed to receive. All that can be done "within the limits of this article is to indicate their nature ; to notice briefly such of them as are not de- scribed in other parts of this volume ; and to point out the principles of treatment. They may be considered according to the following arrange- ment : — 1. Superficial Affections. — Under this group may be included morbid conditions of the skin and. subcutaneous tissues, a. Cutaneous erup- tions are of common occurrence over the chest. Among these may be specially mentioned the eruptions of the exanthemata, herpes zoster, and chloasma, b. The superficial vessels are liable to become enlarged under certain circumstances. This enlargement is usually seen in the veins over the front of the thorax, which may be distended on both sides, or only on one side, or in sonio particular region. The larger divisions may alone appear to be involved ; or a more or less exten- sive network of smaller veins may he visible, and occasionally even the capillaries seem to he im- plicated. This condition generally arises from some obstruction interfering with the circulation through one or other of the principal veins wdiich. either directly or indirectly, receive the blood from the veins of the thoracic wall. Thus the superior vena cava, or either innominate, sub- clavian, or axillary may be implicated, being, for example, pressed upon by new growths or en- larged glands, the distribution and extent of the venous distension varying accordingly. Occasion- ally one of the smaller veins is thus interfered ■with. The writer has met with cases in which considerable enlargement of the veins was visible over portions of the thorax, where the cause was by no means evident, the patients asserting that this condition had existed ever since they could re- member, and being regarded by them as perfectly normal. Probably it has resulted from some local obstruction occurring during early life. It must he remembered that women who are suckling frequently present great enlargement of the su- perficial veins over the front of the chest, which usually subsides when the period of lactation is at an end. Again, more or less venous and capil- lary engorgement in this region may occasionally be observed in cases of cardiac or pulmonary disease, where the general circulation is much im- peded, and due aeration of the blood is interfered with. Sometimes a ring of enlarged veins and capillaries is seen around the lower part of the chest. When the venous distension is due to ob- struction of the vena cava superior, the skin may present a more or less marked cyanotic tint, and in cases of general cyanosis, the chest, in common with other parts, has a cyanotic appearance. Occasionally one or other of the small arteries which supply the thoracic walls is enlarged, and it may attain a considerable size. c. Subcutaneous oedema is sometimes observed over the chest. In most instances this is a local condition, being the result of venous obstruction ; but it may ho a part of general dropsy, particularly in connexior with renal disease. This morbid state is evident on inspection or to the touch, and the affected part pits on pressure. d. The subcutaneous tissue of the therax is also liable to become the seat o£ 232 CHEST-WALLS, MORBID CONDITIONS OF so-called emphysema, as the result of perforation or rupture of the lung and pleura, with the consequent escape of air into the cellular tissue tinder the skin, where it accumulates, and travels to a greater or less extent over the body. The lung may also give way into the mediastinum, the air which escapes subsequently making its way from this part into the subcutaneous tissue. This condition is generally due to direct injury, especially from fractured ribs, but it may also arise, in exceptional instances, from other causes, such as violent cough, powerful expiratory efforts, as in parturition, pulmonary disease — for in- stance, the giving way of a cavity in the lung — or in connexion with empysema. Subcutaneous em- physema is attended with evident swelling of the part, which may be very great, all the normal ana- tomical outlines being obliterated ; the peculiar sensation accompanying this condition is readily elicited on palpation and percussion ; the percus- sion sound is tympanitic ; and on auscultation a superficial crackling sound is heard, e. As be- longing to the superficial affections connected with the chest may be just mentioned diseases of the mammary gland or nipple, which of course constitute a most important class of diseases in females (see Breast, Diseases of). 2. Muscular and Tendinous Affections. — a. The muscles of the chest or their tendinous attachments may be the seat of certain painful affections. These are of the nature of so-called muscular rheumatism or myalgia, of inflamma- tion, or of more or less injury or strain ; being induced by cold, constitutional conditions such as gout, overwork, straining, violent coughing, fatigue from prolonged sitting, and other causes. The painful condition is usually localized, but different muscles are involved in different cases, sometimes those which are superficial being affected, in othors the deeper muscles including the intercostals ; or the complaint may be confined to a single muscle. Pleurodynia, dorsodynia, and scapulodynia are the terms applied to muscular rheumatism affecting the side of the chest, the upper part of the back, and the scapular regions respectively. As the result of severe coughing, muscular pains are very common around the lower part of the chest. The pain is usually more or less aching in character, and not severe, but it may be very intense, especially in acute cases. Whatever brings the affected muscles into play aggravates the suffering, such as moving the arms or shoulders when the superficial muscles are affected, coughing, sneezing, and similar actions. In some instances the pain is not felt when the affected structures are kept quite at rest. There may be local tenderness on pressure, or diffused pressure may give relief ; while posture often influences the sensations experienced, such as whether tho patient assumes the recumbent or sitting posture, or lies on one or other side. Fatigue generally increases the pain. Muscular affections connected with the chest are not neces- sarily accompanied with any other local symp- toms ; and physical examination reveals nothing, except that perhaps the act of breathing is volun- tarily restrained, on account of the pain thus in- duced. b. Themusclesofthechestmay beaffected, on the one hand, with spasm or cramp ; on the other, with paralysis. The former is attended with more or less pain, which may be very severe ; the latter is indicated by loss of power in the muscles involved. These disorders gene- rally depend on some lesion of the central ner- vous system, but may result from local nerve- disease. In cases of hemiplegia from cerebral mischief, the muscles of the thorax on tho affected side are often temporarily weakened, but they usually subsequently regain their power. When the upper part of the spinal cord is injured or diseased at a certain point, all the muscles of the chest become paralysed, which is a very serious matter, as respiration and the acts connected therewith cannot be carried on, except by the diaphragm, and consequently the blood is imperfectly aerated, secretions accu- mulate in the lungs, and the patient dies from suffocation, c. Atrophy or degeneration may involve the thoracic muscles. In cases of pul monary phthisis either the whole of these muscles or certain of them are not uncommonly wasted out of proportion to the general emacia- tion. These muscles may also be more or less implicated in progressive muscular atrophy, and occasionally a single muscle undergoes marked wasting. The writer has seen a striking example of this local atrophy in connection with the peetoralis major, but the serratus magnus or other muscles may be implicated. The wasting is probably in most eases due to disease of the nerves supplying the affected muscles. It is quite evident on examination, and the movements which are usually performed by the involved structures cannot be executed properly, d. On the other hand, the chest-muscles may become hypertrophied. This may be a natural result of training ; or it may occur in consequence of their being called upon, either habitually or at intervals, to act excessively, as in cases of emphysema or asthma. In exceptional in- stances the condition known as pseudo-hyper- trophic muscular paralysis has extended up to the chest, c. The thoracic muscles occasionally present marked irritability under percussion or friction. This has been regarded as an impor- tant sign of phthisis ; but the writer has only observed it in a comparatively few instances of this disease, and has found it equally if not more evident in cases where the lungs were perfectly healthy, f. As the result of injury and other causes, some portion of the muscular structures of the chest may be lacerated, ruptured, or per- forated, either alone or along with other struc- tures. This condition will be further alluded to presently. 3. Nervous Affections. — a. Neuralgia is very common in different parts of the chest, especially in the side, and particularly the left side — intercostal neuralgia. The pain is loca- lised, being usually referred to a point where a branch of nerve becomes superficial. It is more or less constant, but subject to exacerbations, in some cases being very severe at times. It may be increased by deep breathing or coughing, but is not, as a rule, so much affected by theso and similar actions as are other painful chest-affec- tions. Shooting and darting sensations often radiate from the principal point, and certain spots of tenderness — points douloureux — may be recognised in many cases ( sec Lntkhcostai CHRST-WALLS, MORBID CONDITIONS OF. 233 Neuralgia), b. Intercostal neuritis is occasion- ally met with, and this affection is attended with great pain, localised and radiating, with much tenderness, the suffering being aggravated by whatever causes any local disturbance. It is probable that the severe pains experienced in some instances where the complaint is sup- posed to be muscular, are due to branches of nerve being in an inflammatory condition, c. Some individuals, especially females, exhibit a remarkable superficial tenderness over the thorax or in parts of this region, especially the anterior and upper portions. The slightest touch is resented, and the most delicate percus- sion cannot be borne. This condition may exist without any actual disease, or it is sometimes observed in phthisical cases, d. Sensation may be more or less impaired over the chest, or in limited portions, either in connexion with central or local nervous disease, or in hysterical and nervous persons. Various paraesthesiee are also frequently referred to this region by the class of individuals just mentioned. 4. Diseases of the Bones or Cartilages. — The morbid conditions which may be referred to the bony and cartilaginous framework of the thorax are as follows : — a. There may be undue rigidity and firmness of the chest-walls, owing to an excessive deposit of calcareous matter in the sternum and ribs, with ossification or petri- faction of the cartilages. This is a normal con- dition in old people, being one of the degenera- tive changes to which they are liable, but it may also occur in younger individuals, as the result of hard work, or in connexion with certain pulmonary diseases. This state of rigidity interferes more or less with the respiratory movements, and not infrequently causes serious embarrassment, b. On the other hand, the ribs and cartilages may be deficient in firmness, and consequently too yielding and elastic. This is observed in children and young persons who are ill-nourished, and it becomes a condition of great moment when any disease sets in which causes obstruction to the entrance of air into the lungs, such as bronchitis. The chest-walls are then liable to fall in more or less during the act of inspiration, and may become permanently deformed, the pigeon-breast and other abnormal forms of thorax being thus originated. In rickety children the vicinity of the junction of the ribs with their cartilages is the most yield- ing part of the chest, where nodular thickenings may often be felt, and in such subjects this is the portion of the thoracic wall which is most liable to fall in. c. Acute or chronic periostitis or perichondritis is sometimes observed in con- nexion, respectively, with the sternum or ribs, or with the cartilages. The acute affection gives rise to much pain and tenderness, which may be accompanied with superficial redness and swelling, and may simulate some more serious disease. The chronic complaint usually assumes the form of a node, being the result of syphilis. The writer has occasionally observed a small swelling at the junction of one of the ribs with its cartilage, painless, unaccompanied with red- ness, but presenting distinct fluctuation, d. The bony and cartilaginous structures them- colves may be the seat of disease in some part of the chest, and here must be included the portion of the spinal column which limits this region posteriorly. Thus there may be acute inflam- mation, caries, necrosis, or so-called scrofulous disease. Among the more important causes which are liable to originate these conditions may be mentioned injury, syphilis, scrofula, empyaema opening externally, and thoracic tu- mours or aneurisms growing outwards. They may lead to serious consequences, both local and general, and frequently cause more or less deformity of the chest, e. Permanent thicken- ing and distortion of portions of the ribs are sometimes observed after fractures which have united improperly. 5. Inflammation and Abscess. — It is ex- pedient to make a separate group of those cases in which inflammation, resulting in the formation of one or more abscesses, occurs in some portion of the soft structures entering into the construc- tion of the chest-walls. This may be of local origin, arising from injury, bone-disease, or other causes ; or it may be due to the opening of an empyaema into the tissues ; to suppuration ex- tending and burrowing from the axilla or other parts ; or to pyaemia. . If deep-seated, an abscess may be difficult to detect with certainty, but usually the signs of this condition become sufficiently obvious. Sinuses or fistulee may be left as a consequence of suppuration in the chest-wall, especially when pus makes its way outwards from within. 6. Tumours and New-Growths. — These morbid conditions also demand separate notice. They may be connected with any of the struc- tures of the chest- walls, and are of various kinds ; among those which have come under the writer's notice may be mentioned molluscum, fatty growths, cystic tumours, enlarged sebaceous glands, and infiltrated carcinoma. Tumours may make their way inwards from the chest- walls, encroaching upon the cavity of the thorax ; or, on the other hand, the walls may be involved by growths from within. It need scarcely be mentioned that mammary tumours constitute a distinct, and by far the most important group associated with the structures covering the chest. See Breast, Diseases of. 7. Perforations and Ruptures. — The mus- cular structures of the thoracic wall may be more or less destroyed in some part either by sudden rupture or gradually, allowing a hernial protrusion of the lung to take place between the ribs. As already noticed, empysema may make its way outwards through the chest-wall. Aneu- risms and tumours extending outwards from within the thorax frequently cause serious de- struction of the tissues, including the bony and cartilaginous, as well as the soft structures. This destructive process is often attended with severe pain and suffering, and leads to grave mischief. 8. Variations in Form and Size. — The chest often presents deviations from the normal shape and size, and these are so important that they demand separate consideration. See De- formities of Chest. Treatment. — In many cases where the chest walls are in a morbid state, they either do imt need any special treatment, or no treatment can 231 CREST-WALLS, be of avail. The chief circumstances under which the practitioner may be called upon to interfere, and the measures to be adopted, may be briefly indicated as follows : — - a. Painful affections of the chest-walls, de- pending upon conditions of the muscles or nerves, frequently demand local applications for their relief. Thus in different cases it may be requisite to employ hot fomentations, dry heat, or cold applications, in the form of wet rags frequently changed, ice, or evaporating lo- tions; or to use anodyne applications of various kinds, such as belladonna plaster or liniment, opium plaster or a liniment containing laudanum, oleate of morphia, tincture of aconite or ointment of aconitine, or veratria ointment. Anodynes may also sometimes be added to fomentations with advantage. Priction is often of much ser- vice, and at the same time stimulating liniments may be employed, such as one containing cam- phor, chloroform, or turpentine. For ill-defined muscular pains about the chest, which are fre- quently complained of, free douching with cold water every morning, followed by friction with a rough towel, is often highly efficacious. When paiu is localised and obstinate, much benefit may be derived from the application of a sinapism, mustard-leaf, or even a small blister. In other cases the use of tile ether-spray is serviceable, repeated more or less frequently; or sometimes much relief may be obtained from applying over a painful spot a mixture of equal parts of chloro- form and belladonna liniment. Galvanism is another agent which may be of the greatest ser- vice in relieving painful sensations about the chest, whether connected with the muscles or nerves. Subcutaneous injections of hot water, morphia, or atropine may be demanded in some cases, and constitute a most valuable mode of treatment if pain cannot otherwise bo assuaged. In the treatment of many painful affections of the chest-walls much assistanse may be derived from attention to posture, especially in connec- tion with certain occupations; from the avoidance of undue fatigue, or of any violent actions which are known to influence this part, such as cough ; and from the adoption of measures tending to support the structures, or to keep them in a state of rest. The writer has found great benefit in a large number of instances from strapping the side more or less extensively, in the manner advocated by him for the- treatment of pleurisy; and if there is any localised pain, some limited anodyne application, such as a piece of belladonna plaster, may be placed over this spot under the strapping. b. In many affections of the chest-walls, treat- ment directed to the general system, or to some special constitutional condition, is often of the greatest service. Thus, in the painful complaints already noticed, there are frequently marked gene- ral debility and anaemia ; and. essential benefit is derived from the administration of quinine, pre- parations of iron, strychnine, cod-liver oil, pre- parations of phosphorus, and other tonic medi- cines, or such as improve nutrition. Some of these are also most useful when there is disease of bone and its consequences. Again, certain af- fections of the thoracic wall may be associated with rheumatism, gout, ©r syphilis, and then the CHICKEN-FOX. particular treatment indicated for each of thes? several conditions is called for. c. When disorders of the muscles of the chcst- walls occur, such as paralysis or spasm, asso- ciated with some disease of the central nervous system, the treatment must usually be directed to this disease, and but little can be done for the local disturbance. In some instances, however, electrical or other modes of treatment may be of some service, by influencing the action of the muscles, but no definite rules can be laid down. d. Local inflammations in connection with the thoracic walls must be treated as in other parts of the body, and it is unnecessary to discuss this subject in the present article. e. Surgical treatment maybe called for under certain circumstances. Of course this will be the case if the chest-walls are injured in any way. Among other conditions likely to demand sur- gical interference may be specially mentioned subcutaneous emphysema, abscesses, disease of the bones, and tumours. Frederick T. Roberts. CHEST-WALLS, Deformities of. See Deformities of Ciiest. CHICKEN-iPOX. — Svxox. : Varicella; Fr. La Varicelle ; Ger. Wasscrpocken. Definition. — A specific infectious febrile disease, characterised by the appearance, in suc- cessive crops, of red spots, which in the course of about a week pass through the stages of pimple, vesicle, and scab. 2Etiology. — The origin of this disorder is un- known. It is certain that it arises from con- tagion, and that childhood is its predisposing cause. It occurs in children at the breast, and is seen with increased frequency up to the fourth year, at which period it attains its maximum. It is less often found between four and twelve, and after twelve it may ho said to disappear, although it is occasionally seen in adults. Symptoms — The illness commences without any, or with but slightly-marked premonitories. There is usually, however, some feeling of lassi- tude, and the patient goes to bed earlier than usual. Within a few hours an eruption appears, usually on some part of the back or chest, but there are many exceptions to this rule. It may commence on the face, neck, chest, abdomen, or extremities, or upon several of these parts at the same time. The eruption consists of small, faintly papular rose-spots, varying in number from twenty to one or two hundred. These, in the course of eight, t welve, or, at the most, twenty- four hours from their appearance, change into vesicles, which, at first small in size and clear as to their conients, become quicklj’ large ; globular, or semi-ovoid iu form ; translucent, glistening, and opalescent in appearance ; and surrouuded with a faint areola. Towards the end of the. second day of illness, the vesicles attain complete development, and about this time a few may bo seen on the sides of the tongue, on the lip-, cheeks, or palate, and sometimes upion the mucous membrane of the genitals. About the third dav a few of the vesicles may have a pustular appear- ance, and sometimes a few pustules are seen : Inn. regarding the eruption as a whole, pustulatiou forms an incident rather than an essential feature CHICKEN-POX. in its progress. On the fourth day the vesicles begin to dry up, and by the sixth complete scabs are formed. These fall off in a few days, leaving in their place faintly red spots, and sometimes a few pits. A single crop of the eruption may be said to complete itself in five or six days ; and, as two or three crops appear on as many successive days, the illness will last rather more than a week. In the event, however, of there being four or five crops, it may be pro- longed for another week, but this is unusual. With the appearance of the eruption, the tem- perature rises two, three, or even more degrees, and this rise recurs with each successive crop of spots. The pulse is sometimes slightly increased in frequency ; the tongue is moist, and sometimes covered with a light fur. As a rule, however, there is but little constitutional disturbance, although it is occasionally severe. Pathology. — Chicken-pox is due to the re- ception of a specific poison, which after an incu- bation of about thirteen days, shows itself by an eruption upon the skin. What this poison is, how it enters the body, and what, if any, changes it produces upon the internal organs, the present state of our knowledge does not enable us to say. It affects the same individual once only, aud it is perfectly distinct from modified small- pox, as the following considerations will show: — 1. Chicken-pox is characterised by the rapidity *vith which it runs through its stages; modified small-pox, on the contrary, is characterised by an interruption in the course of the disease at one or other of three points — the papular, the vesicular, or the pustular. 2. The chicken-pox eruption attains complete development by the end of the third day; in modified small-pox, should the eruption attain complete develop- ment, this will not occur before the ninth day, however much the disease may be modified. 3. In modified small-pox the premonitory symptoms are usually well-marked, often quite as severe as in the natural disease, and these last forty-eight hours, after which there is an eruption of small hard papules on the forehead, face and wrists, fol- lowed by a fall of temperature. In chicken-pox the premonitories are most often wanting, and when present are slightly marked, and the erup- tion is followed by a rise in the temperature. It appears, moreover, upon any part of the body in- discriminately, and less frequently on the face than on other parts; and within a few hours — at the most within twenty-four— it has become vesicular; whereas in modified small-pox the vesicular stage is only reached forty-eight hours after the appear- ance of eruption. 4. The vesicles of chicken-pox are globular or ovoid in form, without any central depression ; glistening or translucent in appear- ance; and unicellular in structure. They collapse on pricking, and attain their maximum develop- ment in from twelve to eighteen hours. Modified and natural small-poxvesicles are flat and circu- lar in form, always depressed in the centre, and sometimes umbilicated, of an opaque dirty white colour, and multicellular in structure. They do not collapse on pricking, and attain their maximum development at the end of the third day from their origin. 5. Small-pox is an inoculable affection ; chicken-pox, according to reliable authority, is not. G. When cases arise CHIGOE. 235 which all recognise to be modified small-pox, they are always accompanied by others which are more severe ; and in epidemics these latter gradually become more numerous up to a point of maximum intensity, when they decline and the modified forms reappear. In chicken-pox there is no such gradual increase in the intensity of illness, and neither serious nor fatal cases form part of its epidemics, which prevail indepen- dently of small-pox. 7. Small-pox and vaccinia are often early followed, in the same individual, say within two or three years, by chicken-pox, and vice versa. 8. Chicken-pox, vaccinia, and small-pox have been known to follow in imme- diate succession in the same individual. Course, Terminations, SeqPeije. — Varicelh always runs a favourable course, invariably ter- minates in recovery, and has no sequeke. Diagnosis. — It should be borne in mind that a sure diagnosis cannot bemade in less than forty- eight hours. The appearance, however, of a crop of vesicles, followed on the next day by a second crop, points almost certainly to chicken-pox. Attention to this, and to the points noted under the head of pathology, ought to make the diagnosis easy. Prognosis. — This, as has been indicated above, is always favourable. Treatment. — The treatment of chicken-pox consists in confining the patient to his room, or in the more marked cases to his bed, for one or two days; and in the administration of light, unstimulating food. Although no physician has recorded a fatal case of chicken-pox, a child whose temperature may be three, four, or six degrees above the normal, should be watched with care. Alex. Collie. CHIGOE. — Description. — The Chigoe is a minute parasitic insect, common in the West Indies and northern parts of South America. It is also popularly known as the Jigger or Sandflca. Though formerly regarded as an acarus or mite, it is now generally recognised as a true flea be- longing to the genus Pulex ( P . penetrans) ; but several entomologists have advanced solid reasons for separating it from the ordinary fleas. Thus Westwood terms it the flesh-flea, or Sarcopsylla penetrans, whilst Guerin formed the genus Dcrmatophilus for its reception. Practically, these distinctions are of little moment. The Chigoo ordinarily lives in dry and sandy situations, where it multiplies to a prodigious extent. It attacks, however, the feet, chiefly underneath the nails and between the toes ; the impregnated females burying themselves beneath the skin. Here the abdomen of the parasite swells to the size of a pea; and, unless removed by operation, gives rise to acute local inflamma- tion, terminating in suppuration and sometimes in extensive ulceration, with even fatal results to the patient. Dogs also suffer excruciating torment from the bites and immigration of the Bicho do Cachorro, which, however Pokl and Kollar regard as distinct from the human jigger ( Bicho depe). Be that anew correct or not, it would appear from the observations of Kodschild and Westwood that the larvae of the human chigoe aro hatched in the open wounds or ulcers, which some- times extend inwards so as to involve the bones 236 CHIGOE. . Ihemselves. In bad cases amputation of the toes and adjacent parts becomes necessary. Left to themselves, the larvae escape from their host, and probably, after the manner of bots and other parasitic insects, penetrate the soil for the pur- pose of acquiring the pupal stage of growth. Treatment. — As regards treatment, the in- dications are simple. The parasite should bo removed with the utmost care. Where this has not been done, and where, as a conse- quence, open sores exist, frequent washings with tepid water, followed by the application of car- bolic acid lotions (twenty or thirty grains to the ounce), or of ointments (one drachm to one ounce of benzoated lard) will be found most suitable. Or, again, the carbolic acid putty, as sold in shops, or the application of one part of the acid previously mixed with ten or twelve parts of simple olive oil, will, in all likelihood, bo suffi- cient to cause the destruction of any larva; that might remain. In European practice cases of jigger are rarely seen; nevertheless the writer has recorded an instance in which strong men- tal delusions followed the torture produced by these creatures (Worms, p. 141). The pa- tient, a middle-aged married lady, had suffered severely during her residence in the West Indies. Although she had got rid of the parasites, she constantly harpooned her own feet in the hope of destroying the young jiggers which she felt sure were still burrowing beneath the skin. Lastly, it seems almost needless to say that residents and travellers in Guiana, Brazil, and in the West Indies generally, should have their feet properly protected. T. S. Cobboij). CHILBLAIN. — Synon. : Kibe ; Pernio ; Er. Engelure-, Ger. Frostbenle. Definition.— -A state of inflammation of a part of the skin induced by cold. .ZEtiology. — Chilblains are common in children and young persons, and are more frequent in girls than in boys. They occur chiefly in those of a lymphatic constitution, and may be considered as an indication of debility and deficient vital power. In adult age they are rare, and are only met with when the powers of the constitution are reduced. Their occurrence is influenced more by the strength of the individual than by the degree of cold, and they continue in some persons throughout the entire year. Their tendency is to cease with the full development of the organism, and they reappear occasionally in advanced life. Description. — The regions of the body usually affected with chilblain are the feet and hands, to which are sometimes added the ears and nose. A chilblain presents three stages or degrees of severity, namely, erythematous, bullous, and gan- grenous ; and it may be arrested at the first or second stage by the withdrawal of the cause. The erythematous stage is restricted to hypermmia, swelling, and severe burning and itching, the itching being increased by heat, as by that of the fire or that induced by exercise. The congested spot is circular in figure, somewhat tumid, brightly red at first, but later on roseate crimson, purple, or livid in colour. The second or bullous stage exhibits the blain or blister re- sulting from effusion of serum beneath the cuticle; the permanent colour of the swelling is CHLOROSIS. now purple or livid, and the contents of the blister a limpid serum, generally reddened with blood ; sometimes, indeed, the fluid of the blister may be semi-purulent. In the gangrenous stage the blister is broken, the surface of the derma is in a state of gangrene, and the gangrenous layer is subsequently removed as a slough by ulceration. Treatment. — The treatment of chilblain re- quires to be modified to suit its different degrees. In the first, the indication is to restore normal circulation by gentle friction, and, when the part is severely chilled, it is usual to rub it with snow ; then some soothing liniment may be employed ; and, finally, a stimulating liniment, covering the part afterwards with zinc ointment and cotton wool, or shielding it with lead or opium plaster spread on washleather. The lini- ments most in favour for this purpose are tho soap liniment with chloroform, the compound camphor liniment, the turpentine liniment, and the linimentum iodi. In the bullous stage a similar treatment may be used to the erythema- tous portions, whilst the blister should bo snipped and the broken surface pencilled with the compound tincture of benzoin, and afterwards dressed with unguentum resinte or an ointment of Peruvian balsam. In the third stage the erythematous phenomena still require attention, and the ulcer should be dressed with unguentum resinae, either alone, or in combination with spirits of turpentine. To obviate constitutional debility, the diet should be nutritious and generous, and recourse may be had to tonic remedies, such as iron and quinine. Erasmus Wilson. CHILL. — A subjective sensation of cold- ness, accompanied with shivering, and most frequently experienced in connexion with febrile or inflammatory diseases, in nervous individuals, and after exposure to cold and wet. In popular language ‘ taking a chill ’ is used as synonymous with ‘ catching a cold.’ See Rigor. CHIN-COUGH. — A synonym for whooping- cough. See Whooping Cough. CHIRAGRA (xel p, the hand, and &ypa, a seizure). — Gout in the hand. See Gout. CHLOASMA (\\ia, a green herb). — Synon.: Liverspot. hr. Ephelide ; Ger. Leber jkek. A pigmentary discolouration of the skin, of a yellowish brown or liver-colour tint, occurring in blotches, and due to constitutional causes. Its synonym, ephclis gravidarum, indicates its occasional association with pregnancy. See Pigmentary Skin Diseases. Erasmus Wilson. CELOHAL, Poisoning by. See Antidote CHLOROFORM, Use of. See Anaesthetics. CHLOROSIS (x^upbs, green or sallow - ). Synon.: Green-sickness; hr. La chlorosc ; Ger Chlorose ; Bleichsucht. Definition. — A variety of amemia occurrirg in a peculiar diathesis or habit of body, which is characterised by deficient growth of the cor- puscular elements of the blood, and of the vas cular system. CHLOROSIS. The subjects of this diathesis are said to be :hlorotic. They ordinarily enjoy good health, unless exposed to any of the causes of anaemia, when they speedily suffer from aglobulism ; and this aglobulism may proceed to complete anaemia. The term chlorosis is properly applied to the first and simpler form of anaemia in these sub- jects; while the second and more complex con- dition is designated cldor-anxmia ; or, more commonly, anemia (see Anosmia). ^Etiology. — Chlorosis occurs almost without exception in young women about the time of puberty, but is found occasionally in children and married women, and, very rarely, even in men. It is believed to be more common in the higher ranks of life. Beyond these predisposing causes, however, the very origin of the disease lies in a peculiar condition of the blood and blood-vessels, to be presently described, which is believed to be congenital, and perhaps heredi- tary. In such subjects, and under the preceding circumstances, any of the numerous causes of anaemia may be sufficient to excite the appear- ance of chlorotic symptoms, but those which do so most commonly are sexual development, the establishment of menstruation and its disorders, and an insufficient supply of light to the circu- lating blood. Anatomical and Chemical Characters. — The blood in chlorosis presents three definite and distinct imperfections. First, the total quantity of blood is below the normal, though there may be an excess in relation to the calibre of the vessels (plethora ad vasa). Secondly, both red and white corpuscles are deficient in num- bers, and that proportionately. Thirdly, the individual red corpuscle contains less than the normal amount of haemoglobin, and this defi- ciency may be so great that the total amount of haemoglobin in the blood is reduced to one- fourth. It is an important negative fact that in pure chlorosis the quality of the liquor san- guinis is unchanged. With this condition of blood there are asso- ciated remarkable abnormalities of the aorta and arterial system generally. The most strik- ing of these is a hypoplasia, or dwarfed condi- tion of the aorta, represented by small calibre, increased elasticity, anomalous origin of the branches, and unequal thickness of the intima. Along with these there may bo found — probably as a consequence of the preceding — fatty meta- morphosis of the intima, and enlargement of the heart, with traces of endocarditis. The blood-glands and lymphatic structures are not diseased. The condition of the ovaries and uterus has been carefully examined in chlorosis and found to vary extremely. In some cases the generative organs are described as ‘ infantile,’ while in others they are either immoderately developed, or perfectly normal in every respect. Corresponding with the aglobulism, the sub- cutaneous fat is abundant; and the viscera present various degrees of fatty metamorphosis. When the eardio-vascular changes are marked and advanced, there may be extensive secondary disease throughout the body. Symptoms. — The symptoms of simple chlorosis are those of mild anaemia, with certain impor- tant differences, which become fewer and less 237 marked and finally disappear as chlorosis ad- vances to the more serious disease. The appear- ance of the chlorotic girl is peculiar, inasmuch as the pallor of her complexion is accompanied by natural or even increased fulness, from the excess of subcutaneous fat. At the same time the colour of the skin is so remarkable as to have given the name to the disease, the general hue being decidedly yellow. In blondes the transparency of the skin is increased ; in bru- nettes it is diminished, and a dull yellowish- grey colour of skin is the result, which, in con- trast with the greyish-blue of the eyelids, may appear of a sickly green. The patient’s usual complaint is of this alteration of colour, menstrual disorder, de- bility, great breathlessness, cardiac symptoms, and various pains. The menstrual symptoms are always prominent, namely amenorrhcea or menorrhagia, and leucorrhoea. Breathlessness on exertion is one of the most striking symp- toms. The cardiac symptoms and the cardiac and vascular signs closely resemble those of ansemia. But there is this important difference in the phenomena connected with the heart, that in many cases of chlorosis they indicate enlarge- ment, and especially hypertrophy of the left ventricle. The digestive and nervous systems are frequently very seriously deranged. The urine is abundant, watery, and pale. There is no dropsy in simple, uncomplicated chlorosis. Optic neuritis may occur. The chlorotic diathesis may be recognized by the following characters, which are variously asso- ciated in different cases : — Diminutive stature ; im- perfect sexual development ; a history of peculiar anaemia in childhood, of anaemia with menstrual irregularity at puberty, and of previous attacks of symptoms of chlorosis ; evidence of cardiac enlargement or mitral disease in the absence of all the ordinary causes of these; the occurrence of endocarditis during pregnancy or post partam; and the presence of any of the diseases which will be referred to under the head of com- plications. Course, Duration, and Terminations. — The commencement of chlorosis is generally gra- dual, but may be sudden. Its ordinary course is towards confirmed ansemia, in which it may ter- minate, the liquor sanguinis becoming affected, and wasting and cedema being added to the previous symptoms, which are also aggravated. It is for this reason that pure chlorosis is a rare disease, while ansemia associated with the chlo- rotic diathesis is comparatively common. — The duration of the disease is variable ; it rarely declines until the determining circumstances have been removed, and the patient subjected to careful treatment. Chlorosis may reappear in the subject of the diathesis, and that more than once ; but the probability of its return is small after the age of 25, especially in the married female. Death from chlorosis directly is exces- sively rare. Complications and Sequelr. — According to Virchow, serious valvular disease and cardiac enlargement may be traced in some of the worst cases of chlorosis to the associated vascular con- dition; and the mitral valve is peculiarly liable to be attacked by endocarditis in rheumatic, 23b CHLOROSIS, puerperal, or septic feyor. Haemorrhages, gastric ulcer, and exophthalmic goitre are believed to occur with comparative frequency in persons of the chlorotic diathesis. Pathology. — The deficiency of the blood in red and white corpuscles, and of the individual red corpuscle in haemoglobin, described above, indicates an imperfect production of the cellular elements of the blood, and imperfect growth of the red corpuscles. With this blood-state there is undoubtedly associated a hypoplastic or dwarfish condition of the blood-vessels. In the embryo the blood and blood-vessels are de- veloped from the same elements, the former making its appearance within the cells which produce the latter. It is highly probable, there- fore, that the anomaly of blood and the anomaly of vessels are to be considered as together an expression of some congenital defect of the blood- vascular system, leading to imperfect growth both of blood and of vessels. Any individual possessing a blood-vascular system thus an- omalous labours under a peculiar diathesis, or debility of the corpuscles and circulatory system, and is said to be a chlorotic subject. If the other systems of the body are full-sized (which is not always the case) the dwarfish con- dition of the arteries of the chlorotic subject, and the scanty supply of haemoglobin, will tend to fail to supply the ordinary demands for blood, and especially for oxygen ; and at every period of extraordinary demand within the economy the blood-vascular system will be in danger of break- ing clown. Exposure to any of the causes re- ferred to above will be sufficient to produce the symptoms of aglobulism, that is, chlorosis ; and that when they would not affect the blood of an ordinary non-chlorotic individual. This effect is peculiarly striking when the exciting influence is one which is universally recognised as an impor- tant factor in the production of chlorosis, namely want of light ; for light is essential in the forma- tion of haemoglobin, and to the health of the red corpuscle. Thus the special phenomena of un- complicated chlorosis are those of aglobulism or deficiency of the oxygenating substance of the organism ; and they furnish one of the purest examples in the whole range of pathology of the effects of want of oxygen in the system {see Blood, Morbid Conditions of). When chlorosis advances to anaemia, by the implication of the plasma, a new series of phenomena present themselves, prominent among which are loss of flesh and (Edema of the extremities. The relation of the cardiac enlargement and valvular disease to the vascular hypoplasia is a purely physical one. More complex is the connexion between the blood-vascular condition and that of the generative organs. The chlo- rotic diathesis, or actual chlorosis, will mani- festly interfere with the development and activity of the ovaries and uterus ; whilst, on the other hand, disorders of tko sexual functions are amongst tho most frequent exciting causes of aglobulism. Diagnosis. — Chlorosis is to be distinguished from symptomatic and idiopathic anmmia ; and the points by which the diagnosis may be ac- complished have been sufficiently indicated above. Leukaemia may be readily recognised CHOLERA, ASIATIC. by a careful examination of the blood and spleen. Prognosis. — The prognosis is highly favour- able as regards life ; and a speedy cure may be assured in uncomplicated cases subjected to careful treatment. Treatment. — The success of a particular method of treatment of simple chlorosis is one of the strongest arguments in favour of the correctness of the preceding view of the patho- logy of the disease. The condition being one of aglobulism, the treatment employed will he so far simpler than that of anaemia, that the red corpuscles alone have to be restored. While the various measures recommended in the more serious blood-disorder are therefore to be em- ployed, if necessary, it will generally be found that in chlorosis iron alone will be sufficient to effect a cure. The particular form in which the drug is to be presented must be carefully selected according to circumstances which need not he repeated in this article. A free supply of sun- light is essential, and must be insisted upon ; and physiological rest of the blood and of the organs of circulation is equally necessary. J. Mitchell Bruce. CHOLAGOG UE1S (x°*-b, bile, and &ya, I move). — Definition. — Substances which lessen the amount of bile in the blood. Enumeration. — The principal cholagogues are Mercury and its preparations — especially calomel and blue pill ; Podophyllum and Podophyllin ; Aloes ; and Rhubarb. Action and Uses. — The liver has a two- fold action — it forms bile, which is poured into the duodenum ; and it also excretes the bile which has been reabsorbed from the duodenum and carried back to the liver by the portal cir- culation. Much bile thus circulates continually between the liver and duodenum, while part is carried down the intestine with the feces, and its place supplied by newly-formed bile. When the quantity circulating in this way is too great to he completely excreted by the liver, it enters the general circulation and produces symptoms of biliousness. These are removed by the so-called cholagogues, which probably act by stimulating the duodenum, and thus carrying the bile so far down the intestine as to interfere with re-absorp tion. Amongst the best cholagogues are the pre- parations of mercury, which do not increase the secreting power of the liver, nor augment tho quantity of bile formed by it. Their utility is greatly increased by combination with a saline purgative, which stiU further clears out the in- testine, and completely prevents any re-absorp- tion of bile. Other cholagogues, such as podo- phyllin, rhubarb, and aloes, actually increase the secretion of bile by the liver. At the same time, they probably prevent its re-absorption, in a similar way to mercurials and salines. T. Lauder Bruxtox. CHOLELITHIASIS {xo\tj, bile, and \l6o s, a stone). — The condition of system associated with gall-stones. See Gall-Stones. CHOLERA, ASIATIC. — Syxox. : Serous cholera, Spasmodic cholera, Malignant cholera ; Er. Cholera asiatique ; Ger. asiatische Cholera. CHOLERA, ASIATIC. Definition. — Asiatic cholera is a specific dis- ease, characterized by violent vomiting and purg- ing, with rice-water evacuations, cramps, prostra- tion, collapse, and other striking symptoms ; tend- ing to run a rapidly fatal course; and capable of being communicated to persons otherwise in sound health, through the dejecta of patients suffering from the disease. These excreta are most com- monly disseminated among a community, and taken into the system by means of drinking water, or in fact by anything swallowed which has been contaminated by the organic matter passed from cholera patients. In badly ventilated rooms, th-e atmosphere may become so fully charged with the exhalations from patients suffering from cholera as to poison persons employed in nursing the sick. In the same way people engaged in carrying the bodies of those who have died from cholera for burial, or in washing their soiled linen, may contract the malady. In a dried con- dition the organic poison contained in cholera excreta may retain its dangerous properties for a long time. The disease is endemic in certain parts of British India, where from time to time it assumes a virulent type, and is apt then to spread, through the means above indicated, along the great lines of human intercourse, and so to extend over the world. History. — Since the days of Hippocrates medical practitioners residing in various parts of Europe have described a disease which they called cholera. The nosology of this affection was hardly amatter of doubt with them, and it is only in modern times that the question has arisen as to whether the cholera commonly met with among us is identical in its nature with Asiatic cholera. Doubtless, if we compare isolated cases we may find that the symptoms which these affections induce are very similar ; but those who have lived beyond the endemic area of Asiatic cholera, and watched the disease spread from India over Europe and America, can scarcely mistake this malignant malady for simple cholera. Asiatic cholera was unknown in Europe before the year 1829-30, although it has existed in India for many centuries. It is true we have no accounts of cholera extending throughout the whole of Hindustan prior to the year 1817, but this arises from the circumstance that it was only at the commencement of the present century that the British Government began to bind the heterogeneous principalities of India into union, and thus render it possible for us to gather together authentic details regarding the disease as it spreads from one province to another. AVe cannot here fully consider the relations which unquestionably exist between the rapidity of the diffusion of cholera from the East over Europe, and the increased facilities of communi- cation that have lately been established between India, and Persia, and Arabia, also from Hin- dustan to Russia, and the shores of the Medi- terranean. Eor instance, forty years ago the passage from Bombay up the Arabian and Persian Gulfs could only be undertaken at cer- tain seasons of the year when the winds were favourable, and even then the voyage was te- dious and most difficult to accomplish ; now 239 largo steameis run every week from Bombay to Bassorah and the intermediate ports along the Persian Gulf, and others pass with equal rapi- dity to the various towns bordering the Red Sea. But although we cannot enter farther into this subject, we must, in order to appreciate the nature of cholera, glance at the chronological order of some of the principal outbursts of the disease which have been disseminated from British India over the world. In 1817 cholera spread rapidly throughout Bengal ; extending during the following year over the greater part of Hindustan, and from thence to Ceylon, Burmah, and China. The disease was communicated from Bombay via the Persian Gulf in 1820-21, and travelled northward, hut did not extend into Europe. During the year 1826 cholera again hurst out over Bengal, and passing through the Pun- jaub, it entered Cabul in 1828. and from thence extended to Persia, and so to Russia during the. years 1829-30, and over the whole of Europe and the groater p:irt of America. In 1810-41 cholera accompanied a British force despatched from Calcutta to China : it broke out among our troops on their voyage to that country, and having spread throughout the Chinese and Burmese empires, it passed in 1843-44 through Kashgar to Bokhara, and so to Cabul. From Afghanistan the disease extended south into Scinde, and westward in 1845-46 through Persia to Russia and Europe, reaching America in 1848. In 1849 cholera was very fatal over Bengal, and during the season of 1851-52 it was comma nicated through the Punjaub and Bombay re spectively to Persia and .Arabia, and in 1853-54 it spread via Russia and Egypt with frightful virulence throughout Europe and America. During the years 1860-61-62 cholera pre- vailed to an alarming extent throughout Bengal and the Central Provinces, and in 1864-65 in Bombay and along the shores of the Red fc'ea ; thence it passed with pilgrims from Mecca to Egypt, and so to Europe, and for the fourth time to America. These various outbursts of cholera were usually remarkably sudden in their advent, a consider- able number of people in the affected locality being attacked by the disease within a few days after it appeared among them. The malady almost invariably died out from amongst the inhabitants of a country under its influence during the cold seasons of the year, to re-appear on the approach of summer. As a general rule the disease was most deadly during the first year of the epidemic; it decreased in violence the second season ; and then gradually’ disappeared, seldom prevailing in any one locality for more than three consecutive years. .ZEtiology. — The more we study the history of Asiatic cholera the better shall we understand that every outburst of tbo disease which has oc- curred beyond the confines of India might invari- ably be traced back through a series of cases to that country ; the disease has never broken out spontaneously in any other part of the world — no amount of filth, bad food, or climatic influences have up to the present time induced a widespread epidemic of cholera. The inhabitants of couji- 240 CHOLERA. ASIATIC. trios far removed from Hindustan, and having limited communication with that empire, such as Australia, have not experienced the disease; whereas those states which have been brought into intimate relation with India have become frequently subject to outbreaks of cholera. Many of the earliest Anglo-Indian authors declared their conviction that the disease was contagious ; others disputed this idea ; but all agreed tliat cholera when extending over a country often settled on the inhabitants of low- lying, ill-drained, and overcrowded localities, and that it frequently left unharmed people residing beyond the affected area, although they might have been employed in attending patients suf- fering from the disease. It remained for Dr. Snow, in 1854, to explain this apparent mystery, and to demonstrate, as he did by means of the Broad Street case, that the poison which causes cholera is contained in the excrements of those suffering from the disease, and ‘ that if by leakage, soakage from cesspools or drains, or through reckless casting out of slops and wash- water, any taint, however small, of the infective material gets access to wells and other sources of drinking water, it imparts to enormous volumes of water the power of propagating the disease ’ (Simon). Cholera patients cannot, in fact, com- municate the affection to others, unless by means of the discharges which they pass. Per- sons attending them run no risk of contracting the disease provided they are protected from swallowing the organic poison passed by the sick ; but in badly ventilated rooms, this organic matter having been disseminated in consider- able quantities through the atmosphere, may be taken into the system by attendants, and so poison them. Dr. W. Aitken observes that the evidence in favour of the communicability of cholera by means of water or food contaminated with cho- lera dejecta has since 1854 become almost over- whelming. A remarkable instance of the land reported by Mr. N. Radcliffe took place in East London during the year I860 ; and previous to this time the circumstances of a case came under the writer’s notice, in which a small quantity of a fresh rice-water stool passed by a patient suffer- ing from cholera was accidentally mixed with some four or five gallons of water, and the mixture exposed to the rays of the tropical sun for twelve hours. Early the following morning nineteen people each swallowed about an ounce of this contaminated water — they only partook of it once, — but within thirty-six hours five of these nineteen persons were seized with cholera. In this instance the choleraic evacuation did not touch the soil ; as it was passed, so was it swal- lowed, but (and this is most important to remem- ber) it had been largely diluted with impure water, and the mixture had been exposed to the light and heat of a tropical sun for twelve hours. Doubtless we have much yet to learn regarding the nature of the organic substance which causes cholera. Professor Pettenkofer holds that if this material after leaving the human body happens to pass into the ground, it may there, under peculiar conditions of soil, mois- ture, and heat, undergo definite changes, and then, having risen as a miasma into the air, may poison those who are predisposed to the disease ; the earth, according to this theory, seems called on to play the part in the rule of cholera which has been assigned in former times to solar, lunar, electrical, or epidemic influences. The conclusions recently arrived at in Bengal by Drs. Lewis and Cunningham rather incline to- wards this view. The difficulty of working out these problems in relation to the infecting ma- terial of cholera is enhanced by the fact, that the human is the only animal which is incontes- tably subject to its influence. "We must, however, refer our readers to some admirable papers by Dr. E. Parkes, published in the Army Medical Department Deports, for accurate knowledge on this subject. Predisposing Causes . — Persons arriving in an infected area are predisposed to the disease. Beyond this fact nothing certain is known con- cerning the existence of predisposing causes of the disease. Anatomical Characters. — The external ap- pearances of the bodies of those who have died of cholera present the mottled skin, shrunken and livid appearance of the limbs, and other features hereafter described as characteristic of the disease during the stage of collapse. The temperature of the body rises after death, and it remains warm for some time. Rigor mortis sets in speedily and is sometimes accompanied with muscular contractions, which displace the limbs of the corpse. With regard to the internal lesions observed after death from Asiatic cholera, the writer's observations lead him to the conclusion, that almost the only alterations noticed in the tissues are due to the physical and chemical characters of the blood having been changed, consequent on its loss of water. The mucous surface of the stomach and small intestines is injected and swollen, and its epithelial cells contain micro- cocci; this epithelium drops off the surface of the mucous membrane in large patches within an hour and a half after death ; and whatever may be the nature of the changes going on in the epithelial coat of the intestinal canal in cases of cholera, there can be no doubt as to its being extensively affected in this disease. Anatomical changes of a specific nature, es- pecially with reference to the amount of blood contained in the right side of the heart and lungs, have been described by pathologists as being characteristic of Asiatic cholera ; and in manv instances after death from this disease, if the post-mortem is delayed for a few hours, the right side of the heart will be found full of blood, together with the pulmonary artery and its divisions ; while the lungs are collapsed and bloodless. But the writer holds that there are numerous exceptions to this state of the heart and lungs, and that the condition above described is not infrequently due to post-mortem changes ; and if the bodies of those who have died of cholera be examined immediately after death, the left side of the heart will be found as full of blood as the right side, but as post- mortem rigidity sets in, the blood is forced from the left ventricle into the aorta, and in fact from the large arteries of the body into the capillaries and veins. Ho has less hesitation in express- CHOLERA, ing an opinion of this kind, because under “imilar circumstances he was misled into attri- buting an important place in the pathology of cholera to the shedding of the intestinal epithe- lium, as observed after death : more recent re- searches have, however, convinced him that the shedding of the epithelial cells, cn masse, is also a post-mortem change, which takes place usually about an hour and a half or two hours alter death. Symptoms. — Asiatic cholera is most deadly at the commencement of an epidemic, and then usually begins without premonitory symptoms. The patient feels well lip to within a few hours of the attack, or, it may be, goes to bed and sleeps soundly through the night, and imme- diately on rising in the morning is seized with violent purging and vomiting. After the first outburst of the disease, as a rale, cholera commences with diarrhoea, the stools being copious and watery, followed by great prostration of strength, with a peculiar feeling of exhaustion at the pit of the stomach ; the sick person suffers from nausea, but seldom from actual vomiting or pain at the outset of the attack. If judi- ciously treated, many patients recover from this, the first stage of cholera, but if neglected the tendency of the disease is to grow rapidly worse. The stools become very frequent, and resemble in appearance and consistency the water in which rice has been boiled : these liquid evacuations flow away from the sick person with a sense of relief rather than otherwise ; but the patient now commences to vomit, first throwing up the contents of his stomach, and subsequently all the water he drinks, mixed with mucus and disintegrated epithelium ; the fluid is ejected from his mouth with considerable force, and this adds to the increasing prostration which is one of the most urgent and marked features of the disease The patient complains of intense thirst, and a burning heat at the pit of his stomach : he suffers also excruciating pain from cramps in the muscles of the extremities ; he is terribly restless ; and his urgent cry is for water to quench his thirst, and that some one might rub his limbs, and thus relieve the muscular spasm. Although the temperature of the sick person's body falls below the normal standard, he complains of feel- ing hot, and throws off the bed-clothes in order that he may keep himself cool. The pulse is rapid and very weak, the respirations are hurried, and the patient's voice becomes husky. His coun- tenance is pinched, and the integument of his body feels inelastic and doughy, while the skin of his hands and feet becomes wrinkled and purplish in colour. The duration of this, the second stage of cholera, is very uncertain ; it may last for two or three hours only, or may continue for twelve or fifteen hours ; but so long as the pulse can be felt at the wrist, there are still good hopes of the sick person’s recovery. The weaker the pulse becomes, the nearer the patient is to the third, or collapse- stage of cholera, from which probably not more than thirty-five per cent, recover. This, how- ever, depends much on the condition of the patient’s heart ; it is quite possible, although the cases must be rare, that a sudden out- pouring of fluid into the intestinal canal has been oufficient to cause syncope and death, among 16 ASIATIC. 241 persons suffering from a weak heart, before the liquid contents of the bowels have had time to be rejected either by the mouth or anus. In the third stage of the disease the vomiting and purging con- tinue, although in a mitigated form; and the skin is covered with a clammy perspiration, especially if the cramps are still severe. We now cease to be able to feel the pulse at the wrist, the lividity of the extremities and surface of the body in- creases, the patient cannot speak above a low whisper, his breathing is very rapid, his eye- balls are deeply sunk in their sockets, and his features are marvellously changed within a few hours. The urine is suppressed. The tempera- ture of his body may fall as low as 94° Fahr. The patient remains terribly restless, longing only for sleep, and that he may be supplied with water. His intellect is clear, but he seldom expresses any anxiety regarding worldly affairs, although fully conscious of the dangerous condition h& is in; sleep, and a plentiful supply of drinking water, are the sole desires of a person passing through the collapse-stage of cholera. This condition seldom lasts for more than twenty-four hours, and reaction either commences within that period, or the patient dies in collapse, or passes on into the tepid stage, which in ninety- nine cases out of a hundred ends speedily in death. In the tepid stage of the disease the sick person's body feels cold to the touch, but the temperature, as shown by the thermometer, be- gins to rise very rapidly, sometimes marking 99° or 100° F. The purging and vomiting cease, and the patient lies in a semi-comatose state, his eyes half open, the ocular conjunctiva being deeply congested, the cornea hazy, and the pupils fixed ; the pulse can be felt at the wrist, but the respira- tion is very hurried, suppression of urine con tinues, the patient’s body is bathed in a cold clammy perspiration, the skin becomes of a dusky red hue, and death too frequently closes the scene within a few hours. On the other hand, the sick person having been in the collapse-stage of cholera some twenty- four hours (it maybe a longer or shorter period), the temperature of his body may begin to rise, gradually creeping up to the normal standard ; the respiration diminishes in frequency ; the pulse returns ; the patient can sleep, and after some thirty-six hours may pass a little urine ; in fact, the functions of animal life are slowly re- stored, and the sick person recovers his health. This desirable result, however, is not infre- quently thwarted by various complications which arise during the stage of reaction. Of these complications the following are the most impor- tant : — suppression of urine; gastritis and enteritis ; pulmonary congestion ; meningitis ; sloughing of the cornea ; abscesses over the body; the formation of coagula in the right side of the heart or pulmonary arteries; haemorrhage from the bowels ; and roseola-choleraica. Diagnosis. — -The question of the diagnosis of Asiatic cholera is discussed in the article on Choleraic Riarrhcea. Prognosis. — The means of forming a prognosis in cholera will he gathered from the preceding account of the disease. , Speaking generally, the prognosis depends chiefly upon the stage of the disease, and upon the time of the epidemic! — 212 CHOLERA, that is, according as the patient has been seized at the outbreak, at the height, or towards the end of an epidemic. Treatment. — In the first stage of Asiatic cholera we should endeavour to stop the purging, and without doubt opium is the drug upon which we may with the greatest confidence rely for effecting this purpose. When practising in the endemic area of cholera the writer was in the habit of carrying about pills containing one grain of opium and four of acetate of lead, so that, if called to see a patient suffering from the disease in its early stage, no time was lost in administering one of these pills dissolved in water. The next thing done was to make a large mustard poultice, and apply it over the whole surface of the patient’s abdomen. The sick person was ordered to remain in bed, and to be allowed nothing in the shape of food or water ; but he might suck as much ice as he felt iu dined for. If, after the first pill, the patient was again purged, a second was given, and a third (but not more) after each loose motion. It often happened that the first or second pill, together with the mustard poultice, ice, and rest, was sufficient to check the progress of the disease, and the patient recovered. Supposing this treat- ment not to succeed, or that on first seeing the patient it be found that he has passed into the second stage of the disease, we should still prescribe the pill, as above directed, dissolving it in water, because in the solid form it might be rejected entire, and under any circumstances it would take time to be dissolved, by the fluid contained in the stomach ; the mustard poultice also should be applied, and the sick person kept warm and in bed. Icc is invaluable in this stage of the disease, and unless a person has passed through an attack of cholera, it is impos- sible to realise the immense relief it affords ; it should be given in small lumps, the sick person eating and swallowing as much as he chooses ; he will frequently devour a pound or two of ice in the course of an hour, and he canDot take too much of it. In the treatment of cholera there can be no question as to the value of ice. The patient should be prohibited from drinking water or any other fluid beyond that which he gets from the ice. The practitioner must be firm on this point, turning a deaf ear to the entreaties of the sick man or his friends, that he may bo permitted to swallow even a small quantity of water, for if they once break through this rule, it will be impossible to limit the amount of liquid the patient will consume. If this treatment does not check the progress of the malady, we may prescribe three grains of acetate of lead and fifteen drops of diluted acetic acid in water every second hour, and fifteen drops of diluted sulphuric acid in water every alternate hour, so that the patient should take a draught, first of one mixture then of the other, every hour. The writer often combines five drops of spirit of camphor with each dose of the medicine, but this drug requires care in its admi- nistration, and should seldom be continued beyond live or six doses of from five to ten drops each. Should the vomiting be very severe, in spite of the free administration of ice, a second mustard , ASIATIC. poultice should be applied over the abdomen ; all medicine must then be omitted for an hour and a half, after which time a scruple of calomel may be sprinkled on the patient’s tongue, and he should be made to wash it down with a little iced water. The cramps are best relieved by hand-friction, and if very severe, ease may from time to time be given by allowing the patient to inhale some ether. The writer prefers this practice to ad- ministering hydrate of chloral, either by the mouth or by subcutaneous injection. Hot water bottles should be applied to the soles of the patient’s feet, and also to his legs and abdomen. Should the disease have reached the collapse- stage there is but little we can do for the patient. Ice must still be given, and, if the purging is fre- quent, the sulphuric acid draught (butno opium) may be administered every hour ; heat and friction may with advantage be applied to thesurfaceof the body ; and the patient may now be permitted to drink iced water in moderation, provided it does not increase the vomiting. According to the writer’s experience, wine and stimulants, if given by the mouth, do harm in this stage of cholera ; but, if the purging has abated, enemas of warm beef-tea and brandy may be administered by the rectum every third hour. When reaction comes on, we must guard against doing too much — it is very rare indeed to see a patient in this condition sink from exhaustion, but probably many lives are lost by endeavours erroneously made, under the idea of keeping up the patient’s strength. Iced milk or arrowroot is all that should be allowed to be given by the mouth for some time after reaction has set in ; but enemas such as those above-men- tioned, administered per rectum every five or six hours, are often beneficial, especially if the stomach remains irritable ; and under these circumstances we not unfrequently find that a small quantity of solid food is easily digested, when soup and liqttids are rejected. In each case, however, the dictates of common sense and experience must guide the medical practitioner in his treatment of the sick persou through the convalescent stage of the disease. With reference to the treatment of suppres- sion of urine after cholera, we should get the patient to drink about half a pint of water every second hour, so as to add fluid to his blood. Dry- cupping over the loins should be employed ; and ten drops of the tincture of cantharides in water administered every hour, until a drachm of the drug has been given. It need hardly be remarked that suppression of urine after cholera is a most dangerous complication, and there is very little that can be done to restore the suspended func tions of the kidneys. Preventive Treatment. — Among persons pre- disposed to its influence, the infecting material of Asiatic cholera will manifest its effects on the system within five days i of having been swallowed, but the poison does not always engender symptoms of virulent cholera. Never- theless, in milder cases of the disease the evacuations passed by the patient may contain the germs of cholera, and these evacuations are therefore capable, under certain circumstances, of developing a deadly type of the malady : cod- sequently, the following remarks are applicable to instances of so-called cholerine, as well as CHOLERA, ASIATIC, to the severer forms of cholera. If the disease has appeared within a neighbourhood, a searching examination must be made into the condition and source of the local water-supply, not over- looking that of the milk, which is too often diluted with water before being sold. All sur- face and doubtful wells (especially those in tho proximity of drains and. cesspools) should be immediately closed; and it is desirable that the drinking water before being consumed should be careful ly filtered. All accumulations of house refuse and filth must be removed; and dirty places, both within and without uncleanly pre- mises, must be freely disinfected and cleansed. There is no necessity when the disease is preva- lent for making any alteration in the usual diet; but in times of cholera we cannot too strongly insist on at once checking any tendency to diar- rhoea, especially if it be of a watery nature. Many cases of incipient cholera have been pre- vented from running on into dangerous disease, by the early administration of pills containing four grains of acetate of lead ac 1 one of opium, one pill to be taken after each loose motion, to the extent of three pills. If called to treat a case of Asiatic cholera, care should be taken that the rice-water stools, and the matters vomited, are disinfected by means of bichromate of potash or Macdougall’s mixture, which should be poured over the bot- tom of the vessel into which the evacuations are received from the patient ; and directly the dejecta are passed from the sick person, a solution of one part of carbolic acid to twenty of water should be sprinkled over them, and they must be immediately taken from the patient’s room, and disposed of as follows : — If the sewage of the locality is conveyed away by means of a constant water supply, the disinfected cholera evacuation should be thrown at once into the sewer. Drains used for a purpose of this kind must, however, be flushed with a mixture contain- ing about an ounce of ferro-sulphate to a pint of water. But if the drainage of the place passes into a cesspool, the disinfected cholera stools should be buried in a deep hole in the ground, re- moved from wells, and. if possible, from human habitations ; it is a dangerous practice, however carefully cholera-stools have been disinfected, to allow them to gain access to a cesspool. The room in which the patient has been treated must be freely disinfected, and his bedding subse- quently burnt. If the sick person should die, the corpse is at once to be placed in a coffin con- taining a mixture of lime, charcoal, and carbolic acid ; in fact, the body should immediately be buried in a mixture of this kind, and the coffin with its contents committed to the grave within twenty-four hours of the patient’s death. But after all, as Mr. Simon remarks, infinitely the most important preventive measures to be adopted against cholera are to provide a pure supply of drinking water, good drainage, ventila- tion, and cleanliness ; for these means, if rightly enforced, must prevent the cholera contagion, whether disinfected or not, from acting to any great extent on the population. The Vienna Cholera Conference has decided that quarantine is inapplicable to the circum- stances of cholera ; but this subject, together CHOLERAIC DIARRHCEA. 243 noth the duties incumbent on sanitary and port authorities with reference to the preventive treatment of the disease, hardly falls within the scope of this article. 0. Macnamaea CHOLERAIC DIAKRHCEA. Synon. : Simple Cholera ; Sporadic Cholera ; Fr. Cholera sporadique; Ger. sporadische Cholera. Definition. — An acute catarrhal affection of the mucous membrane of the stomach and small intestines, attended with vomiting and diarrhoea. The stools consist of a serous fluid, containing a little albumin. The whole system is implicated to a greater or less extent, through the rapid loss of water from the body. ^Etiology. — As has already been remarked, it is only of late years that the question has arisen as to whether Asiatic cholera and simple cho- lera are identical diseases ; but it seems pro- bable that any obscurity which may exist on the subject occurs from the impression that similar symptoms are necessarily produced from precisely the same causes. It appears reasonable, however, to believe that, if the infecting matter of Asiatic cholera, when introduced into the in- testinal canal, induces changes such as we have described, decomposing animal or vegetable substances, under certain conditions, may excite analogous changes in the mucous membrane of the alimentary canal, the consequence being that in both diseases a drain of serous fluid takes place from the bowels, followed by symp- toms of cholera. In the case of Asiatic cholera, however, we believe that the discharges have the power, under favouring conditions, of pro- pagating the disease, whereas the evacuations in simplo cholera are in this respect barren. Doubtless climatic and meteorological influences very materially affect the susceptibility of the human subject to disease, and-consequently we find that simple cholera, like the malignant form of the malady, is apt to prevail as an epidemic in moist or wet seasons of the year, and especially among people whose bodies are predisposed to pass into a diseased condition, from their having habitually breathed impure air, and consumed unwholesome food and water, or become debili- tated from other causes. In a hot and moist climate like that of lower Bengal, choleraic diarrhoea is an affection which we meet with at all seasons of the year, and it is especially prevalent among infants who are being reared on cow's milk, or on other kinds of food prone to undergo putrefaction. Among the fish- eating Hindoos the writer has frequently seen several members of the same family who have been seized with symptoms of simple cholera, attributable to the patients having partaken of fish which was slightly tainted. In fact, accord ing to his experience, there are few more cer tain sources of this form of cholera than fish which has gone bad ; and it is very evident that whatever the deleterious influence may be which food of this description contains, the mere fact of keeping it in boiling water for some time does not destroy its pernicious qualities. It occasionally happens that cases of choleraic diarrhoea occur among people residing in mala- rious districts, the diarrhoea taking the place of the cold stage of a fit of ague; patients 244 CHOLERAIC under these circumstances have been seized with all the symptoms of severe cholera, but they have, almost invariably, recovered from the at- tack. Symptoms. — Choleraic diarrhoea begins sud- denly ; that is, the patient, whether an infant or an adult, has probably up to the commence- ment of the attack been in good health ; there are in fact seldom any premonitory symptoms. A child may perhaps look somewhat paler than usual, and has a dark ring under his eyes, but beyond this appears to be perfectly well. Shortly after taking food, the infant vomits up a quantity of uncoagulated milk, the evacuation not being curdled like that from an overloaded stomach, the gastric secretion no longer having the power of coagulating the casein of milk. Soon after vomiting, or it may be before, the child com- mences to pass from the bowels an acid greenish- yellow fluid, containing flakes and often lumps of undigested food. The little patient becomes very thirsty, restless, and is evidently in con- siderable pain, crying, and drawing his legs up towards the abdomen. If these symptoms con- tinue the evacuations become colourless, resem- bling in appearance the rice-water stools of Asiatic cholera. The temperature of the body falls, the face becomes of a dusky hue, the features are contracted, and the eyeballs deeply sunk in their sockets; the fontanelles are depressed, the child is evidently terribly prostrated, his pulse can no longer be felt at the wrist, and his crying passes into a weak whimpering, he eagerly drinks wator when offered him; and, as the exhaustion increases, convulsions supervene, and the child dies within a few days or even hours. On the other hand, the symptoms may abate at any stage of the disease, and the little patient gra- dually recovers his health. In the adult tjie symptoms induced by chole- raic diarrhoea are much the same as those above detailed. There are seldom auy premonitory' symptoms, and the attack begins with nausea and vomiting, together with a sensation of ex- haustion referrible to the pit of the stomach; the vomiting is speedily followed, or it may be preceded, by purging ; copious watery dis- charges are thus passed out of the body, and the larger and more rapid the evacuations, the more they come to resemble the serum of the blood, which, in fact, drains into the intestinal canal, and passes away from the stomach and bowels. The patient naturally complains under the cir- cumstances of intense thirst : he is very rest- less, and at the commencement of the attack suffers from colicky pains in the abdomen, and subsequently from spasms and cramps which often seize the muscles of the extremities. The pulse becomes small and weak, the respiration is hurried, the voice feeble, and the counte- nance pale and shrunken. The urine is scanty or suppressed, and the temperature of the body falls one or two degrees below the usual standard. These symiptoms, as a rule, gradually subside, the purging and vomiting cease, and the patient falls off to sleep, waking more or less exhausted in proportion to the severity of the attack, but he usually recovers his health rapidly. Diagnosis. — The question naturally arises, are here any means by which we can distinguish a DIARRHOEA. ease of choleraic diarrhoea from one of Asiat’c cholera? and in reply it may be affirmed that there is no characteristic symptom by which these af- fections can be diagnosed from one another. But, taking all the circumstances of any par- ticular case into consideration, it is difficult, es- cept on paper, to confound the two diseases ; for unless a Datient has recently imbibed the poison which produces Asiatic cholera, he cannot be suffering from that malady. Should the sick person reside in a neighbourhood affected by Asiatic cholera, we must, in forming an opinion ae to the nature of the affection, be guided by the previous history of the case, the nature of the food consumed, and so on, and, above all, by the severity of the symptoms. Choleraic diarrhoea, even in the tropics, rarely passes on within a few hours from the commencement of the attack into collapse, such as is commonly seen in cases of Asiatic cholera ; and, in the early stages of the former disease, there is seldom that complete loss of voice and pulse so characteristic of the malig- nant form of this affection. An experienced medical practitioner, placed at the bedside of a person suffering from Asiatic cholera, even in its earliest stages, feels no doubt whatever as to the nature of the affection, and is at once im- pressed with the grave responsibility of the charge which rests upon him : his anxiety is infinitely less when he meets with an instance of choleraic diarrhoea, although he is unable to lay' down any hard and fast rules by' means of which he could define the difference that exists between the symptoms present, and those occurring in a case of Asiatic cholera. Prognosis. — Although choleraic diarrhoea in its more severe forms resembles mild cases of Asiatic cholera, it is a comparatively harmless disease. Unless among young infants, or old and sickly people, no matter bow threatening the symptoms may be. however great the collapse and depression of the patient may seem, a previously healthy adult seldom dies of choleraic diarrhoea. Treatment. — In cases of simple cholera occur- ring among children, theimporiantpoint wemust enforce in our treatment is that the affected organ shall have rest. In practice, however, it is often difficult to persuade parents and nurses that an infant can exist uninjured for ten or fourteen hours on iced water ; nevertheless, we must insist on a plan of this kind being carried out. The little patient will eagerly swallow cold water, either from a bottle or spoon, and the child may be allowed to take as much cold water as he requires, a ml to suck i -e, which may be wrapped up in the corner of a handkerchief and put into his mouth. A poultice made of equal parts of mustard and flour, applied over the abdomen, is often very useful in this form of disease. With reference to drugs, should the treatment above indicated not relieve the svmp- toms, or should the vomiting he very constant, four grains of calomel may he given, and repeated if necessary in an hour's time ; but if the diarrhoea is the more prominent symptom, calomel is not required, but a teaspoonful of castor oil should be administered, and after tlie bowels have been cleared out, if the serous discharge con- tinues, we should order astringents, in the form of ^ of a grain of acetate of lead every hour. CHOLERAIC DIAERHCEA. or Jg of a grain of nitrate of silver, until the purging subsides. Tannic acid, in combination with dilute sulphuric acid and sugar, is fre- quently a useful combination to administer to children in cases of this description. With re- ference to opium, much as the writer dislikes prescribing it for infants, it may be necessary in cases of simple cholera, but it should hardly be given in a mixture to be administered from time to time by a nurse; opium under these circum- stances can only be admissible when given by the medical attendant himself, in doses of two or three drops of laudanum in a little weak brandy and water, carefully watching its effects. Jf the drug causes the child to sleep for a few hours :t may act almost like a charm ; the infant awakes comparatively well ; but if the opium has no such effect, we may be tempted to repeat the dose, but can scarcely give it a third time, at any rate until some hours have elapsed since the ad- ministration of the second dose. The symptoms having subsided, the child’s diet must be strictly attended to, a good healthy wet-nurse as a rule being an urgent necessity in the case of infants. Lime-water may with advantage be mixed with the child's food. With reference to the treatment of adults suf- fering from choleraic diarrhoea, we must bear in mind the fact that, unless among old and debili- tated persons, the patient will, as a rule, get well without medicine. If therefore called to pre- scribe for a case of this complaint, we may order fifteen drops cf laudanum, or a drachm of the compound tincture of camphor in water, to be taken (supposing the patient is very sick) imme- diately after vomiting ; half the above dose may be given at the expiration of one hour, and again after another hour, unless the symptoms have in the meantime subsided. A large mustard poultice should be applied over the abdomen, and the patient must be confined to bed, and kept on ice and iced water ; he should not, how- ever, be permitted to swallow too much liquid. Among old or weakly persons, and also in the case of infants, it is often very necessary to ad- minister brandy and water from time to time, according to the state of the pulse. If the vomiting is severe, a scruple of calomel may be given to an adult, or in the first instance the effervescing mixture with hydrocyanic acid may be employed to allay the sickness ; on the other hand, should the serous diarrhoea be ex- cessive, we may with advantage prescribe four grains of the acetate of lead and ten drops of diluted acetic acid every second hour ; or pills containing a drop of creasote, a quarter of a grain of nitrate of silver, a grain of camphor, and two grains of Dover’s powder, to be repeated After each loose motion, C. Macnamara. CHOLERINE. — A term applied to a class of cases which occur during the prevalence of cholera, in which the milder symptoms of the disease are present. It has also been used to designate the poison on which cholera is sup- posed to depend. See Cholera ; and Choleraic Diaerhcea. CHOLESTEATOMA ( X o\b, bile; orlop, suet ; and S/ibs, like). — An encysted tumour, consisting chieflyof cholesterine. S:e Cysts. CHORDEE 24fi CHOLESTERINE. See Appendix. CHORDEE (xopSfi, a harpstring). — Defini- tion. — Painful imperfect erection of the penis during gonorrhoea. .Etiology and Pathology.— Chordee is most common in the second and third weeks, and rarely attacks the patient after the third week of gonorrhoea. In exceptional cases, on the con- trary, chordee, absent in the acute stage, is violently developed after the inflammation has become chronic and very slight. The bulbous part of the urethra is generally intensely inflamed when chordee happens ; and, further, chordee is very uncommon when the urethritis is limited to the anterior or posterior portions of the canal. The mechanism, of chordee is imperfectly un- derstood. Two explanations have been put forward : — (a) That the corpus spongiosum sur- rounding the urethra being affected by inflam- mation through the effusion of lymph into its substance, proper distension of its spongy tissue and elongation during erection cannot take place. Hence it is drawn tight like a bowstring by the arching of the distended corpora caver- nosa. (i) That the inflammatory condition of the mucous membrane and submucous tissue at the bulbous part excites reflex spasm of the muscles surrounding that part of the corpus spongiosum. This prevents distension of the parts com- pressed ; while the corpora cavernosa, being un- trammelled, continue to expand in the ordinary manner. The first explanation is insufficient to account for some cases where the inflammatory action is very slight and there is no evidence that lymph has been efiused into the erectile tissue ; for example, after a plastic operation on the penis. Again, natural erection has been known to take place very shortly after the sub- sidence of gonorrhoeal irritation, and, it is fair to suppose, before effused lymph can have been absorbed. The second explanation is unsatis- factory, because spasm of other muscles of the perinaeumis often absent. Probably both methods may be active in producing chordee. The causes of chordee are indirect or direct. The most common indirect cause is urethritis or urethral congestion. Direct causes are the reflex irritants which usually produce erection during sleep, such as stimulating food and drink, strongly acid urine, great superficial warmth of the body, distended bladder, lascivious dreams. &c. Symptoms. — The organ grows suddenly turgid and assumes a bowed or crooked form, causing acute pain, which is felt at the part and towards the perinseum. In severe cases the strain causes rupture of the mucous membrane and spongy tissue, with haemorrhage. The loss of blood is usually limited to a few drops, and gives relief to the pain. Rarely the haemorrhage is rapid and prolonged. Treatment. — Abstinence from stimulants ox all kinds and late suppers; light clothing ; aDd a hard mattress at night are the best means ot preventing chordee. Micturition at short in- tervals during the night must be enjoined. Of medicines the best is a suppository at bed-time of one grain of crude opium in ten grains of cocoa butter. The subcutaneous injection into 246 CHORD EE. the perinaeum of one-sixth grain of acetate of morphia is also an effectual remedy. Both these applications should he followed by an aperient saline draught the next morning. A drachm of spirit of camphor thrown just before it is swallowed into an ounce of water, and taken on lying down at night is also useful, and it may be repeated once if chordee awaken the patient, but it is a very uncertain remedy. More trust- worthy are twenty or twenty-five grains of chloral-hydrate in syrup and water at bed-time, and repeated in four or six hours if needed. Bathing the genitals and perinaeum with very hot water for ten minutes before going to bed some- times proves successful. The application of a spiral coil of narrow india-rubber tubing round the penis and scrotum, through which a con- tinuous current of ice-cold water flows, is also an excellent preventive. — To disperse an attack of chordee the best remedies are voiding urine ; the application of cold to the perinaeum by evaporating lotion or by ice; and the upright posture. Berkeley Hill. CHOREA (x»pt!a, a dance). — Synon.: Chorea Minor; St. Vitus’s Dance; Fr. Danse de St.- Guy, la Choree ; Ger. Veitstanz. Definition. — A disease of the nervous system, characterised by a succession of irregular, clonic, involuntary movements of limited range, occur- ring in almost.all parts of the body. The distinctive features of the movements are the entire absence of either rhythm or method in their recurrence ; that not individual muscles but co-ordinated groups are affected; and notone or more groups only, but almost all the muscles in turn. There is not actual loss of command over the muscles, but voluntary movements are inter- fered with by superaddition of involuntary' move- ments. As a rule the movements cease during sleep. .Etiology. — Chorea is a disease of childhood ; it is most common between the ages of eight and twelve, very rare before six, and rare after six- teen ; it is more than twice as frequent in girls as in boys, especially after the age of nine. It occurs more frequently in families in which ner- vous diseases are hereditary than in others. It is more common in large towns than in the country ; and far more frequent among the poor than among those in comfortable circumstances. Want of proper food, neglect, ill-usage, with the weakness and anaemia induced by these means, are very common antecedents. Children well-nour- ished and with a good colour, exposed to none of these causes, may however suffer. An intimate association between chorea and rheumatism has long been recognised. A large proportion of the children suffering from chorea are found to have had acute or subacute rheumatism, and some of the most terrible cases met with, especially after the age of puberty, are those in which the chorea comes on during or just after acute rheumatism. Whether traceable to rheumatism or not, there is very frequently found in chorea a cardiac murmur, usually mitral systolic, sometimesaortic. This may or may not disappear after recovery. In almost all the fatal cases of chorea which have been exa- mined after death, endocarditis with fibrinous ve- getations on the valves has been present. In adults, CHOREA. pregnancy divides with rheumatism the causatioi of this affection ; recovery generally speedily fol- lows delivery, and can rarely be brought about tiL' this has taken place. Bad habits, and disorders o! menstruation, are also said to be capable of induc- ing chorea. Intestinal worms again have appeared to set up the disease, and instances are on record in which the expulsion of worms has been followed at once by cessation of the movements, but this must be extremely rare. Fright or some power- ful emotion is very frequently assigned as a cause ; and it is seldom that parents are not prepared with the instance required. But, making allow- ance for this, and notwithstanding the fact that endocarditis maybe present in cases said to have originated in fright, it does not seem possible to exclude fright as a cause of chorea. The influ- ence of imitation is less certain. The disease is said to be far less common in negroes. Anatomical Chaeactebs and Pathology. — The study of chorea, as of epilepsy and many other affections of the nervous system, has been hampered by its being regarded as a morbid unity. The view here maintained is that it is a sympton rather than a disease, and that the characteristic movements are in relation not with the nature of the morbid change but with its seat. The seat of the disturbance is tho corpus striatum, its character probably different in different cases ; but the anatomical condition cannot amount to actual breach of structure, since that is known to give rise to hemiplegia, while it must obviously be of a kind to impair the functional vigour of the ganglia. Chorea, as the writer has said elsewhere, has been called ‘ in- sanity of the muscles ’ — a better phrase would be ‘ delirium of the sensori-motor ganglia.’ In de- lirium there is loss of control over the mental processes with rapid succession of incoherent and imperfect ideas ; in chorea loss of control over the motor apparatus, with movements excessive in point of number and extent, but wanting in vigour and precision. In some cases of chorea nothing abnormal has been detected after death, but usually the minute methods of investigation now pursued yield positive results. The largest series of examinations published is contained in a com- munication to the Medico-Chirurgieal Society, in the session 1875-6, by Dr. Dickinson. He describes dilatations of the minute arteries as existing throughout the brain and cord, more especiaUy, however, in the corpus striatum and thalamus, with small haemorrhages ; and considers the disease to be due to a widely-spread hyper- aemia of the nerve-centres. He did not find capillary embolisms, but does not appear to have drawn out the arterioles to look for them. The appearances he describes are very much those producible by impaction of microscopic particles of fibrin in the minute vessels. Capillary em- bolisms have been found by Dr. Tnckwell and other observers, predominantly in the central ganglia, but also in the convolutions and cord, accompanied by patches of softening and minute haemorrhages. In almost all fatal cases of chorea there is endocarditis with deposit of beads of lymph on the mitral or aortic valves or both, whether a murmur has been audible during life or not. CHOREA. The post-mortem appearances consequently do not indicate any localisation of the morbid change in the central ganglia. But it is to be remembered that the fatal cases are those in which there is not only extreme violence in the choreic movements but usually also delirium and other symptoms. There are in fact multiple symptoms just as there are multiple lesions, and we are called upon to distribute the symptoms and assign them to their respective sources by such knowledge of the functions of the different nerve-centres as physiology affords us. The delirium or comparative dementia is thus attri- buted to the lesions in the convolutions ; the loss of speech to lesions in convolutions or in lower centres, according to its character ; the impair- ment of sensation to lesions in the thalami; the chorea to lesions in the corpora striata. The grounds upon which this last localisation — that in which we are immediately concerned — is de- cided, are as follows. We excludo the cerebral hemispheres and cerebellum, rather arbitrarily perhaps, since there is much to be said in favour of their contributing to excite the movement, now especially that convolutional motor areas have been demonstrated by Hitzig and Terrier. The important point to be made clear, however, is that chorea has not its seat in the cord. The arguments and evidences against this are (1) That tonic and not clonic spasm is characteristic of persistent spinal irritation ; (2) Tho degree of control over the movements retained by the will; (3) Their increase under emotion ; (4) Their cessation during sleep. To those which were originally advanced by Pr. Russell Reynolds may be added : (o) The diminished reflex action on tickling; and (6) The phenomena of hemichorea and its relations with hemiplegia. The evidence afforded by hemichorea is so conclusive that other considerations have been merely alluded to. It cannot be supposed, for example, that one lateral half of the entire length of pons, medulla, and cord can be affected without implication of the other half, which would be the case with hemichorea of spinal origin ; and still more con- clusive is the fact that when in hemichorea there is impairment of sensation it is on the same side with the movements, and not, as in hemiparaplegia (due to division of one half of the cord), on the opposite side to the motor paralysis. The paral- lelism between hemichorea and hemiplegia is so perfect as to suggest at once that the two affections represent different conditions of the same nerve-centres, and is made more complete by the very discrepancies, as they may at first sight appear, which have been considered to be objections. In hemiplegia there are certain muscles which more or less completely escape paralysis the motores oculorum, orbiculares palpebrar.um and other facial muscles, the mus- cles of the neck, chest, back, and abdomen. In hemichorea the irregular movements cross the median line and invade the opposite side in these same muscles. This has been explained (rightly or wrongly) by the hypothesis that all these muscles acting in compulsory concert with the corresponding (or other) muscles of the opposite side, the nerve-nuclei of the bilaterally associated muscles will be commissurally associated in the cord, so as to become in effect a single nucleus, 247 and this single nucleus for muscles on each side of the body being connected with both corpora striata is thrown into action by the sound cor- pus striatum when its fellow of the opposite side is damaged, as in hemiplegia, thus prevent- ing paralysis; and, on the other hand, is reached by the irregular impulses from the corpus stria- tum affected in hemichorea, thus causing bila- teral chorea in the parts enumerated. In addition to the correspondence between hemichorea and hemiplegia ju t described, there are transitions from one to the other, and combi- nations of the two to be mentioned below, under the head of complications. Hemiplegia may bo succeeded by hemichorea (the post-kimiplegic chorea of various observers); or chorea may deepen into paralysis ; or, as in a case reported by the writer, there may bo with chorea of the limba on one side, first chorea, then paralysis (hemi- plegiform), and then again chorea of the same side of the face. The conclusion is obvious, that hemiplegia and hemichorea in these cases are indicative of different degrees of damage in the same centre. Hemichorea and hemiamesthesia have been found very constantly associated with structural lesions in the white fibres just outside the posterior extremity of the thalamus, usually- involving also the ganglion itself at this part. The well-known embolic theory of chorea originated by Kirkes, and improved and ably maintained by Dr. Hughlings Jackson, at once finds its place here. Capillary embolism is of all others the condition which might be expected to induce the instability without abolition of function which exists in chorea, and in almost all cases a fertile source of fibrinous shreds is present, in the form of vegetations on the valves of the heart ; the fact of embolism, again, has re- peatedly been demonstrated. While, however, giving to capillary embolism a prominent place among the causes of chorea, it cannot be con- sidered as the only cause. The clinical differ- ences between ordinary chorea and the acute and fatal form are of themselves suggestive of a different pathology ; and the speedy recovery after delivery in the chorea of pregnancy, or (as in one or two cases on record) after expulsion of in- testinal worms, is inconsistent with the existence of embolism. What the precise anatomical con- dition is can only bo matter of conjecture, but it will be some form of innutrition, irritability, and debility, as Dr. C. B. Radcliffe has abundantly demonstrated, going together. Hypera?mia, with capillary blood-stasis, or capillary thrombosis by cohering leucocytes, has been suggested as the cause. Prolonged arterial spasm from per- sistent reflex irritation, uterine or intestinal, or the more brief contraction of tho cerebral vessels from fright, may perhaps lower the functional vigour of the ganglia to the degree required. A very important consideration is the remarkable limitation of chorea to the period of childhood — the period between infancy and puberty. This is a limitation, if not without parallel, certainly unequalled, and it points to a condition of nerve centres in childhood which specially favours the occurrence of the disease. This condition may be said with confidence to I be the fact that childhood is the period of I special activity of the sensori-motor ganglia. CHOREA. 248 Symptoms. — In a slight case the patient, -usually x child, may be perfectly quiet when lying down, and for a short time even when sitting or stand- ing, if not conscious of being under observation ; but when walking or while under examination there will be various fidgety actions, abrupt flexion of the fingers, a sudden pronation of the forearm, or hitching up of one shoulder, or twist of the body, or there is shuffling of a foot on the floor, or again a jerk of the head or twitch of the mouth or eyes. If the patient be told to do anything, the movements will be multiplied and exaggerated in the muscles employed. A small object will be picked up and held, but the hand is brought down upon it hastily and after various irregular excursions. In a more severe case the grimaces, contortions, and jerkings succeed each other without intermission. The gait is now very peculiar, being slow, shuffling, and uneven ; the steps of irregular length and unequal time ; and the line of progress deviating. In the worst forms of this disease every muscle appears to be thrown in turn into violent contraction, the face is distorted this way and that, the eyes roll to and fro, the teeth are snapped or ground together, the whole body writhes, and the limbs are in unceasing motion. It is to be remarked that, even in extreme cases, the movements, violent as they may be, are in some degree circumscribed ; the arms, for ex- ample, are not thrown up over the head, nor do the legs go to the full extent of their range of motion ; the tongue is rarely bitten, though the lips may be. Deglutition is greatly interfered with in a severe attack, and the evacuations may be discharged involuntarily. In the mildest forms, the diaphragm and muscles of the chest and abdomen are affected, causing irregularity in respiration. The action of the heart may also be irregular, but this is probably secondary to the respiratory variations in frequency and depth, and is not attributable to chorea of the heart. There is generally impairment of motor power, and frequently diminution of sensation. This is most readily ascertained in hemichorea, i.e. chorea affecting one half of the body only, when the sound side can be employed for comparison ; but in the violent forms of the disease, when the skin is gradually worn through by incessant friction, there is often so little complaint of pain that sensibility must, it would seem, be blunted. Re- flex sensibility is also, commonly, dull. It has already been stated that the movements cease during sleep ; this is a rule to which ex- ceptions are rare though not unknown, even in mild cases, and especially in hemichorea. Chorea is usually gradual in access, even in the cases which ultimately become severe ; it is very commonly one-sided for a time, and oc- casionally throughout, when the name hemi- chorea is given. It is not, however, strictly unilateral in these cases, as the movements trans- gress the median line and affect the corresponding muscles of both sides of the body at those parts where these are bilaterally associated, and where in hemiplegia there is immunity from the para- lysis, as for instance the oculo-motor muscles, the muscles of the neck, chest, and abdomen. Complications. — The foregoing description ap- plies more or less to ail cases of chorea, but there are often additional symptoms, and it will conduce to clearness if these are considered apart and called complications. Mention has been made of impairment of motor power; at times this amounts to complete paralysis, and the relations and combinations of chorea and paralysis, and especially of hemichorea and hemiplegia, throw much light on the disease. Chorea sometimes succeeds hemiplegia in the paralysed parts ; more rarely chorea deepens into paralysis. Cases again occur in which with facial hemiplegia there is chorea of the limbs of the same side. Speech is very commonly more or less affected and occa- sionally completely lost for a time. The difficulty is usually articulatory, chorea of the muscles of respiration, phonation, and articulation interfering with utterance of words ; but there is in some cases true aphasia, and when this is so, there is the same tendency to the association of aphasia with right hemichorea as with right hemiplegia. The intellect may suffer in various degrees: the face has often an idiotic expression in chorea, usually no doubt from the muscular contortion or atony, but sometimes truly indicative of temporary imbecility. In the violent and fatal forms of chorea there is almost always delirium. Impairment of sensation is common, and hemi- anesthesia is almost always associated with hemichorea. Duration, Terminations, and Prognosis. — The average duration of chorea is about two months; if prolonged beyond three months it may be exceedingly chronic and go on better and worse for one or two years. There is a ten- dency to spontaneous recovery, but on the other hand relapses are common. Chorea is rarely fatal in children ; when it is so the case is usually acute and violent from a very early period of the attack, and it is rare for a case to run the usual course for a time and then take on a very severe character. After puberty and es- pecially when it supervenes on acute rheumatism, it is very dangerous, but less so when associated with menstrual disorders and pregnancy than in youths or men. Diagnosis. — It is only necessary under this head to warn against the mistake of confounding with the movements of chorea the tremor or jactitation of disseminated sclerosis of the nerve- centres, which, though most common in adults, is not unknown in childhood. Treatment. — In a large proportion of cases of chorea, especially such as come into the hospitals of London, rest and food, with perhaps aperients, are all that are required for recovery. But it can scarcely be denied that medicinal treatment often renders important services, especially in cases of a lingering character. The causation and pathological condition being various, it is to be expected that the remedies required will be different, and the attempt should be made to adapt the treatment to the special features of the case, the basis of all being the endeavour to improve the nutrition of the body generally, and of the nervous system, by good food, rest, and warmth. The food may be supplemented by cod- liver oil, and Dr. C. B. Radcliffe attaches im- portance to the free administration of wine or other stimulants. Any recognised cause should be removed, such as constipation or worms; irregularities or suspension of the catamenia CHOREA. should receive attention ; when there is pregnancy it may perhaps he necessary to induce premature labour. When the chorea is accompanied by rheu- matoidpains and feverishness, iodideof potassium with ammonia may have a remarkably good effect. Iron in some form or other is very gene- rally useful, but especially when the patient is anaemic. Another remedy is sulphate of zinc, given in doses gradually increasing from one ur two grains three times a day, to six, eight, or ten, till sickness is induced, when in some cases the disease appears to be cut short. The remedy which in the writer’s experience has been found most generally useful is arsenic. Trousseau sometimes gave strychnine in gradually increasing doses till its physiological effects manifested themselves. On the other hand, conium, recom- mended by Dr. John Harley, has been exten- sively employed; the only reliable preparation is the juice, which should again be given in gradu- ally increasing doses, beginning with a drachm and going up to one or two ounces if necessary, till its depressing effect on the muscles becomes evident. It has not, in the writer’s hands, given satisfactory results ; the same may be said of the application of ether-spray along the spine, which has recently been strongly recommended, except in acute cases in which the freezing of the skin here has in two cases been followed at once by sleep, and in a few days by alleviation of the violence of the chorea. Baths, warm and cold, especially shower-baths, spinal douches, spinal ice-bags, gymnastics, musical gymnastics, i.e. movements timed by music, have advocates and may no doubt be useful in suitable cases. In the terrible cases of acute chorea the great indication is to procure rest for the poor sufferer and keep up the strength. Milk, eggs, beef-tea and other forms of concentrated fluid nourish- ment, should be given freely, together with wine or brandy. Conium, hyoseyamus, bromide of potassium or ammonium, and chloral, have been tried separately or in combination, with more or less appearance of success; chloroform, again, may be administered ; chloral by the mouth or rectum, and hypodermic injection of morphia with free administration of brandy have in the writer's judgment appeared to do much good. It is in these cases that tartar emetic in full doses has been recommended ; it is certainly tolerated in an astonishing degree. Restraint of the violent movements is oft-en a great comfort to the patient ; the limbs should be carefully bandaged with flannel and bound, the legs together, the arms to the sides, a folded blanket, across the abdomen and hips, keeping down the body. If half-done it only adds to the suffering, but when properly carried out it gives a feeling of relief and favours sleep. W. H. Broadbent. CHOROIDITIS. — Inflammation of the choroid. See Eve, Diseases of. CHROMIDROSIS (xpwua, colour, and iSpus, sweat), coloured perspiration. See Perspira- tion, Disorders of. CHRONIC (vpJpos, time). — This word is applied to a disoase when its progress is slow and its duration prolonged. See Disease, Dura- tion of. CHYLOUS URINE. — See Chyeuria. CHYLURIA. 249 CHYLURIA (xuA.i>r, chyle ; and oioov, urine). — Synon. : Galacturia ; Chylous urine ; Er. Urine iaiteuse ; Gor. Die Chylurie ; milchsaf- tiger Harnabgang. Definition. — A diseased condition, occurring in tropical and sub-tropical climates, which manifests itself by a milky appearance of the urine, accompanied usually with more or less distinct traces of blood. On standing, the fluid coagulates, so as to present the appearance of size. A microscopic nematoid entozoon ( Filaria sanguinis hominis) is generally found in the blood and urine of persons affected with the disease. General Description. — The affection known as chylous or chyloid urine has long remained a puzzle to physicians, not only on account of the very remarkable character assumed by the secretion, but also on account of the very erratic course which the disease runs. Scarcely any two persons affected with this malady give a similar account of its mode of onset, of the duration of the attack, or of the symptoms and seasons of its occurrence. The writer has had the opportunity of studying from thirty to forty cases of the disease in Calcutta, and the variety of symptoms presented, and the numerous causes, of the most opposite character, to which the disease has been attributed, are very perplexing. The histories of the cases published by various observers present a like uncertainty, and Dr William Roberts very aptly describes the courso which the disease runs as marked by an irregu- larity and capriciousness which baffles explana- tion. It would seem as though the one symptom which may be looked upon as constant is the condition of the urine implied by the designation which was applied to the disorder by Prout. This symptom, however, although very ap- plicable to the generality of cases met with in India, does not appear to be so generally ap- plicable to the disease as it occurs in Egypt, the Brazils, and the West Indies. In these countries the term luematuria is adopted as being a more correct description of the malady, whereas in India the designation ‘ haematuria,’ though gene- rally more or less applicable at some period or other of the disease, is, nevertheless, not so ap- propriate in the great majority of the cases, and, indeed, in some instances is wholly inappropriate, as occasionally no marked traces of red colouring matter can be detected in the urine from the beginning to the close of the attack. It is. of importance that this feature in connection with the disease should be borne in mind, as it may hereafter be found that what at present are gene- rally considered as merely two phases of one malady may each have a distinctive .Etiology. History and Geographical Distribution.— The phase which chyluria usually presents in India is, in this article, taken as the typical one, and its history may be thus briefly epitomised. To Dr. Vandyke Carter belongs the credit of having observed systematically, and seriously attempted to clear up the pathology of the disease. His researches, published in 1861-62 tended to show that a direct admixture of chyle and urine occurred — a leak from the lymphatic tract into the urinary. 1 In March 1870. when 1 Transactions Med. and Phys. Soc. Bombay , vol. vil. 1861. Meaico-chir. Trans., vol. xlv., 1862. CHYLURIA. 260 examining a specimen of milky urine passed, by a man under the ehargo of Dr. R. T. Lyons in Calcutta, tne writer found that it contained numerous microscopic nematoid worms ina living condition. These were described and figured in a report published in 1870 by the Indian Govern- ment. 1 * Under the impression that no nematoid parasites had previously been found in the urine, specimens were forwarded to the late Dr. Parkes, and by him shown to Professor Busk, who sug- gested that probably they belonged to the Filari- dae. Similar entozoa were detected in the urine of chyluria patients in Calcutta by Dr. W. J. Palmer and Dr. Charles in the course of the next few months. Towards the beginning of July '1872 the writer found nine minute nematoid worms in a state of great activity on a slide containing a drop of blood from the finger of a Hindoo. These wore identical in character with those above re- ferred to. Unfortunately the man could not be found after the observation had been made, so as to be questioned as to his past history, so that the pathological conditions which might have been associated with this the first recorded instance of the existence of nematoid luematozoa in man must continue to remain in obscurity. However, since this period the writer has traced the helminth (named Filaria sanguinis hominis ) to the blood direct in about fifteen, and to one or other of the various tissues and secretions of the body in about thirty-five individuals. All with the ex- ception of the persou just referred to were known to suffer or to have suffered from chyluria or some closely allied pathological condition. 3 These observations have, moreover, been confirmed by others in numerous instances. The more recent history of the variety of the disease usually referred to as ‘ Mmat.nrie grais- seuse,’ ‘ heematuria Braziliensis,’ ‘haematuria Egyptica,’ is also associated with an entozoon — or rather with two distinct ktnds of entozoa — a fiuke and a nematode. Tko former was dis- covered in 1851 by Bilharz. His observation was followed tip, and now it is estimated that about a third of the inhabitants of Brazil harbour this parasite in their bodies. In 1868 Dr. Otto Wuclierer, of Bahia, discovered a microscopic entozoon, which he forwarded to Leuckart to be identified. 3 The latter writer suggested that it might be the embryo of some round worm, probably belonging to the strongy- lidse. Dr. Jules Crevaux, a French naval surgeon, succeeded in confirming Wucherer’s observation by finding (July 27, 1870) similar helminths in the urine of a young creole affected with ‘ hema- turia chyleuse.’ 4 The next link in the chain appears to have been furnished by Dr. Sonsino. who, in January 1874 (having no knowledge of previous observations of a like character), found similar parasites in the blood and in the urine of 1 Vide abstract of this description in British Medical Journal, Nov. 10, 1870. 3 ‘ On a Hjematozoon in human blood ; its connection with Chyluria and other diseases.’ Vide Eighth Ann. Rep. of Sanitary Commiss. with Govt, of India, 1872 ; also Indian A nn. Med. Science, vol. xvi. ‘ On the Pathological Significance of Nematode Hfema- tosoa.* Tenth Report of Sanitary Commiss., 1874; also Indian Ann. Med. Science, vol. xvii. s Gazitta da Bahia , Dec. 1868. * Journ. de V Anat. et de la Physiol. T. xi., 1875 ; and Leuekart’s ‘ Par as i ten,’ Band ii. S. 628 et seq. a Jew lad at Cairo affected with haematuria. Id the latter fluid distomata also were found. This observer, however, considers that these parasites, though bearing a very close resem- blance, differ in some respects from those found in chyluria, and has accordingly added the word Fgyptica to the original designation for the purpose of distinguishing it. It is possible that the microscopic nematode which was dis- covered by Wucherer in Bahia may also be traced to the blood eventually, and that the slight differences in the- recorded characters in the worm as found in Egypt and in the Brazils from that found in India may he shown to be sufficient to indicate a specific difference in the parasites, and thus offer a satisfactory explanation of the discrepancies observed in the character of the urinary disorder in the different countries. In Europe the disease has been investigated by several observers. The cases which have com* nnder their care have occurred with very rare exceptions in persons who have at some time or other resided in countries situated between about 30° north and 30° south latitude. Of the four or five cases which have been recorded as having originally occurred in Europe, one is furnished by Dr. William Roberts, the patient never hav- ing been out of Lancashire ; and another by Dr. Beale, in a person who had never resided out of Norfolk. 1 Symptoms. — So far as is at present known, there are no premonitory symptoms of chyluria. Sometimes the only symptom is the milky condition of the urine — a condition which usually comes on very suddenly; generally, hcwever, the patient complains of uneasiness, scarcely amounting to pain, across the loins, along the ureters, over the bladder, or along the course of the urethra — especially towards the ptrinseum in the male. There is gener- ally marked debility, with mental depression. Occasionally chylo-serous discharges take place from various parts of the body — the axilla, the surface of the abdomen, the groin, and especially from the scrotum, in that con- dition of it which is known as Elephan- tiasis lymphangiectodes (Bristowe), Neevoid elephantiasis, or Varix lymphatieus. The disease is also sometimes observed associ- ated with true elephantiasis of the limbs and scrotum. It occurs at all ages, from childhood to extreme old age, and in about equal proportion among the. sexes — perhaps more frequently in the female than in the male. With regard to the urine, it presents, as already mentioned, a milky appearance, and frequentlj emits a strong milky or whey-like odour, which is made more evident by warmth. After standing a short time the fluid coagulates, so as to form a more or less semi-solid mass resembling blanc- mange. In the course of a few hours the clot breaks down, and tbe urine becomes rapidly de- 1 Dr. S. Mackenzie exhibited to the Pat holcgical Society (October 1SS1) living specimens of filaria from a soldier who had served in India. He noticed the daily periodicity of the filaria, which had previously heen determined by Dr. Hanson of Amoy, and further showed that the peric dicity could be inverted from day to night by chaDgias the habits of the individual. CHYLURIA. composed. In some cases the fluid presents a pink colour, from the admixture of blood, but more commonly — at least, in India — the blood, ivhen present, is seen forming a shreddy adhe- rent coagulum at the bottom of the vessel. Not unfrequently the flow of urine is suddenly stopped during micturition by the blocking up temporarily of the urethra with one of the clots. Sometimes in India, but apparently almost al- ways in the West Indies, South America, and Egypt, the presence of blood in the urine forms, as already mentioned, ’the most pronounced fea- ture. The specific gravity varies greatly — may range in the same individual from 1007 to over 1020. Shaken up with ether the urine loses its milky aspect ; and when nitric acid or heat is applied a precipitate almost invariably results. These characters, and the fact of the coagu- lability of the fluid, indicate the presence of fat, albumen, and fibrin, all of which are to be con- sidered as abnormal constituents. The propor- tion, however, in which they exist in different individuals, and even in the same individual at different times, varies greatly. Dr. Beale’s analyses show, that though a specimen of urine may contain at one time 1'39 per cent, of fat, another specimen, obtained a few hours later, from the same person, may contain none. In the majority of cases the fatty element is usually scanty in the morning before meals, and so are the other abnormal elements, unless exercise have been taken or the circulation otherwise accelerated. Under the latter circumstance, as Dr. Bence-Jones has shown, the albumen is increased, without, however, a corresponding increase of the fat. 1 It is evident, therefore, that in order to institute a comparison between the character of the urine and the character of the various nutritive fluids for the purpose of ascer- taining from which of them the abnormal con- stituents of the urine are derived, the results of analyses of the latter fluids at different times of the day and at different stages of the disease should bo taken. Further, as the nutritive fluids themselves undergo constant changes de- pendent on the quality of the nourishment sup- plied and the time which has elapsed since par- taking of it, it is equally evident that any single analysis would be insufficient. An attempt has been made to bring together in the following table all of what appeared to be the most trust- worthy analyses of these fluids which have been published. In order to simplify the table, only the estimates of the albuminoid and fatty matters have been given, these being the most pronounced of the more readily estimated abnormal con- stituents in the urine Constituents | selected. Urine in chy- luria. [Mean of 15 an- alyses]. Blood in chy- luria. [Hoppe- Seyler.] Blood — Nor- mal human. [Bec- querel and Rodier.] Chyle [M ean of 6 an- alyses : man, cow, horse, ass, dog, cat. Lymph - human [Mean of 4 an- alyses]. Albuminoids Fatty mat- ters. 0-54% 0.80% 3-35% 0-67% 7-00% 0 06% 7-08% 0'92% 2-96% 0‘56% 1 Phil. Trans, of Royal Soc., cxl., 1850, p. 651. 251 A glance at this table reveals the fact that tho relative proportion of the albuminoids to the fatty matters in chylous urine does not corre- spond with the proportion in which they are found in any one of the nutritive fluids of the body. In normal blood, for example, the fatty matter is as 1 to 116 of the albuminoid, whereas in the urine the former exceeds the latter to a very considerable extent. The same discre- pancy, but to a less degree, is found to exist when the urine and chyle are compared — the quantity of albumen in the latter being more than seven times greater than that of fat. The proportion of these substances in lymph ap- proaches more closely to what is encountered in the urine — the fat being to the albumen as 1 to 4 very nearly. The specimen of chyluria-blood recently analysed by Hoppe-Seyler 1 approaches very closely to the average composition of human lymph — the fatty matters being as 1 to 5 of the albuminoid, thus differing in this respert very considerably from Dr. Bence-Jones’ analyses of similar blood where the quantity of fat given is that of normal blood. On the other hand, the urine of the man from whom this blood was ob- tained yielded a proportion of fat almost iden- tical with what Hoppe-Seyler obtained in the urine of the person whose blood he examined — the figures given by the former writer being 0 74 and by the latter 0 72 per cent. The composi- tion of the blood in this affection must be re- garded as hitherto unsettled. Guibort found in a clot of it almost twice, and Hoppe-Seyler about eleven times as much fat as is found in normal blood ; on the other hand, Bayer, Bence- Jones, and Crevaux could detect no change in its composition. It is possible that the discre- pancy in the results of these analyses and macro- scopic examinations of the blood may be due in part to the particular moment when the blood was abstracted. According to M. Claude Ber- nard, ‘ Les urines chyleuses resemblent au sang d’un animal en digestion, ou plutot a celui des oies que l'engraisse.’ 2 With regard to the microscopic examination of the blood, the writer has not observed that the corpuscles or serum presented any abnormality indicative of the presence of fatty matter in any form — the serum has seemed as clear and as free from molecular matter as normal blood. So far as his experience goes, the only feature worthy of special note in connection with microscopical examination of the blood in chyluria, is the pre- sence of the haematozoon already referred to. In searching for it, it will be advisable to abstract by means of a needle a drop of blood from several fingers, and to submit each slide to a thorough examination, which may have to be very pro- longed, employing for this purpose a compara- tively low power — §" or V objective — a higher power being resorted to when the entozoon has been detected. It must not be expected that the blood will present any peculiarity to the naked eye, even though every ounce may contain thou- sands of these microscopic worms. The aecom- 1 Med.-chem. Untersuchungen , 1871, s. 551-56. Abstract by Dr. Ferrier in Joum. Chem . Soc.. voL ix., 1371 : pore 740. 2 Quoted by Crevaux, oj>. cit. CHYLURIA. 252 panying wood-cut, traced from a micro-photo- graph, accurately represents the size and form of the parasite. Its average length is !jt''( = 0-34mm.) ; its breadth alhto" ( = 0'007mm.), or about equal to the diameter of a red blood-corpuscle. It is enclosed in a transparent tubular sac, within which it can be seen to alternately contract and elon- gate itself. This sac is extremely delicate and translucent, and may sometimes, when the worm has shortened itself more than usual, be seen collapsed and folded like a ribbon, and the next moment be instantaneously straightened again, by the extension of the filaria to its ordinary length. After death the worm may occupy either the entire length of the tubular sac, or be so contracted as t o leave the tube empty at one or both ends, as may be observed in the wood-cut. 1 The internal organs are not sufficiently differ- entiated to be recognised with anything like certainty, although when carefully scrutinised from time to time during the twenty- four or forty-eight hours that tho parasites may continue to live, something like differentiation of an alimentary canal may be recognised. Microscopical Characters of the Urine . — The filaria may likewise be detected in the urine. One day it may be readily obtained in the blood but not in the urine, and vice versa ; but, as a rule, the parasite will be found equally readily in both fluids. In making a search in the urino, it is advisable to pick out one of the coagulated shreds generally found in it, transfer it to the glass slide by means of a forceps or pipette, and carefully tease the fragment before applying the cover-glass. The other leading microscopical character of the urine is the minutely molecular matter — fat in an emulsified condition — to which the fluid owes its opaline or milky aspect. There are also numerous white, lymphoid corpuscles, together with red corpuscles, numerous or the reverse according to the degree of sanguinolence of the urine. Casts of the tubular structure of the kid- ney — indicative of organic disease of these organs - — are seldom to be seen ; they were absent in all the eases that have come under the writer’s obser- vation. Anatomical Characters. — The post-mortem examinations of persons who have died wdiilst affected with cbyluria, also testify to the free- dom of the kidneys from disease. This was the case in two autopsies conducted recently ’ The microscopic worms detected by the writer (in July 1874) in the blood of dogs in India — presumably the same species as those discovered by UK. G-rube and DoiAfond, in France, about 1843 — are not enclosed in an envelope of this kind, although in every other way they appear to be identical; and Dr. Sonsino states that the bBematoeoon found in Egypt is also destitute of this en- veloping tube, as is likewise the urinary parasite dis- covered by Wucherer. by Dr. McConnell in Calcu ,ta. The writer had the opportunity of examining the kidneys of the first case, and of all the organs of the body of the other ease, but could find nothing in any of the organs or tissues suggestive of being a cause of the urinary derangement, except the fact that all the vessels — arteries as well as veins —contained the filaria in their minutest ramifica- tions. It may be further mentioned that the entozoon is present in the chylo-lymphous dis- charges which have already been referred to as sometimes accompanying chyluria. Of this tho writer was able to satisfy himself in 1872, and repeatedly on subsequent occasions. In one of the instances the secretion flowed from the inner corner of the eye, several ounces of which escaped daily ; the others were cases of elephantiasis lymphangiectodes, or nse void elephantiasis of the scrotum. For a summary of what is known of the latter affection, the reader is referred to a carefully-written paper by Dr. Kenneth McLeod. 1 ^Etiology and Pathology.— Having consid- ered in detail what seem to he the leading patho- logical features of chyluria, a brief reference may be made to the views which at present prevail regarding its aetiology. These may be comprised under three heads; — (1) Dr. Vandyke Carter advocates the view that a direct communication exists between the chyle-carrying vessels and the urinary tracts. (2) MM. Claude Bernard and Ch. Robin believe that the condition of the urine is hut a symptom of piarrhsemia — fatty blood; the latter condition being but the normal condition of the blood for some time after the partaking of food, aggravated and made perma- nent by derangement of the digestive organs — notably the liver. One of these distinguished authors (M. Robin) suggests, further, that this derangement is probably induced in the liver and elsewhere by the filaria sanguinis hominis. 2 (3) The third view to be noticed is that advanced by Dr. W. Roberts. This view appears to he based mainly cn the history of a very remarkable case, published by him in 1868. It was one in which a eoagulable chylo-lymphous discharge escaped from open vesicles which had formed over the surface of the abdomen: the patient’s indue was, moreover, chylous for two days. Dr. Roberts suggests that a condition somewhat similar to that on the surface of the abdomen existed in the urinary tract, — a sort of eczema — probably on the front of the bladder. Post-mortem ex- amination did not however confirm this view, nor could anything be detected in any of the organs suggestive of a cause, but Dr. Roberts infers that this was probably due ‘ to t’ne fact that in the last few weeks of life the morbid process had retrograded and had consequently left no appreciable marks on the surface of the bladder.’ The examination of the skin in the diseased part showed that the cutis vera and the subcutaneous tissue were traversed by short channels or lacunae from the width of a crow-quill to that of a hair. A careful study of this and other cases suggested to Dr. Roberts the view that one, at least, of the forms of chyluria may be due to hypertrophy of the lymphatic channels and sub- sequent acquisition by them of gland properties. 1 Indian Medical Gazette, August 1874. * ‘Lemons sur les humeurs’ ; 2nd edit. 1S74, p. S4S. Fig. 11. Filaria Sanguinis Hominis. x 300. (Traced from a micro-photo- graph.) CHYLURIA- In the present state of our knowledge, how- ever, it cannot be said that any of these ingenious explanations meet all the objections that might be raised. For example, before the explanation suggested of the direct leakage of the chyle into the urine can be accepted as sufficient, it must be shown that such a leakage is anatomically pos- sible, and, secondly, that the relative proportion of the leading constituents of the two fluids agree more closely than is suggested by the greater number of the analyses hitherto published. M. Robin’s view does not suggest any special anato- mical difficulty, but it remains to be demon- strated more conclusively than has hitherto been done that the blood in man ever contains a sufficient quantity of fatty matter to produce such extreme milkiness by admixture with the urine as is observed in chyluria. Dr. Roberts’ theory is certainly not open to these particular objections, as, given a certain agent to start the formation of these glandular tissues, there does not appear to be any special anatomical or phy- siological difficulty to be got over ; but the result of all the autopsies as yet recorded do not war- rant the inference of the existence of such patho- logical conditions. Futuro observation, howover, may show that they really do exist. Of the setiological significance of the presence of the filaria in the circulation there can, the writer thinks, scarcely be much doubt — more especially when the number of observations re- corded within the short period that has elapsed since attention has been drawn to its existence therein, is taken into consideration. These sug- gest. more than a fortuitous connection; indeed it might rather be said that ehylo-serous effusions may be considered as symptomatic of the para- sitism. Filarias have even been detected shortly before chyluria had manifested itself. Whether they act injuriously by giving rise to rupture of the walls of the delicate channels in which they circulate and thus cause the escape of the dif- ferent nutritive fluids into the urinary tract ; or whether, as M. Robin suggests, they produce de- rangements of the liver and other organs which give rise to piarrhaemia (and, probably hi. Robin would add, to rupture of the capillaries, so as to permit of the escape of the abnormally fatty blood), it would be premature to express a defi- nite opinion. It is possible that both Carter and Robin may be correct to some extent, for the disease presents many phases ; and the writer would suggest further, that it may also be possible that, in addition to giving rise to the escape of fluid in a purely mechanical manner by causing ruptures, local congestions, and so forth, the entozoon may in some way tend to the pro- duction of minute secreting structures (analogous to those described by Roberts as having been formed in the subcutaneous tissues) along the urinary tract, or in other situations, which might permit of the filtration of the ordinary nutritive fluids of the body in a more or less modified condition. — Analyses tend to show that the con- stituents of these fluids do not reach the urine in the proportions in which they are normally found in the body. It is also possible that chyluria may occasion- ally occur unassociated with any parasite, but this remains to be demonstrated. CICATRIZATION 253 Prognosis. — Persons have been known to suffer off and on from this affection for from one to fifty years. This would suggest that the malady usually runs a chronic course, which as a rule it doubtless does ; on the other hand patients ap- parently in fair health otherwise have been known to die very unexpectedly from no recog- nised acute disorder. With regard to the pro- spect of a cure a very guarded opinion should be given, as the probability is that the complaint will return again and again so long as life lasts — even when the disease commences at a very early age, and often after a complete change of climate and avocation. Treatment. — -This has proved extremely un- satisfactory in almost all the cases recorded ; in fact it cannot be distinctly stated that the course of the disease has been materially modified, much less cured, by any known remedy. Iodide of potassium has been tried in large doses, and in some cases appears to have been beneficial ; in others the tincture of the perchloride of iron has seemed to be more successful. A decoction of the bark of Rhizophora racemosa (mangrove) has a reputation in Guiana, just as a decoction of the seed of Nigella sativa (used also as a condi- ment in curries) has in India. The latter remedy has, however, been known to be powerless in mitigating the malady even in cases where on former occasions it had been resorted to with apparent success. Perhaps the most satisfactory results which have been published are those which have followed the administration of large doses of gallic acid — one or two drachms a day. See Fila- ria Sanguinis-hominis. Timothy Lewis. CICATRIZATION ( cicatrix , a scar) is the process by which solutions of continuity in an organ or tissue aro repaired. These solutions of continuity may be duo to injury, ulceration, ex- travasation, or the effusion of inflammatory pro- ducts. The result of the process is the formation of a cicatrix or scar. Pathology. — Cicatrization, as it occurs in superficial parts in surgical practice, may be selected as affording a typical illustration of the process. It is most frequently and easily observed, and it corresponds to what, is met with in deeper tissues. Repair may take place either with or without the occurrence of granulation, and the process of granulation may or may not bo accompianied by suppuration : the existence both of granulation and of suppuration depending on the degrees of abnormal stimulation to which the injured tissues are subjected. In an incised wound favourably circumstanced as to vascularity of tissue, absence of tension, and apposition of edges, epidermic continuity may be re-established in thirty-six to seventy-two hours. The lips of such a wound are temporarily united by a thin layer of lymph and white corpuscles of the blood, and perhapis soon afterwards by cells proliferated from connective-tissue corpuscles, These cells become spindle-shaped, and are ulti- mately converted into ordinary connective-tissuo corpuscles, whilst offsets from the neighbouring capillaries re-establish the circulation throughout the new tissue. Coincidently with these changes the surface becomes covered with epidermic scales. 254 CICATRIZATION. The resulting scar at first appears as a red line, which subsequently becomes white from the dis- appearance of many of its blood-vessels. When an open wound heals by scabbing, the epidermis spreads over the tissues without the intervention of the process of granulation, owing to the protection afforded them by the crust of blood and lymph which has formed upon the wound. Recent antiseptic surgery has shown that even large hollow wounds filled with blood-clot, such as are caused, say, by operation for ununited frac- ture of the femur, may cicatrize completely without suppuration or granulation, if protected from the stimulation of the antiseptic used. In these cases the white corpuscles of the clot become organized directly into fibro-plastic cells and connective-tissue corpuscles, and the new epidermis will probably be formed beneath a thin upper layer of the clot. If a recent wound, too largo for scabbing, be simply loft exposed to the air or treated with water dressing, or with an ordinary antiseptic, there will be a discharge at first of serum tinged with blood, then of pale serum, and latterly of cloudy yellowish serum, replaced in about three days by fully-formed pus. By this time the wound will be studded over with little bright red ele- vations, termed granulations, which ultimately cover the whole surface. Granulation-tissue consists of nucleated cells, amongst which pass vascular loops with thin walls. After an inter- val the edges of the skin are seen to be on a level with the granulating surface, and as it were continuous with it. Perhaps already the wound is much smaller, owing to the shrinking of the granulutionsas their cells assume the spindle-cell type. Then, extending from the cutaneous mar- gin thore may be observed a narrow red line, brighter than the rest of the granulating surface, owing to the presence of a layer of transparent epidermis. Next day this zone will be bluish, owing to the growing opacity of the epidermic cells, and there will be a new red line of newest epithelium. A day later the outer layer will havo become so opaque as to be whitish, and the second to be bluish; and there will again be a fresh inner red line, which will gradually advance until the scar is complete. The new epidermis quickly separates into a horny and a mucous layer. The healing of an evacuated abscess-cavity depends partly upon the contraction, and partly upon the coalescence of the granulations of which its pyogenic membrane consists. Many cases of disease of joints (caries, &c.), and the behaviour of abscesses treated anti- septically and with adequate drainage, may be referred to as instances of the existence of non- suppurating granulations. John Bishop. CINCHONISM. — A condition induced by the administration of quinine, the chief active principle of cinchona. See Quininism. CIKTCXiISIS I move). — This word signifies agitation or motion, and was formerly applied to involuntary winking or movements of the eyelids ; and also to the movements of the chest in dyspnoea. OIBCUT , A TT O 3 , Disorders of. — Abnor- CIRC UL ATION, DISORDERS OF. mal excess and deficiency of blood are known as Hyperemia and Anemia respectively. Each of these may be general or local. I. Hypereemia. — General hypersemia signifies excess of blood in the body, and is also called plethora. Local hyperaemia means excess of blood in a part. Such excess may be caused either by superabundant supply, or by deficient removal of blood through the agency of the blood-vessels. Dilatation of the arteries, how- ever produced, causes more copious afflux of blood, which fills the capillaries and veins in a corresponding degree, so that there is excess of blood in all the vessels of the part. This con- dition is called arterial or active hyperemia , active congestion, or determination of blood,. If. on the other hand, blood is imperfectly removed by the veins, these vessels, as well as the capil- laries, become gorged, and the condition called venous or passive hypereemia , or venous con- gestion, results. There cannot be capillary hypereemia, except as the result of one of these conditions. A. Arterial or Active Hypereemia. — An excessive amount of blood can be conveyed by the arteries only under two conditions : — (1) Enlargement oi these vessels by relaxation of their muscular walls ; (2) Increased pressure within them, from obstruction of collateral channels with which they communicate, i.e. collateral hyperaemia. (1) Relaxation of the muscular walls may be caused directly by violence or by warmth, as is illustrated in the redness of the skin produced by a blow, by heat, or by the reaction aftei intense cold. Sudden withdrawal of pressure has the same effect, as is sometimes seen on evacuating a hydrocele or fluid-collection in a serous cavity. Dry-cupping produces similar but more complex results, the veins being acted upon as much as the arteries. Relaxation of the muscle-fibres is produced also indirectly through the vaso-motor nerves. If these are paralysed, relaxation of the fibres occurs, and the arteries dilate. Experimental section of the cervical sympathetic in animals shows this most clearly; but the same result follows less con- stantly if other nerves containing vaso-motor fibres are divided or injured, such as the mixed nerves of the limbs, or branches of the trige- minus. Wounds of the brachial plexus have been found to cause hypersemia of the fingers (glossi/ fingers of Paget). When the section is com- plete, hypersemia is only transitory, and is soon followed by a return to the normal condition, or even by undue anaemia, which is permanent. In irritative lesions, on the other hand, such as gunshot wounds, hypersemia continues as long as the irritation. In such cases it is possible that the lesion is not. paralytic, but depends upon stimulation of the actively-dilating vaso- motor fibres which physiologists have now shown to exist in many parts of the body, since stimu- lation of these produces the same result as paralysis of the inhibitory fibres. Hypersemia often accompanies neuralgia, both depending upon some morbid condition of the nerve. The starting point of the neurosis in all these cases may be, and often is, in the central nervous system, and hence chronic diseases of the spinal cord or brain are often accompanied by general CIRCULATION, DISORDERS OF. paralytic hypereemia— that is, flushing, or by con- gestion of special parts. The same result may come from reflex nervous action, set up by dis- turbances of the digestive organs, the organs of generation, or of other parts. (2) Collateral hyperaemia is a consequence of the riso of pressure produced by the blocking-up of arterial channels in the adjoining parts. It is usually effected by the enlargement of existing vessels, and the conversion of small, almost capil- lary, vessels into pulsating arteries. It occurs not only in the familiar instances of surgical ligature, and the sudden blocking of an artery by a plug (see Emboxjsm) ; but in the gradual obstruction which accompan'es atrophic and sclerotic processes. When the chief arterial channels to an organ become obstructed, its peri- pheral parts are very liable to become hyperaemic, a principle which when applied to such cases as cirrhosis of the liver, granular kidney, and sclerosis of the brain, will be found fruitful in practical deductions. Signs and Results. — Tho colour of parts in a state of active hyperaemia, is, during life, bright red, the arteries, large and small, being visibly injected, while the capillaries, filled with arterial blood, produce a diffuse red colour. In experimental hyperaemia the blood may remain bright red even in the veins. The temperature of external parts becomes elevated, though not above that of internal parts. Sometimes there is obvious pulsation or throbbing. There may be swelling, which is due to simple enlargement of the vessels, not to exudation of fluid, since this does not occur from arterial hyperaemia alone. The nerves, both those of common sensation and those of special sense, are more excitable than they are normally. There is usually a subjec- tive sensation of warmth, and there may be pain or itching. Arterial hypertemia may last for a long time without producing any change whatever in the part affected, but may, under conditions little understood, give rise to hypertrophy, which some- times, though rarety, results from section of the cervical sympathetic. Transitory but repeated hyperaemic conditions more regularly produce this result, as is seen in hypertrophy from pressure ; in thickening of the skull from excessive exposure of tho head to the sun ; in hypertrophy of the skin and its glands from frequently recurring hyperaemia of the face ( acne rosacea). This kind of hyperaemia constantly precedes, but can hardly be said to produce, inflammation. It does, how- ever, render the tissues more vulnerable, bring- ing them into a condition in which a slight cause will set up inflammation. Unless the vessels are unsound, simple arterial hyperaemia does not lead to haemorrhage. B. Passive Hypereemia or Venous Congestion . — This may be due to —(1) Feeble circulation ; or (2) Obstruction in the veins. (1) Blood may be imperfectly removed from a part, owing to the imperfect action of the forces which normally maintain the flow of blood in the veins. These are, besides the action of the heart, the pressure of muscles (combined with the arrangement of the valves in the veins), an I the movement of the thorax in inspiration. It these arc deficient, the venous current will be 266 everywhere delayed, but notably in those parts where it has to overcome the action of gravity. In the erect posture this will be the case in the lower limbs, and hence venous congestion is com- mon in the legs, ankles, and feet. In decumbent patients, for analogous reasons, the nates, sacrum, shoulder-blades, and the bases of the lungs behind become the seat of what is called hypo- static congestion. Very general obstruction, such as results from imperfection of the heart itself, may lead to the condition called cyanosis, which is essentially venous congestion, and to similar congestion of the lungs, liver, kidneys, and other internal organs, with very serious results. (2) Obstruction of the veins is rarely produced by a morbid condition of the W'alls of these vessels, but may result from coagulation of blood within them. Another cause is external pressure, such as that of tumours, of the gravid uterus, or of the intestinal contents, as in the case of the haemorrhoidal veins. Finally, indurative changes in the solid viscera lead to venous obstruction, as is seen in cirrhosis of the liver, which produces congestion of the whole portal system. Signs and Results. — The colour of parts in a state of passive hypertemia is bluish rather than red, the veins, large and small, being in- jected with venous blood, and the capillaries, in which the blood is also venous, producing a uniform purple colour: If the congestion is extreme, collateral venous channels are likely to be established, which are sometimes the only evident sign of internal venous obstruction. The surface is usually cooler rather than hotter when compared with corresponding parts of the body ; and there is no unusual nervous sensibility or sense of throbbing. Swelling very frequently occurs, and depends on actual serous effusion from the vessels, so that the parts are often anasarcous, pitting on pressure ; while in cavities there is an accumulation of fluid. Venous congestion produces more important and permanent results than arterial. In experi- mental venous obstruction, besides engorgement of the vessels, two nearly constant phenomena are seen — copious transudation of serum, and migration of a number of red blood-disks through the walls of the capillaries and smaller veins. Few or no w'hite corpuscles emigrate, and the arterial circulation is unaltered. The absence or occurrence of dropsy depends upon the ade- quacy or inadequacy of the lymphatics to carry off the superfluous serum. In ordinary patho- logical venous congestion all these changes are seen to some extent ; extravasation of red blood- disks being shown by the pigmentation of parts in chronic congestion, though this is not evident in the acute condition. Chronic venous congestion increases the hardness and density of organs, a change which may, in the first instance, result from simple oedema, but in the end is due to fibroid change (see Degenerations). Such organs are at first enlarged, hut ultimately diminish in size, and suffer fatty atrophy, not only through the general law of fibroid change, but because venous blood is inadequate to the proper nutrition of tissues. These changes are seen in the liver and kidneys in cases of obstruc- tive heart-disease. External parts, as the skin of the lower part of the leg, show by a tendency 256 CIRCULATION, DISORDERS OF. to ulceration that they aro imperfectly nourished, and are also liable to becomo inflamed from blight causes (varicose eczema). Post-mortem Characters. — The appearance of hypersemic parts after death is not neces- sarily the same as during life. The colour of the blood does not enable us to say whether the hypersemia was arterial or venous. All blood contained in the body after death, excluded from the air, is dark or venous, but becomes florid when exposed to the air, unless it have previously undergone some post-mortem change, or some morbid alteration during life. This change may be watched in the lungs when the chest is opened, especially in the case of chil- dren whose lungs have little local colour. The only important point after death is the fulness of the three lands of vessels. Arteries are usually empty, unless diseased ; the larger veins almost always full. If the smaller veins and arteries are conspicuously and brightly injected, the part maybe described simply as congested; a uniform colour indicates fulness of the capillaries, which may be confirmed by the microscope. Uncom- plicated arterial hypersemia leaves no trace after death ; the appearance of it is produced by in- flammation. Simple venous hyperaemia can only be recognised as such after death by comparison, that is, with the same part under normal con- ditions. Chronic venous congestion is indicated by many of the same characters as during life. Care should be taken not to mistake for arterial hyperaemia mere staining with blood-pigment of the walls of the vessels ; nor for venous congestion mere 'post-mortem hypostasis, or the settling down of the blood, if fluid, after death. II. Aneemia .-—General anaemia is a morbid condition in which there is a deficiency of blood, or, more correctly, a deficiency of the red cor- puscles of the blood, throughout the whole body. It is also called oligeemia, or oligocytlwmia (see Anjemia). Local anaemia, with which we are here concerned, signifies deficiency of blood in a part. It may be complete or partial. Complete local anaemia' can only occur when the blood-supply of a part is totally cut off by obstruction of its arteri es. The conditions and consequences of such obstruc- tion are discussed elsewhere (see Emiolism.) Par- tial anaemia or ischasmia may be produced by direct pressure, or else by arterial obstruction, perma- nent or transitory. Permanent anaemia of many parts results from gradual obstruction of arteries by atheromatous change, or, still more strikingly, by a form of endarteritis (endarteritis obliterans) attributed to syphilis ; or, again, from deposi- tion of fibrin on the diseased vascular wall. Temporary anaemia results from spasmodic con- traction of the annular fibre-cells in the muscu- lar coat of the artery. Such a contraction may be produced experimentally by direct electrical stimulation, or by stimulation of the sympathetic' branches distributed to the vessel; and in pa- thological conditions we find such contraction occurring in consequence of some derangement of tho nerve-centres, or from reflex irritation, or even, as it would seem, idiopathically. Neu- ralgia and migraine are often accompanied or caused by spasm of the arteries, and epilepsy has, with less certainty, been attributed to the name cause. In these eases it is possible, as is CIRCULATION, ORGANS OF. held by some authorities, that anaemia of tbt nerve-tissue is the cause of the disturbed inner- vation. Hysterical blindness, and probably other hysterical affections, may be explained in the same way. Signs and Results. — An anremie part is pale, its temperature in the case of external parts is diminished, and there is weakened or arrested arterial pulsation. A permanent con- dition of anaemia, even if only partial, produces degeneration, ending in atrophy of the affected part. The wasting of the skin, and possibly that of the kidneys in old age, is due to this cause. Transitory anaemia causes necessarily a cessa- tion of functional activity in the part, as is obvious in the nerve-centres and the muscles - but does not, so far as we know, produce any permanent change. Compression or obstruction of the abdominal aorta produces symptoms of temporary paraplegia. J. F. Patne. CIRCULATION’, Diseases of Organs of. The organs of circulation comprehend the heart, the arteries, the veins, and the inter- vening capillaries. The diseases affecting each of these structures will be found described under their respective headings. It has, however, been thought desirable to give in this place a general sketch of the different ways in which the inti- mate relations that exist between the parts of the circulatory apparatus maybe disturbed by disease. While tho heart, the arteries, the veins, and the capillaries have each special diseases, related to their differences of structure and of function, the effect of such diseases is rarely or never purely local. The other parts of the circulation on either side of the lesion and the regions to which the vessels are distributed suffer more or less from the local disease. This is true whether the disease be structural or only functional ; and whether, in the latter case, the nervous system or the blood be the primary seat of the disorder. Viewed thus, the sul jeet will be best considered under three heads ; — 1 The structural changes of the several organs of circulation, and the diseases and disorders to which they give rise in other parts of the system, whether general or local. 2. The functional disorders of the organs of circulation due to nervous disturbance, both local and general. 3. The functional dis- orders of the circulation due to changes in the blood. We shall discuss these divisions in the order in which they have been named. (A) — Structural Changes in the Organs of Circulation. — The heart is liable to organic disease either in its propelling muscular walls, its regulating valves, or its controlling nervous sys- tem ; and it will be found that diseases of each of these parts of the cardiac apparatus affect respeo tively its several functions. Thus disease of the walls of the heart affects the force or pressure ; valvular disease primarily disturbs the distribu- tion or quantity of blood in the several parts of the circulation ; while nervous disorder especially in- terferes with the rate and regularity of its move- ments. Diseases of the arteries interfere with the quantity of blood transmitted through them, and produce secondary disturbances of distri- bution or of pressure. When the capillary walls are degenerated or ruptured, or when their canalr CIRCULATION. DISEASES OF ORGANS OF. 257 are Mocked as a result of embolism or throm- bosis in arteries or veins, nutrition is disturbed in various ways. Lastly, the veins may be the seat of a variety of lesions, which prevent the return of blood, and lead to haemorrhage cr to dropsy. We shall consider the diseases that have been above indicated from a common point of view. viz. their effects upon the circulation. 1. The pressure of blood within the circula- tion may be either increased, diminished, or irregularly distributed. The most marked in- stance of increased pressure is seen in simple hypertrophy of the left ventricle without val- vular disease, especially if the hypertrophy be associated with increased peripheral resistance, as obserred in chrouic Bright's disease. The effects of increased pressure on the heart are cardiac enlargement with its consequences, and valvular disease ; in the arteries , they are fulness, elongation, thickening, and atheroma with its results. The pulse is strong and full, and may possess the various characters of the vessel-wall just enumerated. The capillaries are over-dis- tended, and may be ruptured, htemorrhage being the result. The functions of the several organs are, under favourable circumstances, more active ; and the venous circulation is more free. Diminished pressure of the circulation is more common, and is seen in dilatation with thinning of the cardiac walls, in atrophy, in fatty de- generation, and in fibroid hypertrophy or de- generation. The effects of diminished pressure within the circulation generally are the reverse of those of increased pressure. The arteries are comparatively empty and small, and the pulse is weak, small, and often irregular. The capil- laries are insufficiently supplied with blood ; the visible surfaces are anaemic, or passively con- gested; and the various functions are feebly discharged. The backward pressure within the veins is, on the contrary, increased; the blood tends to accumulate within them; the walls are dilated ; the valves are disorganised ; and passive congestion, thrombosis, dropsy, and chronic in- flammation are frequent results. 2. The Quantity of blood distributed . — What has just been said coucerningthe pressure of the blood applies, in a great measure, to the quantity- distributed through the circulatory system. In hypertrophy of the heart, a larger amount of blood passes through it in a given time, and the arteries and pulse are full; while in atrophy and dilatation the quantity is less, and the pulse is empty and contracted. 3. The most frequent disturbance observed is irregularity of distribution. This condition generally affects the pressure and quantity to- gether, but may affect one more than the other. Irregular distribution of blood and of pressure is most markedly present in valvular imperfec- tion, and especially in aortic and mitral regur- gitation. It is also seen in obstruction and other allied conditions of the arteries, especially of the aorta. In the parts of the circulation and in the organs situated behind the seat of disease, irregularity of distribution of blood and of pres- sure is manifested in the form of dilatation, such as enlargement and engorgement of the heart, of congestion and associated changes in die lungs and abdominal viscera, of hoemor- 17 rhage, and of various exudations and effusion; whether as cedema, dropsy, or catarrh. On the other hand, the portions of the circulatory apparatus beyond the seat of disease are under filled and undersized ; the organs are deprived of their sufficient supply of blood : and anaemia, with its further consequences, is the result. 4. Frequency and Rhythm . — Among the mosl common forms of cardiac disturbance are altera- tion of frequency and irregularity of rhythm. Alteration in frequency is generally in the direc- tion of increase ; but unnatural slowing may also occur as a symptom of fatty degeneration and other morbid conditions. The essential causes of modifications in the rate of the heart’s action are very complex and obscure, for the muscular tissue, the intrinsic nervous apparatus, and the extra-cardiac nerves and centre in the medulla oblongata, may, in different instances, be all more or less concerned. As a rule, increased frequency is associated with, and proportionate to, weakness of ventricular contraction. Un natural slowing is believed to be generally ner- vous in its origin ; but it may sometimes be duo to inertness of the muscular substance from fatty degeneration of the walls of the heart. The remarks that have just been made respect- ing frequency apply equally- to disturbance of rhythm and irregularity of contraction. Fre- quency and irregularity of pulse in organic disease of the heart are generally indications of serious cardiac weakness, and are often found in the later stages of heart-disease, whether irs original seat has been valvular or parietal. (B.) Functional Nervous Disorders of thk Circulation. — When the distribution and func- tions of the nervous structures associated with the organs of circulation are considered, the variety and complexity of the disorders of the heart and vessels due to nervous influences will be readily appreciated. Through the medium of the nervous system the action of the heart is affected by every- sen- sory impression received by the brain ; specially by influences proceeding from the following parts : — the respiratory centre, the respiratory- organs, the blood-vessels, the abdominal viscera, the surface of the body, and the cerebrum itself with the organs of sense. Many of the disturbances of the circulation with which the reader is fami- liar in diseases of the lungs are occasioned through nervous channels, especially such respi- ratory diseases as are attended with imperfect oxygenation of the blocd. In the blocd-vessels, the most marked example of nervous associa- tion between them and the heart is afforded by the relaxation of the arteries in cardiac over-distension and embarrassment through the operation of the depressor nerve, which, passing from tho heart to the vaso-motor centre in the medulla, inhibits or controls the constrict- ing influences constantly exerted by this centre on the walls of the vessels, and thus effects the relaxation of these vessels and ‘ depresses ’ the circulation or lowers the blood-pressure. Cardiac disturbance referable to abdominal causes is so familiar that it needs scarcely to be mentioned ; and such disturbance, though frequently- direct, is more frequently indirect or reflex through the nervous centres. Tho 258 CIRCULATION, ORGANS OF. condition of the blood-vessels within the ab- domen has the greatest influence on the heart find circulation generally, as may be seen in cases of shock, inj ury, and inflammation of the peri- toneum and great viscera. The swrfaee of the body, as the seat of impressions of touch, of temperature, and of common sensibility, may prove to be the source of cardio- vascular nervous disturbance. It is through impressions on the nerves of the surface that the circulation may be disturbed until seriously embarrassed, and even paralysed, as in shock, exposure to cold, &c. ; or, on the other hand, roused to activity, by blistering, flagellation, douching, &c. Lastly, the more extreme and frequent, as well as the more irregular and varied nervous disturbances of the circulatory organs are due to conditions of the brain. The most common of all forms of circulatory disturbance is seen in emotional excitement, as palpitation, with vascular throb- bing, and as in blushing or in pallor. The general phenomena of functional disorders of the circulation due to nervous disturbance are — (1) Alteration in the force, frequency, and rhythm ot' the cardiac movements ; and (2) Dis- turbances of sensibility referable to the condition of the nerves, to distension of the cavities, and to irregular muscular contraction. In certain cases the cardio-vascular disorder may be ex- tensive, complex, and serious, and may involve the neighbouring nerves, as is seen in angina pectoris. The remote effects of these attacks of functional failure are fully described else- where. See Heabt, Functional Disorders of. Other disorders of a complex character occur, such as Graves’s disease, which is probably referable to a nervous origin. (C.) Functional Disorders of tub Circula- tion, DEPENDING ON T1IE CONDITION OF THE BlOOD. —The blood is so essentially associated with the organs of circulation, that any alteration either in its quantity or in its composition speedily manifests itself in disorders of the heart or vessels. Besides the effect on the general intra- vascular pressure that follows directly any change in the blood, there are two ways in which any morbid state of this fluid reacts upon the circulation — namely, first, by affecting the nutrition of the cardiac •and vascular walls ; and, secondly, through the agency of the ner- vous centres. Thus, when the amount of blood is below the normal, not only is the circulation comparatively depressed, but the myocardium is ill-nourished and feeble, the tone of the vessels is low, and the excitability of the nervous cen- tres, which directly or indirectly control the heart, is greatly increased. The opposite condi- tion — of plethora, high blood-pressure, enlarged and powerful heart, and energetic nervous system cannot, within definite limits, be con- sidered morbid, but rather an evidence of too robust health. The most frequent changes in the quality of the blood are those which are associated with ansemia, as first described. The next most important group of cases is that in which the blood contains some poison, whether generated within the body or introduced from without. The disturbances of the circulation by poisons of all kinds are very numerous and complex. When the poisoning of the blood is CIRRHOSIS. of long duration, and moderate in degree, chronic disease may be set up throughout the organs of circulation ; and this is probably the mode of origin of the cardio-vascular disease so often found accompanying chronic Bright’s disease. R. Quain, M.D. CIftR.HO SIS (ki ppbs, yellow). — Synon. : Scle- rosis ; Fibroid Substitution ; Fibroid Degene- ration ; Chronic Interstitial Inflammation ; Fr. Cirrhose ; Ger. Cirrhose. The term cirrhosis, which was originally in- vented to describe a particular state of the liver has now acquired a more extended meaning, and is applied to similar morbid processes affect- ing other organs, though the name itself, derived as it is from the yellow colour of the liver in this disease, ceases to be properly applicable. Cirrhosis may be regarded as a chronic non-suppurative inflammation affecting the interstitial, connective, and supporting tissues of the different organs, and not those by ■which the proper physiological function is per- formed. The process begins, after a more or less protracted liyperaemia, by the appearance in the interstitial tissues, between the proper functional elements, of small lymphoid cor- puscles or leucocytes, udiich are arranged in lines or tracts interpenetrating the affected organ. These corpuscles crowd the tunica adventitia of the small vessels, the lymph- spaces, and the cavities in which the connective- tissue corpuscles lie ; and when present in con- siderable amount appear to the naked eye as narrow lines of a slightly translucent greyish material. This condition was formerly termed cellular hyperplasia of the connective tissue, and the corpuscles themselves were supposed to originate from proliferation of the connectivo- tissuo corpuscles. More recent researches have, however, shown that in inflammation the eonnec- tive-tissue corpuscles remain quite passive and take no part in the formation of new cells. The early stage of cirrhosis is therefore more correctly described as cellular infiltration of the connective tissue. The cells themselves are white blood-globules, which have emigrated from the vessels, and their descendants. The amount of this cellular exudation varies very much in different organs in the different forms of the disease. In many cases of cirrhosis of the liver, and in the fibroid induration of the left ven- tricle of the heart, and of the pylorus, it is very considerable, and causes much increase in the bulk of the affected organ. In other instances, as in some forms of granular kidney, it may be very small. Many pathologists consequently regard the process in these cases as essentially one of atrophy of the true physiological tissue, and the indurated fibrous tissue which results as consisting of the withered remains of the vessels ducts, &c. of the organ. The later stages of the process consist in the conversion of these tracts, which may be looked upon as closely analogous to ordinary granula- tion-tissue, into fibrous tissue. A more or less fibrillated intercellular substance appears ; the corpuscles diminish in number; the remaining ones become in part elongated and oar-shaped, and some may pass into true spindle-cells, cr CIRRHOSIS. become stellate : in cirrhosis of the lung tracts of true spindle-cell tissue are often met with. In the liver, -where much of this new tissue is often formed, numerous blood-vessels become developed in it: they are devoid of distinct walls and consist merely of channels lined by endothelium. The fibrous tissue -which is the final result of the whole process, closely re- sembles ordinary cicatricial tissue ; it is usually tough, dense, and imperfectly fibrillated, with a strong tendency to contract. Sometimes, especially in the suprarenal capsules, and less frequently in the liver, portions of it consist of a reticulated connective tissue. The effect of this series of changes on the proper physiological tissue of the organ is to cause its atrophy. This is partly due to the direct pres- sure of the new growth, when it is formed in large quantities, but chiefly to the constriction of the contracting fibrous tissue and the consequent ob- literation of the blood-vessels ; for even where, as in the liver, new vessels are developed, the origi- nal vessels of the organ become obliterated. The atrophy of the proper tissue of the organs ap- pears to take place by a gradual process of granu- lar and fatty degeneration followed by absorp- tion. Sometimes, particularly in the lungs and suprarenal capsules, this change is less gradual, and portions of the original tissue together with the new growth lose their vitality cn masse, pass at once into a state of fatty degeneration, and ultimately become caseous and even calcareous, giving rise to the formation of opaque yellow nodules surrounded by the semi-translucent grey fibrous tracts. In these cases it becomes difficult to draw a strict line of demarcation between cirrhosis and true tuberculosis, and the difficulty is rendered greater from the fact that chronic tuberculosis in itself sets up the cirrhotic process. In the lung the caseous transforma- tion is no doubt most commonly caused by the filling up of the air-vesicles with large epithelioid catarrhal cells coincidently with the cirrhotic change in the walls of the vessels. These catarrhal cells not being in immediate relation with the blood-vessels, are especially prone to caseous change. So, too, in the suprarenal capsules the caseous nodules, if examined early enough, will be found to consist of the tubular spaces of the organ filled with their cells in a state of fatty degeneration. Ill the liver, on the other hand, the secretory cells, being in intimate relation with the blood-vessels, are not liable to this caseous transformation. Again, it is impossible to make a strict demarcation be- tween syphilitic affections of the viscera and true cirrhosis. Even the typical gummata of syphilis originate in and are surrounded by tracts of cirrhotic induration ; and in other cases where true gummata are not found, the only difference between cirrhosis and syphilis is that in the latter there is a greater accumulation of the new growth at particular points and a less general diffusion of it through the organ. Lastly, in 6ome cases, as in the cirrhotic liver of hereditary syphilis, the two processes are identical. If we now proceed to inquire into the causes of drrhosis, we find that it is generally preceded by a protracted hyperaemia of the affected organ produced by some chronic irritation, whether CIVIL INCAPACITY. 25? functional or mechanical. As examples of this may be mentioned cirrhosis of the liver which results from the congestion produced by spirit- drinking; sclerosis of the grey matter of the cerebral convolutions after protracted maniacal excitement; ci-rrhosis of the lung, the result of prolonged inhalation of irritating dust in tho various forms of grinders’ and miners’ phthisis ; the cirrhotic thickening of the pylorus in chronic catarrh of the stomach ; and cirrhotic affections of the lungs and heart extending to those organs in chronic inflammation of their serous coverings. A mere passive congestion, however, if long continued, may cause a simple hypertrophy or overgrowth of the interstitial connective tissue, and more or less induration in consequence. It does not, however, appear to have the same tendency to excite active proliferation and the formation of the contract- ing fibrous tissue characteristic of true cirrhosis. The exception to this rule is that wo usually meet with a slight degree of the cirrhotic change in cases of ‘nutmeg’ atrophy of the liver due to prolonged passive congestion of the hepatic venous system. W. Cayley. CIRRHOSIS OP LIVER, LUNG, &e. See Livee, Lung, &c., Diseases of. CIVIL IN CAPACITY. — One of the causes of this condition is mental weakness or disease, and it is one of the duties of the physician 1 o aid in determining the existence and nature of such conditions. There is a kind of incapacity which is implied in the restriction of a person's liberty when he is placed under care in an asylum or other special place of treatment. The neces- sary information regarding this will be found in the article Lunacy, Laws of. But the question of incapacity is more directly raised when it is proposed that a person should be declared unfit to exercise his civil rights, to require tho shield of the law to prevent his being imposed on, and to obtain special protection for his pro- perty. Medical evidence will require to be taken if it becomes necessary for a Commission of Lunacy to be issued by the Lord Chancellor. This is a proceeding which ought not to be adopted if it can properly be avoided. But it must be remembered that till a person is found lunatic by inquisition he may, though placed in an asylum under regular certificates, exercise his rights un- restricted in the disposal of his property. The acts of any person either in or out of an asylum may, however, be declared invalid if it can be shown that at the time they were performed the person laboured under such an insanity as rendered him incapable of performing them rationally and without injurious consequences. On this principle any person may be found to have been incapable of contracting marriage, of executing a deed, contracting a debt, making a will, or giving credible evidence. The principle, it must be carefully noted, is not that the mere existence of insanity in the person performing them invalidates such actions, but that if the insanity has materially affected the character and quality of the actions they may be thereby invalidated. This is one of the most importaui principles that a medical jurist has to keep ii mind, as it is not an unfrequent mistake to sup CIVIL INCAPACITY. 260 pose that a person is necessarily incapacitated for the performance of every civil act the moment he can be proved to labour under any condition to which the term insanity may hz applied. Per- haps the case in which the validity of a civil act is most easily endangered by the existence of any form of insanity is the contract of marriage. This proceeding is supposed so to affect the whole relations of life that almost any form of unsoundness of mind may be sufficient to inter- fere with that intelligent and deliberate con- sideration which is essential to the giving of rational consent. The different kinds of mental disease will be found described elsewhere (see Insanitv), and it is necessary that the practitioner, when dealing with medico-legal questions, should be fully ac- quainted with them. But it is chiefly important that he should distinguish the two following classes: (1) diseased perversion of the mental faculties, and (2) weakness or enfeeblement of the mental faculties resulting either from de- fective development, disease, or decay. The first class includes all kinds of insanity which are the result of active disease. These would be the simple forms of delirium, mania, melan- cholia, and monomania ; as well as the similar primary conditions which are found in general paralysis, and other diseases which present ma- niacal, melancholic, or monomaniacal symptoms. It is in this class that the special knowledge of the physician can be most successfully applied in aiding the administration of justice. In order to establish the incapacity of a person said to labour under any of these forms of disease, it must be necessary that an experienced physician should not only be able to detect their charac- teristic symptoms, but also to show that the performance of the duties or the exercise of the rights under consideration -would be modified or obstructed by the existence of such disease. The second class includes congenital imbecility, and all the forms of what is called chronic dementia — all those enfeeblements of mind which are some- times the remaining effects of acute disease, some- times the concomitants of chronic disease, and sometimes only the mental phase of senile decay. Here, again, the information which may be com- municated by the physician must be of great importance. But in estimating the extent to which a condition of mere mental weakness will disable a person from the performance of a cer- tain class of actions there is not so much special medical knowledge required as is necessary in the consideration of active disease. Marriage . — As has been already stated, the mere existence of any form of insanity in one of the parties may render a contract of marriage void. In one case which terminated in this manner, a man who had been insane and when in that state had voluntarily contracted marriage instituted the suit himself. Civil Contracts may be held binding although made by lunatics. If the person with whom a contract is made had no knowledge that the person contracting was insane, and if no attempt was made to take undue advantage of him, the contract would be held good. Wills . — -A person is considered to be of a dis- posing mind, that is, capable of making a valid will, if he knows the nature of the act which L: is performing, and is fully aware of its conse- quences. It is. in regard to the making of wills that the law has carried out most thoroughly the principle that the validity of an act ought to be maintained in cases of insanity unless at the time the act is performed the state of mind of the agent can be shown to render him unfit to perform that particular act in a rational manner. Persons have made valid wills while inmates of lunatic asylums. And one will was held to be good though the testator had committed suicide within three days after its execution. The ex- istence of delusion which has been regarded by lawyers as of such importance in cases of al- leged insanity does not invalidate a will ; for it has been declared to be ‘ compatible with the retention of the general powers of the faculties of the mind,’ and to be ‘ insufficient to overthrow the will unless it was calculated to influence the testator in making it.’ On the other hand, a will may be invalidated on account of the exist- ence of mental states which would not be re garded as insanity from either a legal or medical point of view. Drowsiness and stupor resulting from erysipelas or fever, extreme weakness from cholera, and failure of memory in old age, have all been found sufficient to render wills void. It frequently happens that a medical man is called on to be witness to a will. On such an occasion it is his duty to satisfy himself as to the testa- mentary capacity of the testator. His subse- quent evidence in regard to this, will, in case of dispute, bg of almost decisive influence if he has taken proper means of forming an opinion. Ir. all cases, therefore, where there may be a possi bilitv of doubt it is well to require the testator to show that without extraneous aid, and with- out referring to the document itself, he remem- bers and understands all the provisions of the deed. Evidence of the Insane . — Lunacy was, till a recent date, regarded by the law as incapacita- ting a patient from giving evidence in court. But according to the much more extended sig- nification which the term lunacy has received it now includes states of mind which are looked on as compatible with testimonial capacity. Where the judge is satisfied that the lunatic understands the obligation of an oath, and can give a rational account of such things as happen before his eyes, the evidence may be admitted. But the weight to be attached to such evidence will still depend on the extent to which it fulfils the conditions commonly required to constitute credibility. It has been held, however, that when a person has suffered from an attack of insanity between the occurrence of the transaction and the time he tenders his testimony, his evidence cannot be admitted. Management of Property . — Where persons are supposed to be unable from unsoundness of mind to undertake the management of their own pro- perty, it may be necessary that they should be placed under the protection of the Court of Chancery; but this proceeding is not usually had recourse to unless there is urgent necessity or a strong probability that the person’s incapacity will be permanent. It is consequently resorted to chiefly in chronic or congenital cases where CIVIL INCAPACITY. there is no room for doubt as to the mental con- dition of the individual; and in cases of recent insanity where it is necessary to have recourse to an asylum for the protection of the individual it may also be necessary to obtain protection for his property by the aid of the Court of Chancery. In giving evidence or framing a statement in such a case it is important, if incapacity is to be proved, to show that the individual has been found, when placed in cir- cumstances requiring such capacity, unable to perform the acts which the management of property necessitates. In cases of active in- sanity it is especially required to show', not merely that there is delusion or other symptoms of insanity, but that the insanity is of such a nature as specially to disable the person from duly performing the duties which would be re- quired of him. Difficulties most frequently occur n cases of imbecility and dementia ; but the ver- dicts in such cases when disputed will generally do found to rest rather upon the impression pro- duced by evidence of the actual behaviour of the individual than upon the mere medical view of his mental condition. The most effectual aid that the medical witness can render in such cases is to show whether there are or are not such pecu- liarities in the conduct of the person under inquisi- tion as are known to be characteristic of imbeciles or demented persons. In undisputed cases, where the duty of the medical man consists merely in making an affidavit, there is no special difficulty to be encountered. Brevity, scrupulous accurac}', and attention to the fact that such unsoundness of mind as involves incompetency to manage pro- perty must be established, are the most important requirements. A person found by the court to be incapable is placed under the control of a ‘ committee of the person,’ and the property under t. 1 committee of the estate.’ In Scotland an application to the Court of Session for the ap- pointment of a Curator bonis takes the place of the English inquisition. The chief peculiarities of the Scotch process are that it is cheaper, more easily effected and more easily annulled, and that it does not affect the person of the lunatic. The functions of the curator correspond to those of the committee of the estate in the English court. The Scotch procedure for the appoint- ment of a guardian of the person was virtually in desuetude until the passing of a recent statute (31 and 32 Viet., cap. 100). Under this act a brieve for the cognition of an al- leged lunatic is issued from Chancery and tried before a judge of the Court of Session and a special jury. The procedure is similar to that of jury trials in other civil causes in Scotland, and both medical and other evidence must be produced. If the person so cognosced be found ‘ furious, fatuous, or labouring under such un- soundness of mind as to render him incapable cf managing his affairs,’ his person is placed under the guardianship of the nearest male relative found competent. Drunkenness . — This condition is not held to deprive a man of civil capacity unless it has at the time rendered the individual unconscious ot '.That he was doing. J. Sibbaid. CLAP. — A popular name for gonorrhoea. See Goxorrhcea. CLIMATE. 261 CLAVTTS HYSTERICUS (davits, a nail).— An acute pain often associated with hysteria, but occurring also in other conditions, which is felt in a localised point in the head, and is compared by the sufferer to the sensation that might be produced by a nail being driven into the part. See Hysteria. CLIMACTERIC (icA//ia/0Tr)p, a step, KAi^aCjo, I proceed by degrees, or step by step). — This word, which properly signifies ‘ by degrees,’ was originally employed to indicate certain epochs or periods in the life of an individual, which wero looked upon as critical, and at which the body was supposed to have undergone a complete change, so that it had become entirely renewed in its structural elements. The years in which these epochs terminated were called climacteric years — anni climacterici, and their number was variously estimated. Thus, some only recognised three climacterics ; the Greek physiologists held that there were five, ending at the seventh ye»r, the twenty-first (7 x 3), the forty-ninth (7 x 7), the sixty-third (7 x 9), and the eighty-first (9 x 9); others made them multiples of seven or nine, or multiples of seven by an odd number. Most regarded the sixty-third year as the grand cli- macteric, but the Greeks recognised two grand climacterics, terminating respectively at the sixty-third and eighty-first years, and this special denomination was given because there was little, if any, prospect of life being extended beyond these periods. At the present day the word cli- macteric has lost much of its original meaning, and is generally applied to certain times of life, without any reference to numbers of years, at which marked physiological or developmental changes occur, such as tire period of puberty, or that of the cessation of menstruation. A particular climacteric disease has been de- scribed, which is said to occur either about or subsequent to the sixty-third year or grand cli- macteric, and supposed to be distinct from the natural decay and degeneration which takes place in advanced life, inasmuch as recovery often ensues. It is stated that the complaint comes on suddenly, but advances insidiously, the symptoms being at first loss of flesh and weakness, followed by loss of appetite and dys- peptic symptoms with a white tongue, which are regarded as sympathetic, sleeplessness ordisturbed and unrefreshing sleep, constipation, pains in the head and chest, a frequent pulse, swelling of the legs, and an emaciated or bloated appearance of the face. The urine does not present any ab- normal characters, and most of the viscera seem to perform their functions properly. Whether there is any independent disease deserving this special denomination seems to the writer to be more than doubtful. Frederick T. Roberts. CLIMATE, etiology of. See Disease, Causes of. CLIMATE.— Formerly the word climate (from the Greek word K\ivoi, I incline) was a term of astronomical or mathematical geography, which implied a portion or zone of the earth's surface comprised between two lines parallel to the equator, and measured by the length of timo during which the sun there appears during the CLIMATE. >62 Bummer solstice, that is, l>y the sun's inclination. The space between the equator and the pole was diyidod into half-hour climates, in which the length of each day increased by half-an-hour, and also into monthly climates. This unequal division of each hemisphere is now replaced by a division of the interval between the equator and the poles into ninety degrees, which constitute what are called degrees of latitude, and the word climate has received a more extended application. By climate is now understood those conditions of heat, moisture, atmosphere, wind, soil, and electricity, which impress certain conditions, uni- form even when apparently irregular, on given portions of the earth’s surface, and which modify, also in a uniform manner, vegetable and animal life. Climate, when thus interpreted, is still princi- pally dependent on astronomical facts, on the sun's position or inclination with regard to the earth, and on the amount of heat it supplies to different portions of the surface of the latter. Climate may be studied generally and locally. The division of the earth’s climates is necessarily arbitrary, and many different classifications have been proposed. The most simple is that which recognises three principal kinds of climate, each susceptible of subdivision, viz. : warm climates from the equator to 35° lat., temperate climates from 35° to 50° or 65° lat., cold climates from 50° or 55° to the pole. As subdivisions we may recognise equatorial, tropical, sub-tropical, sub- polar, and polar climates ; and also insular and maritime, or moist climates — continental and mountain, or dry climates. 1. Warm climates, extending from the equator to 35° lat., that is, 1 2 J° beyond the tropics, com- prise nearly all Africa and its islands, South Asia, most of the islands of Polynesia, and the portions cf North and South America comprised between California and the north of the La Plata territory. In the equatorial regions tho medium temperaturo for the year is from 80° to 84° F., the min. being 54°, tho max. 118°. Near the equator the annual mean temperaturo decreases slowdy as we recedo from it, the decrease not amounting to more than 2° F. for the first 1 0° lat. Tho difference of tem- perature during the day is slight, but much greater during tho night, owing to radiation. The general variations of the barometer are slight, but the periodical or diurnal variations are very marked. It ascends and descends regu- larly twice in the twenty-four hours. It ascends from 4.13 a.m. to 9.23 a.m., and descends until 4.8 p.m., ascending again until 10.23. Electrical phenomena are very decided. The rainfall is variable, but 40 inches may bo given as a mean. It is generally supposed that heat is greatest at the equator and diminishes as we recede from it ; hut both observation and astronomical induction lead to the conclusion that not only tho maximum of temperature in warm climates is attained at or near the tropics, but also the highest annual mean. The countries in which the highest degree of heat is known to be attained are near the tropic of Cancer, as, for instance, tho hanks of the Senegal, the Tehama of Arabia, and Mehran in Beloochistan. Moreover, the snow-line, or the lino of perpetual snow, is higher at the tropics than at the equator. In the Bolivian Andes, near the tropic, it is 17,000 feet, whereas in the Ecuador Andes, on the equator, it is only 16,000 feet. These facts are partly explained dv the unequal progress of the sun after tho equinox in its course towards the tropic. In the first month it passes through 12° of latitude, in the second month through 8°. At the end of the second month, therefore, it is 20° from the equator, and there remain only 3i° to he traversed in the third month. Tho sun receding from the tropic at the same rate at all places between 20° and 234 ° of latitude, the solar rays during two months fall at noon either perpendicularly or at an angle which deviates from a right only by 3 at most. Another cause which tends to diminish heat in the regions near the equator is the prevalence of rain. For about five degrees north and south of the equator, in the region of the equatorial calms, there are few consecutive days in the year without rain. The principal cause both of the calms and of the rains has been attributed to the meeting in the upper atmospheric regions of the trade winds, north and south. They neutralise each other and precipitate the vapour they hold in solution. Regions that lie between 5° and 10° of latitude have usually two rainy and two dry seasons. Tho greater rainy season occurs when the sun in its passage to themearest tropic passes over the zenith, lasting from three to four months. The lesser rainy season occurs when tho sun on its return from the nearest tropic approaches the parallel of the place. The mins then only last from six weeks to two months, and are much less abundant and continual. Countries more than 10° or 12° from the equator havo only one rainy and one dry season ; the first begins when the sun approaches the nearest tropic, and ends some time after, when in its course from the tropic it has passed the parallel of the place. It lasis from four to six months. Local conditions may modify the course of tho dry and wet seasons, as is the case in India, where the dry and rainy seasons depend principally on the monsoons. The amount of rain that falls in a short time within the tropics is very great, much more so than in more northern regions, hut these heavy rains do not last continuously as is supposed. Days of continued rain, even in the rainy season, are rarer than in the north. Still, heavy rains are apt to cause great inundations, and to cover largo extents of low or level country with water, causing swamps and marshes, very injurious to health. In tho vicinity of the tropics there is a belt, extending over several degrees of latitude, where it seldom rains. This rainless tract is precisely the region which has been already mentioned aa that of greatest heat. These belts of rainless regions, extending around the globe on each side of the equator, may be said to separate the coun- tries which lie on each side of the equator from the temperate zones. Thus in Africa the rains cease on the southern border of the desert, of Sahara at about 16° N., and begin again at 28°N. On the banks of the Nile the rain ceases about 18° or 19°, to begin again between 2S° and 29°. The Tehama, or low coast of Arabia, is all hut rainless. This rainless tract crosses Asia as fat as China, where there is no rainless region, owing, probably, to the fact, that all parts of China bo- GLIM tween 22' and 30° N. lat. are traversed by high mountain chains. The influence of warm climates impresses cer- tain peculiarities on thepeoples who inhabit them. They are the abode of the Ethiopian and Mongo- lian races of mankind, and appear to have im- pressed the samecharacteristics.in a minor degree, on the Caucasian races that inhabit them : a dark complexion and black hair. The inhabitants of those countries are indolent and apathetic. The functions of the skin and liver are peculiarly ac- tive, a circumstance which exposes them to severe disease of these organs. The digestive functions are sluggish, and the nervous system is alter- nately excite 1 and depressed. Eemittentand in- termittent fevers, dysentery and yellow fever are common. During the dry season disease tends to assume the ataxic, during the rainy season the adynamic form. Pulmonary consumption is frequently met with in the towns, in contra- diction to received opinions. 2. Temperate climates may be said to occupy the zones of the earth’s surface comprised between 35° and 50° or 55° lat. They comprise south- ern and central Europe, with its islands ; the parts of Asia which extend between the Black Sea and the Mediterranean, and Japan; the greater part of North America ; a part of Chili and La Plata and Patagonia, in South America. The mean temperature may be stated at from 60° to 50°. The climates in which the mean tem- perature is from 60° to 68° are often spoken of as temperate, but in reality they approximate closely to warm climates. The four seasons, winter, spring, summer, and autumn, are well marked, but very variable both as to barometri- cal and thermometrical conditions. The mean temperature in the central regions is, for winter 38°, for spring dl°, for summer 68°, and for autumn f)3°. The regions which are near the south and north limits of the temperate zones approximate to the meteorological characters of the warm and cold climates respectively. The periods of the year when storms, rain, and general versatility of meteorological phenomena are principally observed correspond with the vernal and autumnal equinoxes. The in- fluence of a temperate climate on the human organisation is salutary, extremes of heat and cold being both trying. Thus the healthiest climates of the world’s surface are found in this zone. Intense heat, or even moderate heat if persistent, throws a physiological strain on the liver, skin, and digestive system, and renders mankind prone to severe and fatal diseases of these organs. Intense cold throws a physiological strain on the lungs and kidneys, and exposes them also to severe and fatal disease. The healthiest temperate climates are those in which the winter is not very cold and the summer is not very warm, and in which, consequently, there is no great or continued strain on any one class of organs. The diseases of temperate regions are those that are the best known, as their study and descrip- tion constitute the foundation of pathological science, ancient and modern. The climate which, perhaps, the best deserves tiie appellation of temperate is that of the Medi- terranean basin. The winters are not severe on any part of its north shores, and the summers are iATE. 263 not intensely hot on its south shores; at least the heat falls short of that of the tropics. There are many conditions of physical geography which conduce to this result. The north shores are protected from north winds by the ranges of high mountains of Southern Europe which skirt them, and the south shores are in close proximity to the hot, rainless tract of Northern Africa — the desert of Sahara, which favourably modifies win- ter temperature. Moreover, the Mediterranean is a warm sea, but few cold rivers of con siderable size flowing into it from the north. & fact which increases the temperature on its shores and islands. 3. Cold climates comprise the regions which ex- tend from 50° or 55° lat. to the poles. They may be subdivided into cold, with a mean of from 50° to 40°; very cold, with a mean of from 40° to 32° ; glacial, with a mean below the freezing point. In the austral hemisphere the zone con- tains but little known land, although the existence of an antarctic continent is suspected ; in the northern hemisphere it comprises, in Europe, the north of Scotland, Denmark, Sweden, Norway, 'Iceland, Finland, Lapland, Northern Kussia, SpitzbergeD, Nova Zembla; Northern Asia, ami some of its large plains below 50° lat., Siberia, and Kamtschatka; in America, Canada, including some regions below 50°, the northern lands and islands of Hudson’s and Baffin’s Bays, and Greenland. In this zone the decrease of the mean temperature is much more rapid as we recede from the equa- tor, than it is in the tropical regions. Thus from the equator to 20° lat. the variation of the mean temperature is not more than 7° or 8°, whereas the variation between 55° and 7o° lat. amounts to from 22° to 27°. The coldest region of the globe is not, it would appear, at or near the pole, but at about 80° lat., or 10 J from the pole, north of Behring's Straits : the cold of the glacial climates has been exaggerated. At the latitudes of from 70° to 78°, the extreme limit of human habitation, the moan annual temperature is be- tween 19° and 17°, i.e. 13° to 15° below the freezing point. The extreme of cold registered, however, reaches a hundred degrees or more below the freezing point. Owing to astronomical condi- tions there is great disproportion between the length of the nights and of the days at different seasons of the year. In the more northern regions, for several months in the winter the sun never appears above the horizon, and in the summer for several months the sun never disappears below it. Spring, during which the extreme cold is mitigated, lasts but a very short time, and is suc- ceeded by summer, which is in its full strength in June and July. Temperature rises rapidly from 35° to 5o c and 60°. In some northern localities it rises to 86° or 90°. Under the in- fluence of the prolonged or persistent days, and of the increased temperature, the vegetation peculiar to each locality passes through all its phases with extreme rapidity. Towards the end of J uly rain and fog reappear, and are followed by snow and intense cold, the highest expression of which is in January and February. The barometrical changes are the reverse of what obtains in the tropics. Above 60° lat. the diur- nal or periodical changes are scarcely perceptiblo, whereas general or occasional variations become CLIMATE. 264 more marked as we approach the pole. Electrical phenomena become less marked, and above 68° lat. they are scarcely perceptible, with the excep- tion of the aurora borealis. The winds which pre- dominate are the N.E andS.W., and they change rapidly from one point of the horizon to the other, and thus frequently occasion tempests which extend over considerable areas. The quan- tity of rain that falls in cold climates is much less than in the tropical and temperate, with some exceptions. Between 60° and 90° lat. it only amounts to a few inches, and falls principally in the form of snow. The influence of cold climates is showm on the inhabitants of these countries, w ho vary much in stature, and possess a vigorous constitution, a sanguineous temperament, great muscular development, active digestive func- tions, and sluggish nervous powers. Notwith- standing the severity of the climate they gene- rally succeed in protecting life, and live to old age, presenting few diseases peculiar to climatic influences. They are, however, subject to opththalmia and amaurosis, owing to the re- flexion of light from the snow' in the polar regions, and to scrofula and scurvy, the result of a poor and incomplete dietary. Agues, and intermit- tent fevers from marsh influences, are rare, and not severe, and disappear entirely' as w'e approach the pole. Continued fevers are met with, but seldom if ever epidemically. 4. Insular climates present important pecu- liarities. The temperature of the sea is more equable than that of the land. Owing to the action of currents, and to the circulation of its waters under the influence of heat, its super- ficial temperature is warmer in winter and cooler in summer — more equable — than that of the land. It has thus a tendency to warm in winter and to cool in summer the island which it surrounds. Moreover, there is constantly w'atery vapour arising from the sea which extends to island atmospheres, veils the sky more or less, shields their surface from the ardour of the sun in summer, and prevents great radiation both in summer and in winter. Thus it is that the climate of all islands is more equable than that of continents. This fact is more especially recognisable in the climate of the British Isles, which is also modified — rendered warmer and inoister, by the waters of the Gulf Stream im- pinging on their shores. The warm Gulf Stream, commencing in the tropics, in the Gulf of Mexico, passes northwards along the shores of North America, crosses the Atlantic to the south of Newfoundland, and strikes the shores of the British Islands, of Norway up to Cape North, of Holland, and of France ; everywhere raising temperature and the annual mean. 5. Maritime climates participate in these influ- ences ; temperature is more equable, warmer in winter and cooler in summer, on the shores of seas and oceans than it is inland. Owing to this cause most of the winter sanitaria have been chosen in islands or on the coasts of oceans and seas : such as Hastings, Ventnor, Bournemouth, Tor- quay, Funchal, Malaga, Cannes, Nice, Mentone, Naples, Salerno, and Algiers. 6. Continental climates exhibit conditions the reverse of those which obtain in maritime climates. The tendency is to cold winters and warm summers, owing principally to the absence of the equalizing influence on temperature of large masses of water. A very short distance from the sea is sufficient to establish this differ- ence. Thus the central parts of France are very much warmer in summer and colder in winter than the coasts of Normandy and Brittany. But it is when we reach the centre of continents — Russia, central Asia, central America — that the difference is the most marked. 7- Mountain climates . — As we rise above the level of the sea, we meet with two important me- teorological conditions. The ai r becomes more and more rarefied, and the heat diminishes, indepen- dently of the more or less obliquity of the sun’s rays. The higher we rise above the sea level the more the air is rarefied, and the more the degree of heat due to the solar rays diminishes. IVe arrive at last, even at the tropics or the equator, at a height, variable according to latitude, where the sun's heat .is insufficient to melt the snow. This is termed the snow-line. Mountains attract clouds and watery vapour, and the coolness of their atmosphere causes the precipitation of the vapour in the form of rain or snow. Thus, mountains, mountain-ranges, and the glaciers they contain, are the principal cause and origin of rivers. The influence of mountain climates, notwithstanding the clouds, fogs, and rain which characterise them, is proverbially a healthy one, owing to the purity of the air, and, perhaps, to the sparseness of population. They have of late been much recommended for phthisis. The t wo conditions above mentioned, however, namely, purity of the atmosphere and sparseness of human habitations, are quite sufficient to account for the rarity of phthisis amongst their inhabitants, and for the improvement of the phthisical who re- sort to them. Soil modifies climate considerably. Wet and marshy soils are cold, engendering fog and mist. Sandy, dry, well-drained soils are comparatively warm. All sandy plains are warm in summer and cold in winter. Such are the features which characterise the climates of the terrestrial globe, generally. Each locality, however, each mountain, plain, and val- ley, each city, village, and house, has a climate of its own, modified bj r all the meteorological ele- ments which we have successively considered. To discover what each climate is, we must study carefully the meteorological conditions and in- fluences which we have rapidly surveyed in their application to it. 8. Isothermal climates . — Owing to the unequal influence of the different elements that constitute climate, the annual mean temperature of regions occupying the samelatitude on the earth’s surface is very variable. Hence the above name has been given to the regions in which the annual mean is the same. The study of a map on which the isothermal lines are marked is an instructive illustration of the facts above described. Thus it will be seen at a glance that the limit of con- stantly frozen ground in the central plains of Asia and in the northern plains of America is below 54° F., which is the latitude of York ! The general influence of climate . — The vege- table and animal worlds, including man himself, have been modified in essential characters b> CLIMATE. 265 climatic conditions. The study of its influence on their vitality and organisation opens out a wide field to the observer. This study leads to the conclusion that geological periods of time have been necessary to impress on ter- restrial life, be it vegetable or animal, the cha- racteristics observed now or formerly in the climates of different regions of the earth. The current of modern research is strongly directed to the elucidation of the influence of climate on life during such geological periods. The investigations of Darwin and his followers may be named as the most remarkable and impor- tant illustration of this fact. We may also mention the researches of modern philologists, which have proved, by the study of languages and their roots, that most of the nations of modern Europe have descended from the same Aryan parents as the inhabitants of the Indian peninsula. Climate, in the course of time, has so modified them as apparently' to produce dif- ferent races. For such a change to take place geological lapses of time are certainly required. Our earliest records, dating back several thou- sand years, show these races such as they are now, quite as distinct. In these days the Aryan races of Europe cannot rear their chil- dren in the climate of India, where their Hindoo relatives thrive and propagate their species. In Palestine and Egypt the biblical records, those of the Pharaohs, and those of Nineveh and Babylon, show these regions to have been in- habited, several thousand years ago, by nations and tribes presenting precisely the same race characteristics as those that now inhabit them. During the historical period, the races of Europe have in vain endeavoured to colonise the valley of the Nile ; but they have not been able to propa- gate their species, and have died away, leaving the valley of the Nile to its ancient inhabitants. Their children cannot withstand the heat of summer. On the north-eastern shore of Africa the Algeria of the present, history presents the same record. The Eomans and the Visigoths occupied its plains for centuries, continually re- cruiting their colonies from the mother-countries ; and yet, except in the mountains, all traces of their presence has disappeared. They could not roar their children so as to occupy the land of the Arabs. What lengthened periods of time must have elapsed to so profoundly modify races deriving their origin from a common parentage, that they can no longer live and propagate their species in the same climates J Therapeutical Applications . — The therapeutical application of many of the above facts is contained in the facts themselves. Reasoning suffices to deduce the therapeutical law, and experience proves the correctness of the deduction. A very brief summary only can here be given. See also Climate, The Treatment of Disease by. Firstly, it is clear that if a local climate pro- duces injurious effects on the health of its inhabi- tants, or of visitors, the latter should leave it, and the regular inhabitants, who cannot leave it, should endeavour by every possible means to modify the pernicious climatic influence to which they are exposed, and to partially escape from .ts action. This rule may be illustrated by the influence of confined mountain valleys in pro- ducing goitre, and of marshy districts in pro- ducing intermittent fevers. The principle ap- plies to all local climates which exercise a pernicious influence of any kind on the human organisation. When possible the climate should be abandoned ; if that is impossible its pernicious influence must be combated by every possible hygienic and therapeutical means. The injurious effects which extreme climates exercise on the human economy — warm climates on the abdominal and cerebral organs, cold cli- mates on the thoracic — point to change of resi- dence as an important therapeutical agent, the value of which is only beginning to be under- stood. Our naval and military surgeons have done much to clear up this branch of therapeu- tics, as regards the diseases of tropical regions. Thus chronic affections of the liver and intestines, incurable in a warm climate, often become quite curable if the patient is transferred to a tem- perate region or to a mountain elevation in the tropics, which reproduces a temperate climate. Inversely, persons suffering from diseases of the respiratory organs, so common in damp tem- perate climates like those of. France, England, and Holland, find relief by migrating, especially during winter, to warmer regions of the earth’s surface, where they escape from the influences which have proved so detrimental to them. Thence the yearly increasing exodus of persons suffering from chronic laryngitis and bronchitis, from bronchial asthma and from phthisis, from the north of Europe to the south. The increased facilities of locomotion, by rail and by steam, have thus opened out, as it were, a new and important brancli of therapeutics, that of the application of climate to the treat- ment of disease. J. Hexky Benxet. CLIMATE, The Treatment of Disease by. — Though we can scarcely say with accuracy that change of climate is a specific for disease, yet much can be effected by it in relieving symp- toms, and in assisting the reparative powers of the organism by thus improving the general health. The diseases in which change of climate has been found of value will be enumerated below, with a short notice of various climates. Here we may notice the rationale of the benefit to be derived from such change. Change of climate, we must premise, is only a relative term. It does not necessarily involve the idea of removal to a great distance from the patient's home. A few miles’ journey from the town to the country, from inland to the seashore, from the plain to the mountain, often suffices to produce marked results. One use of climate being to expose the organism to the effects of contrast, the element of distance comes in most when we wish to make the contrast greater ; for instance, in ordering change from a cold to a warm climate or vice versa. The therapeutic elements of most importance in any climate are (1) pure air free from dust and organic particles ; (2) abundance of sunshine, without excessive heat, so that much time can be spent in the open air ; (3) a temperature without extremes, so that the body is not ex- posed to the risk of great variations of heat and cold— equability ; (4) absence of violent, very 266 CLIMATE, THE TREATMENT OF DISEASE BY. cold, or very hot winds, at any rate of long duration (in this is involved the element of local shelter). These four elements should be present in each of the subdivisions of climate which a thera- peutic classification renders necessary, namely climate of (a) the seashore ; (6) mountains ; (e) inland wooded districts; (d) the open sea. The epithets ‘moist’ and ‘dry,’ which are applied to climates, are merely relative, and depend on local peculiarities of rainfall, soil, &e., as well as to some extent on season ; and the essential differences between the climate of the seashore, the woodland, and the mountain remain everywhere the same. We shall say a few words about each of these, with the indications for their use. The climate of the open sea will be referred to in speaking of sea voyages. (a) Climate of the Seashore. — The special peculiarities of this variety of climate are that — the air is saturated with moisture, except when dry land winds prevail ; it. is dense, and, as a rule, therefore, bulk for bulk, contains more oxygen than air of any higher level ; its density is liable to great and frequent but regular varia- tions, which increase the activity of the circula- tory and respiratory organs, and thus favour their functional activity ; it is more equable ; and, lastly, it contains saline particles in suspension. According to Beneke, sea air cools the body relatively quicker than mountain air, and thus quickens the processes of tissue-change the most. Hence the seaside should be ordered where we wish for a highly stimulating effect, as in persons of scrofulous tendency, in chronic diseases suc- ceeding acute ones, or in the later stages of convalescence from the latter, in convalescence from surgical operations, or in some surgical diseases where we wish to accelerate tissue- change, without exertion on the patient’s part. On account of the equability of the climate, some patients who cannot bear great changes of tem- perature do well at the seaside. Persons suffer- ing from overstrain, mental or bodily, with a fair digestive powex - , and not liable to nervous irritability, may also be sent there. (b) Mountain Climates are distinguished from sea-side climates by the lower density of their atmosphere ; their lower and less equable tem- perature ; by less humidity, though, owing to local winds, mist and cloud often form ; and by relatively lower night-temperatures in clear weather, owing to the dryness of the air, and consequent great radiation. They are cooler also than the inland climates of level districts, and this coolness tends to some extent to diminish the rarefaction and increase the density of their air. The general action of mountain air is to pro- duce a freer circulation of the blood and greater vascularity of the lungs, owing to deeper and more frequent inspirations and greater ease of bodily movement. Owing to the cooling of the body by the lowered temperature more food is required, the appetite improves, and the body becomes better nourished and gains weight. The intensity of the effect is, roughly speaking, directly as the height. The term ‘mountain climate ’ is applied in medical parlance to eleva- tions in Europe of from 1,500 to 6,000feet, though in South America patients have been sent as high as 10,000 feet, or higher. Mountain Climates are indicated (1) in cases of hereditary tendency to phthisis in young persons with narrow, shallow chests, and who are growing too fast ; also in young scrofulous patients. (2) In chronic phthisis and pneumonia ; remembering, however, that phthisis occurs at all elevations. The coolness of the mountain air in the height of summer is an important .element in phthisical cases, which always suffer from great heat. (3) As a tonic and restorative in persons suffering from over-work in business or literary pursuits, and who have no real organic disease. (4) Generally to complete the convalescence from acute diseases of individuals not past middle life, with a fair amount of muscular power and bodily activity. (5) As a prophylactic against hay-fever, cholera, and other infectious diseases, Mountain climates are not advisable in cases of chronic bronchitis, heart-disease, emphysema, Bright’s disease, chronic rheumatism, or for aged persons. (c) The Climate of Wooded Districts (elevations above 1,500 feet are not here referred to) is peculiar in the following points; — (1) It has a temperature lower than that of the surrounding country — on the average 3° Eahr. — during the hours of day- light; tho temperature is also mere equable. (2) The relative humidity is higher (9-3 percent) in summer than in the less wooded country, and hence there is greater liability to rain and mist. (3) It affords greater protection and shelter against winds than other climates. The general effect of woodland climates, as may be deduced from the above, is sedative and tonic. They may be advised in chronic bron- chitis, emphysema, heart-disease, and in hypo' chondriasis, hysteria, and other nervous affections where tranquillity and subdued light are of importance; also in the earlier stages of con- valescence from acute disease when sea or mountain air is too stimulating. In bronchitis pine woods shordd be selected, and in heart- disease level walks are essential. (d) Ocean Climates. — Sea Voyages have of late years been much recommended in the treat- ment of phthisis in its early stages, with a view to enable the invalid to spend much time in an exceedingly pure and fairly equable atmosphere, and to secure a sufficient amount of bodily move- ment without great fatigue. The main drawbacks to the sea are the impos- sibility of escape from bad weather and the confinement to close, ill-ventilated cabins, if such occurs ; the absence of sufficient light and air below decks, the latter being felt very much at night; want of variety in the diet after a certain time, and at all times (except in short cruises, or coasting trips) of fresh food, milk, &c. ; monotony in society and occupations ; and. lastly, the inconveniences arising from crowding of tho maindeck with hen-coops, sheep-pens, &c., and in steamers from the smoke of tho engines, and the smell and vibration of the machinery. The routes generally recommended to invalids are either to (1) Australia, 90 days; (2) the Cape of Good Hope, 30 days ; (3) the Y. est Indies, 14 days; (4) the United States or Canada (in summer), 10 days. Short cruises in the Mediterranean, or to the latitudes of the Canaries and Azores are suitable for certair CLIMATE, THE TREATMENT OF DISEASE BY. eases where expense is no object. Of routes (3) and (4) we may say that they are too short for the full benefit of the sea to be obtained, as improvement does not generally begin for a week or two after sea-siekness has subsided and the patient can remain comfortably on deck. Route (2) does not allow' him to get the bracing effect of high South latitudes. Hence where a long sea voyage is indicated, route (1) is decidedly the best. England is quitted in the beginning of October, Australia (Sydney or Melbourne), or New Zealand (Wellington), is reached early in January, and the return voyage is begun not later than the end of February. Patients should not remain in the coast-towns cf Australia in summer on account of the heat. They should go to the table-land of New South Wales, or to Darling Downs in Queensland, or else they should cruise from port to port, or run over to New Zealand or Tasmania. In returning, the route round Cape Horn should bo avoided on account of the great risk of the climate of the South Pacific Ocean and the chance of encountering icebergs, fogs, and un- favourable winds. Either the patient should come back round the Cape of Good Hope ; or if his strength permits he may cross to California, travel overland to New York and thence by steamer; or, lastly, he may come by the Red Sea, Suez Canal, and Mediterranean. The invalid must expect about 20 wet days on the voyage out. The temperatures met with range from 40° to 80° Fahr., the coldest and most uncertain weather occurring in the North Atlantic and South Pacific Oceans. Choice of Vessel . — The following considera- tions may be useful in deciding between steam and sailing vessels : — For a steamer there is the greater certainty in predicting the length of the voyage, and the calms of the tropics are sooner passed. Against steamers, there is the nuisance of steam and smoke on deck ; much space is taken up by the engines, stokers’ rooms, &c., and hence other parts of the ship are more crowded ; the bilge water is tainted with the engine grease ; there is the wearying grind of the screw by day and by night; while more seas are shipped, because a steamer can run against a head-wind. For sailing vessels there are the advantages of more room, light, and air in the cabins, and the absence of the above-mentioned disagreeable conditions. Against them there is the longer and more uncertain duration of the voyage, and the necessity, of shaping their course by the prevail- ing winds. A word must be added as to the comparative merits of wooden and iron vessels. Briefly stated, iron ships are cleaner, drier, freer from smell of bilge water, and hence healthier than wooden ; but on the other hand they are less equable iu temperature (hotter in hot and colder iu cold latitudes), and less aerated by natural ventilation through their sides than the latter. They are also noisier. The vessel chosen should not be under 1,000 tons, and her age, class of passengers, the character, temper, and standing of her captain, es well as the size of her cabins, should be care- 207 fully ascertained. Of course it is a sine qud nen that she should carry a duly qualified surgeon. The cabin for the outward voyage to Australia should be on the port side, so as to get the breeze in hot weather, and vice versa in returning. The cabin outfit should include a spring mattress, with hair (not wool) mattress over, a folding easy chair, chest of drawers, carpet, curtains, and sponge bath (Faber). Clothes of various degrees of thickness are essential, both for body and head, and a waterproof suit is necessary for bad weather. Plenty of linen must be taken, as washing is difficult on board, and there should be a supply of preserved milk, meat or essence of meat, fruit, and light wines. The indications for a sea voyage are hereditary tendency to phthisis, or the presence of actual but uncomplicated disease in a very early stage, in persons not past middle life, with a fair digestion, absence of severe pyrexia, and general health not much impaired. Patients with a tendency to haemoptysis should not be sent, nor should those of a desponding disposition, who would thus be likely to suffer by the long absence from home, or from fears of their per- sonal safety. Of course a tendency to protracted sea-sickness is a distinct contra-indication. The invalid should be careful not to overtax his digestion too much ; he should take regular daily exercise on deck to the extent of his strength, have some definite occupation to beguile the time, and, if possible, be accompanied by a personal friend (Faber). Choice of a Climate — General Hints. — It is a good plan, if possible, to order a patient a climate with that mean temperature and relative humidity which he is known to tolerate well (Sigmund). The patient’s disposition must be considered, and a lively or a quiet place chosen according to his temperament. We should not send a poor man to a place beyond his means, otherwise he has to grudge himself many com- forts, and loses much, if not all. the benefit of the change. In sending patients to the South of Europe this rule is too often neglected. The special indications for the climates of par- ticular places can only be understood by study- ing their local aspect. Generally speaking, as far as Great Britain is concerned, the climate of the east coast is colder and drier than that of the west and south coasts. In Ettrope the north and west coasts are moister and cooler than the shores of the Mediterranean. As to season, mountain and woodland climates are almost exclusively indicated in summer from May to September. Certain parts of the sea-coast are adapted for invalids at all seasons of the year; but as a rule the northern coasts of Europe and the eastern or south-eastern coasts of Great Britain are best suited for summer, and the south, west, and south-western for winter resi- dence. The Mediterranean coast is only to be recommended from mid-October to the middle or end of May, and Egypt should be quitted not later than April. A word may bo added as to the advantages of wintering in the South of Europe. It is incontestable that the in- valid gets a milder winter, a longer autumn, 268 CLIMATE, TIIE TREATMENT OF DISEASE BY. find an earlier spring. Although there is no place where some days of bad weather do not occur, or where uninterrupted calms are met with, yet the number of rainy days is fewer, there is more sun, little or no fog, and, except in the neighbourhood of the Pyrenees, little or no snow or ice. The scenery is picturesque and attractive, and the invalid is able to spend much time in the open air, and to sit out of doors on many days, e cen in mid-winter. The drawbacks to the South are the risk of chills, owing to the differ- ence between sun and shade temperatures, especially at first, when persons are unaccus- tomed to the climate, and fail to take sufficient care ; the occasional occurrence of high winds, especially in spring ; the more limited accom- modation, owing to the expense of rooms and living; and the absence of many so-called ‘ home comforts.’ Those who visit the South must remember that the curative value of the climate consists in its allowing w.xich time to be spent in the open air, and in its milder temperature and drier air, which protect the respiratory organs from fresh inflammatory attacks. A south room and warm clothing of the texture usually worn in England in autumn are essential, and a coat or wrap should always be carried out of doors in mid- winter to put on in passing from sun to shade. The invalid should strictly avoid the hot atmo- sphere of gaslit salons at night. Patients with acute diseases of the respiratory organs should not be sent to the South; and high fever, excessive weakness, or the necessity of remaining in bed, are also contra-indications, owing to tho fatigue and risks of the journey and the need of home comforts. Cases of mental disease with excitement, where rest and protec- tion of the mind and body is of primary im- portance, should not be sent. In the convalescence from acute diseases occurring in autumn, where a cold northern winter would prevent open-air exercise, and probably set up fresh exacerbations, southern winter climates are of great value. In ordering change of climate the accommo- dation, food and water supply, soil and drainage of the locality’ chosen should be carefully con- sidered, especially if the distance is a long one. The best climate may be unavailable for the invalid, owing to defects in one or more of these particulars. Lastly, the patient’s own feelings should be carefully consulted before he is sent far away from home. In some cases all the benefits of climate are counteracted by ‘ home-sickness.’ Odium non animum mutant qui trans mare currant. Enumeration of Climates.— We shall now enumerate various climates and regions suitable for the treatment of cases that can be benefited. 1. Of the Hervous System. — In neuralgia, Arcachon (for the calm, sedative, yet tonic atmosphere of the pinewoods), Cannes (the dis- tricts away from the sea), 'Upper Egypt (Cairo, Luxor, Helwan), Hastings, Hyeres, the Enga- dine, the Bernese Oberland, Pau, Pisa, Rome, tho Salzkammergut (Ischl, Berchtesgaden). Some of the above climates will also be found suitable to cases of hemicrania and sciatica. In hysteria, hypochondriasis, spinal irritation. and in some eases of protracted chorea, Brighton, Cannes, Ischl, Malta, Mentone, Montpellier, Morocco (Tangiers), Nice, Naples, the Bernese Oberland (Grindelwald, Miirren). Palermo, Pau, Seville, Spezia, and Valencia ; the effect pro- duced being chiefly due to diversion of the atten- tion by the change of scene, although the bracing influence exerted on the system at large must be taken into account. In chronic softening of the brain and spinal cord, in paralysis of cerebral origin, and in some cases of locomotor ataxy the South of France may be advantageously ordered in winter, and Alpine climates of moderate height in summer. As a rule hot climates, or those where the sun has considerable power, are contra-indicated where there is a tendency to apoplexy or hypersemia of the brain. Temperate and bracing climates are, as a rule, to be recommended in nervous diseases, to restore the general tone of the system. The immediate neighbourhood of the sea not nnfrequently causes nervous excitement, neu- ralgia, and sleeplessness. 2. Of the Respiratory and Circulatory Systems. — In chronic bronchitis, emphysema, bronchial and spasmodic asthma, as well as in chronic pharyngeal and laryngeal catarrh and laryngeal ulceration the following climates may be recommended: — Algiers, Australia, the Azores, Bordighera, Bournemouth, the Canaries, the Cape of Good Hope (?), Upper Egypt, Glengarriff, Hastings, Hyeres, Lisbon, Madeira, Malaga, Malta (?), Mentone, Naples (?), Nervi, Nice, Palermo, Pau, Pisa, Queenstown, Rome, San Remo, Torquay, and Ventnor. Change of climate is of great value in con- valescence from the acute, and as a prophylactic and curative measure in the chronic forms of bronchitis ; but we must remember that where there is copious expectoration a dry climate is indicated, while in the irritative forms with scanty sputa ( bronchitis sicca) a moderately moist mild climate is generally suitable. In emphysema we should choose a mild and not too dry climate, if possible in the neighbourhood of pine-woods, such as Arcachon, on the west coast of France. In spasmodic asthma the choice of climate must be partly a matter of personal experience. In the early active, and in the quiescent forms of the later stages of phthisis, as well as in chronic pleurisy, and in convalescence from pneumonia, the following (chiefly winter) health resorts and climates have been favourably spoken of:— Algiers (?), Australia, Bordighera, Bourne- mouth, Cannes, Davos, Upper Egypt, Upper En- gadine (in summer), South of France, Hastings, Hyeres, Queenstown, Ischl (in summer), Madeira, Malaga, Mentone, Natal (?), Nervi, Nice (?), the Oberland (in summer), Palermo, Pau, Pisa, San Remo, Sicily, Spezia, Torquay, Glengarriff, and the Underciiff (Isle of Wight). In chronic endocarditis, pericarditis, and in heart-disease generally, a rather bracing climate, without extremes and of the character suited to chronic bronchitis, is usually indicated. Here both the tonic effects of climatic change and the prevention of pulmonary complications and fresh rheumatic attacks must be taken into account. CLIMATE. Mountain resorts of moderate height, well pro- tected from sudden changes of temperature, may be prescribed in summer (von Dusch). In the neuroses of the heart, including (1) angina pectoris, (2) palpitation associated with chlorosis, hysteria or hypochondriasis, and (3) exophthalmic goitre, bracing climates are in- dicated. In angina pectoris long journeys involving great exertion must be rigorously for- bidden, as must also sightseeing or exciting amusements. 3. Of the Abdominal Organs. — In the various forms of chronic dyspepsia and intestinal catarrh, in chronic hepatic disease, in chronic dysentery (after removal from a malarial district or tropical climate), in diabetes, and in chronic endometritis, pelvic cellulitis, and other diseases of the uterus and its surroundings, the following climates may be selected from : — Cannes, The Engadine, Hastings, Hyeres, Lisbon, Malta, Mentone, Montpellier, Morocco, Naples, Nice, the Nile, the Bernese Oberland, Pontresina, the Pyrenees (in summer), Queenstown, the Falzkammergut, Seville, Spezia, St. Moritz, Valencia, and Ventnor. In convalescence from acute nephritis, and in all forms of chronic Bright’s-disease, but especi- ally catarrhal nepliritis, warm dry climates are indicated. Among the best are Upper Egypt, the Kiviera, the Cape of Good Hope (inland), Bombay ; and in England : Brighton, Folkestone, and Ventnor. In renal calculus removal from particular districts in which stone is known to be prevalent may possibly be of use in some cases. 4. Of the System at large. — Change of climate is here nearly always indicated: — (1) In convalescence from typhus and typhoid fevers, scarlet fever (at the end of the desquama- tive stage), measles, diphtheria, and acute rheu- matism ; also in the third stage of protracted hooping cough. (2) As a prophylactic against all infectious diseases, and especially cholera, yellow fever, hay fever, influenza, and malaria; also against rheumatism and phthisis by withdrawal from damp districts, and goitre and cretinism by removal from the ensemble of conditions to which the latter are due. (3) In rickets, scrofula, chlorosis, general anaemia, and functional debility. Here, where a pure air and a bracing sunny atmosphere are the chief indications, the climates enumerated in sec- tion 1, page 263, are suitable, as are also Algiers, Biarritz (in autumn), the Cape of Good Hope, Ischl, Malaga, Home, Sicily, St. Moritz ; and in Great Britain a number of inland and seaside places (Malvern, Scarborough, &c.) which we have not space to mention. Edwa ud I. Sparks. CLINICAL (/cXhoj, a bed). — This word lite- rally signifies ‘ of or belonging to a bed ’ ; but it has been particularly applied to the practical study and teaching of disease at the bedside ; and has more recently been extended to all that relates to the practical study of disease in the living subject generally. CLONIC (kaSvos, commotion) This word is applied to spasmodic movements which are of COAL GAS, POISONING BY. 269 short duration, and alternate with periods of relaxation. See Convulsions, and Spasm. CLOT. — A clot, or coagulum, is the product of the formation of fibrin. The separation or formation of fibrin is attributed to the union, under the influence of a ferment, of the fibrino- genetic substance or fibrinogen which is con- tained in the liquor sanguinis, the juice of the flesh and most of the serous fluids, with the fibrinoplastic substance which is contained in the blood-globules, the lymph-corpuscles, and the cells of the body generally. Coagulation of the blood within the blood-vessels is described under Thrombosis ; the coagulation of extrava- satecl blood under Hemorrhage and Brain, Haemorrhage into ; and the coagulation of inflam- matory exudations under Lvixammation and Exudation. See also Blood, Morbid Conditions of. CLOTHING. See Disease, Causes of; and Health, Personal. COAGULUM ( coagido , I curdle). See Clot. COAL GAS, Poisoning by. — Coal gas, so largely employed for illuminating purposes, is a compound, containing — in addition to olefiant gas and analogous hydrocarbons, on which the lumi- nosity principally depends — certain so-called diluents which burn with a non-luminous flame, viz., hydrogen, marsh gas, and carbonic oxide along with what are termed impurities, of which the chief are carbonic acid, sulphuretted hydro- gen, and bisulphide of carbon. On these im- purities the characteristic odour mainly depends. This odour, which is perceptible even to the extent of 1 in 10,000, is a valuable safeguard against accidents from escape of gas. A mixture of coal gas with the air inhaled exerts a deleterious effect on the system, and proves fatal when it reaches a certain percentage. In addition to the danger from inhalation, fatal accidents frequently occur from the explosive nature of the compound vdiich is formed when the gas reaches the proportion of 1 to 10 of the atmosphere. Much less than this, however (a non-explosive mixture, therefore), proves fatal if long inhaled. It is difficult to determine the exact propor- tion of the gas present in atmospheres in which fatal accidents have occurred, but we derive im- portant information on this point from experi- ments on animals. Many such have been made. M. Tourdes, who has carefully investigated the subject, finds that pure gas is almost instan- taneously fatal ; ^tli kills rabbits in five minutes, and dogs in twelve minutes ; ith kills rabbits in from ten to fifteen minutes ; ^th still proves fatal after a longer period ; and evident signs of distress are caused in rabbits by an atmosphere containing only ith of the gas. Dr. Taylor ( Edin . Mid . Jour ., July, 1874) has estimated the proportion of gas existing in a room in which a fatal case occurred at three per cent. Sources op Poisoning. — Poisoning by coal gas is only known of as an accident. Occasion- ally suddenly fatal consequences ensue among workmen from exposure to a sudden rush of un- diluted gas from gasometers and mains. More commonly slowly fatal cases result from the gas- 270 COAL GAS, POISONING BY. tap in a bed-room being left open carelessly, from accidental extinction of the light, or from leakage of gas-pipes in a house or at a dis- tance ; the gas gaining access to the house in the latter case through cellars, -walls, and more especially by means of drains and sewer-pipes. Symptoms. — Gas, even when in comparatively small proportion and just sufficient tc cause an unpleasant odour, acts deleteriously if long breathed, and gives rise to headache and general depression of health. In severe and fatal cases She symptoms wh-ich have been noted are headache; nausea or vomit- ing ; vertigo ; and loss of consciousness, passing into deep coma and muscular prostration, which resembles the apoplectic state, the individual lying insensible and incapable of being roused, with livid features, stertorous breathing, and froth at the mouth. Death usually occurs quietly, in this state of coma, but occasionally with con- vulsions. The state of the pupils does not seem to be constant, though they are generally dilated before death. In Dr. Taylor’s case the teeth were firmly clenched, and the eyes were in a constant state of lateral oscillation. Fatal Period. — The fatal period of poisoning by coal gas is extremely variable, and a remittent character of the symptoms sometimes gives rise to fallacious hopes of recovery in cases which ultimately prove fatal. Diagnosis.' — The smell of gas in the clothes, breath, and perspiration, which continues for a considerable time after removal from the in- fected atmosphere, is the best indication of the cause of the coma. Anatomical Characters. — The smell of gas is often very marked. M. Tourdes has found, as the most constant appearances, a dark colour of the blood, which, however, coagulates; a bright colouration of the pulmonary tissue; froth in the air-passages; congestion of the mucous membrane at the base of the tongue more particularly; engorgement of the cerebral and spinal venous system ; and rose-coloured patches on the thighs. Mode of Action. — It is obviously impossible to differentiate between the effects of the various constituents of coal-gas, but we have good reason for believing that the most active agent is the carbonic oxide, which exists in the proportion of from five per cent. (English gas) to twenty-five per cent. The symptoms in the main agree with those caused by carbonic oxide (see Carbonic Oxide, Poisoning by), and the effects, therefore, would be chiefly due to the action of the carbonic oxide on hcemoglobin. Treatment.— Instant removal from the in- fected atmosphere is the first thing to be attended to. Attempts must then be made to cause oxy- genation of the blood by artificial respiration and excitation of the respiratory centres by reflex stimulation of the face, chest, &e. Pure oxygen gas may be administered. As, however, the compound which carbonic oxide makes with the blood-colouring matter is a very stable one, and not easily broken up by the in- troduction of atmospheric air or oxygen, it not unfroquently happens that these measures prove COLD, EFFECTS OF. of no avail. In such cases it would be highly advisable to perform venesection, and then trans- fuse fresh blood, a plan of treatment which has been found successful in poisoning by carbonic oxide. D. Furrier. COARCTATION (coarcto, I straiten). — A pressing together, narrowing, or stricture of any hollow tube, such as the aorta, intestine, or urethra. COLD, A. — A popular name for Catarrh. Set Catarrh. COLD, JEtiology of. See Disease, Causes of. COLD, Effects of Severe or Extreme. — The general effect of exposure to severe or ex- treme cold is to lower, even to extinction, all vital activity. The blood-vessels, especially the smaller arteries and capillarios, after a brief period of congestion, become contracted, the latter to such an extent as no longer to permit the passage of the red corpuscles; the normal condition, composition, and structural integrity of the various tissues are more or less impaired, or altogether destroyed ; and those processes of chemical and physiological change which are essential to every manifestation of life, being only possible within certain very narrow limits of temperature, are hindered or absolutely pre- vented. Effects and Symptoms. — The more special effects vary in degree and kind: — lstly, with the degree of cold, the duration of the exposure, and the medium or manner of application : 2ndly, with the part, and extent of surface ex- posed; and, 3rdly, with the general constitu- tion and physiological condition of the sufferer. Moderate cold, acting during a short time, or even severe cold during a still shorter time, followed by the glow of speedy reaction, ex- ercises a tonic and stimulating influence. But if the cold is too severe, or the exposure too long, no glow of reaction occurs, but a sense of depression is experienced, from which, at best, recovery takes place but slowly. Continued ex- posure to such degree of cold as is yet not incompatible with the maintenance of life, never- theless keeps at low ebb activity of nutrition and function alike. Extreme cold and long exposure lead to congelation and consolidation of the various tissues of the body. Alter complete congelation recovery is impossible. Dry cold is much less readily injurious in its influence than cold associated with wet. The better conductor of heat the medium is, the more speedily and completely does it reduce the temperature of the part with which it is in contact. Immersion in water cools more rapidly than exposure to air of the same temperature : and contact with wool, wood, or metal, of the same degree of coldness, excites in each case a different sensation, and leads to a different result, or to the same result with very different rapidity. Constant renew . 1 of the medium in contact hastens the cooling effect ; and a continuous draught of only mode- rately cold air may do more to chill than tem- porary exposure to an intensely cold, but still atmosphere. If some external part, and a comparatively small extent of surface only, be acted upon, the effect may he simply local, aud COLD, EFFECTS OF SEVERE OR EXTREME. 271 the general disturbance of the system scarcely appreciable. But if the whole body, or a con- siderable extent of surface, or any important internal organs be acted upon, a proportionately serious general effect is produced. The young (infants especially) and the aged alike ill sustain exposure to cold, and are most liable to suffer, not only from its direct effects, but also from the various maladies to which it gives rise. The feeble, ill-nourished, and broken in health, especi- ally the subjects of organic disease, or of de- generation due to habitual intemperance, readily succumb, or only slowly and imperfectly recover. Among the healthy and otherwise vigorous, hun- ger, fatigue, sleep, anxiety of mind, fear and mental depression of whatever kind, lower — too often even to fatal issue — the power of resistance to the deadly influence of cold. For local effects of exposure to cold sec Chil- blain, F rost-mte, and Gangrene. The General Effects produced by exposure to severe or extreme cold vary somewhat in different eases. Temporary exposure produces, first, a sense of coldness or chilliness, associated with paleness and corrugation of tne skin (the so-called cutis anserina), then shivering and tingling sensations, followed by numbness and diminution of muscular activity and power. Healthy reaction restores more or less quickly the normal condition. Prolonged exposure to extreme cold gives rise to a series of symptoms, graphically described by Beaupre somewhat as follows : — Reaction has a limit, and a moment arrives when the powers are exhausted. Shiver- ings, puckerings, paleness and coldness of the skin, livid spots, muscular flutterings, are symp- toms of the shock given to the vital forces ; syn- cope approaches ; the stiff muscles contract irregularly ; the body bends and shrinks ; the limbs are half-bent; lassitude and languor invite to repose ; a feeling of weight and numbness retards the steps ; the knees bend ; the sufferer sinks down or falls ; the propensity to sleep be- comes irresistible ; everything grows strange ; the senses are confused ; the mind grows dull, the ideas incoherent, and the speech stammering or raving; respiration, at first interrupted, becomes slow ; the heart’s action is feeble, quick, hard, irregular, and sometimes painful, and the pulse progressively smaller ; the pupils dilate ; the brain becomes stupified; and finally deep coma indicates the approach of inevitable death. Other, and somewhat different effects and symptoms, attributable to differences of circum- stances and condition, have been from time to time observed. Distressing and almost intoler- able thirst, with loss of appetite for food, is often experienced ; and the attempt to obtain relief, by sucking snow or ice, only adds to the suffering. Somnolence is by no means so constant an effect as is commonly supposed— at any rate, in the earlier stages, and iess extreme cases. On the other hand, inability to sleep has proved a com- mon cause of suffering and consequent loss of strength. The manifestations of brain-disturb- ance due to exposure to cold, varying as they do from dullness, incoherence, wandering and thick- ness of speech to even raving delirium, are especially worthy of note, inasmuch as they re- semble, and are liable to be mistaken for, the effects of alcoholic intoxication. Death from the direct and immediate effects of cold is rare in our country ; but it is estimated that in the Russian Empire, on an average, 694 deaths occur annuallyfrom this cause. The length of time during which exposure can be sustained varies greatly with the condition of the indivi- dual and with surrounding circumstances, as well as with the degree of cold. Under ordinary circumstances, an hour’s exposure to intense cold often suffices to determine a fatal result. At the same time, well-authenticated cases are on record, in which persons buried, for days even, in the snow, have nevertheless survived and ultimately recovered with little permanent damage. i! lode of Death. — The immediate cause or mode of death from cold seems in some cases to be principally shock; in some, syncope; in others, asphyxia ; and in others, again, coma. In most cases it is probable that these several conditions, with others less readily specified, combine to produce the fatal issue. Anatomical Characters. — The appearances presented on post-mortem examination are some- what differently described and estimated by different observers ; but none of them are ab- solutely pathognomonic, and some are as likely to be produced by exposure of the body after death as during the process of extinction of life. Among the more noteworthy are the following ; — strong cadaveric rigidity; paleness or waxy white ness of skin, with patches of more or less bright redness about the face, neck, and limbs, especi- ally on exposed or prominent parts ; a contracted and shrunken condition of the male genital organs ; comparative bloodlessness of superficial and external parts ; accumulation of blood in and about the thoracic and abdominal viscera ; great distension of all the cavities of the heart, with more or less clotted and often bright-coloured blood ; the blood in other parts also some- times of brighter colour than usually seen on post-mortem inspection ; hypercemia and con- gestion of the lungs ; hyperemia cf the brain, overfulness of the sinuses, and excess of serous fluid in the ventricles, and at the base, in some cases; in others, comparative bloodlessness of the surface of the brain, and no distension of the sinuses ; excessive fullness of the urinary bladder ; and, lastly, separation of the cranial bones along the coronal and sagittal sutures. The lines of reddish or brownish staining along the course of the superficial blood-vessels, relied on by some as pathognomonic, are certainly not so, inasmuch as they depend upon exosmosis of the blood colouring-matter set free by disruption of the corpuscles, which may be effected by freezing after death, as well as before. Treatment. — The treatment of sufferers from the effects of cold, consists in the restoration of warmth, and the rekindling of those processes by which the natural heat of the body is maintained. But this must be done gradually, and with great care. As in the treatment of a frostbitten part, so in the treatment of the body generally— all sudden or rapid elevation of temperature must be avoided. The sufferer, divested of the clothing previously worn, and wrapped in blankets, should be placed in the recumbent position in a room. 272 COLD, EFFECTS OF. the air of which is dry, still, and cold, but capable of being gradually warmed. Gentle, but continuous friction should be made over the trunk and limbs, care being taken that rigid or frozen parts be not damaged by rough manipula tion. At first, ice or ice-cold water may be used ; afterwards dry rubbing with flannel or with the hands is better ; later still some stimulating lini- ment may be employed. Some recommend im- mersion of the body in a bath of cold — at first ice-cold — water, the temperature of which can be gradually raised. This method would seem easy and advantageous, if means are at command. When the sufferer can swallow, warm, gently stimulating, drinks — as tea, coffee, aromatic in- fusions, beef-tea, or soup — may be given, at first without, hut later with some wine or spirit. Alcohol, though useless or injurious if taken to fortify against cold, is useful and beneficial when judiciously administered as a restorative after exposure. In all cases of insensibility, and even apparent death from cold, every effort must be made to restore animation; and the attempt must be persevered in for a considerable time before being given up as hopeless. It is often difficult, sometimes impossible, to judge whether life is absolutely extinct or not. And while, on the one hand, it is important that the temperature be not raised too quickly, lest reaction should he too strong or dangerously irregular ; on the other hand, it is equally, if not more important, that the needful measures bo adopted without delay, and carried out not too slowly, lest the chance of revival should he lost. In the less severe cases, restoration of warmth may he comparatively quickly accomplished. The state of the bladder should always be examined, and relief afforded, if needful, by aid. of the catheter. Attention to the general health is often requisite for long after recovery from the more immediate effects of exposure has taken place. Rest, good nourish- ment, and tonics are indicated. Cold as a Cause of Disease. — As a pre- disposing and exciting cause of disease, cold proves, in this country, year by year, more fatal in its effects probably than any other single condition or influence. Any considerable fall in the thermometer below the average standard during the colder months of the year is con- stantly followed by a corresponding rise in the death-rate, and an increase in still greater pro- portion in the amount and extent of sickness and suffering. The Deports of the Registrar- General clearly prove this, so far as the death- rate is concerned. A striking instance may be quoted. In the week ending December 19, 1863, in the London district 1,291 deaths were regis- tered. Severe frost set in, and in the week ending January 9, 1861, the number rose to 1.798. The week following, ending January 16, no fewer than 2,427 deaths were registered. This enormous increase could be attributed to no other cause than the effects of the severe cold which, prevailed. The Registrar-General also shows that after the age of from twenty to forty the mortality from cold increases in something like a definite ratio with increasing years. General depression of the vital powers, con- gestion and functional derangement of various internal organs — the lungs, liver, and kidneys — COLD, THERAPEUTICS OF. [ catarrhal and other forms of inflammation of the mucous membranes, especially of the respiratory tract, but also of the intestinal canal and bladder, paralysis from central or peripheral iesioD, to- gether with rheumatism, chilblain, frost-bite, and gangrene, constitute the list of maladies most commonly caused and fostered by exposure to the influence of cold. Author E. Durham. COLD, Therapeutics of. — The therapeutic uses of cold are various and extensive. Cold may he applied as moist cold, by means of wet compresses and cold lotions or baths ; and it may also be used as dry cold in the form of ice en- closed in a receptacle of metal or india-rubber. Each of these methods has its special advantages and adaptations. Furthermore, cold may he made use of by the mouth, and by injection into the mucous canals of the body. General Principles. — The general effect of cold, however applied, is to lower temperature, to diminish sensibility and fluidity, to contract the tissues and vessels, and so to reduce the volume of parts. The cold bath and cold spong- ing alike have the effect of lowering the tem- perature of the body. The fall of temperature sometimes is hut transient, reaction set ting in and heat of surface returning when the body is with- drawn from thecooling medium. At other times the temperature continues to fall after the indi- vidual is removed from the bath. If the action of the cold bath be prolonged, then athermometer, introduced within the rectum, shows a great de- pression of temperature, and much pain is ex perieneed, similar to the severe pain which is felt in the hand and arm when the former is held for some time in water at a temperature of 41° Fahr., and which soon compels the with- drawal of the hand from the vessel. Cold baths and their uses are treated of in another article, but attention may here be drawn to the practice of cold sponging over the surface as an efficacious means of lowering preternatural heat and reliev- ing acridity and dryness of tho skin during fever. Reduction of hyperpyrexia by means of cold is now a well-established therapeutic method. Temperature ; and Special Diseases. Methods of Application and Uses. — 1. Cold Affusion and Wet Packing. — In the practice of cold affusion, introduced by Dr. Currie, in 1797, the patient is unclothed, seated in a tub, and four or five gallons of cold water thrown over him. Thus, Dr. Currie said, a commeneiug fever might be 1 extinguished.’ In cases where the skin was burning hot and dry, it was observed that after the cold allusion, temper- ature fell, perspiration broke out, aud the patient usually dropped into a refreshing sleep. If the body-heat did not exceed 985° Fahr., or if the patient was damp and chilly, with or without delirium, the cold affusion was regarded as danger- ous and by all means to be avoided. In fevers com- plicated with any visceral inflammation, the cold affusion is prejudicial. Drs. Strauss and Hirtz speak most highly of the marvellous effect of cold affusion in cases of collapse during fever. This kind of collapse appears due to a paralysis of the nervous centres : the heart's action fails, as docs also the respiration ; but while the sur- face of the body is cold, the temperature, taken in COLD, THERAPEUTICS OP. 273 Che rectum, still remains abnormally high. The affusion is applied by pouring a pitcherful of water, at a temperature of, or a little abore 10° C. (50° Fahr.), over the patient seated on a waterproof cloth. The patient, plunged in stu- por, is suddenly roused by the shock ; he draws a long breath, the respiration becomes fuller ; the cardiac ataxy ceases, and the pulse, which, traced by the sphygmograph during the collapse, presented a scarcely broken horizontal line, now regains its normal line of ascension; heat of sur- face returns, and the temperature in the rectum falls. The action of the cold affusion, as thus applied, is to excite immediate and energetic reflex action. In many nervous affections, such as chorea and hysteria, cold douches, shower baths, and affusions are valuable as restorative and cura- tive agents. In the convulsions of robust chil- dren, a stream of cold water directed over the head from a height of two or three feet often has a speedily beneficial effect. Cold affusion has been tried in tetanus, but it has in some instances killed the patient (Elliotson). Other cases in which cold affusions are of service are those where respiration fails, and it is necessary to appeal powerfully to the reflex ex- citability of the nervous centres. To resuscitate those who are in danger of death from a narcotic such as chloroform or opium, slapping the patient severely with a cold wet towel is an efficient me- thod. In sun-stroke cold affusion over the head and neck may be resorted to, provided the skin be not cold and clammy and the patient in a very syncopal state. In conditions of nervous spasm, of the larynx for example, cold douches over the neck may prove useful. Cold affusion to the feet was much commended by Cullen as a means of promoting action of the bowels in cases of obstinate constipation. Spasmodic retention of urine has been relieved by cold douche over perineum and thighs (Currie); and Mr. Erichsen mentions the case of an old man who found his power of micturition increased by sitting on the cold marble top of his commode. In cases of extreme debility, with damp, cool skin, low muttering delirium, and very feeble pulse, cold affusions are dangerous. In some cases of fever, where for any cause a cold bath is objectionable, the patient may be wrapped in a wet sheet and then covered with a few blankets. The sheet as it becomes heated may be changed for one fresh and cold, or very cold water may be squeezed from a sponge over the sheet as the patient lies rolled up in it on a waterproof cloth. In scarlet fever of malignant type, where the rash does not readily appear, this form of cooling pack has been found most valuable. Drs. Hillier and Gee have both added their testimony to its utility. In Dr. Gee’s cases the patient remained packed in the wet sheet for one hour and was then removed to bed. The cases best suited for treatment by the wet pack are those where the skin is very dry and hot, and the patient exceedingly restless and delirious. 2. Cold Compresses, Irrigations, Lotions, and Injections. — Cold maybe continuously ap- plied with a view to abating undue heat of apart of the body. Thus iced-water rags or compresses may be placed over an inflamed throat, or on 18 the head in inflammation of the brain. In acute pneumoniaNiemeyer has commended strongly the use of cloths dipped in cold water, well wrung, and then applied so as to cover the chest and es- pecially the affected side. These compresses are repeated every five minutes. Pain and dyspnoea are much relieved ; somotimes the temperature falls an entire degree ; and if the cold appliances do not arrest the actual attack of pneumonia, they shorten its duration and promote speedy con- valescence. The necessity of so often having to change the compress, and thus disturb the patient , is a great objection to this mode of apply - ing cold. A powerful sedative and antiphlogistic effect of cold can be obtained by irrigation ; i.c. allow- ing cold water to fall drop by drop on a cloth, so as to keep it continually wet with fresh supplies of water. This may be done by sus- pending over the part to be irrigated a bottle of water, in which a few pieces of ice may be put; one end of a skein of cotton, well wetted, is then allowed to hang in the water, while the other end is brought over the side of the bottle. This, acting as a syphon, causes a continual drop- ping upon the part to be irrigated. In injuries of joints, where it is of much consequence to check inflammation, this process, which abstracts heat gradually, and without disturbance of the part, is most valuable. Irrigation of the shaven scalp in cases of meningitis is a very powerful, cooling, and sedative appliance, requiring care and watchfulness. A cap of india-rubber over the head and back of neck, so arranged that a current of cooled water may flow continuously through it, will act as a general reducer of tem- perature. Where pounded ice is applied to the head in a bladder, this should be suspended by a string from the bedstead, so that the head of the patient may not have to sustain the weight of the bag and its contents. Five ounces of sal ammoniac and five ounces of nitre in a pint of water will form a frigorifie mixture, which can be applied in a bladder when ice is not at hand. The ice- bag, and cold water compresses renewed every three minutes, have been used as an appliance to strangulated hernia, and to prolapsed rectum, to reduce the volume of the part and so facili- tate reduction. Care must be taken that the cold application be not continued so long as to cause gangrene. Cold wet compresses should not be applied over dry bandages, with which wounded or broken parts are secured. Several cases are recorded where a hand or arm has become gangrenous, in consequence of having been bound up with dry bandages, and then treated with cold water compresses. The dry bandages, as they become wet, contract tightly on the limb, thus stopping circulation and causing gangrene. A mixture made of spirit of wino and water, or of eau de cologne with water, is a simple form of cooling lotion. The spirit evaporates and so carries off heat from the surface. 1 oz. of rectified spirit to 15 of water makes a good spirit lotion, and the addition of 4 drachms of nitrate of potash, or chloride of ammonium, will add to its cooling and sedative effect. -1 drachms of the chloride of ammonium with hal t an ounce of diluted acetic acid, and the same !7i COLD, THERAPEUTICS OF. quantity of rectified spirit in 15 ozs. of camphor water, is another form for a very serviceable lotion. These lotions, applied by means of a piece of soft rag or lint over the skin, act as refrigerants, cooling the head when it is hot or painful ; reducing heat and arterial excite- ment in tumours or contusions; and tending in the latter to promote the absorption of effused blood. Cold water, and cold lotions of vinegar and water, are familiar means for trying to stop haemorrhage. In cases of severe uterine haemorrhage, injec- tions of ice-cold water into the vagina, or into the rectum, frequently succeed in checking the bleeding. In eases of bleeding internal piles an injection of cold water, after the action of the bowels, braces the parts and constringes the bleeding vessels. 3. Dry Cold. Uses of Ice. — Heatmaybecon- tinuously abstracted from an inflamed part in a safe way, and without undue risk, by applying dry cold by means of a waterproof bag of vulcanised india-rubber filled with ice, snow, or a freezing mixture made of equal parts of salt, nitrate of potash, and chloride of ammonium. Moisture from the air will condense on the exterior of the cold bag, but a piece of lint interposed will protect the skin from damp. The india-rubber is a bad conductor, and too great abstrac- tion of heat need not bo feared. The walls of an animal bladder conduct heat much better than the india-rubber, and it is necessary to watch carefully over the application of ice-blad- ders, for when continuously applied they have been known to cause severe frost-bite of the part. If, when cold is being applied, the patient persists in complaining of severe pain, it is right carefully to examine and see how the part is affected by the cold. Professor Esmarch, in rases of fracture, and in various forms of trau- matic inflammation, has applied ice for periods of twenty or thirty days with the best results. In cases of commencing disease of the vertebrae this surgeon has used cold water placed in a tin vessel, so made as to adapt itself to the part to be treated. Minor cases of bruise with inflam- mation may be treated by cold employed in the form of a common bottle filled with cold water and kept pressed against the part. After opera- tions upon the eye, the extraction of cataract for example, a small ice-bag is very useful in reliev- ing pain and keeping down inflammation. Ice-bags placed along the course of the spine have been found effectual remedies in many forms of nervous disorder. In cases of epilepsy, where the circulation is sluggish, the hands and feet being always clammy and cold, an india-rubber bag of ice applied along the spine has been found to restore warmth, at the same time relieving headache and symptoms of incipient paralysis. Cold to the spine is asserted by Dr. Chapman to lessen the excito-motor power of the cord. In the severe pain of an inflamed ovary or testicle ice in a bag may often be employed beneficially as an anodyne. Lumps of ice swallowed are invaluable in arresting haemorrhage from the throat and stomach. In tonsillitis and diphtheria this same treatment tends to reduce inflammation and cool the throat of the patient. Obstinate vomiting can COLIC, INTESTINAL. often be checked by swallowing fragments of tee. 4. Cold as an Anaesthetic. — Dr. James Arnott. in 1849, brought forward the use of a freezing mixture of ice and salt as a means of producing local anaesthesia, by freezing the part to which the mixture was applied, either in a hag or in a metallic spoon. For small superficial opera- tions this method of anaesthesia by congela- tion answers very well. The part becomes white and hardened to the cut of the surgeon's knife, there is very little haemorrhage, and the wound made usually heals well by primary adhesion. More recently, Dr. Richardson has indicated a very convenient way of inducing local anaes- thesia, by the volatilization of ether in the form of spray, by means of the hand-ball spray atomi- zer. Ether sprayed on the bulb of a thermometer, held about an inch from the jet, brought down the mercury to within 10° Faltr. of zero. When the jet was turned on to the skin, a marked degree of local anaesthesia was produced, but not enough for surgical purposes. By driving over the ether under atmospheric pres- sure, instead of trusting simply to capillary action — or to suction, as in Siegle's apparatus — one may bring the thermometer within thirty seconds to 4° below zero. By the use of this apparatus, at any season or temperature, the surgeon can produce cold even 6° below zero: and by directing the spray upon a half-inch test- tube containing water, he can produce a column of ice in two minutes. For local anaesthesia by cold, the ether spray anwers well. Such opera tions as the removal of small tumours, opening abscesses, and inserting sutures, may be pain- lessly performed. J ohx 0. Thobowgoou. COLIC ( kuiXov , the large intestine). — Origin- ally colic signified a painful affection due to spasm of the bowel, hut though still retaining this ap- plication, it has now come to be further associated with other complaints which are attended with severe pain of a spasmodic character, a qualifying adjective indicating the nature and seat of each particular form. Thus renal colic is applied to the group of symptoms due to the passage of a stone from the kidney to the bladder ; hepatic colic to those accompanying the escape of a gall- stone. See Colic, Intestinal. COLIC, INTESTINAL. — Srxox. : Fr. Coliquc ; Ger. Die Kolilc. Defixitiox. — Painful and irregular contrac- tion of the muscular fibres of the intestines, without fever. JEtiology. — Predisposing causes. — These in- clude the nervous (as hysteria, hypochondriasis), lymphatic, and bilious temperaments ; sedentary occupations; the female sex; and the period of youth or adult age. Exciting causes. — These may be grouped as follows : — 1. Irritation from lodg- ment of gas due to fermentation of undigested food and decomposition of faeces long retained within the large intestine; from faeces, or intes- tinal concretions, undigested or partly digested food, such as pork, shell-fish, salt meats, unripe fruit or septic game ; from cold drinks or ices - from excessive or morbid secretions, especially bile ; from gall-stones : orfrom worms — abundleof COLIC, INTESTINAL, round worms or coiled up tape-worms. 2. Morbid 6tates of the bowel, including obstruction from intussusception, twisting, strangulation, &e. ; ulceration (typhoid, tubercular, dysenteric) ; in- flammation (enteritis, typhlitis, &c.) 3. Keflex nervous disturbance, due to anxiety, fright, anger, jr other emotional disorder ; to disease of the ovaries or uterus; to calculus (hepatic or renal); to dentition ; or to exposure, especially of the feet and abdomen, to cold. 4. Blood-poisoning, as from lead, copper, gout, rheumatism. SniPTOMS.— The characteristic or essential symptom of intestinal colic is pain in the abdo- men, without febrile disturbance. It usually be- gins, and is most severe, in the umbilical region, then spreads to other parts, or to the whole abdomen, and is apt to travel from one part to another. It is almost always relieved by firm pressure and by expulsion of flatus, and is par- oxysmal in character, remitting, or exacerbating, )r completely subsiding at intervals. The suffer- ing is usually severe, often agonising, and to relieve it the patient bends forwards, pressing the abdomen firmly with his hands or against some lard surface, or rolls about. As a rule the ab- domen is distended by flatus ; in lead-colic it is, however, firmly retracted towards the spine, and the movements of the inflated intestines affected by spasmodic contraction, producing loud bor- borygmi, may frequently be seen and may be felt by the hand applied to the abdomen. The muscles of the abdominal wall and the bladder usually participate in the internal spasm : the abdomen becomes rigid or knotted, and. the recti muscles become contracted into round balls, while frequently the navel is retracted ; mictu- rition is frequent or suppressed. Usually there is constipation, and the pain disappears when the bowels are freely relieved ; sometimes, how- ever, it persists for a time. Constipation stands in a twofold relation to colic, either as cause or effect of the spasm. The countenance expresses great suffering, anxiety, and depression, and the features may be pinched. The surface of the body is cold, es- pecially the feet, and the pale skin is covered by a cold perspiration. The pulse is commonly of normal frequency, or is infrequent and feeble. The symptoms vary somewhat with the cause. When due to irritating ingesta the prominent symptoms are vomiting and diarrhoea, sometimes ending in catarrhal dysentery. In children the logs are drawn up upon the abdomen, the bowels are often at first confined, and the evacuations greenish, offensive, and very acid, afterwards becoming loose. In nervous and hypochondriacal subjects, and especially females, severe pain in the intestines, resembling that of spasmodic colic, is apt to occur (sec Enteralgia). Flatulence plays a varying part in different cases; it is often a prominent symptom, and the form of colic thus characterised has been termed Colica flatu- lenta. Vomiting is generally in proportion to the severeness of spasm, and the degree of intestinal obstruction. Duration. — The duration of the attack varies greatly, from a few minutes to several days. The spasm usually ceases abruptly, leaving a feeling of COLLAPSE. 375 soreness in the abdomen, while there is enjoyable relief from suffering. Colic, when violent or intractable, may terminate in enteritis, in peri- tonitis, and, especially in children, in intussuscep- tion. Diagnosis. — A pain moving from place to place, relieved by firm pressure and unattended by fever, separates colic from other affections, more particularly from those due to inflammation, in which pain is always aggravated by pressure. Distension with spasm of the stomach may bo distinguished from a similar condition of the colon, by the pain occupying a higher position in the abdomen (at or around the ensiform cartilage instead of — as in colic — the umbilical or hypochondriac regions), and by the percus- sion note elicited being deeper-toned and more prolonged than that which is produced by a distended colon ; besides in colic the spasmodic contraction of the colon, producing borborygmi, maybe traced by the hand, or may be even seen, and there is tenesmus. It should be borne in mind that enteritis or peritonitis may follow colic, when the pulse, previously unaltered, may become frequent, hard and small, or frequent and soft, and the seat of inflammation becomes tender. Prognosis. — Colic almost always ends in re- covery, preceded by free evacuation from the bowels. Unfavourable signs are those arising from inflammation or intestinal obstruction. Treatment. — In the first place the setiologicai indications should be met. The irritating contents of the bowels should be dislodged by purgatives combined with sedatives, such as calomel (five or eight grains) or rhubarb (twenty grains) with opium (one grain), followed by repeated doses of some saline aperient, such as magnesi® ve! potass® sulph., with tinct. of henbane or opium, and spirits of chloroform, until free action of the bowels is obtained. A suppository containing half a grain each of hy- drochlorate of morphia and extract of belladonna, or a subcutaneous injection of morphia, may secure immediate relieffrom pain before aperients have time to act. Large warm enemaia often relieve quickly. Other suitable measures are — the warm bath, friction with warm oil or stimulating liniments, hot-water fomentations, steamed flannels, mustard or turpentine stupes, flannel bags containing hot chamomile flowers or heated sand, the stomach- warmer filled with hot water, large linseed and mustard poultice. The diet should be liquid. In the prophylactic treatment the diet should be strictly regulated, lodgment of irritating solids and gases within the bowels should be pre- vented (see Constipation ; E.eces, Retention of ; and Flatulence), and the abdomen and feet should be kept warm by a flannel roller or belt and thick woollen stockings. George Oliver. COLLAPSE. — Definition. — Collapse is a state of nervous prostration. When it is ex- treme, the vital functions are in a condition of partial, and sometimes nearly complete, abeyance. It may terminate in death, or be followed by gradual reaction and complete recovery. Collapse and shock have usually been classed together, but it is not accurate to do sc. If is 276 COLLAPSE. ;rue that the ganglionic centres of the medulla oblongata are more or less profoundly involved in both, and that both possess many symptoms in common, dependent upon the derangement of function of one or more of these centres. Some confusion is attributable to the fact that shock is a term applied not only to a state or morbid condition, but to the cause which most frequently produces that condition — a violent impression or ‘ shock ’ to the nervous centres. See Shock. Collapse arises from many different causes, shock being one, of which collapse may be regarded as a final and extreme degree, and into which it often imperceptibly passes. Col- lapse, on the other hand, may occur under con- ditions where there has been no antecedent state of shock. Collapse presupposes previous nervous exhaustion, while shock may instantly appear in a healthy individual. ^Etiology. — Any severe injury, especially if attended by profuse and sudden haemorrhage, may terminate in collapse, such, for instance, as the rupture of one of the abdominal viscera, a penetrating wound of the chest or abdomen, or a wound of the heart or of a large artery. Ex- tensive burns or scalds frequently give rise to typical collapse ; and severe and prolonged pain is capable of causing it. Rupture of the heart or of an internal aneurism, if the patient do not immediately die, causes extreme collapse. Cer- tain poisons, as tobacco and arsenic, will also produce this condition. It is. the terminal stage of some diseases, as, for instance, of Asiatic cholera; severe drastic purgation also, or pro- longed vomiting, from wnatever cause, may occa- sion it. The pernicious malarious fevers and yellow fever often end in collapse. In the acute yellow atrophy of the liver symptoms of severe nervous disturbance, resulting in a species of col- lapse, sometimes suddenly supervene. Pyaemia, septicaemia, prolonged narcosis, frequently ter- minate in collapse. Symptoms. — The severity of collapse depends on the nature of the cause- and the physical and mental vigour of the individual. It may vary from a moderate to an extreme degree. A moderate amount is seen in the course of fever and some other diseases, but this neither modifies the progress of the malady nor attracts the notice of the patient, causing chiefly peripheral coldness. From this trifling amount collapse may pass to the most intense form, where the patient scarcely differs in outward semblance from a dead body. A superficial inspection will fail to detect the existence of the functions of respiration and cir- culation. Vitality may be said to have reached its minimum. In well-marked collapse from severe injury or loss of blood the pulse at the wrist may bo almost or wholly imperceptible, the heart's action scarcely audible, very rapid, fluttering, and irregular ; the surface of the body, the face especially, is deadly pale and cold, and the skin moist with clammy sweat ; the respiration is very feeble, slow, and irregular, accompanied by sighing or gasping inspirations at intervals ; the expression and character of the face are lost; the features are sunken and relaxed; the eye is dull, glassy, staring, or languidly rolling about, and the conjunctiva perhaps insensible to the touch ; the nostrils are dilated ; the sensibility COLON, DISEASES OF. of the whole body is diminished ; and the mus- cular debility is extreme. The patient lies on his back, without a trace of voluntary effort. If a limb is lifted it falls back again as if dead. Yet the consciousness and senses may be almost un- impaired ; if roused by repeated questions the sufferer will with visible effort make a coherent though, probably, inadequate reply. If relief be not given, the respiration may become slower and slower till each one appears the last, when a sudden sigh shows that life is still present; finally, the pulse and heart's ac- tion become more and more faint, and death results from pure asthenia. A condition closely resembling traumatic collapse is often wit- nessed in the last stage of cholera, when in an extreme degree the patient almost resembles a corpse save for the convulsive motions induced from time to time by the painful cramps. The surface is pale or bluish, covered with profuse sweat, but is at the same time cold to the touch. The hands and extremities are icy cold, the tongue is cold, and so also is the breath, which is gasping and paroxysmal ; no pulse can be felt at the wrist; the eyes and features are sunken : the mind is apathetic, but nevertheless the con- sciousness may be perfect, and the patient able to respond to questions with a strong voice. Severe purging and tobacco-poisoning produce a condition extremely like that described as traumatic collapse. Some cases of malignant fever terminate in collapse, which is characterised by extreme anxiety, pallor or lividity of the face and surface, coldness of the skin, sweating, and a small, frequent, and irregular pulse. A decrease of animal heat, especially in the external parts, is characteristic of collapse. The temperature of the internal organs varies; and there may be collapse with high internal tem- perature. This occurs in cholera, intense fevers, and some forms of septicaemia; or the converse may obtain, as is frequently witnessed in the collapse of dissolution. Collapse from loss of blood differs from syncope, although the latter may be described as an acute and transient form of collapse. In syncope the prominent symptom is loss of consciousness, which in collapse may be almost or quite perfect. For the pathology and treatment of col- lapse see Shock. William MacCormac. COLLAPSE, Pulmonary. — A condition in which the lung is simply more or less devoid of air. See Lung, Collapse of. COLLIQUATIVE ( colliquco , I melt). — A term which originated in the belief that in cer- tain conditions the solid parts melted away, and were carried off as liquid discharges. The word is now generally applied to the copious sweats and diarrhoea which occur in certain wasting diseases, such as phthisis. COLLOID (k6\\u, glue, and e75os, like). — A peculiar morbid product resembling in its characters glue or jelly, and found associated with cancer and other forms of new-growth. See Cancer and Degeneration. COLON 1 , Diseases of. — The colon partici- pates to a varying extent in the lesions aud COLON, DISEASES OF, derangements of dysentery, typhoid fever, ente- ritis, peritonitis, and other affections. The special disorders to -which it is most liable are inti- mately connected -with its anatomical and phy- siological peculiarities. The colon is a distensible membranous tube, of large capacity, with chiefly solid contents, which are propelled slowly on- wards by the muscular contractions of the walls. The moving force and the resistance offered to it are often too finely balanced, so that whenever the energy of the former is somewhat reduced, an accumulation of excretory products is apt to be determined. Hence arise retention of faeces and gases, constipation and consecutive evils, such as colic, colo-enteritis, or ulceration of the colon. I. Atony. — Definition. — Loss of contrac- tility of the walls of the colon, leading to accu- mulations and other sequelae. ./Etiology. — The causes of torpor or atony of the colon are mainly those of constipation — sedentariness, indolent and luxurious habits, a sluggish and lymphatic temperament, old age, and general debility or exhaustion, as after a long and tedious illness. Whenever the wall3 of the colon are distended by solid or gaseous accumulations, the contractile power is apt to be enfeebled, leading to further retention and loss of tone. Atony of the colon is an essential element in the patliogeny of constipation not depending on mechanical obstruction. Tympanitic distension of the colon from paralysis of the sympathetic nerve occurs in peritonitis and in fevers, c.g. typhus fever. Symptoms. — Torpor of the colon may be indi- cated only by constipation. There are usually the ordinary signs of retention of flatus or faeces. In hysteria, and in inflammation of the bowels or peritoneum, flatus is apt to accumulate rapidly, ind to produce great distension of the colon. Faeces may collect and form large tumours in any part of the large intestines, but especially in the caecum and sigmoid flexure. Faecal and gaseous accumulations in the colon resulting from atony may produce the follow- ing effects, directly or remotely connected with them: — («.) Local, — 1, Colic. 2, Inflammation of the walls of the colon, or of the mucous and sub- mucous coats, and ulceration. 3, Disturbances from pressure: thus flatulent distension, and large faecal accumulation encroaching on the cavity of the thorax and impeding the descent of the diaphragm, may cause dyspnoea or short and rapid respiration, palpitation aud irregular action of the heart, with remote effects arising from a dis- turbed circulation in the brain, such as giddiness and headache; a distended esenrn or sigmoid flexure pressing on veins and nerves may induce oedema, numbness, and cramps of the right or left lower extremity. 4, Retarded digestion, de- rangement of the stomach and liver, and intes- tinal obstruction. (A) General . — The absorption of excremen- titious matter is said to lead to wide-spread general effects, such as a sallow, earthy, or dirty complexion, lassitude, debility, offensive breath, loaded urine, &c. 1 keatment. — Atony of the colon is usually a euronic disorder demanding prolonged treatment. COLON, DISEASES OF. 277 The hygienic and dietetic rules laid down in the article Constipation require in most cases to be supplemented by medicines. The most satisfac- tory results follow a course of tonics, combined with aperients, such as iron, quinine, strychnia, belladonna, with aloes, colocynth, or rhubarb. The purgative should be adjusted to each case, so as to secure no more and no less than a regular and efficient evacuation ; and while the loaded colon continues to be thus relieved, the dose should be very gradually reduced. This tonic-aperient course may be greatly aided by local stimulation of the colon, as by fric- tion, kneading, electricity, cold-water compresses, or douches. The abdomen should be supported by a belt or roller. Bretonneau and Trousseau strongly advised a course of belladonna, giving gr. y of the extract or of the powdered leaf as a pill in the early morning, — the stomach being empty, — then two such pills if in four or five days the bowels do not respond, and increasing the dose, but not beyond that contained in four or five pills, in twenty-four hours. A teaspoonful of castor oil may be given twice a week to aid this course of treatment. Flatulent distension of the colon in the elderly and in females at the climacteric period is often greatly relieved by the prolonged use of a pill containing compound assafoetida pill and nux vomica after meals. Elec- tricity is sometimes used with benefit. Tympanitic distension of the colon in perito- nitis and in fevers is best treated by free doses of opium. II. Inflammation. — Synon.: Colitis, colonitis, colo-enteritis ; Fr. oolite ; Ger. Kntzundung des Schleimhautcs des Kolons. An inflammation with ulceration of the mucous membrane and submucous connective tissue of the colon, producing lesions undistinguiskable from those of dysentery, has been pointed out by Copland and. Parkes. Colitis is said to be a non- specific local affection, commencing in the sub- mucous tissue, and subsequently attacking the mucous membrane with its glandular structures — the primary seat of dysenteric inflammation. As in dysentery the inflammation induces gangre- nous destruction and ulceration of the mucous membrane and underlying cellular tissue. A catarrhal form of colitis is apt to occur in measles. 1 It often happens that the morbillous catarrh of the intestines exhausts itself by attacking the large intestine, producing that special form of colitis characterised by tenesmus and glairy bloody stools.’ 1 Inflammatory diar- rhoea, particularly in children, often terminates similarly. Colitis arising from retained excreta may in- volve the entire wall of a circumscribed portion of the colon, commonly the ascending colon and sigmoid flexure, or may be confined to the mucous and submucous tissues. In inflammation of the ccecum (typhlitis) the walls of the ascending colon are more or less implicated. In fsecal retention the mucous follicles of the colon may become obstructed, and the distension resulting therefrom may lead to inflammation and ulcera- tion. Irritation of the mucous lining of the colon from the lodgment of faeces may extend to the lymphatic vessels and glands. The glan- 1 Trousseau, Clinique Medical*, 178 COLON, DISEASES OF. dular enlargement cannot, however, usually bo recognised during life. While the symptoms of tabes mesenterica may be traced to enlargement and obstruction of the mesenteric glands, set up by irritation of the intestinal tract, it is doubtful whether such results can follow a similar cause limited to the colon only. Treatment. — The treatment of colitis consists in the local application of fomentations, poultices, opium enemata, or morphia suppositories ; and in the use of gentle laxatives, such as castor oil, combined with sedatives, such as opium or hen- bane. The catarrhal form generally terminates in spontaneous recovery. Trousseau advises the use of albuminous injections, or of injections con- taining about half an ounce of water and nitrate of silver — from f to 1J grains, — or sulphate of copper or sulphate of zinc — from 3) to grains. III. Displacements. — The parts of the colon most liable to displacement are the transverse colon and sigmoid flexure — the former may de- scend as low as the pubes, and the latter may cccupy any position between the left iliac region and the right side of the abdomen. Usually the meso-eolon is elongated ; there is adhesion between the displaced part and the new site; and, the longitudinal bands being elongated, the loculi are obliterated. Displacements are most apt to occur in those who have long suffered from constipation, retention of faeces, chronic dysentery, hernia, or from encysted or other tumours. They may lead to complete obstruc- tion, and cannot usually be recognised with cer- tainty during life. IV. Diverticula. — A loculus of the colon from repeated accumulation may become so distended as to form a lateral appendix. Such a diverti- culum when loaded with faeces may he felt through the abdominal wall as a distinct tumour, which may collapse when pressed between the fi ngers. George Oliver. COLOUR- BLIND NESS. — A defect of vision, the subject of which is unable to distin- guish certain colours. Sec Vision, Disorders of. COMA deep sleep). — A condition of profound insensibility. See Consciousness, Dis- orders of. COMA-VIGIL ( Ku/j.a , insensibility, and vigil, wakeful). Definition. — A symptom, or set of symptoms, where continuous sleeplessness is associated with partial unconsciousness. Coma-vigil occurs towards the end of diseases in which the nervous system is involved either directly or indirectly, especially where sleep- lessness has been a sympttom in the earlier part of the disease. Thus it frequently appears towards the end of an attack of typhus or of delirium tre- mens, when these are about to terminate fatally. Symptoms. — The patient lies quiet with his eyes half-closed, inattentive to everything around, but not absolutely unconscious. If the eyelids are touched, they are closed, and perhaps the head is slowly turned away. The eyes have a dull, half-glazed look, and slowly follow any moving object near them. The pupils are neither much dilated nor contracted, and they COMEDONES. move under the influence of light, but very slug gishly. The mouth is generally somewhat open and dry, as are also the lips. The power of swallowing is much impaired ; if a small quan- tity of fluid be put into the mouth, an effort is mad6 after a short time to swallow it, and this effort is for a time successful; but after the symptoms have been present for some time, the effort is so feeble that no result follows. The patient lies mostly on the back: if turned on the side, he either remains as placed, or often slowly turns to the former position on the hack. The limbs are occasionally moved a little, and ii the hand or arm be raised, a slight resistance is offered. If the bladder or the rectum be emptied, there is slight consciousness of the act, as if a feeling of discomfort preceded it. The pulse is quick and weak. The respiration is weak, but otherwise normal. The symptoms continue unbroken throughout, nothing like natural sleep occurring. Diagnosis.— Coma-vigil is distinguished from, coma by the presence of a certain amount of consciousness, by the quick pulse, and by the absence of stertorous breathing. It is distin- guished from concussion of the brain by the pupil not being contracted, by the history of the case, and by the absence of coldness of the skin, and of any sign of shock. Prognosis, — The prognosis is unfavourable; coma-vigil is almost invariably a fatal symptom. It may last from a few hours to three or four days ; from twenty-four to forty-eight hours being the most common duration. It may deepen into actual coma; hut more usually the symp- toms change but little, save that the pulse be- comes quicker and weaker, and the respiration more feeble, and death by asthenia then results. Pathology. — As being little but a symptom, coma-vigil has strictly speaking no pathology. It seems to coincide with the gradual suspension through exhaustion of the functions of the ner- vous centres ; the cerebral hemispheres being nearly if not quite inactive, while the action of the rest of the centres is kept up weakly hut continuously, till the little remaining nervous power is exhausted, when death ensues. It differs from coma, inasmuch as in the latter, the medulla oblongata is the only centre left active, the functions of the rest being entirely suspended. It differs from concussion, inasmuch as the symp- toms attending the temporary unconsciousness of the latter are more those of irritation than of pure suspension of function. E. Beveridge. COMEDONES ( comedo , I consume). — Stnon. : Grubs. — This is the name applied to the little cylinders of sebaceous and epi- thelial substance which are apt to accumulate in the follicles of the skin, and to appear on the surface as small round black spots. When squeezed out they have the appearance of minut e maggots or grubs with black heads, and thence have derived their name. They may occur in all parts of the body where sebaceous follicles exist, but are most common on the face, the nose, the neck and shoulders, the breast, and within the concha of the ears, in the latter situa- tion often attaining a considerable size. The accumulation of this substance is due to want cl COMEDONES. expulsory power of the skin, and to the slight .impediment which is afforded by the aperture of the follicle to its exit ; and when squeezed out it is found to vary in colour, in figure, and in den- sity, according to the period of its detention. When recent, the comedones are soft and white, and modelled into an exact cylinder by compres- sion through the mouth of the follicle; when impacted for a considerable time they acquire the yellow tint, the transparency and hardness of horn ; and assume a bulbous figure from the dilatation of the follicle below the constricted orifice of the epidermis ; and by their bulk they sometimes stretch the hair-follicle so far as to obliterate it completely. Besides their usual composition of sebaceous substance and epithelial cells, they frequently contain lanuginous hairs, end not rarely the entozoon folliculorum in its different phases of development. When they raise the pore into a minute pimple they have a similitude to acne punctata, and might be mis- taken for that affection ; whilst the black spot on the summit of conical acne is due to a comedo. Treatment. — Comedones are generally asso- ciated with a weak state of the skin as well as of the individual ; they are most frequently met with in young persons in whom the powers of the constitution are not yet established, and will be benefited by generous diet and tonic treat- ment. Locally, soap and water with plentiful friction and ablution will be fotmd of great service; and, as an astringent to invigorate a debilitated skin, a lotion of perchloride of mer- cury, in emulsion of bitter almonds (two grains to an ounce) and spirits of wine. Erasmus Wilson. COMPLICATION' {con, with, and plico, I fold). — It is difficult to give a strict definition of what ought to be included under the term complication , but the word signifies the occur- rence during the course of a disease of some other affection, or of some symptom or group of symptoms not usually observed, by which its progress is therefore complicated, and not un- commonly more or less seriously modified. The difficulty lies in determining what should be looked upon as essentially part of the original disease, and what as a mere accidental occur- rence. For instance, many regard the cardiac affections which so often arise during the pro- gress of acute rheumatism as a part of the complaint, others as complications. The same remark applies to the relationship of renal dis- ease to scarlatina, as well as to numerous other cases. Complications arise in different ways. They may, as just indicated, be considered as develop- ments of the original morbid condition, resulting from the same cause and being more or less allied ; or they are independent and accidental, of which an illustration is to be found in the association of ague with scurvy or dysentery, or in the co-existence of two or more of the exanthemata. The most important class of complications, however, are those which follow the primary disease as more or less direct consequences. These may further be induced in various ways. Thus, for example, in febrile diseases secondary lesions are liable to arise as CONCRETION. 276 a result of changes in the blood ; a mechamral act, such as cough, may lead to complications in the course of phthisis and other pulmonary affections; cardiac diseases frequently bring about consecutive changes in other organs, by inducing obstruction of the venous circulation, or emboli may originate under certain conditions and produce their usual consequences. It i3 of great practical importance to be acquainted with the complications which are liable to b? met with in the various diseases, and especially in those which are of an acute nature, in order- that measures may be taken to prevent them, and that they may be recognized and treated at the earliest possible period, if they should occur Ebedebick T. Roberts. COMPOUND GRANULAR CORPUS. CLES. — Formerly these microscopic objects were regarded as of inflammatory origin, and as affording positive evidence of the occurrence of inflammation. Hence they were termed ‘ com- pound inflammation globules ’ (Gluge.) Almost all pathologists now, however, recognize the fact that they are not products of an inflammatory process, but result either from the degenera- tion of pre-existing cells, in which protein and fatty granules accumulate, or, perhaps, from the aggregation of granules originally distinct, which are present in abundance in degenerating tissues. They may even be formed out of the cells of morbid products, such as cancer. These com- pound granular corpuscles derive their name from the fact that they consist of a large number of minute granules aggregated together, and they either present a delicate cell-wall, or this cannot be detected. Occasionally there is an appearance of a nucleus in the centre. Frederick T. Roberts., COMPRESS. — Folds of lint or other mate- rial, which are used for the purpose of producing pressure, or as a pad by which hot or cold water or medicinal agents may be applied tc the surface. In the latter case the compress may be rendered waterproof by being covered by a piece of gutta-percha tissue or mackintosh-cloth. See Hydropathy. COMPRESSIBLE. — A term implying com- paratively slight resistance, and applied specially to the pulse when it yields readily under the finger. See Pulse, The. COMPRESSION of Brain. See Brain, Compression of. COMPRESSION of Lung. See Lung, Compression of. CONCRETION (con, together, and cresco, I grow). — Synon. : Calculus ; Fr. Concretion, Cal- cul ; Ger. Concrement. Definition. — An unorganised body, formed either in one of the natural cavities or canals, or in the substance of an organ, by the deposit of certain solid constituents of the fluids of the part. In the widest sense of the term, Concro- tions comprehend Calculi. Enumeration and Classification. — The fol- lowing classified list includes the principal varieties of concretions ; — 1. In glandular structures', lachrymal, soli 280 CONCRETION. vary, pancreatic, prostatic, seminal, urinary, hepatic, sebaceous, and mammary. 2. In the circulatory system : cardiac, and venous ( phleboliths ). 3. In closed sacs : peritoneal, and articular. 4. In culs-dc-sac : bronchial, pulmonary, nasal, tonsillar, laryngeal, gastric, intestinal, praeputial, uterine, and vaginal. 5. In the substance of tissues and new forma- tions, especially in the nervous system — Cor- pora amylacea. 6. Various, such as the concretions on the teeth known as tartar. General Characters and Number. — Con- cretions are generally firm or even of stony hardness ; but they may be soft and friable. Their colour varies from white to black through shades of yellow and red. Concretions occur either singly or in groups ; and their shape and size, as well as the character of their surface, vary considerably with their number ; single con- cretions being more frequently rounded, larger, and less smooth than multiple specimens, which often present facets and polished surfaces. Many concretions are composed of concentric laminae. Composition. — The chief constituents of con- cretions are inorganic, that is, mineral salts, in a basis of organic matter. The bulk of the salts are carbonate and phosphate of lime and mag- nesia, with smaller quantities of alkaline com- pounds. The organic basis is composed of albuminous substances, mucus, cholesterin, and colouring matters. Mode of Formation. — Concretions are gene- rally derived from the solid constituents of vital fluids, whether physiological or pathological. In most instances the fluids are delayed in the natural passages by some abnormal obstruction or dilatation ; and under such circumstances a chronic inflammatory condition of the walls con- tributes greatly to the probability of mineral deposit. Most frequently — as in the formation of the salivary and biliary concretions — the fluid portions of the secretion escape by the natural outlet or are absorbed, while the solid constitu- ents are deposited ; the particles being either agglomerated around a nucleus, or deposited in centripetal layers upon the surface of the cavity. In other instances — intracardiac, peritoneal, and articular, a nucleus is furnished by a portion of fibrin, blood-clot, or growth, on which fresh deposits take place, while calcification proceeds in the interior. In a third series, examples of which are found in the alimentary canal, the basis of the concretion consists of foreign or indigestible matter, such as hair, inspissated fasces, and masses of magnesia. Effects and Symptoms. — The functions of a part occupied by a concretion are generally more or less impaired ; the neighbouring tissues fre- quently atrophy ; and inflammation and ulceration are common results, ending probably in the escape of the body. The concretion may be passed along a duct, and this process is generally attended with great pain ; but concretions may remain where formed without causing symptoms. Occasionally they are spontaneously disintegrated or dissolved. Treatment. — The treatment of concretions will CONGENITAL. be found discussed under the heads of the diseases of the organs where they respectively occur. J. Mitchell Bruce. CONCUSSION ( concutio , I shake together). This term is used to indicate a condition induced by a more or less violent shaking or physical commotion of the general system, or of somo particular organ, whereby serious symptoms may be induced, but no definite lesion can be detected to account for them. The nerve-centres are the parts most liable to be thus affected, concussion of the brain or spinal cord being of considerable moment, giving rise to more or loss complete abolition of their functions, though this effect is usually only temporary. See Brain, and Spinal Cord, Concussion of. General con- cussion of the body is highly important at the present day, in connexion with railway acci- dents, after w'hich persons seem to be uninjured, or only to be slightly shaken, but subsequently grave symptoms, associated with the nervous system, set in. See Railway Accidents, Results of. Frederick T. Roberts. CONCUSSION OF BRAIN, SPINE. &c. See Brain ; and Spinal Cord, Diseases of. CONDYLOMA (Lat). — Definition. — Ex- crescences often found about the anus and organs of generation in both sexes. The term has been applied to simple cutaneous growths as well as to those of syphilitic origin ; but since these latter are altogether due to a constitutional taint, and require a different treatment, they will be described separately under the heading of Mucous Tubercles, whilst the term Condy- loma, will be restricted to non-specific growths. Symptoms. — Condylomata are generally situ- ated in the neighbourhood of the anus and genital organs ; and they result from the irritation produced by acrid vaginal or rectal discharges, or by the natural secretions in dirty persons. They consist in hypertrophy of the tegumentary tissues, and generally' form smooth pendulous growths, but they may be flattened, irregular, and ulcerated on the surface. They are vascu- lar, liable to become inflamed and painful from friction, and, as their position favours develop- ment, they may attain considerable size. Treatment. — When all inflammation has been allayed, these excrescences should be removed with a pair of scissors ; and to prevent their re- currence thorough cleanliness must be practised, and any discharge from the rectum or vagina stopped. If the parts he damp and perspiring they should he kept dry, and frequently dusted with zinc or bismuth powder, or bathed with seme astringent lotion. No general treatment is of the slightest service. George G. Gascoyen CONFLUENT ( confluo , I run together). — Applied chiefly to a variety of smallpox and of other exanthemata, in which the eruption runs together or coalesces. CONGENITAL ( con , together, and genitus, begotten). — Existing at birth : a term generally applied to diseases or malformations, such ar Congenital Syphilis, and Congenital Clubfoot. CONGESTION. CONGESTION ( congero , I accumulate). — Overfulness of vessels caused by accumulation of their contents: generally applied to blood-vessels. See Circulation, Disorders of. CONIUM, Poisoning by. See Appendix. CONJUNCTIVITIS. — Inflammation of the conjunctiva. See Eve and its Appendages, Dis- eases of. CONSCIOUSNESS. Disorders of.— The disorders of consciousness are so numerous as to make it desirable briefly to consider them in one article, with a view to their classification and the better comprehension of their mutual relations. We shall, therefore, here group and arrange the various morbid conscious states, not aiming to produce a strictly scientific classification so much as one which will be practically useful. 1. Exaltation of. — Under this head may be ranged certain states of consciousness more or less distinctly bordering upon the un- natural, to be met with in persons under the influence of ‘ mental excitement ’ from various causes, as from sudden good news, or generally pleasant surroundings ; also from a slight degree of poisoning by alcohol, opium, hashish, or other drugs ; or from an early stage of some forms of insanity, or of delirium. In this state of mental exaltation the individual’s powers of perception, apprehension recollection, thought, emotion, and volition, would seem to be all more or less intensified, just as in that of hebetude or dementia they are diminished and conscious- ness is proportionately dwarfed. 2. Perversions of. — Many of the various defects here to be referred f o are very par- tial in the extent to which they implicate consciousness, though others are general. In what is known as an illusion some object of sense is not correctly perceived ; or, in other words, some sensorial impression is quite wrongly interpreted, as when a feverish or a maniacal patient, looking at some inanimate object, de- clares that it is a cat or a dog about to fly at him, or hearing even the slightest noise in any part of his room, interprets it to be the voice of some friend or imagined enemy. In the case of an hallucination, however, forms are declared to be seen, or voices heard (by a patient suffering from delirium tremens, for instance), where no appreciable external realities could have started the notion. And in these cases, it is not that the patient sees or hears without believing ; he implicitly believes that the visions or voices which have been conjured up subjectively by the working of his own brain, have a real existence in the outside world. It is necessary to make this distinction because it is by no means uncommon in regard to the olfactory sense (especially in some epileptics), for odours or smells to be perceived which the patient soon comes to know are purely subjective or devoid of any external correlative. Hallucinations and illusions, though occasion- ally existing alone, are quite commonly asso- ciated with a very important and more general derangement- of consciousness, viz., delirium. This is a symptom very common in many CONSCIOUSNESS, DISOKDEKS OF. 2S1 fevers, in certain low states of the system, after severe frights, in inflammatory or other lesions of the brain and its mombranes, as a result of somo narcotico-irritant poison, or occasion- ally in a person who is recovering from an epileptic attack, or from the stupor sequential to a series of convulsive attacks. The state itself varies much in intensity. Three fairly distinct types exist. In (a) low or muttering delirium the patient lies still and more or less heedless of what is occurring around; or if heeding at all, the impressions which he receives give rise to erroneous perceptions (illusions) which are woven into the incoherent fabric of his rambling thought. In ( b ) delirium tremens the patient is more restless, tremors of the limbs and of the muscles of the face are often easily induced, hallucinations of sight and hearing are common, and the character of the delirium reveals that the patient is, to an un- usual extent, possessed by fears, terrors, and other emotions of a depressing type. In (c) wild or raving delirium we have to do with a much more active state. The patient raves loudly and incoherently, more in regard to his fleeting dream-like thoughts than in connection with external impressions, of which he is more or less heedless. He is often violent in de- meanour, and difficult to be restrained, persons in this state being capable of great and pro- longed muscular exertion. The bodily activity accompanying this form of delirium is, in fact, just as characteristic as the great intensity of the mental processes. It is met with occasion- ally in some fevers, but more commonly in meningitis and in acute mania. In its early stages delirium is. principally noticed during the transition-period between waking and sleeping — at times, that is, when the nervous system most needs the reinvigorating influence of sleep. It is in these cases, too, that beef-tea or stimulants may for a time dispel all traces of the wandering thought. 'Whilst illu- sions and hallucinations enter largely into the mental activity of a delirious patient, delusions also are generally well-marked components. That is to say, the person becomes for a time possessed by an idea, notion, or fancy, for which there is no real warranty, though he believes and wishes to act as though it were true. Somewhat allied to delirium in nature, though much lower in intensity as a mental process, is that incoherence of thought which is met with in many chronic maniacs, or in non-febrile patients suffering from various organic brain-diseases. In its slighter degrees this incoherence displays itself as mere ‘rambling’ talk; the patient has not sufficient brain-power to follow up the mam subject of thought, and is frequently di- verted into collateral channels. This, which is a natural state with some persors, may be dis- tinctly indicative of disease in others whose mental power has previously been of a more vigorous type. At times tho incoherence is seen to be governed principally by mere verbal sug- gestion, the patient being led away from point to point in new directions, owing to the asso- ciations of some word which has been used bo- coming for the time dominant. This state is often well seen in the sub-acute exacerbations ol 282 CONSCIOUSNESS, chronic mania, though it may occur also where multiple softenings or indurations of the brain exist. At other times the incoherence is more absolute — wayward transitions from subject to subject, connected by no discoverable bond, ra- pidly following one another. The result in such a case is a mere unmeaning jumble of words, interspersed here and there with brief propo- sitions having a limited significance of their own, though often wholly unrelated to that which precedes or follows. Hypochondriasis is a perverted state of con- sciousness, having some resemblance to that of illusion, but in which some internal or visceral slate becomes the starting-point of impressions (possibly not actually painful) which, when mag- nified and perverted as they are in the mind of the patient, fill him with false and gloomy ap- prehensions of various kinds. This perversion of consciousness is more generalised than that which exists in the case of illusion ; and also instead of being a more or less temporary defect, it is one that may last for weeks, months, or even years. The state of mind of an hysterical patient is often not altogether different from that of the hypochondriac. 3. Partial Loss of. — Defects of this order arc numerous and may exist in great variety. They may implicate almost equally nearly all the varieties of conscious mental activity, or some more than others. They maybe either con- genital, or acquired during the life of the indi- vidual. In idiotcy we may have from birth defect in the power of concentrating the attention, a de- fective power of apprehension and of thinking, and a defective volition, shown alike by an in- ability to guide or control thought, and by a deficient vigour of bodily movement. Again, ns a result of epilepsy, of organic brain- disease, or of injuries to the head, the patient may gradually lapse into such a condition from one of health, so as to become, as it is termed, ‘ demented.’ Whilst this state of dementia may supervene at any age, it is much more common as a consequence of the brain-diseases frequent in advanced life. There is, moreover, a form known as senile dementia , in which without, any typical disease, but as a consequence of im- paired tissue-vitality and diffused degenerative changes throughout the nervous system, the mental faculties undergo a more marked degra- dation than is usually met with in old age. This condition in its minor degrees goes by the name of hebetude. In all such states or grades of idiotcy and dementia, we meet with an undue tendency to sleep in the day-time as a result of the listless and languid mental condition. This is but another sign of the general lowering of conscious vigour. Here we must include, also, a peculiar group of conditions, having some alliance to one ano- ther, and which are all characterised by loss of consciousness to some extent, either partial in range or general. They are — reverie, somnam- bulism, ecstasy, coma-vigil, catalepsy, hypnotism, and trance. They are merely enumerated here, but are defined or described in their several places. In the latter of these conditions the loss of consciousness, in the ordiuary acceptation of DISORDERS OE. the term (viz. loss of perceptive power) is so absolute, that some may think it ought rather to be included in the next section. Loss of per- ceptive power, however, would not seem to be absolutely synonymous with loss of conscious- ness. There is good reason to believe, for in- stance, that where the influence of chloroform and other anaesthetics is not pushed to the fullest extent, a condition of anesthesia intermediate between slight and profound is produced, in which, whilst there is absolutely no conscious- ness for external impressions, so that pain is altogether unfelt, there is still a certain amount of cerebral activity — as evidenced by rambling and indistinct speech on subjects altogether apart from what the surgeon may be doing. There is mental activity clearly, though the nature of this, as revealed by the patient's speech, may preclude the notion that pain is at the time being felt. Sensorial consciousness is blotted out, whilst a kind of ideational consciousness remains. We have an approximation to such a condition, also, in the case of sleep when dreams are rife. But here sensorial consciousness is not completely in abeyance. Again, in certain rare and anomalous epileptiform attacks we may find the patients, after the first paroxysms, bereft of - some senses, though not of others. They may hear what is said by those around them, though they continue for a time quite unable to see or speak. 4. Complete Lossof. — In very profound sleep (sopor), in that prolonged form of it in which the person, if he can be momentarily roused, drops off again immediately (lethargy), and alsc in profound anesthesia, there is complete loss of consciousness. The terms sopor and lethargy are now rarely used, and authors are not even agreed as to the precise state which should be designated by the latter word. In syncope we have insensibility resulting from a cutting off of the preper supply of blood to the brain ; whilst in asphyxia we have a like result fallowing upon an interference with re- spiration. A condition of narcosis or profound insen- sibility may result from opium or other drugs and poisons, amongst which alcohol is to be in- cluded as one of the most common producers of such a state. Or it may also be due to the deficient elimination of urinary products by the kidneys, when ursemic coma is produced. Complete loss of consciousness exists for some time during the ordinary form of epileptic fit, or during an attack of convulsions ; though in other epileptiform fits, not imfrequently met with — having some of the characters of hyste- rical convulsions — there seems to he a loss of sensorial consciousness only (loss of percep- tion), whilst a certain amount of ideational consciousness remains. In apoplexy also thero may be for hours or days a more or less pro- found loss of consciousness. In the less pro- found attacks, as well as after an epileptic fit or an attack of convulsions, the loss of con- sciousness is not complete, and wo have a con- dition now commonly known as siupor. This state is also frequent as a result of concussion or other injuries of the brain, and it occasionally follows a severe fir. of hysterical convulsions, CONSCIOUSNESS. It may last for hours, days, or even weeks in some cases. In it the patient lies with his eyes closed, taking no heed of what is passing around, though he may show obvious signs of feeling when touched or pinched, and may he capable of being momentarily roused, so as to give a short monosyllabic answer, if slightly shaken or spoken to in a loud voice. On these occa- sions, signs of impatience are often shown. Though such a patient will not ask for food, ho will often drink freely when it is offered. He will of his own accord, when his bladder is full, sometimes get out of bed, find the chamber- pot, use it, aud return to bed without saying a word — and then speedily relapse into his previous state of stupor. When the insensibility is more profound, both urine and faeces arepassed incon- tinently. The state just spoken of is referred to in this section because it. is so intimately allied to and connected by all sorts of transition conditions with another, known as coma, in which the loss of consciousness is more complete and absolute. There are different degrees of stupor and there are different degrees of coma; the former is commonly spoken of as slight or deep, whilst a comatose condition, coma, and profound coma (the latter being what the older writers termed earns) are the phrases ordinarily used to denote the increasing insensibility of the graver state, which is more especially characteristic of the apoplectic condition. Coma may result from long-continued exposure to cold, from sun-stroke, from poisons of various kinds, from erysipelas of the head and face, from inflammations of the meninges, multiple embolisms, the effects of hyperpyrexia, orfrom cerebral haemorrhage. The most common cause of very profound coma is cerebral hsemorrhage (apoplexy). In this condi- tion the breathing is often loud and stertorous, and consciousness is entirely obliterated, so that there is an utter absence of reflex movements when a limb is pinched or when the conjunctiva is touched. The patient in the deeper forms of coma often cannot be roused at all, even for a moment, and if this state does not terminate in one way or another before the expiration of twenty-four hours, or if it does not gradually pass into one of mere rtupor, a fatal result may be considered imminent, H. Charlton Bastian. CONSTIPATION {con, together, and stipo, I cram). — Definition.. — infrequent or incomplete alvme evacuation, leading to retention of faeces. .Etiology. — The causes of constipation may be local — an impediment to the onward movement of the faeces in the large intestine or from the rectum; or general — pertaining to habits, diet, and other conditions. Local . — These include : — (a) Lesions inducing narrowing of some part of the large intestine. (Ij) Collections of scybala, intestinal concretions, &e. in the caecum, sigmoid flexure, or rectum, (c) Pressure on the rectum, by uterine fibroid or ovarian tumours, uterine displacement, the gravid uterus, or an enlarged prostate, (d) Defaecation thwarted, as when the expiratory abdominal muscles are enfeebled, as in pregnancy, especi- ally when repeated or after twins, obesity, old CONSTIPATION. 2SJJ age, or in some painful affection of the abdomen, such as rheumatism of the abdominal walls and diaphragm, chronic dysentery, piles, anal fissure. (e) Peeble contraction of the intestinal muscular fibres, as in distension of the large intestine or a portion of it by gas, faeces, or lumbrici, in- flammatory affections, lead-poisoning, senile atrophy, or in delicate females with lax muscular fibre {see Colon, Diseases of). (/) Pain in the pelvic viscera and probably elsewhere may induce paralysis of the sympathetic nerves sup- plied to the intestinal walls ; thus may be ex- plained obstinate constipation in painful uterine and ovarian diseases, which caunot be accounted for by pressure on the bowels or otherwise. General.— The general causes of constipation are:— (a) Sluggishness of function— lymphatic temperament, anosmia, especially with amenor- rhosa ; or disposition to great activity of the muscular and nervous system. (A) Certain habits, namely, sedentariness ; too great muscular ac- tivity; mental application, especially when exces- sive or prolonged ; the continued use of aperients or enemata after the relief of temporary consti- pation ; habitual disregard of, or hurry in the act of defecation ; prolonged hours of sleep ; the excessive or even moderate use of alcohol, tea, tobacco, or opiates, (e) Dietetic errors. — Diet too nutritious — leaving little intestinal residue — or poor and insufficient; improper feeding, especially in infants and children ; the use of indigestible substances, such as cheese, nuts, or cucumber. Constipation is frequently a prominent symp- tom in diseases of the stomach ; of the liver ; of the heart, inducing congestion of the portal system and of the nervous system : as well as in connexion with diabetes, excessive perspira- tion, prolonged lactation, and discharges. The causes of constipation are such as evi- dently induce one or both of the following con- ditions. — 1. Dryness and hardness of the contents of the large intestine from deficient secretion, oi too active absorption of fluid from the intes- tinal tract. 2. Impaired contraction of the muscu- lar fibres of the large intestine. Description. — In constipation the evacuations are infrequent, solid, deficient in quantity, and sometimes unusually offensive ; they often consist of dry, hard, dark or clay-coloured masses or scybala. Defaecation is generally difficult or even painful. As a rule the depth of colour, and the scybalous character of the motions, are in propor- tion to the duration of the lodgment of faeces in the large intestine. Infrequency of defaecation regarded alone is an untrustworthy sign of consti- pation, or constipation demanding medicinal or other treatment, inasmuch as it often depends on individual peculiarity. Good health is consistent with wide departures from the ordinary rule — a daily evacuation ; not unfrequently there is no relief from the bowels for several days or even for a week, and yet without inconvenience, so long as the infrequent defaecation is habitual, or can be ascribed to idiosyncrasy. The disturbances of function usually associ- ated with constipation may be local, or extend to distant parts. The immediate or local effects are such as may arise from retention of faeces :— signs of faecal CONSTIPATION. >84 collections in the caecum, colon, sigmoid flexure, or rectum ; irritation of portions of the intestine, indicated by colic, inflammation, ulceration, and perforation of the intestines ; intestinal ob- struction ; pressure of faecal accumulations on the intra-pelvic vessels and nerves, inducing menorrhagia, uterine catarrh, seminal emissions, haemorrhoids, cold feet, neuralgia and numbness of the legs (Niemeyer). Constipation frequently exerts a pernicious influence on primary diges- tion, indicated by foul tongue, fcetid breath, anorexia, acidity, flatulence, biliary disturbance — even jaundice, and urine loaded with lithates. The remote or general effects of constipation are lassitude of body and mind ; headache, flushing and heat of head, vertigo ; anaemia and wasting. Treatment.— Constipation depending on in- dividual peculiarity is rarely relieved perma- nently by treatment. The bowels, having acquired from early life the habit of infrequent evacuation, may be stimulated for a time, and are then apt to become more sluggish than before. In all cases the habit of the patient in this respect from childhood should first be determined, either as a warning against active or prolonged treatment, which may prove in- jurious, or as a guide to the adjustment of direc- tions and remedies — affording as it does a limit which should not be over-stepped. 1 . JEtiological, Dietetic , and Hygienic Treatment. — In treating constipation the causes should be met. Local causes — such as those inducing con- traction of or pressure on some part of the large intestine, or feeble or ineffectual contraction of the intestinal muscular fibres or of the ex- piratory muscles, should first be eliminated. Habits disposing to constipation should also be corrected. Persons who are much preoccupied or careless are apt either to disregard the call to stool, or to perform the act of defecation hurriedly, incompletely, and at irregular intervals. The sensibility of the nerves of the rectum becomes blunted by the constant contact of feces. Hence the periodical removal of collections in the lower part of the large intestine is an essential element of the treatment. It is best when this can be done by well-timed natural efforts. The pa- tient should be told to attempt defecation every day after breakfast, and to persevere in so doing even when the result is occasionally or frequently unsuccessful. While straining to relieve the bowels, he may facilitate evacuation by pressing firmly the fingers in front and on each side of the coccyx, thus supporting the levator ani during contraction. Failing to obtain relief on the second day, a small cold water enema should be used to prevent further accumulation of feces in the rectum, and to restore tone and sensibility to the blunted nerves. The enema should never be larger than is required to dislodge the motion from the pouch of the rectum — nor should it be warm ; at first it may be tepid, afterwards cold. When evacuation is obstructed by the lower part of the fecal mass becoming dry, relief may be obtained from emollient enemata and supposi- tories, such as infusion of linseed, decoction of marsh- mallow, solution of white of eggs, olive oil lione or in oatmeal gruel, or glycerine injected in small quantity into tha rectum, and allowed to remain there lor some hours ; or by the use cf suppositories at bed-time, consisting of cocoa- butter, soap, or honey hardened by heat, either alone or combined with a stimulant to excite the flow of mucus into the rectum, or with extract of belladonna or of stramonium. Seden- tary habits should be broken into. Exercise on foot or on horseback is specially to be commended, and carriage exercise to be avoided. While studying or reading the patient should walk about, and stand rather than sit at the desk. Gymnastics and out-of-door games are useful when a limited time only can be de- voted to exercise. Excessive and exhausting exertion should be avoided. It is generally advi sable to recommend early rising and cold bathing in the morniDg. In different cases one or other of the following may be found ser- viceable : a shower- or sponge-bath containing vinegar, baysalt, or consisting of sea-water, or a cold sitz bath ; douches directed to the abdo- men ; a cold water compress applied to the abdo- men during the day or night or for three or four hours in the morning ; friction or kneading in the course of the colon every morning and when at stool ; an abdominal belt (flannel or elastic) — especially if the abdomen be pendulous. The in- terrupted current ox electricity has been success- fully employed as a special excitor of the muscular fibres of the intestines or of the abdominal wall. Diet. — Vegetable should predominate over animal food. Greens (cabbage, lettuce, &c.) are useful, as well as fruits, which should be ripe, and taken on an empty stomach. Prunes or figs stewed in olive oil, or infusion of senna, prune- pulp, oils and fats, such as cod oil or olive oil, are also serviceable when they do not disturb the digestion. Bread made of bran (or three parts flour and one part coarse bran), of corn-meal, or of cracked wheat : oatmeal por- ridge ; or wheat ground in a coffee-mill, boiled and salted and served like rice, only less thick, may assist in preventing constipation ; if there be acidity and other symptoms of dyspepsia, however, these indigestible articles of diet should be avoided. Tobacco-smoking after meals in moderation sometimes relieves constipation. Cold water or carbonic acid water — a tumblerful at bed-time, or preferably on rising in the morn- ing, may be useful. Much must be left to indi- vidual experience; sometimes coffee, cr beer, or cider answers best. As a rule farinacea, astrin gent wines, and tea increase constipation. 2. Medicinal Treatment. — When dietetic and hygienic directionsfail, they require to be assisted by medicinal agents. The ends to he secured are threefold : — 1. To evacuate feces and gases which, d’Stending the large intestine, thwart peri staltic action. 2. To tone the walls of the bowel, and thus prevent reaccumulation of feces and the products of their decomposition. 3. To increase the flow of intestinal mucus. Remedies are usually variously combined for these pur- poses, and should be carefully adjusted to the requirements of each case, so as to meet the leading indications. Among the most useful aperients are aloes or its watery extract, rhubarb, colocynth, gamboge, and podophyllin, and either of these may fie variously combined with extract of hyoscyamus or belladonna, extra»t of gentian CONSTIPATION. extract of nux vomica, quinine, sulphate of iron, or ipecacuanha. The dose of the aperient should not exceed that required to secure gentle evacuation, and it varies with individuals. Purging exhausts torpid bowels, and perpetuates constipation. The bowels should not he pushed to more frequent relief than has been habitual with the patient from early life. The aperient, which should be varied in a prolonged course of treatment, should be very gradually dropped, while the intestinal tonics (belladonna, quinine, nux vomica, iron) are continued. The duration of treatment is prolonged until the aperient is almost entirely withdrawn. The remedies should be taken immediately or two or three hours after the principal meal. The treatment by bella- donna, introduced by Bretonneau, was greatly prized by Trousseau (see Colon, Diseases of). In ansemic subjects afirm and prolonged course of iron should be aided by aloes, nux vomica, and arsenic. In lisemorrhoidal complications aloes should as a rule be avoided, and laxative electuaries should be prescribed ; in some cases, however, it tones without irritating the rectum. Flatulent dyspepsia and tympanites are indica- tions for the prescription of nux vomica, which, however, will not radically cure constipation. In obstinate cases the most useful remedies are colocynth — tincture (Prussian Pharm.) 5 minims or more on sugar or in water throe or four times a day, or 10 to 20 minims an hour before breakfast ; extract or compound pill with small doses of croton oil, or with gamboge, elaterium, or other combinations ; podophyllin with bella- donna (Trousseau), ipecacuanha, and colocynth or aloes. A full dose of opium may liberate the bowels after the failure of the strongest purgatives, and constipation depending on inhibi- tion of the sympathetic nerve from pain, will be relieved by opium with belladonna. Enemata, when frequently required, should be small in quantity, and at first tepid, then cold ; for occa- sional use for the purpose of clearing away faeces loading the large bowel, they should be largo (from two to six pints) and warm (see PiECES, Retention of). The frequent use of large warm injections is injurious. Purgative waters, such as the Friedriehshall, Pullna, Hunyadi, or Carlsbad waters, given occasionally in small doses with warm water in the early morning, are often valuable adjuvants to a well-organised course of treatment. Constipation cannot, how- ever, be cured by a course of saline purgatives, and may be greatly aggravated by it. Numerous other drugs have been recommended in the treatment of habitual constipation, among which are nitric acid; arsenic with food in de- bilitated anaemic females, in the sedentary, or the old; tincture of benzoin — 20 minims thrice daily ; tincture of colchicum — -a few drops after each meal ; carbonate of iron ; compound liquorice powder with sulphur — a teaspoonful at bedtime in water; tincture of veratrum viride — 3 minims four or five times a day ; or ox -gall dried, in pills. George Oliver. CONSTITUTION. — Stnov. : Diathesis, Habit, Conformation of body Fr. Constitution ; Ger. Leibesbeschaffenkeit. The constitution may be sound or unsound. CONSTITUTION. 285 A sound constitution may he defined as the harmonious development and maintenance of the tissues and organs of which the body is made up. It originates with the union of a healthy sperm and germ cell, continues with the growth of the product under the most favour- able conditions to adult life, and becomes gradu- ally enfeebled with advancing age by the process of natural decay. The constitution may be unsound in con- sequence of deficient vitality. This deficient vitality may be general, as is sometimes ob- served in the children of parents one or both of whom are in advanced life, or whose vitality on one side or the other has been reduced by excesses, such as alcoholic or venereal. Ex- hausted vitality from prolonged disease, c.g. phthisis or tertiary syphilis, affecting either parent, may determine the death of the offspring at an early period from mere failure of nutrition, or may cause it to succumb to acute disease not not necessarily associated with any inherited tendency of a special kind. The deficient vitality may be restricted to certain tissues or organs, viz., those concerned in the nervous, vascular, respi- ratory', or digestive systems. Thus amongst tho most strikingly hereditary of diseases are those of degeneracy, such as emphysema, structural heart-diseases, atheroma of' vessels, certain kidney- diseases, &c. Rightly interpreted, these diseases are of the nature of premature senility', attacking certain tissues or organs — as it may be seen to attack the hair or the cornea — from some in- herent defect in their vitality. The constitution may, in the second place, be unsound from some definite inherited form of disease. Although the constitution of an indi- vidual begins with his life, it is nevertheless the resultant of the constitutional peculiarities of many antecedents. This being so, tendencies to disease may date far back in the pedigree, to be called forth from time to time by favouring cir- cumstances. We need, however, practically only go back a few generations in inquiring for those diseases which are well recognised as being hereditary. These form one section of the group of constitutional diseases. — Congenital syphilis, gout, scrophulosis, tuberculosis, cancer, asthma, and certain neuroses are all diseases which are apt to appear at certain periods of the life of the offspring, in consequence of some specific inherent defect of blood or tissue derived from his pro- genitors. The constitution may, thirdly, become unsound at any period subsequent to birth, (a) This may be due to the surrounding conditions of lifebeing evil. Deficient or impure air, insufficient or improper food, defective sunlight, over-work, intemperance, &c., may injure the constitution and give rise to diseases whoso constitutional nature is some- times strikingly shown in the tendency of some of them to become hereditary. Rickets, phthisis, and scrofula are examples. (A) The introduction of certain poisons into the system affects the consti- tution profoundly, and in some cases permanently, after the more obvious effects of the poisons have passed away. All the acute specific zymotic dis- eases, including vaccinia, would come under this category. They render the organism, for a long period or for life, proof against subsequent 286 CONSTITUTION. ittacks of the same disease. Only in certain cases, however, can the soundness of the consti- tution be said to be impaired by such diseases, and then it is usually through the occurrence of sequelae. E. Douglas Powell. CONSTITUTIONAL DISEASES. — These may be regarded as diseases generated from within, in the course of the wear and tear, nutrition and waste of the body, in consequence of inherent or acquired weakness in its con- struction. The applicability of the term ‘constitutional’ to disease is sufficiently explained in the pre- ceding remarks on ‘constitution.’ The term may, however, be associated with a group of so-called ‘ general ’ diseases, in opposition to that which includes ‘ zymotic’ or ‘ specific’ diseases, which are generated by the introduction of some definite poison from without. In our present state of knowledge, however, no very rigid lines can be drawn to separate local, general, constitutional, and specific diseases from one another. See Disease, Causes of. E. Douglas Powell. CONSTRICTION ( constringo , I bind to- gether). — A narrowing, to a limited extent, of a canal or hollow organ, due either to a textural change in its walls, or to the pressure of a band surrounding it. CONSUMPTION {con sumo, I waste).— This is a term for any wasting disease, but it is gener- ally applied to pulmonary phthisis. See Phthisis. CONTAGION. — The word contagion is ap- plied in pathology to the property and process by which, in certain sorts of disease, the affected body or part causes a disease like its own to arise in other bodies or other parts ; and the Latin word contagium is conveniently used to denote in each such case the specific material, shown or presumed, in which the infective power ultimately resides. 'See Zyme and Zymosis. The property of contagiousness belongs to a very large number of the diseases which affect the human body. And in more than this direct way the property is of great interest to mankind. Contagiousness of disease is a fact not only for man, but apparently for all living nature ; and the influence of contagion in spreading destruc- tive diseases among domestic animals, and among those parts of the vegetable kingdom which con- tribute to the nourishment of man, is such as to make it of immense social importance that the laws of contagion should be well studied and understood, further, just as contagion in the case of living bodies and their parts spreads disease from one to another, so, to an immense extent, in the case of certain matters which, though of organic origin, are net living, it spreads various processes of decay. The so- called ‘fermentations’ which yield alcohol and vinegar, as well as that in -which putre- faction consists, are contagious affections of the respective matters in which they cccur : every cheesemonger knows that moulds of different kinds spread by inoculation, each in its own kind, from cheese to cheese ; and if the Greek proverb ‘grape mellows to grape’ is true of the CONTAGION. living fruit, the apple-loft gives analogous ex- periences of contagion among the fruit which is garnered. The rationale of the word ‘ contagion,’ as now used, is that the property is understood to attach itself essentially to a material contact ; not neces- sarily that, when infection is spread frem indi- vidual to indivi dual, the contact of the individuals must have been immediate ; but that in all casss there must have been such passage of material from the one to the other, as was in itself at least a mediate contact between them. And similarly, in those very instructive illustrations of the process of contagion which are furnished within the limits of a single diseased body by the propagations of disease from part to part of it, we can in general easily see that infection advances from part to part, either in proportion as part touches part, or in proportion as the one receives from the other the outflow of lymph or blood or secretion. The various specific matters which effect con- tagion in the living body, the respective ' con- tagia’ of the given diseases, seem all to have in common this one characteristic : that in appro- priate media (among which must evidently be counted any living bodily texture or fluid which they can infect) they show themselves capable of self-multiplication ; and it is in virtue of this property that, although at the moment of their entering the body they in general do not attract notice, either as objects of sense or as causes of bodily change, they gradually get to be re- cognisable in both of these respects. Now. the faculty of self-multiplication is eminently one of the characters which we call vital ; and when it is said that all contagia are self-multiplying things, this is at leastvery strongly to suggestthat perhaps all contagia are things endowed with life. In order to any general consideration of the question thus suggested, contagia may conveni- ently (even if but provisionally) be distinguished as of two main classes, differing, or at present seeming to differ, from each other in their mode of action on the organisms which they infect : one class, namely, that of Parasites; and the other class, that of the true or Metabolic Com- tagia. Of this separation, so far as present knowledge seems to justify it, the assumed grounds are: that each true Contagium, in proportion as it multiplies in the body, trans- forms, in a way which is specific to itself and is different from the ways of other contagia, the bodily material with which it has contact; while, on the contrary, the Parasite, however much it may grow or multiply in the body, produces no qualitative effects specific to itself, but only such effects as are of common kind to it and all other parasites — indications, namely, of its mechanical intrusiveness in the parts which it occupies, and sometimes of the drain which it makes on its host's general nutritive resources. A. — Of Parasites, in relation to processes of contagion, little needs be said in the present article. When an organism or part of it is, in greater or less amount, inhabited by other organisms, animal or vegetable, which subsist on it, or its food or refuse, it of course may bo a centre of infection to other (if susceptible) bodies or parts, to which it can transmit live CONTAGION. 287 parasites or their germs or seeds : for, when this transmission takes place, growth and self- multiplication, as in a colony, are the natural results which hare to be expected ; and in pro- portion as these occur, the newly-infected body or part gradually gets to suffer, like the old, from those particular derangements which make the type of parasitic disease. Some parasitic diseases, especially some of those of the skin, spread actively by direct contagion in ordinary inter- course ; as for instance, scabies by the migration of its acari, and porrigo (among children) by the spores of its microphyte; and the spreading of such diseases where they exist may of course be to any extent facilitated by aggregation of per- sons and uncleanliness of personal habits. There are cases in which parasitic disease spreads from animal to animal only in proportion as the ono feeds on the other, and eats it with para- sites still living in it ; or in proportion as live parasite-eggs or larvae, discharged from the body of one animal, get conveyed with food (especi- ally on raw herbage and in water) into the bowels of another. Considerable epidemics of trichiniasis in the human subject have been traced, chiefly in Germany, to infection from the pig; in cases where pork, abounding with trichinae, has been eaten, as sausage-meat or otherwise, in a raw or imperfectly-cooked state : and in Iceland the very great sufferings of the human subject and the cattle from echinococcus have been traced to the influence of the dogs in spreading contagion from the slaughter-house, where they cat liydatidised offal, to the kitchen-gardens and water-sources and pastures, where they dis- charge tape-worm eggs from their bowels. See Porrigo, Scabies, Trichina, Hydatid, &e. The diseased states which consist in being colonised by parasites are diseases of indefi- nite duration, tending in some cases to indefi- nite increase. In cases where the disease consists in the presence of swarms of blood-sucking or otherwise exhausting animal parasites, symptoms of the blood-drain will of course gradually arise; but otherwise the parasite, whether animal or vegetable, operates only as a mechanical presence. Skin and mucous membrane will be irritated in their superficial layers, and in some cases more deeply, by the animal or vegetable parasites which breed on or in them, just as they might be by dead mechanical irritants : solid organshaving cystic entozoa in them will in like manner show evidence of irritation by encapsulating the colo- nists; and the surrounding tissue will of course suffer compression and displacement in proportion as the colonisation ( e.g . in case of echinococcus) is compact and massive. In the case of trichiniasis — but, in ourordinary experience, in no other — the multiplication of the parasites, the burrowing of their young, and the general diffusion of these in the body, are processes of such extreme activity that, if the quantity of contagium taken into the stomach has been large, the innumerable local irritations suffice to make a very acute fever ; but even in this extreme case, the merely irrita- tive type, though exaggerated, is essentially pre- served. As different sorts of animals are notoriously liable to different sorts of parasites, so, even among animals of one sort, as for instance in the human kind, the liability of different bodies to receive particular parasite-infections, does not seem to be quite equal for all. Especially, the vegetable parasites seem to have their affinitie- determined or modified by the general state of health of the recipient; and there are cases in which it looks as if there ran in particular family- lines (perhaps with some slight chemical idiosyn- crasy) a special liability to particular intestinal worms. There, however, is no reason to believe that in regard of the more important animal parasites, as particularly of trichina and the taeni- adse, the susceptibility of individuals to attacks is other than universal and practically equal. B. — The true or metabolic contagia (to which the rest of the present article will exclusively refer)— the contagia which, in their respective and specific ways, operate transformingly on the live bodily material which they affect, are perhaps the most important of all the inciden- tal physical influences which concern mankind. Whether they may all, at some time hereafter, admit of being named, like the parasitic con- tagia, in terms of biological classification, is a question which needs not in the first instance be raised ; formeanwhile the identityof each separate true contagium is settled in experimental and clinical observation by the uniformity of tho operation of each on any given animal body which it affects. Each of the diseases propagates itself in its own form in as exact identity, as if it were a species in zoology or botany; and in each such repetition of the disease there is a multiplication — always a large, and sometimes an inconceivably immense multiplication, of material which has the same infective property. Evi- dences innumerable to that effect are under daily clinical observation in this climate in instances of smallpox, measles, scarlatina, whooping-cough, enteric fever, mumps, typhus, syphilis, cowpox, diphtheria, erysipelas, hospital gangrene, puru- lent ophthalmia and gonorrhoea, venereal soft- chancre and phagedaena, &c. : for, barring falla- cies, no man ever sees any one of those diseases produced by the contagium of any other of them ; and any man who has before him a caso of any of them can see that, however minute may have been the quantity of contagium by which the disease was started, the patient's diseased body (part or whole) yields for the time an indefinitely large supply of the specific agent. It is more or less habitual to some of the diseases that the infectedness of the patient is first made known to the observer by such general 'pyrexia as tells of change already far advanced in the cir- culating mass of blood ; and it is only after this has shown itself, that other symptoms, adding themselves to the fever, complete the more or less complex type which establishes the identity of the disease. But in many of the diseases it may be the case (either naturally or as result of experi- mental infection) that the first, and in some dis- eases the main or even the only, effects of the contagion are local changes, passing where wo can from the first observe them ; an! the broad facts of metabolic infection, as regards waste of bodily material with concurrent increase of contagium, are, in many such cases, among our most familiar experiences. Most instructive, too, are the facta of contagion which are to be learnt in the study CONTAGION. 288 of tubercle: the contagium. introducible either by tubercular and certain septic inoculations through the skin, or internally by the infective action of the milk or diseased organs of tubercular animals if taken as food ; and the contagium, when intro- duced, gradually spreading as it multiplies, and as lymph and blood carry it from the first infection- spot to other organs which now will repeat the process. And similarly in cancer (though the primary disease is at present of unknown origin and cannot be created by experiment) the repeti- tion of the primary disease in secondary and ter- tiary propagations in the body of the sufferer is one of themoststrikingof all evidences of conta- gion ; because of the great number of structural types which pass under the name of cancer, and the fidelity with which each of them is repro- duced in the organ to which the contagion ex- tends. A further fact of contagion, deserving notice in the present context, is the local spread of certain of these processes by continuity of tissue; as, for instance, in the continuous ex- tension of phagedama or hospital-gangrene from any centre of first inoculation, or of tubercular softening or cancer at the place where it begins : a mode of extension which indicates successive infective actions of matter on matter in spheres of ever-widening circumference ; 1 and the like of which, but in rudimentary degree, may be traced in the areola of any acute inflammation. In the physiology of the metabolic contagia no facts are more characteristic or more important than those which show the eelativeness of par- ticular contagia to particular receptivities of body. First, and in intimate connexion, as would seem, with a chemical electiveness of action which will presently be imputed to contagia, there is the preference which some particular contagia (however introduced into the system) show for particular organs of the body ; so that, by the exercise of this preference, there is given to each of the diseases its own set of clinical and ana- tomical characters. Compare, as instances in this point of view, the respective local affini- ties of smallpox, enteric fever, mumps, syphilis, hydrophobia, &c. — Secondly, it may be noted that, in regard to some of the contagia, different persons, and particularly persons of different family-stocks, show original differences of sus- ceptibility; original, namely, as distinguished from others, hereafter to be mentioned, which are acquired; so that, for instance, the severity with -which scarlatina or diphtheria will strike in particular families contrasts with a com- parative mildness of the same disease in other families, or perhaps even with eases of ap- parently complete personal immunity under ex- posure to the particular danger: and recent researches have seemed to suggest as possible that, in the very wide differences of degree with which tubercular disease prevails in differ- ent families, an essential condition may be, that the families have widely different degrees of original predisposition towards some of the septic contagia. — Thirdly, there is the extremely suggestive fact with regard to many of our best- known febrilising contagia, that they run a * Compare Tennyson’s ‘ little pitted speck in garnered fruit, Which, rotting inward, slowly moulders all.’ course of definite duration, and that in this course, provided the patient do not die, all present, perhaps all future, susceptibility to the particular contagium is utterly exhausted from the patient ; so that re-introduction of the same contagium will no more renew that patient's disease than yeast will excite a new alcoholic fermentation in any previously well-fermented bread or wine. The inference from this fact seems unavoidable, that each such contagium operates with a chemical distinctiveness of elective affinitv on some special ingredient or ingredients of the body ; and that exhausting this particular mate- rial in febrile process, which necessarily ends when the exhaustion is complete, is the bodily change which the contagium ‘specifically’ per forms. — Of not all metabolic contagia, however can it be said that their operation runs so definite and self-completing a course. For, first, there are particular acute infections which, as a rule, kill ; either (as appears to be the case in splenic fever when affecting man) because of the extreme magnitude of the transforming process which the contagium sets up, or else (as appears to he the case in hydrophobia) because the elective in- cidence of the contagium is on an organ indis- pensable to life ; so that in such cases there is in fact hardly such an event as passing alive through the whole process of the disease. And secondly, there are the contagious dyscrasies which are clearly characterised by their tendency to indefinite duration : syphilis, which oftener than not relapses in successive outbreaks, and often as years pass invades the body more and more deeply, and may after all never during life be ended ; and tubercle and cancer, which, with almost invariable persistence, will in general steadily advance month by month to infect more and more of the body till the process eventuates in death. The transmission of various contagious diseases ix communities is of course greatly influenced, both in detail and in aggregate, by such differ- ences of individual receptivity as were men tioned in the last section. Notably, as regards communities through which particular acute in- fections have had full run, fresh sparks of the contagium may find little or no fuel on which to act ; and much new diffusion of the disease may not again be possible, till immigration, or births, or lapse of time operating in other ways, shall have reconstituted a susceptible population. And, given the susceptible population, circumstances of time and place are infinitely various (especi- ally as regards quantity and quickness of per- sonal or quasi-personal intercourse) in determin ing how far this population shall have particular contagia thrown in its way. Also there are conditions, not primarily of a personal kind, which operate on a very large scale in determining the spread of some of the metabolic infections : giving to them respec- tively at certain times, in ways not hitherto understood, a special increment of spreading- power, and in some instances also special malig- nity : and thus enabling them respectively from time to time to come into comparative prominence in national life, and perhaps at once or success- ively in many different countries, in the form of so-called epidemics. Thus, it is matter of familiar CONTAGION. knowledge that the fevers -which are most habitual to this country, scarlatina, measles, 6mallpox, enteric fever, are of nothing like uniform prevalence, — that scarlatina, for instance, will be three times as fatal in one year as in another, and that smallpox is liable to even greater exacerbations : and it is known that temporary differences of this kind are not exclu- sively local, — that, for instance (to quote a late official report) ‘ the epidemic of smallpox which began in England towards the close of 1870 and terminated in the second quarter of 1873 was part of a general epidemic outbreak of that disease, of world-wide diffusion, marked wher- ever it occurred by an intensity and malignity unequalled by any previous epidemic of the disease within living memory.’ The wider the survey which wo take of epidemiology, the more certain it becomes to us, that, outside the conditions which are independently personal or local, there are cosmical conditions which have to be considered. Doubtless there are great epidemiological facts — such, for instance, as the first spreading of smallpox to America, or in our own times the increasing frequency of Asiatic cholera in Europe, which may be ascribed to novel conditions of international intercourse: but there are others, equally great, to which apparently no such explanation can be applied. For what reason it is that cholera every few years has its definite fit of extension in India, — or why diphtheria, which scarcely had a place in history till it overran Europe in the 16th century, and which since then had been rarely spoken of, began again some twenty-odd years ago to be comparatively import antin England, — or why the plague of the Levant has for the last two centu- ries been so unfamiliar to us, — or why the yellow fever of the Mississippi has in particular years raged furiously in parts of Europe, — or why our black-death of the 14th century, though appar- ently still surviving in India, has never but that once been in Europe. — or whither has gone our sweating-sickness of three centuries ago, — or whence have come the modern epidemics of cerebro-spinal meningitis : these, and many like questions, which cannot at present be answered, seem to be evidence enough that, in the making of epidemics, contagion and personal suscepti- bility may be factors in a partly conditional sense. Influences which are called ‘ atmospheric ’ — the various direct and indirect influences which attach to the normal succession and occasional abnormality of seasons, in respect of the insola- tion of our planet, and of the temperature and humidity of air and earth — are in general far too vaguely regarded as elements of interest in the present question, but are possible factors which no epidemiologist should omit from scientific consideration. For any definite knowledge which exists on the relation of particular conditions of season to the prevalence of particular epidemics, the reader is referred to the article Epidemics, and to articles on the respective diseases. In the passage of the metabolic contagia from person to person various agencies may be in- strumental, — bedding or clothing or towels which have been used by the sick, dirty hands, dirty instruments or other utensils, the washerwoman’s basket, foul water-supply, stinking house-drains, 19 289 contaminated milk or other food, the common atmosphere, &e. ; but differences of that sort are only differences as to the means by which stock communication is established with a dis- eased body as brings its products into relation with healthy persons; and the disengagement of infectious products from the bodies of the sick is pathologically the one influential fact. As regards the products which ought to be deemed infectious, the specially-diseased sur- faces and organs of the patient, and the dis- charges and exhalations which they respectively yield, must always be regarded with chief sus- picion; but suspicion, however much it may insist on them, must never disregard other sources of danger. Of some of the metabolic contagia we practically know, and of many of the others we may by analogy feel sure, that, w-hen a given body is possessed by one of them, no product of that body can be warranted as safe not to convey the infection. Presumption against every part and product of the diseased body is by everyone readily admitted where there are vehement general symptoms of disease: but it is important to know that not only in such febrile states, but even in states of chronic dyscrasy, and even at times when the dyserasy may be giving no outward sign, the infected body may be variously infective. Thus, in regard to constitutional syphilis, it is certain that the mere utero-catarrhal discharge of the syphilitic woman, or the sperm of the syphilitic man, or the vaccine lymph of the syphilitic infant, may possibly contain the syphilitic cca- tagium in full vigour, even at moments when the patient, who thus shows himself infective, has not on his own person any outward activity of syphilis. Similarly, in regard to tubercular dis- ease, experiment has proved beyond question that the milk of animals suffering from tubercle will, if taken as food by other animals, infect them through the intestinal mucous membrane : and there are independent reasons for believing that the tubercular contagium (like the syphilitic) will at times during the dyscrasy be contained in the seminal fluid, and that men, tubercular perhaps only in some degree which is not im- mediately important to themselves, may by that secretion convey fatal infection to women with whom they have conjugal relations.' Regarding many of the metabolic contagia, conclusive evi- dence exists that, when they are in operation in pregnant women, the foetus will in general be infected by them ; and this though the diseases (e.g. smallpox, cholera, syphilis) be of the most different pathological types : but with regard to pregnant animals affected with splenic fever it is noticeable that Brauell, in his ex- tensive researches, found the blood of the foetus not to be infective. In general, each contagium has its own favourite w^ay or ways of entering the body ; and these preferences are not only of speculative interest, as attaching to varieties of nature and natural habits among the contagia, but are of obvious practical importance as measures of the widely different degrees in which the different contagia are qualified to spread in communities. Thus, inoculation at broken surfaces of skin 1 See Dr. Weber, in Clin. Soc. Trans., 1874- CONTAGION. 1 90 t mucous membrane has long been known as the ordinary mode by which the infections of syphilis, hydrophobia, splenic fever, cowpox, and tarcy or glanders, get admission to the body; and our best knowledge of some other infec- tious diseases (notably of tubercle) has been derived from inoculations intentionally made with their contagia for purposes of study. While probably all infections which tend to be of general action on the body can be brought into action in that way, and while some infections are not known to pass by any other mode of transmission, there are many infections which spread freely from subject to subject by atmo- spheric and dietetic communication ; and the meaning of these preferences is hitherto not fully known. It seems that some contagia are so acted upon by air and water, that they seldom or never reach the body in an effective state by those common means of communication, — some hardly, if at all, by water, and some not by air except with very close intercourse ; and further, that, of eon- tagia which reach the body in an effective state, some require, while others do not require, that an abnormal breach of surface shall give them special opportunity for taking hold. In some of the cases where a disease can be propagated in both ways, — i.e., certainly in smallpox, and apparently also in bovine pleuro-pneumonia, tbs artificially-inoculated disease tends to bo much milder than the disease otherwise contracted; but pathologically it is difficult to conceive any essen- tial difference between those different modes of contagion. It may be presumed that, in the modes which are not by true inoculation, acts which are comparable to inoculation take place on internal surfaces ; that, for instance, when particles of scarlatina-contagium are caught in the tonsils, or inhaled into the bronchi, or swallowed into the stomach, they begin by pene- trating the texture of the mucous membrane, and by thus effecting as real an inoculation, with regard to the blood, as that which art or acci- dent provides in other cases through the punc- tured skin. That previous abnormal breach of surfaco by artificial puncture or otherwise is not necessary to allow the infection of mucous sur- faces is illustrated in ophthalmia and gonor- rhoea ; where apparently no other condition has to be fulfilled than that a particle of the blen- orrhagie contagiiun shall be deposited on the natural surface of the mucous membrane. It deserves notice that, while a considerable number of the worst diseases of the domestic animals admit of being communicated to man by artificial inoculation atmospheric communication seems to be very inapt, if not absolutely unable, to infect man with any one of them ; and in this connection it may be of interest to remember that syphilis, one of the most familiar of human infections, but hitherto not traced to any brute ancestry, differs from our other current infections in re- quiring inoculation to transmit it. When any metabolic contagium enters the animal body, it requires an interval of time, and '.n most cases a considerable interval, before its morbific effects can become manifest even to skilled observation. The period of latency or so-called incubation varies greatly in different cases. In hydrophobia it is very rarely less than of one month, is certainly often of several months, and is said to be sometimes of years. In syphilis the inoculated spot remains generally for at least a fortnight, and may remain even as much as five weeks, without any ostensible change ; and the roseola of the general infection will not be seen till some weeks later, when generally at least three months will have elapsed since the first inoculation. In the acuts eruptive fevers, when their contagium is trans- mitted by air, the first changes which ensue cd infection are not external, and we cannot be sura what early internal changes may take place ; bnt in smallpox, the fever (which is the first overt sign) does not attract notice till about the twelfth day after infection, nor the eruption till two days later; and in measles the incubation-time, though perhaps less uniform, seems to be little (if any) shorter than that of smallpox. The septic con- tagia and the contagium of splenic fever seem to be of particularly quick operation ; but even the most virulent septic contagium, when without admixtures which tend to complicate its action, will not begin sensibly to derange the infected animal till at least several hours after it has been inoculated. As regards the contagia last referred to, it is conceivable that the self-multi- plication of the contagium in the form in which it proves fatal to life is a process which goes on continuously and uniformly from the moment of inoculation to the moment of death, and that the moment when signs of general derangement be- come manifest is the moment when this uniformly advancing process has accumulated in the system a certain quantity of result : — but it does not seem easy to apply this explanation to the dis- eases of long incubatory period ; and we can hardly conjecture what may be the latent pro- cesses — for instance, of smallpox, during tli6 first ten or more days after contagium has been received. Itisnotyetpossibletosay, many-universal sense, with regard to the metabolic coutagia, what is the essential constitution of ‘ contagious matter,’ or what the intimate nature of the ‘transforming power ’ which the particle of such matter exer- cises on the particles which it infects. — As regards the question of the force, chemists, when they refer in general terms to the various acts which they designate acts of fermenta- tion, allege that certain processes of change in certain sorts of organic matter induce charac- teristic changes in certain other sorts of organic matter, not by the common chemical way of double decomposition with reciprocally new com- binations, but (so to speak) as a mere by-play or collateral vibration-effect of the chemical force which is in movement ; and though language can hardly be more vague than this for any scientific purpose, it expresses clearly enough the conviction of experts that a certain great force in nature lies beyond their power even of definite nomenclature, much more of exact iden- tification and measurement. In that most interesting, but most difficult and hitherto almost uninvestigated, branch of chemical dynamics, we are supposed to have our nearest clue to the scientific problems of the present subject-matter. It may be conceded that ibe ‘ contact-influences ’ which are dimlv rocoeaine i CONTAGION. is causing the fermentatory changes of dead organic matter have apparent analogues in many of the morbific influences of contagion : for the changes -which chemists call ‘ fermenta- tory ’ are all catalytic or disintegrative of the organic compounds which they affect; and when living protoplasm is. brought by contagion into processes of characteristic decay , the analogy seems sufficiently close to justify the word eymotic in the naming of the nature of the pro- cess. But it must not be forgotten that, among immediate effects of contagion in the living body, are cases wherein the process (so far as we can yet see) is primarily not catalytic or dis- ntegrative, but, on the contrary, anaplastic or ffon-structive. Thus, when tubercle gives rise .o tubercle, whether by secondary and tertiary infection in a single diseased body, or by infec- tion from the sick to the healthy, each new tubercle which the contagion brings into being is a growth-product of the texture which bears it. And similarly, when the innumerable varieties of cancerous tumour propagate themselves by contagion, each after its special type, in the bodies of the respective sufferers, it is growth, not disintegration, which we first see. It would seem that in those cases of anaplastic ‘ contact- influence ’ something far beyond the analogy of chemical fermentations must be involved ; and, in view of some of them, the physiologist has to bethink himself of the analogy of that ‘ contact- influence ’ which becomes the mainspring of all normal growth and development, when the ovum receives spermatic impregnation. — -As regards the ultimate organic constitution of the several metabolic contagia — (each of them of course abstracted from accidental admixtures, and seen or conceived in the smallest and simplest units of quantity and quality in which its specific force can be embodied) — modern re- search seems more and more tending to show that the true unit of each metabolic conta- gium must either be, or must essentially include, a specific living organism , able to multiply its kind. For with regard to those other contagia ( as we may properly call them) which spread fermentatory processes in common external nature, and of which it is as clear as of the morbific contagia that they multiply themselves in proportion as they act, it seems to be estab- lished beyond reasonable doubt that the ‘ self- multiplication’ of each of them as it acts is the infinite multiplication of a specific microphyte ; and that this microphyte (acting apparently by means of a matter which it produces and from which it can be mechanically separated) is the essential originator of the fermentation . 1 This being the case in regard of those fermentations, it seems probable that the same is in substance true of the specific morbid changes which extrinsic contagia produce in the materials of ' The doctrine to which the words in parenthesis refer I that the microphyte is not itself the ferment, but the producer and evolver of the ferment) tends to bring the case of these ferments into parallelism with that of the chylopoetic and other functional ferments which more highly organised creatures produce for the purposes i f their own economy. In the latter case the distinc- tion between the ferment-yielding live bodies (say cer- tain gastric cells) and their not-live product (say pepsin) is already familiar. 291 the living body: probable, namely, that low, self-multiplying organic forms, specific in each case for the particular disease which is in ques- tion, are essential to each morbid poison ; that the increase of each contagium as it acts is the characteristic self-multiplication of a living thing ; and that this (however obscure may yet remain its mode of operation) is the essential originator of change in the affected materials of the diseased body. The fact that low organic forms of the sorts now spoken of have often, or generally, been seen in the morbid products and tissues of per- sons with zymotic disease, would not by itself be a proof, or nearly a proof, that the forms are causative of the morbid change : for obviously they might be mere attendants on the necrosis and decomposition of bodily material, availing themselves of the process (just as certain insects would) to feed and multiply : and in many of tho cases in which micrococci have been seen in morbid material, no direct proof could be given that the meaning of their presonee was more than that. There are, however, some cases in which this proof has been completely established; and though such cases are at prosent but few, the significance of each of them in aid of the inter- pretation of other cases is of the highest im- portance. The researches of successive able observers in regard of the splenic fever of farm-stock, and those of Dr. Klein in regard of the ‘pneumo-enteritis’ (as he names it) of swine, have shown that in each of these cases the microphyte which attends the disease is botanically specific; that it and its progeny can be conducted through a series of artificial cultivations apart from the animal body; and that germs thus remotely descended from a first contagium will, if living animals be inocu- lated with them, breed in these animals tho specific disease. It is equally well known that the organisms (spirilla) which are found multi- plying in the blood during the accesses of relaps- ing fever are botanically specific ; but in regard to this disease, experimental proof has not hitherto been given that the spirilla, if sepa- rately inoculated, will infect with relapsing fever. Studies as complete as those which have been made in splenic fever and pneumo- enteritis will no doubt sooner or later be made in regard to many other of the diseases, hut their progress will necessarily be slow; partly because the objects which have to he scrutinised, and to which specific characters have to ho assigned, are so extremely minuto, and often so similar among themselves, that none hut very skilled and very patient microscopical observers are competent to pronounce on them; and partly again because the conditions of the case aresucti as to limit very closely the field within which the essential experimental observations can he made. Meanwhile, however, the two diseases, regarding which the larger knowledge has been obtained, must he regarded as highly suggestive in regard of other diseases of the same patholo- gical group, and particularly as giving impor- tance to fragments of evidence (not by them- selves conclusive) which have been gathered of late years in studies cf some of these other diseases. Eminently this is true of the large family of the septic infections — including on the CONTAGION. 292 one hand erysipelas and pyaemia -with its conge- ners, and haring on the other hand tuberculosis Intimately associated with it ; and almost equally it is true of enteric fever and cholera and diph- theria, and of the smallpox of man and beast. Thus, though it would be at least premature to say of these diseases that they certainly have as their contagia microphytes respectively specific to them, it seems at present not too much to say that probably such will be found tho case ; and if as much may not yet be said of many other diseases which are due to metabolic contagia, it must be remembered that the right lines of study relating to contagia in this point of view have not till within very recent times been opened. Of the naturae history of the contagia, con- sidered independently of the part which they play in the living body, there are hitherto only the beginnings of knowledge. The absolutely first origin of contagia may perhaps not be more within reach of scientific research than the abso- lutely first origin of dog or cat ; but their nearer antecedents — the states out of which they come when first about to act on the living body, and generally the variations which they and the common ferments exhibit under natural and artificial changes of circumstance, are within easy reach of investigation ; and those humbler studies are likely to give very useful results. For some of our cases we seem to have an instructive analogy in the facts which Professor Mosler has put together in explanation of the blue-millt contagium of dairies : facts showing that the omnipresent penicillium glaucum, if its spores happen to alight in particular (morbid) sorts of milk, will operate distinctively on their casein as an anilin-making ferment, rendering the milk blue and poisonous, and imparting to each drop of it the power to infect with a like zymosis auy normal milk to which it may be added . 1 In our own more special field, patholo- gists have already learnt that certain of the so-called ‘morbid poisons’ — the contagia of erysipelas, pyaemia and tuberculosis, are inti- mately related to the common ferment or fer- ments of putrefaction ; and that the most vehe- ment of these contagia can be developed by the artificial culture of successive transmissions in the living body from the comparatively mild contagium of any common inflammatory process . 2 Two other directions suggest themselves as likely to lead to fields of useful observation and experiment. On the one hand, in compara- tive pathology , and with the tracing of contagion from animal to animal, there is the possibility that at last some lower and relatively worth- less order of animals may be found the starting-ground of fatal infections for higher orders ; and this, perhaps, by contagia which in their former relations are of mere inflammatory significance. On the other hand, in geographical pathology , and with the tracing of contagion from place to place, local centres of contagium- 1 Virch. Arch., vol. 43. * See particularly Professor Sanderson’s papers in suc- cessive yearly volumes of Reports of the Medical Officer of the Privy Council from 1868 to 1877. It concerns the second fact mentioned in the text to remember that ap- parently every ‘ common inflammatory process ’ includes more or less of textural changes which are necrotic and of septic tendency. See Holmes’s System of Surgery, first edition, article ‘ Inflammation.’ origination may possibly be f und, in which th< contagium, before it enters the animal body, will show itself an independent microphyte of the earth, first operating on the animal body as the essential force in a local malaria. Some of the worst pestilences known to the human race — yellow fever, cholera, perhaps plague, and alsc some of the diseases of cattle, have in then history facts which suggest that sort of interpre- tation : the supposition, namely, that certain microphytes are capable of thriving equally (though perhaps in different forms) either with- out or within the animal body ; now fructifying in soil or water of appropriate quality, and now the self-multiplying contagium of a bodiiy disease. In regard to our own common ague- poison there seems every reason to suspect that its relation to soil is that of a microphyte ; and though we know ague only as practically a non- contagious disease, we do not know that any little transfusion of blood from sick to healthy would not show it to be (in that way) communi- cable from person to person. It needs hardly be said that exact scientific knowledge of the contagia, and of their respec- tive modes of operation, is of supreme importance to the prevention of disease. With even such knowledge of them as already exists, diseases which have in past times been most murderous of mankind and the domestic animals can, if the knowledge be duly applied, be kept compara- tively, or absolutely, in subjection ; and the fact that at the present time fully a fifth part of tho annual mortality of the population of England is due to epidemics of contagions disease is only because of the very imperfect application hitherto made of that knowledge. In the present article it is not necessary to state in detail the practice which ought to he adopted in the various different cases of infectious disease ; but briefly it may be said that one principle is at the root of all such practice, whatever the disease to which it relates. This principle, which of course becomes more and more important in proportion as the infec- tion is dangerous, and as the persons whom it would endanger are many, is the principle of thoroughly effective separation between the sick and the healthy : a separation, which, so far as the nature of the disease requires, must regard not only the personal presence of the sick, but equally all the various ways, direct and indirect, by which infective matters from that presence may pass into operation on others. Especially as regards the diseases which make serious epidemics, the principle of isolation is not carried into effect unless due care be taken to thoroughly disinfect in detail allinfective discharges from the sick, and all clothing and bedding and towels and like things which such discharges may have im- bued, and finally, as regards certain contagia, the rooms in which the cases have been treated ; and in order to secure these objects, it is essential in all grave cases to make such nursing-arrange- ments and such arrangements of the sick-room (whether private or in hospital) that no reten- tion or dissemination of infections matters wii' escape notice. It is likewise essential that all who attend on the sick should he careful not to carry contagion to other persons; as they may but too easily do, particularly in scarlatina and CONTAGION. in certain traumatic and puerperal infections, if they omit to take special precautions against the danger. See articles Quarantine, Disinfection, and Public Health, and those on the special diseases. The social conditions through 17111011 , in our own country at the present time, the more fatal infectious diseases are enabled to acquire epidemic diffusion are chiefly such as the following : — that persons first sick in families and districts, instead of being isolated from the healthy, and Treated with special regard to their powers of spreading infection, are often left to take their chance in all such respects ; so that, especially in poor neighbourhoods, where houses are often n several holdings, and where always there is much intermingling of population, a first case, if not at once removed to a special estab- lishment, will almost of necessity give occa- sion to many other cases to follow ; — that per- sons with infectious disease, especially in cases of slight or incipient attack, and of incomplete recovery, mingle freely with others in work-places and amusement-places of common resort, and, if children, especially in day-schools; and that such persons travel freely with other persons from place to place in public conveyances ; — that often, on occasions when boarding-schools have infectious disease getting the ascendant in them, the schools are broken up for the time, and scholars, incubating or perhaps beginning to show infection, are sent away to their respec- tive, perhaps distant, homes; — that keepers of lodging-houses often receive lodgers into rooms and beds which have recently been occupied by persons with infectious disease and have not been disinfected; — that persons in various branches of business relating to dress (male and female) and to furniture, if they happen to have infectious disease, such as scarlatina or smallpox, on their premises, probably often spread infection to their customers by pre- vious carelessness as to the articles which they send home to them ; and that laundries further illustrate this sort of danger by carelessness in regard to infected things which they receive to wash; — that purveyors of certain sorts of food, if they happen to have infectious disease on their premises, by carelessness spread in- fection to their customers ; — that streams and wells with sewage and other filth escaping into them are most dangerous means of infection, especially as regards enteric fever and cholera ; and that great purveyors of public water-supplies, so far as they use insufficient precautions to ensure the freedom of their water from such risks of infectious pollution, represent in this respect an enormous public danger; — that ill-conditioned sewers and house-drains, and cesspools receiving infectious matters, greatly contribute to dis- seminate contagia, often into houses in the same system of drainage, and often by leakage into wells. Of the dangers here enumerated, there is perhaps none against which the law of England does not purport in some degree to provide. At present, however, they all are, to an immense ex- tent, left in uncontrolled operation ; partly be- cause the law is inadequate, and partly because local administrators of the law often give little care to the matter; but chiefly because that strong 29& influence of national opinion which controls both law and administration cannot really be effective until the time when right knowledge of the sub- ject shall be generally distributed among the people, and when the masses whom epidemics affect shall appreciate their own groat interest in preventing them. Whenever that time shall come, probably the public good will be seen to require, with regard to every serious infectious disease which is apt to become epidemic, that the principles which ought to be accepted in a really practical sense, and to be embodied in effective law, are some- what as follows : — (1) that each case of such dis- ease is a public danger, against which the public, as represented by its local sanitary authorities, is entitled to be warned by proper information ; (2) that every man who in his own person, or in that- of anyone under his charge, is the subject of such disease, or is in control of circumstances relating to it, is, in common duty towards his neighbours, bound to take every care which he can against the spreading of the infection; that so far as he would not of his own accord do this duty, his neighbours ought to have ample and ready means of compelling him ; and that he should be respon- sible for giving to the local sanitary authority proper notification of his case, in order that the authority may, as far as needful, satisfy itself as to the sufficiency of his precautions ; (3) that so far as he may from ignorance not under- stand the scope of his precautionary duties, or may from poverty or other circumstances be unable to fulfil them, tile common interest is to give him liberally out of the common stock such guidance and such effectual help as may be wanting; (4) that so far as he is voluntarily in default of his duty, he should not only be punishable by penalty as for an act of nuisance, but should be liable to pay pecuniary damages for whatever harm ho occasions to others; (5) that the various commercial undertakings which in certain contingencies may be specially instru- mental in the spreading of infection — water- companies, dairies, laundries, boarding-schools, lodging-houses, inns, &c., should respectively be subject to special rule and visitation in regard of the special dangers which they may occasion ; and that the persons in authority in them should be held to strict account for whatever injury may be caused through neglect of rule; (6) finally, that every local sanitary authority should always have at command, for the use of its dis- trict, such hospital-accommodation for the sick, such means for their conveyance, such mortuary, such disinfection-establishment, and generally such planned arrangements and skilled service, as may, in case of need, suffice for all probable requirements of the district. Persons who are imperfectly acquainted with the scientific and social facts relating to the present subject-matter, or who have never seri- ously considered them, may think it would be over-sanguine to expect any general recogni- tion of principles so peremptory as the above may at first appear to them; but, if so think- ing, they would perhaps have under-estimated the rapidity with which knowledge is now increasing as to the common interests and mutual duties of mankind in respect of danger- m CONTAGION, ous infectious disease. Fourteen years ago, ■when the so-called cattle-plague or steppe-murrain was imported afresh, as a long-forgotten disease, into this country, and was found to affect very large pecuniary interests, primarily of the chief land- owners of the United Kingdom, and second- arily of other classes, an immensely valuable stimulus was given to the education of the country, and especially of its Legislature, in regard to the preventabilitv of the infectious diseases. And the remarkable zeal and ability which have been shown, in providing adequate laws and admirable administrative arrangements against the diffusion of steppe-murrain and other infectious diseases of Farm-Stock, are not likely to be found permanently absent in relation to the interests of Human Life, when once the true bear- ings of the subject shall have got to be popularly understood. John Simon. CONTINUED FEVERS. — Characters. — Under the name of Continued Fevers is included a group of diseases which have the following characters in common : — 1. They are attended with 'pyrexia, or a febrile condition sustained for a more or less definite period of considerable duration, without inter- mission or very decided remission, and not due to any local inflammation. That is, the fever is essential , and not merely symptomatic. The distinguishing feature of pyrexia is unnatural elevation of the temperature of the body, but there are other symptoms scarcely less constant — increased frequency of the pulse, thirst, loss of appetite, furred tongue, headache, chilliness, and — if the temperature is high — various manifesta- tions of disturbance of the nervous system. 2. They are clearly due to the introduction into the body of a poison from without, and this poison is reproduced in the system, so that con tinned fevers are communicable directly or indirectly from the sufferer to others. This statement would not apply to simple continued fever so called ; but simple continued fever, when not a mild or abortive attack of one or other of the specific fevers, has scarcely any- thing in common with them. 3. The continued fevers rarely affect the same individual twice. An attack is protective against subseque7it attacks of the same fever. This is much less manifest in relapsing than in typhus and enteric fever. 4. The continued fevers have a more or less definite duration. A certain time intervenes between the exposure to the poison and the onset of the disease, which is called the period of incubation ; and the disease is divisible into the stages of invasion, dominance, and decline. 5. In two out of the three continued fevers there is a characteristic cutaneous eruption. Enumeration. — The continued fovors are typhus, enteric, and relapsing fever. Common continued fever, or febricula, often associated with them for the sake of convenience, re- sembles them only as consisting in pyrexia not traceable to any known local inflammation. It does not conform to the characteristics enume- rated, and cannot be brought within any defini- tion which applies to the true fevers. Diagnosis. — The continued fevers have to be CONTINUED FEVERS, distinguished from the intermittent and remit- tent fevers on the one hand, and from the eruptive fevers and some other diseases on the other. 1. From intermittent and remittent fevers they are distinguished clinically by the comparatively sustained high temperature ; but were this all, the continuous character sometimes assumed by intermittents and the remittent type occasionally seen in enteric fever — especially in children — would bring them close together. The essentia] distinction is that indicated under the second head, and is mainly setiological. Both kinds of fever are due to a poison received from without; but while in continued fevers the source of the poison is for the, most part a previous case of fever of the same kind, and the poison is gene- rated anew in the subject of the disease, remit- tents and intermittents are of malarious origin, and the poison is never reproduced in the sys- tem, and therefore never communicated by the sufferer. The formation of the specific contagium of continued fevers within the system during the disease is of course the cause of their spread by contagion. The mode of this spread is different for the different fevers. Typhus and relapsing fever are directly contagious in an eminent de- gree ; the poison is contained in the emanations from the skin or lungs, and is capable of en- tering the blood of healthy persons by being breathed or swallowed; it may also be carried by fomites. Enteric fever, if directly' contagious at all, is very slightly so ; the contagium is appa- rently not given off in the breath or perspiration, but chiefly or exclusively from the bowels, and the disease is spread mainly by the contami- nation of drinking water, or, more rarely, by sewer gases or by the emanations from typhoid excreta, especially after long residence in sewers. 2. The distinctions between the continued and the eruptive fevers remain to bo pointed out. They are of a very slight character. All the characters given of the continued fevers, includ- ing the occurrence of a cutaneous eruption, are common to them and the eruptive fevers. The differences are as follows : — a. The liability to the eruptive fevers is almost universal in the absence of protection by a previous attack, and is little affected by the state of health of the individual, while the lia- bility to continued fever is very variable in dif- ferent persons, and even races, and is greatly influenced by external conditions. There is no parallel in the eruptive fevers to the predisposi- tion to typhus and relapsing fever generated by overcrowding and famine. b. The protective influence of a previous attack is more marked in the eruptive fevers, though not to such a degree as would constitute an important distinction. Instances of small- pox after a previous attack, or after vaccination, and second attacks of measles and scarlet fever, are not very uncommon. c. While in the eruptive fevers the specific poison is considered to be invariably derived from a previous case, this cannot be said with the same confidence with regard to the continued fevers. It is true that in by far the larges: proportion of attacks of typhus, enteric, and relapsing fevers the source of the poison can be CONTINUED FEVERS, traced, and that as tha experience and trained skill brought to bear on the search increase, the fever are the examples in which it fails ; but it cannot yet be said definitely that these fevers are not generated anew under certain conditions. The constancy with which typhus and relapsing fever follow in the track of overcrowding and starvation is suggestive of spontaneous origin ; bit in this country typhus is never so completely extinct that foci of infection are wanting, and epidemics of relapsing fever may be imported. Enteric fever, again, appears from time to time under circumstances which appear to exclude the possibility of the poison having been derived from a previous case, though in most instances of epidemic prevalence of the disease, there is conclusive evidence of specific and not merely ge- neral contamination of the air or water. It is not, however, necessary to enter upon this controversy here, or to do more than allude to the question whether or not their contagia are of the nature of organic germs. See Contagion ; and Zyme. The fevers will be fully described under their respective names. "William II. Broadbent. CONTRACTION, Muscular ( contraho , I draw together). — A term applied to the action or to the shortening of a muscle from any cause, whether in health or in disease. See Spasm. CONTRA-INDICATION.- Any circum- stance which forbids the employment of thera- peutic measures otherwise indicated. CONTRE-COUP (Fr.), Counter-stroke.— An injury of a part opposite to and distant from that to which force is applied, as by a fall or direct blow. Contre-coup is chiefly observed in injuries of the skull. CONTUSION ( contundo , I bruise). — A bruise or injury of the soft parts without breach of surface. CONVALESCENCE ( con and valcsco, I grow well.) — The period of convalescence signifies that period during which a patient is progressing towards recovery, and is returning to a state of health after having suffered from an illness. When the health has been completely restored, convalescence is said to be established, and the patient is regarded as convalescent. The word is used most commonly in association with fevers, inflammatory diseases, and other acute affec- tions. Convalescence may be ushered in by a crisis, and become speedily established ; or it may be very slow and protracted in its progress, which is also often interrupted by relapses, com- plications, or sequel®. Patients frequently require careful watching and judicious treatment while becoming convalescent, as they are apt to retard or even prevent their recovery, and to lay the foundation for permanent disease by neglect of due precautions, especially as regards their diet. Much injury is not uncommonly inflicted by the injudicious administration of medicines, and the employment of other means which are sup- posed to hasten convalescence. Frederick T. Roberts. CONVOLUTIONS OE THE BRAIN and CORTEX CEREBRI, Lesions of. — CONVOLUTION'S OF THE BRAIN. 29b The pathology of the cortex cerebri is a subject which, notwithstanding the extensive literature relating to cerebral disease, is still comparatively in its infancy. The older records and observa- tions made while the idea was still prevalent, that the convolutions of the brain had no definite dis- positions and relations, and that the various part? of the hemispheres were functionally equivalent, are not sufficiently exact to be made the basis of trustworthy clinical and physiological conclu- sions. Recent anatomical investigation into tha topography aud homologies of the cerebral con volutions, and the experimental researches of Hitzig, the writer, and others in reference to the results of electrical irritation of the brain, have directed greater attention to accurate topographical descriptions of the lesions of the cortex in connexion with observed clinical symptoms. As yet, however, the reliable patho- logical material is not very extensive, though it, is every day accumulating, more particularly by the labours of Charcot and his followers in France, and Hughlings Jackson and others in this country. Up to a comparatively recent date physicians and physiologists generally held by the views of F’lourens, based on experimental investigation of the brains of the lower classes of animals. According to Flov.rens the hemi- spheres were concerned purely with intelligence — a faculty one and indivisible ; and each part of the hemisphere possessed the functions of the whole, so that, if part were destroyed, functional compensation might he effected by the parts which remained. These views seemed satisfac- torily to explain the cases, not uncommon, in which, notwithstanding the existence of exten- sive lesions in the hemispheres, no symptoms were observed during life. The frequent associa- tion of aphasia with a limited lesion of the cortex cerebri, vaguely indicated by Bouillaud and Dax, and definitely fixed by Broca at the posterior extremity of the third left frontal con- volution, was a step towards localisation of function in the brain, which, however, met with much opposition and counter-facts. The clinical and pathological observations of Hughlings Jackson in reference to the causation of limited and unilateral epileptiform convulsions were an important contribution to the physiology and pathology of the cortex. These convulsions he attributed to irritative or discharging lesions cf the grey matter in the neighbourhood of the corpus striatum in the opposite hemisphere. Physiological experiment has demonstrated the correctness of the views advanced by Hugh- lings Jackson, and shown that, not only can movements be excited by electrical irritation cf certain regions of the cortex, but also that defi- nite combinations of muscular movements uni- formly result from stimulation of certain specia- lised areas within this region. The interpretation of these facts, now no longer disputed, has been much debated, but the views the writer has elsewhere expressed at length ( Functions of the Brain ) seem in accordance with the most recent and careful pathological and clinical research, viz. that the brain is divided into a motor and a sensory region, and that in each there are definite centres with definite functions, and that the symptoms of cortical lesions depend 29C CONVOLUTIONS OF THE BRAIN AND CORTEX CEREBRI, LESIONS OF. on the locality of the lesion, and cn •whether it is unilateral or bilateral. Physiological experiment is, as to precision in its results, considerably in advance of clinical observation, and, from the nature of the two methods, this is what might be expected. The investigation of diseases of the brain is surrounded by special difficulties. Though, as shown by physiological experiment, the brain is capable of being mapped out into different regions possessing different functions, yet the brain acts as a whole, and it is not always easy to analyse the facts of disease, and to distinguish with certainty between the effects directly de- pendent on the locality of the brain and those due to the indirect influence exerted on the functions of neighbouring regions and on the brain as a whole. And when, moreover, we take into account the vague manner in which it has been the custom to define the locality of the lesion, it is not surprising that so little has as yet been accomplished in reference to the locali- sation of cerebral disease. But, besides these difficulties there are others, of greater magnitude and less easy to overcome, inherent in the subject itself. For the brain, besides being concerned with certain functions which we can investigate objectively, viz. sen- sation and voluntary motion, is the organ of mental operations, and as the same parts have an objective and subjective function, it is obvious that cerebral diseases may manifest themselves mentally as well as bodily. These two sides of brain-function and their disordered manifesta- tions have been in a great measure artificially separated for convenience in treatment, and the relation between the physiological and the psy- chological has not been duly recognised. And yet it is obvious that until psychological phe- nomena have been reduced in ultimate analysis to their anatomical and physiological substrata we can have no rational medical psychology, as distinguished from empiricism or mere specu- lation, available as a guide to the diagnosis and treatment of cerebral disease in its subjective or mental manifestations. That the brain is diseased in insanity, func- tionally or organically, is a fact now universally admitted ; but it is also true that the lesions which cause objective symptoms in the domain of motion and sensation need not cause mental derangement, and also that lesions which cause mental derangement need not manifest themselves in any discoverable disorders of sensation or mo- tion. In fact, for purposes of ideation we have practically two brains ; for, though motion and sensation will be paralysed on the opposite side by destruction of one hemisphere, yet intelligence and thought are possible through the hemisphere which remains. Various forms of lesion have been found in the brains of the insane, such as morbid con- ditions as to vascularity, degeneration of the blood-vessels, degeneration of the nerve-cells, neuroglia, membranes, &c. ; but no constant relation has as yet been established between any one form of degeneration and any one form of mental alienation, or between the latter and any localised lesion. Nor has it been clearly estab- lished whether the forms of degeneration found in the brains of the chronically insane are the result or the cause of the mental disorders. An exception, however, is to he made in favour of general paralysis of the insane, where there seems to be a definite connexion between tho anatomical lesion and the symptoms manifested In this disease we find as a constant, if not the only factor, a form of chronic encephalitis, affect- ing chiefly the cortical regions which physio- logical experiment has shown to be the motor zone of the hemispheres. This lesion is asso- ciated with progressive motor paralysis, varied with intercurrent epileptiform and apoplectiform seizures, and with mental symptoms characterised generally by exalted ideas and delusion as to wealth, power, and grandeur. The motor symp- toms are readily accounted for by the locality and character of the cerebral lesion, but the relation between this and the mental symptoms is a subject which psychological analysis has yet to elucidate. Another link between the physiological ami psychological aspects of brain-function is fur- nished by aphasia, in which, with a definite ana- tomical lesion, there is a definite psychological defect (see Aphasia). But beyond these the relation between morbid mental manifestations and morbid conditions of the brain, and their joint relation to the bodily symptoms, remain involved in great obscurity. The objective symptoms of cortical lesions depend on their locality, and on whether they exercise an irritative or destructive influence on the parts they invade. From the localisation point of view alone the intimate nature of the mor- bid process is unimportant, except in so far as its imitative or destructive character is concerned. Lesions, such as tumours, which from their very nature exercise important indirect effects on the encephalon as a whole, apart from their effects on the regions which they directly invade, can rarely be exactly localised, owing to the difficulty of separating the direct and indirect symptoms from each other and referring each to its exact cause. Also no rigid conclusions as regards localisation can be drawn from morbid affections of the hemispheres which extend over a large area, such as the various forms of menin- gitis and meningo-encephalitis. In all these cases the nature of the affection must he diag- nosed from its own general and special cha- racters ; its position and extent in the brain being arrived at approximately from a considera- tion of the effects of accurately circumscribed lesions, as determined by careffii clinical and pathological observation and physiological ex- periment. The brain may he considered as divided into a motor and a sensory zone. Motor Zone. — The motor zone includes the convolutions hounding the fissure of Rolando, viz. the ascending frontal and the bases of the three frontal convolutions, the ascending pari- etal and postero-parietal lobule, and the in- ternal surface of the same convolutions or para- central lobule. In this zone are differentiated centres for the movements of the limbs, head, and eyes, the muscles of expression, and those of the mouth and tongue. The centres of the leg and foot are situated in the postero- CONVOLUTIONS OF THE BRAIN AND CORTES CEREBRI, LESIONS OF. 297 parietal lobule, those for the arm in the upper third of the ascending frontal, those for the hand and wrist in the ascending parietal, those of the facial muscles in the middle third of the ascending frontal and base of the second frontal, those for the mouth and tongue at the lower third of the ascending frontal at the base of the third frontal, and for the platysma at the lower extremity of the ascending parietal, just posterior to the mouth-centre. The posterior third of the upper frontal convolution and corresponding part of the second frontal, contain the centre for the lateral movement of the head and eyes. The frontal regions in advance of this centre, though anatomically related to the motor divi- sion of the internal capsule, do not seem directly connected with motor manifestations as judged by the negative effects cither of irritation or ex- tirpation. Irritative lesions of the motor zone proper, such as may be induced by syphilitic lesions, tumours, spieula of bone, depressed fractures, thickening of the membranes, l four hours. Even when no depression has been occasioned by drugs, a succession of small blis- ters to the chest is of great use. Signal benefit is often obtained by a short and smart purging with calomel and seammony. In all cases, tho legs must be kept enveloped in warm wrappings, moist warmth being preferred if it can be un- flaggingly maintained. In most cases, the breathing is subject to dyspnceal paroxysms arising from spasm of the glottis. The muscular relaxation which follows the emetic action of ipecacuan or tartar-emetic generally relieves this spasm with rapidity and for some hours. Tho vomi- tive effort is also useful in another way — in clearing the air-passages from dangerously accumulating mucus, and so admitting more air into the lungs. When bronchitis and broncho- pneumonia are associated, as frequently happens, with the laryngeal and tracheal inflammation, the treatment is the same as that which has been already described. In protracted cases, and in weak children, it is nearly always necessary to give, for a longer or shorter period, brandy or some other alcoholic stimulant. Ammonia too is generally indicated. The extent to which stimulants are demanded varies with each case, and also with the varying circumstances of each case. Milk ought to be the principal aliment. Beef-tea, and arrowroot made with milk or with brandy, may also be given from time to time. Should diphtheria bo prevalent when we have under treatment cases of common inflammatory sore-throat, we must be specially on the outlook for the supervention of the former. Not in cases of simple inflammatory sore-throat only, but still more in the sore-throat of scarlatina and measles, diphtheria frequently supervenes as a secondary- disease, suddenly declaring itself by an exudation of false-membrane in the air-passages. A new principle of treatment must be adopted when diphtheria engrafts itself on the original in- flammation. W r e have then to treat an asthenic general disease as well as the throat-affection. The possibility of the supervention of diph- theria, with its accompanying prostration of strength and dyscrasia of the blood, is another argument in addition to those already mentioned against the abstraction of blood in the common laryngo-tracheal inflammations of y T oung chil- dren. [The article on Diphtheria should be read in connection with this article.] John Rose Cokmack. CROUP, FALSE. — A term commonly ap- plied to laryngismus stridulus. See Larynx, Diseases of. CROUPOUS, CROUPY (Seot. croup, to croak). — These terms were originally em- ployed with reference to the peculiar crowing or stridulous character of the respiration, cough, and voice in certain affections of the larynx, and signified ‘ belonging to croup’ in its clini- cal relations ; for example, ‘ croupy cough,’ ‘croupous symptoms.’ When morbid anatomy demonstrated the occurrence of a fibrinous exu- dation or false membrane upon the affected 322 CROUPOUS, CROUPY. surface in a special form of croup, the word 1 croupous ’ was used also to designate this false membrane ; thus, 1 croupous exudation ’ and ‘ croupy membranes.’ The application of the term was afterwards further extended; and it is now employed to indicate the process that leads to a fibrinous exudation in any situation whatever; such as ‘croupous inflammation,’ and 1 croupous pneumonia.’ Thus the words “ crou- pous ’ and ‘ croupy,’ which were originally asso- ciated with peculiar -ounds, have come in a remarkable manner to express certain physical, chemical, and microscopical characters in the products of inflammation. See Croup, Diph- theria, and Inflammation. CROWING CONVULSION. — A popular synonym for laryngismus stridulus. See Larynx, Diseases of. CRURA CEREBRI, Lesions of. — Prom anatomical and physiological considerations we should be prepared to find that a solution of continuity of the crus cerebri would interrupt the sensory and motor tracts for the opposite side of the body. And, further, as the roots of the third nerve pass through the inner aspect of the crus to their nucleus underneath the aque- duct of Sylvius, there is considerable danger of their being implicated in a lesion of the crus. Hence we should expect, in consequence of such a lesion, a form of alternate paralysis, viz., oculo-motor paralysis on the side of lesion, and paralysis of voluntary motion and sensation on the opposite side. A typical instance of this form of paralysis has been put on record by Weber (Med. Clin. Trans. 18C3). In this case there was oculo-motor paralysis on the side of lesion, and complete paralysis of voluntary motion and partial paralysis of sensation on the opposite side. The partial escape of the sensory tracts is accounted for by the fact that the sensory tracts are situated more to the outer and back part of the crus, and hence tend to escape destruction from a lesion situated in such a position as specially to endanger the conti- nuity of the third nerve. Vaso-motor paralysis on the hemiplegic side also occurs in a marked degree, and the tem- perature of the paralysed side may be two or three degrees above that of the other. D. Ferrier. CRUSTA LACTEA ( crusta , a crust, and lactea, milk-like) ; milk-crust — A synonym for eczema pustulosum of the face and head, met with in infants at the breast. See Eczema. CRUVEILHIER’S PARALYSIS. — A synonym for progressive muscular atrophy. See Muscular Atrophy, Progressive. CUPPING. — This is a mode of treatment sometimes employed to relieve congestion or in- flammation of internal parts by drawing blood to the surface of the body. When the blood thus attracted to the superficial parts is actually abstracted from the body by means of incisions, the operation is called icrf-cupping, and this has been described in the article Blood, Abstraction of. Wo shall here describe dr§/- cupping, in CUTIS PENDULA. which no scarifications are made, the blood being simply drawn towards the surface by atmospheric exhaustion, hypertemia of the subcutaneous parts or organs being thereby relieved. Formerly cupping was extensively practised, but of late years it has fallen into disuse. In some respects it serves the purpose of, but has a more powerful effect than, counter-irritants ; rapid and marked results being sometimes pro- duced upon the circulation of inflamed or ecu gested tissues. Modes of Application. — Dry cupping is per formed as follows : — The flame of a spirit-lamp, being allowed to burn for an instant in the dome of a cupping-glass, is quickly withdrawn, and the cup is then rapidly and evenly applied to the skin over the affected part. The heat expands the air contained in the glass cupola, and, owing to the contraction which ensues on cooling, the skin is forcibly sucked up into the cup. It is well first to sponge the skin of the selected spot wdth hot water, so as to render it more supple and vascular ; slightly moistening the rim of the cupping-glass helps to increase the degree of exhaustion. An excellent modification of cupping, which has been demonstrated to the writer by Dr. Quain, is practised in the following way: — Instead of allowing the cup to remain station- ary after its application to the skin, as is usual, the operator dexterously slides it to and fro along the surface. When the operation is to be thus performed the amount of surface drawn into the glass must not be considerable. In this way a large tract of skin may be quickly rendered hyperaemic without effusion of blood into its meshes, as happens when the cups are stationary. Precautions. — Cupping-glasses should be applied where the skin is thick and cushiony, as over the loins, nape of the neck, pectoral region of the chest, &e., and not where bony promi- nences, or other irregularities, are likely to in- terfere with complete exhaustion. The edges of the glasses should not be so hot as to burn the skin. Uses. — Cupping may be advantageously em- ployed in sthenic cases of cerebral congestion, tho cups being applied to the nape of the neck ; in hypersemiaof the spinal cord; and in inflamma- tion or congestion of the lungs, kidneys, or other viscera. In renal ischaemia it is eminently ser- viceable. This may be owing to the fact that the blood supply of the skin of the loins is in intimate relation with that of the kidneys ; the vascular supply to those organs being thus directly and immediately influenced. Alfred Wiltshire. CUTIS, Diseases cf. See Skin, Diseases of, CUTIS ANSERINA (cutis, the skin, and anser, a goose). A state of roughness of the skin, resembling that of a goose when plucked, produced by prominence of the pores or fol- licles. It is due to contraction of the muscular structure of the cerium, and is commonly occa- sioned by cold. CYANIDES, Poisoning by. — See Anti- dote ; and Prussic Acid, Poisoning br. CYANOSIS. CYANOSIS ( Kvavbs , blue). — This \yhich is ;eally not a disease, refers to the peculiar blue or more or less livid colour of the surface of the body, especially in certain parts, which is ob- served in several affections that interfere with the circulation and oxygenation of the blood. The condition is most commonly associated with, and reaches its highest development in certain forms of congenital malformation of the heart, for which consequently cyanosis is not uncommonly used as a synonym. Lesser degrees of similar dis- colouration are, however, not infrequently noticed in cases of cardiac disease developed after birth, and they may also accompany pulmonary affec- tions which materially obstruct the circulation ; a cyanotic appearance is also one of the obvious effects resulting from all modes of suffocation, and it is observed in the collapse-stage of cho- lera. The upper half of the body may become extremelycyanotic as the result of obstruction of the superior vena cava. For the pathology of cyanosis, see Heart, Malformations of. CYNABTCHE (/«W, a dog, and tcyxw, I strangle). Synon. : Hr. Angvne ; Ger. die Breiune. This word is used to express an inflammatory condition of the throat, or contiguous parts, in which difficulty of breathing or of swallowing exists, accompanied by a sense or feeling of choking. The term is used synonymously, more frequently on the Continent than in England, with Angina ; an affix, indicative of the seat or nature of the affection, being employed as a desig- nation for each of the several forms or varieties of disease affecting the throat or adjacent parts. Such, for example, are the terms Cynanehe laryngea, or croup; Cynanehe maligna , or malig- nant sore-throat; Cynanehe parotidea, or mumps ; Cynanehe pharyngea, or inflammation of the pharynx ; and Cynanehe tonsillaris , or quinsy. See these several diseases. CYETOMETEH (ki ipros, a curve, and gerpov, a measure). — An instrument for measuring the absolute and relative dimensions of the chest- wall. See Physical Examination. CYSTICERCUS {Kusrts, a bladder, and i cepuos, a tail). — Description. — Cysticercus is a bladderworm furnished with a head, which is dis- tinctly visible to the naked eye. The form usually found in man is specifically identical with the so-called pork-measle, or Cysticercus {tela) celluloses. According to Dr. Giacomiti, however, the human measle commonly displays32 cepha- lic hooks, whilst the pork- measle carries 21; more- over, in the human variety there is a greater adhe- rence of the measle to its investing capsule. The only other form of cysticercus at present known to infest the (telce)ceUulosce, removed human body is the slender- necked bladder - worm, or ters. After Allen Thom- Cysticercus tenuicollis. An son- alleged example is preserved in the anatomical museum attached to King’s College, London. This parasite is of frequent occurrence in the sheep. Fig. 14 . — Cysticercus CYSTIC EKCUS. 326 Situations and Symptoms. — The clinical im- portance of the human measle is chiefly dm Fig. 13. — Portion of measled pork, showing Custicerci. Nat. size. After Lewis. to the circumstance that it is apt to take up its residence in the brain and eye ; those parasites occupying the cerebrum being for the most part situated in the grey or cortical substance. The only serious attempt that has been made to establish diagnostic signs by which brain- cysticerci might be detected during life is that initiated by Griesinger, who based his conclusions on data supplied by the histories of upwards of fifty cases. Symptoms are exceedingly variable. In some cases they are altogether wanting; in a second set, epilepsy exists, without mental dis- turbance ; in a third set, epilepsy is accompanied with mania or imbecility ; in a fourth set, mental disturbance may occur without epilepsy; whilst in another group there is neither epilepsy nor mental disturbance, until shortly before death, w T hen symptoms of irritation or torpor gradually supervene. Since Griesinger has himself re- marked that the epileptiform seizures due to cys- ticercus are in all respects like ordinary cerebral epilepsy, and since also ‘ the psychical disturb- ances have nothing characteristic about them,' the practical physician is naturally tempted to conclude that diagnosis and curative treatment are alike impracticable. The writer, however, ob- jects to that inference, on grounds too wide for dis- cussion here ; but, as one source of encouragement calls attention to the fact that cj'sticerci are not very long-lived. He has demonstrated that a period of eight months is amply sufficient for the setting in of calcareous degeneration, a process which involves the speedy death of the measle. If therefore the presence of eysticerci be so much as suspected in the brain, the prospect of a natural cure is by no means hopeless. Best, both mental and corporal, would of course tand to assist nature’s efforts. Cysticerci may develop in any part of the human body ; their most frequent situation being the subcutaneous, areolar, and intermus- cular connective tissues. Amongst the more remarkable cases are five recorded by Heller, and one by Greenhalgh, where they occupied the lip ; by Fournier, where several occurred in a boil ; and one by Dupuytren, where the parasite lodged in the great peroneus muscle. Mr. R. Davy lately recorded a case in which several were present in the arm ; hut the well-known mul- tiple cases given by Giacomini, Hodges, Delore, and others, show that hundreds of measles may co-exist in the same human host. In Delore’s i2 4 CYSTICERCUS. case there were about 2,000, of which no less than 84 were found in the cerebrum! Of in- stances where the cysticercus occupied the eye we may particularise the cases by Windsor, Logan, Estlin, Rose, and Mackenzie of Glasgow; whilstof additional brain-cases, those given by J. Harley, Hulke, Burton, Bouvier, Er&dault, and Toynbee are particularly noteworthy. Amongst the most recent contributions to our knowledge of cysticerci are the memoirs of Perroncito ( Della panicatura negli animali, in Annali del. R. Acead. d’Agricolt. di Torino, 1872); of Beeoulet and Giraud (Bull, de la Soc. Med. de Gand, 1872), of Giacomini (Sul. Cyst, cell, hominis e sulla Tania med. &e., 1874), of Lewis (Report on Bladderworms, &e., 1872), and of Pellizzari, as reported by Dr. Tommasi in his Italian edition of the writer’s manual of the parasites of our domesticated animals (Appendice Parasiti, &c. Vermi, 1874). A sum- mary of these last-mentioned researches was given by the writer in the Bond. Med. Record for 1874: (p. 641). Lastly, it is important to bear in mind that small hydatids, which are also liable to take up their abode in the brain, may very readily be mistaken for cysticerci, after death; and during life they are apt to give rise to precisely similar symptoms. The writer has collected records of more than thirty cases where bladderworms occurred in the human brain. References to most of these are given in the Bibliography of his Introduction to the study of Helminthology (Entozoa, 1864 ; and Supplement, 1869). See Bladdekworms. T. S. C'OBBOI-D. CYSTINE or CYSTIC OXIDE &rii, the bladder).- — A peculiar substance occurring either in solution or in the form of small crystals in the urine, or as calculi in the urinary passages. See Urine and Calculi. CYSTITIS (kvotis, the bladder). — Inflam- mation of the bladder. See Bladder, Diseases of. CY STS.— Definition. — The word cyst (kvotis, the urinary bladder) is used in pathology for a closed cavity containing fluid or soft matter. The nature of the 'wall is unimportant ; it may be newly formed or a pre-existent structure. The objects thus defined differ much among them- selves, and are associated together rather from convenience than on account of any real patho- logical similarity. Classification. — Cysts may be classified ac- cording to their structure, as simple or com- pound ; according to their contents, as serous, mucous, fatty, etc.; or according to their mode of origin. The latter, though not free from objec- tion, is the basis of description which will be here adopted. Cysts may originate (1) from dilatation of previously existing closed cavities ; (2) from retention of products of secretion ; (3) from exudation, or the metamorphosis of exuded products ; (4) as a part of new-growth ; (5) by a vice of development ; and, finally, (6) from the growth of parasites. 1. Cysts from Dilatation. — Spaces, normal or newly formed, in connective tissue may, by irri- tation and consequent excessive exudation, be con- verted into cysts; or the same result may happen CYSTS. from the confluence of several such spaces. In proportion as the wall becomes smooth, and the shape uniform, they may be called cysts. Bursae, whether normal or pathological, are cysts. Ganglion in the sheath of tendon is clearly a pathological cyst. To these and like structures the name Hygroma has been given. They all contain clear serous fluid, and are lined by an endothelium. Hydrocele, or dilatation of the tunica vaginalis testis — an affection probably always due to a low form of inflammation — is another instance. One class of ovarian cysts comes under this head, those, namely, which arc due to simple dropsy of the Graafian vesicle. Tubo-ovarian dropsy has the same explanation ; and cysts of the broad ligament are enlargements of normal structures which are left as relics of the development of the ovary. The thyroid gland seems from its structure, containing, as it does, so many closed follicles, particularly disposed to this kind of cyst-formation, and this is doubtlesu the explanation of bronchocele. 2. Cysts from Retention. — Cystic formations may result from the obstruction of the natural outlet of a secreting organ, and tho consequent retention of secretion. It is necessary that the walls of the secreting cavity should admit of enlargement, and that the tension should not become so great as to check secretion. All secreting glands present instances of such cysts. The sebaceous glands of the skin are par- ticularly liable to obstruction of their duct, and in this way are formed sebaceous cysts, miliaria, and comedones ; the contents of which are some- times epithelium and the products of normal secretion, sometimes abnormal products, such as pus. See Eolliculab Diseases. The glands or mucous surfaces are liable to similar obstructions, and mucous cysts result, such as are sometimes seen in the mouth. Larger cysts in the mouth ( ranula ) result from the obstruction of the ducts of the salivary glands, or are perhaps connected with an abnormal pro- duction of gland-substance. The stomach very frequently, other parts of the intestinal canal more rarely, show similar cysts, which, when they project and become complicated in structure, are called polypi. They are occasionally seen on the larynx and trachea. In no part are mucous cysts more frequent than in the uterus, where indeed, similar formations, the oval a Xahothi, must be regarded as normal. The varieties here met with have, as Virchow has pointed out, a close analogy with the various forms of retention- cysts in the skin. In the mamma, cysts may result from the cut- ting off of portions of the gland-follicles, but the cysts contained in mammary tumours are not always formed in this way, some being part of new growths. In the testicle obstruction and cutting off of seminiferous tubes may lead to small cysts, but these are more often connected with new- growths. The curious cysts known as sperma- tocele, containing spermatozoa, appear to arise from a similar distension of detached portions of testicle-substance, which, by r an error of develop- ment, have failed to become connected with the excretory duets. The testicle is also liable to a general cystic degeneration, usually called cysto- sarcoma. Cysts of the kidney are of various CYSTS. kinds, but many, no doubt, both large and small, result from the dilatation of uriniferous tubules and capsules of glomeruli when their outlet is obstructed, as occurs in the cirrhotic form of Bright’s disease. The origin of the very nume- rous microscopic cysts has been much disputed. The writer inclines to the belief that they arise from moniliform contraction of the uriniferous tubes, especially such as contain the hyaline cylinders, known as fibrinous casts. Another form of cystic disease of the kidney is developmental. In this the whole of the organ is converted into a mass of cysts, and is usually much enlarged. This condition may be congenital, and the organ may be so large as to obstruct parturition. It is attributed by Virchow to inflammation of the calyces during intra-uterine life. To guard against a common error of language, it should be pointed out that the condition of the kidney which results from the obstruction of the ureter, or of the urinary passages lower down, though sometimes called cystic dilatation of the aidney, is not properly a case of cyst-formation, and is better called hydronephrosis. 3. Cysts from Exudation. — Exuded ma- terials, such as blood and inflammatory products, may, by a process of degeneration, central softening, and external fibrous formation, become converted into imperfect cysts, as is seen in the metamorphosis of a blood-clot in the brain, and in the termination of some abscesses. But since the accumulation of fluid does not go on con- tinually, the tension in such cavities is slight, and they do not approximate to a globular shape. 4. Cysts from Hew- Growth. — In many forms of new-growth cysts are produced, but not always in the same way. Sometimes, as in myxoma and enehondroma, they result from softening of portions of new-growth already formed. In many sarcomata, the production of new tissue goes hand in hand with that of cysts, and is sometimes effected as in glandular organs, by the formation of new follicular structures without an outlet, sometimes by new-growth into the dilated cavities. Polypoid or pedun- culated growths on a free surface may some- times, by the fusion of their extremities, en- close spaces which become converted into cysts. We do not, however, find cysts forming by them- selves a new-growth of so definite a character as to deserve a separate name. 5. Developmental Cysts. — These include («) compound ovarian cysts ; (h) dermoid cysts. Cysts are met with in the ovary which come under none of the definitions just given, viz., the so- called compound multilocular cysts, which con- stitute the well-known formidable cystic disease of the ovary, and sometimes produce tumours of immense size. In these the originally simple primary cyst appears to become complicated by the formation in its walls of secondary cysts, which may encroach upon or project into the primary. Again there may be papillary growths starting from the inner wall of the primary cyst, which either fill it up, or by fusion enclose spaces, which become secondary cysts. Very com- plicated structures thus result. The contents may vary in consistence and colour, from clear, pale, albuminous liquid to gelatinous matter, and 326 may be stained through haemorrhage, or purulent through inflammation. The origin of these struc- tures, which have no precise parallel in other parts of the body, is extremely obscure. It is not even certain whether the primary cysts commence, as might seem prima facie highly probable, in the Graafian follicles ; hut they are plainly due to an error of development, pcssibly beginning in early intra-uterine life, and are not set up by any external causes. The presence of a tubular f land-tissue, such as is found in the rudimentary, ut not in the perfect ovary, confirms this view, by throwing cy'st-formation back into an early stage in the development of the organ. In another, but rarer form of cystic disease of the ovary', equally due to an error of develop- ment, and sometimes congenital, the whole organ is found converted into a mass of small cysts, with no striking inequality of size. This variety resembles one form of cystic disease in the testicle and kidney. Dermoid cysts are those containing seba- ceous matter, and which are lined by a layer of flat cells resembling epidermis. The wall may be complicated with connective tissue, forming papillae resembling those of true skin, and may contain hairs, sebaceous glands, either in con- nection with them or unattached, and sudori- parous glands. The accumulation of fatty matter within the cysts is doubtless the result of the continuous activity of the sebaceous glands, the products of which cannot escape. Large masses of hair may also be found, from con- tinuous growth, and there are often numerous detached epidermic scales. Such a cyst has only the characters of a portion of skin, which might be imagined invested and included by the growth of the surrounding parts in an early stage of development — an explanation formerly' entertained. These simple dermoid cysts are sometimes complicated by containing teeth, it may be in very large numbers ( dentigerous cysts), but since teeth may also be regarded as cutaneous products, the cyst may still have originated in the skin. This explanation no longer holds, however, when masses of bone are found, sometimes serving for the attachment of teeth, sometimes separate ; as well as other tissues, e.g. nervous tissue and striated muscle. Cysts with this variety of contents have been called proli- ferative. Dermoid, dentigerous, and proliferative cysts appear to be always congenital structures, but may show further growth and development in after-life. At least two-thirds of the known cases have occurred in the ovaries. Next to these organs, the testicles are the most frequent seat, but these cysts have been also found in other parts of the body-cavity, in the medias- tinum, lung, and even within the skull. The origin of these growths is extremely obscure ; but it is desirable to reject entirely the hypothesis that a mixod tumour of this kind can be tho remains of an undeveloped foetus included in the perfect individual ; a hypothesis rendered improbable by the extreme irregularity of the tissues produced, the teeth, for instance, some- times numbering one hundred or more. It would rather appear as if a portion of embryonic tissue, from the uppor and middle germinal 326 CYSTS. layers, became misplaced at an early period of development. 6. Parasitic Cysts. — Several parasitic ani- mals infesting the human body may appear in an encysted form, and may resemble in appearance true pathological cysts. The commonest, the larval form of Tenia echinococcus , or hydatid cyst, is known by its laminated -wall, and by containing a fluid which is not albuminous, but holds in solution sodium chloride. Cysticercus cellulose has a transparent wall and clear contents. The other encysted parasites are cither very small, as Trichina spiralis, or unim- portant. , Contents op Cysts.— The serous cysts and hygromata contain an albuminous fluid like that of serous cavities, which may hold enough fibri- DEATH, MODES OE. nogenous material to coagulate spontaneously Leucocytes may also be present. If inflammation be set up, the proportion of albumin and of leuco- cytes becomes greatly increased. In the fluid of mucous cysts mucin is contained; in that of colloid cysts, little-known substances which are allied to gelatin. Sebaceous cysts contain neutral fats — sometimes hard, sometimes fluid, and cholesterin. Both mucous and sebaceous products may harden into concretions, and even become calcareous. In renal cysts urea has been found ; in biliary cysts, bile-pigment; and in general the products of special secretion may be found in cases of retention, at least in early stages, but if retention last too long, special secretion may cease. Various exceptional contents have beer, already enumerated. J, F. Payne. D DACTYLITIS (ScIktuAos, a finger). — A term meaning inflammation of the finger. It is ap- plied to syphilis and struma of that organ, as in the terms dactylitis syphilitica, and dactylitis strumosa. DAWDRITF, or Dandruff (from two Saxon words signifying itchiness and foulness). — Synon. : Furfur; Scurf of the Head. — DandrifF is met with in pityriasis, chronic eczema, and lepra vulgaris or psoriasis of the scalp. DANDY TEVER. — A synonym for Dengue. See Dengue. DARTRE (Fr.). — This term is the French equivalent of the word tetter, and is applied to a variety of cutaneous diseases, without strict limi- tation. DA VOS, in North Engadine, Switzerland. A dry, cold, bracing, winter-climate. Altitude, 5,177 feet. Season, October to March. Winds, N.E. and S. Sea Climate, Treatment of Dis- ease by. DAY-BLINDNESS. — A disorderof vision, characterised by the patient being unable to see during the day : also called Nyctalopia. See Vision, Disorders of. DEAFNESS. — Loss of the sense of hearing. See Ear, Diseases of, and Hearing, Disorders of. DEATH, Modes of. — The proximato causes of death, whether resulting from natural decay, disease, or violence, may be reduced in ultimate analysis to two, namely, first, cessation of the cir- culation; and, second, cessation of respiration. On the continuance of these functions, and par- ticularly of the former (if specialisation is pos- sible where all are essential) life of the body as i whole, or of the individual tissues and organs, depends. These functions may cease from causes directly operating on their mechanism, but they may also be brought to a standstill by causes operating indirectly through the nerve-centres which regulate them. Hence it is usual, in accordance with Bichat’s classification, to de- scribe this as a third mode of death ; so that we speak of death beginning at the heart, death beginning at the lungs, and death beginning at the head. This classification is convenient ; for though death beginning at the head is, in realitv, death from failure of the respiration or circula- tion, or of both, through paralysis of the vital nerve-centres, yet the affection of the nervous system is the primary fact, and the phenomena are sufficiently distinct and characteristic to require separate consideration. It must, how- ever, always be borne in mind that, owing to the interdependence of all the vital functions, there is no such sharp line of demarcation, in reality, as we, for convenience’ sake, make in theory be- tween the various modes of death. I. Death from failure of the Circulation. — This may be (1) sudden, as in syncope and shock ; or (2) gradual, as in asthenia. (1) Sudden failure of the Circulation. — As the circulation of the blood depends on the differ- ence in the pressure in the arteries and veins, the circulation will be brought to a standstill by any cause which annihilates, or very greatly lowers, this differential pressure. The cause may- be in the heart, or in the vessels, or in both. («) In the heart. As the action of the heart is the chief factor in the maintenance of arte- rial tension, any organic or structural disease of the heart, rendering it incapable of propelling its contents into the arterial system, will natu- rally result in cessation of the circulation and death. Under this general head are to be classed all diseases of the heart and its annexes But apart from structural disease, the heart may suddenly be made to cease through nervous DEATH, MODES OF. influence. The heart may be inhibited, or be made to cease finally and for ever either by central causes, such as violent emotion, or a blow on the head ; or by reflex inhibition, as in the case of a violent blow on the epigastrium, or sudden irritation of the sensory nerves of the. stomach, as in corrosive poisoning, and even in the ingestion of a large draught of cold water when the system is overheated. Death from sudden cessation of the heart’s action is death from syncope. Momentary ces- sation of the heart’s action is transient syncope or fainting. There is sudden loss of conscious- ness, due mainly to the cessation of pressure in, and anaemia of the cerebral centres. (Z>) In the vessels. Rapid fall of the blood- pressure, and cessation of the circulation, will naturally be brought about by rupture of the vessels, either from injury or disease, causing death by haemorrhage. But besides actual rupture of the vessels, the vascular area may in certain conditions become so en- larged or dilated that we may practically have death from haemorrhage without any loss of blood externally. This is what we observe in deatli from shock or collapse. In certain condi- tions, such as that resulting from blows on the abdomen, the vascular area of the abdomen and viscera may, become so dilated as practically to retain almost the entire volume of blood in the body. Hence, even though the heart may be acting, yet the circulation throughout the body generally, and especially in the extremities and superficially, is practically nil. The individual may, however, retain his con- sciousness, and thus he differs from a patient in a state of syncope. But very frequently in cases of blows on the abdomen, there is not merely reflex dilatation of the abdominal vessels, but also reflex inhibition, for a time at least, of the heart, so that we have syncope and shock co-existing. But the symptoms of syncope may pass off, leaving those of shock still remaining. Shock, like syncope, may be transient or fatal. (2) Gradual failure of the Circulation . — This constitutes death from asthenia. This is the natural termination of life, and it is also the mode of death after wasting and exhausting diseases, cold, starvation, &c. The vital powers fade gradually, while consciousness may bo re- tained up to the last moment. II. Death, from failure of the Respiration. — The various ways in wh eh the function of respiration may be interrupted, and the pheno- mena consequent thereon, have been described under the head of AsrHYxiA, to which article reference may be made. III. Death from paralysis of the vital nerve-centres — Coma. — As already remarked, death beginning at the head ends by paralysing respiration and circulation. The nerve-centres situated above the medulla and poos are not essential to life except in so far as animal life is concerned, and the possibility of adaptation to surroundings. Diseases of the brain, however, are liable to prove fatal by indirect action on the medulla and pons through pressure, exten- sion of inflammation, and the like. Certain poisons also, whether introduced from without, — such as opium and narcotics generally, — or DEATH, SIGNS OF. 327 arising within, owing to the non-elimination of waste products, as in uraemia, affect the nerve- centres, both cerebral and spinal, and not only produce unconsciousness or coma, but also paralyse the respiratory and cardiac centres. In death arising in this manner, the indivi- dual lies unconscious, reflex action becomes abolished, and the breathing becomes stertorous and ultimately ceases, death occurringquietly or in convulsions. In death from coma, in addition to the usual phenomena of asphyxia, there in, as » rule, more or less marked congestion of the cere- bral and spinal centres. D. F eerier. DEATH, Signs of. — It is not always easy to determine when the spark of life has bocome finally extinguished. From the fear of being buried alive, which prevails more abroad than in this country, some infallible criterion of death, capable of being applied by unskilled persons, has been considered a desideratum, and valuable prizes have been offered for such a discovery. The conditions most resembling actual deatli are syncope, asphyxia, and trance, particularly the last. We cannot, however, say that any infallible criterion applicable by the vulgar has been discovered, and we do not rely exclusively on any one sign, but combine several. The most reliable sign of death is proof of cessation of the heart’s action. This, however, is net to be inferred from mere pulselessness, for the heart may still be beating, and resuscitation may be possible, when no pulse is to be felt in the arteries by ordinary manipulation. The use of the stethoscope is necessary, implying, of course, technical skill. Though, according to Rayer, the heart cannot cease to beat for more than seven seconds without death, yet, consider- ing the very slow and feeble action of the heart (8 to 10 beats per minute) in hybernating animals, which normally have a pulse of 80 to 90 per minute, it is well to regard a similar conditior as possible in man, and to spend in doubtful eases some minutes, up to half an hour, ir auscultation. The so-called cases of life con- tinuing notwithstanding cessation of the circu- lation, as that of Colonel Townsend, or of the Indian Fakirs, are to be set down as altogether apocryphal, and not scientifically investigated. To enable unskilled persons to determine whether the circulation continues or not, Magnus recommends the application of a tight ligature on a finger or toe. If the circulation has quite ceased, no change in colour is produced; but if circulation continues, however feebly, the ex- tremity, in course of a longer or shorter period, assumes a livid tint from strangulation of the venous flow, while a ring of arterial anaemia is observable at the point ligatured. Cessation of the heart’s action, if absolutely established, renders other indications unneces- sary. As accessories they are useful, but the following signs are none of them individually conclusive taken alone. The first is cessation of respiration. Respiration may not be very obvious, and yet it may be going on. The popu- lar methods of holding a cold mirror before the mouth and nostrils, and looking for indications of moisture ; placing a flock of cotton wool on the lips to ascertain whether air-currents exist, 328 DEATH, and placing a cup c.f water on the chest, and observing whether the reflection on its surface moves or remains still, are all well adapted for the purpose in view. With the cessation of the circulation and vital turgor, the skin becomes ashy pale, and the tissues lose their elasticity. The eyeball becomes less tense, and the cornea becomes opaque. The pupils cease to react to light ; and there is no vital reaction on the application of irritants to the ckin. Though the body is dead as a whole, certain parts may continue to retain their in- dependent vitality after somatic death. This is seen in the muscles, which may retain their electrical contractility from two to three hours after death. The existence of electrical con- tractility of the muscles in a body supposed to be dead, indicates life, or death within two or three hours, according to M. Eosenthal. The subsequent changes which occur in the dead body not only indicate the fact of death, but aid in fixing the probable period at which death occurred. These are the following: — (1) The cooling of the body. — The body after death, except under certain special circumstances, as in fatal cases of cholera and yellow fever, ceases to be a source of heat-production, and therefore is to be looked upon as an inert mass possessed of a higher temperature than the average medium, which parts with its heat ac- cording to certain physical laws. The superficial coldness of collapse, which is due to cessation of the peripheral circulation, must not be mistaken for the cadaveric coldness, for there is still an ■amount, of internal heat which has to be parted with, and the body, cold to the touch before leath, may after death rise in temperature, as the internal heat radiates. It is impossible to describe here in detail all the circumstances which modify the rate of cooling of the body, but it may be said in general that all circumstances which favour radiation, convection, and con- duction of heat in inorganic bodies are equally applicable here, while the opposite conditions retard. Therefore a thick coating of adipose tissue, clothing, &c., retard cooling. The exact thermometric observations of Drs. Wilks and Taylor show that at an average temperature, and without clothing, a dead body cools at the rate of about 1° Fahr. per hour. (2) Hypostasis. — After death the blood gravi- tates to the most dependent parts, both ex- ternally and internally, giving rise to livid dis- colourations, termed hypostases. These are liable to be confounded with ecchymoses or extrava- sations externally, and with the results of con- gestion and inflammation in the internal viscera. They differ from ecchymoses in the fact that the blood is not extravasated into the tissues, but still contained in the vessels, as may be shown by an incision into the skin. So long as the blood remains fluid, these discolourations may be caused to disappear if the position of the body be reversed ; they will again form in the parts which are now the most dependent. They usually occur in from eight to ten hours after death. (3) Rigor mortis. — After death the muscles Keeome stiff, giving rise to rigor mortis or cadaveric rigidity. It is due to coagulation of SIGNS OF. the muscle-plasma. This rigidity attacks the muscles usually in a certain definite order, be- ginning in the muscles of the neck and face, and gradually extending from above downwards. It gives way to putrefaction in the same order, so that while the upper parts of the body may be flaccid, the legs may be found rigid. It can only be overcome by tearing the tissues, and if overcome it does not return. In this it differs from cataleptic rigidity. A certain amount of mobility is still observable at the joints. In this it is unlike the stiffness of freezing, in which all the parts are equally rigid, and crackle if beDt. The period of the occurrence of rigidity, and the length of its endurance, are extremely variable, so that no definite practical rules can be laid down. It may be said generally, however, that the greater the store of mus- cular energy at the time of death, the longer it is before rigidity sets in. and the longer it lasts. On the contrary, the greater the ex- haustion, the sooner rigidity sets in,andthe sooner it disappears. Hence rigidity is longer in ap- pearing in subjects dying suddenly in full mus- cular vigour, than in those dying from exhans tiou. As a rule, a period of relaxation intervenes between death aDdthe occurrence of rigidity, bnt in certain cases the last muscular contraction seems to pass directly into the rigidity of death. This is seen more particularly in death during great nervous excitement, as in soldiers in the field of battle, or in suicides. The same is said to occur also in death from strychnia-poisoning and in death by lightning. Bigidity may therefore occur immediately on death or within a few hours. It has never been observed to be delayed beyond a day after death. It may last from so short a time as scarcely to be perceptible, up to a week or more. (4) Putrefaction. — After death the tissues un- dergo changes in colour, consistence, &e., by which they arc ultimately resolved into their simple elements, included under the general term putre- faction. Putrefaction, however, may occur locally during life, and general septic changes may occur to some extent before death. The term, however, is not generally applied until the changes are clearly perceptible in alteration of colour, consistence, and smell. The first external sign is a greenish discolouration of the abdomen. Internally the mucous membrane of the larynx and trachea is the first to exhibit change in colour and consistence. The less compact tissues putrefy first, the fibrous tissues resist longer, and the compact tissue of the uterus resists longest of all. In process of time, however, the soft tissues become entirely disintegrated and the skeleton is exposed and gradually falls to pieces. The rate of putrefaction is very variable, de- pending partly on the state of the body itself, but mainly on external conditions as to tempera- ture, moisture, and exposure. A combination of high temperature, moisture, and free exposure, are the most favourable conditions for rapid putrefac- tion. A high temperature alone without moisture tends to dry the tissues, and thus to produce mum- mification, instead of colliquative putrefaction. Moisture alone, as when a body lies in water or moist earth, tends to produce a saponification of the tissues, more particularly the fatty, with tie DEATH, SIGNS OF. formation of a substance termed adipocere {see Abipocere). The course of putrefaction can be stopped by antiseptics, as in embalming, and in certain cases of poisoning, as with arsenic, as also by freezing. Putrefaction is more rapid in air than in water, and least rapid in earth. Under ordinary circumstances and average temperatures, signs of putrefaction are clearly visible on the third day after death, commencing with the green hue of the abdomen. Many months elapse before the soft tissues become entirely disintegrated. The uterus has been found fit for judicial examination as long as nine months after death, where no antiseptics had been employed. When such has been the case, however, there is practically no limit to the period of preservation — witness the Egyptian mummies. There is still much to be learnt respecting putrefaction, and it is unsafe to lay down dog- matic rules as to how far putrefactive changes shall have advanced at a given time, for even under apparently similar conditions the most extraordinary divergences have been recorded. D. Fkrrier. DEBILITY {debilis, feeble). Synon.: Feeble- ness; Weakness; Asthenia; Fr. Faiblesse ; Ger. Schwdchc. Definition. — The body or any of its organs are said to be in a state of debility when their vital functions are discharged with less than the normal vigour, being reduced in the amount of activity that they display, and of work that they can accomplish. The term debility is also em- ployed in a somewhat different sense in the case of constitutional weakness of an organ, to convey the notion of vulnerability or predisposition to disease. In this acceptation, ‘ pulmonary de- bility,’ for example, signifies a peculiarly delicate ‘ build ’ of the lungs, which renders them more than ordinarily liable to succumb to the causes of disease. ^Etiology. — Debility is frequently constitu- tional and inherited; but it is more often de- veloped after birth. It is most commonly due to impaired nutrition, whether this be prolonged and moderate, as in defective hygiene or chronic illness, or, on the other hand, rapid and extreme, as in acute disease. Another frequent cause of debility is abuse of the affected organ. Over- use of any part leads to fatigue, and if frequently repeated to exhaustion, the chief feature of which is extreme debility, as in cases of sustained mental exertion or of repeated strain of the heart. On the contrary, an organ may become feeble from want of exercise. Paralysed muscles furnish the best examples of this condition, but the same may be seen in all organs after unnatural rest. Symptoms. — Tho natural ability of the or- gans to perform their functions varies extremely with sox, age, previous exercise, and many other circumstances. Debility, or the loss of this functional power, is therefore frequently ill-defined; and, wdien unquestionably present, may vary greatly in different cases, from a con- dition in which fatigue comes on only somewhat earlior than usual, as in muscular debility, to a state in which the slight est exertion may ex- DECUBITUS. 329 haust the whole of the vital energy and the functional life of the part may cease — as is seen in the cardiac asthenia of acute fevers, and less markedly in certain chronic diseases, such as idiopathic anaemia and Addison’s Disease. Debility may be general , affecting the whole body ; or local, individual organs only being involved. Speaking generally, the symptoms of debility of an organ may bo said to be chiefly two. These are, first, increased irritability, or an unnatural readiness of the part to respond to stimulation; and, secondly, a tendency to un- timely exhaustion. The phenomena of irrita- bility and exhaustion naturally vary with tho organ involved. The symptoms of muscular asthenia are few and simple; those of digestive feebleness are more complex ; and in debility of the nervous system the whole of the mental processes, as well as the functions of organic life, may be involved. For a specific account of the phenomena of each of these cases, and of debility of other parts, the reader is referred to the articles upon diseases of the several organs. Diagnosis. — Debility pure and simple is as a rule easily distinguished from disease by the absence of all evidence of organic alteration, and especially of physical signs of anatomical change. It is more difficult to separate debility from dis- order or derangement, but careful observation will generally determine in the case of pure debility that the functions are normally discharged as long as the demands made upon them are not excessive. Prognosis. — Debility due to acute disease ma.y, in the absence of complications, be expected to disappear during convalescence. If the cause have been more chronic, and be less easily removed, recovery will certainly be more slow and less satisfactory. The prognosis of inherited con- stitutional debility, as regards its disappearance, is nearly always unfavourable. Treatment. — Debility must be treated accord- ing to its cause. If nutrition have failed, it must be restored as far as possible; and until this can be done, stimulants and suitable tonics are indicated — especially in the case of acute disease. Rest is of the first importance in most instances; and it is frequently alone sufficient to restore the vital force. In a few cases, how ever, the opposite line of treatment must be followed, as in muscular debility from indo- lence or in some forms of paralysis. Where the vital activity is low from constitutional defect, age, or sex, the condition may not be remediable ; and the treatment of such cases is chiefly prophylactic. The principal indica- tion then is to secure the subject of debility against exposure to damaging influences. J. Mitchell Brtjcb. DECLINE {declino, I decline). — A popular name for any wasting disease; it is especially associated with pulmonary consumption. Tho word is also applied to the period in the course of a disease when the symptoms are abating ; and likewise to the time of life when the physical and mental powers are failing. DECUBITUS (de, down, and cambo, I lie). — The lying posture. See Posture. 330 DEFECATION, DISORDERS OF. DEFECATION, Disorders of. — On the descent of the faeces, •which accumulate in the sigmoid flexure of the colon, into the rectum, the associated movements necessary for their expulsion are excited. These movements are chiefly involuntary, though influenced and con- trolled by the will. Some of the more important difficulties in- terfering with the actions of defecation arise from disorders in the nervoussystem, by which the movements are excited and directed. In injuries and diseases of the brain or cord, the control of volition, especially its influence over the sphinc- ters, is annihilated, whilst the excito-motory move- ments depending on the spinal cord continue. In these cases the actions of defecation take place only when the need of expulsion arises without any power of the patient to induce or restrain them. In injuries destroying the lower part of the spinal cord, the feces escape in- voluntarily in varying quantities and at all times. Serious troubles in defecation may also arise from excessive as well as from weak- ened action of the muscles concerned in this function. The sphincter may he irritable or subject to spasm, and resist too forcibly the ex- pulsive actions of defecation (see Anus, Diseases of) ; or the muscular fibres of the rectum may lose their tone, be defective in power, and inca- pable of properly extruding the feces. Patients thus situated are often obliged, when at. stool, to use the finger to dislodge masses retained in the weakened bowel. An atonic condition of the rectum usually arises from over-distension. It may bo produced by too free and frequent use of enemata, the quantity injected being so large as to dilate the bowel and impair the power of its muscular coat. This atonic state of the bowel is apt to give rise to fecal accumulations. Cases of this kind are not uncommon, yet the nature of the affection is liable to be overlooked. The rectum may become gradually dilated and blocked up by a collection of hard dry feces, which the patient has not the power to expel, being unable from loss of tone in the distended bowel to overcome the resistance of the sphincter to tho passage of so great a body. Some indu- rated lumps from the sacs of the colon, on reaching the rectum, perhaps coalesce so as to form a large mass.; or a quantity accumulated in the sigmoid flexure, on descending into the lower bowel, becomes impacted there. In several instances a plum-stone has been found in the centre of the mass. Such a collection gives rise to considerable distress, producing constipation, a sensation cf weight and fulness in the rectum, tenesmus, and forcing pains which women liken to those of labour. In cases of some duration, where the hardened feces do not quite obstruct the passage, they excite irritation and a mucous discharge, which, mixing with recent feculent matter passing over the lump, causes the case to be mistaken for diarrhoea. Injections have no effect in softening the indurated mass : they act only on the surface, aud return immediately, there being no room for their lodgment in the bowel. The practitioner on passing his linger finds the rectum blocked up with a large lump, which feels almost as hard as a stone. In such cases, the only mode of giving relief is by DEFORMITIES OF THE CHEST, mechanical interference. The mass requires to be broken up and scooped out. After the breaking up and extraction of the larger portions, injec- tions of soap and water will be sufficient for tho removal of the remainder. The persons most subject to these troubles are those enfeebled by age or disease, especially women. They may also occur in infants who have been operated on for im- perforate anus, when the artificial aperture con- tracts or is left too small for tho free passage of the feces. In these cases the distension of the bowel is sometimes excessive, and its expulsive functions are seriously impaired and weakened See Faeces and Constipation. T. B. Cublino DEFERVESCENCE (de, down, and fir- vesco, I grow hot). — The decline of fever, charac- terised by a fall of temperature and of pulse, and by other phenomena. See Fevee. DEFORMITIES. — See Malformations. DEFORMITIES OF THE CHEST.— Under this head are included all deviations in shape from the normal chest. Deviations from the shape of the typical thorax are appreciable by careful physical examination. Of the various methods employed for this pur- pose, by far the most valuable are inspection and mensuration. Although in some few cases it may be important to determine the exact amount of deformity by mensuration, there are very few deviations in shape or size of the thorax, the degree of which cannot he sufficiently estimated for clinical purposes by the eye and hand, without the aid of any special instruments for measuring. Deformities of the chest may he due'either to abnormity of the parietes ; or to disease of internal structures. Description. — Deviations from the form or size of the typical thorax may he either general or local-, i.e. the abnormity may involve the whole thorax, or a part only. I. General Deformities. — 1. General Dimi- nution . — The chest may be too small — that is, diminished in all its diameters without being in other respects deformed. Diminution of the thorax simultaneously and uniformly in its antero-posterior and lateral diameters is effected mechanically by an increase in the obliquity of the ribs. The smaller the chest (having re- gard to the height of the person) the more obliquely are the ribs arranged, and the more acute the angle formed between each of the true ribs (excepting the first) and its cartilage. The intercostal spaces of the true ribs arc widened about the junction of the ribs with their carti- lages, and at the same time the ribs posteriorly are approximated more closely to each other, the closeness of the approximation being in pro- portion to the diminution in the size of the thorax. The vertical diameter of the thorax is lessened by an increase in the height of the arch of the diaphragm. The very oblique posi- tion of the false ribs, and the height to which the diaphragm rises into the chest, cause several of the false ribs to lie in contact with the dia- phragm, and thus no portion of lung is under these ribs. They are, practically speaking, no longer part of the chest-walls. The costal angles are diminished in proport i or. DEFORMITIES fc the diminution of the size of the thorax, i.e. to the obliquity of the ribs. The obliquity of the ribs also causes the shoulders and the sternal ends of the clavicles to droop, and at the same time to incline forwards; the upper part of the scapula is carried by the shoulder forward, the inferior tilted backward. General and sym- metrical diminution in the size of the thorax has one and only one cause, namely, small size of the lungs. Small lungs may be congenital, i.e. due to original conformation ; or the consequence of atrophic degenerative changes incident to age. In both these cases the lungs are, in relation to the length of the ribs, disproportionately small, and as a necessary consequence, the relatively too long ribs are arranged more obliquely than they are in a well-formed chest, and the dia- phragm is pushed by the abdominal organs higher into the thorax. When the small size of the lungs is due to atrophy, the supra-clavieular fossae are deepened and the vertical diameter of the chest proportionately diminished. In ad- vanced life the congenitally small lungs are frequently reduced still further in size by tha supervention of atrophous emphysema. The congenitally small lungs and the consequently small chest is one of the characteristics of tuber- culosis, i.e. of that congenital organization in which tubercle is likely in subsequent periods of life to occur. Atrophous emphysema is especi- ally common in those who have either manifested symptoms of tubercle in their youth, or belong to tubercular families. It is the congenitally small lungs of childhood which are prone to become -the seat of tubercle in youth, and the subjects of atrophous emphysema in old age. 2. General Enlargement . — The thorax may be too large, increased in all its diameters, without being otherwise deformed. It is simply bigger than it should be, having regard to the height of the subject. When the thorax is abnormally large, the ribs, instead of being more obliquely situated than natural, as they are in the small thorax, are placed more horizontally than they are in the normal thorax. The angle formed between each rib and its cartilage is greater than in health; while the intercostal spaces, especially the lower, are widened, and the ribs less closely approxi- mated, the arch of the diaphragm is lessened in depth, and a considerable mass of lung lies under the lower false ribs, between them and the diaphragm. The chest is increased in all its diameters. The shoulders are raised. The costal angles are greater than natural. Increase in the size of the whole thorax has but one cause, viz., increase in the size of the lungs. Increase in the size of the lungs generally, and pretty uniformly, is the consequence of disease, and of one disease only, viz., large-lunged or hy- pertrophous emphysema. When the increase in size of the thorax attending large-lunged or hy- pertrophous emphysema is moderate in degree, the increase in its size is effected by the altered position of the ribs ; but when the lung-disease is extreme, then a certain amount of the enlarge- ment is caused by pressure on the inside of the chest during the violent expiratory efforts of severe cough. 3. Irregular General Deformities . — In the de- OF THE CHEST. S31 formities above described the antero-posterior and the lateral diameters retain more or less per- fectly their normal proportion — both are in- creased or both are diminished; in the formoi case the chest is on the whole more barrel-shaped than natural, but the deviation from the normal form is not considerable. If, however, the chest- walls are from any cause unduly soft or unduly rigid, then the actually or relatively soft portions will recede during each inspiratory act, and local deformity of the chest follows. The diameter of the chest at the part where the absolutely or relatively soft portion of the parietes is placed will be diminished. The special deformities of the chest which result are due, therefore, prima- rily to the state of the parietes, and are not, as those previously described, secondary to con- ditions of the lungs themselves. a. Diminution in the antero-posterior diameter of the thorax . — The antero-posterior diameter of the thorax is frequently loss than that of the normal thorax, the lateral diameter being pro- portionately increased. The chest has an oval form — it is flattened from before backwards. The thorax flattened from before backwards is usually associated with small lungs, but the mechanical cause of the flattened form is the want of full resisting power in the ribs and considerable strength in the cartilages. These conditions of thorax arc common in the subjects of tuberculosis. The flattening of the thorax is increased by all impediments to the free passage of air through the air-tubes. In some children suffering from even slight bronchial catarrh, the flattening of the chest is seen to be increased at each inspira- tion ; and if the impediment to the entrance of the air to the pulmonary tissue be constant or extreme, not only is the flattening increased at each inspiration, but the sternum is also depressed, especially at its lower half below the level of the costal cartilages, and thus the antero-posterior diameter of the thorax is still further diminished in the median line. b. Increase in the antero-posterior diameter of the thorax . — In rickets the cartilages of the ribs are very firm, whilstthe ribs themselves are softer than natural, and especially so near to their enlarged growing ends — the softest part of the ribs; that is to say, just outside the nodule formed at the spot where cartilage is in the process of growing into bone. The consequence of the extreme softness of the ribs at this part is that at each inspiration the weight of the atmosphere presses inward the softest part of the ribs, while the sternum is borne forward by the firm cartilages. The result is great increase in the antero-posterior diameter of the thorax, and diminution of the lateral diameter at the part corresponding to the softest part of the ribs. The depression of the softest part of each rib is increased by the want of resilience of the softened structures. A groove is thus formed in the thoracic walls just posterior to the rickety nodules ; and this groove being deepened at each inspiration, the part of the lung adjacent is compressed in place of being expanded during the inspiratory act. At the same time, in consequence of the 1 cartilages and sternum being thrust forward at DEFORMITIES OF THE CHEST. 332 each inspiration, air enters with undue force into the lung-tissue subjacent to these parts. The consequence of the excessive expansion of the anterior part of the lung is vesicular emphy- sema, and the recession during inspiration of the softened and imperfectly resilient and therefore deeply grooved part of the chest-wall leads to col- lapse of the subjacent pulmonary tissue ; and, as the effect of these two conditions, the lungs, when the chest is opened, present a vertical groove corresponding to the groove in the chest-walls. The antero-posterior diameter of the thorax in rickets is still further increased by the curvation of the spine. The muscles are weak, the child is unable to sit upright, that is to say it is unable, in consequence of the weakness of its muscles, to support the weight of the upper part of its body, the bones of the spine are, in common with the other bones of the body, softened, and the result of the weakness of the muscles and the softness of the vertebrae is the dorsal bow. When deformity of the chest is- the result of undue softness of the chest-walls, the position of the solid organs subjacent to the parietes is fre- quently perceptible to the eye. The liver supports the lower ribs on the right side, the heart supports the ribs and cartilages over it on the left side, and thus these organs cause local prominence of the chest-walls without being themselves in any way abnormal. In the so-called 'pigeon-breast , the antero- posterior diameter of the thorax is increased in the middle line, the lungs are small, the ribs and cartilages are firm, the ribs are placed obliquely and the chest-walls are flattened later- ally, and the sternum as a consequence is thrust forwards ; thus the chest in the pigeon-breasted has a triangular form, the apex of the triangle being the sternum. Impediment to the free entrance of air into the lower lobes of the lungs will favour the production of and increase the de- formity. The chests of children who suffer from repeated attacks of bronchitis, but are otherwise healthy, are commonly the subjects of this de- formity, while there is increased expansion and subsequent enlargement of the upper part of the chest, the lungs being more or less collapsed below and emphysematous above. c. Transverse anterior constriction of the lower part of the thorax is the consequence of small size of the lung, or of imperfect inspiratory ex- pansion, permanent or frequently recurring in youth. In these cases the lower ribs are little used in respiration, while below they are borne outwards or supported by the liver, stomach, and spleen, and thus an imperfectly formed trans- verse depression is produced in the front of the chest on a level with the base of the ensiform cartilage. The deviations from the type of the normal thorax hitherto described are bilateral, and more or less symmetrical. II. — Local, unsymmetrical, and unilateral deformities. — 1. Fulness of the supraclavicular region . — The supraclavicular region, correspond- ing to the portion of the thoracic cavity above the clavicle, may be fuller than natural. The causes of this local bulging are — a. Develop- ment of adipose and cellular tissue, b. Dis- tension of the deep-seated veins, c. Large-lung emphysema, in which disease there is occa- sionally distension of that part of the cavity of the thorax which lies above the level of the clavicle ; the distension is due to pressure on the inside of this part of the thoracic cavity ; air being forced violently into this part of the lung during the powerful expiratory effort of cough. 2. Depression of one supraclavicular fossa is caused by any pathological condition of the apex of the lung which produces diminution of its bulk, e.g. atrophous emphysema, or chronic con- solidation of the apex. 3. Elevation of one shoulder . — Occupation is a common cause of elevation of one shoulder ; thus in clerks, who sit much at the desk, the left shoulder is permanently a little higher than the right, and the upper portion of the spine is slightly curved, the convexity being to the left ; so in those who carry heavyweights on one arm, the opposite shoulder is elevated and the spine curved. Whatever necessitates an increase in the capacity of one side of the thorax causes elevation of the shoulder on the same side : thus, considerable dilatation of the heart, fluid in the pericardium, fluid in the pleura, aneurism of the arch of the aorta or of the innominate, all lead to elevation of the shoulder. The shoulder is depressed and carried forward when, from any cause, the whole or upper part of one side of the chest is diminished in size, e.g. when the apex of the lung is the seat of chronic pneumonia or chronic phthisis! 4. Uniform dilatation of one side of the thorax is due, with one exception, to fluid or air in the pleura ; the exception is those rare cases of encephaloid cancer of the lung, in which the formation of cancer is uniformly diffused through the lung-tissue, and in amount so great that the lung ‘ infiltrated’ with cancer very decidedly ex- ceeds in bulk the healthy lung inflated with ai r by inspiration. In uniform dilatation of one side of the thorax, the shoulder is raised, the ribs are placed more horizontally than on the healthy side, the inter- costal spaces are widened, and the spine slightly curved. When the enlargement is moderate in amount, the increase in capacity is effected by the altered position of the ribs ; but when the increase in size is very considerable, then it is due in part to the pressure exercised by the air, fluid, or cancer-loaded lung on the inner side of the chest-wall. 5. Uniform contraction of one side of the tho rax is the consequence of any pathological con- dition which leads to general and uniform reduc- tion in the size of the lung, e.g. cirrhosis of the lung, infiltrat ed cancer of t he lung, chronic tuber- cular disease of the lung, chronic pneumonia, or the change in the texture of the lung which follows long-continued compression by fluid in the pleura. When the whole of one side of the thorax is reduced in size, the shoulder on that side is depressed, the ribs are placed more obliquely and are more closely approximated than on the opposite side, the intercostal spaces are narrowed, and the spine is curved, often consider- ably, the concavity of the curve being towards the contracted side. DEFORMITIES OF THE CHEST. 6. Lateral curvature of the spine, instead of being the consequence, may be the cause of defor- mity of the thorax : the ribs are then approxi- mated on the side and at the part where the concavity of the curvature is placed, while they are separated and the shoulder raised on the side of the convexity. 7. In angular curvature of the spine the defor- mity of the thorax varies with the seat and the extent of the vertebral disease ; but, speaking generally, it may be said that in angular curva- ture of the spine the antero-posterior diameter of the thorax is increased in proportion to the amount of destruction of the bodies of the ver- tebra, and that the ribs are in a corresponding degree approximated. 8. Extreme depression of the lower part of the sternum is the consequence of softness of the cartilages of the ribs and impediment to the free passage of the air to the pulmonary tissue. This deformity is never congenital, although the subjects of it often affirm it to be so ; it may, however, commence to be formed directly after birth if there be a congenital impediment to the entrance of air into the lungs, e.g. atelec- tasis. The deformity may be the result of direct pressure. In certain occupations pressure has to be exerted on the lower part of the ster- num — thus, some shoemakers use a wooden in- strument which has to be kept in its place by pressure against the lower part of the sternum. For direct pressure to produce this deformity it must have been applied in early youth, while the parts are still flexible, and have been exerted frequently over a long period of time. 9. Congenital deformities of the thorax are few iu number and are due to arrest of develop- ment — for example, cleft sternum, and defective formation of one or more ribs or cartilages. 1 0. Unsymmetrical diminution in size of apart of the thorax is produced by any pathological change which reduces the size of the subjacent part of the lung. All chronic inflammatory or congestive conditions of the apex of the lung, whether primary or the consequence or the con- comitant of the formation of tubercle, are at- tended by diminution of the bulk of the part of the lung which is the seat of the lesion. Con- siderable loss of pulmonary tissue is usually accompanied by falling inwards of the chest-wall over the cavity. 1 The formation of a cavity is almost invariably attended by chronic inflam- matory condensation, and this increases the local depression of the chest-wall. In chronic thick- ening of the pleura, the chest-wall at the part is, by the contraction of the fibrin, drawn inwards, and the lung subjacent to the thickened pleura being condensed, the chest-wall is also forced in during inspiration by atmospheric pressure. Hence, after pleurisy limited in extent it is common to find permanent flattening of the thoracic parietes at the base of the chest on the side affected. In cancerous infiltration of the lung, limited in extent, the lung-tissue is sometimes so much condensed that the bulk of the cancer and lung are less than that of the healthy lung, and the 1 It is said that a very large air-containing cavity may give rise to local bulging. DEGENERATION. 333 I chest-walls as a consequence are flattened over the seat of disease. 11. Unsymmetrical localised bulging. If the ribs are, in relation to the size of the lungs, disproportionately long, and then- cartilages soft, then one or more of the cartilages may be knuckled forwards ; the cartilage, being compressed between the end of the rib and the sternum, bends in an angle outwards. Although the prominence is trifling, it often causes anxiety to parents and its subject. Local deformity of this kind is occasionally the result of repeated lateral compression of the chcst-wall in the ath- letic sports of young boys, e.g. cricket. All the diseases of the chest which are accom- panied by general enlargement of both or one side of the chest, when localised, are attended by local bulging ; thus a common cause of abnormal fulness of the lower part of the left side of the thorax, posteriorly, is emphysema of the corresponding part of the lung ; a moderate amount of fluid in the pleura is attended by ful- ness of the lower part of the chest on the same side. In both these cases the ribs are raised into an abnormally horizontal position ; the chest- walls are not pushed outwards, but the ribs are raised, and the intercostal spaces are to that extent widened. The ribs are put into the posi- tion which gives the greatest capacity to the thoracic cavities containing the fluid or the enlarged lung. Local bulging may be produced by aneurism of the arch of the aorta or of the innominate artery ; by growths, malignant or other, within the chest; by chronic pleurisy with effusion circumscribed by dense false mem- brane ; by hydatids ; or by abscess ; and in all these cases the prominence is due to direct pressure on the inner side of the chest-wall, and to changes in the chest- wall itself. Hypertrophy and dilatation of the heart and fluid in the pericardium are attended by fulness of the pracordial region. The bulging from these diseases is much greater in the child than in the adult. In these cases a little of the ful- ness is produced by a more horizontal arrange- ment of the ribs ; but when the prominence of the pracordial region is at all considerable, it is the result of the pressure exercised by the fluid or by the large and pow-erfully acting heart on the inner surface of the corresponding part of the chest-wall. At the part corresponding to the junction of the first and second bones of the sternum, oppo- site the cartilage of the second rib, the sternum projects forward. This prominence is called the angle of Ludovicus. Any impediment to the free entrance of ah into the lungs may cause depression of the lower part of the sternum ; if the ossification of the sternum is not complete at the junction of the first and second bones, undue prominence of this part is the result. Subsequently a formation of bone takes place at this spot, and increases the prominence. WlLLIAH JENNER. DEGENERATION ( degener , unlike one’s race ; out of kind ). Definition. — The word ‘ degeneration,’ mean- ing etymologically change or deterioration of kind, is used in pathology for any process by DEGENERATION. 834 which a tissue or substance becomes replaced by some other, regarded as less highly organised, less complex in composition, of inferior physio- logical rank, or less suited for* the performance of its original functions. While some change for the worse is thus the essence of degenera- tion, it is of secondary importance by what steps this change is effected. It may be by direct chemical metamorphosis, as of albuminous into fatty material; by infiltration of the tissues with some new material, as in albuminoid de- generation ; or even by substitution of a newly- formed tissue, inferior to the original in organi- sation or in functional efficiency, as in what is called fibroid degeneration. Degeneration is very closely connected with atrophy, since on the one hand it is often caused by imperfect nourishment, and on the other hand may be a stage in progressive wasting; so that it may be difficult to draw the line between the two. Summary. — T he following kinds of degenera- tion may be recognised: — Albuminoid, Fatty, Mucoid or Colloid, Parenchymatous, Calcareous, Pigmentary, and Fibroid, with possibly one or two minor varieties of less moment. The two first - mentioned are described elsewhere ( see Axbuminotd Disease, and Fatty Degeneration). 1. Mucoid or Colloid degeneration is in one sense a physiological process, since it is probably by a partial transformation of the pro- toplasm of epithelial cells into mucin that the secretion of mucus is effected. Mucoid and colloid degeneration are sometimes distinguished. We are unable to recognise any difference except in situation, and this distinc- tion is better expressed in other words. The process consists in the transformation of por- tions, usually albuminous, of the tissues into a semi-transparent homogeneous material, varying in consistency from fluid to a gelatinous solid, and consisting of altered albuminates with vari- able proportions of mucin, a substance allied to albumin, but differing in its entire insolubility in acetic acid, and solubility in alkalies. All masses of gelatinous appearance have not this composition, since the colloid material which fills some ovarian cysts, that of renal cysts, and probably that found in some other cases, is said to contain no mucin. The thyroid gland when enlarged and cystic, as in one form of bronchocele, is a striking instance of colloid degeneration. The enlarged cystic vesicles become filled with colloid material, which plainly results from a transformation of the epithelial elements, and possibly also of some albuminous exudation in the original vesicles. Small masses of colloid material first appear in the cells, which become confluent into homogeneous masses. In colloid cancer a simi- lar process appears to take place, but is rather synchronous with, than subsequent to, the growth of the tumour. The alveolar spaces which in other forms of cancer are filled with cells, here contain colloid material resulting from the metamorphosis of cells, and every transitional stage, from the epithelioid cancer-cell to a homogeneous translucent mass, may often be met with. The stroma is unaffected, and re- mains fibrous. The gelatinous material of colloid cancer is stated to contain more mucin than that of the enlarged thyroid. It is instruc- tive to notice that this form of cancer usually occurs or commences in parts where epithelium is present, which undergoes the mucous trans- formation and secretes mucus, as in the sto- mach and intestines. When colloid or mucoid transformation affects tissues of the connective tissue group, it is the intercellular substance which appears to be chiefly affected. This change is seen in the mucoid softening of car- tilage which sometimes occurs in old age, where the chondrin undergoes chemical change, and the intercellular substance softens into a diffluent or liquid substance containing mucin. The so-called mucous tissue which forms the umbilical cord, and the vitreous body of the eye, as well as certain fee tal structures, consists essentially of a reticulated connective tissue with mucous inter- cellular substance, and the same tissue forms the new growth called myxoma, which may therefore be regarded as formed by mucous transformation of connective tissue. Its cells are quite unaffected by this change, being either fixed stellate connec- tive tissue cells, or migratory lymphoid corpus- cles. This view explains how portions of other tumours, as sarcoma, enchondroma, and lipoma, are often found to have undergone myxomatous degeneration. All these mucoid or colloid sub- stances contain mucin with albuminates. 2. Parenchymatous or Granular degene- ration, also called cloudy swelling, is a peculiar change met with in some epithelial struc- tures, especially liver- and kidney-cells, and muscular tissue, occurring only in the course of some infective febrile diseases, especially typhus, enteric fever, scarlatina, diphtheria, pyaemia, etc. The histological elements are found after death to have lost their transpa- rency, and to be filled with minute granules, so that the general appearance is not unlike that of fatty degeneration. The naked-eye appearance of the organs is also not dissimilar; they are pale, dull, and opaque-looking. This change has been thought to be the precursor of fatty change : but whether this be so or not, it is at once dis- tinguished by the solubility of the granules in acetic acid, and their insolubility in ether. The cause of this degeneration has been asserted to be simply high temperature; still it is not found in all febrile diseases. It has also been regarded as a post-mortem change, which is possible, but still this implies some abnormality in the tissues during life. Another change also occurring in febrile dis- eases is waxy or vitreous degeneration of the voluntary muscles. They are found after death with little or no striation, and the myosin ir- regularly coagulated in lumps. That this is a change occurring after death there can be no doubt.; while it is equally clear that this ab- normal coagulation shows some abnormality cf composition to have existed during life. 3. Calcareous degeneration consists in the deposition of calcareous particles in the elements of a tissue, or in some inflammatory products pre- viously formed. It is more appropriately called calcareous infiltration or d-posit. When ihe normal tissues are thus infiltrated, there is not of necessity any other alteration in the tissues themselves, though the process generally indi- DEGENERATION. catss retardation of the circulation or arrest of tissue-metamorphosis. In the case of inflam- matory products, new-growths, and parasites, as well as in other cases, the calcareous deposit follows on partial necrosis or local death. It is, therefore, if not a degeneration, the consequence or accompaniment of degeneration. See Deposits, Calcareous. 4. Pigmentary degeneration is a name which has been given to the changes produced in a tissue or organ by the deposition or formation of pigment. It is very doubtful whether this should always be described as a degeneration, since this change does not necessarily diminish the vital activity of the part, lower its physio- logical rank, or involve a simpler chemical or anatomical composition. Pigmented tumours do not show less vitality than others, nor is excessive pigmentation of the skin or any organ where pigment normally occurs, neces- sarily an accompaniment of degeneration. On the other hand, the pigmentation of the spleen and liver from intermittent fever, and that which is the consequence of chronic venous con- gestion, are often the accompaniment of fibroid induration, and thus form part of a degenerative process. Pigmentation in general must not, therefore, be identified with pigmentary de- generation. 5. Fibroid degeneration is the name given to a process in which the original tissue becomes replaced by a form of connective tissue. It ia also called fibroid substitution or fibroid change. In the early stages of this process we find the tissues penetrated with numerous cells of the lymphoid type, which become slowly organised into connective tissue — at first of the cytoge- nous form, and rarely very vascular. The in- filtrated lymphoid cells are probably chiefly derived from the blood-vessels ; but some may be, as theory teaches, the descendants of tissue- cells. The process is essentially chronic inter- stitial inflammation ( see Inflammation). Since the final result of the process is that tissue of less physiological value is substituted for the original, the process may be described in general terms as a degeneration, though it is not an actual metamorphosis of tissue. It finally leads to induration, contraction, and partial atrophy. J. F. Payne. DEGLUTITION, Disorders of. — Before describing the disorders of deglutition or swal- lowing. it is necessary to state briefly in what this physiological act consists, and how the process is performed. Physiology of Deglutition. — The act of deglutition is commonly divided into three stages. The first is a voluntary effort, accom- plished by means of the tongue and the muscles of the cheeks and mouth, as far back as the ante- rior arch of the fauces. The second stage is an involuntary act, though certain voluntary muscles are engaged in effecting it ; and it is accomplished by the action of those muscles whose duty it is to retract the tongue, to raise the larynx and close the glottis, to lift the soft palate, to contract tho fauces and bring the tonsils in contact with the bolus of food, to close the posterior nares, and to raise and contract the pharynx. DEGLUTITION, DISORDERS OF. 335 Then the food passes into the oesophagus cr gullet, when the third stage is entered upon ; and as the morsel passes into this tube, a pro- gressive undulatory or peristaltic movement of the gullet is produced, by which the bolus is propelled into the stomach. Definition. — Any condition which interferes with the perfect integrity of this physiological process constitutes a disorder of deglutition. The general term which is commonly applied to this condition is Dysphagia or Deglutitio Irn pedita, as it is sometimes termed. But, in actum fact, such conditions will be found to be dependent for the most part on some other morbid state of the structures immediately concerned in the act of swallowing, or of those in close proximity to them. Yet, although dysphagia must, as a rule, be re- garded merely as a symptom of some more or less serious disorder, still it may be convenient and useful to examine the subject somewhat more in detail than can be done in the consideration of those affections in which it frequently plays so prominent a part. ^Etiology. — All affections of the throat modify in some way the power of swallowing, and render the act of deglutition painful and difficult. Thus: — 1. We meet with it as one of the symptoms in acute catarrh of the pharynx, in tonsillitis, and in ulceration of the throat, which disturbances are dependent upon some alteration in the mucous membrane, the submucous cellu- lar tissue, or the muscular tissue. 2. Similarly, diseases of tho larynx may give rise to disorders of deglutition; such as laryngitis, inflammation of the perichondrium of the cartilages, and laryngeal polypi. 3. Specific diseases, for ex- ample, phthisis, syphilis, cancer, scarlatina, measles, and croup, are another fertile cause of difficulty of swallowing, owing to their affecting the throat in various ways. 4. So also are ner- vous affections, for instance, post-diphtheritic paralysis, hysterical affections, general paralysis of the insane, progressive muscular atrophy, and glosso-laryngeal paralysis. 5. Affections of the salivary glands, such as parotitis, may inter- fere with deglutition. 6. (Esophageal disorders, whether functional, or causing organic obstruc- tion, are important causes of dysphagia. 7. Difficulty of deglutition may result from pressure upon some part of the passage, as by an aneu- rism of the thoracic aorta, a solid tumour, whether malignant or benign, or a retro-pharyn- geal abscess. All these causes, though in differ- ent. degree, offer some impediment to the act of deglutition. Symptoms. — Although difficulty in the act of swallowing is the essential symptom in many and various affections, yet this differs greatly in degree, as well as in the attendant phenomena, according to the pathological condition of the parts involved. Thus, when irritation of any kind is met with in any part of the track through which the bolus of food has to pass, then the act of deglutition is attended merely with more or less pain, which in such cases constitutes the sole difficulty in the process. When, however, the calibre of this portion of the alimentary canal is reduced by disease affecting its own structure, or when it is encroached upon by morbid growths or other disease in its immediate 336 DEGLUTITION, DISORDERS OF. vicinity, a mechanical impediment is set up, which necessitates a certain amount of voluntary effort to accomplish the act. This supplementary aid is usually sufficient to propel the bolus on- wards, and deglutition, though slower than in health, and usually attended with pain, may be successfully performed. It occasionally hap- pens, however, that the obstruction is so great as to prevent the passage of at least the larger portion of the food downwards, and regurgita- tion takes place through the mouth or nostrils. A similar result is brought about when para- lysis affects any portion of tho muscular struc- tures concerned in the act of swallowing, but obviously in a different manner. For example, in post-diphtheritic paralysis, in consequence of the implication of the soft palate and neighbour- ing structures in this loss of power, the food, instead of passing into the gullet, returns through the posterior nares. The dysphagia occasionally observed in hys- terical persons, and which appears to partake of the nature of spasm, differs essentially from those forms already described, in the fact that it is not a constant phenomenon. In addition to those varieties of dysphagia dependent upon morbid conditions of the appara- tus concerned in the act of swallowing, another kind may also be induced by the nature and form of the articles partaken of. Thus, irritant, corrosive, and very hot substances may readily give rise to difficulty in swallowing. In like manner dysphagia of an urgent character is often caused by the impaction of a large bolus of un- masticated food in the (Esophagus. Treatment. — This willmanifestly depend upon the recognition of the cause which gives rise to the impediment in swallowing. Cases of simple catarrh of the mucous membrane of the throat, and those produced by the action of irritant substances generally, yield, after a short inter- val, to the use of bland articles of diet and demulcents, such as olive oil, milk, linseed tea, &e. It must, however, be borne in mind that permanent stricture of the oesophagus may be the result of causes such as those last mentioned. Of course, when abscess is the cause of the dysphagia, the evacuation of its contents will give immediate relief. In that form of dys- phagia dependent upon diminution of the calibre of the oesophagus, the question of its treatment by the use of bougies or stomach-tubes should be considered. See OEsophagus, Diseases of. Tho dysphagia dependent upon specific dis- orders of the larynx, such as that occasioned by phthisis, syphilis, cancer, &c., may often be greatly mitigated by the use of warm medicated sprays of a sedative character, such as bromide of ammonium, chlorine water, or other agents. In cases acknowledging a nervous origin, the treatment must bear reference to the general nervous disorder of which the dysphagia is but a symptom. Thus hysterical dysphagia may be speedily removed by the application of galvanism in the neighbourhood of the oesophagus. Post- diphtheritic dysphagia usually disappears as the health of the patient improves, and is to be treated by the administration of nervine tonics, such as strychnia, iron, and quinine. C. Muirhead. DELHI SORE DELHI SOHE OH BOIL.— Syson. Aleppo Evil; Mycosis Cutis Chronica (V, Carter) ; Lupus Endemicus (Lewis and Cunning- ham) ; Oriental Sore (Fox). Fr . Bouton d Ale-p \ Ger. Beule von Alep. Definition. — An indurated, indolent, and very intractable sore ; papular in the early, encrusted or fungating in the advanced stages ; spreading by ulceration of skin ; single or multiple ; and often occupying extensive surfaces of the exposed parts of the body, such as the face, neck, and extremities. It is capable, if inoculated, of re- producing the disease ; and it also affects dogs and horses. Geographical Distribution. — This disease occurs in India, especially the North-west Pro vinces, Punjab, Cabuland Scinde, Persia, Arabia, Crete, the Sahara of Africa, perhaps China, and doubtless wherever certain peculiar conditions of soil and hot climate co-exist. Though called Delhi boil, it is neither a furunculus, nor is it peculiar to that city. The Scinde boil, the sores of Roorkie, Moultan, Lahore, Meerut, other crowded Indian cities, and Aden, are probably only varieties, if not identical. The same may be said of the Bouton d’Alep, of Biskra, Bus- sorah, Baghdad, and Crete. Slight differences may exist, but essentially they are the same disease. The Yeinan and Cochin China sores are probably varieties, as are other indolent in- durated and intractable sores occurring in per- sons of impaired health, residing in hot and malarious climates, who use certain hard waters, and in whom there is neither syphilitic nor strumous taint. .ZEtiology and Pathology. — Drs. Fleming and Smith, V. Carter, and Lewis and Cunningham give the best account of the disease. Though called a local disease, it is probable that the state of the health has much to do with its production, certain conditions of climate, soil, and especially of drinking water being concerned. Furunculi of a severe and painful though different character are prevalent in hot climates at certain seasons of the year, in enervating and malarious climates like India, especially after the rains, i.c. towards the termination of the most exhausting season, when the vital powers have been depressed during the preceding months, and the functions of the liver and spleen are impaired. The blood, imperfectly elaborated, and not freed from ex- crementitious matter, is then in a condition in which it not only ministers imperfectly to nu- trition, but is prone to fibrinous coagulations, which cause capillary embolism, giving rise to local starvation and death of minute portions of areolar tissue in or under the integument. These result in suppuration, which is set up for the purpose of getting rid of the dead fragment or core. An analogous, though perhaps not pre- cisely similar pathological condition may be con- cerned in the causation of the Delhi sore, and is not incompatible with an otherwise fairly good condition of the general health. Water, soil, food, bites or stings of insects, parasites, insani- tary conditions, such as exist in crowded native cities, have all been charged with causing the disease. Improved hygiene, planting of trees, and change of water, food, and locality, have all been credited with benefit in the treatment of it. The DELHI SORE. fact that this peculiar form of sore manifests itself under similar climatic conditions in other parts of the world, which, it is to be noted, are generally those of the more arid regions, and that it occurs most frequently at the most exhausting season, seems to point to a constitutional state as a pre- disposing cause. The disease is not confined to human beings ; in Delhi it lias been observed that dogs are very liable to be affected, especially in the nose, and this, from the position of the sore, has been ad- duced as strong evidence in favour of the theory that it is due to the presence of a parasitic ovum which finds its way there from the water. In some districts other animals are affected; and it seems probable that the indolent, indurated, and intractable sore that horses are liable to in India, called Bu.rsattie (Rain Sore) is of the same character. Further investigation into the cau- sation and pathology of Delhi boil is needed, especially with reference to the action of drink- ing water, and the nature of the structures that form the essential constituents of the disease. Anatomical Characters. — When the Delhi sore is cut into, yellowish points are seen, con- sisting of minute cellular growths, which have been described by Dr. Smith as the ova of a parasite ( Distoma ), and by others as of vegetable origin, but are probably the result of cell- growth, connected with the hair- and gland- follicles, perhaps an abnormal development of connective-tissue corpuscles, or an imperfect form of granulation. After ulceration has disinte- grated the surface, mycelium or other low forms of organism may be present ; but it is a question if these be the essential cause, and not rather an accident of the disease, introduced from without. Dr. V. Carter refers Delhi boil to a parasitic organism, consisting of spheroids and mycelium, which occupies the distended lymphatic ves- sels in and around the sore, arranged in open and angular meshes, the free ends giving off conidia which multiply and reproduce. Pale, round or stellate granulation-cells are found ; numerous bright orange-tinted particles, arranged as sphe- rical or ovoid groups disseminated throughout the tissues of the tumour. These, it is consi- dered, are the fructification-stage of the fun- gus. Lewis and Cunningham describe lymphoid nucleated cells, the products of a condition which they consider as identical with that of lupus, and which they ascribe to the action of the chemical constituents of certain hard waters. Symptoms. — Delhi sore commences as a small pink and reddish papule, like a mosquito bite, which gradually extends, generally around a hair-follicle as its centre. This is elevated, and after a time desquamates. There is itching and a stinging sense of pain ; on pressure it is somewhat boggy. The progress of the disease is slow, often occupying several weeks, during which time it assumes a semi-transparent ap- pearance, with blood-vessels ramifying near the surfaco. A vesicle then rises, bursts, and gives exit to an ichor which forms a crust ; under ihis, suppuration and ulceration take place and advance until, by the coalescence of several pa- pules and destruction of skin, an indurated sore is formed, which is either crusted over or fun- gates. The sore gradually invades the surrounding 22 DEMENTIA. 337 parts, and destroying the integument, may give rise, especially on the face, to deformity from cicatricial contraction ; and from the irritation and the pain it causes, may, when the number and extent of the sores are large, seriously com- promise the health. An ordinary boil or abra- sion may assume these specific characters. The disease is regarded as contagious, and apparently may be produced by inoculation of the specific cell-matter, though not by the pus which formt on the surface. Treatment. — Preventive. — Cleanliness of per- son, clothing, and habitation, good food, the use of pure drinking water, and careful attention to the sanitary condition of the locality, — avoiding overcrowding and contact with the disease in men or animals, — are the best means of prevent- ing Delhi sore. Curative. — Change of locality, when practic- able ; in some cases early destruction of the sore by the potential or actual cautery; the ap- plication of metallic astringents, iodine, carbolic acid lotion ; pressure ; attention to the state of the health, and any ailment that may be pre- sent; tonics and nutritive diet, and especially change of drinking water ; and change to another climate, — are the most effective measures. In the advanced conditions of the disease similar measures are indicated. The sore, if too extensive to be destroyed, should be dressed with stimulating and astringent applications. Soothing measures are indicated if there is pain. Dlack wash, sulphate and carbolate of zinc, copper, Gurjon oil, and lime water, with change of climate, and the use of tonics, will generally prove efficient. Joseph Eayrer. DELIRIUM ( deliro , I rave). — A derange- ment of consciousness, characterised by inco- herence of thought, and evidenced by various expressions and actions. See • Consciousness. Disorders of. DELIRIUM TREMENS ( delirium tre- mens, trembling delirium). — A form of acute alcoholism, chiefly characterised by delirium and tremors. See Alcoholism. DELUSION (dcludo, I deceive).— A false belief in some fact which almost invariably con- cerns the patient, of the falsity of which he cannot be persuaded, either by his own know- ledge and experience, by the evidence of his senses, or by the declarations of others. Such delusions, when distinguished from merely erroneous judgments upon abstract questions, generally indicate insanity. See Consciousness, Disorders of. DEMENTIA(, I convey). — The act of perspiring. The term is more generally applied to perspiration artificially induced. DIAPHORETICS (Sia. through, and , I convey). Definition. — Remedies which increase the secretion of sweat. When the increase is so great as to cause the perspiration to stand in beads upon the surface, they are usually termed sudorjf.cf. DIAPHORETICS. Enumeration. — The principal diaphoretic measures are — The Vapour Hath, Turkish Bath, and Wet Pack ; AVarm Drinks ; Warm Clothing ; Jaborandi, Pilocarpin ; preparations of Antimony; Ipecacuanha ; Opium and Morphia with their preparations; Sarsaparilla, Guaiacum, Serpen- tary, Sassafras, Senega, Mezereon, Camphor ; Sulphur ; Ammonia and its Carbonate, Acetate, and Citrate ; Alcohol ; Ethers (especially Nitrous Ether); and Chloroform. Action. — The secretion of sweat usually con- sists of two parts, namely, a free supply of blood to the sweat-glands, and the abstraction from it of the materials for sweat by the cells of the gland. These two processes sometimes occur ndependently of each other. In fevers the supply of blood to the glands is abundant, but '.hey do not secrete; and a similar condition is observed in belladonna-poisoning. Belladonna or atropia possesses the power of paralysing the secreting nerves of the sweat-glands, just as it does those of the salivary glands, and thus the skin remains dry, although the cutaneous vessels are much dilated. In collapse the cutaneous glands secrete a cold sweat profuselj-, although tbe supply of blood to them is deficient. The secreting cells appear to be under the influence of nerves, by exciting which secre- tion occurs. The centres for the secreting nerves of the sweat-glands appear to be situated in the spinal cord, and in the medulla oblongata. The.fibres seem to run in the same path as the vaso-motor nerves. The secretory nerves of the sweat-glands may bo excited directly by a stimulation of the nervous trunks in which they run ; and the sweat-centres may also be reflexly excited by irritation of various sensory nerves. Certain substances, such as nicotine and carbonic acid, seem to stimulate the sweat-centres ; whilst other drugs, such as pilocarpin, appear to act upon the peripheral terminations of the secretory nerves in the sweat-glands themselves. Several remedies, at the same time that they excite secretion, likewise increase the flow of blood through the skin, rendering it redder, warmer, and more vascular. Others, again, excite the secretion at the same time that they diminish the cutaneous circulation. Diaphoretics have therefore been divided into two classes, the former kind being termed stimulant , and the latter sedative diaphoretics. The exact mode in which each drug already enumerated produces diaphoresis has not yet been ascertained, but antimony, ipecacuanha, and jaborandi are classed as sedative diaphoretics, and all the others as stimulating ones. The supply of blood and the secretion are both increased by the application of warmth, by the ingestion of warm fluids, and by the action of jaborandi. Uses. — -Diaphoretics are employed to increase the flow of blood to the surface, and possibly to aid the elimination of excrementitious pro- ducts in internal congestion, such as catarrh of the respiratory passages or digestive tract, and in febrile conditions generally. In fevers, the cutaneous circulation is generally active, and the so-called sedative diaphoretics are then most useful. Diaphoretics are also used to increase the elimination of water by the skin, and thus lessen the accumulation of fluid in DIAPHRAGM, DISEASES OF. Sfifi dropsy, or to relieve other excreting organs, such as the kidneys in albuminuria and diabetes insi- pidus, or the intestines in diarrhoea. In these cases stimulant diaphoretics are indicated. T. Lauder Brunton. DIAPHRAGM, Diseases of. — The dia- phragm may itself be the seat of functional disturbance , or of organic lesions ; or it may be affected by neighbouring morbid conditions. For practical purposes its affections may be con- veniently discussed according to the following arrangement: — 1. Mechanical Interference. 2. Functional Disorders, (a) Paralysis. (b) Spasm. 3. Organic Lesions, (a) Injuries, including Ruptures and Perforations, (b) Iafla mm ar tion, acute or chronic, (c) Muscular Rheu- matism. (d) Atrophy and Degeneration. ( e ) Morbid formations. 1. Mechanical Interference. — The dia- phragm is frequently interfered with by morbid conditions within the chest or abdomen, which impede its action, displace it more or less, either upwards or downwards, or render it tense and stretched. The entire structure may be thus affected, or only a portion of it, such as one lateral half or its central part. The chief tho- racic conditions by which the diaphragm may be thus affected are pleuritic effusion or pneumo- thorax, emphysema of the lungs, abundant peri- cardial effusion, enlargements of the heart, and tumours within the chest. The principal ab- dominal conditions deserving notice as being liable to produce this effect are a distended stomach, tympanites, ascites, peritonitis, preg- nancy, large fsecal accumulations, and tumours or enlarged organs which attain considerable dimensions, especially ovarian, hepatic, splenic or renal tumours. It sometimes happens that the diaphragm is interfered with both from its thoracic and its abdominal aspects. The symptoms induced by this mechanical interference are readily explained by its effects. A sense of uneasiness and discomfort is often experienced around the lower part of the chest, amounting sometimes to considerable tension and tightness. There is not any actual pain, but in some instances, whore the diaphragm is much pushed down, the patient complains of a painful sensation referred to the ensiform car- tilage, as if the attachment of the diaphragm at this point were being severely dragged upon. The act of respiration is more or less impeded, and this often seems to be the cause of the dis- comfort experienced. Asensation frequently com- plained of by patients is that they cannot take a lull breath. Respiration may be much hurried, or oppressed and laboured, and not uncommonly the normal relation between the thoracic and abdominal movements is markedly altered, as observed on physical examination, and the diaphragm may so act as to draw in the lower part of the chest-walls in inspiration. Occa- sionally a kind of spasmodic cough seems to be excited by the tension of the diaphragm pro- duced by certain conditions. The act of cough- ing is also frequently rendered more or less diffi- cult and ineffectual. DIAPHRAGM, DISEASES OF. J5C ‘2. Functional Disorders. — Tho affections of the diaphragm included within this group are (a) Paralysis ; ( b ) Spasm. a. Paralysis. — The diaphragm is completely paralysed when the upper part of the spinal cord is destroyed, whether as the result of injury or disease. If one or both phrenic nerves should be cut across, or destroyed by disease, or even se- verely compressed, the same effect will be pro- duced, either one lateral half or the whole of the diaphragm being paralysed, according as one or both nerves are involved. This structure may also be implicated in the course of diphtheritic paralysis. Where paralysis of the whole diaphragm is suddenly produced, death speedily ensues from the grave impediment to the respiratory func- tion resulting therefrom. If it is brought about gradually, or if only part of the struc- ture is involved, the effects are seen in more or less interference with this function, and with the acts in which respiration is concerned. Thus there will be a subjective sensation of dys- pnoea, and of a want of power to breathe; while the respiratory movements will be hurried, shallow, and superior-thoracic. Coughing cannot be per- formed efficiently, and sputa cannot be expelled, while the abdominal acts for which a tense dia- phragm is required, such as defecation or vomit- ing, are also ineffectual or impracticable. The lower parts of tho lungs become more and more congested, fluids accumulate in the air-tubes and pulmonary vesicles, which become by degrees filled up, and the patient ultimately dies of asphyxia. b. Spasm. — The diaphragm may be the seat either of clonic or tonic spasm or cramp. The disorder may depend upon disease of the nerve- centre at the origin of the phrenic nerves ; irri- tation of these nerves in their course; direct excitation of the diaphragm ; or reflex causes. Tonic spasm is most strikingly observed in cases of tetanus ; of poisoning by strychnia, or of hy- drophobia ; but a form of asthmatic attack has also been attributed to this condition of the diaphragm. The symptoms will vary in different cases. Tonic contraction of the diaphragm gives rise to severe pain, and a sense of constriction in the corresponding region, which may come on in paroxysms ; clonic spasms also originate painful sensations after a time, which may become very considerable. Hiccup is probably due mainly to a clonic spasm of the diaphragm. If this structure should become rigidly fixed, respira- tion is gravely interfered with, and the patient soon presents the phenomena of suffocation, which will end fatally if the spasm is not re- lieved. In the form of asthma supposed to be due to diaphragmatic spasm, expiration is very difficult and greatly prolonged, inspiration being short and abrupt; the lungs are distended; great distress is felt; and there may be signs of impending death from suffocation. A spasmodic cough may be due to clonic spasm of the dia- phragm. 3. Organic Lesions. — These may be briefly considered in the order in which they were enu- merated at the commencement of this article. a Injury, Perforation, and Hupture. — The diaphragm may be perforated, lacerated, or ruptured in connection with various forms of injury, such as crushing accidents, fractured ribs, penetrating wounds, or gun-shot injuries. Should the patient recover, a permanent perfora- tion may be left. In medical practice perfora- tion of this structure may be met with as a con- genital condition ; as the result of the bursting of some fluid-collection through it, such as an empysema, a hepatic, renal, or other abscess, or a hydatid-cyst ; or from its destruction in the progress of some organic lesion, such as malignant disease or an aneurism. It may occasionally occur, independently of these causes, owing to the yielding of a weak portion of the diaphragm, especially between the attachment to the ensiform cartilage and tho seventh rib. In rare instances the perforation is congenital, or a considerable portion of tho diaphragm may be deficient. The size and other characters of the perforation differ much in different cases. If it is produced by the opening through the diaphragm of a fluid-accumulation, this fluid escapes from the abdominal into the tho- racic cavity, or vice versa ; in other instances the portions of the thoracic or abdominal organs pass through the perforation, constituting forms of diaphragmatic hernia. The writer had the opportunity of observing a remarkable instance in which the entire stomach had passed through an opening in the diaphragm into the cavity of the chest. In a case reported by Dr. Little, of Dublin, the diaphragm presented an almost circular opening, well-defined, sharp, with some- what thick edges, and through this opening passed a hernia consisting of peritoneum con- taining some omentum, and about fifteen inches of the transverse and descending colon. To recognise clinically a perforation or rup- ture of the diaphragm is generally no easy matter. Often there are no symptoms referable to this structure, though there may be signs indicating that its functions are more or less impeded. The occurrence of sudden perforation may be known from tho previous existence of some condition likely to cause this event, such as empysema, or an abdominal abscess ; the super- vention of acute pain, accompanied with indica- tions of shock or collapse, and the disappearance of the signs of the original morbid condition ; and followed by the development of phenomena re- vealing that fluid has passed through the dia- phragm, and accumulated in the thoracic or abdo- minal cavity, as the case may be, or that some secondary affection lias been set up as the result of the perforation, such as peritonitis or pleurisy. A fluid collection may, however, penetrate the diaphragm without giving rise to any very evi- dent disturbance. When an organ piasses through the diaphragm, the symptoms present, if any, are more likely to be associated with this organ than with the diaphragm, and physical exami- nation may possibly detect the displacement. In the case of hernia of the stomach, already re- ferred to, the chief symptom was vomiting, which occurred immediately after taking any food or drink. b. Inflammation. — The serous covering of tho diaphragm, either on its thoracic or abdomi- nal aspect, is not uncommonly involved in cases DIAPHRAGM, DISEASES OE of acute pleurisy or peritonitis respectively, and the inflammatory process may penetrate its structure. It may also be involved by extension from pericarditis. Inflammation of the substance of the diaphragm may further arise from injury, direct irritation, pyaemia, or without any evident cause. The anatomical conditions observed are in- creased vascularity; the formation of lymph upon its surfaces; softening and degeneration of its musevlar tissue ; or, in rare instances, suppura- tion, an abscess forming in the substance of the diaphragm, or pus collecting under one or other of its serous coverings. Chronic inflammation of the diaphragm may occur, leading to a fibroid change in its muscular portions, either by exten- sion from neighbouring structures, or as the result of chronic local irritation. The symptoms of acute inflammation of the diaphragm aro generally very obscure and ill- defined. The condition may be indicated by severe pain in the region of this structure, obviously increased by breathing, so that the respiration becomes instinctively thoracic, as well as hurried and shallow ; and also much aggravated by coughing, defsecation, or any other act which disturbs the diaphragm. The patient will probably be much distressed. More or less pyrexia will probably be observed. If an abscess should form, this might burst either into the chest or abdomen, and thus lead to secondary pleurisy or peritonitis. Chronic inflammation and its consequences may possibly be suspected from a want of free movement in the diaphragm, associated with conditions likely to originate this change; but it could scarcely be recognised with any certainty. c. Muscular Rheumatism. — The diaphragm may be involved in this complaint, whatever its nature may be ; probably it is attended with structural changes in its tissues. The affection is characterised by pain referred to the dia- phragm, which may be very acute when it is in any way brought into play. So long as it is kept at rest, there may be no discomfort, but deep breathing causes considerable pain, so that the respiration is carried on in a shallow' manner, and may be entirely thoracic. Such acts as coughing or defaecation cause much pain and a sense of aching. d. Atrophy and Degeneration. — The dia- phragm may he involved in the course of pro- gressive muscular atrophy ; it may also be atrophied from causes which produce general wasting; or undergo senile atrophy and degenera- tion; or be similarly affected from local causes, such as interference with its blood-supply from vascular degeneration, want of action, or after chronic inflammation. These conditions might give rise to more or less evident interference with the functions of the diaphragm, which in extreme cases would amount to their total cessa- tion, diaphragmatic breathing being rendered impossible, the symptoms being then the same as when the diaphragm is paralysed. In cases of progressive muscular atrophy the fatal ter- mination may arise from this cause. There would not be any pain, hut uncomfortable sensa- tions might arise from the impeded respiration. c. Morbid Formations. — The diaphragm is occasionally the seat of malignant disease, being DIARRHCEA. 357 usually involved by extension from some neigh- bouring structure. Non-malignant solid growths have in rare instances been found in it. Parasitic formations may also occur in it, namely, hydatids, cysticercus, and trichina spiralis. Tubercle is occasionally found in the diaphragm. Possibly malignant disease might be indicated by signs of impeded diaphragmatic movements, with localised pain, accompanying indications of cancer in other parts. The implication of the diaphragm in trichinosis may also he recognised in some in- stances by severe pains, spasmodic contractions, and serious interference with diaphragmatic respiration. In most cases, however, the pre- sence of any morbid growth in connection with the diaphragm cannot be diagnosed during life, and is only discovered at tlie post-mortem exa- mination. Treatment. — But little can he done in most cases in the way of direct treatment in connec- tion with affections of the diaphragm. The most obvious indication is to get rid, if possible, of any condition which is mechanically impeding its movements, and preventing it from performing its functions. In the next place, any disease of which the condition of the diaphragm is but a part must receive due attention, such as progres- sive muscular atrophy, centric nervous disease, or trichinosis. Painful affections might be re- lieved by local applications of dry heat, fomenta- tions, or anodynes; and if acute inflammation is suspected, a few leeches might be applied. Electricity might prove of service in the treat- ment of some cases of spasm or paralysis of the diaphragm, the continuous current in the one case, the interrupted current in the other. Frederick T. Roberts. DIARRHCEA {flappito, I flow away). — Svnon. : Dcfluxio: Alvi Fluxus ; Purging ; Fr. Cours de Ventre ; Devoyement ; Ger. Per Durchfall ; Bauchjluss ; Durchlctuf. Definition. — A frequent and profuse discharge of loose or of fluid alvine evacuations, without tenesmus. -ZEtiology. — The causes predisposing to diarrhoea are individual peculiarity; childhood — especially the period of first dentition; the climacteric period ; and hereditary or acquired weakness of the digestive organs.- — The exciting causes maybe thus classified; — 1. Direct irri- tation of the intestines bv (a) Food in excess, or of improper quality — for example, salted meat, shell-fish, sour unripe fruit and vegetables — dis- eased, decomposed, or imperfectly masticated ; the products of faulty digestion prematurely passing the pylorus ; imperfectly elaborated and fermenting chyme; impure water, such as that containing from 3 to 10 grains of putrescent animal matter per gallon (Parkes) ; or imper- fectly fermented malt liquors. ( h ) Purgative medicines and irritant poisons, (c) Bile, excessive or acrid. (<£) Faces, retained. ( [e ) Entozoa — luia- brici, taenia, trichinae, and entophyta — mycosis enteralis (Buhl and others). (/) The contents of a ruptured abscess or hydatid cyst. ( g ) Intestinal lesion — such as tubercular or other ulceration. 2. Defective hygiene. — Diarrhoea may arise from the dwelling being damp, cold, dark, and unventi- lated; or from foul emanations from decaying DIARRHCEA. m organic, especially animal matter, sewage, orfaecal collections. 3. Chills , climatic variations, &c. Diarrhoea has been attributed to insufficient clothing; sudden exposure to cold and damp; chills, as fromwetfeet, and damp bed or clothing ; over-heating, as by excess of bed-clothing ; and rapid variations of temperature, such as hot days and cold nights. 4. Nervous disturbances , for ex- ample, depressing emotions — fright, grief; neu- ralgia, hepatalgia (Trousseau), dentition, and other causes of reflex disorder. 5. Defective absorption with augmented, peristalsis, so that the food is passed unaltered — Lienteric diarrhoea. o. Symptomatic in various morbid states, for in- stance, in passive congestion of the portal vein from disease of the liver, heart, or lungs ; perito- nitis, especially puerperal; organic disease cf tho intestines — ulceration (simple, typhoid, tu- bercular, cancerous), lardaceous degeneration, enteritis, acute or chronic; cholera; typhoid fever ; dysentery ; occasionally in pyaemia, measles, scarlatina, confluent small-pox, ma- laria, gout, Bright’s disease (its later stages), and in anaemia and exhaustion, as from over- lactation, phthisis, cancer, Addison’s disease, Hodgkin’s disease, exophthalmic goitre, leuco- cythaemia, and other affections. Frequently diarrhoea arises from the combined action of several exciting causes, as when the disease is epidemic during summer and autumn Foul emanations from decomposing organic mat- ter, over-crowding, food (and especially fruit) in a state of incipientdecay, excessive heat, and chills, may then collectively determine the result. In children the exalted irritability of the nervous system during dentition predisposes to diarrhma from slight determining causes. Description and Varieties. — Diarrhoea may be broadly divided into the acute or occasional, and the chronic forms; and the numerous clinical and pathological peculiarities of different cases are conveniently grouped into typical varieties. The general effects, varying according to the inten- sity and duration of the flux, are mainly these : — Emaciation, and, in children, also arrest of growth — theweight either diminishing or ceasing to be progressive ; ansemia, indicating defective hiema- tosis ; desiccation of the tissues from the rapid draining of serum from the blood — hence the thirst, and the very concentrated, acid, and even albuminous urine observed whenthere is a copious watery outflow from the bowels, as in choleraic and similar forms of diarrhoea. It will be expedient to describe briefly the principal forms of diarrhoea. 1. Irritative Diarrhoea. — Stnon. : Diarrhoea Crapulosa (Cullen). — Simple flux from direct irritation of the intestines is the most common variety of diarrhoea. The evacuations, usually preceded by severe griping pains, are at first feculent and usually fetid and sour, then watery. In children (especially hand-fed) they are often like pale clay or putty, or they contain dense masses of undigested casein before being loose ; after evacuation they frequently become green- ish, like chopped spinach, from contact with very concentrated acid urine converting the brown colouring matter of the bile into green biliverdin; or they are dark green when passed, and may be so acrid as to excoriate the anus, the genitals, the inner parts of the thighs, and even the heels Fever is usually absent. Diarrhoea from irritation is frequently a pre- liminary stage of the inflammatory, dysenteric, and choleraic varieties. 2. Inflammatory Diarrhoea. — Stnon. : Diar- rhoea Serosa. — "When the causes of simple irrita- tion excite inflammation of the mucous membrane of the bowels, fever sets in, and the diarrhoea in- creases. Usually the evacuations become more serous, and contain shreds of fibrin or mucus or pus. Before the attack passes off the large bowels are apt to be the main seat of inflammation; then the motions are scanty, frequent, more mucous or glairy, contain streaks of blood and are passed with severe straining; while the skin is hot and dry. 3. Choleriform Diarrhoea — Stnon. : Cho- leraic diarrhoea; Thermic diarrhoea — prevails mostly in hot weather. The onset, indicated by vomiting and purging, is usually sudden. At first the vomited matters are mucous and bile- tinted, and the dejections are feculent — both quickly, however, becoming more and more abun- dant, watery, and colourless. The copious and incessant outflow of serum may in a short time, and especially in children, induce a striking re- semblance to the symptoms of Asiatic cholera — a drawn, sunken, and cyanotic appearance, loss of temperature, scanty secretion of urine, insatiable thirst, and cramps ; even in extreme cases the fluids from the stomach and bowels are, how- ever, rarely free from bile, and are not so like rice-water as in true cholera. The collapsed algid condition as a rule rapidly gives place to recovery in previously healthy adults, while it is fatal in delicate children, children prematurely weaned, the debilitated, and the aged. Barely, the cold stage being outlived, the patient becomes hot, and passes into a state of stupor, with eithtr bilious vomiting or purging and tympanites — the typhoid stage. In children death is almost invariable if the cold stage exceeds twenty-four hours. 4. Uervous Diarrhoea. — The peristaltic move- ments, and the activity of the glands of the ali- mentary canal, are often increased by causes operating through the nervous system. Diar- rhoea from mental, and especially emotional, per- turbation, is the most common example. Even a chronic looseness may be maintained by de- bility of the nervous system, induced by worry and anxiety. Exalted innervation of the bowels may be natural, a proneness to diarrhoea from slight exciting causes having always existed; or acquired, when, for instance, a flux once estab- lished is apt to be maintained. The unstable nervous system of t he periods of rapid develop- ment and of the climacteric change predisposes to it. It is often an important factor in chronic diarrhoea. The intestinal nerve-centres may become so sensitive (as in delicate children) that every meal, however small, may induce an immediate call to stool, the motions being liquid or pultaceous, and pale, but otherwise healthy. The peristaltic movements may be even so in- creased as to hurry the food through the stomach and bowels, so that it appears unchanged in the stools. Time is not allowed for digestion or absorption to be even begun. This form has DIARRIICEA. been termed Diarrhoea lienterica, and is most fre- quent in children before the period of the second dentition. The increased tonicity of the mus- cular fibres of the alimentary tract may have resulted from previous inflammation of the mucous surface, or is the propagation upwards of some irritation (ulcer, inflammation, &c.) of the mucous membrane of the rectum ; or it arises from the products of imperfect primary diges- tion entering the duodenum. In adults indi- gestion is the usual cause. The appetite is as a rule voracious, and debility may become extreme. In painful or difficult dentition, diar- rhoea arises from irritation of the nerves of the stomach and bowels ; digestion is arrested, and the contents of the alimentary canal become acid from fermentation, and are ejected by vomiting and purging. 5. Vicarious Diarrhoea. — Embarrassment or suppression of the functions of the skin, kidneys, or lungs may be met by the bowels performing additional excretory work. The flux thus set up is salutary, because it is compensatory. Diar- rhoea from chills (suppressed perspiration) is a common instance, while that from renal and pulmonary causes is less frequently observed, and may be misconstrued by the practitioner. Inasmuch as diarrhoea usually diminishes the quantity of urine, even sometimes to the verge of suppression, the reverse of this clinical fact may be easily overlooked or misinterpreted. Even when forewarned, the observer may at times — especially when the urine is free from albumen — find it difficult to determine whether the diarrhoea is a cause or an effect of imperfect renal elimination — a distinction having all- important bearings on the treatment. The uraemic and eliminatory character of it may be easily decided when the kidneys are known to be diseased ; not so, however, when the only thing ascertainable is scanty — maybe albuminous — urine, or total suppression of urine in an elderly patient. In such a case there may or may not be organic disease of the kidneys, and still the diarrhoea may be uraemic, inasmuch as it may depend on ‘ renal inadequacy.’ Diarrhoea from pulmonary embarrassment generally affords re- lief to breathing and cough. The chronic loose- ness of some gouty patients is also eliminatory : when checked, gout is apt to advance and the health to suffer. 6. Diarrhoea from mechanical congestion. — Draining of serum into the bowels is a common result of overloading of the portal vein from an impediment to the flow of blood, either in the vein itself, the vena cava, or the right side of the heart. 7. Chronic Diarrhoea. Synon.: Cachectic diar- rhoea. — Chronic diarrhoea is frequently, if not generally, unconnected with intestinal lesions ; it may be maintained by chronic catarrh of the in- testines, or by an exhausted and impoverished state of the system, as in inanition, either from insufficiency of food or from enfeebled digestion, or in chronic wasting diseases, such as syphilis, malaria, or scurvy. The flux increasing, the debil- ity onwhich it depends thereby perpetuates itself, and this vicious circle tends more and more to destroy life by anrnmia and exhaustion, and even after apparent recovery there is a strong dis- 35b position to revert to it. These clinical features of chronic diarrhoea are well illustrated by the malady which, from the paleness of the stools, is commonly known in India as ‘ White Flux’ — a result of deterioration of health by climate and malaria. When accompanied by fever and night- sweats, chronic diarrhoea is nearly always du* to tuberculisation. Diagnosis. — The different forms of diarrhoea may be readily distinguished from each other by a careful consideration of the causes and symp- toms. The diseases most apt to be mistaken for diarrhoea are epidemic cholera, dysentery, and mucous irritation of the bowels from retention of faeces. a. Cholera, in its less definite forms, may re- semble bilious diarrhoea and choleraic diarrhoea. The probability in favour of it may be deter- mined by the absence of the ordinary causes of diarrhoea, the paleness and watery character of the stools, tormina beingslight or absent, the sup- pression of urine, and the early exhaustion. The presence of bile in the stools is always in favour of diarrhoea. Vomiting is more frequent in cholera ; when it occurs in diarrhoea the vomited matter usually contains bile and undigested food, while in cholera it is a colourless fluid. b. Dysentery is usually characterised by fever, tormina, and tenesmus, and frequent scanty muco-sanguinolent evacuations. Sometimes, however, in the early stage, the motions are copious, watery, and fseculent, as in ordinary diarrhoea; but the presence of tormina uni tenesmus, and tenderness in the regions of the caecum and sigmoid flexure, indicate the dysen- teric nature of the disease. Chronic diarrhoea may be distinguished from chronic dysentery by the absence of a history of acute dysentery, or of mucus and tenesmus, and the less frequent discharge of blood in the evacuations. c. Mucous irritation of the bowels. — Retention of faeces may induce a condition resembling diarrhoea — frequent thin muco-fseculent evacua- tions, which are, however, shown on enquiry to be somewhat scanty, and voided with straining. Treatment. — (a) Diet and hygiene. In acute or occasional attacks of diarrhoea, everything should be taken in small quantity, and tepid or cold, never hot. Farinacea — arrowroot, sago, rice, tapioca, flour, and the like are useful, and may be taken in milk, or in chicken or mutton broth, or weak beef-tea. Animal broths — and especially beef-tea- — w'hen concentrated, or in large quantity, are apt to aggravate diarrhoea. Mucilaginous drinks — white of egg in water or milk, rice or barley or arrowroot water ; and astringent liquids — infusion of dried whortle- berries or roasted acorns, red light wines — may be given. Brandy is often of service, and may be mixed with spices or with the farinacea. Lime- water with milk is in many cases of much value. Rest in bed secures a uniform w'armth of skin, and favours the cessation of diarrhoea. In children, errors of feeding should be cor- rected. Lumps of casein in the motions may be met by reducing the quantity of milk, and regulating the time between meals, providing a wet nurse, or substituting the milk of the goat or ass for that of the cow. Sometimes, however, milk in any form must be given up. The abdo- DIARRHOEA. 380 men should be protected by a flannel bandage, md the feet and legs by warm clothing. Inasmuch as in chronic diarrhoea the flux is perpetuated by the debility and anaemia which it induces, and by the activity of intestinal digestion, it has become a leading principle of treatment to prescribe food rich in materials for the construction of the blood and the tissues, and almost wholly disposed of by the stomach. Hence the happy results frequently observed from a diet exclusively animal, either raw or lightly-cooked, the digestion of which may be aided by hydrochloric acid alone or with pepsin. Individual peculiarity may be gratified, and variety obtained from the use of mutton, veal, chicken, pigeon, and game. Beef, the tough parts of veal, and pork are, as a rule, to be avoided. Milk and farinacea are gradually permitted during the progress towards recovery, but the period during which they should be interdicted may require to be very prolonged — even months. The treatment by raw meat, strongly advocated by Trousseau and Niemeyer, has been success- fully applied to nearly every variety of chronic diarrhoea, but especially to that obstinate one occurring from the time of weaning to the close of the first dentition. The meat may be pounded mto a pulp or finely minced, then mixed with salt, sugar, fruit jelly, or conserve of roses, or diffused through clear gravy soup or chocolate made with water or wine ; or the juice may be extracted from it by pressure. Notwithstand- ing the prohibition of other food, it is best to begin with a small quantity, and to increase it gradually. The only drink allowable is water containing white of egg. Trousseau found opium in small doses, chalk, and bismuth, at and between meals, to assist this regimen. When a restricted animal diet cannot be digested, causes loathing, or aggravates the flux, other varieties of food may be added, and the feeding should be as generous and varied as possible, and adapted to the digestion of the individual. Articles of diet appearing undigested in the motions should be avoided. Low and damp situations should be exchanged for dry and open ones. Warm clothing, flannel next the skin, and flannel waist- belts should be worn. (b) Medicinal Treatment . — The kind and de- gree of interference required should first be decided in each case of diarrhoea. A routine prescription of astringents is much to be depre- cated. When the flux is moderate and salutary — for example, removing undigested or indi- gestible materials or irritating secretions, re- lieving an engorged portal vein, or supple- menting a suppressed secretion — it may be left uncontrolled by medicine, or may be encouraged by laxatives, such as castor oil, rhubarb, or a saline aperient, combined with a mild sedative — for instance, henbane or opium : it cannot be checked without risk. As a rule, the treat- ment of diarrhoea should begin by removing irritating substances from the alimentary canal by aperients guarded by small doses of opium ; and astringents, such as chalk-mixture with kino, catechu, hrematoxylum, and opium, should be held in reserve. A purgative may increase the flux, which, however, soon subsides. Trous- seau advocated the use of salines — sodas sulphas, soda tartarata, magnesias sulphas — in progres- sively decreasing doses, dissolved in a small bulk of water, in the morning fasting, while others prefer castor oil, rhubarb, or other ape- rients. Castor oil is by far the most useful remedy for children, as well as for adults ; for the former it should be emulsified in gum and syrup, and for the latter in yelk of egg, and as occasion requires combined with a small opiate, for example, compound tincture of camphor, vinura opii, or tincture of opium. In choleraic diarrhoea, the best results are obtained from castor-oil guarded by a small dose of laudanum at the commencement, and repeated if the disease is severe; while astringents and opiates alone are withheld until the bowels are relieved of offensive materials, as in the later stages, the stools being copious and watery, griping and distension of the abdomen absent, and the tongue clean. Vomiting should be en- couraged by copious draughts of warm water, and, if need be, by emetics of mustard or ipecacuanha. In children, when the motions are colourless, profuse, and incessant, it is best to give hydrargyrum cum ereta in small doses every hour or two, and a very small enema of starch, containing phumbi acetas or cupri sulphas, with laudanum, which may be repeated if necessary ; and the urgency of the case may likewise demand a firm astringent, such as logwood. In the cold stage there have been recommended mustard baths (for twelve or fifteen minutes, several times a day); emetics (ipecacuanha 2 to 3 grains twice or three times in twenty-four hours) ; diffu- sible stimulants (ether in syrup every hour or half-hour); and mercurials (hydrargyrum cum creta) ; in the stage of reaction, saline aperients or calomel in small doses throughout, white-of- egg in water as a drink ; and, vomiting having ceased and diarrhoea being established, bismuth, chalk, and lime water. In nervous diarrhoea the first indication is to allay reflex excitability by the bromides, or, these failing, by opium. When diarrhoea is ex- cited by food, the dose should be given shortly before meals. In lientcric diarrhoea arsenic is invaluable. Mal-digestion should be met by hydrochloric aci3, bismuth with alkalies, or other appropriate remedies, according to the indications. Occasional doses of castor-oil — alone, or with bismuth or small doses of opium or henbane — are useful in clearing away fer- mentescible matters, which are apt to maintain an irritable state of the bowels. Astringents should only be prescribed after the failure of these or similar measures. In vicarious diarrhoea the skin should be made to act freely by warm baths, or hot air or vapour baths. In renal inadequacy counter- irritation across the loins, digitalis, and nitrate of potash may be likewise indicated. The diar- rh bo carefully screened from currents of air, care being taken that free venti- lation is not interfered with. A thermometer and a steaming kettle are indispensable in the room of the diphtheritic patient. After tracheo- tomy, the maintenance of good ventilation, com- bined with an equal temperature and a warm moist atmosphere, is a paramount necessity ; and, in all cases, and in every stage of cases in which there exists diphtheritic sore-throat, it is impor- tant, as a means of moderating the paroxysms of glotto-pharyngeal spasm, that the air inhaled be soft and warm, and that the temperature be equable. Even in the rare cases in which throat- affection is absent, it is the duty of the physician to take the measures best calculated to secure such an atmosphere as has now been described, for the disease may at any moment manifest itself in the air-passages. 2. Diet . — Nutriment is urgently demanded; but it is useless — nay, it is mischievous — to push attempts at alimentation beyond very moderate limits, so long as the malady is in the ascendant. Assimilation is then very nearly at a standstill, as is shown by the rapid emaciation which goes on, even when large quantities of food are being put within the patient, and likewise also by the albumin which is passed with his urine. The albuminous urine of diphtheria arises from dif- ferent causes ; but, speaking in general terms, it is correct to say that it arises from no renal lesions, and is the expression of rapid waste of tissues and of the non-assimilation of food. Alimentation is the most important, and also the most difficult part of the treatment. Patients — even intelligent adults — often resolutely refuse food, and feel intense loathing, excited by the more sight or mention of any alimentary sub- stance, and the food taken is generally rejected at once by vomiting ; or if retained it is very sparingly assimilated. To press food upon chil- dren in spite of their loathing of it is generally injudicious : to press it upon them in spite of their struggles is sometimes even dangerous, as the excitement and resistance takes more strength out of the already prostrate patient than can be compensated for byforcibly administered aliment. We ought to try quietly to get the child to take frequently small quantities of milk or beef-tea ; and when we fail, we must give enemata of beef- tea and brandy. The food given to diphtheritic patients ought to contain pepsine. The quantity administered mustof course be proportionate to thatof the food. In respect to the dose of pepsine, it is necessary to remember that genuine British pejpsina porci is four or five times as potent a digestive as Boudault’s pepsine, the mixture generally pre- scribed in France. Pepsinated pills of pounded raw beef, with a few teaspoonfuls of the ex- pressed juice of raw or slightly roasted beef, are exceedingly useful in keeping patients alive while the disease is expending its immediately de- structive powers. When the irritability of the stomach does not forbid the trial, strong egg- flips may be given. A strong egg-flip may be made by beating up together one teaspoonful of concentrated Swiss milk, one teaspocnful of DIPHTHERIA. brandy, and two or three teaspoonfuls of water. To these ingredients, two grains of vepsina ford may be added. Patients who have moderately severe attacks of the disease, and convalescents, can generally take such semi-liquid aliments as panada and chicken puree [puree a la reine]. Occasionally, hut not generally, patients can take cod-liver oil. Milk ought to enter largely into the diet of diphtheritic convalescents. In them, as in all convalescents, it is an admirable mainstay ; hut there are some few cases in which it does not agree. 3. Stimulants. — Diphtheritic patients emaciate rapidly ; and together with, as well as before the loss of flesh, extreme prostration occurs. Under such circumstances, the liberal exhibition of alcoholic stimulants is imperatively demanded as the principal, and when food is rejected, as the only means of supporting life during the most critical period of the disease. This great crisis is not generally prolonged for more than a few days, but stimulants may require to be more or less relied on for a long time. Sometimes for hours or days it may be impossible to give any- thing more than stimulants, of which the best are alcohol in some form, tea, coffee, and the juice of meat. When all kinds of food and stimulants excite nausea and vomiting, it is necessary to discontinue for a time nourishing the patient by the mouth. For some hours — for from six to twelve hours — he must be fed entirely by the rectum, so that the stomach may have an interval of complete rest. In such cases it is a good practice to precede renewed attempts at feeding by the mouth, by one or two doses of creasote and oxalate of cerium. Both can be given in very small bulk, which is a great advantage ; and no other gastro-sedatives act less as depressants of the general system. The ordinary so-called crea- sote of commerce is bad carbolic acid, which, in place of allaying, frequently excites nausea and vomiting. If pure creasote cannot be obtained, pure carbolic acid may be substituted for it. The creasote may be given made into pill with breadcrumb ; and the oxalate of cerium either in the form of pill, or wrapped in moistened wafer-paper as a pulpy bolus. The proper quantity of creasote to give at one time is from half a drop to two drops, and of oxalate of cerium from two to four grains. In the twenty-four hours we may administer as a maximum, ac- cording to the age of the patient and the cir- cumstances of the case, from six to eight drops of the former, and from twelve to sixteen grains of the latter. Of the crystals, liquefied by heat, one drop is given in a tablespoonful of thin mucilage. This may be repeated several times in the twenty-four hours. When the remedies now mentioned have failed, the nitrate of bis- muth in two or three successive doses of ten grains each may succeed. There are cases in which the nausea is so urgent a symptom that it is impossible, by any medicines, to over- come it. We must then trust entirely to the ap- plication of warm poultices, sinapisms, or tur- r sntine-stupes to the pit of the stomach. The ypodermic injection of morphia, or the adminis- tration of an enema containing hydrochlorato of morphia, is another method of allaying nausea and vomiting, in the gastric irritability of fever and other diseases, but which is only applicable in a limited number of casos of diphtheria, in those cases in which the asphyxia is far advanced and is advancing. The quantity of hydrochlorate to be administered in clyster depends much on the age of the patient. Sixty drops of the Liquor hydrochloratis morphiae of the British Pharma- copoeia may be given by the rectum to an adult, while from five to tea drops is a sufficient dose in clyster for a child under ten years of age. Besides allaying nausea and vomiting, such a clyster soothes, diminishes the severity of spas- modic dyspnoeal paroxysms, and gives the sufferer rest. 4. Medidnes administered internally are usu- ally employed either to accomplish some parti- cular object ; or to exercise a curative influence on the general disease. There is another special object for which in- ternal medicines are given, namely, the detach- ment and expulsion of false membranes from the air-passages. For this purpose the administration of emetics has been considered by many as one of the essential parts of the treatment of laryn- geal, tracheal, aud bronchial diphtheria. Their use is unquestionably indicated in certain cases, yet the range of their utility is very limited. There are two circumstances which obviously limit the advantages obtainable by emetics; first, if administered at an advanced stage of the dis- ease, or at any stage when there exists great prostration, the vomitive efforts excited must act most prejudicially when they do not produce the desired result of expelling the falso-membrane from the air-passages — they must draw danger- ously upon the waning strength of the patient, and diminish his chances of pulling through with the aid of tracheotomy. Herein lies a great limi- tation of the use of emetics, because the cases are exceptional in which the blockade of the air- passages is effectually relieved by vomitive ac- tion; and when no such relief is obtained, the violent efforts excited by emetics only produce unmitigated evil — a large withdrawal of remain- ing vital power. Again, unless the exudative stage of the disease be endod, the ejection of false- membrano affords only a brief temporary respite, for new layers are speedily deposited to replace those which have been thrown off. These con- siderations show the narrow limits within which benefit can be obtained from vomitive action, and how much evil may accrue to the patient when that action is violent. Should it be judged ex- pedient to induce vomiting, the emetic selected ought to be one which generally acts quickly and certainly, and which if it fail to act will not pro- duce dangerous irritation of the intestines or great depression of the system. Tartar-emetic must not be employed. Sulphate of copper, an emetic much recommended by Trousseau and others under the circumstances now being con- sidered, is also objectionable, because if it does not promptly cause vomiting, it will be nearly certain to excite enteritis and formidable diar- rhoea. Ipecacuap and sulphate of zinc are perhaps the safest emetics to administer to a diphtheritic patient. The repetition of dose after dose of any emetic is dangerous practice in diphtheria. For i example, we may give, without apparent effect. DIPHTHERIA. 380 successive doses to a semi-asphyxiated patient whose functional life is dormant ; and seeing that we give him no relief in the way hoped for, we proceed as our last chance of saving him to admit air into the lungs by tracheotomy. Forth- with the vital powers awake, and the accumulated doses speedily act with violence — the patient has been saved by tracheotomy only that he may die of pharmaceutical poisoning. Dr. Sannd ( Traite de la Diphtheric, Paris, 1877) suggests that the recently discovered medi- cine apomorphia might be tried as an emetic in diphtheria. It possesses properties which seem to recommend it very specially in this disease. This drug is administered hypodermically. It acts very rapidly — in from three to five minutes : and supersedes or greatly reduces the duration of the period of nausea. It frequently succeeds when other emetics have failed to act. The advantages which it possesses are, therefore, facility of ad- ministration, rapidity of action, and less fatigue to the patient. The only objection to its general use is the difficulty of preserving it.’ Another suggestion of Dr. Sanne is noteworthy. He proposes that trial be made of jaborandi, given internally, as a means of producing de- tachment of the false membrane. The medicines which have a curative influence on the general disease are few in number. Cer- tain medicines — preparations of iron, for example, are, under certain circumstances, particularly useful in diphtheria. Of the medicines which have had in their day repute as specifics, or as agents of high thera- peutic value, but have now nearly ceased to be so esteemed, a few may be briefly mentioned. Bromine and its compounds, sulphuret of potash, copaiba and cubebs, chlorate of potash, sulphite of soda, chloride of sodium, carbolic acid, sali- cylic acid, chlorodyne, calomel, quinine, per- chloride of iron, and many other medicines, have all been proclaimed as specifics, or at least as wonderfully potent in the cure of diphtheria. Perchloride of iron has a decidedly beneficial action under certain circumstances ; but this action it possesses in common with other pre- parations of iron. It neither arrests nor modifies the character of the malady in its early and most perilous stages ; but its utility is unquestionable as an adjuvant, when, in the natural course of the disease, a spontaneous curative tendency has begun to manifest itself. 6. Applications to the Throat and Air-passages. — With a view todetach, dissolve, or destroy false- membrane, a greatdiversityof topicalapplications have been employed. Trousseau, and those who wrote underhis inspiration, stronglyreeommended destruction of the false-membrano by various caustics and solvents. In the (1868) edition of his Clinical Lectures which was in the press at the time of his decease, Trousseau insists that the topical treatment is pre-eminently the best treatment of diphtheria, adding that it is as much indicated in this disease as in malignant pustule. Fortunately this doctrine is no longer in vogue, and when topical treatment is still em- ployed in France, it is now seldom by caustics or any irritating substances. Sanne, writing in 1877, expresses the general sentiment of French physicians when he says : — ‘ Cauterization is now generally abandoned : it has serious drawbacks : it is dangerous : it is useless.’ 1 The practice of attempting to destroy the false membrane by caustics and powerful solvents is unquestionably mischievous. It irritates the parts and increases the exudative tendency. The free application of the officinal glycerine of borax, by means cf a camel’ s-hair brush, is at least harmless, and seems to loosen the membranous patches. Frequently washing out the mouth with this preparation, diluted with from four to eight parts of water, is agreeable to most patients, and is useful from the local soothing which it produces. A very dilu- ted solution of hydrochloric acid is equally innocuous, and as a mouth-wash is pleasant and cleansing. Lime-water and lactic acid, used separately or mixed, exercise a powerful solvent action on the false-membrane ; and were it pos- sible to apply them to it without their coming in contact with, and thereby irritating the con- tiguous mucous surface, they might be used with advantage, or at least with impunity. A small quantity of lactic acid added to an aqueous solu- tion of pure glycerine or to the glycerole of borax — one part to fifty of glycerine — is a favourite topical application with some practi- tioners, and is one which may be used without fear of doing any harm. Catheterism of the larynx, and injection of solvents into the trachea, are now generally looked upon as objectionable measures. They still have, however, their advo- cates. Dr. Young of Florence states, as the result of large experience, that he has seen much benefit result from throwing into the throat every hour, by means of a ball sprav-apparatus, a solution- of three drachms of lactic acid in eight ounces of lime-water. Notwithstanding much that has been written in a contrary sense, a careful review of the subject leads to the conclusion that very little advantage is derived from internal local applica- tions, that they are often exceedingly mischievous,- and ought never to be used without the greatest circumspection. They do not curtail or greatly modify the natural course of the general disease ; and the local benefits which they can confer are limited to soothing the parts, and slightly dimi- nishing the obstruction of the air-passages. Moist warmth applied externally to the throat gives much comfort and is in no way injurious. Only soothing, or at least non-irritating sub- stances are admissible as internal applications. It must be remembered that topical applica- tions can hardly ever bo employed in young children without exciting resistant struggles, which agitate and exhaust the patient. The risk of incurring this danger often forbids their employment. 6. Tracheotomy. — Besides the perils of the general disease — prostrating toxaemia, difficult nu- trition, and paralysis of the heart and respiratory muscles — the patient has the special risk of dying asphyxiated from obstruction of the air-passages by false-membrane. This terrible danger is one cf very common occurrence. When nature and art have failed to remove or effectually lessen the mechanical impediment to the admission of air to the lungs, the physician has to decide whether there be anyreason against his giving the patient 1 Sann6: TraiU de la Diphthiru> Paris, 1S77 : p. 419 DIPHTHERIA. d chance of life by making an entrance for the air below the membranous obstruction. If this one remaining chance remain in any degree, how- ever small, he is bound to offer it to his patient. Sometimes no such chance remains. What con- ditions exclude the possibility of saving life by tracheotomy? That is the question. It is not whether the case be a favourable one for opera- tion ; for every diphtheritic patient is an ex- ceedingly bad subject for any surgical operation. The simple question is : — Does tracheotomy give the smallest chance of life to a patient who without tracheotomy must inevitably die from asphyxia ? The answer to this question may, as a rule, be given in the affirmative, if the obstruc- tion be not below the situation in which tracheo- tomy is performed. If this rule be followed, the operation will often be performed in very despe- rate circumstances — circumstances in which the probabilities of success are very small compared with those of non-success. When the pseudo- membranous affection extends to the bronchial tubes — when pneumonia exists — when the diph- theria is an immediate sequel of measles, scarla- tina, or typheid fever — when the asthenia is ex- treme — or when the patient is phthisical — the probability of the operation saving him is small ; and yet, in most unfavourable examples of the classes now mentioned, success has been obtained. John Rose Cobmack. DIPHTHERITIC. — Relating to diphtheria. The term is applied to the membrane formed in diphtheria ; and it is also associated with certain symptoms occurring in the course of the disease, such as diphtheritic paralysis. See Croupous. DIPLOE, Diseases of. Sec Sxuix, Diseases of. DIPLOPIA (Snr\doi, double, and otttoucu , I see). — Double vision. See Strabismus. DIPSOMANIA (8hJ/a, thirst; and fiavla, maduess). — Stnox. : Oinomania ; Fr. Manie ebrieuse, or erapuleuse ; Ger. Trunksucht. Definition. — An irritability of tko nervous system, characterised by a craving, generally periodic, for alcoholic and other stimulants. .Etiology. — This peculiar condition may be brought on by a course of intemperate drinking ; but it is seldom the result of that cause alone, and it is not infrequent in persons who have never been intemperate previous to the develop- ment of the morbid craving. The occurrence of this form of insanity, as of other degenerative nervous diseases, may generally be traced in the family history of the patients. But sunstroke, a blow on the head, or other direct injury to the brain may excite it; and it may be symptomatic of epilepsy, or of structural disease of the brain. It may be developed at any period of adult life ; but most frequently declares itself during the pubescent and. climacteric periods. Symptoms. — An instability of character and indications of peculiar nervous irritability may generally be recognised as having preceded the distinct development of the craving. It is also usual to find such persons as are predisposed to the disorder abnormaUy sensitire to the influence DISCRETE. 381 of stimulants. Sometimes very small quantities of alcohol produce appreciableintoxieation. The duration of the periods of craving is variable ; but most commonly they last one or two weeks. The remissions continue for periods varying from two to twelve months. During the period of craving the whole moral being is enthralled by the morbid desire ; and the regard for truth, decency, or duty is generally altogether lost. Moderate indulgence in a stimulant may bring on the morbid craving ; but the desire is fre- quently developed without any such introduction. Members of the household in which a patient lives can indeed often recognise the indications of a coming attack by a restlessness and depres- sion which precedes any such indulgence. During the intervals the patient seems, except when the brain has been weakened by frequent attacks, to recover completely ; and he gene- rally displays great confidence in his ability to resist the tendency in future. Repeated attacks always produce a permanent degradation, both intellectual and moral ; and if the patient live long enough he lapses into a state of dementia. It sometimes happens that some cerebral lesion, of which the dipsomania had been symptomatic, manifests itself in paralytic or convulsive symp- toms ; and the appearance of such phenomena is often accompanied by a modification of the craving. Diagnosis. — True dipsomania may easily be, and often is, confounded with mere habitual drunkenness. In dipsomania, however, there is, as a fundamental condition, a pathological con- dition of the brain which manifests itself irre- spective of external circumstances of temptation. In habitual drunkenness the craving consists mainly in a desire to keep up a condition of stimulation to which the brain has become accustomed. The habit is the result merely of compliance with a vicious custom, and there is no such periodicity or independence of external influences in the symptoms as is found in the true disease. Treatment. — Prolonged abstinence from stimulants, and adherence to the tonic regimen, are the only measures from which any ameliora- tion can be hoped for. It is seldom possible to restrain the gratification of the craving without seclusion in an asylum or ssene similar institu- tion ; and even when such compulsory restraint has been successfully enforced for a considerable period, the morbid tendency is seldom eradicated. The present state of British law does not, how- ever, permit us to confine either the dipsomaniac or habitual drunkard unless something more mor- bid than an abuse of stimulants can be alleged. And it is difficult to see how a law could be enacted which would be effectual without being open to serious abuse. Public attention has, however, been lately very earnestly directed to the subject, and it may be hoped that something will be done towards rendering efficient treat- ment possible. John Sibbald. DISCRETE ( discerno , I separate). — This adjective is used in reference to certain cutaneous eruptions in which the spots or pustules are separate from each other; for example, discrete small-pox. 362 DISCUTIENTS. DISCUTIENTS ( discutio , I drive away). Definition. — Local applications, which are supposed to romove the congestion and effusion of inflamed parts, and the swelling of the skin over them. Enumeration. — The chief discutient measures or agents are: — Friction; Pressure; Mercury and its preparations ; Iodine and its prepara- tions, including the Iodides of Potassium, Lead, and Cadmium. Uses. — These remedies are generally applied over enlarged joints, enlarged glands, or cystic tumours. The most powerful amongst them are mercury and iodine and their preparations, either alone or in combination. Their action is aided by heat and pressure. The effect of the former is seen in the Indian treatment of goitre, which consists in rubbing iodide of mercury ointment over the tumour, and exposing the patient to the full rays of the sun, or to the warmth of a large fire. The beneficial effects of pressure are ob- served in the diminution which takes place in enlarged and swollen joints under the application of mercurial ointment or strapping, the friction with the hand in applying the ointment, and the pressure exerted by the strapping greatly in- creasing the efficacy of the mercurial preparation in removing swelling. See Feiction. T. Lauder Brunton. DISEASE (des, from, and aise, ease). — Fr. Maladie; Ger. Krankheit. Definition. — Disease may be defined as a deviation from the standard of health in any of the functions or component materials of the body. See Pathology. The expression ‘ a disease ’ is frequently used with reference to a supposed unit of causation. Thus, it may be applied to some simple phe- nomenon, for example, neuralgia, when that phe- nomenon is the sole effect of a cause ; or it may include many concurrent or consecutive resultant phenomena, such as those of syphilis or typhoid fever. General Considerations. — It is well known that changes of function and of structure are brought about and influenced by a great variety of agencies. These agencies, some of which act from within, others from without, are recognised as the causes of disease. Such changes, whether they be functional, affecting more especially the vital properties of the body, or structural, affecting its physical properties, constitute what is familiarly known as Disease, which is hence called respectively functional or structural. These changes are merely the evidence of an altered or perverted action, which is then in operation or has already occurred, the nature of which is considered under the head of pathology. When these deviations from health can be recognised during life they are described as the symptoms or signs of disease. For example, when a person, after exposure, it may be to wet or to cold, or both, is found to have an increased t emperature, with a quick pulse and perverted secretions, and to complain of thirst, and pain at the joints with effusion in and around them, we say that such person is labouring under disease, and we call it 1 rheumatism,’ because that name has been as- signed to a complexus of deviations from health, DISEASE, CAUSES OF. such as those then presented by this individual. When typhoid poison has been introduced into the body, it leads in like manner to a number of functional and structural changes, which, taken together, constitute what we call ‘ typhoid fever.’ Or again, under certain circumstances there ap- pears to be generated in the system, whether as the result of a tendency acquired before birth or by habits of life, an agency which, acting morbi- fically, produces a series of phenomena which we call ‘ gout.’ These several forms of disease may be classified in groups, arranged in accordance wth the causes which give rise to them, their nature, their seat, their duration, &c. Rules are laid down for the modes of distinguishing or diagnosticating one disease from another ; for prognosticating , as far as may be, their result; and for their prevention and treatment. Thus it comes that the discussion or description of any particular disease consists of an account of the causes that give rise to it, or its Etiology ; the changes of structure or of function which constitute it, that is, its Anatomical Characters and Pathology ; the phenomena attending these changes, otherwise, the Symptoms and Signs of the disease ; the facts that serve to distinguish this particular disease from other diseases, that is, its Diagnosis ; the means of forecasting its progress and termination, which constitute its Prognosis ; and finally the measures by which it may be prevented, relieved or removed, that is, its Treatment. Throughout this work the various diseases are, as far as may be practicable, discussed upon this uniform plan. As thus understood — and it is well to re- member it— Disease is an abstraction or relation, and not an entity having a special and inde- pendent existence. Physiology has in recent days diffused a clear and penetrating light over many of the processes of life in health, which were previously dark and obscure. Pathology, which is physiology applied to the study of un- healthy function and structure, anxiously follows the footsteps of the sister science. We are there- fore not hoping and believing too much when we express our conviction, that the time is not re- mote when we shall be able to trace those eurlv and minute changes which constitute disease, and the causes which give them origin, and that we shall thus be enabled to define in a more philo- sophic and practical form what disease really is. In the meantime we must be content to work upon the phenomena before us, to investigate so far as we can the causes of disease, how to recognise its presence and its nature, how to estimate its progress and its duration, and finally how to prevent its occurrence or to cure it when it has occurred. These varied and important points will be found discussed as above stated under suitable headings, in the articles imme- diately following, and in other parts of this work. R. Quain, MD. DISEASE, Causes of. — Definition. — Whatever is capable of damaging the structure of any organ or t issue of the body, or interfering with its function, may be a cause of disease. This definition implies that such causes are- numerous, and that of many- science is yel ignorant. To give a succinct account of thene DISEASE, CAUSES OF. 883 Is therefore difficult, nor is this difficulty dimi- nished by the fact that, in most diseases, we can trace a succession or combination of causes. General Classification. — The causes of disease have been divided into (1) Predisposing or Remote, (2) Exciting or Proximate, and (3) Determining. Illustrations will explain what is meant by these terms : — Two individuals are ex- posed to the contagion of typhus in equal degree; one, wearied by bodily and mental labour, 'catches’ the disease— that is to say, his con- dition has predisposed him to the exciting cause of the malady; the other, in vigorous health, escapes the contagion — the exciting cause of disease. Predisposition in fact prepares persons by rendering them more susceptible to the in- fluence of exciting causes of disease. Many per- sons are predisposed to emphysema because of hereditary taint ; in them the air they breathe is day by day an exciting cause of this disease ; they contract a bronchitis which, by its attendant cough, determines the malady. Such illustrations might be extended to a multitude of diseases, and justify the division of causes which the older physicians made. Predisposition may be in- herited ; or it may be acquired, and be due to various accidental causes. In most cases there is a combination of predisposing causes ; in a man, for example, lowered by fatigue, want of food, and exposure, debauch will readily excite an attack of bronchitis or pneumonia. Prac- tically, it is often difficult to say how much is due to predisposition, but, though many factors unite in the predisposition to disease, it is pos- sible in most cases to estimate the part played by each. See Predisposition to Disease. Moreover it is not always easy to distinguish predisposing from exciting causes. Predispo- sition carried to excess becomes an exciting cause of disease, and in many cases there is a combination of both. There are certain distinct exciting causes — for example, heat, cold, or in- juries of various kinds, but most of these can claim a predisposing power. The eontagia of the acute specific diseases and parasites are good examples of direct exciting causes. In proceeding to discuss tne subject of ^Etio- logy, no attempt will be made to separate de- finitely predisposing from exciting causes of disease. The writer will endeavour rather to indicate as far as possible under the head of each factor of causation the direction in which it especially acts. 1. Age. — This has a most important influence as a predisposing cause of disease. In Wagner's Manual of General Pathology the periods of age are thus subdivided ; — (1) Nursing age (infancy) — from birth to 7th- 10th month. (2) Childhood — from 1st to 2nd dentition. (3) Boyhood — from 2nd dentition to puberty. (4) Adolescence — from puberty to 20th-25th year. (5) Early manhood — from 25th to 45th year. (6) Later manhood — from 45th to 60th year. (7) Old age — from 60th onwards. This division is excellent, but in no definition is there more need to look out for exceptions than in that of age. The term age is strictly comparative ; some individuals are old at forty, others young at sixty. Persons fail with regard to particular organs w.iile young in years ; and, on the other hand, others acquire an increased power in the same as years advance, of which the brain affords an apt illustration. The minor organs of the body betray the like peculiari- ties, and in the early decay of the teeth, the changes in the hair and the skin, we meet with indications of old age, though the individuals are young in years. But, generally, the pre- dispositions of the young and old are striking by their contrast. The young are exempt from fatty degenerations, which are so common amongst those of advanced life, and, in conse- quence, many diseases amongst them are, cateris paribus, less deadly ; and not only does age, by reason of the changes which naturally occur as life goes on, predispose to disease, but all outward conditions become changed. Children — speaking generally — are apt to suffer from acute catarrhal affections of the mucous tracts, glan- dular diseases, skin-diseases, tuberculosis of acute type, scrofulosis, and a variety of com' plaints traceable to improper feeding, bad ven- tilation, overcrowding, and to hereditary taint From acute tuberculosis the aged are almost en- tirely exempt, and they do not suffer from here- ditary taint nearly so frequently as the young. The very young and the very old are equally sub- ject to bronchial catarrh, and the mortality from this disease at each extreme of life is exceed- ingly great. But in the young the predisposi- tion to this affection is almost invariably asso ciated with a predisposition to catarrh of the intestinal tract, and to diseases which indicate a general constitutional depression ; while in the old bronchial catarrh is predisposed to by a degenerative change in the lungs themselves, or in the air-passagos. In childhood there is an active stage of growth and development, and when one important organ is affected the others suffer with extreme rapidity ; the excito-motory system is greatly developed, and hence arises a predisposition to spasmodic diseases — for ex- ample, to laryngismus stridulus, and to general or partial convulsions during the excitement of dentition. In the old the tendency to spasm decreases, and convulsions become much less marked. Some of the exanthemata, especially measles, scarlatina, and pertussis, are more com- mon amongst children than adults, which is partly explained by the fact that the latter class have passed through the ordeal of those diseases, and are thus proof against them. Bickets also is essentially a disease of infancy and early childhood. The onset of puberty is a constant source of predisposition to disease, for with it comes a complete transformation in the mental and physical characters, so that the individual, if not very care- fully watched, deviates from even the most perfect health into a permanent tendency to disease. The system at this period — especially in the case of females — is frequently unable to bear anything wdiich interrupts or interferes with its activity. The generative organs undergo great changes, and with them the whole moral and physical nature is altered. At this period of life there is a predisposition to both bodily and mental dis- eases. In fact, perversions of any organ or faculty may be started, and, once started, they are apt te 384 DISEASE, CAUSES OF. continue , so that there is established, literally speaking, a permanent predisposition to disease, and this predisposition swells very largely the list of affections which are dealt with under the generic term Hysteria. Lung-affections — except- ing pure bronchitis — are more common at and shortly after the time of puberty than in previous years ; but, excepting in the instance of phthisis, hereditary taint is less manifested than during childhood. Even hereditary epilepsy is, if post- poned beyond early years, likely to be postponed to the period of adult life. As has been said, the degenerations of organs and tissues begin to show with much uncertainty, but after the fortieth year of life we almost in- variably meet with one or other of them. Their degree and their consequences vary with the sur- roundings of the individual — with his habits, tem- perament, occupation, andlikeinfluences. Diseases of the large vessels are especially common at this epoch, such as aneurisms of the aorta and of the large arterial trunks in the extremities. Hence- forward all the diseases peculiar to advancing age become common. The results of previous disease are now declared by a decided predisposition to exciting causes which have been hitherto with- stood. Old age is a relative term. A man is old and predisposed to trifling excitants because his lungs haTe lost their elasticity, or his brain its regularity of circulation, or his heart its vigour — in each of these cases, as in a host of others, the predisposition is strictly one of degeneration. Again, inherited diseases do not declare themselves in some cases till the later years of life, and of this car- cinoma is a striking example. The old are pre- disposed to lowering diseases — low pneumonia or bronchitis; and to a variety of nervous affections which the vigorous can resist. In them the failing heart-power tells a tale ; they are the subjects of general vascular dilatation ; and, in short, they succumb to insignificant exciting causes, because of the general or partial decay of the tissues and textures of the body. 2. Heredity is a prolific source of predis- position. There is amongst men not only an inheritance of such prominent diseases as phthisis, but of peculiarities in the manner they meet and pass through minor ailments. Thus, in families with a ‘ nervous history,’ we meet with predisposition to headaches of ner- vous type, irregularities of digestion in the form of diarrhoea and vomiting, and a multi- tude of conditions which have of late been ascribed to vaso-motor disturbances. The members of some families live long in spite of exposure to almost every exciting source of mischief, and contrast most favourably with others who, as far as one can determine, hare all things in their favour. There is no doubt that the effects of syphilis, malformations, gout, the haemorrhagic diathesis, and tuberculosis are handed down from generation to generation. Of many minor complaints there is less certainty; but it is exceedingly probable that persons are predisposed to bronchitis and other catarrhs by inheritance. It is acknowledged that epilepsy descends from parent to child, and that, in fact, individuals, because of heredity, are often the subjects of nervous diseases excited by causes which those free from taint are enabled to throw off readily. The various forms of insanity are striking examples. It is supposed that the in- heritance lies in the tissues themselves— that there is a something in the tissue-elements which predisposes to certain diseases in certain families. It has been asserted that there is even a predis- position by inheritance to the acute specific diseases — such as typhoid fever and diphtheria, and some remarkable occurrences in this country strongly bear out this view'. 3. Intermarriage. — Intermarriage certainly predisposes to disease, but it is not easy to deter- mine how far its predisposing powers extend. Breeders of first-class animals practise inter- marriage, and thereby develop speed, quality, and endurance in the offspring. It is beyond question that this practice of breeders of race- horses is eminently successful for the time, but it by no means follows that the permanent results are good. We are bound to look not only to the immediate, but to the ultimate results of intermarriage — in short, to decide wdiether in termarriages predispose to disease, to the injury of the community. But no rule, free from ex- ception, can be laid down on this subject, for beyond all doubt many intermarriages have led to both physical, moral, and mental advantages. There is no doubt that malformations are handed down, and that vhero these are marked in families it is injudicious for persons to inter- marry. Where also, for example, serious diseases, such as phthisis, have been met with on both sides, it is most advisable that intermarriage should not take place. 4. Sex. — There are great differences in the organs and functions of the sexes, and in conse- quence a great contrast in their predisposition to disease. The female is more delicately constructed than the male, and those organs which tho two sexes possess in common differ in weight and in ‘fineness;’ and a general consideration at cnee indicates that the female is less fitted than the male to resist many exciting causes of disease. This is particularly evident at climacteric periods of life ; with the onset of puberty girls suffer far more than males, and especially from a variety of reflex spasmodic disorders, which require but little provocation for their develop ment. All the phenomena classed under the head of hysteria often occur at this period. At the same time, and shortly afterwards, there is a tendency to ulcer of the stomach, to persistent constipation, to peculiar attacks of neuralgia — especially of the intercostal nerves, and to acute rheumatism, lapsing into the subacute or chronic kind. Anaemia and chlorosis are also common at the period of puberty, and if then neglected they are apt to persist, and predispose the indi ■ vidual still more to disease. Even so early as the period of puberty the external circumstances of the sexes differ, and on this depends, in a certain measure, the difference in their predisposition. Education, domestic habits and customs, and, above ail, occupation, play an important part. But, under- lying these outside influences, there is inherent in the sexes a difference in predisposition ; fer when they are exposed, as often happens, to the same surroundings, they suffer from widely fccjyi DISEASE, CAUSES OF. raxed diseases. Males are more subject to epi- lepsy, tetanus, gout, diabetes, locomotor ataxy, vesical diseases, and acute lung-affections, than females. The list shows that occupations which involve hard mental and bodily work and con- stant exposure explain some of the varieties in predisposition. It is probable that females are more frequently ailing than males, but very often their illnesses are associated with the menstrual functions, and are trifling in degree, and, though more males are born than females, towards the later years of life the average of the sexes becomes more equally balanced, because the mortality of males is greater than that of females. It is sufficient to allude to the fact that pregnancy and lying-in predispose females to diseases from which males are entirely exempt ; and that there is a considerable difference in the sexes as regards venereal affections, both as to predisposition and the effects of that predisposi- tion. 5. Temperament is important as predispos- ing to disease. Persons of sanguine tempera- ment are disposed to congestions of organs, and haemorrhages, on comparatively small provocation. Phlegmatic individuals are the subjects of those diseases which are readily excited by want of mental and bodily energy and activity. A third set belong to the nervous temperament ; they are easily excited and easily depressed, so that excit- ants cause either a form of hysteria or hypochon- driasis, for example. The predisposition amongst this class is constantly met with in diseases of an acute character. Nervous persons suffer quickly from delirium and other brain-symptoms, which aggravate and render dangerous an other- wise hopeful malady. In the acute specific diseases this is particularly manifested ; nervous people are undoubtedly predisposed to them, and when once attacked are predisposed to dangerous complications. Practically we meet with ‘mixed’ temperaments, though one perhaps especially prevails. See Temperament. 6. Climate and. Locality. — These differ widely in their predisposition to disease. Persons who have been accustomed to a particular cli- mate frequently suffer when transferred to one differing from it; and on the other hand tho sick often benefit by change. Particular diseases flourish in particular climates, and particular organs suffer. In the tropics various endemic fevers prevail which are unknown in this country, for they cease to exist when the temperature sinks below a certain level (about 60° Fahr.). Frost very often cuts short epidemics in our own country in like manner. Particular organs are predisposed to disease by climate — the liver in the East Iudies, the lungs and the kidneys in regions where the temperature is capricious. Climates differ as regards air — whether moist or dry, hot or cold ; but besides these things the topography must be considered, and the elevation of districts. Plains, mountains, and valleys have various predisposing influences, and while much of such influence depends on the configuration of the country, no little is due to the nature of the soil. No better proof of the latter fact can be given than that yielded by the observa- tions of Dr. Buchanan, who has shown that where t» proper system of drainageof soil-wateris carried 25 88f out, the tendency to pulmonary diseases is very greatly diminished. Claysoilsare cold and damp and favour diseases aroused by these combined agencies ; sandy and gravelly soils readily drain themselves, are warm and dry, and thus far tend to protect those who live on them against disease. Climates are also modified by trees, rocks, rivers, lakes, &c. Detritus carried down by streams and deposited along their banks or at their estuaries has, like ground vegetation and its decay, an un doubted predisposing influence. Particular dis- trictsalso predispose to certain diseases. Cretinism is most common in close valleys ; urinary calculus is endemic in many districts of Great Britain and elsewhere. In some circumscribed areas in Scotland, in Norfolk, and other district, individuals are especially liable to stone. The influences of climate are well shown by the electric conditions of the atmosphere; some persons are so predisposed that they can foretell a thunderstorm by the change in them- selves. Fogs in large cities depress most people , and it is not too much to say that many diseases may be traced to a predisposition which ‘bad weather’ has started. Alcoholism has been pro- voked in this way. It is clear, therefore, that under the head of climate there are many combin- ing influences, which affect the moral, mental, ami bodily nature of individuals, and through one oi all may predispose to disease. In this country, and probably elsewhere, those who dwell on mountains are less liable to disease than the dwellers on plains ; marshy plains especially predispose. It should be remembered, however, that it is not climate alone which varies the pre- disposition amongst persons residing in different regions, for their habits, diet, &c., differ fat more than the climate in which they dwell, and predisposition to disease should never be ascribed solely to climatic conditions unless accidental influences have been investigated and eliminated. 1 See Climate. 7. Town and Country. — The influences of town and country, as predisposing to disease, re- quire a separate consideration. With them may be considered dwellings, and a variety of minor sources of predisposition. The mortality of coun- try districts is less than that of towns, but towns differ in this respect amongst themselves. The health of the largest city in Great Britain, for ex- ample, compares favourably with any of the large manufacturing towns and with many rural com- munities. It is easy to understand that differences must depend on the occupation, food, and habits of the people, and on their external surroundings —air, light, drainage, and like conditions. In large towns occupations are more lowering than in country districts ; while the physical and men- tal strain is greater, and has fewer interruptions. Late hours, intemperance, and prostitution prevail in towns ; but it is by no means certain that, in proportion to the population, these ills are less frequent in the more remote districts. In towns overcrowding checks ventilation, makes 1 Imperfect drainage leads to what are popularly known as ‘ damp walls ’ in dwellings, and thus predisposes to pulmonary diseases by interfering with ventilation— in fact, by preventing the admission of pure air into such dwellings. This truth bears out the teachings we have derived from Dr. Buchanan’s investigations at Ely and elsewhere. m DISEASE, C drainage difficult, so that subsoils become satu- i rated, clouds the atmosphere with smoke and dust, intermingles the sexes (amongst the lower elasses) so that succeeding generations are stunted in their development, and in a variety of other ways predisposes to disease. But in some towns these evils have been obviated by sanitary measures, and as a consequence towns often pre- dispose less than country districts to diseases due to defective drainage and overcrowding. Some startling illustrations of this fact have occurred since sanitary science has been acknowledged to be of national importance. In villages, for instance, reputedly ‘ model,’ epidemics of disease associated with defectivedrainage and evil domestic arrange- ments have decimated the inhabitants, and the virulence of these epidemics has been greater than that of those met with in large towns. The latter are now-a-days for the most part better drained than country districts ; thus milk-epi- demics of typhoid fever have been imported into large cities from isolated farms where the drain- age alone seemed to be at fault. Amongst children, rickets, scrofula, and tuberculosis are far more prevalent in town than country. The mortality amongst yotrtig ohildren is far greater in towns than country districts. Adulterations are an evil in large communities, affecting people of all ages. From many of these country districts are free, and especially is this true as regards milk. So while dwellers in the country may have had drainage and bad houses, they have pure air as a rule, every opportunity of breathing it out of doors, and unadulterated milk. Even the alcoholised drinks in many country districts are home-made and harmless when compared with the adulterated raw spirits taken by the lower classes of largo towns. 8. Hygienic Conditions.— One of the most common causes of disease coming under this head is want of cleanliness. To this is due a variety of skin-diseases, such as eczema of the scalp in children, diseases caused by pediculi, &c. It interferes with the functions of the skin generally, and by it even a common cold is modified. Clothing is a part of this subject. Insufficient clothing is a most im- portant source of predisposition, amongst the rich as well as amongst the poor ; for, though the climate of this country is so variable, cor- responding adaptations of dress are for the most part neglected. Flannels worn day and night also predispose to disease. Clothing is used to pre- vent the loss of heat, which occurs in three ways — by radiation, conduction, and evaporation, and a careful adaptation enables us to modify these sources of loss in such a way as to obviate a pre- disposition to disease. There is probably more care taken in tropical climates to regulate the heat of the surface than in the temperate zones. A very common cause of predisposition to disease is neglect of proper bedding. Deficient ventilation and overcrowding are prolific sources of mischief. Overcrowding without ventilation is one of the greatest evils of our chief cities and towns ; and not only is it in their homes and workshops that popu- lations are overcrowded, but in their places of recreation, such as theatres, and in their places of religious worship. Briefly it may be said that overcrowding predisposes to moral, mental. IAUSES OF. I and physical deterioration ; to epidemic diseases, and especially to typhus fever; to pulmonary affections ; and to a variety of nervous diseases. By lowering the morale of populations it increases all other predispositions, and, in fact, passes into an active exciting cause of disease. 9. Occupation. — This is a common cause of disease, and is often associated with want of proper hygienic conditions. The overcrowded in work-rooms breathe an impure air, an air loaded with carbonic acid, irritant particles, aiu; various exhalations, and thus are liable to disease. Miners breathe an air laden with carbon ; knife- grinders inhale fine particles of metals ; marble- polishers and masons are in the same plight ; in all three cases occupation, combined with neglect of hygienic precautions, leads to pulmo- nary diseases. Occupation is in many cases a direct exciting cause of disease ; for example, workers in arsenic, antimony, copper, lead, the mineral acids, &c., suffer from the poisonous effects of these substances. But oftentimes they escape the direct influences, yet are subject to a predisposition to various diseases, as a conse- quence of their occupation. Various other occu- pations, such as those of tailors, shoemakers, milliners, and brain-workers, predispose to disease in different ways. Too much work and too little work (mental or bodily) predispose distinctly to disease. Con- tinued overwork reduces the system generally, and special organs in particular, according io its nature. A coachman, who uses for many hours his pectoral muscles in driving, suffers chiefly in them when he has an attack of mus- cular rheumatism. So also those who use the brain too much in intellectual work are pre- disposed to functional, aud even to organic derangements of the nervous centres. Physical overwork is often conjoined with exposure ami improper or irregular food-supply, and the com- bination has a marked effect. It has so predis- posed armies to disease that theirrar.ks have been decimated by fevers, pneumonia, aud bronchitis, far more than by the cannon or by the sword. Not a few medical men have been affected by the contagia of the acute specific diseases, be- cause when exposed to them they were worn out by bodily and mental exertion, and by pro- tracted fasting. Over-work reduces the ner- vous power, and thereby strikes at the very root of the healthy status. On the other hand a sluggish use of the mind and body are favour- able to disease, and some persons are so con- stituted that they cease to be safe when their minds have lost the opportunity of active exer cise; and the very fact that they substitute an abnormal intellectual employment is proof of this truth. And what is true of the mind is true of the body. A sudden change from active bodily exercise to bodily laziness predisposes largely to disease. 10. Air. — The question of air has already beenalluded to, in considering climate, occupation, town and country, overcrowding, &c., and it is scarcely necessary to dwell much more on i : s aetiological effects. Air influences the predispesi- tion to disease according to its degree of rarefac- tion, moisture or dryness, warmth or coldness, and the impurities, mechanical or chemical, which DISEASE, CAUSES OF. may adulterate it. In the article Climate many of these atmospheric conditions are fully dwelt upon, and their tendencies explained. Impurities in the air are exceedingly prevalent ; and mechanical substances suspended iu it can excite irritable conditions of the air-passages which may pass cn to inflammation, and even destruction of the lungs. Throat and laryn- geal affections are a common consequence of these impurities. All these chiefly occur amongst certain classes whose occupation loads the air with fine particles as already described. There .s scarcely a mineral used in the arts which cannot, by inhalation, excite or predispose to disease. The air may also be rendered impure by chemical agencies, and the moment the normal proportion of its elements is disturbed .t becomes a source of disease. Excess of car- bonic acid is especially an element of mischief — causing headache, dyspepsia, and nervous depression. The presence of ammonia and of sulphuretted hydrogen is attended by like results. The human economy is, however, so framed that its organs can often very rapidly throw off the evil effects of these gases when breathed in overcrowded rooms, &c., 10 that no permanent mischief is established. Poisoned air plays a part in the production of scrofula, anaemia, and lowered conditions gener- ally ; but it is an incomplete comprehension of the causes of these conditions to set down all to this one. The air, also, may be poisoned by other gases, such as carburetted hydrogen. The atmosphere is modified by currents — sometimes to the relief, sometimes to the danger of mankind. Winds can remove sources of con- tagion — they can ‘ clear the air.’ But they can also bring contagion into localities according to many authorities. Cholera and other diseases have, it is said, followed aerial currents — that is, have boon carried by them. East winds are a prolific cause of disease ; they excite it directly, and carry off healthy individuals, even though the cold be not extreme. Sometimes westerly winds have a dangerous influence, and in the winter of 1877-1878 a wave of disease, having many of the characteristics of ‘ influenza’ was carried across England by a west wind. 11. Previous Disease. — Previous disease often predisposes to the same or to some other affection, and no clinical history is of value unless it includes an account of former ill- nesses. In difficult and doubtful cases a true statement of these often gives the clue to diag- nosis, and even patients themselves are alive to the value set upon an accurate account of their life-ailments. An attack of croupous pneumonia predisposes to recurrence, especially during the twelve months succeeding the attack ; and it may leave behind a predisposition ex- tending far beyond the original disease. Chorea, acute rheumatism, tonsillitis, and epilepsy tend to recur, as also do the ordinary convulsions of chil- dren ; but in all these and many other cases it is difficult to estimate the exact part played by derived predisposition, because in all the primary predisposition may be the main agent iu the subsequent attacks. In practical medicine it is distinctly recognised that cer- tain diseases predispose to disease, and in 387 their case recurrence is, very properly, jealously guarded against. Pertussis is supposed to pre- dispose to measles, and vice versa. There is distinctly a connection between chorea, rheu- matism, and scarlet fever, and these diseases may follow one another in any order. Again, previous disease may leave behind pathological lesions which remain in abeyance until excited by causes which the healthy individual could readily withstand. Pertussis often ends to all ap- pearances favourably, but afterwards the patienti, may suffer from severe lung-affections, upon tri- fling exposure to exciting influences. Calcareous deposits in the lungs may excite a new catarrhal phthisis ; hepatic mischief followed by collection of gall-stones in the gall-bladder may cause peritonitis and other diseases. Slight complaints are even more marked in their predisposing powers than serious diseases. On the other hand, previous disease sometimes protects individuals and communities ; for example, vaccination can save nations from the most terrible of scourges. In the case of scarlet fever, typhus, pertussis, measles, &c., an almost perfect immunity is ac- quired by those who have already suffered from them. Of course, as with small-pox, no one denies that second attacks of these diseases do occur, but such attacks are wholly exceptional. 12. Mental and Moral Conditions. — Ba/l news may cause sudden death, or, short of tills, may interfere with the functions of par- ticular organs. Sudden mental worry may excite dangerous interference with digestion, or start an abnormal cardiac rhythm. Fright has turned the hair white within a few days or hours in healthy persons. Mental and moral shock can check or increase the flow of urine, and, in fact, can affect all the excreting and secret- ing organs of the economy. Mental overwork can excite, per se, brain-conditions of a dangerous nature, such as hypersemia or anaemia, and. even, it is said, meningitis of simple or tubercular form, according to the inherited predisposition. Undue or sudden emotional disturbances can ex- cite serious mischief, just as they can predispose to it. Again, the mind is affected by imitative influences ; thus chorea is excited in some indi- viduals by watching choreic movements, and a single hysterical patient may arouse in others- symptoms almost identical with her own. The subject of the direct influence of the mental and moral state on disease is, however, too wide to be here dwelt upon. 13. External Physical Conditions. — These are very numerous as exciting causes of disease. Violent over-exertion can cause herniae, haemor- rhages, as from the vessels of the lungs, cerebral congestions, and even ruptures of the valves of the heart, and in one or all of these cases lead directly to death. Over-exertion with the voice may be followed by pharyngitis or laryngitis. Syncope has occurred in the most healthy from violent exertion in hill-climbing, in boat-racing, walking and running matches, &e., acute dila- tation of the ventricles probably occurring. Various forms of direct injury are frequent causes of disease. 14. Poisons. — Poisonous gases are powerful excitants of disease, and so are poisons generally whether animal, vegetable, or inorganic. Thoy 388 DISEASE, CAUSES OF. may kill quickly or excite a disease of long- continued or even permanent nature. 15. Temperature. — Heat and cold carried to excess may prove fatal at once. The influences of severe cold are described unde: the heading cold, and it is only with the diseases excited by heat and cold in the everyday acceptation of these terms that we shall deal here. Long-con- tinued heat lowers the vital powers, and may excite such diseases as slight eczema of a simple character, or such grave affections as in- flammation of the membranes of the brain. Heat may kill suddenly, as in sun-stroke, or excifo cerebral mischief just short of death ; while in persons of tubercular diathesis it may induce tubercular meningitis ; and even more general effects follow severe local applications of heat. Moderate heat applied to the back often de- presses the heart even to syncope. Choleraic attacks in this country usually are associated with exposure to immoderate heat. Cold is the most common cause of disease in temperate climates, especially in the changeable climate of this country. It can excite disease directly, and can affect probably all the organs of the body, causing either disturbed function or organic mischief. Cold, when severe, contracts the vessels ; interferes with the circu- lation, and all vital activity ; and in thi3 way may cause death. But it is witli moderate degrees of cold we have chiefly to deal. A momentary exposure to a cold draught is as frequent an excitant of disease as general ex- posure for a long time. A cold draught playing on the cheek may cause facial paralysis, sore throat, or bronchitis ; that is to say, cold applied locally may excite disease in the neighbourhood of its application or in distant organs. It is probable, therefore, that cold may act in several ways : (1) it may interfere with circulation ; (2) it may affect the extremities of nerves and excite disease by reflex action; or (3) it may check secretions of the skin, the mucous mem- branes. &e. We cannot wonder, therefore, that diseases of the throat, larynx, and lungs are frequently ex- cited by cold, Bronchitis and pneumonia are its most common results ; and as the young and the old aro less enduring of cold than adults, it carries them off with great frequency. Diarrhoea, renal diseases, congestion of the liver, acute and chronic rheumatism, simple dyspepsia, and a host of other affections, are traceable in many instances to cold. Predisposition lias much to do with the effects of cold ; some in- dividuals suffer from one form of disease when exposed to it, others from entirely different affections. In some, ‘a common cold’ is most evidenced by severe muscular pains and fever, in others by a nasal discharge, in others by head- ache, and so on. Some persons never suffer from ‘ cold ’ without having an attack of herpes labialis; and numerous similar idiosyncrasies might be given. The effects of cold should always be considered with almost all predispos- ing causes of disease. ‘Cold’ is a vague term and not thoroughly understood ; there is all the more reason why, when it comes under consideration in individual cases, its precise effects should be most carefully considered and recorded. DISEASE, CLASSIFICATION OF. 16. Diet. — Food and drink can by their abuse excite disease, and gluttony is as powerful an excitant as drunkenness, though in temper- ance outcries this fact is almost completely lost sight of. Excess of food does not refer simply to the quantity taken, but to its quality — its nature, richness, and the times when it is taken. Agricultural labourers eat more than the gentry, but live longer, and the gentry of old-fashioned type are longer-lived than whose who frequent the fashionable world. Excess of food overloads the stomach, makes calls upon it which it cannot meet, and dyspepsia is the result. Excess of food, if digested, charges the blood with materials not demanded by the economy, and disease of excre- tory organs or fatty degenerations may thu3 be excited. Want of fool also excites disease, such as pneumonia, bronchitis, or other catarrh, espe- cially in children, many deaths amongst whom are the direct consequence of improper feeding. When the proper admixture of the elements of food is neglected, disease results, as, e.g., scurvy. Particular foods will immediately ex- cite violent gastric catarrhs in some individuals, while others can bear them perfectly well. Putrid food is an active poison. Certain kinds of fish arc poisonous in themselves, and some vegetable foods laden with salts of lime are supposed to cause urinary calculi. Water and milk are prolific sources of mischief, through the impurities they so often contain. The drinking waters of large towns are usually derived from rivers, and fil- tration is not a sufficient purification, so that disease may be excited by their use. Alcohol is a most extensive source of disease : it causes, when taken in excess, cerebral, gastric, intes- tinal, hepatic, and renal affections, and can lower the system so far as to predispose to other dis- eases. See Alcoholism; and Poisonous Food. 17. Epidemic Diseases, Contagion, Mala- ria, Parasites, and Growths are treated of under separate headings. It i3 now generally es- tablished that the diseases known as the acute specific diseases are mostly 1 direct consequences of some contagium. So among the most common exciting causes of disease we must class the contagia of the several fevers, of syphilis, &e. See Pehsonal Health ; and Public Health. J. Pearson Irvine. DISEASE. Classification of. — Various classifications of diseases, or systems of nosology, have been adopted by different writers, but it is beyond the province of this work to discuss these arrangements, neither of which fulfils all that is required, or can be regarded as satisfactory. All that can be done here is to point out the characters upon which the chief divisions of diseases are founded. The first classification deserving of mention is that into (1) General and (2) Local. Gene- ral diseases include those in which the whole sy'stem is involved from the commencement, and it comprehends as sub-divisions (a) The acute specific fevers, and certain other diseases due to the introduction of some morbific agent into the body from without, or in some instances developed within the system, for example, typhus and typhoid fevers, scarlatina, small-pox, malarial fevers, hydrophobia, syphilis DISEASE, CLASSIFICATION OF. pyaemia and septicaemia. (i) The so-called constitutional , cachectic , diathetic , or blood- diseases, some of -which seem to depend upon the production of deleterious elements within the system, which are capable of recognition, such as rheumatism and gout; while others are independent of any such obvious patholo- gical causes, but are supposed to bo severally associated with a peculiar dyscrasia or diathesis, for instance, cancer, tuberculosis, scurvy, rickets. Local diseases are those which primarily affect particular organs or tissues, each being liable ;o its own peculiar lesions. Thus we have diseases of the lungs, heart, stomach, liver, kid- neys, brain, and the other organs ; of the mucous membranes, serous or fibro-serous membranes, skin, periosteum, bone, and other structures. This division into general and local diseases is useful within proper limits, but it must be re- membered that general maladies are often re- vealed or accompanied by local lesions, and that complaints which are originally local often more jr less speedily set up general disturbance. More- over, it is still a question whether some maladies are to be regarded as general or local in the first instance. See Symmetry in Disea.se. Another division of diseases, which applies more particularly to those which are of a local nature, is into (1) Organic or Structural, and (2) Functional. These terms are self-ex- planatory, the former implying that there is some organic change in the affected part, which we can discover and demonstrate ; the latter indicating that there is mere functional disorder, which is independent of any recognis- able lesion. That there are structural changes in many affections which are regarded as func- tional is, however, highly probable, though our means of observation are not sufficiently powerful to enable us to detect them. In con- nection with each organ, a special classification of its individual complaints under one or other of these primary headings is usually adopted, this sub-division depending upon the affections to which the particular organ is liable. As illustrations of functional disorders may be men- tioned disturbed action of certain organs, as of the heart, causing palpitation; derangement of the secretory or excretory functions, as in the ease of the stomach, liver, or kidneys ; and many nervous disorders. Organic diseases are exem- plified by inflammation and its consequences; alterations in growth and development; degene- rations ; malformations ; and new growths. In this work it has not been deemed advisable to describe the diseases of the several organs ac- cording to any definite scientific arrangement, but in some cases an alphabetical order has been adopted, while in others individual writers have been allowed to classify the affections of a par- ticular organ according to their own judgment. Again, diseases may be classified according to their causation and mode of origin. Thus they are divided into(l) Hereditary, or those which are transmitted either directly from parents to children, or indirectly, as the result of a family taint ; and (2) Acquired, or those which are developed anew in persons free from hereditary taint. When a morbid condition exists at birth, it is said to be Congenital. Other divisions, DISEASE, DIAGNOSIS OF. 38S founded on an aetiological basis, are into (1) Contagious or Infectious, and (2) Non- contagious; and into (1) Specific, or those diseases which are due to a specific cause, and (2) Non-specific. There are other classifications of diseases, which need only be mentioned here. Thus, ac- cording to their intensity and duration, they arc said to be (1) Acute ; (2) Sub-acute ; or (3) Chronic. Another arrangement, founded on their mode of progress, is into (1) Continuous; (2) Periodical, or affections which come on at more or less definite intervals ; (3) Paroxysmal, or those which are characterised by sudden or acute paroxysms ; and (I) Kecurrent, or diseases which tend to recur. Lastly, according to their mode of distribution amongst communities or in districts, complaints are said to be (1) Sporadic ; (2) Epidemic ; (3) Endemic ; and (4) Pandemic. The meanings of these terms are defined under their several headings, but they are sufficiently familiar as indicating the mode of distribution of the diseases to which they respectively belong. With regard to the classification of diseases which is likely to be permanently adopted in the future for general use, it is probable that this will be founded on a pathological basis, and that, as our knowledge of morbid conditions and pro- cesses becomes more extensive, accurate, and definite, it may become possible to establish a system of nosology which will be both scientific and practically useful. Frederick T. Egberts. DISEASE, Diagnosis of (5ia, intens., and yu'itoKco, I know). — Synon. ; Fr. Diagnose-, Ger. dcr Diagnose. Definition. — Diagnosis is the art of recog- nising the presence of disease, and of distinguish- ing different diseases from each other. The term is also applied to the result obtained. General Considerations. — The general prin- ciples only of diagnosis will be here discussed. Special diagnoses will be treated of in connec- tion with the several diseases to wdiich they have reference. In many respects diagnosis is a subject of great interest and importance. First, in a scien- tific point of view, it is essential that all know- ledge should be accurate. Secondly, accuracy of diagnosis, founded upon a sound pathology, en- ables us to frame a scientific classification of disease in its diverse forms. It is also by accu- rate determination of the nature of the disease which may be present in any given case that we are able to anticipate its course, and to employ the right kind of remedies in its treatment. It is imperfection of diagnosis which leads in many instances to an under-estimate of the value of therapeutical agents ; for when the nature of a disease is mistaken we are led to employ im- proper and unsuitable remedies, the failure of which is then erroneously attributed to the inefficiency of the agents, and not to the unfitness of the treatment employed. If our diagnosis had been correct or complete, the remedy selected would more often have had the desired effect. In order to arrive at a diagnosis we must study the phenomena or characters of each id- 590 DISEASE, DIAGNOSIS OF. dividual case, and trace its connexion -with those groups of symptoms which have been pre- viously recognised and described as belonging to special or distinct diseases. Assuming that the classification has been already made, we pro- ceed to deal with the means which enable us to identify each individual case, and to connect it with a previously classified disease. Means of Diagnosis. — To obtain accuracy in diagnosis we must bo prepared with a know- ledge of the several forms and varieties of disease ; we must be familiar also with the functions and structure of the several organs '•f the body in health. It is by observing and comparing the changes caused by disease in the t hese functions and structures, that we are en- abled to discover the presence of, and to deter- mine the nature of disease. In forming, then, a diagnosis in any particular case, the physician must, as far as possible, keep in view the real or the ide.al condition of the patient in a state of health. Ho must endeavour to place him in xs natural a position as may bo, and as little disturbed by the presence of his attendant, or by external circumstances, as possible. The phy- sician must then obtain a history from the patient himself or from others of the incidence of the disease ; and having done this he must proceed to investigate for himself thecondition of thepatient. 1. Previous history of the patient. — The history implies of course a statement of the age and sex of the patient, as well as of his home aud his em- ployment — each of which may have a special rela- tion to disease. It should also include an inquiry into the antecedent generations of the patient, and how far he may have any proclivity to con- genital disease or malformation. This inquiry should have reference to both positive and nega- tive facts. It should extend not only to the previous existence of disease in the family, but also to the absence of particular diseases or types of constitution. The patient’s history should include a statement as regards the diseases and injuries from which he may previously have suffered; the remedies used for them ; and the climatic and other influences to which he has been exposed. Nor must the physician neglect to ascertain the history of any children that the patient may havo had, as the nature of disease from which the offspring have suffered in many instances throws light upon the health of the parent. 2. History of present illness. — The history of the present illness should include the determina- tion of the date of its commencement; its probable cause ; and its progress as influenced by external circumstances, including treatment. 3. The present condition of the patient. — Here we have to deal with two classes of phenomena; namely (a) those feelings or facts of self-con- sciousness which the patient describes to us — - subjective phenomena ; and ( b ) those signs which we ourselves observe — objective phenomena. a. Subjective phenomena.— The patient describes to us his feelings — as of strength or weakness, of numbness, tingling or pain, of wakefulness or wandering ; he can tell of affections of vision, of hearing, of smell, or of taste; of breathlessness, cough, palpitation, or of feelings of sinking or faintness; of difficulty of swallowing, thirst, loss of appetite, nausea or sickness, or various sensa- tions and actions connected with the abdomen; of feelings associated with the genito-urinary organs, such as pain or difficulty in passing water; of cramps, spasms, or other alterations of sensa- tion or motility; or of disturbances of sensibility and activity, &c. Each of these signs of deviatiob from health will have its own value and signi- ficance. The physician must at the same time carefully note how far the condition of the pa- tient is in accordance with his statements, and whether there may not be present some reason or cause for concealment or exaggeration. b. Objective phenomena. In studying the ob- jective phenomena connected with disease, the physician makes use of his special senses, assisted by the several instruments with which modern science has provided him. First, in matters of eye-sight , he sees the general aspect and expression of the patient, which will include the colour of the skin (such as may result from the fulness or emptiness of the blood-vessels, from the yellowness caused by jaundice, from the blueness of cyanosis, or from pigmentation, &c.) ; the presence and character of cutaneous eruptions (especially in the exan- themata) ; the expression proper, such as that of ease or suffering, and of depression or excite- ment ; the conditions of obesity and plethora, or of wasting and bloodlessness. He will also ob- serve the position of the patient, how he lies, or sits, or stands, and how breathes ; the appearance of the eyes, the tongue, etc. Further, the sense of sight will be employed in determining conditions of a local or less general nature. Observation must be made of the size, the shape, and move- ments of parts, and of their expansion or con- traction. With the aid of special instruments, such as the ophthalmoscope, the laryngoscope, the various specula, sounds, &c„ the physician will be able to examine parts of the body of the patient, beyond the reach of the unassisted eye. The chest-measurer or the stethometer willrender more exact the information already obtained by the eye ancf hand as to the size and mobility of parts. The use of each of the several instruments above mentioned, as a means of diagnosis, will be found described under the heads of their re- spective names, or in the article on Phtsical Examination. The sense of hearing tells of the character of the breathing, the voice, and speech of the patient, including cough, hoarseness or aphonia, ‘ aphasia,’ &c. But the ear is especially applied to the study by auscultation of the sounds produced in con- nexion with the heart, the lungs, and other or- gans. The signs thus elicited will be found fully described elsewhere. The sense of touch or feeling will communi- cate a knowledge of the temperature, of moisture or dryness, of size, shape, elevation ordepression. of smoothness or roughness, of the pulse or pul- sation, vibration, fremitus, of extent of move- ment, resistance, softness or hardness, and of fluctuation. The accuracy of the results of these observations by touch may be tested by the use of the thermometer, the calipers, and the tape- measure. The sense of smell aids diagnosis in certain cases. The general odour of the patient ma) DISEASE. DIAGNOSIS OF. 39, be observed in small-pox, in rheumatism, and some -wasting diseases (such as phthisis), and in syphilis; and the odour of particular parts and secretions, as the urine in diabetes, and in cases of the use of certain drugs, or in poisoning. In- formation is also afforded by the odour of certain discharges, as in ozaena, leucorrhcea, cancer, &c. The sense of taste is seldom employed in clinical investigation, but the physician may make use of the patient's taste, as in tasting the urine in diabetes. Further aids in Diagnosis. — Having thus sum- marily described the employment of the special senses in diagnosis and given examples of their use, we may briefly mention some other agencies of more general application. The acuteness of the patient's sense of touch may be determined by the sesthesiometer ; the capacity of the lungs may be measured by the spirometer, and the strength of muscles by the dynamometer; the contractility of muscles by galvanism ; the force and character of the pulse aro determined by the sphygmograph ; constant use is found for the microscope, the test-tube, the spectroscope, and polariscope, which aid in determining the character of the various secretions or morbid matters that require to be submitted to inves- tigation. The result of treatment may also be mentioned as an aid to diagnosis, as for example, when an indurated sore yields to the use of mer- eury. Again, the knowledge that a person has been in a malarious district enables us to decide on the intermittent nature of certain symptoms that may be present. In some cases it may be necessary to render a patient insensible by anaes- thetics, with a view to making a complete ex- amination, or in investigating feigned diseases. The administration of small doses of charcoal has been suggested as a means of determining tho presence of a passago through the bowels when more or less obstruction exists. Such then are the means used for taking note of those deviations from health which occur in the several functions and structures of the body, and which constitute what are known as the Symptoms and Signs of Disease ; these aro terms which will be found more specially treated of under the heads Disease, Symptoms and Sigus of ; and Physical Examination-. The Difficulties of Diagnosis. — It needs scarcely be said here that the practice of diag- nosis is not free from great difficulties. Wo know how hard it is to obtain in ordinary daily life a reliable account or description of any past or present event. There must, be still greater difficulty in obtaining an accurate medical history of a patient’s case. He has to tell of facts of which practically he may know much, but scien- tifically very little. He may be forgetfnl or ignorant on points about which we most need to be informed. He may be inclined to ex- aggerate or to suppress facts of material import. Nor are the difficulties less in regard to the objective phenomena with which we have to deal. The symptoms of a disease are rarely so clear and definite as to mark its nature, that is, to be pathognomonic. They are more often slight, undefined, obscure, and to be found with diffi- culty. The symptoms of one disease may very closely resemble thoso of another, whilst those of the same disease will vary at different stagea and in different individuals. Again, the symp- toms of a disease may be complicated by thu co-existence of those of another disease ; whilst a symptom sufficiently striking in itself may- be common to, and present in several different diseases. We need only mention, for example feverishness, pain, cough, breathlessness, and blood-spitting. These are some of the difficulties which he who has to study the operation of disease in life, has to contend with. He must come prepared for the duty with a knowledge, as we have al readi- said, of the body 7 , its structure and functions iu health, and with a knowledge too of thoso com- binations of morbid actions which constitute special forms of disease. For as regards this latter knowledge, all the observations made would remain as isolated phenomena if they could not in each case be grouped as constituting distinct diseases. We have thus indicated the difficulties of obtaining accurate knowledge as regards both the. subjective and objective phenomena. The difficulties aro not less when the exercise of the intellectual and reasoningfaculties is called upon to analyse, to compare, and to group these pheno- mena. The physician may commence his inquiry by- tracing up the history of the case and its several incidents, a method which is called the synthetical-, or he may commence by ascertaining the present condition of the patient, and going as it. were backwards in his inquiry — a method which is known as the analytical. As a general rule, both methods are combined in the practice of diagnosis. Observers can sometimes arrive at a direct diagnosis , aided by the presence of some charac- teristic symptom or sign of disease. When diseases which are essentially different have symptoms more or less common to both, the physician will have to institute a comparison between them, until he finds sufficient evidence, in the presence or in the absence of some dis- tinctive symptom or sign, to satisfy him as to the nature of the disease which is present. By being able thus to trace the absence or the presence of a given symptom, he may be able to exclude the possibility of the existence of one or other of the diseases under investigation. These modes of investigation will be found fully illustrated in the diagnosis of the several dis- eases described throughout the work. In conclusion, it must be remembered that these investigations, which call for the exercise of the highest mental faculties, should be conducted without prejudice and without haste. We should never be ready to accept as clear that which is obscure, as established that which is open to question : above all we should remem- ber that, though to err is human, it is our duty to endeavour to ascertain in each and every case, before commencing its treatment, what its real nature is, as far as it may be possible for us to do so. It cannot be too often repeated that the application of a right remedy depends on an accurate diagnosis, and that the prevention and the cure of disease are the aims and ultimate objects of our science. E. Qcain, MJ5. *92 DISEASE, DURATION OF. DISEASE, Duration of. — The duration of a disease signifies the period ■which elapses be- tween its onset and its termination, in whatever way this may take place. In some instances disease can hardly he said to have any duration, a sudden lesion occurring, which instantaneously, or in a very short time, destroys life ; under such circumstances, however, some previous disease has usually existed, though perhaps without giving any clinical evidence of its presence, which determines the occurrence of the sudden result. This may be illustrated by some cases of apoplexy, and of rupture of the heart or of an aneurism. Most affections, as regards their duration, come under one of the three categories already referred to under the classification of diseases, namely, acute, sub-acute, or chronic, but it does not serve any useful purpose to fix any definite limit of time as specially expressed by each of these terms. See Acute, and Chronic. Acute diseases are of limited duration, and in many of them this is remarkably uniform, as may be illustrated by the acute specific fevers and acute idiopathic pneumonia. Even in such affections, however, there are deviations from the ordinary course, instances occurring in which the duration is longer or shorter than that usually observed, and this feet de- pends on various circumstances, of whicli the most obvious are the intensity of the disease in any particular case, the previous condition and surrounding circumstances of the patient, the occurrence of complications, and the treatment adopted. Complaints which are sub-acute as regards their duration may be exemplified by many cases of whooping-cough and chorea, and by some cases of pleurisy, phthisis, pneumonia, gastric or enteric catarrh, and certain skin-affec- tions. A large number of diseases are chronic in their duration, and many of these when once established become permanent, whilst others are ultimately capable of being cured. As illustra- tions may be mentioned organic diseases of the heart, most cases of phthisis, cirrhosis of the liver, ehronic Bright’s disease, dyspepsia, many skin- affections, and also morbid growths in various structures. Some complaints, as regards their duration, can only belong to one or other of the groups just indicated, but a considerable proportion may in different cases be either acute, sub-acute, or chronic. Again it must be borne in mind that a disoase may be acute or even sudden in its origin, but afterwards may subside into a chronic malady. Certain affections are chronic as regards t.hoir entire duration, but are characterised by the occurrence at regular or irregular intervals of acute or even sudden attacks, lasting a more or less definite time, which course of events is exemplified by cases of ague, epilepsy, and asthma. Frederick T. Roberts. DISEASE, Germs of. — See Germs of Disease. DISEASE, Prognosis of (irpl >, before, and ; nemi. I know). — Synon. : Fr. Pronostic; Ger. I 'rognose. Definition. — Prognosis is the art of forecast- ing the progress and termination of any given > DISEASE, PROGNOSIS OF. ease of disease. The term is also applied to the foreknowledge thus obtained. General Considerations. — It is a matter of interest and often of great importance to be able to indicate with precision how a case of disease or injury will he likely to advance and terminate. This question must be always present to the phy- sician’s mind ; and it can rarely be absent from that of the patient and of those who are in- terested in his well-being. It can easily be seen how much depends upon the answer of the physician to the questions constantly proposed to him, How long is this illness likely to last ? How is it likely to terminate ? If in recovery, will the recovery bo complete or partial ? If in death, when and how? Grounds of Prognosis. — The knowledge which can give trustworthy answers to such questions as the preceding must be founded upon an accu- rate diagnosis of the nature of the disease from which the individual is suffering ; upon the capa- bility of remedies to control it; and, lastly, upon an estimate of the constitutional and vital powers of the patient. First, as regards the nature of the disease. Some diseases which are mild in their nature run a definite course and end favourably; take, for example, a simple catarrh. Others commence with great intensity, and come to a favourable or unfavourable termination very rapidly, for in- stance, Asiatic cholera, of which many of the sub- jects die in less than twent3‘-four hours from the time of their first becoming manifestly ill. A third group, such as typhus, typhoid fever, and certain of the exanthemata, run a longer and more defined course, seldom terminating in death except after the lapse of many days, nor in re- covery except after a period of some weeks. Another class of maladies, chronic in character, rarely acute, such as we see in tubercular diseases of the lungs, render the patient more or less an invalid so long as he lives, and generally end fatally. The like observation will apply to the so-called malignant diseases. Secondly, the intensify of the particular attack affords further grounds for prognosticating the result. Thus iu a fever, great prostration, high temperature, and rapid pulse, indicative of the severity of the disease, must lead to the forma- tion of an unfavourable prognosis; just as great debility and wasting, with disturbance of the nu- tritive functions generally, would indicate a like result in chronic diseases. Thirdly, in regard of local diseases or compli cations, whatever the nature of the disease may be, the organ affected must form an important element in prognosis. Thus disease of the brain, or of the heart, or of the lungs, or, in a lesser degree, of other viscera, must, even when not specially severe, be looked upon as affording abounds for anxiety, from a prognostic point of view. Fourthly, as regards the constitution, age, and sex of the patient, it may be safely anticipated that in a patient with a good consticution the prognosis will be more favourable than in a per- son with a feeble or broken-down constitution. Persons whose vital powers are unimpaired wil! resist disease, and recover under circumstances which would be fatal to other individuals, is DISEASE, PROGNOSIS OF. rhom, on the one hand, plethoric habits may predispose to acute and rapid changes, or who, on the other hand, by degeneration of tissues may be rendered liable to succumb, and that rapidly, to morbid influences which healthier textures could resist and overcome. Disease is badly borne by the very young and the very old. In very young children disease rapidly runs its course, favourably or unfavour- ably. The aged have little power of reaction or of resistance ; and disease in them, though less pronounced, more frequently ends unfavourably. In middle life, disease may be expected to assume an acute or sthenic form. As a rule, sex has little influence on the prog- nosis of disease, except that usually diseases of equal severity are more amenable to treatment in females than in males. Nervous symptoms are however more easily developed in women, exaggerating a condition that might not other- wise "be unfavourable. Menstruation, pregnancy, parturition, and lactation have all a certain amount of influence, sometimes favourable and sometimes the reverse, on disease in the female. Fifthly, with respect to treatment ; a more or less favourable prognosis may be founded upon the fact that the patient can enjoy all the ad- vantages afforded by rest, diet, change of climate, &c., which may not be available under other circumstances for like cases. It is well known that there are some remedies which have a spe- cific effect upon certain diseases, as quinine upon intermittent fever; mercury in some forms of syphilis ; iodide of potassium in certain stages of the same disease ; and colchicum in gout. In such cases a much more favourable prognosis can, of course, be given than in those for which no such remedies are known to exist. Experi- ence tells us that favourable results follow in many other cases in which suitable though not actually specific remedies can be applied. Taking into consideration, then, the above conditions— the nature, the intensity, and the seat of the disease ; the constitution, the resist- ing-power, the age, and the sex of the patient ; and the possibility of applying suitable and efficient remedies — we are able, in a large num- ber of cases, to arrive at an accurate conclusion as to what the course and result of a disease will be. Difficulties of Prognosis. — Still, to arrive at an accurate prognosis is often very difficult. Disease is not always identical in its character, nor definite in its progress or results. The con- stitutions of individuals vary, and it is often very difficult to measure their powers of resistance. Remedies, too, vary in their action and their operation; and sometimes we are deceived in the best-founded conclusion as to the results that they will accomplish. There are few physicians who cannot recount the errors of prognosis made by themselves or by their colleagues. Many per- sons now live who had been doomed to die ; and many persons have died whose death was not anticipated. It is the duty of the physician, whenasked for his opinion, to state it honestly, but with great discretion, and in general with as much hope as is fairly admissible. He must be guarded as to the manner in which his view is communicated to the patient, for there are many individuals whose temperament is suet that the DISEASE, SYMPTOMS OF. 393 progress of their disease would bo greatly influ- enced for good or for evil by the expression of a favourable or of an unfavourable opinion. At the same time, the physician must avoid deceit-, and if there be risk or danger in communicating an unfavourable prognosis to the patient, he must, at least communicate it to some judicious indi- vidual amongst the patient’s friends. Altogether, too much caution cannot be exercised in stating, in any obscure case, what its progress and result will be. There are many cases in which the medical attendant will be justified in replying that he is a physician, and not a prophet. He cannot always foretell results, his aim and object ever being to mitigate the patient's suffering, to prolong life, and to cure the disease if possible : full often to profess or to do more than this is beyond his art. R. Quain, M.D. DISEASE, Symptoms and Signs of. — When disease affects any of the functions or structures of the body, it produces certain altered actions or changes, which, when observed during life, be- come evidences of its presence and often of its nature, and which then are called the symptoms and signs of disease. The terms symptom and sign are often used sy- nonymously, though the derivations of the words are by no means the same. Symptom , according to its derivation ( tri'ixivTaya = a coincidence) means simply a coincidence, that is to say, it coincides with the presence of certain phenomena. The term sign (from sianum ) is more distinctive, and seems more directly to point to some special or pecu- liar condition. Recently, however, an attempt has been made to give a more special meaning to these terms. Symptom, more especially if it be characterised by the prefix vital, is intended to refer to modifications of functions, or to such subjective phenomena as we can learn from the patient’s account of his feelings. On the other hand, the term sign, more markedly with the pre- fi s. physical, indicates those morbid changes which are objective or may be recognised by the senses of the physician, assisted by other appliances. It would possibly be well if the meanings of the words— symptoms and signs of disease — as above stated, were to come into general use; but there are many difficulties in the way. For example, if the ear be applied to the chest in the case of incompetence of the aortic valves, we hear a murmur, and we say that there are ‘ physical signs ’ of aortic valve imperfection ; but the loco- motive pulse and its peculiar beat, would by many be called a ‘symptom’ of incompetence of the aortic valves. It is therefore extremely difficult to draw the distinctionbet ween the terms symptom and sign. By whatever name these phenomena may be called, we must rely upon them as the means by which we are enabled to form our diagnosis. The more accurate and complete our knowledge of the functions of the body and of its component parts, and the more capable we are of interpret- ing, with all the completeness possible, the changes produced by disease, the more accurate will be our diagnosis as to its presence and its nature. How these phenomena maj' be best observed will be found discussed under the articles on Disease, Diagnosis of, and Physicai Examination. R. Quain, M.D. m DISEASE, TERMINATIONS OF. DISEASE, Terminations of. — The termi- nations of a disease must be regarded both from a pathological and from a clinical point of view. Each pathological process or condition has modes of ending peculiar to itself, but it is beyond the province of this article to discuss these at any length, and one or two illustrations must suffice. Thus, inflammation may terminate by resolu- tion ; by the formation of different effusions or exudations ; or by causing suppuration, softening, induration, ulceration, or gangrene. Fever, if it end favourably, may terminate by crisis, lysis, or a combination of these modes, or in an irregular fashion. An effusion of blood may remain more or less altered ; may undergo organization ; may soften and undergo a puriform change ; may form a cyst; or may be altogether absorbed. The clinical terminations of diseases are highly important, and demand more consideration. In the first place, a disease frequently terminates in the death of the patient. This event may take place suddenly or very rapidly, from the occur- rence of some serious lesion, or of grave func- tional disorder of an organ essential for carrying on the phenomena which constitute life. In other cases death is the termination of a more or less acute illness, either affecting a person previously in the enjoyment of good health ; or, what is not uncommon, being the consummation of a chronic malady, which has existed for a longer or shorter period. In still other instances, death is a slow and chronic process, the patient gradually sinking, several causes and morbid conditions often ultimately contributing to the fatal event. The modes in which death occurs are described elsewhere, and therefore need not be discussed in this article. See Death, Modes of. In the next place, a large proportion of cases of disease end in complete and entire recovery , the patients being restored to theii previous 6tate of health, and no organic mischief estab- lished. This result may be expected in most of the ailments or functional disorders which are of such common occurrence, provided proper treatment is carried out. Again, the great majority of cases of acutedissase terminate incom- plete recovery, taking them in the mass, though several affections of this class, when they do not prove fatal, are liable to leave behind them more or less serious deterioration of the general health, or even actual organic disease. In this class of eases, when recovery does ensue, it is usually only after a more or less prolonged period of convalescence. Chronic complaints, if they are of a structural nature, cannot in most instances end in complete recovery, although to all appearance the patient may often be quite restored. Even in these cases, however, an actual cure may sometimes be effected, and that after a disease has had a prolonged duration. This is illustrated by several chronic skin-affections, syphilis, and chronic inflammation of mucous surfaces. Or it may happen that the patient recovers perfectly, only with the destruction of some structure which is not essential to life, such as the lymphatic glands. Thirdly, partial or incomplete recovery is a i very common mode of termination. This is ob- served in many cases of acute disease, where DISEASE, TREATMENT OF. either the patient remains permanently in a state of general ill-health, without any actual structural lesion being discoverable; or some positive organic affection has been established, of which phthisis remaining after acute pneu- monia, or cardiac disease following acute rheuma- tism, afford apt illustrations. An attack of an acute malady may also serve to bring out some latent constitutional predisposition; or may leave the patient in such a condition that certain so-called corstitutional maladies are readily originated from slight causes. Partial recovery, amounting often to very marked im- provement, may take place in many serious diseases of a chronic nature. This is illus- trated by numerous cases of pulmonary con- sumption, in which disease great improvement is often observed, not only as regards the symptoms, but also in the local lesions, so much so that patients not uncommonly regard them- selves as eurod. Again there are some com- plaints in which apparent recovery is brought about, but a tendency to recurrence remains, either without any obvious reason or from slight causes. Such affections are exemplified by ague, asthma, neuralgia, intestinal catarrh, bronchitis, and certain skin-diseases. As instances of in- complete recovery may be also mentioned the cure of some prominent symptom or symptoms, while the disease which originates these pheno- mena continues unaltered. Thus, it may bo possible to get rid of ascites, which the patient regards as the disease from which he suffers, while cirrhosis of the liver, upon which the ascites depends, is a permanent condition; ex- tensive dropsy and other symptoms associated with cardiac diseases may also be got rid of. while the organic mischief still remains. Sudden lesions may terminate in partial recovery. For instance, a case in which a sudden haemorrhage into the brain has occurred, attended with marked apoplectic and paralytic symptoms, not uncom- monly improves remarkably in course of time, the clot being moro or less absorbed. Some com plaints, which are usually sudden in their onset, may apparently be recovered from completely, but sometimes set up conditions which ultimately lead to permanent disease. Thus the passage of a gall-stone or of a renal calculus may excite such irritation as to cause an inflammatory pro- cess to be set up, which may induce perma- nent mischief, such as closure of the bile-duct or of the ureter in the several instances, and the effects may not be perceptible until a con siderable interval has elapsed. Lastly, it must be remarked that some affec- tions can hardly be said to have any termina tion. They- continue during the life of the indi- vidual, perhaps interfering but little or not at all with the health, or at all events not in any way contributing to the death of the patient, when that event does happen. This applies to many of the ailments from which people suffer; as well as to many chronic organic diseases not in themselves serious or giving rise to any impor- tant symptoms, and not implicating structures essential to life. Frederick T. Roberts. DISEASE, Treatment of. — This term ha« reference to the means by which disease may be DISEASE. TREATMENT OF. 39.« prevented — prophylactic or preventive treatment; or its effects counteracted when it occurs — reme- dial or curative treatment. 1. Preventive treatment will be found dis- cussed under the heads — Contagion; Climate; Disease, Causes of ; Disinfection ; Malahla ; Personal Health ; Public Health, &c. ; as well as in the several articles treating of special diseases. It is therefore unnecessary to say more upon the subject in this place. 2, Curative treatment.— Bearing in mind that disease is a deviation from health in the functions or component materials of the body, it must be remembered that there is in organized bodies a tendency to maintain their healthy function and structure, and in case of disease or injury to recur to it. This is especially manifest in tl'o lower types of animals, which when mutilated are capable of resuming more or less completely their original form, to tho extent even of the re- storation of parts that have been lost. In man and the higher animals this power of complete restor- ation is confined to the elementary cells and least complex structures of which the body consists ; the more complex tissues are not reproduced, nor are lost parts restored. There is, however, in man, as in all organised beings, a tendency to rectify deviations from health, and to restore the or- ganization to its normal condition. To remove or subdue the causes of disease, and to aid this re- storative power in the establishment of healthy function and structure, is for the cure of disease the most philosophical indication that can be adopted. But our knowledge of disease and of remedial agents is not sufficient to enable us always to carry out these principles. As the treatment of disease has been directed sometimes to the one object and sometimes to the other, frequently to neither, it has given origin to a greatvariety of sys- tems or methods of practice. Thus iu the earliest history of the healing art, means the most diverse wore used for the relief of suffering. Sometimes the suffering or the disease yielded whilst these means were being employed ; and it was concluded, on very insufficient grounds, that these agents had 1 cured ’ the disease. Persons who had felt, as they supposed, the beneficial effects of these particular remedies, communicated them to others as the result of their experience; and thus was established what has been known in Medicine as Empiricism. — This mode of practice has its ad- vantages and its disadvantages. When aided by accurate knowledge and discrimination it often leads to satisfactory results ; and many remedies suggested by experience, and that alone, are now found to be in accord with our more ad- vanced scientific knowledge ; take, for example, the use of mercury in syphilis, which though long used empirically, is now known to act by its control over the nutrition of young cellular growths. So also with respect to quinino and other remedies of now established usefulness. On the other hand, mere empiricism, when vaguely applied, taints and damages to this day the treat- ment of disease. It is this practice which, for ex- ample, suggests opium to quiet a cough or a colic, without reference to the cause of the one or the other, and when an expectorant or a purgative Would have been the suitable remedy; and it is this empiricism which does such liarin in the hands of amateur practitioners, leading them to recommend for the relief of symptoms remedies which they supposed had relieved like symptoms in other eases, however different the real nature or causes of these symptoms may have been. Rational Treatment. — On tho other hand, modern science endeavours to take cognizance of the nature of disease, and also of the specific action of remedies ; it seeks to counteract the operation of the one by the influence of the other. This constitutes the rational treatment of disease. To extend this system should bo the object of the scientific practitioner. On tho one side, it is his duty to study the nature of disease itself, its causes, and their effects; on the other, to study the action of various agents on the living body in health and in disease ; and if possible to trace how far the one is capable of combating and subduing the other. This study of scientific therapeutics is of comparatively recent date, and is now pursued with great zeal. The results already arrived at are alike satis- factory and encouraging. As rational treatment becomes more firmly established, scientific medi- cine will take a more elevated and nobler position. The modes or methods by which the two great principles just alluded to, the foundations as they are of tho healing art, have been applied are extremely various, and, although these different methods may be traced to the one or to the other, they have received distinctive names, according as they are marked by some special characteristic. A few of these modes of treatment may bo briefly enumerated. 1. Expectant treatment.— This mode of treat- ment is founded on the principle that the resto- rative power should be allowed entire freedom of action, the practitioner neither assisting nor in- terfering with its operation. 2. AVhat is called Homcecpatldc treatment would by some persons be included under the preceding head. It proposes to treat disease by giving in in- finitesimal doses substances that aro supposed to be capable of producing a diseased condition like that which they are intended to cure. It may be described in the words of Moli&re, who wrote long before Hahnemann, the inventor of homceopathy, as Vart d'amuscr le malade pendant gae la nature gverit. There is no doubt that in this and in similar methods of treatment, the imagination plays an active and useful part. 3. Palliative treatment consists simply in the adoption of means which are calculated to soothe, and to lessen suffering, and thereby to prolong life when the cure of disease is not possible. 4. Stimulant treatment is founded on a doc- trine which regards most forms of disease as associated with or dependent on a lowered state of the vital powers, and which teaches that in such cases the free use of stimulants is the prac- tice most to be relied on. See Stimulants. 5. Antiphlogistic treatment is the converse of the preceding. It recognises in many forms of dis- ease increased nervous, excitement and vascular fulness, which are to be remedied by depressing agencies, such as low diet, bleeding, purgation, &c. See Blood, Abstraction of, and Depletion. 6. Purgative, diaphoretic, or otherwise eli- minative treatment aims at removing by thf SO 6 DISEASE, .TREATMENT OF. intestinal mucous membrane, by tlie skin, or by the secreting glands respectively, certain morbid matters ; and thus allowing the restorative power of the system to operate more efficiently. See PURGATIVES, &C. 7. The Water mre, including baths, acts partly on the principle of elimination, partly by exert- ing a tonic influence. See Baths and HYDRO- PATHY. 8. Revulsive treatment acts by producing coun- ter-irritation by means of blisters, setons, issues, and the like. See Counter-irritants, Revul- sives, &c. 9. Dietetic treatment constitutes a greater or less portion of all modes of treatment. It implies a reference to the kind of food which is adapted to the circumstances in which the patient is placed, and which is suitable in the form of dis- ease from which he is suffering. See Diet. 10. The treatment by Climate operates more or less by removing the patient beyond the region of noxious influences, and placing him in circum- stances which promote healthy action of the several functions. It is well known that under these several and varied modes of treatment disease may yield and patients may get well. Hence it has been said that as different means are made use of to obtain a single result, the treatment of disease can never be absolutely scientific. Phthisis is pointed out, for example, as a disease which one person seeks to relieve by cod-liver oil, another by climate, n third by tonics, a fourth by sedatives, a fifth by attention to the digestive organs, and a sixth by counter-irritation. We need scarcely say that the disease bearing the name of phthisis is an aggregate of phenomena or conditions, the relief of any ono of which may lead to the amelioration of the others. Thus the general health might be improved by climate, and with it all the other symptoms. Cod-liver oil, with remedies calculated to improve the digestion, may lead to healthy nutrition, and thus to miti- gation of all the symptoms. Tho like remark applies to the other agencies mentioned. The treatment of disease must not, then, be con- demned as unscientific because it cannot remedy a variety of morbid states by a single agent, but would aim, on still strictly scientific prin- ciples, by different agencies to overcome disease the effects of which are manifested in different forms. In conclusion, it may be repeated that the end and aim of the practitioner should be, if possible, firstly, to discover tho cause or causes on which the disease depends, and to remove or counteract them if practicable ; and, secondly, to endeavour, by every available means, to restore to health the functions of the body, and with that object to guide and assist Nature, but never to thwart her operations. R. Quain, M.D. DISEASES, Types and Varieties of. — In tho case of many diseases more or less distinct varieties are recognised, which in some instances constitute well-defined types. It is important to understand the precise significance of these terms in different cases. In the first place the varieties of a particular affection may be founded upon diversities ob- D1S1NFECTION. served in its clinical history. Thus, according to the intensity of the symptoms and their dura- tion, a large number of complaints are, as has already been pointed out, divided into acute, sub- acute, andchronic varieties. Agai n‘, many diseases, while presenting in the majority of cases a cer- tain group of symptoms, upon which their general clinical description is founded, exhibit striking differences in the exact nature of the phenomena observed, as well as :n their gravity, when the mass of cases is fatten into account, and on these differences varieties or types are founded. This is well exemplified by some of the acute spe- cific fevers, such as typhoid fever, scarlatina, measles, and small-pox. Of those affections several varieties are described, dependent upon the severity of the symptoms, the nature of those which are most prominent, or the characters of the eruption. In the next place, tho classification of a disease into varieties may be founded upon a pathological basis. For instance, pulmonary phthisis may arise from different morbid processes, and many attempts have been made to arrange the cases of this disease into corresponding groups. Illustrations of these pathological varieties are also found in tho different forms of cancer ; varieties of pneu- monia, of laryngitis, and of fatty disease of the heart ; and in the classification of serous inflammations according to their morbidproducts, such as fibrinous, serous, purulent, &c. Again, such a pathological condition as dropsy or fever may be divided into varieties. Thus dropsy is ar- ranged according to its situation and distribution, as anasarca, ascites, &c. ; or according to its pathological cause, whether cardiac, pulmonary, hepatic, &e. Fever is recognised as having seve- ral important types, founded upon its intensity, its course, and the exact nature of the phenomena accompanying the pyrexial state. Another division of a disease into varieties is (etiological , the cases being grouped accord- ing to their causation, either the immediate pathological or the more remote exciting causes being employed as the basis of division. Thus we have the different forms of meningitis (simple, tubercular, rheumatic, &c.) ; the setio- logical varieties of pleurisy or peritonitis (idiopathic, traumatic, perforative, tubercular, secondary, &c.) ; those of joint-inflammation, (simple, rheumatic, gouty, scrofulous, &c.): or those of intestinal obstruction. .Etiological varieties are often at the same time charac- terised by differences in the pathological results and products. Lastly, it must be mentioned that sometimes a certain group of symptoms is summed up for convenience under some single term, which symptoms really depend upon very different morbid conditions and causes ; and therefore it often becomes necessary to classify affections thus named into varieties. Dyspepsia, neuralgia, apoplexy, epilepsy, and paralysis will afford illustrations of such an arrangement. Frederick T. Roberts. DISINFECTANTS. See Disinfection. DISINFECTION. — Stnon. : Fr. Disinfec- tion ; Gcr. Desinficiren. Definition. — Disinfection, in the proper sense DISINFECTION. of tlio term, means any process by which the contagium of a given disease may be destroyed or be rendered inert. Disinfectants, however, are used in practice for several objects, and in consequence the term has often been vaguely applied to the use of hea>t or chemical means for preventing the gene- ration or for the destrnction of noxious agents, whether products of specific disease or not. In this vague and erroneous sense disinfectants have been confounded with deodorants, which merely cover or destroy offensive odours without affect- ing the contagia; and with antiseptics, which ‘ are fatal to the growth and multiplication of microzymes.’ Following the line indicated by Dr. Baxter in his valuable report on an experi- mental study of certain disinfectants, it is neces- sary to distinguish — - 1. The true meaning of the word — that of acting on the specific poisons of communicable diseases in such a way as prevents their spreading. 2. That of acting upon organic substances in sucli a way as renders them less liable to undergo molecular change and decomposition, whethor spontaneously or under the influence of catalytic agents, as in the case of emulsin upon amygdalin, or under the influence of living or- ganisms, such as are connected with fermenta- tion and putrefaction. Examples of this kind of action are seen in salting meat, and in preserving small animals in weak solutions of carbolic acid. Ij. That of preventing or arresting decompo- sition by killing the torulae associated with fer- mentation in slightly acid media, or the bacteroid organisms associated with putrefaction in neutral or alkaline media. Properly speaking, this is the action of an antiseptic, but the relative power of disinfectants has been largely estimated by their efficacy in this respect, partly, no doubt, because antiseptic power is desirable in a dis- infectant, but chiefly because it is so difficult to submit disinfectants to their proper test by ex- perimenting upon contagium. 4. That of the destruction of the noxious pro- ducts of the metabolism of dead organic matter, however brought about. These products consist chiefly of gases or vapours, many of which, such as sulphuretted hydrogen, ammonia, and sulphide of ammonium, are easily destroyed by appro- priate agents, even when used in a very dilute state, and success in this respect is no proof of the value of a disinfectant in its true sense, though the power of destroying such emanations is possessed by almost all disinfectants of prac- tical utility. Mode of Action. — The manner in which dis- infectants are supposed to act is very various. Some, such as permanganate of potassium, ozone, and oxygen, set free from water by chlorine, oxi- dise organic matter. Others, such as sulphurous acid, withdraw oxygen, and have a reducing influence ; or. like chlorine, may combine with hydrogen and remove it, or form substitution- compounds. Those of a fourth class, such as chloride of zinc and some other metallic salts, are supposed to owe their activity to the power which they possess of coagulating albumen or combining with it. Another class, of which carbolic acid is the type, is supposed to arrest 3S7 molecular changes, whether they be those neces- sary for vital manifestations or for decompo- sitions. And finally, the mineral acids are supposed to be efficacious, in part, at least, be- cause they alter the reaction of the media con- taining contagia. Most disinfectants act in several of these ways. Gexerai, Remarks. — It has been proved that the contagia of several diseases must consist of minuto solid particles, for they are neither soluble, nor diffusible, nor volatile, and we may infer that all other contagia are particulate likewise. A characteristic of contagium, due to its particulate nature, is that dilution lessens the chance of infection, but has little effect upon the case if the disease be taken. There is either no effect at all, or a full specific effect. Con- tagium particles are apt to exist as clouds in air, water, or milk, instead of being equally distributed throughout ; and this bears upon practical disinfection. The particulate and non- gaseous form of contagium floating in the atmosphere prevents it from being absorbed by any liquid or solid disinfectant which does not wash or come into intimate contact with every portion of the air, and as this is impracti- cable, infected air can only be puaified by gaseous disinfectants, such as sulphurous acid or chlo- rine. Disinfectants of this kind, to be effective, must be present in such a quantity as is incom- patible with the existence of human beings. 1 From this it follows that saucers of disinfecting fluids, or irritating vapours and gases in the sick-room, are merely a useless annoyance to the patient, except in so far as they may be desired as deodorants. The best method for dealing with infected air is to replace it by ven- tilation, especially by means of ventilating open fire-places. The proper use of volatile disin- fectants is the purification of walls, ceilings, and inaccessible places ; and for this purpose, if pos- sible, enough should be used to saturate the atmosphere, remembering that the virulent par- ticles are most likely protected by being buried in a bit of epithelium or surrounded by an albu- minous envelope. The nature of the medium in which contagious particles are suspended has the most important bearing upon the selection of a disinfectant. The presence of albumen is found to protect septic germs to a considerable extent against the action of permanganate of potassium and chlorine, but has little or no influence upon the action of sul- phurous acid and carbolic acid. Dr. Baxter gives reasons for believing that the comparatively uniform quantitative action of carbolic acid upon contagia and septic microzymes, as compared with the striking differences between the disinfectant action of chlorine and permanganate upon con- tagia on the one hand and septic microzymes on 1 Though disinfectant or antiseptic gases of such strength as can be tolerated in the sick-rocm are utterly inept as regards useful effect upon contagium, it is just possible thatthey may be of service in destroying or ren- dering incapable of change the organic matters evolved from the skin and lungs, which are always very noxions. and may be especially so in disease. These organic mat- ters are necessarily more or less re-breathed unless tho patient be placed in a current of air. If ventilation suffi- cient to prevent all odour cannot be provided, then some gas, such as chlorine or ozone, that will destroy the caua» of the odour is certainly desirable. DISINFECTION. 398 the other, is chiefly or entirely due to differ- ences in the media in which the respective par- ticles are suspended, and not to differences in resisting power possessed by the particles them- selves. This points to an important advantage enjoyed by substances like sulphurous acid or carbolic acid, which appear less influenced by the nature of the medium, and also shows the necessity of thoroughly mixing disinfectants with liquids or substances to be disinfected. The alkaline or neutral character of virulent sub- stances led Dr. Dougall to select dilute hydro- chloric acid, which has little action upon lead soil-pipes in the cold, as the best disinfectant for excreta. A cardinal principle in disinfection is that it should he carried out at the source, or as near the source of the contagion as possible. Inunc- tion with lard, with carbolised oil (1 to 40), or with glycerine, to clog epithelial scales, and regular washing and change of clothing, will do much to protect the purity of the air against con- tagium proceeding from the skin in such dis- eases as scarlet fever and small-pox. One of ethereal solution of peroxide of hydrogen to 8 of lard is an excellent application for the skin in typhus. Discharges from the mouth, nose, and bowels, as well as the urine, should he received in vessels containing disinfecting solutions to cover them and give protection to the air ; and then larger quantities, or more concentrated solutions, as tbe case may be, should be thoroughly incorporated with the discharges before they are removed from the original vessels. Of all agencies for preventing the spread of communicable disease, cleanliness is one of the most- important. Facts have been adduced point- ing to the conclusion that filth, when undergoing change of a fermentative or putrefactive nature, is in a condition the most conducive to the extension of infectious disease. Pending the removal of accumulations of dirt, and for the protection of workmen, fermentation may he delayed by the application of crude carbolic acid, chloride of zinc, or bichromate of potash, used in moderate quantity as antiseptics, and the whole accumulation might then be earthed over if it had to remain any time. For real disinfection the large quantity required and the mixing necessary would be prohibitory. The ultimate fate of eontagium is to be de- stroyed by putrefaction, and this appears invari- ably to destroy its specific infective power. In cer- tain cases where real disinfection is impracticable, as in dealing with the accumulation of manure and litter from a number of animals suffering from cattle-plague, the natural processes may he hastened by stacking the material so that it shall ‘ heat,’ or may oven he destroyed by sponta- neous combustion. Certainly putrefaction should not be delayed by small additions of disinfec- tants, which cannot accomplish the destruction of all noxious matter present. Special Disinfectants. 1 . Heat. — Heat, dry i)T moist, is perhaps the best disinfectant we. possess. The experiments of Drs. Henry, Baxter, W. Roberts and others have shown the effects of this agent, upon vaccine, malignant pustule, septic microzymr.s, scarlet fever, plague, &e. High temperature and length of exposure are, to a certain extent, mutually compensatory, but it appears that a temperature below 140° F\ (60° C.) will not disinfect vaccine even with long exposure. Tyndall points out that some germs seem to be in a dormant condition, in which they resist the action of heat unless applied very long or intermittently, so as to start their vitality into growth, when they are easily killed. Ex- perimental facts show that excessive tempera- tures are as unnecessary as dangerous in practical disinfection. It is extremely improbable that any eontagium can withstand a temperature of 220° F. (104 o C.), maintained during two hours. When eontagium is shielded by thick material, into which heat penetrates slowly, the time necessary to reach the disinfecting temperature may he long, and hence the necessity fdr spreading cloth- ing and opening out bedding in special hot-air chambers, where the heat ought not to be less than 220° l'\ (104 o C.), nor more than 250° F. (121'1° C.). Hot-air chambers are usually built of trick, and are furnished with wooden sup- ports for clothing, which should not come in contact with metal. Dr. James B. Russell, Medical Officer of Health for Glasgow, has communicated to the writer the most important fact, that at the In- fectious Diseases Hospital of that city no further disinfection of the linen and clothing of the patients is carried out than is afforded by the boil- ing, washing, &c., requiredin the judgment of the washerwomen to cleanse and dress the clothing ; and yet a continuous careful scrutiny has failed to discover a single case of disease propagated by such clothing. It is probable that soda is used in the boiling, in some cases at least, and the extreme softness of Glasgow water doubtless helps by its osmotic and dissolving power. 2. Carbolic Acid.— A solution of this sub- stance of the strength of 5 per cent.., or 1 in 20, is the only one fit for use in disinfection. For steeping fine clothing a solution should be made from crystals. The solution generally useful is that obtained by making up one gallon of crude 80 per cent, acid to sixteen gallons with water. To disinfect a suspected liquid, an equal volume of one of these solutions is needed The results of the experiments of Baxter and others prove that ‘ no virulent liquid can be considered disinfected by carbolic acid unless it contain at least 2 per cent, by weight of the pure acid.’ A preparation called MacdougaWs Pou'der contains carbolic acid, but is inferior to the pure kinds, though safer and more applicable in many cases to prevent odour. .Tu.lging from the light of experiments, carbolic acid vapour is quite useless, though clinically Mr. Crookes and Mr. Hope thought it of use in cattle-plague, but the animals and surroundings were drenched with liquid acid or solution. Though carbolic vapour appears impotent asregards effect upon eontagium it will preserve the freshness of a bit of meat, suspended in it for months. Very small quan- tities of the liquid acid mixed with organic fluids ‘enables them to remain fresh and resist- decay for a long time. So little as one-fifth per cent, preserves milk. It is obvious then that small quantities of this disinfectant, instead of destroying eontagium. may actually preserve its DISINFECTION. activity, when otherwise it would have sue cumbed to the action of natural agencies. This danger may accompany the limited use of any disinfectant that has a ‘pickling’ or preserva- tive action in small quantity. Owing partly to the volatility of carbolic acid, w'hich removes it in time, and partly to the peculiarity of its action, another danger attends its use in any- thing short of full strength and full doses when applied to kill eontagium. The acid may, for a time, deprive the eontagium of its infective power without permanently abolishing it, and the virulent properties may be regained when- ever the acid has evaporated. This has been proved experimentally by Dr. Dougall, of Glas- gow, who found that vaccine mixed with carbolic acid (1 in 50) regained its infective power after 10 days’ expostire to the air. Carbolic acid coagulates albumen when in sufficiently strong solution ; while it restrains putrefaction, and limits the growth of low forms of animal life. It decomposes potassium per- manganate, and therefore cannot be used in conjunction with this agent or with chlorine. Though it does not destroy sulphuretted hy- drogen, it is a good deodoraut in some cases. When Demonstrator of Anatomy to the Uni- versity of Edinburgh, the writer experimented on a large scale with different substances for removing odour from the hands of the stu- dents, after working in the dissecting-room, and found that a 1 per cent, solution of carbolic acid is superior in efficacy to permanganate, even when strong enough to stain the skin, and is also preferable to chloride of lime. In this connection it is worthy of remark that the ‘septic ferment’ connected with scpticsemia, ery- sipelas, &c., appears to be destroyed by rather less carbolic acid than vaccine requires. 3. Sulphur Dioxide. — The aqueous solution of this substance contains sulphurous acid. Bax- ter’s experiments show that it is the most potent volatile disinfectant known ; and as it is very soluble, and is little affected by the presence of albumen, it is also powerful in the disinfection of liquids. It destroys sulphuretted hydrogen thus, SO., + 2H,S = 2H..0 + S 3 , and combines with ammonia. A strong solution of sulphurous acid is sold, but is difficult to use, on account of its suffocating odour. The solution can be made by deoxidizing hot concentrated sulphuric acid with copper-turnings or charcoal. For aerial disinfection the best plan is simply to burn sulphur in very large quantities. This dis- infectant forms sulphites, and is a reducing or deoxidizing agent, in the first place, for it unites with the oxygen of many compounds to form sulphuric acid; but it may give up oxygen, and when mixed with much vegetable matter the sulphur may come off as sulphuretted hydrogen. Sulphur dioxide and chlorine, as well as this substance and permanganate of potash, mutually destroy each other, and therefore should not be used together. Sulphur dioxide destroys the activity of dry vaccine on points very rapidly, and even when much diluted stops the amoeboid movements of living cells, kills vibrios, and acts deleteriously on vegetation. ‘Whether chlorine or sulphur dioxide be chosen, it is desirable that the space to be disinfected should be kept satu- 399 rated with the gas for not less than an hour.’ ‘ A virulent liquid cannot be regarded as cer- tainly and completely disinfected by sulphur dioxide, unless it has been rendered perma nently and strongly acid. The greater solubility of this agent renders it preferable, cateris paribus, to chlorine and carbolic acid, for the disinfection of liquid media ’ (Baxter). According to Baxter’s experiments, a larger percentage of sulphur di- oxide than of carbolic acid is required for the disinfection of the virus of infective inflammation, but a smaller percentage for other eontagia. Sul- phur dioxide preserves meat nndother substances, when in closed vessels, for very long periods. It bleaches vegetable colours, attacks iron, and is absorbed by cloth and leather — facts to be remembered in practical disinfection. I lb. of sulphur, when burned, produces 11 '7 cubic feet of sulphur dioxide gas. 4. Chlorine is most easily obtained from chlo- ride of lime or bleaching powder, by adding hydrochloric or sulphuric acid. Exact propor- tions cannot be stated, as the value of the bleaching powder varies ; but rather more acid than equal parts of bleaching powder and strong hydrochloric acid may be taken. The acid should be diluted before use. Another method is to pour strong hydrochloric acid upon heated binoxide of manganese ; this method of disinfec- tion is impracticable compared with burning sul- phur. For deodorizingwater-closets, some crystals of potassium chlorate may be thrown into a wide- mouthed bottle containing dilute hydrochloric acid. Euchlorine comes off gradually, and is both more effective and more agreeable than chlorine. The most marked character of chlorine is it a strong affinity for hydrogen, which enables it to break up compounds containing that body, and to set free in a nascent or active state the oxygen combined with hydrogen iij water. It is, there- fore, one of the most universally applicable and powerful deodorizers in existence. Direct ex- periment shows that ‘ there is no security for the effectual fulfilment of disinfection short of the presence of free chlorine in the virulent liquid, after all chemical action has had time to sub- side.’ Chlorine is soluble in water to the extent of 2| volumes in one, and this solution may be used for disinfection. AVhen merely used as a deodorizer, enough euchlorine may be expelled from moist chloride of lime by the carbonic acid of the air for most purposes. 5. Permanganate of Potassium. — This sub- stance is non-puisonous, and is a good deodo- rant, especially for the emanations from organic bodies. It is, moreover, free from odour, and its aqueous solution shows, by loss of colour, when it is exhausted. It is a very suitable deodorant for the sick-room, as, when dissolved in water and a large surface of the solution ex- posed to the air, it will absorb gases to some extent. Contagium being non-gaseous, is not affected, unless in contact with the solution. Permanganate of potassium is a true disinfec- tant, oxidizing and destroying eontagia as well as putrid matters ; but the quantity required and the price render its use almost impossible, for enough permanganate has to be used to de- stroy the medium or vehicle bearing contagium I as well as the contagium itself. Condy’s fluid if DISINFECTION. 400 a solution of this substance in water. ‘When permanganate of potash is used to disinfect a virulent liquid containing much organic matter, or any compounds capable of uniting with the permanganate, there is no security for the effec- tual fulfilment of disinfection, short of the pre- sence of undecomposed permanganate in the liquid, after all chemical action has had time to subside’ (Baxter). When the virulent liquid or matters are small in quantity, permaganate solution forms a capital receptacle, and may stand by the bedside as a deodorant till re- quired as a disinfectant. The safe rule in employing permanganate as a disinfectant is to add it and mix till the colour is retained. Permanganate has no effect in restraining the appearance of bacteria, or preventing the onset of putrefaction. 6. Acids. — The mineral acids and glacial acetic acid have all disinfecting power when used in sufficient quantity ; but, except sul- phurous acid, there are serious difficulties in the way of their use, and we have better disinfect- ants. Hydrochloric is inferior to chlorine as a gaseous agent; but the solution is extremely cheap, and is useful for disengaging chlorine, as well as for employment as a disinfectant. Chromic acid, which lias remarkable power in preventing putrefaction and killing microzymes, is too dear to be used outside the laboratory. 7. Nitrous Acid. — Nitrous acid can be easily disengaged as a gas by putting bits of copper into nitric acid, or pouring nitric acid upon saw- dust or starch. It is the best deodorant for the deadhouse, and, without doubt, it is a vigorous disinfectant, but is too dangerous for ordinary- use, as it may easily be breathed in quantity sufficient to cause fatal bronchitis. 8. Chloride of Lime. — Bleaching -powder gives off chlorine easily, and this probably ex- plains its disinfecting power. It is very- cheap and manageable, and hence of much importance. In regard to the agents hitherto considered, we have more or less of the sure light of direct experiment upon contagium ; but the claims of the following and a legion of other substances asserted to be ‘ powerful disinfectants, of which it is impossible to speak too highly,’ rest entirely upon chemical theories, or the opinions of phy- sicians, or upon their power of coagulating albu- men, or of delaying or preventing putrefaction and fermentation, or of deodorising. It will be scarcely necessary to do more than enumerate the best, as follows : — 9. Metallic Salts, including — a. Bichromate of Potash, b. Sulphate of Copper, c. Chloride of Zinc (Burnett's Fluid) which can be made very cheaply by pouring hydrochloric acid upon calamine, the native carbonate, or upon zinc. It seems to be the most useful of the metallic salts, d. Chloride of Aluminium, e. Ferric Chloride, which, if strong, liberates offensive fumes from animal matters, but is a fair anti- septic and preservative. f. Ferrous Sulphate, g. The Waste Chlorides, from the manufacture of chlorine, contain MnCl 2 , Fe 2 Cl 6 , and free HC1, which cost next to nothing, and might be used for larger masses of filth or drains, 10. Ozone. — This body, got by half immers- ing a stick of phosphorus in tepid water, or mixing gradually 3 parte strong sulphuric acid and 2 parts permanganate of potassium, oxidibes organic matter-, and so destroys odours. Tere- bene and cupralum, a preparation containing terebene, are good deodorants, and give rise to ozone. 11. Charcoal. — Charcoal condenses gases within its pores where combustible gases are de- stroyed by the condensed oxygen. Contagium, unless in water, does not enter the pores, for, being particulate, it is not absorbed from the air as gases are. Pkacticae Disinfection. — In conclusion a few remarks may be offered as to the modes of carrying out disinfection under circumstances in which it is commonly required. 1. Clothing and bedding. — In dealing with the ragged and worthless articles of the poor, local authorities will generally find it most satisfac- tory to both parties to burn them and replace with new. By such discreet generosity danger is averted, and good-will created, which helps in getting early information and carrying out measures, and so, by shortening epidemics, saves expense. If not burned, clothing may be baked (see Heat), or well boiled with soda. Before coming to the washhouse they may steep in 5 per cent, carbolic solution, or chloride of zinc (1 to 240), or chloride of lime (2 oz. to the gallon). 2. Booms. — The foundation for disinfect ing rooms is thorough cleansing with soft soap and hot water, which may contain a per cent, carbolic acid, but the carbolic solution is not so easily handled. The walls and ceiling should be brushed, and wall-paper removed. Furniture, if iron, is to be washed with carbolic solution, and removed from the room. Textile fabrics should be baked or boiled, or spread out in the room for fumigation, but this is not so effective, and colours are bleached. The chimney, doors, and windows are to be closed, and crevices covered with paper pasted on. Then one or more tubs of water are to be placed in the room, and an earthenware saucer containing sulphur placed over each, supported by a pair of tongs laid across to prevent danger from fire. The sulphur can be lighted by pouring a little alcohol upon it, or by means of a live coal. The usual rule is to use 1 lb. of sulphur for each 1,000 cubic feet of space, but this only gives 1-17 percent. S0 2 to the air, and 3 lbs. is a more satisfactory quantity. The door is to be shut until next day, when the windows and doors are all to be opened, and kept open for twenty -four hours. In whitewashed rooms the walls should be scraped, and then washed with hot lime in addition to the fumigation. 3. Drains, Water-closets, &c. — Proper drains remove sewage so swiftly and completely, that little or no sewage-gas is formed if ventilation is given. For bad drains carbolic acid, chloride of zinc, or waste chlorides from the manu- facture of chlorine are fair palliatives. The excreta from cases of infectious diseases require a very large quantity- of disinfectant, which should be applied in a concentrated form before they are thrown into the water-closet or house pipes. When a reliable amount of disinfectant is in these cases sent down the pipes, it is apt to corrode them unless it lias been allowed to DISINFECTION. expend its energy on the excreta alone in the first place. If small quantities of disinfectants are poured down water-closets, it is better to mix them with the after-flush water which fills traps and basins, so that the little energy available maj' be devoted to the destruction of any slime adhering, or portions of organic matter retained. Permanganate of potash is the most pleasant agent for thispurpose, though expensive. Chloride of zinc, from its cheapness and preservative power, is worthy of mention. "When there are no water-closets, the excreta in cases of cholera and typhoid fever should be received in a vessel containing half a pint or more of a 1 in 20 solu- tion of commercial hydrochloric or sulphuric acid, and then put along with some chloride of lime into a covered stoneware vessel in the back yard. After a few hours the contents of this vessel may be thrown into the cesspool or upon the midden. 4. Dead bodies, if putrid or bearing conta- gium, should be wrapped in sheets wet with 1 in 20 carbolic solution, or 1 in 40 chloride of lime; or, if coffined, sawdust saturated with one of these solutions should be packed around them. It is necessary clearly to keep in view the object desired when selecting disinfectants, deo- dorants, or antiseptics ; whether it be destruc- tion of contagium, merely ‘pickling’ and pre- serving, arresting pmtrefaction and fermentation, or deodorisation. From all that has been said it is evident that the different ‘disinfecting’ nostrums, applied as their inventors direct, can have little effect upon contagium, but may have more or less power in the other directions indi- cated. James A. Russell. DISLOCATION OF ORGANS (dis-, apart, and locus, a place). See Organs, Dislocation of. DISPLACEMENT OF ORGANS. See Organs, Displacement of. DISSECTION -WOUNDS. Sec Post- Mortem Wounds. DISTOMA (Sis, double, and cttS| ua, a mouth). — Synon. ; Fluke ; Fasciola ; Fr. dis- tome ; Ger. Leberumrm . — A genus of trematode parasites, vulgarly called flukes. The term was founded by Retzius in 1786; but the title Fas- ciola, previously employed by Linnaeus, is the more correct, especially when applied to the common liver-fluke, which is an occasional in- habitant of the human body. Nearly twenty in- stances of the occurrence of this parasite ( Distoma kepaticum of some writers) in man have been placed on record. Besides infesting the liver- ducts and gall-bladder, it has been found under the skin behind the ear (Fox), beneath the scalp (Harris), and in the sole of the foot (Giesker). Several other species of fluke are known to infest mankind, but with the exception of the Egyptian haeinatozoon ( Bilharzia hcematohia) none of them are of frequent occurrence. Thus the lancet-shaped fluke ( Bistoma lanceolatum) has thrice occurred, leading to a fatal result in a single instance, whilst the minute Disioma hy- terop/iytes has only once been recorded. The large human fluke, sometimes known as Busk's fluke ( Distoma crassum ) had also, until lately, only once been noticed; but, through Dr. George Johnson, the writer has become acquainted with 26 DIURETICS. 401 two mor6 instances of infection from this para- site, and there is some ground for believing the. - , the cases of fluke described by Dr. Leidy of Philadelphia refer to the same parasite. More recently also (Lancet, 1875) Dr. McConnell has recorded the occux-rence of an un- doubtedly new species from a Chi- nese, for which the writer has pro- posed the title of Distoma sinense. Large numbers infested the ducts of the liver. Professor Leuckart subsequently proposed the term Distoma spathulatum. Professor McConnell has also discovered an- other fluke in man ( D . conjunctum, Cobbold) previously only known to infest the fox and dog. Taken as Fig. IS. a whole the human flukes referable D -ur!r”umx'~i to the genus Distoma have very diameters, little clinical importance; but, since After McCon- there were striking symptoms in ne!1 - connection with the above-mentioned cases of Distoma crassum (affecting an English missionary and his wife during their residence in China) it may be as well to mention that these large para sites, individually varying from one to three inches in length, appear to be capable of inducing severe diarrhoea and colic. Their organisation is totally distinct from that of the common fluke. They probably never gain access either to the liver or its ducts. ( Proceed . Linn. Soc., Peb. 1875.) The administration of santonine, male fern, and other anthelmintics has been unat- tended with positive results ; those specimens that were expelled seeming to have been, as it were, starved out by the patients having been put upon a milk diet, recommended by Dr. Johnson. The missionary and his wife having returned to China were again attacked by Distoma crassum. In tire spring of 1878, they again consulted the writer in London, not only on their own account, but also on behalf of one of their children, a little girl, who had also contracted the fluke-disorder in China. Flukes have twice or thrice been de- tected in the eye, but they appear to have been sexually immature worms, referable probably, as- Leuckart has suggested, to the Distoma l anccola- tum. The flukes described by Treutler and Delle Chiaje, if genuine, have no clinical importance. See Bilharzia. T. S. Cobrold. DIURESIS (Sia, through, and ohpeu, I pass water). — A free excretion of urine, whether natural or artificially induced. DIURETICS (Si a, through, and ovpiw, I pass water). Definition. — Remedies which increase the secretion of urine. Enumeration. — The following comprise the most important diuretics: — Water; salts of' Potash, Soda, and Lithia; Alcohol, Nitrous Ether, Turpentine, Juniper, Copaiba, Cantharides, Digitalis, Squill, Tobacco, and Scoparium. The action of diuretics is often aided by brisk purga- tion, depletion, counter-irritation over the loins, and sometimes by the use of mercury. Action. — The secretion of urine appears to consist partly of mechanical filtration of fluid 102 DIURETICS, through the glomeruli of the kidney, and partly of secretion by the cells of the urinary tubules. The filtration in the glomeruli is increased by anything which raises the blood-pressure throughout the system generally, or in the renal arteries locally. The systemic blood- pressure may be raised by cold to the surface, digitalis, squill, and tobacco. Digitalis, and possibly other drugs have also a local action on the renal arteries, which are more readily affected by some drugs than other arteries in the body. The exact mode of action of the other diuretics is not determined, but common salt, nitrate of potash, urates, and urea increase the flow of urine, even although the pressure in the vessels of the kidney is very low. It is there- fore probable that they stimulate secretion by acting on the nerves or cells in the kidney itself. Uses. — Diuretics are employed to increase the flow of urine, and thus remove water or ex- crementitious products like urea from the body. They are used in cases of general dropsy, or of accumulation of fluid in the peritoneum or pleura. In febrile conditions they are given to aid in the elimination of waste matter. They are also employed in order to render the urine more watery, and thus prevent the deposition of solids from it, and the formation of calculi in the kid- ney or bladder, or to redissolve such concretions when they are already formed. Digitalis and squill are most useful in dropsy dependent on heart-disease; the other remedies are more effec- tive in dropsy dependent on disease of the kid- neys or liver. The action of digitalis and squill is greatly assisted by the addition of a little blue pill, and when the kidneys are much congested or pressed upon from without by accumulation of fluid in the abdominal cavity, diuretics some- times fail to act until the congestion has been relieved by depletion from the loins or the use of a brisk purgative, and the pressure removed by paracentesis. T. Lauder Brunton. DIZZINESS. See Vertigo. DOGEMIUS (Sbx.uos, twisted). — A genus of nemutoid worms established by Dujardin. Sec ScLEROSTOMA. DOTHINENTEKITIS (SoBtrjy, a pustule, and evrepov, the intestine). — A synonym for a form ( f enteritis, accompanied by an enlargement of the follicles, which causes them to resemble pustules. Sec Intestine, Diseases of. DOUCHE (Ft.). — Definition. — A jet of water propelled against some part of the body through a doccia or pipe. The size of the jet of water, the degree of its impetus, and its tempera- ture, can all be regulated. A douche differs from simple affusion in its application, being more local, and the force with which it is applied being- greater. AppuiciTioN and Action. — Douches of cold and of hot water, of vapour, and occasionally of gas are employed; but those by far the most commonly used, except where there are hot natural waters, are of cold water. The immediate effect produced by a cold douche on those who are unaccustomed to it is a feeling of shock, spasmodic shortness of breathing, palpitation of the heart, and some DOUCHE. times pain in the back of £he head. Locally the first effect of a douche is to deaden the sensi- bility of the part to which it is applied; but if the douche be powerful enough, reaction of the part comes on in about forty seconds. This continues for a time ; but if the douche be kept up for three or four minutes, the pulse falls seven or eight beats, the deadening of sensibility re- turns, and the temperature of the part is greatly lowered ; when the douche is withdrawn re- action again takes place. This alternate seda- tive and stimulating effect, producing emptiness and turgescence of the vessels, quickens the action of the capillaries of the part, and thus favours the transmutation of tissue. The mecha- nical effect of the force with which the douche is applied must not be overlooked. If great, it produces the highest amount of stimulation, which may almost amount to inflammation. Different portions of the body have different degrees of tolerance of the douche. Thus the extremities and the head bear it better than the chest, and the chest somewhat be:ter than the abdomen ; and the posterior aspect of the body bears it much better than the anterior. Patients soon get accustomed to the cold. Warm douches produce less shock, and are more easily borne, but they are, comparatively speaking, little cm ployed in private houses. An alternation of hot and cold douches, known somehow by the name of Scotch , is a valuable remedy ; in it the hot water rapidly restores the irritability of the part deadened by the cold water, and there is a maxi- mum of action and reaction of the part obtained. Under particular circumstances it may be expe- dient to use a jet of steam, but this, of course, must be used with caution ; and a jet of carbonic acid is sometimes propelled against the eye or ears, or the neck of the uterus. What are called ascending douches are used for the rectum or the vagina. Douches for the eye and the ear have been used of late years. In a certain sense what the English call pumping is a variety cf the douche, and the shower-bath is in reality merely a multiplication of fine douches. The action of douches is more or less general according to the portion of the body to which they are applied. Thus the application of a douche to the head has the most general action, and that to the spine the next so. In either case it is impossible to limit it very strictly, and there is a certain amount of affusion besides the direct douche. A douche, again, applied to one of the extremities may easily be localised ; and a douche may be applied only to one part or to several parts of the body in succession. Douches merely require a pipe with nozzles of various sizes in connection with a cistern at a certain elevatioD, or with a pumping machine, and can easily be improvised. Shower-baths can be procured with equal facility. A vapour douche can be got by attaching a pipe to a vessel of boiling water. In the case of the fine douches used for the eye. the water is propelled with suf- ficient force by the action of a caoutchouc bag worked by the hand. Carbonic acid is practically little used, and only where there is an abundant natural supply of the gas. Perhaps 50° may be considered the arerajfc temperature of a cold douche, and from tout DOUCHE. minutes to a quarter of an hour its average dura- tion. The course of douching will probably ex- tend at least over a fortnight. As to the actual temperature of the water, the sensation it pro- duces in the patient depends most on his con- dition. Thus water of 45° may feel ice-cold to one who has just quitted a hot bath. In like manner a douche of slightly-heated water may appear quite warm when applied to a part cooled by a cold douche. The temperature of a douche should vary according to the condition of the patient. Uses. — As a general rule we may say that douches are only applicable in cases of chronic disease; that cold douches are most useful in constitutional diseases; and that warm douches, and the alternation of hot and cold, are most suitable in local affections. The cold douche, when it is employed gradually and with judgment, is found serviceable, in chlorotic and hysterical conditions, in hysterical paralysis, and in over-sensibility of the skin, with tendency to catch cold ; and of late years it has formed a part of the special treatment of phthisis in elevated places. As cold affusion on the head is very serviceable in infantile con- vulsions, so the application of a douche of cold water to the head is a calmative and hypnotic in maniacal cases. It is, perhaps, not so much used in this way as formerly, as it has, like the shower-bath, come to be considered a sort of pun- ishment to troublesome lunatics. Still it is a valuable agent. Hydropathic practitioners have found douches useful revulsives in congestion of t he liver and of the uterus. Locally douches have been used, but with moderate benefit only, in some cases of skin- affections and of chronic ulcers. Their prin- cipal local application, however, is in cases of old sprains, in chronic rheumatism or gouty thickenings of joints, in lumbago, in some neu- ralgias, and in paralysis when it is not too recent. The Scotch is far the most effective for these purposes, and there seems to be some evidence nf its having been efficacious in threatened tabes dorsalis — certainly more efficacious than any other remedy. Douching might be used more extensively in private houses ; still, as assistance is always required by the patient, public baths have advantages for their application. John Macfherson. DRACTTNCUXTIS (dracunculus, a little dragon). — A synonym of the guinea- worm. Under this title the parasite was described by Lister (Phil. Trans., 1690), and afterwards by Kaempfer (1694). Following the latter autho- rity the writer has elsewhere recognised the term as of generic value, but the majority of helminthologists, after Gmelin, prefer to place Fig. 17 . — Dracunculus Jfedinensis . Reduced to J. the worm under the genus Filaria (F. medi- nensis). The Dracunculus was known before the time of Lister, having been described in a remarkable work by Velscius (1674) and by Agatharchidas as quoted by Plutarch. There is. DROPSY. 40! indeed, every reason to believe that the so-called fiery serpents of Moses answer to the dracuncnli of Plutarch. The matter is fully and learnedly discussed in Kiichenmeister's treatise ( Parasite o. S. 305 ; also in the English edition, p. 390 el seq.). See Guineaworm. T. S. Cobbold. DRAINAGE. See Public Health. DRASTICS (Spaa, I act). Definition. — Violent purgatives. Enumeration. — The drastics most frequently employed are; — Hellebore, Podophyllin, Gam- boge, Elaterium, Scammony, Jalap, and Croton oil. For action and uses of drastics, see Purga- tives. T. Lauder Bbunton. DRIBTJRG, in Westphalia. Strong Chaly- beate Waters. See Mineral Waters. DROITWICH, in Worcestershire. Com- mon Salt Waters. See Mineral Waters. DROPSY (lid paip ; from voap, water, and ap, aspect, appearance). — Synon. ; Fr. Hydro- pisie; Ger. IV asserts ucht. Definition. — Accumulation of serous fluid in the subcutaneous cellular tissue, or in a serous cavity. Dropsy is known by various other names, according to the portion of the body affected When confined to the subcutaneous cellular tissue it is termed (edema or anasarca-, to the peritoneal cavity, ascites. The term is often limited to these two forms of the disease ; and exudations similar to that of ascites in other cavities are termed hydropericardium, hydroce- phalus, hydrocele, hydrops oculi, hydrops articuli. and hydrothorax or pleural effusion, according as they are contained in the pericardium, arach- noid, tunica vaginalis, eye, joint, and pleura re- spectively. Pathology.— The accumulation of fluid in tho tissues, or in a serous cavity, depends upon more fluid exuding from the blood-vessels than can be taken up by the absorbents. So long as no obstruction to absorption occurs, it rarely happens that more fluid can exude from the blood- vessels than the absorbents can again take up Absorption is partly carried on by the veins, and partly by the lymphatics ; principally, however by the veins. AVhen venous obstruction takes place, fluid is apt to accumulate in that part ol the body from which the blood ought to return by the obstructed vessel. But it does not always so accumulate ; for it may happen that the lymphatics are able to absorb all the fluid which exudes from the capillaries, and to return it into the general circulation. Thus it has been found by Banvier that ligature of the vena cava in a dog does not usually produce oedema of the lower extremities, but if one sciatic nerve be divided in such an animal, tho corresponding leg at once becomes (Edema- tous. The reason of this is that so long as the nerve is intact, the lymphatics can absorb all the fluid which exudes from the capillaries but when the nerve is divided the artoriec dilate, more fluid is poured out than the lym phatics can absorb, it accumulates in the tissues and (Edema ensues. This oedema is not due u DROPSY. 104 paralysis of the limb, but to paralysis of the vessels. For if the sympathetic fibres through which the vaso-motor nerves pass to the sciatic nerve are divided before they join the motor fibres of that nerve in the sacral plexus the power of movement remains unimpaired, but oedema occurs just as if the whole nerve had been divided. If, on the other hand, the motor strands of the sacral plexus are cut before they are joined by the sympathetic fibres, the limb is as completely paralysed as if the sciatic nerve had been cut, but no cedema takes place. Any obstruction to the venous flow will operate in the same way as ligature of a vein, though to a less extent, the effect varying accord- ing to the amount of obstruction. Thus regurgi- tation of blood through the tricuspid valve tends to produce general anasarca, and obstruction to the portal vein by cirrhosis of the liver tends to cause accumulation of fluid in the abdominal cavity. It has been mentioned how great an influence dilatation of the arteries from vaso-motor paraly- sis has upon the production of oedema in cases where the veins are obstructed. Arterial dilata- tion may also produce a local oedema, even when no such obstruction is present, as, for instance, in the tissues around an inflamed part. It has been shown, however, by Winniwarter, that the walls of vessels in an inflamed part are more permeable, and allow fluids to pass through them more easily than healthy vessels will do. It is probably in consequence of this that we find that a slight stimulus, such as scratching the skin, which ordinarily produces in a healthy person only slight dilatation of the capillaries, and consequently redness of the part scratched, will produce an effusion from the vessels, and local swelling of the part at the point scratched in persons suffering from urticaria. The same thing takes place when the skin is scratched in the neighbourhood of a part stung by a wasp. But this alteration in the vessels is not the only cause of the oedema, which may occur without any obstruction to the circulation. An alteration in the composition of the blood ap- pears to allow it to permeate more easily into the tissues, and to produce oedema, even when there is no obstruction of the veins. In cases of anaemia we find oedema occurring at the ankles, although there is no obstruction to the venous circulation other than that caused by the weight of the column of blood itself. In these eases, however, we have dilatation of the vessels, as is shown by the form of the sphyg- mographic tracing, and an altered composition of the blood is evidenced by tlie anaemic look of the patient. The dropsy of scurvy is probably also due to blood-vascular disorder. In albu- minuria tlie altered composition of the blood appears to be the chief factor in the production of cedema, as the pulse in such cases may bo hard, evidencing arterial contraction, and not relaxation. _2Etioi,ogy. — General dropsy affecting the subcutaneous tissue, the peritoneal cavity, and the internal serous cavities and organs generally, is usually the result of albuminuria, and most frequently of that form which depends on fatty degeneration of the kidney. In cirrhotic disease of the kidney the loss of albumen in the urine is much less, and the alteration in the com- position of the blood consequently is not so great as in the first-mentioned form. The arte- rial tension also is greater than usual, instead of being less. In the amyloid form the oedema is generally moderate. The next most common cause of dropsy is tricuspid regurgitation, obstructing the venous circulation throughout tho body. This regurgi tation generally depends on dilatation of the right ventricle consequent upon obstruction tc the flow of blood through the lungs, either from chronic bronchitis and emphysema, or mitral obstruction and regurgitation. Dropsy from cardiac disease generally appears first in the feet if the patient has been for some time in an upright position, while dropsy from albuminuria is often first remarked by a puffiness of the eye- lids. In the former it appears where the greatest obstruction to re-absorption takes place, and in the latter case in those parts where looseness of the cellular tissue most readily allows of exuda- tion. Local dropsies have, as a rule, local causes. Even the swelling of the feet in antemic young women, although dependent on a general cause, viz., dilatation of the vessels, and altered com- position of the blood, is determined locally by the greater obstruction to the venous circulation which the pressure of the long column of blood in the veins between the feet and the heart presents. In general dropsy also, those parts which are most dependent are apt to become most swollen. It is not, however, always so, as in certain cases the dependent parts have been noticed to be less dropsical than the others. This curious phenomenon seems to be due to some vaso-motor nervous influence on the vessels of the dependent part. The local cedema of a brawny character, often noticed around in- flamed parts, is partially due to swelling of the tissues themselves, and partially to effusion of fluid between them. This effusion, as has already been mentioned, appears to be caused both by the dilatation of the vessels observed in inflamed parts, and by the greater readines- with which fluids pass through them. Dropsy in Serous Cavities. — The serotu cavities of the body, the arachnoid, pleura, peri cardium, peritonaeum, &c., are now known to be large lymph-sacs, in communication with the general lymphatic system of the body. Tlie fluid which exudes into them from the blood- vessels is, in the peritonaeum and pleura, removed, at least in part, by a pumping action in the movements of respiration. The central tendon of the diaphragm contains spaces, the walls of which are alternately drawn apart and pushed together during its ascent and descent. Their separation draws up lymph from the abdominal cavity, and their compression forces it onwards through tho lymphatic vessels. The same thing occurs in the costal pleura, during tlie respiratory expansion and contraction of the chest. The accumulation of fluid in serous cavities may be due, like its accumulation in the cellular tissues, cither to diminished absorption or increased exudation. The diminished absorption occurs here in conse- quence of pressure upon veins, and possibly alsr DROPSY. from interference with the pumping action just described. Accumulation of fluid in the ven- tricles of the brain, or in a sub-arachnoid cavity, is chiefly due to compression of the veins of Galen. In the peritonaeum it may be due to obstruc- tion of the portal vein by cirrhosis of the liver or by the pressure of tumours, and it may occur to a greater or less extent in all cavities of the body — from general obstruction of the venous circulation, by disease of the heart or lungs, in the same way as anasarca. It may also occur in these cavities from alteration in the flood, as in Bright’s disease. Active dropsy may occur in a serous cavity from inflammation, and here the exudation of fluid is much more rapid than in passive dropsy, the vessels of the in- flamed part being dilated and more pervious than usual. Treatment. — The first thing to be considered in the treatment of dropsy is the removal of its cause, if this be at all possible. Where it is due to obstruction of a vein we must hinder, as much as possible, the accumulation of fluid in the vein, bv preventing the part from remaining in a dependent position, whiie at the same time we try to aid the absorption of fluid by the lymphatics by gentle upward friction. Where it is due to obstruction of the circulation in the lungs, we must diminish, as far as possible, all obstructions to the pulmonary circulation by inhalations, emetics, and expectorants, pushed if necessary so far as to cause nausea or even vomiting. Where, the obstruction is due to dilatation or valvular lisease of the heart, we must aid the organ to ontraet more powerfully by the use of cardiac stimulants, such as alcohol and digitalis. Digi- talis probably has a threefold action in cardiac dropsy, by strengthening the heart, by contract- ing the vessels, and by stimulating the kidneys. It strengthens at the same time that it slows the cardiac pulsations, and by making the heart con- tract more powerfully it keeps up the onward current of the blood more efficiently, and at the same time lessens the dilatation which tends to render the valves incompetent. Besides its effect on the heart, digitalis has also an action on the vessels, causing the arterioles to contract, and probably reducing the dropsy in this way. For the contraction of the arterioles produced by digitalis is exactly the converse of the condition which occurs after division of the vaso-motor nerves, and which, as we have seen, produces dropsy whenever any obstruction of the circula- tion exists. It is not known at present whether digitalis also causes increased absorption, but it seems highly probable that it does so, because we know that it stimulates the vaso-motor centre, and stimulation of this part of the nervous system has been shown by Goltz to increase greatly the rapidity of absorption from the lymph-sac of the frog. In addition to this action on the heart and vessels generally, digitalis possesses a specific action upon the vessels of the kidney. It is a powerful diuretic, and by thus lessening the amount of water in the blood it will tend to in- crease the absorption of serous fluid either from the cellular tissue or serous carities. AVhen ".igitalis alone does not succeed, the addition of squill and of a small quantity of blue pill fre- quently increases its efficacy. Digitalis succeeds DROWNING, DEATH BY. 405 best in dropsy caused by valvular disease or dilatation of the heart. It is not so useful in dropsy arising from renal disease, and here other diuretics are preferable. One of the best is spirits of juniper, given either as a mixture or in the form of Hollands gin. Spirits of nitrous ether, nitre, bitartrate of potash, and broom are useful in all forms of dropsy. Copaiba occasionally succeeds where other diuretics fail. It seems to be most successful in dropsy due to cirrhosis of the liver. Hydragogue cathartics, such as com- pound jalap powder, elaterium, &c., which cause copious watery secretion from the intestines, sud- plement the action of diuretics, and by removing water from the body, as well as altering its nutrition, relieve or remove dropsy. In some cases of Bright’s disease considerable relief has been obtained by the profuse sweating induced by vapour baths, hot-air baths, jaborandi. or pilocarpin. AVhen the dropsy does not yield to other remedies, the fluid must be removed by paracentesis in the case of serous cavities, and by very small superficial incisions or punctures, or by the insertion of very fine troehars with drain age-tubes attached, in the case of the limbs. T. Lauder B run ton. DROAYNTiN'G, Death by. — Drowning is employed, in an extended sense, to signify death from submersion in a liquid medium, and in a more restricted sense to signify death in conse- quence of obstruction of respiration so caused. Now, though death must necessarily ensue from asphyxia, when the air-passages are submerged, apart from any other complication, asphyxia is not always the mode of death in those who were alive at the moment of submersion. For death may result from mechanical injuries, concussion, shock, syncope, or apoplexy in the very act, or at the moment, of falling into the water. Devergie estimates that 12'5 per cent, of deaths occur from one or other of these causes. In the remain- ing 87'5 per cent., the phenomena of asphyxia pure and simple are present only in 25 percent.., while in 62 5 per cent, these are more or less modified by the causes above-mentioned, to which must be added the benumbing influence of cold. AATien death is not sudden from shock, &c., the ultimate result is the same in the swimmer or non-swimmer, if there be no escape or rescue. All efforts to keep above water fail, vain cluteh- ings are made at whatever comes within reach, water is drawn into the lungs and more or less swallowed, all struggles finally cease, and the body sinks. The indications of such instinctive efforts form the most important evidence of submersion during life. Drowning is not necessarily to be inferred in the ease of a dead body removed from the water ; for the body may have been thrown in after death from other causes — asphy r xia among the rest. The Evidence of Death from Drowning is cumulative, for we can scarcely say that there is any one indication invariably present which can be looked upon as due to drowning and nothing else. But one or other, or more, of the following appearances are generally found. External . — The face is either pale, or more or less livid, or frequently bloated if the body hi.s 106 DROWNING, DEATH BY. lain some hours in the water. Foam at the mouth and nostrils is very common; and the tongue is swollen and congested, closely applied to the teeth, or even clenched between them. The skin is pale, or marked here and there by livid dis- colorations, and the muscles of the hair-bulbs are rigidly contracted, causing the appearance of goose-skin, or cutis ayiserina. The penis is re- markably retracted, so that it appears quite small in proportion to the size of the individual. Indications of struggling are frequently seen in excoriations of the hands, mud and sand under the nails, or even weeds, straws, or other small objects, tightly clenched in the hands. Internal . — The trachea, bronchi, and smaller air-tubes are congested and filled with a mucous froth, more or less tinged with blood. The lungs themselves are congested, cedematous, and pit on pressure. Pressure on them causes froth to exude into the smaller bronchial tubes, and on section a sanguinolent froth and water escape. Indications may be seen of sand, mud, or small weeds drawn deep into the air-passages along with the water in which submersion took place. The stomach contains water. If this has any special character by which it can be identified v/ith that in which submersion occurred, and not likely to have been drunk to quench thirst, it ex- cludes the theory of its having been swallowed before submersion ; and is a strong presumption, if it cannot be said to be a certainty, that it was swallowed during the death-agony, and did not find its way into the stomach after death. The same may be said of water in the lungs. The right side of the heart and venous sys- tem in general frequently present the appearances characteristic of asphyxia ; and the brain is often congested. Without relying on anyone sign as conclusive, we may say that a body which exhibits goose- skin, retraction of the penis, excoriations, &c., of the hands, froth at the mouth, water in the lungs and stomach, and congestion of the right heart and venous system, certainly died from drowning. In the presence of some and in the absence of other indications, a careful weighing of all the facts is necessary ; but in most cases a satisfactory conclusion can be arrived at. Complete submersion is usually sufficient to cause death within two minutes ; but cases have been recorded of resuscitation after a much longer period. Many of these can be attributed to the exaggerated estimation of time by anxious on-lookers ; but there are other well-authenti- cated instances, which may be explained by the supervention of syncope and temporary cessation of the respiratory process. That which renders resuscitation after submersion less likely than after a corresponding period of mere suffocation is the entry of water into the lungs by aspiration. Treatment. — The treatment of the drowned consists in the persistent use of artificial respira- tion (see Artificial Respiration, and Resus- citation) so long as any signs of life remain, together with the application of means to coun- teract the great abstraction of body-heat which occurs even when the aerial temperature is com- paratively high. Before commencing the move- ments of artificial respiration, the mouth and nostrils should bo freed from water and froth, DUMBNESS by holding the head somewhat low, face down- wards, for a few seconds. Artificial respiration should then bo immediately proceeded with ; and at the same time the wet clothes should ba removed and the body wrapped up in warm clothes obtained from bystanders, pending the arrival of warm blankets, hot bottles or bricks, &c., from the nearest house. Assiduous friction of the extremities should also be kept up. These directions — artificial respiration excepted— natu- rally presuppose assistance. If this be not at hand, the operator must rely mainly on artificial respiration. In the performance of artificial respiration by Sylvester’s method, especial care must be taken against pressing on the stomach, for as it so frequently contains water, this may be pressed up the oesophagus, and drawn into the lungs by the next inspiratory movement. When spontaneous respiratory movements commence, attention should be directed to main- tain life, by the application of warmth exter- nally, assiduous friction of the limbs upwards, and the administration of a teaspoonful of brandy and water, wine, or coffee. Lung-complications should be watched for and counteracted. D. FaaRiBB. DROWSINESS. — Inclination to sleep. See Sleep, Disorders of. DRW. — A term applied to certain morbid conditions, to express the entire or comparative absence of fluid exudation or secretion, which is often present in such conditions ; for example, Dry Gangrene, Dry Cavity, Dry Catarrh, and Dry Pleurisy. The word is also associated with certain ausculatory signs, which cbnvey the impression of want of moisture ; for example. Dry Rhonchus and Dry Crackle. See Physical Examination. DUCHENNE'S PARALYSIS. See PsETJnO-HYPERTEOFHIC PARALYSIS. DUCTUS ARTERIOSUS, Patency of.- Scc Heart, Malformations of. DUMBNESS. — Definition. — The condition of an individual incapable of articulating sounds. Dumbness may arise from a variety of causes, and its prognosis and treatment vary accordingly. 1. Dumbness due to Deafness. — The most frequent cause of so-called dumbness is congenital or early acquired complete deafness, or defective power of hearing, so that the patient is unable to acquire in an ordinary way the knowledge of ar- ticulate sounds. It is important to hear in mind that complete deafness is not essential to this peculiarity. Dumbness is frequently met with in children and others where the only cause is defec- tive power of hearing. Treatment. — Whether the outcome of com- plete or partial deafness, the treatment must be based on the belief that the articulating power is latent, and may be developed by imitating the process of speaking in others, and by a methodical training in lip language. It is most important that sign language should not bo cultivated at the same time, and that if a lan- guage of signs, whether by the hand or gesture, have been previously taught, it should he tho- roughly and at once discarded. With patients DUMBNESS. who have full intellectual power, and who are trained as indicated above, it will be found that for them dumbness is a misnomer, articulate sounds, although with a defective modulation, being readily acquired. Individuals comingunder this categoiy are erroneously called deaf-mutes. 2. Dumbness from Central Lesion of the hypoglossal nerve.— This may arise from cere- bral haemorrhage, tumours, or embolism, and the prognosis is most unfavourable. It is usually associated with other paralytic conditions, but is of all the most persistent. 3. Dumbness from peripheral lesion of the hypoglossal nerve. — This is much less frequent as a cause of dumbness than central lesions ; nevertheless cases are met with where hydatid or other tumours result in dumbness through pressure on the nerve itself. 4. Dumbness from Lead Poisoning. — Among the paralyses arising from the slow i fleets of imbibition of lead is paralysis of the tongue, with consequent loss of articulating power. This defect is usually associated with grave impairment, of other parts. Treatment. — T he treatment of dumbness duo to lead-poisoning will be best effected by elimi- nation of the poison by the administration of iodide of potassium, and the judicious employ- ment of galvanism to the spinal system. 5. Dumbness from congenital defects of the tongue or of the palate. — Various con- genital local lesions are met with giving rise to dumbness. Treatment. — Many of these cases are reme- diable by surgical or surgico-dental help, fol- lowed by methodical teaching. G. Dumbness from emotional lesions. — - Dumbness occasionally arises from great emo- tional disturbance, such as great anger or sudden fright. Moreover, it is often met with, without suchmarked cause, in individuals, especially of the female sex, having a highly developed emotional life. Treatment. — Cases of this kind arc usually successfully treated by faradisation about the muscles of the neck ; the patient at the same time being encouraged to call liis articulating power into action, and in proportion to his success the faradic current being discontinued. The moral treatment here indicated may be greatly assisted by promoting the general health, and placing the patient under the best possible circumstances as to hygiene and moral disci- pline. 7. Dumbness from intellectual disorders. — This is by far the most common cause of true dumbness. It may arise from idiocy or im- becility of a congenital nature ; from that which has been acquired early in life ; or from dementia as the outcome of acute or chronic brain-disease in middle or advanced life. Among the con- genitally feeble-minded, dumbness is a very frequent phenomenon. This arises from the ussociation therewith of deformed mouths and highly-arched palates ; from defective power of co-ordination of the muscles of the tongue; and from an inability to transform ideas into word- signs. In the most profound cases there is such an absence of ideas that language of any kind is not required. DUODENUM, DISEASES OF. 4(.; Treatment. — The treatment of this kind ol dumbness is one which requires great tact, patience, and energy ; and the success will be commensurate with these aids. The physical health of the individual should be carefully attended to, so as to induce, by judicious food, frequent bathing, and warm temperature, the highest amount of nervous energy. The power of co-ordination should be sedulously cultivated by methodical exercises, especially of the hands, leading up to well- devised tongue-gymnastics. He should then be taught monosyllabic sounds, by being shown the object represented by the sound, while he imitates the sound when watching the teachers lips. Having thus acquired the power of producing the word-sign by imitation purely, he is next taught to repeat it from memory when shown the object only. After nouns have thus been taught, the names of qualities and adverbial expression^ should be added, and in this manner articulate speech built up. Where the feeble mindedness has been ac- quired after birth, the dumbness resulting there- from should be treated in a somewhat similar manner to that having a congenital origin, but the prognosis is not so good. Still more unfavourable is the forecast of dumbness when the result of dementia. J. Langdon Down. DUODENUM, Diseases of. — These may be considered under the heads of — 1. Functional disorder ; and 2. Organic diseases. 1. Functional disorder of the duodenum is said to produce a form of dyspepsia, characterised by pain in the epigastrium and right hypochondrium two or three hours after meals, vomiting, and the distant effects of ordinary dyspepsia — ver- tigo, headache, drowsiness, burning sensation in the soles of the feet and palms of the hands, & c. Imperfect chymification which attends ordinary dyspepsia may induce these symptoms by gene- rating products which irritate the duodenum. The treatment is mainly that of disordered digestion. The bowels and the diet are to be carefully regulated; and such remedies as alka- lies, bismuth, oxide of manganese, prussic acid, or hydrochloric acid, exhibited, according to the special requirements of each case. 2. Organic diseases .— These are inflammation : ulceration ; and new-growths. a. Inflammation. — Synon. : — Duodenitis; I'r. Duodcnite. — Acute inflammation of the duodenum is usually of a mild catarrhal character. It either forms part of an enteritis, oris an extension down- wards of a similar affection of the stomach. The ordinary exciting causes are exposure to cold, and irritating ingesta or acrid bile. Usually the symptoms of slight gastric catarrh — a loaded tongue, anorexia, nausea, vomiting of tenacious mucus — are followed by jaundice. When the duodenum is invaded there is said to be ful- ness and tenderness of the right hypochon- drium. As a rule, however, new symptoms are not set up unless the bile-ducts become ob- structed by mucus from extension of the catarrh into them, when jaundice supervenes without pain. The attack usually lasts a week or a fort night, and, with suitable hygienic and dietetif 103 DUODENUM, DISEASES OF. treatment, passes safely off; it is, however, some- times followed by jaundice unusually prolonged, and, even when the bile-ducts are free, by pros- tration and wasting out of proportion to the mild- ness of the disease in itself. While catarrhal duodenitis does not present characteristic symp- toms, it is, however, usually suggested by pain- lessjaundice following exposure to cold, catarrh of the stomach, and enteritis. Treatment. — This consists in rest in bed, warmth, liquid diet, counter-irritation by mustard and hot poultices, and effervescing salines. Chronic inflammation, resulting in thickening of the mucous and submucous tissue, and even adhesion of the duodenum to adjacent organs is usually associated with chronic ulceration, or with cancer of the duodenum, pancreas, liver, or other structures. Contraction of the duodenum produces symptoms of obstruction similar to those arising from stricture of the pylorus. b. Ulceration. — Perforating ulcer, similar to that of the stomach, is said to be more frequent in men than in women, and hardly ever to occur during childhood ; while it frequently follows severe and extensive burns and scalds. The ulcer, usually found in the upper horizontal portion, when recent has clean-cut edges free from swelling. The wall of the duodenum may be perforated, either without previous adhesion, being followed by the signs of general perito- nitis ; or with adhesion to adjacent parts, such as the liver, the gall-bladder, the pancreas, the colon, the hepatic artery, or the posterior wall of the abdomen — into which ulceration extends to a variable extent. Cicatrisation may induce stric- ture of the duodenum or obliteration of the bile- duct. As a rule the symptoms greatly resemble I hose of perforating ulcer of the stomach; more frequently, however, the disease is latent, and induces very obscuro dyspeptic symptoms prior to fatal perforation. Jaundice is not more com- mon than in the similar affection of the stomach. In burns and scalds perforation seldom occurs before the tenth day. The duodenum may be ulcerated by the action of a gall-stone passing into it directly from the gall-bladder. c. Kew growths. — The most important of these is scirrhous cancer, which may involve the walls of the duodenum, usually by extension. It tends to produce obstruction, or it may set up chronic duodenitis, or block up the bile-duct, and thus give rise to jaundice. George Oliver. DURA MATER, Diseases of. See Meninges, Diseases of. DURATION OP DISEASE, see Disease, Duration of. DYNAMOMETER (dvrapis, power ; and perpoi a measure). Description. — The dynamometer is an instru- ment originally invented by M. Duclienne, of Boulogne, for measuring and accurately recording the strength of the hand-grasp, and also for measuring the traction power capable of being exerted by other groups of muscles. The result is shown by an index, which traverses a semi- circular dial bearing a scale graduated so as to DYSENTERY. enable the observer to record the number of kilo- grammes which the applied pressure or traction represents. In practice this instrument has been principally employed for estimating the absolute or comparative force of the hand-grasp ; and in view of this restriction, Duchenne’s instrument is needlessly complex. It has, moreover, the abso- lute disadvantage of being a little too broad, and of requiring too much strength on the part of the patient to move the index over the lower figures of the dial. A patient with a small amount i>. motor power, especially if the hand is small, is often unable to set the index of this dynamo- meter in motion. A cheaper, simpler, and nar- rower instrument has, therefore, been devised by English makers, the index of which can be moved by the application of a much smaller amount of power. This consists of a simple elliptical ring of steel, to the inner and anterior face of which is attached a brass semi-circular dial graduated with two rows of figures repre- senting pounds instead of kilogrammes. The compression of the steel ring, by lessening it* shorter diameter, moves a metal bar projecting from and sliding in a groove behind the dial, and this by rack-work communicates its move- ment to tho index. Uses. — The dynamometer is a useful instru- ment, inasmuch as it enables us accurately to as- certain the relative compressing powers of the two hands in cases of incipient or actually developed hemiplegia, and also to learn in a positive and definite manner, from time to time, the amount of improvement or the reverse which may have taken place. Since the power of the muscles of the fore-arm and hand, like that .of other groups of muscles, varies a good deal with the general state of health of the patient, the dynamometer is also capable of yielding valuable informa- tion concerning the strength of the patient, even where wo have not to do with a case of paralysis. Any instrument which, in the place of fleeting and more or less vague impressions made upon the mind of the practitioner at the time, enables him to make a more accurate record in figures in his note-book, is a clear gain to practical medicine — more especially when it* use involves no appreciable loss of time. H. Charlton Bastian. DYSESTHESIA (Si's, with difficulty, and aia-6a.vop.ai, I feel). — A term applied to impair- ment of any of the senses, but especially to that of touch. See Sensation, Disorders of. DYSCRASIA (Sts. difficult or bad, and Kpdff.s, a mixture). A morbid condition of blood. This term signifies more than a disposition to disease ; it implies tho presence of some general disease exerting its pernicious effects upon the blood. Hectic fever, septicaemia, and metastatic inflammations are diseased conditions referable to dyscrasiae. A person sickening for a fever is the subject of a specific dyscrasia. See Blood- Disease. R. Douglas Powell. DYSENTERY (Sf/s, with difficulty, and HvTepov, an intestine). Synon. : Fr . Dysenteric i Ger. Dysenteric. Definition - -A specific febrile disease, eharse DYSENTERY. ierized by considerable nervous prostration and inflammation of the solitary and tubular glands of the large intestine; sometimes ending in reso- lution, but frequently terminating in ulceration, occasionally in more or less sloughing or gan- greno ; always accompanied by tormina and tenes- mus, the latter being most marked when the disease is located in the rectum or lower end of tho sigmoid flexure ; stools at first more or less feculent, later on yielding dysenteric products without much if any feculence, such as blood, mucus, slime, and gelatinoid exudation, or — as in the sloughing or gangrenous forms — like the washings of meat, and possessing a putrid or gangrenous odour, and so-called epithelial, ash- coloured, black, gangrenous, pus-infiltrated or tubular sloughs, chiefly consisting of tough, im- perfectly organised exudation. .Etiology. — In almost all, if not in all, situa- tions where malarious fevers abound, as in the vicinity of the swamps and sluggish rivers of tropical and sub-tropieal countries, dysentery prevails in proportion to the intensity and fre- quency of these fevers. When, on the other hand, intormittents and remittents have been extin- guished by improved drainago and the conversion of marsh into cultivated land, it becomes equally unknown. In orneartho tropics, Great Britain, Canada, the United States, and in many other parts of tho world, its diminution has proceeded pari passu, with the decrement of malarious fevers. There would, therefore, seem to he some intimate connexion between the causation of dysentery and intermittent and remittent fevers. Paroxysmal fevers interfere materially with the nutrition and functions of the digestive organs, and with the proper nourishment and constitu- lion of the blood. Violent congestion of the abdominal viscera is one of the special conditions of the different forms of ague. Both the liver and spleen are liable to temporary and repeated engorgement, and so in fact are all the organs which minister to gastric and intestinal diges- tion. Even where malarious poisoning may never have resulted in any of the various forms of periodic fever, it may impair the power of the organic nerve-centres and the muscular tone of the blood-vessels, thus disturbing the balance of the portal circulation, and leading to more or less permanent repletion or congestion. As tho congestion is most embarrassing during diges- tion, interfering with the appetite, and the capacity for digesting and assimilating food, its repeated and prolonged existence must deterio- rate the quality and modify the quantity of such important secretions as the gastric juice, the bile, the pancreatic juice, and those furnished by the follicles of Lieberkiihn, and by Brunner's and the solitary glands. Crude alimentary prin- ciples are thus assimilated from the intestinal tract. The liver is especially liable to func- tional derangement from the stagnation and slowing of the portal circulation, and thus it happens that in dysentery hepatic impairment is almost an invariable accompaniment. Such being some of the abnormal conditions produced by the operation of malaria in its active or latent form upon the chylopoietic viscera, it is not surprising that, under the prolonged strain, cer- tain portions of the alimentary mucous membrane 409 should break down. Why the solitary glands of the large intestine should be the special seat of dysentery, whilst the corresponding glands it* the small intestine should, with few exceptions escape, it is, in the present state of our know- ledge, impossible to say. The most that can he hazarded is, that the elementary structures of these glands take on morbid action through the operation upon them of a matcries morhi derived directly from their blood-supply. That this poison exists in the blood may be inferred from the fact that constitutional disturbance invari- ably precedes and accompanies the earlier stages of acute dysentery. Unwholesome drinking-water is a fertile prox- imate and exciting cause of dysenteric disease. Bad and unwholesome food of whatever descrip- tion, by providing aliment incapable of being perfectly digested, may act in producing t.!;e disease. In like manner impure air may, by preventing the proper aeration and depuration of the blood, and by promoting the retention in it of inassimilable material, light up dysenteric inflammation of the solitary glands. The transit of acrid and vitiated bile and other secretions poured into the digestive canal, often operates as an exciting cause, and frequently determines a morbid action which might be otherwise righted by resolution, to advance to ulceration, sloughing, or gangrene. It is thus that many a simple hut neglected case, scarcely at first distinguishable from diarrhoea — unless indeed every evacuation is most carefully washed and scrutinised — ends in destruction of large masses of the mucous membrane, and death, from the conjoint effect of exhaustion and shock from tho separation of the sloughs. Indigestible articles of diet, which cannot be reduced by the juices of the digestive tract to a condition admitting of ready absorp- tion, may act as local irritants and exciting causes. Not only is this so in the earliest visible stage or that of active congestion, hut it becomes much more susceptible of demonstration in tho exudative and ulcerative phases of the disease, by the repeated investigation of the subjective and objective indications. Tims the aggravation of the tormina and tenesmus in adults and children is traceable to indiscretion in diet, or to the passage of undigested morsels of food, re- cognisable in the stools. Sudden vicissitudes of temperature from a high to a low range, or ex- posure to damp and cold combined, especially when the vital powers are physiologically de- pressed, by checking the excretory action of the skin and diminishing tho cutaneous circulation, augment the portal congestion and excite dysen- teric disease. This is probably the reason why, in a large proportion of cases, the onsetof thedisease is ushered in towards midnight or the early morning. The influence of epidemic states of of the atmosphere in the causation of dysentery, signifies only that it is most prevalent at those seasons when malarious fevers are most abundant. As there is an intimate connexion between the existence of malaria and the prevalence of dysen- tery, it is not difficult to understand why, both as regards type and seasonal frequency, dysentery should bear a striking relation to the severity and seasonal prevalence of malarious fevers. Is dysentery a contagious nr communicabU DYSENTERY. no disease ? — Whilst many of the older physicians held that it might be spread by contagion from person to person, it may -be affirmed that the experience of most modern practitioners is alto- gether opposed to this view. There is no clear and unimpeachable evidence to demonstrate that it is propagated in the same way as typhus or smallpox. It may possibly be communicable, like typhoid fever, through air, water, or food — liquid or solid — charged with material derived from the undisinfected and putrefying products of the disorder. Be this, however, as it may, the complete disinfection or destruction of the alvine evacuations should always be regarded as a sanitary measure of supreme importance. Anatomical Characters and Pathology. — The dysenteric process generally consists of a specific inflammation of the solitary glands (Parkes, Baly, and others). The first visible change is congestion, the vessels surrounding and penetrating the capsules being turgid and en- gorged with blood. The second change is aug- mentation of their contents from the accumulation of albuminous exudation, and enlargement ‘ from t he size of a millet seed to a small shot’ (Baly). I’lie third change is, provided the inflammation advances, rupture of some of the capillaries in i he interior of these little vascular glands, ex- travasation of blood, with the area of the ordinary dark point on the free aspect increased. Th & fourth stago is now marked by atrophy and molecular disintegration of the free aspect of the capsular wall, and escape of its morbid gelatinoid blood- tinged contents into the canal of the intestine. This is the rule, but, in very exceptional cases, the capsule may burst through the attached por- tion. lighting up inflammation in the neighbour- ing connective tissue and muscular coat. In a large number of instances, the morbid process may stop short, under proper treatment, at any of the first three stages, and repair is then i ffectod by resolution. In many cases the morbid action is cut short after the completion of the fourth stage, without further extension of the diseaso. The adjoining follicles of Lieberkiihn do not, in these cases, necessarily participate, to any great extent, in the diseased process. Under these conditions, when the whole of the exudation has been expelled, the glands regain their tone and functions, and recovery — rapid and complete — ensues. It is not often possible to illustrate these conditions in the post-mortem room ; because, when death supervenes from dysentery alone, the ravages committed upon every structure of the mucous membrane are so extensive as to destroy the earlier physical phases of the disease. In some cases, however, which have died from intercurrent affections, the writer has been able to demonstrate the earliest stages successfully to nis students, at a period prior to the implication of Lieberkiihn's follicles, of which the mucous membrane is in great part composed, and to ex- hibit to them the gelatinoid exudation, termed by others ‘ gelatinous mucus.’ free from or tinged with blood taken from enlarged and diseased solitary glands ( Indian Annals of Medical Science, p. 190, No. xxiii., 1368). When, owing to neglect, to constitutional de- fect in spite of the most careful therapeutic and hygienic management, or to intensity or quantity of the specific poison, the disease is not cured by resolution, tho disintegrating or ulcerative pro- cess is developed. The whole of the solitary glands engaged perish. The ulceration involves the neighbouring tubular glands, leading to ulcere varying from the size of a mustard-seed to that of a florin or more, in depth generally extending to the submucous connective tissue, and not in- frequently laying bare the circular lamina of th.i muscular coat, sometimes involving the Icngiti- dinal layer and perforating it as well as th t peritoneal coat, thus admitting of the extravasa- tion of the contents of the bowel into the peri- toneal cavity and lighting up peritonitis, which, if genera], is invariably morial. but which, if local and confined to the close vicinity of the perforating ulcer, is not necessarily so. The ulcers vary in appearance, size, and shape. They may be mere abrasions without much loss of structure, minute though penetrating rather deeply into the submucous connective tissue ; irregular, serpentine, or rodent, with here and there portions of the surrounding mucous mem- brane undermined and patulous ; transverse, embracing partially, or completely, the entire circular outline of the mucous membrane ; circu- lar, or oval, with regular and even margins ; or tubercular, involving the whole substance of the mucous membrane, looking as if they had been punched out of it. These ulcers, as generally observed in the post-mortem room, are free from sloughs, and present a pale ashy appearance. Sometimes they are of a vermilion or purple colour, from active or passive congestion. They arc often covered with flakes of tenacious lymph or exudation, and this may sometimes be seen spread over the neighbouring mucous membrane. The floors of theso ulcers are usually formed by inflamed and thickened submucous areolar tissue : but sometimes this has all been destroyed, and then they are constituted of the muscular coat, thickened and infiltrated by inflammatory pro- ducts ; and when the muscular structure has itself yielded to the ulcerative process, they are made up of congested and swollen peritoneum which, as already stated, occasionally becomes perforated. When the ulceration proceeds solely by mole- cular disintegration massive sloughs are not observed. But when, as not uncommonly happens in asthenic, malaria-stricken, tubercular and worn-out constitutions, tissue-death occurs on masse, at an early period of the attack, slough- ing of the mucous membrane, together with portions of the muscular coats, or gangrene, is to be seen. These sloughs, or gangrenous portions of tissue, may be limited in extent. Some or all of them may be successfully detached during life, and can be identified as they are examined from time to time in the stools. In the pest-mortem room they may be found partly detached and lying loose, mixed with the fluid contents of the bowel, or attached more or less firmly, sometimes compiact, nodular, eechymosed. gray or olive- coloured, green or yellow and pus-infiltrated, black, flaky, shreddy, shaggy, floeculent like pieces of teased cotton-wo >1, or ragged and stringy. In the truly gangrenous dysentery, the mucous and muscular coats are enormously thickened, and large portions are found gangre- DYSENTERY. nous, varying in colour from a pale olive to purplo or black. These appearances and conditions may be restricted to the caecum and ascending colon, or to the sigmoid flexure, but sometimes they are eo-extensive with the internal structure of the large intestine from the ileo-colic valve to the anus. When the ileo-colic valve becomes de- stroyed, invagination of the lower end of the ileum into the caecum sometimes happens, causing intestinal obstruction, Occasionally many inches of the gangrenous mucous membrane, with or without the muscular coat, is either found hang ing loose in the lower part of the gut, or in pro- cess of being detruded from the anus. In ordinary acute dysentery, advancing to ulceration c>r sloughing, repair is, doubtless, accomplished, as a general rule, by granulation and cicatrisation. This process can be readily observed in dysenteric lesions of the mucous membrane of the lower end of the rectum, and in healing of the surgical ulcer within the verge of the anus. The reason why repair is frequently accomplished so slowly is because, owing to the irritation caused by 7 the exalted vermicular con- traction of the gut and the passage of flatus, feces, and other products, it is impossible to command the physiological rest necessary for speedy and substantial granulation and cicatri- sation. Unless the destruction of tissue is very great, the contraction due to cicatrisation does not occasion much future inconvenience. But if it embraces a large portion of or the whole circum- ference of the mucous membrane, the subsequent contraction may produce dangerous narrowing of the calibre of the gut, or stricture of the sigmoid or rectum. The thickening and contraction, especially in the .attenuated victims of chronic dysentery, can be identified by physical exami- nation. These constrictions are frequently the mechanical cause of constipation and fecal accumulations. There is no valid reason for believing that, in true dysenteric ulceration, the lost tissue is ever actually reproduced. When the ulcers have been small, the contraction following repair issufficient to bring the follicles of Lieberkiihn on all sides into close juxtaposition. And this it is which has given rise to the impression among some pathologists, that the lost tissues have been renewed by 7 a process of development and growth. But whenever the ulcers have been too large to admit of obliteration, microscopical examination shows that they have been bridged over by cica- tricial tissue, devoid of solitary and tubular glands and sparingly supplied with blood-vessels and absorbents. In addition to the above anatomical characters, the mesenteric glands are generally found to be enlarged, and as an accompaniment or sequel, organic disease of the liver or abscess is not infrequently discovered to complicate the disease. Symptoms. — Every attack of acute dysentery is preeedod by disordered digestion and constitu- tional disturbance, indicated by loss or capricious- r.ess of appetite and furred tongue, constipation alone or alternated with looseness, dryness of skin, occasional chilliness and general malaise, with sught rise of the evening temperature. These signs may be viewed as cotemporaneous with the progress of the morbid action going on in the soli- 411 tary glands. As tho disease advances, there if more marked chilliness, succeeded by distinct feverishness. If the bowels have been confined, they now act spontaneously — expelling, at one oi more acts of defecation, almost the wholo of the contents of the large intestine. If they have been loose, with or without aperient medicines, the feeu- lence is not so great in quantity. But in either case, beyond a little mucus, there is not as yet any discoverable dysenteric product in the stools. Prior to this conservative evacuation of the bowels, the febrile excitement sometimes runs high ; there is thirst, bad taste in the mouth, flatulency, a variable amount of nervous and muscular debility, griping, an accelerated and irritable pulse, restlessness, disturbed sleep, oi actual insomnia. During, and immediately after, each evacuation there is tenesmus or painful straining — most intense in those cases where the disease is located in the descending colon, sig moid flexure, and rectum. The stools are offensive, but there is nothing at this stage pathognomonic in their odour. If, as frequently happens in private practice, the patient comes under treat- ment at this period, a small dose of castor oil guarded by laudanum, or a full dose of ipecacuanha, with absolute rest in bed and bland liquid nourishment, is sufficient, in a certain proportion of cases, to put a stop to the morbid action, and to promote cure by resolution in from twenty- four to forty-eight hours. When, however, the disease persists, the symp- toms continue in an aggravated form. The tormina and tenesmus become intensified ; the desire to go to stool is more frequent, and to remain on the stool or bed-pan more irresistible and enduring, especially if the disease be concen- trated in the sigmoid flexure or rectum. In rectal dysentery, there is dysuria, frequent micturition, and sometimes retention, from spasm due to reflex action, necessitating catheterism. The consumption of solid food — even of the most digestible kind — provokes and aggravates the tormina. The griping and tenesmus are now so intensified in degree, and increased in frequency, that each recurrence of them produces much depression and exhaustion, and a pinched and anxious expression of the countenance, with aug- mented frequency aud weakness of the pulse. There is abdominal tenderness. During the acme of the tormina, the patient experiences dif- ficulty in localising this tenderness. He will then declare that ho feels agonising pain over the greater part of the abdomen, with or without the application of pressure. But in the absence of the tormina, careful palpation will enable the practitioner to localise it in those portions of the intestine above the rectum affected by dysenteric inflammation. At this stage the tumefaction of the walls of the gut is seldom great enough to be distinguished through the abdominal parietes. The scanty stools are now characteristic, consist- ing of mucoid exudation tinged with blood, or bloody mucus or slime from the inflamed tubular glands, with isolated portions of gelali- noid exudation, more or less coloured with blood from inflamed and ruptured solitary glands, and with little or no feculence. These conditions are cotemporaneous with the rupture of the affected solitary glands, and a highly inflamed state of DYSENTERY. 112 the adjacent follicles of Lieberkiihn, as well as of the subjacent and. intervening connective tissue. The muscular tissue, though not yet ne- cessarily inflamed, is nevertheless hyperC one being given night and morning so long as their use is considered necessary. The signal for the relinquishment of these doses is freedom from tormina and tenesmus, with the occurrence of refreshing sleep, feculent, bilious, or ipecacu- anha stools, and restoration of the primary pro- cesses of assimilation. If no great amount of disorganisation of the mucous membrane has taken place, these favourable changes are fre- quently noticed after the administration of the first or second dose, and even if undoubted ul- ceration has set in, they aro generally discerned on the second or third day, or earlier, In either case the drng should be abandoned, as the dis- appearance of the tormina and tenesmus and the absence of mucus, blood, and slime from the stools indicate the cessation of dysenteric inflam- mation, and that tho affected portions of the bowel have been placed in the most favourable condition to undergo cure by ‘ resolution,’ if the case has not proceeded to ulceration, or b} r ‘ granulation and cicatrisation,’ if rdceration or even sloughing has already taken place. Chalk- mixture with hyoseyamus and astringents is now quite sufficient to wind up the cure. In some cases ferruginous and bitter tonics are demanded, to give tone to the digestive organs, and to improve the condition of the blood. Counter-irritation by means of turpentine epithems and mustard plasters to the abdomen, or fomentation, are valu- able adjuncts in the management of the disease. The diet should consist of chicken broth, beef- lea, essences of chicken, mutton, or beef; sago, arrowroot, or tapioca; and small quantities of port wine or brandy. During tho active period of the disease all food should be given in a liquid form. The disturbing effect of the ipe- cacuanha given as above directed is only tem- porary. Abundance of time is, therefore, avail- able between the large doses for the digestion and assimilation of liquid food. As the stools become more feculent and consistent, solid food in the shape of tender chicken, lamb, and mut- ton, with biscuit and bread, light sago, rice, or tapioca pudding should be allowed. Potatoes and other vegetables should be avoided until the tone of the digestive system has been fully re-established. When the dysentery is compli- cated with a purpuric or scorbutic condition of the blood, the administration of the juice of the grape, orange, pomegranate, lime, and bael sherbet, are essentially necessary as dietetic rather than therapeutic agents. Opium by the mouth is seldom required. When swallowed it ‘ locks up ’ the secretions of the liver, pancreas, and alimentary mucous mem- brane, rather favouring than reducing the inflam- mation of the solitary and tubular glands. These bad effects counterbalance the benefits derived from the sleep, diminution of peristaltic action, and temporary decrease of tormina and tenesmus consequent on narcotism. This ex- plains why the real character of the disease is often completely masked by opium, acd why apparent amendment is taking place, whilst de- structive ulceration and sloughing of the mucous membrano is rapidly extending. As ipecacuanha speedily brings about all the good without any of the evil effects of opium, this narcotic, in any form, excepting as an enema or suppository to relieve tenesmus, particularly in sigmoidal or rectal dysentery, is not ODly superfluous but in- jurious. There is less objection to uniting '.he ipecacuanha with such remedies as are acknow- ledged to possess the power of lessening the irri- tability of the stomach, and of increasing its tolerance of the drug, without interfering with the functional activity of those organs whose secretions we are endeavouring to promote with a view to rectify the disturbed balance of the portal circulation. On the contrary medicines cf this order may he beneficially associated with ipecacuanha — such as carbonate of soda, bismuth, chloroform, camphor, and hyoseyamus. When dysentery occurs in pregnant women, large doses of ipecacuanha are not contra-indi- cated ; Decause, if the disease be allowed to pro- ceed (which is more likely to happen under the old than the ipecacuanha treatment) abortion or premature labour is almost certain to follow ; and when such a complication supervenes, in tho later months of gestation, the mortality almost surpasses that of any other disease. "When the dysenteric inflammation is summarily put a stop to by the ipecacuanha, abortion or premature labour is prevented. Under the opiate method of management, premature labour is not averted, but, in the majority of cases, occurs at the acme of the disease, when the sloughs are being thrown off ; and the patient succumbs to the conjoint shock to the system. In dysentery complicated with pregnancy opiate enemata to relieve irrita- tion in the rectum aro more essential and per- missible than under other circumstances. In the acute dysentery of children ipecacuanha is invaluable. For a child of six months a grain, and for a child of one year two grains, should be given with an equal quantity of carbonate of soda, night and morning, until the tormina, tenes- mus, and slimy and bloody stools are replaced by relief from pain and by feculent evacuations. It will not often be necessary to continue the drug beyond two or three days at a time. But it shouldbe recollected that tho disease adheres with greater tenacity to children than to adults ; and although we observe that ipecacuanha has an im- mediately beneficial effect in diminishing the blood, mucus, slime and frequent stools, still we find that dysenteric or slimy motions with undigested food continue to pass. In that ease the ipecacu- anha, combined with chalk, bismuth, carbonate of soda, or aromatic powder, should be repeated, once or twice a day, for a certain period, till healthy evacuations are restored. The gums must be lanced when necessary ; turpentine liniment or stupes may be applied to the abdo- men ; weak chicken-broth or arrowroot should be temporarily substituted for mill; ; and, above all, food must be given in small quantities at a time, and at regularly stated periods. From the age of one year the dose is regulated by adding one grain for each additional year of age up to eighteen, when the doses indicated for adults should be employed. DYSENTERY. In cases where evident malarious taint per- vades the system and complicates acute dysen- tery, disulphate of quinine is indispensably necessary. A scruple of the antiperiodic will be most speedily absorbed if dissolved in water acidulated with sulphuric acid, and the exhibi- tion of this may precede by an hour the first dose of ipecacuanha. Ten-grain doses should be given midway between the large doses of ipeca- cuanha, or during abatement of febrile excite- ment. mtil the feverish symptoms have been subdued. Quinine here s quite as important as ipecacuanha, lor. until it h;.3 successfully cheeked 1 he disturbing influence which malarious poison- ing exercises upon the capillaries of the portal and general circulatory systems, the good effects which ipecacuanha produces are only temporary and incomplete. The mildest febrile exacerbations of a miasmatic origin re-excite dysenteric action, and thus undo the good effected by the action of the ipecacuanha. Hence, the urgent necessity for removing without delay every vestige of masked or active malarious fever complicating dysentery. No drug enables us to accomplish this object so safely and so quickly as the disul- phate of quinine in large dose i. When ipecacuanha fails to preserve the life of the patient, its failure may be generally attri- buted to— ( 1) coexistence of abscess of the liver ; (2) unchecked malarious poisoning; (3) per- manent enlargement of spleen or liver, or both ; (4) irretrievable constitutional cachexia ; (5) Addison's disease of the supra-renal capsules ; (6) morbus Brightii ; (7) phthisis or tubercu- losis ; (8) strumous disease of the mesenteric glands; (9) peritonitis with or without per- foration of the gut; or (10) the existence of ex- tensive sloughing or eangrene. The advantages of the ‘Ipecacuanha Treat- ment’ (for the revival of which the profession are indebted to Mr. Scott Docker, of the 2nd battalion of the 7th Royal Fusiliers, stationed at the Mauritius, — Lancet of July 31 and August 14, 1858) in the congestive, exudative, and ulcerative stage of almost every form and type of acute dysentery, as well as in the acute at- tacks supervening upon chronic dysentery, may be briefly stated to consist in (1) its simplicity, (2) its safety', (3) its certainty compared with any other method, (4) the promptitude with which the inflammation is stopped, (5) the rapidity with which repair takes place — (a) by reso- lution or (b) by granulation and cicatrization, (0) conservation of the constitutional powers, (7) abbreviation of the period required for con- valescence, (8) decrease in the frequency of chronic dysentery, (9) decrease in the frequency of abscess of the liver, (10) diminution of mor- tality to cases treated — all of which are accom- plished, ( a ) without local or general blood- letting, ( b ) without salivation, (ci without calomel and irritating purgatives, and (d) with- out opium by the mouth. Ipecacuanha in large doses may be said to fulfil many important indications. It produces (1) all the benefits that have been ascribed to blood-letting without robbing the system of one drop of blood, (2) all the advantages of mercurial and other purgatives without their irritating a tion, (3) all Ihe good results of antimonials 416 and sudorifics without any of their uncertainty, (4) all the euthanasia ascribed to opium without masking, if not aggravating, the disease whilst the mischief is silently accumulating within. Thus, we possess in ipecacuanha a non-spoliative antiphlogistic , a certain chologogue and unirrital- ing purgative, a powerful sudorific, and a harm- less sedative to the heart and the muscular fibres of the intestines. The objections which have been urged against large doses of ipecacuanha in dysentery are, first, its ‘depressing influence’ kept up by nausea and vomiting ; and, secondly, that it is liable to set up ‘uncontrollable vomiting.’ First, the depressing power, nausea, and vomiting have all been over-estimated. Nausea is only a temporary and evanescent effect. Vomiting is an exceptional occurrence ; and even when it does supervene, it seldom lasts long. As much nourishment, therefore, as may be required to support the strength can be al- lowed in the intervals between the large doses of ipecacuanha. But what contributes more to the conservation of the patient’s stamina and to the prevention of depression or asthenia, is the speedy cessation of the dysenteric process accom- plished by the drug, followed by refreshing sleep and the power of digesting and assimilating nourishing food. Such remarkable results as these soon reconcile any patient suffering from dysentery to an otherwise disagreeable remedy. Secondly, when uncontrollable sickness and vomiting succeed the employment of this drug in the manner already recommended, the exist- ence of one or other of the serious conditions previously enumerated may be more than sus- pected. In the absence of these complications, unmanageable vomiting is seldom if ever wit- nessed. Hence, in a preponderating majority of the cases of dysentery met with this ob- jection is quite untenable. The truth is that every physician who has used ipecacuanha in heroic doses soon learns that depression of the vital powers from it is not to be feared, and is surprised at the small amount of vomiting that follows its administration, and at the unexpected ease with which the stomach tolerates its presence. When dysentery becomes chronic no time should be lost in counselling removal from a malarious to a non-malarious and mild climate A sea voyage — provided easily digestible food can be secured — is often attended by the hap- piest results. To men so afflicted ‘the salt ration,’ as remarked by Dr. Maclean, 1 is simply destruction.’ The clothing should be warm, and flannels always worn around the abdomen; Dr. Maclean also recommends ‘the use of a water belt over the abdomen for some hours daily. This acts as a fomentation, and the steady uniform pres- sure it maintains seems to favour the absorption of the fibrine effused between the intestinal coats. If there be much uneasiness about the fundament, a water compress over the anus affords more relief than opiate enemata.’ The food should be chiefly concentrated soups, milk and lime-water, and sago, cornflour, arrowroot &c., egg-flip with port, sherry, or brandy; or, if solid food can be digested, the tenderest chicken, lamb, or mutton, with bread and biscuit, may be allowed. Beyond airing in a carriage nr chair, an 410 DYSENTERY. exercise should be attempted. Thepositionshould generally be recumbent or semi-recumbent. The erect position excites peristaltic action, and thus disturbs the physiological rest required to facili- tate the repair of the ulcers. Antiscorbutic juices should be given where there is the least taint of scurvy or purpura. Frequent blistering does much good. All forms of counter-irritation are beneficial. Gallic acid, acetate of lead, sulphate of copper, nitrate of silver, are reputed to act beneficially. Dr. Maclean’s favourite remedy, ‘particularly in men returning from tropical regions, anaemic from loss of blood and the de- praving influence of malaria, is the solution of the pernitrate of iron. Under this remedy the whole system often rallies wonderfully, the con- dition of the blood improves, colour returns to the blanched cheek, the stools become more natural and less frequent, the appetite improves, and digestion is more perfectly performed. The citrate of iron and quinine may after a time be substituted.’ As nearly all chronic cases are underlain by a malarious taint, quinine should form an important element in the therapeutic management, and the greatest care should be taken to secure for the residence of the patient a climate at once mild and temperate and free from suspicion of malaria. Bathing during con- valescence is an efficient and welcome auxiliary. Tepid or warm baths medicated with Tidman’s sea-salt or with nitro-muriatic acid act in stimu- lating the secreting function of the skin. But it will often happen that, in spite of the most careful dietetic, hygienic, and therapeutic ma- nagement, no substantial progress towards the repair of the ulcers is made, and the patient eventually dies, worn out from suffering and the asthenia consequent literally on inanition. Joseph Ewart. DYSIDROSIS (fit's, with difficulty, and iSpcos, sweat '. — This is a disorder of the sweat- folliclcs hitherto confounded with eczema, and first differentiated therefrom and accurately described by the writer. It occurs in winter as well as in summer, and often in those who per- spire freely ; and it attacks the hands chiefly, and especially the interdigital and the palmar sur- faces. The disease is characterised by the development of vesicles, which are not formed in the usual way in the rete, but are distensions of the sweat-apparatus by sweat secreted in excess, and which fails to find its way outward free upon the surface. These sweat-vesicles are at first situated beneath the level of the skin, and indeed appear as little boiled sago-grains im- bedded deeply in the substance of the skin, and when once seen arc readily recognised again. If pricked, a little sweat oozes out. In the earliest stage the reaction of the fluid may be acid, but it soon becomes alkaline from admixture of seros- ity. These vesicles are distinct the one from the other at first, and are scattered about the inter- cligital surfaces or the palms, or they may be grouped. In some cases their fluid contents dry away, and a little dryness and perhaps slight degeneration follow. They may enlarge and be- come prominent upon the surface, or run together into bullse, and if the sweat-secretion is free, large bullae may form. Usually the cuticle becomes DYSURIA. white and opaque from maceration in the fluid which collects beneath it ; and subsequently it peels off in a membranous manner, leaving be- hind, however, a dry reddened surface, but not a discharging one as in eczema. One or both hands may be affected ; and the feet may also be attacked. The disease occurs in connection with nervous debility. It may be attended with much itching or burning pain ; and may be accompa- nied by miliaria. Anatomical Characters. — If a portion of skin be excised and examined in the early stage of the disease, it will be observed that there is no true dermic inflammation, but that the mor- bid changes are limited to the sweat-apparatus, as the writer has shown ( Pathological (Society's Transactions , 1879). The sweat-gland-coils are congested, and the results of such congestion are also seen in the duct-walls as they run upward to the Malpighian layer, where the vesicles are formed. In the early condition the sweat- ducts are dilated, and choked by epithelial debris, and gradually this portion and the rete layer immediately outside the ducts, dilate into vesiculations under the pressure of the fluid poured out into the tube. In later stages the effusion is so free, and the distension of the tis- sues so decided, that the nature of the original formation of the vesicles is not recognised, and the vesicles may simulate those of eczema, save that the amount of inflammatory products is less, and there is no distinct connection between vesicles and engorged papillary vessels beneath. In the earlier stages of the vesicles, however, ducts can be distinctly traced entering the vesi- cles from above and leaving them from below, which conclusively proves that the vesicles are formed in connection with the sweat- apparatus. Treatment. — This consists, internally in ex- hibiting diuretics, to be followed by nervine tonics according to circumstances, and locally in the use of soothing and astringent applications. TrLBURT Fox. DYSIIENOEEHCEA (Ms. with difficulty; mv, a month ; and pew, I flow. — Difficult and painful menstruation. See Menstruation, Dis- orders of. DYSOREXIA (Ms, with difficulty, and opefts, the appetite). — An obsolete term for im- paired or depraved appetite. See Appetite, Disorders of. DYSPEPSIA (Sis, with difficulty, and ireVru, I concoct). — A synonym for indigestion. See Digestion, Disorders of. DYSPHAGIA (fit's, with difficulty, and owt), the voice). — Difficulty in producing vocal sounds, so that the voice is more or less en- feebled. See Yoice, Affections of. DYSPNOEA (fits, with difficulty, and I breathe). — Difficulty of breathing. See Res- piration, Disorders of. DYSURIA (fits, with difficulty, and oipia, 1 pass water). — Difficult or painful micturition See Micturition, Disorders of. E EAR, Diseases of. — The natural division of the ear into external, middle, and internal, suggests a rational, as well as a convenient classi- fication of the disorders to which the auditory apparatus is liable. I. External Ear. — In examination of the ex- ternal meatus and tympanic membrane, bright diffused daylight, or, when this is not obtain- able, light from a bull’s-eye lamp lit with gas, is the best for illumination, and the light should be reflected from a concave perforated mirror of eight-inch focus down a tubular spe- culum. In any operative proceedings the mirror should be worn on the forehead, as in examining the throat, but otherwise should be held in the hand. As great variations in the calibre of the auditory meatus are mot with, it is necessary to be provided with specula of several sizes, the most convenient form being that known as Gruber’s. Of the affections of the external ear the most important are the following: — 1. Eczema. — Although the acute form of eczema occasionally affects the auricle and ex- ternal auditory meatus, it is far more common to meet with the chronic variety. Elderly females are especially subject to eczema of the ear, and it is to its long continuance that the remarkable narrowing of the external meatus throughout its whole extent, met with occasionally in the sub- jects of this complaint, is generally attributable. Such narrowing will often amount to almost com- plete closure, and it is in these instances that, eczema becomes the cause of greatly impaired hearing ; for when this condition is arrived at, the passage down to the tympanic membrane is at times so small as only to admit of a very small probe. It is for this reason that, although no special methods of treatment are called for, beyond what is necessary when parts other than the ear are affected with eczema, it is of the greatest importance to keep the meatus sedu- lously free from secretion, and this occasionally is not a very easy matter. 2. Changes in cartilage. — Another condi- tion, in which the external passage becomes sub- ject to partial closure, is shrinking of the carti- laginous part of the meatus. This again, is a complaint of old age, and is attributable to no known cause. It is readily relieved by the patient wearing a piece of silver tube, to keep the passage patent. 3. Bony growths in the. osseous part of the canal present two entirely distinct phases : one in which, beyond the enlargement of bone, there is no discoverable disease, and no impairment in hearing power ; the other where the growth would seem to owe its origin to some irritation. In the first case, the enlargements are very frequently symmetrical in either ear, and syn- chronous in their growth. So exactly is this so, that of;en where they exhibit three curves iu one part of the boDy canal on one side, the curves will be found to be precisely similar in size ■md position in the other ear. As the enlarge- 27 ments are not attended with pain, the patient will obviously bo quite ignorant of his con- dition, until his attention is directed to one tn< by a slight accumulation of cerumen, which will suffice to obstruct the passage of sound to tin tympanum. In the other example alluded to, disease of the tympanum precedes the so-termed exostosis, and a perforation of the tympanic membrane, attended with a purulent discharge, will be present perhaps for some years before the growth of bone is discovered. It is in such a case that sometimes the exostosis, by preventing the escape of pus, becomes the indirect cause of death due to cerebral abscess. This is especially so where, in addition to the exostosis in the meatus, there is a polypus growing from the tympanic cavity. Treatment. — With this complication, or where the meatus becomes completely closed, and in these two cases alone, it occasionally becomes imperative to remove the bony growth. The position of the tumours, and their extreme hard- ness, make this no simple task ; and (except in the instance mentioned by the late Mr. Syme. w'hen they were exceptionably friable) their re- moval has been attended with great difficulty. Up to the present time two modes of proceed- ing have been the most successful. The first of these is as follows : — -Two needles being inserted into the base of the growth, holes having been drilled for this purpose, the continuous current derived from ten to twenty pairs of plates (Stoh- rer’s battery) has been passed through them for a few minutes, and in the course of about six weeks the bone thus destroyed has become loose, and is readily removed with forceps. The second . method consists in grinding the bone away by means of a drill, now in common use with den- tists. Either proceeding is attended with so much pain that an anaesthetic is necessary. 4. Inflammation. — The external auditory- meatus is subject to inflammation, diffused or circumscribed, the latter occurring in the form of small abscesses or boils. Both affections are attended by acute pain, and in each the general health of the patient has been out of order for some time previous to the local trouble. Treatment. — Treatment in the direction of improving the general health ; and local bleed- ing by means of leeches applied in front of the tragus, will often rapidly relieve the diffused form of inflammation ; hut when it has con- tinued for a long period (as it not infrequently does), in addition to the soft tissues the pe- riosteum becomes affected. The passage then throughout its whole extent becomes so swelled as to nearly close the external opening, and pain is constant. The only treatment which gives complete and permanent relief under these cir- cumstances is to make two or three free incisions down to the hone, along the whole extent of the osseous part of the canal. A convenient instru- ment for this purpose is a small sharp-pointed curved bistoury. As to the propriety of openiug U8 EAR, DISEASES OF. abscesses in this situation there can be noquestion, for, owing to the extreme denseness of the tissues and their approximation to bene in the external auditory canal, abscess in this part is slow in its progress and attended with very great suffering. These abscesses being especially liable to recur, a proper regimen and medicines appropriate to the failure in general health are required. 5. Fungi. — The external auditory meatus has been occasionally found to be the seat of two varieties of vegetable fungus, namely, Aspergillus flavus and nigricans. The symptoms which they have given rise to have been great irri- tation, and a slight discharge. They have been readily destroyed by syringing, and the local application of spirits of wine. 6. Polypus of the ear is usually preceded by inflammation in the tympanic cavity and perfo- ration of the membrane ; and is considered along with diseases of the middle ear. 7. Hffimatoma Auris. Sec ILtsmatoma AlTRtS. II. Middle Ear. — All affections of the mid- dle ear originate in some part of that tract of mucous membrane which, commencing where the Eustachian tube opens into the pharynx, forms the lining of this tube, and of the cavity, of the tympanum, finally becoming the inner- most layer of the tympanic membrane. To the character of this tissue is due the term catarrh, which, in its two forms of purulent and non- purulent, is used in describing any deviation from health which, directly or indirectly, is the cause of pathological change in the Eustachian tube or tympanum. 1. Obstruction of the Eustachian Tube. — One of the most frequent conditions under which the Eustachian tubes become the seat of ob- struction is that met with in children or young persons. The subjeots of this affection present a very characteristic aspect. They breathe almost entirely through the mouth, which, sleeping or waking, is kept partially open ; their tonsils are often enlarged, and they snore loudly during sleep. The mucous membrane of the nares and pharynx is swollen, and secretes in excess; owing to this tumid state of the fauces the passages to the Eustachian tubes in this situation do not admit of the constant necessary supply of air to the tympana. The air in these cavities undergoes partial absorption, and thus becomes more rare than that external to the tympanic membrane ; the density of tho outer air remaining tiro same, the equilibrium from pressure is destroyed ; the membrane, conse- quently, is retracted, the chain of ossicles are pressed inwards, and thus the conduction of sound becomes interfered with — in short, the patient is more or less deaf. In these cases inspection of the tympanic membrane at once reveals the state of affairs. As the cavity of the tympanum is notinvolved in the catarrhal change, its translucency and lustre are not impaired ; the handle of the malleus is tilted inwards, the head of this bone is unusually prominent, and there is a distinct fold crossing the upper part of the posterior section of the membrane. Where the obstruction has lasted for a long period, the membrane will appear to be almost fallen in dpon the walls of the tympanum, and the pro- montory and incus may be distinguished. If under these conditions the tympanum be in- flated on Politzer's plan, 1 an instant return to good hearing follows, but in the course of a few days the improved hearing partially dies away, leaving the patient, however, in some degree better than before the operation. Treatment. — This should be twofold. In the first place the tympanum should be regularly inflated, and this may be practised at first every three or four days, and gradually at longer inter- vals. Secondly, astringent applications should be applied to the pharynx. Of these applications one of the best is a solution of perchloride of iron, 2 drachms to 1 ounce of water, and it should be used daily by moans of a curved camel’s-hair throat-brush. When the nares are much ob- structed, great benefit will follow the use of sa- line solutions through the nasal douche, or they may be insufflated, that is, drawn up through the patient’s nose into the pharynx and then spat out. If the tonsils are so much enlarged as to in- terfere with the respiration, it will be necessary to remove them ; but the reason for this pro- ceeding is not that they press upon the opening of the Eustachian tube, but because their pre- sence keeps up the unhealthy condition of the pharynx. Under this routine of treatment the patients completely recover their hearing ; the space of time during which it is necessary to continue treatment varying according to the obstinacy which each case manifests. Obstruction of the Eustachian tubes in adults presents certain well-marked differences from the affection as it prevails in children. An ordinary cold is the beginning of the trouble. It is m«re usual to find one instead of both tubes ob- structed, and more often than not the tympanic cavity is involved in the catarrh. Where this is not the case — and it will be evident from the retained lustre and transparency of the mem- brane — the same principles of treatment as are pursued in the ease of children will hold good, except in so far that the affection in grown-up persons is less persistent after the tube has beer, once artificially opened ; and that, to effect tins, Politzer’s method is sometimes not sufficient, or. even if so, not as efficacious as the Eustachian catheter. It must also be borne in mind that in the treatment of cases in which one ear is healthy, by means of the catheter the affected car exclusively may be subjected to the air- douche, whilst with Politzer’s method it is im- possible to avoid forcing a stream of air into the healthy tympanum, and this is not always an advisable proceeding. The Eustachian Catheter. — The following is the mode of using the Eustachian catheter: — ‘ Place the patient in a chair, and let him lean back; steady his head with the left hand firmly fixed on the top of it; hold the catheter lightly in the right hand, with the curve downwards 1 This method of inflating the middle ear (now in such general use) consists in passing a stream of air from an india-rubber bag through one nostril whilst the patient swallows some water. The operator at the same tilin’ closes one nostrilwith the forefinger of the left hand, soil completes the closure of the other with the thumb. T . - month must lie kept firmly shut. EAR, DISEASES OF. And piss it quickly in this position through the inferior meatus of the nose to the posterior wall of the pharynx. When this is felt, -withdraw the catheter about half an inch, and tilt the point of the curved end rather upwards, and to the left or right, according to the side which is being operated upon. Now hold the catheter and end of the patient's nose steadily between the thumb and the first two fingers of the left hand. All this time the ear of the patient and that of the surgeon are connected with the otoscope. The point of the catheter is now supposed to be in the pharyngeal orifice of the Eustachian tube, but the only certain sign of this being the case is that when air is forced into the catheter it will be heard through the otoscope to impinge upon the tympanic membrane when a stream of air is passed down the catheter.’ The catheter may be made of silver or of vulcanite, but, of whatever material, it must be inflexible whilst being used. Beyond this, suffice it to say here that in practised hands its em- ployment is invaluable, and indispensable in the treatment of most affections of the middle ear, not only in overcoming obstruction of the Eusta- chian tube, but also as a means by which injec- tion of fluids may be applied to the cavity of the tympanum. In making use of the air-douche an indiarubber bag fitted to the catheter should be employed, and in using injections to the tym- panum a similar arrangement is necessary. 2. Catarrhal Inflammation of the Tym- panum. — When the tympanic cavity has be- come involved in the catarrhal state, or when the affection, instead of proceeding up the Eustachian tubes, begins in the tympanum, as it frequently does, those changes have commenced which, of all others, form the most frequent impediments to the conduction of sound — in other words, which make, the subjects in which they are found more or less deaf; and it may be broadly stated that the extent to which this affection is reme- diable depends directly upon the time at which the patients suffering from it apply for treat- ment. In the early stages, the obstruction to the passage of sound through the tympanum is solely due to the effusion of mucus in this situ- ation, and this is easily demonstrated by the moist gurgling sound which inflation of the tympanum produces, as may be heard upon con- necting the ears of the patient and surgeon by means of a piece of indiarubber tubing. 1 After- wards comes what may be termed the dry stage, i.c. when the fluid portion of the mucus has suf- fered absorption, and when any of the products of inflammation ma} T have become more or less organised, or at least in a condition which, if not interfered with, suffers no further change. The morbid conditions which result from non-puru- lent catarrh of the tympanum are twofold. First, those which affect the tympanic membrane, and are, therefore, demonstrable during life ; secondly, those which are met with after death in the tym- panic cavity. The first of these include changes in curvature, in colour, and in consistence. The slighter changes in curvature have been 1 This tubing should always be used, whether air or fluids are being injected through the Eustachian tube, for upon the sounds thus heard, as well as on the patient's own perception, the answer to the question whether the inflation is complete depends. 419 noticed in speaking of obstruction of the Eusta- chian tube, which condition is necessarily more or less present m all eases where the tympanum has been the seat of catarrh, and these changes are met with indefinitely increased until the state of complete collapse is reached. In this condition the membrane has the appear- ance of being in close apposition to the walls of the tympanum, and iapped round the ossicles, so that the forms of the malleus, incus, and some- times the stapes are distinctly traceable. In so extreme an example, the membrane is generally bound down to the tympanic wall by adhesions. The first change which the mem- brane exhibits is a loss of its lustre and trans- parency ; it becomes opaque. Further altera- tions iu colour, in cases of longstanding, consist in the formation of patches of brown, yellow (colour of parchment), and white. Variations in consistency will include thickening throughout the membrane, or in parts of it, especially in the cases of dense chalk deposits (phosphate oflime) ; and thinning in places, so observable sometimes that inflation will induce bladder-like protrusions, which, as inflation is suspended, fall back again : changes in all these respects completely meta- morphosing the appearance of the membrane. After death, within the tympanum may he found collections of dried mucus around the ossicles ; thickening of the lining membrane; hands of adhesion in all directions ; and anchylosis of the ossicles to each' other, as well as between the stapes and fenestra ovalis. As additional evidence during life of obstruc- tion in the tympanum, it may be mentioned that sounds from a vibrating tuning-fork placed on the vertex are intensified witen such obstruction exists, and the nerve remains unimpaired : this test is especially valuable where one ear is healthy, inasmuch as the sound will be heard exclusively on the deaf side, this being due t- the fact that vibrations of sound thus conveyed to the auditory nerve, on their passage outwards through the tympanum, meet with the obstruc- tion in this position, and are reflected on to the labyrinth. The appearances above described, together with the history of the case, serve sufficiently to distinguish affections of the con- ducting from those of the nervous apparatus, and the sounds which are produced upon inflation of the tympanum, whether of a moist or drv character, give evidence as to whether the mucu- in the cavity of the tympanum is in a more or less fluid state, or has reached the dry stage where the fluid part of the secretion has become absorbed, the more solid portion remaining. In the first of these conditions, the inflation at once increases the hearing power ; in the second, it produces no change in the hearing. An indica- tion in this direction is a most useful guide iu respect of treatment, for whatever differences in opinion may exist as to details in relation to this subject, experience has amply shown that the injection of fluids into the tympanum is for the majority of cases the treatment of all others the most successful, and, speaking generally, it may he said that when the sounds which accompany inflation of the tympanum are of a moist charac- ter (showing that undue secretion from the mucus membrane is going on), astringents, such as su! 120 EAR, DISEASES OF. phate of zinc, 1 to 2 grains to the ounce of luke- warm water, will be found most efficacious ; and that when the dry stage has been arrived at, alkaline solutions — bicarbonate of soda or potash, 5 grains to the ounce, or still better an injection containing hydrochlorate of ammonia, 5 grains to the ounce — should be substituted. Injecting the Tympanum .- — There are three modes of injecting the tympanum, and their order of efficiency stands as follows : — Firstly, when the Eustachian catheter has been placed in position, a few drops of the injectionare introduced intoit from a small glass syringe, and forced into the tympanum by means of an indiarubber bag, the nozzle of which is made to fit the open end of the catheter. Secondly, a few drops are placed in the inferior naris, on the same side as the ear under treatment, and injected in front of a stream of air blown to the tympanum on Politzer'splan, the patient’s head being inclined to the side to be acted upon. Thirdly, the fluid being arranged in precisely the same way, the patient forces it up the Eustachian tube by attempting to blow through the nostrils, whilst the mouth and nose are closed. The injection may with benefit generally be repeated every other day for from two to four weeks, but for this no rule can be laid down which would apply in every case. Such is the briefest outline of the treatment under which these cases recover in greater or less degree. The degree of improvement varies within wide limits, but the greater benefits may always unhesitatingly be predicted during the moist stage of the catarrh. Indeed, the necessity for early treatment is abundantly shown, in the instance of catarrhal affection of the middle ear, by the extremely satisfactory termination of cases treated early in the disease, and the slight relief which but too often follows when the affec- tion has been allowed to proceed for years un- checked. In such cases as the latter, the fact that considerable quantities of inspissated mucus have been found in the tympanic cavities first suggested the operation of making an incision into the tympanic membrane, and attempting the removal of mucus through the incision bypassing a stream of air through the tympanum. This proceeding, with certain modifications afterwards introduced, is no doubt very useful in cases favourable for its employment, but it should be reserved for those which have defied the less severe means, and where there is unmistakable evidence of an obstruction to the passage of sound through the tympanum. Experiments with tho tuning-fork, . already referred to, give valuable evidence in this direction; but for a detailed account of this method of treatment, introduced some years ago by Mr. Hinton, the reader is referred to Questions of Aural Sur- gery. Suffice it to say hero that an incision about one-eighth of an inch in length is made in the posterior section of the membrane with a cataract- needle, and this is followed by passing a stream of fluid (a weak solution of soda) through the tympanum and Eustachian tube by means of a syringe made to fit the external meatus. In appropriate cases it is often undoubtedly of very great service, and is neither a dangerous nor a harmful proceeding so long as there is no nervous complication ; where, however, this is present, surgical interference has at times proved most disastrous. Another operation, performed by Dr. Weber Leil of Berlin, consists in the division of the tensor tympani muscle, but up to the present time the results at the hands of others do not warrant it as a recognised operation for the re- lief of conditions inducing deafness. 3. Purulent Catarrh of the Tympanum- Perforation, — The form of tympanitis in which the effused products become purulent, is an acute and generally an extremely painful affection. Usually the pus rapidly makes its escape from the tympanum into the external meatus, by a process of ulceration through the tympanic mem brane, leaving as its result a perforation of this structure. In quite the early stage the affection may often be cut short by the free application of leeches in front of the tragus, followed by foment- ations, but more often than not the membrane has given way before tho patient comes under observation. Even then, if the tympanic cavity be emptied of the pus by the free use of Folit- zer's inflation and repeated syringing, the open- ing will often close, and leave very little, indeed sometimes hardly any appreciable deafness. If, however, a purulent discharge through the open- ing be allowed to go on unheeded for any length of time, it is the exception for the perforation to heal. This condition is constantly seen after scarlet fever, measles, or any of the exanthemata. A perforation of the tympanic membrane pre- sents an infinite variety of aspects, from a small pin-hole to nearly complete loss of the membrane, but there will always be a slight remaining external rim of membrane. This latter is perhaps the most frequent of all forms of per foration, and especially when the ulceration dates from an attack of scarlet fever. Although the handle of the malleus occasionally remains, it more usually comes away in these and other cases where the loss of tissue is very extensive. The head of this bone, however, may always be distinguished, unless there has been complete disorganisation of the tympanic cavity. Among other forms of perforation commonly met with may be mentioned those in which the anterior or posterior half of the membrane is left, and is bounded internally by the handle of the malleus ; the so-called reniform perforation, where the lower part of the membrane is lost and the umbo of the malleus indicates the position of the hilus of the kidney ; and the small, smooth- edged circular perforation which is common alike to all parts cf the membrane. Occasionally, though not very often, the tympanic membrane is the seat of a double perforation. Similar variations in hearing accompany this condition, between slight deafness and total loss of hearing power. The size of the perforation affords no guide in this respect, extreme loss of heariDg being met with when the perforation is very small, and very slight deafness where the less of tissue has been most extensive, so that it may be unhesitatingly stated that the loss of the mem- brane is but in a very small degree the cause of the deafness in these cases, the disorganisation in the tympanic cavity mainly accounting for this. Such disorganisation is at times so com- EAR, DISEASES OF. 421 plcte (especially after scarlet fever) as to include the loss of all the ossicles, total deafness, and paralysis of the muscles supplied by the portio dura. A very small perforation in the anterior and superior part of the membrane may from its position escape notice, but the diagnosis can bo always verified by the facility with which air may be made to pass through the opening, or the reverse, provided that the communication botween the Eustachian tube and the tympanum is not closed by cicatricial tissue — a very rare condition when so little of the membrane has suffered ulceration. Treatment. — The treatment of purulent tym- panitis and perforation will include assiduous cleanliness ; keeping the Eustachian tube free from obstruction ; and the use of astringent injections. When the exposed surface of the tympanum is covered, as it sometimes is, with exuberant granulations, much benefit will be derived from the application of solid nitrate of silver to the granular surface, care being taken not to touch any other part. As the condition of the ear improves under these measures, so will the hearing power vastly in- crease when it has not been completely lost; but there still remains the ofttimes invaluable appli- cation of what is spoken of as the artificial mem- brane. Of all kinds, the best undoubtedly is the flattened pad of moistened cotton-wool, applied by the patient, every morning, with a pair of forceps constructed for the purpose. Until this be tried in each case it is impossible to say whether it will do good; but when it is useful — as it is in a large number of cases — by its help the patient will recover very good hearing, and this even when the perforation has existed for a period of many years. That its effects de- pend upon the support which it gives to the ossicles, thus re-establishing the normal pressure of the stapes upon the fenestra ovalis, has been unquestionably demonstrated. 4. Polypus. — One of the most frequent com- plications in cases of perforation of the tympanic membrane is polypus, a term employed to desig- nate a fleshy tumour in the ear. Although polypi are occasionally present in the meatus indepen- dently of perforation, the most usual situation from which they arise is the lining membrane of the tympanum. Sometimes the exact point of origin is the edge of a perforation, and still more rarely the sides of the meatus. In size these growths vary from a small protrusion through a perforation, to a tumour which entirely fills the meatus and projects externally from the ear. In this latter instance the growth presentsa very dis- tinctive appearance, not unlike a raspberry. Sec- tions of aural polypi hardened in chromle acid with few exceptions show the structure to be fibro- eellular, the fibrous element preponderating over the cellular in proportion to the age of the tumour. Treatment. — In all cases polypi should be re- moved, and the best instruments for this purpose are the rectangular ring polypus forceps, or, in the case of a large growth, a Wilde’s snare. Owing to their remarkable tendency to recur, removal is only the preliminary step in treatment. The prin- cipal part of 1 his consists in their complete eradi- ation bv caustics. Of these, the most efficacious and convenient is chlor-acetic acid, and later in the treatment nitrate of silver. The acid may be applied on a very small camel’s-hair brush, or on the point of a probe defended by a small twist of cotton wool, and a convenient form of nitrate of silver is a bnlb of the melted salt fused on to a probe or platinum wire. The caustic should be applied daily for some time after the polypus has been removed, and then less frequently. The treatment should also include the same scrupulous cleanliness and application of astringents, so de- sirable in the case of perforations. It is simply to the want of attention to details that failure in the treatment of aural poly'pus may be ascribed. Complications of Tympanic Disease. — a . Facial Paralysis . — This is due to inflammation around the portio dura in its passage through the aqueduct of Fallopius. When suppuration in the tympanic cavity, with caries of the bony canal, precedes or accompanies the loss of function in the nerve, recovery is hopeless; but when the paralysis follows a subacute catarrh of the tym- panum, not ending in a perforation, as is some- times the case, the paralysis in time disappears no less certainly than when it is dependent upon an affection of the nerve at a point after its exit from the temporal bone. b. Pytcmia: Cerebral Abscess ; and Meningitis. When the mastoid cells become the seat of in- flammation, the pain, tenderness, and pitting on pressure over the mastoid process, will at once suggest an early incision down to the bone, and it maybe truly said that this is often delayed too long, and perhaps is never done too soon. Again, when the symptoms point definitely to pus within the mastoid cells, the bone should bo pierced so as to make the external opening com- municate freely with the cells. Relief given in this way will occasionally be the means of saving life, by preventing the absorption of poisoned material into the lateral sinus. Besides pyaemia thus induced, other fatal issues which suppura- tion in the middle ear frequently entail have their starting point in the tympanic cavity, and in such instances cerebral abscess cr meningitis may be the immediate cause of death. In the latter case a post-mortem examination reveals pus in the arachnoid cavity, or between the roof of the tympanum and the dura mater ; in the former, the seat of the abscess may be either in the cere- brum or cerebellum ; this portion of the brain (the cerebellum) being more generally, though not always, the part affected when the mastoid cells are involved as well as the tympannm. The pathology of cerebral abscess, as a result of ear-disease, cannot with truth be said in all cases to bo completely explainable, and this for the follow- ing reason ; — Whilst in most cases a distinct com- munication can be traced between the diseased roof of the tympanum and the sac of the ab- scess, in a few the most careful examination fails to show any connection between the two, the abscess being separated from the bone by healthy brain-tissue. Occasionally, no disease can be detected in the bone itself, and this even after the bone has been macerated and sections of it made. Fatal terminations of this nature most fre- quently occur when cleanliness and local treat- ment of the ear have been neglected. Hence the necessity for such care. EAR, DISEASES OF. 422 Bat the fact that even under the most favour- able conditions such evonts are possible when there is a fistulous opening: in the tympanic cavity should induce caution with Insurance offices in taking the lives of persons with this lesion, at the ordinary premiums. Fatal cases of this kind might seem in practice to be almost divisible into two classes, namely, those in which cerebral symptoms come on soon after the estab- lishment of the perforation ; and others where Lhere has been a purulent discharge from the ear ( that is, from the tympanum) for many years before the advent of such symptoms. In this latter class must be included those cases in which the tem- poral bone has become the seat of caries ; and it may be stated, subject to no exceptions, that whenever exposed bone can bo detected by means of examination with a probe within the cavity of the tympanum, the subjects of this condition are always more or less in a perilous state, and that at any time fatal symptoms may commence with a severe rigor, the earliest of all succeeding symptoms. For this reason, even when exposed bone cannot bo absolutely demonstrated in the way mentioned, the existence of bone-granulations where there is a perforation of the tympanic membrane should he regarded as a most serious complication. The same danger, though in a very much less degree, may be said to be present when dead bone can be detected in the mastoid process — in a less degree, because the outer table of the bone is often affected whilst the inner remains healthy. The dead bone then in the former position becomes exfoliated, and the ex- ternal wound heals. Such are briefly the points of importance in connection with caries of the temporal bone. How caries of the mastoid process may be obviated by a timely perforation of the mastoid cells, and how the chief part of the temporal bone may when carious be removed and the patient survive, may be seen on reference to a paper entitled ‘ Disease of the Mastoid Bono’ by the writer of this article in the Tran- sactions of the Medical and Chimrgical Society for 1879. c. Malignant Disease.-— In the paper just men- tioned is also reported a case of malignant disease of the ear, in which the cavity of the tympanum, having been the seat of suppuration for some time, became affected with epithelial growth, which caused the death of the patient. From all recorded cases of malignantdiseaseof the ear it would seem that the seat of origin of the new-growth will be found to be the lining membrane of the tympanic cavity, and that a purulent discharge from this surface always precedes the appearance of the cancer, and must therefore bo regarded as the exciting cause of the growth. In its early stages cancer in this situation bears a strong resemblance to the ordinary forms of polypus. The same cause, then, which in some cases calls into being a polypus may occasionally give rise to malignant disease, and this without any predisposing cause (so far as can be ascertained) in the patient towards cancerous growth. III. Internal Ear. — -Apart from deafness due to local changes in the external or middle ear, the function of hearing is subject to impair- ment from causes which have their seat in the aervous structures of the ear; in other words, although the conduction of sound may be good, the perception of sound may be faulty. The in- ability to hear the vibrations of sound conveyed through the cranial bones, such as from a vibra- ting tuning-fork placed upon the vertex, is in- dicative of this condition. For the rest, the absence of tympanic disease, and the history of the case, must supply the evidence required fora diagnosis. Familiar examples of this nature are the deafness which often accompanies old age, or which is left after fevers when the middle ear has not suffered; the two forms of syphilitic ner- vous affection mentioned below ; the sudden and sometimes total loss of hearing which occasion- ally follows severe mental shock ; the deafness after loud explosions near the ear, so common in artillery-men and naval men ; and that which is caused by blows on the head and boxes on the ear. An attack of mumps will sometimes leave behind an irremediable loss of hearing in one or both ears, unattended with any discoverable change in the tympanum. In a similar way weakly women occasionally become more or less deaf during their confinement, and this symptom becomes aggravated when each successive child is born. In connection with this subject, prolonged suckling may be mentioned as one of the numerous debilitating causes which undoubtedly aggravate the trouble of an already impaired ear. Among the nervous affections of the auditory apparatus possessingeertain characteristics which serve to distinguish it from others is the so-termed Meniere’s disease, an attack of whichat times gives cise to symptoms whi ch would be alarming if their true origin passed unrecognised. A patient who suffers in this way is seized with an attack of vertigo so severe that he not infrequently falls, and for some hours afterwards requires assistance in walking ; occasionally vomiting succeeds the giddiness ; and he recovers to find himself very deaf in one ear, with which previously he had heard well. Milder attacks of the same nature generally follow the first, and each one leaves the patient more deaf. Although the presump- tive evidence is in favour of the theory that the seat of morbid changes in Meniere’s disease is in the semi-circular canals, up to the present this point has not been quite satisfactorily deter- mined. No treatment appears to exercise any influence upon the disease. Syphilis. — The affections of the ear due to syphilitic disease demand separate consideration, and they occur under the following varieties: — Firstly, in the form of sores and warts in the external meatus, which yield to local treatment. Secondly, affections of the middle ear during the secondary ulceration of the throat, the treatment for which, beyond specific medicines, in no way differs from what is useful in the ordinary catarrh of the same parts. Thirdly, failure in hearing power during the secondary stages, unattended with any change in the middle ear. This disap- pears under constitutional remedies. Fourthly, the loss of function in the auditory nerve, so com- monly met with in the subjects of inherited syp ■ ilis. In these patients the hearing power begins to fail between five and fifteen years of age (very sel- dom later in life) ; and proceeds to very great and often total deafness, the period between good hear EAR, DISEASES OE. U'g and the extreme point of deafness arrived at varying from a few weeks to several years. From this cause children sometimes become in the course of a month or six weeks totally deaf, but such rapidity is exceptional. Experience has shown how powerless treatment is to arrest the progress of this affection, so that attention should be confined to preventing its subjects from becoming dumb, if they are attacked after they have acquired speech and before they are likely to forget it, viz. from about four to seven years of age. This is best attained by teaching them lip- reading, and if they can read, by making them do so {aloud) several times each day. In tfois way a child will retain its recollection of lan- guage when otherwise speech would pass away. W. B. Dalby. EAUX-BONNES, in France. — Sulphur waters. See Mineral Waters. EAUX-CHAUDES, in France. — Sulphur waters. See Mineral Waters. EBUBNATION ( ebur , ivory). — A state of bone-tissue in which it assumes the whiteness, smoothness, and hardness of ivory, in consequence of an increased deposit of calcareous matter. It occurs chiefly in rheumatoid arthritis. Rheu- matoid Arthritis. ECBOLICS (e/c^oAr;, abortion). — This name is given to the measures that produce abortion. In moderate doses echolic drugs act as emmena- gogues. See Emmenagogues. ECCHYMOSIS {Ik, out of, and x^ s , juice). — An extravasation of blood into the cel- lular tissue, due either to injury or to disease. It presents at first, a more or less blue or bluish- black appearance, which changes with age, passing through green to yellow. See Extravasation. ECHINOCOCCUS (e’xiVor, a sea-urchin, and k/i«kos, a grain). — This term, in its original gene- ric signification, was employed by Rudolplii for the purpose of including several varieties of blad- der-worm infesting man and animals {Echino- coccus ho minis ; E. veterinorum; E. granulosus, Qc.) These different bladder-worms are now col- lectively spoken of as hydatids, and all of them are known to be mere varieties of the common hydatid, which (as proved by the experimental researches first successfully instituted by Von Siehold, and subsequently verified by Haubner, Kuclienmeister, Leuckart, Nettleskip,and others) forms one of the larval or sexually immature stages of growth of a small tapeworm, normally resi- dent in the intestinal canal of the dog and wolf {Tania echinococcus). From a physiological point of view, a thorough knowledge of the mode of origination and development of tho so-called echinococcus becomes most instructive ; hut a full exposition of the histological and other changes that accompany the metamorphoses cannot he given in this place. Practically, the term echino- coccus has at length come to ho employed in such a restricted sense as to refer only to the scolices, or heads of the future Ttenise, which are normally developed from the granular layer or internal membrane of the hydatid. Different opinions exist respecting the precise structural changes involved in their formation, but what is already known and accepted by helminthologists ECSTASY. 42 ? is the result chiefly of the labours of Leuckart Naunyn, Rasmussen, Wilson, and Huxley. The clinical and hygienic bearings of this subject in relation to the so-called echinococcus-disease will be discussed elsewhere. See Hydatids. T. S. COBBOLD. ECHINOEHYNCHUS {Ixivos, a sea-ur- chin, and pvyxos, a beak). — A genus of thorn- headed worms, belonging to the order Aeantho- cephala. Until the year 1857 there does net appear to have been a well-authenticated instance of the occurrence of this form of entozoon in the human body. In that year a young example {E. hominis, LanibD, was found, post mortem, in the small intestine of a hoy. nine years of age, who died of leukaimia {Prayer V icrtdjalirschrifi, 1859.) This specimen measured less than a quarter of an inch in length. It has been sup- posed that the parasite was an immature example of Ech. gigas, hut this view lias been disproved by Leuckart. Whether it ho a new and alto- gether distinct species remains uncertain. The more recent instance alleged by Welch cannot be accepted as genuine, hut must he referred to Pentastoma. T. S. Cobbold. ECLAMPSIA {luXafiTra, I flash, I explode). — This term is now used as a synonym for con- vulsions, whatever may be their cause. See Convulsions. ECPHYMA (e/c, out of, and (pvga, a swelling). A growth from the integument. The term was em- ployed by Mason Good as a designation for warts and corns, hut is at present almost obsolete. ECSTASY I amaze). — Definition. The term ecstasy has been applied to certain morbid states of tho nervous system, in which the attention is occupied exclusively by one idea, and the cerebral control is in part with- drawn from the lower cerebral and certain reflex functions. These latter centres ma)' he in a condition of inertia, or of insubordinate activity, presenting various disordered phenomena, for the most part motor. Description. — The subjects of ecstatic phe- nomena are commonly of the female sex, or are men who lead celibate and ascetic lives. To these individuals they are in tho present day almost confined. In the middle ages, on several occasions, under special circumstances, an in- tense dominant emotion, with some attendant ecstatic manifestations, spread widely by a sort of moral contagion. Women who are the subjects of this morbid state are usually single, frequently present menstrual irregularities, and often distinct evi- dences of hysteria, of which the ecstatic condi- tion may he but a part. The immediate cause of the attack is usually some repeated vivid emotion, commonly religious, sometimes one of fear. The direction taken by tho motor or other phenomena, of the ecstatic state is often very obviously de- termined by imitation. With this are associated, in some cases, assertions of supposed facts, which transcend the ordinary course of natural phe- nomena, and which have been proved, in many instances, to depend on intentional fraud. As forms of ecstasy we have the condition oi 424 ECSTASY. religious enthusiasts, -who lose, in their one dominant emotion, all control over the other mental processes, and the latter may act in entire subordination to their religious feeling. Dreams and visions are determined by the ecstatic emotion, and add to its intensity. All conscious- ness of the body may be lost, so that all sensation may seem to be gone for a time: -while the cor- poreal functions, ingestion and egestion, are re- duced to a minimum, and a little exaggeration may represent them as in complete abeyance. Hence the ‘ fasting girls ’ of various countries, by whom ‘stigmata’ marks, in the position of the nails employed in crucifixion, are sometimes pre- sented, probably by artificial production, possibly by the influence of the mental state on the pro- cesses of nutrition. In some hystero-epilepties a state of ecstasy — of rapt, intense emotion — forms part of the paroxysmal seizures, and then wild muscular spasms replace the tranquil repose of the more volitional ecstatics. Occasionally — - when an intense emotion is shared by many per- sons — insubordinate muscular movements occur, of a rhythmical character, seen in the Jumpers and Shakers of the present day, and more strikingly in some of the dancing religions cere- monies of half-civilised races, and in the dancing epidemics of the middle ages. Such were the original dance of St. Vitus, in which the exciting emotion was religions ; and the tarantella, in which the excitant was terror at the supposed consequences of the bite of the tarantula, which the dance was intended to avert. Treatment. — It is rarely now that ecstatic manifestations have to he treated except as part of pronounced hysteria, and the treatment is that of the hysterical state which underlies the ecstasy. The measure of paramount importance is the substitution of a ‘ healthy moral atmo- sphere ’ for that under which the symptoms have arisen ; and the exposure of actual fraud. Oc- casionally, oven now, examples of solitary ecstasy come under observation. In these considerable care and tact are needed. Ecstatics are not amen- able to the motives which influence most per- sons, and if there is actual fraud, will some- times die rather than be found out. In the case of fasting girls, due observation of the body- weight during a short time will answer as well as, and is much safer than, a long exclusion of food. But the removal of the ecstatic to other surroundings is the most important step for both detection and cure. W. R. Gowers. ECTHYMA (tK0icv, I burn out.) — A pustule or pimple ; pathologically occupying a mid-place between a pustule and a furuncle. The so-called tar-acne, the small inflammatory pustules deve- loped around a mother-boil, and the commoner eruptions produced by iodine and bromine, are examples of ecthyma. See Skin, Diseases of. ECTOPIA («k, out of, and Tiiiros, a place). — An abnormal protrusion or displacement of a part; for example, ectopia vesica, protrusion of tho bladder. See Organs, Displacement of. ECTOZOA (errbj, without, and fuor, an animal). — A term employed by some naturalists to embrace all the external parasites. See E?izoa. ECZEMA. ECTROPION - ) , . - , ECTROPIUM//*’ 0Ut ° f > 3Dd 'P'™' 1 turn). — A condition in which the eyelid becomes everted, so that the conjunctival surface is ex- posed. See Eye and its Appendages, Diseases of ECTROTIC (Jktitp&itku, I miscarry).— A term applied to arresting the course of a mor- bid process, fur example, the development of small-pox. The agent by which the pustule is made to abort, namely, the ectrotic, may in this instance be a point of nitrate of silver. A coating of plaster, and especially substances which will exclude the light, such as mercurial ointment, or an ointment of lampLlack, are like- wise employed as ectrotics of small-pox. Erasmus Wilson. ECZEMA (^x- sorbed by the stomach. They may thus produce vomiting and evacuation of the stomach without being taken into the stomach at all, and on this EMETICS. account they are < ermed indirect emetics, although they act directly upon the vomiting centre. Such are ipecacuanha, apomorphia, and tartar emetic. SimilarljAhe drugs that excite it reflexly are still ternM direct emetics, because they are ap- plied directly to the stomach. Such are the sul- phates of zinc, copper, and alumina ; carbonate of ammonia; salt; mustard ; and chamomile, which irritate the nerves of the stomach. Tick- ling the fauces with a feather, or with the finger, also excites reflex vomiting, and may be adopted either alone, or in order to aid the action of other emetics. The terms direct and indirect, there- fore, as applied to emetics, relate to the stomach and not to the centre for vomiting. Direct emetics, as they stimulate the nerves of the stomach only, have little action except that of simply exciting vomiting. The indirect emetics, which excite vomiting by their action on the medulla oblongata, act also on other parts of the nervous system, and cause secretion of saliva, secretion of mucus from the oesophagus, stomach, and bronchial tubes, an 1 perspiration. They also cause much nausea, depression of the circulation, and loss of nervous and muscular power. Further, the vomiting they induce is more continuous and violent, and often expels the contents of the gall-bladder, causing part of tho bile to flow into the stomach, and be thus evacuated. Uses. — Emetics are employed to remove the contents of the stomach under various circum- stances. Firstly, when the food is causing irri- tation, and not undergoing proper digestion, as, for example, in dyspepsia, or sick-headache ; and in' such cases large draughts of lukewarm water, of mustard and water, or of an infusion of cha- momile are usually found beneficial. Secondly, in cases of poisoning ; and here mustard, sulphate of zinc, or sulphate of copper are best, as they empty the stomach most quickly and effectually. Thirdly, to cause the expulsion of bile from the gall-bladder, or remove bile from the body in biliousness, fevers, and ague. When the bile- duct is stopped by a small gall-stone, the pres- sure exerted on the gall-bladder during vomit- ing has been known to cause the expulsion of the calculus. In biliousness, excess of bile is more readily removed by vomiting than by purging, as there is no opportunity for the bile to be ab- sorbed on its way from the gall-bladder to the mouth, whereas it may undergo absorption on its passage through the intestines. It is supposed by some that various poisons circulate occasionally in the bile, such as the malarious poison which occasions ague, and possibly other septic poisons which give rise to fevers. The advantage of emetics in ague is undoubted, as it can certainly sometimes be cured by them without quinine, and the action of quinine is always aided by their use. They have also been recommended in the early stages of continued fevers. In such cases tartar emetic or ipecacuanha are most service- able. Fourthly, to cause expulsion from the air- passages of false membrane in croup or diphtheria, or of secretions in bronchitis and phthisis. For these purposes ipecacuanha is the emetic most frequently chosen, but if it does not act rapidly ,r - croup, sulphate of zinc or sulphate of copper may be employed, and in cases of either croup or EMMENAGOGUES. 43.1 bronchitis where there is great depression of the circulation carbonate of ammonia may be used with advantage, as it not only causes vomiting, but at the same time stimulates circulation. T. Lauder Brunton. EMMENAGOGFES (efj.fj.qra, the menses, andayw, I move or expel). Definition. — Emmenagogues are remedial agents which stimulate or restore the normal menstrual function of the uterus, or cause ex- pulsion of its contents. Enumeration. — Emmenagogues may be either indirect, as Iron, Strychnia, and other tonics, Warm Hip-baths, Leeches, Mustard Stupes, Aloetic purgatives, &e. ; or direct, as Rue, Borax, Savin, Myrrh, Cantharides, Guaiacum, Apiol, Quinine, Digitalis, and Ergot — most of which, when given in larger doses, produce abortion, and are called Ecbolics. The most efficient means, however, of obtaining this last-named action are those of a mechanical nature, so well known to obstetricians, and directed either to the actual rupture of the membranes, or to their separation from the cervix. Action. — T he indirect emmenagogues act by improving the quality of the blood, giving tone to the nervous system, or irritating adjacent parts or organs, from which a stimulating influence is conveyed by reflex action to tin- womb. The direct drugs in moderate doses gently stimulate the uterus, promoting the menstrual flow, or even checking it when in excess; but when further pushed they cause powerful con- traction of the unstriped muscular fibre, of which its walls are mainly composed. Ergot, which is the principal, and in fact almost the only really useful member of the group, is be- lieved to act either directly on the museulai tissues themselves, or through the intermediate intervention of some central orperipheral Dervous influence. Uses.— Checked or retarded menstruation fre- quently results from anaemia or general debility, and the indirect emmenagogues will under these circumstances usually effect a cure. If. however, the case prove more obstinate, a little ergot added to the iron will often restore the sus- pended function. If even this do no good, some mechanical impediment probably exists, or some altered physical condition of the womb which mere drugs cannot rectify. Ergot is fre- quently employed in cases of lingering labour from simple inertia of the uterus, but its use must bo strictly confined to those eases in which there is no marked disproportion between the maternal passages and the head of the child. Advantage is also taken of its contractile powers in the treatment of uterine haemorrhages, or for the destruction of the smaller varieties of polypi, which are so frequently contained within the womb, by cutting off their blood-supply. Finally, it may be necessary, under certain con- ditions, to induce abortion or premature labour, as when constant sickness, or albuminuria, or compression of adjoining neighbouring viscera seems to endanger the mother’s life, or when pelvic distortion renders it impossible for a living child to be born at full term. lYhen fh> 436 EMMENAGOGUES. medical attendant has made up his mind that interference is necessary, he generally has re- course to one or other of the mechanical methods ■which are fully described in works more particu- larly devoted to obstetrics. ItoBERT FaRQUHARSON. EMOLLIENTS ( emollio , I soften). — Defi- nition.— Substances that soften and relax the parts to which they are applied. . Enumeration. — The principal emollient ap- plications are : — Warm water, Steam, Poultices made of substances which retain heat and mois- ture, for example, linseed-meal, bread, bran, flour, oatmeal, and figs; Fatty Substances, as linseed, olive, almond, and neat’ s-foot oil, lard, and suet; Spermaceti, Wax ; Soap Liniment and other lini- ments ; Glycerine ; and Paraffines, such as vase- line, unguentum petrolei, &c. To these may be added such substances as do not properly relax tho tissues, but protect the surface from irritation, such as White of Egg, Gelatine, Isinglass, Collo- dion, and Cotton-wool. Action. — Emollients relieve the tension and pain of inflamed parts by their action both upon the blood-vessels and upon the tissues them- selves. They cause all the contractile tissues to relax and dilate, and thus, lessening pressure upon the nerves of the part, they relieve pain. They soften superficial parts by supplying them with either fat or moisture, and by increasing the supply of blood. In this way they prevent the skin from cracking after exposure to cold. When the cuticle is lost they form a covering, under which the skin may heal; and they pre- vent the injurious consequences of friction from without. Uses. — Fatty emollients are used to prevent the skin or mucous membranes from cracking; to prevent irritation or ulceration between parts constantly in contact, as on the limbs of children near the joints ; to prevent bed-sores ; to aid the healing of blisters ; or in skin-diseases, such as eczema. They are also used, especially in the form of linimentum calcis, as applications in burns and scalds, for which purpose such substances as cotton-wool are likewise frequently employed. Mucilaginous substances are useful when swal- lowed to relieve pain and irritation in the throat, and to lessen irritable cough ; and such substances as figs are employed to protect the intestines from injury by hard and pointed substances which have been swallowed. Warmth and moisture are applied in the form of poultices to the surface in pustules, boils, carbuncles, and deep-seated in- flammation of the limbs, and in inflammation of the internal organs {sec Pouetices). In the form of vapour they are useful in inflammation of the air-passages (sec Inhalations). T. Lauder Brunton. EMPHYSEMA of Lungs. See Lungs, Emphysema of. EMPHYSEMA, SUBCUTANEOUS (eV, m, and , all, and Sijfios, the people) extension of the malady. The acutost observers were taken by surprise with the ma- lignity and diffusibility of the disease during the epidemic — phenomena wholly unforeseen. Here, again, the study of the diseases preceding or accompanying the epidemic yields no facts of variation in their prevalence, from which the approach of a great epidemic might have been inferred, nor give any hint that they were depen- dent with it on some common cause. There were concurrent phenomena of disease during both epidemics, hut they were concur- rences of certain diseases existing at the same time among the population affected by the great epidemic, and some of them probably Jiaving certain secondary elements of causation in com- mon. This is a different question to that of an assumed "epidemic influence’ or ‘epidemic con- stitution.’ The subject of the concurrence of epidemics is a new field of investigation, which has lately been opened by an arithmetical study of George Buchanan's, relating to epidemics iu numerous extra-metropolitan registration sub- 442 EPIDEMIC. districts in England. This study -was directed to ascertain- — as necessarily introductory to a statistical investigation regarding community of causation or mutual antagonism of various epi- demics — the arithmetical probability of their concurring as a mere matter of chance. The data used were taken from a particular quarterly return of the Registrar- General, and they ex- tended to 946 occurrences of epidemics (small- pox, measles, scarlet-fever, diphtheria, whoop- ing-cough, fevers, and diarrhoea and simple cholera) in 1,490 districts. The result showed a good deal of general correspondence between the calculated number of concurrences and the actually observed number, but with departures, of more or less magnitude, of the actual from the calculated degree of concurrence, which de- serve to be followed up by further investigation. The departures were shown in an excessive fre- quency of the concurrence of measles with the other epidemics, of diarrhoea with all other epi- demics except small-pox, and of scarlet-fever with the ‘fever’ of the Registrar-General. On the other hand, it is of interest to observe that there was an absence of any notable excess of frequency of concurrence between scarlet-fever and diphtheria, or between scarlet-fever and whooping-cough. In view of the extreme looseness with which the word epidemic is used in medicine, some- times simply as a descriptive term, sometimes as a technical or quasi-technical term involving various hypothetical and theoretical conceptions inconsistent with each other, and sometimes as implying an occult influence, it would be well if it could be discarded from medical literature and language. Epidemic, in its present medical uses, is an instance of words which, as E icon says, when writing of the effects exercised by a bad and inapt formation of words on the human mind, 1 force the understanding, throw everything into confusion, and lead mankind into vain and innumerable controversies ’ (Nov. Org. App. 43). But the retention of the word, from its long and familiar usage, is practically a necessity in medicine; moreover, it would bo difficult if not impossible to find a substitute which, if the word he used in its ordinary signification, would supply its place. It is suggested here that the technical mean- ing of the word epidemic should he assimilated to tho common meaning; or, more accurately, that the technical meanings now attached to the word should he abandoned, and the word used in medicine in the same sense as in general literature and in ordinary converse; that is to say, as a merely quantitative term appli- cable to particular phenomena, whether patho- logical, mental, or social, in so far as they are ‘ common to a whole people, or to a great number in a community ; ’ or in a word are ‘ prevalent ’ or ‘general.’ In this way not only would the con- fusion arising from the present medical uses of the word be got rid of, but the scientific study of epidemic phenomena would he facilitated iu the only direction which gives promise of suc- cessful issue. As Leon Colin has aptly written ; — ‘ It is the disease which constitutes the epi- demic, not the epidemic the disease. The evil always remains the same, the number of affected EPIDEMIC MENINGITIS. alone being increased.’ The medical study ,! epidemics is essentially a study of the indivi- dual diseases which are apt to become epidemic, and not, as has been too commonly the ease hitherto, of some figment of the imagination (epidemic constitution, or influence, or genius), apart from the diseases. It is only in propor- tion as researches have been directed to particu- lar diseases liable to become epidemic, and to the conditions under which they prevailed epide- mically, that recent advances in our knowledge of epidemics have been made. In this country the two most important events which have oc- curred in this connection of late years were the discrimination of typhus from typhoid , by A. P. Stewart and Wm. Jenner, and the researches on the typhus of horned cattle (steppe-murrain, cat- tle-plague), promoted by the Royal Commission of 1865-66, on Cattle-Plague. The discrimina- tion of typhus from typhoid proved that the volu- minous speculations which to that time wero cur- rent on the epidemiology of the continued fevers of this country, then regarded as hut one disease presenting several varieties, were for the most part meaningless verbiage, by showing that the two most common forms of fever were distinct diseases clinically, pathologically, and setiolo- gically. This discovery proved to he the in- auguration of a true method of investigation concerning epidemics, by making evident that epidemic phenomena did not admit of accurate study, except in so far as it was based upon a just discrimination of the diseases manifesting them, and upon their clinical and pathological histories. The same lesson was taught, not less clearly, although in another fashion. by the re- searches promoted by the Royal Commission on Cattle Plague, with which the names of Lionel Beale and Burdon Sanderson are especially con- nected. These researches demonstrated the essentially infectious nature of the malady, and that its prevalence was dependent upon the dis- semination of the infection, directly or indi- rectly, from animals sick of the disease to the healthy. It was shown, indeed, in the patho- logical laboratory, that, preconceived doctrines of some occult epidemic influence which had been submitted to the Commission as determining the prevalence of the cattle-plague had no existence in fact when the disease was subjected to ex- perimental study, and that its conditions of pre- valence were fully within human control. These researches proved the starting-point of those im- portant investigations on the intimate pathology of contagion carried out by Burdon Sanderson and Klein, for the Privy Council, under the direction of John Simon, and to which Wm. Roberts and others have independently contributed so largely — investigations which promise speedily to revo- lutionise our knowledge of the intimate pathology of infectious diseases. It is interestiwr to note that the Royal Commission on Cattle-Plague in- cluded the following medical members: — Richard Quain (M.D.), H. Bence Jones, E. A. Parkes, T. Wormald, and B. Ceely. See also Pk.riodicitv ix Disease. J. Nettex Radcliffe. EPIDEMIC CEREBRO-SPINAL ME- NINGITIS. — A synonym for cerebro-spir.ai fever. See Cerebeo-spixai. Fevek. EPIDEMICS, OCCURRENCE OF. EPIDEMICS, Occurrence of. See Perio- dicity in Disease. EPIDERMIS, Diseases of. See Skin, Diseases of. EPIDERMOPHYTON (eVl, upon; Sep^a, the skin ; and (purer, a plant). — The name of the epiphyte, or parasitic fungus, of phytosis versi- color, also called Microsporon. See Epiphyta. EPIDIDYMITIS (eVl, upon, and S lSu/jos, a testicle). — Inflammation of the epididymis. See Testes, Diseases of. EPIGASTRIC REGION. — This region is situated at the upper and central part of the abdomen, just below the ensiform cartilage, and between the sloping margins of the thorax down to the level of the ninth cartilage, corresponding to what is popularly known as the ‘ pit of the stomach.’ The structures within the abdominal cavity which normally occupy the epigastrium are the greater part of the stomach, a small portion of the liver, and more deeply a part of the pancreas, the aorta giving off thecceliac axis and superior mesenteric branch, the vena cava inferior, the veins forming the commencement of the portal vein, the receptaculum chyli, and the solar plexus. Clinical Investigation. — Clinically, it will be found that patients frequently complain of abnormal sensations specially referred to the epigastrium. These are generally associated with the stomach, and may merely amount to a sense of discomfort, fulness, or tightness ; or to actual pain of varying character, more or less severe according to the condition upon which it de- pends, and often much influenced by the inges- tion of food. Sensations of trembling, throbbing, or sinking in the pit of the stomach are also of common occurrence, especially in females. These are often merely of a nervous character. In some cases there is evident tenderness, either over the entire epigastrium or in some limited spot, and it is important to recognise whether this is superficial or felt more or less deeply, for it may be connected with the supierficial struc- tures, the peritoneum, the liver, the stomach, or the pancreas. The sensation experienced in connection with hunger is referred mainly to the epigastrium, and it may be of a painful cha- racter. Here may also be noticed the epigastric pain termed gastralgia or gastrodynia, which is usually feit chiefly when the stomach is empty, being relieved by taking food. A most unpleasant sensation at the pit of the stomach accompanies nausea, which may be of a horrible but indescribable character; while violent vomit- ing or retching causes considerable pain or aching in this region, partly associated with the stomach, partly with the abdominal u'alls. Heartburn is another sensation which seems to start from the epigastrium. Sometimes the pain is situated deeply, or shoots towards the back. This may depend upon disease affecting the posterior wall of the stomach, pancreatic disease, aneurism, or other causes. A sensation of tension or actual paiu is sometimes experienced just below the Dnsiform cartilage in cases where the diaphragm is much pressed downwards, as from extreme EPIGASTRIC REGIO N 4-13 emphysema, abundant accumulation of fluid or air in the pleura, or extensive per.oaalial eliUsion. A deep pain is not uncommonly "eferied to the epigastrium in cases of Addiucn’s disease, and also in those of pernicious anaemia. Probably this is connected with the sympathetic plexuses. Physical examination of the epigastric region is often of the greatest value, ai d important objective signs of various morbid conditions may thus be readily recognised. Of course organs wdiich are normally confined to other regions may enlarge so as to extend into the epigastrium, or may become very movable and consequently be felt in this region. It may, moreover, be occu- pied, along with other parts of the abdomen, by growths or accumulations of fluid. The objec- tive signs and conditions which are more espe- cially connected with the epigastrium may be indicated as follows : — 1. It is customary to apply the hand over the epigastrium for the purpose of counting the respirations, if these cannot be reckoned by merely watching the patient breathing. 2. Morbid conditions of the abdominal walls may be confined to the epigastric region, such as an abscess ; and here it may be remarked that the recti muscles frequently become veiy hard and rigid when palpation is practised over this part, and so might be in danger of being mistaken for some serious lesion, unless care wero exercised in the examination. 3. Growths connected with the peritoneum, especially the great omentum, may be felt chiefly or entirely in the epigastrium in some instances. 4. Abnormal states of the stomach are neces- sarily revealed mainly by corresponding signs in the epigastrium. Thus there may be evidence of dilatation of this organ ; carcinomatous infiltra- tion of its anterior wall ; a localised tumour ; or of some accumulation in its interior, whether solid or liquid. It must be remarked, however, that the stomach, when diseased, frequently extends into other regions beyond the epigas- trium. 5. When the liver is the seat of organic disease, this is often revealed in the epigastric region, usually along with other regions, but sometimes the abnormal physical signs are noticed specially in this part. Thus a cancerous mass may present here, or a hydatid tumour or hepatic abscess may tend in this direction. The gall-bladder has also occasionally been found, when the seat of some accumulation or of malignant disease, to have been displaced towards the epigastrium and be- come fixed there. 6. Pulsation is not uncommonly felt in toe epigastrium. When situated at its upper part, just below the ensiform cartilage, it depends upon the heart, usually its right side, being duo either to shortness of the sternum, displacement of the heart, or enlargement of its right cavities. Very often a pulsation is felt, and sometimes even seen, due to a pulsating aorta; and an impulse from this vessel may be transmitted through an enlarged pancreas, or through an abscess of the liver, of which the writer has seen a mprked example. Occasionally an impulse in the epi- gastrium is connected with an aneurism, either of the aorta or of one of its branches. A pulsation in this region has also been attributed to regur- 844 EPIGASTRIC REGION, gilation of Hood from the right auricle into the inferior vena cava and hepatic vein, in cases of tricuspid incompetency. A murmur may some- times be heard in the epigastrium. Usually this is a conducted cardiac murmur, but occasionally it depends on an aneurism. Frederick T. Roberts. EPIGLOTTIS, Diseases of. /Ste Larynx, Diseases of. EPILEPSY (c-jnAa/ijSavw, I seize upon'. — Synon. : Morbus comitialis, sctcer, major , c$c. ; Er. ftpilepsie, haut mal, §c. ; Ger. Fcdlsuchi. Definition. — An apyretic nervous affection, characterised by seizures of loss of consciousness, with tonic or clonic convulsions. Of these two features — muscular spasms and loss of consciousness, neither is alone sufficient to establish the existence of epilepsy. Still, each of these two kinds of symptoms, when occurring in the form of an attack, is an epileptiform mani- festation, as we find that patients who generally have convulsions only, are sometimes simulta- neously seized with unconsciousn ess, and vice versa. that in those very rare cases in which patients are attacked only with loss of consciousness, without any marked spasmodic action of any muscle, there are sometimes complete fits of epilepsy. The relationship between the two essential character- istics of epilepsy was well exemplified in the cases of t.wo patients who were placed under the writer's care in London, in 1860, by his lamented friend, Dr. W. Baly. These patients, who were brother and sister, were both incompletely epi- leptic: one had only attacks of convulsions, the other only attacks of loss of consciousness. Their father had been completely epileptic, and one of these two young patients had inherited one aspect of the disease, the other the other aspect. Efforts in two absolutely opposite directions ntve been made to modify the significance of the word Epilepsy. Some writers give that name only to the special affection which others call Idiopathic Epilepsy. Other physicians have considered as belonging to epilepsy, most if not all of the non- febrile affections consisting in attacks of aphasia, of amaurosis, of paralysis, &c., or of disordered involuntary movements (choreic, tremulous, ro- tatory, &c.). There is no doubt that all apyretic nervous affections, appearing in seizures, have in that feature a common link with epilepsy, and it would be important to have a name for that group of paroxysmal neuroses. But the word epilepsy must remain for the special morbid manifesta- tions that we have mentioned. As regards the application of the word epilepsy to those cases only in which no organic disease either of the nervous centres or other organs can be looked upon as a cause of that convulsive affection, neither the symptoms, nor the prognosis, nor the principal rules of treatment, show that we must entirely separate the idiopathic from the other kinds of epilepsy. It is, however, important, as will be shown hereafter, to try to find out, in every case of epilepsy, whether this convulsive affection is of the kind we call idiopathic, or proceeds from a peripheric or central organic lesion or irritation, or from some alteration of the blood. Pathology. — Under tiiis head it is only ne- EPILEFSY. cessary to give an idea of the state of the ner- vous system that seems to exist in epilepsy. As early as 1857, the writer, in his work on this affection, showed that it essentially consists in an increased excitability of certain parts of the nervous system. This augmentation of excita- bility may exist only in the cerebro-spinal centres, or partly there and partly also in some peripheric parts of the nervous system. The analysis of phenomena when epilepsy is gradually produced in animals leads forcibly to that view. We find in these animals, that, after a few days have passed from the time of the lesion which causes epilepsy (either a section of the sciatic nerve or of a lateral half of the spinal cord, in the dorsal region), the first change manifested consists in an increase of the reflex power of certain parts of the skin of the face and neck, while a greater excitability takes place in the medulla oblongata, in the upper part of the cervical region of the spinal cord, and in some parts of the trigeminal and of the two or three first cervical nerves. Gradually the reflex excitability of the nerve-cells in direct communi- cation with the fibres of the nerves we have named increases, so that the irritation of the skin of the face andneck, instead of producing only, as at first, a reflex contraction of the neighbouring muscles, causes a tonic spasm of all the muscles of the trunk, neck, and head, on the side of the lesion and of the irritation. Later on the reflex spasmodic action extends to the other side, and at last, a complete attack of epilepsy (a month or later after the traumatic injury which acts as a cause) supervenes, characterised, as in man, by loss of consciousness, with tonic or clonic couvuisions. In cases of injury to certain parts of the base of the brain in some animals, the same changes may take place, but with two differences : 1st, the rapidity of increase in the reflex excitability of the parts above-named is very much greater than after an injury to the spinal cord or to the sciatic nerve; 2ndly, the zone of skin that ac- quires the power, when irritated, to give rise to an attack, is on the opposite side to that of the brain-injury, while it is on the corresponding side to that of the lesion of a nerve or of the spinal cord. Want of space prevents the writer from giving the many reasons which show that what takes place in animals rendered epileptic by the lesions mentioned, applies in a great measure to the pro- duction of epilepsy in man. It will suffice to state that thero are abundant facts which tend to establish the conclusion that in all nervous affections in which there are seizures, attacks, or fits of any kind, the essential feature is a morbid increase of the reflex excitability, while the dif- ferences between the various symptomatic mani- festations depend on what nerve-cells are altered in their vital properties. In other words, we would say that, although there is the same morbid change, there are epileptiform, choreic, amaurotie, paralytic, aphasic phenomena, according to the particular nerve-cells in which tha: change takes place. Nothing has resulted from the efforts that have been made to establish the theory that epilepsy depends on disease in any part having a special name in the nervous centres. The so-called scat oj epilepsy has been successively placed in the cere EPILEPSY. bellum, the cornu ammonis, tlio pons Varolii, the medulla oblongata, the convolutions of the brain, &c. There is just as much reason to place that seat in those parts, as there would be to place it in the mucous membrane of the bowels or in the sole of the foot, or in aDy peripheric part of the nervous system, where an Irritation is found causing epilepsy. In cases such is these last, as well as in the preceding, the very same things occur ; an irritation starts from the place tv Here wo find an organic lesion, and proceeds to nerve- cells in the base of the brain and in the upper part of the cord (or in one of those parts alone). Through this irritation those nerve-cells havo their nutrition altered, and after a time they acquire that morbid excitability which is the essence of epilepsy. We do not think it will ever be possible to recognise what cells are altered, as it is quite likely that the change in them is more dynamical than physical, and that no more microscopical differences could be detected be- tween two of them, one normal and the other possessing great morbid reflex power, than there are visible differences between two pieces of magnet — one poor, the other rich in magnetic power. The true seat of epilepsy therefore is in nerve- cells, having the power of producing morbid reflex muscular contractions ; but the location of these cells must be variable, as is shown by the fact that the first symptom of an attack may be in the most different parts of the body. That these cells are located chiefly in the base of the brain is a conclusion borne out by many facts. But as we have ascertained, experiments on ani- mals show that the very same kind of epi- leptiform convulsions can take place after an irritation of the skin, whether the nervous system is left entire or diminished notably by the abla- tion of the brain and cerebellum, and also of the pons Yarolii and part at least of the medulla oblongata. The spinal cord has therefore a share in the production of epileptiform convulsions, and as we know that it can, in man as well as in animals, arrest the activity of the brain under some stimulation, we may easily admit that it may help in producing in man an arrest of cere- bral activity during a fit of epilepsy. -SvrionoGT. — Heredity deserves to be noticed first in this respect, not because it is the most frequent, but because it is a most undeniable cause. If we canvass what has been said by many writers on the subject of the heredity of epilepsy, we find that most statistics published do not give sufficient details to enable us to ascertain what are the morbid states of the brain in a parent which can cause epilepsy in the offspring. Pritchard has justly shown that all neuroses have the greatest relationship one to another. It is but natural, therefore, that epileptics are very often found to have had a father or a mother attacked with some nervous disorder. Moreau has shown that epileptics often have insane per- sons as their parents. If we put together those three groups of affections — organic disease of the brain, neuroses, and insanity — we find that epi- lepsy will often exist in the offspring of people who have been attacked with an affection be- longing to one of those three groups. As regards the influence of sex, we believe that there is a marked difference among women and men of somewhat advanced age, the proportion of women being larger than that of men : but this is not the case, and it is even in seme degree the reverse, for people under twenty-five years of age. Age has certainly, independently of sex, a de- cided influence on the appearance of epilepsy. The following table given by Hasse is important, as it is the most extensive. It agrees fully with the results of the writer’s own observation : e at commencement Xo. attacked Congenital 87 Under 1 year of age . 25 Erom 2 to 10 . . 281 ., 10 „ 20 . . 364 „ 20 „ 30 . 111 „ 30 „ 40 . 59 „ 40 „ 50 . . 51 „ 50 „ 60 . 13 „ 60 „ 70 . •i 995 It is difficult to say at what age hereditary epilepsy is most prone to make its appearance. The writer's experience seems to show that it is between ten and twelve in beys as well as in girls. It is certainly by far more frequent to find that inheritance manifests itself before than during the period of change that puberty causes. Romberg, Dr. Russell Reynolds, and several other writers have already pointed out that such is the general rule. Is puberty itself a cause of epilepsy? This is clearly proved by the large number of epileptics who, as shown in the preceding table, have been attacked between the ages of ten and twenty (364 out of 995). Of other causes the most powerful are not those usually stated. In patients under fifteen years of age the most frequent cause after heredity is some more or less obscure altera- tion of nutrition of the brain, or congestion of that organ or of its membranes, remaining a more or less considerable time after typhoid fever or scarlatina. It is frequent, indeed, that in examining such patients (even when there are reasons to believe in heredity), there are a num- ber of symptoms showing some deficiency in the action of the brain, as regards its motor, sensi- tive, or sensorial functions. It is most important to detect those symptoms (and they are so slight generally that they would not be noticed if not most carefully looked for), as the form of epilepsy, due to or allied with the cerebral alteration which then exists, is often curable, or at least can be considerably benefited by treat- ment. Of the different tetiological factors we havo mentioned — heredity, age, puberty, sex, fevers — ■ none but heredity can be looked upon as a real and direct cause of the form of epilepsy which is called idiopathic. The other factors only give origin to predisposing conditions ; excepting fevers, which can do more, as they may cause diathetic, sympathetic, or symptomatic epilepsy. Purely ‘psychical and emotional causes seem to be by far less frequent than has been supposed. They act chiefly, if not only, as means of bring- EPILEPSY. m ing on attacks in persons more or less ready to have them. If idiopathic epilepsy he set aside, we find that the aetiology of the other forms of that affection is much more easily found out, and that almost al- ways the cause is some recognisable irritation of a part of the nervous system. Diseases or injury of any part of the trunk and limbs or of the viscera; diseases or injury of any part of the eerebro-spinal centres or of their meninges, oft en produce epilepsy. The mucous membrane of the bowels and the cerebral meninges are the parts most capable of giving rise, not only to simple convulsions, but also to sympathetic epi- lepsy. Among the various organs constituting the encephalon, those having the greatest power of giving rise to symptomatic epilepsy are the optic thalami and the convolutions, especially those of the parietal lobes. Bat it would be quite wrong to conclude from the facts recently discovered by Fritsch and Hitzig, in their experi- ments on dogs and other animals, that certain parts of the cortex cerebri, near the fissure of Rolando, are much more connected with epilepsy than any other. The truth is that that neurosis can be caused by a disease of, or an injury to, any part of the eerebro-spinal centres : the anterior, the posterior, as well as the middle lobes, the base of the brain as well as the cerebellum or the spinal cord. Sympathetic epilepsy is very frequently due to an irritation of the sexual organs, especially brought on hv masturbation. In Anglo-Saxon countries, where children of the two sexes are less watched and less warned against the dangers of that fatal habit than in other civilised countries, epilepsy due to that cause is particularly fre- quent. Alterations of blood, in quantity or quality, are certainly favourable circumstances, if nothing more, in the production of epilepsy. As regards the experiments of Kussmaul and Tenner, we will say that although a rapid and considerable loss of'blood can cause an epileptiform attack, it has not been shown that such a cause has produced epilepsy. It is nevertheless true that anaemia is a very frequent factor in the causation of epilepsy or any other neurosis. A weak and slow action of the heart also is found in a num- ber of cases to be among the causes of epilepsy. But the reverse is sometimes observed; and we have not rarely seen cases of epilepsy in which the pulse was strong and beating more than 100 times a minute, without any disease of the heart or of any other organ, that could account for this great activity of circulation. In these cases the only morbid condition that could he looked upon as a cause of epilepsy was the abnormal circula- tion. In a case of this kind, placed under the writer’s care by Sir Thomas Watson, the patient was rapidly benefited by treatment, and has had no more attacks since 1863, so that that lend of epilepsy is sometimes curable, as is the form due to anpemia. Whether epilepsy due to syphilis or to Bright’s disease, or to affections of the liver, is ever pro- duced in a direct way, and exclusively by some alteration of the blood, is not yet established ; 1 ,ut it. ; s certain that, especially where there exists one of tiie two last causes just mentioned, the state of that fluid has a notable share in the production of the neurosis. But other astiolo- gical factors then exist: an irritation of the nerves of the kidneys, or of the liver, or of the meninges, and some alteration of structure of blood-vessels or of other parts of the brain, or sometimes a morbid deposit in the encephalon, or its membranes. Symptoms. — We shall consider this part of the subject under three heads : — the premonitory , the 'paroxysmal, and the inter-paroxysmal. symp- toms. 1. Premonitory. — The frequency of premoni- tory symptoms, according to the writer's expe- rience, is much greater than is generally known. It is extremely important to find out the existence of these warnings, as in many cases attacks may easily he prevented if we know when they are on the point of taking place. When we say that premonitory indications are extremely frequent, we do not mean that the classic or Galenic aura is often found. That vague, queer, and unex- plained sensation, whether accompanied or not by a muscular contraction, is certainly more fre- quent than is admitted, but is by far less often observed than the other kinds of warnings. Among the premonitory symptoms, there are four oftener observed than others : — one is a change of temper (irascibility appearing or increasing); another is a vascular contraction in the feet or hands, producing a diminution of temperature ; and the two others a spasmodic state of some muscle, cr an optical illusion or hallucination. It is impossible to sum up the various manifes- tations which indicate that an epileptic attack is forthcoming. Alterations of the various functions of the brain, sensations of all kinds, headache or backache, vertigo, sensorial disturbances, sleep- lessness or sleepiness, palpitation, dilatation or contraction of blood-vessels anywhere, altered breathing, diminution or increase of the various secretions (of the skin, mucous membranes, or of the visceral glands), haemorrhages from the nostrils or other parts, fever, more or less marked weakness (general or local), hunger or thirst, disgust for food or drinks, sexual appetite or the diminution or loss of sexual desire or power, erection of the penis, spasm of the bladder, sometimes with involuntary evacuations of urine, involuntary expulsion of feces, cramps, trembling, choreic movements, tendency ro run forwards, backwards, or round, rigidity or convulsions of a limb or other parts, paralysis of a limb or other parts, etc., — such is an abbreviated list of the forerunners which have been noticed by a num- ber of observers, and all of which we have seen, or have been found in our patients. Sometimes one or several of these symptoms will appear a day or two before the attack, hut generally the warning shows itself a few hours, or a very much shorter time (even only a few seconds or a minute or two) before the seizure. In cases of epilepsy due to organic cerebral disease, or to cerebral congestion (much more rarely in other cases), there occurs rather fre- quently, either during the attack or before it. drawing of the head towards one shoulder. If this occur before the loss of consciousness it is a most valuable warning, as it is then almost always possible to produce an abortion of the EPILEPSY. attack. Premonitory symptoms unfortunately are sometimes deceptive, as they may appear more or less frequently -without being followed by the attack ; and in cases in which warnings usually precede the seizures, there are some- times attacks without any forerunner. 2. Paroxysmal . — As regards the paroxysmal symptoms, they vary considerably according to the kind of attak. If the attack is one of petit- mal ( epilepsia mitior), there may be no other symptom than a loss of consciousness, with either a fixed state of the muscles of the eye, or a slight contraction of one or more muscles of the face or neck, or a movement of the lips, tongue, and throat, as in the act of swallowing. If we spoke according to our personal observation, we should affirm that an attack of petit-mal never con- sists in a loss of consciousness only, without the least trace of any other trouble whatsoever. CAUSES. 1. Excitation of certain parts of the excito- motor organs of the nervous centre. 2. Contraction of the facial blood-vessels. 3. Contraction of the blood-vessels of the cere- bral lobes. 4. Extension of the excitation in the excito- motory organs of the nervous centre. 5. Tonic contraction of some respiratory and vocal muscles. 6. Further extension of the excitation in the excito-motory organs. 7. Loss of consciousness alone, or with tonic spasm in trunk and limbs. 8. Laryngismus, trachelismus, and rigid spasm of some respiratory muscles. 9. Insufficient breathing; rapid consumption of oxygen, and detention of venous blood in the encephalon. 10. Asphyxia and perhaps pressure by accumu- lated venous blood in the base of the brain. 11. Exhaustion of the nervous power generally, and of the reflex excitability especially ; return of regular respiratory movements. Space does not permit of our insisting on the explanations given in this table. We will only say that the loss of consciousness is too rapid, too complete, to be due only or chiefly to a con- traction of the blood-vessels of the cerebral lobes. In that case, as well as in cases of loss of percep- tion and volition from a hnemorrhage, a softening, or some other disease of the brain, it is owing to an inhibition of the activity of cerebral nerve- cells that this symptom appears. We will add to the above-given list of symp- toms that besides t.hesudden loss of consciousness, with tonic spasm of the muscles of the eye, face, neck, chest, and limbs, and the uttering of a loud cry r , which we observe iu the beginning of a complete attack of epilepsy, there is sometimes biting of the tongue or lips. After the first stage, which is usually extremely short (not last- ing generally more than from 10 to 20 seconds), general clouic convulsions appear, the face be- comes more or less violet or purple, the tempera- 447 Dr. Bussell Reynolds, however, states that he has seen such attacks, and therefore we must admit that sometimes a pure and simple loss of per- ception and volition is all that exists in a seizure of epilepsia mitior. In such an attack the patient may, if walking, continue to walk, but if talking, he stops — generally for so short a time, however, that the trouble may pass absolutely unnoticed by listeners. Usually an attack of that kind lasts only from one to four or more seconds. An attack of complete epilepsy ( epilepsia greo- vior) is a very complex series of phenomena. Years ago (in 1857) the writer gave the follow- ing table, which shows at the same time in what order and by what mechanism the symptoms ap- pear. Only on a few points has he to alter the views held twenty years ago. It will be seen that in this table the effects successively pro- duced become causes in their turn. EFFECTS. 1. Contraction of blood-vessels of the brain and face ; tonic spasm of muscles of the eye and face. 2. Facial paleness. 3. Loss of consciousness ; congestion in the base of the brain and the spinal cord. 4. Tonic contraction of the laryngeal, the cer- vical, and some respiratory muscles (laryngismus and trachelismus). 5. Epileptic cry. 6. Tonic contraction reaching most muscles of trunk and limbs. 7. Fall or precipitation, forward or backward, to the ground. 8. Insufficient breathing; obstacle to entrance of blood into the chest, and to its issue from the cranio-spinal cavity. 9. Increasing asphyxia. 10. Clonic convulsions everywhere; contrac- tions of the bowels, the bladder, the womb; in- crease of secretions ; efforts to inspire. 1 1 . Cessation of the tit ; coma or fatigue ; head- ache ; aud sleep. ture of the body rises, the skin becomes covered with perspiration, and saliva, reddened by blood or not, flows out of the mouth. After the cessation of the convulsions, the patient is often so exhausted that the limbs fall, if lifted up, as if they were quite paralysed ; the respiration is stertorous ; and the heart beats with great force and rapidity. If care be not taken to have the tongue brought forward, and if the head be not placed on one side, the heavy breathing and the comatose state which often exist, con- tinue for a long time. Even if care be taken about the position of the tongue, these disturbed states of the brain and breathing may last an hour or longer, in very bad cases. In some epi- leptics who have a series of fits in rapid succes- sion, there is a more or less prolonged period of coma after each attack. Sometimes in such cases death terminates the scene after a more or less considerable number of attacks. On waking up either from the coma or the EPILEPSY. 448 sleep following an attack, most patients are, very tired ; their limbs and trunk aching as well as their head. Usually there is some mental alte- ration, often consisting of confusion or stupor, and sometimes delirium. The mind, however, may be quite clear, even after a violent attack, and the head free from pain, the only effect of the fit being general lassitude. On the contrary, after an apparently slight seizure, there is some- times considerable mental disorder. The degree and duration of stupor after an attack have no relation to the duration of the convulsive period. Stupor is an effect of asphyxia and is, therefore, in direct relation with laryngismus, trachelis- mus, and the spasms of the thoracic muscles, of the diaphragm, and perhaps of the bronchial tubes also. It has been stated and denied that the urine passed after an attack of epilepsy some- times contains albumen, in patients free from kidney-disease. In at least two cases the writer has ascertained that there was a notable amount of albumen in the first issue of urine after attacks in which there had been violent spasmodic con- tractions of the abdominal and thoracic muscles. These two patients afforded no evidence of disease of the kidneys or of the heart. Attacks of epilepsy are sometimes very slight, consisting only, besides the loss of consciousness, of an extremely short tonic spasm of muscles of the trunk, the neck, the head, and the limbs. But even in the shortest and slightest attack of that kind the epileptic cry may be uttered and the tongue may be bitten. The symptoms of a seizure of epilepsia mitior ( petit-mal ) are very different from those of a vio- lently convulsive attack of epilepsy ( haut-mal ). The loss of consciousness occurs only for one or a few seconds, and the spasmodic contractions take place in a few muscles only, in the face, tongue, throat, eyes, and neck. If seized while standing up the patient very rarely falls, and on the contrary, if walking, he may continue his movement as regularly as before the fit. If at- tacked while speaking, he stops while the con- sciousness is lost, and on recovering it he may complete the unfinished sentence, so that the by- standers may know nothing of what has occurred. Sometimes, however, the patient’s mind is deeply altered, even when the attack of petit-mal has been as short and slight as possible. Nocturnal attacks of epilepsy may occur with- out any knowledge of their having taken place. Indeed, the writer has sometimes been consulted by persons who only asked for advice on account of headaches, and who had no pain in the head except after nocturnal attacks of epilepsy oc- curring without their knowledge. In such cases the patient, after a seizure during sleep, wakes up tired, as if he had walked considerably ; he has pains in the limbs, the back, and the head. He finds his mind confused, and his memory affected; he feels disinclined to get out of bed or to exert himself in any way; and he often is excitable or depressed. Sometimes his tongue or his lips are sore, and if the pillow is examined it shows bloody spots. More rarely it is found that an involuntary evacuation of urine has soiled the bed. Anyone sleeping within hearing distance of the patient may be wakened by the piercing epileptic cry, and then hear the noise of the shaking of the bed, caused by the con- vulsive movements. Such attacks, although very frequent and also very violent, may remain alto- gether unknown and unsuspected by the patient and liis friends. 3. inter-paroxysmal . — The general health of epileptics is usually very poor. Besides the alterations of their mental powers, and especially of their memory, the)' show a great deal of ex- citability and often depression of spirits. Their circulation and their digestion are often affected. There is nothing special to them, however, either in the morbid state of their mind and of their feelings, or in the disturbances of their physical health. We do not consider the mental aber- rations observed in the inter-paroxysmal state as elements in the symptomatology of epilepsy'. These aberrations can exist without epilepsy, and in a great majority of cases epilepsy is un- accompanied by them. The frequency of attacks varies immensely in epilepsy. In one case the writer learned that for more than seventeen years the patient had passed no night without a fit, and for more than ten years the average nightly number of fits had been about twelve, which gives a total of more than forty thousand attacks in ten years. On the other hand, he was once consulted by a patient, sixty-two years old, who has had hut seven attacks since the first occurred, forty-three years ago, the interval between that and the second fit having been thirteen years, and the interval between the two last seizures having been seven years. Between extremely different cases like the two just mentioned, we find the greatest variety as 'regards the frequency of attacks. Usually, however, there are a number of fils every month. If there are attacks with ex- tremely violent convulsions, the frequency is gene- rally much less than when the convulsions are slight. Seizures of petit-mal are usually very frequent. A perfect periodicity is extremely rare, but an approximation to periodicity is not rare, especially in women. Singular and inex- plicable periods will sometimes exist ; the writer knows of a number of cases with a weekly periodicity, and of a case in which for years attacks recurred every forty-nine days. Diagnosis. — In most eases it is easy to dis-> tinguish epilepsy from the few affections which resemble it. Sometimes, however, difficulties exist. There is no essential difference between the attacks of eclampsia in women and children and attacks of epilepsy, except the existence in eclampsia of a peripheric cause of irritation, which is likely to disappear. But those purely reflex epileptiform attacks of women and chil- dren are sometimes succeeded by genuine attacks of epilepsy, changes in the nervous centres occur- ring during the eclamptic attacks, which lay the foundation of persistent epilepsy, showing itself after the peripheric irritation, which was the first cause, has ceased to exist. It is some- times, therefore, almost impossible, in children especially, to say if we have to deal with eclampsia or epilepsy. The same may be said of all kinds of attacks of loss of consciousness and convulsions due to a peripheric cause, whether we call the affection eclampsia or reflex epilepsy. {See I Convulsions.) The first cause in those eases mat EPILEPSY. cease to exist without our discovering positively that it has disappeared, and still attacks may continue. As the treatment is to be very much the same, except that in purely reflex epilepsy we have to fight against the peripheric cause besides making use of means against epilepsy itself, a mistake is not dangerous. Hysteria sometimes borders on epilepsy, so much so that we must accept for certain groups ot nervous symptoms, the name of hystero- epilepsy. Usually, however, there is no com- plete loss of consciousness in hysteria : there is rather a disordered consciousness. The con- vulsions generally do not follow the ordinary cycle of those of epilepsy : they are not merely tonic first and then clonic ; they often are alter- nately, and many times successive!} 7 , clonic and tonic. They sometimes resemble voluntary movements rapidly executed. The attack is not followed by the stupor that follows so often a fit of epilepsy. Before and after the attack, the patient exhibits (or has done so) purely hysterical symptoms. Usually, pressure on the ovary during the attack stops or increases it, while nothing of the kind is found in a fit of epilepsy, except, of course, one of hystero- epilepsy, in which case the two affections are blended in one. Epilepsia mitior ( 'petit-mal ) sometimes cannot be easily distinguished from syncopal attacks. Usually, however, the pulse does not lose so much in frequency and force in petit-mal as it does in fainting. The loss of consciousness lasts for a shorter period in peiit-mal than in syncope. Between idiopathic epilepsy and cerebral epilepsy, there are generally very marked differ- ences. In epilepsy due to disease of the brain, attacks are almost always preceded by an aura, consisting either in referred sensations or in cramps ; in such attacks, convulsions hften occur without loss of consciousness ; very frequently the convulsions are unilateral, either on the paralysed side or on the other side ; and almost invariably, if they are not clearly unilateral, differences in intensity, in kind, and in duration exist as regards the spasmodic contractions be- tween the two sides of the body. . Prognosis. — Inherited epilepsy is very rarely cured. The writer can positively state, how- ever, that it may be cured. Among other good cases of persistent cure, he has seen two ex- tremely remarkable. The patients were first cousins, and had inherited the disease from a grandmother: one of them died from a fall while intoxicated, five years after his last attack of epilepsy; the other died in China, from typhoid fever, seven years after his last attack. They had both been treated for about two years, in 1852 and 1853. There is a very great difference as regards prognosis between pure idiopathic epilepsy and other forms of that neurosis. The chances of cure, although never great, are by far greater when some curable or amendable organic altera- tion exists, as a cause of epilepsy, than when no such thing exists. One form of this nervous affection — that which is due to some congestion or even a more serious alteration of the brain, —consecutive to typhoid fever, scarlatina, or measles, is very often much benefited by treat- 29 44‘J ment, if not cured. Epilepsy caused by disease of the brain — syphilitic or not — is much more curable than any other form of that neurosis. Epilepsy beginning in childhood, from teething or a bowel-complaint, and having lasted many years, is almost incurable. Complications and Sequelae. — Epilepsy has no necessary or usual complication. The dis- eases which accompany it often are frequently its causes and not complications. Bright's dis- ease and other organic affections of the kidney, diseases of the liver, the womb, and other viscera, when allied with epilepsy, if they have not been the first and only cause of it, are powerful addi- tional causes. There are no sequelae of epilepsy- worth mentioning except some amnesia, which we invariably find in patients cured of that affection, after having suffered from it for many years. Treatment. — A most important fact ouaht at first to be pointed out under this head: it is that as every attack causes in the nervous centres changes which prepare other attacks, it is essen- tial to produce, if possible, the abortion of attacks whenever warnings occur. The treatment to obtain such an abortion varies with the kind of warning. In cases in which a real aura exists many means can be employed with the greatest benefit. The writer long since showed that the old-fashioned mode of prevention of attacks, consisting in the application of a ligature round a limb, acts not as the Galenic doctrine supposed that it did, that is, by barring the way to something going up to the brain; but, on the contrary, in doing just the reverse, that is, bysendingan irritation towardsor rathc-r to the nervous centres. The writer has also shown that the ligature need not be left appliod, and that a greater success is obtained by tying suddenly and very quickly a handkerchief or a band, and repeating this tying several times in succession, than by applying the ligature even very tightly and leaving it so. He has also demon- strated: — 1st. That the ligature can do good even when applied on another limb than that where the aura is felt, although it is usually more effi- cacious on the latter ; and 2nd. That pinching or striking the skin, or irritating its nerves by heat, by cold, by galvanism, or by repeated pricks with a needle, will generally do as much good as the ligature. In those cases in which an involuntary mus- cular contraction takes place before an attack — that is before the loss of consciousness — one of the most efficient means to produce an abortion cf the fit is to draw forcibly on the contracted muscles, so as to elongate them. Eor instance, in those cases in which the unconsciousness is pre- ceded by a contraction of the muscles of the neck, drawing the chin towards one shoulder, turning forcibly and rapidly the head towards the opposite shoulder, gives in most cases a very good chance of checking completely the tendency to the fit. In case of contraction of the flexor muscles of the forearm, forcible extension of the hand over the fore-arm may succeed in preventing the attack. A blow, pressure, or friction on parts where some muscles become rigid, may have the same favour- able effect. If there are disturbances of breathing among the premonitory symptoms, the inhalation of ether or chloroform may prove successful. Ir EPILEPSY. 150 cases of laryngismus similar means cr the cau- terisation of the fauces by a strong solution of nitrate of silver has been found most useful by the writer. The ise of anaesthetics as a means of warding off an attack is too much neglected. By the help of ether in inhalations we have suc- ceeded, with Mr. It. Dunn, in preventing an attack in a patient who had had a fracture of the arm in a previous seizure, and who used to have a fit regularly every week. A whole week was gained in that way. In some cases the re- currence of attacks has been warded off by giving chloroform or ether (by inhalation) to patients who had had the first of what would have been otherwise a series of many fits. There is, in cases in which a fit is expected, a considerable chance of preventing it by etherisation or chlo- roformisation. According to the kind of warning and to its seat one means or another out of a very large number (only some of which we shall mention), ought to be used. An emetic, a purgative, a stimulant, the immersion of the two hands in hot water, the application of a lump of ice to the hack of the neck or between the shoulder-blades, the subcutaneous injection of a solution of ,3 of a grain of atropine with 5 of a grain of morphine, powdered asarum taken as snuff, a dose of 25 grains of hydrato of chloral, the inhalation of a small doso of nitrite of amyl, extremely rapid and ample voluntary respiratory movements for five or six minutes, jumping, running for at least ten minutes, reading very loud and fast — such are some of the means which wo have found to be the most successful. The second point of importance about treat- ment is to try to discover a part of the body which can by irritation give rise to a premonitory symptom of an attack, or even to an attack it- self. If such a part is discovered, counter- irritation of some kind is to he applied there. Our remarks must be confined to saying, that hard pressure on certain parts of the head, the spine, the breast, the abdomen, or the limbs, has in a number of cases produced an attack or some symptoms of it. We have seen the passage of a galvanic current produce the same effect. In such cases a blister or other local application has done good in diminishing the violence or frequency of attacks, and even, in a few instances, helped notably to a cure. The modes of treatment of epilepsia gravior or mitior which chiefly deserve to he noticed are the following : — - Against idiopathic epilepsy the most powerful means consists in the simultaneous use of some tonic remedy (such as strychnine or arsenic) in a solution to he taken after meals ; and of a mix- ture composed more or less like the following: — R Potassii iodidi, 3ij. Potassii bromidi, 3j. j\ mmonii bromidi, 3iij. Potass® bicarbonatis, 3j. Tinct. calnmb® f. 31 Aqu® destillat® f. Jvj. Of this solution may he given to adults four doses a day, three of one teaspoonful each before meals, and the fourth of three teaspoonfuls at bed-time with as much water as desired. Ac- cording to many circumstances the dose of one or another of the ingredients is to be changed. For example, if the petit-mal exists alone, o' coexists with the complete epilepsy, the dose of the bromide of ammonium must he larger, and that of the other bromide diminished. If there is a weak pulse the sesquicarbonate of ammonia is to be substituted for the bicarbonate of potash. In the writer’s work on functional nervous affections all the rules relating to that mixture are given, and we will only say now that ice use is by far more beneficial than that of any of its ingredients alone or of two of them. Twc essential rules are to be followed when either such a mixture or any of the many bromides is employed against epilepsy ; the first is, that there ought to he no interruption whatever in the use of such remedies, as the whole benefit that may have been obtained may be lost at once after an inter- ruption of even only a few days; the second is that the treatment must he persevered with for at least two years after the appearance of the last attack. There is no marked harm in the great majority of cases from a prolonged use of a mixture like the above ; many patients have taken it for several years, and some for six, eight, or ten years without any marked bad effect. Idiopathic epilepsy (either the complete or the incomplete, that is the jietit-mal) has been suc- cessfully treated (very rarely cured, hut often benefited) by the use of a number of remedies. Judging by his own experience, the writer names, as the most powerful, atropine and the ammo- mated sulphate of copper. Although not able general^ to produce as much and especially as prompt a good effect as the above mixture, these two remedies have the superiority over this mix- ture that they need not be constantly used, and that there is no necessity of continuing to employ them longer than eight or ten months after the last attack, liext in importance after the three means spoken of, will come the cotyledon umbili- cus, the, nitrate of silver, and zinc preparations, especially the bromide of zinc. The other forms of epilepsy require pretty much the same modes of internal treatment ; hut, of course, according to the cause of each form some special means should be employed. In the above prescription the dose of the iodide of potassium must become as large as that of the bromide of potassium, when syphilis is considered to he the cause of epilepsy, and, if needed, mercury should he administered also. If epilepsy depends on some visceral affection it is clear that the treat- ment should he directed against that affection. But if the liver is diseased from some influence of malaria the sulphate, of quinine should not he given, as it is almost always a bad remedyagainst epilepsy, often more hurtful than it can be useful. Arsenic then should he the remedy used against the sequel® of fever and ague. If quinine must he employed in eases of clearly periodical epi- lepsy, the valerianate should be given rather than the sulphate. It may seem strange that we do not name iron among the remedies against epilepsy. The writer s experience shows that in most cases iron is rather harmful than useful. It is only in cases of epi- lepsy allied with or caused by chlorosis or con- siderable anaemia that its good effect is often EPILEPSY. EPILEPTIC INSANITY. 451 very marked. Even then, we have sometimes found manganese more serviceable. There is, however, one salt of iron — the citrale — which, although less powerful against a deficiency of olood-globules, is however less apt to give rise to attacks than are most ferruginous preparations in a number of cases. Of other internal remedies, cod-liver oil if well borne is certainly useful, especially against th e petit-mcd. The importance of giving simul- taneously with the bromides either arsenic or strychnine has been already mentioned. Ar- senic alone can do much against any form of epilepsy, perhaps chiefly against petit-mal, but the writer does not personally know of a single case of cure by its use. Strychnine can also alone do good, but less than arsenic. Digitalis or digkaline have been credited as having effected cures ; so have turpentine and a number of other medicines. The writer has obtained only a very .imited good from the use of digitalis or tur- pentine. As regards the curative influence of the nitrite of amyl, it is yet sub judire. From counter-irritation there is a great deal to be expected. Ice (not in a bag) the actual cautery, blisters, &c., applied to the back part of the neck and between the shoulder-blades, are most useful in any form of epilepsy, especially when there is a great deal of headache and considerable heat in the head. When attacks are very violent and frequent, there is some good, and at times a de- cided amelioration to be obtained from croton oil applications on a great part of the shaved head. Setons and issues very rarely do any good, and often weaken and irritate. A circular blister round a limb, a finger or a toe, is most useful in cases of an aura starting from those parts. It is known that in such cases a nerve has been divided, sometimes with great success. Of more serious operations, there is one which ought to be completely rejected, unless there is good reason to suspect the exist- ence of an intracranial aneurism on the carotid artery or one of its branches, namely, the liga- ture of that artery in the cervical region. Al- though beneficial in a few cases it is a dangerous operation, and much inferior to many other means of treatment. Trepanning the cranium, except on clear, rational ground, is certainly to be avoided, although it has in a few such cases cured or ameliorated the condition of the patient. But when the attacks are ex- tremely violent and frequent, especially if they seem to endanger the life of the patient, and when there is a clear evidence of pressure exerted on the brain, that operation, which in such cases has often been useful, ought to be resorted to, after the failure of other means. Laryngotomy or tracheotomy are to be rejected, except in those instances in which the operation would have to be performed even if there were no epilepsy. In cases of laryngeal epilepsy the writer has found the cauterisation of tho fauces and of the larynx itself with a strong solution of nitrate of silver a very useful means, and even in one case a means of complete and persistent cure. During an attack of epilepsy, excepting what simple common sense suggests, there is very little to be done. Pressure on one or on both carotid arteries, which we now know to act on account of the accompanying pressure on the par vagum and on the cervical sympathetic nerves, will sometimes considerably shorten an attack, especially if there is violent action of the heart. At the time convulsions cease, the tongue ought to be drawn forward and the head of the patient, if not his body, turned sideways, so as to avoid the covering of the larynx by the half-paralysed tongue. No other interference at all with the patient should be tho rule after the attack. C. E. Brown-Seqcard. EPILEPTIFORM EPILEPTOID . — Partaking of the characters of epilepsy ; terms generally applied to convulsions. See Convulsions. EPILEPTIC INSANITY.— The different classifications of mental diseases agree generally in making a separate division of the intellectual derangement related to epilepsy. This latter ranks prominently among the predisposing causes of insanity, but has not been found to proceed from it, unless the epileptiform convulsions ob- served with the majority of mental affections be improperly regarded as epilepsy. Evidently, the fits of petit mal are associated with insanity more frequently than even the most violent <>! grand mat-, however, from this association it does not necessarily follow, as currently believed, that insanity should be a mere consecutive acci- dent of the fit. Falret, endeavouring to recon- cile the views on the subject put forward by French alienists, asserts that insanity chiefly occurs as a consequence of epileptic attacks re- curring at short intervals after a prolonged sus- pension of the disease — which is very true. Yet, insanity may besides break out after nocturnal attacks, or seizures of petit mal, without any relation whatever to the length of their suspen- sion, or number ; and mania — usually of the most furious character — may also appear as a fore- runner instead of the sequel of the fit; or it may originate with the very first epileptic seizure and recur continually thereafter. Lastly, the existence of epilepsy and paralysis brings about - from the beginning, a gradual though obvious impairment of the intellectual faculties, whirl: becomes exacerbated by the fits, and terminates in dementia. No less open to objection is the kindred nature of the physical and psychical manifestations of epilepsy, admitted by Falret. to establish thereupon the intellectual petit mal and the intellectual grand mal. The first cor- respond with the incoherent and violent state described as furious mania. The second may continue from several hours to several days, con- stituting an intermediate condition between the irregularities of character which attend the fit, and the highest disturbance of the furious mania- cal seizures. In the midst of this confusion of mind epileptics recall to their memory the painful past impressions, which spontaneously spring up in their imagination, always the same at every new access, and give themselves up to instanta- neous, sudden acts of violence. After such fit of violence, the epileptic either quickly returns to himself, regaining his consciousness and ren- dering an imperfect account of his misdeeds, or, on the contrary, he escapes, running away a a 152 EPILEPTIC bewildered and greatly agitated condition. In either case the confusion, if not the complete oblivion of what has happened, is almost always a striking essential feature of this mental state, bo much resembling the awakening from a dread- ful dream. The foregoing phenomena are, indeed, exhibited by the insane epileptic ; but the dis- tinction between the intellectual grand mal and the intellectual petit mal, and their respective reference to the physical paroxysms of epilepsy, supposed by Falret, implies an essential connec- tion which is far from being constant. The most fearful fits of rage, or frenzy, may follow the petit mal, or may burst out without any visible attack at all, while nocturnal fits, or petit mal and grand mal, recurring separately or together, may often herald a harmless insanity with the highest degree of melancholia with stupor, with- out the least violent reaction — which, as set forth by Falret, should exclusively occur upon the physical grand mal. In other common in- stances, the epileptic, without any dejection or stupor, but excessively disposed to react violently on the slightest moral or physical incitation, talks and acts coherently, in an apparently rational manner, but actually without any appreciation whatever of his outward relations — a strange state that may occur along with diurnal or noc- turnal fits, or irrespective of any manifest physi- cal paroxysm, as the only exponent of the epi- leptic malady. For all these reasons, instead of attempting to establish an immediate relation of cause to effect — which cannot be proved — between the psychical and physical paroxysms, it is safer to regard epileptic insanity, or, using a more adequate term, cerebral epilepsy — as one of the manifestations per sc of the spasmodic neurosis, recognising its essential source, not in this or that kind of fits, nor in their frequency, but in the very pathogenetic elements of the disease. Unconsciousness, with an excessive reflex susceptibility, displays itself as the chief characteristic of cerebral epilepsy, capable of occurring either alone, or coupled with any other form of the epileptic malady, preceded sometimes by an aura, identical to that which may foretell other attacks. Description. — Assuming the practical view above maintained, it is readily observed that epi- leptic insanity — like every other variety of in- sanity-manifests itself under an intermittent, a remittent, and a continuous form. The intermittent form is characterised by periodical attacks, breaking out at irregular in- tervals, either before or after the fits, which, moreover, often explode as though they were an interenrrent accident of the maniacal seizure. When this latter directly follows the grand mal, the patient instantly passes from the clonic stage of the fit into the maniacal, without any intermediate period of sleep or coma. The inter- mittent attacks of cerebral epilepsy rarely last less than two or three hours ; they may be de- veloped one or more days after instead of closely accompanying the fits, and ordinarily have then a longer duration ; or, again, the intellectual disorder may reach its most dreadful stage without any spasmodic fit being seen or sus- pected. Morel proclaims that in these cases the occurrence of convulsions never fails to disclose INSANITY . the true nature of the insanity, as such patients ultimately arrive at the convulsive fit and die. This, however, is too absolute a statement, for undoubted cases of cerebral epiiepsy are fre- quently met with, without the supervention of any spasms in the final state of cerebral conges- tion, the patient sinking into a profound coma, but sometimes executing automatically in this insensible state the same movement of the head, or some other habitual gesture. It is in inter- mittent cerebral epilepsy that unconsciousness appears most strikingly, although no reference has been hitherto made to its clinical or far- reaching medico-legal significance, nor to the explanation it furnishes to the strange oblivion or amnesia, so peculiar to epileptics after the commission of their criminal acts. Eeligious monomania and erotomania are common in the earliest stages of intermittent cerebral epilepsy. However, the peculiar disposition to wander about in an aimless manner, the volubility and instan- taneous changes characteristic of the deportment of individuals labouring under this stage, maybe transformed into an opposite manner of acting, the epileptic then remaining for hours or days entirely motionless and silent, with a sullen ex- pression of countenance, in a physical and mental condition which almost verges on catalepsy, and involuntarily passing his urine and excrements, like those suffering from stupidity or melancholia attonita. No complete recovery of intellectual sound- ness takes place between the paroxysms or maniacal exacerbations of remittent epileptic insanity. In the continuous form the mental trouble persists throughout, not essentially modi- fied by the recurrence of the fits. In either instance dementia, imbecility, or a range of symptoms very similar to those of general paresis, is more noticeable than the uncon- sciousness with high irritability and sudden violent acts observed in the intermittent cases. The remittent and continuous forms offer no em- barrassment as to their diagnosis, and affor .. upon close examination, the most typical exam- ples of folic circidaire. The intermittent cerebral epilepsy, which occurs in no proximate connection with any fit of grand mal or petit 'mal, corresponds to the lariated epilepsy of Morel, intellectual epi- lepsy of Maudsley, psychical epilepsy of Ivraft- Ebing ; and most of the cases of the so-called instinctive mania ( manic sans delire), and of mania transitoria also belong to this category. The main points to observe in this perplexing aspect of the spasmodic neurosis are the follow- ing:- — Cerebral epilepsy implies an advanced stage of the epileptic malady, but may and does nevertheless appear at any time throughout its progress, even when it has been developed in a sort of hidden or larvatcd manner. The dis- crimination between larvatcd epilepsy and other forms of intermittent mania is rendered easy by a reliable account of the antecedents of the patient. The demonstration of parents stained with any constitutional nervous disease, or addicted to in- temperance, an extreme susceptibility to anger, with strange peculiarities of character, moral depravity, and a more or less dwarfed develop- ment of the intellectual faculties, in addition to EPILEPTIC 'lie onset of fits during infancy, or adolescence, and subsequent vertigo or fainting fits or in- stantaneous absence and giddiness, are elements of diagnosis which evince the true epileptic Dature of any transitory, instinctive, or mental disorder that has recurred without variation, or with such a complete resemblance to the preceding paroxysms as we notice but excep- tionally in any other kind of mania. The at- tacks of cerebral epilepsy recur with the period- icity and similar premonitory symptoms peculiar to other epileptic paroxysms. When displayed from the beginning, as after traumatic injury to the head, syphilis, &c., they ordinarily recur at shorter intervals than otherwise. The mani- festations of cerebral epilepsy are never soli- tary, they involve a repetition of fits of men- tal or physical character. Consequently, sueh insanity, as already advanced, discloses an active but not ultimate progress of the epileptic malady, and hence the possibility of its cure or relief. Epileptic insanity is rarely manifest before nuberty, for idiotcy accompanies congenital epi- lepsy in idiotic epileptics, and imbecility the epilepsy which develops itself during childhood in epileptic imbeciles. There is a clear relation between the intensity and length of the epileptic insanity and the impediment to the cerebral cir- culation, which in its extreme degrees may ter- minate in meningitis. Giddiness withperspiration of the head, sometimes very profuse, and epis- taxis, are symptoms existing during or imme- diately after the paroxysms. The cerebral congestion is further betrayed by the bloated and livid appearance of the face; the injection of the conjunctivse, with a thick white discharge col- lected in the angles of the eyelids ; and the heavy look of the patient. The pupils during the ex- acerbations of the paroxysm — when the patient becomes boisterous and violent, exhibit a dilata- Lion and contraction, like that which may last for several seconds or even a minute after the fits of petit mal or grand, mal. Slowness of the respiratory activity, with marked loss of its normal relation to the pulse, is regularly detected in every case where the epileptic habit has become well established, as also an increased temperature of the skin before the explosion of the attack, ordinarily attended with incontinence of urine when it takes place during sleep in nocturnal epilepsy. There is always at the close of the fit of epileptic insanity a period of sleep, which effects the transition to a sound condition of mind. This sleep may bo prolonged several hours, accompanied by a heavy breathing or snoring, which makes it easily mistaken for the sleep of drunkenness, a mistake strongly coun- tenanced by the quick recovery of the patient. Another conspicuous sign of epileptic insanity is the epileptic echo, or repetition by the patient of the same word or phrase addressed to him, or present in his mind. Romberg has described the echo sign as indicative of softening in cere- bral diseases, but in epilepsy it chiefly evinces a perverted will. The phenomenon renders itself very evident in the writings of the epileptic in- sane. even during the very occurrence of tbe fit, thus affording confirmation of the automatic repetition of motory and intellectual acts so peculiar to epilepsy. INSANITY. 453 Morbid sensorial phenomena of various kinds existed in 80 per cent, of 267 cases of epileptic insanity. Hallucinations of hearing were re- corded in 62 percent. of the said number; of sight in 53 per cent. ; of hearing and sight in 42 per cent. ; of smell in 6 percent. ; and finally about 30 per cent, of the cases showed some disturbance of general sensibility, such as anaesthesia, hy- persesthesia, &e. If we take into account the almost constant occurrence of some of these mor- bid sensations, and the hyperaesthetic condition attending epileptic insanity, it will not be diffi- cult to realise the manner in which its victims are fascinated by the feelings they experience, which ordinarily assume the most frightful and deceitful character. Whenever we have data for comparison, we shall see that the hallucinations of hearing are the most frequent, as shown by the foregoing statistics. Morel has, with great propriety, insisted on the unmistakable character of these hallucinations of hearing, and the piercing sudden noises, usually heard by epileptics, dif- fering entirely from the noises complained of by those labouring under the delirium of persecu- tions, which always lead an attentive observer to a definite diagnosis of cerebral epilepsy. Tbe intellectual aura, which like precursory clouds of a threatening storm may anticipate the outbreak of a fit of cerebral epilepsy, is an acces- sory symptom common to all the attacks, already noticed in the general description. In regard to the moral and intellectual changes which cha- racterise epilepsy, and may be superinduced from its very outset, effacing — as Maudsley says — the moral sense as it effaces the memory, there is one brief remark to be made. Such moral depravity is more apt to occur from the very inception of tbe attacks, when epilepsy is induced by a trau- matic injury to the head ; its appreciation is beset with difficulties, and although these morbid dispositions do not constitute a state of insanity, they must place tbe epileptic — as justly declared by Baillarger — beyond the common rule, and ex- tenuate at least his legal responsibility. Legai. Relations. — Bearing in mind, the reflex nature of the physical and mental phenomena inherent in epilepsy, and our inability to avoid tbe effects of reflex actions, it follows as a matter of course that epileptics should be regarded irre- sponsible for any criminal act they might commit under the influence of a paroxysm. Those familiar with epileptics know that the majority have no knowledge, or at least a very imperfect idea, of their misdeeds, such state of unconsciousness being the chief characteristic of epileptic insanity generally. This unconscious cerebration exhibits itself in a high degree in epilepsy, but is not peculiar to it, for we observe it more or less in all forms of insanity, and notably in somnambu- lism. Finally, a clear demonstration of the above- described phenomena is indispensable before we can fully appreciate or decide upon tbe nature of any act perpetrated during an alleged condition of epilepsy. The reasons here briefly presented for the ir- responsibility of confirmed epileptics prove no less forcibly that society, in its turn, must be protected from their misdeeds, since they are unquestionably thexnost dangerous class of in- dividuals. Therefore criminal epileptics should 154 EPILEPTIC INSANITY. never be allowed to go at largo until sufficient time has elapsed to demonstrate the arrest of their malady, upon continued observation by a competent physician. Treatment. — The treatment of epileptic in- sanity does not differ from that of epilepsy gene- rally (see Epilepsy). Let it be simply noticed thatergotine in doses of three to six grains, and succus conn in doses of three drachms to one ounce, in often repeated doses, with counter-irri- tation to the lower part of the neck (seton or cautery), and cold shower-baths or packing, are among the most reliable means to be resorted to, to abate or prevent the great excitement of the insane epileptic. M. Gr. Echeverria. EPIPHORA (eirl, upon, and e'p«, I carry). A flow of tears, so persistent that they run down the cheek, due either to obstruction of the lachrymal duct or to excessive secretion. See Lachrymal Apparatus, Diseases of. EPIPHYTA (eirl, upon, and tpurby, a plant). These are the plant-like organisms found on the skin, and its appendages or on mucous sur- faces, the so-called vegetable-parasites, originating certain diseases, such as the various forms of tinea and thrush. The more important of them are the Achorion, Trichophyton, and Microsporon. The achorion Schoenleinii is the vegetable fungus which constitutes the mass of the crusts of favus, and belongs to the group of Oidiie. The tricho- phyton is the dermatophyte of tinea and sycosis, and is found in the substance of the hair as well as in the epidermis. The microsporon, termed Epidermophyton by Bazin, is the parasitic fungus of phytosis versicolor. Both the latter are mem- bers of the group of Torulacese. See Epiphytic Skin-Diseases, and Aphthae. Erasmus Wilson. EPIPHYTIC SKIN-DISEASES,— Synon. : Vegetable parasitic skin-diseases ; Tinea ; Dermatophytic diseases. Definition. — Epiphytic diseases are diseases due to the attack upon the integuments of para- sitic fungi. Description. — Speaking generally it may be said that an epiphytic disease consists of three component elements— (a) a soil favourable to the growth of the attacking epiphyte ; ( b ) the grow- ing epiphyte itself ; and ( c ) the effects produced upon the skin-tissues by the development and increase amongst them of the epiphyte. Epiphytic Soil. — As regards the soil it is difficult to exactly describe it, but it is indis- putable that the young, those whose assimila- tion is at fault, the lymphatic, and fair children, furnish a soil peculiarly favourable to the growth of vegetable parasites. The Epiphyte. — The epiphyte itself consists of reproductive cellular bodies called conidia or sometimes spores, formed of an outer envelope composed of cellulose, and an inner membrane or utricle, enclosing granules floating in a liquid, and mycelial filaments. The spores are round (as in tinea tonsurans) or oval (as in favus). having an average diameter of ’006 mm., and furnished in most cases with a nucleus. These co- nidia are double-contoured, solitary, or arranged in rows, or massed in groups (tinea versicolor). The mycelial threads vary somewhat in appear- ance ; they may be fine transparent filaments, or EPIPHYTIC SKIN-DISEASES. large distinct double-walled tubes. They are jointed by real dissepiments, and more or less con- stricted, and contain granules and cells, whilst the terminal filaments bear various forms of fructification. In many cases there is a stroma, made up of a number of very small grannies, resulting from the subdivision of the grannies and cells in the interior of the filaments, and even of the conidia. Some question the vegetable nature of these fungus-elements, and aver that they re- present a granular degeneration of normal skin- structure ; but no transitional stages have been discovered betwixt the two structures. Further, these fungi can he made to develop the character- istic fructification of the common moulds of un- doubted vegetable nature, and similar fungi occur in situations — as the hard structure of corals, &e. — in which they could not have been derived from any kind of epithelial or other animal tissue. Conidia may readily be mistaken for fatty gra- nules and vice versd. But the former refract light strongly, are nucleated, and unaffected by ether in the least degree. Effects. — Concerning the effects induced by their growth in the skin, it may he said that fungi act like ordinary irritants, inducing in- flammation of the skin ; and as the fungi grow equally in all directions from a given centre, the eruption is usually circular. Its signs are most marked at the circumference, where the fungus is in its most active state ; but, in ad- dition, the fungus invades the epithelial tis- sues ; grows downwards into the follicles, causing irritation and effusion therein ; then gra- dually attacks the hairs or hair-shafts, absorbing their moisture, separating the component fibres, and causing the hairs to become thickened, more or less opaque, twisted, uneven in size along the shaft, and brittle, so that they easily break. Nothing but the growth of fungi in them can produce the disease of the hair observed in the epiphytic diseases. Varieties. — There are seven clinical varieties of undoubted epiphytic diseases, and an ad- ditional one, about which great difference of opinion has been expressed. The seven are as follows : — 1. Tinea favosa or favus, or honeycomb ring- worm, caused by the achorion Schonleinii. 2. Tinea tonsurans (ordinary ringworm of the scalp), the fungus occurring in connection with it being termed trichophyton tonsurans. 3. Tinea kerion, a modification of the last- named, having the same parasite, and being characterised by inflammatory prominence of the follicles, and exudation therefrom of viscid fluid. 4. Tinea circinata (ordinary ringworm of the body), including the ringworms of Oriental places, — Burmese, Chinese, Indian ringworm, &c., having the same parasite as tinea tonsurans, and only differing from it essentially in the fact of its occurrence on the non-hairy parts. 5. Tinea sycosis, or ringworm of the beard ; the parasite being microsporon mentagraphytes. C. Tinea versicolor or phytosis versicolor, the chloasma of English writers ; the parasite of which is microsporon furfur. 7. Onychia parasitica or onychomycosis, para- sitic disease of the nails, caused by the growth EPIPHYTIC SKIN-DISEASES, in the nail of the fungus of tinea tonsurans or tinea favosa ; in other words, the trichophyton or the achorion. At one time it was thought that the disease known as tinea dccalvans was parasitic and caused by the growth of the microsporon Audouinii, but this is at present a disputed point. See Alopecia. These several variecies of tinea will be de- scribed in detail under that heading. Treatment. — The principles of treatment in parasitic disease consist in improving the tone of the nutrition, and in bringing parasiticides into contact with the fungus-elements, so as to ensure their destruction ; the latter, however, is a matter of much difficulty when the fungi are imbedded deep in the hair-follicle, or in the lower parts of the shafts of the hairs of the scalp. See Tinea. Tilbury Eox. EPIPLOITTS (eiriTr \oov, the omentum). — Inflammation of the epiploon or great omen- tum. See Periton.t;um, Diseases of. EPISPADIAS (eVl , upon, and o-ttoco, I draw). — A malformation of the penis, in which the urethra opens, on its upper surface. Sec Penis, Diseases of. EPISPASTICS ( eVl, upon, and atrda. Idraw). Substances which, when applied to the skin, are capable of producing a blister. See Counter- irritants. EPISTAXIS (fVI.upon, and ardfa, I drop). Synon. : Er. Epistaxis ; Ger. Nascnbluten. Definition. — Epistaxis signifies a bleeding from the nose. ^Etiology. — Epistaxis is either traumatic or idiopathic. The traumatic form may be occasioned by violent sneezing, by snuffing up irritating sub- stances, or by direct violence ; hut in these cases there frequently appear to he general or local predisposing causes, to account for the readiness with which it occurs, such as a hsemorrhagic diathesis, an inflammatory or congestive hyper- emia, or some ulceration of the mucous mem- brane. The idiopathic form of epistaxis frequently occurs in children, particularly hoys, just before or about the age of puberty, and in girls as a form of vicarious menstruation. Epistaxis may he one of the forms of bleeding in persons of hremorrhagie diathesis, inwhich case it is a source of anxiety and difficulty. Occurring in advanced life, it may he indicative of over-distension or obstruction of the cerebral venous system from chronic Bright's or cardiac disease ; and the blood which flows is then often venous in ap- pearance, Occasionally it occurs as a spontaneous relief to determination of blood to the head, in which form the blood generally proceeds from one nostril only. In other instances epistaxis is connected with serious disorder of the blood, ns in the specific fevers. Thus it is often asso- ciated from the outset with remittent, enteric, typhus, or scarlet fever, and is indeed regarded in some degree as pathognomonic of enteric fever. It may also attend scurvy, purpura hse- morrhagiea, splenic disease, pyaemia, and erysi- pelas, being a sequence of the septic condition. In its passive form, epistaxis is often associ- EPISTHOTOKOS. 45b ated with organic disease of the heart, pleurisy, emphysema; or with ascites or ovarian dropsy, on account of pressure on the diaphragm inducing a stasis of the venous circulation. It may occur spontaneously from exposure either to great cold or great heat, or a sudden change from cold to heat, or from the diminution of atmospheric pressure, as in going up high mountains. Symptoms. — Haemorrhage from the nose is too familiar to demand description in this place. The flow' of blood may be either continuous or drop by drop. As a rule, the escape of blood is from one nostril, bleeding from both being rare. It may last a very short time, or for some hours, and in severe instances for days, causing syncope, or even being attended with fatal results. It is at times met with as occurring periodically. Diagnosis. — Epistaxis must not be confounded with haemoptysis, as may happen if the epistaxis takes place posteriorly, and the blood passes into the mouth. Treatment. — "When epistaxis is obviously a salutary process, as it undoubtedly is in a good many instances, it subsides spontaneously ; where it occurs frequently and severely, recourse must be had to mechanical, cutaneous, and internal remedies. The local application of cold in the form of cold water or iced compresses to the nose, neck, or forehead is most useful, acting as these agents do either directly or by inducing a reflex effect on the vaso-motor nerves. Simple pressure upon the nostril, or upon the septum nasi, by compressing the bleeding nostril with the finger of the opposite hand, while the arm of the affected side is raised above the head, is the most readily practicable and effectual of ail measures. The application of mustard over ths stomach or upon the ankles is sometimes success- ful. When simple means fail, astringents, either in the form of solution or powders, may he in- jected into the cavities, or applied on plugs of lint or cotton-wool, such as alum, acetate of lead, the salts of iron, or gallic or tannic acid. Internally, the frequent administration in small doses of tinctura ferri perchloridi, tur- pentine, bromide of potassium, or belladonna and quinine may he necessary in cases of periodic attacks. In very severe cases the operation of plugging the nares, and thereby favouring the formation of a clot, must he resorted to, and the most ready and easiest method is by the employment of Bel- locq’s sound, or more properly canula. If, how- ever, this instrument be not at hand, a catheter or an eyed probe should be threaded with a stout silk or hemp ligature, and pushed along the floor of the nose, until it protrudes beyond the velum palati ; one end of the thread should now he pulled out of the mouth by the fingers or forceps, and a roll of lint or a piece of sponge tied to it, and then pushed up behind the velum. Tbs catheter and the attached thread being now with- drawn through the nostril, the plug is pulled forcibly against the posterior nares, and by the pressure exerted the haemorrhage can generally be arrested. Edward Bellamy. EPISTHOTONOS (imo-dev, forwards, and tAvw, I extend). — A synonym for emprosthotc nos. See Empeosthotonos. t56 EPITHELIOMA. EPITHELIOMA (eVl, upon, &£\\a, I grow — epi thelium ; and &ybs, like). — A variety of cau- ser, consisting essentially cf epithelial elements. See Canceb. EPITHELIUM, Diseases of.— The differ- ent kinds of epithelium must be separately con- sidered, as they differ in their pathological relations, namely, squamous and cylindrical epi- thelium of mucous surfaces ; serous epithelium, or endothelium ; and finally spheroidal or glandular epithelium. The last kind will be better treated of under the heads of the several glands. A. Diseases op Squamous and Cylindrical Epithelium.— 1. Catarrhal Inflammation. — Both varieties of epithelium occurring on mucous surfaces are subject to inflammation, which usually takes what is called the catarrhal form. Catarrhal inflammation is characterised by hyperaemia, swelling of the tissue, rapid pro- duction and casting-off of cells, and increased production of the normal mucous secretion of ihe parts, without the production of any coagu- lable exudation, or any layer of new material. The cells thrown off are partly epithelial, partly leucocytes or pus-cells. The secretion contains mucin. The proportion of the various factors of catarrhal inflammation varies greatly, sometimes hyperaemia with swelling, sometimes cell-produc- tion, sometimes fluid secretion predominating ; and these differences sometimes mark different degrees or stages of the inflammatory process. When the number of leucocytes thrown off is very large, the catarrh becomes purulent, which differs only from the other in degree. Catarrhal inflammation is the ordinary result of irritation applied to a mucous surface ; but it persists after the irritation has ceased, and has a marked tendency to become chronic. While the chief share in producing and maintaining the phenomena of catarrh must be referred to the condition of the blood-vessels of the mucous membrane, the part played by the epithelial eells in these processes is a point of great in- terest and importance, though as yet imperfectly determined. These cells, whether squamous or cylindrical, enlarge and alter in shape, while there must be (since so many are shed) a rapid new formation of them ; but the seat of this new formation, whether in the normal or the pa- thological condition, is still obscure. Further, it is not unusual to find swollen epithelial eells which show division of the nuclei or partial division of the cell itself, and others which show within their substance several smaller, round- ish bodies, with the general character of young cells. These appearances have been regarded as indicating (1) multiplication of cells by fission, (2) endogenous cell-formation within the mother-cells, and (3) the origin of the numerous pus-corpuscles seen on the inflamed surface. There is, however, no reason for thinking that new epithelial cells are thus formed. By others again the presence of pus-corpuscles or young cells within the epithelial cells is regarded as an unimportant and accidental complication, the young cells which possess the power of migra- tion being absorbed into the protoplasm of the epithelial cells, so as to appear as if originally formed there. The production of vacuoles or EPITHELIUM, DISEASES OF. spaces in the altered epithelial elements is also explained in two ways, either as a part of the process of cell-proliferation, or as indicating partial absorption of the substance of the celL It must therefore be regarded as still uncertain, whether epithelial cells do, by a process of pro- liferation, give rise to any new elements. 2. Croupous Inflammation. — Croupous in- flammation is distinguished by showing, in addi- tion to hyperaemia and swelling, the production of a layer of new material, or false membrane, easily detached from the surface. This form is usually, if not exclusively, seen on surfaces covered with cylindrical epithelium, as in the air-passages. The false membrane, composed of fibrin cementing together layers of detached epithelium and leucocytes, does not owe its origin to any alteration of the epithelium itself. Croupous inflammation of epithelial surfaces has been regarded as always indicating some specific form of inflammation. It now appears, however, that it may be produced by simple irritation, such as that which produces the catarrhal form, provided the irritation be suffi- ciently intense. 3. Diptheritie Inflammation. — This is a name used with much variation of meaning, hut generally to signify a process in which there is production of a false membrane closely adherent to the epithelial surface, and which is accom- panied by some degree of necrosis or gangrene. In the production of the diphtheritic false mem- brane an important part has been assigned to the epithelium, it being held that the new material which appears like exuded fibrin is really produced by a metamorphosis (the so-called fibrinous transformation) of the . pavement epithe- lium. It is pretty clear that when this condition occurs on surfaces covered with this variety ot epithelium some such change in the epithelium does take place, but not that the membrane is made up wholly or even in any large degree of such altered cells. Moreover, even this cannot, be clearly traced on surfaces covered with cylin drical epithelium. The membranes consist in large measure of cast-off epithelium, and also (as the writer holds) partly of fibrin, though the pre- sence of the latter constituent is denied by some authors. It should be noted that the terms croupous and diphtheritic inflammation, as here used, are not synonymous with the diseases named croup and diphtheria. 4. Patty Degeneration. — It is very common to find the protoplasm of both squamous and cylindrical epithelial cells dotted with oil-glo- bules, so much so that this must be considered normal, to a certain extent, in some glandular epithelium (as kidney), and does not appear to interfere with the function of the cells. When the fatty change, however, is extensive, and more especially when the whole body of the cell is opaque, the condition must be regarded as one of fatty degeneration (see Fatty Degeneration). This is seen in the stomach in cases of alcohol- ism, in poisoning with metals or phosphorus, and in cases which are probably nothing more than chronic catarrh. It is also seen in the alveolar epithelium in pulmonary emphysema. Fatty degeneration appears in epithelium to b< a process leading to atrophy. EPITHELIUM, DISEASES OF. 5. Mucous or Colloid Degeneration. — Epithelial cells, especially in parts which are naturally adapted to the production of mucus, particularly cylindrical epithelium, are liable to undergo a form of degeneration in which a portion of their protoplasm becomes converted into mucous substance, and thus liquefied. Cells having this character are often seen in catarrhal conditions of the mucous membrane of the air- passages, but the change does not appear to occur as a substantive disease. It has not been traced in squamous epithelium. C. Albuminoid (Waxy or Amyloid) De- generation. — This form comparatively rarely affects epithelial cells, but still in cases of albu minoid disease we may sometimes find that the mucous surface of the intestines is stained with iodine in the characteristic manner. In one or two cases the writer has observed a similar change in the surface of the pelvis of the kidney, and even the bladder, where there has been albuminoid disease of the kidney. B. Diseases of Endothelium. — The single layer of flat epithelium found on serous surfaces, which differs so much from the other forms as to be now generally known by another name, endothelium, differs also in its pathological re- lations. 1. Catarrhal Inflammation is unknown on serous membranes, their characteristic form of inflammation being exudative and fibrinous, corresponding thus to the 2. Croupous Inflammation of mucous sur- faces. In this inflammation the endothelium does not necessarily take any part, though when the inflammation is once established the endo- thelium is, in part, simply shed, in part shows changes of a proliferative kind ; cell-division, multiplication, and endogenous cell-formation being observed here with less ambiguity (as it appears to the writer) than in the epithelium of mucous surfaces. Similar changes appear to occur in chronic inflammation of serous sur- faces, and to play an important part in the pro- duction of fibrous adhesions between opposing surfaces. 3. Fatty Degeneration. — Endothelial cells are also subject to fatty degeneration, which may be very clearly seen in surfaces macerated by a collection of fluid, as in serous effusions of the peritoneum or pleura. The other pathological changes of endothelium have not been studied. The epithelium (or endothelium) lining the inner surfaces of the walls of arteries and veins, closely resembles the endothelium of serous surfaces. It is very subject to fatty degenera- tion, as maybe seen on examining atheromatous arteries. Proliferative changes have also been traced by some observers in the process of occlu- sion of ligatured arteries or veins obstructed by thrombosis ; but they do not appear to play any important part in idiopathic disease. C. Diseases of Glandular Epithelium. — The diseases of glandular epithelium are best spoken of under the head of diseases of the several g'ands. See Breast, Diseases of ; &c. J. F. Payne. EPITHEM (eirl, upon, and -rlBripi, I place). ERGOTISM. 457 A general term for a class of external applica- tions which are soft and moist, such as poultices and fomentations. See Fomentations, and Poul- tices. EPIZOA (eVl, upon, and (dor, an animal). — A term formerly much used by zoologists to charac- terise a peculiar and distinct group of parasitic creatures which attach themselves to fishes, but now more generally employed to embrace all kinds of parasites having the habit of residing in or upon the surface of the body of man and animals. In the w r riter’s judgment the more com- prehensive term F.ctozoa is preferable, and the distinctions which have been created as to the relative value of these two terms ought to be abolished. In any case it should be understood that the equivalent terms epizoa and ectozoa have no zoological significance, being simply em- ployed for convenience’ sake when we are speak- ing of external parasites, of whatever character ; in contradistinction to the term entozoa. The epizoa comprise such parasites as lice and mites ( Dermatozoa ), and the term might also be made to include fleas, bugs, and other creatures whose residence on the surface is only occasional, and of very short duration. See Parasites, and Entozoa; also Acarus, Demodex, Chigoe, Pe- diculus, and CEstrus. T. S. Cobbold. EPULIS (eirl, upon, and oZ\ov, the gum). See Mouth, Diseases of. EQ/ULNIA ( equus , a horse). — A synonym for glanders. See Glanders. EQDXNTA MITIS. See Glanders. ERETHISM (ipeOifa, I irritate). — A con- dition of excitement or irritation, affecting either the whole system or a particular organ or tissue. The word has been especially ap- plied to the condition of the body in the early stage of acute diseases, and also to that in- duced by the too free use of mercury ( mercurial erethism'). See Mercury, Poisoning by. ERGOTISM. — Synon. : Morbus cercalis; Fr. Ergotisms ; Ger. Ergotismus, Kriebclkrankheit. Definition. — A disease due to the action of ergot upon the organism. Aetiology. — This disease derives its name from the fact that it is the result of the ingestion of ergot — the stroma of a fungus called Clavi- ccps qmrpurea, which grows parasitieally in the ear of the Rye. In some seasons this form of blight affects the grain so extensively that ten per cent, of the meal may consist of ergot. The phenomena to be described as symptoms of er- gotism have been regularly and exclusively traced to the use of articles of food made from rye-meal thus contaminated. The appearance and severity of the disease vary with the amount of ergot consumed. Children at the breast are never attacked. Ergotism h; is frequently broken out in well-marked epidemics, after unfavour- able harvests. In ruder times it constituted a severe form of scourge ; but now it usually oc- curs sporadically, or is limited to families or small communities. Anatomical Characters. — Nothing definite is known respecting the morbid anatomy a i ergotism. 158 ERGOTISM. Symptoms. — "Within a few days of the first ingestion of meal poisoned with ergot, the ordinary phenomena of irritant poisoning are developed, namely, vomiting, diarrhraa, severe abdominal pains and cramps, and general depres- sion — giddiness and headache being specially marked. Along with the preceding, certain special symptoms gradually make their appearance. The first and most characteristic of these is formi- cation, attended with severe itching of the skin of the extremities. The other special senses, such as vision and hearing, may also become disordered. Occasional spasms occur in the muscles. Ravenous hunger is said to be a strik- ing symptom in some instances. The pulse is infrequent and small. Respiration is not markedly disturbed. The remaining phenomena peculiar to ergot- ism are usually described ns belonging to two forms, tba gangrenous and the spasmodic, accord- ing as the circulation or the nervous system is chiefly affected. a. Gangrenous Ergotism. — Gangrene, due to ergot, is peculiar only in respect cf its cause. The toes, fingers, feet, ears, and nose are the parts most commonly attacked. The incipient discolouration, pain, and swelling are observed within a period of two days to three weeks from the commencement of the other toxic symptoms. The necrotic process passes through the ordinary stages of development; may be either ‘wet’ or ‘ dry ; ’ and advances to complete separation of the part, if this have not been previously re- moved by operation. b. Spasmodic Ergotism. — The leading symptom of this form of the disease is the occurrence of severe intermittent cramps or painful spasms, specially affecting the lower extremities. These develop into tonic contraction of the muscles, with fixation of the limbs; and end perhaps in general convulsions, prostration, unconscious- ness, and death. Abortion does net appear to be of frequent occurrence. Course, Duration, and Terminations. — Many cases of ergotism are acute rather than chronic ; but when gangrene appears, the course may he vei'y protracted and variable. Spasmodic er- gotism may last from two weeks to as many months. The mortality is said to have fallen from sixty to ten per cent. In a few cases, reso- lution occurs in affected extremities. Pathology. — Beyond its effect as an irritant poison, the specific influence of ergot is exerted upon the organs of circulation, upon the central nervous system, and upon the uterus. The Circulation. — Ergot produces a remark- able slowing of the cardiac rhythm ; the ar- teries become contracted, with diminution or even disappearance of their channel, or formation of thrombi ; the blood-pressure falls ; and the veins become dilated and distended. The most recent and consistent theory respecting these phenomena is, not that the muscular coats of the arteries actively contract, hut that the venous walls are primarily relaxed. The veins are thus overfilled, and the arteries drained of blood ; the biood-pressure is lowered ; and the heart being insufficiently fed, contracts feebly and slowly. The Nervous System . — Certain of the spinal ERUCTATION. centres, both motor and sensory, are first stimu- lated and afterwards paralysed by ergot — di- rectly, according to some authorities, indirectly according to others. The Utencs. — The unquestionable action of ergot upon the uterus is explained by some authorities as due to stimulation of the centre for the uterus in the cord. Others consider that ergot acts upon the muscular fibres of the organ, either directly or indirectly through the blood- supply. Whatever may be the value of the several ‘ ex- planations ’ of the action of ergot, the facts con- nected with it suffice to account for the specific phenomena of ergotism. The small, feeble, and infrequent pulse are due to interference with the circulation; while the painful spasms, aswell as the formication and other sensory disturbances, are the direct result of the action of the poison upon the cord. The gangrene may also be partly due to the latter cause. Diagnosis. — The occurrence of gangrene in a number of young and previously healthy persons should remove all difficulty from the diagnosis of ergotism. The spasmodic form of the disease may be distinguished from epidemic cerebro-spinal fever by the absence of pyrexia. Prognosis. — The prognosis depends chiefly upon the early recognition and removal of the cause. The probability of the escape of affected extremities may he estimated by the degree to which the gangrenous process had advanced. Treatment. — The treatment of ergotism con- sists in removing the cause of the disease; in hastening the elimination of the poison by the cautious administration of emetics and purga- tives ; in allaying the symptoms of gastro-ente- ritis ; and in supporting the strength of the patient by internal and external stimulants, such as alcohol, warmth, and friction. Gangrene must be averted by careful local stimulation, by means, for example, of warm fomentations; or treated, if it should arise. See Gangrene. J. Mitchell Bruce. EROSION (erodo, I gnaw). — A superficial destruction of tissue, caused especially by fric- tion, pressure, corrosion, or certain forms of ulceration. EROTOMANIA (epas. love, and pctv'ix, mad- ness). — Synon. : Lore-melancholy. Satyriasis (in men); Nymphomania(inwomen) ; Fr . Monoinanu irotique ; Ger. Licbcswuth. — Insanity character- ised by excessive sexual excitement ; sometimes symptomatic of cerebral lesion, sometimes of dis- order in the reproductive organs. See Insanity. ERRATIC ( erro , I wander). — Wandering, shiftiug, or irregular. Applied to pains, erup- tions on the skin, and other morbid phenomena when they shift or move from place to place. ERUCTATION {cructo, I belch).— Defini- tion. — The sudden escape or expulsion of gas from the stomach upwards, with or without an admixture of portions of liquid or solid food, or of gastric juice, or other liquids. . Description. — The act of eructation may be voluntary or involuntary. In the former c.ise a small portion of air is first swallowed, and b) ERUCTATION. the oTer-distension thus produced the escape of a portion of the caseous contents of the stomach is favoured. When involuntary, we must sup- pose that the cardiac orifice, which is closed in the normal state of digestion, is relaxed, and thus permits the rejection of portions of un- digested matter. Erom the violence with which eructations often fake place, we may also assume that the muscular coat of the stomach contracts spasmodically at the same moment that the relaxation of the cardiac opening oc- curs. The nature of the material rejected varies greatly. Sometimes it is tasteless, in others acid, and in rarer instances alkaline. ZEtiology. — Eructations occur in all gastric diseases attended with an undue formation of gas. They are constantly complained of in atonic dyspepsia, more especially in that form which occurs in elderly people, and are probably the result of an imperfect contraction of the sto- mach, preventing the due expulsion of the digested food into the intestine. They' form a prominent and distressing symptom in dilatation of the stomach. In such cases the patient often complains of a sense of fermentation in his abdomen, and immense quantities of gas are expelled, generally mixed with an acid or acrid fluid. Treatment. — The indications in the treat- ment of eructations are to prevent the decom- position of food, and the formation of gases and other products ; to restore tone to the stomach, and remove any r morbid condition of this organ; and to give remedies with the view of absorbing gases, or assisting the act of eructation. See Stomach, Diseases of. Samuel Fexwick. ERUPTIOH ( eruptio , a bursting forth). — ■ This term is commonly applied to a pathological manifestation in the skin ; more or less general ; sometimes marked by' colour, sometimes by pro- minence, but more frequently by both. When sudden and hypercemic, a term derived from the efflorescence of a plant, namely, exanthema, is employed, as in the instance of the exanthematous eruptions — scarlatina, rubeola, roseola, and va- riola. The term is equally applicable to less acute forms of dermatosis, such as urticaria, eczema, impetigo, ecthyma, acne, and furunculus ; and is also used for still more chronic forms of disease, for example, lepra vulgaris ; and for outgrowths cf the skin, due to aberration of nutrition, as in the instance of warts and molluscous tumours. Erasmus Wilson. ERYSIPELAS (ipva, I draw, and w e\as, near). — Syxox. : Lat. Erysipelas ; Er . Ert/sipele; Ger. Erysipelas. Popular names : — St. Anthony’s Fire (English) ; the Rose (Scotch) ; der Rothlavf, and die Rose (Ger.) Definition. — Inflammation of the integument tending to spread indefinitely ( Royal College of Physicians' Komcnclature of Diseases). The vague- ness of this definition indicates the looseness with which the term is employed. The features common to all inflammations usually spoken of as erysipelatous are fever, usually preceding the local phenomena ; and an inflammation tending to spread indefinitely by means of the lymph- spaces and lymphatic vessels of the affected part. ERYSIPELAS. 459 Summary of Varieties. — Erysipelas is usually divided into (a) Simple Cutaneous, ( b ) Phleg- monous or Ccllulo-cutaneous, and (c) Cellular, or Diffuse Cellulitis (Nunneley). In addition to these three chief varieties, erysipelatous inflam- mation of the lymphatic vessels and veins, and of serous and mucous membranes, is also de- scribed. Pathology. — All the inflammatory affections thus loosely classed together, as erysipelas in it s various forms, have one feature in common. They all belong to the class of infective inflammations — that is to say, the inflammatory products pos- sess the property of setting up an inflammation similar in character to that at the original focus in any part with which they may come in contact. In erysipelas these infective products diffuse themselves by the lymphatic vessels and lymph- spaces, and thus set up a spreading lymphatic inflammation. As the poison diffuses itself, it seems in most cases to lose its intensity, and thus the spreading is finally arrested. Of the exact nature of the poison we know nothing definite. As in other infective inflammation the exudation-matter contains minute organisms (micrococci) ; but the part these play in produc- ing the disease, and their mode of- origin, are matters of dispute. The poison, whatever it may be, is communicable from one individual to another. It is probable, however, that simple cutaneous erysipelas differs entirely in nature from cellulo-cutaneous and cellular erysipelas. The two latter are in most cases purely local in origin, and the poison which causes them pro- bably varies, both physically and chemically, in different cases. In some cases it may be merely decomposing animal-matter, in others it may be something as truly specific as the infective pro- ducts of malignant pustule or the poison of a venomous reptile. The effect produced by the inoculation of such poisons depends to a great extent npon the susceptibility of the individual. This is increased by all bad hygienic conditions, and above all by the abuse of alcohol and con- sequent visceral disease. When these affections commence apparently spontaneously, careful in- quiry will almost invariably show that the start- ing point has been some local injury occurring in a person previously in ill-health. Simple cutaneous erysipelas, on the other hand, par- takes much more of the nature of an acute specific fever. It is communicable not only by direct inoculation, but by infection ; there is a distinct period of incubation, the duration of which is uncertain (variously stated from a few days to two weeks) ; the constitutional symptoms precede the local inflammation, often by a day or more ; and the disease occurs in epidemics. It differs from other acute specifics in its extremely irregular course, and by its not conferring on the patient any immunity from a second attack; in fact, one attack predisposes to another. Two views are therefore held by different authors with regard to it. On the one hand some con- sider it primarily a general disorder, the local manifestation of which is a diffuse inflammation starting from any wound that may exist on the person of the patient, or, failing that, choosing by preference the points of junction of mucous membrane and skin. On the other hand it is ERYSIPELAS. 160 described as originally a purely local inflam- mation, infective in character, and secondarily giving rise to constitutional disturbance. Others again suppose both forms to exist, and describe them as traumatic or surgical , and idiopathic or medical erysipelas. At the present time the question cannot be considered as definitely settled. 2Etiology. — I. Infection. Erysipelas -,s un- doubtedly infectious and inoculable, as the ex- perience of hospitals sufficiently teaches us. Its power of infection is, however, not very great, certainly much less than that of measles or scarlet .fever, and probably about equal to that of diph- theria. The development of the disease will de- pend, therefore, to a great extent upon the patient and his surroundings. II. Predisposing causes. A. In the patient: 1. Constitutional predisposition. This is said to be increased by a previous attack, and some- times to be hereditary. 2. Disease of some im- portant viscus, especially liver and kidneys. 3. The presence of a wound. 4. Age. This has little effect ; the disease affects all ages alike. 5. Sex. Erysipelas is said to be most common in women, especially at the menstrual period. 6. Intem- perance arid want of proper food are great predisposing causes. B. In the patient’ s surroundings. 1. Meteoro- logical conditions. East winds, low temperature, excessive moisture, cold and heat, have all been considered causes. It is said to be most com- mon in spring and autumn. On all these points there is no really reliable evidence. 2. General hygienic conditions. Overcrowd- ing in hospitals, want of ventilation, dirt of all kinds, bad food and impure water are all pre- disposing causes. S. Epidemic influences. Erysipelas undoubt- edly occurs in epidemics, and the type of the disease often varies in different outbreaks. We shall now proceed to discuss in detail the several varieties of erysipelas summarised above. I. Simple Cutaneous Erysipelas. — This is the most typical form of the disease. Anatomical Characters. — The post-mortem appearances of erysipelas are by no means characteristic. The redness of the inflamed area of course fades after death, leaving a faint yellowish tint. The skin feels hard and inelastic, and the subcutaneous tissue contains an excess of serous fluid. In very acute cases there may be the usual signs of blood-change seen in all malignant fevers — early post-mortem staining, imperfect coagulation of the blood, subserous peteehi®, swollen and soft spleen, and cloudy swelling of the liver and kidneys. Hiller states that microscopic examination of the blood before death shows many of the white corpuscles to have undergone degenerative changes and be- come converted into masses of highly refracting granules. Busk has described plugs of such altered corpuscles in the small vessels of the lung, and Bastian has observed a similar condi- tion in the vessels of the brain. Microscopic examination of the affected part of the skin shows large numbers of migrating leucocytes, lying in the spaces of the fibrous tissue, amongst the fat-cells, and in the lumen of the lymphatic vessels. They are especially abundant round the small vessels. Lukomsky (Virchows Arcliiv , Band lxv.) has described the presence of micrococci filling the lymph-spaces and lym- phatic vessels at the advancing margin of the erysipelatous inflammation. These are not ob- served where the rash is receding, nor in those parts which have been affected for any length of time. This observation has been confirmed by subsequent observers. Symptoms. — In simple erysipelas the constitu- tional symptoms usually precede the local. The invasion is marked by chilliness, seldom by an actual rigor; loss of appetite; general malaise; nausea, but seldom actual vomiting; headache; pain in the limbs ; and the usual signs of pyrexia. The invasion is tolerably sudden. The temper- ature rapidly rises to about 103° F. or higher. The rarer symptoms at this stage are epistaxis in adults, and convulsions in children. Usually within twenty-four hours of the invasion the characteristic cutaneous inflammation appears, It may, however, commence simultaneously with the febrile disturbance, or be delayed even for two or three days. Frequently the lymphatic glands nearest to the part are swollen before the cutaneous eruption appears ; afterwards they are invariably enlarged and tender. The local inflammation usually, if not always, starts from some wound, scratch, or abrasion. It commences indifferently in a fresh wound or a granulating sore. When no wound can be recognised as its starting-point it usually starts from the junction of mucous membrane and skin, most commonly from the corner of the eye, causing a swelling across the bridge of the nose. It may also start from the angle of the mouth, the externalauditory meatus, or the anus. It may commence in the nasal fossae or pharynx, and extend outwards to the skin of the face. Possibly in all cases it starts from some slight abrasion which is scarcely to be detected (Trousseau). The inflamed skin is bright red in colour, with s metimes a yellowish tinge ; the redness advances in all directions, but tisually most rapidly in that of the lymph-stream. The advancing margin is irregular, sharply defined, and very slightly raised. The cutis is cedematous, and pressure with the finger-nail leaves a deep and abiding mark. Where the subcutaneous areolar tissue is lax, as in the eyelids or scrotum, it also becomes greatly swollen. In the limbs the sub- cutaneous swelling is great only in severe cases. In many cases small vesicles rise, which may coalesce, formingblebs of considerable size. These ordinarily contain clear yellow serum, which, in bad cases, may bo stained with blood-pigment. As these bull® burst they dry up. forming scabs on the surface, but no ulceration takes place benea,tb these scabs. The inflammation has but little tendency to end in suppuration ; when this does occur it is in those parts in which the. oedema has been greatest, as the eyelids. There is heat, tension, and pain in the affected part, and a peculiar sensation of stiffness, which may even precede the appearance of the redness. The febrile symptoms which usher in the a'.taek re- main unrelieved so long as the redness continue?, to spread. The pulse is at first quick and full, but it soon loses force, and in bad cases be- comes extremely rapid and feeble. It is by the ERYSIPELAS. pulse, more than anything else, that the gravity of the case is marked. The temperature seldom rises above 106° E., though 107'5° F. has been recorded. The daily variations are not great, there being merely the usual slight morning fall and evening rise. Delirium is not uncommon at night, even in mild cases. In erysipelas of the head it may be a prominent symptom. It is usually due to theblood-condition, and not, as was formerly supposed, to extension of the inflam- mation to the membranes of the brain. This, however, does occur in rare cases, especially in erysipelas of the orbit or in that following a compound fracture of the skull. The tongue is always foul and usually dry, in bad cases becom- ing cracked and brown, with sordes on the lips and teeth. In erysipelas of the head the fauces are always red and congested, even when the inflammation has not actually extended to that part. The bowels are sometimes confined, but diarrhoea with offensive motions is liable to occur. There is nothing characteristic about the urine. As in other acute febrile diseases it frequently contains a small quantity of albumen. In erysipelas of the head, when the disease reaches its height, the appearance is often hideous in the extreme, thefeatures being completelyobliterated by the swelling of the lax subcutaneous tissue, and the face further disfigured by the scabs formed by the dried blebs. The duration of simple erysipelas is very uncertain. The cessation of the disease is marked by the inflammation ceasing to extend, and by a simultaneous fall of temper- ature, often very sudden. This may occur as early as the fifth day, or be delayed till the end of the second or middle of the third week. As the rash fades its margin loses its distinct out- line, and the redness shades off insensibly. It is not uncommon to see the inflammation spreading at one part, fading at another. After the sub- sidence of the inflammation there is desquama- tion of the cuticle, and in erysipelas of the head often complete loss of hair, which is, however, never permanent. Suppuration occasionally takes place in the nearest lymphatic glands. Even after a mild attack the patient’s strength is much reduced, and he often remains -weak and anaemic for a considerable time. Relapses are by no means uncommon. When death occurs from simple cutaneous erysipelas, it arises most fre- quently from exhaustion. It may also be due to the gravity of the blood-change. Occasionally the fatal termination is preceded by violent delirium ending in coma. Sometimes it is due to some complication, as pleurisy or pneumonia, or in very rare cases meningitis. When sloughing of the skin or suppuration occurs, death may take place from septicaemia or pyaemia. Varieties. — Some waiters have divided simple erysipelas into medical and surgical — or idio- pathic and traumatic — and have described these varieties as distinct diseases. They are, however, probably identical, for the following reasons : — they closely resemble each other in mode of inva- sion, course, and pathological changes; infection from so-called idiopathic erys ; pelas will give rise to the traumatic form in patients suffering from tm open wound ; and during an outbreak of .rysipelas in a surgical ward patients without open wounds are occasionally attacked by the 4111 idiopathic form Erysipelas has also been sub- divided according to the part it attacks, as erysipelas faciei, capitis, scroti, &e. Erysipelas occasionally affects the mucous membrane of the pharynx and upper part of the larynx. This form presents some peculiarities, and is spoken of as erysipelatous pharyngitis and laryngitis. The invasion and constitutional symptoms are similar to those of simple cutaneous erysipelas. There is a bright redness of the back of the pharynx and the fauces, always ac- companied by considerable oedema of the soft palate and some swelling of the tonsil. The glands at the angle of the jaw are swollen and tender. The danger of this affection arises from extension to the glottis, causing oedema glottidis, with intense dyspnoea, expiration being more easy than inspiration, and both liable to ob- struction by spasm. In such cases tracheotomy or laryngotomy may be required at any moment to prevent death from asphyxia. In other case-- the inflammation may extend forwards and ap- pear on the face, either at the nostril or mouth, and afterwards extend as ordinary facial erysipelas. Erysipelas occasionally attacks new-born infants, starting from the navel or genitals. This form has been spoken of as E. neonatorum. Serous membranes, especially the peritoneum, are said sometimes to be affected by erysipelas following w'ounds. In lying-in women the poison of erysipelas seems, in common with that of many other unhealthy inflammations, to be capable of causing puerperal fever. Dermatologists have, according to their wont, invented a name for every possible variation. Thus when the inflammation spreads at one part while fading at another it has been called E. am- bulans or erraticum ; wflien spreading in a winding course, E. serpens ; when causing small vesicles, E. vesiculare or miliare; when blebs form, E. bullosum; when there is much swelling, E. cedematosum, &c. Such names are useless, and may be multiplied ad infinitum. Diagnosis. — When the eruption is fully de- veloped it is scarcely possible to mistake the disease. During the stage of invasion, before the appearance of the rash, diagnosis is impos- sible. Simple diffuse inflammation round a wound or abscess is distinguished from erysipelas by the absence of the characteristic invasion, and of the sharply defined border. Simple erythema differs from erysipelas in the absence of fever, and in the eruption being composed of numerous isolated patches. Occasionally, in malignant small-pox, there may be much redness and swell- ing of the face before the appearance of the vesicles, but the symptoms of invasion are much more severe than those of erysipelas. Prognosis. — The prognosis depends chiefly upon the gravity of the general symptoms. The following are bad signs : — high fever, violent delirium, excessive diarrhoea, early prostration, and very dry tongue with sordes. Tho extent of the inflammation is of less importance. Old age, disease of the kidneys or liver, and especially chronic alcoholism, add greatly to the gravity of the case. When erysipelas affects the pharynx there is always danger from oedema glottidis. In uncomplicated cases the death-rate is not high 462 ERYSIPELAS. Of 25 eases treated in the medical wards of University College Hospital from 1872 to 1876, only one died, and lie was suffering from chronic Bright’s disease. Treatment. — 1 . Constitutional. Erysipelas being a most exhausting and depressing disease, no antiphlogistic treatment is ever justifiable. Clear the bowels at the commencement cf the attack, but avoid violent purgation. Only two drugs have any reputation in the treatment of erysipelas. The tincture of perchloride of iron, in large and repeated doses, has been strongly recommended by Hr. Reynolds and others, and is stated by some to act as a specific. To be of any use it must be given in doses of forty minims every four hours. Aconite if administered as soon as the temperature begins to rise is said to cut the attack short. It may be given in half- minim or minim doses of the tincture, at first every quarter of an hour for on 6 or two hours, and afterwards hourly till the skin becomes moist and the temperature falls, but its effects must be very carefully watched, to avoid danger- ous depression. The diet must be as nourishing ns possible ; beef-tea, eggs and milk, &c. Solid food can never be taken during the advance of the disease. Stimulants are usually required, and the amount must be regulated by the pulse. Large quantities are often necessary. 2. Local. — Local treatment is very various. Warmth and avoidance of variations of temper- ature are essential. Cold is utterly inadmissible : it aggravates the inflammation, and tends to cause ruppuration or even sloughing. Hot fomenta- tions or hot baths may be employed when the part affected renders them admissible. In other cases dry warmth must be used; it is best ob- tained by covering the affected part with a thick layer of cottonwool. Poultices should be avoided, ns they needlessly irritate the skin, and are dirty and apt to get cold. With the application of warmth innumerable varieties of local applica- tions have been recommended. These may be divided thus: — (a) Indifferent applications. These are intended only to exclude the air, but they have the disadvantage of shutting in the secre- tion of the skin. The most common of these are collodion, oil, and a thick layer of flour or starch under cotton wool. {]>) Sedative applica- tions. The most important remedy of this class is belladonna. It is best applied as a paint com- posedof equal parts of the extraetand glycerine. It is especially useful when there is much in- flammation of the lymphatic vessels and glands, (c) Fowerful Astringents. Valette of Lyons recom- mends a 30 per cent, solution of perchloride of iron ; Kigginbottom a solution of the ‘brittle stick of nitrate of silver’ 20 grains to one drachm of water. Before applying either of these the skin must be carefully washed with soap and water to free it from grease. The perchloride of iron must be rubbed in with a glove. ( d ) Antiseptic appli- cations. Marshall recommends creasote made into a paste with kaoline ; Dewar, equal parts of sulphurous acid (B.P.)and glycerine; tincture of iodine is a common application. Lately Hueter has practised the subcutaneous injection of a 30 per cent, solution of carbolic acid. He states that this causes an immediate arrest of the inflammation for a email distance round the puncture ; if, therefore, the treatment is adopt ed at so earl)' a stage that the area of inflammation can be surrounded by four or five punctures the disease may be checked. Beyond this there would be danger of carbolic acid poisoning, (e) Drawing a limiting line in front of the advancing rash. This has been done with solid nitrate of silver and with blistering fluid. It is utterly useless. Erysipelas of the fauces is best treated by the local application of a strong solution of per- chloride of iron. If there is oedema gloltidis the swollen parts must be scarified, and if that fails to give relief, tracheotomy maybe necessary. II. Phlegmonous or Cellulo-cutaneoue Erysipelas was described by Dupuytren under the name of ‘ diffuse phlegmon.’ Anatomical Characters. — Incisions made into the inflamed part in the early stages show the spaces of the areolar tissue distended with serous fluid ; a little later on the fluid is found to be turbid, resembling thin pus ; later still the subcutaneous cellular tissue is represented by masses of shreddy sloughs soaked in a puriform fluid. Unless exposed to the air by incisions or by sloughing of the skin these sloughs are free from any odour of decomposition and contain no gas. There is nothing characteristic in the post- mortem appearances of the internal organs. Symptoms. — The invasion is usually marked by chilliness or a rigor, elevation of tempera ture, nausea, headache, and general malaise. The local inflammation may commence in some wound or abrasion, but it may also arise spon- taneously. Erom the beginning there is marked (ndema of the subcutaneous tissue. The skin is reddened, but the margin of the redness is not sharply defined, and swelling and tenderness of the lymphatic glands is often absent. As the area of inflammation extends, the affected part becomes tense and brawny, and vesicles or large blebs form. The tension may become so great that firm pressure with the finger scarcely makes any impression. In a few clays from the com- mencement of the disease, the greater part of a limb may he involved. If unrelieved by treat- ment the tint of the redness becomes more dusky, and dark purple patches appear. At the same time the tension becomes less, and gives place to a soft, boggy feeling, indicating slough- ing of tile subcutaneous cellular tissue. Then livid patches appear, which break down into sloughs. As these sloughs separate, large shreddy masses of gangrenous cellular tissue can be drawn out, leaving the undermined skin connected with the deeper parts only by bands containing the larger vessels. Finally, the re- maining skin being insufficiently nourished may thin and melt away, leaving large tracts of the fascia and muscles beneath exposed to view. In this way if proper treatment be not adopted in time, the greater part of a limb may be denuded of its cutaneous and subcutaneous covering. The extreme stage may be reached in a week or ten days, but a longer time usually elapses before all the sloughs are separated. In the earlier stages there is much burning and tensive pain, but this subsides as gangrene sets in. The con- stitutional symptoms are grave from the begin- ning. There is high fever, the thermometeroften ERYSIPELAS. 403 reaching 105° F. The tongue is dry and brown, and sordes accumulate on the lips and teeth ; there is total loss of appetite ; and diarrhoea is a frequent symptom. The pulse, at first full and bounding, soon loses force, becoming rapid and weak. Delirium, usually of the muttering type, is always present in severe eases. Death occurs from exhaustion or from some complication, such as pneumonia, pleurisy, &c. During the sepa- ration of the sloughs septicaemia and pyaemia are of frequent occurrence. The disease most commonly attacks one of the limbs, but it is occasionally seen in the scrotum, and a peculiarly virulent form has been described as affecting the face. Phlegmonous erysipelas most commonly occurs in adult patients of broken constitution, suffering usually from the effects of the abuse of alcohol, or from some disease of the liver or kidney. Diagnosis. — From simple erysipelas the phleg- monous form is distinguished by the great swell- ing and brawny hardness, by the want of a sharply defined edge, and by the early tendency to sloughing; from spreading gangrene by its slower progress, and the absence of the rapid decomposition and development of gas in the tissues. Acute necrosis somewhat resembles it, but this disease is limited to young subjects, the swelling is less brawny, and when pus forms there is distinct fluctuation and not the boggy feeling of phlegmonous erysipelas. Prognosis. — The prognosis is always grave, especially if there is any delay in adopting the proper treatment. Early failure of the heart’s force, excessively dry tongue, diarrhoea and vo- miting are bad signs. The gravity of the case increases directly with the area affected. Treatment. — The patient must be supported by good beef-tea. milk and eggs, and stimulants are usually required to be freely given. No de- pletory measures are ever justifiable. Ammonia- and-bark is sometimes of service. Locally tbe treatment in very mild and doubtful cases must consist in the application of hot fomentations, and extract of belladonna made into a paint with an equal amount of glycerine. As soon as there are any signs of tension, free incisions must be made to relieve it. The patient's danger will be greatly lessened if these are made with all the precautions of Lister's antiseptic method. III. Diffuse Cellulitis, or Cellular Ery- sipelas. — In this disease the inflammation is confined to the subcutaneous cellular tissue, or to the planes of areolar tissue amongst muscles or beneath fasciae. The course of the inflam- mation is similar in many respects to that of phlegmonous erysipelas, the only important dif- ference being that the skin remains unaffected, or is only implicated in the later stages as a consequence of the sloughiiig of the subcuta- neous tissues. Anatomical Characters. — The post-mortem appearances are similar to those of phlegmonous erysipelas. Symptoms. — The local signs of diffuse cellu- litis when occurring in the subcutaneous tissue or beneath the superficial fascia, are marked oedematous swelling, gradually becoming brawny, slight redress of the skin, and usually mottling from over-distension of the superficial veins. There is no sharp limit to the swelling. There is intense tensive or burning pain, increased by movement, and acute tenderness on pressure The neighbouring lymphatic glands are in most cases swollen and tender. As the disease ad- vances, the swelling becomes doughy, and pos- sibly an indistinct sensation of fluctuation may be felt. The skin now becomes redder, and the gangrenous inflammation may even extend to it, unless prevented by treatment. An incision in the osdematous or brawny stage merely shows the areolar spaces distended with serum, sometimes clear, more often turbid. If the incision be delayed till the later stages the affected cellular tissue is reduced to a mass of shreddy sloughs soaked in pus. Gas does not form amongst these sloughs till after air has been admitted from without. In mild cases the inflammation may localise itself, and lead to the formation of a large abscess. The constitutional symptoms are always grave. The temperature is high, 10I 0 to 105° F. There are tho usual symp- toms of fever ; the tongue is foul and speedily becomes dry ; vomiting and diarrhoea are not uncommon ; the pulse, at first quick and full, soon becomes feeble and rapid. There is almost always delirium. Tbe disease usually runs a rapid course, two or three days sometimes being sufficient for it to reach its extreme stage. Diffused cellulitis, as above described, is most frequently the result of a poisoned wound; it may then start from the wound or make its ap- pearance at a distant part. It forms the most fatal variety of post-mortem wound ; and, as is well known, in such cases the puncture may ap- pear healthy, whilst tho areolar tissue in the pectoral region may be the seat of most acute diffuse inflammation. The bite of the less poi- sonous reptiles causes a similar diffuse inflam- mation. Diffuse cellulitis of the pelvis is a common cause of death after lithotomy, and is not uncommon in women after labour. Diffuso cellulitis beneath the pericranial aponeurosis is of frequent occurrence after scalp wounds. Oc- casionally the disease arises spontaneously, and it is then most common in the upper limb, but it has been seen in the areolar tissue of the neck and in many other regions. In pyaemia and septicaemia patches of diffuse cellulitis may appear in intermuscular spaces, or in the subcu- taneous tissue. Diagnosis. — The diagnosis of cellulitis is often difficult when the mischief is deep-seated. The cedema, pain, and tenderness, with the severe constitutional symptoms, are the chief guides ; but even when these are well marked, the extent of the inflammation, an 1 the necessity for active treatment are often difficult to determine. Prognosis. — This depends much upon tho cause and upon the previous health of the patient. It is a very bad sign when the gravity of the general symptoms is out of proportion to the local mischief. In the pelvis cellulitis may be fatal from peritonitis; in the neck it is very fatal ; it is much less dangerous in the limbs. When it occurs as a part of pyaemia or septicaemia the prognosis is of course very grave. Treatment. — Early incisions into the inflamed cellular tissue, with antiseptic applications, and abundant support, form the only reliable treat- m ERYSIPELAS, ment in severe cases. In slight cases the appli- cation of extract of belladonna and glycerine (equal parts), -with hot fomentations, may lead to resolution or limitation of the inflammation. IV. Erysipelatous Lymphangitis. — In- flammation of the superficial lymphatic vessels is a common accompaniment of all varieties of erysipelas ; but in some cases it forms by far the most prominent local morbid condition. Symptoms. — This affection is characterised by red lines running in the course of the lymphatic vessels from some local sore or wound. The lines are at first tolerably sharply defined, and about a quarter of an inch in width, but after a short time they spread out and several may coalesce, forming a patch exactly resembling simple cu- taneous erysipelas. There is slight cedema, some pain and stiffness, and acute tenderness on pres- sure. The lymphatic glands to which the vessels lead are swollen and tender. The constitutional symptoms are the same as in simple erysipelas. Diagnosis. — This affection can only be mis- taken for phlebitis, but the diagnosis is easily made by observing the course of the lines, and by the absence of the knotted cord formed by the coagulation of the blood in an inflamed vein. Treatment. — The treatment is the same as in simple erysipelas. The extract of belladonna and glycerine is especially useful in this form of erysipelatous inflammation. V. Erysipelatous Phlebitis. — Inflammation of the superficial veins, rapidly spreading in the course of the circulation, accompanied by throm- bosis, redness of the skin, and acute tenderness, has been supposed by some authors to be ery- sipelatous in character. The only evidence in favour of this view is that the invasion and' the constitutional symptoms resemble those of ery- sipelas, and that the affection is not uncommon during epidemics of erysipelas. See Veins, Diseases of. Various other diseases have been classed as erysipelatous : the chief of these are whitlow, some forms of puerperal fever, and diffuse perito- nitis after operations affecting the peritoneum ; all these will be described elsewhere. Diffuse inflammation not unfrequently occurs after punc- tures made to allow of the escape of the fluid in the dropsy of Bright’s disease. That punctures made into feebly nourished tissues bathed in decomposable serous fluid should set up diffuse inflammation is not surprising, hut evidence is wanting to prove that such inflammation is necessarily connected with erysipelas. Marcus Beck. ERYTHEMA (ipvSpbs, red). Svnon. : Rose- rash ; Fr. Err/theme ; Ger. Hautrothe. Definition. — A non-infeetive superficial in- flammation of the skin.theessential characteristic of which is redness, which disappears on pres- sure by the finger, reappearing when the pressure is removed. The hue may vary from a bright rose to a dark blue red ; it may or may not he accompanied by swelling; the part may he hot- ter than natural; and the appearance may pre- sent itself as spots, circumscribed or diffuse, or as wheals. It is sometimes attended by a sensa- tion of slight burning or itching, but generally gives rise to no subjective symptoms. After it ERYTHEMA. has disappeared the skin is either normal, or remains slightly pigmented, or desquamates. Generally there is an increase of temperature, with slight feverish symptoms. Erythema may he either symptomatic or idiopathic. a. Symptomatic Erythema. — .Etiology and Varieties. — Erythema occurs in rare instances after the administration of drugs. Cases are re- corded after the ingestion of arsenic, belladonna, chloral, copaiba, cubebs, digitalis, iodides, opium, quinine, salicylic acid, stramonium, strychnia, and turpentine. The rash usually appears immediately after the absorption of the medicine into the circu- lation ; after arsenic it appears at a later period. Exposure to heat or cold, and contact with various acrid or poisonous substances are also common causes of erythema. Friction and, in the absence of cleanliness, the secretions of the skin itself, may give rise to it, as when erythema intertrigo is produced between the scrotum and thighs by the imitation of profuse sweat and sebaceous secretions. The blush of shame and anger is an erythema produced by the immediate action of the vaso-motor nervous system. Variola, cholera, enteric fever, rheumatic fever, and various other less distinctly defined febrile conditions, are frequently accompanied during various stages of their course by a more or less generally diffused aud mostly ephemeral form of erythema. The roseola infantilis of authors is an ery- thema that accompanies intestinal disturbance, teething, and various other disordered condi tions of the system in children. Its appearance may exactly simulate that of measles or scar- latina, but it differs from these in disappearing in less than twenty-four hours, and in leaving no desquamation behind it. The erythema that accompanies small-pox — roseola variolosa — appears generally on the second day of the disease, either as a diffuse redness of the whole integument, or as bright red spots, which are seen first on the face and then on other parts of the body. It lasts from twelve to thirty-six hours, aud disappears when the small-pox eruption begins to show itself. A special limited form of erythema has been ob- served on the second and third days of small- pox, extending from the hypogastrium down the front of the upper two-thirds of the thighs ; the affected surface, when the legs are closed, having the form of a triangle the base of which is across the lower part of the abdomen. This surface remains almost or entirely free from the variolous pustules, and many of the cases in which it is present end fatally. From the third to the eighteenth day after vaccination, small or large erythematous patches — roseola vaccina — are sometimes seen, generally on the arms, but also ou other parts of the body. They usually disappear within twenty- four hours, and leave neither desquamation nor pigmentation. The forms of erythema mentioned above can not be considered as being in themselves specific varieties of disease, and pathologically consist in a temporary injection of the capillary blood- vessels of the skin. They are to be distin guisbed from the erythemata that run a distinct course, terminating in pigmentation and desqua ERYTHEMA. /nation, and in -which the capillary injection is accompanied by exudation. b. Idiopathic Erythema. — I. Erythema mul- tiforme . — This form of idiopathic erythema is most commonly seen in spring and autumn, and is distinguished by its localisation. It begins on the backs of the hands and feet, and fre- quently is found in these situations only. In some cases it extends up-wards to the shoulders and hips, and in very rare cases is also found on the trunk. The appearance consists in flattened papules from the size of a pea to that of a bean, of a dark blue or brown-red colour. They are sur- rounded on their first appearance by a red zone which soon disappears, and the border of the papule then stands out in fuller relief. The mildest form of this disease consists in papules which disappear after a few days — erythema papulation seu tuberculatum. Instead of thus disappearing it may spread outwards from the edge, and flatten and become pale in the centre, thusforming a red ring, the condition beingknown as erythema annulare. While the first circle persists a second ring may form round it, and the circles may be constituted by small papules, forming the condition recognised as erythema iris seu mamellatum. Another stage may be reached by the enlarging circles meeting, and so forming segments of a circle, constituting the form known as erythema gyratum seu marginatum. At any of these stages the eruption may dis- appear. The sequlae are slight pigmentation and desquamation. The disease, whose different stages have re- ceived the different names above indicated, has been designated, on account of the different forms under which it may be seen, erythema exsudativum multiforme. It is accompanied by a slight feeling of burning, or by veryslight itching. Constitutional symptoms are only present excep- tionally, and when the eruption is universal. Hebra relates that in a woman who died whilst an eruption of erythema gyratum was on the skin, similar red rings were found in the small intestine. It is most common in adolescence, and is more frequent in males than in fe- males. II. Erythema nodosum . — This name is given to a disease characterised by the appearance on the skin, and chiefly on that of the lower extremi- ties, of pale red hemispherical or oval swellings. These vary in size from that of a pea to that of a hen’s egg, and are painful on pressure. Fever is sometimes present. The swellings are at first pale red with a yellowish tinge, later dark red, and finally livid; after they disappear they leave behind them a yellow pigmentation similar to that which follows a contusion. The number of swellings may vary from a very few on the lower extremi- ties to successive crops on different parts of the limbs and trunk. In the latter case the feverish \ symptoms are well-marked. The course of the disease is completed in two to four weeks. The swellings never suppurate, never itch, are always painful, and the redness never spreads to the adjoining skin. This variety can occur in com- bination with the previously described forms of erythema multiforme. It is a disease of child- 30 EUSTRONGYLUS GIGANS. 465 hood and adolescence, and is chiefly seen in females. Prognosis. — The prognosis of the special forms of erythema — multiforme and nodosum — is always favourable. Those varieties seen in the course of other diseases do not modify the prognosis of the particular disease which eacli accompanies. Treatment. — The treatment of erythema con- sists in palliating the attendant symptoms. Dusting with flour, or the application of spirit- lotion, should be employed when productive of a sense of comfort to the patient. In erythema nodosum warm applications of infusion of poppies or chamomile are soothing; while aperients, and, when fever is present, gentle diaphoretics may be given internally. In many such cases tonics, especially quinine, are required. George Thin. ESCHAROTICS ( itrxapa , a slou^i). Definition. — Escharotics are substances that completely destroy the tissues to which they are applied, and produce a slough. They are dis- tinguished from other caustics simply by the greater intensity of their action. Enumeration. — The chief escharotics are : — The hot iron, Sulphuric Acid, Nitric Acid, Po- tash, Chloride of Antimony, Chloride of Zinc, Acid Nitrate of Mercury, Bromine, Chromic Acid, and Lime. Weaker caustics are — Nitrate of Silver, Sulphate of Copper, Sulphate of Zinc. Iodine, Carbolic Acid, Arsenious Acid, Sulphide of Arsenic, and Dried Alum. Action.— Escharotics combine with the tissues and destroy them. Around the part thus killed inflammation is set up, and the part is separated as a slough. Besides their local action these agents act reflexly on other parts of the body through the nerves of the region to which they are applied. Uses. — Escharotics are employed, first, to destroy the virus in, and the tissues around, a poisoned wound, and thus prevent the absorption of the poison, for example, in bites by snakes or rabid animals, or in cases of inoculation with syphilis, or with animal-poisons in dissection or post-mortem examinations. Secondly, they are used to destroy unhealthy tissue, such as exu- berant granulations, and to remove excrescences and morbid growths, as warts, condylomata, nsevi, polypi, haemorrhoids, and cancer. Thirdly, they are used to open abscesses, especially those of the liver. For this purpose caustic potash is usually employed. Lastly, by means of escha- rotics it is usual to establish issues, and thus react beneficiallj' on distant organs. T. Lauder Brunton. ESSENTIAL PARALYSIS.— A synonym for infantile paralysis. See Infantile Paralysis. ETHER, Uses of. See Anesthetics. ETIOLOGY. See Disease, Causes of. EUSTACHIAN TUBE, Diseases of. Sf< Ear, Diseases of. EUSTRONGYLUS GIGAS. ,5* SCLEROSTOMA. 168 EVACUANTS. EVACUANTS ( evacuo , I empty). — Defini- tion. — Medicines used to produce some evacua- tion from tlie body. Enumeration. — The chief evacuants are:— Sternutatories, Expectorants, Sialagogues, Eme- tics, Cholagogues. Purgatives, Diaphoretics, and Diuretics. See the several articles upon these subjects. EXACERBATION ( exacerho , I make vio- lent). — Increase in the severity of the symptoms of a disease. EXANTHEMA, EXANTHEMATA.— (d£, out, and avdeui, I blossom). — S ynon. : Fr. ExantMme ; G-er. Ausschlag. Definition.— A rash or eruption on the skin. The use of this term, once denoting any cuta- neous eruption, is now restricted to the eruptive fevers called the exanthemata. Dermatologists discriminate the febrile rashes or exanthems of local or individual origin — urticaria, erythema, and roseola — from the true exanthemata, which are acute specific infectious diseases, namely, Typhus, Variola, Varicella, Morbilli, Rotheln, Dengud, Scarlet Fever, Typhoid or Enteric Fever, and perhaps Erysipelas. In this article some leading features of these diseases will be shortly stated ; and, as each of them will be found fuilv discussed under their several heads, it is only necessary further to notice certain less defined and regular eruptions associated with fever. All the exanthemata are attended with fever and enlargement of the lymphatic glands. Typhus-. — The mulberry rash appears suddenly on the fourth and fifth days of illness as a dull red mottling of irregular, persistent, non-elevated spots ; the fever, high at the commencement, con- tinues so after the rash is fully developed. Typhoid. — In typhoid fever the small, raised, rose-spots do not appear till the second week of fever; sparsely scattered on the trunk, the}' fade on pressure, disappearing in three or four days, while new spots arise. Small-pox. — Marked fever of sudden ingress occurs two day's before the raised eruption; sometimes arose rash first appears, but the severe symptoms begin a full day before this and not more than two day's before the characteristic spots appear. The cervical glands are enlarged. Varicella. — The eruption begins on the first day of illness ; the fever is often high and comes on suddenly, but enlarged cervical glands and spots somewhere are always to be found at the same time. Measles. — Three days of fever and catarrh, with palpable enlargement of the cervical glands, precede the rash ; there is then sudden increase of fever, subsiding while the rash is at its height. Rotheln ; Rubeola sine catarrho. — The rash appears within a few hours of the first feeling of illness, which is slight and soon over. The rash is at first spotted rather than finely diffused. By the time it is fully out the fever has subsided, but the enlarged cervical glands which marked the ingress alway'S remain to indicate a specific disease; fine desquamation rarely follows, and there is no albuminuria. Rotheln is invariably transmitted by contagion, the incubation being fr mi two to three weeks ; this long period of incubation causes the source of infection to be EXANTHEMA. often overlooked, and even the possibility of it to be denied; when carried to a family or school either an unnecessary alarm of measles is raised, or the next sufferers are said to have all drunk cold water together after being heated. Dengue. — Widely-spread in Africa, the warmer parts of America, and both the Indies, dengue may possibly bo limited to hot climates ; its pre- sence with us is as yet undetermined. The rash is at first discrete, like that of measles, but fol- lows soon after infection, and the disease in its general course is allied to scarlet fever. Scarlet h ever . — The finely diffused redness is found on the skin and in the mouth and throat often within a few hours of the sudden ingress offerer; the fever increases with the develop- ment of the rash, both persisting for several days. Often the throat is first complained of; the glands at the angle of the jaw are full and tender. Scarlatina is often declared three or four days after surgical operations. The skin is not swelled as in erysipelas, nor the redness so circumscribed ; the throat also is redder; the cervical glands are enlarged in both. Epidemic Roseola. — An epidemic roseola, having such relation to scarlet fever as rotheln to measles, has but slender claim to autonomy. Mild cases of scarlet fever often begin with a finely-diffused redness shortly after some feeling of faintness or giddiness ; an incubation of from three days to a week is observed ; sometimes albuminuria occurs as an early symptom. The finely-diffused rash, enlarged cervical glands, and slight sore-throat, even with very little elevation of temperature, raise the suspicion of scarlet fever; should albuminuria follow', or any shreddy desquamation of the hands and feet, no uncertainty remains. Scarlet fever so modified often spreads and gives rise to the severer forms of the disease when it has been called only rose rash or roseola ; the use of these terms without a distinctive quali- fication always leaves a doubt as to the complete- ness and safety of the diagnosis. Erythema comes nearest to these cases in ap- pearance, so near as often to be spoken of as re- current scarlet fever or erysipelas, but there is no enlargement of the cervical glands in erythema, and so little fever that the temperature of the reddened skin is barely elevated above the nor- mal. Since Fuller’s Exanthcmatologia this kind of flush passes under different names of roseola, according to the variations in shape of the red patches, or the seasons of the year at which they occur. Erythema nodosum is often preceded by slight fever for a day or two; this may reach 102°, but subsides as the red swellings appear ; locally there is little or no elevation of temperature even when the tender part feels hot. Exanthematous Roseola occurring in the course of otner specific diseases is distinguished from the roseola which depends on nerve-irritation, caused, for example, by acrid ingesta, by the presence either of high fever, or of glandular enlargement, or of both, as when it precedes the true variolous eruption. During enteric fever this form of roseola may' occur quite independently of the special lenticular rose-spots. An eruption of this kind is not infrequent iu the early stages of diphtheria, sometimes as a EXANTHEMA. diffused rash limited to certain parts of the chest and body, or as discrete spots on the limbs and back of the hands and feet. Influenza, and some forms of catarrh, winter ‘ colds,’ or summer diar- rhoea a3 noticed by Bateman, may begin with punctiform roseola on the back, shoulders, and chest, - the cervical glands are perceptibly en- larged, though there may be little fever. In these cases it is not the roseola, but the specific disease on which it depends, that might, without precautions, be communicated to others. Syphilitic Boseola. — A special roseola marks the secondary stage of syphilis ; in appearance it resembles the rash of measles ; so does the roseola ab ingestis when produced by cubebs, but this has neither fever nor glandular enlargement. The absence of fever from the roseola after raccination refers this form of eruption, like that occurring from dentition, to the class of rashes from nerve-irritation. Vaccinia is itself an ex- anthem in the wider definition of the term, re- produced after a definite period of incubation by inoculating a special contagium. Wanting this character the different forms of herpes are ex- cluded, though resulting from a general febrile disturbance: though inoculable, ecthyma and im- petigo are local affections not belonging to the exanthemata. William Squire. EXCITANTS ( excite , I excite). — It seems hardly necessary to give any special considera- tion to this therapeutical class, as all that may be said on the subject ranges itself with greater propriety under the heading Stimulants. Stimu- lation is, in fact, a degree of excitement, and it is only when its effects are more vigorously pushed that we obtain that inebriation or exhilaration which is so commonly observed to follow the use of alcohol, ether, and the anaesthetic vapours. See Stimulants. Robert Earquuarson. EXCITIN' O- CAUSE. See Disease, Causes of. EXCITO-MOTOR Disorders. See Reflex Disorders. EXCORIATION (ex, from, and corium, the skin). — The superficial destruction of a portion of the skin or mucous membrane. EXERCISE. — Definition. — In its widest and most correct signification, exercise is the setting in motion any active body ; and when the term is used in a physiological connection, it may refer to the functional activity of any of the or- gans, whether muscular, nervous, nutritive, se- cretory, or reproductive. In this very compre- hensive sense, the subject of Exercise includes a large portion both of hygifene and of thera- peutics. The popular signification of Exercise is, however, much more limited than the preceding, having reference only to the muscles directly, and to the parts called into play through the same — especially the circulatory and rospiratory systems. Whether in its wider or in its narrower sense, exercise has several important relations to Medi- cine. 1. It is essential to the preservation of health ( see Personal Health). 2. It has to be regarded as frequently associated with the •ousation of disease ( see Disease, Causes of). 3. EXERCISE. 467 Exercise is a most rational and successful means of treatment in certain disorders and diseases (see Movement, Therapeutics of). 4. Exercise is often abused; and excessive indulgence in some forms of it gives riso to serious consequences. The present article will be devoted to the con- sideration of Exercise in the last-named aspect only ; and the subject will be discussed accord- ing to the more limited and popular definition of the term. Abuse of Exercise. — From the moment an infant is born until the end of life, exercise, duly apportioned to rest, is the normal state of ex- istence; and whilst continued overstrain of any portion of the human machine is the forerunner of disease, so, on the other hand, is equally, if not more so, that want of exercise which induces wasting and degeneration. Principles. — Dr. Parkes, in his Practical Hygiene , has given a very complete statement of the results of the investigations of himself and others on the changes effected by the stimulus of muscular exercise on the various organs and tissues of the body, from which he has drawn the following conclusions ‘ The main effect of exercise is to increase the oxidation of carbon, perhaps also of hydrogen. It also eliminates water from the body, and this action continues — as seen from Pettenkofer an i Voit's experiments — for sometime; after oxer cise the body is therefore poorer in water, especially of the blood ; it increases the rapidity of circulation everywhere, as well as the pres- sure on the vessels, and therefore it causes in all organs a more rapid outflow of plasma and a more active absorption — in other words, a quicker renewal. ‘In this way, also, it removes the product of their action which accumulates in organs ; and restores the power of action to the various parts of the body. It increases the outflow of warmth from thebody by increasing perspiration. It there- fore strengthens all parts. It must be com- bined with increased supply both of nitrogen and carbon (the latter possibly in the form of fat), otherwise the absorption of oxygen, the molecular changes in the nitrogenous tissues, and the elimination of carbon, will be checked. There must also be an increased supply of salts, certainly of chloride of sodium, probably of potassium phosphate and chloride. There must be proper intervals of rest, or the store of oxygen, and of the material in the muscles, which is to be metamorphosed during contrac- tion, cannot take place. The integrity and perfect freedom of action both of the heart and lungs is essential, otherwise neither absorption of oxygen, nor elimination of carbon, can go on, nor can the necessary increased supply of blood be supplied to the acting muscles without in- jury.’ Tho proper amount of exercise requisite for health is difficult to determine, in consequence of the varied constitutions of individuals. It may, however, be accepted that whilst in youth the great spirit of emulation tends to an overstrain of mind or body, so, as life advances, one or other or both are liable to be allowed to pass into a state of unhealthy inactivity. Since the recent more general practice of 468 EXERCISE. gymnastics in this country, and the stimulus that has been given to aquatic exercises by our University competitions, great attention has been drawn to the efleet of bodily exercise on health, and more especially with regard to the heart and lungs, these being the organs upon which its influence is most immediately exerted. a. Prolonged and Excessive Exercise. — Of all exercises, rowing is the one which is generally accepted as the best variety to select if we are to endeavour by a consideration of its influence upon those who practise it to form an estimate of the effect of a continuous strain on the cir- culation and respiration ; yet the difficulty of procuring trustworthy evidence on such a sub- ject is extreme. Dr. Morgan, in his University Oars , by collecting the various experiences of nearly all the men who rowed in the University races from 1829 to 1869, has obtained about the most accurate testimony available in regard to one aspect of the subject. These men are unani- mous in their belief that they experienced no injury from the great strain they underwent in their youth. But it must be borne in mind that they were the picked athletes of their colleges, men with large frames and full chests, typical specimens of health, capable of undergoing very prolonged exertion with but passing fatigue, and to whom no permanent injury could be antici- pated, aftercareful training, from an exceptional display of strength. Such evidence affords no clue to the effect of the strain imposed on the heart by the two hundred or more of each Uni- versity, who annually use the utmost exertion to belong to the chosen few, and many of whom, unguided in their violent efforts to achieve suc- cess, have in after-life to pay the penalty of al- lowing mere feeling or spirit of emulation to overrule their reason. b. Exercise under Unnatural Conditions. — But it is not only the case that exercise which is excessive or too prolonged proves highly dele- terious ; even a moderate amount of exercise under unnatural conditions may prove equally harmful. Thus the young soldier of light frame, with irritable palpitating heart, who has broken down in his preliminary training, is a marked and good example of the early injurious effect of overstrain of the heart, under the impediment caused by tight clothing and accoutrements to the free expansion of his chest. Mhen at rest he feels perfectly well, and has little or no sensa- tion of throbbing in his chest. So soon, however, as he puts on his tunic and accoutrements, and begins his drill, throbbing occurs with more or less violence, accompanied with a feeling of op- pression, and with difficulty of breathing, and this being followed by a sensation of faintness, sick- ness, or dizziness, he has to fall out of the ranks. At first the condition of the heart is one purely of functional disturbance, which, though render- ing him unfit for the duties of a soldier, does not interfere with his gaining his livelihood as a civilian. This functional derangementof the heart, which is readily shown by the dicrotism in the sphyg- mographic tracing of the radial pulse when auscultation can detect little or no change in the heart-sounds, is frequently found in those EXFOLIATION". youths of delicate frame in our schools and col- leges, who, ‘ breaking down ’ in attempting feats of strength or in the preliminary training, ex- perience no ill-effects in the ordinary avocations of after-life from that overstrain of heart which, if neglected, would be apt to lead to graver forms of heart-disease. Whether it be by sudden or prolonged violent exertion, by rowing, or by running, or by the many other severe exercises of the body entailed be- labour or pleasure, there can be no doubt that the heart and lungs have at times an inordinate amount of strain forced upon them, which, in a state of health, or under favourable circum- stances, they may reasonably be expected to bear with no more injury than temporary dis- tress, and that this capability to bear strain is greatly enhanced by careful training. It is customary for the healthy boy, however, owing to the character of his amusements, always to be in training, so far as his body is concerned, and with very little supervision he ought to suffer no harm from sudden and exceptional strains. But it is very different with men who have settled down into the real business of life, but who, during their nominal periods of rest from their daily labours, undertake violent exercises with- out any preliminary- training, and thus throw such an unexpected strain on the heart and great blood-vessels, that instead of mere functional disturbance, as in early life, they sow the seeds of organic disease. Such being the case, how much more injurious must sudden overstrain be to a heart already weakened by disease ? There is often found amongst men a great aversion to having their hearts examined, and when disease is discovered it is sometimes considered of ques- tionable advantage to inform the sufferer of his condition ; but this is a mistake, for from warn of knowledge of his state he may, by unnecessary- strain, rapidly aggravate it, and thus shorten a life which might otherwise have been much pro longed. The purport of these observations is thus tf point out that: — Firstly, whereas exercise is necessary- to preserve our bodies in a proper state of healthy activity, its tendency, when carried to extremes, is to set up organic lesions. Secondly, that, as in some athletic competitions a very great strain is thrown upon the thoracic organs, it is essential that no boys of delicate frame should be allowed to take part in them, or in the preliminary training, excepting under careful medical supervision. And. thirdly, that in man- hood no violent competition should be under- taken, which would throw a great strain upon the thoracic organs, without their being pre- viously examined and pronounced sound, nor until their full powers have been brought into play by careful preliminarv training. A. B. R. Mtebs. EXFOLIATION {ex, from, and folium, a leaf). — The separation of a portion of dead bone or cartilage from the living tissue, in the form of layers ( see Bone, Diseases of). The term is also applied to the separation of a false mem- brane which has been mistaken for the whole mucous lining of the bladder or uterus. Si J Bladder, Diseases of. EXHAUSTION. EXHAUSTION (cx, from, and haurio, I draw out). Definition-. — Exhaustion is a phenomenon which all irritable tissues can be made to mani- fest, and consists in a failure to respond to stimu- lation. Exhaustion of muscle and nerve is brought about by excessive, quickly repeated, or continuous stimulation. It is favoured by cut- ting off, or by an alteration in the quality of, the blood-supply ; by previous insufficient exercise of function ; by exposure to extremes of temper- atore; by an insufficient supply of oxygen; by an excessive supply of carbonic acid ; and by exposure to certain toxic agents. These facts, which have been established by physiological experiments, are fully borne out by clinical ex- perience. Exhaustion may be general or local. 1. General Exhaustion. — General exhaus- tion is brought about by over-work, whether physical or mental, and especially by unremit- ting and monotonous duties which keep the same paths of action in a state of constant ac- tivity. It is not often, if ever, that any per- manent harm is produced in a healthy man by mere physical labour, however great; but ex- cessive mental labour, especially if it be mo- notonous, is certainly capable of permanently damaging the nervous tissues. When in addi- tion to hard mental work, which is performed voluntarily, some constant stimulus, which can- not bo arrested, unceasingly works upon the brain, exhaustion quickly results ; as when, for example, a man who is harassed by trying to earn sufficient for his family meets with some shock to his nervous system (such as a railway accident, the sudden death of a dear relative, or a severe money loss) which haunts him like a spectre day and night, robs him of his rest, and deprives him of his appetite. General ex- haustion is favoured by all conditions which give rise to ausemia or faulty nutrition, such as hemorrhage, prolonged pyrexia, inadequate diet, persistent morbid discharges, or venereal excess ; by the retention in the tissues of the products of their activity, which is favoured ly working in a foul atmosphere, or by derangement of the excreting functions ; by exposure to extremes of temperature ; and by a previous condition of excessive slothfulness. General exhaustion may occasionally be suddenly induced by physical causes, such as a severe injury (collapse from shock), or psychical causes, such as fright. Symptoms. — The symptoms of general exhaus- tion are; — 1. Loss of sleeping power, persistent dreaming, talking in the sleep and somnambulism. The patient may wake in the morning feeling to- tally unrefreshed. 2. Incapacity for work, and inability to seriously apply the mind to one sub- ject for any length of time. 3. Headache, and a feeling of oppression in the head. 4. Languor and general lassitude. 5. A rapid feeble pulse. 6. An anxious expression of face ; and (as stated by Dr. George Johnson) a contracted and sluggish pupil. In addition to these we may get tremor, delirium, hypochondriasis, hysteria, epilepsy, chorea, mania, and general paralysis. Two in- etances have come within the writer’s know- ledge of transient hemiplegic symptoms having been induced by excessive application to literary EXOPHTHALMIC GOITRE. 469 work. The digestion is often deranged, and functional disturbance of the heart is common. Occasionally the urine is altered in quality, and may contain alkaline phosphates or sugar. More rarely it manifests excessive acidity. 2. Local Exhaustion. — Local exhaustion is the result of excessive local stimulation, and it is particularly liable to occur as a prominent symp- tom in patients who are suffering from general exhaustion. The loss of power in the rectum which results from the excessive use of purga- tives ; the failure of the uterus in eases ci protracted labour ; and the failure of the volun- tary muscles which occurs ia those professional ailments of which ‘ writer’s cramp ’ is the type, may be taken as examples of local exhaustion. Treatment. — In the treatment of exhaustion the main indications are to lighten the labour, and obtain rest. In cases of general exhaustion it is often advisable to administer narcotics, such as opium, hydrate ofehloral, or bromide of potassium, and it will be generally found that, when once refreshing sleep has been established, the more aggravated symptoms will subside. Fresh air and a good diet are most necessary. Stimulants must be used with great caution, for it is clearly not desirable to goad the exhausted organs into further action, although it may be necessary to employ stimulants to give temporary power while the faculty of sleeping is being re-established. All causes of anamia must be removed. When recovery is established, the patient must be en- couraged to relieve the monotony of his life by some pursuit which should be, as it were, the complement of his ordinary occupation. Thus the head-worker should endeavour to amuse himself in his leisure hours by gentle out-docr exercise, by music or painting, or by practising some handicraft. Sec Debility, and. Fatigue. G. Y. Poore. EXOMPHALOS beyond, and ofidd curves at the margin of the disc; this alteration of their original course having been due to the swelling, and remaining after the swelling had subsided. The contraction of the effusion, and the conse- quent atrophy of the nerve-fibres and closure of the capillary vessels, would be likely to occur earlier in some parts of the disc than in others; and hence, at the time when commencing failure of sight, first induced the patient to seek advice on account of it, the disc was commonly seen to be invaded by sectors of whiteness, but to retain its vascularity, or perhaps more ihan its normal vascularity, in other parts; while, at the same time, the sight was first lost in those regions of the retina the fibres from which were first com- pressed. Hence it follows that a partial invasion of the disc by atrophic changes, and a pirtial invasion of the field of vision by blind portions, are am- mg the earliest symptoms in eases of tho class under consideration ; and these symptoms were at one time referred rather to the nervous centres than to the retina or the disc itself, to changes in which they are now attributed. A not uncommon clinical history in such cases is that there lias beeu constitutional syphilis, im- perfectly treaied, and ultimately producing head- ache or other cerebral symptoms, which have probably called for the administration of iodide of potassium and have been relieved by it. Some weeks afterwards there is for the first time a complaint of failing sight; and then the ophthal- moscope reveals that the discs are passing into atrophy, that the retinal veins are lifted into prominent curves at tne disc-margins, and that their further course over the retina is generally serpentine. In many cases, the recovery of the patient, as far as general hf ,ith is concerned, leaves the precise character of the intra-vranial mischief doubtful; but, in tatal cases, a tumour is the morbid condition most frequently dis- covered. See Ophthalmoscope in Medicine. When the merely passive dropsical effusion into the disc becomes complicated with inflam- matory changes, as results of the disturbance of the tissues, the sight begins to fail before atrophic changes become manifest; and such cases are very difficult to distinguish from those in which there is (If) primary or descending neuritis. The blood-supply of the optic nerve beingderived from the anterior cerebral artery, we may reasonably expect to find capillary engorgement of the nerve- substance of the disc in connection with arterial hypersemia of the brain ; and this capillary en- gorgement may pass into inflammation, either of local origin or by transmission down war, s from above. In any case, if the first changes in the disc are of the character of neuritis rather than of ob- struction, we see capillary or arterial hypenemia of the nerve-substance rather than venous conges- tion ; and effusion of plastic material upon the disc itself, with comparatively little prominenco 484 EYE, AND ITS APPENDAGES. DISEASES OF. or di&o-swelling, and ■with comparatively little extension over the disc-margins upon the sur- rounding retina. At the same time, even in die early stage of the affection, we find great impair- ment of sight, the conducting power of the nerve- fibres being seriously injured. Such cases are frequently syphilitic, and, unless the absorption of the effusion should be quickly brought about by treatment, its contraction, like that of the effusion of obstruction, soon occasions atrophic changes. In these cases, however, the swelling having been absent or inconsiderable, the vessels do not show that elevation into bold curves at the disc-margin which has already been described ; and the contraction beinginterstitinl in the nerve- substance, and from the first affecting veins and arteries in an equal degree, the arterial intlowis diminished pari passu with the diminution of the vein-channels, and the latter vessels are seldom distended in such a manner as to render them distinctly varicose or tortuous. The u'timate re- sult is a white disc, on which the arteries and veins are dwindled to threads, or at least greatly reduced from their normal calibre. We may therefore have three conditions which in their typical forms are tolerably distinct, but which are prone to run into one another by al- most imperceptible gradations, and which may all lead on to atrophy and complete blindness : namely, perineuritis, neuritis, and choked disc. The liability to the last-mentioned condition should be carefully remembere 1 by physicians, and should lead to careful ophthalmoscopic ex- amination in all cases of obstinate headache or other cerebral symptoms of obscure origin, more especially in a patient with a syphilitic history. Treatmemt. — It is manifest that the best hope of preventing ultimate blindness, in persons in whom choked disc has occurred, will be secured oy the administration of medicines calculated to assist the absorption of the effusion, and by con- tinuing these medicines, with comparatively small reference to the general symptoms, until the discs have cleared. The writer has seen such clearing occur, without loss of sight, in circum- stances which rendered it almost certain that neglect of the disc-effusions would have been followed by blindness at no distant date. The same general rule will apply, of course, to the more directly inflammatory effusions of neuritis or perineuritis ; and, when we find any one of the three conditions passing into atrophy, or when we find commencing atrophy in discs which show traces of past effusion, the principle of treatment is to endeavour to promote the ab- sorption of any contracting material which may be the physical cause of the atrophy : and then, when this has been done, to seek to stimulate the nutrition of the nerve-fibres, and to assist them to recover from the shock which they have sus- tained. The mode of fulfilment of the first in- dication must depend mainly upon whether there is a history of syphilis, and, if so, upon the manner in which it has been treated. In the numerous cases in which a short course of mer cury has been administered, enough to alleviate secondary symptoms, but wholly insufficient to eradicate the disease, it will generally be desir- able to give iodide of potassium in full doses for a time, and to follow this by the prolonged ad- ministration of the perchloride of mercury, in the hope of really curing the patient. There are, in the writer’s opinion, few things better worth remembering in therapeutics than that the iodide, immeasurably the most va'uable drug which we possess as a remedy fora late syphilitic symptom, is none the less almost useless as a reme iy for constitutional syphilis. It will remove the pre- sentsymptom. speedilr and otten completely ; but it can scarcely be said to have any tendency to prevent the recurrence of syphilitic symptoms at a future time, in the same or in some different form. For this purpose, the only trustworthy agent is mercury; and therefore, while 1 1 . e ad- ministration of the iodide for a sufficient time, and in sufficient quantities to test its power of do'mg good, will be enough in the cases iD which syphilis is neither known nor suspected, the iodide must be followed by mercury whenever a syphilitic history of the affection is either clear or highly probable. The second indication, to stimulate the nutrition of the nerve-fibres, is usual 1, best accomplished by strychnia, given at such intervals and in such doses as to produce evidence of its constitutional effect before its administration is abandoned. It may perhaps bo most effectually given by hypodermic injection; but this is a point which must be settled in ac- cordance with the circumstances of the case in each individual instance. 3. Sclerosis of the Optic K erve . — Besides the consecutive forms of atrophy above enumerated, there is yet another of common occurrence, which is either a prmary sclerosis of the optic nerve, or a sclerosis secondary to a similar affection of other parts of the nervous centres. This form of atrophy is not preceded by effusion, nor is it attended by any marked decrease in the ealibro of the central vessels of the retina, even when the capillary circulation of the disc has almost wholly disappeared. It is often seen in connec- tion with disease of the spinal cord, as in lo- comotor ataxy; and also occurs in apparently healthy people, seemingly as a purely local affoc. tion. Sclerosis is easily distinguished from the atrophies consecutive to effusion, whether activo or passive, by the circumstance that the effusion, as it undergoes contraction, tends to render the nerve-tissues opaque as wed as to bleach them, and thus leaves a disc-surface of an almost ivory whiteness and of uniform colour. In sclerosis, on the other hand, the nerve-tissue disappears to a great extent, ant* reveals the mottle I surface, often of a bluish-white tint, of the lamina cribrosa When this is plainly seen, and when, at the same time, the vessels are neither much diminished in calibre nor altered in their normal curvatures, sclerosis may be assumed to exist; and this form of atrophy may also be distin- guished front that which is produced by the mast chronic forms of glaucoma, by the circumstance that in the latter the vessels bend into the ex- cavated disc at its margin, while in the former they pass over the margin in straight lines or nearly so. Chronic glaucoma would also bo distinguished by the character of the failure of sight, which would be marked by regular or almost concentric contraction of the field of vision, even when central vision was only a little EYE, AND ITS APPENDAGES, DISEASES OF. 480 impaired; and also by the gradual hardening of the eyeball, which would be present in glaucoma and absent in nerve-sclerosis. Still it cannot be denied that this particular diagnosis is not with- out its difficulties, and that iu certain cases it has given rise to differences of opinion between men of large experience on all sides of the ques- tion at issue. The diagnosis is important as well as difficult ; since the mischief of glaucoma may admit of arrest by iridectomy or sclerotomy; so that to mistake chronic glaucoma for atrophy, and to neglect, operation, may be to condemn the patient to unnecessary blindness. The opposite error can at least do no harm ; and therefore, whenever a doubtreally exists uponlhe point, the most proper course is to give the benefit of that doubt to the patient, and to advise the performance of an opera- tion which cannot injure, and which may relieve him. The atrophy of sclerosis scarcely admits of treatment, but it may perhaps sometimes be de- layed, or even prevented from becoming complete, by the administration of full doses of strychnia and iron. 4. Atrophy from other causes . — Besides the foregoing forms of atrophy, there is a variety which appears to be associated with chronic lead- poisoning, and in which the discs may acquire a peculiar gray or bluish tint ; and the optic nerves may also undergo secondary wasting in conse- quence of other conditions presently to be men- tioned, such as obstruction of the central artery by an embolus, or the long continuance of pig- mentary retinitis. o. Retinal Hemorrhage . — The chief disorders of the retin il cireu ation displayed hy the oph- thalmoscope are haemorrhages, which may be attended by very different circumstances, and may present widely different characters. a. Single . — When blood proceeds from one of the larger veins of the retina, which yield a con- siderable quantity, and which are situated im- mediately underneath the limiting membrane, the haemorrhage usually spreads out over the fundus as a red patch of uniform colour and aspect., and vision is suddenly, and sometimes almost totally, obscured. The writer has seen such bleeding occur from the yielding of a vessel during par- turition ; hut this accident is extremely rare, and the large haemorrhages in question are cer- tainly more common in women at the period of cessation of the menstrual function than under any other circumstances. At this time, and when the health is not seriously affected, a favourable prognosis may be given with some confidence; for the blood will before long be absorbed, and restoration of vision, at least in a considerable degree, may be expected. The writer has once seen complete restoration to the normal standard, but this is an exceptional occurrence. Treatment. — The only treatment necessary is to pay attention to the requirements of the general health; and to prescribe sucli diet, medicines, regimen, and habits as may tend to calm and equalise the circulation, and to prevent local con- gestions. The occurrence of sudden loss of sight in one eye will justify the suspicion of haemor- rhage; but the suspicion can only be converted into certainty by the ophthalmoscope. b. Multiple . — A form of venous- haemorrhage which at first seems less formidable, because it is attended by a smaller degree of immediate interference with sight, hut which calls for a less favourable prognosis, is that in which the haemor- rhages are multiple, often singly of small size, and scattered over the whole fundus of the eye. The appearances which tney present differ, ap- parently in accordance with their precise position in the retina. If they proceed from vessels which are superficial, the blood is spread out, as in the last variety. in round or oval patches beneath the limiting membrane, but, if the vessels lie a little deeper, and are fairly engaged in the fibre-layer, the blood will separate the fibres and find its way between them, forming flame-shaped or brush-like jatches, which are often very numerous. Such multiple haemorrhages aro very slowly absorbed, and have a tendency to recur ; so that they must always be regarded as placing the sight in serious jeopardy. They are often monocular, and they do not poirt to any definite disturbance of the general health. The only endeavour so to con- nect them with which the writer is acquainted was made by Mr. Hutchinson, v ho described some cases of flame-shaped haemorrhage in persons all of whom he said were ‘gouty ; ’ but it will cer- tainly be the experience ol most practitioners that flame-shaped haemorrhages occur in manypatients who are not ‘ gouty ’ in the ordinary sense, and that they do not occur in vast numbers of those about the reality of whose gout there can be no question. The presence of multiple haemorrhages is sometimes attended by a considerable degree of irritation, or even inflammation, in the tissues among which the blood has been effused ; and this condition, in which the retina between the blood-spots may become opalescent or turbid, has been described as a form of retinitis — Retinitis apoplectica. I he element of inflammation, in such instances, is probably merely a reaction consequent upon the injury inflicted upon the- tissues, and it cannot be inferred that the bleed- ing is itself the result of any inflammatory pro- cess. Treatment. — In this, as in the former variety, there is no special indication for treatment, which must be confined to the correction of any mani- fest disorder of the general health, followed, in most instances, by the administration of iodides or bromides, as medicines calculated to assist in the absorption and removal of the effused pro- ducts. Any indication of a general haemorrhagic tendency, or of a state allied to purpura or scurvy, would require, of course, full consideration and appropriate treatment. The extent of the ulti- mate injury to sight will usually depend upon the extent to which the perceptive elements of the retina have been compressed or disorganised, either by the bleeding itself, or by other changes consecutive to it. c. Arterial . — Haemorrhages which are distinctly arterial are not uncommon in the fundus of the eye, and can generally be distinguished with- out difficulty from the venous variety, not only by the colour of the effused blood, but also by the situation of the hloodpatch, and by its mani- fest relations to a small arterial branch, which may often be seen to have dwindled or closed be>ond the point at which it has given way. Ar- terial haemorrhages are mostly multiple, but of J86 EYE, AND ITS APPE! small individual extent ; and, when not in the immediate neighbourhood of the optic disc, are most commonly seen near the outer limits of the ophthalmoscopic field of view. Tiey are gene- rally attended by sufficient impairment of vision to occasion complaint, and thus to lead to their detection ; but they seldom occasion blindness. They call for an examination of the urine for albumen, and, failing any evidence of renal mis- chiof they are chiefly important as indications of a weakened and brittle state of the arterioles, likely to lead to intracranial hmmorrhago. Treatment. — Arterial hsemorrhages into the . retina point to the necessity of diminishing, as much as may be possible, the strain upon the arterial coats, by such means as the avoidance of muscular exertion or mental emotion, and by seeking to diminish the quantity of the circulating blood by a diminution in the quantity of fluid ingested. Even when all precautions have been taken, arterial retinal haemorrhages are common forerunners of apoplexy. G. Embolism of the Central Artery of the Retina. Embolism of the central artery of the retina, or of one of its branches, is a condition of not in- frequent occurrence. Symptoms. — When sudden blindness of one eye occurs in a person who is the subject of valvular disoaso of the heart, the diagnosis can scarcely be doubtful; but the ophth dmoscopic appearances will suffice to remove doubt it it should exist. The immediate effect of the sudden arrest of the arterial circulation of the retina is to render that membrane opaque and of a milky whiteness, ex- cept over the macula lutea, where the absence of connective tissue prevents any such change from being produced. Here, and here only, the original transparency is retained, and the colour of the choroid is seen through ; with the result that the macula appears as a cherry-red spot in the midst of a white surface. When not concealed by the opacity, the larger veins of the retina are diminished in calibre and contents, and their blood is sometimes broken up into detached por- tions separated by interspaces. The arteries are ernptyv and are either invisible or traceable as white lines of fibrous tissue in the general milkiness of the fundus. The disc is usually bleached, but it will sometimes happen that its condition may bo temporarily obscu red by arterial haemorrhage, occurring from some twig given off just below the seat of the embolus, and entering the eye independently. The driving home of the embolus will throw upon such a twig the whole force of the circula tory vis a tcryo. and may thus rupture it — an oc- currence of which i he writer has seen several ex- amples. The blood so effused is usually absorbed in a very’ few days, revealing the white disc and the collapsed arteries, and removing any uncer tairity which might have existed with regard to the diagnosis. The opalescence of the retina also disappears before long, and then only the secondary nervo-atrophy and the disappear- ance of the arteries remain to disclose the nature of the original affection. Embolism seems to be a perfectly hopeless condition, because there is no anastomosis between the retinal and other Vessels of a sufficient extent to maintain a col- lateral circulation. The writer has met with one DAGES, DISEASES OF. instance in which only a sector of the field was affected, and wi h one in which embolism of a very small branch produced Ess of sight over all the peripheral parts of toe field, leaving central vision almost intact; but such cases are among the curiosities of ophthalmology, and complete and permanent loss of sighi of the affected eye is the result which must always be anticipated. 7. Retinitis, Ib tin'tis is commonly described as occurring in three chief forms, the albumin- uric, the S’/yhilitic, and the pigmentary ; bat tho writer is inclined to believe that only the last of these three is a genuine retinitis, and that in tho others the inflammation, if it should exist, is merely a secondary consequence of the irritation produced by the presence of adventitious deposits. a. Albuminuric Retinitis. In the so called albuminuric retinitis, the sequence of events appears to lend some support to the contention of Sir Wdliam Gull and Dr. Sutton, to the effect that the renal disease is not an original affection, but only a result of morbid or degenerative changes which are common to the whole of the small arteries of the body. Symptoms. — In many cases of albuminuria, the sight is not affected from first to last, and the retinae remain healthy. In some, the retinal changes precede the appearance of al- bumon in the urine; and, in the majority, the renal and retinal changes are coincident. The retinal changes are of two kinds ; namely, arte- rial haemorrhages, occurring in the tibre-laver, so that the blood-patches assume a (b rillated aspect with brush-like terminations; and the formation of white patches, either of cholesterine deposit or of fatty degeneration, or of both com- bined, scattered irregularly over the fundus, but often grouped into a stellate figure around the macula lutea, and into an irregular ring aronnd the disc. To these appearances are added, in some cases, those of swelling of the disc-margins with effusion into the retinal fibre-layer; and, when the last-named appearances are presented, there is always a far greater deteri 'ration of sight than when they are absent. It is a matter of daily occurrence that the existence of renal disease is not suspected until impairment of sight loads to an ophthalmoscopic examin Hon, and this to the discovery of the retinal changes ; and, in every hospital, cases which apfly for re- lief to the ophthalmic department are ei.iiStantly, on this ground, transferred to the physician. Treatment. — The treatment of the renal maladies which produce albuminuria is in no way modified on accountof the presem-eef a reti- nal complication ; and the unfavourable prognosis which must generally be given as regards life throws into comparative insignificance the gra- dual failure of vision, which seldom proceods to complete blindness. t>. Syphilit c retinitis. This is usually an inci- dent of the most advanced stages of tne disease, and is most frequently seen in persons who have been inadequately treated during the primary stage, but who have for some months or even for a year or two been true from symptoms. Symptoms. — Dimness of sight is then com- plained of, ana the retina is found to present scattered patches of very irregular outline, and of a filmy whitish aspect. Such patches may EYE. AND ITS APPENDAGES. DISEASES OF. be more or less obscured by slight general tur- bidity of the retina itself, or of the vitreous body in its immediate vicinity, the latter condition being of itself almost conclusive of the nature of the malady. Treatment. — The treatment must be greatly governed by the past history of the case, but may in most instances turn upon the use of iodide of potassium for the relief of the retinal troubles, followed by a sufficient course of mercury for the eradication of the syphilitic taint. c. P gmentary Retinitis. This appears to be a true inflammation of the retina, differing from the foregoing affections in that it attacks the percipient elements, instead of the fibre-layer or the connective tissue of the membrane. ./Etiology. — The subjects of pigmentary reti- nitis are of all ages, from nine or ten years to seventy; and, in some instances, the duration of the disease has been as much as twenty years, from the first appearance of the symptoms to their ultimate termination in blindness. As a rule, however, the patients are young adults, or persons not past middle age. It is a remarkable feature of pigmentary re- tinitis that it almost invariaoly attacks more than one member of a family; and it has been said to be especially frequent in the offspring of marriages of consanguinity, but this statement is not borne out by English experience. During the last twenty years the writer has only met with one family in whom the malady had this history. Anatomical Characters.— From the extreme chronicity of its course, from its obstinacy, and from its peculiar anatomical distribution, pig- mentary retinitis should probably bo regarded, together with some forms of choroiditis, as having its analogies among some of the chronic okin- diseases rather than with any other re- tinal affection. It commences in a n irrow annulus near the equator of the eyeball, and gradually spreads inwards towards the optic disc; the tissues affected are the perceptive and pigmentary layers of the retina and the subjacent ch'irio-capillaris, which slowly become disorganised and matted together in one com- mon and undisticguishable ruin. Coincidently with the. progress of the disease, pigment is deposited in the parts affected, and in the retina superficial to them, in the form of irregular lines and striations, and especially along the course of the main arterial branches. As the annulus of disease gradually doses in upon the macula, the optic disc undergoes atrophy of a kind which gives it a peculiar > int of whiteness, Very readily recognisable when it has once been noticed, and the central vessels, both veins and arteries, dwindle in size. Symptoms. — The subjective symptoms are as characteristic as the ophthalmoscopic appear- ances. Over the region actually invaded, the perceptive elements of the retina are destroyed, and the power to receive visual impressions is lost. The fibre-layer not being implicated, the conduction of impressions from parts of the re- tina more peripheral than the disease may remain unaffected ; and hence wo may havo a b ind zone surrounding the centre of the field of vision, and miiTounded itself by a zone still more external, 487 in whicb dim vision is preserved. But. the salient symptoms are two : the gradual contraction of the field of vision due to the progressive en- croachments of the disease; and night-blindness, due to the nerve-atrophy, which interferes with the conduction or perception of any but strong im- pressions. When these symptoms co-exist, when the field of vision is small and becoming gradu- ally smaller, and when the patient, who can still see fairly in the daytime, can scarcely find his way about as dusk begins to fall, we may predict the ophthalmoscopic appearances with a very near approach to certainty. The optic disc will be unnaturally pale, and the fundus overstrewn, towards the periphery, with irregular black lines and stripes, of which it is quite possible that none may be visible within that portion of the field of the ophthalmoscope which includes the disc. Diagnosis. — Pigmentary retinitis may pos- sibly be mistaken for the most chronic form of glaucoma, on account of the contraction of the field of vision ; but it may be distinguished by the absence of high tension, by the nig' t-blind- ness, and by the pigmentation of the retina. It may also be mistaken for the at rophy of sclerosis, but only if the ophthalmoscopic examination is limited to the nerve-disc, to the exclusion of the surrounding parts of the fundus. Treatment. — In the treatment of a disease so essentially chronic, it is difficult to arrive at any trustworthy evidence concerning the efficacy of a remedy, but the prolonged administration of iron, rather as a food than as a medicine, is at least of a certain degree of util ty in arresting the progress of the malady. The preparation employed is probably not material, and some may be found to suit particular persons better that others ; but the writer is accustomed to be- gin with the tincture of the perchloride, in dosea of five miniins, well diluted and given three times a day as part of a meal. 8. Detachment of the Retina. Synon. ; — Sub- retinal dropsy. This is a con lition the causes of which have never been satisfactorily explained. The first symptom which attracts the attention of the patient is the loss of part, usually either the upper or the lower part, of the field of vision ; and it is manifest that loss of the upper part of the field means detachment of the lower part of the retina, and vice versa. Detachment is some- times produced by a blow or injury, but more frequently it occurs without any assignable cause, either local or constitutional. One or both eye3 may be affected. The diagnosis of the disease is rendered easy by the ophthalmoscope, which exhibits the de- tached portion as a sort of floating prominence, projecting into the interior of the eyeball, gene- rally bluish-white in colour, and crossed by the retinal blood-vessels. The prognosis is very unfavourable in the majority of instances, and treatment is seldom effectual. Treatment. — Cases have been recorded in which disappearance of the sul>-retinal fluid, and restoration of vision, have followed prolongod confinement in the supine posture ; and the occur- rence of improvement after spontaneous rupture of the detached portion suggested to Von Graefe 188 EYE. AND ITS APPENDAGES. DISEASES OF. the advisability of producing such a rupture by artificial means. Various operations have been undertaken for this purpose, and also for the evacuation of Gie sub-retinal fluid through a puncture in the outer tunics of the eye, and arb said by those who have performed them to have been in a few instances partially successful ; but l he evidence in their favour is at present very fee’le, and hardly establishes more than that attempts of such a nature may be made, if it is certain that the sight will be irretrievably lost in the absence of interference. The tendency of de- tachment, especially in the npper portion of the retina, is to increase until the whole membrane is elevated from the choroid, aud vision is en- tirely destroyed. It must be borne in mind that detachment, may be simulated, or may even be caused, by the growth of intra-ocular tumours, sarcomatous or gliomatous, which may demand the early removal of the eyeball. Such cases would be distinguished from simple detachment by the increased hardness of the eyeball, which the morbid growth would necessarily occasion, and which would be the more significant in- asmuch as detachment alone is usually accom- panied by diminished tension. 9. Glioma. This name has been given by Virchow to a malignant growth which has its origin in the neuroglia, or connective tissue of the nervous system, and which was formerly described as encephaloid cancer. When origina- ting in the retina, it early produces loss of sight, and presently shows through the pupil as a substance of a primrose-yellow colour, by which the still transparent lens is pressed for- ward towards the cornea. It is chiefly a disease of childhood, and has been seen by the writer as early as the fifth week of infant life. It is liablo, by superficial observers, to be mistaken for congenital or infantile cataract, an error which must be carefully guarded against, be- cause the early and entire removal of the eye, together with as much of the optic nerve as can be reached, furnishes the only hope of preserving the life of the patient. When the operation ; s performed sufficiently early, it has in a few in- stances been completely successful, cases having been recorded in which no recurrence of cancer has happened after the lapse of years. In the great majority, however, recurrence and death have terminated the history. 10. Sarcoma. This differs from glioma in having its origin in the choroid, and in being of a darker colour, and sometimes pigmented or melanotic. It is at least equally malignant, produces similar symptoms, and requires the same treatment. VIII. Diseases of the Choroid. — Diseases of the choroid, recognisable by the ophthalmo- scope, are almost limited to certain chronic forms of inflammation and of atrophy ; for, in any acute choroiditis, there is always too much tur- bidity of the vitreous body to allow the state of the membrane to be seen. 1. Chronic Choroiditis . — The chronic forms of choroiditis are remarkable for leading to an un- due formation, or to a great displacement, of the choroidal piixment ; and to the ultimate com- plete wasting and disappearance of the portions of the choroid which are affected, so that over these portions there will ultimately be no cho- roid visible, and the ordinary re 1 colour of the fundus will be replaced by the ivory whiteness of the inner surface of the sclerotic. Chronic choroiditis may bo divided into two chief varieties, the disseminated and the diffused. The disseminated occurs chiefly in children, and chiefly, perhaps exclusively, in those who are the subjects of inherited syphilis. It is seldom seen until its period of activity is past. A child is brought on account of defective vision, which has probably existed from birth or from a time but little subsequent to it; and the ophthalmoscope disp'ays a number of small while spots, with black borders, scattered irregularly over the fundusof theeye. The white spots are patches of choroidal atrophy, and the black borders are rings of increased pigment-formation, by which the spots of inflammation, which must have been com- parable to little pimples, have been surrounded. Treatment. — Such cases admit of no treat- ment, except in the rare instances in which some active mischief may be detected, in the shape of small patches or spots in which effusion has not yet passed into atrophy, and in which such an antisyphilitic treatment should be employed as the state of the patient may otherwise permit or indicate. Diffused choroiditis is more frequently an affec- tion of adult age ; and, although very trequently syphilitic, is not invariably so. It differs from the foregoing chiefly in the absence of any defined shape or precise limitation of rho parts affected. In the early stages the choroid is seen to be troubled by congestion or effusion, and these conditions pass gradually into abnormal pigmen- tation and atrophy. The course of the disease may be very chronic and irregular, aud different stages of it may be seon at the same time in different parts of the same eye. The prognosis m ay in general be moderately favourable ; for, although the choroiditis destroys the portion of retina immediately in front of it, its extension is very capricious, and it may often be arrested in time to leave large portions of the eye, and espec : ally the central portions, unhurt. When it occurs in the vicinity of the macula lutoa, so as to imperil central vision, it is much more formidable than when confined to the more peripheral parts of the choroidal membrane. Treatment. — Whenever there is a history of syphilis, this must be taken as the clue to treat- ment ; and, if no syphilis can be discovered, the chief reliance must be placed upon rest of the eyes, occasional depletion from the temples by Heurteloup's leech, counter-irritation by blisters or setons, and such internal medication as the general state of the patient may suggest. IX. Diseases of the Vitreous Body. — Diseases of the vitreous body are as yet very imperfectly understood, and we know little more concerning them than that this substance is liable to become turbid in certain forms of acuto general inflammation of the eye; and that it is sometimes rendered turbid, without inflammation, by the presence of floating films which may be readily seen by the ophthalmoscope, and which may be so numerous as to forma serious impedi- ment to vision. 1. Turbidity. Turbidity of the vitreous is very EYE, AND ITS APPENDAGES, DISEASES OP. common in syphilitic cases ; but the films referred io are seen when no syphilis can be suspected. Their number, and their free movements, show that the vitreous must in great measure have lost its natural semi-solid consistence, and have become fluid ; but little or nothing is known of their actual pathology. Treatment. — The most effectual treatment for flocculi in the vitreous is usually diaphoresis by the subcutaneous injection of from two to four minims of a 10 per cent, solution of hydro- chlorate of pilocarpine, which may be repeated on alternate days. Local counter-irritation with iodine may also be practised; and iodide of potassium may be given internally in such doses as circumstances will allow. 2. Mnscte VoLitantes. A phenomenon referred to the vitreous body is the appearance of the moving particles, or strings of beaded filaments, which are commonly called musoee volitantes. True muse* are known by the negative cha- racter that the particles which produce them cannot be seen by the ophthalmoscope; and by the positive character that they never so intervene between the eye and an object, how- ever small, as to exclude the latter from view. They are seen most readily against a white field, as a white wall, or a white cloud, or in the illuminated field of a microscope when there is no object in view ; and they float about with uncertain movements, but always a little out of the direct line of sight. They are occasioned by the filamentous framework of the vitreous body, and by the cell-nuclei or other irregu- larities upon the filampnts. These bodies, wirhout being opaque, yet differ in the precise degree of their transparency from the fluid which surrounds them ; and hence they cast upon the retina shadows, which are then mentally projected outwards into space as floating objects. The projected shadows appear, of course, enormously larger than the micrascopic specks which pro- duce them, and the latter are wholly unimportant and of no morbid signification. Muse* may be discovered by any person by the simple expedient of looking through a very fine perforation in a metal disc at a bright surface ; and they are more conspicuous to some persons than to others, on account of the varying differences which may exist in different eyes or in the same eyes at different times or under different conditions, between the index of refraction of the filaments and nuclei and that of the surrounding fluid. Moreover, by the operation of an obvious physi- cal law, the more distant the particle from the retina, the larger will be its shadow upon that membrane, and the larger and more conspicuous will i' appuar. For this reason, and on account of the elonga'ion of the myopic eyeball, muse* are usually more complained of by the short- sighted than by others. They are often sources of great uneasiness to patiems; but, when om-e their true churn e'er is known, they may bo entirely disrcgaided as harmless appearances, the natural results of physiological structure. It is often important that the phy-ician should bo able to make their nature understood, in order that ne may dissipate, once for all. the unfounded apprehensions which may be occasioned by their presence. X. Diseases of the Eyelids.— The external surfaces of the eyelids, as parts of the common integument, are liable to all its diseases, and may thus participate in ervsipelatous inflamma- tion. in eruptions, and in the results of injury, besides becoming the seats of naevi, molts, warts, and other growths. Among the diseases special to the formation of the eyelids, the most important are the variations of shape to which they are subject, generally from the contraction of inflammatory exudations, but someiimes from perverted muscular action; the cystic tumours which are produced by obstruction of the orifices of meibomian glands ; the inflammation of the follicles of the eyelashes, or blephariris ; spas modic closure, from abnormal muscular contrac- tion ; and either patency or passive closure, from paralysis. Many of these affections are distinctly surgical, and others are only parts or symptoms of more general disorders. 1. Blepharitis. Blepharitis, or inflammation of the follicles of the eyelashes has received a great variety of names from different writers, and is frequently known as tinea tarsi, or, in its more advanced stage, as lippitndo. The disease consists essentially of an inflammation of the lining membrane of a hair-follicle from which an eyelash springs. Symptoms. — The first manifest symptoms are a small swelling close to the edge of the eyelid, generally of the upper lid ; and the formation of a crust around the bases of the cilia whi h pro- ceed from the swollen part. The swelling does nor. exrend farther up the lid than to the breadth of about a line, but it soon spreads along the border until the whole length is involved, and it usually spreads also to the lower lid, manifestly in consequence of the contagious character of the discharge. If the crust is removed, and if the part from wh ch it springs is magnified and carefully examined, it will be seen that the mouths of the follicles are sompwtat open, no longer fitting closely to the issuing hairs; and, in a few moments, a clear fluid will I e seen to exude, and speedily to dry into a crust or film, which covers the opening as if with a varnish. Many of the hairs in the affected follicles are loosened, and fall readily, or may be removed painlessly by slight traction. If the case is neg- lected. the follicles are before long destroyed as hair-hearing organs, so that the lost cilia are no longer reproduced ; and. at the same time, the exudation which constitutes the subcutaneous swelling of the lid-margin begins to undergo contraction, and in this way gradually everts the cartilage of the lid. The edges of the lids become red, swollen, and unsightly; the lach- rymal puncta are displaced outwards in such a manner that they can no longer take up the tears ; the eyes have lost the protection of the lashes, and are exposed to numerous sources of irritation from atmospheric particles and other causes, so as to be esp-eially prone to con- junctival and corneal inflammations; and these results are almost incurable. It is therefore very important that blepharitis shoul I be effec- tually treated in its early stages, when, if only due care be taken in the selection and use of remedies, it is an exceedingly trivial affection. Treatment. — T he must essential part of the 490 EYE, AND ITS AI PENDAGES. DISEASES OF treatment is to remember that the secret ion which forms the crust is of such a nature that it is not very easy of removal, and t hat while it remains in situ , no remedies, however judiciously chosen, can obtain access to the parts really affected by the disease. The crust is composed partly of the already mentioned secretion fr m the inflamed surfaces, partly of the greasy secretion of the mei- bomian glands, and it istheadmixture of thelatter which renders the crusts difficult of removal by water alone. A solution of bicarbonate of soda., of the strength of five grains to the ounce of warm water, will remove them readily ; and this solu- tion should be applied in such a manner as to soak into the crusts and loosen them thoroughly be- fore any attempt is made to detach them. As soon as they are detached, the surface beneath should be gently dried with a morsel of absorb nt rag, and then an astringent should be applied immediately, so that it may find its way down into the depths of the hair follicles, and may thus reach the seat of the malady. The best astrin- gent is generally the ointment of the precipitated yellow oxide of mercury, or Pagenstecher's ointment, already recommended for the cure of ulcers of the cornea; and ibis may he applied to the affected part by the tip of a finger. If amendment does not speedily follow, it may be suspected that the crusts have been imperfectly removed, or the applications imperfectly made, and it will be well for the practitioner person ally to superintend the process. When this has been done, if the affection continues obstinate, some other astringent should be tried, and the nitrate of silver is among the best for this pur- pose. Amendment of the lid-margin may gener- ally be quickly produced ; but the disease will for a long time lurk in the depths of the follicles, and the trea'met t must be continued until all subcutaneous swelling has disappeared from the lid-margins. Unless this be done, speedy re- lapse is inevitable, the inflammation soon creeping out of the follicles again and recovering the ground of which it had been deprived. Such a result is constantly seen in hospital practice, in spite of all elforts to guard against it, and, in undertaking the care of blepharitis, it is always desirable to warn parents of the perseverance which will lie required, and of the great impor tance of obtaining a radical cure. There can be no doubtthat blepharitis is exceedingly contagious through the medium of its secretion, conveyed upon sponges, towels or fingers, and thisshould be fully recognised whenever it attacks children who are attending a school. The name ‘ tinea tarsi ’ may perhaps be takej) as the expression of a belief that the disease is allied to tinea tonsurans, and that it is produced by the growth of a parasitic fungus. The writer does not at present see any sufficient ground for the adoption of this opinion. 2. Entropium and ictropium. Incurvation and excurvation of the eyelids maybelook-d upon as purely surgical maladies. The former exposes the eyes to injury from the irritation of inturned eyelashes ( trichiasis ); the latter from foreign bodies of various kinds. Treatment.— T he remedy for both, when any is practicable, must usually bo sought in a surgical operation. An exception depends upon the fact that ectropium is sometimes produced by paralysis of the facial nerve, which renders the orbicularis muscle flaccid and powerless, and permits the lower lid to fall downwards under the influence of gravity. The cure of the gene- ral nerve-affecti in may restore the power of the muscle, and may in time lead to complete recovery of the natural position of the lid. In such cases, even if .electricity does not form part of the general treatment of the paralysis, it may generally be applied with benefit to tha orbicularis. 3. Blcpharospasmus. This term is generally employed to denote an intcrmiitont closure of the eyelids by an involuntary action of the or- bicularis in response to some concealed source of irritation ; and is thus broadly distinguished from the spasm which accompanies photophobia. Symptoms. — The spasm is most liable to occur in circumstances of mental excitement. Thus, in one of the writer’s patients, who was a skilful cook, the eyes were apt to close, and to remain closed for some minutes, at the critical period of an important dish. Another patient was a schoolmistress, and tile spasm would inter- rupt the progress of a lesson to a class, being doubtless to some extent excited by the dread of its occurrence. In a third case, the patient being a gentleman habituated to riding and driving, the spasm would be excited by physical irritants, such as wind or dust, and, almost cer- tainly, by circumstances which required the eyes to be wide oppn as a condition of safe guidance. The motor nerves appear, as a rule, to be merely the passive conductors of a reflected impulse, and the trouble seems usually tu be dependent upon a morbid condition of the fifth, or upon a source of irritation in some peripheral [part from which a twig of the fifth passes to the centre. Treatment. — In the treatment of such cases, it is sometimes possible to find the twig which conveys the impression ; that is to say. to dis- cover a point where pressure, sufficiently firm to arrest conduction, will at once relax the spasm. Such points should be looked lor at the supra-orbital notch, over the malar bone, and in any other situation suggested by special circum- stances; and, if a p int at which pressure will arrest the spasm is discovered, we learn at once by what branch of the fifth, and therefore approxi- mately from what region, the irritation is con- veyed, and where its source is to be sought for. If nothing can be discovered by careful examina- tion, decayed teeth, accumulations of cerumen in the ears, and conjunctival granulations are possible conditions which should he looked for. and which should receive attention if they aro found. When all other treatment has failed, the spasm has sometimes !>een stopped by sub- cutaneous section of a sensory nerve ; and this may always be practised hopefully if the spasm can he arrested hv pressure on some definite spot, which must then serve for the guidance of the knife. If no such spot can be found, section of the supra-orbital nerve, and next of the sub- cutaneous malar, may be attempted ; since neither of these are sufficiently important for their temporary disablement to be set against even the possibility of relief from a very dis- tressing attention. In some cases, however, it would appear that the mischief must be cettial EYE, AND ITS APPENDAGES, DISEASES OF. and that no section of an afferent nerve can be useful. The division of the motor nerves of the orbicular muscles, if it could be successfully accomplished, would produce a paralysis even more injurious than the spasm; and the cases in which the latter is due to central irritation or other trouble, unless they can be relieved by medicine, and by the rectification of whatever may be manifestly wrong in the condition of the patient, offer very small hope of improve- ment. iec Facial Spasm. 4. Ptosis. — Ptosis is a condition of permanent passive closure of an upper eyelid as a consequence of paralysis of its levator muscle, or it may hap- pen in consequence of this muscle having been torn from its attachment to the tarsal cartilage, so that it can no longer modify the position of the lid. Symptoms. — Paralytic ptosis may be either pariial or complete, according to the degree of the nerve-affection ; and as the levator palpehr® is supplied by the third nerve, which supplies also the superior, the internal, and the inferior rectus, as well as the inferior oblique, the sphincter papillae, and the ciliary muscle, ptosis is usually accompanied by paralysis of one or more of these muscles. When they are all affected, the eyeball is turned outwards by the action of the external rectus, and is immovable in other directions excepting feebly by the su- perior oblique. The pupil is dilated, and tho power of adjusting the eye for near vision is im- paired or lost, although when the lid is raised, near objects can still he distinctly seen by the aid of a convex lens. When all the muscles supplied by the third nerve are affected, the I inference is that the cause of paralysis is acting upon the common trunk of the nerve ; and such a cause is not unfrequently the presence of periosteal swelling at the sphenoidal fissure. If only some of the muscles are affected, the in- ference is that the cause of the paralysis is either limited to the central nuclei of origin of certain filaments, or else that it is situated an- teriorly to the division of the main trunk into the branches which proceed to different parts ; 491 and it is conceivable that the limitations of tht paralysis may point, with tolerable certainty, to the precise locality of the disorder. The causesof ptosis, as of other paralytic affec- tions of single cranial nerves, apart from injuries and the pressure of morbid growths, may almost be reduced to syphilis and to impaired nutrition of the centres, the latter usually connected with hard mental work and worry. In every case, evidence of syphilis should be carefully sought for; and, if found, should determine the nature of the treat- ment, as it will also of the prognosis, which, in such instances, may he generally favourable. In cases of the second class, where there is no evi- dence of syphilis, and where the symptoms point to general impairment of nervous eneigy, tho administration of iodide of potassium, in com- bination with tonics, will sometimes be useful, but the main reliance must be placed upon rest, good living, and external surroundings favour- able to the restoration of health. 5. Diplopia . — Double vision, although it has no proper relation to the subjects treated of in the present section, is yet so far allied to ptosis that, when occurring suddenly, it is almost always an effect of paralysis or of paresis either of the sixth nerve of one eye, supplying its external rectus, or of the branch of the third which supplies its internal rectus. In the former case the affected eye will deviate inwards, and will have limited range of movement towards the outer canthus ; while in the latter case these conditions will be reversed. As regards tho causes and treatment of these limited forms of paralysis, there is nothing to add I to what has already been stated about ptosis. It is sometimes desirable, while the diplopia con- tinues, to exclude the deviating eye from vision by a shade, an opaque spectacle glass, or other suitable contrivance, on account of the vertigo and uncertainty of gait which may bo occasioned by the double images. See also Exophthalmic Goitre. ; Lachrymal Apparatus, Diseases of; Lagophthalmos; Orbit, I Diseases of ; Strabismus ; Stye ; and Vision. Dis- orders of R. Brudexell Carter. F FACIAL PARALYSIS.— Synon.: Paraly- | sis of the Portio dura ; Bell’s Paralysis. Definition. — Paralysis of the muscles of the face, due to disease or injury of the nucleus or fibres of the portio dura of the seventh pair of nerves. Above the nucleus, in the middle of the pons, the motor tract decussates and mingles with that from the arm and leg; damage, therefore, in the upper part >f the pons, crus, corpus striatum, or hemispheres produces facial paralysis as a part of hemiplegia. This paralysis, on the same side as in the limbs, is partial only, affecting chiefly the muscles of unilateral use (as the 2 ygomatici and muscles about the angle of the mouth) ; and very little those of bilateral use, in the upper part of the face (orbiculares palpebrarum, and frontales). In this article paralysis from damago lo the fibres or nucleus of the nerve will alone be considered. ./Etiology. — (1) The most common cause of facial paralysis is damage to the nerve as it passes through the narrow canal in the temporal bone. There the slightest effusion will cause pressure on tho nerve. Such effusion may he due to exposure to cold — ‘rheumatic;’ contiguous bone-disease — caries; syphilis; or haemorrhage ; but often occurs without discoverable cause. Cold has been supposed to act most commonly by paralysing the peripheral nerve-twigs, bul FACIAL PARALYSIS. 192 this is rarely, if ever, the case ; since in all cases lasting more than a few days, evidence of changed nutrition may be detected in the nerve-trunk as it emerges from the stylomastoid foramen. (?) Injury to t lie nerve outside the skull by blows, or incised wounds, or parotid and other tumours, is an occasional catse. (3) Within the skull the nerve may be damaged by meningitis, acute or chronic, and especially by syphilitic inflammation, or by pressure of neigh- bouring growths This' radicular fibres within the pons, or the nucleus beneath the fourth ventricle, may be damaged by haemorrhage, softening, or growth affecting that part. Doubl e 'facial par ay sis is very rare, and is due to damage to the nerves at the base cf the brain from meningitis, or symmetrical syphilitic dis- ease ; or to an affection of the nuclei by disease of the pons, or by loss of function of the n-rve- cells composing the nuclei. Syphilis and diph- theria are the most common antecedents. Symptoms. — The onset of facial paralysis is usually gradual, occupying from a few hours to three or four days in its development. It is found, for instance, one morning that in drink- ing the fluids run out of ihe side of the mouth ; the face is noticed to be a litile unsymmetrical ; at night the eye cannot be completely closed ; and next morning the paralysis is fonncl to be complete. In complete unilateral facial paralysis all the muscles on one side of the face are paralysed. At rest, the smooth forehead and lowered angle of the mouth are the chief indications, but on move- ment the difference between the two sides bee mies very marked; the one half of the forehead moves alone in frowning or elevation of the eyebrow. The eyelids cannot be bi-ought together, and in the attempt to close the eye the eyeball is rolled upwards so that only the sclerotic appears be- tween the gaping lids; the patient commonly imagining that the eye is shut. During sleep the eye remains open. In smiling, the lips may he displaced altogether to the healthy side, from the unopposed ac ion of the zygomatic muscles, the nostril of the affected side cannot be dilated, the upper lip cannot be raised, the cheek flaps loosely from the relaxation of the buccinator, and from the same cause food accu- mulates between the jaws and the cheek. Whistling is impossible, from the paralysis of half of the orbicularis, and the lips cannot be approximated sufficiently ev< n to permit of a caudle being blown out. When the lesion is between the origin of the large petrosal and the chorda tympani nerves, taste is pari ly or entirely lost in the front of l he tongue. The loss of power of recognising acid and saline substances is most marked, but bitters and sweets are also not tasted in this part. In rare instances loss of taste has followed division of the nerve outside the skull. When the disease is above thj origin of the great superficial petrosal, the uvula is said to be oblique, from paralysis of its muscle, and the pala'e to be motionless on that side. Of this there is much doubt. Obliquity of the uvula is common under normal conditions. The writer has never seen paralysis of the palate or uvula in these cases In some cases giddiness marks the onset of facial paralysis. In less severe cases there mav not be complete loss of power, but the loss is at first pretty equally distributed over all parts of the face. In cases which recover, some return of power takes place in from a week to two months, uDd improvement is u-ually earliest in the upper part of the face; the power of frowning, wink- ing, and closing the eye being soonest regained, that of moving the lip and mouth returning last. Kven after several months of immobility, re- covery may take place, but in these cases it is rarely complete, and a troublesome condition is apt to supervene: some of the muscles, espe- cially the zygomatici, become shortened in late rigidity, and hence at rest the naso-labial wrinkie is deeper on the paralysed than on the healthy side, although the possible movement may be much slighter. This condition some times comes on rather suddenly. If, in addition, a troublesome associated over-action of muscle manifests itself, whereby the orbicularis pal- pebrarum and the zygomatic and other muscles about the mouth act togeiher, in smilii g the eye shuts, and on closing the eye the mouth is drawn upwards. The electrical condition of the muscles is very important. It is that always seen in para- lysis from nerve-lesion. The muscles, after a day or two of slightly increased irritability to both 'aradisation and the slowly interrupted battery current, lose gradually their irritability to the former, retaining that to the latter, and even ex- hi- iting to it increased irritability, so that they act to a smaller number of cells than on the healthy side. In the nerve, on 'he other hand, the irritability is lost to both forms of electricity, this loss p receding pari passu wi t h the degene- ration which follows separation of the Dcrvo from its nutrient centre. In slighter and more transient forms of facial paralysis the change in irritability of muscle and nerve may be slight, but even in most, which last but a few days, a slight change in irritability may be discovered. Diagnosis. — The diagnosis of facial paralysis is easy. It is important to observe all the muscles of the face, and to ascertain ihe electri- cal reaction, in order to d termine whether it is the variety now described, or is cerebral and part of an unnoticed hemiplegia. The recogni- tion of ilie place of tile lesion is less easy. When within the pons, ii is often associated with paralysis of the sixth nerve, or with hemiplegia of the opposite side from damage to the fibres from the limbs. At the base of the brain the auditory nerve is u-ually affected at the same time. AVhere there are no other paralyses, the disease is probably within the bony canal. Deviation of the uvula is a guide of most doubtful value. Special inquiry should be made for ear-disease, for syphilis, or for a blow. Prognosis. — The majority of cases of facial paralysis are due to rheumatic affection of the nerve, and recover, but the duration of some of these is con-iderable. In recent syphilitic cases the prognosis is good. In caries of the temporal hone and in intracranial disease, unless syphi- litic and recent, the prognosis is less far urable. Whatever be the cause, the electrical reaction of the nerve and muscles affords valuable infmna- FACIAL PARALYSIS. l ion, since in proportion to the slightness of the change in relation to the length of time the symptoms have lasted, will the degree and dura- tion of the affection be less. In double facial paralysis the probability of central mischief will render the prognosis less favourable, but recovery may be hoped for if there are no symptoms of disease damaging structures contiguous in position, and not merely- related in function, and if the disease bo of short duration. Treatment. — The treatment jf facial paraly- sis will depend on the probable cause. When due to the effects of cold, hot fomentations to the side of the head and face may be employed in the early stage of the affection, and afterwards counter-irritation by blisters behind the ear. At first, diuretics and small doses of iodide of potassium, and subsequently tonics, aro useful. Electricity to the muscle and the nerve is of great service ; faradisation should be used if the muscles will respond to it; if nut. the voltaic current, slowly interrupted by a commutator, or by the negative pole being moved over the individual muscles, and only such strength being employed as shall produce distinct muscular contraction. If the faradic irritability be lost at first it will return as the muscles recover, and faradisation should then be employed. If electricity does no more, it keeps up the nutri- tion of the muscular fibres and aids the recovery of function in the nerve. Ultimate recovery is thus more speedy and more complete than with- out local treatment. Rubbing may be employed, the individual muscles being subjected to a pro- cess of gentle shampooing. The treatment of the late contraction which occurs in severe cases is often difficult. Faradisation of the opposite side of the face lias been suggested, but can scarcely be of service. The zygomatic muscles may be elongared a little by frequent gentle traction, and the other contracted muscles should be gently rubbed, so as to lengthen them. In- unctions of oleate of morphia may be tried. The muscles that are contracted should not be fara- dised. The condition usually lessens after a time, but often remains fur many months, or even years. Where facial paralysis is due to syphilis, it usually readily yields to antisvphi li tie treatment, if recent; but even here electricity is use ul, since degeneration of nerve and muscle rapidly occurs. In intracranial disease the Treatment of the ficial paralysis is usually subordinate to that of its cause. When there is indication if sudden and increasing mischief at the nucleus of the nerve, galvanism must be employed with caution. The treatment of double facial paralysis pre- sents no special points for consideration. W. R. Gowers. FACIAL SPASM. — Synon. : Mimic cramp. Fr. Tic convu/sif. When affecting the eyelids, Blepharospasm ; Nictitation. Definition-. — Spasm, sometimes tonic but more often clonic, involving some of or all the muscles Supplied by the facial nerve. jEnoi.o ;y and Symptoms. — Spasm in the face may be part of a wider convulsive movement, as FAUCES, EXAMINATION OF. 49a in epilepsy, hysteria, chorea, or torticollis, dis- e'-isss dependent on central change. Secondly, it may be due to irritation of the trunk of the facial nerve by growths, pressure, or caries of the tem- poral bone. Spasm of this form may follow facial paralysis. Thirdly, it is very commonly reflex, produced by the application of cold, by intestinal worms, or especially by some disease or injury oi the fifth nerve. Affections of the eye frequently lead to spasmodic closure of the lids — blepharo- spasm. Lastly, in other eases no cause can be ass : gned for it, especially in the local clonic spasm affecting the eyelids — one or both — and known as involuntary winking or nirtiiation. The latter form is seen especially in neurotic persons ; in nervous children it is not uncommon, and in hysterical girls. It is markedly increased by emotion and attention. All forms cease during sleep. Prognosis.— The prognosis of facial spasm is good, if the cause can be discovered. Where there is no discoverable source of reflex irritation the affecrion is often most obstinate. Treatment. — General tonics and local seda- tives are the most important elements in the treatment of most forms of facial spasm. When irritation affects the fifth or the facial nerve, counter-irritation by blisters is useful. A care- ful search must be made for reflex or other causes, and if possible they must be removed, decayed teeth extracted, and neuralgia relieved. When there are tender places in the course of the fifth nerve, pressure on which stops the spasm, mil'll improvement can usually be ob- tained. Morphia, belladonna, and aconite are the best local sedatives ; the former may be used its a hypodermic injection or by inunction. Ar- senic may be injected in some cases with ad- vantage. Iron and quinine arc useiul, especially the latter. Bromides and phosphorus are of little value. Where the affection runs into an habitual movement, facial gymnastics may be of service. A weak voltaic current, applied from the ear to the muscles, unbroken, may do some good; but it rarely, if ever, affects a euro. The same is true of the application of vultaism to the sym- pathetic. See Eye, and its Appendaoes, Dis- eases of. W. R. Gowers. FACIES HIPPOCRATIC A (Latin).— A peculiar expression of the face, so named from having been graphically described by Hippo- crates. It is most strikingly observed in persons exhausted by copious discharges, as in cholera, by prolonged wasting diseases, or by starvation ; and especially before impending death. It is thus described by Hippocrates: — ‘A sharp nose, hol- low eyes, collapsed temples: the ears eld, con- tracted, and their lobes turned out; the skin about the forehead being rough, distended, and parched; the colour of the whole face being green, black, livid, or lead-coloured.’ FAUCES, Examination of. — Ati examination of the faces frequently atibrds valuable ev denco of the condition of the organs engaged in the process of digestion, and furnishes important data on which to found a diagnosis, and suggest, a rational treatment. Not only may structural changes in the alimentary tract be discovered, but also the completeness of action of iho various 194 FJECES. EXAMINATION OF. digestive juices be recognised. As with the examination of the renal secretions, a previous knowledge of the healthy characteristics is an essential; that being granted, the investigation may be pursued on the same lines in both cases, as regards the general, microscopic, and chemical characters. Since, however, these characters are more directly dependent on the ingesta, and less upon the excretions, their examination cannot be so valuable an index of tissue-change as is the investigat'on of the urine. 1. Physical examination. — 1. Quantity. This is extremely variable. Taking the normal average for an adult to be about o ounces daily, it may vary from to lllj ounces. The quantity would seem to bear no relation to the size or weight of the indivi lual,but is rather intiuen :ed by the quantity and kind of food, and the acti- vity of the secretions of the alimentary canal. As a rule, the amount is increased by a vege- table diet. In children it would seem the total daily amount is relatively slightly greater, whilst in old age there is an absolute diminution. When in disease the quantity is increased it is chiefly of the fluid portion, whilst a diminution affects both the solid and fluid parts. Tea is said to diminish the quantity of the faeces (Chambers). See Constipation, and Diahrucea. 2. Co.nsistknce ANi> Appearance, — Depar- tures from the normal cylindrical shape are fre- quent, and depend very much on the existence of constipation or diarrhoea. In infants the evacua- tions should be unformed and of a pappy consis- tency. The contents of the bowels pass from a semifluid condition in the ileum to the firmer state in the colon, mainly from an absorption of fluid constituents ; should thero be any delay in the passage the motions are liable to become hard and nodular (scybala), and this may occa- sionally be extreme, the farces having all the appearance of sheep's dung, and being passed with considerable piin. On the other hand, an increased frequency of action of the bowels (diar- rhoea), is associated with motions of all degrees of fluidity. Tins is very marked in the various forms of irritation to which the intestinal mucous membrane is liable, from the simple effects of a saline purg- to the extreme conditions of ulcer ation, as in typhoid fever or dysentery. The existence of haemorrhoids, rectal growths, or an enlarged prostate, may be recognised by groovings and marks on the excrement. Among drugs, iron and vegetable astringents will render the faeces hard and firm. Occasionally the mo- tions are passed in a fermenting condition, due to the presence of sarcinse, and present a frothy brown, or yeast-like, appearance, similar to cer- tain vomits. 3. Colour. — This is dependent on the bile- pigments, and is subject to considerable variation even within the limits cf health. The usual brown colour becomes much darker if long re- tained, or with an exclusively meat diet, and pale yellow with milk food, as seen in infants, and tends towards a greenish tint when vege- tables form the bulk of the food. The most important abnormal causes affecting the colour are the following: — (a) Bile — Obstruction to the passage of bile :UwO the duodenum, causing the motions to be clay-coloured, or putty-like. Such evacuations are often combined with distinctly bile-coloured fluid, which is secreted by the mucous membrane of the bowels from the bile-laden blood, &c., as is the coincident high-coloured urine. In extreme anaemia and the rickety cachexia ihe stools are usually pale from deficiency of bile-pigment. ()3) Blood .— This may either appear as streaks or patches of pure blood on the surface of the motion, as is the case when haemorrhoids or ulceration of the rectum exists. Or the fsecer may be of a uniform brick-red or almost black colour when there has been a haemorrhage from the intestinal surface, the blood becoming inti- mately mixed with the faeces, and more or less affected by the sulpherrtted hydrogen of the bowels, forming a black sulphide of iron. If the blood has escaped into the stomach the action A the gastric juice on the blood-pigments is such as to convert the faeces into a tarry- looking material of a very characteristic appearance. See Helena. (y) Articles cf Diet, Drugs. stinal concretions, mu- cous or membranous casts of the intestines, por- tions of bowel sloughed off from intussusception, Je- ll. Microscopical examination. Method. — The evacuations, when of ordi- nary consistency, require to be shaken up with two or three times their bulk of distilled water and al : owed to stand. This may be repeated several times, and the washings successively submitted to microscopic examination, as well as the final sediment. When the discharges are very fluid this process is not needed. Constituents. — The usual microscopic con- stituents of the faeces are— (a) Undigested and indigestible residues of the food. Such are starch-cells, woody fibres, par- ticles of husks of corn and other seeds ; muscu- lar fibres with their characteristic structure and generally bi e-stained ; shreds of elastic tissue and fibres from the blood-vessels; portions of cartilage; hairs. (5) Epithelium. — This is derived from the mucous membrane of the canal. The cells may be more or less distinct and separate, or form by co- hesion amorphous yellowish masses which consti- tute a considerable portion of the solid matter. ( 7 ) Oil.— Occasional oil-globules are seen. (8) Crystals of triple phosphates. (e) Amorphous granular matter. Since the nature of the food varies so widely it is impossible to state anything in regard to the relative proportions in which these objects occur. In certain states they are found absent or in excess. When from any cause the fats are imperfectly digested they may be recognised in the discharges. Crystals of ammonio-magnesian phosphates are very abundant in typhoid eva- cuations. The spores of fungi, and the ova of intestinal parasites, and the hooklets of hydatids may be met with, and bacteria would seem to be very frequent, possibly in connection with pan- creatic digestion. III. Chemical examination. — The imperfect knowledge we possess of the actual chemistry of the tissues and secretions, with the exceeding variety in the composition of the ingesta, pre- vents our obtaining, from any analysis of the fteces, much information of a practical character. It is seldom if ever that such examination fur- nishes evidence of primary importance, as dees the urine ; it. is only occasionally that the results correspond to what other signs and symptoms indicate to be the case. On an average the faeces contain about 23 per cent, of solid matter to 77 per cent, water, but this proportion is liable to the widest varia- tions both in health and disease. Thus in cholera-stools the solid residue may be but a few grains per pirn. 1. Special Constituents. — Two bodies — ex- cretin and stercorin — have been described as characteristic of the faeces. Both are non-ni- trogenous, crystallizable, non-saponifiable bodies, the former containing sulphur. They differ in their crystalline form and solubility in alco- hol and ether. They appear to be closely re- lated to cholestprin, with which in many points they agree. It is found that when the bile which normally contains cholesterin is prevented reaching the intestines, that neither of these bodies occur in the faeces; and that they are also absent, being replaced by cholesterin in the meconium, and in starving an i hybernating ani- mals, when there is no obstruction in the bile- flow. Flint considers about ten grains per diem to be the average amount of stercorin and the excretin of Marcet to be about a fifth of that. Cholesterin itself, except in very small quanti- ties, cannot be regarded as a normal constituent of the faeces, but the precise significance of its occurrence is uncertain. 2. Fatty Acids, Fats and Soaps. — Excre- tolic acid, one of the fatty series, is described b}’ Marcet as a constant ingredient. Free stearic and margaric acids only occur in minute pro- portions, in ordinary circumstances, but are readily increased to considerable amounts when the alkaline secretions of the liver and pancreas are prevented entering the intestines. A vege- table diet is also said to increase them. Butyric acid does not seem to be of normal occurrence in human faeces. The presence of neutral fats in the excrement may be taken to indicate that there has been excessive ingestion or a dimi- nished digestion, since under ordinary circum- stances they would be absorbed. The soda and potash soaps ordinarily formed by the ingested fats with the bile and pancreatic juices should be in great part taken up by the lacteals ; but a portion meeting with any lime or magnesian salts that may be in the alimentary canal, form with them insoluble hard soaps which are passed in the fseces. Marcet describes a case in which a large quantity of bi-stearate of soda was voided, the bile and pancreatic juices having been absent from the intestine. 3. Salts. — They form but a small amount, and are chiefly the earthy and triple phosphates, with small quantities of iron and silica; there is a marked absence of chlorides. When the stools are very alkaline the triple phosphates may be very abundant, and in cholera-dis- chirges the whole amount of salts is largely increased, there being nearly an ounce in every hundred fluid ounces of evacuation, a large pro- portion of which consists of chlorides. 4. Pigment. — The ordinary colour of the fieces is due to a modification of the bile-pigments, but the exact nature of the change is unknown. The absence of colour from the discharges when there is an arrest of bile-flow has been referred 406 F2ECES, EXAMINATION OF. to ; but though clay-coloured stools as a rule do indicate such arrest it is not invariably so, for the writer has met with a caso in which normally coloured faeces in the small intestines were absolutely deprived of their pigment in passing over a diseased portion of the lower end of the ileum. 5. Mucus, Ai.nuMEN', Ac. — There is usually a small amount of mucus passed with the faeces, and this may be considerable in amount, re- sembling jelly, when any irritation of the rectum or colon exists, or occasionally more condensed, forming cylindrical casts of portions of the canal. Albumen as such can scarcely be looked upon as a normal ingredient of the evacuations, but the fluid part of cholera-stools, which resembles blood-serum in composition, contains a very ap- preciable quantity. Ferments similar in action to ptyalin and pepsin are described as existing in the feces, but how they may be modified in disease is quite unknown. Next to the undigested and indigestible resi- dues of food, the feces may be regarded as an excretory channel of certain materials from the blood by means of the bile. The other digestive juices are probably re-absorbed. As an index, however, of bile-excretion, the freces are very unreliable, inasmuch as no ingredient of the bile is normally found in them as such. Whether pigment, bile-acids, or cholestearin, they all undergo a change. The occurrence, therefore, of any of these materials in the alvine dis- charges m iy be taken as evidence that the changes in the biliary constituents which should take place in the intestines are interfered wirh. 6. Reaction. — As a rule, the reaction of the feces is acid, showing that, there is no putrid decomposition. Occasionally, however, it may he slightly alkaline. When the strongly alka- line secretions of the liver and pancreas are prevented through obstruction or disease irom entering the canal, the motions may he strongly acid from the existence of free fatty acids. For the Diagnostic Characters of the Faeces in disease, see Stools, Characters of. AV. H. Allchin. F2ECES, Involuntary Discharge of. — Under normal circumstances the feces are re- tained within the rectum by the closure of the sphincter ani. AVhen defecation takes place the sphincter is relaxed, there is increased peri- stalsis of the lower bowel, and there is pressure on the intestines, from the contraction of the expiratory muscles with the glottis close 1. The nerve-governance of these three phases of the act is different in each case. Tiie contraction of the abdominal muscles is mainly due to an effort, of the will. The activity of the colon and rec- tum is reflex, from irritation of the intestinal gangli i by the accumulated feces. Lastly, the relaxation of the sphincter depends on the inhibi- tion of the tonic centre in the lumbar enlargement of the spinal cord : such inhibition being brought, about either in a reflex manner from the rectum or directly from the cerebral centres. It is ob- vious that the relaxation of the sphincter is the most important stage in the act, for until that takes place no discharge can occur. Up to a cer- F.ECES, IN\ T OLUNTARY DISCHARGE OF. tain point the increased peristalsis and prc-sure on the bowels may be resisted by a voluntarily increased contraction of the sphincter, but at a certain stage the inhibiting influence is exerted, and relaxation results. Since this influence is beyond the control of the will, it would follow that the chief causes of the involuntary discharge of the feces are to be found in those conditions which interfere with the normal tonicity of the sphincter. At the same time, any circumstances which may increase the pressure of the abdomi- nal muscles or the activity of the bowels much beyond what ordinarily occurs, may lead to an involuntary discharge. ./Etiology. — The causes of involuntary dis- charge of feces may be thus tabulated: — 1. Violent contraction of the expiratory muscles , such as may be induced by strychnia-poisoning. It is of rare occurrence in tetanus. 2. Increased peristaltic action of the intestines. This is chiefly dependent on causes of irritation situate in the bowels themselves, such as inflam- mation or ulceration of the walls ; irritating con- tents ; worms. Ac. Extreme fluidity of the faeces is frequently sufficient to induce their partially involuntary discharge, and is noticeable in the diarrhoea of infants and children. 3. Abnormal relaxation of the sphincter ani. As already said, the previous mentioned causes are powerless to produce the discharge of the feces until the sphincter yields : and how far the sphincter may relax as a result of their efforts, or independent of them, is not easy to determine. The nervous influence emanating from the lumbar centre which normally determines the tonic state of the sphincter may be inhibited-— a. Rejlcx/y, as from worms, fissure of the anus, or calculus vesicte. It is quite true that the immediate result of irritating the sphincter is to determine in a reflex manner an increase of its contraction, as may be experienced in introducing instruments, Ac., into the rectum ; but it would also seem that at a certain point the irritation may lead to an arrest of the tonic influence, and so allow the sphincter to yield, and this is parti- cularly the case with affections of the bladder. /3. From cerclral disease. That certain emo- tional conditions may lead to involuntary d-. fe- cal ion is well known, and that a similar result follows some diseases of the cerebral centres is not uncommon. The paralysis of the sphincter that occurs under these circumstances i- brought about by inhibiting the normal tonic stimulus emanating from the lumbar centres. Involun- tary evacuations frequently occur in epileptic fits ; iu profound coma'ose states induced by apoplexy, opium and other forms of poisoning; and in death by hang ng or suffocation. Its occurrence can scarcely be regarded as indicating lesion of any one part of the cerebral centres, but rather as a result of what at present are termed general brain-states. It constitutes a troublesome com- plication iu such chronic forms of brain-disease as general softening, paralysis of the insane. Ac. y. From spinal disease. The relaxation of the sphincter may of course be produced by disease or injur)' of the lumbar enlargement of the spinal curd. Inasmuch as it is from the cells of this region that the normal tonic influence is under- stood to emanate, a destruction of the nervous FAECES, INVOLUNTARY DISCHARGE AND RETENTION OF. tissue can readily be understood to prevent the origination of such stimulus to contraction. It is noticeable that changes in the substance of the cord itself, myelitis, &e., are more frequently accompanied by paralysis of the sphincter than is spinal meningitis. 8. From local disease. The control over the sphincter may be lost from injury to the muscle itself, as occurs in laceration of the perinaeum, in- volving the lower end of the bowel. Treatment. — Beyond removal, when possible, of the cause, no direct treatment of incontinence of faeces is of avail. As a distressing complication of certain diseases of the nerve-centres, which are too frequently incurable, little remains to be done for it beyond adopting such measures as will permit of the escape of the discharge with evory regard to cleanliness. W. H. Allchin. E.33CES, Retention of. — 2Etiolojy. — In the absence of mechanical obstruction, such as adhe- sions, bands of false membrane, uterine pressure, stricture, tumours, morbid growths, or haemor- rhoids, the main causes of fecal accumulation are: — (a) a sub-paralysis of the intestinal mus- cular fibres from defective innervation, or from over-distension of the walls of some portion of the largo bowel ; ( b ) loss of reflex irritability of the rectum ; and (c) dryness of the mucous sur- face of the colon. Hence it is frequently met with in the debilitated, the bedridden, the para- lysed, the aged, and the sedentary, and women are more prone to it than men. Loss of reflex sensibility in the rectum is frequently the sole cause. The feces delivered into the rectum by the contractions of the sigmoid flexure and the descending colon no longer excite the act of de- fecation, and collecting there as a large dessicated mass, determine a gradual and painless retention in the colon, and particularly in the most disten- sible parts — the sigmoid flexure and the caecum. The accumulation once set up tends also to per- petuate itself by arresting more and more the peristaltic movements, and leading to atrophy of the walls of the bowels. Symptoms. — Faeces often accumulate slowly and without the knowledge of the patient ; hence in cases in which sensibility has been blunted by age, disease, or great debility, the discovery of large collections in the rectum or colon may surprise even the practitioner, who is generally led to a local examination by disturb- ances set up by the retention. There is usually constipation or an insufficient discharge of solids ; a regular and even excessive relief of the bowels does not, however, exclude accumulation, for even fluid feces may pass through the centre of or over old collections. The evacuations are lumpy, or consist of detached hard, dry, dark scybala, or of a single mass ; when the accumu- lated matters are dislodged by aperients, they often emit an offensive and sour odour. Faecal collections in the rectum and sigmoid flexure are apt to excite tenesmus and frequent voiding of mucus and blood, but without the putrid flesh- like odour of dysenteric evacuations; and the linger encounters a mass of hardened feces in the rectum. An accumulation in the caecum, or any part l 'f the colon, may be detected through the abdo- 32 491 minal wall as a tumour more or less movnbk and uneven, and doughy to the touch; and in rare cases the large bowel throughout may be so greatly distended as to apparently fill the abdomen with a solid mass which, like other fecal collections, yields to the firm pressure of the finger. A tympanitic state of the abdomen may. however, so obscure the examination as to prevent the recognition of even moderately large accumulations. Flatulence, colicky pains, inflammation, (typhli- tis, colitis), ulceration and perforation — the caecum is by far the principal seat of this accident — and intestinal obstruction, are not uncommon results of retention of feces, concerning which the reader is referred to the articles on Constipation ; C-ecum, Diseases of ; Colon, Diseases of ; Flatu- lence ; and Colic. Treatment. — A hard ball of feces or of agglutinated scybala in the rectum resisting dis- lodgment by aperients, or enemata, should be broken up and removed, by introducing within the sphincter two or three fingers, a scoop, or the handle of a spoon. This may be facilitated by introducing the fingers within the vagina in the female. Faecal concretions in this situation, even though not impacted, may require similar me- chanical aid ; and in consequence of the hardness and size of these bodies the extraction is fre- quently difficult. When purgatives and injec- tions fail — the former perhaps aggravating the vomiting induced by the obstruction— a long elastic tube should be passed through the indu- rated mass which resists its progress, and warm olive oil, followed by milk or gruel, should be gradually injected by the stomach-pump or Davidson’s syringe; sometimes, however, large injections as ordinarily administered, repeated twice or three times a day, render this proceed ing unnecessary. The removal of collections of hard feces in the rectum may be facilitated by macerating them with suppositories of cacao- butter, or of glue or isinglass softened in cold water, While a brisk aperient, such as a full dose of calomel, or castor oil with croton oil, may afford timely aid, the general medicinal treatment of the accumulation should consist of a prolonged course of gentle, yet efficient evacuants combined with tonics. The gradual collection of feces, the toneless state of the walls of the large bowel, the scanty secretion of intestinal mucus, and the loss of reflex sen- sibility in the rectum, require the persever- ing use of these remedies. A pill containing aloes, belladonna, and nux vomica — to which extract of colchicum is often a useful addition — generally affords the most satisfactory results- When aperients fail to dislodge the fecal collee tions, and the abdomen becomes painfully dis- tended, a combination of opium, belladonna, and aloes, given at regular intervals — the dose of aloes, at first small, being increased as the pain diminishes — may enable the bowel to overcome the difficulty; but when there is severe pain, and above all obstinate, and especially sterco- raceous vomiting, opium and belladonna should be given alone or with nux vomica until the subsidence of these symptoms, when aloes may be prescribed along with these agents with the best effect. Obstruction from paralysis of a portion oi' m F^CES, RETENTION OF. the bowels in which faeces have accumulated may be met by strychnia, ‘ restoring capacity of action,’ followed by a mild aperient which promotes peristalsis, or by the interrupted galvanic current. Distressing tympanites, which, thwarting the peristaltic movements, intensifies the obstruc- tion, has been overcome by puncture of the caecum with a fine trochar or aspirator after failure of other means; but this proceeding is not unattended with danger of fatal peritonitis from fsecal extravasation, or from perforative ulcera- tion set up by the punctures, and cannot be safely recommended. George Oliver. FAINTING, — A popular synonym for syn- cope. See Syncope. FAINTNESS. — Faintness signifies a feeling of great weakness or exhaustion, as if the sub- ject of it were about to become exhausted, or to sink or faint. FALLING SICKNESS. — A popular synonym for epilepsy. See Epilepsy. FALLOPIAN TUBES, Diseases of. — The oviducts are liablo to the following morbid conditions: — 1. Malformations; 2. Displace- ments; 3. Contractions; 4. Dilatations; 5. In- flammation ; 6. New Growths ; and, 7. Tubal Pregnancy. 1 . Malformations. — The Fallopian tubes may be congenitally wanting, either on one or on both sides ; or they may be impervious ; and, instead of a single opening into the abdominal cavity there may be two or more. 2. Displacements. — • The tubes may bo stretched or widely displaced from their normal position by growths or effusions in their neigh- bourhood, such as ovarian, parovarian, &c. 3. Contractions. — These canals may be im- pervious, from inflammation of the lining mem- brane, or from peritonitis, pressure, or torsion. 4. Dilatations. — The Fallopian tubes maybe distended, even to a great degree, by (a) mucous or serous fluid ( hydro-salpinx ) ; ( b ) pus ( pyo-sal - pinx ) ; or (c) blood ( hcemo-salpinx ). In hydro- salpinx the tubes, if much distended, become sac- culated, giving rise to a string of cystic tumours. The fluid collects chiefly at the abdominal end of the tube, but occasionally it may escape, and in large quantity, through the uterus. Should the tube burst and discharged contents into the peri- toneal cavity serious results may ensue, especially if the fluid be pus. When haemo-sa'lpinx is the result of menstrual retention from atresia uteri, bursting of the tubes internally is apt to follow operations for the relief of the obstruction. 5. Inflammation. — Inflammation of the Fal- lopian tubes ( salpingitis ) is apt to be caused by gonorrhoeal infection, or it may occur during the puerperal state. Stenosis or pyo-salpinx may be the result. 6. New Growths. — The Fallopian tubes may be the seat of the following new growths — fibroid tumours, mucous polypi, cysts, cancer and tubercle. Lipomata, involving the integrity of the tubes, may also arise in the adjacent tissues. Fibroids resemble those of the uterus, and may attain a considerable size. Small polypi growing into the canal may partially obstruct the duet. The cvsts are usually the so-ealled hydatids of FASCIAE. Morgagni, an embryological relic ; but other small simple cysts may be met with at the orifice of the tube, around the morsus diaboli. Pri- mary cancer of the tubes rarely, if ever, occurs. Tubercle, however, may be primary, and may occur before puberty. It usually begins at the abdominal end, and may lead to blocking of the tube. 7. Tubal Pregnancy. — An important affec- tion of the Fallopian tubes is that arising from the variety of extra-uterine pregnancy called tubal, where the product of conception grows within the tube in some part of its course. This abnormity is apt to be attended with very serious results, bursting of the tube frequently occurring about the third month of gestation ; and serious, sometimes fatal, internal haemorrhage may hence ensue. Tubal gestation usually occurs on one side only, while other affections of the tubes are often symmetrical, a point of diagnostic impor- tance. See Pregnancy, Disorders of. Regurgitation of blood, of septic matters, and of fluids injected into the uterus, sometimes takes place along the Fallopian tubes, and this accident is always attended by grave conse- quences. Mechanical Obstruction of the Fallopian tubes is not an infrequent cause of sterility. Treatment. — The diagnosis of affections of the Fallopian tubes being difficult, their treatment is likewise obscure ; and must be in a measure guided by general principles in each case. In pyo-salpinx severe peritonitis and death may re- sult from rupture of the sac, as may speedy dis- solution from internal haemorrhage in tubal ges- tation. In the former case, and in hydro-salpinx, puncture with the aspirator might be permissible were a clear and unequivocal diagnosis made. In the latter case proximal ligature of the impli- cated tube might save life, but the diagnosis is surrounded by so many difficulties that such an operation can only rarely be justified. Alfred Wiltshire. FALSE MEMBRANE. — An inflammatory exudation of a fibrinous character, which is de- posited in layers, chiefly on mucous surfaces, and occasionally on abrasions of the skin. It is well exemplified by the deposit in diphtheria and plastic bronchitis. FAMILY DISEASES.— Diseases which are found to run in families, or diseases to which members of tho same family seem peculiarly liable. See Disease, Causes of. FARADISATION, Uses of. See Elec- tricity. FARCY. — A synonym for glanders. See Glanders. FASCIAE (, fascia , a band). — The fasciae are subjects of medical and surgical interest, with re- spect both to their anatomical relations, to the diseases to which they are liable, and to points of diagnosis in connection with them. I. Anatomical Relations of Fasciae. — The situation and connections of the fasciae, according as they are fasciae of investment or fa-vice of attachment, are of the grtai<-?t practical impor FASCIAE. 490 tance in the following classes of diseases: — 1. Suppuration ; 2. Extravasations, and Cellular Emphysema ; 3. Eternise ; 4. Dislocations ; 5. Diseases of Encapsuled Organs ; and, 6. New Growths. 1. Suppuration. — The physical influences exerted by fasciae upon pus are chiefly two. First, fasciae may limit the size of an abscess, determine its tension and the many results of the same, and thus affect both the local phenomena and the general symptoms. Secondly, when the pus is not confined, the fasciae serve to deter- mine the course that it will take and the situa- tion in which it will discharge. Every abscess may be said to be influenced in this way by tlie relations of fasciae, but certain fasciae havo to be specially noted as causing pus to burrow, and hence they should be enumerated here : — a. Fascia of the Head and Neck. — The fasciae of the scalp ; the temporal fascia ; the cervical fascia ; and the post-pharyngeal fascia, which conducts pus from the cervical vertebrae to the parotid region and tonsil, and to the region of the carotid vessels. b. Fascia of the Upper Extremity. — -The axil- lary fascia ; and the deep fascia of the upper extremity generally, including the palmar fascia and the sheaths of the tendons. c. Fascia of the Thorax . — The fasciae of the in- tercostal spaces and of the mammary region ; the fascia reaching from the neck to the upper part of the pericardium and the aorta, and to the posterior mediastinum, respectively; the fasciae of the anterior mediastinum ; and the fasciae con- nected with the diaphragm — all of which deter- mine the course of intrathoracic abscesses. d. Fascia of the Abdomen and Pelvis. — The transversalis fascia ; the fasciae connected with the transversalis muscle, especially posteriorly, which influence the course of lumbar abscess ; the sheaths of the psoas and the iliacus ; the pelvic, recto-vesical, obturator and anal fasciae ; the fascial investment of the prostate ; the superfi- cial and deep layers of the superficial fascia of the perinaum ; the superficial and deep layers of the triangular ligament ; and the fascial in- vestments of the rectum, bladder, uterus, and vagina, which determine the course of purulent collections in the pelvis. e. Fascia of the Lower Extremity. — The fascia lata and its processes ; the tensor fasciae femoris ; the popliteal fascia ; the deep fascia of the leg ; and the plantar fascia and its compartments. 2. Extra vasations and Cellular Emphysema. — When blood or urine escapes from its natural reservoirs, or when air or gas has found its way amongst the tissues, the direction that the ex- tra vasated substance takes is markedly influenced by the fasciae with which it comes in contact. The principal fasciae of importance in this re- spect are as follows : — a. Fascia of the Head and Neck. — The fasciae of the scalp, and the cervical fascia. b. Fascia of the Thorax. — The fasciae of the intercostal spaces ; and the mediastinal fasciae, through connections with the cervical. c. Fascia of the Upper Extremity , — The deep fascia in general. d. Fascia of the Abdomen and Pelvis. — Scarpa’s fascia, or deep layer of the superficial fascia ; both layers of the superficial and of the deep perineal fascia ; and the fasciae of the prostate and bladder — all being of the greatest import- ance in cases of extravasation of urine or fieces. e. Fascia of the Lower Extremity. — The fascia lata in general ; the popliteal fascia ; the deep fascia of the leg ; and the plantar fascia. 3. Hernle. — The occurrence of hernia, and the direction that they take, are in a great measure determined by the condition of the fasciae in contact with the viscera. Most important in this relation may be mentioned — the fascia transver- salis, the iliac fascia, the sheath of the femoral vessels, the obturator fascia, the cribriform fascia, and the fascia lata. 4. Dislocations. — Certain fasciae serve as supports for the heads of bones, and for the vis- cera ; and these will have an important influence either in promoting or in preventing dislocation, displacement, or other injury of these parts, as the case may be. The shoulder is supported by the costo-coracoid fascia, and this relation con- siderably affects the signs of dislocation at that joint. In fractures of the patella, the fasciae of the knee-joint promoto separation of the fragments. The fascia of the neck helps to support the pericardium, and must limit the displacements of the heart. The bicipital fascia of the fore- arm protects the brachial artery beneath it in venesection, at the bend of the elbow. On the other hand, the attachment of the cervical fascia to the jugular veins facilitates the entrance of air into the circulation through a wound at this point. And, lastly, the pelvic viscera are supported by the transversalis, pelvic, iliac, and recto-vesical fasciae ; whilst the cord and testis have their special fasciae to keep them in position. o. Diseases of Encapsuled Organs. — A con- siderable number of organs, many important vessels, and a great variety of muscles are con- tained in distinct fascial capsules, sheaths, or envelopes, which will affect the course of the diseases of these structures in many ways — de- fining their limits, or determining the direction in which they spread, and thus influencing both their local and general phenomena. This has been already alluded to under the first head ; but it is necessary to enumerate here the principal fasciae that act in this way, namely : — a. Arterial sheaths : — of the carotid, subclavian, thoracic- aortic, and femoral. b. Muscular sheaths: — of the masseter, buccinator, psoas, iliacus, quad- ratus lumborum, erector spinae, pectineus, rectus abdominis, levator ani, tensor vaginae femoris, and the palmar and plantar muscles, c. Visceral capsules of the thyroid gland, parotid and sub- maxillary glands, tongue, prostate, penis, vagina, bladder, rectum, and mamma. 6. New Growths. — The direction, rapidity, and extent of spread of new growths are con- siderably modified in certain situations by the relations of the fasciae above described. II. Pathological Relations of Fascia. — The principal diseases of fascia are: — 1. In- flammation and its results ; 2. Ossification ; 3. Calcification ; 4. Rheumatism ; 5. Gout ; G Syphilis; 7. Contraction; and 8. Extension. — None of these conditions can be said to be com mon, or of serious importance. 500 FASCLE. 1. Inflammation. — Inflammation involving a fascia is usually secondary, having spread to it from the neighbouring structures, and especially from the muscle or organ of -which the fascia may form the sheath. Even under these circum- stances, a fascia rather resists than participates in the inflammatory process, as has been de- scribed above ; and when it is involved it tends to ulcerate on account of its feeble vitality, and to !>e discharged in the form of sloughs. The heal- ing process is extremely slow in fasciae, and after serious lesion their function is never completely restored. 2. Ossification. — Occasionally in aged per- sons portions of fasciae are found transformed into bony tissue. 3. Calcification.— C alcification is very rare in fasciae. 4. JRhecmatism. — The condition known as muscular rheumatism, or according to its situa- tion as lumbago, torticollis, &e., is believed by some authorities to involve the fibrous coverings or fasciae of the affected parts. In the same way, many of the aches of some forms of ‘chronic rheumatism’ may possibly have their seat in fasciae ; and certain cases of neuralgia are pro- bably to be referred to rheumatic inflammation of the nerve-sheath. 5. Gout. — Amongst the pains of the gouty subject are some which are no doubt due to affections of fasciae, such as pains in the heel and instep, and neuralgia of the sciatic, the anterior crural, and the brachial nerves. 6. Syphilis. — Syphilis may attack the fasciae iu the form of nodes, which in places of low vas- cularity are apt to ulcerate, as, for example, at the inner aspect of the knee. 7. Contraction. — Contraction is the most obvious of the morbid conditions of fasciae, giving rise as it does to well-marked deformities. The fascia of the hand and foot are most liable to this change, with the result of unnatural flexion of the fiDgers and toes. Such contraction of the palmar and plantar fasciae may be due to wounds, burns, or inflammation from any cause, or to gout or rheumatism ; it is sometimes congenital ; and it sometimes occurs without evident cause. 8. Extension. — A fascia or sheath, though extremely inelastic, is liable to be stretched by swelling of the parts which it envelopes ; and, if the cause do not speedily disappear, may remain more or less permanently extended. The best instance of this condition is pendulous abdomen after pregnancy or other form of abdominal en- largement. J. 3Iitchell Bruce. FASCIOLA (fasciola , a thin band). — A genus of trematode parasites of which the common liver- fluke forms a good type. This entozoon (F. he- patica) is characterised by the possession of a branched intestinal canal, thus differing from the flukes belonging to the genus Distoma, in which the canal is simple and bifurcated. The liver- fluke is of rare occurrence in man, though ex- tremely abundant in, and destructive to, rumina- ting animals. See Distoma. T. S. Coisbold. FASTIN' G. — The manifestation of vital activity implies consumption of material; and unless the supply of material in the form of FASTING, food is equivalent to the loss occurring, a pro- gressive wasting of the body and failure ot power must ensue. Hence these phenomena constitute the necessary accompaniments of fasting; and with its prolongation the question resolves itself into one of time — when the exhaus- tion of material shall have proceeded to such an extent as to render the continuance of life im- possible. Pathology. — To Chossat we are indebted for showing that the immediate cause of death from fasting is a reduction of the bodily temperature. At first there is a gradual, but not very ex- tensive fall. Afterwards a more rapid decline occurs, until the reduction amounts to about 29° or 30° (Fahr.) below the normal point, when death ensues. Chossat noticed that if, whilst in the state of torpor preceding death, the tempera- ture of the animal experimented on was raised by exposure to artificial warmth, a restoration of consciousness and muscular power was induce':; and some of his subjects of experiment which were thus rescued from impending death after- wards thoroughly revived on being supplied with food. Symptoms. — The most prominent symptoms arising from fasting are those due to the special sensations produced by the absence of food and fluid, and those attributable to a decline of the physical and mental power. In the first place there is great uneasiness in the epigastrium. This is followed by a sense of sinking in the same region, accompanied by insatiable thirst ; and if fluid be persistently withheld as well as food, the thirst becomes the chief source of distress. The countenance assumes a pale and cadaverous appearance, and a look of wildness is presented about the eyes. Emaciation becomes more and more marked, and with it there is a decline of the bodily strength. There is also failure of the mental power. Stupidity may advance to im- becility ; and a- state of maniacal delirium fre- quently supervenes. Life terminates either calmly by gradually increasing torpidity, or, it may be, suddenly in a convulsive paroxysm. Duration of Life. — The usual duration of life under complete absence of food and drink may be said to be from eight to ten days. The special circumstances, however, existing may exert a modifying influence, and from the nature of these the period may be either diminished or increased. A stout person, as may be readily understood, has a chance of living loDger than a thin one, on account of the store of combustible material which may be drawn upon being larger. Exposure to cold in conjunction with starvation very much hastens death. The presence of moisture in the atmosphere favours the pro- longation of life, by diminishing the exhalation of fluid from the body. It may be assumed to be owing to the existence of warmth and mois- ture that persons buried in mines, or otherwise similarly placed, have been known to live con- siderably beyond the ordinary period. The Welsh fasting girl, about whom so much excitement was created in 1869. lived exactly eight days from the time she was placed under systematic inspection to solve the problem of whether she could exist, as had been alleged bj her parents, for an indefinite period without fooa! FASTING. It appears that during the first part of the time she was cheerful and exhibited nothing extra- ordinary. Later on it was found that she could not be kept warm, and ultimately she sank into a state of torpor, from which she could not he roused and which speedily terminated in death. In the Troedyrhiw colliery near Pontypridd an inundation occurred in 1877, which led to the imprisonment of four men and a boy in one of the headings of the mine. The accident hap- pered on Wednesday evening, the 11th of April. Efforts were at once made, by means of a cutting, to reach the chamber in which the imprisoned persons were confined, and to release them. This was not accomplished till the afternoon of Thurs- day, the 19th, when all were rescued alive and did well. They had been imprisoned in an at- mosphere of compressed air nearly eight days, without food but within reach of water. The more recent case of Dr. Tanner throws no new light upon the subject. Treatment. — Caution is required in the ad- ministration of food after prolonged fasting. Sudden transitions of all kinds are trying to the body ; and, instead of allowing the rescued sufferer to gratify his desire to eat and drink according to his inclination after several days’ abstinence, the supply of both food and drink should at first be limited, and afterwards gradually in- creased. There is reason to believe that the non-observance of this rule has upon some occasions been followed by disastrous conse- quences which a different plan might have averted. F. W. Paw. PAT. — Fat becomes a disease under the fol- lowing circumstances : — 1. As Obesity. — Fat may be found generally diffused in excessive quantity beneath the skin, beneath serous membranes, and in and upon the various tissues and organs of the body. This condition constitutes what is known as Obesity. The subject will be found fully discussed under that head. As a Partial Growth of fat, which some- times occurs in paralysed muscles, and consti- tutes a characteristic feature of what is called pseudo-muscular hypertrophy. See Pseudo-Hy- PEBTEOPnic Paralysis. 2. As Fatty Interstitial Growths. — Fat as fat-tissue becomes more especially a disease when it is deposited upon and in the textures of organs, interfering with their structure and func- tions. It does this by pressing upon the elements of the organ invaded ; and its effects are more particularly seen when it invades the muscular tissue of such an organ as the heart, the fibres of which, becoming more or Jess atrophied and dis- torted in their course and direction, are rendered inadequate for the performance of their functions. See Heart, Fatty Diseases of. 3. As Fatty Tumours. — Fat may also occur in isolated or circumscribed masses, constituting what are known as Fatty Tumours or Lipomata. See Tumours. 4. As Fatty Infiltration. — Fat in the form of oily particles is found to be present in excess in the cells of various secreting organs, constitu- ting fatty infiltration. Thus it appears in the epithelium of the intestinal mucous membrane FATIGUE. 501 during digestion ; in the cells of the liver and biliary passages ; and in the kidneys of certain animals — for instance, the cat. When this con- dition becomes permanent it must be considered as a disease. Glandular organs thus affected, as in the case of the liver, assume a buff or yellow colour, and become softer and more friable than normal; while microscopically their cells are found to contain one or more large well-defined oil-globules, which tend to eoalesce and occupy the cell. The quantity of oily matter in the cells may, however, vary from time to time, and the infiltration may be either of a transient or of a permanent character. In the one case, the func- tion of the organ may not be materially interfered with ; in the other case, the activity of the cells may lie so far affected as greatly to impair the secreting functions of the organ. The causes of fatty infiltration are of two kinds — general and local. First, the general causes are (1) a superabundance of fatty matters in the blood, as occurs in persons who indulgo in rich food and in beverages containing alcohol ; (2) imperfect oxidation, as in chronic tuberculosis of the lungs; and (3), according to some observers, the metastasis of fatty deposits from one part of the body to another. Secondly, with respect to the local causes of fatty infiltration, one is a peculiar affinity or selective power of the cells of certain tissues, by virtue of which they incorporate with their sub- stance oily or fatty matter. This facility has been explained in the case of the cells of the liver and of the passages traversed by bile, by the pre- sence of that fluid, which, as Virchow and others describe, is a powerfully determining cause of the infiltration of fat into protoplasm. Another local cause of the accumulation of oil in cells is their inactivity or imperfect power of eliminat- ing it, as is found to occur in the cartilages of the aged, and in inactive muscles. It must be said here, with respect to the ap- pearance of fat in the last-named situations, that though, in some cases, it is derived unques- tionably from the fat contained in the blood or chyle, it may in other instances be derived from the disintegration of the protein elements of the tissues. This subject, however, will be found discussed in the article upon Fatty Degenera- tion. E. Quain, M.D. FATIGUE ( fatigo , I weary). General Remares. — Fatigue is a regular and constantly returning symptom experienced by all persons. Periods of functional activity invariably alternate with periods of repose during which the waste caused by the exercise of function is re- paired. We are indebted to Sir James Paget for having pointed out that * rhythmic nutrition is a law of nature,’ and although the truth of this dogma is recognised on all hands, and may be said to be axiomatic, it has hardly received that careful consideration at the hands of practical physicians which it deserves. Our whole life is composed of a series of vibrations — periods of tension alternating with periods of relaxation ; and although the rapidity of these vibrations varies immensely, they are recognisable in all our acts, whether voluntary or otherwise. The vibrations of the heart are about seventy in a FATIGUE. 502 minute, those of the respiratoiy organs about sixteen. The whole body requires a certain period of absolute and continuous repose in each twenty-four hours (amounting to nearly one-third of the period), so that we may say its rate of vibration is once in the twenty-four hours. In like manner tho period of relaxation of the heart is about one-third of the total period of a revolution, and this proportional correspondence between a local and a general condition is not a little interesting and suggestive. Again it is universally ordained amongst civilised nations that once in every seven days there shall be a remission of labour and a change of occupation ; and we recognise the fact that it is highly ad- visable for those who are occupied in one pursuit to break away from it at least once a year and indulge in that variety of work which we call amusement. Fatigue occurs directly we attempt to alter the rhythm of our vital vibrations by prolonging the periods of tension at the expense of tho period of relaxation, or by demanding for any length of time a quickening of the normal rate of vibra- tion. We recognise the fact that athletes who over-train run risks of cardiac troubles and loss of wind ; that the man who from any cause is unable to sleep runs a serious risk of permanent impairment of health ; and when we find patients pursuing their avocations too zealously we know that, if such offence against the laws of nature be persisted in, general paralysis, or other forms of • break-down,’ are likely to be the result. Fatigue may be general or local, and both forms may be either acute or chronic. That fatigue in all its forms is due to impaired nutrition there can be little doubt, and we shall find that tho symptoms of chronic fatigue are often the prelude of definite and recognisable degenerative changes. Description. — General Fatigue. — General fatigue is recognised with ease both in its acute and chronic forms. There is a disability to per- form either mental or physical work, and this dis- ability is noticed first in work requiring attention or sustained effort, and last in those acts which have become automatic or secondarily automatic. The symptoms of general fatigue are usually re- ferable to the nervous centres. Local Fatigue. — Local fatigue is either acute or chronic, and the symptoms of it are referable usually to the muscles ; but we must always bear in mind that muscle and motor-nerve are prac- tically one and indivisible, and that recent experiments have given great probability to the idea that every muscle is connected with a cer- tain definite spot in the brain. When, there- fore, we speak of a sense of fatigue, we must necessarily be in doubt, notwithstanding the fact that the symptoms are apparently located in the muscles, whether thebrain, nerve, or muscle, ono or all of them, be really at fault. Acute local fatigw . — The symptoms of acute local fatigue are, first, loss of power to a greater or less extent. By too frequent or too prolonged stimulation the irritability of the muscular tissue becomes exhausted, and it either refuses to respond, or responds but feebly to the stimulus of the will ; whilst our power of adjusting the force of contraction to the act to be accom- plished is lessened, and accuracy of movement and delicacy of co-ordination are destroyed. The second symptom of acute fatigue is tremor, as everyone must have experienced who has been called upon for any unusual exertion. The third symptom is cramp-like contraction ; and the fourth is pain, the pain being the pain of fatigue, and absolutely distinct from other varieties of pain. Fatigue is caused far sooner by prolonged muscular effort than by repetitions of short mus- cular efforts having due intervals of relaxation be- tween them. Anyone who has attempted to hold out a weight at arm’s length knows the impossi- bility of continuing the effort for any length of time; and it is proverbially true thatstanding in one position is, to most people, far more tiring than walking, the reason being that in standing the muscles which support the body are subjected to a prolonged strain while in walking we use the muscles on either side of the body alternately. The great increase of power which we obtain by using the muscles on either side of the body alternatively would seem to be one of the chief reasons for the bilateral symmetry of the body. Not only is sustained effort a far more potent cause of fatigue than repeated effort, but we find that when fatigue supervenes, actions requiring sustained effort are the first to fail, and in this local fatigue resembles general fatigue. The last acts to be affected by fatigue are such as are automatic, and are accomplished without mental effort, and by the expenditure of the least possible amount offeree. It isquite possible to exhaust a muscle by artificial stimulation, and if ono of the small interossei muscles be con- tinuously faradised, it will be found that in a very short time its power of contraction to any form of stimulus may be absolutely abolished. It is tolerably certain that the brain can have no share in artificial fatigue thus produced, and there seems good reason to suppose that, in some people of energetic temperament, the irrita- bility of a muscle may be exhausted, while the power of mental stimulation remains almost un impaired. Chronic local fatigue . — This form of fatigue has causes and symptoms similar to those of acute local fatigue, and there can be little doubt that this condition is a common cause of many of those chronic maladies which seem to result from overwork, and are characterised by irregular muscular action. That some cases of writer's cramp (see Writer's Cramp) are due to chronic fatigue of certain muscles employed in writing, and particularly of those subjected to prolonged effort, there can be little doubt. Some cases of torticollis seem due to the same cause. Duchenne and Brudenell-Carter have pointed out how, in cases of ‘ short sight,’ the strain on the internal recti has caused troubles of vision, and oven brain-symptoms, and quite lately Mr. C. B. Taylor, of Nottingham, has shown reason for including in the category of fatigue-diseases a peculiar form of nystagmus, occurring amongst miners, who try their eyes by working in the dark. Treatment.— The treatment of fatigue in all its forms is rest, and the restoration of the proper rhythm of nutrition, if this be found per- verted, by substituting rhythmical exercises for unrhythmical efforts. G. V. Poorr. FATTY DEGENERATION'. FATTY DEGENERATION. — Synon. • Fr. btghierescence graisseuse ; Ger. Fettige Meta- morphose. Definition. — The process by which protein ele- ments are converted into a granular fatty matter. Seats of Occurrence. — This change may oc- cur in any of the component elements of the body, whether normal or abr-ormal. Physiologically. The production of milk from the protoplasm of the mammary cells, and of sebum from the cells of the sebaceous glands, are instances of fatty degeneration. The cells of the corpus luteum are partly in a condition of fatty degeneration ; and it is by a similar change in the peripheral cells of the mature fetal por- tion of the placenta that normal involution of ;hat organ is accomplished. Non-vascular struc- tures, such as the cartilages, the cornea, and the intima of blood-vessels, frequently undergo fatty transformation of part of their substance. In a less marked form, fatty degeneration occurs in the walls of the uterus and other muscular or- gans when returning to their ordinary size after temporary hypertrophy. Pathologically. As a purely morbid process, fatty change is most frequently met with in the muscular tissue of the heart, in the walls of capillaries, and in the urinary tubules ; but it also occurs in the central nervous system, consti- tuting the condition known as ‘ white softening’; in the liver; and in tubercular deposits, cancer- ous growths, infarcts, and inflammatory products in any situation whatever. Anatomical Characters. — Physical Charac- ters. — An organ that has undergone fatty de- generation presents the following physical cha- racters. The bulk and weight are generally increased ; the consistence is reduced, sometimes to a pulp, as in white softening of the brain ; the colour is changed, either as a whole or in the affected portions of the organ, into a buffy or yel- lowish bloodless hue ; and the resistance or firm- ness is diminished, so that the affected tissue is markedly flabby, and readily yields to pressure. The solid cut surface may appear compact and shining; and the section leaves a greasy stain upon the knife and fingers. When fatty degener- ation is greatly advanced, as it may bo seen, for example, in the liver, a portion of the organ l hrown into water will float. Microscopical Characters. — In fatty degenera- tion the muscular tissue of the heart and the walls of capillaries are most suitable for microsco- pical investigation. The earliest changes in the i ardiac muscle in fatty degeneration are loss of sharpness of the individual striae and theappear- auce of minute particles of oil between the ele- ments. These changes, beginning near the nu- clei, spread throughout the fibres in a longitu- dinal direction, while the particles increase in size and assume the well-known characters of oil- globules. When the process is advanced, the whole of the sarcous substance is replaced by fatty particles contained within a delicate albuminous envelope. Finally the degenerated fibres either become atrophied by absorption of certain parts of the fat, and so disappear ; or suffer rupture with discharge of their contents. The fatty nature of the change is proved by the solubility in ether of the particles that have escaped from the fibres. 5011 Fatty degeneration of the walls of vessels ia best seen in the capillaries and smallest arteries. The tunics first lose their normal translucency ; minute granules appear in their substance ; and these increase to form unmistakable oil-glo- bules. Finally the vessel gives way, and the oily particles and blood are discharged into the peri- vascular space. In the other organs referred to, the microsco- pical characters agree with those just described, with certain differences dependent upon the special structure of each. Thus fatty degener- ation of a leucocyte leads to the formation of the body known as a compound, granular cor- puscle, in which the oil-drops finally replace the whole of the protoplasm. In ‘ white softening ’ of nervous tissue, the nerve-cells and probably all the nuclei of the part are converted in a great measure into granular corpuscles ; and theso breaking down into afatty detritus, the whole con- stitutes a soft ereamy-looking substance, which, as Virchow expresses it, ‘ is milk in the brain, instead of in the mammary gland.’ ‘ Yellow tu- bercle ’ consists in part of cells and nuclei that have undergone fatty degeneration, and of fatty detritus. In the case of the uterus during in- volution the fat is probably rapidly absorbed, so that the appearances presented to the eye are those rather of atrophy than of replacement of the muscular substance by fat. Pathology. — -We have now to trace whence comes the fat that is found in this form of do- generation, and how. It is evident that in a number of instances — such as the production of milk and sebum — fatty degeneration is a truly physiological change, which is subservient to health when active, while its derangement or cessation constitutes disease. In other cases the process is essentially pathological, as, for example, in fatty degeneration of the heart and white soft - ening of the brain ; the functional activity of the part being impaired, or so abolished that the name of necrobiosis, or death-in-life, has been given to the condition. The fatty change in the two instances is, however, manifestly one and the same. The condition known as fatty de- generation had long been described, and it has always been a favourite subject with pathologists to discover its nature and its cause. It was generally assumed that the fatty matter present was introduced from without, being deposited from the blood as morbid material in place of the pre-existing tissues which were absorbed. Modern research has demonstrated that this is not so, and that fat is derived from a molecular change in the tissue or textures in which it is found. The subject is one of immense impor- tance, involving the whole field of pathology ; and it is but right to state that our acquaintance with the true nature of the process, is almost entirely due to the investigations of Dr. Quain, which were published in the Medico-Chirurgical Transactions for 1 850, and with reference to which Sir James Paget has remarked: — ‘Dr. Quain has candidly referred to many previous observers by whom similar changes were recognised ; but tho honour of tho full proof, and of the right use of it, belongs to himself alone.’ — Lectures on Sur- gical Pathology, 1st ed. vol. i. p. 107, note. Dr. Quain’s conclusion was that the molecular fattj 504 FATTY DEGENERATION, rjattcr in the degenerated fibre was the result of a chemical or physical change in the composition of the tissue, occurring independently of those processes which we call vital. The arguments which he adduced in support of this view were the following : — (1 ) That in the formation of the substance known as adipocere from albuminous material after death, the places of the muscu- lar fibres, blood-vessels, and nerves are occupied by fatty matter which could not have existed in them as such during life. (2) That a true fatty degeneration may be artificially produced post mortem. (3) That masses of albuminous mate- rial deprived of nutrition in any part of the body, or the centre of non-vascular structures such as tubercle, undergo fatty degeneration to a marked degree. (4-) That the circumstances nnder which fatty degeneration occurs in the living body exhibit impairment of general and local nutrition, such as blood-disorder, or dis- ease of the nutrient vessels. More than twenty years later (1871), Dr. Quain’s conclusions re- specting the nature of fatty degeneration were experimentally confirmed in the living animal by the investigations of Bauer and Yoit, of Munich. On administering phosphorus to a starving dog, in which the amount of nitrogen (urea) daily ex- creted had become constant, these experimenters found that the amount of the excretion was thereby increased threefold; that this nitrogen was derived from the albumen of the tissues and net of the blood ; and at the same time that three times the normal amountofoil had accumulated in the viscera. This oil could have its origin only in the transformed or decomposed albumen of the organism; the other product being the urea which had been excreted. The same results have been observed in poisoning by phosphorus in the human body. Many other instances of the formation of a fatty from a nitrogenous body might be adduced if .necessary, such as the ripening of cheese ; the increased flow of milk on a meat diet ; the for- mation of wax by bees from sugar and albumen ; the production of fatty acids and their allies from proteid compounds in the process of pan- creatic digestion; the increase of oil in olives by keeping ; and the development of a rancid oil in the flake of salmon under similar circumstances. The numerous instances just adduced combine to strengthen the position — which was, however, sufficiently established by Dr. Quain— that m true fatty degeneration, the nitrogenous material of the tissues themselves, and not the blood, must be considered the source of the oily matter. It has been said that the circumstances under which fatty degeneration occurs are further con- firmatory evidence in the same direction. These must now be considered. Conditions of Occurrence. — The circum- stances under which fatty degeneration occurs are either such as affect the nutrition of the whole system generally, or of a given organ, or portion of it, specially. General . — When the amount of blood in the body is quickly reduced, for example, by severe but not actually sudden haemorrhage, death may occur from fatty degeneration of the heart, the voluntary muscles and the other viscera being likewise, but less seriously, affected. Again, FATUITY. general fatty degeneration is frequently due to depraved quality of blood, and especially to the presence in it of certain poisons, such as phos- phorus, arsenic, antimony, and the more complex animal- poisons of the acute specific fevers. Local . — Disease of the nutrient artery of a part is the morbid condition most frequently as- sociated with localised fatty degeneration. A good instance of this is furnished by fatty de- generation of patches of the muscular tissue of the heart corresponding with degeneration, ob- struction, or compression of a branch of a coro- nary artery. Another excellent example of the same is white softening of the brain from vas- cular degeneration. This is analogous to what occurs in dry gangrene, with the exception that decomposition takes place in the latter, probably from the admission of air. Summary. — When wo review the circumstances under which fatty degeneration is found to occur, we discover that the condition that is common to them all is interference with nutrition, and especially with the process of oxidation. The red corpuscles are believed to be primarily- affected in phosphorus-poisoning: they are nu- merically reduced in continued haemorrhage: and they do not reach the tissues in sufficient numbers when the vessels are obstructed, or otherwise diseased. In the cases of the hyper- trophied uterus and heart, of the placenta, and probably of the corpus luteum, the degeneration is probably due to the decline or cessation of functional activity, and the consequent decrease in the blood-supply to the large mass of proto- plasmic structures. With respect to the intimate or essential nature of fatty degeneration, it may bo stated as highly probable, as far as our present knowledge ex- tends, that the metabolism or decomposition that is constantly- going on in living protoplasm is not simple or immediate ; but that a primary decomposition occurs of albuminous substances into urea (or its allies) and fat, and a further or secondary decomposition of the fat into car- bonic acid and water. If the amount of oxygen furnished by the blood is deficient, whether absolutely or relatively, the primary decom- position of the protoplasm alone may be effected; and the secondary decomposition, or the oxida- tion of fat into carbonic acid and water, m3y not occur. The result therefore of an absolute or relative deficiency of oxygen in protoplasmic tis- sues will be the aceumufation of fat within them. Effects. — The physical effects of fatty de- generation of a tissue have been already de- scribed under the head of physical characters, being chiefly — change of colour, diminished con- sistence and resisting power, softening, rupture, dilatation and excavation, and alteration cf size. The chief physiological effect is diminished functional power or activity, which is especially marked in muscular parts such as the heart, and in the kidneys. Treatment. — T he subject of the treatment of fatty degeneration will be found discussed under the head of the diseases of the several organs which it may affect. J. Mitchell Bruce. FATUITY I fat nus, silly). — Mental imbeca lity. See Imukciuty. FAUCES, DISEASES OF. FAUCES, Diseases of. See Thboat, Dis- eases of. FAVUS ( favus , a honeycomb).— Synon. : Tinea favosa ; Fr. Favus; Ger. Wachsgrind. .ZEtioloqy.— Favus is very uncommon in Eng- land; it is more frequently seen in Scotland and abroad. It usually attacks the scalp, rarely the body, of young children amongst tho poorer members of the community. It may be contracted from certain animals, especially mice. Anatomical Characters. — If the favi be ex- amined microscopically — that is, if small portions be placed in potash and put under the microscope — they are seen to be made up entirely of fungus. The fungus by its growth irritates the scalp, and making its way down the hair-follicles, it finds access to tho hair-shafts, which are swollen, altered in texture, and loaded with fungus- elements, whilst the hair-forming apparatus be- comes more or less destroyed and the hair falls. The fungus ( achorion Sch'onleinii ) consists of oval, nucleated conidia, gAg inch in diameter, free, jointed or constricted; large branching or tortuous mycelial filaments, gA_ inch or so in diameter, filled with granules and spores ; and stroma made up of minute cellular elements. Description. — The characteristic feature of the disease is the development of light sul- phur-coloured, circular, cupped crusts, called favi, penetrated by the hairs in their centres. At first a minute opaque spot is visible beneath the epidermis, and this gradually enlarges into a favus. These favi are about the size of a split- pea, or larger, varying, in fact, from 5 'j to j| of an inch in diameter, and A to ^ of an inch in depth. They lie or are imbedded in a depression of the derma, and are convex therefore on their under aspect, but concave above, and the surface has a stratified appearance. These favi maybe discrete orcrowd together into an irregular mass, in which the distinctness of the several favi is more or less lost. In severe cases redness, soreness, tume- faction of the scalp, and baldness result. Diagnosis. — Favus may be mistaken for im- petigo at first sight, but only by a careless observer, because characteristic favi are always present. Treatment. — The treatment is both disap- pointing and tedious. The patient must be placed under the best hygienic regime ; his nutrition must be improved by good living, and tho exhi- bition of cod-liver oil, steel, and quinine; the favi must be removed by poulticing; and para- siticides must be continuously applied, in con- junction with the practice of epilation. At first sulphurous acid lotion (one part to three or four of water) may bo continuously soaked-in for some time ; and this may be followed by the infriction of iodide of sulphur ointment, double strength, if it can be borne, to which is added oil of cade in tho proportion of two drachms of the latter to an ounce of the former. Tilbury Fox. FEBRICULA ( febricula , slight fever). — Synon.; Fr. Febriculc ; Ger. Febricula. Definition. — Simple fever, of one {Ephemera) cr not more than a few days’ duration ; not pre- ceded by any one known invariable antecedent; and not attended by any one definite organic lesion. FEBRICULA. 505 It may well be doubted, however, whether such a thing as simple fever, in the strict sense of the term, exists ; anyhow it must be one of the rarer forms of disease. The conditions which, from our necessarily imperfect knowledge, it is con- venient to call Febricula are numerous and of great practical importance. They may be some- what roughly grouped as follows : — 1. Abortive or incomplete forms of some one or other of the specific continued fevers, namely, typhus, typhoid, or relapsing. The writer’s own experience leaves no doubt in his mind that such irregular forms are met with during epi- demics of those diseases. 2. Instances of some of the exanthemata, es- pecially scarlatina and modified variola, in which the usual rash is either absent or so slight or brief as to pass unnoticed. 3. Intermittent fevers in which for some reason or other the paroxv-sms do not recur, or only at uncertain and distant intervals. 4. Cases in which the local symptoms usually attending certain forms of fever are very slight or very obscure, and therefore difficult, perhaps impossible, to detect. Instances of this occur in connection with tonsillitis, erysipelas, rheumatic fever, and tubercular disease. 5. Cases in which considerable febrile move- ment is present during the development of the primary as well as of the secondary symptoms of syphilis, and of which it is not easy to ascer- tain the real cause. 6. Fever as the consequence of exposure to a high external temperature, for instance, th efebris ardens of tropical climates (Murchison); and of violent and prolonged muscular exertion. 7. Fever as the consequence of irritation of any organ or tissue, such as the stomach by in- digestible matttr, of tho colon by scybala ; or of catarrh of a mucous surface, for example, urethral fever. 8. Certain ill-understood but not uncommon disorders of nervous centres, cerebral, spinal, or sympathetic, are often followed by febrile move- ment. Anatomical Characters. — Fever, however caused, which runs high produces congestions and tissue-changes in the viscera, especially in the lungs; but, in view of the short duration of febricula, it would in most cases be impossible to decide whether any pathological change found after death were the consequence or the cause, of the febrile movement. It is possible, but not yet proved, that there may exist some contagion capable of producing febricula, and febricula only. Symptoms. — Febricula is characterised by a rise of temperature, rarely exceeding 102'5°F., but sometimes, especially in cases due to ex- posure, reaching 105° F. or even higher, al- though only for a short time. The access of fever may be gradual, or marked by slight rigors ; and some or all of the common clinical sj-mptoms of fever may be present in varying proportion and in greater or less degree, such as general malaise ; dry skin ; frequent pulse, amounting to 100 or 120 per minute; tongue furred and with a more or less distinct central dry reddish- brown streak; thirst, loss of appetite, and nausea ; constipation ; scanty high-coloured urine ; 506 FEBR10ULA. and headache, intolerance of light, slight deaf- ness, restlessness, sleeplessness, and slight de- lirium at night. Diagnosis. — The diagnosis of febrieula rests upon the exclusion of all the other recognised kinds of idiopathic or of symptomatic fever. As a matter of practical diagnosis at the bedside, almost every disease attended by rise of temper- ature is now and then, at its outset, mistaken for febrieula. Puognosis. — The prognosis depends upon the degree and duration of the pyrexia, but in this country is almost always favourable. Treatment. — In the absence of any special indication, rest in bed for a day or two, liquid food until the desire for solids returns, and, if constipation be a marked feature of the case, a moderate dose of some mild purgative, will be sufficient. It is, however, always prudent to remember that what seems to be febrieula may be the beginning of some serious and perhaps highly infectious disease. Cooling drinks such as Citrate of Potash in effervescence, Liquor Am- monite Acetatis with a little Spirit of iEther ; or Nitro-hydrochloric or Dilute Nitric Acid (one drachm to a pint of water) with some fresh lemon-juice added, may be given according as the one or the other is grateful to the patient. Anything like active treatment, except the use of the cold or tepid bath in cases of heat-fever, is unnecessary, rarely does good, and is almost always positively injurious. J. Andrew. FEBRIFUGES ( febris , a fever, and fugo, I drive away). Svnon. : Antipyretics. Definition. — External applications or in- ternal remedies which tend to lower the bodily temperature when it has been abnormally raised by the processes of fever. « Enumeration. — The principal febrifuges, given in the order of their activity, are: Cold Baths; Cold Affusion or Wet Pack; Alcohol, and Dia- phoretics ; Salicylic Acid, Quinine, Digitalis, and Aconite ; Trimethylamine ; Iron ; and Water and Diluents generally. Action. — Following Professor Binz, we may divide febrifuges into two classes: — 1. those which directly withdraw heat from the fevered organism ; and, 2. those which lessen its pro- duction. 1. In the first division we must give the fore- most place to cold baths, which powerfully ab- stract caloric from the surface of the body and rapidly cool down the blood. Diaphoretics and alcohol act more feebly in the same direction, by dilating the cutaneous arterioles, and thus allow- ingthe mass of the circulating fluid to be effec- tually exposed to the chilling influence of the air. See Cold, Therapeutics of ; and Diaphoretics. 2. Secondly, we have to consider those drugs which actually check the febrile condition itself, and our explanation of their effects must natu- rally depend on the views held regarding the intimate nature of fever. If we believe in an over- borne or paralysed condition of the nervous sys- tem as any essential factor, or if we look upon the vascular structures as primarily at fault, then we must shape our theories accordingly ; but if we believe, with our best authorities, that the true explanation must be looked for in the introduc- FEIGNED DISEASES, tion of extraneous ferments or septic material into the blood, the matter is much simplified. Quinine and salicylic acid then merely act in virtue of then- antiseptic power over protoplasm ; aud if malaria really depends on the fermenting influence of vegetable germs from decaying vege- tation, then the so-called specific action of quinine is readily explained. Again, temperature may be lowered by checking the oxidation of the tissues, and interfering with the oxygenating function of the haemoglobin, and alcohol is said more particularly to act by lessening the activity of secreting cells. The free use of water tends to promote excretion, and thus to remove the products of oxidation. Uses. — Antipyretic treatment is not adopted in this country as a matter of routine, holding as we do that temperatures raised within certain limits are not per se elements of danger, and that even although we may effectually cool down our patient, the progress of the disease may go on quite unchecked. Butwhen thethermometerregis- ters 105°, and still tends upwards, we know that dangerous limits are reached, and that as a rule life is not long sustained after 107°. It then becomes our duty to interfere, and this is best done by plunging our patient into a bath at 95°, and gradually cooling it down to 65°. When the temperature goes down to within 4° or 5° of the normal we remove him to bed, remembering the dilatation of vessels which must follow the con- tracting effect of cold, and the consequent cooling process which must continue to go on. Here, as in all febrile conditions, the thermometer is onr surest guide, and we must be directed by it as to when to resume the treatment, for frequent repeti- tion may be needed, and on the Continent as many as 200 baths have been given in the course of a single illness. Along with this the Germans com- bine theuseof largedosesof quinine; but notwith- standing the marked tolerance of the drug under pyrexial conditions, the danger of perilous depres- sion from such free medication is no imaginary one ; and, putting ague apart, we find this valu- able drug most beneficial in such fevers as seem to owe their origin to septic poisoning. Digitalis is not a powerful antipyretic, and in large doses is too depressing to the heart, and too apt to produce gastric derangement, to inspire much confidence ; while veratria seems simply to act by throwing the patient into a form of col- lapse. The influence of salicylic acid over acute rheumatism is remarkable, as it seldom fails to reduce temperature and relieve pain in forty-eight hours, but in other feverish condi- tions its beneficial action is by no means so well marked. Iron is of value in erysipelas, and exerts some controlling power over acute rheumatism. Aconite and diaphoretics are of undoubted ser- vice in aiding the defervescence of some of the minor febrile disorders. II. Farquharson. FEBRIS (Latin). See Fever. FEIGT7ED DISEASES. — No insignificant part of the real difficulty in the practice of our profession depends on what we may call feigned diseases. The art of diagnosis consists in the power of recognising morbid conditions with skill and promptitude ; and in proportion to th' natural sharpness and weli-digested experience FEIGNED DISEASES. of the medical man, is his success in the discri- mination of one symptom from another which resembles it more or less superficially. Many disorders possess a strong family likeness in their very early stages, whilst others may prove deceptive throughout their whole career, and if to this we add tho efforts at deception occasion- ally resorted to by impostors, we see the caution which must of necessity be adopted by those who exercise their calling within wide limits. In considering, therefore, the subject of Feigned Diseases a greater amount of order may attend our studies if we adopt the following simple classification : — 1. Those diseases which naturally resemble one another, and in the deception attending tho diagnosis of which tho patient has no share. 2. Those diseases which are also difficult of diagnosis, but in which the patient involuntarily deceives under some morbid nervous impulse. 3. Cases in which tho patient sets himself deliberately and elaborately to deceive those around him. 1. Under this heading we may perhaps in- clude the exanthemata and other acute feverish affections, which are confessedly difficult of diag- nosis before the eruption or other marked points of difference are fully established. Important though it may be, in the case of public schools or large bodies of men, to act promptly in the faco of such an emergency, the medical man will often feel himself compelled to postpone his de- cision, but he should at the same time act on the defensive by tho timely exercise of quarantine and hygienic precautions. Some diseases, again, are difficult to distinguish from one another, even after their prodromata have passed away, and among these we may include small-pox and pustular syphilis, which occasionally in our own experience have caused more than a shade of suspicion to pass over the mind ; whilst mild variola and severe varicella must always have too many points in common, to render them otherwise than stumbling-blocks even to the initiated. Various forms of roseola may closely simulate measles ; scabies is often hardly to be picked out from amongst the eruptions which its irritation causes; whilst throat-affections may ap- parently overlap each other and engender the idea of diphtheria where nothing more than super- ficial or aphthous ulceration really exists. But it is when the ailment under which our patient labours resembles something else during its whole career, that mistakes are naturally most likely to arise. We are frequently shocked with some scandal in which the innocent victim of brain- or other organic disease has been consigned toapolice-cell, and where the plea of drunkenness Las been attempted to be sustained by the guar- dians of the public peace. So difficult i s it to make a really trustworthy diagnosis between the coma of alcohol, of uraemia, of opium, and of certain apoplectic conditions, that the really cautious and well-informed practitioner would prefer not to attempt to do so offhand. It is impossible to lay down any general rules, but we may remember that alcohol in poisonous doses lowers the tem- perature and dilates the pupil ; that in uraemia an examination of the urine will put us in the tight track ; whereas opium will produce a con- 53? tracted pupil ; and in cerebral haemorrhage some elevation of the body-heat may not improbably be observed. But all these points may fail us from time to time, and we had best act at all times as though the case were really a serious one, and worthy of being treated by all the best resources of the medical art. A very little consideration will enable every experienced practitioner to recall other instances of this sort of natural mimicry ; of the difficulty he must often experience in deciding between syphilitic and other brain-affections ; of the close affinity between pulmonary' consumption and dilatation of the bronchial tubes ; of the resem- blance between specific and malignant ulcera- tions ; between various diseases of tho testicle, the bladder, and the stomach, respectively'. All these form part of the regular teaching of medicine and surgery, and will be treated of at greater or loss length elsewhere. 2. We must now consider the cases in which diseases are feigned not by the direct action of the patient himself, but because he is unable to resist the vagaries of his weak and excitable nervous system. Problems of the greatest complexity and diffi- culty are here presented to the medical man and require for their due solution much tact and ex- perience. Functional affections so closely simu- late organic disease under these circumstances that suspicion is often completely disarmed, and treatment adopted the very opposite of that which would most probably prove curative. Hysteria, in its protean forms, supplies the greater number of these cases, and may very closely simulate a large variety', more especially of neurotic conditions. Paraplegia, incon- tinence of urine, joint-affections — in short, almost any disease which does not admit of palpable objective demonstration — may thus be feigned, and very severe treatment may even be adopted under the belief that real organic changes have to be met by the usually appro- priate remedies. It is only necessary for us to refer thus briefly to these perplexing cases here ; but it must always remain an interesting pro- blem as to how the mechanism of causation here works, so to speak, and whether the patient actually suffers the acute pain of which she com- plains so forcibly. Sympathy, as we well know, however, is quite thrown away when dealing with these persons ; and apparent roughness, with nervine tonics, and mental discipline, will often effect a cure, when the most elaborate combina- tions of other drugs ignominiously fail. A sudden shock, the pressure of poverty, or the absolute necessity for immediate exertion, will often effec- tually and permanently arouse the bedridden hypochondriac of many years, and restore him to his friends as a useful member of society, and wo need never despair of success even under appa- rently hopeless circumstances. And although in minor measure the hypochondriac may fancy that every organ in succession is the seat of disease, and may even succeed in thus imposing on the unwary, the experienced practitioner will speedily detect the fiction and be able to relieve the un- happy sufferer from the weight of his woes. But let it not be forgotten that ■ expectant 508 FEIGNED DISEASES, attention,’ or the constant direction of the mind to the supposed morbid condition cf any par- ticular organ, may actually catch the unconscious deceiver in his own net by converting mere functional disturbance into organic disease. ■ To the third division of our subject the term Feigned Diseases can perhaps alone strictly be applied. Here we are met face to face with deliberate and premeditated imposture, and there is nothing for it but to match our own wits against those of the deceiver, and to thwart his native cunning by the superior sharpness of science. Now, there is nothing in the history of medicine more remarkable than the elaborate ex- pedients adopted, and the amount of actual dis- comfort and suffering endured, by persons who have been desirous of escaping military or other duty. The exhaustive works of Gavin and Mar- shall, and Boisseau and others, give us details no less ingenious than interesting of these devices ; but it is curious to note in how limited a range the more traditional modes of imposture seem to run. and how the same old stories are made to do duty over and over again. Thus we read of blindness, and deafness, and epilepsy, and para- lysis being carefully imitated, and can hardly withhold our admiration from the astonishing tenacity with which the apparent symptoms were duly maintained. Incontinence of urine, dysentery, haemoptysis, jaundice, and insanity were among the most favourite roles in the repertoire, and ingenious as were tho prepara- tions for duly sustaining the part, no less in- genious were the means for detection, which usually proved successful. However carefully the impostor had studied his character, some little point was usually omitted. The yellow conjunctiva of jaundice can hardly be feigned ; the incontinence of urine was generally found to bo attended by an expulsive effort; the blood apparently proceeding from the lungs was by no means intimately mixed with the pulmonary mucus ; the blindness, or the deafness, or the paralysis were not proof against some sudden shock or mental impression. Most of the cases so carefully described by writers on military medicine are now mere matter of history, and are hardly likely to occur again. And the reasons for this are twofold. First : the in- ducement for deception is practically gone. In former days, when the soldier’s pay was small and his hygienic condition bad, discharge from the service as an invalid was eagerly prized as a means of escaping irksome duty, but things have greatly changed for the better of late years. Not only is the emolument and the comfort of our army vastly increased, but short service and the Eeserve enables men to retire early into civil life, whilst the abolition of bounty has removed the principal pecuniary inducement for frequent desertion and re-enlistment. It is now found much easier for a man simply to desert than to go through any elaborate process for the per- sonification of disease. Again, the savage process of forcible impressment for naval service was naturally productive of many attempts to escape from the hard work and ferocious discipline of our men of war. Secondly: the process of science and improved means of diagnosis have rendered the task of the impostor difficult, if not FEVER. well-nigh hopeloss. Feigned blindness can hardly resist the test of the ophthalmoscope ; electricity will clear up many apparently anomalous nervous symptoms; the stethoscope and the sphygmograph will tell us the real condition of the heart ; and careful observation will detect the rougher at- tempts to deceive. Again, malingering may often be exposed by examination under chloroform or ether. We are not likely now to be taken in by a piece of liver tied to the breast to simulate cancer, or by an artificial nasal polypus; and although skin-diseases and ulcerations may be made or kept up by local applications, we only require a suspicion to cross our minds to put us on the right track for discovery. We are not, however, to suppose that all attempts at deception have finally passed away, that feigned diseases are now things of the past. Anyone whose practice lies ameng prisoners or soldiers or schoolboys will very soon be convinced to the contrary. Experience, however, will soon show him what the schemers are, and enable him t; circumvent their endeavours ; and the range of symptoms simulated will soon be found to bo singularly narrow. Subjective sensations are of course very difficult to detect, and if a headache, or pain in the back or leg or arm, be complained of by the sufferer, real or assumed, we may often find it best for our own reputation to give him the benefit of the doubt. A case which hap- pened to the writer whilst medical officer to Rugby School, forcibly illustrates this position. A little boy complained on several successive mornings of most severe pain in- the right calf, rendering him almost or quite unable to walk. Inspection could discover nothing wrong, there was no redness nor tenderness, and he had no recollection of any injury. Some suspicion of malingering was aroused, but it was thought most prudent to allow him to remain at rest. Four days later a red spot appeared about the middle of the calf, followed by a superficial abscess, which broke in due course, giving exit to half an ordinary sewing needle, which had evidently been working its way gradually upwards among the muscles of the leg. How it obtained admittance could not bo ascertained. Whilst proceeding, therefore, with due caution, the practitioner must endeavour to hold the balance bet ween an excess of suspicion and a too credulous attitude, remem- bering that the good of society and of the public service must be fairly considered, whilst all care must be taken not to confound the innocent with the guilty in dealing with disorders which in- genuity has occasionally been enabled to feign. Robert Fakquharson. FEIGNED INSANITY. -See Insanity, Feigned. FESTEB. — A superficial suppuration result- ing from irritation of the skin ; the pus being de- veloped in vesicles of irregular figure and extent. The suppurating inflammation caused by a thorn or splinter of wood forced into the flesh is a com mon example of a fester. FEVER (Jcrveol am hot). — Synon. : Purexiu : Fr. Fievre ; Ger. Ficbcr. Definition. — One of the most remarkable facts in connection with disease, is the rise of temperature which is attendant upon almost FEVER. every disturbance to ■which the body is sub- jected. This rise of the temperature of the body, when it attains a certain height, and lasts a certain time, is called Fever, and is accompanied by derangement of function, attributable to the febrile condition itself, and in a measure inde- pendent of the initial cause. General Considerations. — Fever plays so important a part in acute disease generally, is accepted so universally as a mark of the severity of the disease, and so often presents itself as apparently the chief antagonist with which the physician or surgeon has to contend, that the at- tempt to penetrate the secret of its essential nature lias always been a favourite task, and every school in every age has had its theory of the febrile pro- cess. It is only, however, within comparatively fow years that exact measurement of the body- heat by the clinical thermometer, combined with chemical examination of the various excretions at different temperatures, and aided by the ex- perimental method of investigation, has furnished the data for such a theory. A minute descrip- tion of fever in the abstract, distinguishing, as would be required, between phenomena proper to fever, and phenomena due to the condition or lesion on which the fever depended would be lengthy, and so crowded with qualifications and exceptions as to be vague and unsatisfactory. The attempt, indeed, would have a more radical defect. Either some variety of fever must be taken as a type to which other forms are re- ferred, which is vicious in principle ; or all the phenomena of all febrile conditions must be enumerated and classified, which would con- found the accidental with the essential, and would result in a heterogeneous collection of facts without due relation among themselves. A mere outline therefore will be given of the principal deviations from normal functional ac- tion observed in fever, and the space set apart for the subject will be reserved for an exposi- tion of what is known of the nature of the febrile process. Description. — In every attack of fever there are traceable the three stages of invasion, domina- tion, and decline, with or without an antecedent period of incubation. They may all be run through in the course of a few hours, as in a paroxysm of ague, or they may extend over weeks. The period of invasion is characterised by a rising internal temperature, while the surface may remain cold and pale, the patient feeling chilly and suffering from rigors or shivering ; the pulse is frequent, but generally small and long, from contraction of the arteries. During the dominance of fever the temperature re- mains high, the skin is hot, and the shiverings are replaced by a subjective sense of heat ; the pulse is now full and bounding from relaxation of the arterial wall. The decline is indicated by a falling temperature, a softer and less fre- quent pulse, and by a return towards normal conditions generally ; it may be initiated or ac- companied by a critical sweat or other evacua- tion. Death may take place at any period of the disease. Taking the temperature as the index of the duration and character of each stage, we may find it in the first stage rising abruptly or 509 gradually, continuously or with remissions. If the invasion extends over several days as in enteric fever, nocturnal exacerbations and morn- ingremissions are, as a rule, observed. A rapid rise of temperature is usually continuous, or nearly so. When the opportunity occurs of making the observation, as in intermittent or relapsing fever, or when fever is experimentally induced in animals, or in man by surgical opera- tion or accidental septic inoculation, the increased heat is found to be the initial phenomenon, pre- ceding the rigors and all other symptoms. The end of the period of invasion, and the setting in of the stage of dominance, is more distinctly marked by the change in the character of the pulse, and by the determination of blood to the surface, together with the substitution of the subjective sensation of heat for that of cold, than by the thermometer. During the dominant stage the temperature remains at, or oscillates about, a given point, and the fever is considered to be moderate if the morning temperature is 102° or under, and the evening not above 103°; to bo high when it ranges between 103° in the morning and 101° in the evening; and to be severe when these limits are exceeded ; while, with rare exceptions, a temperature of 100° indicates great danger. As the stage advances, the heat may gradually rise or fall; the oscillations being slight or consider- able, and at times irregular and extreme. Except when the fever is due to local inflammation, or to continual entry into the blood of morbid par- ticles or fluids, the duration of the dominance is usually in proportion to the time occupied by the invasion. The decline again is generally abrupt, and has the character of a crisis when the invasion has been rapid, and is protracted when it has been gradual. A fatal termination may be ushered in by hyperpyrexia ; more commonly the temperature falls below the normal point and there is collapse. The pulse is always increased in frequency by fever, but while during the height of the disease there is usually some relation between the body- heat and the pulse-rate, the pulse is often ex- tremely frequent before the temperature has reached its height during the invasion, and it does not in all cases fall with it pari passu in the decline. The different stages are marked rather by differences in the character of the pulse than in its rapidity; during the period of invasion the arteries are more or less in spasm, and the pulse is small and long ; during the dominance, with certain exceptions, the arterial walls relax, the vessels are large, and the pulse full and bounding; as the fever declines the arteries are still further relaxed, but the action of the heart is less powerful, so that the pulse becomes softer. Respiration is frequent, following as a rule the pulse : the amount of carbonic acid expired is greatly increased. The tongue is generally more or less furred, its appearance varying with the degree and kind of fever and with its cause. It becomes brown and dry, or unnaturally red in protracted and adynamic fever, when the teeth and lips may also be ceated with sordes. There are almost FEVER. 310 always thirst and loss of appetite. The bowels are usually confined. The secretions are all more or less modified. The perspiration may be greatly increased as in acute rheumatism, or apparently checked, caus- ing the skin to be dry and burning. The amount of urine will vary to a certain extent inversely with the amount of perspiration ; but the ten- dency is to increase, and the solid organic mat- ters — urea and other nitrogenised substances— are always considerably augmented in quantity. The chloride of sodium, on the contrary, ,‘s dimi- nished. The characteristic nervous phenomena of the stage of invasion are rigors, which may be slight, and represented only by shivering or chilly sensa- tions, or, on the other hand, may be intensified to convulsion. Severe headache is more common at this period than in the later stage, and there is usually considerable depression. When the fever has reached its height the rigors will have ceased, and there maybe little or much delirium according to the severity of the attack, or the idiosyncrasy of the patient, or, again, accord- ing to the kind of disease giving rise to the fever. Pathology. — The description of the febrile state has been cut short in order to leave, place for a discussion of the nature and cause of the febrile process. This will be facilitated by a brief reference to the production and regulation of the heat of the body in health, and would be compara- tively easy had physiologists arrived at a com- plete and satisfactory solution of this problem. In the normal state the main source of animal heat is blood- and tissue-combustion. Another very slight and unimportant cause will be ob- structed motion of the blood in the capillaries : of direct conversion of nerve-force into heat we know nothing definite. The interesting and difficult part of the question is that which re- lates to the regulation of the temperature. It has been found that the changes which evolve heat are most active in muscle, in the nervous structures, and in the abdominal viscera ; while in the lungs, any combustion which may take place is not more than will counteract th6 loss of heat by evaporation and by the expired air. The skin, on the other hand, is the great cooling agent; there is little combustion of its struc- tures and it is continually losing heat by conduc- tion when the surrounding temperature is low, but still more abundantly by evaporation under all conditions of external temperature. Heat is thus abstracted from the blood circulating in, and immediately beneath, the skin. At first sight then it would seem that the mechanism by which the temperature was regulated was extremely simple, and that it was to be found in the vaso- motor system of nerves. There being an internal heat-producing mass of tissue, and an external refrigerating surface, to raise the temperature, the arterioles of the skin are contracted, shutting off the blood, while those of the deeper structures are relaxed, allowing it to reach them in greater abundance ; in this way a double influence is exerted, less heat is lost by the skin, and more is produced in the muscles and other internal parto. Conversely, the temperature would be lowered by flushing the skin wi‘h blood — which would thus be exposed to cooling influences — and diverting it from the heat-forming, deep-seated structures. This explanation, however, is inade- quate ; it is true that the distribution of the blood, superficially or deeply, by means of the vaso-motor nervous system, contributes largely to the regulation of the temperature, but heat- production in muscle or gland is not directly proportionate, simply to the amount of blood circulating through it; tissue-combustion, and consequent evolution of heat, are excited or re- pressed by cerebro-spinal nerves not governing the arteries. The nervous system thus inter- venes directly in heat>production as well as indirectly through its influence on the circula- tion, and it has been shown that the stimulus to tissue-change and heat-production is a reflex from peripheral impressions. This is not the place to discuss the question whether there are special thermal nerves and centres, but it may be said that this has not been proved. Taking the increased heat as the charac- teristic of fever, the first question which arises is whether this is due to increased production of heat, or to diminished loss. While the diminished circulation in the skin, in the early stage, will obviously tend to retain heat within the body, there is now no room for doubt that there is increased heat-production ; the temperature rises in spite of profuse perspiration, when of course heat is very rapidly lost, as in acute rheumatism, or when perspiration has been induced by jabo- randi before a paroxysm of ague (Ringer) ; and it has been shown by direct experiment that in fever a man raises the temperature of a given quantity of water in which he is immersed more quickly, and to a higher point, than in health (Liebermeister). It is unnecessary to give other proofs or further refutation of the hypotheses which explain the heat of fever solely by diminished escape of heat from the body. It may further be taken as certain that the immediate cause of the increased generation of heat is increased blood- and tissue-oxidation. This is shown by the increased products of com bustion given off in the different excretions. The febrile elevation of temperature is attended at once by increase in the amount of carbonic acid expired. This is more marked during the rise than when the heat has attained its maxi- mum, because the increasing temperature expels the gases of the blood, and the greater rapidity of the circulation sends the blood more freely and quickly through the lungs, and exposes it more to the air. At first there will thus be eliminated not only the carbonic acid formed under the influence of the febrile process, but that which was held in solution by the cooler blood, and is driven off as its temperature rises ; when the expulsion of dissolved carbonic acid is completed, the amount excreted will be dimi- nished by so much, but it still remains larger than at the normal temperature. A similar indication of increased tissue-com- bustion is furnished by the urine. The amount of urea is usually absolutely increased, notwith- standing a diminished consumption of nitro- genised food ; or if the urea itself is not excreted in larger quantity, there is more nitrogenised FEVER. waste in other forms. The total of nitrogenised matter contained in the urine is always aug- mented by fever. The real difficulty of the problem arises when we inquire what is the cause of the in- creased tissue-combustion. It has been already stated that the distribution of the blood to the deep structures and organs and to the skin respectively is not a sufficient explanation of the physiological balance of heat ; but it might be supposed that the greater rapidity of the circulation in fever renewing the supply of oxygenated blood within the structures more frequently and more freely, would account for the greater oxidation. The rise of temperature, however, is not in proportion to the flow of blood through the vessels, and hyperpyrexia is often coincident with a failing circulation, the heat, indeed, apparently in some cases actually increasing after death. One step towards the solution which may be considered certain is that the nervous system is concerned in the maintenance of the heat of fever. Each disease has its own characteristic range and variations of temperature, and this fact alone, that febrile heat is not vague and irregu- lar, but that there is the substitution of a morbid for a normal balance, is evidence of nervous control. Numerous observed facts and experiments point to the same conclusion. We need only mention the hyperpyrexia often re- sulting from injuries to the brain, and following section of the cord in the cervical region. Another item of positive knowledge obtained by experiment is that pyrexia may be excited by the introduction into the blood of septic or ether matters, which, it is important to note, need not be particulate, but may be diffusible fluid. The increased heat may therefore be in- dependent of capillary embolisms and of bacteroid or other organisms. Now in disease or after injuries we have almost always both causes in possible operation — an impression on the nervous system, and the entry of altered organic matters into the blood. In endeavouring to assign prominence to one or other, we have, on the one hand, such facts as the hyperpyrexia of cerebral lesions, which cannot be due to blood-contamination, and, on the other, the teachings of antiseptic surgery, which demonstrate that absorption of putrescent discharges is the great cause of surgical fever. It still remains to be determined whether the presence in the blood of foreign matters gives rise directly to increased activity of oxidation, or whether the poison, as we may call it, pro- duces this result through its action on the ner- vous system, either by affecting the nerve- centres themselves, or by producing irritation in the capillaries, which is carried to the nerve- centres, and reflected along efferent nerves. In the present state of our knowledge this question cannot be definitely settled. If a theory of the febrile process is to be formed it must be based upon a theory of the relation between the nervous system and the rrocesses of nutrition and oxidation, and es- pecially the latter. Numerous facts of disease and of experiment point to the conclusion that the circulation of duly oxygenated blood through the oil tissues at the usual rate would, without some check to oxidation, result in more rapid tissue- change and the production of a higher tempera- ture than the established norm. The restrain- ing power is supplied by the nervous system, the loss of this influence being illustrated in hyperpyrexia. The mode in which the nervous system acts may be represented as being through the tension maintained in the nerve-centres. All nervous actions have the character of phe- nomena of tension, and the tension generated in the cells is sustained in the nerve-fibres to their peripheral terminations, where they are merged in the structures, and so blended with them that all nutritive and oxidative changes are common to the nerve-endings and the tissues in which they end. If we suppose that the nerve-tension can modify chemical, action, as can electrical tension or thermal conditions, and that, vice versa, the nutritive and oxidation changes in the tissues can influence the tension of the nervous structures, we can represent to ourselves the interaction between the nervous system and the blood and tissues in the febrile process. When from disease or injury of the great nerve-centres their power of maintaining tension is abolished, and their influence destroyed, the affinities of the blood and tissues have unrestricted play, and the result is hyperoxidation and pyrexia. When, on the other hand, septic matters or other sub- stances are introduced into the blood, acting as ferments or in some other way, they increase oxidation, and directly raise the temperature, overpowering the restraining influence of the nerves until this is reinforced, which may pos- sibly occur through increased evolution of energy, resulting from the increased activity of meta- morphosis. We cannot, however, here develop or fully elaborate this hypothesis. Theatjeent. — The treatment of fever is of course primarily directed to the removal of the cause on which it depends, but together with the measures adapted tothis end are usuallvemployed means for the moderation of the febrile process as such, and these may at times take the first place. We can do little more than mention the more important of them, taking first- what may be called the general methods, andpremisingthat rest in bed, simple food, &c., are taken as under- stood. Venesection is now scarcely ever practised as a means of combating fever. Purgatives are often useful, as are also diaphoretic and diuretic salines, with abundance of water to drink, either alone or in the form of some agreeable tisane. Free action of the secretions, which is the object of these remedies, is of service in removing the increased products of oxidation, the water taken co-operating by acting as a solvent and vehicle, and it is possible that medicines which promote this activity may directly bring down the tem- perature. When, for example, perspiration has been induced, a coincident fall of temperature may be due more to some change antecedent to the perspiration than to the loss of heat by transpiration and evaporation. Of special measures for the reduction of febrile heat when this is becoming dangerous, either from its intensity or duration, the first to be mentioned is the cool or cold bath. This should be resorted to in all cases of hyperpyrexia, fron 512 FEVEIi whatever cause; its efficacy, first established in the high temperature of acute rheumatism and enteric fever, has been proved also in cases of septic hyperpyrexia after ovariotomy, and even in injuries to the brain. Here the water may be positively cold. When the bath is employed to control temperature, not dangerous from its height, but from its duration, as in enteric fever, it need not be lower than 70° or 65° Fahr. An ice-cap devised by Mr. Knowsley Thornton, for applying cold of 32° to the entire head, has been found useful in hyperpyrexia following ovariotomy. Many alkaloids havo the property of reducing febrile temperatures when taken in large doses. The most powerful, and the one most generally employed to combat fever, is quinine. When given for this purpose, it is administered in doses of from ten to twenty or even thirty grains once in twenty-four or forty-eight hours, or three to six grains of the neutral sulphate may be injected under the skin. Salicylic acid has a remarkable influence on the temperature in acute rheumatism, and some effect, though far less marked, in fever from other causes. It may be added that when pericarditis has come on in rheumatic fever, this drug usually altogether fails to influence the temperature. The only other drug which need be specially mentioned is aconite, the mode of action of which is totally different from that of quinine, and of which it may almost be said that it antagonises the fever process rather than reduces temperature ; its most marked influence being on the force of the heart and the contraction of the arteries. The opportunity for the manifestation of its powers occurs in the early stage of catarrhal fever, the result of chill. Given in frequent small doses (a drop or two of the tincture every five minutes till twenty minims or half a drachm has been taken) when the temperature is rising, the pulse frequent and hard, with headache and burning skin, the effects are often striking. When a local inflammation is established, it is no longer of much use ; and when the fever is protracted, as in enteric fever, or when there is pneumonia, it may he dangerous, from its depressant influence on the heart. W. H. Broadbent. FIBRILLATION, Muscular.— A local- ised quivering or flickering of muscular fibres. See Motion, Disorders of. FIBRINOUS CLOT. See Clot. FIBRINOUS CONCRETION. See CON- CRETION. FIBROID DEGENERATION.— A mor- bid change which consists in the substitution of a tissue somewhat resembling fibrous tissue for other structural elements ; some pathologists consider this change to be of the nature of a de- generation. See Degeneration, and Cirrhosis. FILAR IA SANGUINIS-HOMINIS FIBRO-PLASTIC GROWTH.— A form of new growth, composed of fibro-plastic ele- ments. See Tumours. FICUS UNGUIUM (ficus, a fig; unguis, a nail). — A disease of the posterior wall of the nail. See Nails, Diseases of. FILARIA SANGUINIS-HOMINIS.— In the article Chtlukia a full account is given of the embryo-Filaria sanguinis-hominis, the hoe- matozoon which is ordinarily found associated with this disease. Since that article was written, the writer has succeeded in obtaining what is beyond question the mature form of the helminth. On the 7th August, 1877, two living specimens were found — a male and a female — in the per- son of a young Bengalee, affected with well- marked naevoid elephantiasis of the scrotum, as- sociated with the presence of embryo-filari® in the blood. 1 The diseased tissues were removed by the late Dr. Edward Gayer, of Calcutta, to whose kindness the writer is indebted for the opportunity of examining them. Unfortunately the specimens were much injured by the needles used to tease the clot in which they were found : the terminal ends of the male could not be found, nor the caudal end of the female, although the fragments of both specimens manifested active movements. They were attenu- ated, fine, thread-like worms, of a white colour ; the cuticle was smooth and devoid of trans- verse markings. The fragment of the male speci- men measured half an inch in length, and ^| 6 " transversely ; it was thinner than the female, but of firmer texture, and manifested Fio. IS. Anterior end of Filaria san- guinis-hominis. — Mature form x 100 diameters. Fio. IP. A portion of the mature Filaria sanguinis llominis, showing uterine tubules filled with ova in various stages of develop- ment; also the intestinal tube, x 100 diameters. FIBROID PHTHISIS. — A name given to certain cases of phthisis in which a considerable development of fibroid tissue is found to occur in the lungs. See Phthisis. greater tendency to coil. The intestinal canal measured [*030 mm.] across, and the sperm- tube jjoo" t'016 mm.]. The length of the portion of the female worm FIBROMA. — A form of tumour composed of fibrous tissue. See Tumours. ' For further details, see Indian ifedieal Gatette, Pent 1, 1877 ; The Lancet, Sept. 29, 1877 ; and CenlraiHaa.** die medicinische Wissemcha/len, No. <3, 1877. FILARIA SANGUINIS-HOMINIS which had been secured was 1|", and its greatest width about ylD'. It was packed with ova and embryos in various stages of development ; the latter, especially those which were mature, mani- fested active movements. The head is slightly club-shaped ; the mouth does not manifest any very distinctly marked labial sub-divisions, nor are there any chitinous processes evident either before or after death. The following measurements may prove use- ful to future observers : — of an in. mm. Oral aperture to end of (Esophagus ~ or •45 Diameter of oral aperture . i :iooo ’> •008 Width of extreme end (anterior) l 517 ’» •047 Ditto anterior end at ‘ neck ’ Ditto opposite junction of in- 1 545 »* •0+5 testine with oesophagus Ditto about ^ inch from an- 1 222 ” •112 terior end . . . . Width where packed with ova and 1 153 »’ •162 embryos .... Width of uterine tube filled with 1 100 >» •25 ova ..... 1 •112 Ditto alimentary tube . 1 6G6 » •037 The ova do not possess any distinctly marked ‘shell’; from the smallest to the largest nothing but a delicate pellicle can be distinguished as enveloping the embryo in all its stages. The average of six measurements of the least advanced kinds of ova, that is, those in which the outline of the embryo was not distinctly evident, was [•01 S mm.] by s " [-012 mm ] ; whilst the Fig. 2il. Ova and embryos of Filaria sanguinis-hominis x 303 diameters. average measurements of three ova in which the embryos were visible were ^ " [-037 mm.] by ['03 mm.]. A\ hen the latter, after having arrived at this stage of development, are examined during life, it is in many instances difficult to state whether they are to be considered as freed embryos or not, as the ‘shell’ has become so attenuated and translucent as only with difficulty to be distinguished. It is possible that when the embryo acquires worm-like proportions the en- velope is not lost in this species so long as it con- tinues in the blood. With regard to the relation of the mature fdaria sanguinis-hominis to pathological pheno- mena nothing very decisive can be said ; hut when it is considered that the blood of some animals is found occasionally to harbour minute, active organisms, in great numbers sometimes, without appreciable injury, it seems not improbable that the parental forms of nematoid haematozoa, rather than the embryos, may be the more hurt- 33 FISTULA. 613 fill to the animal economy. The lesions induced by the growth of the filaria sanguinolenta in the arterial walls of dogs, to which the writer lias elsewhere drawn attention, appear to lendsupport to such a view. In 1877, Dr. Cobbold announced that Dr Bancroft, of Brisbane, had discovered specimen-* of what were believed to be mature forms of the filaria. A dead specimen was found in a lyn ■ phatic abscess of the arm ; and on a second occasion four living specimens were obtai. ed from a hydrocele of the spermatic cord. They were of the thickness of a hair and from 3 to -4 inches in length. A minute description of thorn by Dr. Cobbold appeared in the Lancet of ti e 6th October, 1877. The persons from whom the specimens were obtained had not suffered from either chyluria or naevoid elephantiasis, nor wire they known to harbour embryo nematodes in their blood. 1 Timothy Richards Lewis. FILARIiE ( filum , a thread). — A genus of nematoid worms, not very clearly defined, but which contains a variety of thread-like parasites whose body is of uniform thickness throughout, and at least fifty times longer than it is broad. Under this head are often included several human parasites, such as the Dracunculas, or Guinea- worm (Filaria medinensis), and the lung strougle (F. bronchialis), in addition to a variety of larval or sexually immature nematoids, whose genetic relations aro only very imperfectly understood. In the latter category may be placed Bristowe and Rainey's entozoon (F. trachealis) ; Von Nordmann's eye-worm (F. uculi-humani or F. lentis) ; the laa , infesting the eyes of the Angola Coast and Gaboon negroes (F. loa); and lastly, the nematoid hsmatozoon (F. sanguinis-hominis) recently described by Lewis in his illustrated memoir. It may be doubted if any of the above- mentioned parasites ought to be included in the genus Filaria, as understood by modern hel- minthologists, but, practically, it is still found convenient thus to speak of them. The Dra- euneulus will be found described under Guinea Worm; whilst the microscopic nematoid infest- ing the blood will be found noticed under the articles H.hmatozoa, Chyluria, and Filaria Sanguinis-hominis. T. S. Cohbold. FISH-SKIN DISEASE — A synonym for ichthyosis. See Ichthyosis. EISSUEE (findo, I cleave). — A narrow and superficial crack or solution of continuity, ob- served on the skin and mucous membranes, and especially near the line of junction of these structures, as on the lips and anus. See Anus. Diseases of ; and Chaps. FISTULA (Jistula , a pipe). — A narrow track or canal leadingfrom a free surface, and extending more or less deeply to some seat of local irrita- tion, or it maybe constituting an abnormal com- 1 The researches o£ Dr. Hanson, of Amoy, confirmed by Dr. Lewis, show that embryo filarise in the blood aie imbibed by the mosquito, or other intermediary host ; undergo developmental changes ; and are discharged inlo water with the larvae of the insect. Infection probably occurs through this medium. Dr. Hanson has recently stated ( Medical Times, June 1881) that the habitat of the parent filaria is in the lymphatic trunks. — E d. J14 FISTULA, aranication between two or more cavities, as in the case of vesico- vaginal or recto-vaginal fistula. See Abscess. FISTULA IN ANO. See Rectum, Dis- eases of. FIT. — A popular synonym for a sudden seizure characterised by loss or disturbance of conscious- ness from any cause, with or without convulsions. ( See Convulsions, Epilepsy, Hysteria, and Syn- cope.) The term is also applied to a sudden or acute seizure of certain diseases, such as gout, asthma, and ague. FLATULENCE {flatus, a puff of wind). Synon. : Fr. Flatulence ; Ger. Flatulenz. Definition. — The undue generation of gases in the stomach and intestines. .(Etiology. — The principal cause of flatulence is fermentation or decomposition of the contents of the stomach and bowels — a condition usually induced by embarrassment of function. Hence it is a common symptom in dyspepsia — especially the atonic forms as met with in the debilitated and the aged — constipation, gastritis, enteritis, hepatic disorders, intestinal obstruction, &c. When flatus is generated too rapidly to be ac- counted for by fermentation, as in hysteria, hypo- chondriasis, and other forms of nervous debility, it has been ascribed, but incorrectly, to secretion of gases from the mucous membrane. Symptoms. — The clinical phenomena vary as flatus is retained or discharged ; and with the seat of its formation, whether chiefly in the stomach or intestines. In the former the concomitant symp- toms are those of dyspepsia, and in the latter there is usually constipation. As a rule, how- ever, flatulence pervades at the same time more or less all the hollow viscera, and indicates torpor of the digestive organs. It is apt to lead to these further evils: — {a) Pain from distension or from irregular and forcible contractions of the walls — hence gastrodynia and colic are apt to arise; (b) arrest of the normal movements of the stomach and intestines, and consequent accumulation within them of fermentable matters, with further gene- ration of gases, leading to paralytic distension : hence dilatation of the stomach and colon, tym- panites or meteorism, and aggravation of pre- existing dyspepsia or constipation may ensue ; and (e) pressure on adjacent organs, e.g. on the heart and lungs, inducing palpitation and irregular ac- tion of the heart, precordial anxiety, faintness, vertigo, dyspncea or even asphyxia. In tympanites there is a rapid generation of flatus, which overpowers the contractility of the hollow' viscera; and the abdomen is round, tense and tympanitic. When this condition is accompa- nied by fever and diarrhoea, typhoid fever should be suspected ; but if fever be absent, while there is bilious or stercoraceous vomiting, probably intestinal obstruction exists — intussusception, internal strangulation, hernia, &c. Treatment. — (a) Imprisoned flatus should be dislodged by friction of the abdomen with stimu- lating liniments, and gentle kneading of the most distended parts ; large draughts of hot water; spirit and hot water; ammonia, ether, or spirits of chloroform ; aromatic stimulants — ginger, cloves, mint, anise, cajeput, camphor, eascarilla. &c. FLUKE. When flatulence is chiefly intestinal, enemata containing laudanum with assafeetida, turpen- tine, or rue ; and pilula assafeetidse composita with extractum nucis vomica, and an aperient are the most useful measures. ( b ) The generation of flatus should he arrested. Fermentation may be checked by sulphite or sulpho-carbolate of soda, sulphurous acid, car- bolic acid, creasote, or charcoal — from the poplar or vegetable ivory — immediately after food, and by correcting and toning the digestive organs. Food likely to ferment or lodge, such as starch, sugar, fruits or vegetables, and warm liquids — es- pecially tea and soups — should be avoided ; the meals should be well masticated and solid through- out, and liquids should only betaken sparingly at the close or an hour after. In some eases, however, flatulence is connected with an insufficient supply of fluids, and can only be met by increasing it. Alkalies — carbonate of magnesia, soda, or lime— and bitters, especially strychnia, are often useful in the flatulence of hysteria, hypochondriasis, the very nervous and the aged (Trousseau, Niemeyer) ; but perhaps the best results follow alkalies with nux vomica and bismuth an hour before, and hydrochloric acid alone or with Liebreich's Pepsin Essenz or other reliable preparation of pepsin after food. It is also essential to see that the action of the liver is healthy. George Oliver. FLEXION (. fleeto , I bend).— A bending This term is applied either to the act of bending, as in some methods of treatment, for example the cure of aneurism or the reduction of dislo- cations; or to the condition in which parts are bent, as tbe result of disease or of disorder, as when the limbs or certain internal organs aro bent upon themselves. See Womb, Diseases of. FLOODING. — A popular term for excessive discharge of blood from the womb. See Men- struation, Disorders of; and Pregnancy. Dis- orders of. FLUCTUATION {fluctus , a wave). — A physical sign consisting in a wave-like or undu- lating sensation. It is elicited by a peculiar mode of palpation with the one hand while per- cussion is made with the fingers of the other; and is due to the presence of a fluid in a natural cavity such as the peritoneum, or in an abnormal closed space, such as a cyst {see Physical Examination). The term fluctuation as used by the surgeon has a somewhatdiflferent signification, being applied to the sensation of the presence of a fluid which may be felt when alternate pressure with the fingers is made, as over the seat of an abscess. See Abscess. FLUKE. — In its original signification this term means anything flat; but, in connection with internal parasites, it refers generally to the common liver-entozoon and its allies, which happen to be more or less flat or leaf-shaped. Tho liver-fluke belongs to the genus Fasciola , though more commonly spoken of as a Distoma. Some of the flukes of man, as well as of ani- mals, have a rounded form, quite unlike that shown ly the ordinary liver fluke. IV ith <>• e or two notable exceptions, the flukes are destitute of clinical importance. Under this head mils' FLUKE. also be mentioned a remarkable fluke recently discovered by Dr. Lewis in India, and called by him Ampkistoma kominis. As there is ground for believing that several allied species (A. Haw- /cesii, A. Collinsii, &c.) prove injurious to ele- phants and horses, it is possible that the human amphistome may be productive of severe intes- tinal mischief. See Distoma, and Bilharzia. T. S. CoBBOLD. [ (Latin). — A flow or excessive dis- charge from a mucous surface through any of the natural passages, of serum, blood, mucus, pus, or the various secretions. As illustrations of fluxes may be mentioned salivation, bronchorrhcea, biliary flux, diarrhcca, dysentery or bloody flux, jholera, and leucorrhcea or white flux {Fluor ilbus). i’CETUS, Diseases of the.— Two classes of abnormal conditions are seen in the fetus, namely: — Those which depend upon some inter- ference with the process of development, such as malformations, monstrosities, &c., and those which are the result of disease. This article treats of the latter only. 1. AmptUation. — Amputation, partial or com- plete, of fetal limbs, may take place, from con- striction of the limb by a band of the amnion. An attempt at reproduction of the lost limb is sometimes seen, in the shape of rudimentary fingers and toes, projecting from the stump. That such a stump is the result of amputation is proved by the fact, that the part cut off has been found in utcro. 2. Spontaneous fractures and dislocations . — Fractures and dislocations occur in utcro, the latter being the more rare. They are due to some condition of the bones and ligaments re- spectively, leading to undue fragility of those structures ; for they are always multiple, and are not accompanied with bruising of the adjacent soft parts. 3. Tumours. — New growths are met with in the fetus— cysts of various kinds, fibromas, lipomas, &c. That most special to the fetus is a tumour situated over the coccyx, which may be as large as a fetal head. Such tumours are spheroidal or ovoidal in shape, elastic in consistence and present rounded inequalities on the surface. On section they are found to con- sist of strong fibrous trabecula?, in the meshes of which are numerous small cysts lined with epithelium. It is thought by many that they originate in Luschka’s gland. Another special kind of tumour is that known as a fatal inclusion — a swelling usually on the lower part of the trunk, and containing some part of another fetus, more or less imperfectly developed. 4. Inflammation of serous m'mbrancs. — This form of disease may occur in the foetus, such as pleurisy and peritonitis. The morbid anatomy of these changes does not differ from that in the adult. Peritonitis is often found associated with syphilis ; and it appears to be almost always fatal ! to the fetus. I 5. Visceral Inflammation.— Inflammation of the lungs has been met with, in the form of grey or white lobular hepatization. It is most frequent in syphilis. Enteritis has also been described. FfETUS, DISEASES OF THE. 515 Various malformations of the heart which are met with can be explained by supposing the oc- currence of endocarditis during fetal life ; but there is no proof that the fetus is subject to rheumatism. Virchow describes encephalitis. 6. Specific Fevers. — The morbid changes of enteric fever havo been found in the fetus In pregnant women suffering from intermittent fever, paroxysms of convulsive movements of the child have been felt to occur as regularly as the attacks of ague in the mother; and the child when brum has been found to have a large spleen. Chil- dren have also been born with skin-eruptions thought to resemble those of measles, scarlatina, and smallpox. The facts as to the last-named disease are the most numerous and probable. The eruption of variola in the fetus differs somewhat from that seen after birth, because, the skin of the fetus being bathed with fluid, no crusts form, and the pustules run a course like those on mucous membranes. 7. Diseases of the Skin. — The fetus is subject to skin-diseases. Pustules of ecthyma ; patches of erythematous redness ; ulceration of the skin, and syphilitic eruptions have been seen. Intra- uterine ichthyosis is met with. Children have been born jaundiced, but only by mothers them- selves suffering from that disease. But women with jaundice do not always bear jaundiced chil- dren. Jaundiceisnotnecessarilyfatultothe fetus. 8. Si/philis. — Syphilis leads to various lesions in the fetus, and while it usually proves fatal, the subjects of it that may survive till birth are feeble and badly nourished. Flat tubercles occur on different parts of the skin, especially round the mucous orifices; and pemphigus, affecting chiefly the palms of the hands and the soles of the feet, may be seen. The occur- rence of peritonitis has already been mentioned. Yellow indurated nodules, of varying size and number, may be found in the liver, as well as similar nodules in the lungs. A peculiar change has been described in the thymus gland, in which this structure externally appears healthy, but when cut into and compressed exudes a whitish puriform fluid. Other changes have been re- corded, affecting thu spleen, pancreas, and supra- renal capsules, but they are not distinctive. Changes in the bones have also been described, consisting of an osteo-chondritis, affecting the ends of the long bones, most frequently the lower end of the femur. 9. Rachitis. — Rickets is met with in utcro. The changes it produces are like those seen after birth. It is thought to be one of the causes of spontaneous fractures. 10. Tuberculosis. — Tuberculosis sometimes commences in the fetus, tubercles having been found in the mesentery and in the lungs. 11. Dropsies. — Dropsy is met with in the fetus, sometimes of the serous cavities, of which hydrocephalus is the most common. It is often associated with rickets. Next in frequency comes ascites, and lastly hydrothorax, which in very rare. These affections may destroy fetal life in utero\ but they more often lead to death because they render destructive operations necessary before delivery can be accomplished. General anasarca is also met with, and there ie reason to believe that it depends upon disease of 51 C FCETUS, DISEASES OF THE. the placenta, impairing the excretory function of that organ. It is always fatal, if not before, within a few hours after, birth. 12. Visceral diseases. — Hypertrophy of the liver, spleen, or kidneys may occur in the feetus. Cystic disease of the kidney may be met with, the organ being converted into a mass of cysts con- taining no trace of secreting structure. Both kidneys are usually affected, and the disease is generally associated with some malformation elsewhere. Hydronephrosis, single or double, along with dilatation of the ureter, or ureters and bladder, has been seen, dependent upon im- permeability of some part of the urinary passages. Any of these visceral diseases may form a tumour so large as to impede delivery. None of thorn can be diagnosed before birth. Concretions of uric acid and urates are not uncommon. The Causes of Death of the Foetus. — The various causes of death of the feetus in utero may now be briefly considered. The first of these is injury, as when the mother receives a blow upon the abdomen, or has a fall. Such occurrences rarely directly injure the foetus, al- though this has been known to happen. When they prove fatal to the feetus, they do so by lead- ing to haemorrhage into, or separation of, a por- tion of placenta, and consequent disturbance of the foetal circulation. Poisons in the mother’s blood, such as lead, urea, or carbonic acid (as in the case of heart-disease with cyanosis), may lead to death of the foetus. Syphilis has already been referred to. Epileptiform convulsions may de- stroy foetal life, either by asphyxia, or by leading to haemorrhage into the placenta. Extreme ancemia and the cancerous cachexia, are among the causes of foetal death. Any kind of disease attended v/ith. pyrexia will also destroy foetal life if the temperature rise high enough. A tempera- ture exceeding 105° Fahr. appears to be invari- ably fatal to the foetus. Certain diseases of its appendage smay lead to death of the feetus, such as fatty degeneration, or oedema, of the placenta ; obliteration of the umbilical vessels ; or inter- ruption of the circulation in the cord by knots in it, or pressure upon it. It is believed that there are some diseases of the mother's uterus which lead to death of the foetus ; but what they are is not known. It is said that some women acquire a habit of having dead children. This means that there are cases in "which an apparently healthy woman will repeatedly have dead children, the cause of whose death a skilled observer cannot find out. In other words, there are causes of foetal death as yet unknown. The Consequences of Death of the Feetus. A dead foetus while retained in utero, and thus protected from the air, does not putrefy, but un- dergoes a process of maceration. The whole body becomes soft and flaccid, its tissues being infiltrated with fluid ; but it has no putrid odour. The skin presents bullae filled with reddish serum, and the epidermisis readily detached with slight friction. The surface is of a cyanotic colour, which after exposure to the air becomes of a more or less bright red ; it is not greenish, as is seen in putrefaction. The cellular tissue is infiltrated with bloody serum. The viscera have lost their distinctive tints, and become of a reddish-brown colour. The cranial bones are FOMENTATION. abnormally mobile, overlapping one another to a greater extent than normal; and the periosteum may be stripped off them. These appearances are much the same, whatever be the cause of death, but they vary in degree according to the length of time whichhas elapsed since death. Besides the diseases of the foetus described above there are others which are not fatal, and the chief interest of which lies in their courso and treatment after birth. These are discussed in other articles, and for that reason are not mentioned here. G. E. Hebmax. FOLIE ClftCULAIHE {French). — This term is applied by the French psychological physicians to a variety of insanity characterised by alternations of excitement and depression. The patient passes through an attack of mania of perhaps an ordinary character but when he appears to have recovered he sinks into melan- cholia, and thence emerges again to become maniacal and excited. The duration of each stage may vary from weeks to months ; some- times one state will follow the other immediately ; in other cases a period of convalescence will intervene, during which the patient appears well, and can hardly be considered insane. Yet the prognosis is extremely unfavourable in all such cases, and it is of great importance in estimating the extent of recovery of a patient that it should be clearly ascertained that the attack is not one of a series following one another in the manner mentioned. G. F. Blaxdfoed. FOLLICLES, Diseases of ( follietilus , dim. of follis, a bag). — The name ‘ follicle ’ has been applied to a great variety of different structures, which have in common the shape of a bag or sac, whether circular or elongated in outline ; for example — the Graafian follicles, the lymphatic (Peyerian) follicles of the intestine, and the fol- licles of the mucous membrane of the stomach, intestine, and uterus. The name has been fur- ther extended to include glands somewhat more complex in structure, such as the sudoriparous glands or sweat-follicles, the sebaceous follicles, and the tonsils; as well as the saccular depres- sions in which the hair and the teeth take thoir origin. The name Synovial Follicles is sometimes given to processes of synovial membrane inva- ginated in the capsule of a joint. For an account of the diseases of these various structures, the reader is referred to the several articles uuder which they are discussed; but so far as the true follicles are concerned, the fol- lowing may be said to be the principal morbid changes to which they are liable : — Atrophy ; Hypertrophy; Obstruction, and Distension; Inflammation; Ulceration; Cystic Disease; New Growths ; Tubercle ; Acute Specific pro- cesses, such as the typhoid ; and Parasitic disease. FOMENTATION {fovea, I keep warm). Synon. : Fr .Fomentation-, Ger. Balling. Definition". —Fomentation is the application to the surface of the body of flannels, cloths, or sponges moistened with hot water, either pure or containing some medicinal substance in solution Action. — The action of a simple fomentation is the same as that of a poultice. By its warmth and moisture it tends to relax the muscular fibre.- 1 fomentation. sf the skin, end soften the cuticle, thus relieving tension, and diminishing pain and irritation. In the early stages of inflammation it favours re- solution, by maintaining the temperature and promoting active circulation through the area which has suffered from the injurious influence which has started the process. In the later stages it promotes and hastens suppuration, by causing dilatation of the vessels, and hastening exudation and cell-multiplication. A fomenta- tion is superior to a poultice in lightness and cleanliness, but unless care be taken it loses its heat more quickly. This disadvantage may be overcome by covering the fomentation with a thick layer of cotton-wool. Application and Uses. — A fomentation is thus applied : — A piece of coarse flannel, or of spongio-piline, sufficiently large to cover the af- fected part when folded into two layers, is put uto a basin and boiling water is poured upon it. It is then lifted from the basin with a pair of tongs or some convenient instrument, and dropped on lie wringer. This is a stout piece of towelling with a stick attached to each end. The sticks then being twisted in opposite directions, as much water as possible is squeezed out of the flannel. It is then immediately placed on the affected part, and covered with a large piece of oiled silk or indiarubber sheet extending at least one inch on each side of it. Over this may be placed a thick layer of cotton-wool, and a bandage. If the flannel be not squeezed sufficiently dry it will wet the bed or clothing. If not sufficiently covered with oiled silk and wool it soon becomes cold. Whatever means may be taken to retain tho heat of a fomentation, it can be kept above the temperature of the body only for a few minutes. If, therefore, the full effect of fomen- tation is desired to he obtained, the flannels must be changed every twenty minutes. In many parts a sponge, or a piece of spongio-piline, wrung out of boiling water forms a most convenient form of fomentation. When the fore-arm or hand is affected, a bath of hot water may he substituted for fomentations. The temperature of the water must he maintained by the repeated addition of small quantities of boiling water. Fomentations are especially useful in all cases of erysipelas and diffuse cellulitis, and in boils. In peritonitis they are borne more easily than poultices, on account of their greater lightness. Whenever they can be employed they are superior to poultices on account of their cleanli- ness. They are not applicable to cases in which there is a discharging wound or abscess, asunder such conditions the cloths become foul. Varieties. — If it is desired to add some slight counter-irritation to the warmth and moisture, the fomentation may be sprinkled with turpen- tine before it is applied. This forms the ordinary turpentine-stupe. The sedative action of the fomentation may be increased by sprinkling it with laudanum. The ordinary poppy-fomentation is efteu used with the same intention. It is thus prepared Half a pound of poppy-heads with the seeds taken out is boiled for ten minutes in four pints of water, and the liquid then strained off. The decoction is kept warm over a fire and the flannels lipped in it and applied as before described about every half-hour. The term FOECIBLE FEEDING. 51', ‘dry fomentation’ is sometimes applied to bags of salt, hot bran, or chamomile flowers ; or piece3 of flannel toasted before a fire and applied hot. These often give relief in cases of intestinal, renal, or biliary colic. hi Ait errs Beck. FOMITES ( fomes , fuel). — Substances ca- pable of retaining contagium-particles, and thus of being the means of propagating any infectious- disease. The most important fomites are bed- clothes, bedding, woollen garments, carpets, cur- tains, letters, &c. See Contagion. FOOD. See Aliments, and Diet. FOOD, .iEtiology of . — See Disease, Causes of ; and Digestion, Disorders of. FOEAMEN OVALE, Patency of . — Set Heart, Malformations of. FOECIBLE FEEDING.— In the treat- ment of insanity it not unfrequently happens that we are compelled to administer food by force to patients who, for one reason or another, refuse to take it. The majority of them are melan- cholic persons who think they ought not to eat, or try to commit suicide by starvation, and many axe in a feeble bodily condition when they com- mence this refusal. Such persons must be fed by force without delay. Strong patients may be allowed a longer time, for many refuse from whim or obstinacy, and hunger will soon overcome their disinclination. Some patients in a state of acute delirium will take no food ; they must be fed at once, and it is important that they should be fed without a protracted and exhausting struggle, for they will resist desperately unless completely overmastered. In almost every case feeding should he done early : the sooner it is done, tho shorter will be the period during which it will he required. What method is to be adopted ? The various plans range from merely feeding with a spoon as one feeds a child to sending food down the oesophagus with a tube passed through the mouth or nose, tho patient being restrained in a chair or on a bed by attendants or mechanical restraint. The mode of feeding varies according to the resistance, and no one method is applicable to every case. There is no need to pass an oesophageal tube down the throat of a man whose resistance is passive and easily overcome ; on the other hand we occasionally find patients of great muscular strength and indomitable will, who can hardly be fed with safety in any way except by the stomach-tube. Of these we may speak first. In what position are they to be fed, sitting or lying down ? If they are to he held by attendants no doubt the recumbent posture is the one in which the latter can exercise most power. But when a man is so strong that, as we axe told, five attendants must hold him, a struggle will not be unattended with danger, for tho five are not all acting together, and he gets loose now a leg and now an arm, to the great discomposure of the operator : more- over this struggle repeated three times a day soon renders him a mass of bruises. He should be placed in a strong wooden chair, and by sheets wound round his body, arms, and legs he can he fastened to the chair so completely that he is as incapable of movement as if he were paralysed, 518 FORCIBLE FEEDING. yet. lie gets no bruise, and the operator acts upon bitn free from all inconvenience. Some -writers advocate feeding by the nose, and prefer this method to passing a tube through the mouth. But if a long tube is used it is apt to get into the larynx, and if the food is passed into the nose through a funnel or feeder, it is often ejected again. The only advantage of feeding through the nose is that we are not compelled to force open the mouth. This is a work of difficulty if the patient is strong and his teeth perfect, unless we are provided with the screw-key invented for this purpose : with this there is little difficulty, and only bungling will injure the teeth or gums, if the patient is properly secured and the head held by an attendant, not between his knees but in his hands. If the oesophageal tube be of good size it cannot enter the larynx. The wooden termination of the tube must be short, so as to allow of its curving. The operator standing in front passes the tube through the hole of the gag, inclining it to the patient’s loft, so as to avoid the vertebrae. It may be held by the tongue, but at the first inspiration the hold is relaxed, and it glides down the asophagus. The food may be poured down it by a funnel or pumped down by the pump. The next class of patients, making less resistance, may be fed by Paley's feeder, a glass vessel with a flattened spout which goes over the tongue : the food is emitted, a little at a time, by means of a spring, and finds its way down the gullet. A certain number of patients may he fed by getting a funnel behind the teeth and pouring food into it; and others by holding the mouth open by means of two spoons, and then pouring food in. Tho objection to the latter method, and to its many modifications, is the time taken up in the. opera- tion, whereby great fatigue and exhaustion are produced. G. T. Blandford. FORMICATION' ( formica , an ant). — An abnormal subjective sensation referred to the skin, which is described as of a ‘ creeping charac- ter, and as resembling the crawling of ants upon the surface. See Sensation, Disorders of. FOURTH NERVE, Diseases of. — Morbid states of the fourth nerve are shown in spasm or paralysis of the superior oblique muscle which it supplies. Little is known of overaction of this muscle. Clonic spasm in it is seen in rotatory nystagmus. Paralysis is not uncommon. Its usual causes are inflammation of the nerve-sheath from cold ; syphilitic affections of the nerve or of its membranes ; cerebral tumours &c., pressing on or injuring the nerve at its origin from the valve of Vieussens, or in its course around the crus ; aneurism ; exostoses or growths in the orbit; and degeneration of the nucleus, in common with the nuclei of the other nerves of the ocular muscles. Symptoms. — Even in complete paralysis of the superior oblique muscle there is little obvious deviation of the affected eye. Movement down- wards is, however, defective, and therefore diplo- pia exists when the eye is moved below a line which runs obliquely downw r ards from the healthy to the paralysed side, through the point of mid- fixation. Movements which necessitate a down- ward position of the head are therefore chiefly FRAMBCESIA. intertered with, and it is common for the first discovery of a defect to be that the patient becomes giddy when he goes downstairs, in con- sequence of seeing two flights of stairs before him instead of one. The chief visible defect in movement of the affected eye (examined alone) is downwards and inwards, because it is when the eyeball is moved in these directions that the superior oblique has most influence on the ver- tical position of the eyeball. The defect in tho rotation of the eyeball is greatest when it is moved downwards and outwards. The diplopia which exists when both eyes look down is homonymous, that is, the image formed by the affected eye is on the same side as that eye. The left eye being higher than the right, its image (the left) appears lower than the right image. The action of the superior oblique being to move the upper end of the vertical axis of the eye inwards, there is in its paralysis an abnormal divergence of the upper ends of the vertical axes, and the double images (being always inverted) will cor. verge : theirnpper ends being nearer together than the lower. This is due to the obliquity of the false left image, and this obliquity is greatest when the eyeball is moved to the left and downwards, because in this position the rotatory powerof the superior oblique is greater, and the obliquity is least in looking inwards and downwards. Thus the convergence of the images is greatest when the difference in height is least, and vice versd. When the paralysis of the superior oblique has existed for sometime, a secondary contraction of the inferioroblique may cause crossed diplopia in looking upwards. Treatment. — The treatment of paralysis of the fourth nerve is in the main that of its cause. AVhen due, as it very commonly is, to syphilis, iodide of potassium in full doses, with or without mercury, is necessary. Smaller doses of iodide with quinine or iodide of iron are also useful for rheumatic paralysis. Blisters to the templo in the early stages are useful. A little, but not much, good may be effected by applying the constant current from the eyelid to the forehead (Benedikt), a few cells only being used. W. R. Gowers. FRAGILITAS CRINIUM (. fragilitas . brittleness ; crinis, the hair). See Hair, Diseases of. FRAGILITAS OSSIUM. — A diseased condition of the bones in which they are ex- tremely fragile, so that they are liable to fracture from very slight causes. See Bone, Diseases of. FRAMBCESIA ( framboise , a strawberry). — Synon. : Yaws ; Fr. and Ger. Plan. Definition. — Framboesia consists of an erup- tion of yellowish or reddish-yellow tubercles ; which gradually develop into a moist exuding fungus without constitutional symptoms, or with such only as result from ulceration and prolonged discharge, namely, debility and prostration. ^Etiology. — This disease is peculiar to the African race, both in their native country and in the West Indies. Yaws are epidemic; they are also contagious by actual contact, and conse- quently inoculable. The period of incubation of the poison ranges from three to ten weeks, and except in rare instances, the disease occurs onl f once in a lifetime. FRAMBCESIA. Symptoms. — The tubercles begin with little or no hypersemia, and range in size between that of a pin’s head and a prominent mass one or two inches in diameter. Some subside without piercing the cuticle, and disappear without causing dis- organisation of the skin. When the cuticle is' penetrated, the tubercles assume the appear- ance of a fungous mass of spheroidal figure, yellowish or pinkish in colour, and moistened with a dirty-yellow, foetid secretion. At a later period the fungus shrinks in size, and is converted into a yellow and brownish scab ; at other times the ulceration extends deeply and widely into the tissues. The subsidence of the eruption is succeeded by a pigmented stain, and the healing of the ulcers by a pigmentary cicatrix. The eruption selects by preference as the seat of its development, the face and neck, the limbs, the feet, and the genital region, and is frequently found around the mouth, the apertures of the nostrils, the eyelids and the anus, where it is apt to present a thick fringe of tubercles or a broad prominent band or ridge. Course and Terminations. — Tho ordinary duration of framboesia extends from two to four months, but frequently this period is prolonged to one or several years. AYhen it is irregular in its development the constitution is apt to suffer, ulcers form around the joints, the joints swell, the discharge from the ulcers is excessive, the ex- halations of tho body are highly offensive, and the patient is crippled for life, or in some in- stances relieved only by death. Treatment. — The treatment of j'aws, accord- ing to the best authorities, consists in cleanliness, generous diet, the local use of carbolic acid lotions and diluted nitrate of mercury ointment ; and the employment of constitutional remedies, of which the most useful are mercury, with sar- saparilla or a decoction of the woods, iodide of potassium, and tonics. Erasmus Wilson. FRANCE, South of.— The eastern part (Mediterranean Coast) is dry and bracing, with a very clear atmosphere. The chief resorts in it are Cannes, Mentone, IIteres, and Nice. The western part is moist and mild but variable, the principal places in it being Arcachon, Biarritz, and Pau. See Climate, Treatment of Disease by. FRANZENSBAD, in Austria. — Alkaline Bulpbated waters. See Mineral Waters. FRECKLES. — Synon. : Lentigines ; lenti- culte ; Fr. ephelides ; Ger . Sommersprossen, Som- merjlecJcen . — A freckle is a pigmentary discolora- tion of the skin, which has received its Latin or technical name from a resemblance in colour, figure, and size to a lentil. It varies in tint from yellow to olive, from brown to black ; and is met with on the exposed parts of the skin, particu- larly the face, neck, and hands, and occasionally on the covered parts of the body (‘ cold freckles '). It is usually found in children and women in whom the skin is sensitive and delicate, and has ob- tained its German synonyms from its greater frequency in the summer season. See Pigmenta- tion, Disorders of. Erasmus Wilson. FREMISSEMENT CATAIRE (fremisse- fnent, purring ; catciire, connected with a cat). FRICTION. 51 V A physical sign felt on applying the hand over the region of the heart or great vessels in certain morbid conditions ; and compared to the sensa- tion conveyed to the hand by the purring of a eat This sign is more commonly known as ‘ thrill ’ or ‘ purring tremor.’ See Physical Examination. FREMITUS {fremitus, a loud noise). — A group of physical signs, elicited by placing the hand over the respiratory organs, while the patient speaks {vocal fremitus), or coughs {tussive fremitus)-, or in certain morbid condi- tions when the patient simply breathes ( rhoi s- chal, and friction- fremitus). A fremitus may sometimes also be felt over the cardiac region in connection with the movements of tho heart, when the surfaces of the pericardium are much roughened. Another form of fremitus is a peculiar sensation called hydatid fremitus, which may be elicited by a special mode of per- cussion over hydatid tumours in some cases. See Physical Examination. FRICTION. — Synon. : Rubbing ; Fr. Fric- tion ; Ger. Beilmng. Definition. — By friction we mean surface- rubbing, as distinguished from shampooing, or as it is sometimes called medical rubbing, a process of manipulation by which deep pressure is made upon the muscles. Applications and Uses. — Friction is usefully employed over the surface of a limb, or the trunk, for a variety of purposes. It is especially useful when the circulation is enfeebled, either by the ex- ternal application of cold, amounting when in a severe degree to frost-bite, or in eases of paralysis. The effect is still further increased by the use of various stimulating liniments and embrocations, more especially when it is desirable to excite a certain amount of counter-irritation over a large cutaneous surface for the relief of congestion or inflammation of internal organs. Another object with which friction is largely employed in medicine, is to facilitate the ab- sorption and introduction into the system of various remedial agents applied externally, instead of being administered internally by the stomach. By this means gastric irritation and disturbance are avoided, and tho effects of the remedies upon the system can be more closely watched and regulated. In this way mercury is frequently introduced into the system by tho process commonly spoken of as rubbing in, and salivation can be more easily avoided or checked at its commencement than when mercury is ad- ministered by the mouth. The part of the body selected for this purpose is that along the inner side of the thigh up to the groin, and mercury, rubbed in, in the form of ointment, every night and morning, will generally affect the system in a few days. Another instance of friction is to he found in the fattening of children by the process of rub- bing in oil — fresh neat's-foot oil is the best — every night and morning, over the chest, abdo- men, arms, and thighs. Emaciated children thus treated gain in weight by the absorption of the oil ; and not only do they fatten, but their general nutrition and health are im- proved, often with the diminution of glandular swellings and the disappearance of coughs, so 520 FRICTION. Ihat there is some ground for the belief in the curative influence of this method of medication in incipient phthisis. William Adams. FRICTION-FREMITUS.— The form of fremitus produced by the rubbing together of surfaces roughened by various morbid conditions, as of the pleura in breathing, or of the pericar- dium from the movements of the heart. See Fremitus, and Physical Examination. FRICTION-SOUND.— A physical sip, heard on auscultation, and due to the rubbing against each other of serous surfaces that have lost their natural smoothness and moistness from any cause. See Physical Examination. FRIEDRICHSHALL, in Germany.— Sul- pliated waters. See Mineral Waters. FROST-BITE. — A local effect of extreme cold upon any of the tissues of the body. Sec Cold, Effects of Extreme or Severe. FUMIGATION (fitmigo, I smother). Definition. — This is a mode of employing certain medicinal agents which are capable of being volatilised by heat, the vapour being then allowed to escape into an apartment, or to come in contact with articles of clothing and other objects, for purposes of disinfection {see Disin- fection) ; or being allowed to act upon the sur- face of the body as a whole, or upon certain parts of it, for therapeutic purposes, either local or general, on being absorbed. The chief agents which are thus used are sulphur and mercury. Modb of Application and Uses. — The mode of using sulphur as a disinfectant will he found sufficiently explained under the article Disinfec- tion. The vapour may also he brought with a therapeutic object into contact with the body or any part of it in the dry state, the sulphur being burnt in a suitable apparatus. As a general application it is used for the cure of itch ; as a local application in diseases of the throat, and various other affections. Mercurial fumigation is now commonly effected by means of the moist mercurial vapour bath, in which the skin is exposed to the fumes of mer- cury volatilized by heat and mixed with steam, in a suitable apparatus. This process is more effectual than dry fumigation, for the moistened skin is more capable of receiving and absorbing the mercurial vapour which settles upon it. It is not desirable to produce profuse perspiration, as this exhausts the patient, and washes the mercurial film from the body. Various preparations of mercury have been tried, but by far the best is calomel as recom- mended by Mr. Lee, which is capable of being more completely volatilized than any other form and with aless degree of heat, whilst the amount administered is more accurately known. The quantity used for each bath may be varied from 10 to 30 grains, and given daily or at such inter- vals as circumstances indicate. The body should be protected from cold after leaving the bath, and night is the best time for its use, as the patient can then go to bed enveloped in the cloak or blanket which has been employed in the process, and upon which much of the vapour has collected. Salivation is readily and often ED NG U .5-DISEASE OF INDIA. quickly produced by this method, so that the gums must be carefully watched and the doee regulated. The time ordinarily required for the hath is about 20 minutes, but if headache or lassitude be caused, it must not be so pro- longed. The advantages of this practice are that mer- cury can be introduced into the system withon. giving rise to the intostinal derangements, loss of appetite, &c., which its exhibition by the mouth sometimes occasions, and its direct action upon the skin often appears to he of service. There is, however, the disadvantage that in some cases the mercurial fumes may cause a syphilitic eruption to inflame and spread. Mercurial fumigation has been employed for primary syphilis, but it answers best in the secondary stage of the disease, and especially for the dry eruptions. Sometimes it is useful for the tertiary manifestations which resist iodide of potassium, but it should be tried very cautiouslv in these cases. In certain cases where, from feeble health or other causes, it is not advisable to influence the system with mercury, the calomel vapour may be directed upon some local parts, such as an ulcerated spot. This local application has been found serviceable in treating intractable sores in advanced syphilis, in severe and obstinate ulcera- tion of the throat, and in some other conditions Geo. G. Gascoten. FUNCTIONAL DISEASES — A class cf diseases in which an anatomical change cannot be detected to account for their presence. See Disease, Classification of. FUNGI, Diseases due to. See Parasites, Diseases from ; and Mushrooms, Poisoning by. FUNGOID {fungus, a mushroom). — A term applied to superficial granulations and morbid growths, especially those of a malignant nature, when they sprout rapidly and assume an appear- ance somewhat like a mushroom. See Cancer, and Ulceration. FUNGUS -DISEASE OF INDIA — Synon. : Madura Foot, Mycetoma ; Morlus tu- bcrculosus pedis ; Fr. Degeiicrcscence endemiqut des os die pied • Perical. Definition. — A diseased condition of the hands and feet, occurring in India, characterised by enlargement and distortion of the affected extremity, due to thickening of the cutaneous tissues, with degeneration and subsequent frac- ture of the osseous structures. Two forms of the malady are described — one, the pale or ochroid form, characterised by the presence of minute globular fatty particles like fish-roe, and, though very rarely, by the existence of minute pink concretions not unlike red-pepper granules ; the other, the melanoid or dark form, characterised by the existence of black or dark brown masses, varying in size from that of a grain of gunpowder to a walnut, and composed of fungoid filaments, cells, and pigmentary de- posit. Description. — This remarkable disease of the extremities does not appear to have been ob- served hitherto beyond the limits of Bindostan. FUNGUS-DISEASE OF INDIA. and has rarely been seen to affect any but the natives of that country. No case of a European or half-caste has been recorded as suffering from a typical form of the malady. The foot has been observed to be affected more often than the hand ; hence it was common formerly to find the malady referred to as one peculiar to the foot. It has been recognised as a distinctive disease in India for more than thirty years, and was described by Goodfrey, of Madras, in the Lancet in 1816, and by Eyre in the Indian Annals of Medical Science in I860. It is to Dr. Vandyke Carter, however, that we are chiefly indebted for what is known of the malady, clinically and pathologically, and his writings date as far back as 1860. His recently published memoir on the disease (Mycetoma, or the Fungus Disease of India , 1874) contains a summary of all that had been written regarding it up to the period of publication. 1 The foot or hand affected with the disease presents appearances not unlike what are observed in some of the forms of caries — especially those of scrofulous origin. When it is the foot that is affected, it is found to be con- siderably increased in circumference, the enlarge- ment seldom extending far beyond the ankle ; the foot is prone to run in a line with the leg, and may be everted or inverted. It is not, however, in the aspect presented by the limb that the leading peculiarity consists, but in the character of the discharges from the sinuses, the openings of which are scattered all over the surface of the affected tissue. It is this peculiarity which led Dr. Carter to separate the disease into two forms, (1) the ‘pale’ or ‘ochroid,’ thedischarge ofwhick consists of whitish-yellow roe-like bodies of about the size of millet-seed ; and (2) the ‘ dark ’ or ‘ melanoid,’ so called from the dark brown or even black granular bodies that constantly escape through the sinuses, not unlike grains of coarse gunpowder. The first form may be said to present two or three varieties, according to the modified character of the discharges : these will be referred to more definitely farther on. The malady would appear to occur more fre- quently in Madras, Bombay, and the more west- erly and north-westerly parts of India than in Bengal proper. This, however, seems to apply more especially to the dark variety ; for, whilst no well-authenticated case of this form has been recorded as having manifestly originated in the last-named province, cases of the pale variety are not unfrequent. So far as the foot is concerned, the pale form is manifestly the one most com- monly met with all over India, at least, if any inference may be drawn from the fact, that whilst the writers have had the opportunity of examining two or three hands affected with the 1 Bibl : Carter, H. V. Trans. Med. & Phys. Soc. of Bombay, 1860-02. Trans. Path. Soc. of London, vol. xxiv. 1878. On Mycetoma, or the Fungus-dLease of India, London, 1874. Carter, H. J. Ann. and Mag. Mat. Hist., vol. ix. 1862. Jour- nal Linn. Soc. vol. viii. 1865. B rkeley, Inlell. Observ. No. x., November, 1862. Journal Linn. Soc., vol. viii. p. 135, 1865. Quart. Journal Micr. Sc., New Series, vol. xiv. 1874. Nature, Novembrr 9, 1876. Bristowe, Trans. Path. Soc., vol. xxii. 1871. Ho certain Endemic Shin and other diseases of India. &c., .876. 521 dark variety, they have not seen one affected with the pale ; nor can they find any account of such a case having been witnessed. The distor- tion of the hand affected in this manner is very peculiar — it is shortened and thickened, owing to the destruction of tho carpus and metacarpus, and the consequent irregular tension of the ex- tensor and flexor tendons. Anatomical Characters. — On laying open a characteristic specimen of the disease, the bones are found to be extremely softened, so that they can readily be divided by means of a common knife. The interior of the hand or foot is found to be occupied by a series of sharply defined cavities, some quite isolated, but the majority communicating with one another and with the exterior by a series of complex channels or sinuses containing glairy fluid and solid con- cretions in various proportions. Both cavities and channels are lined by a dense, glistening membrane composed of white fibrous and elastic tissue. The surrounding tissues are generally in a very fatty condition, and, where the disease is of long standing, are more or less completely blended into an indistinguishable mass. So far a common description is applicable to both forms of the disease ; but on proceeding to the con- sideration of the contents of the cavities, great differences present themselves. Pale Form . — The paleor ochroid form iscapable of subdivision into several varieties, according to the nature of its morbid products. In the com- monest and most characteristic variety the cavi- ties and Channels contain masses of spherical bodies like fish-roe, of a pinkish-yellow or white colour, surrounded by gelatinous glairy matter. In certain cases, however, the roe-like bodies are almost or eutirely absent, and the gelatinous matter and liquid oil are generally diffused throughout the tissues. In a third and very rare variety the section looks as though be- sprinkled with grains of red-pepper, from the presence of innumerable minute concretions of a bright red hue. Dark Form . — The appearances presented in the dark form of the disease are strikingly different. Here, in place of the roe-like bodies of the previous form, the cavities and channels contain masses of a dark brown or black colour. These masses vary greatly in size, some not being larger than the nor- mal fat-lobules surrounding them, others attaining to the size of a small orange. The larger masses greatly exceed any of the roe-like masses of the pale variety in size, and their consistence is also much firmer than that of the latter. They are tuberculated on the surface, and closely resemble truffles in appearance. On section, they present a more or less distincrly radiating structure, and the interior is generally somewhat lighter in colour than the tuberculated exterior coating. In some cases they are tightly fitted into the cavi- ties in which they lie, but in others they lie loose and are surrounded by a certain amount of gelatinous matter. The amount of the latter present is, however, much less than in the pale form. The masses of morbid material in both forms are primarily situated in spaces normally abound’ng in fat. Long series of them are frequently interpolated among the loculi in the FUNGUS-DISEASE OF INDIA. 522 subcutaneous tissue, between healthy fat-lobules ; others occupy the interior of the bones; and a third series are developed in the pads of fat lying around muscles and tendons. The muscles and tendons in such cases may frequently be found quite intact, although surrounded by masses of the morbid material. Due to this persistence, fracture and crushing of the softened bones often occurs, and it is on this that the dis- tortion of the affected part is in many cases in great measure dependent. Minute characters of the morbid products . — The roe-like particles are composed of a nucleus of granular, waxy consistence, surrounded by a fringe of radiating crystals. They appear to be almost entirely composed of fatty matter, and no traces of the presence ot parasitic organisms of any kind can be detected in them. The bright red particles occurring in certain cases of the ochroid form are concretions, consisting iu great part of phosphates and carbonates, and contain- ing a considerable proportion of iron. The dark masses present in the other form of the disease are of much more complex structure. In all, or almost all, cases they contain septate fungoid filaments in greater or less proportion. These are sometimes difficult to distinguish, but may generally be detected by allowing portions of tho material to soak for some days in liquor potassae. Tho proportion which the filaments bear to the entire muss when thus separated, is in any case very small, and in some cases extremely so, for on the completion of the soaking only a very small quantity of colourless fiocculi, consisting of masses of branched filaments mixed with empty cyst-like cells, is left behind in the fluid. The latter has assumed a brown colour from the solu- tion of the dark mass. The filaments and cysts (see tho accompanying figure) in so far as tests Fin. 21. — Fungoid Filaments and Capsules obtained after prolonged maceration of the black suhstance in caustic potash, x 500. have yet determined, are indistinguishable from undoubted fungal elements. They are, as a rule, quite empty, aud show no signs of growth, or indeed of life. The basis iu which they are im- bedded varies greatly in different cases. In some instances it is soft and contains much oily matter, but in the more advanced cases this is almost absent. It is then only soluble by means of alkalis. The ash consists mainly of calcium phosphate and is red, due to the presence of oxide of iron. The fungoid filaments have never yet been shown to bo capablo of any further development. All attempts at cultivation have failed in causing them to assume any form by which their true nature and relationships may be determined. They have never given any unequivocal signs of life external to the body, even when exposed to conditions favourable to the growth of tungi as demonstrated by the development of various ex- traneous moulds upon the surface of the black masses themselves, or on the media in which they were immersed. Symptoms. — Dr. Carter writes: ‘As a rule the local indications of this disease are the same for all its forms ; for commonly it. is not possible to discriminate the several varieties by simple in- spection or bare clinical history of the case ’ The statements made by the patients as to the mode of origin and progress of these complaints are very various, but, taken generally, they seem to imply that tho symptoms are analogous to those usually observed in deep-seated di.-ease of the osseous and adjoining tissues. Eventually a more or less hard lump is felt in the solo of the foot or palm of the hand, or in several places. Generally one or more abscess-like formations occur, and ultimately several sinuses are estab lished, the latter, as a rule, preseuting a peculiar mamillated appearance — the ‘ tubercles,’ appa- rently, of earlier writers. Along with these changes, enlargement and distortion of the affected member take place, but unaccompanied with severe pain. Discharges set in, more or less offensive, according to the nature of the sub- jacent degeneration, and the limb becomes not only useless, but a burden to its owner. In this manner the sufferer may go on for from one to fifteen or more years, unless relief he sought in a surgical operation. Pathology. — The occurrence of the fungoid filaments in the. products of the dark variety of the disease, has caused many author- to regard them as the essential cause of it. There are, however, good grounds for rejecting such a conclusion. Had the dark form of the disease been theonly one with which we were acquainted, there might have been some cause to regard tt as due to parasitic agency. When, however, we find that the pale form, whilst causing all the important lesions present in the other, shows a total absence of all fungoid elements in its products, we are forced to regard such elements as of secondary importance. The only means of overcoming this objection would be a demonstration that the products of the pale form are due to a degeneration of the black matter, in the course of which the fungoid elements disappear. No such demonstration has been given, and, on the contrary, it has been shown that each form is capable of running an entirely independent course, the gradual trans- formation of the normal fat having been traced in the one case to the production of the r 'e-like particles, and in the other to that of the black masses in which the fungoid elements are im- bedded. Were the pale form the only one known the disease might be described as a mere de-gene- ration of the fatty tissues, with tho results con- sequent on the presence of the morbid products of the process in the surrounding parts ; but this explanation, although so far applicable to the dark form, throws no light on the source o f FUNGUS-DISEASE OF INDIA. GALACTAGOGUES. 523 the fungoid elements. They are present in masses which are entirely isolated in the tissues, having no communication wkh one another or with 'he exterior. There is no evidence of their passage from one cavity to another — on the contrary they are absolutely limited to the contents of the cavities, the membranous walls of the latter and the intervening tissues never showing any traces of a spreading mycelium, or of any other fungal elements. Assuming the filaments to be of undoubted fungal origin, the facts point rather to their simultaneous and independent development in multiple centres, than to their spread from one to another. The fact of the necessity of a suit- able soil or nidus, in addition to the mere pre- sence of germs, in order to secure the development of organisms, is generally accepted. That germs of most various kinds must constantly be intro- duced into the blood, is a self-evident fact. Putting their introduction by means of the lungs out of the question, their constant introduction from the intestinal canal can hardly be denied. It can he demonstrated that the intestinal con- tents abound in vegetable organisms — spores, bacteria, &c.— in a living condition. As it is an ascertained fact that solid particles of inorganic matter of far larger size than many of these germs can enter the circulation, it can hardly he denied that the latter may, and indeed must, enter also. So long as such bodies do not meet with conditions favourable to development, they are no doubt, destroyed and utilised by the living matter of the blood and other tissues. If, how- ever, they are deposited in a medium favourable to them, they will grow and undergo such de- velopment as they are capable of. The morbid products of the disease here described are practi- cally dead material, external and extraneous to the bodj-, and it has been experimentally demon- strated that when removed from the body they form a basis capable of supporting the growth of fungal organisms. Given these two conditions — the constant presence ofgerms in the circulation. and the possession of a suitable soil for fungi — and the difficulty of accounting for the presence of fungal elements in the latter appears in great part to disappear. Prognosis. — Both forms of the disease run a very chronic course, and often without very materially affecting the general health of the patient ; in some cases, however, great emaciation accompanies the disease. With regard to the duration of the malady, it may be stated that cases have been recorded as having existed for various periods up to twentv-six and thirty years. Treatment. — There are no instances recorded of a spontaneous cure having been effected, nor have remedial applications proved of material permanent value in either form of the disease. Removal of all the diseased tissue, by amputation of the affected extremity, is the only remedy which meets with general approval. The subse- quent treatment resolves itself into that of an ordinary surgical operation. D. D. Cunningham. . T. E. Lewis. FUNGUS BYEMATODES ( fungus , a mushroom ; aijict, blood, and eTSoj, like). — A synonym for soft malignant growths, which are exuberant and highly vascular, and therefore peculiarly liable to bleed. See Canceb, and Tumours. FURFUH. — -Synon. : Scurf, Dandruff. — A branlike desquamation of the skin, met with in several cutaneous diseases, more especially pity- riasis, psoriasis, and ichthyosis. Sec Skin, Dis- eases of. FURFURACEOUS {furfur, bran).— A term applied to a condition in which the epidermis is shed in the form of bran-like scales. See Furfur. PURUN CULU S {fervio, I boil). — A synonym for boil. See Boil. Gr GADFLY. — The popular name for a genus if insects whose larvie infest man and the lower animals. Sec (Estrus. GALACTAGOGUES (ya\a, milk, and ay a, I move). Definition. — Agencies which increase the se- cretion of the mammary gland. Enumeration. — The most common galacta- gogues are : — Mental Emotions , Local Nervous Stimulation ; Warmth ; good Food ; Alcohol ; Ja- borandi ; the fresh leaves of the Castor Oil plant ; Tonics ; and Electricity. Action. — When wo consider how powerfully mental processes may affect the activity of nerves supplying the secreting structure of glands, we can understand how these may influence the secre- tion of milk, as of the sweat, the saliva, and the tears. The maternal feelings of joy, as well as the reflex stimulation of the infant’s lips, act most rapidly in developing the functions of the breast. Warmth and good diet also play their part in the process. Alcohol in the form of malt liquors, or malt-extract, is a useful adjunct ; and so are such tonics as iron, which counteract in some measure the severe drain on the constitutional resources. Little use has yet been made in actual practice of those drugs which are specially credited with galactagogue properties ; but we are told on good authority that a poultice made of the fresh leaves of the castor-oil plant, aided by teaspoon- ful doses of a fluid extract prepared from the 624 GALACTAGOGUES. same, have a markedly stimulating influence on the mammary secretion. Belladonna is well known to dry up the milk; and jaborandi, which is its antagonist in so many respects, has been shown to have here also a directly opposite effect, and to be a drug of which further use may yet be made when we wish to excite or re-establish the proper functions of the mammary gland. Robert Farquharson. GALACTIDROSIS (yd\a, milk, and iSpdr, perspiration). — A term signifying milky perspi- ration. See Perspiration, Disorders of. GALACTORRHCE A (ya\a, milk, and peco, I flow). — An excessive flow of milk. See Lac- tation, Disorders of. GALL-BLADDER AND GALL-DUCTS. Diseases of. — These affections may be con- sidered in the following order:— 1. Catarrh of the Bile-passages. — This dis- ease very rarely gives opportunities for examin- ation after death. At the time after death that it is customary to make post-mortem examin- a'ions in this country, all redness of the duct has usually disappeared ; and there are left only swelling and pallor of the mucous membrane, which is covered with a tenacious glassy or purulent secretion. By this swelling and secretion, the bore of the duct is often greatly narrowed ; and it can be seen that no bile has passed over it for some days, as all colour has disappeared from the affected part of the tube. In judging of this, however, no pressure must have been made upon the gall-bladder during the earlier part of the examination. These appearances are most pronounced in the common duct and the gall-bladder ; they are gradually lost in the hepatic duct and its branches in the liver. Ths process seems most intense at the duodenal end of the gall-duct, and the orifice of the papilla itselfis often found plugged by mucus, an appearance which certainly favours the notion that the catarrh is propagated from the stomach and duodenum. This is believed to be the com- monest source of catarrh of the bile-ducts. It is also seen in nutmeg-liver and cirrhosis; and a tendency to chronic catarrh is set up by tho presence of foreign bodies in the ducts, such as gall-stones. Symptoms. — Jaundice is often the first symp- tom which draws the attention of the patient to his health in a case of catarrh of the bile-duets, although in a certain number of cases this is preceded by symptoms of gastric disorder, such as vomiting or -wise of sickness, loss of appetite, and furred tongue ; or, on the other hand, by diar- rhoea. The jaundice lasts about three weeks, sometimes as much as six or eight weeks. After this, suspicion should be aroused whether some- thing more than a simple catarrh be not present. Diagnosis. — The diagnosis depends upon the absence of any physical signs indicating organic change in the liver; and on the presence of gastric symptoms. Thus nearly all cases of simple jaundice are diagnosticated by some physicians as cases of catarrh of the bile-ducts. As the greater number of the patients recover, eery few opportunities are given for verifying this diagnosis; but in those which have been GALL-BLADDER AND GALL-DTJCTS. examined, plugs of mucus in the ducts have not unfrequently been found. The catarrh caused by gall-stones is lost in the jaundice and pain associated therewith. Treatment. — The treatment should at first be directed to the gastric symptoms, beginning with a purgative, followed by a course of effer- vescing alkaline medicines, and restricted diet. Later on, dilute nitro- hydrochloric acid taken before meals is often very useful. 2. Inflammation and its Results. — In some cases of typhus and typhoid fever, and in other typihoid states, the gall-ducts and gall-bladder become ulcerated , or filled with purulent fluid, or covered with croupous exudation. The same thing may happen when gall-stones are impacted in the ducts. The gall-ducts are sometimes obliterated by fibrous bands passing over them. Sometimes they suffer a congenital obliteration by the over- growth of the fibrous tissue around them. 3. Dilatation. — The gall-ducts and gall- bladder become dilated whenever there exists an obstruction, either pressing on the ducts from the outside, or formed within them. The first result is dilatation of the ducts behind the obstruc- tion. The gall-bladder becomes much dilated, often filled with a thick green bile. If the obstruction last loDg, the coloured part of the bile is absorbed, and its place taken by a colour less fluid, either viscid or limpid. This fluid contains neither bile-pigment nor bile-acids, is often albuminous, and contains abundance of mucus. The ducts outside the liver may he enormously distended. It is common to see them as big as the middle finger. Within the liver they are also dilated, but not to so great a degree ; and they are more dilated on the left than on the right side. The dilatation of the ducts may become cystic, and sometimes moni'.i- form. The writer has always been able to find columnar epithelium in these dilated ducts. In some cases of long-continued obstruction, the contents of the bile-ducts become colourless ; in other cases, purulent; and small abscesses form around the bile-ducts, and open into them. These abscesses may be multiple ; or, more com- monly, only a single large one is formed. The abscess or the dilated gall-duets may rupture into the peritoneum, and cause fatal peritonitis. 4. Cancer. — Primary cancer of the gall-ducts and gall-bladder is sometimes met with ; or they may be aflfeeted secondarily. 5. Foreign bodies are occasionally met with in the gall-ducts. The most common of all are, of course, gall-stones. Much less common are en • tozoa, such as the Distoma hepaticum, hydatids. or the two kinds of ascaridcs. Symptoms. — In all these different morbid states, it is usually only possible to say at the bedside that the large bile-ducts are obstructed ; a more complete diagnosis is commonly impos- sible. Jaundice is an important symptom, as without it diseaso of the bile-ducts cannot be diagnosticated. It is commonly very intense, the urine being deeply coloured, and the faeces quite colourless. The enlargement of the liver, if present, is commonly uuiform, the surface being smooth, and the edges well-defined. The gall-bladder may often be felt at the edge of the right lobe as a rounded tumour ; this is GALL-BLADDER AND GALL-DUCTS. then a sure sign of the obstruction of the gall- ducts. In simple diseases of the gall-ducts there is an absence of splenic tumour, of ascites, and of other symptoms of portal obstruction. In many cases, however, diseases of the liver and of the gall-ducts are so intimately bound up together, that they cannot, during life, be separated. Prognosis. — The prognosis, if simple catarrh of the gall-ducts and gall-stones can be excluded, is unfavourable. Treatment. — The treatment must be con- ducted on general principles. 6. Enlargement of the Gall-bladder.— The gall-bladder cannot be felt in health during life. But it may often readily enough be made out where there exists any obstruction in the common or cystic duct, so that it becomes dis- tended with fluid. It may also be felt when the walls become fibrous or ealeified, or the seat of cancer ; or when its cavity is filled with gall- stones. A tumour may then be felt under the Iwrder of the right lobe of the liver, in the situ- ation of the gall-bladder. When filled with fluid, a rounded, sometimes oblong, sometimes pear- shaped tumour is felt; in other cases it has an irregular shape, or a somewhat rounded outline. A greatly-distended gall-bladder has been mis- taken for ascites, and tapped. The diagnosis de- pends chiefly on the situation of the swelling, and even then the distended gall-bladder maybe mis- taken for hydatid-disease of the liver-substance nr of the omentum, or for a tumour of a neigh- bouring organ which has pressed against the liver. The difficulty of the diagnosis is much increased if the liver be moved from its natural place, for then the position of the gall-bladder be- comes uncertain. Bamberger says he has often mistaken a softened cancerous nodule of the liver for a distended gall-bladder. If it be certain that a fluctuating tumour be the gall- bladder, and no jaundice be present, a diagnosis may safely be made of hydrops cystidis felleae, or dropsy of the gall-bladder ; but if jaundice be present, or if the tumour do not fluctuate but appear solid, there are then no definite rules for diagnosis ; all depends upon the surrounding facts of the case. Dropsy of the gall-bladder is not a dangerous disorder, and requires no treatment; while the prognosis and treatment of the other states depend entirely on their respective causes. 7. Perforation. — Perforation of the gall- bladder or of the gall-ducts is generally the re- sult of ulceration, due to gall-stones, inflamma- tion, and other causes. Fatal peritonitis ensues if tlie perforation occur into the abdominal cavity. Frequently, however, previous adhesions have been formed between tho biliary reservoir or duct, and the neighbouring organs or the abdo- minal wall, and the result of this is — - 3. Biliary Fistula. — This may exist between the gall-bladder or gall-ducts and the surface of the body, the stomach, colon, or duodenum. Very rarely gall-stones find their way into the urinary tract. J. Wickham Legg. GALL-STONES. — Synon. : Hepatic Cal- culi ; Cholelithiasis; Fr. Calculs biliaires ; Ger. Gallcnsteine. Description. — Gall-stones are seen in man and GALL-STONES. 525 most of the vertebrate animals, and in some mol- luscs. They are especially common in oxen. They are found in the biliary passages ; most usually in the gall-bladder, or the cystic and common duct ; more rarely in the hepatic duct, and in its branches within the liver. They vary in size from fine gravel to concretions five inches long. The largest are commonly single, and then they are rounded or oval in shape. The smaller ealeu' i are usually numerous, being then tetrahedral o: wedge-shaped, showing the facets or plane sm - faces caused by mutual pressure. They are never lighter than water when first removed from the body. Only after drying do they float. Their consistence when raised to the ordinary tem- perature of the body becomes much less, so that they can be moulded by the fingers. Their colour varies from white to almost black ; most commonly it is brown. Dr. Thudichum thinks that the nuclei of gall- stones are mostly formed of casts of the hepatic ducts. There is rarely more than one nucleus. Its chemical composition is a compound of lime and bile-pigment, or traces of mucus and phos- phatic earths. The chief chemical constituent of human gall-stones is cholesterin ; some gall- stones are wholly composed of this substance ; most contain 70 or 80 per cent. Other constitu- ents of gall-stones are the bile-pigments, either by themselves, or in combination with lime. Very small quantities of the bile-acids are found, and these are also in combination with lime. It is rare to find gall-stones with any large amounts of carbonate or phosphate of lime, though the ash of nearly all gall-stones shows a large amount of carbonate of lime, the product of the combustion. Traces of copper, iron, and manganese are found in nearly all gall-stones. Lime-salts of the fatty acids are likewise found. TEtiologt. — Age has a very great influence in the production of gall-stones ; they are ex- ceedingly rare in infancy and childhood, their frequency increases after the age of puberty, and they become still more common after thirty. Women are thought to be more liable than men to gall-stones. In cancer of the liver, gall-stones are certainly very commonly found, while on the other hand in cirrhosis they are scarcely ever seen. Want of physical exercise and indulgence in rich diet seem to favour their production. Pathology. — What is the cause of the first formation of a gall-stone? It is not simply con- centration of the bile, since the cholesterin and pigment remain in solution so long as the bile is unchanged ; but the beginning of decompo- sition of the bile-acids causes a precipitation. The cholesterin is likewise thrown down when the reaction of the bile changes from alkaline to acid. Gorup-Besanez and Dr. Thudichum have kept bile several months, and found the reaction at the end of that time acid, with an abundant sediment. It is thus probable that the retention of bile in the gall-bladder or gall-ducts favours the growth of these concretions. It is also pro- bable that gall-stones are sometimes dissolved spontaneously, as erosions may sometimes be seen on them ; or they may break up, and thus pass out. Symptoms. — Gall-stones while still in the gall-bladder rarely give any signs of their 526 GALL-STONES. GANGLION. presence. They are frequently found in the gall- bladders of persons who during life had no symptoms which could be referred to the liver. It is when they begin to leave the gall-bladder, and escape into the cystic and common duct, that symptoms arise of gall-stone colie. They often begin with a dull pain near the liver, with vomiting, rigors, and elevation of temperature; or, quite suddenly, a severe pain in the right hypo- chondrium comes on, described as shooting, stabbing, burning, &c. The pain extends into the epigastrium, rarely to the left hypochon- drium, to the right shoulder, and, according to some, even into the extremities. The pain is very intense, and may give rise to delirium and con- vulsions in nervous persons, or to hysterical attacks in women. Vomiting is usually present ; and, as the attacks most often come on after eating, at first only the food taken is thrown up, and then a colourless mucus. The right hypo- chondrium is usually very tender, and the muscles are rigid. The pulse is not increased in frequency, being indeed rather below than above the natural number. In violent attacks the pulse becomes very frequent and small, or almost imperceptible ; the eyes are surrounded with dark marks ; the nose is pointed; the breath is cool; and cold sweats break out over the body. In this state death may occur, but it is a rare event. A few hours after the attack, the conjunctiva may show a yellow tinge, which will gradually spread from the upper part of the trunk all over the body. The jaundice is more or less intense according to the shape of the gall-stone — whether com- pletely obstructing the duct, or merely causing a hindrance to the passage of the bile. In some cases jaundice may bo altogether wanting, as when the stone is in the cystic duct. The jaun- dice may last an indefinite time. The duration of the attack of colic itself varies ; usually not lasting more than a few hours, it may extend over several days. As soon as the gall-stone reaches the duodenum the attacks are over, the stools become dark, and the jaundice begins to disappear. When the gall-stones reach the in- testine, they are commonly evacuated with the faeces; some cases have, however, been recorded in which they were so large that symptoms of intestinal obstruction were caused and death re- sulted. Diagnosis. — The diagnosis of gall-stones is often more or less difficult. Some physicians think that the diagnosis should not be made unless the concretions be found in the stools ; and tho search for them should be made by passing the feces through a sieve. It is agreed by nearly all that it cannot be made if there be no jaun- dice present. Cancer of the head of the pancreas may readily be mistaken for gall-stones in the common duct. Prognosis.— It is almost impossible to make a trustworthy pirognosis in these cases. The physician can never speak confidently, or feel quite happy when treating a case which he looks upon as one of gall-stones. Treatment. — The treatment of gall-stones may be discussed under two heads : during the paroxysm of the colic ; and between the attacks. During the paroxysm, the great object of the physician is to relieve the pain. This may best be done by full doses of morphia ; and if this be rejected by vomiting, it may be administered hypodermically. The patient may be put in a warm bath and kept there, the heat being main- tained by the renewal of the warm water. Should these means fail, chloroform or ether may be inhaled. J Between the attacks of biliary colic a great number of remedies have been propped : the most popular is Durande’s, which consists of three parts of ether and two parts of turpentine : the best plan is to give 10 to 20 minims of this mixture three times a day, enclosed in capsules or pearls. The German physicians have great confidence in thp alkaline mineral waters, especi- ally Carlsbad. Some think this due simply to the large amount of water daily ingested, causing a large flow of bile. Others recommend purga- tives,^ as castor oil, or taraxacum ; or aqua regia. Emetics.have been employed, but they are danger- ous on account of the straining which they cause, and which may lead to the rupture of a vessel. ’ J. Wickham Lego. GALLOPING CONSUMPTION. — A popular name for phthisis when it runs an acute or rapid course. See Phthisis. GALVANISM, Uses of. See Electhicitt. GANGLION (yay-yKibv, a hard gathering). This term is applied to a variety of somewhat different affections, including: — 1. The simple ganglion. This is a cystic tumour formed in con- nection with the sheath of a tendon. 2. The com- pound or diffuse ganglion, which consists of a chronic effusion into the common sheath of a group of tendons, giving rise to a fluctuating swelling. One variety of this contains the so- called melon-seed bodies. 3. The term is ex- tended by s*>me writers to enlargements of the bursae mucosae. See Bursts, Diseases of. 1. Simple Ganglion. — Description. — The simple ganglion forms a rounded tumour, occa- sionally lobulated, situated in the immediate neighbourhood of some tendon. The most com- mon situations are the dorsum of the hand, the dorsum of the foot, the palm of the hand at the root of a finger, and behind the outer or inner malleolus. The tumour varies in size from a pea toa pigeon’s egg. It may fluctuate distinctly, or be so tense as to seem absolutely solid. It is not adherent to the skin or to the tendon with which it is in relation. It is painless, hut often gives rise to a sense of weakness iu the affected part. The wall is composed of a more or less delicate fibrous tissue, fusing with the surround- ing areolar tissue, and lined by an imperfect layer of endothelial cells. Its contents are most usually semi-solid, like apple-jellv, but sometimes fluid. They are said to be neither albuminous nor gelatinous, but colloid in character. As to the exact nature of the tumour opinions differ, and probably it is not always the same. It is said to arise in the following ways ; 1st. by a hernial protrusion from the sheath of a tendon, the neck of which becomes gradually contracted and finally closed, so giving rise to a cyst in intims.te connection with the sheath. 2nd. Gosselin has described small follicles or sub-synovial crypLT, which he believes may become dilated, so na tc GANGLION. form ganglia. 3rd. The tumour may be a cyst of entirely new formation. Treatment. — Painting with iodine is of little or no use. Forcible rupture of the cyst by a blow or pressure sometimes effects a cure ; but the besf, treatment, is to puncture the tumour with a clean grooved needle, and to squeeze out the contents, afterwards applying pressure or a blister over the collapsed cyst. This treatment may require to be repeated more than once. 2. Compound or Diffuse Ganglion.— Description. — This disease is almost exclusively confined to the sheath of the comm^ti flexors of the fingers. It may consist of a tdmple dropsy of this sheath, forming an hour-glass-shaped swelling in the front of the wrist, the constric- tion being caused by the annular ligament ; or, in other cases, the tumoui may contain melon- seed bodies, which give riixi to a sense of soft crackling when it is manipuluted. These melon- seed bodies are smooch, oval and flattish in shape, and of a pearly-white colour. They are of almost cartilaginous toughness, and on sec- tion present an aeper ranee of concentric lamina- tion. Under the microscope they are found to be composed of very imperfect fibroid tissue. Their origin is somewhat doubtful. They have been supposed to be due, first, to hypertrophy of the fringes, normally found on a synovial mem- brane, the pedunculated projections so formed being ultimately broken loose by the movement of the tendons ; secondly, to the form>tion of pedun- culated warty outgrowths on the synovial mem- brane, which become free ill the same way ; thirdly, to fibrinous deposits taking place from the fluid in the ganglion ; and, fourthly, to the results of accidental haemorrhage. AVlien these bodies are abundant, the fluid is usually scanty. Aetiology. — The cause of this affection is un- certain, but it must be remembered thatinmany cases it is due to the irritation caused by the earliest stage of disease of the carpus. Treatment. — T he treatment of compound ganglion is unsatisfactory. Iodine is useless. Aspiration followed by the injection of iodine has occasionally been of service. An incision made into each end of the tumour, followed by drainage under antiseptic dressing, is often of use. In extreme cases Syme recommended lay- ing the whole cyst open, and allowing it to granulate. This always left much stiffness in the tendons. When melon-seed bodies are pre- sent, they must be removed by incision, and the case treated antiseptieally. Marcus Beck. GANGLIONIC NERVOUS SVSTEM, Diseases of. r diminution of the urethrameter's bulb allows GLEET. the obstruction to be passed, and denotes the degree to which the normal expansilo capacity of the urethra has been contracted. 2. Chronic congestion of the prostate. — Prostatic gleets are caused by (a) extension of gonorrhoeal inflammation to the prostatic urethra — chronic prostatitis; or (6) irritation and con- gestion of a sympathetic kind, excited by mastur- bation, excessive coitus, stone in the bladder, or piles — the ‘ irritable,’ or ‘ relaxed ’ prostate. (a) In chronic prostatitis, with a history of preceding gonorrhoea, there is a scanty dis- charge, seen only at the meatus when several hours have elapsed since micturition ; or there are shreds in the urine. The pain consists of a sensation of heat extending along the whole urethra, often radiating to the buttocks, hut felt most after micturition. At other times there is dull pain in the perinaeum, a sense of weight or fulness of the rectum, rather worse when lying down, and by night than by day. Micturition is performed once or twice, or more times, by night. When micturition is attempted, the urine is often slow to come, and usually a few drops dribble off after the stream ceases. Walking fatigues easily, and brings on the sense of fulness in the rectum. The finger in the rectum generally finds no en- largement, but slight tenderness of the prostate. A bullet-bougie or sound, bent one inch from the point at an angle of 136°, traverses the urethra without causing pain tili the bulbo- membranous part is reached. The instrument is there grasped for a few seconds, to pass on again to the neck of the bladder ; here, again, pain is felt and resistance made; tho latter ceases suddenly as the sound enters the bladder, though the pain still remains. As the instrument is withdrawn, it is expelled rapidly until it is beyond the bulb, where it lies quietly enough, and all pain ceases. The urine withdrawn from the bladder through a catheter is normal, and free from muco-pus. (A) The ‘ relaxed ,’ or ‘ irritable, ' prostate is caused most often by masturbation, or by un- satisfied sexual excitement, which lead to frequent determination of blood to the prostate, without also obtaining that speedy evacuation of the blood which follows the sedative influence of the natural gratification. The gland is turgid, very sensitive, and tender, the crypts and follicles secreting an abnormal quantity of mucus. The swelling of the gland may be sufficient to alter the shape of the urethra; hence micturition may be impeded, and occasionally accompanied by smarting pain. A dull heavy sensation, hardly amounting to pain, is referred to the anus or perinteum ; and the pressure of hard faeces during defecation is often distinctly 7, painful. The pas- sage of a bougie along the urethra causes little pain till the prostate is reached, when the patient may even scream with exaggerated expression of the pain he feels. The instrument is grasped by spasm for a few seconds, when it passes into the bladder, and no more pain is felt. The dis- charge observed by the patient is transparent, colourless, glutinous, scanty, except when lie strains, or is excited by erotic desire, when several drops may come away at a time. In middle-aged men urethral stricture is sometime GLEET. 537 also present, and aggravates the prostatic irrita- tion. The reflex and sympathetic derangements attract more attention than the local condition. An almost invariable accompaniment, if not a consequence, is dyspepsia with its various symp- toms ; very common, also, are aches and pains in the lower extremities, loins, and other parts. There is often great weariness, especially after sexual intercourse. Intellectually and morally the patient is much affected. Dread of impo- tence, of loss of memory, of insanity, or even of paralysis, is often a leading symptom. 3. Warts and. granular patches. — Warts, which are most commonly situated just within the meatus, may stud the whole length of the urethra. Near the meatus they are arboriform, lower down sessile or only slightly peduncu- lated. Identical in structure with the warts on the glans or furrow of the penis, they are ordi- narily papillomata. 4. Follicular sinuses. — Follicular sinuses, inflamed during acute gonorrhoea, often secreto discharges long after the gonorrhoea is ended. In the anterior urethra rarely more than one or two crj-pts are thus chronically inflamed ; but in the prostatic portion several crypts secrete a thin translucent fluid, and this form may be looked on as one of chronic prostatitis. In cases of hypospadias, at the extreme end of the ex- posed urethra, there is in many persons on each side of the orifice a natural crypt three-quarters of an inch long. These often continue to dis- charge thin rnuco-pus long after gonorrhoea has subsided. Other sinuses, but shorter ones, open in the situation of the lacuna magna of the uormal urethra. None of these follicular sinuses ever form indurated patches iu the substance of the urethra ; hence they never cause stricture. This may, however, sometimes result from the bursting of an inflamed and suppurating sub- mucous gland, which before its evacuation may have projected on the wall of the urethra, and thus temporarily produced a narrowing. The discharge from such a cavity is much more copious than from a simple follicle, and very slow to dry up, though that usually happens spontaneously if there be no stricture to prevent the easy outflow of the urine. Treatment. — 1 . Inflammatory 'patches. — When the pain experienced from passage of the exploring sound is acute, the resistance small, and the discharge white and thick, the condition is mainly one of congestion ; and the injection of three or four minims of a solution of ten to twenty grains of nitrate of silver to the ounce, by means of a Guyon’s bullet-catheter and syringe at the places where pain is felt, is then a useful measuro. This may he repeated in three or four days, if needed. If there be cling or hitch as the bullet passes along the urethra, the passage of a lull-sized (No. 25 or 26, French) metal sound twice weekly is requisite. When no cling exists, the last remains of the discharge may be dried up by using soluble bougies at night (‘ Porte remede Eteynal ’) for ten to fourteen nights. When con- gestion has become induration, or even contrac- tion, which does not yield to gradual dilatation, die fibrous band should be divided by a urethra- :ome of suitable shape, uni il the urethrameter, expanded to the largest size in which it moves freely along the unaffected parts, travels without hitch or cling past the contracted patches. 2. Chronic prostatitis. — Usually the euro is slow, and depends much on regimen and diet ; with abstinence from alcohol, fatigue, lascivious thoughts, and sexual excitement. To relieve pain and irritation, mild belladonna and opium suppositories may be employed ; when the dis- charge is opaque and tolerably copious, two minims of copaiba in essence of cinnamon and water, or a drachm of solution of sandal- wood oil, with buchu and cubebs, are useful. Locally, when the prostatic tenderness has subsided, cool hip-baths for five minutes night and morning, beginning at 85° F., and gradually lowering the temperature to 50° F., are beneficial. After a week or two the bath may be taken at 50 J F., and lowered by ice to 40° F., with advantage. The sitting should not exceed five minutes, but the baths should be continued for several weeks. Counter-irritation is most useful when there is pain and considerable irritation. It should be applied over a large surface by the caustic solu- tion of iodine. It is at best an uncertain remedy. The ‘ relaxed' prostate requires great tact and perseverance for its cure. Regulation of the digestion, prescription of suitable occupa- tion, and encouragement of the patient to throw off his mental despondency, comprise the general treatment. Locally, if the prostate be not extremely sensitive, the passage of the steel sound on alternate days is most beneficial. Dreaded as is the first passage of the sound, the relief that follows is so satisfactory that the patient seldom objects, and generally demands its repetition. When the passage of the instru- ment is really agonising, the patient should be aDtesthetised, his bladder emptied by catheter, and ten to twenty minims of a twenty-grain to the ounce solution of nitrate of silver thrown into the prostato-membranous urethra by Thompson’s prostatic injector. This may ba followed by a subcutaneous injection of one- third of a grain of morphia before the patient recovers his consciousness. He should keep his bed for one or two days afterwards, and his room three or four days more. Repetition is seldom required, as the sound is then well borne. As a completion of the cure, a long voyage and a year spent in Australian or New Zealand sheep-farming are most useful. 3. Granular patches. — These are best treated by passing along the urethra a bougie, which has been dipped for three inches or more into an ounce of melted cacao butter holding sus- pended in it five to ten grains of peroxide of mercury or nitrate of silver. When cold, this bougie may be inserted into the urethra for teu or fifteen minutes, till the warmth of the body has melted off the cacao butter, by which plan the stimulant is directly applied to the granular patch. Again, twenty drops of a thirty-graia to the ounce solution of nitrate of silver may be thrown on to the granulations by a bulbous syringe. These strong injections should be made only when the patient can rest in his room for twenty-four hours afterwards. The pain is sometimes severe, and needs hot baths, opium, and other anodynes, to allay it. li’arts should ba exposed by an aural specu- 533 GLEET. turn or endoscope, and touched by a wire armed with lunar caustic. 4. Follicles.— The follicles can also be reached through the speculum, and a slender wire armed with caustic run into the mouth of the follicle. Usually, when the discharge is due solely to follicles, it is better let alone. The long sinuses met with at the end of the urethra in hypospa- dias may be first cauterised ; and then, if caustic be not sufficient, slit up with a fine knife and ranaliculus-direetor. Berkeley Hill. GLEICHEHBEKG, in Austria. Muri- ated alkaline waters. See Mineral Waters. GLOBUS HYSTERICUS ( globus , a ball ; hysteria's , connected with hysteria). — Synon. : Er. globe hysterique; Ger. hysteriscke Kvgel. — A subjective sensation experienced by hysterical patients, as of choking, or of a ball rising in the throat. See Hysteria. GLOSSALGIA (yXaocra, the tongue, and tiAyos , pain). — Pain in the tongue. See Tongue, Diseases of. GLOSSITIS (y\au G ON AGRA. GONAGEA, (yivv, the knee, and aypa, a sei- £uro ). — An attack of gout in the knee. See Gout. G-ONABTHRITIS {yow, the knee, and Ep9pov, a joint). — Inflammation of the knee- ioint. See Joints, Diseases of. GONORRHOEA ( yovr/ , seed, and pica, I flow). — Stnos. : Clap, Blenorrhagia ; Fr. Chaude- pisse ; Ger. Tripper. Definition. — A contagious purulent inflamma- tion, affecting, in men, the urethral mucous mem- brane and its continuations ; in women, the vaginal mucous membrane and its continuations. Occasionally the conjunctival and rectal mucous membranes, to which the nasal has been added on doubtful evidence, are attacked by gonorrhoea. Certain rheumatoid affections and other compli- cations, to be hereafter mentioned, also attend the disease. Aetiology. — The causes of gonorrhoea are predisposing and exciting. The chief predispos- ing causes are the lymphatic temperament ; great sexual excitement and other fatigue ; alco- holic excess ; gout ; previous attacks, especially an uncured gleet ; and lastly, a peculiar proneness to urethritis in certain persons. The exciting causes include: — (1) Contagion with (a) gonor- rhoeal pus, or (b) acrid discharges not generated by gonorrhoea ; (2) excessive irritation of the ure- thra by prolonged or repeated coitus ; (3) mas- turbation ; (4) instrumentation; and (o) the use of injections after coitus. Gonorrhoea differs so considerably in the two sexes, owing to the diversity of seat of the dis- order, that its description may be conveniently divided into two parts. (A.) Gonorrhoea in the Male. — Anatomical Characters. — The seat of urethri- tis is at first the mucous membrane of the fossa navicularis, whence it travels onwards, commonly net extending further than to the bulbous or membranous portion of the urethra. The inflam- mation then dies away gradually, leaving patches of the mucous surface here and there still in- flamed. But the inflammation may extend to the submucous tissue, to the glands abcut the urethra, to the prostate, to the neck of the bladder, and to the epididymis in one direction, or to the bladder or even to the kidneys in another. Renal inflam- mation nevertheless is most frequently excited by sympathetic irritation, when the neck of the bladder is attacked, and cnly with excessive rarity by continuous extension alcng the bladder and ureters. As the inflammation localises itself in the urethra, it penetrates more deeply, reach- ing the follicles and submucous tissue, and may thus cause thickening and induration of the ure- thra at these points. In the acute stage there is general uniform congestion ; as inflammation subsides, the gene- ral redness becomes patchy, arborescent, and punctiform. The swelling disappears, leaving areas of thickened mucous membrane, fine gra- nulations which develop occasionally into warts, and a plugged condition of the ducts of the sub- mucous and. mucous glands, which possibly may cause peri-urethral abscess or subsequent gleet. After a lapse of time the indurated patches may contract, and thereby cause irregularity and stric- ture of the urethra. GONORRHOEA. 541 Symptoms. — The length of the interval be- tween contagion and the development of the symptoms in gonorrhoea varies from twelve hours to eight days ; but the great majority of claps are evident on the fourth or fifth day after inter- course. Usually early manifestation of inflamma- tion denotes a severe attack. Urethritis from contagion differs in no respect from inflammation otherwise excited, and has no necessary period of incubation. In the first stage, redness, scanty sticky dis- charge, and smarting in micturition are the leading symptoms. Febrile disturbance at this early period is most rare. On the other hand, the discharge in many cases precedes all other symptoms. Towards the end of the first week, swelling generally of the penis, especially of the urethra, sets in, accompanied by copious yellow- ish-green discharge, smarting in the urethra, and aching in the penis, perinseum, and groins. Painful micturition and erections at night are frequent ( see Chordes) ; and general febrile dis- turbance is sometimes present. Naturally the disorder subsides in four or six weeks, by gradual cessation of the symptoms ; but it is frequently prolonged or brought back to its first intensity by neglect of the precautions necessary against irritation. The patients’ habits often induce variations from the ordinary course, as regards the amount of discharge and the severity of the symptoms. In all cases relapses or re-kindling of the acutely inflammatory stage are common. The acute stage of the disorder terminates in one of three ways : — Cessation of pain and discharge ; cessation of pain, with diminution of the still purulent dis- charge; cessation of all symptoms, except a mi- nute quantity of thin whitish discharge or gleet. This scanty discharge is most commonly caused by chronic inflammation at one or two places, continued after the inflammation has ceased else- where. Sometimes a stricture, a small wart, or a relaxed prostate secretes shreds of mucus, and thus causes gleet. Sec Gleet. Thus the course of gonorrhoea has been di- vided into four stages: — Preliminary congestion, lasting three or four days ; acute increasing inflammation, lasting ten to twenty days ; station- ary stage, of uncertain duration ; and, lastly, subsiding stage, also of uncertain duration. The discharge varies from its usual form of yellow pus, being in some cases viscid, like mucus, in others serous and very liquid ; in rare in- stances it is rosy or pinkish for some days. Diagnosis. - — The distinction of urethritis caused by contagion from that excited by other causes is impossible when the history of the patient's antecedents is wanting. Certain com- plications of gonorrhoea are said to follow urethritis only when that is excited by contagion. This proposition is not so clearly established that it may serve to decide the origin of a given case to be contagious or non-contagious. To distinguish urethritis from urethral chancre is easy : urethral chancre is never more than one inch from the meatus, nearly always situate just within the entry, and the ulcerated surface can be seen if the lips of the urethra be separated, or a short aural speculum be introduced. The discharge also from a chancre is not creamy, but GONORRHCEA. 542 shreddy. The pain in micturition is stinging, but limited to one spot. Syphilis may accompany urethritis, but the disease has its proper initial sore or other characteristic symptoms. Occasion- ally a slight muco-purulent discharge 'without pain or much swelling is present during the period of the initial lesion in syphilis. This always subsides spontaneously in one or two weeks. In balanoposthitis {gonc^rhoia externa ) there is no urethral discharge. When the free border of the prepuce is exceedingly small, it may be most difficult to be certain that the discharge does not come from the meatus tirinarius as well as from the surfaces of the prepuce and glans. Usually, a thorough syringing under the fore- skin will wash away the pus, and permit the meatus urinarius to be watched while the urethra is pressed ; if pus oozes forth it is secreted in the urethra. Abscess of the prostate or peri- nseum may cause urethral discharge, which is distinguished from gonorrhoea by the history and condition of the patient. Pitoois'osis. — The prognosis of gonorrhoea is favourable if proper precautions be taken early. But in spite of precaution, the disease is sometimes most severe, especially in younglads of lymphatic temperament, or in men of nervous irritable constitution. Gonorrhoea is said also to be liable to run a severe course in persons who suffer from acne. During its continuance any of the complications hereafter mentioned may arise. Further, gonorrhoea has caused death through pysemia ; and more often still it origi- nates anchylosis or destruction of joints, or other painful disablements; while it is the predomi- nating cause of stricture. Treatment. — The treatment of urethritis may be (1) abortive ; and (2) systematic. Abortive treatment is intended to cut short the disease by large doses of specifics, or by caustic injections, before acute inflammation arrives. It is always dangerous, and rarely successful. Systematic treatment consists in at first removing all sources of irritation and allaying acute inflammation. Abstinence from alcoholic liquors, sexual excite- ment, and severe exercise is necessary. Tepid baths and great cleanliness, with support for the penis and testes, are useful. Painful micturition is often relieved by immersi )Z the penis in ice- cold water during the act. A light diet of fish, milk, and vegetables, with salines and laxa- tives, should be ordered. When the acute stage is passed, the continuance of the congestion is shortened by astringent injections and the ad- ministration of copaiba, sandal oil, and cubebs. But these should he withheld while there is smarting, copious greenish discharge, and dull- red congestion of the urethra. Complications and Seque^e. — The compli- cations of gonorrhoeal urethritis are — (1) Ba- lano-posthitis ; (2) Phimosis or paraphimosis; (3) Retention of urine; (4) Lymphangitis and Adenitis (Sympathetic bubo) ; (5) Hcemorrhage from the urethra ; (6 ) Peri-urethral abscess (a) near the glans. ( b ) between the layers of the perinceal fascice, (e) Cowperitis; (7) Inflammation of the neck of the bladder ; (8) Prostatitis ; (9) Inflam- mation of the spermatic cord, epididymitis, and orchitis ; (10) Inflammation of the rectal mucous membrane; (1 1) Conjunctivitis by contact ; (12) Sclerotitis and iritis; (13) Rheumatism of the fasciae, great nerves, or joints ; acute synovitis, bursitis, abscess, pyaemia; (14) Stricture; and (15) Warts. Several of these complications are described in special articles, to which the reader is referred ; but a few of them require brief notice here. Stricture, or the development of tough fibrous bands in the submucous tissue in limited areas of the urethra, which prevent the canal from expanding during the flow of urine, is caused by long-lasting congestion and inflammation ; the most common seat being the penile portion of the canal, and especially the inehnearest themea- tus urinarius, whilst those causing most trouble are commonly at the bulbo-membran- >us portion. Slowly produced, these contractions seldom attract attention till two or three years have elapsed, and very frequently not until eight or ten years have passed away. Easily curable, in the early stages, these con- tractions, by exciting reflex irritation, first of the bladder, subsequently of the kidney, in- directly cause parenchymatous induration and atrophy of the secreting tissue of the latter, and thus seriously affect the nutrition of the body, thereby generating a long chain of morbid changes, which not infrequently end in death. Retention of urine is produced by gonorrhoea in two ways: — (1) During the acute inflammatory stages by muscular spasm closing the congested mucous membrane at the bul bo-membranous por- tion. This is of course a temporary evil, though often very painful while it lasts. The bladder should at once be emptied by passing a small (No. 6 or 7 English scale) flexible catheter, and the recurrence of the spasm prevented by saline purges, rest, warm baths, and opiates. (2) In the tightly-narrowed urethra, when stricture lias formed, a small amount of local swelling or spasm may block the passage. The immediate treatment consists in passing a catheter fine enough to get through the contraction with the adjuvants just mentioned, and subsequently di- lating the contracted parts by one of the various methods employed by surgeons for that purpose. Hcemorrhage from the urethra is caused by rupture of the blood-vessels of the corpus spon* giosum during the violent erections of chordee. Rarely copious or serious, in some cases it has, like hcemorrhage from other trivial causes, been dangerous from its obstinacy. Ice-cold wrap- pings, notably the india-rubber coil with ice- cold water flowing through it, generally arrest the bleeding speedily. If requisite, a catheter may bo passed, and the penis compressed by a bandage tightly wound round the organ. Inflammation of the neck of the bladder , or. as it is often called, inflammation of the bladder, though real cystitis is rare in gonorrhoea, con- sists of extension of the mucous inflammation to the neck of the bladder, and is a tedious, often very harassing accompaniment of gonorrhoea. It seldom occurs until the gonorrhoea has lasted two or three weeks, and it may develop at aDy time during the contiruance of that disease. It is denoted by very frequent calls to micturate; great pain during, and especially scalding at the end of micturition, caused by muscular spasm of the deeper peri-urethral muscles ; with cxtrusios GONORRHCEA. along with the last drops of urine of a small quantity of muco-pus or blood. The usual gonorrhoeal discharge ceases almost entirely during the attack, bur, usually returns when the inflammation of the neck subsides. Never dan- gerous, this affection derives its importance wholly from the great amount of distress, mental and bodily, which it causes. It is best com- bated by rest, warm baths, anodynes, and very light diet. It is very prone to relapse. Prostatitis, that is, inflammation of the sub- stance of the prostate, is a severe complication. It causes swelling of the prostate ; painful, slow micturition, and often complete retention ; a sense of fulness or weight at the anus ; and sometimes great irritation of the bowel, with constant de- sire to defaecate. Prostatitis may cause abscess, and usually leaves enlargement of the organ. If suppuration takes place, pain increases till matter escapes ; then sudden relief follows. The abscess most commonly opens into the urethra, and the pus comes away with the urine ; but it may open into the rectum, the perinmum, or the bladder. The treatment consists mainly in allaying irritation and pain by hot baths, fomentations, and opium ; and when retention occurs, the regu- lar passage of a catheter is requisite. "When fluctuation is evident, abscesses must be opened in the rectum or perinseum. "When the abscess has burst spontaneously, it visually closes in course of timo,and the discharge ceases altogether or dwindles to a scanty gleet of no importance. Should the discharge continue copious without abatement after several weeks, or the patient suffer much distress, an incision through the perinseum is proper, through which to drain and close the abscess. (B.) Gonorrhceain the Female — Vaginitis. This may be acute or chronic. The inflamma- tion begins at the fore part of the vagina, extend- ing to the uterus in one direction, and to the urethra in the other. W T hen attacking the vulva, it causes occasionally abscess of accessory parts, for instance, of Bartholini’s gland, or of the lymphatic glands. In the cervix uteri and in the urethra it becomes very obstinate. Stmptoms. — These consist, in the acute stage, of swelling of the genitals, heat, or itching, smart- ing on making water, and aching pains in the back and loins. The mucous membrane becomes dry and bright red. At first the mucus is thin and transparent, but soon becomes thick, creamy, and copious. The mucous membrane is more or less studded with little eminences ( vaginitis granulosa ). The inflammation becomes chronic in from six to ten or twelve days ; the pain, swelling, and congestion diminish or cease ; the discharge, less creamy, remains plentiful. It is usually secreted in the cul-de-sac, or in the cer- vix, or seme other part less easily cleared than the anterior part of the vagina. These parts, while inflamed, retain a brighter red colour than the rest of the mucous membrane. Not in- frequently, when the inflammation has ceased in the vagina, pus can still be squeezed from the meatus urinarius or some of the crypts opening round that orifice, if the finger be drawn for- wards along the under surface of the urethra. The duration is extremely variable ; if assidu- ously treated, so that extensiou to the cul-de-sac 543 or cervix uteri is prevented, the disease has a duration of about three weeks. But when theso parts or the urethra are invaded, the duration is most uncertain, the disease lasting often for months or even years. The length of time that the discharge remains contagious is also most uncertain. Probably any discharge, however scanty and serous it may have become, may cause disease if increased by accidental irritation. Tuagnosis. — This depends on the swelling and red congestion in the acute stage, and on partial excoriation and copious discharge in the chronic stage. The distinction between vaginitis from contagion and vaginitis from non-specific irrita- tion is always difficult, and sometimes impossible, being mainly determined by collateral evidence. It generally has a contagious origin if there be pus in the urethra. Prognosis. — This is favourable. Sometimes the disorder is cured before it becomes chronic; and dangerous complications are very uncommon. Treatment. — The treatment of vaginitis in the acute stage consists in allaying irritation by rest, in bed, warm baths, frequent injections of warm water, or warm but very weak, astringent solu- tions, and moderate purgation. The habits and health of the patient must be regulated, and all causes of excitement withdrawn When conges- tion has subsided, stronger astringent injections should be efficiently applied, so that the whole mucous surface of the vagina, especially that of the cul-de-sac, is thorougtdy laved. Alum or tannin should be applied in powder, by means of the speculum, to the dt-eper parts of the canal. Complications.— The complications of gonor- rhoeal vaginitis are various. Among the earliest is vulvitis. The labia and clitoris grow red, swell, and a foetid discharge is secreted. The patches of epithelium peel from the mucous surfaces, pro- ducing excoriation and occasionally ulceration of the mucous follicles. Usually, if the parts are kept clean, the irritation subsides in a few days. Urethritis is the most constant accompaniment of gonorrhoea. Barely so acute as to cause much irritation, it may produce severe suffering. It begins with itching and smarting at the meatus, which is red and swollen. A purulent or mucous discharge oozes from the passage, unless the patient have just micturated ; even then a little can be found in the mouths of two follicles which open close to the meatus. This discharge is very persistent, and is probably a source of contagion long after the disease is cured else- where. The treatment of urethritis consists of frequent baths, astringent injections, and copaiba internally. Obstinate chronic discharges maybe arrested by caustic solutions, carefully applied. Acute inflammation of the cervix and os uteri is a frequent consequence of gonorrhoea. The neck of the uterus is swollen, red, and often excoriated about the os, whence a copious dis- charge issues, at first clear and viscid, then purulent. This subsides to a thin mucus, and either shortly ceases, or more commonly passes into chronic catarrhal flux, which lasts an indefi nite time, aud long retains its contagious quality. The acute inflammation is best treated by com- plete rest, warm baths, warm injections, and saline aperients. In the chronic stage its treats ment is that of uterine catarrh. 64-1 GONORRHCEA. Metritis, perimetritis, and ovaritis may also result from gonorrhoea. See Ovaky, Diseases of ; and Womb, Diseases of. Berkeley Hill. GONOESHCEAL RHEUMATISM. — An affection of the joints associated with gonorrhoea. See Rheumatism, Gonorrhceal. GOOSE-SKIN - . — -A condition of the skin in which this structure is rough and wrinkled, like that of the goose. It is of a transient character, being due to contraction of the muscular fibres of the skin, producing wrinkling of the integuments, and prominence of the hair-follicles ; and is ob- served as the result of the direct application of cold, or of a shock, and in the early stages of fevers. GOUT ( guttci , a drop). — Synon. : Podagra, Chiragra, Gonagra (when the disease affects the foot, hand, or knee respectively) ; Fr. Goutte ; Ger. Gicht. The name gout is supposed to have originated in the idea of the dropping of a morbid fluid into the joints, and is of very ancient date. Definition.— Gout is a general or constitu- tional disease, probably depending upon the presence in the system of excess of uric acid, the complaint being, in fact, a manifestation of the lithic or uric acid diathesis , lithiasis , or lithce- mia. It may be hereditary or acquired ; and is characterised ordinarily by a peculiar inflam- mation of the joints — articular or regular gout, attended with the deposit of urates in their struc- tures, affecting usually and especially the smaller joints, and at first more particularly the meta- tarso-phalangeal articulation of the great toe, but afterwards extending to other joints. Similar deposits of urates may occur in other tissues in course of time ; and certain organs of the body are liable to become the seat of functional dis- orders, or of pathological changes, during the progress of the disease — non-articular or irre- gular gout ; while it is also often attended with general symptoms. Gout in the early part of its course is usually an acute affection, occurring in periodic attacks or ‘ fits ’ ; but subsequently it tonds to become more or less chronic and per- manent, though even then generally presenting exacerbations from time to time. The gouty diathesis may, however, be present without giving rise to any joint-affection or other evident organic mischief. .Etiology and Pathology. — The aetiology and pathology of gont are intimately associated, and must be considered in their mutual relations ; and there are certain definite points which re- quire to be noticed in this connection. 1. It is necessary to determine the immediate pathological cause of the gouty diathesis and its accompanying phenomena. Many views have been advanced, but they all belong to either of two groups, namely, the humoral or anti-humoral, the former attributing the complaint to some morbid condition of the blood and secretions ; the latter to some functional disorder or organic change affecting certain systems of the body, and especially the nervous, vascular, or digestive systems. Loss of nervous tone,atropho-neurosis, venous and capillary congestion, and plethora of the chylo-poietie viscera, are among the con- ditions to which gout has thus been attributed. In the writer's opinion an essential element GOL'T. in the development of gout consists in the pre- sence of some special morbific agent in the system : and it is now almost universally ad- mitted that this agent is uric or lithic acid, which accumulates in the body in abnormal quantity • A variable amount of this substance is being constantly formed in the system during the pro- cesses connected with nutrition, but within cer- tain limits, which probably differ in different persons and under different circumstances, it is capable of being eliminated by the kidneys or of being destroyed, and only when the acid accumu- lates beyond such limits are the gouty phenomena developed. In short, gout may be regarded as a manifestation of the so-called lithic acid dia- thesis, lithiasis, or lithcemia. The acid exists in the body as urate of soda, and in the gouty diathesis this salt is present not only in the serum of the blood, but also in the fluid that diffuses from it into all the vascular and non- vascular structures of the body (Bence-Jones). There are several arguments in support of this view: — (1) Gout occurs under circumstances which are known to induce in various ways the presence of excess of uric acid in the sys- tem ; and, further, the causes which, are most liable to bring on a gouty paroxysm are those which temporarily increase this excess. (2) While in the blood of healthy persons the quan- tity of uric acid present is so minute that it cannot he detected by any ordinary tests, in gout this substance may be obtained from blood -serum, even in a crystalline form, either before or during an acute attack in early cases, or at any time in chronic cases. It has also been found in the fluid contained in blebs raised by blisters, provided they are applied at a distance from the seat of any acute gouty in- flammation ; in inflammatory effusions in serous cavities; and in dropsical fluids, such as ascites. (3) Along with these indications of the presence of excess of lithic acid in the system, during an attack of acute gout the absolute quantity dis- charged in the urine is considerably diminished; while in chronic cases of the disease it is habi- tually more or less deficient, and at times may be almost entirely absent. (4) Deposits of urates, especially of urate of soda, are formed in the joints and other structures in gout, and this is the only disease in which such for- mations are found. Every attack of gouty in- flammation is attended with the deposit of urates in the affected tissues, but the quantity is not in proportion to its intensity, and therefore can- not be merely the effect of such inflammation. Assuming this view of tli9 essential nature of the gouty diathesis to be correct, different theories are held to account for the excess of lithic acid in the system, and they are probably all more or less true in different cases, in some instances the accumulation being explicable in more ways than one. Undoubtedly uric acid is often formed in excess, so that it cannot be adequately got rid of by elimination or in any other way. This excessive formation occurs in many cases without giving rise to the pheno- mena of gout, because so long as the kidneys are in good condition, and the nutritive processes are satisfactorily carried on, the acid is elim:- nated or destroyed. Again, it is supposed that GOUT. lithic acid may undergo imperfect oxidation and destruction in the body. Both these dis- orders have been attributed by some writers to a supposed influence of the nervous sys- tem. Others attach considerable importance to hepatic derangements in the causation of gout; and here- it may be remarked that a distinct connection has been traced in some in- stances between this complaint and diabetes. Furthermore, the presence of an undue quantity of other acids in the blood may in some instances account for lithoemia. If, from various causes, such as deficient action of the skin, excessive consumption of acids or acid-producing food, or the formation of acids in undue quantity during the process of digestion, these acids are present in excess in the blood, from their greater affinity they combine with the alkalies in this fluid, and diminish the alkalinity of the blood-serum, so that it is less able to hold uric acid or urate of soda in solution. Deficient elimination is an important cause of lithiasis, and is often asso- ciated with other causes. It has been proved experimentally that in birds, if the ureters are tied, uric acid is deposited all through the tissues, but especially in the kidneys. It has been suggested that in some cases of the gouty diathesis the kidneys are congenitally small, and therefore cannot properly excrete even a normal quantity of uric acid, but especially any excess of this substance. Functional disturb- ances of the kidneys are also liable temporarily to interfere with their eliminating power, being often associated with, and probably due to, ex- cessive formation of urates; while in course of time these organs become the seat of serious organic mischief in gouty eases, which gravely limits their excretory power, and in extreme cases arrests it entirely. 2. We are now in a position to discuss the circumstances under which the gouty diathesis is developed, and the more obvious causes with which this condition is associated. There are certain causes which may be regarded as more or less predisposing , and these will bo subsequently considered ; but setiologieally cases of gout may be conveniently arranged into three main groups, according as the disease arises from : — a. Heredi- tary transmission, b. Certain errors in regard to food and drink ; often associated with deficient exercise, c. Impregnation of the system with lead. In not .a few instances, however, it must be remembered that these causes are more or less combined. a. Hereditary transmission. Gout is one of the most striking examples of a hereditary dis- ease, and once established, it may be trans- mitted for several generations, even when every endeavour is made to eradicate it ; but as the con- trary is generally the case, the malady being as a rule more or less intensified by pernicious habits, it becomes in most cases a permanent legacy, handed down from one generation to another. Garrod found that in more than half his cases hereditary taint could be traced distinctly ; and the proportion is much greater in the upper classes. It sometimes happens that when gout becomes developed de novo in an individual, children born previously are free from the com- plaint, while those born subsequently are liable 35 64,‘> to bo affected. Hereditary influence may be so powerful that gout arises without any other cause whatever; but most commonly this is aided by indulgence in certain habits to be pre- sently mentioned, perhaps not to an extent which would be considered excessive for people in general, but which is excessive for persons pro- disposed to gout. This complaint sometimes ex- emplifies the so-called ‘law of atavism,’ but this is usually due to the fact that in the generation free from gout every precaution is taken to avoid causes which tend to originate a gouty paroxysm, these precautions being subsequently neglected The hereditary nature of gout is shown not un- frequently in the age at which the disease reveal- itself. Should the predisposition be powerfu the complaint may appear even in children ; and the younger the subject who is attacked with gout, the more likely is there to be an hereditary tain;. The explanation of the transmission of gout in this manner is a mere matter of theory, and tlir excess of uric acid in the system has been ac- counted for in all the ways already mentioned. b. Errors relating to fond , drink, and exercise. In a considerable number of cases gout is origi- nated de novo, in consequence of certain errors affecting the diet and habits ; or an inherited ten- dency to the disease is considerably aggravated and promoted in this way. In general terms these errors may be summed up as excessivn eating, especially of particular articles of food ; undue indulgence in alcoholic drinks ; and in dolent habits, with deficient exercise. They are frequently associated in the production of gout, and not a few persons who eat and drink to excess, are saved from becoming gouty because they are of active habits, xvork hard, and take a considerable amount of exercise. Although all kinds of food may assist mon- or less in developing the gouty diathesis, those elements which aro rich in nitrogen are most injurious, and especially meat. Beef is believed by many to be particularly baneful. The writer has heard vegetarians affirm that meat is the great cause of gout, and that it never occurs when a vegetable diet is adhered to, but for such a statement there is no adequate proof. At the same time it must be acknowledged that this- complaint is often in no small degree attributable to the amount of meat which is consumed. Many articles of diet, either from their own nature, or from tho manner in which they are cooked, may help in the production of gout, by giving rise to digestive disorders. The relation of intemperance in the use of al- coholic drinks to tho gouty diathesis is highly important, and is abundantly proved by every day experience. The more potent wines have the greatest influence in causing gout, and port- wine has proverbially been regarded as the most injurious of all. Burgundy, madeira, sherry, and marsala aro also undoubtedly capable of developing gout, or of keeping up the disease. The lighter wines are much less injurious, but champagne, and especially sweet champagne, certainly often promotes the gouty condition. Hock, sauterne, moselle, and light claret seem to be least injurious, but even these, if in- dulged in to excess, may in course of time set up, or, at any rate, intensify the gouty dia- GOUT. 546 thesis. Malt-liquors stand next to -wines as originators of gout, and undoubtedly those -who partake very freely of this class of alcoholic beverages are not uncommonly affected. In this way the di-ease may be usually accounted for when it occurs among the labouring and poorer classes, but it muBt be remembered that in these persons an inherited tendency to the complaint may exist. Brewer’s draymen espe- cially drink large quantities of ale or porter, and the writer has met with instances in which the habitual daily consumption has been ac- knowledged as averaging from two to four gallons. Spirits are comparatively feeble in their power of producing gout, as is proved by the rarity of the disease in those countries where this class of drinks are chiefly used, such as Scotland. Rum is said to form an exception to this statement. Cider and perry may unques- tionably set up gout, if taken to excess, but they are much more powerful when sweet and not properly fermented. Excessive indulgence in a mixture of alcoholic drinks is probably more de- leterious than if one is adhered to. The expla- nation of the differences in the tendency to develop gout exhibited by the various kinds of beverages is not very clear. They do not depend directly upon the amount of alcohol which they severally contain, but the admixture of certain other ingredients with the alcohol renders it far more potent in producing this effect, and the more alcohol then present, the greater is the like- lihood of gout being originated. It is not, how- ever, definitely known what these ingredients really are. At the same time it may be affirmed, as regards wines, that their quality has much to do with their tendency to induce gout. 1'ae- titious wines and others of inferior quality, as well as those which are very sweet, or which contain much tannin, aro most liable to produce this complaint. Drinks which cause a marked diuretic action are less capable of inducing the gouty state than those which have but little of such an action. The modes in which the errors as regards food and drink induce lithiasis are probably various. They often directly lead to the for- mation of excess of nitrogenous products, and especially of uric acid, more than can be elimi- nated or destroyed in the system. Again, over- eating and drinking frequently cause undue pro- duction of other acids during digestion, which take the place of uric acid, and prevent its elimination. Moreover, these habits disorder the digestive functions, cause congestion of the cliylo- poietic viscera, interfere with the hepatic func- tions, and ultimately setup a permanent dyspeptic condition, all of which assist in the develop- ment of the gouty diathesis. It has been sup- posed that indigestion from any cause might originate this condition, but according to tbe writer’s experience this is certainly not the case. Persons who are hereditarily gouty often suffer from dyspepsia, hut the disease may appear in such individuals when digestion has always been carried on without the slightest discomfort. Those who indulge in the habits which originate gout de novo are generally dyspeptic, as the -esult of these very habits. So Disc. With respect to deficient exercise, this un- doubtedly promotes the development of gout in many cases. Persons who follow sedentary occu- pations, or who live indolent and lazy lives, are certainly more liable to the disease , and not a few become gouty because they are able to ‘ keep a carriage,’ and thus are deprived of the exer- cise which they were previously accustomed to take. This cause probably acts by limiting the conversion of uric acid int i other waste products, which can be more easily got rid of; and also ly increasing dyspepsia, in consequence of the organs which are concerned in the process of digestion doing their work slowly and imperfectly. c. Another group of cases of gout which origi- nate de novo, are those which occur in connection with lead-impregnation of the system. Dr. Garrod found among his hospital patients, that about 30 per cent, of those suffering from gout had been subjected to the influence of lead in their various occupations ; and in the writer's experience, no; only has the relation between lead-poisoning and gout been frequently exemplified, but some of the worst cases of this disease in its chronic forms occurred in persons who were distinctly under the influence of lead. This metal does not appear, however, to originate the gouty diathesis, unless aided by more or less indulgence in alcoholic drinks, though the amount of the latter consumed is usually far less than would alone account for the condition. It bus also beeu found that gouty persons are remarkably sus- ceptible to the influence of lead ; and that wh"ti this metal is given to such persons for medicinal purposes, it is very liable to bring on a severe attack of acute gout. Garrod's observations seem to show that lead acts by diminishing the excretion of uric acid by the kidneys ; and this authority states that the blood of individual* suffering from lead-pAralysis always contains an abnormal amount of uric acid, and that the same probably holds good in all cases of lead-colic. 3. Predisposing causes. — It is next requi- site to notice briefly the predisposing causes of gout. Beginning with age, distinct gouty attacks in a large majority- of cases make their first appearance in persons between thirty and thirty-five or forty years old. Those which occur under thirty are, with rare exceptions, more or less hereditary. 'Well-marked gout is exceedingly rare under twenty-, but it may occur even in children, being then, however, invariably strongly hereditary. The complaint usual’y appears before fifty, and becomes progressively less frequent in its manifestation for the first time after this period of life. It is quite exceptional for gout to commence after sixty-five, but it may- begin even in extremo old age. The cases in which the disease is developed during or after middle life mainly- originate de novo, and one of the reasons assigned for the less frequent appear- ance of tho complaint as ago advances is, that then people usually become more careful in their mode of living, and more temperate in their habits. With regard to sc- r. males are far more commonly the subjects of well-marked gout than females. This is mainly accounted for by the difference in tho habits of the two sexes. It has also been partly attributed to the • ccur- renee of menstruation in females, which .acts to some extent as a safeguard, and in these GOUT. subjects gout generally appears after the cessa- tion of this function. When strongly heredi- tary, gout may appear even in young females, of which the writer has seen some well-marked examples. Bodily conformation and temperament have been credited with a predisposing influence, per- sons of a sanguine temperament, and of corpulent, fuil-blooded, plethoric habit of body, being sup- posed to be most subject to this disease, and to have it in its most acute form. These conditions are often produced by the very habit s which origi- nate gout, and certainly persons who are gouty by inheritance often do not present any of these characteristics, while those presenting marked contrasts in appearance and temperament seem to be equally the subjects of the complaint. It is not uncommon in individuals of a nervous tem- perament, thin and wiry in frame, aud they are said to be more subject to the irregular and asthenic forms of the disease. Social 'position and occupation materially influence the occur- rence of gout. Formerly the complaint was met with almost entirely among the higher classes, and it was looked upon as an aristocratic disease. Now, however, it is common enough among the middle classes, chiefly those who are in affluent circumstances ; while there are several occupa- tions in connection with which the disease is very prevalent, such as butlers, coachmen, butchers, publicans and barmen, coal-heavers, porters, hair- cutters, and painters, or others who have to do with lead. It was at one time believed that high mental endowments predisposed to gout ; this was obviously a mistake, although ex- cessive mental labour, prolonged worry, and other causes which exhaust and depress the nervous system, do seem to predispose to the disease. As regards climate, those climates which are cold or temperate, and especially at the same time damp and changeable, present by far the greatest number of cases of gout, and in most tropical countries this complaint is un- known. This depends partly upon the differences in the nature and amount of the alcoholic drinks employed ; partly upon the effect of climate as regards the functions of the skin. 4. Thus far we have been concerned with the pathology and {etiology of th e gouty diathesis. Now we have to discuss briefly these points in relation to the local manifestations of the disease, and especially to the occurrence of acute attacks. Athough the presence of excess of uric acid in the system is an essential element in the pathology of gout, such excess is often present, and yet none of its more characteristic phenomena are observed. An individual in this condition is, however, at any time liable to an attack of dis- tinct gout, from the action of certain causes which would have no such effect upon other per- i sons. If from any cause the amount of lithic acid m the blood is suddenly or rapidly increased, an acute attack of articular gout may be expected, or some internal manifestation of the disease. This is believed to be directly due to the action of the urate upon the tissues of the joint, which is supported by the fact that even after the first attack a distinct deposit of lithates is found m them, which increases with each subsequent attack. Two views are held as to the explana- 541 tion of its mode of action. According to one view the urate merely acts as a local irritant, it being supposed that different morbific agents in the system affect different tissues, and that this one acts specially upon the structures which are found in joints, setting up an inflammatory pro- cess. The degree of inflammation is, however, by no means in proportion to the amount of lithatea which are deposited ; indeed, the contrary is usually the case, for as a case of gout becomes more and more chronic, the deposit often becomes very abundant, though the paroxysms pro- gressively diminish in intensity; while it is often found in other structures besides those connected with articulations, without causing any evident inflammation. The second view is that the acute paroxysm is the result of an attempt on the part of the articular structures to eliminate the morbid material, a chemical process of oxida- tion being set up in the parts where urates are most able or liable to accumulate, by which they are converted into urea, carbonates, &c., and so got rid of. This process gives rise to congestion, followed by inflammation and its attendant phe- nomena. It has been proved that the inflam- matory process does destroy the urate in the blood of the affected parts, and probably the salt which has actually been thrown out is also partly destroyed. No uric acid can be detected in the fluid of a blister placed directly over an articula- tion which is the seat of acute gout. According to this theory the gouty paroxysm is to some de- gree salutary, as it helps to get rid of the excess of uric acid in the system. It is a well-known fact that gout tends spe- cially to attack the smaller joints, and above all the metatarso-phalangeal joint of the great toe, which is the one usually first affected. This is explained in the following way ; in gout it is believed that those tissues are chiefly attacked which are either non-vascular, or which are sup- plied with but few vessels, and through which the fluids pass with difficulty, especially cartila- ginous, fibrous, and ligamentous tissues. Such tissues are found in large proportion in the smaller joints. These are also distant from the centre of circulation, and the blood passes through them in a comparatively feeble and languid stream. They are, moreover, much ex- posed to the influence of cold and wet. And lastly, with reference to the metatarso-phalan- geal joint of the great toe more particularly, this joint is peculiarly liable to injury from pressure, supporting the weight of the body, sudden shocks, &e. Another point observed in the history of gout is, that during an acute paroxysm several joints are often attacked in succession, while the inflammation subsides in those first affected, often with striking sudden- ness. This is accounted for by the deposit of urates in different joints successively, and when inflammation is thus excited in them, it tends to subside iu those previously affected. Not un- commonly corresponding joints on opposite sides of the body are implicated alternately, probably through their nervous connection in the spinal cord. As gout advances in its progress, the articulations become more and more involved with each attack, because those first involved become, as it were, saturated with urates, and GOUT. 548 therefore new tissues of the same class are in- vaded. An acute paroxysm of gout may come on without any evident exciting cause whatever, especially if the disease is strongly hereditary, or has been long established. Under these cir- cumstances outbreaks of the complaint seem to become habitual at certain seasons, or they arise from, very slight causes, which need to be less and loss obvious as the case progresses. Often, how- ever, some distinct exciting cause can be made out, affecting the digestive organs, the vascular or nervous systems, the functions of the skin or kidneys, or disturbing the system in other ways. The most important are eating or drinking too much, either on some particular occasion, or habitually for a longer or shorter period, until at last a fit of gout terminates the indulgence, it being borne in mind that even apparent moderation may be excessive for a gouty person ; indigestible articles of food ; neglect of the act of defaecation, or constipation ; undue physical work or exertion ; exposure to cold or wet, or suppression of perspiration ; excessive men- tal work or worry; emotional causes, sudden, powerful, or depressing, such as sudden joy, a fit of rage, or deep grief ; haemorrhage, acute illness, or other debilitating causes ; or in- jury. The implication of a particular joint may be also due to injury, which may be very slight, such as the pressure of a boot, or the toe being trodden upon. Injury to the knee has caused that articulation to be first affected. As predisposing causes of acute gouty attacks, climate and season are highly important. Their characteristics have already beeu indicated, and undoubtedly gouty paroxysms may often be averted by residence in a warm climate, either permanently or during the colder seasons of the year. Early attacks seem to be most frequent ia the spring ; then they occur also in the autumn ; and subsequently they become more frequent and irrogular in their onset. One seizure predisposes to another, and it is a special feature of gout that it tends to recur, this ten- dency increasing with each succeeding paroxysm, until finally, in many cases, the patient cannot be said to be ever free from the complaint. The occupation of an individual may predispose to the occurrence of gout in particular joints ; thus butlers have it in the feet, coachmen and washer- women iu the hands. It is found in process of time that gouty con- cretions form in other parts besides in the joints. This is easily explained by the fact that urates tend to deposit in certain other structures which are but slightly vascular, besides those forming part of the articulations. Vascular tissues seem to destroy urates iu their passage through them, and thus they are prevented from doing any harm to these tissues. The presence of urates in the blood will account, not only for the chronic gouty state, but also for acute attacks affecting internal organs, or so-called irregular gout. It lias been maintained that the development of gout m other structures besides the joints is influenced by the diathesis and habits of the individual, but, it is doubtful how far this is borne out by actual experience. Anatomical Chabactebs. — In its most typical manifestations gout is characterised anatomi- cally by the occurrence of a peculiar form of inflammation affecting certain joints, this being invariably attended with the deposit of urate in connection with their structures. Taking an individual articulation, this is at first the seat of an acute inflammatory process, indicated by the usual signs of increased vascularity and redness, tumefaction, and serous effusion into the interior of the joint, as well as into the surrounding tissues. The results of post-mortem examina- tion show that even iu the very earliest period a deposit of urate takes place ; and as the attacks become repeated again and again, the signs of in- flammation become less and less prominent, while the deposit increases, until at last it may form considerable masses, and infiltrate extensively all the structures entering into the formation of the articulation. The joint then becomes perma- nently enlarged and distorted, while the liga- ments are thickened and more or less stiff or quite rigid, and ultimately complete anchylosis may be produced. The deposit seems to com- mence in the substance of the cartilage covering the ends of the bon es, starting near its superficial or free surface, and gradually extending more deeply, though for a time a thin layer of carti- lage lies between it and the cavity of the joint. This deposit at first forms a whitish opacity, but as it becomes more abundant it encrusts the car- tilages, and also the inner surface of the liga- ments, and the surfaces of fibro-cartilages where these exist. More or less extensive spots or patches become in time distinctly visible, and even the entire surfaces of the bones forming a joint may be covered with a chalky-looking sub- stance. The synovial membrane may also pre- sent white points, but the synovial fringes at their margins seem to escape, on account of their vascularity. In the larger articulations the synovial fluid may be thickened, and may even contain separate crystals or tufts of the urate. Subsequently the ligaments and adjoining struc- tures are infiltrated, and it is to this cause that the stiffness or rigidity of gouty joints is mainly due. Distinct masses of deposit may, however, form, and these also interfere with movement. They are known as tophi or chalk-stones. In course of time the tissues covering a gouty joint may be destroyed, including the skin, the chalky- looking substance being thus exposed, and un healthy suppuration and ulceration set up. The opaque white substance characteristic of gouty inflammation is found on microscopic exa- mination to consist of fine crystals, in the form of needles or prisms. They are chiefly arranged in minute clusters, radiating from a centre ; and in the cartilages they form a more or less compact network. Chemical examination shows that they are composed of urate of soda. With reference to the joints which are affected in gout, as has been already indicated, the meta- tarso-phalangeal articulation of the great toe is the one primarily attacked in a large majority of cases. In rare instances, where an opportunity has been afforded of making a post-mortem ex- amination after only one or two gouty fits hav6 occurred, this joint, on one or both sides, has alone presented any change, even after many years have elapsed since the occurrence of tue GOUT. attacks. As usually seen, however, the disease has progressively involved many joints. In the feet it may implicate all the articulations, but it is a curious fact that the tarso-metatarsal and the phalangeal joints of the great toe generally escape, or are but little affected. Similarly all the joints of the hands and fingers are often in- volved. The gouty change not uncommonly extends to the larger joints, more especially those of the legs, but the shoulder and hip- joints aro but little liable to be attacked. In exceptional cases other articulations are found involved, such as the temporo-maxillary, those of the spinal column, of the pelvis, or even of the larynx. Coming now to other structures, deposits of urate may occur in various parts of the body, in connection with bursae, tendons and aponeuroses, sheaths of muscles, the sclerotic coat of the eye, the cartilages of the external ear, eyelids, nose, or larynx, or under the skin. More or less effusion may be present iu burs* at the same lime. In a case which came under the writer's notice, and in which there was not the slightest hereditary taint, in addition to numerous tophi in the auricles, there was a mass in the bursa over the right, olecranon as large as an egg, a smaller one over the left elbow, several distinct deposits over both patellae, and others in con- nection with the tendons of the hands, especially .he right. As regards bone, the periosteum is often affected, and some writers have described a de- posit of urate in bone itself ; but Garrocl has not found evidence of its having originated in this tissue. He considers that the periosteal formations sometimes acquire sufficient size to press on the osseous tissue, and to cause its ab- sorption. The condition of the kidneys induced by the gouty diathesis is of great importance, and these organs probably begin to be diseased at a very early period ill the history of a case of gout, for they may be found distinctly affected when there have been little or no external manifestations of the complaint. In the 'first instance a deposit of urate of soda takes place, probably within the renal tubuli, which afterwards involves their walls, and penetrates to the intertubular tissue. This is seen in the form of white streaks in the course of the tubuli, and of white points at the extremities of the papillae. The deposit goes on increasing, and a chronic inflammatory pro- cess is set up, ending ultimately in the production of the ‘ granular contracted kidney’ (see Bright's Disease). Other morbid states in connection with the urinary organs observed in some cases of gout are the presence of calculi, consisting of uric acid, urates, or oxalates; chronic cystitis; or urethritis. In the course of gout morbid changes of other kinds often arise, affecting different structures and organs, and either occurring as acute events, which may even prove fatal, or being of a chronic nature. These need be only mentioned here, and they mainly include congestion, catarrh, or severe inflammation of some part of the alimentary canal ; catarrh of the air-passages, chronic bronchitis, and emphysema of the lungs ; fatty disease of the liver; meningitis, neuritis, cerebral haemorrhage ; 543 cardiac changes, including chronic valvulitis and degeneration of the valves, and hypertrophy, followed by degeneration, of the cardiac walls ; atheromatous changes in the vessels, hypertrophy of the muscular coat of the small arteries, or arterio-capillary fibrosis; and various diseases of the skin, such as erythema, urticaria, eczema, psoriasis, &c. How Jar some of these conditions can be attributed to the gouty diathesis, or are merely the result of the same causes which have induced this diathesis, may be fairly disputed. It is worthy of remark that acute inflammation in connection with the heart is not met with in cases of gout, and this has been attributed to the great vascularity of the endocardium and other cardiac tissues, for which consequently the urate has no affinity, or it is destroyed in its passage through them. The condition of the blood in gout may be here noticed. In early cases the chief deviation from the healthy state presented by this fluid is that during the acute paroxysms the serum contains a distinct excess of uric acid, in the form of urate of soda ; and this can be obtained in appreciable quantity, even in a crystalline form. In the intervals the blood is quite nor- mal. When the gouty condition becomes chronic, the excess of uric acid is constant, and oxalic acid can also be frequently detected. In course of time the serum becomes lowered in its specific gravity, its albumen is deficient, and its re- action is less alkaline, in extreme cases be- coming almost neutral, owing to the presence of excess of acids. When the kidneys are impli- cated, urea also tends to accumulate in the blood, and may be obtained in variable quantity. The red corpuscles often diminish in number; and the blood deteriorates in quality as a whole in many cases of chronic gout. Symptoms. — The clinical history of gout is a very varied one, and the symptoms observed in different cases which are regarded as of a gouty nature are exceedingly numerous and diverse. Whether the phenomena attributed to this disease are always fairly explicable by the pre- sence of excess of uric acid in the system is, to say the least, a matter of considerable doubt. It must ever be borne in mind that the habits which generate gout often give rise to sy T mptoms, and even to definite morbid changes, which cannot justly be looked upon as part of this com- plaint. Again, the custom which some practi- tioners adopt, of looking upon every acute illness particularly inflammation of organs, occurring in gouty subjects, as being due to the lithsmie condition, and of a special nature, and applying the term ‘ gouty ’ to every such complaint, is certainly going too far, though it may be acknowledged that gout does often modify their clinical history. It is not easy within a limited space to give even a sketch of the various clinical phases of gout, but. before considering the symptoms in detail, it may be well to in- dicate their general nature. 1. In its typical form gout is in its early stages attended with acute symptoms referable to certain joints, and these tend to recur at intervals, constituting ‘ fits of gout,’ the intervening periods becoming shorter and shorter as the case progresses — Acuti Articular or Begular Goat. 2. These attacks GOUT. 550 culminate in obvious chronic changes in the affected joints, with corresponding symptoms — - Chronic Articular Gout — but even then acute paroxysms are liable to arise from time to time. 3. In connection with the acute attacks, and somet mes preceding them, general or constitu- tional symptoms are usually observed ; and symptoms belonging to this class become per- manent in most cases of chronic gout. 4. When gout affects other organs and structures besides thejnints, corresponding symptoms are developed, according to the part implicated. In general terms these may be grouped as cases of so-called Non-articular , Irregular, Misplaced, or Anomalous Gout ; and when such symptoms are acute in their character, affecting some internal organ, and coming on during the course of an attack of acute articular gout, the joint-symptoms at the same time subsiding, this constitutes what is termed Retrocedent gout. It is supposed to be due to exposure to cold or other causes checking the articular inflammation, the elimination of uric acid being thus interrupted, so that it accumu- lates in the system. The symptoms thus grouped together may, however, be conveniently sub- divided as follows : — (a) Those indicating more or less functional disorder of certain organs, varying much in intensity, and either being con- stantly present, or only coming on at intervals. ( b ) Those due to acute inflammatory affections of organs, (c) Those resulting from the chronic changes in tissues and organs induced by gout, and from the deposit of urates in different parts. Having given this outline, we may now discuss the symptoms of gout in some detail, but it will be convenient in doing so to adopt a somewhat different arrangement from that just sketched. 1. Premonitory Symptoms. — There are cer- tain symptoms, of a somewhat indefinite char- acter, and not of any marked intensity, which are often met with in gouty subjects, or even in persons who have never actually suffered from declared gout, but which distinctly depend upon the lithaemic condition. These may be regarded as premonitory symptoms, for they frequently give warning that the gouty condition is in process of development, and if duly recognized, enable the patient so to regulate his mode of living as to ward off the disease. Indeed, it will bo found on careful inqttiry that gouty phenomena, which may be very marked, are commonly noticed from time to time before the first actual fit of gout occurs, and there may even be suspicious twinges or uncomfortable sensations about the toes or fingers now and then. In a large number of cases, however, no definite premonitory symptoms immediately precede the first gouty paroxysm ; but iu connection with subsequent paroxysms, prodromata are usually marked, so that confirmed gouty patients can predict when an attack is imminent. As to the nature of these symptoms, they vary in different persons, and this is sup- posed to depend upon individual predisposition. The most obvious are digestive and hepatic disorders, attended with marked flatulence and eructations, heartburn, acidity, and constipation or diarrhoea, with unhealthy stools, the tongue being often large, flabby, and much furred ; palpitation or uncomfortable sensations about the heart ; catarrh of the throat and respiratory passages, violent fits of sneezing, or asthmatic attacks ; derangements of the nervous system, indicated by a liability to headaches, giddi- ness. noises in the ears, disorders of vision, marked irritability of temper and fretfulness or lowness of spirits, languor, impairment of mental vigour and intellectual hebetude, heaviness or drowsiness, sleep, however, being restless, dis- turbed, attended with unpleasant dreams, and often with grinding of the teeth, numbness or tingling in the limbs, especially in the fingers or toes, neuralgia in various parts, twitchings, startings in the limbs, or muscular cramps, especially in the calves of the legs ; prefuse perspirations ; certain skin-affections ; and changes in the urine. This excretion usually tends to become high-coloured, deficient, and to deposit lithates abundantly, or even lithicacid crystals, though at the same time the quantity of this acid eliminated within the twenty four hours is below the normal. In advanced cases of gout, however, the urine presents very differ- ent characters from those just stated, as will be hereafter pointed out, and when habitually de- positing urates, it may become pale, watery, and clear immediately before an acute attack super- venes. Some patients are warned of the approach of a gouty fit by feeling unusually well, both physically and mentally. 2. Acute Articular Gout. — It is only with the occurrence of the first acute attack of gout that the disease is usually regarded as estab- lished. The paroxysm as a rule comes on during the night, while the patient is asleep in bed, and it is said to commence usually between 2 and Oi.M. The patient is disturbed out of his sleep by uneasiness or pain, generally referred to the ball of the great toe on one side, and the corresponding joint is found to be inflamed, the inflammation increasing in intensity, until it usually becomes extremely severe. In some instances the cor- responding joints on both sides are attacked simultaneously, in rapid succession, or alter- nately. Although, however, in the majority of cases gout first attacks the metatarso-phalangeal articulation of the great toe, it must not be for- gotten that it may start in any of the smaller joints of the foot or hand, or even in the middle-sized joints, especially the knee or ankle. Indeed, exceptional cases have come under the writer's notice, which there was every reason to believe were of a gouty nature, and in which the disease implicated several joints at a very early- period of its course, the feet, however, being free. In such instances it may be that there is a true combination of rheumatism and gout. Proceeding now to notice the clinical charac- ters of the joint-affection, severity’ of the pain is certainly a striking feature in the majority of cases of acute gout, especially in early attacks. When the foot is affected, any attempt to stand causes much pain from the first, and the suffer- ing speedily increases, until it becomes very in- tense, in some instances almost unbearable. In character it varies, and is described in different cases as burning, throbbing, aching, tearing, plunging, boring, piercing, &c. The pain pre- vents sleep during the night, but towards morn- ing it tends to diminish, and during the day there is usually’ comparative ease, an exacerba- GOUT. tion again taking place as evening approaches, which goes on increasing towards night. Ten- derness is very marked, and is often so exquisite that the patient dreads to be touched, and can- not bear the least movement or jarring of the affected part, or sometimes even the weight of the bedclothes, or the slightest shaking of the room. The objective signs of inflammation in con- nection with a gouty joint also soon become very prominent as a rule. These are marked redness, which may be very deep and sometimes tends to lividity, while the veins are often enlarged and turgid; considerable local heat, as evidenced to the touch and by the thermometer ; and much swelling, the skin covering the part assuming a tense and shining appearance, or even a con- siderable extent of the limb being oedematous. When several joints in the foot or hand are affected, diffused redness and swelling are no- ticed. The tumefaction is not only due to effu- sion into the interior of the articulation, but also into the surrounding tissues, oedema being a marked feature in connection with gouty inflammation. This can be better appreciated when the acute symptoms subside, so that pres- sure can be borne, which shows the pitting characteristic of cedema, and this ma.y hold on for some time after the other signs have dis- appeared. However intense the objective signs of inflammation may bo, acute gout never ends in suppuration. As they subside, marked desqua- mation of the skin usually takes place, which is partly due to the intensity of the inflammation, partly to the oedema, the vitality of the epi- thelium being thus destroyed. As the swelling increases, the subjective sensations generally diminish in severity; but during the progress towards recovery, intense itching is apt to super- vene. An acute attack of gout is almost always attended with more or less general symptoms; but it is an important fact that their severity depends upon the extent and intensity of the local manifestations of the disease, and upon the accompanying symptoms. Chills or even actual rigors may be felt at the outset, followed by febrile phenomena, sometimes slight, in other cases considerable, the pyrexia being ns a rule strictly secondary or symptomatic. The skin feels hot, and usually perspires, but not pro- fusely ; the temperature is moderately raised, presenting no definite variations, though marked remissions are generally observed towards morn- ing ; the pulse is increased in frequency; and the digestive organs are much disordered, as evi- denced by anorexia, thirst, furred tongue, and constipation. The urine is generally deficient in quantity, and may be very scanty, high- coloured, and concentrated ; its acidity is in- creased ; and on standing an abundant deposit of amorphous lithates often forms, varying in colour according to circumstances, being pale- buff, yellowish-red, dark or brick-red, or intense pink if the fever is high. The relative quantity of uric acid in a particular specimen of urine is often increased, but the absolute amount dis- charged within the twenty-four hours is much diminished. The patient is usually exceedingly restless, and cannot lio with comfort in any position ; sleep is much disturbed or altogether 551 I prevented ; and cramps of the calves of the legs or of other muscles may still further increaso his sufferings. All these symptoms tend to increase the constitutional disorder. The temper is generally very irritable, or may even be violent. The duration of the first fit of gout varies according to circumstances, such as the severity of the attack, the diet and regimen adopted, and probably the kind of treatment which is em- ployed. It usually ranges from four or five days to a week or ten days, but may last two or three weeks or more, there being then commonly intermissions or remissions, and several joints being involved in succession. The termination of the gouty paroxysm may be attended with critical phenomena, such as free perspiration, diarrhcea, or a very abundant discharge of urates. After the attack the patient may not recover hia former state of health for some time ; but not uncommonly he feels better than before, and as if the system had got rid of some deleterious element. As a rule the affected joints are appa- rently quite restored after early attacks of gout ; but it must be remembered that even after a single fit they are the seat of permanent morbid changes, and these may be distinctly evidenced by more or less deformity or stiffness. (Edema may also remain for a considerable time, especi- ally if the inflammatory condition has been pro- longed. One of the characteristic features of gout is the tendency which it exhibits to recurrence in its acute form. This may not happen if the patient is sufficiently careful, but such an event is of rare occurrence. The rule is for the attacks to be repeated, and to recur with ever-increasing frequency. In not a few instances the second fit does not occur until an interval of two or three years or more has elapsed, but in most this is not prolonged beyond a year. The same in- terval may be noticed between the next few paroxysms, but as the disease progresses they return twice a year, then more frequently, and at last become more or less constant. At the same time the mischief extends as regards the joints. It may be limited to the great toe for some time, but in successive fits spreads to the other articula- tions of the foot, to the hands, the ankles and knees, the wrists and elbows, and occasionally even to the hips and shoulders. In short, gout tends in time to involve nearly all the joints indiscrimi- nately, and several may be implicated during a fit. Moreover, those articulations which are re- peatedly attacked become more aud more dis- abled and deformed, until a condition of chronic gout issetup. The symptoms in connection with a particular joint tend to diminish in intensity the more often it is affected. As additional i articulations become involved, however — and many may be implicated at the same time — the general symptoms often increase in severity, and the patient does not recover in the intervals. The duration of the attacks becomes longer as their frequency increases. The rapidity of the pro- gress of gout is very different in different cases : and the time taken to produce permanent mis- chief in the joints varies considerably. It must be borne in mind that variations in the intensity and exact characters of the symp- toms of acute gout are observed in some cases GOUT. >52 fn feeble persons the subjective and objective symptoms may be comparatively slight, the in- flammation assuming an asthenic character, but then the ultimate effects upon the joints are often much worse. Again, the pain in connection with a particular joint depends considerably on its structure, being usually much more marked if its ligaments, or the parts around, are rigid and unyielding. Previous injury or disease affecting a joint may likewise modify the symptoms. Some individuals suffer much more than others, being more susceptible of painful impressions. 3. Chronic Articular Gout. — In course of time more and more of the joints become per- manmtly and obviously changed, and prevented from fulfilling their functions properly, so that a condition of chronic articular gout is esta- blished, exacerbations still occurring, however — indeed with much greater frequency — but being much less acute in their intensity than in the early stages of the disease, and longer in dura- tion. It need hardly be remarked that there is no distinct line of demarcation between acute and chronic gout. The hands are par- ticularly liable to be much altered by the effects of gouty inflammation. The permanent changes are indicated by the articulations becoming enlarged, deformed, and irregular in shape, often presenting nodulations or bulg- ings, which may attain a large size, owing to the abundance of the deposited urates. They are also stiff and crippled in their movements, at last becoming quite immovable and rigid, or even completely anchylosed ; and being either perma- nently flexed, extended, or sometimes even bent backwards. The interference with movement and the deformity do not bear any necessary proportion to each other, the one or the other predominating according to the mode in which •lie deposit of urate of soda has taken place. Tho more this infiltrates the ligaments and sur- rounding tendons, the greater becomes the im- pediment to movement. Gouty concretions in connection with joints feel hard, and by their mere mechanical and irritative effects they are liable to cause damage to the adjoining struc- tures. They may be seen stretching or shining through tho skin, and causing it to assume a bloodless appearance, or, on the other hand, rendering it congested and bluish, the veins also being enlarged. Ultimately a gouty ab- scess may form around the concretions, which opens externally ; or the skin may merely give way from the continued pressure. Thus the chalk-stones are exposed, and come away either in a liquid form or as solid particles or masses, or occasionally there is a free discharge of pus as well. Ulcers are left, of an unhealthy end atonic character, and usually presenting no dis- position to heal. There may be a number of these ulcers in the same individual, on tho hands and feet. When bursae are involved, much deformity is produced. They are easily felt, usually presenting a combination of hard- ness and fluctuation, due to the presence of concretions and of fluid in the bursal cavity. These signs are chiefly noticed in the bursa over the olecranon. Abscesses may also form in connection with these deposits, and the latter may thus be completely got rid of, the abscess subsequently healing rapidly. In cases of chronic articular gout the general system necessarily tends to become affected. The patients are generally more or less feeble and wanting in tone; they may be thin and pale or sallow-looking ; or plethoric, but with flabby tissues, and presenting signs of languid circula- tion, with enlarged capillaries about the face. They often suffer from disorders of digestion and other symptoms already described; but not un- commonly, as gout assumes a more chronic form, patients feel better, becoming habituated to the morbid condition of the blood. It is remark- able that those suffering from numerous gouty abscesses often exhibit but little general dis- turbance, probably because the system is thus rid of the morbid materials. The urine in chronic gout generally becomes abundant, very watery and pale, of low specific gravity, deficient in solid ingredients, especially in uric acid, which at times may be almost completely wanting, or it may be thrown out in an intermittent manner. Deposits of urates are not often observed in cases of advanced chronic gout, except perhaps before the occurrence of an acute exacerbation. 4. Irregular Gout. — The clinical pheno- mena which are recognised as irregular manifes- tations of gout may assume either an acute or chronic form. They may be observed in persons who are distinctly subject to articular gout ; or in those in whom the disease is not so obviously revealed. Moreover, their intensity is often in an inverse ratio to that of the joint-affection, and the two classes of symptoms may exhibit a remarkable tendency to alternation, when the articular symptoms are prominent those con- nected with other parts being slight or absent, and vice versd. This may be noticed with both acute and chronic symptoms, and the former are particularly liable to arise when, from any cause, during the progress of a gouty fit the joint- inflammation is suppressed suddenly or rapidly — retrocedent gout. At other times the internal symptoms seem to be due to a want of develop- ment of the external phenomena — suppressed gout, and when the latter appear, the former subside. It must suffice to indicate here the general nature of the symptoms of irregular gout. The acute symptoms are mainly associated either with the alimentary canal, the vascular system, the respiratory organs, or the nervous system. In connection with the alimentary canal, acute dysphagia may occur, attended with spasm of the pharynx and oesophagus. The most important symptoms belonging to this group are, however, those due to some gastric disturbance. This may be of the nature of severe cramp or gastralgia, characterised by a sudden, acute, spasmodic pain in the epigastrium, relieved by pressure, and accompanied with a sense of great weight and oppression ; the patient presenting an aspect of much suffering, distress, and anxiety ; or being even more or less collapsed and prostrated. In other cases the symptoms are those of acuto gastritis, bilious vomiting being prominent. Intestinal colic, or even muco-enteritis, may also occur in connection with gout. The vascular system is not uncommonly implicated. The GOUT. 5b 3 heart is liable to be disturbed in its action during the attacks of gastralgia, but this dis- turbance may also be observed independently. It is usually of nervous origin, and may be evidenced in various ways. Thus there may be severe palpitation, the action of the heart being very rapid, irregular, or even intermittent, this being accompanied with most unpleasant sensa- tbnsover the cardiac region, praecordial anxiety, >ften a feeling of oppression or constriction, dys- pnoea or a sense of suffocation, and much distress, anxiety, and dread of death ; the pulse tends to be weak and small, or may be irregular ; some- times the attacks aro attended with signs of collapse. In other instances the cardiac disorder is evidenced by vi-ry feeble or slow action, with a tendency to syncope. Again, there may be all the phenomena of a severe anginal attack, this probably partly depending upon the circulation in the vessels being impeded. It must be once more noted here that there is no true gouty acute inflammation connected with the heart, although certain chronic changes some- times observed at post-mortem examinations have been attributed to such a condition. Irregu- lar gout affecting the respiratory system is mainly indicated by asthmatic attacks. In some cases there is a marked liability to acute catarrh of tho air-passages. Pulmonary con- gestion is also supposed to be a manifestation of retrocedent gout in some cases, but there is no such special disease as gouty pneumonia. In connection with the nervous system gout may give rise to attacks of severe headache ; delirium or even acute mania ; epileptiform fits ; cerebral nr spinal meningitis ; acute neuralgia, either external or internal, and especially sciatica, probably due to neuritis; or severe muscular cramps. Apoplexy from cerebral haemorrhage has been often attributed to suppressed or retro- cedent gout, and if the vessels of the brain are diseased, it is possible that there may be some connection between them. Cerebral congestion might also occur in gout, and give rise to a temporary apoplectic attack. Among the acute forms of irregular gout are, for example, sldn- affoctions, eczema, erythema, or urticaria ; affec- tions of mucous membranes, such as the conjunc- tivse and lachrymal passages ; functional renal disorder, with albuminuria, or irritability of the bladder ; and local signs of inflammation, associ- ated with the deposit of urates. Many of the mure chronic symptoms asso- ciated with gout have already been pointed out, when speaking of its premonitory symptoms, and only certain phenomena need be alluded to here. Chronic skin diseases are of frequent occurrence, namely, psoriasis, chronic eczema, prurigo, either local or general, and acne. These may alternate very distinctly with articular gout, and they are often intensified by causes which increase the lithaemic condition. In *ome gouty subjects daily paroxysms of heat and redness of the nose, attended with severe itching and irritation, cause considerable annoy- ance or distress. Many of these individuals are also liable to chronic catarrh, affecting the throat and the air-passages ; and in time they t'ftvn becomo permanently asthmatic, the lungs bting emphysematous, and dry bronchial catarrh being established. Gravel or urinary calcu- lus gives rise to symptoms referred to the urinary organs ; and those indicative of chronic urethritis or cystitis may be present, espe- cially in persons advanced in years. Perma- nent disorders of sensation, or slight local paralysis may be observed in gout, owing to chronic changes involving particular nerves. Gouty persons are usually very sensitive to pain. Tophi can he seen or felt, provided they are superficial. Those connected with the helix of the external ear are most common ; but they should also be looked for in the sclerotic or eyelids, in the nose, and under the skin, in the region of tendinous aponeuroses, es- pecially in the log or thigh. The xvriter had the opportunity of observing a case in which an ex- tensive formation of urates occurred in the outer part of the thigh, apparently associated with the fascia lata. These gouty concretions are origi- nally liquid, and if one is punctured at an early period, an opalescent or milky fluid escapes, which on microscopic examination is found to contain an abundance of delicate, acieular crys- tals ; subsequently they become more consistent, and ultimately quite solid and hard, being then made up entirely of these crystals, which are closely aggregated together and interlaced. Taking the ear as an illustration, at first a small elevation appears under the skin of the helix, like a vesicle, having a soft feel. This gradually hardens, until finally a little bead-like or pearl- like body is formed, presenting a whitish colour as seen through the skin. In course of time the cutaneous covering may be destroyed, leaving the little chalk-stone exposed ; or this may even become detached, so that only a small depres- sion is left. 5. Symptoms due to chronic organic diseases. — In addition to what has been stated under the preceding heading, it is desirable just to notice separately certain diseases of organs which may be associated with the gouty diathesis. Disease of the kidney is indicated mainly by the changes in the urine, which may be slightly albu- minous, or even contain a few casts. Other symp- toms of chronic Bright’s disease maybe present, but it must be remembered that in the form of renal disease associated with gout the symptoms are often very obscure. The chronic cardiac diseases observed in gout aro revealed mainly by their respective physical signs ; and there may be symptoms, first of excessive cardiac action from hypertrophy, and subsequently of cardiac failure. The vascular changes are evidenced by examination of the arteries ; and by their effects upon the circulation. Fatty liver can only be discovered by physical examination. Diagnosis. — -The degree of difficulty expe- rienced in arriving at a diagnosis with respect to gout, is very variable in different cases, whether in definitely fixing upon this disease, or in distinguishing it from other affections. Often the diagnosis is perfectly clear, but in some instances it may be extremely difficult to form a positive opinion. It must be remembered that there may be a distinct gouty diathesis present, and symptoms resulting therefrom may arise, which it is important to recognise, whilo the joints are quite free from any apparent mis- GOUT. 554 chief. It is also desirable to be able to make out any tendency to the development of this diathesis. In most cases, however, the diagnosis has to deal with the nature of an articular affection, and to determine whether this is gouty or not. The chief diseases from which gout has thus to be distinguished are acute or chronic rheumatism, and rheumatoid arthritis. The data upon which a conclusion has usually to be formed with regard to a first attack, are the presence or absence of a hereditary tendency to gout, as well as its intensity; the age and sex of the patient; his social position, occupation, and previous habits; the presence or absence of any obvious cause for the attack, or of premonitory symptoms ; the localisation and characters of the joint-affection ; the general symptoms; the characters of the urine; the duration of the ill- ness ; and the condition of the heart. These different points have already been sufficiently discussed in their relation to gout, but the dis- tinctions presented by acute rheumatism may be briefly indicated. The absence of any hereditary tendency to gout in any doubtful case may be in favour of rheumatism, and possibly this com- plaint may be hereditary. It occurs most fre- quently for the first time in early life, from sixteen to twenty years of age, aDd is not uncommon evon in young children. Rheumatism, though more common among males, often attacks females. This complaint is not favoured by the habits which generate or promote gout, and affects all classes of persons, but especially those who from their occupation are liable to be exposed to cold and wet. Such exposure, or some other definite cause originating ‘ a cold,’ usually accounts for an attack of acute rheumatism, and it is not pre- ceded by any particular premonitory symptoms. The joints involved aro the middle-sized or the larger oues, several of which are generally im- plicated in succession during the illness, the rheumatic inflammation exhibiting an erratic character ; the local sj'mptoms tend to be less severe than in gout; there is less marked oedema about the joiuts, and no enlargement of the veins or subsequ-nt desquamation are observed. It must not be overlooked, however, that gout may attack the middle-sized joints. Pyrexia is high as a rule, and is often quite out of proportion to the extent of the articular affection ; while profuse acid perspiration is almost always a prominent phenomenon. The urine is simply febrile. The attack lasts a considerable time, perhaps several weeks, if it is at all severe ; while during its course some acute cardiac inflammation is liable to supervene, and this may happen even when the joint-affection is but slight. The subsequent progress of gout is important in diagnosis, for its tendency to periodic recurrence is a marked feature in its history, and if the metatarso-phalangeal joint of the great toe is alone inflamed several times in succession, or even if only the smaller joints of the feet and hands are implicated, the diagnosis of gout is tolerably certain. The permanent articular changes induced bj r gout also become evident in time ; as well as, perhaps, tophi in other parts, which should be carefully searched for in any doubtful case, especially in connection with the external ear, the nose, and bursae. Moreover, the urine presents peculiar changes as the disease progresses, and may give evidence of renal mischief. In very doubtful cases it might be desirable to raise a blister, or even to take a little blood from the patient, and endeavour to obtain crystals of uric acid from the serum. Rheumatoid arthritis is usually met with in females between twenty and forty years old. There is no hereditary taint, or a history of any such habits as generate gout, but, on the contrary, the patients are generally poor, hard- worked, anci badly-fed, and consequently weak and wanting in tone ; all joints seem to be equally liable to he affected, both 1 irge and small, and the symptoms are not of a very acute character, though the p.iin may be very severe, but they tend to continue for a long period ; the general symptoms are mainly those of debility and anaemia. Rheumatoid arthritis is a disease which tends to progress, involving joint after joint, but it presents no periodicity in its attacks, and often advances without any intermission, as a subacute orchronic disease. Ultimately it often causes much defor- mity and crippling of the articulations, but this results from a very different pathological change from that which takes place in gout, for there is not the slightest deposit of urates, either in the joints or elsewhere , nor in the most extreme cases can any uric acid be obtained from the serum. The urine presents no special characters ; and the kidneys are not diseased. As exceptional points bearing upon the diag nosis of gout in joints, the following may he mentioned. It has happened that pysemia be ginning in the great toe has been mistaken for gout, but the progress of the case would soon clear up any doubt under such circumstances. Again, articular inflammation from injury might resemble gout ; and, moreover, it must be borne in mind that such an injury may really set up gouty inflammation for the first time, so that the joint may not recover properly. In some indi- viduals the ends of the phalanges of the fingers aro enlarged, especially terminal ones, and cause nodulations — digitorum nodi — which resemble those of gout, and are by some regarded as being of a gouty nature. The importance of recognisinor the signs of the gouty diathesis, apart from the joint-affection, has already been alluded to. Equally important is it to he prepared for the acute symptoms in connection with internal organs which occur in this diathesis, whether along with or indepen- dent of articular disease. Lastly, in any gouty case the detection of the organic diseases liable to be set up in its course is of great moment in diagnosis, especially renal disease ; and also the association with their proper cause of catarrhal affections, skin-diseases, and other complaints, when these are due to gout. Prognosis. — The first point relating to the prognosis of gout which calls for notice refers to the immediate dangers in any particular case. A simple acute attack of articular gout rarely, if ever, kills the patient. When, however, in- ternal organs are implicated, the mitter becomes much more serious, and a fatal result may occur, so that the prognosis must be a guarded one under such circumstances. The danger then becomes much greater if the complaint has been GOUT. luug-cstablished, and if the kidneys or other organs have become structurally diseased. Indeed these diseases of organs themselves are attended with grave dangers, and may give rise to fatal con- sequences at any time. Again, any acute inflam- mation occurring in a confirmed gouty subject is the more serious on this account ; and the same remark applies to injuries and shocks of all kinds, so that in such cases the prognosis is less favourable than it otherwise would be. In the next place the future of a gouty patient has to lie considered, as regards the prevention of subsequent attacks, or, indeed, the cure and eradication of the disease. It must always be recognised that gout is a recurrent affection and complete immunity can never be guaranteed, once the complaint lias declared itself. At the same time undoubtedly not a few cases have occurred in which there lias been but one attack, but this can only be expected under cer- tain conditions. In giving an opinion on this point, the prognosis in any individual case will depend upon: — 1. The degree of hereditary tendency to gout. 2. The age of the patient ; for the earlier the period at which the disease begins, the less hopeful is the prospect of a cure. 3. The time the complaint has lasted from its commencement ; and the frequency and duration of the gouty fits. If gout has become established, and especially if distinct chalk-stones have formed, it is quite impossible to eradicate it. 4. The habits, mode of living, and occupa- tion of the patient. It is only when the patient is prepared to adhere strictly to proper rules of liviug that a cure can be hoped for. Those who in their occupation are liable to drink much, or who are exposed to cold or wet, are less likely to be cured. It may bo remarked here that gouty subjects are less able than others to resist exposure. Another point bearing upon prognosis refers to the duration of life in gouty persons. If the disease comes on late in life, and the paroxysms only occur at long intervals, w hile the organs are free from any organic mischief, gout may not appreciably shorten life, and the patients may even enjoy good health up to an extreme old age, provided they are sufficiently careful in their mode of living, and no accidental complications arise. Chronic gout unquestionably does tend to shorten the duration of life, to a greater or less degree in proportion to its severity, and more especially to the indications present that the kidneys, heart, or other important organs are organically diseased. This tendency is now re- cognised by most life-insurance companies. It has been supposed that gout is a protection against certain other diseases, such as phthisis and diabetes, and therefore its presence has been in some instances regarded as a benefit, but how far there is any real foundation for this belief is a matter of considerable doubt. Treatment. — It is important at the outset to lay stress upon the fact that, although there are certain well-definel principles applicable to the treatment of gout in its various phases, it is a great mistake to follow a regular routine method under all circumstances, and every case must bo considered on its own merits, both as regards the patient himself and his surrounding?. It 65 5 will be convenient to discuss this subject under certain general headings, premising that the administration of medicines is often the least important part of the treatment, and that the habits of life of the patient always need thorough supervision in all their details. 1. Preventive and Curative Treatment. — - In a number of cases the primary object whieli should be aimed at is to prevent the develop- ment of gout; or to eradicate the tendency to subsequent attacks, if it has one? declared itself, and to rid the system of the conditions which induce this complaint. These objects have espe- cially to be kept in view in dealing with indi- viduals who have a marked hereditary pre- disposition to gout; in cases where it has appeared at a comparatively early period of life, whether as a hereditary or acquired comp'aint, or where it is in an early stage; and in persons who, from their occupation, known habits, or the symptoms they present, are likely to be- come gouty. Moreover, even when confirmed gout has been established, preventive tre itment may be carried out, with the view of diminish- ing the number of acute attacks, or even possibly of averting them altogether; and of obviating the implication of organs essential to the well-being of the economy. In order to carry out these objects in any particular case, the patient must intelligently recognise the fact that success in treatment mainly depends upon himself, and upon his willingness constantly to regulate his mode of living according to principles suitable to his condition, which nee I to be more or less strict in different instances. The general nature of the rules to be adopted will be evident from a consideration of what has been stated in discussing the aetiology and pathology of gout, but they require to be briefly noticed here. The ends sought in carrying out these rules are to prevent an undue formation of urates in the sys- tem ; to maintain the digestive and assimilative organs in a condition of healthy activity ; and to promote the elimination of urates by the kidneys, especially 7 if at any time there appears to be a tendency to their accumulation in the body 7 . (a) Diet . — Moderation iu the quantity of food is the first point to be attended to in the treat- ment of the gouty diathesis. It is not neces- sary or desirable to restrict persons who are gouty to a very low diet, as is sometimes done, especially if they are in any way weak, but an amount sufficient for proper nourishment in each individual case must be consumed, and at no meal should the stomach be uncomfortably filled. The meals must be taken at regular times, and not hurriedly, so as to avoid boiling of the food. Very late dinners, as well as suppers, should bo prohibited, but it suits many persons better to dine at six or half-past six o'clock than at mid- day. The nature of the food is highly important. It is quite unnecessary, and probably would be in most instances injurious, to restrict the pa- tient to a vegetable diet, but a due proportion of animal and vegetable substances should be allowed. At the same time, in persons who have any tendency to gout, an essential part of the treatment often consists in diminishing the amount of meat which they consume, this being far in excess of what is needed, or can be got GOUT. 656 rid cf by the system ■without injuring it. In- deed, the aim must be to reduce all kinds of nitrogenized food, whether animal or vegetable, to such an amount as the system can satis- factorily dispose of, due regard being had to the proper nutrition and strength of the body, and thus to diminish the waste-products result- ing therefrom. As regards the kinds of animal food which are suitable for gouty subjects, white fish, chicken or fowl, game, and mutton are the best forms. Tender and underdone beef may be taken in moderation from time to time. Pork or veal, dried and salted meats, and rich dishes of all kinds, had better be avoided. Such vege- tables should be partaken of as are known to be digestible, but those which contain much woody fibre, or which create flatulence, must not be indulged in. There is a notion that celery is beneficial in gouty cases, and the writer has recently met with an intelligent person, who has long been a martyr to gout, and he strenuously affirms that he has derived much benefit from taking celery freely, both in an uncooked form and stewed. Gouty subjects should either ab- stain altogether from, or only take a very limited quantity of, sugar and saccharine articles of diet. Hence, although digestible fruits may often be taken with advantage in moderation, those which are very sweet must be used with particular caution. Stewed and baked fruits often agree well, but fruit-tarts, and, indeed, pastry of all kinds, should be interdicted. The juice of oranges or lemons is considered beneficial for gouty per- sons, and perhaps with good reason. It may be laid down as a rule to be invariably followed, that such persons should always limit themselves to simple meals, and not indulge in a number of courses ; and that they should avoid everything which their experience tells them is, in their case, indigestible. It has been recommended that salt should be avoided by gouty subjects, so as not to add sodium to the system, for com- bination with uric acid. (b) Drink . — The question of drink demands the most careful consideration and attention in every case in which gout is either threatened or has become established. It may he affirmed that no strict rules can be laid down, applicable to all cases, but there are certain broad prin- ciples which have to be borne in mind. An abundance of good and pure drinking-water is to be commended, but it should be taken mainly between meals. It is a good plan for the sub- jects of lithiasis to take a tumblerful of water before retiring to rest at night. Effervescing potass- or lithia-water may be substituted for ordinary water with advantage, the dissolved salts forming soluble compounds with uric acid, but soda-water must be avoided. Tea and coffee may be taken in moderation, provided they do not disagree. With reference to alcoholic drinks, in a considerable number of instances one of the first objects in the treatment of the gouty diathesis should be the regulation of the use of this class of beverages. This indication is ob- vious enough when the condition is evidently due mainly to excessive indulgence in these bever- ages ; but even when the patient is temperate, it may he that in his case the amount consumed Deeds to be reduced or total abstinence enforced, especially if there should be a strong hereditary predisposition to gout, or if the complaint appears in early life. Some patients are undoubtedly better if they take no stimulants whatever; others, however, can take proper kinds in mode- ration with advantage. It may be laid down as a general rule that malt liquors and all stronger wines are injurious, and should be interdicted. Those which are most suitable are good claret, hock, urosello, chablis, or sauterne. Even these must, however, be only indulged- in in strict moderation. A small quantity of good dry sherry suits some gouty patients very well. A little brandy, well-diluted, often agrees better than any other kind of alcoholic liquor ; or in some cases whisky or gin may he substituted. What- ever stimulant is selected, it should only be taken at meal-times, and the habit of drinking between meals is strongly to be deprecated. Persons who are distinctly gouty should avoid any excess on every occasion ; and even if they do not abso- lutely abstain, they may find it beneficial to do so from time to time, especially if there should be an abundant deposit of lithates in the urine, or if symptoms should occur which the patient recognises as being of a gouty nature. It is highly important that any alcoholic drink em- ployed by gouty subjects should be sound and of good quality, There can be no doubt but that due attendance to the rules just sketched will prevent the development of gout where it is threatened, and will also check its progress, and avert the occurrence of acute attacks. The difficulty is to persuade patients to carry them out properly. (c) General hygiene . — Inadequate exercise is a hygienic error which has frequently to be rectified in the treatment of the gouty state Sedentary habits must be combated, whether due to the occupation or to indolence ; and it must be insisted upon that a due amount of out-door exercise is taken daily, though violent exertion, tending t.o cause fatigue and exhaus- tion, must be avoided. Walking and horse- exercise are highly beneficial, especially in the case of those who live rather too freely. Even carriage-exercise is useful, so that th? patient may have the benefit of the fresh air. General active habits should be encouraged, and any disposition to undue luxuriousness in the mode of living checked. The patient should retire to rest and get up early. Another point of importance, more particularly with reference to the vocation of the patient, whether profes- sional or other, is that he should as much a? possible avoid excessive mental labour, or any great strain upon the mental faculties, but especially worry and anxiety of all kinds. The writer has at present under observation a case in which the influence of these causes in bring- ing out eczema and other irregular symptoms of gout is strikingly illustrated. It is also im- portant to pay attention to the cutaneous func- tions, and to protect the surface of the body from the injurious effects of cold. Warm cloth- ing should be worn, in keeping with the weather, and those who can hear it may wear flannel next the skin. With regard to baths, many persons are decidedly the better for using a coll or tepid bath every' morning, followed by energetic friction ; in other cases the employ- ment of the warm bath at proper intervals, or even of the Turkish bath, answers best. It is certainly beneficial in some instances, either for those who are already afflicted, or those who are threatened with gout, to go through a course of treatment in a hydropathic establishment from time to time, under due medical supervision. Climate demands attention, whenever the cir- cumstances of the patient allow a choice to be made. It may be advisable for gouty patients to reside permanently in some warm and equable climate, or at any rate during the winter and early spring. In this way attacks may often be warded off, and the disease thus prevented from making progress. Those who are obliged to remain in this climate during the inclement seasons should avoid exposure to wet and cold, ;is well as sudden changes of temperature, and night air. Their bedrooms should be warm and well-ventilated ; and during cold weather it may be desirable to keep a small fire burning during the night. Heated and badly-ventilated rooms, as well as crowded places of public resort, must be eschewed. (d) Medicinal treatment . — There can be no doubt but that the judicious use of certain medicines may assist materially in warding off or mitigating the gouty condition, and in pre- venting the occurrence of acute paroxysms. Those which are specially called for in cases of estab- lished chronic gout will be presently considered. In the meantime, it may be stated that the digestive functions require particular attention, and medicines which promote these functions are often of the greatest service, if they should be disordered, and especially if there should 'be a tendency to undue formation of acids in the stomach. A course of alkalies or acids, accord- ing to the indications in each case, may prove most serviceable, combined with some simple bitter in- fusion or tincture. Certain alkalies and alkaline earths are also valuable on account of their power in promoting elimination of lithic acid, by forming soluble salts with this acid, which pass away in the urine, and some of them pro- bably act beneficially in other ways. Those which are most useful for this purpose are salts of potash and lithia, but some practitioners prefer magnesia or lime. The best alkaline salts are the citrate or carbonate, or bromide of lithium may be employed, the urate of lithia being the most soluble of all. Soda-salts should not be used, except when it is desired merely to influence the digestive functions. Either of the salts above-mentioned may be em- ployed from time to time, and they must be taken well-diluted, and on an empty stomach. Magnesia or its carbonate may be given with advantage if there is much acidity, and if the bowels are habitually constipated, Saline aperients are often of great service, and they may be beneficially administered in small doses, freely diluted, and regularly repeated, when they also act on the other excreting orgafis. In many cases other aperients may be employed at intervals with advantage, but strong pur- gatives must only bo used with much caution, and this especially applies to mercurial prepa- rations, which, if taken too freely, may preve GOUT. 557 highly injurious to patients who have any ten- dency to gout. The administration of chcla- gogues from time to time may be of considerable service. Medicines may be given to assist the action of the skin, if this should be defective, such as liquor ammonite acetatis. (c) Mineral Waters and Baths. — Certain mineral waters are of the greatest value in the treatment of the gouty diathesis, and they offer the advantage that patients will often use them, habitually or at intervals, when they will not undergo a course of regular medicinal treatment ; while the water thus taken internally is itself of service. Many of these agents must, however, be employed only under proper medical super- vision, otherwise they may do considerable harm. Space will not permit any lengthy discussion of this subject here, and it must suffice to mention that in different cases the kind of mineral water employed must be varied according to the object desired to be accomplished, and according to the indications presented by' the patient, for what suits one may be highly injurious to another. These waters are employed both in- ternally and in the form of baths, some of them belonging to the class of thermal waters. Those chiefly' used in gouty- conditions are the waters of Bath, Buxton, Harrogate, Leamington, and Cheltenham in this country; Strathpeffer and Moffat in Scotland ; and Carlsbad, Vichy, Wies- baden, Baden-Baden, Ems, JRoyat, Aix-la-Cha- pelle, Aix-les Bains, Friedrichsliall, Hunyadi Janos, Pullna, Seidlitz, Homburg, Kissingen, Wildbad, Bagatz, Gastein, Elster, Tarasp, Apol- linaris, and similar waters from foreign countries. Some of these may be taken regularly or at in- tervals, for the purposes which they- respectively fulfil ; or if circumstances permit, a systematic course of treatment from time to time, at certain of the places mentioned, may be recommended. See Minerax, Waters. Before leaving the subject of the preventive treatment of gout, it needs to be insisted upon that those who are particularly liable to this disease, whether from their occupation or any other cause, should pay special attention to preventive measures ; and also that those in whom the disease has already manifested itself must take every precaution to avoid the known causes of acute attacks, for each attack tends to make matters worse. 2. Treatment of Acute Gout. — When a fit of acute articular gout sets in, it is on no account to be permitted to run its course unmodi- fied by treatment, else serious mischief is liable to arise. At the same time it is requisite to refrain from adopting too active measures. Out objects should be to shorten the attack ; to restore the affected parts to their normal condition ; and to relieve symptoms. In the first place, atten- tion must be paid to the diet. The aim should be to make this as low as is compatible with the condition of the patient, ^specially if the attack presents an acute and sthenic type. In young and strong patients the diet should at first consist of farinaceous substances, a little milk, and abundance of water, barley- water, or toast-and-water. Those who are advanced in years, weak, or broken-down in health, or who have long suffered from gout, GOUT. 568 require a more nutritious diet, but it should be easily digestible, consisting of beef-tea and good soups, milk, eggs beaten up, and such articles, the quantities being regulated by the requirements of each case. As the symp- toms subside, the food must be gradually improved, fish, fowl, and meat being allowed in succession, but in strict moderation, and due care must be exercised subsequently. If possible, r.ll kinds of alcoholic stimulants should be interdicted, but it may not be desirable to cut them off entirely in some cases, either on account of the previous habits or present condition of the patient, and then it is best to give a definite quantity of brandy or whisky, well -diluted, with the food. Tor those who cannot take spirits, the writer has found a little good hock or sauterne answer well. As regards medicinal agents, colehicum has long held the most prominent place in the treat- ment of acute gout, and is regarded almost as a specific. There can be no doubt as to the influence of this drug in relieving the inflam- matory symptoms, and shortening the paroxysms of gout, although it is by no means settled how it acts. Its effects must be watched, however, for it does not agree in every case. It has been alleged that colchicum renders the patient more liable to subsequent attacks of gout, but for this notion there does not seem to be any real foundation. The tincture or wine of colchicum maybe given in doses of ten to twenty or even twenty-five minims every four or six hours, and either of these may be combined with the citrate or carbonate of potash or lithia, these salts being also of great service in tho treatment of acute gout. It is necessary to keep the bowels acting freely by means of suitable aperients, and saline purgatives are of considerable value for this purpose. Other aperients, such as compound rhubarb pill, colocynth, podophyllin. or even calomel or blue pill, may be employed in appropriate cases. Diluents may be given freely, in order to promote the action of the kidneys ; and if the cutaneous functions appear to be defective, some mild dia- phoretic may be administered, or it may even be desirable to employ the hot-air or vapour-bath. Medicines may be needed for the relief of symp- toms, especially pain and sleeplessness, for which Dover’s powder or other preparations of opium, chloral, or bromide of potassium may be indicated. In very severe cases hypodermic injection of morphia is of much service. Venesection ought never to be practised in the treatment of acute articular gout ; for although immediate improvement may perhaps be thus produced, the ultimate results are highly unsatis- factory. Even the local removal of blood, by means of leeches applied near an affected joint, is dangerous, and had better be avoided, on account of the permanent local mischief which such a measure is lip.blo to induce. Local treatment . — The affected parts in acute gout should be kept entirely at rest, and placed in a comfortable position, supported by pillows, and either horizontal or elevated, according to tho feelings of the patient. In ordinary cases it is sufficient, to wrap up the joints in flannel, or to surround them with cotton-wool completely covered with oil-silk or other impervious mate- rial, by which means a kind of local vapour-bath is kept up. If the pain is considerable, local applications must be used, of which the most useful are warm fomentations, to which tincture of opium or belladonna may be added, poppy fomentations, localised steaming, belladonna liniment, tincture of aconite, oleate of morphia, or a solution containing morphia and atropine. Those last-mentioned may besmeared or painted over tho surface, or applied by means of lint covered with oil-silk. A blister in the neigh- bourhood of a gouty joint may be of service, if the attack he asthenic, and also if effusion or much stiffness remain. During recovery, benefit may be derived from car ful friction with some stimulating liniment, shampooing, gentle passive movements, douching with salt and water, or the application of a light bandage or elastic support, should there be a tendency to permanent thickening and stiffness, or to oedema and enlargement of the veins. The acute forms of irregular gout must ho treated according to their nature, and here it must suffice to offer a few general remarks on the subject. If serious internal symptoms arise, which are distinctly of a gouty nature, and especially if they occur as retrocedent pheno- mena, it is important to try to excite inflam- mation in the joints, by means of local heat, friction, and sinapisms. Colchicum may be of service in the n on-articular, as well as in the articular form of gout. In painful affections opium or other anodynes are called for; and frequently the administration of alcoholic and other stimulants is indicated, with anti-spas- modies, such as ammonia, ethers, camphor, musk, or belladonna, especially when tho sto- mach or heart is affected. In conditions at- tended with signs of much depression or collapse, external heat may he applied over the body, or sinapisms to the limbs and over the cardiac region. In the treatment of inflammatory dis- eases associated with gout much care is required, especially in resorting to depletory measures. The existence of the diathesis must always be borne in mind. 3. Treatment of Chronic Gout. — When gout becomes an established chronic disease, the same general rules of treatment a re to be observed as in the prevention or attempted cure of thecorn- plaint, but they often need modification in par- ticular cases, according to the conditions present. Similar medicines are also indicated, and lithia is particularly valuable, and may even aid in removing gouty deposits ; but others may be added to the list, which are suitable in different cases. Thus, colchicum is often of much service, taken habitually or from time to time, in the form of extract at night, or a few minims of tincture or wine two or three times a day, com- bined with other medicines. Among the many therapeutic agents employed in the treatment of chronic gout under different circumstances may be mentioned benzoic acid or benzoate of ammo- nia, phosphate of ammonia, phosphate of soda, iodide of potassium, bromide of potassium, car- bonate of alumina, lime-juice, guaiaeum, ammo- niaeum, and tonics, especially quinine, tincture or infusion of cinchona, or mild ferruginous GOUT. preparations. Undoubtedly most of these are of use in appropriate eases of chronic gout, to serve their special purposes. Symptoms con- nected with various organs frequently call for attention in this disease, and they must be treated by appropriate remedies. It may be remarked that if diarrhoea should set in in gouty cases, it should not be hastily arrested, as this may bo a tr.rde of relief to the system. With regard to I he local conditions in chronic gout, it .s affirmed I hat the prolonged use of some of the mineral waters previously mentioned, both internally and in the form of baths, such as those of Aix-la- Chapelle, Aix-les-Bains, and Baden-Baden, may succeed in removing to some extent deposits of urates, and in diminishing stiffness and thicken- ing of joints. For these purposes local measures may also be of service in some instances, pro- vided the morbid changes are not too far ad- vanced, namely, occasional blistering or appli- cation of iodine; the prolonged use of wet ban- dages ; friction with liniments ; shampooing and passive movements ; or systematic compression by means of some plaster. Solutions of alkalies or alkaline carbonates, and especially of carbonate of lithia, have been kept applied to gouty joints and other parts for along time, under the belief that deposits of urates may be thus dissolved. In the writer’s experience no such effect has ever been thus produced, although the constant ap- plication of moisture may be useful. Superficial accumulations of urates should not be interfered with unless they become troublesome, when it may be desirable to puncture the skin, and let the contents out. The propriety of removing large masses by operation may come up for con- sideration, but this should only be attempted if there is every probability that they can be en- tirely removed without any difficulty, and if the patient is in a fit state for the operation. When abscesses or ulcers form, they come under the treatment of the surgeon; hut it may be observed that simple dressings usually answer best in these cases, and they may sometimes be advan- tageously dressed with solution of carbonate of potash or lithia. It must not be attempted to heal them up too rapidly, as the discharge may be a relief to the system, and it may even be necessary to enlarge the opening of an abscess. Uuder an}- treatment it is by no means an easy matter to induce gouty sores to heal. The treatment of the various chronic organic diseases which are liable to arise in the course of gout must always be kept in mind, but the reader is referred to other appropriate articles for a consideration of this part of the subject. Frederick T. Roberts. GRAIN'D MAL. (Fr.) — A term applied to epilepsy when it assumes the form of a severe convulsive attack. See Epilepsy. GRANULAR KIDNEY. — A morbid con- dition of the kidney, in which this organ is the seat ot fibroid change, and as a result becomes contracted, hard, and granular. See Bright's Disease. GRANULAR LIVER . — A synonym for cirrhosis of the liver, in which the organ presents GRAVEL. 659 a granular appearance, on its surface and on section. See Liver, Diseases of. GRANULATION ( granulum , a littlcgrain). In medical pathology, granulation is synonym- ous with tubercle in its isolated form, the indi- vidual tubercles beiug called ‘grey’ or ‘ yellow' granulations, according to their appearance. See Tubi«cle. In surgical pathology, the term granulations is applied to small vascular pro- minences, consisting of embryonic tissue, growing on the surface of wounds or ulcers, and by which the healing process is carried on — whence the expression ‘ healing by granulation.’ When granu- lations assume the appearance of an exuberant growth they constitute what is called ‘proud flesh’ ( see Cicatrization, and Ulcer.) GRANULIE (French).— A synonym for tuberculosis. See Tuberculosis. GRAVEDO, ( gravis , heavy). — A sjmonym for common catarrh ; so applied on account of the sensation of weight in the head present in that affection. See Catarrh. GRAVEL. — Definition. — The deposit in, and escape from the urinary passages of grittv particles with the urine. JEtiology. — The same causes which produce dyspepsia are frequently productive of lithie acid gravel, such as indolent habits, excess of food and drink — especially of nitrogenous and saccharine articles, and the too free indulgence in the use of fermented liquors. Endemic causes connected with climate and the nature of the drinking water, hereditary predisposition, and many slight or serious organic diseases, may explain the appearance of gravel in those, and especially in women, who commit no dietetic excess, or who are total abstainers. See Oxalic Acid Diathesis, Phosphatic Diathesis, and Uric Acid Diathesis. Varieties. — Gravel maybe composed of (1’] litbic acid and its compounds ; (2) oxalate of lime; (3) phosphate of lime; or (4) the triple phosphate of lime, magnesia, and ammonia. By far the most common form of gravel, and that which alone need now be considered, is the lithie acid. This, owing chiefly to its great insolubility, is frequently deposited in the kid- ney and bladder, and is seen in the newly- passed urine in the form of the well-known reddish-brown crystals, often described as re- sembling Cayenne pepper grains. The super- natant urine is generally clear, rather dark in colour, and of a distinctly acid reaction. Symptoms. — The passage of uric-acid crystals or gravel frequently eaus-s no subjective symp- toms, and is consistent with perfect health. Sometimes, however, it gives rise to, or is accompanied ly, both general and local dis- turbance of function. The general symptoms are those of dyspepsia, namely, flatulence and heartburn after meals, eructations, headache, muscular cramp, depression of spirits, and a sense of malaise. Locally, there is dull aching in the lumbar region, not increased by move- ment ; frequent micturition ; a sense of heat and irritation at the neck of the bladder and along the urethra, especially during and after voiding water ; and sometimes the appearance 560 GRAVEL. of a faint cloud of mucus or a slight tinge of blood in the urine. Treatment. — -From what has been said, it follows that the most important points in the treatment of gravel are strict limitation as to the quantity of food; the avoidance of highly- seasoned, very rich, or sweet dishes; the pre- ference for vegetable rather than for animal food ; abundant exercise in country ai r ; and the absence or very sparing use of alcoholic liquors. Medicinally there maybe given diuretics, to increase the quantity of the urine and facilitate the escape of gravel ; pure water, alkalis, and alkaline waters freely diluted, to act as solvents of uric acid; and saline aperients and saline waters, to promote digestionaud assistin ensuring the free action of the liver and alimentary canal. W. Cadge. GRAVES’ DISEASE.— A synonym for exophthalmic goitre, to which the late Dr. Graves of Dublin called special attention. See Exoph- thalmic Goitre. GREEN-SICKNESS. — A popular synonym for chlorosis, applied on account of the greenish colour of the skin sometimes present in that dis- ease. See Chlorosis. GRIPPE (Fr.) — A French synonym for in- fluenza. See Influenza. GROWTH, Disorders of.— See Atropht, Hypertrophy, and Malformations. GRUTUM. — A term applied to small, hard, white globules developed from the epidermis, and commonly met with on the face, especially on the eyelids, cheeks, and temples. They are called grutum, from bearing some resemblance to oatmeal grits ; and have likewise boen named milium, as comparing them in size and roundness of figure to millet-seeds. Other of their syno- nyms are miliary tubercles and pearly tubercles. Erasmus Wilson. GUINEA-WORM. — Synon. : Dracunculus ; Filaria medinensis. Supposed by some persons to be the ‘ fiery serpent ’ of Mosaic history. Description.- — The Guinea-worm is a nema- toid parasite, usually measuring from one to three feet in length, and having a breadth of about one- tenth of an inch. Examples have been described as reaching six feet in length. In the adult con- dition it infests the feet and legs, as well as other parts of the body that are much exposed. The female only is known, but its more or less finely pointed and subulate tail has often caused it to be described as the male parasite (by Owen and others). The anatomy of the worm has been de- scribed by Busk, Carter, and Leuekart, and more particularly by Bastian, who has also thrown much light upon the structure and development of the embryos as they are found within the body of the parent worm (Linn. Trans. 1863, p. 101 ct seq.) The discovery of the viviparous mode of reproduction of the dracunculus is probably due to Jacobson, whose observations were subsequently verified by Owen, Busk, Bastian, the writer, and also by Robin, Carter. Davaine, and Moquin- Tandon. As regards the development of the worm outside the body of the parent, the only obser- vations of importance are those of the Russian GUINEA-WORM. traveller, Eedschenko. According to the deceased savant (as verbally communicated to the writer during his visit to England), the escaped em- bryos of the Guinea-worm perforate the skin of minute aquatic crustaceans (Cyclops). Here, after a period of only twelve hours, the embryos undergo a first change of skin, parting with their long fine tails, which eventually become compara- tively blunt and forked. At the expiration of one month and six days they acquire their highest larval stage of growth within the Cyclops, traces of the reproductive organs being already seen ; and thus, aloDg with the intermediate hosts, as young males and females, they are transferred to the human stomach. Eedschenko expressed his belief that it was either in the stomach or in the intestine that they subsequently copulated, pro- ducing a progeny after the manner of Trichina; the males perishing and passing away per annm, whilst the females migrated through the tissues towards the surface of the body. Whether or not this view be correct, Fedschenko's discover)' of the fact that the dracunculus needs to pass through the body of an intermediary bearer loses none of its practical and scientific interest. In Dr. Bas- tian’s opinion the young dracunculi are the pro- duct of a non- sexual process. It should not be forgotten that Dr. Carter, who is a great authority on all matters connected with the nat ural history of the guinea-worm, has stated that in a school of fifty boys bathing in a pond, the sediment of which swarmed with microscopic tank-worms ( Urobales palustris), no less than twenty-one were attacked with dracunculus during the year ; whilst the hoys of other schools, bathing else- where on the island of Bombay, were, with one or two individual exceptions, not affected. Facts of this kind long led the writer and others to suppose that sexual maturity was attained prior to the entrance of the worms into the human hearer. Thus, the writer has stated it to be probable ( Entozoa , 1861, p. 388) that ‘ the sexes associate in muddy waters during the monsoon, after which act the males perish, whilst the females are left to find their opportunity for a mode of direct entrance into and further develop- ment within the human body.’ It is clear that some waters are more infested by young guinea- worms than others. It is also tolerably certain that human infection is due to the passive immi- gration of the parasites. We fear, however, that the notion of ingress in a direct manner through the ducts of the skin must now be abandoned. Its former acceptance appeared to he in entire harmony with the data supplied by Indian army surgeons and other observers. The geographical distribution of the guinea- worm is limited to inter-tropical climates, being, for the most part, confined to certain districts id Asia and Africa. It occurs also iu the island o: Cur.-njoa and in Brazil. [On this subject see Dr. J. F. daSilva Lima's Memoir in The Veterinarian for February, 1879.] It is endemic in its action, all races of mankind, without reference to age or sex, being liable to be attacked in the guinea- worm districts. Treatment. — Clinically speaking, the mode of treatment pursued at the present day does not differ materially from the old method adopted by the Persian surgeons, who extracted the worm GTJINEA-W OEM. by gentle and continuous traction, winding the exposed end of the worm round a small stick of iron-, bone, or wood. If the parasite be rup- tured, local and even severe constitutional mis- chief is apt to ensue. SccDracunculus. T. S. Cobbold. GUMMA (Lat., gum). — A growth occurring in syphilis, so named on account of its supposed superficial resemblance to gum. See Syphilis. GUMS, Diseases of. — See Mouth, Diseases of. GURGLING. — A physical sign heard on auscultation of the chest or abdomen in certain conditions, due to the movement of gas and fluid within a cavity, whether normal or abnormal. H HEMACYTOMETER. 501 A gurgling sensation may also be felt at times in the intestines, as over the csecum in typhoid fever. See Physical Examination. GUTTA ROSACEA (gutta, a drop; rosa- cea, rosy). — A synonym for Acne rosacea. Set Acne. GYMNASTICS ( yv/xvds , naked). See Exfb cise. GYNAECOLOGY {yvvij, a woman, ami \6yos, a word). — This term in its literal sense means a doctrine or discourse concerning women. In medical language, it comprehends the study of the diseases peculiar to women. See Women, Diseases Peculiar to. H HABIT OE BODY. — This expression sig- nifies the sum of the physical qualities of an individual, and is sometimes used synonymously with constitution. Thus we speak of a full habit, a spare habit, and an apoplectic habit. HABITS. See Disease, Causes of; and Pehsonal Health. HAEMACYTOMETER (aTpa, blood, kotos, a cell, and pirpov, a measure). — Definition. — An instrument by the aid of which the number of corpuscles contained in a given volume of blood can be ascertained. Description. — All methods employed for this object consist in making a definite dilution of a certain quantity' of blood, and counting the number of blood-corpuscles in a certain volume of this dilution. Vierordt, who originated the method, drew uniform lines of diluted blood upon a slide, and, after it was dry, counted the cor- puscles in a certain length of line. Cramer substituted for these lines what may be termed a capillary- cell ; and Potain and Malassez em- ployed a capillary tube, and a microscope pro- vided with an eyepiece ruled in squares. Hayem substituted for the tube a cell, the depth of which gave one dimension of the volume of dilu- tion, while the lines upon the eyepiece furnished the others. The writer’s instrument is an adapta- tion of Hayem’s, with certain modifications; the diluting apparatus is similar, but of different capacity, and the lateral dimensions of the vo- lume of dilution are obtained, not by a micro- scope-eyepiece, but by lines engraved upon the glass slide at the bottom of the cell. The in- strument can thus be used with any microscope, m important convenience in practical use. The alteration in the capacity of the diluting mea- sures facilitates the counting, and provides a much simpler mode of statement of the result. The apparatus, which is made by Hawksley, consists of (1) a pipette graduated to 995 cubic 36 millimeters for measuring the diluting solution (2) a capillary tube for measuring the blood, containing five cubic mm. ; (3) a small glass jar and stirrer for making the dilution ; and (4) the cell for counting, -2 mm. deep, and ruled at the bottom in squares, each -1 mm. in length and breadth. The slide bearing the cell is fixed on a small metal plate, to which two springs are attached ; these keep the cover-glass in posit ion when applied. Various solutions have been employed for making the dilution. That which the writer has found to answer best, as differentiating most clearly the red and white corpuscles, consists of sulphate of soda, 10A grains ; acetic acid, 1 drachm ; distilled water, 6 ounces. In using the hsemacytometer, a drop of the dilution is placed in the centre of the cell ; the cover-glass and springs are applied ; and in a few minutes the corpuscles have sunk to the bottom of the cell, and are seen lying within the squares. The dilution of 5 cnim. of blood in 995 emm. of solution is 1 in 200 ; each square contains the corpuscles from a volume of dilution • 2 mm. in one, and -1 mm. in each of the other dimensions — that is, 2 cubic T nun., or the '002 part of a cubic mm. But the dilution being 1 in 200 this volume of dilution contains just -00001 cm. of blood. The number of corpuscles in a square, multiplied by 100,000, is thus the number in a cubic millimeter of blood — the common mode of statement. In order to limit error, the number of corpuscles in ten squares should be counted, and this number multiplied by 10,000 is the number per cubic millimeter. The average number in health is about 5.000,000. Blood of normal richness, then, contains about 50 corpus- cles per hsemacytometer square. Therefore the number in two squares of the instrument will always represent the proportion of the corpus- cular richness to normal blood( = 100) — that is, the percentage proportion to normal. It is, there- 562 HEMACYTOMETER, fore, convenient to take the volume of blood represented by the two squares ('00002 cubic millimeter) as the standard volume, or ‘ hsemic unit.’ Eor instance, it is found that the blood diluted presents in ten squares 375 corpuscles or 75in two squares (‘haemic unit’) — that is, 75 per cent, compared with the normal. To learn the number per cubic millimeter we have only to multiply 375 by 10,000, = 3,750,000. In counting the white corpuscles, if they are not in considerable excess, it is most convenient first to ascertain the number of red corpuscles per square, and note how many squares are con- tained in a field of the microscope. If then the focus is raised so that the corpuscles are becom- ing indistinct, the white ones, from their higher refracting power, will appear like bright points, and the number in a series of fields can easily be counted. Eor example, the number of red corpuscles per square has been found to be 40, and the field contains 15 squares, that is, 600 corpuscles per field. Ten fields contain 1 5 white corpuscles ; the proportion of white to red will, therefore, be 1 to -— = 1 to 400. 15 With this apparatus we may readily ascer- tain, within a small limit of unavoidable error, the corpuscular richness of the blood, an impor- tant element in many morbid states, such as anaemia; and we can thus ascertain the indi- cations for, and observe the effect of, therapeutic agents. It is, however, very desirable in these cases to ascertain also the richness of the cor- puscles in haemoglobin ( sec Hjemoglothnometeu). The instrument may also be employed for ascer- taining the globular richness of milk or other liquids. W. R. Gowers. HiEMATEMESIS (alyta, blood, and e’yuew, I vomit). — Synon. ; Fr. Hematemesc ; Ger. Blut- brechen. Definition*. — Vomiting of blood, dependent on a variety of morbid conditions. .ZEtiology and Pathology. — Haemorrhage into the stomach may arise — 1. From the laying open of an artery. 2. From venous or capillary congestion of the mucous membrane. 3. From causes affecting the blood itself, so that it tends to transude through the vessels under pressure of the circulation. 1 . The most frequent cause of haematemesis is an ulcer of the stomach. It occurs, according to the late Dr. Brinton, in about one-third of all the cases of gastric ulcer that come under treat- ment. The bleeding usually takes place shortly after a meal, and the quantity rejected varies greatly. In some cases, it is so small that it may require careful examination to discover it ; whilst in others enormous quantities are vo- mited, and often also passed through the bowels. The splenic artery is most frequently the source of the bleeding, but it may arise from the coronary, the superior pyloric, or, more rarely, from the blood-vessels of some of the neigh- bouring organs, such as the pancreas, liver, or spleen, to which the stomach has become at- tached, and which may happen to form the base of the ulcer. It is not necessary that the ulcer should be of large size to produce haemorrhage. Although it is most apt to occur in chronic H2EMATEME8I3. cases, instances have been recorded in which a large vessel had been laid open by an ulcer so small as to require careful search for its detec- tion. It must be borne in mind that extensive bleedings may take place without any vomiting, and the source of the fatal illness be overlooked. Such cases are not of infrequent occurrence, and warn the practitioner that he should be on the alert, whenever signs of haemorrhage present themselves, and that he should not rely too much on the absence of pain and vomiting. In cancer of the stomach profuse haemorrhage is less com- mon than in simple ulcer; the larger vessels being probably compressed by the new growth, which ordinarily commences in the submucous tissue immediately above them. But a constant oozing of blood is, on the contrary, more common than in simple ulceration. This blood, acted on by the gastric juice, constitutes the ‘ coffee ground’ vomiting of the older authors. Its occurrence used to be looked upon as pathognomonic of malignant disease, but it is now known that its presence only shows that the bleeding has taken place slowly and in small quantities at a time. Occasionally profuse haemorrhage takes place from the rupture of an aneurism into the stomach ; and in a case which came under the writer's notice at the London Hospital, fatal vomiting of blood resulted from the perforation of the aorta by a fish-bone that had become im pacted in the oesophagus. 2. Congestion of the portal system is a very frequent cause of hoematemesis. The most marked and fatal cases ot' this kind occur along with plugging of the vena portse or its large branches with blood-clots or cancerous matter. Such cases are very rare, and vomiting of blood, arising from venous congestion, ordinarily results from cirrhosis, chronic congestion, and other dis- eases of the liver, in which the portal circu- lation is obstructed. More rarely the like oc- currence is observed in persons suffering from diseased heart, especially* where there is narrow- ing of the mitral orifice. In such cases, ther^ is generally a co-existence of chronic catarrhal gastritis, and in all probability the bleeding takes place from the haemorrhagic erosions so common in that condition. In one form of this disease enormous quantities of mucus are dis- charged. Sometimes there is considerable bleed- ing in these cases, but they are distinguishable from ulcer by the absence of pain ; by the vomit- ing being only occasional; and also by the fact that the blood-stained vomit generally follows a profuse evacuation of colourless mucus, and is always of a dark colour. In females thus af- fected the catamenial discharge is generally pro fuse ; and the attacks of vomiting do not neces- sarily coincide with the menstrual periods. It has always been held that hsematem< sis may re- place the menstrual discharge. Without denying this, the writer has never met with a well-marked case of the kind. Hsematemesis due to acute congestion is also a coustant result of irritant poisoning. 3. Hsematemesis also arises from causes affect- ing the blood, and predisposing it to ooze through the walls of the veins or capillaries. It occurs in this way in purpura, yellow fever, and in some cases of typhus. In jaundice, where bleeding H2EMATEMESIS. hom tho gams and other mucous membranes is 60 often observed, life may be suddenly destroyed by htematemesis. Occasionally a haemorrhagic tendency manifests itself suddenly, without apparent cause, as in a case observed by the writer, in which a woman, about fifty years of age, was affected with severo bleeding from the nose, followed by excessive menstrual dis- charge, on the cessation of which profuse haema- temesis took place, from which she sank. She had no jaundice nor other apparent cause for her illness, and after death the most careful scrutiny failed to detect disease in any organ. To this class of causes we should probably refer the htematemesis occurring in acute atrophy of the liver, and in pyaemia, as, in all probability, the oozing of blood through the vessels arises from changes effected in its chemical or physical com- position. Symptoms. — Generally the patient in haemate- mcsis is suddenly attacked with faintness, accom- panied by a feeling of weight at the pit of the stomach, the countenance is pale, the pulse f eeble and compressible, and in some cases actual syncope occurs. This state terminates by vomiting, and a greater or less quantity of blood is rejected from the stomach. When a large blood-vessel has been laid open, and the bleeding has taken place rapidly, the blood may be florid ; but generally the haemorrhage goes on so slowly that time is given for the action of the gastric juice upon it, and consequently it is of a dark colour. It is not often that the stomach is completely emp- tied, or perhaps the bleeding persists in small quantities after the vomiting has ceased, so that the stools are generally of a dark or pitchy character, from the admixture of blood that has passed into the intestines. The haemorrhage may cease soon after the stomach has been emp- tied, or the vomiting of blood may recur from time to time, or — and this is very apt to occur in gastric ulcer — months or years may elapse before it again takes place. Diagnosis. — In some cases, when the blood has been slowly effused into the stomach, there may be difficulty in determining whether the dark colour arises from bile or blood. The micro- scope or spectroscope will be enough to settle this point ; or the liquid may be boiled with alco- hol, and tested for the biliary salts. It is not always easy to ascertain whether the blood has come from the lungs or from the stomach, as the patient is sometimes so much alarmed that he cannot say whether it was brought up by cough- ing or vomiting. As a general rule, the blood from, the lungs is florid, mixed with mucus, alkaline, and frothy; that from the stomach of darker colour, intermixed with particles of food, and in masses. Again, haemoptysis is generally preceded by symptoms referable to heart or lungs, such as cough, expectoration, and dyspnoea ; , haematemesis by tho symptoms indicative of ' gastric or hepatic disease, such as those de- scribed above. Prognosis. — As a general rule this is favour- j, able in haematemesis, more especially in first attacks. Dr. Brinton calculated that death re- sulted from this cause in only 3 to 5 per cent, of tho cases of gastric ulcer ; and it is still less frequently fatal where it proceeds from hepatic ILZEM ATINU RIA, PAROXYSMAL. 563 congestion or cirrhosis. Still, the possibility of the bleeding arising from flooding of the portal vein, from the opening of a large artery, or from the bursting of an aneurism, should be kept in view, and the patient carefully watched. Treatment. — Where a large quantity of blood has been ejected from the stomach, the treatment must be prompt and decided. The patient should be maintained in a recumbent posture, and kepi perfectly quiet. All food must be forbidden, and pieces of ice placed in the mouth to suck. If faint- ness he present, it is better not to give brandy, which almost always brings on vomiting, but to apply ammonia to the nostrils ; or, if necessary, an enema containing brandy may be given. The best styptics are gallic acid, alum, and acetate of lead. The gallic acid may be given in 10-grain doses, along with 10 or 15 minims of dilute sulphuric acid, and should be repeated frequently. Alum may be prescribed in infusion of loses; and the acetate of lead in 2-grain doses in the shape of a pill, or combined with acetic acid. Oil of turpentine is also used. Where the bleeding is slight, and there is good reason to believe it arises from portal congestion, the best treatment is to give a small dose of calomel, fol- lowed bysulphate of magnesia and dilute sulphuric acid in infusion of roses every three or four hours, until purging is produced. For some days after severe hasmatemesis, t. 1 ■« strictest quiet should be maintained; and, in toe case of ulcer of the stomach, opium should be used, and the diet most carefully regulated; it rendered necessary by persistent bleeding, nutri- tive enemas should be substituted for food by the mouth, and all purgatives avoided. When tho haemorrhage has arisen from portal congestion, a free action on the intestinal canal should be com- menced in a few days after the cessation of tho htemorrhage, so as to diminish the amount ot blood in the venous system of the alimentary organs. S. Fenwick. HIEMATHIDROSIS (aTpa, blood, and ISpas , sweat).— Bloody sweat. See Perspira- tion, Disorders of. H-ZEMATHORAX. See Hjemato-thorax. H-ZEMATTN". — See Hjemoglohin. ELZEMATINTTRIA, PAROXYSMAL (hsernatin ; and olpov, the urine). — Synon. : Haemoglobinuria. Definition. — A paroxsymal affection of the system ; manifesting itself by changes in the urine ; caused sometimes by malaria, and some- times by other conditions not yet determined ; consisting in no anatomical change as yet recog- nised ; and characterised by the occasional occur- rence of constitutional disturbance, with discharge of dark, blood-stained nrine. jETiot-oGY. — The most important extrinsic cause of the tendency to this disease is malarious poison, the most important cause of the parox- ysm is exposure to cold or wet ; but the tendency may exist without malarial poison, and the attack may occur apart from any special exposure Amongst intrinsic causes, sex is evidently im portant, for the disease is almost confined to males. It may occur in children, and may occa sionally recur during a period of years. 564 HiEMATINURIA, PAROXYSMAL. Anatomical Characters. — The disease not being fatal, there is no evidence as to the exist- ence of any anatomical change in the kidneys. Symptoms. — Hsematinuria is paroxysmal, but not distinctly periodic. It may commence in child- hood or during adult life. The attacks may occur once, twice, or thrice a day, on alternate days, once a week, or quite irregularly. The paroxysm may commence abruptly without any premonitory symptom, but is more commonly ushered in by a feeling of uneasiness in the loins and limbs, by shivering, and general chilliness. Sometimes it is preceded by slight jaundice, furred tongue, and other symptoms of gastric catarrh ; and sometimes albuminuria precedes by a few hours or a day the occurrence of hsematinuria. The more abrupt attacks frequently terminate by the discharge of the peculiar urine, and the next urine is normal, or nearly so. In some cases albu- minuria lingers for a time after the discoloration h as passed off. The characters of the urine are very peculiar. Its colour is like porter, or like muddy port wine ; its specific gravity ranges from 1015 to 1035; it is acid, or faintly alkaline; highly albuminous ; sometimes it contains excess of urea ; and throws down a copious sediment. This con- tains very few or no blood-corpuscles, but an immense amount of granular blood-pigment, with numerous tube-casts— hyaline or epithelial, often loaded or coated with amorphous granular matter, and with minute crystals of oxalate of lime. The colour is not due to blood-corpuscles, and it is said not to be due to haamatin, but to haemo- globin. In some cases the urine is less affected, being merely albuminous, and not depositing pig- ment. It may be doubted whether this condition should be admitted to the same category as the disease under discussion, but cases which have come under the writer's observation seem to show that it is entitled so to rank. Diagnosis. — The only diseases with which in- termittent haematinuria is likely to be confounded are haematuria, and renal calculus or gravel. From the former it is distinguished by the abundance of 'the blood-pigment, and the extreme rarity of blood-corpuscles; from the latter by the short duration of the attacks, the presence of the cha- racteristic deposit, with the fact that the pains affect both loins, not merely one. It is some- times important to distinguish the milder forms, in which merely albuminuria occurs, from conges- tion or from commencing inflammatory Bright’s disease. It is not always possible to distinguish these during the early hours of the attack ; but the amount of general disturbance, the state of the tongue, the slight jaundice, the suddenness of the onset, and the absence of dropsy, generally suffice to make it clear. Prognosis. — The prognosis is good in paroxys- mal hsematinuria, as to the individual par- oxysm. The tendency to the disease is also not unfrequently got rid of. It has not proved fatal in any case. But it appears sometimes to usher in, or to constitute, an early symptom of Bright’s disease — the cirrhotic form. Treatment. — As the paroxysm is spontane- ously recovered from, little need be done, except- ing with the view of alleviating the discomfort of the patient. He should go to bed and be kept warm, and have abundance of warm drinks. HEMATOCELE. In respect of diminishing or removing the ten dency to the malady, various remedies have been found useful, among which may be mentioned quinine, tincture of cinchona, iron, arsenic, and chloride of ammonium. T. Grainger Stewart. HAEMATOBIUM (uT/ia, the blood, and Bios, life). — A synonym for haematozoon. See Hema- TOZOA. HA1MATOCELE (aTyua, blood, and kt)A7j, a tumour). — Synon. : Fr. Hematocele ; Ger. Illut- geschwulst. — Definition. — The swelling occa- sioned by effusion of blood in the sac of the tunica vaginalis, or in a cyst connected with the testicle. Aetiology and Symptoms. — The extravasa- tion of blood in hsematocele may take place in a healthy state of the parts, or it may suc- ceed or be combined with hydrocele. In both cases it may be occasioned by a blow, or by vio- lent efforts made in straining, especially in old persons, or when the blood-vessels are diseased. It may happen also from the accidental wound of a vessel in tapping a hydrocele. The blood effused, if small in quantity, mixes with the fluid of the hydrocele, occasioning slight enlargement without disturbance. If it be large in quantity, coagula are formed ; inflammation is excited in the tunica vaginalis ; and plastic exudation occurt on its inner surface, sometimes forming layers, and rendering the sac extremely dense and firm. The testicle preserves the same relation to the remainder of the tumour as in hydrocele, being situated at its posterior part. Its position, how- ever, is liable to similar alterations as occur in hydrocele, which are very difficult of detection, owing to the great thickening of the parts. Diagnosis. — A hsematocele may be distin- guished from a hydrocele by the absence of trans- parency ; the obscure character of the fluctuation; the heavy feel of the tumour when balanced in the hand ; and tho sudden and accidental mode of its occurrence. In old chronic cases, in which the tunica vaginalis and its envelopes have be- come much thickened and indurated, the tumour possesses so firm a character, and feels so heavy and solid, that it is very liable to be mistaken for a chronic enlargement of the testicle ; and the diagnosis, at all times difficult, in some instances cannot be satisfactorily made out by the most experienced hands. The records of surgery fur- nish many cases in which castration has beeD performed owing to a mistaken diagnosis. "When doubt exists, it should be removed by the intro- duction of a trochar or by an incision before any serious operation, such as castration, is under- taken. Treatment. — When hsematocele succeeds a hydrocele, the blood, if small in quantity, mixes with the fluid of the hydrocele without producing irritation. The tinged fluid may be removed by tapping, and the operation can be repeated after- wards at intervals until the fluid is free from discoloration. Even when inflammation arises, if the sac be tapped and tension removed, and the patient be kept at rest, with ice applied to tho part, the inflammation may subside. When, however, the blood eSused is large in quantity, and when the inflammation is acute and threatens suppuration, the tumour should be punctured at HEMATOCELE. ,t 3 upper part, a director introduced, and the sac freely laid open by incision. This must be done with care, so as to avoid wounding the testicle. A chronic haematocele with a very thickened sac must be cut into in the same way ; and lateral portions of the sac may be excised, so as to lessen i he wound for healing. The practitioner must bear in mind that the testicle is sometimes situated in front, as in cases of inversion, and is then very liable to injury in the operation of in- cision, and even in tapping. Encysted hsematocele.— Encysted hsemato- cele implies an effusion of blood in the sac of an encysted hydrocele : and the treatment is the same as that required for ordinary haematocele. Hsematocele of the Cord. — Blood may also be effused in the areolar tissue of the spermatic cord, constituting diffused haematocele of the cord ; or in a cyst in the cord, constituting en- cysted hsematocele of the cord. Such cases are very rare. T. B. Curling. HAIMATOIDIN. — See HAaiOGLoniN. HEMATOMA (ai/iaria, I fill with blood).— A peculiar form of bloody tumour, or a collection of extravasated blood that has undergone cer- tain changes. It is observed more especially in connection with the ear, the scalp, and the meninges. See Cephalhematoma ; HMmatoma Aueis ; Meninges, Cekebrax, Haematoma of ; and Tumours. The term is sometimes also ap- plied to fungus haematodes. HEMATOMA A HE. IS (aiyaToa, I fill with blood ; auris, of the ear). — Synon. : The Insane ear ; Fr. Othematome ; Hematome de l' oreille dcs alicnes ; Ger. Othamatoma ; Ohrblut- gesckwalst von Geisteskranken. Definition. — An affect ion of the auricle, which occurs almost, if not quite exclusively, in the insane, and consists in the effusion of blood or bloody serum between the cartilage and its peri- chondrium, to such an extent as to form a distinct tumour. Etiology. — In most of the few cases of hsema- toma auris which have been published to show that this disease may occur in the sane, the de- scription given of the patients rather points to their insanity than otherwise. It is most com- mon in cases of general paralysis and mania (acute and chronic), but also occurs in melancholia, dementia, and idiocy. It is about four times as frequent in men as in women ; and more often affects the left ear than the right. Sometimes both ears are affected, but seldom at the same time. There would seem to be, in many or all of the insane, a morbid condition of the vessels or other tissues of the auricle, which predisposes to the occurrence of hiematoma. If this condition be present to a sufficient degree, the disease may arise spontaneously; in other cases a very slight injury may be sufficient to cause it; whilst in others very considerable violence is necessary for its production. Symptoms and Course. — The disease first makes itself evident by the appearance of a swelling of about the size of a horse-bean ; this is almost always upon the anterior surface of the pinna, and usually in the neighbourhood of tile fossa of the antihelix. The skin over the tumour is generally of a reddish or bluish- HEMATOMA AUEIS. 065 red colour, but may be unaltered at first ; the temperature of the ear is sensibly raised; the swelling is very painful and tender ; there is no extravasation of blood from the cutaneous vessels ; and the tumour is not oedematous. At this stage, the effusion which has taken place between the cartilage and its perichondrium consists of dark red fluid blood. In rare cases the swelling does not increase further ; the inflammatory symptoms subside after about a week; absorption gradually takes place ; and only a slight thickening remains. More usually the tumour increases and may at- tain the size of a hen’s egg ; it becomes tense, elas- tic, distinctly fluctuating, and hot ; and is often of a bright red colour. Its prominent anterior wall, consisting of skin, cellular tissue, and peri- chondrium, is felt to be thinner and less resisting than the posterior, which contains the ear-car- tilage. In certain cases, however, owing to the brittle cartilage having split up, and portions of it having adhered to either wall, both walls present irregularly alternating characters. The time which a haematoma takes to attain its largest size varies from a week to a month ; it then generally involves the whole of the concha, occluding the external auditory meatus ; the folds of the auricle are lost, with the exception of the helix (which appears as a band running round the tumour), and the dependent lobule. The weight of the tumour causes the whole ear to fall somewhat forwards and outwards. Some- times, especially in the presence of constant or repeated irritation, the inflammatory stage may last many weeks, and the deformity which always results from the affection is thereby greatly in- creased. Unless subjected to violence, it very rarely happens that the tumour opens spontane- ously, although its tense and inflamed appearance often seems to indicate that such an occurrence is imminent. If rupture does take place, suppu- ration ensues ; portions of cartilage come away; the cavity closes very slowly ; and great defor- mity results. The most common course is for the inflammatory symptoms gradually to subside. The anterior wall becomes firmer, owing to a new deposit cf cartilage upon its inner surface ; the sense of fluctuation is gradually lost ; and the tumour slowly diminishes in size, often yield- ing a somewhat doughy sensation to the touch. Occasionally, at this stage, some gaseous contents have been observed in the cavity. The colour of the skin over the tumour becomes gradually more dusky ; it then passes into yellow and, later on, into an unnatural pallor. As the fluid contents become absorbed, the tumour becomes harder and smaller; folds again appear in the auricle, but do not correspond to the original ones; and the pinna remains permanently thick- ened, puckered, and often nodular. Anatomical Characters. — Many of these have been given above in explanation of symptoms, and do not require to be repeated. A shrivelled auricle, which has previously been affected by bsmatoma, presents, on section, two distinct layers of cartilage ; these are of varying thick- ness, and separated from each other by vascular fibrous tissue, which often contains within it other small isolated plates of cartilage, and some times also small portions of bone. The fibrous tissue is the organised product of the original C66 H2EMAT0MA AURIS. effusion ; the two layers of cartilage, hare been developed upon the inner surfaces of the peri- chondrium; the loose portions of cartilage and bona which are occasionally seen, are developed from the fibrous tissue. It used to be supposed that the bone (which is soft, vascular, and con- tains well-developed Haversian systems) resulted from ossification of the ear-cartilage ; but the writer has shown elsewhere {Brit. Med. Jour- nal, Oct. 1873) that this is not the case. Pkognosis. — The local affection is in no way dangerous, but it always leaves behind it a per- manent characteristic deformity of the auricle. The sense of hearing is only affected by the oc- clusion of the auditor}’ meatus ; but this condition very rarely persists after the acute stage. The occurrence of haematoma auris affects tne prog- nosis of the mental disease unfavourably, but does not necessarily indicate the approach of a fatal termination to the case. Treatment. — Protection of the part from injury is usually all that is necessary. Cooling applications might be useful if inflammation were excessive. The tumour should not be opened; nor should a portion of the anterior wall be removed, as has been recommended; these procedures only lead to suppuration. It is useless to empty the cavity by aspiration, as it fills again with great rapidity. The treatment by pressure is very painful, and yields no good result. Chas. S. W. Cobbold. H JEM ATO -PERICARDIUM (cupa, blood ; repl, about ; and xap^ia, the heart). — An extra- vasation of blood into the sac of the pericardium. See Pericardium, Diseases of. HJEMATO-THORAX (aTfta, blood, and 6wpa£, the chest). — An extravasation of blood into the pleural cavity. See Pleura, Diseases of. HJEMATOZOA (aTjaa, blood, and an animal). — This term is of general application to all kinds of animal parasites dwelling in the blood and blood-vessels ; but its employment is often restricted to certain of the nematoid entozoa, which display this habit in a more marked degree than the other parasites are wont to do. All classes of helminths are liable, at some time or other in the course of their life- time, to take up their residence in the blood, but in the case of the Tania, or rather of their prosco- lices, this period is of very short duration. One or two species only of fluke-worms or trematodes play a similar role in man, the most important being the Bilharzia, which gives rise to an en- demic hsematuria at the Caps, and elsewhere in Africa {see Bilharzia). Our knowledge of the nematoid hsematozoa dates at least as far back as the time of Ruyseh (166.5) who was acquainted with the strongyles which produce aneurism in the horse and other solipeds; whilst more than half a century later the subject received additions from the writings of Schulze (1725) and Chabert (1782); and subsequently from the memoir by Rayer (1843). About the latter period also the observations by Grube and Delafond ‘ on a verminiferous condition of the blood of dogs, caused by a great number of liaematozoa of the genus Filaria,’ excited much attention ; but until quite recently it was not so much as suspected HJEMATURIA. that similar microscopic filariae infested tne human body. In 1872 Dr. Lewis announced the important discovery of the existence of nematoid worms in the living human subject also. See Chyluria; and Filaria Sanquinis-Hominis. T. S. Cobbold. HEMATURIA ( alxa , blood, and ovpoy, urine). — Synon.: Fr. Hematurie ; Ger. BkUhamen. Description. — Hsematuria is a symptom of many different morbid conditions of the system, and of the urinary tract. The quantity of blood discharged in the urine varies greatly, and the ap- pearance of the urine corresponds. Sometimes it is dark, loaded with clots ; sometimes it is merely smoky, or of a faintly pink hue. It is albuminous, and corpuscles (often altered by soaking in the urine) may be discovered by the microscope, some- times becoming swollen, sometimes shrunken. The following are the best tests' for detecting the presence of blood in the urine. — 1. Guaiacum. When equal parts of tincture of guaiacum and oil of turpentine are shaken together to make an emulsion, and the urine is cautiously added, an intense blue colour is produced if blood be present. 2. Spectrum analysis. Very minute quan- tities of blood in the urine show absorpt : on-lines between Frauenhofer's lines D and E in the yellow and green of the spectrum. See Spectroscope. The blood in haematuria may be derived from the urethra. If so, it precedes the stream of urine, sometimes forms a long thin clot, and may escape in the intervals of micturition. Sometimes it is derived from the prostate gland or the bladder. When it has lain in the bladder and been poured out in considerable quantity, it is often in clots ; and when the urine is voided, the first part is frequently clear, the last loaded with blood. Blood may also be derived from the ureter or the pelvis of the kidney. Some- times clots in the form of moulds of these struc- tures may be recognised. At other times the blood is derived from the substance of the kidney, and then is intimately mixed up with the urine, which frequently exhibits bloody tube-casts. ./Etiology and Pathology. — Urethral haemor- rhage is due to local inflammation or rupture of vessels. Prostatic haemorrhage may be due to malignant disease, to tumours, to inflammation, or to scrofulous affection of that organ. Vesical haemorrhage results from malignant disease, from simple villous growth, inflammation, ulceration, tubercular disease, or the irritation of calcu- lus. Haemorrhage from the ureters or pelvis of the kidney may be due to the presence of calculi, or to unexplained causes. Haemorrhage from tho kidney may be due to cancer, tubercle, suppura- tive nephritis, or to the irritation of crystals or amorphous concretions within the uriniferous tubules. Haemorrhage occurs also in all the forms of Bright's disease, especially in the early stage of the inflammatory form, and the advanced stage of the cirrhotic. It results moreover from over-doses of turpentine and cantharides, and from rupture of the kidney. Sometimes it is a manifes- tation of purpura haemorrhagica, more rarely of scorbutus ; and occasionally it occurs in the course of, or as a sequel of eruptive or continued fevers. It is alsooccasionally vicarious. Renal haemorrhage occurs in Egypt, Mauritius, and other localities HAEMATURIA. in consequence of the presence in the pelvis of tile kidney of a minute parasite, the Bilharzia haematobia ; or of the presence in the blood of the Filaria sanguinis-hominis. See Bilharzia ; Chtlokia ; and Filaria Sanguinis-Hominis. Treatment. — The treatment of haematuria must vary according to the lesion to which the haemorrhage is due, but where the symptom is so urgent as to demand treatment for itself, the most important points to be attended to are rest ; free relief of the bowels ; the application of ice- bags over the source of the haemorrhage ; along with the internal administration of astringents, especially gallic acid, ergot of rye, perehloride or pernitrate of iron, turpentine, or acetat6 of lead, with or without opium. If these do not succeed, the subcutaneous injection of ergotine is often efficacious. Surgical interference may be required for relief of symptoms due to co- agula. T. Grainger Stewart. H-33MIC ASTHMA. — A form of asthma, dependent upon an abnormal condition of the blood. See Asthma. H2EMIC MURMUR. — A murmur connected with the condition of the blood, as in anaemia. See Antemia ; and Physical Examination. HAEMIN.— See Hemoglobin. HAEMOGLOBIN" (euga, blood, and globus, a ball). Synon. : — Haem,atoglobulin ; Hfemato- crys tiffin ; Crnorin (Stokes).— This substance, which is of great physiological interest, is of an extremely complex nature, being a compound of two bodies, the one a proteid known as globulin or globin ; and the other a nitrogenous derivative called hsematin. These two substances are com- bined in the proportion of 8 7 '5 per cent, of globulin to 12‘41 per cent, of haematin (Schmidt) ; and the provisional formula of hfemoglobin, ac- cording to Hoppe-Seyler, is C 600 H 960 N 151 Fe S 3 0 1,9 . If w r e estimate the red corpuscles as form- ing about 32 per cent, of ordinary blood, haemo- globin may be considered as forming 13 to 14 per cent, of the same blood. Haemoglobin presents a singular exception to the general law of diffusion, inasmuch as, though it readily crystallises, it will not diffuse through membrane as such without decomposition. A considerable variety in the shape of the crystals is met with in different animals ; in man they occur as elongated prisms. The most important property of this compound ts its affinity for oxygen. In some obscure man- ner this gas enters into a loose combination with haemoglobin, forming oxy-hcemoglobin ; and is then conveyed by the red corpuscles through- out the body; separating again from its con- veyer in the tissues. The haemoglobin thus deprived of its oxygen is known as reduced hemoglobin, and is of a purplish colour, whilst the oxy-haemoglobin is of a scarlet tint. It is thus that the difference in colour between arte- rial and venous blood is mainly to be accounted for. It is to be noted that whatever be the [ nature of the combination that exists between the oxygen and its carrier, it is such that the gas retains its properties as a gas, and the union may bo roughly compared to a mere solution of the gas in a fluid. The recent experiments of Malassez, Uayem, Gowers, and others have furnished HAEMOGLOBIN 567 us with means of estimating within very reason- able limits the quantity of red corpuscles coniaine ! in any sample of blood (see Hemacytometer) : and further by a comparison of its colour with that of a solution of known strength the per- centage of haemoglobin in it may be ascertained with tolerable accuracy ( see Hiemoglobinomb- ter). We are as yet unacquainted with the varia tion in its amount in the majority of diseases, but a very considerable diminution, even to the extent of 25 per cent., has been met with in chlorosis. Whether with the alteration in quantity of haemo- globin there is any change in its composition i3 uncertain ; from the improvement following the administration of iron in certain cases of anaemia it would seem that there may be. As regards the iron constituent of this compound, amounting to •4 or -5 per cent., it has been suggested, although on no very good grounds, that the oxygen-carry- ing property is due to this element. It is notice- able that in some of the lower animals copper has been met with, taking the place of iron. From a pathological point of view, haemo- globin is chiefly of interest in respect to its derivatives, which are easily obtained by the action of heat, acids, alkalies, &c., and also on account of the relationship that exists between this substance and the various pigments met with inthebody. The chief derivatives of Inemoglobin, namely, haematin, liaematoidin, and haemin, will now be described. Haematin. — C 6S H 70 N 3 Fe 3 O 10 (Hoppe- Seyler). Haematin may be obtained from red blood, cor- puscles by treatment with alcohol, acidulated with sulphuric acid. Hsematin is an amorphous dark-brown powder. A solution gives a characteristic absorption-band in the spectrum, different from those produced by licemoglobin. It gives a green solution when boiled with caustic potash. .Hoematoidin (aig a, blood, and eTSos, appear- ance). (C 1; H 1S N- O 3 ). — Hsematoidin maybe pre- pared from haematin by the action of acids, which remove the iron. This substance is crystalline (rhombic prisms or needles), and of a red or greenish-red colour ; a fact which shows that the colour of haemoglobinis not dependent on theiron. It is of considerable pathological interest, being frequently found in old clots, and in the cavity of ruptured Graafian follicles ; it is the cause also of the staining so often seen in the neighbour- hood of extravasations of blood, varying from lemon-yellow up to reddish black. Haemin (C tt9 H 70 N 9 Fe 2 O 10 2 HC1). — Haemin, which may be prepared from dried haemoglobin by treatment with glacial acetic acid, in the pre- sence of an alkaline chloride, is a hydrochlorate of haematin. It crystallises tolerably readily in needles or rhombic plates, and thus becomes an easy means of detecting the presence of blood in stains of a doubtful nature. The relationship of haemoglobin, haematin, hsematoidin, and haemin to the pigments of tho body is of the greatest interest. It would seem that the haemoglobin is the source of all — biliary, urinary, &c. Bilirubin is closely allied to, if not identical with, liaematoidin ; and a play of colours — the result of oxidation — may be ob- tained from the latter when treated with nitric acid, similar to that produced by the bile-pig \ 568 HAEMOGLOBIN Rents under the same condition. The injection of haemoglobin into the blood is followed by the presence of bile-pigments in the urine, and an increase of bilirubin in the bile. Melanin, the black pigment often found in connection with new-growths, especially with those of a malignant character, also appears to be directly drawn from haemoglobin. The colouring matter of the blood is obviously associated, in some way other than that of its oxygen-carryiDg func- tion, with the nutrition of the tissues, in con- nection with the obscure but unquestionable influence of pigments. W. H. Allchin. HA®MOGLOBINOMETER(Hmmoglobin; and jit eVpon, a measure).— Definition. — An in- strument for the clinical estimation of the amount of haemoglobin in blood. Description. — The promotion of haemoglobin may be ascertained by estimating the amount of iron in the blood, or the amount of dilution necessary to obscure a certain absorption-band in the spectrum (see Spectroscope). Neithercf these methods is, however, available for clinical use. Simpler methods have therefore been contrived, which proceed by comparing the colour of diluted blood with that of solutions of carmine and picro- carmine. By this combination the tint of blood and even its spectrum may nearly be obtained (Malassez). Coloured discs have been employed for the same purpose (Hayem). In these methods a given dilution of blood is made, and this is com- pared with the tint of the standards. In the haemoglobinometer designed by the writer (and made by Hawksley) the blood is progressively diluted until it reaches the tint of a standard the colour of which corresponds to a dilution of 1 part of healthy blood in 100 of water. The degree of dilution necessary to make the two correspond represents the amount of hsemoglobin. The apparatus consists of two tubes of exactly equal diameter, and a capillary pipette, holding 20 cubic mm., for measuring the blood. One tube is filled with a standard, consisting of glycerine jelly coloured to the required tint. The other is graduated, each division being equal to the vo- lume of blood taken (20 cubic mm.), so that 100 divisions equal 100 times the volume of blood. The dilution is made by a pipette stopper, and the number of degrees of dilution necessary in- dicates the percentage proportion of the haemo- globin of the blood examined to normal blood. For example, the blood of a patient being pro- gressively diluted, is found to reach the tint of the standard when the amount of water added cor- responds to 4-5 degrees of dilution ; the blood ex- amined therefore contains 45 per cent, of the nor- mal quantity of haemoglobin. W. R. Gowers. H-EMOPERICARDITTM. See IIaiuato- PERICARDIUM. HAEMOPHILIA (alua, blood, and ain be con- nected with a gcuty diathesis, then these disorders must be treated with their appropriate remedies. If during the paroxysms the head be hot and the face flushed, warm or cold lotions, iced water, or eau-de-Cologne may be applied ; a warm douching may be useful in some cases. Occa- sionally in severe attacks a few leeches may be placed on the temples with advantage, or a blister to the nape of the neck, but never if the face be HEADACHE. pale, and the pulse feeble. Compression of the temporal arteries ■with a pad, sustained pressure around the head, or holding the arms high above the head, will sometimes relieve severe headache. The treatment of sick-headache is discussed inder the article Megrim. P. W. Latham. HEALTH, Maintenance of. See Disease, Causes of ; Personae Health ; and Public Health. HEARING, Disorders of. — These disorders may be grouped under three classes, namely : — (a) Partial or complete loss of hearing, or deaf- ness ; ( b ) Exalted hearing (so-called) ; (c) Per- verted hearing or Tinnitus. They may be due to various conditions quite independent of any actual disease of the auditory apparatus, and only such causes of disordered hearing will be considered in the present article as are not due to changes in the conducting portion of the ear, which can be demonstrated by the different methods of examination, or to recognised affec- tions of the nervous apparatus connected with hearing. These will be found discussed under he article Ear, Diseases of. (a) Partied or complete loss of hearing.- — Per- haps the deafness due to accumulations of ceru- men, which so frequently interfere for a time with the hearing of persons whose ears are free from disease, should be regarded as disordered hear- ing, rather than as a symptom of a pathological condition. As nothing more energetic than careful syringing is required to remove such obstructions, it will be sufficient to observe that in this proceed- ing the nozzle of the syringe should be directed along the roof of the external canal. Amongst a very large number of people with the organs of hearing in an apparently healthy state, some few will be found upon whom, throughout their lives, lertain notes produce no response. They will iot, for example, be able to hear the sounds made by grasshoppers, or the singing of some birds — the call of a partridge, for instance; and in most persons, as age advances, the very high notes are lost. To prove this, it is only necessary toblow one of Mr. Galton’s whistles in a room full of people, when a considerable proportion of the assembly will fail to catch the high notes, which are distinctly heard by the rest ; and although this failure is also noticeable in many nervous affections, all other sounds will perhaps be heard quite normally by these individuals. Emotional influences play a very large part in the destruction or suspension of hearing, and this is especially ob- servable in the case of women. The unexpected sight of a dead husband, hearing of the death of a dear friend, the proposal of a severe surgical operation on a relative, a quarrel, an alarm of thieves, and witnessing a carriage accident, have each within the knowledge of the writer been followed by intense and sudden deafness, which has only been partially recovered from. The same effect has been noticed with men who have been subjected to prolonged mental strain, in con- nection with literary work, or during commercial crises. It has been recorded that adeaf and dumb child has suddenly recovered hearing, after the discharge from the bowels of eighty-seven lum- brici, and a large number of oxyurides ( Journal ~f Med. Society , 1844). Complete loss of hearing, HEART, DISEASES OF. 581 extending over several months, was on one occa- sion followed by perfect hearing in a girl of fifteen, on the first appearance of menstruation. The temporary effect of quinine and salicylic acid on the hearing is well known, but when quinine has been administered in large doses, and for a long period, this special sense is not unusually injured permanently. Amongst the diseases which often induce a lasting deafness, without any perceptible local change in the conducting portion of the ear, may be included mumps, many of the fevers, and diphtheria ; for although in the two latter examples the middle car often suffers, this is not always the case, and the immediate cause of the deafness must be sought in the products of inflammation which have been left within the cranium. The same explanation is probably also the correct one in those instances where children lose, for ever all hearing power, after cerebral excitement or con- gestion. Habitual and obstinate constipation is sometimes attended with loss of hearing, which returns after the action of purgative medicine. A clot of blood within the cranium, whilst caus- ing hemiplegia of the opposite side, may de- stroy the hearing of the same side as the effu- sion ; and a case is on record in which closure of the cerebro-spinal foramen gave rise to this symptom. (b) Exalted hearing. — What is termed ex- alted hearing will generally, on careful examina- tion be found to be not so much a definite change in the capacity of the hearing apparatus to re- ceive impressions, as an inability on the part of the patient to receive such impressions without an undue effect on the nervous centres being pro- duced. Thus in many inflammatory states of the brain or its membranes this symptom is often a prominent one. It is also not uncommonly met with in hysterical and nervous persons. (c) Perverted hearing . — Attendant on most of the above examples, and closely allied to deaf- ness, is the often persistent tinnitus ; but there are conditions in which this distressing symptom is the chief and solitary trouble. Thus tinnitus, with a feeling of pulsation in the ear, is occasion- ally the first warning of an intracranial aneurism ; whilst a furious tinnitus and the hearing of strange noises sometimes precede an attack of acute mania. Patients who have been the subjects of malarial fevers and sunstroke often complain of tinnitus ; and, as in all cases of disease of the ears, when present it is the most intractable of symptoms, so it is when the ears have not been the seat of any malady or injury. Treatment. — Insomuch as all the above states of disordered hearing may strictly be said to be due to causes which are in themselves abnor- malities of one part or another of the organism, it is to these that the treatment will naturally be directed rather than to alterations in hearing which in truth are merely symptoms. See Ear, Diseases of ; and Tinnitus. W. B. Dalby. HEART, Diseases of. — The study of this class of diseases has reference to the immediate pathological changes which occur in the heart itself, and to the consequences or results of these changes upon its function, that is to say, I upon the circulation of the blood. The latter 582 HEART, DISEASES OE. portion of the subject will be found discussed under the head Circulation', Diseases of Organs of ; and it will therefore be necessary in this place to summarize only the morbid changes which affect the heart itself, and this merely as an in- troduction to the full description of those changes contained in the articles which follow here, or which will be found in other parts of this wort. 1. The heart may be displaced, misplaced, or malformed. 2. Its various textures, including the coverings, the lining membrane, the valves, and the walls, are liable to acute and chronic iip- fiammation and their effects. 3. The organ itself may be increased in size, either by general dilata- tion of one or of more of its cavities, or partially, as by aneurism of the walls ; or by the addition to its volume, by hypertrophy of its muscular struc- ture, of the fatty tissue which exists beneath the pericardium, or of the connective tissue which binds the muscular fibres together. 4. Its vol- ume may be diminished by simple or general atrophy, or by the walls of one or more of its cavities being wasted and thinned. 5. Its walls are liable to various forms of degeneration — more especially fatty, granular, calcareous, and pig- mentary. 6. They may be the seat of fibroid disease ; and of various morbid growths, such as cancer, tubercle, and syphilitic formations, or hydatids. 7. Congestion and hcemorrhage may occur in the walls of the heart. 8. These are liable also to such injuries as rupture — whether spontaneous or as the result of violence ; and to various kinds of wounds and their effects. 9. And lastly, the reader will find discussed under the head of functional disorders of the heart, certain disturbances in its action and sensibility which cannot be clearly referred to any structural lesion. HEART, Abscess of. Sec Heart, Inflam- mation of; and Heart, Pyaemic Abscess of. HEART, Aneurism of. — Definition. — A depression or a sacculus formed in the wails of the heart, communicating with one or more of its cavities. The term aneurism of the heart has not been always used in this sense. It was first applied by Lancisi and subsequently by Bouilleau to every dilatation of the heart, whatever its cause or its character. The first case of the disease, as the term is now understood, was published by Galeatti in 1757. In this country, Dr. Thurnam, Dr. Peacock, and others have treated the subject fully. In France aneurism of the heart liasbeen described specially by Breschet and by Pelvet ; whilst in Germany, Lobstein, Lobl, and Hartmann have written upon it at length. A full account of the researches of these and several other writers will be found in the work of M. Pelvet — Des An'e- vrysmes du Cxur, Paris, 1867. TEtiology and Pathology. — The essential con- dition which leads to aneurism of the heart is a change in a portion of the heart’s texture, by which the resisting power of the affected part against the pressure of the blood from withm the cavity is diminished. Under such circumstances a simple depression, corresponding to the weakened spot, may he first formed on the inner surface of the heart. This gradually continues through the cardiac wall towards the external surface, wliero HEART, ANEURISM OF. tho resistance becomes less, and where a pouch or sac is then formed, communicating with tho cavity of the heart, it may be by a neck. The weakened condition referred to is attributable in different instances to inflammation of the sub- stance of the heart, whether acute or chronic ; to syphilitic or other growths; and to fatty de- generation. (a) Inflammation of the heart, affecting either the endocardium or the substance of tho heart itself, may lead to ulceration and softening ; and both conditions have been found in connection with aneurism. Inflammation may also lead to the formation of pus in the walls of the heart; and cases are recorded in which, the contents of the sac thus formed having been discharged into the circulation, the cavity became converted into an aneurismal pouch (Dr. Wilks, Path. Soc. Trans., vol. xii.). Cases of aneurism of this character may be regarded as originating in acute inflammation of the heart. In a still larger number of cases, in which the endocardium and pericardium, as well as the muscular walls, are involved, we find a develop- ment of fibroid tissue — a cirrhosis, as it were, of the heart, as the result of chronic inflammatory action. In these cases the fibroid tissue is stretched at each systole of the heart, and it re- turns less and less to its former dimensions, owing to its want of elasticity. Thus by degrees the portion of the heart affected yields and is pushed outwards, forming a sac of a more or less globular shape. ( b ) Growths in the heart, whether syphilitic, or tuberculous, undergoing the process of soften- ing, may lead to the formation of aneurism, as in the conditions just described. (c) Fatty degeneration may give rise to the for mation of aneurism. First, a circumscribed spot of softened tissue in the wall of the heart, the result of fatty degeneration, yields without rup- ture, to the pressure of the blood from within, and thus allows of the formation of an aneurismal pouch. Secondly, partial rupture may take place in the muscular wall, and hsemorrhage occurring at this point, constitutes what is called * cardiac apoplexy ’ ( see Heart, Haemorrhage into the Walls of). The clot thus formed undergoes tho changes usual in extravasated blood ; and a cyst results, which may ultimately communicate with one of the cavities of the heart. Meriedec Laennec, who wrote on aneurisms of the heart, believed that this form of disease was almost exclusively thus developed. With reference to the relative frequency of the various causes of cardiac aneurism, just enumerated, the writer finds that out of a total of 56 cases, the histories of which were collected by himself, in 21 the walls had undergone fibroid changes ; in 6 there was fatty degeneration ; in o the disease was the result of ulceration; in 2 cases it appeared to have originated in abscess ; and in 24 the materials were not sufficient for arriving at an accurate conclusion. Age. — With regard to the age at which this disease occurs, in 51 of the 56 cases just alluded to the oldest was eighty-two, the youngest a child of twelve. Two cases occurred between ten and twenty years of age. 9 betw-een twenty and thirty, 8 between thirty and forty, 7 bo HEART, ANEURISM OF. tween forty and fifty, 7 between fifty and sixty, 10 between sixty and seventy, 6 between seventy and eighty, and 2 between eighty and ninety years of age. Sex . — Of the 56 cases, 39 were males and 17 females. Anatomical Chaeactees. — Keeping in view the several conditions just described, under which aneurism of the heart can occur, we may expect to find a corresponding variety of morbid appearances. On laying open the pericardium in cases in which aneurism of the heart exists, adhesions which are more or less universal or which may be limited to the seat of the disease, are very frequently found. The heart itself is generally enlarged ; and where the aneurism projects externally it is altered in shape, so much so in some instances that the organ looks like a double heart. The sac may project from the walls as a rounded or conical tumour; or, as in an instance that came under the notice of the writer, it may assume the appearance of an elongated sac winding round the base of the aorta. Again, no appearance of anything abnormal may be observed until the heart is laid open, when a depression or an opening may be discovered in the walls of the ventricle, or in the septum. In some instances more than one pouch is formed, in communica- tion with the cavity of the heart by a separate or by a common opening. The size of the tumour may vary from that of a small bean to that of an average-sized cocoa-nut. The opening leading into the pouch may be the widest part of the sac, the aneurism being a mere depression like a watch-glass or half-an-egg ; or there may exist a constricted or defined neck, leading to a tumour bulging from the walls. The size of the opening may vary from a couple of inches across, to one capable of admitting only a probe. The neck is, in a few cases, described as hard and cartilaginous ; in others, as being smooth and regular, or jagged and irregular. The walls of the tumour may be formed by the dilated and thin walls of the heart ; or by the walls consider- ably thicker than natural, and altered in tex- ture. A very usual condition to find is that the walls of the sac consist, proceeding from within outwards, of endocardium ; fibroid tissue, with or without portions of muscular tissue; and pericardium. This condition was described as oc- curring in eleven cases. In eight cases the walls were said to consist only of the endocardium ani pericardium, with fibroid tissue between ; but it was found that at the base of the tumour, in all these cases, all the layers of the heart- tissue were present, and that it was only towards the apex of the swelling that the muscular layers disappeared. In three cases the walls of the aneurism were said to be composed of a thin membrane, which appeared to consist of endo- cardium and pericardium only. In three cases I the walls were of cartilaginous consistence, with bony plates interspersed in the tissue. The thickness of the walls of the sac varied from that of paper to three lines or more. In fourteen cases the wall of the tumour was strengthened by the adherent pericardium. The aneurismal cavity in the majority of cases was lined by smooth membrane ; but in a few instances, ap- patently of acute formation, the walls consisted 583 of muscular fibres, torn and separated by the blood which had been extravasated amongst them. The contents of the sac are generally in the form of blood-clots or layers of fibrin, the outermost layers of which may be more or less organised and adherent to the wall. Heat . — Of the 56 cases already alluded to, 52 were in the left ventricle, 3 in the right ventricle., and 1 in the right auricle. Of the 52 cases in which the aneurism was situated in the left ventricle, 22 occupied the apex, 1 1 the base, and 17 were in intermediate situations. Several cases have been recorded, in which the aneurism was situated in the muscular septum between the ventricles; in the ‘undefended space;’ or at the base immediately below the aortic valves. A cose of the last-named form was recorded by the writer in the third volume of the Trans- actions of the Pathological Society. These two last forms are generally associated with endo- cardial inflammation and ulceration. Symptoms. — In 13 of the 56 cases referred to, the aneurism was not discovered until after death ; no mention being made of signs or symptoms of its previous existence. In the remaining cases, symptoms, more or less marked, indicative of heart-disease were present. These symptoms were chiefly — pain, dyspnoea, liviclity of the sur- face, palpitation, and ix-regularity of the pulse. In It) cases murmurs were heard, accompanying or replacing the sounds of the heart. We thus see that the symptoms of aneurism are such as may exist in common with other lesions of the heart : and it is extremely doubtful, except in presence of some special circumstances indicative of this condition, whether we have at our command the means of diagnosing the existence of cardiac aneurism. The writer not long since saw, with Dr. Holman, of Reigate, a case of grave heart - disease, in which extended dulness to the lefl and below the usual situation of the apex-beat, with a feeble impulse in the same situation led to a suspicion of the probable existence c t cardiac aneurism. Peogress, Duration, and Terminations. — • Pathological testimony fully justifies the infer- ence that certain cardiac aneurisms — such aa those which originate in inflammatory softening, ulceration, or the opening of cysts into the cavities of the heart — are acute in their forma- tion. But the like evidence further testifies that the formation of most other aneurisms, and the progress of all, are of a slow or chronic character. Still, it would seem to be difficult if not impos- sible to determine the duration of the disease in any given instance, inasmuch as many cases, for example, have been found ill tho post-mortem room, which had not given rise to any special symptoms ; whilst in other cases the pre-exist- ence of heart-disease before the formation of aneurism rendered it equally impossible to fix a date for the development of the latter special disease. Death may result from the disturbance of the heart’s action, induced by the presence and extent of the disease ;' from the aneurism opening into the pericardium; or from its burrowing in the wall of the heart, and opening into another cavity oi the organ different from that in which it origin- ated. Lastly, one or two cases are recorded ir 584 HEART, ANEURISM OF: AND CONGENITAL MISPLACEMENT OF which a cure of the disease had apparently been effected by the walls of the sac becoming in- durated or calcified. Diagnosis and Prognosis. — Seeing how ex- tremely obscure the clinical history of these cases is, it would be impossible to speak more definitely either as to the diagnosis or the prog- nosis of the disease than has been done under the preceding head. Treatment. — The treatment of cardiac aneu- rism must be such as would be adopted in any other form of grave heart-disease, and according to the circumstances of each case. We can only seek to mitigate the more urgent symptoms, whether local in the heart itself, or more gene- rally affecting the distant organs. R. Quain, M.D. HEART, Apoplexy of. See Heart, Hae- morrhage into Walls of. HEART, Atrophy of. — Definition. — A diminution in the size and weight of the heart as a whole ; or a diminution in size of one part of the heart in relation to the whole organ. .Etiology. — The causes of atrophy of tho heart are either general or local. With respect to the general causes of atrophy, the heart is found reduced in volume together with the other organs of the body, in cases of marasmus, of phthisis, of syphilis, cancer, Sec. Probably one of the smallest hearts on record — one which weighed but 3^ ounces — was found by Dr. Church in the body of a woman aged forty- seven, who died of cancer of the pylorus, after an illness characterised by ‘gradual starvation’ of more than seventeen months’ duration. With reference more especially to phthisis, as affect- ing the size of the heart, an analysis of 171 cases made by the writer at the Brompton Hospital, showed that this organ was below the average weight in 54’4 per cent. Diseases of a sub- acute character, such as typhoid fever when pro- tracted in its course, may lead likewise to wast- ing of the heart. The heart is also occasionally congenitally small. The local causes of atrophy of the heart are chiefly two, namely (1), pressure by pericardial adhesions upon the heart in certain cases of generally impaired health, by mediastinal tu- mours, by fatty growth beneath the pericardium, and other conditions; and (2) interference with the circulation in the coronary arteries, as in the conditions just enumerated, or as a result of mal- formation or of disease of the vessels themselves. Partial atrophy of the heart, when it occurs, is generally referable to insufficient blood-sup- ply from vascular disease or local pressure ; or -to fatty infiltration. Anatomical Characters. — The heart in sim- ple atrophy presents a general uniform diminution in size, as regards both its walls and its cavities ; and in its weight. In local atrophy, a portion of the cardiac wall, more or less extensive, or of one of the divisions or cavities of the heart, may be found to be below the ordinary dimensions. The colour of the atrophied heart may be nor- mal ; it is frequently pale ; and it is occasionally of a deep reddish-brown. The pericardium, not shrinking proportionately with the muscular substance, may present a puckered, opaque, and cedematous aspect, ‘like a withered anple’ (Laennec) ; and for the same reason the coro- nary vessels may be tortuous and prominent. The consistence of the walls is generally firmer than natural ; and the muscle may be even tougher, except where the atrophy is due to the presence of fat, in which case the fibres are friable, and on microscopical examination pre- sent the appearances of fatty degeneration. In simple atrophy of the heart, the muscular fibres undergo diminution in volume ; and they may also be actually reduced in number. Atro- phy of individual muscular fibres is also found as the result of interstitial fatty or fibroid growth ; and this when extensive has been somewhat erroneously named ‘ yellow atrophy.’ Another variety, which is most frequently found in the marasmus of old age, is known as brown atrophy of the heart. In such cases the muscu- lar tissue is of a dark or dirty reddish-brown colour, which proves on microscopical examina- tion to be due to the presence of numerous shining yellow or brown pigment-particles with- in the muscular fibres, and specially abundant either around the nuclei or between the ultimate fibrill®. Symptoms.— The symptoms and signs of atro- phy of the heart are those which might be ex- pected to result from diminished size and power of that organ. The characteristic phenomena are those of feeble circulation. The physical signs are chiefly diminished praecordial dulness : a feeble impulse, the apex -beat being within and above the usual situation ; diminished area of audible sounds ; and a small, weak pulse. Diagnosis. — The above signs and symptoms, in association with general wasting, afford suffi- cient grounds for the diagnosis of atrophied and feeble heart. Emphysema, pericardial effusion, and other causes of diminished cardiac dulness and weakness of impulse, must be excluded by the ordinary modes of investigation. There are no special means by which partial atrophy of the heart can be diagnosed, except, possibly, that the presence of this condition may be assumed where the functions of the organ are disturbed in the absence of valvular or other of the more common forms of cardiac disease, sufficient to explain the symptoms. Treatment. — The treatment of atrophy of the heart is the treatment of the primary disease upon which it depends, so far as is possible. R. Quain, MJD. HEART, Calcification of. See Heart, De- generations of. HEART, Cancer of. See Heart, Morbid Growths in. HEART, Cirrhosis of. See Heart, Fibroid Disease of. HEART, Congenital Misplacement of. — Synon. : Ectopia Cordis (Breschet), Ectocardia (Alvarenga). The heart is occasionally found to occupy & wrong position, and such misplacement may either be within the cavity of the' thorax, or external to it. 1. Of the internal malpositions — ectopia ccrdu HEART. CONNECTIVE-TISSUE HYPERTROPHY OF. 585 intrathoracica or ectocardia intrathoracica — the most common is that to which the term dexio- cardia has been applied, in which the heart is in a very similar position on the right side of the chest to that which it should occupy on the left. This condition may coexist with transposition of the other viscera of the body, or it may occur alone. Instances of the former kind have long been placed on record, cases having been met with in Rome in 1643, in Paris in 1650, and in London in 1694. When the heart is misplaced, the aorta generally follows an irregular course, crossing the right bronchus and passing down to the right side of the bodies of the vertebrae ; and the right carotid and subclavian arteries are given off as separate vessels, while the brachio- cephalic trunk is situated on the left side. In some instances, however, the vessels at the arch are not transposed; whilst in others the aorta, after passing over the right bronchus, crosses the spine and follows its usual course to the left of the bodies of the vertebra. In cases of transposition the heart itself may be well-formed ; or it may be very imperfectly developed. In another kind of misplacement, mesocardia, the heart is situated more in the median line than natural — a position which it occupies in the foetus at the earlier periods. Cases have also been recorded in which the organ occupied a transverse, and an antero-posterior direction. 2. Of the external misplacements, those in which the heart is situated external to the tho- racic cavity — ectopia or ectocardia extrathoracica — the most common is that in which, from deficiency of some part of the sternum, the organ lies in front of the chest— ectopia cordis or ecto- cardia pectoralis. In other cases, from deficiency in some portion of the diaphragm, the heart is placed in the abdomen, either lying in the canty, or, if the integuments are partially defective, in a sac in the pracordia — ectopia cordis or ecto- cardia ahdominalis. In a third form the heart lies at the root of the neck — ectopia cordis or ectocardia cephcdica. Of these forms, examples are related or referred to in the memoirs of Breschet and Alvarenga, and various others have been published since the appearance of the memoir of Breschet. Symptoms, Duration, and Terminations. — When the heart is well-formed, its malposition within the thorax does not necessarily cause such interference with its functions as to be pro- ductive of symptoms, or materially to curtail the duration of life. Indeed, cases are on record in which the heart and other viscera have been transposed in persons who had never presented any signs of disorder of the circulation, and who lived to very advanced ages. When, how- ever, the organ is also defective, and especially when the displacement is external to the thoracic cavity, life is usually only of short duration — though some remarkable cases of external dis- placements are on record, in which the patients survived to advanced ages. Malformation of the Pericardium. — Closely allied to the cases of misplacement of the heart are those in which the organ, though occupying its natural position, is not covered by the pericardium, but lies in contact with the lung in the left pleural cavity. Of this form of ano- maly various instances are recorded — the first undoubted case of the kind being probably that represented by Dr. Baillie, in 1778. The defect seems to consist in the pericardium, which is apparently reflected from the external coat of the aorta, not being prolonged so as to cover the front of the heart and become attached to the diaphragm. The imperfectly developed mem- brane is represented by a kind of loose fold, or pocket, which is found on the right side or upper part of the heart. Effects. — This condition does not seem mate- terially to interfere with the functions of the organ. Cases are recorded in which the sub- jects lived to middle age ; and the writer has himself seen it in a man who died of heart- disease at seventy-five. T. B. Peacock. HEART, Congestion of. — Attention was first directed to this morbid condition of the heart by Sir William Jenner ( Medico- Chirur - gical Transactions, vol. xliii. p. 199). The coro- nary veins, like the veins of other parts, are subject to engorgement, when the flow of the blood from them into the right auricle is inter- rupted. The most common cause of this is dilatation and distension of the cavities of the right side of the heart, which conditions are themselves usually due either to emphysema or to valvular disease of the heart. Disease of, or pressure on, the trunks of the coronary veins may be regarded as less frequent causes of the same result. Anatomical Characters. — Congestion of the heart is recognised, when recent, by the fulness ol the veins on the surface of the organ; cedema ol the loose connective tissue at the base ; and ecchymosis of the pericardium and endocardium. The pericardial sac contains some serous or sero-sanguinolent effusion ; and the mouth of the coronary sinus may be found to be dilated. When the congestion is slight, gradually developed, and of long standing, the venous fulness gives rise to an increased formation of connective tissue in the walls of the heart, which become, in con- sequence, tough and indurated ; whilst the dila- tation of the cavities, with which the congestion is associated, is rendered permanent by the same cause. When divided with the knife, the cardiac walls do not fall inwards ; their substance feels like a piece of leather; and the section has a smooth homogeneous appearance. Microscopi- cally, the connective tissue seems to be increased in quantity ; and the muscular fibres are in a condition of granular, fatty, and pigmentary de- generation. Congestion of the heart possesses no direct clinical relations. J. Mitchell Bruce. HEART, Connective-Tissue Hypertro- phy of. — D efinition.— A n excessive develop- ment of the connective tissue which exists be- tween the muscular fibres of the heart, causing an increase of the volume of the organ. Anatomical Characters. — In connective- tissue hypertrophy the heart is enlarged more or less uniformly as regards the walls of its several cavities, and usually greatly, weighing in some instances as much as forty ounces. The thickness of the walls is increased, as in simple hypertrophy ; and their density and 586 HEART, CONNECTIVE-TISSUE HYPERTROPHY OF; AND DEGENERATION' OF. consistence are such that they present a firm, tough, leathery character. When cut the edges do not collapse, but continue stiff and prominent. The colour of a heart in this condition may vary from pale buff to deep purple, according to the amount of connective tissue and of blood pre- sent in the vessels. Microscopically there is seen — not the usual limited amount of intermuscular fibrillar tissue and connective-tissue cells, but a decided hyperplasia of these elements, in the form of connective tissue, of which all stages of development may sometimes bo observed, from the round and spindle-shaped cell to the perfect bundle of fibrillae. Betweon the individual bundles of connective tissue lie the muscular fibres, which are also hypertrophied, but which are more or less compressed, and are occasion- ally in a condition of granular or fatty degene- ration. There is a certain amount of anatomical re- semblance, but a very clear pathological dis- tinction between this form of heart-disease and the change described by Sir William Jenner as fibroid disease of the heart resulting from con- gestion (see Heart, Congestion of). Connective- tissue hypertrophy may also to some extent be compared with the fibrosis described by Sir William Gull and Dr. Sutton as existing in the walls of arteries and other tissues. ZEtiology. — Cases of hypertrophy of the heart have been described by several writers in which there was disease neither of the valves, vessels, nor kidneys to account for it, and which the writer believes to be due to the pathological changes here described. A remarkable specimen is preserved in the museum of St. George’s Hos- pital, consisting of a heart weighing forty and a half ounces, which was removed from the body of an under-butler, in the post-mortem examina- tion of whom nothing was found which could satisfactorily explain the occurrence of the en- largement. The writer is indebted to Dr. Whip- ham for an opportunity of examining this specimen, which was found by his friend, Dr. Mitchell Bruce, to possess the microscopical characters above referred to. This and similar cases exhibit no appearance of chronic inflamma- tory action, and thus differ altogether from exam- ples of that form of fibroid degeneration which is described under a separate heading (see Heart, Fibroid Disease of). In the cases now described there is a simple hyperplasia of con- nective tissue, the origin of which cannot be fully explained. In Germany similar enlarge- ment of the heart is said to have been more especially found in gourmands, and hence it derived a characteristic appellat ion. The existence of connective-tissue growth being thus deter- mined, the effect of its presence on the muscular tissue is obvious. The connective tissue, sur- rounding, as it must do, the muscular fibres, in- terferes with their free action, to overcome which there will be a natural tendency to increased action, and consequent hypertrophy of the mus- cular fibres themselves. It is very probable that it is to these two processes going on simulta- neously that the great increase in the size of the heart is due. Symptoms and Diagnosis. — In a remarkable case recorded by the late Dr. Hyde Salter, which the writer believes to have been of the nature here described, acute or severe cardiac dyspnce.a and haemoptysis, from which the patient had suf- fered for several weeks, were the most prominent symptoms. The heart-sounds were natural, ex- cept that the first was dull and defective. Tho pulse was 84. The symptoms increased in seve- rity, and were aggravated by excessive epistaxis. The patient died after being in hospital for fourteen days. At the post-mortem examination the heart was found to be of great size, and there was no disease either of the valves or of the vessels or of the kidneys to account for it. In the case of the butler in St. George's Hospital, it is recorded that he continued going about until within a few days of his death. These and some like cases indicate that we can do little in the way of diagnosis beyond recognising the presence of cardiac hypertrophy by the usual signs ; and if the hypertrophy be considerable, and if there be no valvular disease and no kidney disease, we might not be far wrong in considering that the hypertrophy was caused bv increase of some other element than that of the muscular fibres. Treatment. — If the opinion be co rrect that this form of disease finds its origin in excessivo alimentation, it would he well to place the patient in such circumstances as would prevent this, giving attention at the same time to other hygienic conditions. The more aggravated symptoms of cardiac disease must be treated on general principles. R. Quaen, M.D. id WART, Coverings of. Diseases of. See Pericardium, Diseases of. HEART, Degenerations of. — The degene- rations that affect the heart may he enumerated as follows: — 1. Fatty; 2. Parenchymatous; 3. Albuminoid ; 4. Pigmentary ; 5. Cartilaginous : 6. Calcareous ; and 7. Vitreous. The condition which has been called ‘ fibroid degeneration ’ of the heart is described under the heads of Heart, Fibroid Disease of ; and Heart, Syphilitic Disease of. 1. Fatty. — This form of degeneration of the heart being of special importance is discussed in a separate article. See Heart, Fatty Degene- ration of. 2. Parenchymatous, — S tnon. : Granular de- generation; Cloudy Swelling; ? Parenchymatous inflammation. ZEtiology. — This form of degeneration of the heart is generally met with in the acute specific fevers, especially typhus, typhoid fever, diph- theria, and septicaemia ; and is probably refer- able to the action either of the poison or of the high temperature attending the disease-process upon the muscular substance. Anatomical Characters. — The disease gem- rally attacks the heart as a whole. The orgaD appears somewhat enlarged, extremely soft- flabby as well as friable, and of a dirty grayish- red colour. The pericardium is ecchymosed, dull, and swollen, and the epicardial flit has more or less completely disappeared. Microscopically, the muscular fibres are found to be dull and granular, swollen, and variously ruptured ; theii HEART, DEGENERATIONS OF. etriations are indistinct; and the addition of acetic acid removes many of the granules from the fibres, whilst it brings more distinctly into view a few fatty globules, and frequently an increased number of pigment-parlicles. Symptoms. — Inasmuch as parenchymatous de- generation of the heart is usually but a compli- cation of some acute specific disease, the condition of the patient is one of great febrile prostra- tion with cardiac asthenia. The physical signs, which are regarded as more distinct evidence than the symptoms of the condition of the heart, are — feebleness, advancing to complete absence, of the apex-impulse, or more rarely palpitation ; and progressive weakening, and finally loss of the first sound. The pulse has been described os corresponding with the condition of the heart, except in some cases where it is imperceptible, although associated with cardiac palpitation. Course and Terminations. — The course and terminations of granular degeneration of the heart are inseparable from those of the pri- mary disease. In typhus the average date of the appearance of the symptoms and signs just described is the sixth day of the fever, and they usually cease on the fourteenth day. A large proportion of cases prove fatal at or before that time. Prognosis. — The existence of this kind of degeneration of the heart adds seriously to the gravity of a case of fever ; and the danger in- creases with the rate and weakness of the pulse, and the feebleness of the cardiac impulse and first sound. The return of the latter under treatment justifies a favourable prognosis. Treatment. — The treatment of parenchyma- tous degeneration of the heart is in no respect different from that of the fever in which this condition originates. The appearance of the characteristic symptoms and signs of the cardiac affection is, however, to be regarded as an im- portant indication for the use of alcoholic stimu- lants, which are, as a rule, well borne in such cases, and act very beneficially. 3. Albuminoid. — This kind of degeneration has been said, with a certain amount of possi- bility, to have been found in the heart. It is certainly excessively rare. 4. Pigmentary. — Pigment-granules, in the form of shining yellow particles, are almost invariably found in the muscular fibres of the heart in chronic cardiac disease. In certain cases of atrophy known as ‘ brown atrophy,’ as well as in tile granular degeneration just de- scribed, these pigment-particles are decidedly increased in number, and collected towards the axis of the fibres. A somewhat similar appear- ance is seen in the heart in jaundice. The condition is of purely pathological in- terest. 5. Cartilaginous. — Portions of the myocar- dium have frequently been described as ‘carti- laginous ’ or 1 fibro-cartilaginous,’ but it would appear that in theseinstances the muscular tissue was replaced by dense firm fibroid tissue only. See Heart, Fibroid Disease of. 6. Calcareous. — Calcification of pericardial adhesions is not very rare ; and in some of the recorded instances of this condition, plates of the same material have been found projecting HEART, DILATATION OF. 587 into the substance of the heart, appearing as if formed within the myocardium. Besides this class of cases, instances of true deposit of calca- reous particles within the individual muscular fibres have been described. This appears in the form of small, pale, gritty deposits, taking the place of the normal muscular tissue on the sur- face, in which, on microscopical examination, the muscular fibres were found to have become solid and opaque, whilst hydrochloric acid or sulphuric acid removed the opacity with the evolution of gas, the addition of the latter acid also pro- ducing gypsum crystals. It is probable that in other recorded instances, the calcareous parti- cles were situated outside the muscular fibres, and may have been the products of a caseous nodule, whether syphilitic or ‘ tubercular’ in origin. This form of disease appears to possess no special clinical relations. 7. Vitreous. — Vitreous, waxy, or colloid degeneration, as described by Zenker, occurs in the myocardium, as it does in the voluntary muscles. J. Mitchell Bruce. HEART, Dilatation of. — Definition. — Dilatation of the heart may occur in two forms, in the one it involves only a limited portion of the cardiac walls and constitutes an aneurism ; in the other there is uniform enlargement of one or more of the heart's cavities, and dilatation in the usual acceptation of the word is present. To this latter condition, however, the names ‘ aneurism’ and ‘ passive aneurism ’ of the heart were formerly applied. Dilatation is probably always associated with hypertrophy. BStiologt. — The occurrence of dilatation im- plies that the wails of the heart which yield, are too weak to resist successfully the internal pres- sure to which they are exposed. This defective relation may be due either to actual enfeeble- ment of the heart’s walls, which renders them unequal to the task normally devolving on them ; or to excessive blood-pressure, which even the healthily-constituted walls are unable to with- stand. The enfeeblement of the heart may be a consequence of fatty or other degeneration ; or, as is probably more frequently the case, may be inherent but unconnected with visible textural disease. The excessive blood-pressure may be dependent on actual obstruction to the circula- tion which the heart is called upon to surmount ; or on undue rapidity of action which (other things being equal) implies an unwonted expen- diture of force. As a matter of fact, however, dilatation and hypertrophy are generally if not always associated ; and the processes by which these combined conditions are attained are more complicated than the foregoing statement might lead one to suppose. It will be convenient, therefore, to consider certain cases seriatim. 1. In obstructive disease at the aortic orifice ; in general stricture of the minute systemic ar- teries, such as occurs in connection with con- tracted granular kidneys ; and indeed in all cases in which resistance is offered to the free discharge of blood from the left ventricle, pro- gressive hypertrophy of the walls of that ven- tricle takes place. But the hypertrophy is com- plicated even from the beginning with dilata- HEART, DILATATION OF. 688 tion. The hypertrophy, at any i-ate at first, is sim- ply compensatory, and may be taken as a mea- sure of the excess of resistance which the heart is called upon to overcome. The dilatation, however, is in no sense compensatory, and is probably to be regarded as a measure of the in- ability of the walls to cope successfully with the extra work required of them. It is, moreover, obvious that the occurrence of dilatation, by in- creasing the area of resistance to the endo-ven- tricular blood-pressure, increases pro tanto the muscular effort requisite for the propulsion of the blood into the aorta ; and by enlarging the capacity of the ventricular cavity and conse- quently the amount of blood to be discharged from it. on that account also throws additional labour on the muscular walls of the ventricle. Thus the hypertrophy and dilatation react on one another ; and the hypertrophy, which was probably at first simply compensatory of the mechanical obstacle to the discharge of the nor- mal contents of the ventricle, ends by becoming — or rather striving to become — compensatory not only of this but of the virtual weakness of the heart which dilatation entails. 2. In regurgitant disease at the aortic orifice, hypertrophy and dilatation of the left ventricle also take place. But in this case, while the hypertrophy probably reaches a higher degree of development than in simple obstruction, dilatation preponderates from first to last; and the ventricle attains larger dimensions than in perhaps any other form of disease. But to what are the hypertrophy and dilatation due in this case ? There is no impediment to the escape of blood through the aortic orifice, and therefore primd facie no need for compensative hyper- trophy. There is no doubt that here hypertrophy waits on dilatation. The first effect of regur- gitation is, that during diastole the ventricle becomes more rapidly and completely filled with blood than it does under other circumstances, and that the subsequent contraction of the au- ricle tendsTo distend it unnaturally with blood. The result is that, on the principles above enun- ciated, the walls of the ventricle have to en- counter a larger area of pressure, and to expel a larger amount of blood than natural, and hence are called upon to make excessive effort, and hypertrophy ensues. Thus the tendency to dila- tation causes the tendency to hypertrophy ; and both acting continuously promote the progressive increase in the capacity of the ventricular ca- vity, and in the thickness of the ventricular walls. It is probable in both cases, but more espe- cially in the latter of them, that ere long the ventricle fails to expel the whole of its contents into the aorta at each contraction, and that the retention of this residual blood becomes an im- portant factor in promoting dilatation. 3. The effects of continued violent action of the heart, whether caused by nervous influence or by muscular effort are much the same as those of obstructive disease. For both increased rapidity of contraction, and increased amount of blood to be expelled at each beat, other things beiDg equal, imply increased expenditure of force ; and the persistence of either or both of these conditions, therefore, the supervention of hypertrophy and dilatation. 4. The above discussion relates especially to dilatation and hypertrophy of the left ventricle. But, mutatis mutandis, ft applies with equal force to dilatation and hypertrophy of the other sections of the heart. Thus, in mitral valve disease, the left auricle undergoes hypertrophy and dilatation — the dilatation preponderating in regurgitant disease of the valve, the hyper- trophy preponderating in obstructive disease. 5. In pulmonic valve disease the right ven- tricle becomes hypertrophied and dilated— the dilatation being greatest where there is pulmo- nic regurgitation, the hypertrophy being greatest where the disease is obstructive. 6. In tricuspid valve disease the right auricle suffers, becoming chiefly dilated in the presence of tricuspid regurgitation, chiefly hypertrophied when there is obstruction. And thus, also, just as when the systemic circulation is impeded the left side of the heart suffers, so when the pul- monic circulation is obstructed, the right side of the heart undergoes enlargement. In all cases, therefore, hypertrophy and dila- tation seem to result concurrently ; but whether the one or the other condition preponderates, depends partly on the particular nature of the cause to which the hypertrophy and dilatation are due, partly on the inherent strength or weak- ness of the cardiac walls. In all cases, too, the other cavities of the heart, besides that primarily and directly implicated, suffer according to their position from the effects of the greater or less work which sooner or later is cast upon them. The temporary dilatation which is described as occurring in acute febrile disorders, such as typhus, is due mainly to enfeebiement of the cardiac walls. Anatomical Characters. — In dilatation of the heart, the cardiac walls may be either thin- ner or thicker than natural, or may retain their normal thickness. It is a question, however, whether, excepting in the case of partial dilata- tion or aneurism, dilatation ever takes place independently of hypertrophy ; for even as re- gards the auricles, where dilatation with atten- uation is chiefly observed, there is reason to believe that the attenuation is not commensu- rate with the extension which accompanies it, and consequently that the total bulk of muscular tissue is increased. When dilatation is asso- ciated with no apparent change in the thickness of the walls, hypertrophy is of course present. It must be mentioned, however, that it is often very difficult to determine on post-mortem examination the true relation between the thick- ness of the cardiac walls and the capacity of the cardiac cavities. For their apparent rela- tion is largely dependent on the condition of the cavities at the moment of death, as to systole or diastole ; and on the state of the heart as to cadaveric changes at the time of post-mortem examination. The form which the heart assumes in dila- tation is the same as that which it assumes in hypertrophy-, and indeed as the two con- ditions are probably always associated, it is needless to endeavour to establish any distinc- tion between them in this respect. If the dila- tation be general, the form of the heart remains unchanged, but its size is uniformly augmented. HEAKT, DILATATION OF. If the left ventricle be mainly affected, the heart appears not only enlarged but elongated, the Left ventricle taking more than its due share in the formation of the cardiac apex. If the right ventricle be specially implicated, the heart be- comes enlarged, in its transverse diameter ; it is more rounded in its contour as seen from the front than it should be ; and its apex is obtuse, and either bifid, from the fact that the apices of both ventricles take an equal share in the formation of the cardiac apex, or formed wholly by the right ventricle. If the auricles be dilated, they constitute large masses on both sides of the root of the aorta and pulmonary artery. The walls of the dilated heart vary not only in thickness but also in quality. Thus they may be preternaturally firm or preternaturally soft; they may be healthy in structure, or may pre- sent more or less degenerative change. Consequences of Dilatation. — Dilatation of the ventricles, especially if it be considerable, is apt to disarrange the mechanism of the auriculo- ventricular valves. It was shown many years ago by Mr. Wilkinson King that even in mere temporary distension of the right ventricle a kind of safety-valve action of the tricuspid valve took place, in consequence of which regurgitation of blood was permitted from the ventricle into the auricle. And since his time it has been clearly demonstrated, both by clinical and by post- mortem evidence, that established dilatation of the right or left ventricle is liable to be attended with persistent regurgitation of blood through the corresponding auriculo-ventricular orifice. The defaulting valve under these circumstances has a natural aspect; but careful examination shows either that the orifice has undergone dilata- tion in company with the ventricle — the valve itself presenting no corresponding increase, or that there is a want of relation between the size cf the musculi papillares and chordae ten- dine® on the one hand, and the capacity of the ventricle on the other, which interferes with the due closure of the valve. It is obvious that if regurgitation becomes established, the usual consequences of regurgita- tion will presently ensue ; namely, in connection with affection of the left side of the heart, dilata- tion and hypertrophy of the left auricle, and sub- sequently congestion of the lungs and pulmonary apoplexy ; and in connection with affection of the right side of the heart dilatation and hyper- trophy of the right auricle, fulness of the systemic veins, anasarca, nutmeg liver, and congested, in- durated kidneys. It is also obvious that, even if no regurgitant condition be developed, dilatation of heart, which implies feebleness of heart and im- perfect circulation, must ultimately induce the ordinary remote consequences of heart-disease. A further consequence of dilatation and other cardiac affections attended with feeble circula- tion is the formation of thrombi during life, both in the heart itself, and in other parts of the vascular system. Mr. Wilkinson King has de- monstrated that dilatation of the left auricle may cause compression of the left bronchus. Symptoms. — Since dilatation of the heart rarely if ever exists alone, but is associated with hyper- trophy, valve-disease, degenerations, and other eonditions, it is almost impossible to make any 589 definite statement with regard to the signs and symptoms by which its presence may be recog- nised. Still there is no doubt that dilatation is one of the most important factors of heart- disease, clinically considered; and that its super- vention materially affects the patient’s condition, and prospect of life. Dilatation implies weakness, and as a rule over-distension of the implicated cavities with blood, which probably never becomes wholly expelled. The physical signs of dilatation are necessarily in many respects the same as those of hyper- trophy. The praecordial dulness is increased in area — the extent and form of this area, and the situation of the apex-beat, being determined by the general size of the heart, aud the relative dimensions of its component parts. In propor- tion, however, as dilatation preponderates over hypertrophy, the impulse of the heart becomes weak, and possibly to some extent diffused. In extreme dilatation, as in extreme weakness from other causes, the sounds of the heart, and espe- cially the first sound, are enfeebled. And it may be asserted that generally the tendency of dilatation is to shorten the first sound, and to give it the characters of the second sound. It has nevertheless been observed over and over again that it is in the concurrence of hypertrophy and dilatation that the cardiac sounds are apt to attain their greatest intensity. The feebleness of the heart’s action is generally attended before long by more or less irregularity ; and even in the absence of valve-disease, a mitral or tricuspid systolic murmur, implying regurgitation, is apt to be established. The symptoms of dilatation are to a large extent those of cardiac obstruction, and more especially of mitral disease. The patient com- plains of weight, oppression or uneasiness in the cardiac region, with probably a sense of flutter- ing there, and of a tendency to sighing respira- tion. He becomes short-breathed, and may have extreme dyspnoea. His face is apt to be- come livid ; his surface pale or ghastly ; his ex- tremities cold and blue ; and his pulse weak and irregular. Dilatation of the systemic veins arises sooner or later ; and subsequently general anasarca, pulsation of the veins in the neck, epigastric pulsation, and pulsation of the liver, together with the other usual consequences of heart-disease. The chief of these are — conges- tion of the lungs, with pulmonary apoplexy, cough, and expectoration of blood ; congestion, enlargement, and tenderness of the liver, with jaundice; and congestion of the kidneys, at- tended with the discharge of scanty, high- coloured, heavy urine, containing albumen and possibly blood. Other symptoms referable to the nervous and digestive organs, which need not be enumerated, are also liable to supervene. The symptoms will vary, of course, according as the left or the right ventricle is mainly affected. In the former case we are liable to have at first irregularity and feebleness of pulse with tendency to faint ; then pulmonary complications ; and at a later period, symptoms referable to the systemic venous circulation. The latter case is one of considerable interest ; because in a large number of instances it is, in its most marked form, a consequence of emphysema of the lungs, or of 590 HEART, DILATATION OF. other analogous conditions, and moreover is apt to come on very rapidly. Under these circum- stances, there is necessarily much dyspnoea, but the systemic venous and capillary systems speed- ily become over-loaded ; extreme cyanosis often develops rapidly ; and, before long, all the other symptoms referable to disease of the right side cf the heart become established: namely, pulsation of the veins in the neck, epigastric pulsation, pulsation of the liver, general anasarca, with perhaps petechial extravasations, jaundice from nutmeg liver, and albuminuria from conges- tion of the kidneys. Prognosis. — There is no doubt that some degree of dilatation of the heart, and more especi- ally of the right ventricle, may arise, either from over-exertion, or from functional disturbances, and in connection ■with pulmonary disorders. But such dilatation is for the most part tempor- ary or remediable ; and only by continuance of its cause becomes established and a matter of serious importance. In the same way there is no doubt that the dilatation which comes on in the course of organic disease of the heart or lungs, or of other organic diseases which influ- ence the action of the heart, is remediable within certain limits by due attention to the conditions under which it arises. Nevertheless it is certain that the presence of dilatation of the heart in connection with other diseases, more especially those of the heart, lungs, or kidneys, is a grave source of danger; and that in the great majority of cases it is of fatal omen, aggravating the patient’s cardiac symptoms, and hastening his death. Treatment. — The treatment of dilatation of the heart merges in that of the other cardiac conditions with which it is associated, and in that of other diseases in the course of which it may have supervened. It may be stated, gener- ally, however, that the treatment is that of cardiac debility, and of distension of the heart with blood. The chief indications, therefore, are rest of mind and body ; avoidance of exposure to ccld and wet ; the exhibition of ample nutritious and readily digestible food ; due attention to the action of the bowels, kidneys, and skin ; and the employment of medicines likely to regulate and strengthen the action of the heart. For the last purpose digitalis in small doses is universally acknowledged to be of great value. And it is in most cases desirable to combine the digitalis with iron, or some vegetable tonic. Ammonia and other diffusible stimulants are often called for, and are of great service. In cases where there is much lividity, and evidence of stagnation of blood in the right side of the heart, removal of blood by venesection may he of use. When the dilatation is due to pulmonary dis- ease, this of course requires primary and especial treatment. J. S. Bristowe. HEART, Displacements of. — Besides the displacements of the heart that occur as the re- sult of disease, there are certain changes of position which this organ undergoes in health. The most important of these physiological dis- placements of the heart are — first, its vertical HEART, DISPLACEMENTS OF. movements in respiration ; and, secondly, the alterations in its situation corresponding with changes in the bodily posture. The present article, however, will deal only with the former class, or abnormal displacements of the heart. ^Etiology. — The heart may he congenitally displaced — a condition which is described under the head of Heart, Congenital Misplacement of. These cases being excepted, the causes of displacement of the heart may be arranged in two classes — namely, (1) conditions that exert pressure ; and (2) conditions that exercise trac- tion upon the heart. (1) The heart is pressed or pushed out of position by effusions of fluid — inflammatory, serous, or bloody — into either pleural cavity; by pneumothorax of either side ; by intratho- raeic tumours — whether mediastinal (including aneurism and abscess), pulmonary, or parietal ; by hypertrophous emphysema, or other causes of enlargement of the lungs ; by extensive pneu- monic consolidation ; or by abundant pericardial effusion of any kind. Certain conditions of the abdominal contents produce a similar effect, for example — gaseous distension of the stomach and intestines; enlargement of the liver and other solid organs ; abdominal tumours of all kinds ; the pregnant uterus ; and ascites, when considerable. Hernia of the abdominal viscera through the diaphragm, and abscesses connected ■with the diaphragm, also cause displacement of the heart. (2) The heart suffers traction, or is drawn out of position during absorption of pleuritic effusion with imperfect expansion of the lung, on either side ; by the contraction of pleuro-pericardial adhesions, of pulmonary cirrhosis, or of cavities in phthisis; in collapse of either lung from pressure on the main bronchus ; and in some forms of deformity of the chest from curvature of the spine. Mechanism of Displacement. — The causes just enumerated constitute in each instance what may he called the displacing force. When this force belongs to the first or pressure class, it acts against the surface of the pericardium and heart that is opposed to it, and presses or pushes it, a tergo, away from its own seat, in the direction of least resistance. Thus the heart is, speaking broadly, pushed towards the left by effusion into the right pleural cavity ; towards the right by similar disease on the left side; downwards by tumours in the region of the base ; and upwards by gaseous distension of the stomach. On the other hand, when the displacing force is of the nature of traction, the heart is drawn a fronte , that is, towards the seat of the force. Thus, when a cavity in a phthisical lung is con- tracting, the pericardium and heart, as well as the walls of the chest, are displaced towards the healing area. It must be observed, however, that in this class of cases, actual traeti n, in the strict sense, is rare, and that the displacing force is, in reality, the atmospheric pressure; the heart and the other organs being ‘sucked’ towards the potential vacuum, in the same way as water is ‘drawn’ into a syringe. Still, in a very small number of cases, the pericardium does actually become involved in a healing pro- HEART, DISPLACEMENTS OF. cess in the, lungs ; and it and the heart are dragged towards the cicatrix. Besides the displacing force, there are at work in dislocation of the heart certain other agencies, which contribute to the result, -whether their effect be to increase or to diminish that of the chief cause. a. The weight of the heart manifestly favours displacement in different directions, according to the posture. Thus, in the erect posture, it favours downward, and limits upward displace- ment. However, the weight of the heart is com- paratively insignificant, and ma j be practically disregarded. h. The resistance, positive or negative, of neighbouring parts must be taken into account. '1 he heart when disturbed from its position will move in the direction of least resistance. Thus it cannot be displaced to any extent either for- wards or backwards ; but is moved with com- parative ease towards either pleural cavity. The resistance interiorly is greater under the right half of the diaphragm than under the left. On the other hand, the resistance around may be- come negative ; for example, in left pleural effusion the corresponding half of the diaphragm is pushed downwards, and the accompanying downward displacement of the cardiac apex is thus increased. c. The heart is attached at its root; and, speaking broadly, this is a fixed point, at the right and upper extremity of the long cardiac axis. This attachment will limit and otherwise modify displacements of the heart in all direc- tions, especially downwards. Round this point as a centre, and with the long axis as the radius, the apex of the heart will describe an arc of a circle, cutting the surface of the chest in the left axilla, the left submammary region, the epigastrium, the right submammary region, and the right axilla. d. The tendency that the heart has to rotate or roll on one or other of its axes is also affected by its attachment at the root. If the. heart lay free in the pericardial cavity, there would be no limit to such rotation under the influence of pressure or of traction. The base being fixed, rotation is greatly limited, and does not occur to any extent except around the longitudinal axis; the left ventricle, for example, being rotated more forwards or more backwards, as the case may be. Rotation round the transverse-hori- zontal and the antero-posterior-horizontal axes is very limited. Anatomical Characters and Effects. — The only essential change that the heart is found to have undergone in displacement is an alteration of its relations to the surrounding parts. The softer parts of the cardiac wall, however, such as the auricles, are sometimes compressed to a moderate degree. The pericardium is partly dislocated and partly stretched. The great ves- sels at the base of the heart and at the root of the neck may be elongated, shortened, twisted, or bent, according to the particular form of displacement ; and the circulation within them impeded The neighbouring organs are variously displaced and compressed. One of the effects often seen after displacement is permanent fixation of the pericardium and heart in their 591 new position, for example, in the pleural cavity, on the disappearance of the original cause. The effects of displacement of the heart upon its functions differ greatly in the two classe- of dislocation to which we have referred : — In displacement duo to pressure, the heart is compressed between the displacing force and the resistance in other directions, and the dis- location is generally' rapid. Fortunately, in most cases of such displacement the resistance is slight ; and the heart, if healthy, suffers little or no real compression of its substance or cavi- ties between the two forces, the mobile and compressible lung especially yielding before it. But if the heart be diseased — and especially if its walls be weak, degenerated, or dilated — moderate compression may cause embarrassment of the cardiac action and even fatal paralysis ; and the rapidity or even suddenness with which displacement generally occurs when due to pres- sure — for example, in pneumothorax, is another and perhaps the principal cause of this embar- rassment. On the other hand, when the heart is drawn out of its normal situation towards a phthisical cavity, or towards either pleural cavity from which an inflammatory effusion is being absorbed, the displacement occurs, not because there is want of space, but because there is excess of space within the thorax. The process is also very gradual. The effects, therefore, upon the func- tional activity of the heart may be said to be few, though the unusual pulsation may be a source of inconvenience, and even of anxiety to the patient. In very rare cases, the heart and peri- cardium when thus displaced, may be involved in the fibrotic process goiDg on in the lung or pleura, and the adhesions thus established may ultimately interfere with the cardiac action. Symptoms. — In displacement of the heart, special symptoms are frequently slight or alto- gether wanting; or they are inseparable from the symptoms of the original cause. This may be said to be almost invariably the case when the displacement is due to gradual traction, as in phthisis. In the pressure class of cases, on the contrary, there are frequently developed, and that rapidly or suddenly, symptoms due to com pression of the heart, such as a sense of dis- tress, stifling, and pain over the prrecordium or at the epigastrium, or even true angina ; dyspnoea, perhaps amounting to orthopncea; palpitation; blueness of the surface ; and irregularity and feebleness of the pulse. When the displacement is due to upward pressure from gaseous disten- sion of the stomach and intestines, the above symptoms may be associated with flatulence or ‘ spasms,’ and are relieved by the erect posture, eructation,, vomiting, and the administration of carminative and absorbent remedies. If this condition be not removed within a short, time, it may become aggravated, pass into a state of collapse, and end in death. Varieties and Physical Sions. — The va rieties of cardiac displacement, according to the direction in which the dislocation occurs, may. for clinical purposes, be said to be as follows : — towards the left, towards the right, downwards, upwo.rds, backwards, and forwards. It must be observed, however, that this is only a broad 592 HEART, DISPLACEMENTS OF. general classification, and that the heart is very rarely displaced in an absolutely horizontal, or in an absolutely vertical plane. The exact direc- tion taken in each variety will now be described, as well as its special causes, and the physical signs by which it may be recognised. 1. Displacement towards the Left. — This, the most common variety of marked cardiac dis- location, is most frequently caused by contraction of the left lung from any of the conditions already enumerated, and effusions into the right pleural cavity. Right pneumothorax, and tumours con- nected with the right side of the chest, with the mediastinum, or with the right lobe of the liver, are less common conditions that lead to the same result. The distance towards the left to which the heart is dislocated varies, the extreme limit being probably the vertical axillary line. During its progress towards the left, the heart is rota- ted around its longitudinal axis, so that the right ventricle is more exposed anteriorly ; and the apex is moved, at first somewhat downwards, and afterwards upwards. The visible and palpable impulse is found to the left of its normal situation, and either lower or higher than it, or on the same level with it, according to the degree of displacement. In some cases due to contraction of the left lung, the impulse may be found in any one or in all of the left intercostal spaces from the base to the apex of the heart, and of different rhythm in the different spaces. If the displaced heart be the seat of valvular disease, thrill may be felt in an unusual situation, for example, in the left axilla. The area of percussion- dnlness is altered in outline, being invaded on the Tight side either by the dulness due to effusion there, or by resonance due to pneumothorax or to encroachment of the right lung -border; whilst it is either transposed towards the left axilla, or blended with unnatural dulness over the left lung. The cardiac sounds are reduced in loudness over the normal praecordium, whilst they are un- naturally loud towards the left axilla and up the left front. Structural murmurs if present are similarly transposed, as regards the seat of their greatest intensity and the lines of their convexion. A systolic murmur may be developed at the base of the heart from distortion of the great vessels. 2. Displacement towards the Eight. — This form of dislocation of the heart is the re- sult of effusion into the left pleural cavity ; of contracting processes connected w'ith the right lung or pleura; of left pneumothorax; and of tumours of the left side of the chest or in the mediastinum. The heart may be displaced to- wards the right side until the impulse is found in the axillary region. During its lateral move- ment, the heart is rotated on its longitudinal axis in such a manner that the left ventricle is more exposed ; and, at the same time, the apex is first depressed towards the epigastrium, and after- wards raised towards the right axilla, as the dis- placement increases. The physical signs correspond closely with those enumerated under left displacement — the two sides being, of course, exactly reversed. The cardiac impulse is most frequently transferred to the epigastrium and the region between that and the right nipple. A new area of pulsation is sometimes developed in the second and third right interspaces, close to the sternum, and indi- cates the displaced position of the right auricle, if prsesystolic, or of the aorta, if systolic and followed by palpable shock in diastole. The description of the auscultatory phenomena, as regards both sounds and murmurs, does not re- quire to be repeated. 3. Displacement Downwards. — This is an exceedingly common form of cardiac displace- ment, though seldom extreme in degree. It is the constant result of hypertrophous emphysema of the lungs ; and may also be caused by the downward pressure of tumours at the base of the heart, such as aneurism, and by collapse of the stomach and intestines. Displacement of the heart downwards is limited by the diaphragm, and by the attachment of the pericardium and great vessels at the root of the heart. At the same time the apex may either move somewhat towards the left in its descent if the downward pressure be uniform, as in emphysema; or it may ascend somewhat towards the left if the pressure be exerted chiefly upon the base. The ordinary cardiac impulse is generally quite imperceptible in this form of displacement, on account of enlargement of the lungs ; or it is greatly weakened, and situated in the sixth left space, or lower, to the left of its normal position. A new area of systolic pulsation is perceptible in the epigastrium, generally well marked, and connected with the right ventricle. The praecordial dulness is usually completely replaced by pulmonary resonance ; or, more rarely, confused by the dulness of some form of mediastinal tumour. The cardiac sounds are feeble, or absent, over their usual seat ; and are heard, instead, over the epigastric triangle and the lower left cartilages. 4. Displacement Upwards.— The many ab- dominal causes of this form have been already mentioned, as well as the symptoms due to compression of the heart which characterise it when so produced. The heart, as a whole, is moved upwards in the chest, and at the same time the apex passes more or less towards the left, and the right ventricle may become some- what more exposed anteriorly. The cardiac impulse is elevated until it is found on the nipple-level, or even higher; or it is lost, along with the area of percussion-dul- ness, behind the inferior border of the left lung. The sounds of the heart are transposed upwards and weakened. The displacement of the cardiac apex towards the left axilla in pericardial effu- sion is described elsewhere, < See Peeicabdioi, Diseases of. o. Displacement Backwards. — This variety of displacement of the heart is very uncommon ; and when it does occur, is generally referable either to abundant pericardial effusion, or to backward curvature of the spine (kyphosis) in the dorsal region. A certain amount of back- ward displacement is, however, not so rare in extensive excavation of the left lung, in associa- tion with other forms of dislocation. The base of the heart is then the part most transposed into the left paraspioal groove, and the apex is tilted somewhat forwards as well as elevated. HEART, DISPLACEMENTS OF; AND FATTY DEGENERATION OF. 693 The physical signs of back-ward displacement are those of the cause of the malposition rather than any that can be referred to the condition itself. 6. Displacement Forwards. — Displacement forwards is also very rare, although it is fre- quently simulated by bulging of the prsecordium in enlargement of the heart. The chief cause of it is the presence of a tumour in the medias- tinum — especially aneurism of the descending aorta, or enlargement of the bronchial glands. The amount of actual transposition is neces- sarily exceedingly small, the anterior border of the lungs being compressed or pushed aside, but the further progress of the heart forwards being arrested by the anterior wall of the chest. The physical signs are, therefore— increase of the area and strength of pulsation and of per- cussion-dulness over the prsecordium ; bulging of the same in young subjects ; and increased loud- ness of the cardiac sounds in that situation. 7. Complex Displacements. — Ithas already been indicated that displacements of the heart, strictly speaking, occur almost without excep- tion m more than one of the directions described, - and they may all, therefore, be said to be gene- rally more or less complex. Dislocation at once upwards and towards either side is especially common, as the result of contracting processes in the apex of the lung. Diagnosis. — After the full account that has been given of the several forms of displacement of the heart, there ought to be no great difficulty in diagnosing them from each other, as well as from the conditions which simulate them. These must be carefully remembered. The chief of these are: — (1) physiological displacements, already referred to ; (2) cardiac enlargement, especially when attended with bulging of the prsecordium ; (3) pulsating tumours of the chest and abdomen, particularly aneurism of the aorta ; (1) adhesion of the pericardium ; and (5) atrophy of the lungs from any cause. Treatment.- — The rational treatment of dis- placement of the heart would he to remove its cause ; but when the cause is of the nature of traction, treatment is very rarely called for, even if it were possible. In displacement due to pres- sure, on the contrary, treatment is often urgently indicated, perfectly practicable, and highly suc- cessful. The unpleasant sensation of pulsation complained of in some instances of displace- ment — for example, in phthisis — is frequently relieved by an assurance on the part of the physi- cian that the palpitation is of no import ; and by the application of a simple plaster, containing iron, belladonna, or opium. J. Mitciieix Bruce. HEART, Embolism of. Sec Heart, T hrom- bosis of. HEART, Fatty Degeneration of. — Stnon. ; Fr .Degenercscencegraisseiiscd.it Cceur ; Grev.Fettige Metamorphose des Herzens. Definition. — The process by which the mus- cular fibres of the heart are converted into a gra- nular fatty matter. The term is also used to express the state of the heart in which this chango has been accomplished. -Etiology and Pathology. — The process by which the protein elements of animal bodies, in- 38 eluding muscular fibre, are converted into gra nular fatty matter, as well as the circumstances under which this change occurs, have been al- ready so fully discussed under the head of Fatty Degeneration, that it is unnecessary to repeat what will be found there. It will suffice to sav here, that when the process of nutrition is inter- fered with in the tissue of the heart, this change takes place, and is best illustrated in the local ot limited form of disease, which occurs when the coronary circulation is obstructed. This is seen in cases of thickening or calcification of one of the trunks, or of the branches of these vessels, and is more marked by reason of the fact that the coronary arteries do not freely communicate with each other. The fatty change is found to occur in the more diffused or general form in those diseases in which the vital powers are lowered, as in certain forms of chronic eaclieotie disease, in poisoning by phosphorus, or after loss of blood. In certain other conditions, such as acute specific fevers, the tissue of the heart becomes softened, and under the microscope presents a granular appearance, which is be- lieved by some pathologists to be an incipient stage of fatty degeneration. We might also refer to the more or less diffused form of fatty de- generation which takes place in cases of enlarged heart, the result, not, as Rokitansky supposed, of a disturbance of the nervous functions, but of the fact that these enlarged hearts require a larger supply of the materials for nutrition than can be furnished to them by the coronary arte- ries, which in such cases are frequently them- selves diseased, both at their origin and in their course. Lastly, fatty degeneration of the heart is found to occur after delivery in some instances, in which the organ had become en- larged during pregnancy. Certain other circumstances connected with the origin of the disease require to be mentioned here. In reference to sex, the disease is more frequent in males, in the proportion of nearh- two to one. With respect to age, in his original memoir on this subject, the writer found that nearly one-half of all the cases observed were over sixty years of age. In the late Dr. Hayden's valuable work on Diseases of the Heart, the pro- portion stated of cases under sixty years of age shows a larger number of young persons whose hearts have undergone this change as a result of wasting disease — a result which is evidently due to the greater care with which microscopical examinations of the heart have been made in recent times. As regards social position, of thirty-three cases formerly noted by the writer, the subjects of the disease are stated to have belonged to the higher ranks in nine cases ; to the middle class in eight cases; and to the lower class in sixteen cases. This enumeration con- trasts with the proportion in which fatty growth appears on the heart ; seven of fifteen cases belonging to the first class ; six to the second ; and only two to the third. Fatty degeneration and fatty growth on the heart are thus seen to occur under very different conditions. Tho lat- ter is the result of the accumulation in the blood of the elements of fat; the former is the result of decay and disintegration. Anatomical Characters. — In fatty degenera- HEART, FATTY DEGENERATION OF. 594 iion the heart is found to be enlarged in about two-thirds of the cases recorded both by Dr. tlayden and the present writer. It is not imfre- ■puently simply dilated. To find a fat heart of an average size, or even occasionally below it, is not a very exceptional occurrence. The colour of the heart’s substance is pale, sometimes as pale as ‘ a dead leaf,’ but more generally it is of a yellowish- brown or buff, or muddy pink colour. This discolouration is generally seen in spots or patches ; and though the whole heart may be pale, the spots being still paler when seen beneath the endocardium, give the tissue a mottled look. The same appearance may be seen beneath the pericardium, and in the sub- stance of the heart. With the progress of disease the spots run together, giving portions of the walls a uniform buff-coloured character, whilst the rest of the organ retains its ordinary aspect. The consistence also varies from that of mere flabbiness or softness, to such a condi- tion as permits of the tissue being torn like wet brown paper. The organ then feels like a piece of wet chamois leather, or a wet glove. In other CHses the heart retains in appearance much of its ordinary solidity, but the tissue nreaks down on pressure, as does a lung con- solidated by pneumonia. This is a state which more frequently occurs in hypertrophied hearts. In addition to these changes in size, colour, and consistence, others have to be noted. The fibrous character of the heart’s structure, even to the naked eye, disappears ; in some cases the tissue resembles that of a fatty or boiled liver. In other instances the cut or torn surface has a granular appearance, notunlike that of the lung m an early stage of grey hepatization. These different appearances may in a great measure he duo to the greater or less fluidity of the oily mat- ter present, as well as to the extent and degree to which the disease has advanced. Further varieties in appearance may he caused by the presence of a greater or less quantity of blood, or of its colouring matter, in the heart’s texture or in its cavities, by which the lining membrane may in the latter case he dyed of a deep purple colour. Microscopical characters . — The microscopical characters of this disease will be found so fully described under the head Fatty Degeneration, that it is needless here to do more than refer me reader to that article. All parts of the heart’s fibres are subject to fatty degeneration, but not equally so. It is most frequently found in the left ventricle ; next in the right ventricle; then in the right auricle; and least frequently in the left auricle. It is generally more evident in the column® carnc®, and in the inner layers of the muscular walls, than elsewhere. Effects. — Of the structural lesions occurring in the heart when the seat of fatty change, one of the most important is rupture, which was found in twenty-five out of sixty-eight cases of fatty or softened heart, the histories of which were col- lected by the writer. Partial rupture leading to the formation of what has been called cardiac apoplexy, is another condition which has been described. The clot in such cases, if it lose its colour, may produce an appearance like an en- cysted abscess ; and a consecutive false aneurism of the walls of the heart may be thus formed, as well as by simple yielding of a portion of the 6cftened cardiac wall. Tho involvement of the column® carne® may lead to imperfect action of the valves. Valvular disease itself is not often present in connection with fatty heart. Dr. Henry Kennedy, in a recent interesting work on this subject, points out that the valves are affected only about once in nine cases ; and he further shows that, when the valves are affected, it is chiefly the aortic valves that are involved. Of the effects of fatty degeneration upon the functions of the heart, the most prominent are those which exhibit the deficient powers of the organ. Coma, preceded or not by giddiness, has been described by several winters in connection with feeble powers of the circulation. Dr. Adams of Dublin has mentioned as many as twenty attacks in one of his cases of fat heart ; and the writer has noticed the occurrence of evenmore fre- quent seizures. Syncope — ‘cardiac syncope’— is a term very frequently used by the older writers ; and it is a term which may be well applied to the condition of faintness which is frequently found in connection with fatty heart. In some cases the feeling of syncope amounts to nothing more than a simple sense of faintness — that the patient must fall if ho do not lay hold of some- thing. In other instances this symptom is accompanied by a feeling of impending death; and such patients do frequently die. In the cases collected by the writer, thirteen out of thirty-three died of what he proposed to call syncope Icthalis, or ‘ fatal syucope ; ’ and it would be possible, no doubt, now greatly to extend the number of eases that have proved fatal in this way. Death may result in such cases from cardiac failure, as indicated by a flabby heart containing blood in tho left ventricle; or, where there is a less amount of degeneration, by irregular action or spasm, with emptiness of the ventricles. Pain is another effect. It may occur inde- pendently of, or he associated with syncope — syncope anginosa. See Angina Pectoris. The respiration is considerably affected, m all cases of fatty degeneration, either as simple breathlessness, especially on exertion, or in that peculiar form which has been called Cheyn* Stokes respiration. Symptoms and Diagnosis. — There is no doubt Jits. ££. Fatty Degeneration of the Heart, x 400 diam. HEART, FATTY DEGENERATION OF. that many cases occur in which fatty degenera- tion is found in the heart after death, where its presence during life had not been suspected. This is more especially the case in those examples of exhausting disease in which the heart parti- cipates. In such cases the requirements of the system may not be out of proportion to the powers of the heart; and death may come on slowly and insidiously without, our attention being attracted to the state of this organ. In a second class of cases, in which the heart suffers from some local cause, as, for example, from disease of the coronary arteries, whilst the sys- tem generally maintains its powers more or less fully, the balance between the system and the heart is lost, and diagnostic evidence of the change that has occurred in the central organ, sufficiently clear and pointed, may be traced without difficulty. Amongst the symptoms of the disease we then observe various modifica- tions of the phenomena of drowsiness and coma ; faintness and syncope; disordered respiration; pain in the region of the heart ; and disturbed pulsation. For example, the patient complains in the earlier stages of being easily exhausted, particxdarly by mounting heights; he feels, he says, faint on reaching the top of the stairs; though not giddy, he feels ho must fall ; though not breathless or fainting, lie sighs deeply and seeks the air. Any unusual excitement, a heated jr a close atmosphere, produces the like effects. At the same time there is often experienced an uncomfortable feeling of choking or fulness in .he chest. In the intervals the individual may bo fairly well. As the disease advances, the attacks become more frequent and severe, and often disturb and distress the patient at night. The temper is observed to become irritable. The expression of the features frequently appears anxious, and the countenance sallow. Copious perspiration from very slight causes, sometimes coldness of the extremities and swelling of the ankles, appear amongst the incidents of the disease. The pulse is generally affected ; but how must no doubt depend in a great measure upon the part of the heart affected, and on the extent and degree of the disease. In the writer's opinion, iutermittenee and irregularity are the more frequent alterations ; weakness is another ; and slowness — often remarkable — is a third. Quick- ness of the pulse, more especially when it in- creases with age, has been dwelt upon by Dr. Kennedy as a symptom deserving of attention in the diagnosis of fatty degeneration. The irregularity may be constant. The writer has seen it present during the slight disturbances above described ; and he has seen it disappear altogether when the patient was in tolerable health, to return as the effect of any depress- ing cause, the more marked because that cause may be far too inefficient to affect a sound heart. The breathing is always more or less affected in cases of fatty degeneration of the heart. In some instances it is represented as a sense of choking or suffocation ; the person feels as if he were breathing through a sponge. The difficulty in some instances is so slight as scarcely to be re- garded; in others so severe that the smallest effort, particularly in mounting ascents, is most 595 painful. A peculiarity sometimes observed is that the ascent of a gentle height is distressing, while the person can read aloucl without incon- venience. A character of the respiration first described by Dr. Cheyne of Dublin, and after- wards by Dr. Stokes, is by some regarded as diagnostic of fatty degeneration of the heart. It is thus described by Dr. Stokes : ‘ A form cf respiratory distress peculiar to this affection (fatty degeneration of the heart), consisting of a period of apparently perfect apnoea, succeeded by feeble and short inspirations, which gradually increase in strength and depth until the respi- ratory act is carried to the highest pitch of which it seems capable, when the respirations, pursuing a descending scale, regularly diminish until the commencement of another apnceal period. Dr. Hayden, in writing on this sub- ject, mentions a case in which during the period of apnoea there was no change in the heart’s action ; a second case in which the action of the heart and the pulse underwent no change during the period of apnoea and dyspnoea ; whilst in a third case, during the paroxysm of dyspnoea, the heart’s action was remarkably irregular. It should be stated with regard to this symp- tom that, though frequently present, it is by no means characteristic of fatty degeneration only. It is by some said to be more frequently asso- ciated with disease of the aorta. Various ex- planations of this phenomenon have been given. Dr. Little (Dublin Journal of Med. Sci., No. 91) believes that it is due to derangement of the dynamic adjustment between the right and left ventricles of the heart. Dr. Hayden (op. cit.) connects it with atheromatous or calcareous change with dilatation of the arch of the aorta, involving loss of elasticity in its walls. The late Professor Laycoek thought (Dublin Journal of Med. Sci., July 1873) that this phenomenon de- pended upon ‘ sentient palsy of the respiratory centre,’ or ‘ a paresis of reflex sensibility of the mucous membrane of the lung.’ See Respira- tion, Disorders of. Another phenomenon, said to be diagnostic of fatty degeneration of the heart, is arcus senilis — a pearly crescentic opacity of the upper and lower portions of the circumference of the cornea, which must be distinguished from the opaque annulus which occasionally surrounds the entire cornea. Mr. Canton was the first to describe the nature of this change as fatty degeneration. It is quite true that when fatty degeneration is present in the cornea it may possibly bo found in the muscular fibres of the heart and in the arteries. Still it by no means follows that the degeneration must exist in any particular part or organ ; and therefore this appearance in the cornea cannot be regarded as at all pathognomonic of fatty degeneration of the heart. As the disease progresses still farther, the symptoms become more marked ; the various effects of feeble and languid circulation show themselves; angina may perhaps become fully developed ; or the patient may be cut off suddenly by one or other of the effects connected either immediately or remotely with the lesion itself. Of eighty-three cases of ‘ fatty disease ’ of the heart collected by the writer, sixty-eight died suddenly. SO 6 HEART, FATTY DEGENERATION Physical Signs. — The physical signs that characterise fatty disease are not many. They are — a feeble impulse of the heart, proportionate to the extent and the degree of the disease ; a feeble muffled first sound, under like conditions, sometimes scarcely audible. When the heart is enlarged, the impulse ■will be extended, and so likewise will be the dulness. A murmur may be present, as suggested by Rokitansky, from de- generation of the column® carnese. The second sound is often distinct and clearly accentuated, as compared with the first. Diagnosis. — The diagnosis of the presence of this degenerative change in the absence of any alteration in the size of the heart must be founded upon a consideration of the symptoms and physical signs above described. When the heart is hypertrophied or dilated only, the pre- sence of fatty degeneration is more difficult of diagnosis by its physical signs. We must then seek to trace how far the usually well-marked signs of hypertrophy of the organ are modified by those wo have described as being present in, and characteristic of, fatty degeneration. The same observations will apply to dilatation or thinning of the walls. This special condition has its own well-marked phenomena, which will be found described elsewhere {sec Heart, Dila- tation of). These signs will be more or less modified in proportion to the degree and extent of any fatty change that may be present. Progress, Duration, and Terminations. — It is impossible to determine the duration of a disease the date of origin of which is in most cases very obscure. Still there are grounds for believing that persons with a certain amount of degenerated tissues in their hearts have gone on living during periods extending over thirty or forty years. On the other hand, death has oc- curred from fatty degeneration of the heart, deter- mined -post mortem, in which the entire absence of symptoms until a few months before the fatal event justified the opinion that the duration of the disease had not much exceeded the period just mentioned. AVhen fatty degeneration occurs as the result of phosphorus-poisoning, or of certain exhausting diseases, the progress of the change, which can be determined, is rapid. In such cases, the morbid process is not confined to the heart alone, and therefore when death occurs, it cannot well be attributed solely to the condi- tion of this organ. Death from fatty disease of the heart is fre- quently sudden, the proportion being as five to one compared with other modes of death, this disease existing to a noticeable extent. The immediate causes of death are those which have been already alluded to when treating of the effects of the disease, namely, syncope, coma, and rupture of the heart; the first and last of these contributing nearly the whole number of those that die suddenly. Such facts indicate very strongly the necessity of avoiding any mental excitement or physical exertion which might lead to these results. Here it might also be well to remember, with reference to the ad- ministration of anaesthethics, that chloroform has an especially depressing effect on the heart's action, and that when the heart’s power is enfeebled by the disease which we are here describing, a very OF; AND FATTY GROWTH ON. small dose of this anaesthetic, which would have little or no effect on a healthy heart, may prove fatal. This opinion was first expressed by the writer many years ago, and it has been fully con- firmed by numerous cases of death which have oc- curred during the administration of chloroform. Prognosis and Treatment. — The prognosis of fatty degeneration of the heart will depend in a great measure upon a knowledge of its causi and its extent. In cases where the disease origi nates in constitutional causes, such as in phos- phorus-poisoning, and in cases where it is of the nature of involution — for example, after parturi- tion — there is good ground for believing that, tLe cause being removed, the effect will cease, and a fairly healthy condition of the organ be restored. On the other hand when the coronary arteries are obstructed, and degeneration is thereby set up, or when nutrition generally is impaired, and all the tissues are more or less undergoing this change, the prognosis must be in the highest degree unfavourable, more especially so if in the latter case the patient cannot be placed in a condition by which this degenerative tendency may be counteracted. The treatment consists in the adoption of all the measures calculated to improve the general health — such as pure fresh air, wholesome food, and temperance, together with moderate exercise, either carriage, riding, or walking, if it can be accomplished without causing pain or breathlessness. Everything which may tend to lay stress on the heart’s action, such 3S walking uphill or making efforts, or mental excitement, should be avoided. With reference to drugs, such tonics as can be best tolerated by the patient might be given. We may mention iron — especially dialysed iron — ■ phosphorus in small doses, and strychnia. Special attention must be paid to the condition of the excretory organs, such as the kidneys and liver, which are liable to become congested when the cardiac action is feeble. Lastly, it may he said that in cases of syncope, in addition to the administration of the usual stimulants, galva- nism applied from the back of the neck to the prsecordium by the interrupted current, has in a few instances been known by the writer to be useful. For further information on the subject of Fatty Degeneration of the Heart the reader may consult the complete and very valuable article by Dr. Hayden in his work on Diseases of the Heart; and a memoir by the writer in the 3Srd volume of the Mcdico-Chimrgicul Transactions (1850). R. Quain, M.D. HEART, Fatty Growth on. — Synon. : Fr. Hypertrophic graisscusc du Coeur\ Ger. Fettioe Infiltration des Herzens. Definition. — The growth of fat on the surface and in the substance of the heart, in quantity sufficient, to interfere with its functions, and thus to constitute a disease. FEtiology. — In our inquiries concerning the cause of this condition, we are met with the problem, still to be solved, Why are certain individuals, and certain parts of the body, more prone to the formation of fat than other persons and other parts ? We can ascertain with some degree of certainty the circumstances which pr<* mote the formation of fat in general ; and obsei- HEART, FATTY GROWTH OH. 597 rations collected by the writer and others show that when fat is thus formed throughout the system, the heart is likely to partake largely of the accumulation. We may accordingly refer to the article Obesity, in which the causes of fatty growth in general will be found discussed. Of fifteen cases of extreme fatty growth on the heart collected by the writer, eleven occurred in very fat individuals, and only one in a person who was described as being ‘ thin.’ Age seems to exert a decided influence upon the formation of fat upon the heart. It is very scanty in infancy, and is rarely present in any quantity before the thirtieth year. Corvisart, however, quotes from Hercking the case of a child whose heart seemed wanting, so great was the quantity of fat in which it was embedded. Of the fifteen cases just referred to, thirteen were above fifty years, and one only under that age. Males, according to the same data, are more liable to accumula- tion of fat on the heart than females, the re- spective numbers being as twelve to three. Anatomical and Pathological Characters. A certain amount of fat-tissue, which is not inconsistent with health, occupies a definite position in the structure of the heart. It is seen most abundantly in the groove between the auricles and the ventricles; and as the distribu- tion of this tissue bears a relation here, as in other parts, to that of the blood-vessels, it first appears in the course of the primary branches of the coronary arteries; then in the course of the secondary branches — that is, in the groove over the septum, which marks the boundary between the ventricles; and, lastly, it follows the distri- bution of the small lateral branches. These branches are more superficial over the right ven- tricle than over the left ; hence the former is found always and more abundantly covered with fat. A fringe of fat is also found at the apex of the heart ; and frequently around the margins of the auricles. A mass of superabundant fat will of itself be sufficient to press on and em- barrass the action of the heart ; but fat rarely exists in this abundance on the surface of the organ without insinuating itself between, and encroaching on, the muscular fibres. In this way the muscular portions of the walls of the organ become thinner and thinner, until the columnae carneie may appear to arise from a mass of fat. This state constitutes what was once regarded as fatty degeneration of the heart, and which has also been called ‘fatty metamor- phosis;’ but it is in many cases nothing more in reality than a simple hypertrophy of fat. In parts of hearts which are less affected, that is, where fat is not very abundant, simple striae of yellow tis- sue will be observed lying amongst the mus- cular fibres — an appearance often found in the auricles. Microscopical appearances. — 'When a portion of heart suffering from fatty growth in a high degree is examined with the microscope, it will be found that where the growth is most ad- vanced, that is, towards the external surface, very few muscular fibres can be seen, and that the very wide intervals between them are occu- pied by fat-cells. (See Fig. 23.) Proceeding in- wards, themuscular fibres become more evident; the fat-cells become fewer ; and, finally, we reach the muscular fibres beneath the endocardium, with a few fat-cells lying here and there amongst them. It is worthy of note that the fibres, though overwhelmed by fat, may still retain their orga- nisation. In all cases, however, the course and direction of the fibres are more or less modified and distorted. The fact that the fibres still exist, though concealed, affords an explanation of Fso. 23. Fatty growth in the substance o£ the Heart, x 400 diam. the persistence of the heart’s action in those in- stances in which the muscular walls appear to a greater or less extent replaced by fat. It might also be mentioned that small masses of fatty tissue sometimes appear beneath the endocar- dium, varying in size from that of a pin’s head to that of a pea. The writer has seen these little fatty tumours in cases where . there was a con- siderable, but not an excessive, amount of fat upon the surface of the heart. Effects. — The fat accumulated on the heart and in its substance, may be supposed to act mechanically; and by its pressure upon the mus cular fibres, on the nerves, and on the blood- vessels, to impede the function of the organ, embarrass its nutrition, and produce those effects which may be briefly enumerated as — a languid and feeble condition of the circulation, with a sense of uneasiness and oppression in the chest ; embarrassment and distress in breathing, drow- siness, even coma; syncope, perhaps angina pec- toris, it may be death. Rupture of the heart sometimes results. Such an enumeration of evils, in which there is no evidence of any other lesion of the heart’s texture, save an accumulation of fat , would suffice to render this condition a source of very grave import, but we cannot always be quite clear on the subject, because in the par- ticular cases quoted we cannot be certain that some degeneration of the muscular fibres did not co-exist. It would be well, therefore, not to dwell too much on such effects as proceeding from and dependent on fatty growth alone. Diagnosis. — The presence of an excessive de- posit of fat about the heart must, in a great measure, be a matter of inference during life. Where one or more of the effects mentioned above as having been noticed in cases of this kind, are present ; when the pulse is small and weak; when the first sound of the heart is ■398 HEART, FATTY GEOWTH OH. feeble, and the impulse weak ; when the extent of dulness on percussion is increased; and when these phenomena occur in a fat person, it may be inferred that the heart is too fat. 1 But, on the other hand, it must not be overlooked that these symptoms and signs may be found in cases of fatty degeneration of the walls of the heart, in cases where the amoimt of fat-tissue is but moderate. Hay, more, as already stated, both conditions are often present in the same heart, thus rendering distinctive diagnosis im- possible. It is said that the presence of water in the pericardium may be confounded with the presence of fat upon the heart ; but the history and general features of the case in the former condition should be sufficient to prevent all difficulty in the diagnosis. See Pericardium, Diseases of. Treatment. — The treatment of fatty accumu- lation on the heart is so intimately associated with the subject of the formation of fat in ge- neral, that this point can be discussed with more advantage in its wider relations (see Obesity). Whilst the treatment directed to this point is being carried out, we can do little more for the heart itself than aim at giving strength to the portion of its texture still available for duty — by tonics, steel, quinine, phosphorus, &c. ; se- condly, by lightening as far as possible the work which the heart has to do ; and thirdly, by at- tending to the excreting organs, so as to prevent congestion there, and consequently embarrass- ment to the weak heart. R. Quain, M.D. HEART, Fibroid Disease of. — Synon. : Chronic Myocarditis. Definition. — A morbid condition in which the muscular fibres of a portion of the walls of the heart are replaced by fibroid tissue. .ZEtiology. — Fibroid disease of the heart is met with most frequently in middle-aged male subjects. The disease is supposed to be occa- sionally but an extension between the muscu- lar bundles of a chronic process that has com- menced with endocarditis or pericarditis. The cause of this, which is generally rheumatism, is then regarded as the cause of the fibroid growth ; but in reality it is more probable that in such cases the serous inflammation is the result, and not the cause, of the fibroid change. Fibrosis is sometimesthe consequence of acute in- terstitial myocarditis. In a considerable number of cases of fibroid disease, and in most of the cases of so-called ‘ fibrinous deposit,’ the change is pro- bably syphilitic in its nature. In other instances it appears to be senile, and to be associated with degenerative changes in the vessels, or 1 Dr. Henry Kennedy, of Dublin, in a recently pub- lished special monograph on Fatty Heart, states that the points upon which the diagnosis of fatty growth on the heart mainly turn are the following: — ‘First, a large full pulse, beating at the natural standard of fre- quency ; secondly, evidence derived from percussion of the heart's dulness being more extended than natural ; thirdly, the possible presence of a soft systolic murmur over the aortic orifice, occupying the first sound of the heart only, and leaving the second normal ; and, lastly, the condition of the individual as to his being fat or otherwise ’ (p. 30). The present writer hesitates to agree with Dr. Kennedy as to the condition of the pulse gene- rally, and certainly this description will not apply in the cases of those persons of small frame, noth small arteries, who often become obese and present symptoms of fat- hcart after the middle period of life. HEART, FIBROID DISEASE OF. chronic disease of the kidneys. Increase of fibrous tissue in the myocardium may also he the result of prolonged moderate congestion of tho coronary veins. Very frequently no evident cause of the disease can be discovered. Anatomical Characters. — Our knowledge of the pathology of this disease is in a great mea- sure due to the remarkable number of cases that havo been described in the Transactions of the Pathological Society, the first speeimi , of which was presented by Dr. Qnain in the year 1850. Fibroid disease of the heart occurs most frequently in the walls of the ventricles. It is met with under several different forms. In rare instances, which are best described as cases of connective-tissue hypertrophy of the heart, there is an uniform increase of fibrous tissue between the muscular fibres throughout the whole organ {see Heart, Connective-Tissue Hypertrophy of). In other instances, the disease appears as a local thickening of the connective tissue underneath an opacity of the endocardium or of the pericar- dium, whence septa run outwards or inwards between the muscular bundles. Most frequently, however, it presents the appearance of a fibroid patch, generally situated near the apex of the heart, replacing the muscular substance through- out its whole thickness, and over a greater or less extent of surface, even to as much as a consider- able portion of one ventricle, and consisting of dense, firm, inelastic, greyish-white fibrous tissue. Smaller patches, nodules, scars and streaks may be found in the deeper parts of the myocar- dium. The apices of the papillary muscles, again, may become fibroid, especially in chronic valvular disease. Polypoid tumours, composed of fibrous tissue, have been met with ou the endocardial surface of the heart, that is, pro- jecting into one of the cavities ; more especially into the left auricle. Possibly the detachment of such a polypus may be one mode of origin of the ‘fibrinous balls’ or ‘concretions’ occasion- ally found lying free in the auricular cavities. Fibroid and ‘ fibrinous ’ formations due to syphilis are described in the article Heart, Syphilitic Disease of. Microscopically, fibroid disease of the myo- cardium presents a concomitant increase of the connective-tissue elements, and decrease by atrophy of the muscular fibres. Occasionally, in an early stage, as well as at the margins of the older patches, round and spindle-shaped cells and bundles of young fibrillae have been observed. The latter increase in size and in number, press upon the intervening muscular fibres, and finally unite and form bands or patches of ordinary fibroid tissue. Meanwhile, the muscular fibres gradually become attenuated, granular, or fatty ; and at last they disappear by absorption, or patches of them may be imprisoned within the fibroid growth. The effects upon the heart of fibroid changes in its walls vary with their situation and ex- tent. If a large portion of the wall of cno cavity is fibrotie, irregular patchy dilatation of the chamber ensues. Localised fibrosis, espe- cially’- if it commence beneath the endocardium, gives rise to aneurism of the heart, by the yield- ing of the diseased area to the intra-ventricu- lar pressure (see Heart, Aneurism of). Deeper HEART. FIBROID DISEASE OF: AND FUNCTIONAL DISORDERS OF. 59!} or more limited patches or lines of cirrhosis cause irregularity or puckering of the cardiac walls; and valvular insufficiency may result from this, or from fibrosis and functional dis- turbance of the papillary muscles. Lastly, fibroid disease occasionally involves the conus arteriosus in an annular form, giving rise to con- striction and the formation of so-called ‘ cardiac stenosis.’ Symptoms. — The symptoms of fibroid disoase of the heart vary greatly in different instances, according to the extent, situation, and other conditions of the growth. When the fibrosis is very limited, few symptoms can be expected to be present. In the majority of cases in which a considerable portion of the cardiac wall has been found diseased, the symptoms have been described as those of ‘ordinary heart-disease’; namely, dyspnoea on exertion; praeeordial pain or distress; occasional palpitation; small, weak, or irregular pulse; dropsy; and visceral complications. Asa rule, no endocardial murmur has been present ; but fibrosis of the papillary muscles may some- times give rise to the signs of incompetence of the auriculo-ventricular valves. The symptoms of cardiac aneurism and of syphilitic disease of the heart, as well as those of connective-tissue hypertrophy, are elsewhere described. Course ax’d Terminations. — The course of fibroid disoase of the heart is generally' chronic, although urgent symptoms are sometimes ob- served a short time only before death. At- tacks of ?oain, palpitation, and dyspnoea may occur and subside long previous to the last fatal illness. The development of cardiac aneu- rism, and its possible terminations, will modify the course of the disease. Sudden death may occur, with or without previous cardiac symp- toms, and must bo regarded as a special mode of termination of fibroid disease of the heart. Otherwise the cases generally end by pulmonary complications, dropsy, and exhaustion. Diagnosis. — Fibroid disease of the myocar- dium has to be diagnosed from chronic valvular disease; from enlargement due to extracardiae causes, such as renal disease, gout, or emphy- sema ; and from fatty degeneration. Under all circumstances, an accurate diagnosis is extremely difficult, if not impossible. The presence of a murmur does not exclude fibrosis, as the valves may become secondarily involved ; and valvular disease is not always att^ided by a murmur. The other cardiac lesions mentioned must be ex- cluded in the ordinary way. Prognosis. — When fibroid disease of tbe heart is attended with symptoms sufficient to establish a diagnosis, the prognosis is unfavourable as regards life, although it may not be imme- diately so. Treatment. — This consists in relieving and supporting the heart by every possible means, especially by rest and cardiac stimulants, such as alcohol and ether. Iodide of potassium may bo given with benefit in some cases, especially if there be a history of syphilis. Digitalis will have to he administered with great circum- spection. J. Mitchell Bruce. HEART, Functional Disorders of. Definition. —A disturbance in the functions of the heart, with or without pain ; having origin in causes other than inflammation, or struc- tural changes in the heart itself ; and for the most part paroxysmal in character. This definition comprises various disorders in the dynamical functions and sensibility of the heart, from the slightest disturbance of only momentary duration, to urgent symptoms of ccn- siderabie persistence. ^Etiology. — The frequency of the occurrence of functional disorders of the heart, and the similarity of many of the symptoms exhibited t. those met with in organic diseases, as well as the fact that these functional disorders may co- exist with organic disease, thus greatly exagge rating the apparent gravity of the latter, render it important to accurately determine how much of the disturbance may be due to the one or to the other of these causes. To estimate the immediate or proximate cause of functional disturbance of the heart, regard must be bad to its structure ; and how this is nourished, and its motions regulated. For ade- quate and equable dynamical movement, the pri- mary requirement is a healthy development of muscular structure. Weak muscular fibre, apart from degenerations by disease, becomes a pre- disposing cause of feeble and irregular action. But as the regular recurrence of the muscular contraction and expansion must, moreover, be ascribed to the agency of the cardiac ganglia, the vagus nerve, and the nerves and ganglia of the sympathetic system, all nourished and excited by the blood, any abnormal conditions of those have also their effect. Interference with the func- tions of these several nerves may so modify the ac- tion of the heart as to cause deficiencies of power of every variety and extent, giving rise to illustra- tions of abnormal contractility and irritability, which the heart exhibits in common with all other muscles. Bat the heart further possesses the distinguishing feature of rhythmical action. There are cogent grounds for the belief that this is not only due to the intrinsic ganglionic system of nerves ; but, as errors of rhythm are certainly induced by such causes as improper diet, dyspepsia, the presence of worms, consti- pation, injuries or deformities of the chest, and diseases of the lungs, there can be no doubt that ibe heart is also liable to reflex irritation of the pneumogastric and sympathetic nerves. The rhythmical action is also shown by experiment to be dependent on the blood, whether venous or arterial ; for without a supply of blood rhyth- mical action ceases. The healthy action of the heart, and the controlling energy of its nerves, greatly, if not entirely, depend on the supply of healthy blood ; and any failure of the supply, whether in quantity or quality, shows itself by disturbance in the functions of the heart. Moreover, the muscular substance of the heart itself is nourished by the blood circulating in the coronary arteries, and thus becomes sus- ceptible to the quality and condition of the blood so distributed ; hence a blood too rich in fibrin or red globules, and thereby inducing plethora, fre- quently causes over-action of the heart and pal- pitation, whilst in anaemia a deficient amount of blood induces a weak and often excited and irre- gular action. The predisposing causes, in addi HEART, FUNCTIONAL DISORDERS OF. 400 lion to those already named, may, therefore, be classed thus : — ( 1 ) Those conditions aeting through or upon tlio nervous system, such as the general exhaustion of the nervous system, all forms of reflex irritation, venereal excesses, vain longings, purposeless occupations and amusements, pro- tracted mental exercise, abstinence from ade- quate repose, &c. (2) Those conditions acting upon the general blood-supply of the body, and consequently affecting the special blood-supply of the heart, such as the turgid and plethoric states of gross feeders, depraved states caused by bad and deficient diet, and all forms of blood- disorder, as anaemia, gout, scurvy, &c. To these must be added the special temperament and per- sonal peculiarities of the individual, a congenital or superimposed want of vigour, general debility, deformities of the ribs and spinal column, a small weak heart, uterine irritation, hysteria, adynamic fevers, and the special sanitary influences under which the individual is placed. Amongst the immediately exciting causes may be named mental shock or distress ; protracted and unusual physical exertion ; various articles of diet, as tea, coffee, &c. ; tobacco in excess ; many medicines, as aconite and digitalis ; as also prolonged ab- stinence, exposure to cold, and notably blows on the epigastrium. Symptoms. — A paroxysmal attack of a func- tionally increased impulse is often accompanied by a series of nervous sensations — such as a feeling of choking, at times amounting to a true globus hystericus ; flushing of the face,- heat and pain of the head, with a sensation of a whizzing, or rushing upwards of the sounds of the heart ; dimness of vision, with photophobia ; and a ten- dency to syncope, and to clammy perspirations with cold shivering. The voluntary muscles may refuse to act, so that the gait becomes tottering, or the patient grasps adjacent objects to steady himself, yet there is neither paralysis nor ver- tigo. The respiration, though not generally em- barrassed, may become irregular and oppressed, presenting the phenomena of a short inspi- ration with a prolonged expiration ; but if the paroxysms have been induced by a congested 1 state of the right heart from using undue exer- tion, independently of any frequency of cardiac impulse, the breathing may he accelerated and accompanied with dyspnoea, or even apneea, and a short dry cough. Illustrations of this class of symptoms often occur in those of sanguine and nervous temperaments; and maybe the result of violent and too protracted exercise, of emotional excitements, or of the over-indulgence in stimu- lants or food when associated with lives of idle- ness and inactivity. Should the increased im- pulse be associated with rhythmical disturbance, there is for the most part consciousness of the existence of such states, more especially on the first ingress of the attack, so that it be- comes a source of much anxiety and even of terror, inducing the self- conviction of the exist- ence of organic disease. The head-symptoms also become more marked, and associated with local pains and tinnitus aurium ; whilst the breathing is marked by sighing, and often be- comes lessened in frequency. The irregular form of nervous palpitating heart is often asso- ciated also with haemic diseases, and with ner- vous affections, as chorea, masturbation, &c. When such diseases as scurvy or chlorosis exist, the attacks become less paroxysmal and more persistent ; there is more pectoral complication, even to dyspnoea ; the headache is sometimes so bewildering that the mind becomes alarmed with vague apprehensions of danger, which give rise to general restlessness; the integu- ments over the region of the heart, as well as of the face, and even of the extremities, may become puffy and oedematous, especially in cases of ex- treme chlorosis, with enlargement of the thvroid gland and exophthalmos, where the morbid con- ditions inducing these may also possibly cause the irregular palpitation. When functional disorder occurs with a diminished impulse, the general symptoms group themselves under anxiety and lowness of spirits, or actual despondency, with mental and bodily incapacity for exertion ; flatulent dys- pepsia, with cold clammy extremities ; anorexia, or, may be, depraved appetite ; exhaustion, with tendency to faintness ; and, should irregularity of cardiac action be very marked, there may be a sensation of praeeordial pain. Males are more subject to this form of functional disorder than females, and it chiefly occurs in persons having a normally small and feeble heart, or where a state of general nervous debility is super- imposed. When the distinctive feature of functional dis- order is rhythmical error, and this is appreciable to the patient, the special symptom is that of extreme anxiety, even to the fear of impend- ing death ; occasionally a single intermission is so prolonged as to induce the impression that escape has only occurred by a miracle. These alarms often induce a palpitation not belonging to the rhythmical disorder. But if the rhyth- mical error be associated with a deficiency of systolic force, temporary' paralysis of the heart's action or syncope may be induced, and in some extreme cases the functions may be weakened even to extinction. Such forms of disorder occur in those having normal but weak hearts; in the dyspeptic ; in the gouty, especially if an attack is impending ; and in those whose habits and occupations involve exhaustion of the ner- vous system. They are a characteristic of old age, hut may be sympathetically induced in the young; and may be observed in the course of many diseases, such as tuberculosis, rheumatism, liver-affections, or when malignant disease is making its ravages. Prmcordial pain is by no means an unusual symptom accompanying functional affections of the heart ; it may aggravate the urgency of these disorders, yet appears to be little influenced by them. The pain does not march pari passu with the irregularity or strength of the impulse. The pain may be persistent, while the asso- ciated disease may be paroxysmal ; and in this respect it differs from prcecordial anxiety, which is essentially paroxysmal, and acquires urgency from the symptoms with which it may be asso- ciated. Physical Signs. — The physical signs referring to the cardiac action may be conveniently sepa- rated iuto the following groups, although in practice they will be found mingled or associated HEART. FUNCTIONAL DISORDERS OF. G01 with each other: — (1) Increased or diminished impulse, connected or unconnected -with increased rapidity or rhythmical irregularity ; (2) rhyth- mical disturbance , with intermissions, the im- pulse being normal or diminished ; (,3) increased or diminished frequency, the rhythm and force being normal. (1) The eases in which an increased impulse is the distinctive feature of the heart’s disturb- ance present many varieties, chiefly referable to force and regularity ; but to the simple forms of increased and accelerated impulse there is so very frequently added rhythmical disturbance, that this complication is perhaps the one most usually occurring. The rhythmical disturbance may occur both in the force and the rapidity of the systolic contractions, or it may result in a true intermittence, or occasionally the irregularities thus induced may be so great as to defy definite appreciation, save as a tumultuous whole. On palpation, the impulse, abrupt in stroke, pre- sents the characteristic of a sudden bound, now strong, now failing, sometimes so rapid as to com- municate the impression of a fremitus or agita- tion, then a pause, or true intermittence followed by hurry, or more evident irregularity. On auscultation, the sounds are more difficult of appreciation than in simple palpitation ; they are loud and clear, and sometimes so exaggerated and pronounced as to be audible both in the mammary and epigastric regions. But whether the exaggerations of sound and impulsebe more or less, they w : ll be found to act in unison with each other ; the impulse and sounds increase together and diminish together. When there is an un- usual amount of irregular functional excitement in systole, there may be occasionally heard, as a passing not permanent occurrence, a reduplica- tion of the second sound, very rarely of the first; and usually the first portion of the divided or cleft sound is the most accentuated. This redu- plication, though it may' be met with in active inflammatory diseases, is chiefly the concomi- tant of functional disorders of the nervous heart only, and it rarely or never occurs in chronic diseases of the heart. The pulse is generally sharp and jerking; it does not always beat in unison with the systole of the heart ; if there be plethora, it has a force and fulness not otherwise observable ; and if there exist congestion of the right ventricle, it becomes contracted and dimin- ished in force. In cases where the impulse is diminished in effort, the special characters are somewhat nega- tive ; the impulse and sounds being feeble, but otherwise normal, unless the systole be excited by mental shock or any undue bodily exertion, when irregularity and increase of impulse, with some slight sharpness of the sounds, take place. The first sound may suggest, rather than have, a sharp ringing tone ; while the second is pro- longed. (2) With respect to errors in rhythmical action, separately considered, it must here be noted that the chief and characteristic errors may be classi- fied under the distinct heads of irregularity and intermittence Irregularity may be in the force or in the fr u quency of one or more beats, and presents the many varieties which a want of normal uniformity may suggest ; the minute and particular enumeration of these is rather satisfy- ing to curiosity than instructive. It is sufficient to say that every variety of irregular frequency may occur ; while, with certain beats, force may be increased or diminished. Sometimes there appears to be a kind of order in rhythmical dis- orders, that is, short series of varying irregu- larities may regularly succeed each other; there maybe a fluttering or trembling, or that vibratory or vermicular motion to which the term ‘thrill’ has been given. True intermittence is not so fre- quent as irregularity; but when intermittence does occur, it is generally associated with irre- gularity. These disturbances may be only momentary or of long duration, slight or con- siderable; but, however this may be, their character is determined by the irregularity of the systole, or the prolonging of the period of intermission. The physical examination of this form of func- tional disorder shows no marked peculiarities, excepting those of systolic irregularity. To the ear is revealed irregularity in the recurrence and duration of thesounds, from the slightest appreciable pause to the most rapid and confused trembling, with very manifest alterations in tone and pitch. The sounds generally aro intensified, the first, sound being sometimes heightened to the extent of a sharp knock ; whilst the second, save in intensity, is not materially altered. In extreme cases there may be so much ventricular irregularity as to induce in place of sounds an ill-defined fremitus ; and so much force as to pro- duce a metallic ringing, with a rubbing murmur on the systole. Thus the impulse of the heart, which in health is rarely appreciable, and its friction never, respectively become so to the touch and to the ear ; and the abnormal sounds may exist to such an extent as to entirely obscure the first sound. Occasionally there is met with an appreciable rhythmical disturbance in the pulse, which is not found to exist in the heart — false intermittence. The heart only indicates irregularity of power ; and as there is occasional failure of force in the already weak systolic contractions, the impulse is not communicated to the artery at the wrist. These false intermissions accompanying irregu- larity most frequently occur when the heart is oppressed by flatus in the neighbouring viscera, or is excited by injurious articles of diet, as tea, or by the use of tobacco, &c. The sensation com- municated to the patient is that of a disagreeable flutter or ‘tumbling over’ of the heart, which tends to alarm, although habit may to a certain extent ameliorate the terror. Rhythmical irregularity occasionally appears as a normal condition, having a life-long exist- ence. Some cases are marked by an extension of the pause, with unsteadiness of the systolic impulse ; others by its apparent extinction, so that there exists a rapidity of beats defying all analysis. There is in these cases usually a small weak heart, with systolic impulse devoid of energy. Both these classes of cases present t he remarkable feature of losing much of their dis- tinctive irregularity when under the influence of a febrile attack ; the slow pulse becomes quicker and more steady, the rapid one less frequent and more distinct ; but the feeling is, ne"erthelesa, HEART, FUNCTIONAL DISORDERS OF. 502 not so comfortable as when the heart’s action is in its state of normal irregularity. (3) Functional disorder occasionally assumes the form of either increased or of diminished frequency, while the force and rhythm remain normal. Each of these conditions may be con- genital and proper to the individual, or may be the result of abnormal influences. The func- tionally fast beat is generally induced by other diseases, as fever, diabetes, tuberculosis, &c., and is indicative of injury to normal innervation. The slow and drawling beat is generally met with where the nerve-power is healthy, but the heart itself is weak or fatty ; or there is a pervertod in- nervation under the influence of digitalis, aconite, or injury to the ganglionic system — a blow in the epigastrium offering a familiar example. Inorganic murmurs are frequently heard in functional disorders of the heart, and more especially in those cases of haemic disorder where the systolic impulse is increased, with rhythmical irregularity. These murmurs have the special characters usually attached to such sounds. They are systolic, basic, and chiefly heard in the prsecordial region, with conduc- tion in the course of the great vessels. There is no apex-murmur ; but at the apex, synchro- nously with the murmur, the first sound is clearly defined, with a metallic ringing sound. The tone of these murmurs is musical, cooing, soft, of low pitch ; the seat is in the aortic valves, and, as a rule, they are always accompanied with palpi- tation : this palpitation may be persistent, while the murmurs are not so. It is remarkable how large may be the amounts of blood drained from the system, and the frequency of the discharges, provided there be no diseased condition of the blood itself, without inducing the presence of a murmur. But under these circumstances, though there be no murmur, the first sound is usually flapping in character, and the second ringing in tone. The murmurs in chlorosis and spansemia, and, when they occur, in ichorrhoemia and leukae- mia, have their seat for the most part in thepulmo- nary valves, and are not traceable in the courso of the larger arteries ; they are also generally associated with the venous hum to be heard in the jugular veins. OoxirncATioxs and Sequelae. — The several functional disorders of the heart are often com- plicated with other diseases — many external to the heart, and some of the heart itself. The more prominent of the former are disorders of the nervous system and of the blood. Many of these have been already referred to. For the most part, those associated with a perverted innervation are examples of irritability, and ex- hibit rhythmical disorder, with pain. Haemic diseases induce the simpler forms of palpitation ; anosmia, gout, and dyspepsia induce palpita- tion with rhythmical disorder ; spansemia and chlorosis induce all these disorders, with mur- murs superadded. The diseases of the heart with which functional symptoms of disorder are often found complicated are mainly degenera- tions of the walls, or valvular diseases. In all these eases the amount and urgency of the functional heart-disease is no indication of the urgency of the disease with which it may be complicated. Are there any distinct morbid states or othei sequela traceable to functional disorder of the heart ? This may be a difficult question to answer dogmatically. Doubtless frequent and prolonged attacks of functional disorder are seen to occur without inducing any such. On the other hand, the long continuance of functional disorder is often marked by a depreciation of mental and bodily vigour. More specific organic changes are generally found to be due to some one or other of the diseases with which the functional dis- order has been in its course associated. Diagnosis. — In order to make a correct diag- nosis, the first consideration is to ascertain the entire absence of organic disease; and, if it be present, whether it is adequate to cause the full amount of the symptoms exhibited. Supposing this to have been done, if the agitation of the heart is not only excessive, sudden, and appa- rently increased in strength, even to violence, but has often the features of spasm rather than the calmness of rhythmical order; while the sounds are pari passu increased in sharpness and intensity, and diffused over a larger area than is proper to them ; and the pulse does not partake of the simulated force of the heart — the presence of an excited functional impulse may be assumed. The concurrence of some symp- toms usually associated with organic disease, as dyspnoea or even apncea and oedema, may, as has been shown, be due to the presence of chlorosis. So also where there is a deficient impulse, if the heart have its normal position and dimensions ; if the sounds though weak be natural in tone and quality, in the absence of any abnormal physical disease, it maybe con- cluded the cause is functional only. The same may be said of rhythmical irregularities. "When any of these symptoms are associated with haemic murmurs, the character of the murmur, its seat, and its persistency must be considered in connection with the absence or the presence of haemic diseases. The symptoms of each of these several forms of functional disorder have been so fully described that there is no need to repeat them here. It must, however, be always borne in mind that the absence of the physical signs of disease is not always conclusive of there being no structural lesion, for there may be lesions, and important ones too. that do not yield evidence of their existence. The occurrence of the secondary changes, the immediate result of various congestions, is often an indication that the heart-symptoms are due to the presence of organic disease ; still it is not. always so. f r congestions of the lungs and liver, and cedenrr may be the consequence of spansemia or ot other morbid conditions of the blood. Hence, when these are present, the symptoms exhibited by a disordered heart may not be due to struc- tural disease ; and the same may be said of the effects of muscular exercise and of position, for either or both of these may distress if there be present any anaemic condition or an intercostal neuralgia. Nor, on the other hand, does the occasional subsidence of urgent symptoms, so frequently the case in functional disorder, ab- solutely affirm the conclusion that there is no organic disease ; for occasionally in the latter the normal rhythm and force of the heart roa* HEART, FUNCTIONAL DISORDERS OF. Gu3 reassert themselves; but then in these cases there remain the other characteristics of the organic affection. Frequent examination and an accomplished experience will generally lead to a just diagnosis. Prognosis.— -The prognosis of functional dis- orders of the heart, for the most part, is favour- able. Where there are baneful constitutional tendencies, or complications with other diseases, the prognosis must not, however, be always so considered. In the leucophlegmatic temperament the paroxysms may be severe and abiding, and generally distressing to the nervous system. If the symptoms be so urgent as to distend the right heart, the liver may become loaded, and dropsy may ensue. In this temperament mental shocks may induce palpitation, irregularity, and syncope, whence may ensue not only permanent heart -affection and eventually disease, but even immediate death. When functional disorder is the concomitant of scurvy or anaemia, the prog- nosis is not always favourable. Still in the young and middle-aged there is good chance of ultimate recovery; for if these diseases be sub- dued the functional disorder subsides. When occurring in the aged, or in those having a con- stitutional tendency to hypochondriasis, or when associated with organic, diseases, or excited by inflammations of the endocardium, a less favour- able prognosis must be given. Functional rhythmical irregularity, for the most part, does not indicate danger, but it may do so if asso- ciated with some obscure structural lesion. Nevertheless, cases of simple functional dis- order, so severe as apparently to indicate an immediately fatal termination, prove, for the most part, manageable, and result in a restora- tion to health. The freedom of the heart from all agitation and other indications of disease, before and after an attack, is due to its being a normal and uninjured organ ; and though liable during an attack to the morbid influences of 6pasms and congestive loading, it still may be a healthy organ. This holds whether the pa- roxysms be short or prolonged, occurring rarely, or frequently recurring. They are distressing but not dangerous. Treatment.— Treatment should have refer- ence primarily to the paroxysm, and then to its exciting causes, the indications being, first, the mitigation of the symptoms ; and, secondly, the prevention of their recurrence. Treatment of the paroxysms . — Towards the former, it should be ascertained, where possible, whether the attack be essentially due to irri- tability in the heart itself, or whether it have its origin in some co-existing excentric cause. The constitutional tendency and the exciting causes should be well considered ; for the treat- ment of apparently similar attacks under the widely opposite causes of a plethora or an anaemia must be varied accordingly. Slight cases subside of themselves ; but in more per- sistent attacks, for the most part, relief is ob- 1 tamed by warm carminatives or stimulants, or by antispasmodics, as ammonia, camphor, ether, assafcetida, musk, valerian, or sumbul. Where irritability of the heart itself is the cause of the attack, it is generally best met by seda- tives, as opium, hyoscyamus, hydrocyanic acid, and in some cases digitalis. If the attack be due to derangement of tho stomach, as from the presence of the gouty acids, an alkali may be useful. In extreme cases, and where head- symptoms supervene, the extraction of a small quantity of blood by leeches or venesection may be useful. The mental or moral treatment is of the greatest moment. A confident and cheering prognosis conduces to recovery, and prevents the nervousness which exhausts and tends to pro- long the disorder. Treatment between the paroxysms . — The pa- roxysmbeing allayed, it is then well to examine carefully into the state of health, so as to ascer- tain if there be any of those disordered condi- tions which may probably have been its exciting cause. Dyspepsia is to be relieved, the liver is to be set right, the uterine functions are to be restored to regularity, loaded bowels relieved, plethora subdued; spanaemia and chlorosis strengthened into health, exhaustion compen- sated for, and debility counteracted ; and the over-worked must seek renovation in travel and cheerful recreation. In persons prone to these disorders many precautions should be observed. The young and the plethoric must avoid ex- tremes of diet and exercise ; the food should be moderate in quantity and unstimulating in quality; and exercise should be unfatiguing, and chiefly taken in the open air. Hot and ill-ventilated rooms, and the postponement of sleep by late hours, should be especially avoided. A careful mental discipline should be observed ; and this must be sought in a healthy exercise of the brain, and restraining, by a well-ordered intellectual culture, the tendency to vain imagi- nings and emotional passions. The constitu- tionally nervous and irritable in mind must sedulously avoid exciting situations, as well as exhaustion by overwork. The sluggish and hy- pochondriacal must resist the temptations to inaction, seeking to overcome these tendencies by exercise ; by cold bathing, more especially by means of the shower-bath ; and, if the bowels be confined, by the judicious use of aperients. As all the varieties of functional disorder of the heart are peculiarly under the influence of a morbid will, it becomes of the first importance that the medical attendant should generally encourage and cheer; and as soon as careful investigation has satisfied the requirements of a just prognosis, further inves- tigations by tho stethoscope should be avoided. Empirical investigations tend to prolong the disordered action, and perhaps so to impress the imagination as to forbid recovery. Tiiojias Shatter. HEART, Htemorrhage into the "Walls of. — Synon. : Cardiac Apoplexy. Definition. — Extravasation of blood into the substance of the heart. •/Etiology and Pathology. — Blood is extra- vasated into the substance of the heart in various pathological conditions, but as these are de- scribed under their respective headings, it will not be necessary in this place to do moro than refer to them. Rupture of the heart is the most frequent origin of haemorrhage into the walls of the organ. 504 HEART, HAEMORRHAGE INTO WALLS OF; AND HYPERTROPHY OF Tbe blood in these cases may be derived from the cavity of the ventricle, and forced between the muscular fibres at each contraction. More rarely, a partial rupture of the wall may occur, unconnected with the cavities, and haemorrhage take place into the seat of the lesion from one of the coronary vessels or their branches, con- stituting what has been called cardiac apoplexy. In both classes fatty degeneration is generally the cause of the rupture. The formation of false consecutive aneurism of the heart may be attended with haemorrhage into the walls ; an abscess, blood-cyst, hydatid- cyst, or gumma having burst or made its way into one of the cavities. The coronary arteries may be the source of the haemorrhage ; for instance, in rupture of co- ronary aneurism ; in cases of cancerous ulcera- tion of their walls ; and in embolism or throm- bosis of their lumen, leading to infarction. Ecchymosis of the heart is a form of haemor- rhage belonging to a different category. It is generally met with in association with paren- chymatous degeneration of the heart, for ex- ample in the acute specific fevers; with that form of fatty degeneration which is produced by certain poisons, such as phosphorus and arsenic; and with other pathological states in which ecchymoses occur in the viscera generally, as in purpura and scurvy, and especially in cardiac and pulmonary disease. In cases of non-fatal haemorrhage into the walls of the heart, the blood undergoes the changes usual in extravasations, and gives rise to the collections of pigment-particles which are sometimes found between and upon the muscular fibres ; to blood-cysts ; or to collections of puriform matter. Hiemorrhage into the myocardium possesses tn special clinical relations. •T. Mitchell Bruce. HEART, Hydatid-Disease of. — A con- siderable number of cases have been recorded, in which hydatids, in the wider sense of the term, have been found in the human heart. According to Dr. Cobbold. 3'5 per cent, of all cases of hyda- tids in man occur in this situation. Anatomical Characters. — Hydatid-cysts of the heart are either simple or multiple, the latter being the more common of the two forms. They are situated in the myocardium of either side of the heart ; but tend naturally by enlargement to project either into the pericardial sac or into one of the cardiac cavities, in the form of a pro- minent cystic tumour. In this condition they have generally been found post mortem ; but it is probable that in other cases the parasite may undergo degenerative changes in the heart, as in other organs, without its existence being sus- pected during life or discovered after death. In other instances, the hydatids rupture or are dis- lodged from their seat in the cardiac wall — either inwards or outwards, or in both directions at once. In the first event, the parasite or its contents or fragments become impacted in the cardiac cavities or orifices, or give rise to embolism of the great vessels or of a distant branch. Rupture of a cyst into the pericardial sac causes pericarditis; and rupture both inter- nally and externally has given rise to haemoperi- cardium. Hydatids of the heart are frequently associated with the same disease in other viscera. The appearance and structure of the entozoon do not require to be described here. See Hydatids. Symptoms. — In several cases of this disease, the subjects have died suddenly during exertion, or, as in a case recorded by Dr. Wilks, after a hearty meal. These persons were not known to have suffered previously from symptoms referable to the heart. In other instances, the ordinary phenomena of chronic cardiac disease were pre- sent, including endocardial murmurs; but it is not certain that these were always due to the pre- sence of the hydatids in the heart. A sudden fatal termination will be the result of internal rupture and embolism, or of liaemopericardium, as described above. Diagnosis. — Hydatid-disease of the heart does not appear to have ever been suspected during life. Cardiac symptoms and signs, or sudden death, occurring in an individual known to be suffering from hydatids of other viscera, would suggest that the heart was also affected. Treatment. — The disease cannot be said to have any special interest therapeutically. J. Mitchell Bruce. HEART, Hypertrophy of. — Synon. : Fr. Hypertrophie du Occur ; Ger. Hypertrophic des Herzens. Definition. — Hypertrophy of the heart, in a wide acceptation of the term, may be said to ex- press an increase in the size and weight of the organ, due to an excessive development of somo one of the constituent elements of its walls. In the sense in which it is generally used, however, hypertrophy of the heart signifies an excessive development of the muscular substance only. Such hypertrophy may be regarded as a conser- vative process; and is not intended to include those changes in the size of the heart in which the connective and fatty tissues are in excess. Varieties. — The varieties of hypertrophy of the heart were first carefully described by M. Bertin in 1811, who demonstrated that the change in hypertrophy is the result of an increase of nutrition. He described three forms, which most succeeding writers have referred to, namely: — (1) Simple Hypertrophy, in which the parietes of the compartments are thickened, the cavities retaining their natural dimensions ; (2) Hyper- trophy with Dilatation ( Exccntric Hypertrophy), in which the cavities are increased in capacity, while the parietes are either of natural or of augmented thickness; (3) the so-called Con- centric Hypertrophy, or Hypertrophy with Dimi- nished Cavities, in which new material was sup- posed to be added, chiefly in the interior of the ventricular walls. Cruveilhier and Budd pointed out that the condition called concentric hypertrophy is the result, not of hypertrophy, but of a powerful contraction of the organ sud- denly' arrested, ns it were, by death. Budd found that the hearts of persons who had died a violent death presented this so-called concentric, hypertrophy : but that such hearts became re- laxed. nnd showed the normal size of cavitiej and thickness of walls, after maceration. Roki- HE/iKT HY P EItTR 0 P H Y OF. tansky and Bamberger acknowledge the rarity of concentric hypertrophy, hut think it does sometimes occur. It is said to have been found in the right ventricle in some cases of congenital malformations. Hypertrophy may affect only one compartment of the heart, or more than one, but the organ is seldom enlarged throughout. The ventricles are much more frequently hyper- trophied than the auricles, and the left ventricle more frequently than the right ; but the right auricle more frequently than the left auricle — which last shows the change very seldom. iETioLoav and Pathology. — The heart being a muscular organ, whatever calls forth increased frequency and force of its action induces hyper- trophy of its muscular tissue. The great causes of this hypertrophy are certain obstructive con- ditions in the circulatory apparatus, which will be noticed in detail. But many circumstances might be enumerated as predisposing causes. Thus, males, from the nature of their occupa- tions, are twice as prone tocardiachypertrophy as females. In advanced age degenerative vascular changes are apt to induce this result. Dr. Quain ( Lumlcian Lectures, 1872) has classified the exciting causes of hypertrophy under three heads : — nervous, mechanical, and nutritive. 1. Amongst nervous causes are those emotional conditions that produce frequent pal- pitation, and prolonged mental excitement or strain. The immoderate use of strong coffee, tea, or spirituous liquors might come under this head. 2. Amongst mechanical and physical causes are all those obstructive conditions to be after- wards specially examined. Violent athletic or other exercises, which notably accelerate the con- tractions of the heart, or produce excessive blood- pressure, may be mentioned here. It has been pointed out that great muscular exertion with the arms is specially prone to cause hypertrophy, as in the case of hammermen, &c. Prolonged working in a bent or constrained position is also mentioned as a cause. In fact, any prolonged impediment to the free action of the heart, or to the onward current of the circulation, tends to cause hyper- trophy of the heart. Thus, in addition to val- vular lesions, pericardial adhesion is an important cause. Diseases of the vessels, by diminishing their elasticity and increasing the friction, dis- placements of the heart, and deformities of the chest or spinal column, by twisting or constricting the aorta, are all causes of some obstruction to the blood-current. The heart becomes enlarged in pregnancy — but resumes its ordinary size by involution — as the womb itself does. A very important cause of cardiac hypertrophy is chronic Bright’s disease. Aneurisms also some- times induce hypertrophy, for the physical rea- son that the resistance encountered by a liquid flowing through a tube is increased by the pre- sence of any abrupt dilatation and contraction of the calibre of the tube. Conditions of the lungs associated with persistent obstruction to the passage of blood through them (emphy- sema, asthma, phthisis, compression from hydro- thorax, &c.) may induce hypertrophy of the right side of the heart. Hypertrophy also fol- lows upon dilatation, because additional force is required to propel the larger volume of blood, »part from any valvular lesion. So mere plc- 6t>rf thora may tend to cause hypertrophy, which also ensues upon the distension of the cardiac walls which results from myocarditis. 3. With regard to the nutritive causes of hypertrophy of the heart, the state of the local nutrition and the nutritive quality of the blood have both to be taken into account. Ilicli nitrogenous food, and the use of ferruginous medicines, will favour hypertrophic changes. AVith the increase of tho muscular structure there is proportional enlarge- ment of the coronary arteries, so that the hyper- trophied organ has an increased blood-supply. The most important conditions of obstruction connected with cardiac hypertrophy are the fol- lowing : — (a) Stcjwsis of the aortic valves is a common cause of hypertrophy of the left ven- tricle. The opening is not only narrowed, but is also rendered more rigid, and thus increased force is necessary to propel the blood. Along with the valvular lesion there may also be, especially in advanced life, a loss of elasticity and a rough- ening of the inner coat of the aorta from degene- rative changes — conditions which increase the mechanical strain upon tho left ventricle. ( b ) Aortic regurgitation often induces so great en- largement of the left ventricle, from hypertrophy and dilatation, that the heart in such cases merits the name cor bovinum. The back-flow of blood increases the intra-ventricular pressure, tends to dilate the cavity, and calls forth augmented efforts of ventricular contraction, (c) Aortic aneu- rism is usually instanced as a cause of cardiac hypertrophy, and we gave above the physical explanation of this result. But, as a matter of fact, many cases of aortic aneurism have been recorded not accompanied by cardiac hyper- trophy, though some degree of this change is usually expected. Of course, other tumours, by pressing upon any of the great arterial trunks, may induce cardiac hypertrophy. ( d ) Chronic Bright's disease (contracted kidney) is a very important cause of left-heart hypertrophy, the hypertrophy being often of the purest type, with- out dilatation. This change is the result of the great increase of blood-tension produced by the resistance offered to the blood in the small arteries through the whole body, as well as in the kidneys, (e) As the result of mitral stenosis, the left auricle becomes somewhat thickened and dilated; and the further backward blockage of the blood produces pulmonary engorgement, and hypertrophy with dilatation of the right-heart. (/) Similar results follow the more common lesion — mitral incompe- tency. Blood regurgitates at each ventricular systole into the left auricle, which has thus to sustain the ventricular impulse in addition to the pressure from excessive fulness. H 3 r pertrophy and dilatation of the left auricle, engorgement of the lungs, and hypertrophy with dilatation of the right-heart, are the natural consequences. In- deed, hypertrophy of the right ventricle is almost always associated with dilatation, and the double change is, in almost every case, consequent upon pulmonary obstruction, which may be caused by primary changes in the lungs themselves (see g), but is far more frequently secondary to left- heart disease (mitral lesions). (g) In emphy- sema, fibrosis, and consolidated or compressed conditions of the lungs, the impediment to the pulmonary circulation induces hypertrophy with HEART, HYPERTROPHY Of. 406 dilatation of the right ventricle. Diseases of the 'pulmonary orifice are very rare ; so, too, is tri- cuspid stenosis. (h) But tricuspid regurgitation is common as a result of dilatation of the right ventricle ; and this, in its turn, causes dilatation, usually with considerable hypertrophy, of the right auricle. General systemic venous obstruc- tion follows upon right-heart blockage ; and Hope says that venous retardation may "work backwards through the capillaries to the minute arteries, the consequent increased resistance in which may induce left-heart hypertrophy. Anatomical Chaeactees. — -The fundamental anatomical change in cardiac hypertrophy is an in- crease of the proper muscular tissue of the heart. There is no growth of new tissue different from the normal heart-muscle; there is simply an increase in the number of muscular fibres in all respects similar to those normally occurring in the organ. Along with the hypertrophy of the muscular tissue, there may be also more or less increase of the connective tissue between the muscular bundles ; and this fibrous hyperplasia may be excessive, as Dr. Quain has pointed out, constituting a so-called ‘ false hypertrophy,’ in which the colour of the cardiac walls varies from the natural to a light grey hue. There may be hypertrophy of only one part of the cardiac walls, abnormal thinning being found in other parts. The organ may be greatly enlarged from general dilatation, without any notable thickening of the walls ; but the capacity of the chambers should always be carefully noted in estimating the de- gree of hypertrophy, as there may be a greatly augmented extent of wall, although its actual thickness seems normal. Simple hypertrophy is neai’ly always the first condition, preceding hy- pertrophy with dilatation. The greatest cardiac enlargements result from left-sided hypertrophy. Some examples of cor bovinum have attained the enormous weight of 40 oz. The wall of the left ventricle may become thickened to one or even one-and-a-half inches, instead of the normal six or seven lines ; and the thickest part is usually about the middle of the ventricles. The inter- ventricular septum is not so liable to hypertrophy as the rest of the ventricular parietes. The right ventricular wall maybe thickened to the ex- tent of one inch, instead of the normal two-and- a-lialf lines, and its greatest thickness is at its base. The column* carnese of the right ventricle are even more liable to hypertrophy than the wall. In dilatation with hypertrophj' the column* carne* become stretched and attenuated. The substance of an hypertrophied left ventricle can generally be torn with ease, whilst that of an hypertrophied right ventricle is usually tough aDd leathery. The auricular walls are rarely thickened to more than twice the natural thickness, and are almost always dilated considerably if hypertrophied at all. In marked hypertrophy, the heart pre- sents a change of configuration, becoming more globular, and having the apex tilted up. If the enlargement is mainly on the right side, the sphericity of the organ is a marked characteristic, and its long diameter has a tranverse direction in the chest. Of course, other pathological con- ditions, as valvular lesions, or the results of endo- carditis or of pericarditis, may also be present. In true hypertrophy the coronary arteries become enlarged. There may sometimes be found accu- mulations of fusiform involuntary fibres, which have not developed into the higher state of striped fibres. Symptoms and Signs. — Precise physical signs are all-important in establishing a diagnosis in cardiac enlargements, and it is always exnedieut at once to ascertain which chamber or chambers is or are affected. It must not be forgotten that simple hypertrophy may exist without producing symptoms attracting the attention of the patient, and that there is a natural tendency to some degree of cardiac hypertrophy with the advance of age. Dyspnoea . — In moderate hypertrophy without complication, there is usually easy and natural breathing when the patient’s body and mind are at rest. But mental excitement or bodily effort at once induces more or less of temporary dyspneea. In some cases the due expansion of the lungs may be mechanically impeded by the increased volume of the heart. In excentric hypertrophy with dilatation, more especially when the right cavities are thus af- fected, pulmonary congestion and oedema arc very usually present, and then marked dyspnoea is a prominent and distressing symptom. Cough. — In simple hypertrophy there may be an occasional dry irritating cough, and in young phlethoric women a wheezing cough may be complained of. In right-side enlargements when pulmonary obstruction and dropsical effusions supervene, cough is, in most cases, a very fre- quent and painful addition to the other sources of discomfort to the patient. Heemoptysis and other hemorrhages . — Hsemoptysis from capillary engorgement is common, being generally active and. sudden. Niemcyer points out that, in left- heart hypertrophy, there is often active disten- sion, and sometimes rupture, of the branches of the bronchial arteries. In left hypertrophy, too, the cerebral arteries are specially liable to give way. In right-side enlargement with pul- monary obstruction, the blockage may influence the vessels of the liver and the portal system generally, so as to produce liaematemesis or melrena. Epistaxis may also be due to cardiac enlargement. Palpitation is a common symptom in all organic diseases of the heart, and is often very marked in cardiac enlargements. The least excitement, bodily or mental, may induce a greater or less degree of this symptom. Especi- ally in excentric hypertrophy with dilatation, most distressing paroxysms of palpitation are apt to occur from time to time. Besides bodily and mental excitement, other conditions, such as indigestion, flatulence, or an overloaded stomach, readily call forth this symptom. "When there is much dilatation, the palpitation may be irregular and intermittent, and is then more particularly a very alarming symptom. Pulse . — In s.mple hypertrophy the pulse is stronger, fuller, tenser, less compressible than natural, and dax .s longer under the finger, the hypertrophied walls re- quiring more time for contraction, and contract- ing with greater force than normal. When dilatation relatively exceeds the hypertrophy there is diminished strength, hut more fulness, and sometimes marked slowness of the pulse. In aortic obstruction with left hypertrophy the pulse is strong, incompressible, small, and. sustained HEART. HYPERTROPHY OF. C07 In aortic regurgitation it feels as if liquid balls passed under the finger. In mitral obstruction it is frequently small and irregular. In mitral regurgitation it is irregular in size (not necessarily in rhythm). In enlargement of the right ventricle the pulse, as a rule, is small, -weak, and perhaps intermittent or irregular. When atheroma of the vessels is associated with cardiac hypertrophy, the pulse is bounding. In the mere hypertrophy of old age it is full and slow, but not very incom- pressible. Certain cerebral symptoms ought to be mentioned in connection with the other more direct signs of cardiac hypertrophy. A feeling of fulness, or perhaps of throbbing, may be felt in the head after great muscular exertion or mental excitement. In pronounced cases there may be headache, ringing in the ears, vertigo, muses volitantes, and disturbing dreams. The bright and shining, or perhaps the blood-shot, condition of the eyes, is an indication of the hypersemia of the cerebral vessels. Hypertrophy of the Left Ventricle.— Simple hypertrophy of this portion of the heart does not tisually produce much disturbance of re- spiration, but palpitation is a prominent symp- tom, and cerebral complications are, as we have seen, by far most frequent in this form of cardiac change. On inspection , the prsecordium sometimes shows a bulging, more especially in young subjects, whose sternal cartilages are less resistant. Walshe says there may be some convexity of the cardiac region from the third to the seventh cartilages, and that the interspaces are rendered wider, but do not bulge. In simple hypertrophy the area of impulse may be seen to be enlarged, and to be located more to the left and lower down than normal. On palpation the apex-impulse may be felt to be greatly augmented in force, and to extend perhaps over the fourth, fifth, and sixth interspaces. When there is very great hypertrophy of the left ven- tricle, without pericardial adhesion or much dilatation, the apex-beat may be felt, powerful and well-defined, even in the seventh or eighth intercostal space. Dr. Walshe describes the sensation as a slow heavi ng, or a pushing forward as if against an obstacle. The duration of the heaving impulse is in proportion to the degree of hypertrophy. The impulse is often strong enough to visibly move the bed-clothes, and even to raise the head of the auscultator by the im- pact against the stethoscope. Of course a larger portion than usual of the heart’s surface impinges against the chest-wall. With coexistent valvu- lar lesions, a vibratory jarring sensation may be felt on palpation ; and with pericardial ad- hesions the impulse may be a sort of jogging motion. In hypertrophy with dilatation the impulse is less powerful, but is seen and felt over a wider 1 area than in simple hypertrophy. The contrac- tions are felt more like sharp blows or shocks, and the vibrations are conveyed to greater dis- tances, in some cases extending to the top of the i chest-wall. With great dilatation the pulse may be very slow, weak, and compressible. On l percussion, the areas of both the superficial and the deepcardiacdulness are found to be increased, especially towards the left. In excessive hyper- trophy with dilatation, the dulness may extend from the upper border of the third rib down to the eighth rib, and from an inch to the right of the sternum to the anterior axillary line. Dulness may also be detected in the left back. Emphy- sema and possible consolidation of the lungs must be borne in mind in marking out the area of cardiac dulness. On auscultation, the systolic sound is less clear and defined than normal in simple hypertrophy; it is prolonged in proportion to the degree of hypertrophy, and is muffled in character, as the muscular sound is excessively pronounced, and obscures that of the auriculo- ventricular valves. When there is much hyper- trophy, the first sound may be of a metallic cha- racter. The post-systolic silence is shortened, and the second sound is loud. When there is dilatation with hypertrophy the first sound is more audible and distinct, and the second sound is louder. Hypertrophy cf the Bight Ventricle — In en- largements of this ventricle, inspection may re- veal a rounded smoothness of the epigastrium, with perhaps some bulging of the ensiform and lower left costal cartilages. The apex-beat may be seen to be very diffused, extending towards the tip of the ensiform cartilage. Facial livi- dity is frequently seen; and jugular pulsation may be observed when there is tricuspid re- gurgitation. Palpation over the lower part of the sternum detects an impulse, which feels as if immediately under the hand, and wants the heaving character of the impulse of a hyper- trophied left ventricle. Epigastric pulsation is often very pronounced. The liver-pulsation in such cases may result either from venous regur- gitation, or from right systolic action exerted through the diaphragm. On percussion, the inferior line of dulness is found to extend lower down and farther towards the right than normal, sometimes reaching an inch or more beyond the right sternal edge. The dulness may be con- tinuous with that of the liver. On auscultation, the first sound is more distinct than natural, and seems quite superficial. The second sound is also louder, and its reduplication is not uncom- mon. Hypertrophy of the Auricles. — It is always difficult to speak very definitely of the condition of the auricles during life. They are never hy- pertrophied without being also dilated, and such states are uniformly connected with lesions of the auriculo-ventricular valves. Dulness due to an enlarged left auricle may extend up to the second left intercostal space ; that due to an enlarged right auricle may be found in the third and fourth interspaces at the right sternal edge. Jugular pulsation maybe found along with right auricular enlargement, which itself can hardly ever occur without an abnormal condition of the right ventricle. Complications and Sequel.®:. — Simple hyper- trophy of the heart may go on quietly for a long time, just balancing the obstructive in- fluence, and giving rise to no other form of disease. But when there is dilatation as well as hypertrophy, then palpitation, dyspnoea, venous congestion, and serous effusions are the ordinary results. Diseased conditions of the arteries may occur simultaneously, or rnav he induced by the long-continued additional strain put up n them 603 HEART, HYPERTROPHY OF. by a hypertrophied heart. Cerebral haemorrhage often occurs in connection with an hypertrophied left ventricle, as in Bright’s disease ; although there are very frequently other factors, besides the mere excessive propulsive power of the heart, in the production of apoplexy. Pulmonary and general congestion and cedema are the usual attendants of mitral lesions with right-side en- largements. Pulmonary hsemorrhagic infarction (the so-called 1 pulmonary apoplexy ’) generally results from embolism of the branches of the pul- monary artery, and takes place in connection with right-side enlargement. Sanguineous exudation in the tract of the bronchial mucous membrane may occur in left-heart hypertrophy. Persons suffering from cardiac hypertrophy are apt to be gravely affected by acute febrile diseases, because the resultant acceleration of the heart’s action increases the embarrassment of the organ. Of course, hypertrophied cardiac walls are sub- ject to the fatty degenerative changes described elsewhere. As has been alluded to already, the chief result of right-side dilatation is obstruc- tion to the venous return. The hepatic circula- tion and the portal system generally are, in particular, rapidly overfilled, the whole venous system being ultimately affected. The kidneys likewise suffer. The natural results, in addition to characteristic changes in the chronically con- gested organs, are serous effusions into the cavi- ties and subcutaneous areolar tissue. Diagnosis. — An extended area of dulness ; dis- placement of the apex-beat; anda slow, heaving systolic action, with augmented force of impulse, are the chief diagnostic physical signs of cardiac hypertrophy. In young and thin people the last of these signs may seem to be present, but the accompanying conditions readily exclude hyper- trophy, especially the non-extension of the car- diac dulness. An emphysematous left lung may mask hypertrophy when present ; and lung-con- solidation might, though only for a moment, suggest it when absent. In pericardial effusion the triangular shape of the area of dulness, with the apex of the triangle upwards, is a distinctive feature ; there would, moveover, be the history of an acute disease, with lancinating pain, dys- pnoea or suffocative sensations, and other symp- toms not found in mere enlargement of the heart. Pleuritic effusion or aneurism would be still more readily discriminated. The differential diagnosis between left-heart and right-heart enlargements has been sufficiently discussed in speaking of the symptoms and signs. Dilatation as dis- tinguished from hypertrophy, is characterised by the feebleness and diffuseness of the apex- beat, which may even be quite imperceptible ; by t he great irregularity and intermittency of the heart’s action ; and by the general signs and symptoms of a feeble circulation. Prognosis. — Simple, uncomplicated hyper- trophy, as in the young, and in athletes, is not incompatible with long life, if the cause be re- moved in time. According to the extent and degree of complication, whether in the form of valvular lesions or co-existent pulmonary dis- ease, the prognosis will be unfavourable. When the cardiac change is itself producing secondary lesions, as degenerations of the arterial coats, when dilatation is advancing, and when there is HEART, INFLAMMATION OF. Bright’s disease, the prognosis becomes very unfavourable. Treatment.— -Hypertrophy being in itself a conservative change, protective from worse re- sults, the primary object is to remove, if possible, the cause of the hypertrophy. To aim merely at reducing the hypertrophy, irrespectively of its cause, as by lowering the nutrition, would gravely favour the worse evil of dilatation. General therapeutic principles, and the morbid conditions accompanying the hypertrophy, must therefore be carefully attended to. All mental and bodily exertion which excites the circulation must be scrupulously avoided. All alcoholic stimulants should be interdicted, and no more wine allowed than such as may seem to benefit digestion. The diet should be carefully selected, nitrogenous food being generally necessary. . The digestive organs must be sedulously looked after, not only because good nutrition is very important, but also because flatulence and dyspepsia directly embarrass the heart's action. Mild saline and aloetic aperients should be given. Diuretics will be necessary if there is a tendency to dropsy, and in all cases great attention must be paid to the removal of congestion when it affects important organs, and the restoration of their functions when affected, more especially of the liver and the kidneys. When there is great excess of cardiac action, direct cardiac sedatives, as digitalis, hydrocyanic acid, conium, and bel- ladonna, are called for. When there is dilatation and feebleness of texture with the hypertrophy iron and digitalis are the chief remedial drugs. J. R. Wabdell. HE-ART, Inflammation of. — Inflammation of the heart may affect either the lining mem- brane, or the substance or walls of the organ; and the subject will be best discussed under the separate heads of Endocarditis and Myocarditis. Inflammation of tho investing membrane of the heart is described in the article Pericardium, Diseases of. I. Endocarditis. Synox. : Fr. Endocardite; Ger. Endocarditis. Definition. — Inflammation of the lining mem- brane of the, heart. Inflammation of the endocardium maybe either acute or chronic. The acute form alone will he discussed here; chronic endocarditis being re- ferred to under the head of Heart, 1 alTes of. Diseases of. •/Etiology. — -Endocarditis generally occurs in association with acute rheumatism : less fre quently with the other acute specific febrile diseases, such as scarlet fever, measles, erysipe- las, pysemiaand septicaemia — including pnerper.d fever ; and much more rarely with typhoid fever and variola. Occasionally it is observed in the course of pregnancy, and after parturition; in acute and chronic Bright's disease ; and in syphi- lis. Wounds and other injuries of the heart, such as rupture of the valves, may also leal to endocarditis ; and local inflammation of the en docardium is frequently the resultof the unnatural contact of one part of it with another during the cardiac revolution, as. for example, by growths from the walls or valves, or by unnatural blood- HEART, INFLAMMATION OF. currents. It also occurs in chorea, perhaps from the last of the causes just enumerated. Age is an important predisposing factor in the aetiology of acute endocarditis, the occurrence of which as a complication of acute rheumatism is certainly most frequent in young subjects, and declines. as age advances. "Women are also more subject to rheumatic endocarditis than men. The localisation of the endocardial inflamma- tion appears to be determined chiefly by pressure and tension, rather than by any peculiarity of the membrane itself, or of the blood in contact with it. Thus the left ventricle is almost the sole seat of the disease in the adult, and the right ventricle in the foetus ; whilst endocarditis is rarely seen beyond fhe boundaries of the valves, that is, the parts most subjected to strain. In the same way, chronic endocarditis is usually due to increased pressure within the heart, as in chronic Bright’s disease, and in con- ditions that entail prolonged severe strain upon the valves during exertion. A similar cause is at work in pregnancy. In a certain number of instances of the ulcera- tive form of endocarditis, the origin of the disease has been traced in connection with the presence of an ulcerating surface or foul wound in some part of the body, most frequently in the female genital organs post partum. Axatomical Characters. — Inflammation of the endocardium affects chiefly the valves and the chordae tendine®, and especially the lines of contact or the surfaces of the valves exposed to the force of the blood-current. The endocardium of these parts at first appears slightly swollen, velvety, soft, and of various shades of red ; whilst the lines or points of contact of the valves present warty enlargements of a similar character, which are known as ‘ vegetations.’ As the process advances, the inflamed areas become more opaque and firm; and a fibrinous deposit is entangled with their surface. When the endocarditis has gone thus far, resolution is probably rare ; and the most common result is what is known as ‘ chronic valvular disease,’ that is, that the affected parts are left opaque, puckered, and thickened by growth of connec- tive tissue, whilst the vegetations develop into firm fibroid or even cartilaginous-like bodies. As a consequence of these changes, the valves may become much altered in size and shape, and the ostia contracted and irregular, so that the mutual adaptation of the parts is greatly disturbed. Other results of inflammation are not uneonvmon :n the progress of endocarditis, such as adhesions , between the neighbouring structures, and ossifi- , cation or calcification of the altered tissues. La- ceration of the valves and rapture of the chordae tendine® during the stage of diminished resist- ance, ulceration, suppuration, and the formation of aneurism are rarer events. The microscopical appearances of inflammation of the endocardium correspond with the naked- eye characters. In the early stages, the proper tissue of the endocardium is swollen by hyper- emia, oedema, aud the appearance between its fibres of a number of leucocytes ; the latter rapidly multiply to form the bulk of the vege- tations; and the surface presents various thick- nesses of deposited fibrin, which in its turn may 39 60 “ become organised. The further development of the new cells into connective tissue gives rise to the opacity, thickening, and puckering o f the valves, and to the formation of permanent vegetations. The effects of these changes upon the fuve tions of the valves and their appendages are de scribed in the article Heart, Valves of, Diseases of. Particles of fibrin, and even of the vegetations are occasionally detached from the endocardium and give rise to embolism. In a special form of the disease, which is knowi as ulcerative endocarditis, the morbid appeu ances are at first not unlike those described abovt as characterising the early stage of the ordinary affection ; but the process pursues a differem course, and becomes mainly destructive in it; nature. The edges or surfaces of the valvrs then present spots or patches of loss of substance having an eroded appearance, and an irreguD > base, covered with granular matter, and fringe;! by vegetations. These diseased are* may ad- vance to actual perforation, burrowing abscess, or aneurism. Microscopically examined, the patches prove to be are* of ulceration, and the granular matter of their base has been found by Virchow and others to contain organisms, which were seen at the same time in the capillaries oi distant parts of the body. Symptoms. — The symptoms of endocarditis are inseparable from the symptoms of the disease with which it is associated, and the diagnosis of it is made almost entirely from tho presence of physical signs. Thus fever probably precedes the advent of endocarditis, in every case ; and it cannot be said that the simple uncomplicated disease in any respect affects either the pyrexia or any other element of the same. Local symp- toms are almost equally rare, unless the endo- carditis leads to serious lesion of the cardiac valves. As long as these remain sound, and the disease is acute and does not involve deeper structures, pain in the heart, prmcordial distress, syncope, shortness of breath, and other symptoms of heart-disease cannot be said to occur at all frequently in endocarditis. The cardiac contrac- tions are necessarily increased in frequency; and palpitation and dyspncea may occur on movement. It is otherwise when the inflammation has lasted so long as to render the valves incompetent, or to obstruct the orifices ; or when the myocardium is attacked, and dilatation ensues. The symptoms just enumerated then make their appearance, as well as those of secondary involvement of the lungs, of the circulation, and of the system gene- rally. Ulcerative endocarditis, unlike the ordinarv form of the disease, is manifested by severe and striking symptoms, although amongst these the phenomena of cardiac inflammation are compa- ratively subordinate to those of general infection. It is on this account that ulcerative endocarditis has only recently been definitely recognised as a distinct form of disease, the condition of tho endo- cardium post mortem having apparently been disregarded in the presence of serious lesions of the other viscera, of the blood-vessels, and of the blood itself. Commencing with a sudden rigor, in the course of acute rheumatism, during the puer- peral state in women, or in a case of chronic 1 HEART, INFLAMMATION OF. 310 valvular disease, ulcerative endocarditis either resembles a simple continued or typhoid fever from first to last, or assumes a markedly' pyaemic character. In the former case, gastro-enteric symptoms and splenic enlargement may be strongly marked ; whilst in the second case, vomiting and diarrhoea, jaundice, albuminuria, and various eruptions, with pyrexia of a pysemic or remittent type, are prominent phenomena. In both forms the case steadily progresses towards a fatal termination. A loud systolic murmur is generally present from the first, and may point to the heart as the primary skat of disease ; but in ulcerative endocarditis, as in simple endocar- ditis, special local symptoms are rare. Physical Signs. — The physical signs of acute endocarditis are — increased extent andfrequency, with variable strength, of the visible and pal- pable impulse; moderate increase in the area of prsecordial duiness ; and various alterations in the cardiac sounds. At the beginning of endo- carditis, the first sound at the left apex is fre- quently heard prolonged and hollow, or muffled ; and, as the process advances, this alteration of character may gradually pass into a murmur, which is at first indistinct, but afterwards well- formed. If the aortic valves are affected, the second sound may similarly lose its characters, become dull, and finally be converted into, or be complicated with, a murmur. The most frequent murmur in acute endocarditis is mitral systolic ; aortic murmurs are decidedly less common ; and mitral prsesystolic murmur is very rare. Various inorganic murmurs may appear, and either dis- appear or continue during the course of the disease. Complications, — Endocarditis is itself always a complication of the diseases previously men- tioned. Myocarditis and pericarditis may be cor- rectly regarded as complications of endocarditis, when the inflammation begins in the lining mem- brane of the heart. According to some authorities, clots may form in the heart in endocarditis, and give rise to very urgent symptoms (see Heart, Thrombosis of). Embolism may arise from de- tachment of fragments of coagula or vegetations ; and this condition, and the development of pycemic symptoms are essential elements in the course of the ulcerative form of the disease. Congestion or inflammation of the lungs fre- quently occurs in association with endocarditis, and so may albuminuria. Course, Terminations, and Sequels. — The course of simple endocarditis is very uncertain, and varies with the course of the original disease with which it is associated, as well as with the complications. If acute rheumatism be checked in a few days, inflammation of the endocardium may bo expected to be also arrested. In a con- siderable number of cases, however, endocarditis passes on to chronic valvular disease. For ex- ample, the late Dr. Sibson found that seventeen jut of seventy cases of endocarditis with mitral systolic murmur ended in established valvular disease, and less than a half of the cases with diastolic basic murmur. simple endocarditis very rarely proves fatal; hu' the ulcerative form is believed to be uni- f.itmly so in the course of a few days, or it may be weeks. On the other hand, simple endocar- ditis, being by far the most common cause at valvular disease of the heart, leads indirectly to much suffering, and, as a rule, ultimately to death. Diagnosis. — The diagnosis of endocarditis depends upon the discovery of the development of an endocardial bruit of organic origin during the course of one of the diseases alrea ;y named. From functional murmurs the bruits of vsirular inflammation may be diagnosed under different circumstances — first, by their locality, which is most frequently the mitral area ; secondly, by their time, diastolic or prsesystolic murmurs Leing al- ways organic ; and, thirdly, by their association with pericardial friction. The special characters of inorganic murmurs are described elsewhere. Chronic valvular disease may he diagnosed from acute eudoearditis by the presence of cardiac enlargement and other weil-known signs ; of marked cardiac symptoms — especially pain and dyspnoea ; and of visceral complications. Much more difficult of diagnosis is acute endocarditis occurring in the course of chronic valvular dis- ease. Change of the character of the murmur, if this have been observed previously, may lead to the suspicion of fresh inflammation, but cannot establish the diagnosis of its existence, which may not be discoverable. The diagnosis of the precise seat of endocarditis on the various valves is discussed in the article Heart, Valves and Orifices of, Diseases of. It is often impossible to diagnose ulcerative endocarditis from typhoid fever or pyaemia re- spectively, according to the form that it assumes; unless the aetiology of the case, the precise cha- racter of the pyrexia, and the occurrence of ms- tastases he very carefully regarded, along with the development of a murmur at one or more of the cardiac orifices, and possibly of pericarditis. Prognosis. — The immediate prognosis of acute endocarditis is generally favourable, and maybe safely estimated by the absence of local symp- toms. The remote prognosis, on the other hand, as regards both life an 1 health, is exceedingly bad, inasmuch as endocarditis so frequently ends in chronic valvular disease. The proba- bility of this result of acute inflammation of the valves is frequently difficult or impossible to esti- mate. A feeble, soft, and smooth murmur, or a feeble and grave murmur, is much more likely to disappear than a loud extensive well-defined bruit. The probability of the disappearance of diastolic basic murmurs may be best estimated by the absence of the effects produced by aortic incompetence upon the heart and vessels. Treatment. — The treatment of acute endocar- ditis has to be discussed under three heads, namely, first, preventi ve ; secondly, immediate ; and thirdly, subsequent treatment. a. Preventive treatment . — When a patient is suffering from any disease which may become complicated with endocarditis, and especially if lie be suffering from acute rheumatism, every means must be adopted to prevent, as far as possible, the occurrence of this complication. Thus, in acute rheumatism it is all-important to cheek at once the intensity of the disease by recourse to salicylic acid or its salts, and ether means ; for experience shows that endocarditis, when it does occur in acute rheumatism, generally HEART, INFLAMMATION OF. 611 makes its appearance within the first week. Again, the duration of the primary disease must be curtailed if possible, inasmuch as endocarditis, although it generally appears early, may pos- sibly occur at any period of the disease. Thus the medicinal preventive treatment of endo- carditis in these cases resolves itself into the medicinal treatment of acute rheumatism. Ano- ther point of equal importance in the prevention of endocarditis is diminution of the cardiac activity. We have seen that the pressure within the heart is an important factor in the causation of endocarditis; and this pressure must be reduced by diminishing the work to be done by the heart, without lowering the cardiac power. Rest must therefore be enforced in the recumbent posture — an end which is usually already secured by the presence of acute rheumatism of the joints. The personal comfort of the patient must be zealously attended to, and pain relieved, so that restless- ness and irritability may be avoided, and for this purpose carefully selected anodynes may be ne- cessary. Stimulants must be cautiously ordered ; the bowels should be regularly and fully moved; and the various secretions are to be kept as active is possible. b. Treatment during an attack. — When endo- carditis has actually made its appearance, the various means just insisted upon must be en- forced as rigorously as before, so as to diminish the intensity of the inflammation, and to limit the extent of surface involved. Rest is still of the first importance. The medicinal treatment of the original disease — especially of acute rheu- matism — must be persevered in. Local applica- tions to the prscordium, such as cataplasms, or, in cases- of sthenic inflammation, leeching, are often of great service. The administration of stimulants will require the greatest care; excite- ment of the heart, on the one hand, being avoided, and, on the other hand, digitalis, am- monia, or alcohol being employed, if symptoms of cardiac distress supervene. Equal caution is demanded' in the use of anodynes which may be indicated to relieve distress connected with the joints ; and local applications, such as cotton- wool, poultices, aconite, and belladonna, should be employed in preference to opium, chloral, and other cardiac depressants. In ulcerative endocarditis, quinine in large doses, and salicylic acid are the remedies which appear to promise most success ; and all the ordinary measures for support in fever must be persevered with. c. Treatment after cm attack. — When the pri- mary disease, such as rheumatism, has subsided, and the restoration of the various functions in- dicates that convalescence has commenced, the physician must not forget the state of the endo- cardium that has recently been inflamed, which is probably still in a condition of great physical weakness, and the seat of new cell-growth. In- stead of urging the patient to sit up and walk about under these circumstances, as must have ; been frequently done under the ‘rival methods ’of I treating acute rheumatism, we should recommend a very gradual return to exercise, and the most jealous avoidance of actual exertion. There can | t-e no question that, at this stage, rest for several weeks is of more importance than medicinal treatment. At the same time various tonic and other remedies should be employed. II. Myocarditis. — Synon. : Carditis; Fi\ Myocardite ; Gcr. Myocarditis. Definition-. — Inflammation of the walls of tha heart. This disease may he either acute or chronic ; but the latter form, which is attended with the formation of fibroid tissue in the myocardium, is described under the head of Heart, Fibroid Disease of. Pyaemie inflammation of the sub- stance of the heart also constitutes such a special form of disease that it is treated separately (see Heart, Pysemic Abscess of). Acute myo- carditis alone, therefore, has to be considered in the present article. .Etiology. — A certain amount of myocarditis is sometimes associated with acute endocarditis and pericarditis, and depends upon the samo causes; the most frequent being acute rheuma- tism. Jn a small proportion of cases, rheumatic myocarditis appears to occur independently cl inflammation of the lining or of the covering membrane. In the great majority of recorded cases of localised myocarditis ending in ab- scess, the cause of the disease was altogether obscure. It has been observed most frequently in males, and before the twenty-fifth year of life. Exposuro to cold, severe exertion, and local in- jury are mentioned amongst exciting causes, but with questionable correctness. Anatomical Characters. — Acute inflamma- tion of the myocardium generally involves the connective tissue as well as the muscular fibres ; but in a few instances the latter alone have been found affected, constituting so-called ‘parenchy- matous myocarditis. The ordinary form of the disease is charac- terised by the appearance of leucocytes between the muscular fibres of the heart. In one class of cases, the inflammation is moderate in intensity but diffused in extent, affecting one or more layers of muscle underlying the endocardium or pericar- dium, which are also inflamed ; in another class of cases, the inflammation is more active, and proceeds to the formation of abscess, whilst it is, as a rule, comparatively localised. In the first or diffused form, the myocardium, as it is seen through its inflamed covering, ap- pears of a mottled opaque huffy colour, and is somewhat swollen and softened. The micro- scopical characters consist chiefly in the appear- ance of leucocytes and inflammatory eifhsion in the intermuscular connective tissue; swell- ing, opacity, nuclear proliferation, and rupture of the muscular fibres, followed by fatty de- generation and atrophy of the same; and the ordinary inflammatory changes of the vessels of the part. Beyond this stage, unless the case prove fatal, the diffused form of myo- carditis passes into a chronic condition : and it ends either in fibroid disease with a moderate amount of atrophy, by development of the inflam- matory products and atrophy of the affected fibres; in fatty degeneration; in calcification; or in cardiac aneurism. Suppuration of the heart, on the other baud, generally takes the form of swollen yellowish- white patches or abscesses, surrounded by dirty- red or ecchymosed tissue, boggy or pulpy to t h. 312 HEART, INFLAMMATION OF. finger, and containing on section a small quantity of variously-coloured puriform matter, consisting of pus and muscular debris. In the same cases a, great part of the walls of the heart may be in a condition of parenchymatous degeneration ; and in some recorded instances the whole of the cardiac tissue is described as infiltrated with pus. Abscesses resulting from acute loca- lised myocarditis are generally very small, vary- ing from the size of a pea to that of a nut. They may either burst externally into the peri- cardial sac, or internally into one of the cavi- ties or through one of the valves, leading to pyaemia, and to the formation of an acute cardiac aneurism ; or the pus may make its way both externally and internally, and lead to fatal haemor- rhage into the pericardium. In other cases the pus undergoes the usual changes, and becomes inspissated or cheesy, or calcification takes place. In both forms of interstitial myocarditis the left ventricle is most frequently the seat of in- flammation. Symptoms.' — The principal symptoms of acute rheumatic myocarditis are restlessness and urgent dyspnoea; severe pain and distress referred to the prsecordium ; and palpitation, which gradually passes into irregularity and greatly increased fre- quency, and finally into complete cardiac failure. The pulse corresponds. The countenance is an- xious and pale, or cyanosed. The mind is fearful and distressed at first, and delirium frequently supervenes before death, especially in young sub- jects. Vomiting is not uncommon, The physical signs are generally associated with those of endo- and peri-carditis ; but when un- complicated may be described as — violent cardiac impulse at first, which rapidly loses in strength and regularity, while it increases in frequency ; a somewhat increased area of cardiac dulness ; and short sharp sounds, afterwards becoming duller and more feeble. When these symptoms and signs make their appearance, they generally run their course ra- pidly, and end in death. In a small number of cases they as rapidly disappear. The symptoms of localised suppurative myo- . carditis leading to abscess are not unlike those just recorded. There are the same distressing symptoms locally, with restlessness and anxiety, passing on to delirium, and ending in collapse. Rigors have been observed in some cases ; and a peculiar pustular eruption on the skin in other cases. The physical signs also are not special ; excepting that a murmur may be suddenly de- veloped by rupture or perforation of part of the wall or of a valve. The majority of cases of abscess of the heart prove fatal by asthenia ; hut the other termi- nations of abscess mentioned above will be attended by their respective symptoms, and the possibility of sudden death is especially to be noted. Diffuse parenchymatous myocarditis is clini- cally known only as a cause of sudden death. Complications. — The complications of acute myocarditis have already been sufficiently indi- cated, such as, first, setiologically, pericarditis, endocarditis, acute rheumatism, and other causes of these forms of inflammation ; and, secondly, pathologically, rupture of the cardiac walls or HEART, MALFORMATIONS OF. valves, acute cardiac aneurism, hsemoperieardiutn embolism, and septicaemia. Coubse and Terminations. — The course ot acute interstitial myocarditis, as already stated, is generally rapid, extending from a few hours to eight days in different cases. Death occurs, in the great majority of cases, from the effects of cardiac failure, if the inflammation be extensive or pro- ceed to suppuration. The formation of acute aneurism by internal rupture, the production cf pericarditis by external rupture, and other com- plications will variously modify the progress and termination of cardiac abscess. Simultaneous rupture both externally and internally causes sudden death. Diagnosis. — The diagnosis of acute myocar- ditis is extremely difficult. Occurring in con- nection with acute rheumatism, it has to be distinguished from endo- and pericarditis. The absence of murmur and of the characteristic signs of pericarditis, along with symptoms of cardiac failure and severe local phenomena, such as pain, distress, dyspnoea, and finally collapse, should generally serve to establish the diagnosis of inflammation of the walls of the heart. It cannot be said that cardiac abscess has ever yet been diagnosed; but the careful consideration of all the points in the case, and the sudden de- velopment of a murmur indicative of rupture of portion of the wall, or of a valve, may here- after ensure greator success. In the event of the development of the last-named sign, and of septicaemia or embolism, cardiac suppuration would have to be carefully diagnosed from ulce- rative endocarditis. In children, acute myocar- ditis has to he distinguished from acute meningeal inflammation, an object which may be effected by the careful observation of the signs and symptoms connected with the heart. Prognosis. — The prognosis of myocarditis, when it is either so extensive or so intense as to give rise to unequivocal symptoms, is extremely unfavourable. Treatment. — The two principal indications of treatment in acute inflammation of the sub- stance of the heartare to support and strengthen that organ, and to relieve the pain and distress. Local anodynes, especially in the form of the preparations of belladonna and poultices ; and stimulating ‘counter-irritants,’ such as mustard cataplasms, will conduce tofulfil the second indica- tion. Such relief is the first essential, if rest is to be secured. The patient must be spared the very smallest exertion. Food must be given in small quantities, and be easily digestible ar.d highly nutritions ;■ the bowels must be kept open ; and the flow of urine should be as free as possible. Alcoholic stimulants will be urgently called for: and palpitation may be regarded as an indication of the necessity for these, as .much as weakness of the impulse. Digitalis, ammonia, and other cardiac stimulants should he given cautiously, at the same time, so as to strengthen the car- diac action, whilst diuresis is encouraged. J. Mitchell Brcce. HEAET, Malformations of. — Synon. : Ft Affections Congenitalcs du Cceur ; Ger. Missbil- dunqcn des Her sens. Classification and Description — The car- HEART, MALFORMATIONS OF. diac anomalies of development may be classed as follows : — I. Those dependent on arrest of the process of development at an early period of foetal life, so that the organ retains its most rudimentary form, the auricular and ventricular cavities being still single or presenting only slight indications of division, and the primitive arterial trunk being retained, or the aorta and pulmonary ar- tery being very imperfectly evolved. II. Those in which the defective conformation occurs at a more advanced period, when the auricular and ventricular partitions are already partly formed, and the aorta and pulmonary artery more or less completely developed. Such are the cases in which, with imperfect separation of the ventricles and auricles, the arterial or auriculo-ventricular passages are constricted or obliterated, and the origins of the aorta and pul- monary artery are misplaced. III. Cases in which the development of the or- gan has progressed regularly till the later periods of fatal life, so that the auricular and ventricular septa are complete, and the primary vessels have their natural connections, but in which there are defects which prevent the heart undergoing the changes which should ensue after birth : such are the premature closure of the foramen ovale, the non-development of the ductus arteriosus, or the occurrence of slighter sources of obstruction at the arterial or auriculo-ventricular passages or in the course of the aorta. IV. Cases in which there is some irregularity in the formation of the valves, or in the connec- tions with the vessels, or in the vessels them- selves, which, though not immediate sources of obstruction, may become so during the progress of life, so as to lay the foundations of subsequent disease. I. Cases of the first class are of very infre- quent occurrence, and are the more rare accord- ing to the extent of the imperfection. The first case of simply biloeulate heart was placed on record by Mr. Wilson, in the Philosophical transactions, in 1788, and the specimen is pre- served in Dr. Baillie’s museum, in the possession of the Royal College of Physicians. The ano- maly was found in the body of a child, which survived for seven days. From defect in the diaphragm, the heart lay in a sac on the upper surface of the liver ; and the organ was found to consist of an undivided auricle and ventricle, and a single artery, evidently the primitive arte- rial trunk, which first gave off a vessel which fur- nished the branches to the lungs, and the vessels to the head and upper extremities. The coronary arteries arose by a common trunk from the aorta before its final division. Since the publication of this case, others have been placed on record illustrating the gradual advancement from the simple to the more complicated forms — the ven- tricle becoming more completely divided, the septum of tho ventricles being more fully de- veloped, and there being two vessels given off from the ventricle, though in some cases one of these may be abortive, or if there be only a single vessel, that being shown by the origin of the coronary arteries from its commencement to be really the aorta. II Of the second class, the examples which 613 have been described are much more numerous. In cases of this kind the auricles and ventricles are fully formed, though the septa which divide them are incomplete, and there is usually more or less displacement of the origins of the primary vessels, so that the aorta more especially may come to arise partly or almost entirely from the right ventricle ; or the points of origin of the vessels maybe transposed, the aorta arising from the right ventricle, and the pulmonary artery from the left. Cases of the former description, in which the septum of the ventricles is incom- plete, and the aorta misplaced to the right, are almost always found to coexist with some ob- struction to the passage of the blood from the right ventricle, either (1) from smallness of the pulmonary artery ; (2) from imperfection of the valves ; (3) from constriction at the outlet of the right ventricle, or at the end of the conus arteriosus or infundibular portion of the ven- tricle ; or (4) from constriction at the com- mencement of the conus or point of union be- tween that portion of the ventricle and the sinus. A case of the second description was published by Sandifort, in 1777, and one occurred to Dr. Hunter in 1761, but was not published till 1763. The fourth form of obstruction, or that occa- sioned by constriction between the sinus and the infundibular portion of the right ventricle, has only recently been explained, though cases of the kind have for some years been placed on record. It is indeed probable that the existence of a very decided partition in this situation led to the idea entertained by some of the older pa- thologists, that the heart occasionally had three ventricular cavities. The abnormal septum is partly formed by hypertrophy of the muscular structure, and partly by the endocardium be- coming thickened; and in some cases very decided obstruction is so caused. The defect is generally developed at an early period cf foetal life. The septum of the ventricles is therefore incomplete, the defect being at the posterior part, so that the aorta comes to arise from the sinus of the right ventricle, while the pulmonary artery takes its origin from the infundibular portion, which seems to constitute a distinct cavity. The heart thus, as pointed out by Mr. Grainger, bears an almost exact resemblance to the condition of the organ in the turtle. In the turtle there are two aortic ventricles and one pulmonic ventricle ; the right aortic and the pulmonic ventricle being the analogues of the sinus and infundibular portion of the right ventricle, and being in connection, while the left aortic ventricle is distinct. Much more rarely there has been found an entire obliteration of the orifice or trunk of the pulmonary artery, the first case of this descrip- tion of anomaly having also been published by Dr. Hunter at the same time as the former case. Much more rarely the defect in the ventricle has been found in connection with obstruction or obliteration of the right auriculo-ventricular, the left auriculo-ventricular, or the aortic aperture. AVhere the septum of the ventricles is incom- plete, the defect generally exists at the base, at the part which has been termed the undefended space — the space which intervenes between the contiguous sides cf the left and posterior semilu- nar segments, where on the left side the muscle is HEART, MALFORMATIONS OF. 514 naturally deficient; and in this way a connection may exist between the left ventricle and right auricle or ventricle, either immediately above or below the right auriculo-ventricular opening. More rarely the septum between the left ventricle and the conus arteriosus of the right ventricle is defective ; and still more rarely an aperture exists at a lower part of the septum. The portion of the septum dividing the left ventricle from the sinus of the right is termed by Rokitansky the poste- rior — that between the left ventricle and conus arteriosus, the anteriorseptum. With the defects now mentioned, the auricular septum may also be incomplete, or the foramen ovale may be still open, or the ductus arteriosus pervious. Indeed, when the pulmonary artery is much contracted or impervious, one or other of the former conditions necessarily exists, and the ductus arteriosus be- comes the means by which the blood is conveyed to the lungs, though occasionally there are com- pensatory branches derived from the aorta or one of the large vessels also distributed to the lungs. The transposition of the aorta and pulmonary artery also occurs at an early period of fcetal life. The first case of the kind recorded was related by Dr. Baillie in 1797 ; the specimen is figured in his plates, and still exists in the museum in the possession of the Royal College ofPhysicians. In this anomaly the septum of the ventricles is generally defective, and the two fcetal passages open, and the organ may indeed be very defective in conformation. The heart also is often mis- placed in the chest. Another form of defect is that in which the descending aorta is given off from the pulmonary artery through the ductus arteriosus. This condition is apparently the result of imperfect development of the isthmus aortse between the origin of the left subclavian artery and the point of entrance of the duct, so that an adequate supply of blood cannot be conveyed from the ascending into the descending aorta. Generally the condition coexists with defect of the septum of the ventricles, as in two cases formerly in the possession of Sir Astley Cooper, and now contained in the museum of St. Thomas’s Hospital, described by Dr. Farre in 1814. In some instances of this kind the por- tion of aorta between the loft subclavian artery and the duct is imperforate, and yet in others, as in a case related by Steidelle and referred to by Hein in 1816, there is no connection between the two portions of the aorta, the ascending part giving off the vessels to the head and upper extremities, the descending portion being wholly- derived from the pulmonary artery. This form of defect is closely allied to the cases which are occasionally seen in after-life, in which there is constriction or obliteration of the isthmus aortse beyond the left subclavian artery, the circulation being maintained through collateral channels. III. The third class of cases consists in the premature closure of the foramen ovale ; or the non-development, or disappearance, at an early- period of foetal life, of the ductus arteriosus ; or in diseased conditions of the valves, which pre- vent the heart undergoing the changes which should ensue after birth. The first condition is of very rare occurrence. The first case recorded was related by Vieussens inl715. In these cases the blood during foetal life being all transmitted through the right cavities and the pulmonary artery and duct, those portions of the heart are unduly developed, while the left side of the organ becomes atrophied. In the second class of eases the heart is defectively- de- veloped, and the right ventricle gives origin to the aorta, and often also vessels are distributed from the aorta to the lungs, while the ordinary- pulmonary artery may be very small in size, or may- be entirely absent. In a case of this kind, described by Dr. Ramsbotham, the pulmonary artery- is said not to exist : but bv ex- amination of the specimen preserved in the Lon- don Hospital Museum, the writer has ascertained that this is not correct. The artery exists as a very- small vessel, but the scanty supply of blood to the lungs which itfurnished was complemented by small vessels from the aorta. In eases which are not of uncommon occurrence, and may be classified with the malformations now spoken of, but which are closely- allied to the next class, there exists some source of obstruction to the transmission of the blood from or into the right ventricle, which determines the imperfect clo- sure of the foramen ovale, or the patency of the ductus arteriosus. The obstruction in these cases generally depends on disease of the pulmonic valves, or obstruction at the end or beginning of tile conus arteriosus, or at the right auriculo- ventricular aperture. IV. The fourth class of malformations con- sists of defects, of a slighter description, of the valves, or narrowing of the orifices, or of the isthmus aortse. The semilunar valves may be excessive or de- fective in number. The former condition probably does not materially interfere with the functions of the heart — the latter often does so, and es- pecially- when, as is very frequently the case, the valves become the seat of disease in after-life. If there be only two valves, one of them imper- fectly representing two distinct segments, there is great liability to incompetence. If there be only- one valve, representing three imperfect segments, obstruction is almost necessarily occa- sioned. It is probable that the cases in which the tricuspid valve is found represented by a kind of membranous diaphragm, stretched across the orifice and perforated in the centre, and some of the so-called cases of button-hole mitral, are also of congenital origin. It is not considered necessary in this article to refer to many examples of these different forms of malformation, or to allude to other of the less important deviations from the natural con- formation of he heart. The subject will be found more fully treated of in the works of Dr. Farre 1 and Gintrac 3 and Freidberg, 3 in the papers of Dr. Che vers, 4 and in the writer’s own work. 5 The more recently published cases also are ah- 1 On Malformations of the Human Heart. London. 1S14. 3 Observations et Recherches sur la Cyanose , ou JJaladie Bleue. Paris, 1S24. 3 Die angebornen Kranl’heitcn des Herzens etc. Leipzig, 1S44. * Collection of facts illustrative of Morbid Conditions of the Pulmonary Artery. London, 1851, and Medical Gazette, 1845 to 1851. s * Malformations of the Human HearL Second edition 1SGG. HEART. MALFORMATIONS OF. 61c ftr&cted in the treatise of Taruffi, 1 and numerous examples of different forms of malformation are gi'-en by Rokitansky. 2 Mode of Formation. — It is probable that all the different forms of irregularityin the develop- ment of the heart are due to arrest of develop- ment, occurring at different periods of evolution, so that the heart retains the forms proper to it at such stages. The cause to which this arrest is to bo ascribed can rarely, however, be traced in cases where the defect is great, such as those cf biloculato heart, or where the vessels are transposed with or without very marked imper- fection in the organ itself. These defects must be ascribed to the imperfect evolution of the double set of cavities, and of the pulmonary artery and aorta from the primitive trunk and branchial arches. In the less marked defects, however, the irregularity can often be traced to a source of obstruction to the transmission of the blood through one or other of the apertures or vessels. Such obstruction is much the most common in connection with the right ventricle and pulmonary arlery. In cases of this kind the septum of the ventricles is deficient, so that the aorta arises wholly or in part from the right ventricle. Dr. Hunter, in the paper before referred to, when describing a ease of obstruction of the pulmonic orifice with defect in the septum of the ventricles, suggested that the imperfection in the septum was probably caused by the pul- monic obstruction. Meckel, however, adopted the view that the primary defect was in the septum of the ventricles, and that the pulmonary artery became more or less abortive from being thrown out of the course of the circulation by the ready outlet afforded for the blood from the right ventricle into the aorta. The former view seems, however, to afford the more satisfactory explanation, and is in accordance with the almost constant occurrence of disease of the valves in those cases. According to the view of Meckel, the pulmonary artery should simply be small, as when the ductus arteriosus is absent, like the case of Dr. Ramsbothain before referred to, but such a condition is very rarely found. The excess in the number of the semilunar valves might seem to afford an example of redundant development, but this condition also probably depends on ar- rest of development ; though, as we do not clearly understand the mode in which these valves are developed, it is impossible to express a very decided opinion as to the cause of the apparent oxcess. Symptoms and Diagnosis. — There cannot generally be much difficulty in recognising a case of malformation of the heart during life. Not only in cases of a very marked kind is there generally a complete history of the condition of the subject during its short life, hut the symp- toms are also very characteristic. The child is very markedly cyanotic; the cheeks, lips, hands, and feet are excessively livid; the fingers and toes are clubbed; the nails are incurved; and the patient is liable on any excitement, or ou exposure to cold, to attacks of dyspnoea, otten followed by convulsions. There are also often present difficulty of breathing, cough, and 1 Sullc Malallie congenite , etc., del cuore. Bologna, 1875. 1 Die defecte dcr Scheideicande des Herzens. Wien, 1875. expectoration of blood; with palpitation, and often pulsation of the vessels of the neck. If also there be any obstruction at or near the pulmonary orifice, there will be a harsh systolic murmur heard in the course of the pulmonary artery; and if there be a defect in the septum of the ventricles, the murmur will be heard probably also in the course of the aorta. Often there are unhealthy ulcerations about the fin- gers, toes, and anus or Y'ulva. If the case do not attract notice till late in life, there will probably be less marked signs of obstruction to the circulation, and possibly they may be entirely absent, and there may be no history of the patient's previous condition. In cases of this kind the probability will be that if there is e murmur at the pulmonary artery there is some defect at or near the orifice of that vessel, with or without an aperture in the septum of the ventricles or an open state of the ductus arteriosus. The former condition is so rare as the result of disease in after-life, that if the signs point to pulmonic valvular disease, its congenital origin may safely he surmised. The open fora- men ovale and ductus arteriosus could prohahlj not be diagnosed with any certainty, though cases have occurred in which peculiar murmurs • noticed during life ivere supposed to ho so pro- duced. It might he supposed that when so small a proportion of the blood is subjected to the influence of the air, as in some of these cases, the temperature of the patient ivould not reach the natural standard, hut the most careful obser- vation of the temperature of children lahourina under congenital cardiac cyanosis has generally failed to detect any marked difference between them and other children of about the same age. Cyanosis. — There are few subjects which have excited more discussion than the causes of Cyanosis or Morbus Coerulus. Morgagni, in 1761, when describing the case of a girl who had ob- struction at the orifice of the pulmonary artery with an unclosed foramen ovale, expressed the opinion that the general congestion was probably the cause of the remarkable lividity which had been noticed during life; and Dr. Hunter, in 1783, in describing a case of pulmonic obstruction with imperfection in the septum of the ventricles, ascribed the lividity to the intermixture of the venous and arterial currents of blood. These views have since received support from various writers. The view of Morgagni has been main- tained by Louis, and that of Hunter by Gintrae. It has been i-ery fully shown that there is no just and constant relation between tho intensity of the cyanosis and the amount of intermixture, and in- deed that very marked cyanosis may exist without any intermixture ; while on the other hand in all cases of marked cyanosis there are present causes capable of producing great venous congestion. The writer is, therefore, of opinion that the evidence is very greatly in favour of the correct- ness of the views of Morgagni and Louis, that the cyanosis results from stasis of the blood, though probably other causes conduce to the in- tensity and peculiarity of discoloration. Thus, probably, the defect must he congenital, or. at least, of very long duration, so that the smaller vessels may become greatly dilated ; the integu- ments must be thin, so as to allow the colour o / 516 HEART, MALFORMATIONS OF. ‘he blood more readily to be seen, and lastly — probably also from the very small portion of the blood which can be subjected to the influence of the air — the whole mass is of an unusually dark colour, and so the intensity of the lividity is increased. Duration and Terminations. — The duration of life in the subjects of the different forms of malformation varies greatly, according to the degree of the defect in the heart. In cases in which the organ presents a very rudimentary condition, life can only be prolonged for a few hours or days ; while in the slighter forms of defect the patient may survive to puberty or to manhood or womanhood, or even to more ad- vanced age. Thus, in cases of contraction of the pulmonary artery, without other defect in the organ, cases are on record in which patients lived to 44 and 63 ; when, with the pulmonic disease, the foramen ovale was unclosed, the subjects have reached 40 and 57- Where the septum of the ventricles was deficient, nine patients are stated to have lived to between 20 and 30. Where the ductus arteriosus was still open, patients lived to 13^ and 19 years ; but of course these ages are the extremes, and by far the largest proportion of the subjects die much younger. When the pulmonic orifice or artery is impervious, but few patients survive for more than two years, but cases are cn record in which 9 and 12 years of age were attained; the age being greater according to the facility afforded for the transmission of the blood from the right side of the heart, as when the septum of the ventricles was imperfect, than when the ventri- cles were completely separated. Transposition of the aorta and pulmonary artery is a defect incompatible in any of its forms with the prolongation of life for any lengthened period. Four cases are, however, on record in which the patient survived to between 2 and 3 years of age— the imperfection of the septum of the ventricles tending in these cases also to the prolongation of life. The most common causes of death in cases of malformation of the heart are affections of the brain and lungs, haemoptysis, &c. ; and, if the pa- tient survive for a sufficient period, tuberculous affections. Notwithstanding the very great ob- struction to tlie circulation, dropsical symptoms do not generally arise to any marked degree. Treatment. — It is scarcely necessary to speak of the treatment of these cases. It must consist in protection against cold ; in the main- tenance of bodily and mental quiet ; and in the use of a nutritious and easily digestible diet. T. B. Peacock. HEART, Morbid Growths in. — The various forms of morbid growth that have been met with in the heart may be thus enumerated in the order of their frequency : — 1. Malignant disease ; 2. Lymphomatous or lymph-adeno- matous growths; 3. Non-malignant tumours; and 4. Cysts. Fibroid growths, syphilitic gum- mata, and tubercle, as well as hydatids affecting the heart, are discussed separately under their respective heads. Calcareous, cartilaginous, and osseous changes of the myocardium are noticed in the article Heart, Degenerations of. HEART, MORBID GROWTHS IN. 1. Malignant Disease of the Heart. — Cancer, although the most common if the new formations found in the heart, is still very rare in this situation, and is a subject chiefly of pathological interest. IEtiology. — Malignant disease of the heart is, with very few exceptions, always secondary; and the primary growth may have its seat in any part whatever of the body. Occasionally the heart becomes involved by continuity, the lungs and mediastinum being the seat of the primary disease. Cases have occurred at all periods of life, from infancy to old age ; but at least one-half of the subjects have been in the middle period of life. The disease has been most frequently found in males. Anatomical Characters. — Carcinoma, epi- thelioma, and sarcoma, inclnding colloid cancer and melanosis, have all been found in the heart in different instances. Any part of the organ may he affected, and the right side appears to be more frequently invaded than the left ; but the disease is generally multiple. The morbid growth generally presents itself at or upon either of the surfaces of the heart, rather than in the sub- stance of the myocardium. In these situations there appear one or more masses of malignant disease, which are generally easily distinguished from the cardiac tissue around; and which pos- sess the ordinary characters of such formati ns. according to their respective forms, encephaloil being the most common, and epithelioma by far the most rare. Any difficulty in the recognition of the disease is removed by section and micro- scopical examination. The extent of cardiac wall involved by the growth is sometimes great. When the masses of malignant disease project exter- nally, they arc frequentlyasscciated with pericar- ditis, either local or general. Prominent nodules in the interior of the heart may cause local endocarditis ; and in other instances the valves and their appendages may he so involved that incompetence results. In very rare cases malig- nant disease of the heart proceeds to ulceration. Symptoms. — Of thirty-six cases of mal-gnant disease of the heart, the histories of which were collected by Dr. Quain, in thirty either there were no symptoms present, or they were not recorded. In one of the remaining six cases, the subject of the disease, a man of thirty seven, in whose heart a single large mass of encephaloid cancer was found post mortem, had been subject to attacks of excruciating pain in the praecordial region, to dyspnoea, palpitation, and vomiting ; and death occurred suddenly. Pain in the chest and oppression, not referable to other causes, are recorded in two other cases ; and in the fourth there were anginal seizures. Iu cases of cancer of the heart spreading from the mediastinum or lungs, dyspnoea, cough, ar.d pain are necessarily frequent symptoms. With respect to the physical signs of malig- nant disease of the heart, tenderness on per- cussion over the prseeordium (in association with local pain), pericardial friction, and endo- cardial murmurs duo to involvement of the valvular apparatus in the new growth, appear to be the only phenomena that have been specially observed. The disease naturally ends in death: and iv HEART, MORBID GROWTHS IN. more than one instance this termination was Midden, and perhaps directly due to the affection of the heart. Diagnosis. — This condition has probably never been diagnosed during life. The appearance of true cardiac pain, or of any of the physical signs just mentioned, in the course of a case of cancer, would, however, bo strong evidence that the heart was secondarily involved. Treatment. — The treatment of malignant disease of the heart is necessarily limited to the relief of any symptoms that may be present, and does net differ from the treatment of cardiac distress from other causes. 2. Lymphoma of the Heart. — Lympho- matous or lymphadenomatous growths have been met with in the heart in several cases in which the disease was general, but this affection of the organ cannot be said to have any clinical im- portance. 3. Non-Malignant Tumours of the Heart. These growths are also of purely pathological interest, and are amongst the very rarest of morbid appearances in connection with the heart. Myomata have been recorded as instances of this class of diseases. Lipomata lying under the endocardium are referred to in the article Heart, Fatty Growth on. 4. Cysts of the Heart.— The occurrence of true cysts in the myocardium (hydatids, ab- scesses, hsematomata, and softening gummata being excluded) is doubtful. J. Mitchell Bruce. HEART, Palpitation of.— S ynon. : Fr. Ptlpitation da Coeur ; Ger. Herzklopfen. Definition. — Abnormal movement of the heart, whereby the force of the systolic contrac- tions is increased to such a degree as to give rise to a sensation of discomfort or distress on the part of the patient. 2Etiology. — The immediate or proximate cause of palpitation is an over-stimulation of the excitability of the muscular structure of the heart, induced by functional errors of the cardiac ganglia and of the vagus, or of those nerves which, proceeding from the ganglia of the great sympa- thetic, supply tho heart. It is therefore a true neurosis. The disordered action of these nerves may be induced either directly or by reflex action ; but in either case the phenomena as regards the heart are the same, namely, the morbid activity of a normal function, which must be here con- sidered as independent of any accompanying or- ganic lesion. The predisposing and exciting causes of palpi- tation of the heart are various. The chief pre- disposing causes are to be found in the nervous and excitable temperaments; general debility; inanition ; exhaustion, whether bodily or mental; early age; hysteria; venereal excesses; and in deterioration of the blood, as occurs in gout, scurvy, chlorosis, or spansmia. Amongst the exciting causes may be classed violent exercise ; mental shock, emotion, and all forms of sudden excitement of the nervous system; dissipation; injurious articles of diet ; and dyspepsia. Symptoms. — Palpitation may be found in the form of (1) a single action ; or (2) a series of ac- tions, which may become prolonged, and of such HEART, PALPITATION OF. 617 a character as to be esteemed chronic. The single abnormal beat not unfrequently occurs during a first sleep, and the patient is wakened by a con- sciousness of it. Sleep may then return, and the attack subside without other inconvenience ; or it may be associated with a feeling of weight, ful- ness, anxiety, sinking, or even pain of the prte- cordia. More frequently, however, the attacks are prolonged and paroxysmal, recurring with an accelerated and uncertain frequency, and varying rapidity. In the patient the act of palpitation causes various and widely different sensations. There may be a mere occasional flutter, or a slightly increased action continuing for a time ; or there may be increased action attended with great rapidity, and such violence that the heart appears forcibly to strike the chest- walls, dif- fusing its influence over the whole sternal region, and even at times agitating the whole body (a phenomenon probably due to an associated general nervous agitation) ; or the heart, again, may seem to the sufferer to rise, as it were, into the throat. With these several forms there may be the accompanying symptoms of choking — the globus hystericus ; vertigo ; tinnitus aurium ; impaired vision, with a feeling of distension of the eyeballs ; a copious secretion of pale limpid urine; a clammy coldness of the extremities; fear of death ; partial unconsciousness ; or actual syncope. Paroxysms such as these may be pre- ceded by a somewhat prolonged state of cerebral disturbance, as evidenced by heat of brow and vertex, headache, and an inaptitude to think or regulate the thoughts ; and as there is generally a self-consciousness of the abnormal action of the heart, the anxiety on this account serves to impress the mind with so much fear and inquie tude, as to tend to increase and prolong the dis- order that has induced them. Physical Signs. — The physical examination of the heart shows the apex-beat to be normal in position, but diffused and much exaggerated in force. The area of dulness, as a rule, is not enlarged upwards, but it may be temporarily enlarged, under certain circumstances, towards the right side. The sounds, always exaggerated, at times become very much so, and usually with a sharp metallic ring. Occasionally a kind of remit- ting humming sound is superadded, and maybe heard even by the patient ; but this is never con- stant. Sometimes the sounds are heard over a great extent of surface ; but this extent is no measure of their intensity, for they may not be loud, but abnormally clear and distinct only. Oc- casionally there is a pericardial rubbing accom- panying the mitral apex-shock, simulating the friction-sound of pericarditis, but there is never true friction-sound. The basic second sound, more frequently than the first, presents the me- tallic ring. Sometimes it becomes lower-pitched and less clicking than in an ordinary paroxysm of palpitation; and may even, as also the first sound, so lose sharpness and abruptness as to assume somewhat of the character of a soft murmur. The aorta, carotids, and large arteries also throb, and have an excited impulse. Tho smaller arteries are not sensibly affected. The pulse at the wrist is often no indicator of the amount of action exhibited by the heart. Some- times it has the character of being sharp and 518 HEART, PALPITATION OF. jerking, -without force ; or, should the right side of the heart become loaded with blood, it may be small and soft, and weak. On the subsidence of a paroxysm, the ventricular impulse may drop to its natural force and frequency, and the sounds be unaccompanied by any exaggerations. Nevertheless, though the attack may have sub- sided, there may be some slight irritability of the heart’s action perceptible for some short time afterwards. Diagnosis. — Though the diagnosis of palpita- tion of the heart in some cases may present dif- ficulty, yet, in the absence of evidence of struc- tural lesion, an increased impulse presenting the above distinctive characters may be assumed to be functional in its origin, and not dependent on any organic disease of the heart itself. We have, in fact, to do with an exaggeration, some- times highly marked, of the natural nervous susceptibilities of the heart ; and this nervous increase of impulse, even when only slight, is usually more appreciated by the patient, more painful, and more a source of anxiety lhan is that attending organic disease, especially in its earliest stages. Treatment. — The treatment of palpitation should in every case be directed to remedy or to remove the exciting cause of the attacks, and to render the nervous system less susceptible. In the simpler forms that which is prophylactic is all that is necessary. In more marked attacks general care, with quiet, may be sufficient ; or tho administration of an alkali with warm restoratives. In the protracted and severer forms of attack, besides ether and ammonia, digitalis, aconite, colchicum, chloral hydrate, and tho bromides may be occasionally resorted to. T. Shapter. HEART, Pyaemic Abscess of. — Defini- tion. — Abscess of the heart occurring in pyaemia. ./Etiology. — Abscess of the heart has been most frequently observed in cases of pyaemia following acute necrosis of bone or diffuse peri- ostitis, and less frequently after phlebitis, chronic or acute arthritis, urethral stricture, chronic abscess, and cancerous ulceration. In eleven out of fourteen cases, the histories of which were collected by Dr. Quain, the age of the patients was seventeen years or under; and twelvo out of the same fourteen cases were males. In other words, pyaemic abscess of the heart has been most frequently found in eases following injury to a bone or to a joint in boys. In older subjects it has been associated with pyaemia secondary to one or other of the diseases just mentioned. In a few cases no primary dis- ease was discovered. Anatomical Characters. — Pyaemic disease cf the walls of the heart has been most fre- quently observed in the left ventricle, towards the base and in the papillary muscles. In the great majority of eases, pericarditis co-exists, and very frequently endocardial inflammation also. The pysemic foci are generally multiple ; and appear at first as small, slightly elevated, yellowish or buff-coloured, softened patches, projecting either on the external or on the inter- nal surface of the heart, and covered with in- HEART, PYeEMHJ ABSCESS OF. flammatory deposit. On section, these patches either present an appearance of diffused yellowish softening, or contain one or more collections of dark dirty puriform matter, with ragged, ill- defined boundaries, as if formed by destruction of the discoloured tissue around, and varying in size from that of a pea to that of a pin’s I, cad. Microscopically examined, the yellowish pat- ches prove to be portions of the myocardium which are infiltrated with pus and granular matter ; the muscular tissue itself being in a condition of granular or fatty degeneration. Tha puriform material represents an advanced stage of the same change, consisting of granular mat- ter and other muscular debris, blood, and fre- quently pus-corpuscles. The several stages of the pyaemic process have been found side by side in some cases ; and embola have been discovered in the branches of the coronary arteries, where they may have served as the foci of the abscesses. The walls of the heart are sometimes in a con- dition of softening throughout. Pyaemic abscess of the heart occasionally hursts ; and the con- tents either make their way into the left ven- tricle — producing cardiac aneurism, and perhaps giving rise to further embolism and pyaemic disease— or into the pericardial sac. Symptoms. — Whatever the symptoms of py- semic abscess of the heart may be, they have in recorded cases been completely obscured by the general symptoms of pyaemia, and by the local symptoms and signs of pericarditis. Thus, the patients are described as presenting a febrile, typhoid, or pyaemic appearance, an anxious look, dyspnoea, and praecordial pains; pericardial friction has been generally discovered over the heart. Delirium probably occurs more frequently than in ordinary cases of pyaemia, hut may he referable to the accompanying pericarditis. Tho physical signs found in these cases are chiefly those of acute pericarditis. Sometimes an en- docardial bellows-murmur may be heard, duo either to valvular lesion, or to the formation cf an acute aneurism of the cardiac wall. Course and Terminations. — The cases of pyaemia in which the heart has been found post mortem to be involved, have generally proved rapidly fatal, the patients dying from exhaus- tion. Rupture of the abscess in either direction may tend to accelerate the fatal termination: but complete rupture of the wall iu both direc- tions, with sudden death from lise mo-pericardium, as in non-pyaemic abscess of the heart, does not appear to be on record. Diagnosis. — In every case of pyaemia the physical condition of the heart should he regu- larly investigated ; and there should no longer be any risk of acute inflammation of the heart or pericarditis being mistaken for meningitis or simple delirium. Pyaemia with multiple arthritis and involvement of the heart is more difficult of diagnosis from ordinary acute rheumatism with cardiac inflammation ; and mistakes iu such cases have not unfrequently occurred. The history of the case, including the evidence of a definite in- jury, however slight, is of the greatest value : but a careful consideration of all the facts of the case alone can prevent mistakes. The only dii- fieulty that remains in the diagnosis of pyaemic abscess of the heart is the determination of its HEART, PYjEMIC ABSCESS OF. existence in the presence of pericarditis, which is rarely absent. For this purpose the facts of the aetiology of the case are more important than the symptoms ; and especially the occurrence of an injury to the periosteum of a youthful subject as the original cause of the pyaemia. As a matter of fact, the symptoms, either general or local, appear never to have suggested the diag- nosis of pysemic abscess of the heart. Prognosis. — If a diagnosis of abscess of the heart can be made in pyaemia, the only possible prognosis that can be given is one of speedy death. Treatment. — The treatment of pyaemia affect- ing the heart cannot be said to differ in any important respect from that of ordinary cases of the disease (see Pyaemia). The accompanying pericarditis will call for local treatment. J. Mitchell Bruce. HEART, Rupture of. — The heart is liable to rupture from external injuries, and from causes acting from within. The latter are called spontaneous ruptures, and these only will be con- sidered here. Spontaneous ruptures may affect either the walls or the valves. The latter form of lesion will be found discussed under the head of Heart, Valves of, Diseases of. .ZEtiology'. — Rupture of tho walls may be said never to occur spontaneously when the heart is healthy. The following have been enumerated by different writers as tho diseased conditions of the heart’s walls that predispose to rupture: — a thin or atrophied condition, simple softening, a ‘ gelati- niform’ condition of the walls, apoplectic or hte- morrhagic effusion into the walls, abscess, ulcera- tion, and fatty degeneration. The writer finds from a table of 100 cases of rupture, the his- tories of which he has collected from different sources, that the heart had undergone fatty de- generation in 77; in 6 the walls were described simply as being softened ; in 1 there was rup- ture of an aneurismal dilatation ; in 1 there was bursting of an abscess; in 12 the heart is said to have been healthy in texture, or not to have been examined ; but in most of these latter cases mention is made of the previous existence of endocarditis, or of changes in the coronary arteries, fully justifying the impression that there was disease of the texture of the heart. The influence of age in relation to rupture of the heart can be distinctly traced. For example, of the 100 cases just referred to, 63 were above the age cf sixty years. Arranged in decades, the cases stand thus : — 2 were between ten and twenty ; 1 between twenty and thirty ; 3 between thirty and forty ; 6 between forty and fifty; 13 between fifty and sixty ; 33 between sixty and seventy ; 21 between seventy and eighty ; G were over eighty ; and in 2 the age is not stated. With respect to sex, of 98 out of 100 cases in which it is mentioned, 54 were males and 44 females. The exciting cause of rupture of the heart is usually some mental excitement or physical effort ; but the accident may occur when the subject of it is at rest, or pursuing the ordinary avocations of life. Anatomical Characters. — Scat. In 76 cases out of the 100 to which we have already alluded, HEART, RUPTURE OF. 619 the left ventricle was the seat of the rupturo ; and in 43 of these cases the lesion was in the anterior wall. Tho right ventricle was found ruptured 13 times, nine instances occurring in its anterior wall. The right auricle was ruptured seven times; the left auricle twice; and a rupture was found in the septum four times. These re- sults correspond remarkably with those of other writers on the subject. Elleaume (Mon. des Hopit., 1858) in 55 cases found the rupture 43 times in the left ventricle, seven times in the right ventricle, three times in the right auricle, and twice in the left auricle. On examining a heart in which rupture lias occurred, the torn part is found to present different characters in different cases. The lesion may be complete, causing perforation of the wails ; or it may be incomplete. In com- plete rupture the opening is sometimes barely sufficient to admit a probe, whilst in other instances it may bo two or three inches in length. The rent is sometimes longer exter- nally, and sometimes it is longer internally. There may be but one, or there may be more than one, rupture ; and in the latter case the ruptures may or may not communicate with one another. In incomplete rupture the injury may be confined to the internal surface, or to the ex- ternal surface, or it may occur in the substanee of the walls. The edges of the rent are ragged, irregular, and sometimes ecchymosed. The irre- gularity of the edges is due to the manner in which the muscular fibres are torn, whether across or split longitudinally. This description refers more correctly to rupture iu a heart that is the subject of fatty degeneration. The appearances are different when the rupture is secondary to an abscess, or to ulceration, or to certain other causes presently to be described. In such cases the lesion has been described as a rent, tear, ulceration, or perforation. The condition of the heart in the majority of cases of rupture has been already referred to in this article under the head of JEtiology. Ecchymoses are some- times found in the vicinity of the lesion. The pericardium generally contains an effusion of blood, which often surrounds the heart with coagulum, leaving the sac filled until serum, to the amount, it may be, of thirty ounces, as in an instance which came under the writer’s notice. Mechanism. — Rupturo of the heart is doubt- less nearly always the result of a strain or of pressure acting upon the muscular walls. The walls of the healthy heart are sufficiently strong to resist any ordinary force to which they are exposed. But when they are softened by de- generation, or are very thin, as is sometimes the case in the auricles or the rightventricle, theymay give way before the pressure to which they are exposed during muscular efforts or strains, or even in the ordinary action of the organ. Thus, when a part of the wall of the heart is weakened by softening or other cause, this spot may be, as it were, torn across by the contraction of the healthy fibres among which it is situated. Or again, when the walls of the heart are thick, it may be that the outer surface, being strained over the contents of a distended ventricle, as would be the outer surface of an overbent hoop 620 HEART, RUPTURE OF. gives way, tears, and the opening gradually extends from without inwards. These facts enablo us to understand why rupture is more frequent in the left than in the right ventricle. A further explanation is to be found in the fact that the left ventricle is more frequently than the right the seat of fatty degeneration, from causes elsewhere alluded to (see Heart, Fatty Degeneration oj.). There is yet another way in which softening leads to rupture. A softened spot occurs in the substance of the heart, and into it hoemorrhage takes place, constituting what is termed apoplexy of the heart. At times this haemorrhagic softening may yield either exter- nally or internally, and give rise to rupture. Lastly, the writer has seen more than once a small spot of softening with loss of substance occurring on the internal surface of the ventri- cular wall, most frequently in the left ; this softening and breaking down of tissue gradually insinuates itself amongst the muscular fibres, until finally perforation of the outer wall of the heart occurs. Symptoms. — The symptoms of rupture of the heart may be described as those which are pre- monitory ; and those which occur at the time of the accident. The former are such as indicate a diseased condition of the organ— namely, breath- lessness on exertion, palpitation, more or less irregularity of pulse, and faintness. In some instances recorded these symptoms were so slight as hardly to attract attention ; in others so severe as to cause intense suffering. In the majority of the cases noted in the table referred to, no mention is made of any preceding symp- toms, death being sudden. In several cases it is .distinctly stated that no symptoms preceded the fatal attack. The occurrence of the lesion itself, when the patient has lived long enough to describe his sensations, has always been marked by intense cardiac suffering, more or less distress in breathing, restlessness, rapid and irregular pulse, faintness, pallor, coldness of the skin, sometimes vomiting, and by various nervous Bj'mptoms. When life is prolonged beyond a few minutes, there may be more or less intermission in the progress of these symptoms ; but the whole attack is marked by anguish more or less severe. The duration of the attack itself from the first fatal seizure varies remarkably. In 71 out of the 1 00 cases alluded to, death w r as sudden, occur- ring within one or two minutes. One patient, however, lived eight days, 1 six days, 1 three days ; 5 lived over forty-eight hours, 3 lived under twenty-four hours, and 1 9 under twelve hours. The special symptoms indicative of a fatal seizure are, in addition to those already men- tioned, severe praecordial pain, dyspnoea, vomit- ing, cyanosis, pallor, loss of consciousness, and convulsions. These symptoms, or some of them, were noted in 44 out of the 100 cases ; and in 24 of these the patient lived for more than five minutes after seizure, and in some of the Cases for more than twelve hours. These cases, doubtless, are instances in which the muscular fibres are torn apart layer by layer successively. In the other 20 cases ti« patient was seized with severe pain, and then expired ; or with HEART, SOFTENING OF. dyspnoea and some of the other symptoms men- tioned above, and lived but a few seconds. T\\e physical signs of complete rupture having occurred, so far as can be ascertained, are merely — a greater or less amount of dulness in the re- gion of the heart; the impulse diminished; the Bounds muffled, distant, or imperfectly developed ; and the pulse weak and intermittent. Course and Terminations. — The difference in the progress of ihe fatal malady depends much upon the seat of the rupture, on the size of the opening, and on the rapidity with which the extension of the laceration takes place. In the cases in which the septum is torn, there is no external haemorrhage, and life is pro- longed until the patient dies from disturbance in the functions of such an important organ as the reart. ( See a case reported by Dr. Peacock, Pathological Transactions, vol. v.) The progress of the symptoms is also influenced by the direction and course of the rupture. If the torn fibres overlap from the inside or from the out- side, the injury penetrates slowly through the cardiac wall, and the fatal progress is also slow. (See cases recorded by the writer in the Patho- logical Transactions, vol. iii., and also in vol.xii.; and a case by Dr. Peacock in vol. xvii. of the same Transactions.) Prognosis. — As far as is known, rupture of the heart is always fatal. Still it is possible that such an accident, owing to the small size of the opening, its incomplete character, and its occlusion by a coagulum, may not prove fatal. Numerous instances are recorded of severe wounds of the heart, the subjects of which have survived. Ollivier has collected 29 such cases, only two of which proved fatal within forty-eight hours, the others living from four to eight days. Cases are recorded in which persons have survived many years severe wounds of this important organ. These cases, however, differ from thoso of rupture in this particular, that they occur in the healthy organ, whilst spontaneous rupture occurs in the heart when it is seriously diseased (sec Heart, Wounds of). Treatment. — In the way of treatment of rupture of the heart little can be done. The patient's sufferings may perhaps be relieved by the hypodermic injection of morphia, or by the use of other sedatives. Perfect rest should, if possible, be maintained. E, Quain, H.D. HEABT, Softening of. — This term was formerly applied to several conditions of the heart in which the consistence of the cardiac tis- sue was diminished, whilst the process to which it was due was obscure or anomalous. It is probable that under the name of softening of the heart there were especially included instances of acute myocarditis, parenchymatous degeneration, and fatty degeneration. In the present more advanced state of cardiac pathology, it seems desirable that the expression ‘softening,’ while retained to express a familiar physical condition, should cease to he employed as a classifying term — that is, to designate any specific anato- mical state. J. AlrrrHEi-L Bruce HEART, SYPHILITIC DISEASE OF. HEART, Syphilitic Disease of. — Syphilitic disease of the heart is by no means a rare con- dition, haring been found in a large number of instances in which the specific nature of the lesion was determined 'with certainty ; -whilst, in another series of cases, similar anatomical ap- pearances were present, although the existence of syphilis -was not ascertained. Syphilitic disease of the heart is therefore of much pathological interest ; but it cannot be said that a great deal is known as yet with respect to its clinical history. -•Etiology. — There appears to be nothing of importance known as to the causes of the localisation of syphilis in the heart. The con- genital as well as the acquired form of the dis- ease has been met with. Anatomical Characters. — This morbid con- dition presents two leading appearances post mortem. The first is the well-marked syphilitic gumma, which closely resembles the same form of growth as it is met with, for example, in the liver and testicles. Gummata of the heart appear as pale 3 'ellow patches in the cardiac wall, or as yellowish nodules which are found on section. They present a Yariety of appearances, according to their age. When young they are firm or even scirrhoid ; elastic, and homogeneous ; creak on section ; and are very slightly succulent : but when older, they become soft and cheesy, like a mass of ‘ yellow tubercle.’ In either form' the masses are not isolated, but pass continuously into the myocardium, either directly, or through the medium of soft vascular connective tissue, so that they have generally been described in this country as ' infiltrations ’ or ‘ deposits.’ The supeijacent endocardium or pericardium is vascularised and dull in the early stage of the nodules ; opaque and thickened in the more advanced. The masses or nodules occur in various numbers in different instances, but are generally multiple. They may be found in any part of the heart. Gummata most frequently become caseous in the centre, as described ; and they maj r then soften more completely and dis- charge inwards, leading to acute cardiac aneurism and ulcer of the wall ; but more frequently the cheesy products are in a great measure absorbed, leaving a puckered fibroid patch behind. The second form of syphilitic disease of the heart is the fibroid patch. This is sometimes well-defined and localised, and in such instances it represents the stage of full development of an area of ordinary syphilitic interstitial inflam- mation. In other specimens, the fibroid patches appear as irregular masses of indurated fibroid tissue, occupying part of the wall of the heart, and sending septa into the depth of the myocar- dium, whilst the endocardium and pericardium that correspond to them are opaque, thickened, and puckered. The syphilitic nature of such patches may be determined by the presence of specific lesions in other viscera. A form of the disease intermediate between the two forms just described is one in which the outer zone of the gumma has undergone development into fibroid tissue, and the caseous centre remains as a ‘fibrinous’ mass. The microscopical characters of syphilitic growths do not require to be described here. HEART, THROMBOSIS OF. 621 In the heart, the primary seat of the disease is the intermuscular tissue ; the muscular fibres lying imbedded in the gummatous products ur in the fibroid growth being either healthy in appearance, or fattily degenerated and broken up. Syphilitic endarteritis ( obliterans ) may also occur in the vessels of the myocardium, and give rise to infarction of the walls of the heart. Amongst the occasional effects of syphilitic disease of the heart are chronic aneurism of the walls ; distortion of the ostia and of the valves and their appendages ; and, more frequently, adhesion of the pericardium. Some of the other viscera present, as a rule, evidence of syphilitic disease. Symptoms.— The subjects of syphilis of the heart may. from a clinical point of view, be divided into three classes. The first class of patients suffer from some one or other of the ordinary symptoms of chronic cardiac disease, such as dyspncea, cardiac distress, palpitation, pulmonary complications, and general dropsy; whilst the physical signs are those of cardiac enlargement, and perhaps of valvular incompe- tence. Praecordial uneasiness, syncopal attacks, and remarkable infrequency of the pulse, have been prominent features in several recorded cases. The second class of subjects of this disease die suddenly, after few if any complaints refer- able to the heart. The third class die of syphilitic marasmus, and may or may not present some evidence — by physical signs or otherwise — that the heart is not sound. In many of the cases, other symptoms of visceral syphilis — for example, phenomena con- nected with the brain and nervous system — have been prominent. Diagnosis. — "Well-defined symptoms or physi- cal signs, such as these just mentioned, con- nected with the heart, occurring in a syphilitic subject, would, in the absence of other more probable causes, such asahistory of endocarditis or Bright’s disease, furnish considerable grounds for the diagnosis of specific cardiac disease. Prognosis. — If such a diagnosis were posi- tively made, the prognosis would be more favour- able than it is perhaps in any other form of chronic heart-disease, inasmuch as the condition might be successfully removed by treatment. Treatment. — Anti-syphilitic remedies, espe- cially iodide of potassium, should be freely tried, along with the other remedies indicated on general principles. J. JHitctiell Bruce. HEAbRT, Thrombosis of. — Synon. : Heart- clotting ; Fr. Thrombose cardiaque ; Ger. Geriii nungen im Herzen ; Hcrzpolypen. Definition. — Coagulation of the blood within the cavities of the heart during life. ./Etiology.— Thrombosis of the heart is most frequently due to local arrest of the movements of the blood, comparatively or absolutely, within its cavities. Such arrest is itself generally referable to weakness of the cardiac contractions, whether associated with dilatation secondary to valvular or pulmonary disease, or due to some primary affection of the muscular walls. Tbe peculiar saccular condition of the extremities of HEART, THROMBOSIS OF. 522 the auricular appendages, and the trabecular arrangement cf the column® earnene of the ventricles, as well as the distance of the same parts from the main blood-currents, determine the favourite localisation of the thrombosis. Roughening of the endocardium is another cause of thrombosis, but one which is to be considered less common than the causes already men- tioned, unless the fibrinous coagula of endocar- ditis, or vegetations, be regarded as thrombi, which, in the strict sense of the term, they partly are. Possibly certain conditions of the blood may contribute to the occurrence of car- diac thrombosis. Finally, thrombi once formed tend to promote the further progress of the con- dition. Anatomical Characters. — Coagula found within the heart are of two kinds, which have been termed active and 'passive, according as they are formed during life, or at or after death, respectively ; and the characters of the former, with which alone we are here concerned, cannot be understood until those of the latter have been briefly described. Passive coagula are found in the heart in most necropsies, occupying the track of the principal blood-currents. Frequently they appear as black or red blood-clots, occupying the auricles princi- pally, and moulded in their cavities. In other cases they take the form of masses of firm whitish fibrino, cleaving with some tenacity to the endocardium, but not truly adherent ; matted with the chordae tendine® and column® carnese ; and projecting some distance into the pulmo- nary artery. Or, thirdly, passive coagula may be a combination of the two previous forms, the upper part (according to the position of the body) being decolourised or fibrinous, and the deeper part resembling more an ordinary blood-clot. In certain cases these passive clots are peculiar. In phthisis and other diseases proving fatal by very slow exhaustion, they are remarkably firm and fibrinous, and closely matted amongst the chord® tendine® — appearances which seem to indicate that coagulation was slowly proceeding for some time before tho heart had finally ceased to beat. In an®mia they are jelly-like and translucent. In leuk®mia they are soft and creamy in appearance, and yield, when broken up, a puriform fluid. In the acute exanthemata these passive clots are soft and friable ; and in many cases of these and of other forms of acute disease and of sudden death, no coagula are found in the heart, which contains only fluid blood. Active coagula — the result of thrombosis of the heart — are, on the contrary, situated in the saccular appendages of the auricles, at the apex of the ventricles, and in the recesses behind and between the column® earne® — in other words, as far as possible from the track of active blood-currents. In these situations they may be seen projecting in the form of fleshy knobs or globes, with their free surface smooth and rounded. Their deep surface is ad- nerent to the endocardium, from which, however, it can generally be separated without much diffi- culty, leaving behind it a discoloured mark. If the thrombus be incised, it will be found to be laminated in structure, somewhat after the fashion of an onion.iheeolourofthesection being greyish- brown or yellowish, with irregular patches of red and black. In most instances the centre is less firm than the periphery ; and usually it is of a fluid consistence, in the form of a foul, sanious, puriform substance. If the process of thrombosis have been pro- ceeding for some time, these formations may extend in all directions, embrace the column® carne®, coalesce in front of them, and finally may fill up a considerable portion of one, or even of more than one, cavity. The thrombi are generally friable ; but sometimes they gain in firmness by the deposit of lime-salts within them ; and at other times it is possible that they become detached and form into the ‘ fibrinous balls’ which have occasionally been found lying free in the cavities of the auricles. Cardiac thrombi may, in part at least, be reabsorbed. They frequently give way during life ; and portions of them, as well as of their puriform contents, are conveyed into the circulation, causing embolism and pyaemia. It may be added that embolism of the heart has frequently been found— thrombi or simple clots, sometimes of remarkable size, having been carried from the veins, and arrested in the heart or in the mouth of the pulmonary artery. Symptoms. — The clinical phenomena associated with true cardiac thrombosis may be best de- scribed as those of the last stage of chronic dis- ease of the heart. Prmcordial distress and restless- ness ; irregularity and feebleness 'of the pulse; oedema and coldness of tho extremities : pulmo- nary congestion, infarction, and oedema ; dulness of expression, and sopor, broken by low weak de- lirium ; with other symptoms, as well as with tho signs of cardiac failure and imperfect emptying of the cavitiesin systole — all these phenomena are associated with the process of active coagulation within the heart. It would not, however, be correct to describe these phenomena as symptoms directly referable to the thrombosis. All that can be said is. that in such a case thrombosis is probably going on and increasing the embar- rassment and the gravity of the condition. An unusual dcgrc-e of cyanosis appears in some instances. Tho symptoms of arterial embolism may suddenly make their appearance from de- tachment of particles of the clots ; and, if the puriform contents find their way into the circu- lation, septiemmia may result. The dislodgment cn masse of a large venous thrombosis, and the impaction of the same, or of a ‘ fibrinous ball,’ in one of the ostia of the heart have caused sudden death in several cases. Passive coagulation. — It should be added that the appearance of the ‘passive’ form of coagula- tion w-ithin the heart, which has been already referred to as a postmortem process, or one oc- curring in articulo mortis, has been otherwise interpreted by some authorities, who regard passive coagula as formed ante mortem, and as giving rise to severe symptoms by the embar- rassment which they produce in the circulation. The symptoms caused by this condition are said to be — gr«at prscordial pain and distress; tumul- tuous action of the heart, passing on to irregu- larity, flickering, and finally arrest, whilst tho pulse is very feeble ; urgent dyspnoea; cyanosis - HEART, THROMBOSIS OF. hemoptysis; coldness of the extremities ; deepen- ing stupor; and coma ending in death — in short., the congeries of symptoms which would be re- ferred by most authorities to failure of the muscular walls of the heart, the coagulation being regarded by the latter as only another result of the same condition. Diagnosis. — In the presence of the very se- rf uis and complex conditions with which cardiac thrombosis is usually associated, the question of its existence can hardly be said to occur to the physician as a point of great importance. An unusual degree of cyanosis, especially if it be progressive, favours the recognition of this state ; and in the absence of valvular disease, the occur- rence of embolism or pyaemia would tend to con- lirm it. Treatment. — The treatment of cardiac throm- bosis consists in the treatment of its cause ; and nothing is demanded or can be done for the former which is not indicated for the relief of the latter. Those authorities who see in ‘passive’ coagula the evidence of rapid ante-mortem thrombosis, recommend the use of . stimulants, and even of certain drugs which are supposed to have a sol- vent effect on fibrinous deposits, especially am- monia. J. Mitchell Beuce. HEART, Tuberculosis of. — Independently of the pericardium, the heart itself is believed to be rarely the seat of tubercular disease. Grey miliary tubercles have been found in the connective tissue of the wall of the heart, in some cases of acute general tuberculosis. In other instances the ‘ tubercle ’ has been of the yellow or cheesy kind, in the form of small nodules lying at various depths in the muscular tissue beneath the pericardium ; the latter also being frequently afiected, as well as the lungs, intestines, and other organs. There appears to bo no evidence that tubercu- losis of the myocardium gives rise to definite Bymptoms, or that it can be recognised during life. J. Mitchell Beuce. HEART, Valves and Orifices of, Diseases of. — Classification. — The diseases of the valves andorificesof the heart which produce mechanical disorders of the circulation, by establishing ab- normal relations between those parts, are of two kinds — obstructive and regurgitant. Valvular disease, on the one hand, is said to be obstruc- tive when narrowiug of an orifice presents an obstacle to the passage of the blood-current — a condition better named stenosis. On the other hand, when the blood regurgitates or flows back through an orifice, in consequence of imperfect ; closure of the valves, due either to valvular changes or to widening of the orifice, the condi- tion is called regurgitation or insufficiency. Aneurism of the valves of the heart will be discussed separately. See Heaet, Valves of, Aneurism of. ^Etiology. — Each of the orifices may be affected with one or both forms of disease, but the frequency with which the several orifices are attacked varies. The results of organic disease are chiefly met with in the left side of the heart, and are duo .o local inflammation — endo- HEART, VALVES OF, DISEASES OF. 623 carditis and its consequences ; or to chronic degenerative changes, such as atheroma. In adult life the valves of the left side are more frequently affected than those of the right, be- cause they have to bear a much greater pres- sure ; but in fcetal life, when the condition is reversed, the right valves suffer more. Endo- carditis is commonly of rheumatic origin, and attacks the mitral more frequently than the aortic valves ; the former having to sustain the full force of the ventricular systole, while the latter only bear the force of the aortic recoil. In addition to rheumatic fever, the chief diseases which tend to develop endocarditis are — pyaemia, puerperal fever, the exanthemata, chronic renal disease, and syphilis. The aortic valves are more commonly affected than the mitral by chronic endarteritis extending from the aorta, the chief causes of which are gout, old age, syphilis, and the abuse of alcohol. These facts explain why mitral affections (commonly rheu- matic) occur mostly in early life, and aortic affections in later life. A T alvular lesions are more common in men than in women, from the strain of the heart incidental to more laborious occu- pations. Strain helps to sw»-ll the greater pro- portion of disease of the aortic valves, which are liable to rupture from effort ; but similar acci- dents may occur to the mitral valve and its tendinous cords. Anatomical Characters. — The pathological changes in the valves and orifices of the heart, which cause valvular defects, are mostly the results of acuto or chronic endocarditis. In the acute form, the valvular defect is caused by the growth of vegetations which prevent the action of the valve-segments ; or by softening and ulceration of the valve-structure, which lead to valvular aneurism and perforation, or to loss of substance and consequent insufficiency. The more chronic form of inflammation produces thickening of the valves from overgrowth of the connective tissue, with subsequent calcareous degeneration and retraction from shrinking of the hyperplastic connective tissue ; or adhesion of the valve-segments causing stenosis. Aortic stenosis is generally the result of thickening and calcareous degeneration of the valves, or of deformity of the valves from vege- tative growths, which obstruct the free passage of the blood from the ventricle. Sometimes it is due to adhesion of the valves preventing their elevation, and causing them to form a diaphragm with a narrow central aperture. More rarely it is caused by contraction of the fibrous ring of the aortic orifice, or by endocardial thickening producing contraction immediately beneath the valves. Mitral stenosis results most frequently from thickening and rigidity of the valves,' which adhere at their edges to each other, so as to form a diaphragm between the auricle and the ventricle. This diaphragm is usually funnel- shaped, with a button-hole aperture sometimes not larger than a goose-quill. In these cases the tendinous cords of the valve are shortened, and their muscles thickened. In some cases the valves are smooth and thin ; in others they are thickened, studded with vegetations, rough and calcareous. This latter state may cause stenosis. HEART, VALVES AND ORIFICES OF, DISEASES OF. 624 without any funnel-formation, as may also fibri- nous clots or polypi obstructing the orifice. In many cases of mitral stenosis, the valves are also insufficient. Aortic insufficiency often depends on dilatation of the aortic orifice, due to softening of the aortic coats, with little or no change in the valves, which are incapable of closing the en- larged orifice. Vegetations, thickening, retrac- tion, calcareous degeneration, adhesions, per- forations, loss of substance, and rupture of the valve-segments by effort are all causes of aortic insufficiency. In rupture of the valves, a full description of which was first given by Dr. Quain (Edin. Monthly Journ. 1846), the valve-segment is torn from its angles of attachment, and its free edge retroverted towards the ventricle. This accident happens more frequently in cases where the valves were previously diseased, and in such cases further laceration may occur. Mitral insufficiency is due to thickening, re- traction, or deformity from vegetations of the valve-curtains; adhesion of the curtains to each other or to the ventricular wall ; and calcareous degeneration. In some instances, one of the valves is perforated or torn ; and sometimes the tendinous cords are shortened and thickened, or ruptured as the result of degeneration, prevent- ing the normal action of the valve-curtains. In rarer cases associated with dilated ventricle, the papillary muscles are so weakened by degene- ration that they can no longer aid in the closure of the orifice. Dilatation of the left auriculo- ventricular orifice is also a cause of mitral in- sufficiency. Valvular defects on the right side of the heart are due to similar changes. They arise chiefly during fcetal life, when the right cavities hare to bear greater pressure. In adult life these defects are generally associated with diseases of tho lungs, which cause increased tension in the right cavities, leading to their dilatation. Combined valvular lesions are not infrequent. The most common are stenosis and insufficiency of the aortic valves, and the same morbid changes of the mitral valves. In the last stages of both forms of aortic valve-disease, the mitral valve becomes insufficient, either from chronic endocar- ditis, or from dilatation of the ventricle and of the auriculo- ventricular orifice. Mitral stenosis is not very frequently associated with aortic in- sufficiency, but is more commonly connected with some degree of narrowing at the aortic orifice. Tricuspid insufficiency is usually met with in the last stages of diseases of the left heart. Symptoms. — Valvular diseases of the heart produce a series of morbid phenomena, which are connected together by a necessary sequence. Each and every form of valvular defect impairs the perfection of the heart as a pumping machine, and disturbs the normal relations between the contents of the arteries and of the veins. Wher- ever the valve-mischief is, and whatever its nature, it robs the arterial circulation and en- riches the venous. In front of the lesion there is less blood; behind it there is more. In aortic valvular diseases, the first effects are increase of the blood-pressur6 in the left ventricle, and lessened blood-pressure in the aorta ; next, from tlie difficulty which the auricle has in emptying all its contents into an overful ventricle, there is produced increased pressure in the left auricle and pulmonary veins. Mitral valve-lesions cause similar results : first, increased pressure in the left auricle, less pressure in the left ventricle, and consequently lessened pressure in the aorta; with a gradual increase of pressure extending from the left auricle to the pulmonary veins. Aortic affections thus act first on the arterial, and secondly on the pulmonary circulation ; while mitral lesions affect the pulmonary vessels more immediately. The final results of the two forms are, however, identical, and may be stated in the form of a law, namely, that all valvular diseases of the heart tend to lessen the quantity of blood in the arterial system, and to produce overfulness and stasis in the veins. From this there follow various associated visceral dis- orders. These disorders, how'ever, vary greatly in the period of their occurrence, and in the intensity of their manifestations. This result is due to the more or less perfect way in which the original valvular defect has been compen- sated for, by changes in the power of the car- diac muscle and in the capacity of the cardiac cavities. These changes often suffice to maintain fairly the normal balance between the arterial and venous contents, thus compensating for the valve-lesion ; and the process by which this is effected demands careful consideration. Compensation . — Compensation is effected dif- ferently, according to the form of disease. It may be stated generally, that it consists in hy- pertrophy of the cavity immediately behind the defect. Now hypertrophy means increased con- tractile power, and this means better filling of the arteries, and consequently increased arterial tension. Thus it makes up for the valvular in- competency, which tends to lessen arterial ten- sion. When the increased power of the ventricle exactly balances the effects of the valvular mis- chief, the compensation is complete. In aortic stenosis, hypertrophy of the left ventricle is the mode in which compensation is effected ; the obstacle to the blood-current is overcome by increased power. In aortic insufficiency there is some dilatation of the ventricle as the primary result of the lesion. This is counterbalanced by greater hyper- trophy, and as long as the dilatation does not progress, the insufficiency is compensated for. A sufficient excess of blood is thrown into the aorta at each systole to allow for the regurgita- tion during each diastole, and thus the balance is maintained, though not always equably. In mitral lesions the left, auricle is dilated as the primary consequence of the condition of the valves ; hypertrophy follows, but is insufficient to prevent increased fulness of the pulmonary veins. This impedes the circulation in the lungs ; and increased tension in the pulmonary artery soon begets the necessary hypertrophy of the right ventricle. It. is by means of this increased power of the right ventricle, that the blood is driven through the lungs in spite of the defect in tho left heart, and pulmonary stasis is prevented; and the blood entering the left auricle under greater vis a tergo, the cornpen sation of the valvular defect is effected. The compensation, from the nature of the means on HEART, VALVES AXD ORIFICES OF, DISEASES OF. c>2o which it deDends, is manifestly less perfect than m aortic lesions. On the right side of the heart similar modes of compensation are observed. The basis of the salutary changes just de- scribed is increased cardiac nutrition ; and consequently a free coronary circulation is a necessity. Conditions which interfere "with this prevent compensation, and so diminish the dura- tion of life. Wherever the compensation begins to fail, dilatation of the cavities and vessels behind the lesion commonces. This may, however, be checked, and the power of the heart restored for a time. Sooner or later, however, changes in the nutrition of the cardiac muscle, in the vessels, and in the general nutrition, bring on failure of compensation. The cardinal symptom in such eases is weakened contractile power of the heart, or asystoly (Beau). In this state, the cavity chiefly affected has no longer power to expel its contents fully into the vessels, and consequently becomes gradually and increasingly distended. Failing compensation in aortic valve- disease manifests itself by dilatation of the left ventricle, and the development of secondary mitral insufficiency. Similar retro-dilatation marks the failure in mitral cases, only here it is the right ventricle which dilates, and tricuspid insufficiency and general venous stasis are added to the pre-existing pulmonary engorgement. The earliest symjjtoms of Jailing compensation are attacks of palpitation from very slight exertion or excitement, or during sleep. Irre- gularity of the pulse soon follows, if it have not previously existed. This is especially the case in mitral disease. The irregularity is due not so much to true cardiac intermission as to abortive contractions, which do not reach the wrist ; or to contractions unequal in force or in the quantity of blood expelled. The pulse is small, unequal, irregular, and compressible. In aortic valvular disease true intermissions occur, and are of grave import. With failing cardiac power there usually supervene cardiac oppression, anginous attacks from distension of the cavities of the heart, and faintness and giddiness from cerebral anaemia. Visceral complications . — The most important of the associated disorders of chronic valvular disease, depending on defective contraction of the heart, are the visceral congestions. In the lungs, the habitual engorgement of mitral diseases produces a hyper-secretion of mucus and a state of chronic catarrh. Tho blood-vessels also undergo changes from the excessive intra-vascular pressure, and become dilated, varicose, and atheromatous : whence oedema and haemorrhage arise. In mitral stenosis especially, grave and frequent attacks of hsemor- . rhage, with laceration of the pulmonary substance, ‘ are liable to occur. The lungs, from repeated at- i tacks of this kind, undergo brown induration. The varicose condition of the vessels in the alveoli interferes with oxidation, and so aids in the deterioration of blood, which the other visceral , congestions favour. In the liver, tho general venous stasis is felt by the obstruction to the passage of blood from The hepatic veins into the inferior cava. Passive congestion ensues, and ‘ nutmeg liver ’ results. 40 This term ‘ nutmeg liver ’ refers to the rough changes in the viscus, the dark congested centre of each lobule being surrounded by a paler area. In course of time the compression of the central cells of each lobule by the distended veins leads to atrophy ; the liver, from being large, shrinks in very chronic cases to half its size; and the condition may, 1 ike true cirrhosis, lead to ascites. The passive congestion in the liver, as in the lung, causes catarrh of the tubes, and may thus be productive of jaundice. Amongst othor symptoms associated with the hepatic congestion may be mentioned haemorrhoids and epistaxis. The spleen is a very easily distended organ, and suffers like the liver, buc frequently before it; and this may partly account for the pain which is often complained of beneath the left ribs. In long-standing cases the spleen becomes tougher, and the capsule opaque and thickened ; while haemorrhagic infarcts arc common. From the hepatic congestion there naturally follows distension of all tho other radicles of the portal vein : hence the congestion and chronic catarrh of the stomach and intestines, which im- pede digestion and assimilation, and so reinforce the other causes producing the cachexia of chronic valvular disease. In all cases of valvular disease, when the mechanical effects extend to the general circula- tion, the function of the kidneys is more or less disordered. The first stage of general circu- latory trouble is lessened arterial tension ; this makes itself felt in the Malpighian tufts, and is manifested by scanty, dense, high-coloured urine. When the more advanced circulatory trouble — namely, general venous stasis — is deve- loped, a further change takes place in the urine. The arterial anaemia keeps it still scanty and dense, but the venous stasis in the kidney leads to the transudation of serum — a dropsy of the kidney as it were ; and consequently albumen appears in the urine. Long-continued venous congestion ends in structural changes, which, as elsewhere, consistin connective-tissue hyperplasia and degenerative (rarely fatty) changes in the tubules. Theso renal changes sometimes add uraemia to the patient’s ailments. In the brain, decided alterations are not found, except when a detached vegetation produces embolism and its special phenomena. The brain- substance is, however, generally cedematous, and the membranes are thickened. Delirium is an occasional symptom in heart-disease, and when present to any degree is of evil import. Tho blood-vessels of the general circulation are fre- quently affected with atheroma in hypertrophy of the left ventricle, and it is these degenerative changes which favour the occurrence of apo- plexy. General dropsy . — Themechanical impediments to tho circulation which produce these several visceral congestions, also manifest themselves in the general dropsy which is common in the last stages of heart-disease. The dropsy begins as a puffiness of the ankles at bed-time. The general venous stasis, thus first indicated, ad- vances slowly and surely, if not checked, to general anasarca, and even to dropsy of tho serous cavities. The increased venous tension, and the hydraemia of blood-deterioration, are I 526 HEART, VALVES AND ORIFICES OF. DISEASES OF. the causes of this serous transudation, which shows itself first in the feet, the most dependent portions of the body, where the pressure of the blood-column is naturally greatest. The hori- zontal posture, by distributing the pressure, is sufficient at first to disperse the oedema of the ankles. General anasarca is much more frequent in mitral than in aortic lesions. In some cases a solid form of edema is ob- served. This occurs mostly in the last stages of valvular affections, and is due to thrombosis of venous trunks, in which, the circulation being much impeded, coagulation easily takes place. The termination of the external jugulars is a common site for such thrombosis ; and the left innominate vein, from its transverse position, and from its emptying almost at right angles to the current in the superior vena cara, is, in the writer's experience, more commonly obstructed than the right. Solid oedema is consequently seen more frequently on the left side of the head and neck and in the left arm, than on the right side. Defective compensation . — The phenomena just described are associated with valvular diseases of the heart, as the consequences of partial or defective compensation. These conditions are more or less developed according to the indi- vidual case, and consequently give rise to symp- toms in varying degrees. These symptoms will now be described. Palpitation is intimately related to the state of cardiac nutrition and innervation, and lias no special connection with any form of valvular dis- ease. Cardiac pain, varying in intensity from mere uneasiness to the agony of angina, is most common in aortic cases, and is associated with endarteritis, or with dilatation of the left ven- tricle, oris a neuralgia of the cardiac plexus. In mitral affections, pain arises from over-distension of tho left auricle, and its pressure on neighbour- ing parts, and later on from dilatation of the right ventricle. Dyspnoea may be present in any form of valvular disease, but it is often ab- sent from the earlier history of aortic cases, while some dyspnoea is always present in mitral cases. This difference is due to the absence of pulmonary congestion in aortic affections, whilst it is more or less present from the first in mitral affections. The dyspnoea is a breathlessness rather than a difficulty of breathing. It is panting and gasping in its character, with ac- celeration of the rate. It is aggravated by any movement, and often compels the patient to sit upright (orthopncea). Headache, vertigo, dream- ing, night-frights, and sleeplessness are other symptoms, which depend on disordered cerebral circulation. Sleeplessness is one of the most distressing of all symptoms, and can only be relieved when tho dyspnoea is lessened. Other more special symptoms will be found in certain cases, and will be traceable to the disturbances in the circulation, which the particular form of valvular disease has engendered. Physical signs . — The physical signs associated with valvular affections may be said to be — first, lliose of alteration in the size of the heart; and secmdly, those of mechanical disorders of t he circulation; together with one or more endocardial murmurs. The persistence of a murmur is the cardinal sign, and if the murmur be either diastolic or prsesystolic in its rhythm it is of absolute value. A systolic murmur may- be caused by poverty of blood — antemia, espe- cially at the base of the heart. But in such a case— that is, in haemic murmur — there is no cardiac hypertrophy-, as indicated by increased cardiac dulness, though there is often nervous overaetion of the heart. There is no accentua- tion of the pulmonary second sound, inasmuch as there is no extra fulness of the pulmonary blood-vessels from obstructed circulation. The pulse in anaemia is generally quick, ample, and compressible, but, withal, jerky ; while with an organic systolic murmur it is generally- slow, rising gradually under the finger, and not very compressible, (aortic stenosis), or small, irregu- lar, and unequal (mitral insufficiency). The clinical methods of investigating valvular lesions are mainly inspection, palpation, percussion, and auscultation. The signs of each form of valve- disease are stated below; and on these the special diagnosis rests. Diagnosis. — In Aortic stenosis there is often some prominence of the praecordial region, and a steady forcible impulse is perceived below and to the left of its normal position. A thrill, systolic in time, may often be felt at the base of the heart. On auscultation, a loud, frequently rough, rasping, sometimes musical, murmur is heard with the first sound at mid-sternum, and also at the second right intercostal space. The murmur, commencing with the first sound, ex- tends to the succeeding second sound, which is often not very distinct. The murmur is audible all over the upper part of the thorax, especially on the right side ; is conducted along the great vessels to the left vertebral groove, and it may bo even to the lower dorsal vertebrae ; and is occasion- ally heard at the apex of the heart. The pulse is regular, slow, retarded by the narrowing ol the aortic orifice, and slowly developed under the finger. The spby-gmogram (see tig. S2) shows the line of ascent to he oblique or broken, instead of nearly vertical; the summit is generally blunt ; and the line of descent shows small or no secondary waves, and ill-developed dicrotism. Aortic stenosis when moderate, requiring only hypertrophy of the left ventricle for its compen- sation, is often very- perfectly remedied by this change, and produces little or no disorder of the circulation. When the stenosis is great, epileptiform and syncopal attacks may occur, and lead to sudden death. When the com- pensation fails, the mitral valve often yields, from the dilatation of the left ventricle, and degeneration of the papillary muscles. Then the pulmonary second sound becomes accen- tuated ; the pulmonic circulation is embarrassed ; and dyspnoea, bronchial catarrh, pulmonary hae- morrhage, oedema, and cyanosis supervene. In Aortic insufficiency, inspection discovers a more forcible and diffused impulse, lower than natural, sometimes as low as the seventh inter- costal space, and outside the nipple line. The praecordial region may be bulging from the violent action of the heart; pulsation may he seen in the upper intercostal spaces at the right edge of the sternum ; and a thrill may some- times be felt there. The great vessels of the neck HEART, VALVES AND ORIFICES OF, DISEASES OF. 627 pulsate visibly. The area of cardiac dulness is increased in all directions, but mainly verti- cally. On auscultation, a murmur is heard, re- placing and folio-wing the secoud sound, of a blowing or hissing character, rarely rough. It is usually loudestat mid-sternum and in the second right intercostal space ; and it is conducted up- wards to the right clavicle, but mainly down- wards to the xiphoid cartilage. It is not heard at the back of the chest. It may be conducted to the apex of the heart rather than to the ensi- form cartilage; and this occurs, in the writer’s opinion, when the posterior or mitral segment of the aortic valves is the incompetent one, as the regurgitant current then falls on the mitral valve, and the murmur is thus conducted to the apex. The second sound may be wholly lost at the base of the heart, being replaced by the murmur; but in some cases it is audible — this being due either to normal closure of one or two aortic segments, or to the propagated pul- monic second sound. If audible in the carotids, the second sound is aortic, and is of some value as indicating partial competency of the valves. The second sound is often audible at the apex. The first sound at the base is almost always modified, being generally murmurish and often obscured by a systolic murmur, due to slight obstruction from thickening of the valve-seg- ments, and the vigour of the ventricular systole. In some cases there is no distinct first sound audible at base or apex ; its absence being pos- sibly due to noiseless closure of the mitral valve by the intra- ventricular blood-pressure before the systole occurs. In the majority of cases the insufficiency is no doubt associated with some stenosis, and the murmur is double; a short rough systolic portion, with a softer, longer, and more hissing diastolic portion. This double murmur might be well called the vp and down murmur of aortic valve-disease : the two descriptive words indicating the length, and, to some extent, the characters of its component parts. The signs connected with the pulse in aortic insufficiency are very significant. As the pulsa- tions of the aorta are visible to the right of the sternum, so the arteries often beat visibly all over the body, even to the radial, temporal, and dorsal arteries of the foot. The ophthalmoscope has shown the same phenomenon in the central artery of the retina. This remarkable move- ment of the arteries is due to two causes: — first, to the hypertrophy and dilatation of the left ventricle, w hich throws an excessive quantity of blood into the vessels at each systole; and, secondly, to the sudden collapse of the arte- . ries, due to the aortic insufficiency. The arterial recoil during the ventricular diastole is not op- posed, as iu health, by the resistance of the per- fectly closed aortic valves and. consequently, the : blood-column is not sustained, and the arteries i collapse. These locomotive features in the pulse are generally increased by elevating the arm. The pulse is sudden, short, large, regular, rapidly collapsing, and vibratory. The sphygmographic tracing bringa out these characters: the line of ascent is vertical and lofty; the summit is sharp wd pc.nted ; the li e of descent falls rapidly, and a broken by a series of secondary waves due o vibratory conditions, but has an ill-developed dicrotism. The post-dierotic portion of tho tracing falls rapidly, from the absence of a sus- tained blood-column. The longer and more ob- lique this portion of the tracing, ceteris parilms, the less copious the regurgitation (see fig. 81). Aortic insufficiency often lasts for many year9 without producing any obvious disturbance of the systemic and pulmonic circulations ; lienco the absence of dyspncea and oedema. The hyper- trophy and dilatation of the left ventricle, which form the compensation, suffice to prevent ill effects. At each systole the dilated ventricle throws sufficient blood into the aorta to allow for the reflux, and to maintain a fair arterial lension. Thus the compensation is perfect. In many cases, however, if the reflux is free, and the coronary segments of the aortic valves are affected, the coronary arteries, which are mainly filled by the arterial recoil, are deprived of the full force of the blood-wave, and the nutrition of the heart consequently suffers. This is the great source of failing compensation, and the mal-nutrition of the cardiac muscle soon leads to dilatation of tho ventricle, secondary mitral in- sufficiency, and atrophy. When the hypertrophy is excessive, as it is iD some cases, there are flushings of the head and face, headache, vertigo, and violent arterial action all over the body. In Mitral stenosis there is rarely any promi- nence of the praecordial region ; and in its earlier stages neither increase of the cardiac dulnesc, nor alteration in the position of the impulse. The impulse, when regular, is fairly distinct, bait it is often very irregular and is associated with a thrill, which precedes, runs up to, and termi- nates in the impulse. In advanced cases, the area of cardiac dulness is increased laterally; the impulse is diffused, and may be seen in the epi- gastrium; and the left auricular systole may be noticed, if the chest be thin, in tho third left intercostiil space. The sounds heard on auscul- tation in this lesion vary. The pathognomonic sign is a murmur preceding the systole, and ending with its commencement. This is best called the prcesystolic murmur (also ‘ auricular systolic’) ; and is produced when the contracting auricle forces blood under high pressure into the ventricle. It is the passage of a stream of blood in a state of high tension into blood already in the ventricle which causes the murmur. The first portion of the blood passes from the auricle into tho ventricle noiselessly ; and it is only when a stream of higher tension is forced into it by the true auricular systole that the murmur is developed. The murmur is, therefore, short in most instances, occupying the last part of dia- stole ; runs up to the first sound ; and ends abruptly in it. The position in winch the mur- mur is best heard in its typical praesystolic form is at the left apex itself or a little above — that is, lower than a mitral regurgitant murmur. The funnel-like shape of the mitral valve-curtains iu these cases accounts for this, as the button- hole aperture through which the blood passes is closer to the apex. The murmur in this form is not heard far from its seat of production, is soft and puffing, but may be harsh. It fills commonly only the last part of the diastolic period. In some cases the murmur ij- 328 HEART, VALVES AND ORIFICES OF, DISEASES OF. longer, rougher, more rolling or grinding, and ends abruptly with the first sound, which is very flapping in tono, and might easily be mistaken for the second sound conducted. The careful observation of the impulse or of the carotid pulse with the finger while auscultating, is necessary in order to avoid the error. A special peculiarity of the praesystolic mur- mur is its variability: it is the only organic murmur which disappears and reappears as the heart-conditions change. For instance, a mur- mur, inaudible while the patient is at rest, is developed by a little exercise ; or again, an irre- gular tumultuous action of the heart masks all murmur, which becomes distinct as the heart steadies down under the action of digitalis. In other cases there is no distinct murmur, but only a slightly prolonged and rough or grinding first sound. In cases of mitral stenosis there is ac- centuation of the pulmonary second sound, from the greatly increased tension in the lesser circu- lation ; there may also bo a doubling or redupli- cation of the second sound at the base. This re- duplication is a sign of great value in cases in which the prolonged or grinding first sound is the only sign. The reduplication of the second sound is due to a want of synchronous closure of the pulmonic and aortic valves, from their altered relative tension. A doubling of the first sound is sometimes noticed, probably duo to retarded closure of the mitral valve, from lessened fulness of the left ventricle. The rhythm of the heart is frequently greatly disordered in mitral stenosis, and also in mitral insufficiency. A few beats occur regularly, or nearly so, and then a series of very small hurried ones follows, to be again succeeded by stronger and better pulsations. These irregularities are referable to the varying charges of blood on which the ventricle contracts. The over-dis- tended right cavities and the left auricle con- tract rapidly to expel their contents, but the narrowed mitral orifice does not allow a full charge to pass into the ventricle; the diastole is too short for this purpose; and the wave of contraction passes on to the ventricle from the auricle, producing a series of small ineffective pulse-beats, each representing the small charge sent into the aorta. When the series of ineffec- tive contractions ceases, the next diastole is longer; and the succeeding systole sends, as the sphygmograph shows, a fuller charge into the arteries. During the small irregular beats the prresystolic murmur is often indistinguishable, but is again heard with the succeeding slower and more effective beats. This irregularity in the heart’s rhythm, however, is not present in all cases of mitral stenosis. In some instances the heart’s action and the pulse are regular. The sphygmograph in such cases records a small pulse of low tension, with a little inequality in the volume of the beats ; this inequality is often increased by exercise. In other cases the pulse- tracing is small, irregular, and unequal in its pulsations, and marked by true and false inter- missions (see fig. 84). In the earlier stages of mitral stenosis tho face may be pale, and the congestive symptoms which mark mitral insufficiency are absent till the later stages. This form of valvular lesion gives rise more commonly than mitral insufficiency to haemorrhagic infarction in tho lungs ; but in other respects the pulmonary and systemic circu- lations suffer in the same way as described in the other form of mitral disease. In Mitral insufficiency inspection discovers some slight prominence of the praecordial region, with increased impulse, the apex often beating to the left of the nipple line. The area of car diae dulness is augmented mainly in a lateral direction, from the hypertrophy of the right ventricle. On auscultation, a murmur is heard with the first sound, and following it; loudest at the apex ; loud along the left edge of the heart ; but absent or not so distinct over the right heart and at the base. The murmur is propagated to- wards the left axilla, and is audible in most cases in the left vertebral groove. The murmur is usually loud, blowing, and distinct in its cha- racter, keeping the same tone throughout. The true first sound is generally obscured by it, but in some cases may be heard through it, and is then due to the partial closure of the mitral, or to the action of the right aurieulo- ventricular valves. The pulmonic second sound is commonly accentuated. The pulmonic first sound has iD some cases a murmurish character, due pro! ably to the vigour of the right ventricular systole. The radial pulse in cases of fairly perfect com- pensation is regular, but quick, small, weak, and easily compressible ; and the sphygmograph shows low tension, and an inequality in the sizo of the pulsations. In cases of less perfect compensation, it becomes irregular and inter- mittent. In all cases the pulse-heat is weak in comparison with tho vigour of the ventricular systole ( see fig. 83). There is no unusual fulness of the superficial veins in the earlier stages of mitral insufficiency. Later, when the right cavities become over- distended, the veins of the neck become full and may even pulsate. This is very distinct when the tricuspid valve gives way. In all cases slight exertion is sufficient to induce dyspnoea ; and there is an ever-present tendency to bron- chial catarrh, from the congested state of the lungs. When asystoly comes on, the murmur becomes less distinct ; the heart’s action is rapid, irregular, and tumultuous ; the accentuation of the pulmonary second sound is lost; dyspnoea becomes orthopncea ; and cyanosis, oedema, and haemorrhagic infarction of the lungs, with general and visceral dropsy close the case. Many cases of mitral regurgitation obtain fairly perfect compensation; but the disease, like mitral stenosis, of necessity entails some dyspnma on exertion, and keeps up constantly an engorged state of the pulmonary vessels. Valvular affections of the right heart, arising from disease, are rare. Those of the pulmonic valves are very rare ; cases are on record, how- ever, of pulmonary stenosis, and a few of pul- monary insufficiency. In the first case the systolic murmur is loud and superficial, and is heard loudest at the third left costal cartilage close to the sternum, and in the second left inter- costal space ; it is not usually conducted across the sternum, nor upwards to the right clavicle, as is an aortic murmur. A diastolic pulmonic murmur is soft and blowing ; and is heard loudest HEART. VALVES AND ORIFICES OF, DISEASES OF. 629 in the same situations, and downwards towards the ensiform cartilage. The tricuspid valves are more frequently af- fected. Tricuspid insufficiency is indeed a common sequence of disease of the left side of the heart. Structural changes in these valves are, however, rare. Tricuspid insufficiency does not always produce a murmur; when present this is soft and short, and is heard nearer the middle line than a mitral murmur, at the base of the ensi- form cartilage. The pulsations of the cervical veins may indicate the lesion when the murmur is absent. Tricuspid stenosis causes a praesystolic mur- mur, harsh in character, loudest at the base of the ensiform cartilage and towards the left edge of the sternum, not propagated towards the left heart, and not audible at the back of the chest, though faintly conducted along the sternum to the base of the heart. A praesystolic thrill may be present. Mitral stenosis has been observed in association with this lesion, and two praesys- tolic murmurs may be made out in such cases. The physical signs and the diagnosis of com- bined valve-lesions remain to be described. The mitral and aortic valves may each be affected with stenosis and insufficiency, from a single attack of endocarditis, or from one lesion arising as a consequence of the other. The double aortic murmur, above described, indicates the aortic combination ; but it must be always remarked that the systolic murmur in these cases may exist with little or no actual stenosis. In the double form of mitral disease, either defect may exist alone at first, and afterwards be associated with the signs of the second. In some cases the praesystolic murmur may fail to be heard, and a systolic murmur may alone be audible ; in other cases, there is a prolonged apex-murmur which slightly changes tone ; in other cases, again, a short grinding praesystolic murmur is followed occasionally, at an interval, by a soft, blowing, systolic one. The combination of aortic with mitral disease may be recognised by the presence of their special murmurs. Prognosis. — It is very difficult to state general rules of prognosis in valvular affections of the heart, as so much depends on the pecu- liarities of each case. There are, neverthe- less, certain broad rules. As regards origin, rheumatic inflammation is less serious than degenerative change, which occurs later in life, and is necessarily progressive. Accidental rup- ture is the gravest form of origin. The valve affected is also a prognostic element; but any attempt to arrange cases in order according to the seat of the valvular defect, must be open to so many exceptions that it must not be too much trusted. Speaking generally, however, tricuspid lesions are gravest, mitral less so, and aortic — especially aortic stenosis — probably least so. When the heart fails, and asystoly supervenes, the prognosis is worse, however, in aortic cases than in mitral. Aortic cases are often free for years from any grave symptoms. When the murmur is conducted to the left apex, the prognosis is more favour- ; able, as, the aortic segment affected being non- coronary, the muscle of the heart is not robbed of its blood. The presence of the second sound over the carotids is favourable. The pulse- tracing also affords valuable aid in prognosis, as it gives, by the size of the dicrotic wave and the obliquity of the line of descent, a rough measure of the amount of insufficiency. There is much more risk of sudden death in aortic cases than in mitral. In mitral lesions the dangers arise from the pulmonary complications ; embolism is more common than in aortic affections. Mitral cases can be rescued from asystoly more commonly, and die of advanced cardiac cachexia, generally with dropsy. Under favourable conditions of life, requiring little physical exercise and causing no emotional excitement, both forms of mitral disease are compatible with many years of life. When they are conjoined, the prognosis is more unfavourable. In cases of sudden insufficiency, produced by rupture of the valve-curtains or of the tendinous cords, death may occur very rapidly from the disturbance of the circulation. The whole question of prognosis turns princi- pally on the state of the myocardium. So long as this is sound, compensation maybe maintained; the moment degeneration sets in, asystoly and all its evil train of symptoms come on. Thus asys- toly coming on gradually, without any previous overstrain of the heart, is always most grave. Each successive attack becomes graver, and the visceral congestions which accompany it more stubborn. Albuminuria is a good index of the gravity of the congestion, and is serious in proportion to the frequency with which it has occurred. In some cases a copious flow of lim- pid urine is a very grave symptom. Dropsy of the extremities, and of the cavities more espe- cially, is bad, as indicating failure in the peri- pheral circulation. Next to the cardiac muscle, the state of the peripheral vessels is most im- portant; thus, atheroma and other conditions, such as febrile attacks, add to T.he danger by interfering with the circulation. The general nutrition of the patient suffering from valvular disease also enters into the prognostic problem. There is a cachexia proper to the end of heart- cases, which is clue to the gradual deterioration of the nutritive fluids by the long-continued visceral congestions which hinder assimilation and excretion. Blood is less perfectly made and less perfectly purified ; hence the steady deterio- ration of cardiac cachexia, which is always of evil import as regards duration of life. Valvular diseases are, however, in numerous instances compatible with many years of life. In some the healthy expectation of life may be attained ; and, in many, years of comparatively active life are enjoyed. In the poor, the prognosis, as to duration, is not favourable ; but in the well-to- do, all observers see many cases extending over a great number of years. Treatment. — Valvular affections of the heart, whether the result of rheumatic inflammation or of degenerative change, are, as a rule, incurable. Some few cases of rheumatic origin lose the signs of valvular disease, and are practically restored by the after-processes (for example, contraction) in the inflamed valve ; and some few cases also of mitral insufficiency, associated with dilated left ventricle, are cured by treatment. These excep- tions are, however, few ; and as we cannot repair the valve-mischief, in the vast majority of cases HEART, VALVES AND ORIFICES OF, DISEASES OF. £30 our treatment must be directed to aid the com- pensatory hypertrophy, and to check the develop- ment of the consequences of the defect. The maintenance of the nutrition of the substance of the heart is, therefore, the main object of treat- ment; just as the state of the nutrition of the heart is the key to the prognosis. On this account the general regimen of heart-cases is very im- portant. General regimen . — The diet should in all rases of valvular disease of the heart be un- Btimulating but sustaining, consisting of a good proportion of albuminous food (underdone meat, eggs, and fish), with wine in moderate quantity, and some chalybeate water. There should be no unnecessary excitement of the heart, either by exercise or emotion. All atliletics and violent efforts should be avoided by the young, espe- cially in mitral cases. In aortic cases, steady exercise without strain is beneficial. The resi- dence should be so situated as to avoid the necessity of exertion, sudden changes of tem- perature, cold, and damp. The chief object of the regimen should be to prevent ansemia; hence plenty of fresh air is essential. Tobacco is injurious. In early life over-exertion and exposure to cold — in adult life, emotional, sen- sual, and dietetic excesses, are the chief dangers. The propriety of marriage must be considered in each case on its merits. AVomen, as a rule, should not marry ; when affected with mitral disease they are' often barren. To men marriage is more generally permissible. Medicinal treatment . — The therapeutics vary according to the stage of the cardiac disease. The mechanical defect of a valve first makes itself felt by palpitation and praecordial pain ; these symptoms pass away when compensation is effected, but till then require treatment. In cases of mitral disease, tincture of digitalis (n\x doses) relieves the palpitation ; chloric ether is also a useful adjunct. In aortic cases, ether, diffusible stimulants, small doses of opium and belladonna, with the local application of bella- donna to the praecordial region, are valuable remedies. The prsecordial pain, mostly retro-sternal, may, when severe, require a few leeches or cupping, but generally yields to mild counter-irritants, such as turpentine or mustard. Internally, the bromides are useful ; when the pain occurs paroxysmally, ethereal preparations and am- monia act well. AVhen the compensatory changes in the heart are effected, the palpitat ion and pain decline, and the chief indication is to keep up the nutrition of the heart by the hygienic rules above given, and by the administration of preparations of steel, combined with arsenic, strychnia, quinine, and mineral acids. Chalybeate waters are also useful adjuncts. The syrup, infusion, and tinc- ture of the prunus virginica are preparations of value in some cases after the use of digitalis. The secretions should be carefully watched, and the bowels opened freely every day, so as to avoid straining, and to relieve the portal circulation. The quantity of urine should be daily noticed, as it is a capital index of the state of arterial tension. Patients in whom the most perfect compensation exists, are, nevertheless, in a state of imminent trouble, for an exaggeration of a physiological act or emotion may disturb the unstable equilibrium of their health. In most cases the compensation breaks down sooner or later ; and then begin the symptoms depending on pulmo- nary congestion and general visceral engorge- ment, with the consequent impoverishment of the blood. Dyspnoea marks the beginning of these troubles ; anaemia and dropsy the close. The pulmonary congestion soon manifests itself by bronchial catarrh, which requires expectorants in various combinations, while friction, poultices, and counter-irritation are applied to the chest- walls. In capillary bronchitis with rapid pul- monary congestion, it is sometimes necessary to bleed from the arm to relieve the over-distended cavities of the right side of the heart. Nausea- ting doses of ipecacuanha, or actual emetics of sulphate of zinc, are sometimes very useful. For the general visceral congestions our chief remedies are, firstly, diuretics ; and, failing these, hydragogue cathartics. Of diuretics, the salts of potash, squills, broom, chimaphiln, spirits of nitrous ether, juniper and digitalis are the most useful. The hydragogue cathartics, which relieve the over-distended portal vessels primarily, and the general circulation secondarily, are also most valuable ; of these the compound powders of scammony and jalap in 20- to fO-grain doses : bitartrate of potash in electuary, 3j to 3ij, every morning; sulphate of magnesia; pi- lula scammonii composita ; elaterium ; senna ; and gamboge are the most trustworthy. By the judicious use of an occasional purgative, and the administration of a suitable diuretic, aided by cupping, poultices, and sometimes a small blister over the loins, combined with rest and stimu- lants, the worst cases of dropsy from cardiac failure are often saved. For the dyspnoea and the insomnia, two of the worst symptoms, we have a remedy of great power in the subcutaneous injection of morphia in doses of one-sixth of a grain upwards. This remedy acts often like a charm, and may be used even in the worst cases of both mitral and aortic disease, but always with caution. Albumen in the urine does not necessarily contraindicate its use. In some cases chloral and bromide of potassium, alone or in combina- tion, are valuable remedies for the insomnia, but they must be given cautiously. The bromides may also be prescribed with other sedatives for the dyspnoea. The compressed air bath in some cases also relieves the last symptom. Dropsy, like the visceral congestions with which it is associated, requires the use of diure- tics and hydragogue cathartics. AVhen these foil, the swollen limbs may be sometimes punctured with benefit. Continued friction of the limbs, by stimulating the vessels, will often cause consider- able anasarca to disappear. The drug on which main reliance must be placed when general dropsy supervenes is digitalis. This remedy has so great a share in the therapeutics of heart- disease, and a knowledge of its action is so im- portant, that it must be discussed separately and last. Whatever views may be held as to the physiological action of digitalis, its greatest triumphs are seen clinically in the treatment ci valvular diseases, when cyanosis, distended jucro HEART. VALVES OF, DISEASES OF, AMD ANEURISM OF. fi3) lars, dyspncea, congested viscera, dropsical limbs, scanty urine, tumultuous heart-action, and quick, irregular, and failing pulse, indicate asystoly. This assemblage of symptoms is mostly seen in mitral cases, and it is precisely in this class that the drug is most valuable. Under its use ‘ the pulse grows in force, fulness, and regularity ; the arterial tension rises; the pulmonary congestion diminishes; the kidneys, before inactive, wake up to their work: and the advancing dropsy recog- nises its master and beats a sullen retreat.’ In mitral stenosis these good results are due not only to the increased vigour given by the drug to the contractile power of the heart, but also to the fact that by its slowing action the dia- stolic period of each revolution is lengthened, and the time thus increased during which the over-full auricle can force its contents through the narrowed mitral orifice into the left ventricle. Digitalis here not only obtains a better filling of the ventricle, but a more effective discharge of its contents when filled ; and thus, under its use, beat by beat, the general and pulmonary venous congestion is relieved. In mitral insuffi- ciency it is almost equally potent. In both forms certain of its good effects would seem to be due to some influence, probably through the pneumo- gastric nerves, in producing contraction of the pulmonary blood-vessels. It is perhaps this property which makes it valuable in pulmonary haemorrhages independent of heart-disease. In aortic valvular diseases digitalis is not so valuable a remedy. In these cases the assemblage of symptoms mentioned above is not met with, except sometimes in the later stages, when the mitral valve is secondarily affected, and the case is not one of pure aortic disease. In these compound cases the drug is valuable, especially in combination with stimulants. In aortic in- sufficiency alone, f he slowing action of the digitalis produces evil by increasing the length of the diastolic period of each revolution, during which the regurgitation takes place. The force it may give to the systole is no gain in the face of this slowing action, inasmuch as the aortic recoil gains in the same proportion as the ventricular systole, and thus forces blood back into the ventricle with increased vigour during the lengthened diastole. It is important in aortic insufficiency to encourage the frequency of the cardiac action ; hence these cases are so constantly the better for bodily activity ; and so, when the toning effects of digitalis are required, it should always be given in combination with ether and ammonia, to keep up quick action of the heart, and to prevent the vertigo and syncope which may otherwise occur. When there is excessive hyper- trophy in cases of aortic insufficiency, digitalis is useful sometimes in quieting palpitation, reducing excessive frequency, and lessening headache and ; vascular excitement. Caffeine and veratrum viride also relieve these symptoms ; but a few drops of nitrite of amyl inhaled from cotton- wool are more rapidly and surely beneficial than any other remedy. In aortic stenosis digitalis is rarely required. The simple mode of compen- sation makes these cases require little treatment . Digitalis is sometimes useful in combination with stimulants to give vigour to the myocardium, and check the tendency to dilatation. If it slows the action of the heart notably, its effect becomos hurtful. Nux vomica often prevents this. In combined valvular lesions, the predominant lesion must be the guide in the use of digitalis ; but it may be given advantageously whenever the general signs of venous stasis are present. The diuretic power of the drug is one of the best test* of its beneficial action. Relying on th's test, the writer often gives digitalis for weeks, nay, months at a time, and obtains improvement in the nutrition of the heart which lasts long after its discontinuance. Digitalis effects this improve- ment by increasing the vigour of the coronary circulation, and thus builds up new heart-muscle to compensate a valvular defect. The preparations of digitalis which may be used are, the powder in I- to 1-grain ; the tincture in tux. to xxx.; and the infusion in Jj to ovj doses. As a diuretic in cases of dropsy, the old combination of squill, digitalis, and blue pill is invaluable. Balthazar Foster. HEART, Valves of, Aneurism of. — Defi- nition. — A valvular aneurism is a circumscribed pouching or sacculation of one of the valve- segments. Description. — Two forms of aneurism of the valves of the heart are met with. In the one, the whole thickness of the valve is dilated by the blood-pressure to form the pouch; in the other, one of the lamellae being ulcerated by endocarditis, the blood pushes the remaining lamella before it to form a sac. The second form, which is sometimes called ‘ acute valvular aneurism,’ occurs most commonly in ulcerative endocarditis. Valvular aneurisms vary in size, from a pea up to a pigeon’s egg. The orifice is almost invariably towards the greatest blood- pressure — those on the mitral valve opening to- wards the left ventricle; those on the aortic valves towards the aorta. They are usually rounded in shape, but may have irregular prolongations between the lamellae of the valves. Valvular aneurisms are sometimes multiple. The valves of the right side of the heart are seldom affected. The mitral valves are the seat of the larger aneurisms, and are twice as often aneurismal as the aortic valves. Valvular aneurisms terminate commonly by early rupture, giving rise to perforation and consequent insufficiency of the valve, and often leading to considerable laceration. Rupture occurs more rapidly in aneurism of the aortic valves. Mitral aneurisms occasionally become chronic, and filled with coagulum ; and aortic valve aneurism may also be found filled with solid clot. Symptoms. — The clinical history of this form of disease is defective. When seated on the mitral valve, aneurisms usually give rise to no signs until the perforation and laceration of the valve suddenly develop the murmur of mitral insufficiency. An aneurism of one of the aortic segments causes a soft systolic murmur over the valves, which one day, as the sac ruptures, is supplemented by the murmur, and accompanied by the symptoms of aortic insufficiency. The phenomena of this accident are similar to those of sudden rupture of an aortic valve. Balthazar Foster. 632 HEART, WOUNDS OF. HEART, Wounds of. — Synon. : Fr. Bles- sures du C) Local Effects of Severe Heat : Burns and Scalds. — The local effects of heat vary with the degree, the length of exposure, the medium of application, and the part acted upon. Bums result from ‘ dry,’ Scalds from ‘ moist ’ heat. Symptoms. — A comparatively slight degree of heat causes vascular turgescence, redness, ting- ling, pain, and tenderness, which soon subside. Desquamation of the epidermis may follow, but no permanent trace of injury is lelt. A higher degree causes severe burning pain, and great redness of surface, followed by effusion of serum beneath the cuticle (vesication.) Complete re- storation without scar is usually effected. Still higher degrees of heat or longer exposure cause intense pain, and immediate destruction, or con- secutive destructive inflammation, of the true skin to a greater or less depth. Sloughing and sup- puration follow, and permanent scarring results. Violent heat and prolonged exposure cause com- plete disintegration and charring of the struc- tures especially acted upon, followed by de- structive inflammation and sldughing of others to a still greater depth and extent.. Loss of parts and more or less serious deformity and scarring necessarily result. The separation of sloughs, and the processes of repair after severe burns, take place slowly ; and as a rule the patient suffers much more acutely, and during a much longer period, than after other forms of injury involving equally extensive destruction of tissue. The constitutional effects of burns and scalds vary with the superficial extent and situation, rather than with the depth of the injury. Thus an extensive burn or scald over the abdomen affecting only the skin is much more likely to prove fatal than a deep burn of one of the extre- mities, penetrating oven to the bone, but of comparatively small superficial area. If more than half the surface of the body is affected the sufferer rarely recovers. Death may result from shock to the system, either immediately on receipt of the injury, or after a period of from two or three to forty-eight hours or more. During this time the sufferer remains in a state of collapse or prostration, with pallor of complexion, lowness of temperature, coolness of breath, small or imperceptible pulse, dryness of tongue and mouth, and sometimes de- lirium, rigors, or convulsions. In such cases, post- mortem examination shows only congestion of the viscera, and especially of the brain. In some instances, characterised by painfully laboured and frequent efforts at respiration, tumultuous, irregular, feeble and very frequent action of the heart, and great prcecordial distress, death would appear to be due to cardiac thrombosis, rather than to simple nervous shock (Brown). In many severe cases the blood has been found on micro- scopical examination altered in appearance, the red corpuscles being separated into ‘ numerous little bits’ (Ponfick and Schmidt). And it is readily conceivable that such destruction of corpuscles may give rise to severe symptoms, or even cause death. In about forty-eight hours, more or less if 63a the immediate effects of the injury have been survived, the stage of reaction and inflammation sets in. The patient revives, and some degree of general pyrexia becomes manifost. The pulse becomes quicker and fuller; the temperature rises ; and the burnt part begins to discharge pus, usually of an offensive odour. Thirst, with dry red tongue, want of appetite, vomiting and constipation, followed by diarrhoea — some- times with blood in the evacuations — are com- monly experienced during the ensuing period ; and inflammation of internal parts often occurs, although the special signs and symptoms afforded may be obscure. The pleurae and lungs, the peritoneum, and the gastro-intestinal mucous membrane (particularly that of the duodenum) are especially liable to be affected. Evidence of inflammation of one or more of these parts, and not uncommonly of ulceration of the duodenum, is afforded on post mortem examination in cases in which death has occurred during this period. It has been suggested that capillary embolism, from the presence of disintegrated blood in the ves- sels, may cause in some cases the lesions of the internal organs (Brown). In the course of about a fortnight after the inj ury, as a general rule, the sloughs will have separated, the acute symptoms will have sub- sided, and granulation and suppuration will have been established. But a low form of chronic inflammatory mischief in the internal organs may still be going on, and lead to fatal result ; or the patient may sink, worn out by suffering, and ex- hausted by the profuse discharge from the sup- purating surface, or by persistent diarrhoea, accompanied or not by blood in the motions. Sometimes the kidneys are affected, and blood or bloody casts may be found in the urine. Pyae- mia, erysipelas, or tetanus may occur and cause death ; but there would not appear to be any special liability to these diseases after burns or scalds. Treatment. — Local treatment . — Slight super- ficial burns of small extent require little in the way of treatment. Immersion in cold water ac- cording to some, in hot water according to others, or exposure before the fire, affords the readiest means of obtaining immediate relief. After- wards the part maybe covered with flour, starch, oxide of zinc, bismuth, or collodion, and wrapped round with cotton-wool to protect it from the air and from accidental irritation. In cases in which there is vesication, the blisters should be pricked, the serum evacuated, and the cuticle left to form a natural protective covering, which may be advantageously strengthened and kept in position by a layer of collodion. But the punctures should be left open. Lint soaked in oil, or smeared with vaseline or some such mate- rial, should be applied, and the whole covered with cotton-wool. A mixture of chalk or whitening and vinegar, of the consistence of thick cream, is said to form an excellent application in such cases, speedily relieving pain, and helping to constitute a good protective covering. Severe and extensive burns and scalds de- mand in their treatment the most careful management, and the greatest possible patience, gentleness, and firmness; for even if life be preserved, the most pitiable disfigurements and C3G HEAT, EFFECTS OF SEVEKE. deformities are liable to result from cicatricial contractions, unless proper preventive measures are perseveringly carried out. So soon as may be after the injury, the clothes should be re- moved from the patient with the greatest care — being cut away piecemeal if needful, and not removed in such way as to tear off epidermis or scorched or charred parts. The whole burnt surface should then be covered as quickly as possible with the dressing considered best, and enveloped in thick layers of cotton-wool lightly bandaged on. Different dressings have been ad- vocated from time to time, but probably there is none better, or more generally and readily applic- able in hospital practice at any rate, than Carron oil (a mixture of equal parts of linseed oil and limewater). The addition of a little carbolic acid is advantageous. A less disagreeable ap- plication may be made by substituting olive or aimond oil for linseed oil. White lead, putty made thin by addition of oil, calamine ointment, carbolised oil, solution of carbonate of soda, car- bolic lotion, flour, and starch, are among the other materials that have been recommended. Whatever the material selected, it should be slightly warmed, and applied very thickly spread on broad strips of lint, in such way as to facili- tate future dressing bit by bit, and so as to avoid extensive exposure of raw surface. The first dressing should be allowed to remain undisturbed as long as possible — until, indeed, the offensive- uess of the discharge, or the discomfort of the patient, indicates the necessity for its removal. The earlier dressings, however gently carried out, occasion so much suffering to the patient that — in the case of children especially — it is often desirable to administer chloroform. Poul- tices are sometimes useful in aiding the separa- tion of sloughs. Any needful washing or clean- sing is best done by aid of the steam spray- producer, a weak solution of carbolic acid or of borax being used. AVhen suppuration is es- tablished, and the surface clean, the applica- tion may be varied according to the indications afforded. Calamine or zinc or lead ointment, with or without the addition of some anodyne; and lotions of lead, morphia, and glycerine, or of sulphate of zinc, are amongst those commonly employed. Iodoform, with extract of hemlock and spermaceti ointment, has been strongly recommended as tending to soothe pain, to deo- dorise the discharge, and favour healing. Exu- berant granulations may be treated with nitrate of silver in solution, or by the application of the solid stick. When the granulating surface is in a healthy state, cicatrisation may be very mate- rially expedited by skin-grafting. During cicatrisation, and even for some time afterwards, it is of the greatest importance to keep all parts in such position as that there shall be as little deformity as possible from growing together of surfaces, and contraction of scars. This is to be effected or attempted by position, by mechanical apparatus, and by the application of strips of adhesive plaster and bandages in manner determined by the circumstances and conditions in each particular case. Constitutional treatment. — In the early stages, alcoholic stimulants, or ammonia, and external warmth are especially requisite, and such light HEAT, THERAPEUTICS OF. nourishment as can be taken. Opiates or other anodynes, as chloral or bromide of potassium, are to be administered according to the indica- tions afforded, for the purpose of allaying pain and soothing the nervous system. AVhen sup- puration is established, a full allowance of good nourishing food, with some alcoholic stimulant, should be given, and such tonics as seem most suitable. Small doses of opium at regular in- tervals often prove very beneficial. The com- plications that may arise, such as affections of the internal organs, &c., must be treated in accordance with general principles, but all de- pressing medicines as a rule should be avoided. Arthur E. Durham. HEAT, Therapeutics of. — Principles. — The primary effect of external heat applied lo- cally to the animal body is that of an excitant or stimulant. There occurs redness with tur- gescence of the small vessels, in the part to which the heat is applied, along with slight augmentation of temperature, and pain. In- creased beyond a certain degree, heat ceases to be a stimulant, its prolonged action causing greater pain, exhaustion, depression, and, if the action be very intense, decomposition of the or- ganized tissues. See preceding article. Experiments have shown that by increased heat the electric currents in the nerves are de- stroyed. It may therefore he assumed that the nerves become less able to conduct impressions either to or from the brain, and that heat may act as a sedative to painful nerves. Moderate heat applied generally, that is, to the whole body, produces a number of important physiological effects which are fully described in the preceding article, to which the reader is referred. Applications and Uses. — Heat is employed in the treatment of disease as a general or local stimulant, a local depressant, a caustic, or a counter-irritant; and that in the form either of dry or of moist heat. Dry heat. — The primary exciting and stimu- lating action of heat may be made available to rouse the nervous and vascular systems. The use of the hot air bath (Turkish Bath), and that of the sand-bath are discussed in the article on Baths. In some parts of the South of France, baths of hot sand ( arena catida ) are used in the treatment of rheumatism, paralysis, and spasm; the sand acting as a stimulant and sudorific. To restore the circulation, bottles of hot water are placed in the axillae, and against the feet and thighs, in cases of collapse of the system, with coldness of the extremities and great failure of circulation, as in the treatment of collapse from the shock of an injury, or from such diseases ss cholera, or of the apparently drowned. Dry heat may also be applied to the abdomen, in the form of tins or bottles of hot water, or bags of heated salt or sand, to relieve painful spasm and colic. Hot water enclosed inan india- rubber bag is sometimes of service to allay undue irritability of the spinal nerves. The therapeutical application of heat as a counter-irritant will be found described elsewhere. See Counter-irri- tants. Moist heat. — Heat and moisture together tend HEAT, THERAPEUTICS OF. to cause relaxation of the tissues, thus removing the tension and pain due to inflammation. Moist heat is employed locally in the form of the local vapour hath, fomentations, and poultices. See Fomentations ; and Poultices. Moist heat is applied to the surface of the body generally, chiefly in the form of the va- pour hath. See Baths. John C. Ihorowgood. HEAT - STROKE.— A synonym for sun- stroke. See Sunstroke. HECTIC EEVER (Iktikos, habitual). — Synox. : Fr. Iiectique ; Ger. Hecti&ch. .Etiology. — The variety of fever thus named has long received special recognition, inasmuch as it presents certain prominentandpeculiarfeatures, as regards its course and attendant phenomena. It occurs in association with some wasting and ex- hausting disease, especially when this is accom- panied by a profuse and constant drain from the system, and more particularly when there is chronic suppuration, with an abundant discharge of pus. Hectic fever is most frequently noticed in cases of pulmonary phthisis, in a large proportion of which it appears in various degrees during some part of their course, chiefly in the advanced btages. Other conditions deserving of mention in connection with which it may supervene are empysema, especially if there is an external fis- tula, tubercular ulceration of the intestines, chronic purulent discharge from the kidney, hepatic abscess, chronic dysentery, and any form of external chronic abscess attended with much discharge. Fever of a hectic type sometimes occurs in cases of acute inflammation ; and it is occasionally observed in chronic affections un- attended with suppuration, such as cancer and lymphadenoma. Pathologically it seems to be connected with the absorption of pus or other morbid products into the blood. See Fever. Symptoms. — Hectic fever is established gra- dually, becoming more and more distinct, until it assumes its typical characters. It is more or less paroxysmal, being at first indicated by slight pyrexia towards evening and during the night, the temperature being a little raised, and the pulse hurried. During the day there is no fever at this time, but as the case progresses it becomes constant, though exacerbations occur at night, and, it may be, also in the morning, tho parox- ysms thus occurring either once cr twice within the twenty-four hours, and the pyrexia being re- mittent. In typical hectic there is a complete febrile cycle, beginning with chills or even a dis- tinct rigor, followed by considerable heat of skin, the temperature continuing to rise, and ending in more or less profuse perspiration, especially about the head and chest, sometimes so abundant as to saturate the bed-clothes or even the bed- ding. Patients often feel subjectively very hot, the palms of the hands and soles of the feet having a burning sensation. The pulse tends to become very frequent and quick, and is easily hurried and excited, being at the same time weak, soft, and compressible. Not uncommonly a bright red or pink spot appears on each cheek during the paroxysm, known as the hectic flush, and this may contrast markedly with the general pallor of the face, tho eyes being also bright, HEMERALOPIA. 637 clear, and sparkling. The mind is unaffected, and the mental faculties may be unusually bright and vivid. After a febrile exacerbation the urine may present excess of lithates. Hectic fever does not always show all its typical features, and even in the same case variations are noticed in tho precise characters of the paroxysms. It is usually accompanied with other symptoms due to the disease with which it is associated ; while it itself tends to cause wasting and debility, as well as a sense of exhaustion after each attack. In most instances a fatal termination ultimately ensues, but if the condition upon which hectic depends is curable, recovery may take place. Treatment. — The first principle in the treat- ment of hectic fever is to attend to, and cure, if possible, the condition upon which it depends, and especially to diminish or stop suppuration. General tonic treatment will also help in prevent- ing the paroxysms. These may he directly checked in appropriate cases by full doses of quinine, sali- cine, or other antipyretics, given before the usual time for their occurrence. Sponging the skin freely may also prove of service in some instances. The treatment of hectic in phthisis runs into that of night-sweats, and can he more conveniently discussed under that disease. See Phthisis. Frederick T. Roberts. HELIOSIS ( , I expose to the sun). — A method of treatment for certain diseases, which consists in exposing the patient to the rays of the sun. The term is also employed as a syno- nym for sunstroke. See Sunstroke. HELMINTHIASIS (eA/j-ivs, a worm) —The condition of system upon which the development of worms in any part of the body depends. The term is also applied to the diseases characterised by the presence of worms. HELMINTHICS (e\jaiw, a worm).— Of or belonging to worms. A synonym for anthel- mintics. See Anthelmintics. HELMINTHS (e'X/ii vs, a worm). — This term is often employed in preference to ods or other of the various synonyms with which it is regarded as equivalent (worms, intestinal worms, vermes, entozoa, internal parasites, and so forth). Thus, Yon Siebold (who speaks of the Helminths as forming a class of animals, nearly all of whose members are parasitic) admits that tho only character common to the greater part of the whole group is their peculiar mode of life. The study of the helminths forms what is often called the science of Helminthology. In accord- ance with professional custom, it has beer, thought desirable, in the present work, to speak of the helminths as constituting the class Ento- zoa, under which heading, therefore, more de- tailed references are given. T. S. Cobbold. HEMERALOPIA. — The etymology of this term is uncertain, and its real meaning has never been definitively settled. Some winters derivo the word from yp-lpa, the day, and &12 HICCUP OR HICCOUGH, hiccup it never occurs during ordinary inspira- tion. or without the spasmodic action of the diaphragm, although the latter phenomenon may occur without the former. ■(Etiology. — Hiccup may be produced by any irritation of the phrenic nerve — its origin, its course, or the ultimate twigs which are distributed to the under surface of tile diaphragm. Undue distension of the stomach by being overfilled with food or drink, or by an accumulation of wind due to faulty digestion, is the most common cause of hiccup. Its occurrence from this cause is far more common in children than in adults. Con- vulsions and muscular spasms generally are more easily caused in the young, and hiccup in this respect follows the ordinary rule. Hiccup is produced by direct, or by reflex irritation. With many persons the introduction of hot spiced or peppery foods into the stomach imme- diately produces hiccup, and the writer knows one or two persons in whom hiccup is produced by the passage of hot fluids through the pharynx. It is a frequent symptom in peritonitis when the peritoneal covering of the diaphragm becomes affected. It sometimes occurs in cases of cancer of the stomach ; occasionally, perhaps, from over- distension of the organ, but more often- from an extension of the cancerous disease to the peri- toneal surface of the stomach. It is occasionally a troublesome symptom during convalescence in cholera, and is often accompanied by eructations of wind, and sometimes by vomiting. If hiccup occur with any persistency in the course of typhoid fever, it is often an indication of per- foration and the onset of general peritonitis. Although most frequently a symptom of gastric or abdominal disturbance, hiccup occasionally occurs as a true neurosis. It may accompany hydrocephalus or meningitis, and is then due probably to an implication of the cerebral origin of the phrenic nerve. Cases of obstinate hic- cupping in hysterical subjects have been recorded, and cases of paroxysmal hiccup have been ob- served by Liveing, Prichard, and others, which have been regarded as instances of modified epilepsy. Treatment. — The treatment of hiccup will depend upon the cause. An emetic to empty the stomach, or a stimulant to increase its natural peristaltic action, will often give relief. If we can succeed in producing a forcible action of the diaphragm, we may often succeed in curing it, as it were, of the trick of spasmodic action. Attempts to count a hundred without drawing breath, or to hold the breath for a minute, are familiar remedies for hiccup, and, by producing a feeling of suffocation, and necessitating a vio- lent descent of the diaphragm, they are often successful. Warm applications or counter- irritation applied to the diaphragmatic region or over the cervical spine, may occasionally give relief. Pressure upon the trunk of the phrenic nerve by means of the finger applied over the scalenus anticus muscle, is said also to have given relief occasionally in obstinate cases. Amongst the drugs wdiich have been recommended for the relief of hiccup are chloroform (administered in- fernally), either alone or combined with opium, camphor in the form of a spirit solution, in doses if twenty drops and upwards, valerianate of zinc, HORNS. belladonna, bromide of potassium, musk, art- acids, 'and in very severe cases morphia adminis- tered hypodermically. G. V. Poonp.. HIPPURIA GViroj, a horse, and ohpor, urine). — The condition of the urine in which it contains hippuric acid in excess. See Urine, Morbid Conditions of. HISTRIONIC SPASM (liistrio, an actor). A synonym for facial spasm, so called on account of the contortions of the face to which th:6 affection gives rise. See Facial Spasm. HIVES. — A popular term for chicken-pox. See Chicken-pox. HOARSENESS (Sax., has, having a rough voice). — Roughness of the voice, due to disease or disorder connected with the larynx. See Voice, Disorders of. HOBNAIL LIVER. — A name given to a cirrhotic liver, when it presents small promi- nences on its surface, resembling hobnails. See Liveii, Cirrhosis of. HODGKIN’S DISEASE. — A synonym for Lymphoma. See Lymphoma. HOMBHRG, in Germany. Common salt waters. See Mineral Waters. HOMICIDAL INSANITY. See Criminal Irresponsibility ; and Insanity, Impulsive. HOMOLOGOUS (<5 fibs, like, and \6yos, na- ture). — Jn pathology this term is applied to new growths presenting the same structure as nor- mal tissues, such as fatty or fibrous tumours. HOOPING-COUGH. See Whooping Cough. HORDEOLUM (Jiordeum, a barley-corn). A synonym for stye. See Stye. HORN-POX. — A popular term for a variety of chicken-pox. See Chiceex-pgx. HORNS — Synon. : Cornua. Definition. — Horns are epidermic and epithelial formations, consequent on hypertrophy of the horny product of the integument. Description. — Horns generally occur singly. Sometimes they attain a size of several inches in length and in circumference. They have been met with on all parts of the body, more particu- larly on the scalp, the face, the glans penis, and the glans clitoridis. Pathology. — When the inspissated product of the follicles of the skin, consisting of laminated epithelium and sebaceous matter, is exposed to the air, it dries, becomes hard and transparent, and is in fact converted into a mass having most of the properties of horn. This is the prin- cipal source of the horns of the integument — an accumulation of the contents of a follicle ; the protrusion of that substance through the dila- ted aperture of the follicle, sometimes through a large opening resulting from atrophy or ulcera- tion ; its dessication by the atmosphere ; and its growth by continued additions to its base. lieing essentially the protrusion of a soft substance through a constricted aperture, the surface of tbs HORNS. Lorn will be modelled in figure by the shape of that aperture ; in consequence of desiccation, its shaft will be smaller than its base ; and it will be liable to be bent or twisted in the operation ot' protrusion. Hence these horns are generally curved or twisted, and have been compared to the beak of a bird, or the horn of the goat. A section of the horn affords similar evidence of its manner of formation and growth, it being always laminated n structure. Another kind of horn is sometimes met with on the glans penis and clitoridis, and is the pro- duct of hypertrophy of the papillae. This form of errowth is fibrous in structure, like a wart, which in fact it closely resembles; whilst in the same situation concreted masses are occasionally formed, constituted by a combination of both processes, namely, papillary hypertrophy and accumulation of follicular substance. There is, however, an important difference between the two kinds of horn, the sebaceous and the epidermic, namely, that the former is the mere result of increased activity of function, whilst the latter is the con- sequence of hypersemia or inflammation. Treatment. — Horny matter being susceptible of disintegration by moisture, the sebaceous horn may be so thoroughly softened by envelopment .n a waterproof covering, or by a poultice, as to be easily broken away at its base. The folli- cular bed from which it has been removed may then be cleared by a small scoop, when the sac will contract and close. Sometimes it maybe thought desirable to sponge the surface with a solution of chloride of zinc or sulphate of copper ; but opera- tion by the knife seems quite uncalled for. In the instances of epidermic and epithelial horn, however, it will be necessary to have recourse to caustics, especially potassa fusa ; and when the case evinces great obstinacy, or where an epi- theliomatous degeneration is suspected, the use rf the knife becomes essential. Erasmus Wilson. HORRIPILATION ( horreo , I bristle up, and pilus, a hair). — A sensation of chilliness and creeping, the hairs appearing to stand on end. HOSPITALS. — The subjects having rela- tion to hospitals will be treated of under the ! following heads : — I. Hospitalism ; II. Hos- pitals, Administration of ; JII. Hospitals, Con- struction of; IV. Nursing ; and V. Nurses, Training of. The reader is referred to these several articles. HOSPITALISM. — The term ‘ Hospitalism ’ was introduced into medical literature by Sir J. Simpson ( Edinburgh Medical Journal, March, 1869), but, as far as the writer can see. no exact de- finition of it was given by its author. It, however, was evidently intended to signify ‘the hygienic ' evils which the system of huge and colossal hos- pital edifices has hitherto been made to involve’ — lo use Sir J. Simpson’s own words. These evils .Appeared to him so evident, and so necessarily con- nected with the size of the hospital, that he taught and in fact the sole object of bis papers was o teach) that our system ought to be revolution- sed — ‘hospitals changed from being crowded Maces, with a layer of sick on each flat, into illagcs or cottages, with one, or at most two 'atients in each room — the village constructed of HOSPITALISM. 643 iron instead of brick or stone, and taken down and rebuilt every few years.’ Mr. Erichsen has, to some oxtent, accepted the teaching of Sir J. Simpson, though he allows that some of it is very questionable. His tract on the subject of Hospitalism has the advantage of being written in a more sober style than Sir J. Simpson's, and also of putting the question in a clearer light. By the term, 1m says, ‘ is meant a general morbid condition of the building, or of its atmo- sphere, productive of disease. . . . Doubtless,’ says Mr. Erichsen, ‘ all the septic diseases that are met with in hospitals may be encountered in the practice of surgeons out of these institutions, but they are unquestionably infinitely more com- mon in hospital than in private practice, and their causes are certainly different.’ 1 The writer believes, on the contrary, that if a hospital bo properly managed there is no general morbid condition of the building — that there is no reason for thinking that septic diseases are more com- mon relatively in hospitals than out of them, and that their causes are identical wherever they occur. And if the term Hospitalism is to be taken in the sense in which Sir J. Simpson evidently in tended, that is, as meaningto convey the idea that there is an inevitable tendency to the generation of septic disease in large hospitals, that that tendency becomes greater as the size of the hospital is increased, and that it increases as tho hospital grows older, the writer has no hesita- tion in saying that there is no such thing as Hospitalism. No doubt the aggregation of the sick and wounded in hospitals is a cause of dan- ger, and much care and vigilance is required to keep hospitals healthy. But the clangers are-in no sense peculiar to hospitals. The surgical affections which spring up in hospitals — ery- sipelas, phagedsena, pyaemia, and allied affections — all of them prevail in private practice, and, as far as has been shown, prevail equally. 2 Further, although the perfect publicity of ourhospital prac- tice enables us to obtain tolerably accurate data for a comparison of the experience of the smaller and larger hospitals of this and other towns, no one has ever seen the least reason for believing that the smaller are in any respect healthier than the larger, while several of the hospitals that have been longest built are renowned for their healthy condition, and in many large hospitals, parts of which are ancient and other parts modern, the former, if equally or better constructed, arc (under similar conditions of cases and manage- ment) as healthy or more healthy than the parts more recently built. The subject is not one which can be passed over as dealing with an insignificant question, or one of verbal interest only. The doctrines which Sir James Simpson taught led him to deprecate 1 On Hospitalism, p. 37. 2 It is not. of course, meant that pyiemia, for instance, is seen as often in private as in hospital practice, because its causes are less often met with in the former than the latter; but, if due allowance be made for this obvions con- sideration, there is much reason to acquiesce in the con elusion to which Sir J. Paget's ample experience bus led him, that pycemia is just as frequent in private as it. hospital practice (Cit'n. Soc. Trans vol. vii. p. lvi.). Ery- sipelas seems to be more frequent and more fatal at the present time in London private practice than in hospitals HOSPITALISM. 344 altogether the construction of any hospital of con- siderable size, and to advocate some extravagant scheme for substituting small detached tempo- rary sheds for our present permanent hospitals. The same views led Mr. Erichsen to say that when a hospital had become, as he phrased it, * pyaemia-stricken,’ it ought to be destroyed, 1 while similar ideas have led others, such as Dr. Farr and Miss Nightingale, to question whether hos- pitals had not destroyed more lives than they had saved. Such doctrines should not be passed over in silence, since they exercise a great in- fluence on the public, on whose co-operation the efficiency of our hospital system is to a great extent based. And certainly a theory which has received the support, however qualified, of so eminent a hospital surgeon as Mr. Erichsen, cannot be considered as of no importance. It is therefore necessary to point out to the reader that the theory, as so stated (and stated quite correctly after Sir J. Simpson’s writings), is utterly disproved by the experience of all well-managed hospitals, both before and after the introduction of the antiseptic method of dressing wounds. It must be noticed, in the first place, that the basis of the theory was entirely what is called ‘ statistics,’ that is, a hasty infer- ence from figures, showing the results of a large number of cases on either side. Now nothing is more dangerous than to draw conclusions from such figures, which are quite unsupported by any histories of the cases on which they are founded. 2 The success of a surgical operation depends more on the antecedents of the operation than on its consequents, and the healthiness of hos- pitals depends far more on other circumstances than on their construction, size, or age. Nay more, the success of surgical operations does not necessarily vary with the healthiness of the hos- pital. In the healthiest hospital a careless sur- geon, house-surgeon, or nurse may make havoc of the major operations while all is going on well with the general run of patients. For all these reasons, any one of which would be sufficient, the conclusions of Sir J. Simpson aro to be utterly repudiated, and to be considered the more mischievous because, while they allege imaginary causes of danger, they thereby conceal those which aro real and certain, and necessarily induce surgeons and managers of hospitals to overlook details, attention to which is always followed by success in the treatment of grave surgical cases, and by a condition of hospital hardly if at all inferior to the best circumstances under which private practice is carried on. The writer must not be misunderstood, as if he thought the details of hospital-construction unimportant. The principles of construction which are now accepted for the building of a hospital will be found at pp. 647-652 ; but it has been shown to demonstration that, provided wards be well, but not excessively, ventilated, and kept perfectly clean, and provided the beds are far enough apart, the precise ground plan of the hospital matters little — that the 1 On Hospitalism, p. 98. ‘ The writer lays less stress on the total absence of any guarantee for the accuracy of Sir J. Simpson's table of cases in private practice, and is willing, for the sake of arguni mt, to assume that the figures are correct. doctrines so much insisted on Dy the French writers on hospitals as to the superiority of the ‘ pavilion plan,’ as to the unhealthiness of upper storeys and so on, and which have been adopted as if they were unquestionable truths by many writers on the subject, have led to much waste of money on buildings too scattered for hospital service, which have turned out to be no healthier than the more compact and convenient structures which they superseded. But we ought not, in reaction from these exag- gerations. to undervalue the importance of good ventilation, good aeration, proper isolation of beds, and, above all, scrupulous cleanliness, in hospital wards. These essentials being secured, the writer is persuaded that a hospital may be just as healthy with thirty wards as with three, with twenty patients in each ward as with two, and with five storeys as with one. Far more important, and far too- little thought of, till within the last few years, is the amount of attention given to the personal care of the pa- tients. This is particularly the case in the treatment of open wounds. Everyone who has been much in hospitals must have often seen, and especially abroad, surgeons, dressers, and nurses hurry from one patient to another, hardly washing or wiping their instruments, still less their hands, and using thesamo dressingmaterials for one case after another. Surgical practice cannot be safely carried on in this way, how- ever healthy in itself the hospital may be. The first care of a surgeon in charge of hospital- wards ought to be to impress upon all his assist- ants, and never to forget in his own person, that the success of surgical practice depends more upon minute care in the dressing of cases, than on all other matters put together. Our surgical wards have become far more healthy since the introduction of antiseptic surgery; 1 and that this must be largely due to the increased care in the minuti* of surgical treatment which has followed on the discussion of this method is proved by the fact that it is as conspicuous in some of those who reject as those who follow Mr. Lister’s teaching. If it were not true that the septic diseases, or erysipelatous diseases, which interfere so much with the success of operations in our hospitals, depend in a very large proportion of cases on the method of dressing the wound and not on matters conveyed by the atmosphere, how could the success of the so-called ‘open method’ of dressing wounds be explained? In this method the wound is left freely exposed to that hospital air which is. we are told, charged with deadly miasma. The size of the wards, number of beds, &c., are all of course unchanged; but care is taken to see that the wound is well drained of all putrefiable discharges, and kept perfectly clean. If Sir J. Simpson's theory were true, we ought to have an increased mortality following on the freor exposure to this deadly atmosphere. On the contrary, the perfect drainage of the wound, and tlie care taken to keep it free from a., putrefying matters, are followed by results 1 The late Mr. Callender stated it as his deliberat opinion that the great surgical operations are ten tines more successful in hospitals now than they used to be in the past generation. HOSPITALISM. which can hardly be surpassed. Thus Dr. James Wood, of the Bellevue Hospital, New York, re- lates, that in wards which had been recently vacated on account of an outbreak of puerperal fever, he treated fourteen successive cases of unselected amputation of the limbs successfully, by merely leaving the flaps ununited, the raw surfaces exposed to the air, but carefully drained, and all putrescible matters continually removed ; 1 and this is only one of many proofs which have recently been given of the fact that there are many other plans of treating wounds besides that which is specially designated ‘ antiseptic,’ under which, conjoined with proper construction and general management, a hospital may be as healthy as a private house. This statement, which is made after long ex- perience, and with a conscientious conviction of its truth, by no means asserts that it is as easy to keep a hospital healthy as a private sick-room, or, in other words, that the aggregation of the sick and wounded involves no dangers. Such a doctrine would be absurd ; but the dangers are the same in kind, and the precautions required are the same, with a single exception. Hospitals, like private houses, must be kept well-aired, well-drained, scrupulously clean, properly, but not excessively, lighted, 2 and so forth. The great difference in the precautions required to ensure the salubrity of hospitals and private houses is, in one word, to guard against direct infection, and this may occur in two ways. Surgically, infection is carried directly by careless dressing — and every hospital surgeon must have remarked that as he himself is more watchful and careful, and as he has the good fortune to be surrounded by more careful assistants, his cases do better; and in the present healthy condition of most of our large LondonHospitals, such precautions of themselves suffice to raise the success of surgical practice to the same level as it reaches in private houses. The second way in which infection may be carried is by direct proximity or contact. This is more important in medical cases, and the obvious danger of the spread of infectious fevers has led the managers of most of our general hospitals to exclude such diseases from their wards as small- pox, scarlet fever, and typhus, while other affec- tions are admitted, which, though contagious, are so in a less degree, as tj’phoid fever, erysipelas, diphtheria, &c. Enough, or more than enough, has been done in this direction — that is, the public safety might be.as well consulted if typhus and scarlet fever cases were still admitted (as before the institution of special hospitals for such cases they used to be) into the wards of our general hospitals in small numbers, and under striet pre- cautions. Anyhow, it appears that there is little if any evidence of spread of disease from such cases reputed to be infectious as are still to be found in our general hospitals. Hearing that some distinguished surgeons teach confidently that pyaemia and erysipelas are usually propa- gated by contagion, the writer has often watched the progress of such cases when originating in 1 New York Medical Journal , Jan. 1876. ’ Most of our hospitals are too light, and too des- titute of the means of excluding the light. No doubt ( flood of light in the ward is very useful in detecting (lilt, but it sadly interferes with the repose which many medical and surgical cases require. HOSPITALS, ADMINISTRATION OE. 645 hospital or admitted from without, but has never been able to verify any spread of the disease from them, though he does not deny the possi- bility of such an occurrence. To sum up the whole matter — the writer would define the term ‘ Hospitalism ’ as expressing the danger which exists in hospitals of contamination from the aggregation of patients — and would add that the extent to which such contamina- tion prevails has been greatly exaggerated by theoretical writers ; that, as far as the general atmosphere of the ward is concerned, the danger maybe, and appears in all well-managed hospitals really to be, obviated by ventilation and cleanli- ness ; and the more immediate danger from the contiguity of patients cannot be shown to produce any appreciable effect, while the danger of con- tamination of wounds by putrefying materials demands constant vigilance to counteract it ; but with such vigilance seems to he so far counter- acted that hospital practice is, for anything we know, as successful as private practice in similar cases. This is not an entirely satisfactory result, inasmuch as practice in a hospital, where every patient is under the strictest regimen and sur- veillance, ought to be much more successful than private practice, where the conditions are very different in these respects ; but we are making rapid advances towards this desirable and per- fectly attainable end. T. Holmes. HOSPITALS, Administration of. — The administration of a hospital should be so framed as to enforce the necessary economy consistent with the due supply of the requirements for the sick. Governing Body . — The administration is in the hands of a governing body, which usually consists of a committee or board, with an officer in direct communication with them, who acts as their representative. The governing body provides for the general supervision and disci- pline of the establishment, and for the financial arrangements. In this body is vested the ap- pointment and removal of all members of the staff of the hospital. It makes all general regulations after consultation with the profes- sional department, as to internal economy, admission and discharge of patients, distribution of beds, dietary and other matters. It takes steps for raising the funds to support the hos- pital, and regulates the expenditure. Governor or Treasurer . — The active represen- tative of the governing body is generally termed Governor or Treasurer. He exercises a general supervision over the structure and the disci- pline of the establishment. The chief executive officer immediately under the governing body is called the Steward , or sometimes the Secretary. He has the control of all servants not included in the nursing staff — such as porters, ambulance- men, engine-man, bath-assistants, and other male attendants. He sees that all structural appli- ances are in good order, and that cleanliness and discipline are maintained throughout the building. He controls the issue of all orders for the supply of goods, provisions, fuel, &c., and watches that they are used with a due re- gard to economy. He countersigns all orders for payment after they are passed by the treasurer HOSPITALS, ADMINISTRATION OF. 546 and is responsible for the hospital accounts. He sees that the records of admission, discharge, a,nd death are duly kept by the professional staff. He is responsible for the safe custody of clothiDg, money, and property brought in by the patients, till their discharge. He has charge of the correspondence. Clerk; or Assistant Steward. — The secretary or steward is assisted by an assistant or clerk. This latter receives all provisions and stores, sees that they are correctly delivered, and is responsible for their safe custody until distri- buted to an authorized person. He sees that the diet-tables are prepared from the pre- scription papers, and that the articles of food supplied to patients are strictly in accordance with the diet-table, or else specially ordered by the physician or surgeon. Professional Staff. — The professional staff di- rects the proceedings to be taken for the well- being and cure of the patients. It consists of the consulting and visiting physicians and surgeons ; the assistant physicians and surgeons ; and the resident and house-physicians and surgeons, and assistants continually present in the hospital. Medical Committee. — The professional staff forms a medical committee with a specified quo- rum. This committee is consultative only, and advises the governing body on all matters con- cerning the medical and surgical departments of the hospital, the admission and discharge of patients, the distribution of beds, the dispen- sary, the in-patients, out-patients’ department, and the students. The medical committee, more- over, puts forward recommendations for the pur- chase of instruments, apparatus, and medicines. The committee provides for a descriptive record of cases admitted into the hospital; and for the efficient instruction of students. Physicians and Surgeons.— The physicians, surgeons, assistant physicians and assistant sur- geons undertake the charge of the wards and 'out-patients’ departments, and attend at the hospital at fixed times. The physicians and surgeons order the diet of the patients, and no article of diet which does not appear in the diet-table is supplied unless specially ordered by them. Resident Medical Officers. — The resident medi- cal officers control the treatment of patients in the absence of the physicians and surgeons ; and have a disciplinary control over the dressers and clinical clerks. They decide on the admis- sibility or otherwise of applicants for relief, when not admitted directly by the physicians and surgeons, as well as on the wards in which the in-patients are to be placed, and are respon- sible for their care until seen by the physicians and surgeons. They visit the wards and dispen- sary, according to the regulations, to see that the patients are duly attended to. They super- intend the conduct of the assistants of the medical officers, and of the dispenser and his assistants, of pupils (if any), and of patients ; give notice of any misconduct of the nurses and servants to the matron or lady super- intendent; and inform the governor or secretary, the physician, surgeon, and governing body, of any matter requiring their' attention. They are responsible that the records of cases are properly made out. In most cases, however, tfci» duty is now performed by registrars. Dispenser. — The dispenser acts under the resi- dent medical officer, subject to regulations laid down by the governing body. Nursing Department. — The nursing depart- ment is under a trained matron, who should be lady superintendent of the training school, and head of all the women employed in the hos- pital. Matron or Lady Superintendent. — The whole responsibility for nursing, internal management, care of linen and housekeeping, and the discip- line and training of nurses is vested in the trained female head of the nursing staff, by whatever title she be called. To the governing body of the hospital she is responsible for the conduct, discipline, and duties of her nurses. To the governing body and the physicians and suigeons in charge of wards she is responsible for the care and cleanliness of the wards, for the care and cleanliness of the sick, and for the linen. She is responsible to the medical officers that their orders about the treatment of the sick are strictly carried out. To fulfil these responsibili- ties, she has the power of engaging, appointing, and dismissing all Durses, female servants, and probationers, subject, of course, to the general control of the governing body. The nursing establishment cannot be made responsible on the side of discipline to the medical officers, or the governor of a hospital. Simplicity of rules, plac- ing the nurses in all matters regarding manage- ment of sick absolutely under the orders of the medical staff, and in all disciplinary matters ab- solutelyunder the lady superintendent or matron, to whom the medical officers should refer all cases of neglect, is very important. Any remiss- ness or neglect of duty is as much a breach of discipline as drunkenness or other .bad conduct, and can only be dealt with to any good purpose by report to the matron. But neither the medical officer nor any other male head should ever have power to punish for disobedience. His duty should end with reporting the case to the fe- male head, who is responsible to the governing authority of the hospital, as all her nurses and servants are, in the performance of their duties, immediately responsible to the matron only. If the matron or lady superintendent does not exercise the authority entrusted to her with judgment and discretion, it is then the legiti- mate province of the governing body to into fere and to remove her. The matron resides in the hospital where liei nurses and probationers are at work. In a hospital of, say, above 300 beds, and with a training school of. say. above twenty proba- tioners (which all such hospitals ought to in- clude), the trained matron should have three trained representatives or assistants — one in the training school as mistress of probationers or home-sister ; and two 'in the hospital, — one by day as assistant matron (or superinten- dent), and one by night as night superintendent of nurses ; and of these two the night repre- sentative is the more important. Besides the trained assistant, matron (superintendent'! who should have such inspection of the wards as the matron may commit to her, the matron will HOSPITALS, ADMINISTRATION OF. require one linen-assistant and housekeeper, who might also have the charge and inspection of the nurses’ rooms, if the trained assistant matron has not time. She should ‘ mother ’ the -ward- maids, and have some ‘ gathering ’ for them. Nurses and Servants. — Under the matron there should he distinct grades of nurses, and distinct duties for each grade : — 1. Trained chief nurses (ward sisters.) 2. Trained nurses (day). 3. Trained nurses (night), at least equal in pay and status to the day-nurses. 4. Probationers in training. 5. Ward-maids, and nursemaids for children's wards. 6. Dormitory and stairs women. 7. Fe- male cook, and her assistants under the house- keeper. The hospital cook in a large hospital would probably be a man, and under the steward. The sisters, nurses, and probationers would re- quire a female cook, under the matron. All women employed in the hospital should reside in the hospital. Night Superintendent. — The (trained) night superintendent of nurses should be in charge of the night-nursing, in communication with the ward sisters, as well as of the night-nurses; should see that the ventilation and tempera- ture of the wards is maintained — directed by the medical staff. She must be one qualified not only to have charge of nurses and have some ‘gathering’ for night-nurses by day, but to train probationers told off to accompany' her at night, to their own benefit and hers. Assistant Matron. — The assistant matron is to have special charge over the nurses’ rooms, to see that the nurses rise in time to wash themselves, strip their beds, empty their slops, and have breakfast, beforo going on duty ; that later they make their beds and put their rooms in order ; that they never wash their own clothes in their own rooms, but all nurses’ washing should be done for them; that they go quietly to bed at night, and lights be put out at a certain hour ; that their rooms are always clean, in order, wholesome and cheer- ful. Without this constant supervision what is necessary for the nurses’ health is not done ; the same for night nurses is yet more important. Nurses’ meals should always be presided over by some such authority. The hospital night nurses should have two hot meals in the common dining room, it might be in the probationers’ home, say at 9.30 a.m. and 9.30 p.m., ready and prepared for them. And sisters, staff nurses, and ward-maids should have, though at different hours — as all cannot be absent from the wards at once — dinner and Rupper, each set together in a common dining- room, away from the ward air. No nurse should have to prepare her meals for herself. Laundry. — In small and moderate-sized hos- pitals, when there is a laundry attached to the hospital, the supervision should be under the lady superintendent or matron. In large hospitals, it would be advisable for the laundry, which should in all cases be in a building entirely detached, to be worked independently, under the general supervision of the governor or secretary’. Chaplain. — The religious care of the patients is generally provided for by the appointment of one or more permanent chaplains, or by visits and religious services of other ministers whom the HOSPITALS, CONSTRUCTION OF. 647 patients may desire to attend them; subject, however, to the opinion of the medical attendant. as to how far the state of health of the patient will admit of such visits, and to the visits being made at such times as do not interfere with the discipline of the hospital. DonGLAS Galton. HOSPITALS, Construction of. '—A hos- pital or infirmary is a building intended for the reception and treatment of sick aud injured persons, under conditions favourable for their recovery. A hospital must be so constructed and ar- ranged as to enable a limited staff of medical men, nurses, and assistants to minister to the necessities of a large number of sick, and to pro- mote their speedy restoration. The conditions essential for such objects are as follows ; — (1) Pure air. There should be no appreciable difference in purity between the air inside the wards and that outside the building. (2) The air supplied should be capable of being warmed to any required extent. (3) Pure water should be supplied for internal use, and sufficient also to ensure the removal of impurities to a distance from the hospital. (4) The most perfect cleanliness within and around the building should be enforced. These conditions depend on — (1) The site of the proposed hospital. (2) The form of the rooms or wards in which the sick are to be placed, so as to ensure purity of air and convenience of nursing; these rooms forming the principal units of hospital-construc- tion. (3) The distribution of these units, and of the other accessories, which combined constitute the hospital. 1. Sites of Hospitals. — The local climate should be healthy, and there should be a free circulation of air over the district. Town site? should be avoided as far as possible. When necessarily placed in a town, a space free from buildings should be reserved on all sides. There should be no nuisances, damp ravines, muddy creeks, undrained or marshy ground, near the site, or in such a position that the prevailing winds would blow effluvia arising from them over the hospital. The site selected for a hos- pital should not receive the drainage of higher ground, and the natural drainage outlets should be sufficient. There should, if possible, be no buildings near a hospital except those connected with its object. The number of sick to be al- lowed per acre will depend practically upon the arrangement of the buildings in which they are lodged. 2. Form and Distribution of the Parte of a Hospital. — The structural arrangements of a hospital should be such as to secure free circulation of air. The Warp. — The basis upon which the struc- tural arrangements rest is the ward. The ad- ministration, means of access, and disciplino must be made subsidiary to the question as to 1 This article has reference more especially to penxm- nent general hospitals. The principles apply equally to special temporary field or other institutions for ‘ the cure of the sick.’ HOSPITALS, CONSTRUCTION OF. 348 how the sick arc to get well in the shortest pos- sible time, and at the least expense; and this, so far as the structure is concerned, is mainly determined by the form of the wards. Size . — The size of a ward depends upon the number of patients which it should contain, and upon the cubic space and floor space which should be allotted to each patient. The dis- ciplinary and economical dispositions in a hos- pital require that each head nurse should have (he patients allotted to her placed under her immediate eye. Economy of labour requires that the hospital should be so laid out as to enable the largest number of patients to be nursed by a given number of nurses. The number to be placed in a ward therefore depends upon the number which can be efficiently nursed ; and the form of the ward must be as much cal- culated to facilitate nursing, as to ensure free circulation and change of air. From twenty to thirty-two beds have been taken as the unit for ward-construction. In hospitals where cases of more than ordinary severity are likely to be received, it would be necessary to diminish the size of the wards on grounds of health. Small wards containing one or more beds are also re- quired for isolating certain cases or for various necessary objects. Form of ward - construction. — The general form of ward-construction is mainly governed by the question of the renewal of air. The air within an inhabited space, enclosed on all sides, is vitiated by the emanations proceeding from the bodies of those who inhabit it, and espe- cially by the effect on it of their respiration. In all sickness, and all surgical cases, wounds with discharge, or sores, these emanations are greater in quantity, and more poisonous in quality, than from persons in health ; whilst , at the same time, most cases— medical and surgical — are more susceptible to these emanations. Stagnation in the movement of the air leads to rapid decom- position of these emanations. If they diffused themselves uniformly throughout the space, which in fact they do not, ventilation would be comparatively simple, and, whatever the cubic space, the air would attain a permanent degree of purity, or rather impurity, theoretically de- pendent upon the rate at which emanations are produced, and the rate at which fresh air is ad- mitted. Hence the same supply of air would equally well ventilate any space ; but the larger the cubic spaee, the longer it will be before the air in it attains its permanent condition of im- purity, and the more easily will the supply of fresh air be brought in without altering the temperature, and causing injurious draughts. The amount of air which should be removed, and its place supplied with fresh air, is at least 3,000 cubic feet per patient per hour ; but this must depend to some extent upon the emana- tions of the patients, which vary with the dis- eases or injuries they are suffering from. The ventilation of each ward should be kept inde- pendent of other wards or rooms. Means of ventilation. — The change of air may be effected in various -ways. For instance, the air may be drawn out by a fan ; or it may be removed by a shaft, whose act ion depends on the difference of the temperature of the air in I the shaft and that in the outer atmosphere. Of this the ordinary fireplace is one example ; a caldron of water kept boiling for the use of the hospital by a steam pipe is another; a sunlight is a further example ; and a heated shaft con- nected with flues led from holes in the wall near the patients’ beds, through each of which air is drawn into the shaft, is another method. Theo- retically it is thus quite possible so to arrange the ventilation mechanically that a specified quantity of air at a fixed temperature shall be brought into the ward by day and by night. Practically, however, hospitals dependent upon such means alone for ventilation, require an attention which they can rarely or never receive, and, except under favourable circumstances, are not healthy. The emanations from the body do not uni- formly diffuse themselves; they hang about as the smoke of tobacco may be said to do. In wards into which a fixed quantity of air is forced, there is not even a uniform degree of impurity; consequently it is necessary, in order to ensure the purity of the air of a ward, that means should exist for absolutely sweeping out at intervals all the impure air from it, and start- ing afresh with pure air. This is best effected by the direct action of currents of fresh air brought in by open windows placed on opposite sides of the wards. The distance between windows for this purpose must not be too great to-prevent their efficient action in moving the air. Twenty-four feet is a good width, but opposite windows for such an object should in no case be more than from thirty to thirty-five feet apart. The space between the windows should not be obstructed by walls or partitions. The number of patients — that is to say, the sources of impure emanations — placed between opposite windows, should be limited to two rows. In the daytime, and when the weather admits of open windows, a ward with windows opening on both sides can easily be kept fresh ; but for other seasons it is necessary to provide openings for the escape of impure air, and for the admission of fresh air which shall not cause draughts. For the purpose of removal of air, shafts carried up from near the ceiling-level to above the roof are convenient, the lower ends being louvered to prevent patients feeling down- draughts which may occasionally prevail. The most powerful engine of ventilation for drawing out the air is an open fire-place. In order to prevent the temperature of the ward from being lowered by the extraction of air, that is, to maintain an equable temperature, and to prevent draughts, air warmed to a moderate degree should replace that removed by the fire- place or by other openings. Means for the admission of air in an upward current should be provided direct from the open air, independent of the windows and doors; for this purpose tubes with bends, which favour the collection of dirt, are objectionable. Sherringham's ventilators, which are easily cleaned, placed between the windows near the ceiling answer well; they admit the air without perceptible draught, and also fre- quently act as outlets when open on the leewanl side of award. The external air may be warmed as it enters by being made to pass over hot-wara \r), the head). — A synonym for Tuber- cular Meningitis. Tuberculosis plus a meningeal inflammation is the generating condition ; and acute hydrocephalus is only the occasional, though very frequent, concomitant. See Mex- exgitis, Tubercular. HYDROCEPHALUS, Chronic.— Stxon.: AVater on the Brain ; hydrops Capitis ; Fr. Ey- drociphale ; Eydropisie du Cerveau ; Ger. Dcr Wasserlcopf ; Hirnwassersucht. Definition. — A gradual accumulation of se- rous fluid within the lateral and third ventricles of the brain ; causing them to become more or less distended, and the head enlarged ; occurring principally in infants or very young children ; and leading to restlessness, irritability, or con- vulsions, followed by dulness, drowsiness, mo- tor weakness or actual paralysis, together with failure of mind and of the special senses. The essential condition in this malady is the intra-ventricular effusion. The cases in which the fluid has been found outside the brain and within the arachnoid sac are, in all probability, merely examples of the disease in which intra- ventricular effusion having previously been well- marked, the distended corpus callosum, or, it may he, the floor of the third ventricle has given way, and allowed the fluid to pass beneath the arachnoid. The so-called extra- ventricular form of the disease is, therefore, in the majority of cases, merely a secondary and altogether acci- dental condition. As a sequence of a large arachnoid hoemor- rhage, serous fluid may also he found within the araclmoid cavity ; this, however, is a condition which has no real title to he mentioned under the head of chronic hydrocephalus, as some- writers have done. And the same remark applies to those accumulations of serous fluid which take place beneath the arachnoid, as a sequence of wasting or atrophy of the cerebrai hemispheres, one or both. The collection of fluid in such cases is to he regarded as a simple se- quence of the atrophy, and is of itself unpro- ductive of morbid symptoms. ^Etiology. — Two principal groups of causes are appealed to as productive of chronic hydro- cephalus. In certain cases the affection is believed to be idiopathic , due to an ‘ essential dropsy,’ oc- casioned by an inflammatory affection of the lin- ing membrane of the ventricles. In other pa- tients, however, this affection is distinctly second- ary or symptomatic , and then may be caused by one or other of two principal sets of conditicns. Thus (1) it is often occasioned, as writers of the last century pointed out, by the pressure of scrof- ulous or other tumours upon the ‘ straight sinus,' producing mechanical congestion of the great veins of Galen as well as of their radicles on the walls of the lateral ventricles, and, as a conse- 560 HYDROCEPHALUS, CHRONIC. pence, an increasing dropsical condition of the former pass, -when the disease lapses into a ventricles themselves. (2) More rarely it seems chronic and stationary condition. to be produced or to remain as a sequence of an attack of acute hydrocephalus. This latter mode of origin is admitted by some authors, and denied by others. It is at least a possible mode of origin, although one which is difficult to be established with certainty. By far the largest percentage of cases probably belong to the first set of the ‘ symptomatic ’ category. The disease is sometimes congenital, and may be so far developed during uterine life as to cause great difficulties in parturition — frequently ne- cessitating the sacrifice of the life of the child. At other times the enlargement of the head begins to show itself soon after birth, or at some period before tho end of the first or second year. Or it may reveal itself later still in childhood; much more rarely during adolescence ; and more rarely still in adult life. Congenital ‘ microcephalism ’ must not be con- founded with hydrocephalus. It is true that in certain small-headed infants, having the cranium malformed and the sutures ossified, an excess of fluid may be found within the head ; but then the fluid in these cases is situated outside the atrophied brain, and not within the ventricles. The two conditions are, in fact, totally opposite m nature. Atvatomicai, Characters. — Three different states, in regard to size of head, have been de- scribed as existing in this affection : — (1) where the head is smaller than natural ; (2) where the head is of natural size ; and (3) where the head is more or less considerably enlarged. Those of the first category ought not to be ncluded at all. They are the cases of ‘ mi- crocephalism ’ above referred to. Those of the second category could never be diagnosed with any degree of positiveness during life; and it. may, indeed be questioned whether such cases exist to any large extent, except as more or less transitory stages of instances of the disoase per- taining to the third of the above categories. Of course, in all tho cases in which the head ultimately becomes enlarged from the presence of mi excess of fluid within the lateral and third ventricles, there must have been a stage during which these ventricles were merely full of fluid, and during which pressure-symptoms were more or less marked — even without the existence of actual enlargement of the head. Such symptoms alone, however, do not often form a sufficiently precise combination to enable us to do more than entertain a vague suspicion that we may have to do with a case of chronic hydrocephalus. We mostly need the objective sign of enlarge- ment of the head, to enable us to arrive at a positive diagnosis of this disease ; but as soon as this sign declares itself to a well-marked ex- tent, there are few affections of the brain which can be diagnosed with more certainty than the one which we are now considering. Even the cases in which the head is distinctly enlarged differ amongst themselves, since in some of them (a) both sutures and fontanelles are widely open ; whilst in others (4) the sutures, and perhaps the fontanelles, are completely closed. It seems probable that the latter may represent conditions into which some of the Owing to the separation of the cranial bones in young infants, this disease, when it occurs ir. them, soon becomes associated with an actual enlargement of the head, which increases rapidly. In consequence of the distending pressure from within, caused by the increasing size and fulne-s of the ventricles, the bones entering into the for mation of the vault of the cranium become separated from one another, though the bones of the face remain unaltered. The frontal, parietal, the superior part of the occipital, and a small part of the squamous portion of the temporal bones become expanded and thinner than natural, at the same time that they are separated from one another — especially in the regions of the anterior and posterior fontanelles, and of the sagittal suture. In such regions, when the enlargement is extreme, a sense of fluctuation is often recognisable. The forehead becomes prominent and overhanging, whilst the eyeballs are depressed; and as the face remains unaltered or even becomes emaciated, it seems altogether unnaturally small, and thus contributes to produce a most characteristic appearance (‘facies hydrocephalica ’), which is often intensified by the old-looking, and more or less blank, expressionless, aspect of the face. The cranial bones are often very thin, bnt occasionally they may be unusually thick through- out — even in young children. The circumference of the head, even of a young child, may in hydrocephalus easily reach 24 to 30 inches or even more. Where the en- largement becomes extreme, the weight of the head is so great that it cannot be maintained iD the upright position. It has to be supported by the hand or some artificial support ; or else the child does not attempt to rise from the recum- bent position. The size attained by the head in certain cases has been comparatively enormous . thus, in an altogether exceptional case, recorded by Cruikshank, it is said to have measured, in a child sixteen months old, no less than 52 inches in circumference, and the amount of fluid con- tained within the crauium was found to weigh as much as twenty-seven pounds. The fluid is generally slightly albuminous ; possesses some saline constituents ; and has a specific gravity ranging from 1,006 to 1,014. Its composition agrees pretty closely with that of dropsical fluids generally. In the great majority of cases, as already stated, the fluid is contained within the more or less distended lateral and third ventricles of the brain. The upper and lateral parts of the cere- bral hemispheres, as well as the corpus callosum, become thinned and distended, so as to resemble a mere bag, the walls of which are represented ex ternally by pale unfolded and much flattened cow volutional matter, and internally — next the fluid itself — by the lining membrane of the ventricles. This latter has become much thicker and tougher than natural ; it may also be more or less granu- lar on the surface ; and often shows an increased number of distended vessels. These appearances are, however, not to be taken as an indication of the inflammatory origin of the malady, as some observers seem to suppose. They may be found, as the writer has seen, well-marked. HYDROCEPHALUS, CHRONIC. 661 in cases where the effusion and distension has been the result of a mere mechanical congestion, produced by pressure upon the commencement of the straight sinus, owing to a tumour in the middle lobe of the cerebellum. On the other hand, some years ago the writer examined the head of a hydrocephalic child who died in Univer- sity College Hospital, in whom the most careful search revealed nothing that could have produced mechanical congestion, and in which there was, moreover, no sign of anything like an inflam- matory condition of the walls of the greatly dis- tended lateral ventricles. To fall back upon the hypothesis of an ‘ essential dropsy’ was felt to be far from satisfactory. Such a phrase cannot indeed be regarded as conveying any real explanation of the condition in question. The shape of the ventricles and of the com- pressed ganglia about the base are, of course, greatly altered. The foramen of Munro may be half an inch or more in diameter. The optic and olfactory tracts and lobes are also often much altered by pressure. The brain-substance may be even tougher than natural, because the long-continued mecha- nical congestion, which exists in so many cases, favours the overgrowth of the neuroglia ; and, indeed, it would appear probable that in some instances the overgrowth of this mere connective substance is well-marked. For, notwithstanding all the pressure upon and distension of the brain- substance, this rarely shows signs of atrophy. It is rather the reverse. The mere brain alone of a jj hydrocephalic child, after the fluid has been eva- i euated, commonly weighs more than the brain j of a healthy child of the same age. Thus in an instance that came under the writer’s notice, j the brain of a child five years of age weighed .•other more than 52 oz. In those cases in which during life the fluid has j escaped from the ventricles through a rupture in ' the corpus callosum, the brain has been found more or less flattened and collapsed in the lower . part of the enlarged cranium, whilst the escaped fluid occupies the arachnoid cavity above it. Symptoms. — Chronic hydrocephalus begins to I manifest itself in various ways, and also, as above M:ated, at various ages. The great bulk of the cases j are either congenital, or commence before the fifth . month. But in certain rare instances, the head may begin to enlarge long after the union of the • sutures, in early adult life, or even beyond middle age. As to modes of commencement, at least four, pretty distinct from one another, may be en- | countered. (1) The disease maybe ushered in I by a period of fretfulness and irritability, with or without the occurrence of convulsions and strabismus, before any enlargement of the ■ head is detected. Or (2) slow enlargement of the head may be noticed as the first event. In •ome cases, this enlargement not only sets in, but I may continue for months, till notable increase n size has taken place, and yet the child may .exhibit no morbid symptom whatever. The wri- er has seen a well-marked instance of this in a I'.hild whoso head had been enlarging for eighteen nonths(the process beginning when it was a year •Id), and in whom, though the head was twenty- cur inches in circumference, no other morbid signs or symptoms presented themselves. (3) Chronic hydrocephalus may supervene in a child after a fall, through the intermediation of cere- bellar disease. The writer had under his care a little girl four years old, who, after falling from a table and striking the occiput severely, suf- fered for from twelve to eighteen months from symptoms indicative of cerebellar disease, after which the head began to enlarge, and hydroce- phalus became the apparently dominant condi- tion. Complete blindness ensued, then convul- sions set in, and in the midst of one of these the patient died. A tumour of the middle lobe of the cerebellum was found, plus all the signs of a well-marked hydrocephalus. (4) The disease may occur as a sequence of an attack resembling acute hydrocephalus (tubercular meningit is) : that is to say, a child appears to suffer for a time from what is regarded as tubercular meningitis ; the symptoms then undergo some mitigation ; they become more or less chronic ; and ulti- mately the head begins to enlarge, as it does in chronic hydrocephalus. There is some doubt about the real nature of the starting-point in this mode of origin. The initial symptoms may not in reality have been those of tubercular meningitis. The chronic disease and its symp- toms may occasionally be initiated in an acute manner. It may be easily imagined that the subsequent course of the symptoms in persons suffering from chronic hydrocephalus, beginning in these various ways, may also be subject to great variations. As the head enlarges, or as thepressure within increases, sensations of weight or pain may be experienced. The child may show increased fretfulness and irritability ; or its manner may become more dull and heavy than natural. At other times there is no noticeable change in theso respects. In the ‘ symptomatic ’ forms associated with tumours, there is apt to be vomiting of a very obstinate and paroxysmal character, together with continuous pain, marked by exacerbations. Convulsions, either unilateral or general, may also occur, as well as paralysis of one or other of tho ocular muscles. In such cases, too, in compara- tively early stages, ophthalmoscopic examination will frequently reveal optic neuritis, which has a tendency to go on to white atrophy, with tho production of more or less complete blindness. In later stages of the disease mental action becomes increasingly impaired, there is loss cl memory, dulness, and a great tendency to sleep during the day. There may be marked weak- ness or actual paralysis of limbs. Children affected to this extent often keep to the recum bent position, having at last no power of sitting up, or even of raising their head from the pillow. The appetite sometimes remains good ; at other times ic becomes much impaired, and a gradual emaciation ensues. Blindness, more rarely deaf- ness, loss of smell, and impairment of other senses tend gradually to reveal themselves after a time. Complications. — In all cases where the hydro- cephalus is itself symptomatic of some primary intra-cranial disease, interfering with the proper return of blood from the ventricles and cenrral portions of the brain, the symptoms reselling from this latter state of things are necessarih 662 HYDROCEPHALUS, CHRONIC. complicated with others immediately produced by the original morbid condition. Hence the very great variations encountered in the grouping of symptoms in different cases. Diagnosis. — Some remarks have already been incidentally made upon this subject under the head of Anatomical Characters. "Where the head becomes distinctly enlarged, with widely separated sutures and open fonta- nelles, there can be scarcely any room for doubt about the diagnosis. But before the head is distinctly enlarged, the diagnosis of' chronic hy- drocephalus with any degree of certainty is im- possible. In many cases also where the head is only slightly enlarged, and the sutures are not opened, it may be very difficult, for a time, to pronounce an opinion as to whether or not an infant or young child is hydrocephalic. Natural variations in the size of the head are consider- able ; and it may also be enlarged from rickets, or from that very rare condition known as ‘ hy- pertrophy of the brain.’ Even great thickenings of the bones of the head have occasionally given rise to uncertainties in regard to diagnosis. But in all these cases, in order to enable the prac- titioner to arrive at a trustworthy opinion, the particular form of the head has to be considered, together with the sum-total of the various symp- toms which may have preceded or accompanied its increase. Whether in any particular case we have to do with an instance 'of ‘ idiopathic ’ or of ‘ sympto- matic ’ hydrocephalus, often cannot be settled ; but in others it can be decided by reason of the ex- istence of a set of symptoms distinctly pointing to the presence of an intracranial new growth. Prognosis. — Hydrocephalus often proves fatal in the course of a few months ; or it may be less r.ipid, entailing death only after a year or two. Its progress is variable, however. Remissions and stationary conditions are apt to occur, chequered by periods in which there are distinct exacerbations of all the symptoms. Occasionally one of these stationary condi- tions becomes prolonged, and the individual may live for years. Some hydrocephalic subjects have subsequently lived on to the age of twenty, thirty, or even forty years. In a few exceptional cases a cure seems to have been effected, either naturally or under the influence of remedial agencies. Death may take place in convulsions ; from .slow exhaustion with emaciation ; or from inter- current pneumonia or some other acute disease. Treatment. — Very little, unfortunately, can be done, in the majority of cases, to produce decided or lasting improvement. This is espe- cially so in those instances — only too numerous — in which the hydrocephalus is due to some scrofulous or other tumour interfering with the retimi of blood from the ventricles. Blistering of the scalp, with mercurial inunc- ; lMis. formerly much lauded, may do a great deal more harm than good ; and the same may be said in reference to pressure of the enlarged bead by strapping or bandages. This latter is a barbarously coarse method of treatment, which has happily fallen into disuse. Blistering may do good in some cases, but it should bo cautiously had recourse to. HYDRONEPHROSIS. The general health of the child must be main tained as much as possible, by the aid, if neces- sary, of tonics and cod-liver oil. Purgation and diuretics may also be had recourse to. Iodide of potassium may be given internally in gradu- ally increasing doses, as even young children bear this remedy well. Bromide of potassium will also help, perhaps, to mitigate vomiting and convulsions, when those are urgent symptoms. It may be worth while in suitable cases to try the effect of greatly diminishing the amount of fluids taken, so as to reduce the fulness of the vascular system. The writer has had reason to believe that this method is well wor- thy of being attempted, where other means hare failed, and where there is any chance of being able to carry it out. Puncture of thehead has been much landed, and practised by many, but with an amount of fail- ure and fatality that has caused the method almost to have fallen into disuse. If in any given case we could be reasonably certain that the hydrocephalus belonged to the ‘ idiopathic ’ variety (if there really are such cases), the method might be had recourse to, with much more chance of success than if it wfre occa- sioned by some mechanical pressure, which persists and prevents the return of blood from the central parts of the brain. Puncture of the head can scarcely be compared with puncture of the chest, because (even apart from the greater risks attaching to the former opera- tion), a puncture of the chest in a case of pleurisy lias a fair chance of being actually curative, whilst puncture of the head in hydrocephalus, in the ma- jority of cases and for the reason above indicated, could only be palliative. Still the cases of this disease are so grave that where the sutures are opened, where the patient's condition is rapidly getting worse, and death seems otherwise in- evitable, the question of performing the opera- tion. at least once, ought to be entertaiued as a barely possible means of affording relief. H. Charlton Bastiax. HYDKOMETEA (55up, water, and py-rpa, the womb). — Dropsy of the womb. See IYojib, Diseases of. HYDRONEPHROSIS (vSatp, water, and vftppbs, the kidney). Svxox. : Dropsy of the kid- ney ; Fr. Hi/drojiephrose ; Ger . Hydronephrose. Definition. — A chronic disease of the kidney caused by obstruction of the ureter ; consisting in dilatation of the pelvis, and commonly of the ureter, with more or less extensive atrophy of the substance of the organ ; usually affecting ono kidney, sometimes both ; characterized clinically by the presence of a soft fluctuating tumour in the renal region, but most distinctively by sudden discharge of urine with collapse of the tumour ; and resulting, if not relieved, in complete de- struction of the kidney. ^Etiology. — Among the most common causes of hydronephrosis are obstruction of the ureter at its lowest part, in consequence of pressure by new formations, particularly carcinoma of the uterus; the impaction of calculi of various kinds ; and tumour of the ovary. More rarely it is induced by new formations in the bladder; stricture of the urethra; the pressure of the hydronephrosis. pregnant, prolapsed, or retroflexed uterus ; and exceptionally it is met with without apparent cause. In such eases it is to be referred to some contraction, due to inflammation or other cause, which has disappeared. The condition is also sometimes congenital, being due to malformations, such as impermeable ureter, or valve-like obstruction to the passage of urine downwards. From whatever cause the obstrue- may spring, accumulation of urine takes place behind it, leading to gradual distension of the organ. See Ureters, Diseases of. Anatomical Characters. — In the earlier stage of hydronephrosis there is simple dilatation of the pelvis of the kidney. As the disease advances, the dilatation increases, the organ becomes more p.nd more distended, and the ureter often becomes bo dilated or elongated as to present the appear- ance of a bluish-white tube, as large as or even larger than the inferior vena cava. Coincidently with this distension the substance of the kidney atrophies. At first the apices of tho cones become flattened and wasted, but gradually the renal substance becomes more involved, until at length, in old-standing cases, scarcely any trace of it remains, and the kidney is represented by a large lobulated bag, whose fibrous walls are distended by clear fluid. Commonly one kidney only is affected, especially when extreme dila- tation exists, but in some instances both kidneys are involved. There is a case on record where the whole abdominal cavity was occupied by an enormous tumour, containing sixty pounds of fluid. Symptoms. — In the slighter cases of hydrone- phrosis there are no symptoms of such a kind as to attract attention. This condition is often an un- important complication of other serious diseases. In the more severe cases there are no consti- tutional symptoms, but the local changes are well-marked. There is a tumour situated in the lumbar region, extending upwards, downwards into adjacent regions, or forwards towards the anterior abdominal wall. The colon is usually in front of the tumour, and always displaced and compressed, so that constipation frequently co- exists with hydronephrosis. The mass is often lobulated, always undulating in character ; and frequently fluctuation may be detected. The most conclusive evidence of the condition is afforded by the discharge of a large quantity ot' urine, generally of low specific gravity, and often con- , tabling mucus, coincidently with the disappear- ance or diminution of the tumour. It sometimes happens that the obstruction is permanently re- moved, and dilatation alone remains as evidence of the old obstruction. Hydronephrosis, when double, sooner or later proves fatal by suppression of urine or urtemia. When only existing on one 6 ide, it has proved fatal by pressure upou neigh- bouring parts ; by the supervention of impaction of stone in the kidney of the opposite side ; or from other causes. Diagnosis. — The distinction of hydronephrosis from ascites may be sometimes difficult when the disease affects both sides. The diagnosis is , partly to be made by observing the effects of change of posture, hydronephrosis being much less influenced thereby than ascites. The history and mode of origin of the affection also afford indi- nYDROPHOBIA. S6a cations. From hydatids of the kidney it is some- times impossible to discriminate hydronephrosis, but the history of the case and the characters of the urine often afford a clue. If there be tumour on both sides, it is extremely unlikely to be hydatid. From ovarian tumour the diagnosis is to be made by the history of the case ; the position of the mass; its relations to the colon; and- by vaginal and rectal examination. From peri- nephritic abscess hydronephrosis is distinguished by its being less hard, and by tho absence of pain and fever. Prognosis. — The prognosis is always serious ; but if one of the kidneys be sound it becomes enlarged, and does double work, and so long as this condition continues, the patient may suffer little inconvenience. Treatment. — Careful manipulation of the tu- mour is often useful in extreme conditions ; and tapping with the aspirator may be employed. T. Grainger Stewart. HYDROPATHY (SSap, water, andirdflor, a disease). — A synonym for hydrotherapeutics. See Hydrotherapeutics. HYDROPERICARDIUM (05 up, water; and •pericardium , the pericardium). — An accu- mulation of serum in the pericardium, either dropsical or inflammatory. See Pericardium. Diseases of. HYDROPHOBIA (uSap. water, and 4 arise from the Lite of a healthy dog, but this is improbable. Cases are on record, however, in which the disease ha3 followed the bite of adog, which did not at the time, or for several weeks afterwards, present the recognised symptoms of the disorder. It seems possible that in rare cases rabies may affect a dog as a mild and in- significant malady. When no preventive measures are adopted, at least half, perhaps two-thirds, of persons bitten escape. The immunity maybe due partly to the bites being inflicted through clothes; partly to individual insusceptibility, which has been found to exist in animals as well as in man. When preventive measures are adopted as soon as possible, the proportion of those who escape is much greater. More males than females suffer, the propor- tion being three to one. So, too, in dogs. The largest number of cases occur in the middle period of life, doubtless from greater exposure to the cause. Children, however, often suffer, being helpless and bitten about the face. Most cases are contracted from straying or pet dogs. Th a period, of incubation is longer than that of any other acute specific disease, and is singularly variable. It is rarely less than a month, the short- est on record having been about twelve days. The average period is six or seven weeks. In about half the cases it is between one and threo months. In some cases it is longer, reaching six, nine, or twelve months. Cases have been recorded in which two. three, five, and even ten years in- tervened. Most authorities believe that such cases were either not true hydrophobia, or were due to a second unknown infection. If we admit, however, as we must do, that twelve or eighteen months may elapse, we can scarcely deny the possibility, or oven probability, of longer periods. It is as hard to explain an incubation period of one year as of five years. Anatomical Ckaeactebs. — General fluidity of the blood, such as is met with after death from acute septic diseases ; redness of the throat and pharynx, and occasionally of the salivary glands ; together with, in some cases, evidence of con- gestion of the brain and spinal cord, constitute the chief morbid appearances visible to the naked eye. The microscope has shown that there is evidence of inflammation (congestion and leucocytal infiltration) in the salivary glands (Coats) ; and that minute changes in the nerve- centres are almost constantly to be found (Clifford Allbutt, Hammond, Benedikt, Coats, and the writer). Of eight eases examined by the writer, the minute changes in seven were dis- tinct, and in character and position so far characteristic that, given the fact of an acute disease, a post-mortem diagnosis might, in the vast majority of cases, be made with certainty by the microscope. The essential change con- sists in the accumulation of leucocytes around the vessels, and their infiltration into the adjacent tissue ; this change having a special distribution, being either confined to, or most intense in, the region of the medulla which is contiguous to the lower part of the fourth ventricle, that is, the neighbourhood of the respiratory centre. Here we have also the convulsive centre, and the centre for deglutition. The change is most intense in the hypoglossal, glosso-pharyngeal, and vagal nuclei and their neighbourhood. There is little or no change in the upper part of the medulla, corpora quadrigemina, cerebellum, or basal gan- glia. In the convolutions a similar but slighter alteration is present in some cases. It may occur throughout the grey matter of the cord, but is here usually slight, and often absent. In the most affected regions, traces of ante-mortem clots and even of inflammation of the walls of the minute vessels may be found in some cases. Perivascular areas of disintegration are com- mon ; but such frequently occur apart from hydrophobia or any other disease. Minute extravasations are common, partly mechani- cal. The only change in the nerve-elements themselves consists in a granular degeneration of the ganglion-cells of the regions chieflv diseased. In the dog the changes are quite similar in characters and distribution. Symptoms. — During the period of incubation of hydrophobia there are commonly no symptoms. V esicles under the tongue were formerly described, but their occurrence has not been confirmed. Occasionally pain and discomfort have been felt in the seat of the wound, explicable, in part, by the attention directed to it. Mental depres- sion has been noted, also probably due to anxietv regarding the possible consequence of the bite." The onset of the acute symptoms is commonly attended by no local disturbance, sometimes by pain, rarely by actual inflammation, in the wound. The first evidence of the impending disorder is usually malaise, mental depression, disturbed sleep, and some discomfort about the throat, with a difficulty in swallowing, especially liquids. The attempt occasions some spasm in the throat, which soon, if not at first, involves the muscles of respiration, causing a short, quick inspiration, a 1 catch in the breath,’ resembling that due to an affusion of cold water. In a few hours this increases to a strong inspiratory effort, in which the extraordinary muscles of respiration take more part than the diaphragm ; the shoulders are raised ; the angles of the mouth are drawn outwards. The saliva, which is abundant and viscid, cannot be swallowed. It hangs about the mouth, and the patient is annoyed by his efforts to get rid of it. As the intensity of the spasm increases, so docs the readiness with which it is excited. The mere contact of water with the lips, or cutaneous impressions, as a draught of air, will bring on a paroxysm. The distress it occasions leads to a mental state which in- creases the readiness with which the spasm is produced. The mere sight of water, or the sound of dropping water, will cause it (hence the name), and even analogous visual impressions, as a sudden light or the reflection from a looking- glass. Thus the respiratory spasm excited by swallowing liquids, which is, as it were, the key-note of the disease, extends on the one hand to widely-spread muscular spasm, and on the other to mental disturbance. In each of these directions the symptoms develop. The spasm, from being limited to the muscles of respiration, may become general and convulsive (tetanoid or co-ordinated) iu character ; still excited by the same causes. The mental distress passes intc disturbance, in which the balance of reason « HYDROPHOBIA. lost, continuously or during the paroxysms. In the frenzy, the horror of the distress is trans- ferred to the attendants by whom any discom- fort may have been occasioned, and during the paroxysms the patient may attempt to bite them, and even others. Consciousness may so far remain that in the intervals he may beg those whom he regards to keep away. The saliva is ejected with force, and the patient hawks it up with a noise ‘like a dog.’ The sight of a dog has been known greatly to inten- sify the disturbance ; and this, strangely enough, in eases in which the sufferer had no suspicion of the nature of his affection. The delirium may, in some cases, be continuous and violent. As the mental disturbance increases, the respiratory spasm and convulsion may lessen, or the latter may persist to the end. Vomiting is common, and is often an early symptom, a greenish-brown liquid being ejected. Priapism or nymphomania occasionally occurs. The temperature is usually raised two or three degrees. Albumen is often present in the urine ; and sometimes sugar. Duration and Terminations. — The duration of hydrophobia is usually from one to four days ; sometimes it lasts six, eight, or ten days. In the rare cases which have recovered, the duration of the acute affection has been from four to ten days, although slight spasmodic symptoms have lasted for a longer time, as does the spasm of whooping cough. The common cause of death is exhaustion from the attacks of fury and convulsion, often aided by manifest cardiac failure, which may occur early, and be out of proportion to the gene- ral asthenia. Sometimes the patient has died asphyxiated in a paroxysm of respiratory spasm ; partly, perhaps, from spasm of the glottis. Varieties. — The relative degree of the above- described symptoms varies in different cases. The mental disturbance, or general muscular spasm, may, respectively, predominate over the respiratory throat-spasm, even in the early stages, and may impress a special character on the attack, so that it resembles in the one case a pri- mary mental affection, in the other general con- vulsive affection, as tetanus. Pathology. — We know nothing of the nature of the poison of rabies. It has been thought thatitis not at once generalised, but develops in the wound, and subsequently affects the system. The symptoms indicate a primary action on the uerve-centres, especially on the respiratory re- gion of the medulla, spreading more widely, in its ultimate action, in the medulla and to the brain and cord. The vascular changes, from their variability and occasional absence, are probably secondary effects of the disturbed action of the nerve-centre, produced by the poison car- ried by the blood. The first effect of the poison is probably to lessen the ‘ resistance ’ of the medullary centres. Their action becomes spasmodic ; is excited with undue readiness, especially by reflex influences ; and spreads too widely. The secondary vascular changes may have their own effects. They are, esin other functional diseases, somewhat random in distribution within the affected area. By the infiltration of leucocytes, the tissue may be broken 665 1 up, and what are practically tninute points of suppuration may result. If the part damaged is important, grave consequences may ensue. The nucleus of thepneumogastric is often so damaged, and thus we can understand the occurrence of cardiac failure. The changes in the convolu- tions and the spinal cord are probably propor- tioned to the mental or tetanoid symptoms re- spectively. The mental excitement no doubt acts upon and increases the irritability of the medulla (Putnam). Conversely, the disturbance of the latter may help to determine the direction of the mental disturbance due to the poison. Diagnosis. — The symptom of greatest diagnos- tic value is the respiratory spasm excited by attempts to swallow, increasing until it re- sembles a convulsive action, and accompanied after a time by mental disturbance. In certain diseases of the throat and chest, especially oeso- phagitis and pericarditis, a reflex throat-spasm may occur, but in such cases there are commonly pain or other obtrusive signs of the local affec- tion. When the mental disturbance occurs early, the affection may be confounded with acute mania : the association with slight respiratory spasm is still the most important diagnostic in- dication. In cases (if such occur) in which this symptom is absent, the diagnosis is a matter of great difficulty, and can only be made by the history of the antecedent bite, the rapid course of the disease, and its association with other con- vulsive phenomena and with salivation. Prom tetanus, hydrophobia is distinguished by the lato period after the bite at which the symptoms develop ; the absence of trismus and of con- tinuous spasm ; and the presence of paroxysmal respiratory spasm, of ' aversion to liquids, and of mental disturbance. Too much weight must not be given to the general character of the con- vulsive symptoms, if other signs of the disease are present, since there is probably a tetanoid form of hydrophobia, in which general spasms occur early; but they intermit, and are excited by attempts at deglutition, and there is no trismus. Organic brain-diseases accompanied by delirium and convulsions, occurring after a bite, have been mistaken for hydrophobia, as in a case in which the nature of the disease was only dis- covered when, after exhumation, meningeal hae- morrhage was found. Here also the respiratory spasm is absent. Mere mental excitement, directed to the dis- ease, may determine symptoms of dysphagia somewhat resembling the genuine disease — ‘spu- rious hydrophobia’ as it has been termed. After a period of anxiety regarding the consequences of a bite, spasm in the throat is felt in swallow- ing. The patient's fears are intensified, the symptom increases, and even the medical atten- dant may be deceived. The spasm, however, is not of the respiratory character of genuine hy- drophobia. Recovery commonly ensues on the mind being tranquillised, or by the application of some remedy in which the patient has confidence. It must be remembered that in some cases of genuine hydrophobia the influence of the patient’s mental state has been very clearly traceable even in the early symptoms. The distinction of genuine from spurious hydrophobia is often rendered difficult by the S66 HYDROPHOBIA, fact that the latter usually follows suspicious bites, and that the former may be distinctly in- tensified by the patient’s nervous fears. The untypical character of the spasm in the spurious disease (mere dysphagia) ; the fact that an effort removes this difficulty, and that once overcome it does not return ; the stationary condition : the absence of mental symptoms beyond anxiety ; and I lie disappearance of the symptoms when this is removed, are the important guides. Prognosis. — Hydrophobia is practically fatal, but not certainly so; and the patient personally should unquestionably receive the ‘ benefit of the doubt.’ Cases differ in the intensity and rapidity of their course ; and the less rapidly the symptoms are evolved, the greater is the hope, slight though it still is, that an exception to the common fatality may be obtained. The prog- nosis is better the longer the spasm remains limited; it is worse if there are general con- vulsions, mental disturbance, and signs of exhaus- tion or of disproportionate heart-failure. Treatment. — Adequate measures against the spread of rabies would undoubtedly lessen, per- haps entirely prevent, the occurrence cf hydro- phobia in man ; but the discussion of these is beyond the scope of this article (see Rabies). When a person has been bitten by a suspicious or doubtful animal, the circulation in the part should, if possible, be at once arrested by a tight ligature above the place; the wound should be washed ; and then it should be allowed to bleed freel) r . It may probably be sucked with im- punity if the mouth is rinsed with water, or better still with vinegar and water, after each act, and if there are no abrasions in the mucous mem- brane. The act has been supposed tobe dangerous ; but all experience is opposed to this. Poisons have to remain for some minutes in contact with a mucous membrane before they are ab- sorbed, and during the act of sucking there is a How from the mucous membrane into the mouth, which must be opposed to absorption. As soon as possible the wound should be cauterised. Of chemical caustics, nitrate of silver, freely applied at once, is probably effectual. If any time hare elapsed, nitric acid or liquid carbolic acid is pre- ferable. The actual cautery, applied deeply and freely, is an efficient and ready means. If prac- ticable, free excision of the bite is wise ; and should not be neglected, even though the cautery has before been used, if there is any doubt as to the thoroughness of the application. The methods adopted for the treatment of the developed disease have been numerous. All so- called ‘specifics’ have been proved to be useless. An attempt has been made to eliminate the poison by administering large doses of mercury, and by diaphoresis. The two have been combined in the mercurial vapour bath. Two or three cases are on record in which this method has been success- ful ; many in which it lias been powerless. Of late it has been but little tried. Attention has been lately directed to curara as a remedy for hydrophobia. Hirst recommended half a century ago by an Englishman (Sewell), it was tried in small doses and failed. Niemeyer suggested larger doses, and in a ease by Offen- burg it was apparently successful ; and since then another case, in America, has recovered HYDRORHACHIS. under its use. In many cases it has failed — in all cases in this country up to the present time. It is recommended that it should be used in in- jections of from -jb to 3 of a grain, repeated every quarter or half an hour, until the severity of the paroxysms is lessened. This point ma”v not, however, be reached until general mus- cular paralysis is imminent or produced, ami then artificial respiration may be necessary until the effect has passed away. As often as this w the case, and the spasms recur, another injection must be given. In hydrophobia there is remark- able tolerance of the drug, poisonous doses (one grain repeated) of active curara having in one case been without any effect (Curtis). This is, perhaps, a hopeful fact, as it indicates that curara has an action to which the changes in the central nervous system are opposed. Sedatives have been the remedies commonly employed, and of these the best are chloral anil morphia. One case (probably genuine), in which morphia and calabar bean were used, recovered (Nicholls) ; and one in which chloral was em- ployed lived for ten days (Sansom). The effect of the two on the respiratory centre in animals suggests their joint use. The morphia should be given by hypodermic, the chloral by rectal in- jection. Chloroform is useful in moderating the paroxysms, but appears somewhat inferior to chloral. Other sedatives — Indian hemp, &:c. - have appeared of inferior value. Cold affusions to the cervical spine and head were used in India in two cases which recovered, the throat and spine being blistered with nitrate of silver, and chloroform administered. Ice to the spine has been tried without effect. Tra- cheotomy was recommended by Marshall Hall id one case. Death from laryngeal spasm, is, how- ever, too rare to justify the measure. In all cases tranquillity is of the greatest impor- tance. Every excitant of spasm should he avoided; the patient being kept in a dim still room, and friends as much as possible excluded. Next in im- portance is nourishment, which should be given by the rectum, if spasm is excited by the attempt to swallow. Restraint, which may be necessary, should he as little as possible, but it should he effectual. The saliva of persons suffering from hydro- phobia has been proved to be capable of com- municating the disease to animals. Henco th# attendants should be cautioned to have no un- covered abrasion on the hands, and to wash from the eyes or face any saliva which may have been spit on them; and if they are bitten hv the patient, the wound should he treated as if it had been inflicted by a rabid animal. These precautions remove all danger ; and any anxiety the subjects may feel may be relieved by the assurance, that of the thousands of persons who have attended on patients with hydrophobia, no authentic in- stance has ever been recorded in which the disease was contracted either by attendance during life, or inspection after death. W. R. Gowers. HYDROPS (SSwp, water). — A synonym f' r dropsy. See Dnorsr. HYDRORHACHIS (uScep. water, and fia.\is. the spine). — A collection of fluid in the spinal canal. The term is commonly used as a synonym for spina bifida. Sic Spina blfida. HYDROTHERAPEUTICS. HYDRO THERAPEUTICS (SSap, water, Hid depairevu, I treat). — Synon. : Water-cure ; Hydropathy; Fr. Hydrothcrapcutique ; Ger. WasserhcilkiLr.de. It would bo out of place were we to enter here into a description of the sources and the composi- tion of the numerous varieties of water used for hygienic and dietetic purposes ; but we may refer to Dr. Parkes’ instructive Manual of Practical Hygiene. We intend to divide this article into (1) a short sketch of the history' of the water-cure or hydrotherapeutics ; (2)notesontke internaluseof water, and on the more common hydrotherupeunic procedures ; and (3 ), a consideration of the morbid conditions suitable forhydrotherapeutic treatment. History of the Water-cure. — Although the old Greek and Roman physicians occasionally employed water internally and externally in the treatment of disease, the systematic water-treat- mentseemsto have gained ground for the first time in the 15th and in the beginning of the 16th cen- tury in Italy and France, and again after a period of oblivion in the 17th century, especially in Eng- land (Floyer, T. Smith), and in the beginning of the 18th century in Germany (F. Hoffmann). The next important scientific application we owe to J. G. and J. S. Hahn, who, towards the middle of the 18th century, treated febrile diseases with cold sponging, and were so convinced of the beneficial result, that one of them when attacked with typhoid ■ fever subjected himself to this treatment. It fell, however, again into neglect, until towards the latter part of the 18th century, when Wm. Wright, James Currie, W. Jackson, and others resuscitated the cold water treatment in fevers, and strengthened their reasoning by thermometric observations. In spite of the results obtained, not only in England but also in Ger- many, amopgst others by Reuss, Frohlieh, Bran- dis, and Horn, the method was again falling into disuse, when, soon after 1820, a small farmer, Vincent Priessnitz, of Graefenberg, in Silesia, began to treat every kind of ailment, chronic as well as acute, with various hydrotherapeutic pro- cedures, and added to the external applications the abundant internal use of water, combined with active exercise, and a very simple diet ; prohibit- ing at the same time nil alcoholic beverages, and also tea and coffee. Priessnitz gradually made considerable changes in his method of treatment. For the original packing during several hours in dry woollen blankets covered with feather-beds, and followed by cold affusions, he substituted packing in wet linen sheets during several hours, followed by a full bath or a douche ; and at a still later period, he frequently employed cold wet packing of only 1.5 or 20 minutes’ duration, repeated several times on the same day ; he introduced also the method of rubbing the whole body with a cold wet or dripping sheet instead of the full bath, and made extensive use of partial baths, as hip or sitz baths, baths for the hands, the arms, the feet, wet abdominal belts, and wet compresses over different parts of the body. Priessnitz seemed to search for a univer- sal method applicable to all cases. One of the guiding ideas was that disease of the most diflerent nature was caused by an acrid humour >n the blood, and that the skin was the organ through which this humour was to be removed. 66 “ Though the success of such treatment, com- bined with active exercise in a healthy mountain- ous country, and simple diet, w.^s considerable in many cases, the indiscriminate, too energetic, and protracted use often led to unfavourable results, and the system was beginning to be regarded as a species of quaekerv, when, about thirty years ago, some establishments were placed under the superintendence of regularly educated physicians, who studied He phys iological effects of the different forms of bacninu. and modi- fied them with regard to duration, temperature. &e., according to the requirements of individual cases, combining pharmaceutical remedies witli hydrotherapeutic procedures when required. Thus a more or less modified water-cure has at last become a branch of rational medicine, at least in France and Germany ; and a new impulse has been given to it lately, by the employment of various forms of baths in the treatment of fevers. In this country there is as yet, very little system- atised relation between the special hydrothera- peutic and the general medical treatment ; and the experience gained at hydrotherapeutic establish- ments is not communicated and discussed in our medical societies, and scarcely ever in the general medical journals. This is much to be regretted, for there can be no doubt that hydrotherapeutic measures might be more widely introduced with great advantage into our hospitals, as well as into our private practice ; but this is not likely to be the case so long as the medical profession has not fuller opportunities for studying the effects of water treatment. The fault may lie to some de- gree in the nature of most of the establishments for the water-cure ; but this might be remedied if more establishments were to be erected under the guidance of superior members of the profession — establishments where the usual medical treat- ment would in suitable cases go hand in hand with hydrotherapeutic management. Internal Therapeutic Use of Water, and the more Common External Hydrothera- peutic Procedures. — The dietetic necessity of water is well known ; life cannot exist without it, ; all our tissues contain an indispensable pro- portion of water; we constantly lose a large amount -by respiration, and by all excretions; all the internal functions of tissue-change are depen- dent on a certain quantity of water ; this want is supplied by the solid and fluid food which we take, water included; while temporary excess of supply leads to increased discharge by the excre- tions, and temporary deficiency to a diminution of the water of the excretions. An increased in- gestion of water further leads, for a time at least, to an increased removal of the products of retro- gressive tissue-change ; the tissues and the blood itself are, so to speak, washed out by it ; and, as the consequence of the increased removal of the used-up material, the body is enabled to take in a larger amount of new substance, and hence we observe not rarely increase of weight as the effect of plentiful water-drinking, if not carried to excess as regards quantity and time ; the secretions of the urine, bile, saliva, and pancreatic juice, appear to be increased by the abundant internal use of water, as weUas the perspiration , though the latter to some degree requires the concomitant influence of high external temperature or bodily exercise. HYDROTHERAPEUTICS. 668 Water lias also an important share in all internal courses of mineral waters. Used by :tself, it can exercise some good influence in cases of gout and gravel, in haemorrhoidal com- plaints, imperfect secretion of bile, and constipa- tion from sluggish peristaltic action. As, how- ever, excessive water-drinking, according to Priessnitz’s original plan, is apt to cause dys- peptic troubles, water is now, in general, used internally only either for dietetic purposes, or to assist in other courses of treatment. The external use of cold water admits of a very great variety of applications, and a corre- sponding variety of effects on the body. The two main effects of the different forms of cold baths are abstraction of heat, with its further influences on the functions of the body; and. stimulation of the cutaneous nerves, and through these of the nerve- centres. Both effects are usually combined, but in some forms of bath, the stimulation or the exciting effect preponderates; in others the ab- straction of heat, with its calming or depressing ivjlumce. Hence the different forms of baths, or rather hydrotlierapeutic procedures, may be divided into stimulating and calming, but it is to lie borno in mind that there is no strict line of distinction. With this limitation we may regard as stimulating— the full cold batli of short duration, the stimulating action of which is increased by motion of the water, be it natural or artificially imparted; the rapid wash-down, either by means of a large sponge, or by means of a wet sheet, with or without friction ; the spouting of the back, and the pail-douche; the needle-bath or circular shower-bath ; the different forms of the rain-bath, and the usual shower- bath; the great variety of other douches; and the running or flowing sitz-bath. The immediate effects of these stimulating forms, in a constitu- tion endowed with a certain amount of reactive power, are exhilaration, increased activity of cir- culation and muscular force, and improved appe- tite and digestive power. By altering the dura- tion of the bath, and the temperature of the water, the effects may be considerably modified, and thus adapted to different conditions. The more calming forms are — the wet sheet- envelope, entire or partial; the impermeable wet compresses; the full cold bath of long duration and without motion; the sitz, tile shallow, and foot baths without motion ; and the full bath of higher temperature. Depression through ab- straction of heat exceeds the stimulation in these forms : diminution of nervous irritability, of sen- sation and mental activity, and of the frequency of the pulse and energy of circulation : a feeling of lassitude; and a tendency to sleep, are the principal effects. These forms can, however, bo modified, and the effects vary in proportion. Thus the wet sheet-envelope allows ample variation by using warm or cold water, by using the sheet dripping or wrung out, by making the sheet fit tightly round the neck, by moving the sheet to and fro, by frequently changing the sheet, &e. The calming and stimulating form may be further combined by using, first, the wet sheet-envelope, or the woollen blanket-envelope, for a sufficient period to produce perspiration; and then a more or less cold bath or shower-bath of short dura- tion. The physician has, indeed, infinite varieties of application at his disposal, to be used accor- ding to necessity. Powerful and most important hydrotherapeu- tic helps are the different vapour- and hot air- baths (Russian, Roman, Turkish baths), com- bined with douches and baths of various tem- peratures. These kinds of baths are, however, treated of in another article. See Baths. A plain nourishing diet, without or with only a limited amount of stimulants; outdoor exercise in proportion to the strength of the individual; and in some cases active or passive gymnastics, are likewise to be regarded as valuable adjuvants in the hydrotherapeutic treatment of chronic diseases ; for muscular exercise means not only increased action, oxidation, excretion, and de- velopment of muscle, but also increased gene- ral circulation and respiration, increased inhala- tion of oxygen, and increased production of heat, so necessary in the cold water-cure. There is also no reason whatever why pharmaceutic-, 1 remedies should not be combined with the water- cure treatment — a method which, as already mentioned, is frequently adopted in the best esta- blishments. Therapeutic Effects, and Morbid Condi- tions Suitable for Hydrotherapeutic Treat- ment.— The principal results of weil-adapted courses of cold water treatment arc : — improved nutrition and action of the skin ; increased tone of the nerve-centres ; regulation of the circulation ; amelioration of the sanguification and nutri- tion ; and acceleration of the retrogressive tissue- changes. It is essential for such successful results that the organism be able to stand a certain amount of abstraction of heat ; that it be capable of more or less energetic reaction ; and that the digestive and assimilative organs be able to take up a fair amount of nourishing material, which is required by the increased demand on the body. Acute febrile diseases. — Amongst the oldest therapeutic uses of the cold bath, though it has only lately been more extensively revived, is the employment of different forms of cold baths in acute febrile diseases, attended with a high de- gree of pyrexia. The moderately cold or the cooled-down bath, as proposed by Dr. von Ziems- sen of Munich, is the form principally employed: but cold affusions, the shower-bath, the wet en- velope frequently changed, cold compresses, the application of ice in substance, washing with iced water, and iced enemas are likewise appli- cable ; and the liberal internal allowance of cold water forms an important part of the dietetic management of this class of diseases. Typhoid fever. — Typhoid fever is the disease in which this treatment, with numerous modifica- tions, has been most generally adopted. As soon as the temperature of the patient reaches 102’0° to 103° Ruhr., he is placed in a bath of about 90° Fahr., and the temperature is gradually cooled down, by the addition of cold water, to 80° or 60° Fahr.. according to the patient’s power of reaction. The patient is kept in the bath generally from 10 to lo or 20 minutes, when slight shivering often manifests itself. The patient's temperature, me i- sured in the rectum, is usually reduced by this procedure about 1 )° to 5° Fahr., not immediately, but within the first hour after the bath. As often as the temperature may again reach 102 ’O’ HYDROTHERAPEUTICS. to 103°, the patient is again placed in the bath. Thus, during thp height of the pyrexia three to five baths may be required in twenty-four hours, while later on about two are usually sufficient, and often only one. Instead of the bath gra- dually eoolcd-down, a bath of a. temperature between 60° and 90° Fahr., may be given, accord- ing to the condition of the individual patient. The frequent and careful use of the thermometer is an essential element in this method of treat- ment, which may be, as it often is, advantageously combined with the administration of alcohol, quinine, and other remedies. The earlier the baths are commenced, the greater seems to be their influence in mitigating the severity of the disease and its sequel®, and in shortening its duration. In the numerous accounts of Ger- man physicians (Brand, Ziemssen, Zimmermann, Jixrgensen, Liebermeister, &c.) it is claimed that the mortality is considerably less with this than with the expectant or any of the other usual modes of treatment. Hyperpyrexia. — A still bolder use may b6 made of the cold-water treatment, in those rarer cases of hvperpyrexia occasionally occurring in the course of rheumatic fever, when the temperature rises to 10S° Fahr. and more; and where very cold and prolonged baths, the application of ice- bags, &c., appear to be the only means of saving life. ( See Dr. Wilson Fox, Treatment of Hyper- pyrexia ; the writer's case in the Clinical So- ciety’s Transactions, vol. v. ; and several other papers in the Clinical Society’s Transactions.) Scarlet Fever. — In scarlet fever we have found warmer baths (80° to 98° Fahr.) more generally applicable than quite cold or cooled-down baths, though in cases attended by a high degree of pyrexia and brain-symptoms these are preferable. Hectic fever. — In hectic fever, connected with various chronic diseases, the effect of hydro- therapeutic treatment is less decided, and not yet sufficiently tested. Digestive derangements of the most different kind, associated with sluggish venous circulation in the abdominal organs — conditions which may be grouped together under the term abdominal venosity, tendency to haemorrhoids, to hypochon- driasis, &c., are ofteu the objects of the water cure, which may be useful bystimulating the phy- sical and psychical energy of the nervous system, as well as the nutrition and tissue-change, by in- vigorating the skin. Habitual constipation from this cause is often relieved by the hydrothera- peutic belt. In this class of cases the common salt waters, and the alkaline sulphatic waters are more frequently used, and are often preferable ; they may, however, be advantageously combined with judicious hydrotherapeutic treatment. Chronic metallic poisoning may be treated in some cases with equal benefit, if there is' suffi- cient reactive power, at cold water establishments, as at the thermal sulphur and simple thermal spas. The external hydrotherapeutic procedures aiming at increased perspiration and tissue- change. are in this class aided by the abundant internal use of water, in order to wash out the tissues, and especially the liver. Skin-weakness or atony of the skin is often the cause of frequently recurring attacks of diarrhoea with neuralgic pains, of tendency to catarrh of 669 the respiratory mucous membrane, and of rheu- matism. Gently stimulating hydrotherapeutic appliances, with gradually increasing energy, are here mostly useful, unless, as in impeded con- valescence, the reactive power is so reduced that the gaseous thermal salt baths and mountain-air are preferable, while in others sea-air and sea- baths are successful competitors cf the water- cure. Hysteria. — In hysteria and hysterical affec- tions the water cure has obtained many good results, not by the internal use of water, but by the milder forms of baths. Functional hyper- aethesia and anaesthesia, hemicrania, spinal irrita- tion, intercostal neuralgia, and other forms of neuralgia depending on imperfect nutrition and tissue-change, are likewise often benefited. Organic diseases of the nerve-centres are not suitable for treatment in cold water establish- ments, excepting occasionally for palliative pur- poses. Bheumatism and gout. — In muscular rheuma- tism the original supporters of the water-cure considered their plan as infallible, but this is by no means the case. The diaphoretic methods, namely, the woollen blanket-pack and the wet sheet-envelope, often prove useful ; but we know also of many failures in even good establishments. The exposure toall weathers during the cure ought certainly not to be imitated by such invalids, and the access of cold air to the wet body is to be more carefully avoided than it often is. The course must not be prolonged too much at one time, but may be repeated after an interval of months, which may he spent with advantage at sheltered seaside localities, at moderate elevations, with the help of pine-leaf baths, or at one of the gaseous thermal saline spas. Hheumatic and gouty swellings of joints require great care in their management. The enfeebled invalid is rarely a fit object for the water-cure ; but the stimulating local compress, more or less impermeable, is a useful element in the treatment of such cases. Milder cases of gout may expect benefit from the usual hydrotherapeutic treatment, in so far as it aims at increased retrogressive tissue- change, and invigoration of the nervous system, especially if this treatment is associated with great moderation in the use of stimulants, and also of food in general; but local packing not rarely causes fits of gout. The more serious forms of gout are too much complicated with various defects of constitution to encourage us in recommending cold-water treatment. Chronic affections of the skin. — In some dis- eases of this kind, such as prurigo, urticaria, eczema, and local perspirations, a more or less modified hydrotherapeutic treatment is an im- portant adjuvant. Syphilis. — The favourable results obtained in syphilis, or rather in the often complicated con- ditions of lues, have greatly contributed to the reputation of the water-cure ; but the latter is only an excellent adjuvant to pharmaceutical treatment in these cases, in a similar way as the sulphur waters are ; and many of the cures of so-called lues may he regarded as cures of mcr- curialism. Catamenial irregularities are not rarely treated r, 70 HYDROTHERAPEUTICS. at hydrotherapeutie establishments. Profuse menstruation is often checked by the regular use of the colil hip bath of short duration, namely, three to fire minutes ; in insufficient menses, on the other hand, warm hip-baths of ten to fifteen minutes’ duration are frequently useful, combined ia some cases with the wet sheet-envelope; and dysmenorrhcea is likewise occasionally treated with advantage by the partial wet sheet- envelope. This list of morbid conditions which tnay be more or less benefited, might easily be increased ; and this is not astonishing if it is considered that hydrotherapeutie treatment can be infinitely modified and adapted to the powers of the con- stitution; and that it may be assisted by varying hygienic, climatic, dietetic, and pharmaceutical influences ; for there does not exist any antagon- ism between hydrotherapeutie and other rational treatment, the former being, in fact, only part of tho latter. Hence, however, it is also evident that the treatment in well-arranged hydrothera- peutie establishments ought to be under the guidance of the most intelligent physicians, just as is the case at all the best spas ; indeed the phy siciar. at such an establishment ought to be of a very superior kind, possessing in a more than usual degree the gift of recognising all the in- dividual peculiarities of the constitution, espe- cially the amount of reacting power, adapting the principal remedy to every individual case, and combining other elements of treatment with hydrotherapeutie management wherever this is necessary. In the same way as wo demand in suitable cases the administration of other re- medies together with water-treatment in bydro- therapeutic establishments, so we must also express a wish, that our, of such establishments, hydrotherapeutie elements should be more gene- rally combined with the usual medical treatment. For this purpose it is to be desired that well- conducted establishments should bo in or near large towns, in order that persons following their usual occupations might undergo certain kinds of treatment at. such establishments, or that at- tendants from such establishments might bo sent to tho house of invalids. Hermann Weber. HYDRO THORAX (u'Soi p, water, and edpat;, the chest). — Dropsy of the pleura. See Pleura, Diseases of. HYDRUBIA (l!5ojp, water, and ovpov, urine). A profuse flow of watery urine. See Urine, Morbid Conditions of. HYERES, ia Var, Eranee. Dry, warm climate. Town three miles from the sea. Much exposed to N.W. wind (Mistral) in spring. See Climate, Treatment of Disease by. HYGIENE (uy.Gi a, health). — The science and art relating to the preservation of health. Sec Personal Health ; and Public Health. HYPAEMIA (u7 rb, under, and aT/xa, blood). — Deficiency of blood in a part; a synonym for local anaemia. See Circulation, Disorders of. HYPASSTHESIA ({mb, under, and ataBnais , sensation).— Diminished sensibility of a part. See Sensation, Disorders of. HYPERAEMIA(6ivip, over or excessive, and HYPERTROPHY. OL/ia, blood), — Excess of blood in a part. Set Circulation, Disorders of. HYPERJESTHESIA (imbp, over, and af is frequently characterised by a logical a curacy which fails him, however, in some point of great importance, by which the conclusions are inva- lidated. The melancholic patient, on the otliei hand, is often suicidal and always despairs of any relief to his condition, the description of which as given by him is confused, frequently incoherent, and unintelligible. Prognosis. — Early and marked hypochondri- asis occurring in a person with a strong heredi- tary taint of insanity, without any definite cause of mental depression, is of ill omen. Such a case very often drifts into melancholia. The prognosis is favourable, perhaps, tho less strongly marked the hereditary predisposition and the more evident and adequate the immediate causes to which the patient has been exposed, the most potent of which are sexual or alcoholic excesses, mental strain or shock, or the sudden change from a life of activity to one of forced and, as the sequel shows, uncongenial leisure. Treatment. — Moral treatment is alone of any influence in a large majority of cases. Where there is, however, manifest anaemia, a history of syphilis, evidences of gouty mal-assimilation, ac- cumulation of faeces, catarrh of the intestinal canal, or haemorrhoids, the therapeutics proper to these conditions should be employed. Alco- holic stimulants should be avoided. Travel especially under judicious companionship, an-, the encouragement of regular, definite, and nsetu! employment for the attention and the i.mwI powers, are the most potent means of treatment, by which the disease may bo often much amt- hypochondriasis. .iorated, and sometimes cured Ridicule of the patient's sufferings will rarely or never be of service, but at the same time a habit of pre- scribing for all the symptoms as they arise must oe avoided. T. Huzzaed. HYPODERMIC INJECTION (uwb, under, and S 4pna, the skin).— The effective introduction of remedial agents into the system by subcuta- neous injection was rarely possible until the dis- covery of the alkaloids enabled us to administer an active dose in very small bulk. Dr. Alexander Wood, of Edinburgh, undoubtedly deserves the credit of bringing this principle practically before the profession ; and, improved as it has been by Mr. Hunter and others, the hypodermic method is now justly regarded as one of the most active and reliable of our therapeutic resources. It may be used in two essentially different ways. I. The remedy is thrown into the subcutaneous cellular tissue by means of a sharp-pointed hollow needle, attached to a carefully graduated glass syringe. The little prick must be made as ra- pidly as possible, either by direct puncture, or in a mors valvular direction, through a pinched- up fold of skin ; and care must of course be taken to avoid the neighbourhood of all important structures. The solution employed must be small in quantity and bland in quality, and must be slowly introduced, as pain usually follows the too sadden or forcible depression of the piston ; and we must satisfy ourselves before we begin to in- ject, that the point of the instrument has passed fairly through the skin, without imbedding itself in the substance of the muscles. When carefully performed, the advantages of this plan are great, for not only is it economical, drugs administered in this way acting much more powerfully than : when given by the mouth ; but absorption is very rapid, and the desired effect is swiftly and surely produced. The drawbacks of the hypodermic j method are — the pain of puncture (which may be alleviated by a slight preliminary freezing of the skin); an occasional tendency to irritation and the formation of abscess; and, where morphia is concerned, the risks of nausea and syncope, and the dangers attending the. not very remote possi- bility of acquiring opium-eating habits. The principal drugs used hypodermically in this way are the following : — 1. Morphia . — Morphia thus administered forms by far our most effectual remedy for the relief of suffering. In all varieties of neuralgia, in the wearing agony of cancer and other in- curable disorders, as well as in a host ot painful iud irritative affections, we derive invaluable aid rom the use of the hypodermic syringe : remem- bering that the dose must at first be small, not ■xceeding i of a grain, and that we derive no iPecial advantage from injecting directly over 'lie spot whero the uncomfortable sensations are pit. Recollecting also the occasional occur- 'encu of sickness and faintness, we shall do well : o enforce the recumbent posture; to keep our atient under observation for a few minutes fter the operation is over : and perhaps to com- inOyH grain of atropia. which seems to have in brne measure the power of preventing the de- pressing action which morphia occasionally dis- ays when administered alone. HYPOGASTRIC REGION. 076 2. Atropia. — Anstie had great faith in atropia, as the best of all remedies for pain in the pelvic viscera; and its injection hypodermically has been attended with good results in the nocturnal sweating of phthisis in doses of ylg to ^ grain ; and also as an antidote in opium- poisoning, even up to half-a-grain. 3. Ergotine. — Ergotineaets most effectively in- cases of htemorrhage, its chief disadvantage being the development of black painful lumps at the site of puncture. The average dose is 2 grains. 4. Quinine. — This useful drug has been ex- tensively used in tropical climates by hypodermic injection for ague, sunstroke, &c. ; but the great pain attending the operation, and the subsequent liability to the formation of abscess, have proved effectual barriers to the general introduction of the practice into this country. 5. Other drugs. — Chloral, where subcutane- ously used, also causes severe suffering, with the production of unhealthy ulcerations of the skin. Many persevering attempts have been made, but have not yet been successful in overcoming the very irritating effects of mercury when employed in this way. Out of the large number of other drugs, the subcutaneous use of which has been tried from time to time, we are unable to report, any substantial advantage thus gained over their administration by the mouth. II. The second hypodermic method is that re- commended by Bartholow and various Ameri- can and Continental physicians, and usually called the deep or parenchymatous method. This essen- tially consists in plunging the point of the needlo into the muscles, and forcing the fluid freely amongtheir fibres, and into the immediate neigh- bourhood of painful nerves. Wo are told that in this way chloroform is a very certain remedy for neuralgia; that strychnia is indicated in infantile, reflex, hysterical, and Lad palsy; and that carbolic acid is useful in erysipelas. As yet, however, there is not much British ex- perience to quote in confirmation of this prac- tice. In conclusion, we may note that most hypoder- mic solutions are readily destroyed by mould ; and that Dr. Sansom has suggested a very handy series of gelatine disks, which will keep well in all climates, and which may readily l< melted down when required for use. Robeet Farquharson. HY'PO GASTRIC REGION (M, under, and yaiTTTip, the belly). — The hypogastric region is conventionally described as lying between the right and left inguinal, below the umbilical, and above the pubic regions. Anatomical Relations. — The surface of the hypogastric region in ordinary persons is flat, showing the muscular reliefs ; it is rounded in children ; and in some individuals, much ema- ciated from disease, it becomes concave. The median furrow disappears below the umbilicus, owing to the approximation of the recti muscles. The integument is very elastic and movable especially at the sides. The superficial fascia consists of two lamina., between which lie the subcutaneous vessels : but in the middle line these laminse are blended. B 676 HYPOGASTRIC REGION. is strengthened at its lower part by the tri- angular fascia. The aponeuroses of the external and internal oblique muscles are united in the linea alba, and form a portion of the sheath of the rectus. The recti muscles themselves have their inferior attachments in this region, along the line ex- tending between the spine and the symphysis of the pubes; their outer edges curve outwards, and become straight as they enter the sheaths. The pyramidales, two small triangular muscles, arise from the pubes, lie in the same sheaths as the recti, and assist in closing in the abdo- minal parietes anteriorly and below. Immediately beneath the recti is the fascia transversalis, with a little loose areolar tissue and fat, the fascia being tolerably adherent along the central line. Beneath the fascia trans- versalis there is a considerable amount of loose areolar tissue, between it and the parietal peri- toneum, which in this region is very loosely attached, and reflected off the bladder on to the fascia transversalis. Enclosed in folds of the peritoneum lie, on either side, passing upwards to the umbilicus, the remains of the hypogastric arteries ; and from the apex of the bladder in the middle line, passing to the umbilicus, is the obliterated urachus, which acts as the superior ligament of the bladder. The viscera corresponding to the hypogastric region are : — the bladder when full ; and the small intestine, covered by the great omentum. When the bladder is full, the intestines are pushed aside, and the former then lies against the pubes and recti. In children the bladder, being an abdominal rather than a pelvic viscus, always lies in this region. During pregnancy the uterus also corresponds with the hypogastric region. The vessels are the deep epigastric, with the veins which pass obliquely inwards from the internal iliac. They lie between the peritoneum and the transversalis fascia. The nerves are derived from the lower inter- costals and lumbar. The lymphatics pass into the inguinal, superficial pubic, and lumbar glands. Clinical Relations. — The hypogastric re- gion is of clinical importance chiefly from an operative point of view. It is in the median furrow of this region that the operation of tapping in ascites is usually performed ; and that the principal incision is made in ovario- tomy, the Caesarian section, and supra-pubie lithotomy. The bladder is occasionally tapped above the pubes. The presence of the distended bladder or of the pregnant uterus, forming a tu- mour in the hypogastrium, has been already re- ferred to. Enlargements here from these causes have to he diagnosed from pelvic tumours of va- rious kinds, which, in growing upwards into the abdomen, occasionally occupy the middlo line in- stead of either groin. The only morbid con- dition of the abdominal parietes in the hypo- gastric region that requires special mention is abscess connected with disease of the lumbar spine, which occasionally points above the pubes, on either side of the middle line. The pus in such a case is situated between the peritoneum and the fascia transversalis. Edward Bellamy. HYPOGLOSSAL NERVE, DISORDERS OP HYPOGLOSSAL ITESVE, Disorders of The hypoglossal nerve is the motor nerve for the tongue, and for most of the other muscles which are attached to the hyoid bone, the excep- tions being the stylo-hyoid, the mylo-hyoid, and the middle constrictor of the pharynx. It also supplies the sterno-thyroid muscle. 1. Paralysis. — Paralysis of this nerve is shown chiefly by the resulting interference with the movement of the tongue — ‘ glossoplegia.’ .^Etiology. — The nerve may he damaged in any part of its course by the growth of tumours ; but is most commonly affected at its origin within the spinal canal, by pressure from tumours, meningitis, or syphilitic growths, or by caries of the upper cervical vertebra. The tongue is also paralysed by disease of the nucleus of origin of the hypoglossal fibres, hut its paralysis is then associated with that of the lips, and commonly also of the palate, pharynx, and glottis {see Labio- glosso-Laryngeal Paralysis). Disease of the motor tract above the nucleus also causes para- lysis of the nerve, together with the face, arm, and leg of the same side. Bilateral glossoplegia commonly results from disease of the nucleus or its neighbourhood. Unilateral paralysis is due to disease of the motor tract, above the nucleus, rarely of tho nucleus itself, often of the fibres of the nerve within or outside the medulla. Symptoms. — In unilateral paralysis, the tongue at rest is in its normal position in the mouth, but its root is higher up on the paralysed than on tho normal side, in consequence of the loss of the tonic, or voluntary, contraction of the posterior fibres of the hyoglossus. Within the mouth the tongue is moved freely to the healthy side, but is not moved to the paralysed side. When protruded it deviates towards the paralysed side, because the protrusion is the result of the action of the fibres of the genio-glossus, and the tongue is pushed over towards the weaker side. In bilateral paralysis the tongue lies in the mouth behind the teeth, and cannot bo pro- truded. If the loss of power is complete, the tongue cannot be projected over the lower teeth. It is broad and flabby, if there is no atrophy, and sometimes when atrophy is associated witli fatty overgrowth. When there is much wasting, the part affected is shrunken and wrinkled. In unilateral paralysis, articulation and deglutition are little impaired. The pronunciation of labials, and the production of falsetto notes may, how- ever, he difficult. In bilateral paralysis, articu- lation is impossible. Phonation is not impaired, unless the larynx is also paralysed. The masti- cation of food is impeded, because the food can- not be moved about the mouth. Deglutition is also interfered with, because the food cannot be rolled into the fauces ; and soft foods, when j they reach the pharynx, may be driven again into the mouth in consequence of the absence of the natural supporting movement of the tongue. Taste is not primarily affected, but may be some- what dulled, because the patient is unable to move substances about the mouth. Diagnosis. — The position of the lesion is in- dicated bythe associations of the paralysis. If the disease is in the motor tract above the nucleus (pons, crus, or hemisphere), there is hemiplegic weakness on the side of tho paralysis HYPOGLOSSAL NERYE, DISORDERS OF. jf the tongue. In disease of the nucleus the paralysis is commonly bilateral, is associated with paralysis of the lips and throat, and there ,s usually wasting. Disease of the fibres of oipgin within the medulla is associated with paralysis of the opposite limbs, so that the tongue deviates from the paralysed side. When the disease is at the surface of the medulla, the paralysis is commonly unilateral, and is asso- ciated with paralysis of the corresponding half of the palate and vocal cord (Hughlings Jack- son.) In disease of the fibres of origin within or outside the medulla, there is commonly wast- ing. The diagnosis of the pathological cause of the paralysis rests on the course of the affection, and on the presence of any causal and associated iondition. Prognosis. — This is usually unfavourable, on account of the gravity of the disease which lamages the nerve or centre. Even in syphilitic rases, recovery is often incomplete. T reatment. — -The treatment of paralysis of the hypoglossal nerve is that of the causal lisease. Tonics, counter-irritation, iodide of potassium and mercury, with occasionally the application of electricity to the tongue, are the most important remedies to be employed, accord- ing to the setiologieal indication. The most con- venient method of applying electricity is by means of a tongue depressor in a wooden handle, ;he blade being insulated by a coating of sealing rax where it comes in contact with the lips. 2. Spasm. — Spasm in the parts supplied by the hypoglossal nerve is rare. The tongue parti- cipates in the convulsive movements in epilepsy, is jerked between the champing jaws, and thus becomes bitten. Cases have been met with in which the tongue is affected with a ‘functional spasm’ in speaking, analogous to ‘ writer's cramp,’ but these are so rare as scarcely to need detailed description. W. R. Gowers. HYPOSPADIAS (™b, under, and o-n-dSiov, a space'). — A malformation of the penis in which the orifice of the urethra is underneath or behind the glans. See Malformations.' HYPOSTASIS (uirb, under, and crraoi, I stand). — Definition. — This term is applied to that condition of the vessels of a part, which consists in an overfulncss, caused mainly by a dependent position, with a varying degree of diminution in the. rate of flow of the contained fluid. Pathology. — The entire conditions of the venous circulation are such as to readily favour a stasis or stagnation of the blood-flow ; and a trifling cause, such as would in no way affect the arterial flow, may easily impede the venous current. The veins also are, as a rule, less firmly supported by the surrounding tissues than the arteries; and this, with their thinner coats, slighter elasticity and resistance, render them easily liable to distension by the blood in congestion. If a dependent position be added to these conditions, thereby offering a resistance to the return flow of the blood, whilst it favours '.he circulation in the arteries, a combination jf circumstances exists to which the term ii/postatic congestion is applied. The liability >f the veins of the leg to become congested, HYSTERIA. 677 leading to a varicose condition and its results, is an example of this state. If, in addition to all these factors, the heart be enfeebled and the arterial tone he diminished, obviously’ an- other cause for stagnation is introduced, and of necessity will manifest itself most in those situa- tions predisposed to stasis. Such a state is seen in the hypostatic congestion of the lungs, which usually attends in a greater or less degree all pyrexial conditions. The recumbent attitude, the enfeebled heart, and the lax vessels emi- nently favour an overfulness of the veins. It is obvious that although the excess of blood primarily occurs on the venous side of the capil- lary system, very soon the arterial area will share in the. engorgement, and the whole vascular sys- tem of the part become overfilled. Results. — The pathological results of such a state are very much the same as those following any congestion. The distended vessels, with the increased blood-pressure that co-exists, readily permit of a transudation of the fluid part of the blood, hence oedema; if the conditions be extreme, capillary rupture may take place, and haemorrhagic effusions result. Any continuance of this state will lead to malnutrition of the tissues affected;- the proper supply of arterial blood is interfered with; and the part is loaded with an effete venous blood, and infiltrated with serum. Hence the structural repair of the tissues is improperly performed, and there is a tendency to the development of an imperfect form of connective tissue ; or, on the other hand, the destructive ratherthanthe productive aspect may predominate, and ulceration follow. When the hypostasis is associated with an acute general state, as of the lungs in any specific febrile disease, it is very apt to pass on into a form of inflamma- tion characterised by a want of acuteness. There are the same inflammatory products, the same changes in the vessels and tissues of the lungs, and very much the same symptoms as occur in the course of an ordinary pneumonia, but they are less severe in character, and on the whole do not tend so readily to a favourable resolution. Treatment. — Recognising the cause, altera- tion of position is obviously the rational treat- ment of hypostatic congestion ; additional sup- port by bandaging is often advisable. In acute febrile diseases stimulants are of much service in the prevention or relief of this condition in connection with the lungs, should the heart’s action he enfeebled. AV. H. Allchin. HYSTERALGIA ( itr-rtpa , the womb, and &\yos, pain). — Pain in the womb, frequently supposed to be of a neuralgic nature. See Womb, Diseases of. HYSTERIA (boTtpa, the womb). — Synon. : Fr. Hysterie ; Ger. Hysterie. Hysteria is a term the etymology of which is misleading, and had best, therefore, be disre- garded. It is often improperly applied to cases of simple malingering, and others which do not ad- mit of ready explanation. Its use is best restricted to a condition of the nervous system fairly defined, but the intimate pathology of which is not known, characterised by the occurrence of convulsive I seizures and by departures from normal function I of various organs, leading to very numerous and HYSTERIA. G7S often perplexing symptoms. These are apt to simulate those commonly arising from definite alterations of structure, but differ from the latter in the fact that they may often, even when at their worst, be removed instantaneously, usually under the influence of strong emotion. It would ecem that there is a disturbed or congenitally defective condition of the cerebral substance, in- volving in all cases the highest nervous centres, and in various examples extending more or less also to some of those which preside over auto- matic phenomena. Partial or complete suspen- sion of inhibitory influence would appear to be the most patent result of the condition, whatever it be, and this is recognised as well in regard to the mental as to the more evidently physical processes belonging to cerebral function. A laugh which cannot be checked, but continues until tears flow, or the limbs become convulsed, is a typical example of such a suspension of con- trol, and, if studied, throws light upon the nature of a considerable portion of the phenomena of hysteria. The jerking expirations of laughter arise from excitation of the respiratory centre, and when this excitation, uncontrolled by higher centres, acquires an abnormal strength, it extends to other parts of the medulla oblongata and spinal cord, and produces general convulsions. It over- flows, as it were, into other nervous centres which in health would receive none of the exciting impulse. Between the lowest (automatic) func- tions of the cerebro-spinal nervous system and the highest (psychical) there is an evcr-in- creasingly complex system of excito-motor pro- cesses, which may be in part or wholly under the pathological influence, whatever it be. Hence the bizarre character of the hysterical pheno- mena, and the circumstance that the symptoms always include modifications of those processes which underlie the mental faculties. The sus- pension of the power of control possessed by the higher centres explains the irregular movements, spasms, and convulsions. Hyperaesthesia and pain are dependent, probably, in hysteria, upon such a molecular change being initiated in the sensory ganglionic centres as is ordinarily propagated from the periphery. Hysterical paralysis, on the other hand, signifies that the power of the higher centres in liberating movements is in abeyance. In hysterical anaesthesia it is pro- bably feeling or sensory perception and not tho function of the sensory apparatus which is in abeyance, whilst the reflex actions which result from excitation of sensory nerves are performed iu an orderly manner. A patient may work a needle with fingers which can be touched or pricked without the act being felt. Tactile im- pressions are conveyed to the ganglionic centres by the afferent nerves, and excite the action of efferent nerves so that the muscles are con- tracted. What is wanting is the participation uf those higher centres in which consciousness runs parallel to this physiological action. .ZEtiology. — Predisposing causes . — A state of more or less imperfect development of the higher nervous centres of congenital origin very frequently underlies, it is probable, the various circumstances which apparently conduce to the hysterical conditions. The female sex is much more prone than the male to the affection, which usually occurs le- tween the ages of fifteen and thirty, and most frequently of all between fifteen and twentv. Luxury, ill-directed education, aDd unhappy surroundings, celibacy where not of choice but en- forced by circumstances, unfortunate marriages, alcoholism, premature cessation of ovulation, and long-continued trouble — all predispose to hysteria. A somewhat frequent antecedent is a long and wearisome nursing of a sick relation, with much broken rest. The disorder is only ex- ceptionally found in women suffering from dis- eases of the genital organs, and its relation to uterine and ovarian disturbance is probably neither more nor less than that which obtains in other neuroses. Exception must be made in the case of prostitutes affected with venereal disor- ders, who are very prone to hysteria. In this class, however, the condition is complicated hy the physical and moral influences to which their life subjects them, and amongst these alcohol frequently occupies a very important place. Like epilepsy, migraine, and some forms of in- sanity, hysteria is prone to ho intensified at the catamenial period. The occurrence of hysteria (although compara- tively rare) in males is sufficient of itself to dis- prove the uterine theory ofcausation. Determining causes . — These include painful impressions; long fasting; strong emotions; imitation ; and shock to the nervous system, phy- sical or moral. Symptoms and Diagnosis. — In the limited space in which it is necessary that the subject of hysteria should be treated, it will be best to describe together some of the most frequent forms which the neurosis takes, and the principles upon which a diagnosis can be made. Hysteria produces symptoms which may be referred t > every function of the body. For consideration they may be roughly classed in the following groups, it being understood that all may occur either coincidontly or in succession : — 1. Mental. 2. Sensory. 3. Motor. 4. Circulatory. 5. Visceral. 1. Mental . — The intelligence may be apparently of good quality, the patient evincing sometimes re- markable quickness of apprehension ; but. carefully tested, it is found to be wanting in the essentials of the highest class of mental power. The me- mory may be good, but judgment is weak, and the ability 7 to concentrate the attention for any length of time upon a subject is absent. So also regard for accuracy, and the energy Deccssary to i ensure it in any work that is undertaken, are defi- cient. Tho emotions are excited with undue readi- ness, and when aroused are incapable of control. Tears are occasioned not only hy pathetic ideas but by 7 ridiculous subjects, and peals of laughter may incongruously greet some tragic announce- ment. Or tho converse may take place; the ordinary sigus of emotion may he absent, and I replaced by 7 an attack of coma, convulsion, pain, or paralysis. Perhaps more constant than any other phenomena in hysteria is a pronounced desire for the sympathy and interest of others. This is evidently only one of the most charac- teristic qualities of femininity uncontrolled by the action of the higher nervous centres, which in a healthy state keep it in subjection. Then is very frequently not only a deficient regard fa HYSTERIA. truthfulness, hut a proneness to active deception and dishonesty. So common is this, that the various phases of hysteria are often assumed to bo simple examples of voluntary simulation, and the title of disease refused to the condition. But it seems more reasonable to refer the symptom to impairment of the highly complex nervous processes which f> >rm the physiological side of the moral faculties. 2. Sensor//. — Pain, hypereesthesia, and anaes- thesia occur with perhaps equal frequency. The diagnosis of the hysterical origin of such altera- tions of sensibility is effected partly by excluding the presence of other causes, and partly by con- sideration of any accompanying or antecedent peculiarities of manner and conduct. Hysterical pain, where it is associated with some evident local change, is found to be greatly in excess of that which would ordinarily accompany the ob- served cause. Where pain or hyperesthesia is complained of in situations and of a character which would commonly point to some existing in- flammation, it is necessary, by examination of the pulse and temperature, to exclude such a condi- tion. Hysterical pain is apt to cease suddenly when the attention is diverted, and to be in- creased by inquiry and sympathy. Some of the most common seats of pain and tenderness are the following : — ( a ) The lower part of the side of the chest (usually the left) simulating intercostal neu- ralgia, but distinguished from it by the tenderness being wide-spread, superficial, and not confined to certain points. Pressure here will sometimes occasion disturbances of respiration and circu- lation. (4) Some of the vertebral spines, ttsually in the cervical and upper dorsal region. Prom the error of mistaking this for commencing disease of the vertebrae numbers of young women have been confined to a couch for months or years, and their health permanently damaged. The points of diagnosis are the patient’s antecedents; there is often a history of aphonia, or paraly- sis, or hysterical fits. Or it may happen that, long after tho pain has been first complained of, the patient has been seen to take a prodigious amount of exercise on some one occasion without complaint. A very much slighter pressure, too, causes pain than is at all usual in vertebral caries. It lias to be remembered, however, that a patient affected with vertebral disease may also be hysterical. (c) Acute pain in a joint, occurring usually some little time after a slight injury and giving riso to suspicion of inflammation, hut distin- guished from this by the fact that after a few days of great pain the joint does not feel hot to the touch, and is not swollen, and that the thermo- meter shows no rise of temperature. The pain is more easily excited, too, by touching the skin than by pressing the articulatory surfaces , against each other. It is necessary to remember that in locomotor ataxy there may be exquisite pains (of a shoot- ing character) having their seat in a joint or its ; neighbourhood, and accompanied by some local- t 'sed hyperesthesia of the skin. The disease rarely affects ycung females, but it may do so, tnd the condition is then extremely liable to be GiD mistaken for hysteria. The chief points 0 / dia- gnosis are, that in locomotor ataxy then, will be — 1. absence of patellar tendon reflex , 2. a peculiar character of the pains— lightning-like ; 3. probably some analgesia of the extremities ; and 4. an ataxic gait. See Locomotor Ataxy. ( d) Tenderness of the mamma or dar' ing pains through its substance, recalling those cx scirrims. The absence of any lump, and tho effect, of en- gaging attention, will serve to distinguish. ( e ) Pain in the head of very severe character ‘ like a nail being driven into the skull ’ (claims). This is probably neuralgic, and is by no means confined to the hysterical. There is also a more diffused pain, described as of great violence and exceedingly obstinate. This pain is sometimes suggestive of cerebral tumour, from which, how ever, it may often he distinguished by the fact that the ophthalmoscope shows no optic neuritis, and that there is no vomiting. But gTeat caution is necessary in coming to a conclusion that severe and long-continued pain in the head is hysterical. And here it may he well to say that in an accu- rate knowledge of the characteristics of the dis- ease stipposed to he simulated lies the only safety as regards diagnosis. Nor must it he for- gotten that persons with serious organic disease are frequently affected also with hysterical symp- toms. (/') Epigastric tenderness. Careful pressure will often show that the tenderness is at the origin of the recto-abdominalis muscles, and not in the stomach. But there is sometimes pain in the stomach itself, and this may he associated with disgust for food or depraved appetite. ( g ) Tenderness in one or other iliac region, deep pressure upon which will sometimes evolve hysterical symptoms, and also in some cases of hysterical convulsions will check the paroxysm. Anasthesia may involve (though rarely) the whole body. It is more commonly confined to one half, and this the left, and is then frequently associated with tenderness in the iliac region of the same side ; or it may be limited to a small patch. The sense of touch often remains whilst painful impressions and those of temperature cannot be perceived. The antesthesia may be confined to the surface, or involve as well the deeper structures, into which pins may he stuck without evoking signs of pain. The left con- junctiva is often the seat of anaesthesia, so that it may be touched or even rubbed without any reflex movements of the eyelids being excited. So also the pharynx may be tickled without exciting the ordinary spasmodic contraction, and the epiglottis touched by the finger without inconvenience. .Such affections of cutaneous sensibility may have to be looked for, as thev are often unsuspected by the patient herself. As regards diagnosis tie existence of peripheral nerve-lesions may be excluded, by theabsence of trophic disturbance. The condition is not likely to be confounded with hemiplegia, unless perhaos when it has immediately followed a convulsive attack, and is accompanied by apparent loss of power in the limbs. Examination of the patient and her history will suffice for the diagnosis. The other special senses also may be disordered in hysteria. There may be intolerance of light, subjective sense of taste or smell, roaring noise; I HYSTERIA. 580 n the ears ; or, conversely, loss of sight (either n Half of both eyes, or in one eye), loss of smell, jv taste, or hearing. Or there may be feelings an of a limb i9G INFANTS. DISEASES OF. vous system becomes gradually less and less manifest, until it finally disappears almost en- tirely. It is of importance to the practitioner to bear this fact in mind, for in a child much reduced by chronic illness, the presence of an intercurrent acute complication — such as inflam- mation of the lung — may be indicated by very few symptoms, the system having become almost insensible to nervous impressions. Another peculiarity, which strikes the atten- tion of anyone accustomed only to disease as it occurs in the adult, is the vast preponderance in infantile disorders of mere disturbance of func- i ion. and the disastrous consequences which may ensue from such derangements. Infants rapidly part with their heat, and are easily chilled. They are therefore excessively sensitive to changes .of temperature. A catarrh is a common ailment in the young child, and is attended by various dangers according to the part of the mucous tract which is affected by it. Gastric catarrh with violent and repeated vomiting, and intestinal catarrh with uncontrollable diarrhoea, are answerable for a large proportion of the deaths amongst young children during the warmer months. Even in cases where the catarrh affecting the digestive organs is of a less acute and violent character, the issue is often very serious. The gradual failure in nutrition, which is the result of such an impediment to the digestion of food, is a common cause of wasting in young children ; and unless measures be taken early to restore the proper working of the alimentary functions, the case may end fatally. In tho autumn and winter the bronchial mucous mem- brane is more frequently attacked. In such cases, however apparently slight may be the catarrh, a weakly infant is always exposed to the danger of pulmonary collapse; and a rapid interference with the respiratory function, such as takes place when collapse of some extent of lung is quickly brought about, is often a cause of sudden death. It is in consequence of this frequency of func- tional derangements, and their dangerous cha- racter, that post-mortem examinations in infants are so often unsatisfactory in finding any appear- ances explanatory of the cause of death. Clixicat, Exawixatiox. — The clinical exami- nation of young children requires tact and patience, but unless the child be very unruly it is not difficult. The patient cannot himself de- scribe his symptoms, but all necessary informa- tion can be gained from the parents. Mothers are, as a rule, good observers, and allowing for their natural anxiety and a slight tendency to exaggeration, their statements can usually be relied upon. We can thus learn the previous state of the child, the exact date at which his symp- toms began, and the order in which they ap- peared. "infants should be always stripped for examination, so that the whole body may be exposed to view. Before, however, ordering the removal of the clothes, we should be careful to satisfy ourselves upon certain points which can only be properly observed while the child is in repose. Thus, in order to count the pulse and respiration, perfect quiet is ind spensable, for the least movement quickens the heart’s action, and alters the rapidity of the breathing. At the same time the temperature can be taken by the thermometer in the rectum. The whole body should then be examined for spots or swell ings ; the condition of the skin can be noted — whether dry or moist; and we can ascertain the state of the belly, with regard to hardness or softness of the abdominal walls, and the size of the liver and spleen. If the child cry at the time, we mark the character of the voice, for hoarseness is an early sign of congenital syphilis. In the physical examination of the chest in a child, it is important to attend to tho following points : — To employ percussion of the two sides at the same period of the respiratory movement, that is, during expiration or during inspiration ; to strike gently with two fingers, for by this means a larger volume of sound is brought out, and slight dulness is more easily detected ; alwave to use a stethoscope instead of the unassisted ear, in order to limit the area listened to ; and to manage so that the child’s mouth be open during auscultation, so as to hinder the transmission t* sounds from the throat. In an infant the back is best examined by placing the child on the nurse's left shoulder, with his left arm round her neck. If the chin be now depressed by the nurse’s hand on the child’s head, the muscles of both shoulders are relaxed. The front and sides of the chest can be examined as the infant lies on his back. AVe must rememberthat the breath- sounds, especially that of inspiration, are of a more blowing quality in the child than they are in the adult; and that there is naturally less resonanco at the right base, on account of the proportionately greater size of the liver. At the end of the examination the mouth should be looked at for signs of aphthte or thrush ; and the condition of the gums, as to heat and swelling, should be ascertained. Lastly, the throat is to be inspected — depressing the tongue with the handle of a spoon. If there be disorder of the digestive apparatus, such as sickness, constipation, or diarrhoea, it must not be for- gotten to examine always and carefully the dis- charges. The urine should not be overlooked. Diagxosis. — Diagnosis in the young child is sometimes very difficult, but it is often easy enough. Being aware of the nervous excita- bility in young subjects, we are prepared for evidences of general disturbance, and look for more special symptoms — such as will indicate local distress, and direct our attention to a par- ticular organ. AYo are also guided by a history of the attack, as gathered from the mother, and can put our suspicions to the test by a careful exploration of the whole body. In the investi- gation our general knowledge of the course of disease will be of service. Thus, many disorders have known pathological consequences, and are apt to be followed by special sequelae. Measles and hooping-cough leave behind them a tendency to catarrhal pneumonia, and a liability to tuber- culosis. Scarlatina often leads to acute desqua mative nephritis and dropsy. Other diseases again encourage particular susceptibilities — as rickets, which renders the body exceptionably sensitive to changes of temperature, and provokes catarrhal derangements. In doubtful cases wo must not forget to take prevailing epidem es into account, as the beginning of zymotic diseases in often excessively puzzling. In all cases, especially INFANTS, DISEASES OF. if the patient be an infant, it is important, to inquire into the hygienic and dietetic arrange- ments to which the child is subjected. When we are still undecided, after having exhausted all means of investigation, we must be contented to wait for further indications, and no positive opinion should be hazarded while any doubt remains. Treatment. — Children, as a rule, respond well to treatment. This may be explained partly by the large proportion of mere functional derangements in the illnesses to which they are subject, and partly by the state of constant change through which the body is passing ; growth and development are active in organs, and the tendency is to repair. The term treat- ment, however, includes far more than the mere giving of physic. A complete change in all the influences acting upon the patient — a recon- struction of the dietary', and a reformation in the hygienic arrangements, especially' with regard to air, light, and clothing — will often prove of immense service, and be of far more value than actual drug-giving in furthering the recovery' of the child. In the treatment of acute illness we must remember that young children cannot bear lowering measures ; but we must not therefore rush to the opposite extreme, for unless suffer- ing from temporary exhaustion, they are far from being benefited by profuse stimulation. In the beginning of acute inflammatory diseases stimulants are injurious. Even in chronic ail- ments, such as rickets, where a certain amount of alcohol is often of service, wine should be given with caution, and its effects upon the digestion carefully watched ; it can only be given with advantage so long as it im- proves the appetite, and increases the digestive power. With regard to medicines little need be said in this place. It may be remarked that, on account of the tendency to acid dyspepsia in all children, alkalies are of especial service ; and that they should be always combined with an aromatic, on account of the value of the latter in stimulating the alimentary mucous membrane, and relieving the flatulence and other painful consequences of indigestion. It is important also to remember that children are wonder- fully tolerant of certain drugs, while they bear others very badly. Belladonna may be given to infants and children in very large doses. They are also more tolerant of arsenic than their elders. To the action of opium, however, they are excessively susceptible, and the drug should be given — to infants especially' — with extreme caution. Eustace Smith. INFARCT ( infarcio , I cram in).- — This term was formerly applied to any kind of infiltration of an organ ; but its use is now almost confined to the expression hemorrhagic infarct. A haemorrhagic infarct is a firm, red, usually wedge-shaped patch, which is found in certain organs as the effect of arterial embolism, or, nore immediately', of the congestion and ex- ravasation of blood to which the embolism gives ise. See Embolism. INFILTRATION. 697 INFECTION j INFECTIOUS l (inficio, I stain).— There INFECTIVE j is much ambiguity and want of precision in the application of these terms, and it is only intended here to attempt to define them according to their several uses, the reader being referred for fuller illustration to the appropriate articles. Usually, they are coupled with diseases which are known to be capable of transmission from eno animal to another of a different class, or from one individual to another of the same species. In general language such diseases are said to be infectious, and to be conveyed by' infection. These words are, however, often employed in a more definite and limited sense, as signifying the transmission of affections of this kind without the necessity of any direct contact between the individuals, or of any obvious application of the morbific agent to the body, or its immediate introduction into the system, this agent being conveyed through the atmosphere, and taken in mainly by respiration. This limited meaning is employed in contradistinction to contagion and contagious, which then imply direct contact, and to inoculation-, in this sense some affections being regarded as infectious but not contagious, and vice versa. The word infection is sometimes used as synonymous with the contagium or agent by which a communicable disease is conveyed. An important application of the term infective is that in relation to the effects resulting from certain morbid products, which have been made evident during recent years, mainly by the investigations carried on in experimental pathology. Thus it has been found that the introduction of tubercle subcutaneously will lead to the formation of a similar product in different organs of the body'; and the same result may follow mere suppuration under certain conditions, as well as the accumu- lation in the body of caseous material. The morbid products are absorbed, and originate tuberculosis by an infective process. It is even maintained that tuberculosis may be produced in this way by merely introducing tuberculous material into the stomach, as in the form of diseased meat. Again, the inoculation of septic matter has been proved to cause septicaemia and pysemia by a similar process. When certain morbid con- ditions have been established within the system, other parts, more or less distant from the pri- mary seat of mischief, often become involved by infection within the body itself, in consequence of the products being conveyed by the blood- vessels or ly'mphatics to these remote parts, and there undergoing further multiplication and growth. Indeed the whole system may thus become tainted, including the blood and other fluids. Illustrations of this signification of infection are afforded by cancer, syphilis, tuber- culosis, and suppuration, the last-mentioned not only being liable to originate secondary collec- tions of pus, but also being the usual cause of pytemia. See Contagion-. Frederick T. Roberts. INFILTRATION [in, into, and filtro, I filter). — This term was formerly applied to the effusion of a fluid into the interstices of a tissue, especially connective tissue. Now, however, its I 898 INFILTRATION, meaning has been extended to imply the diffu- sion of any solid or fluid morbid product in the midst of tissue-elements, such as is seen in cal- careous, albuminoid, fatty, and tubercular infil- tration. See Degeneration. INFLAMMATION (inflammo, I set on fire). Syxon. : Fr. Inflammation-, Ger. Entziindung. Definition. — Very numerous definitions have been given of inflammation. The most generally received has been that attributed to Celsus, which gives the four marks of inflammation as rubor, tumor, calor, dolor-, but this appears to have been really due to Erasistratus, who, according to Galen, first gave precision to the conception of simple burning, as understood by the older Greek physicians, and applied the name cpXeyixovri ^previously synonymous with y internal (general) methods even of directly ac- cessible inflammations, is much less satisfactory than the local. The first indication is to give the part actual rest, mechanical or physiological ; the next, to consider if there is any way of reducing the inten- sity, either of the local reaction, or of the fever. Of such means the chief are general blood-letting: the general application of cold; and certain drugs called vascular depressants, such as mercurials, antimonials, purgatives, digitalis, aconite, qui- nine, and a number more. Of general blood-letting we cannot say much here. There can be little doubt that it often lowers the energy 7 of inflammatory processes in an early stage. If it has gone out of use, it is probably because the course of many diseases is now better known, and we do not expect to cut them short ; because the list of infective dis- eases is enlarged ; and because the benefits are supposed to be outweighed by the supposed draw- backs in diminishing the strength of the patient. Of cold baths we need only here say that they are far more potent in checking the condition of fever, than in stopping local inflammation. Of drugs. digitalis is supposed to act by depressing the heart’s action ; but in theory this is doubtful, and in practice we see little effect on organic inflam- INFLAMMATION. mations. Aconite also has little local effect, but does modify the febrile state. Quinine is thought, on theoretical and experimental grounds, to check the emigration of leucocytes, and to kill organ- ised bodies or germs resembling bacteria. The first belief is experimentally true if the drug is in a certain degree of concentration; but we have no safe meaus of introducing it, in this degree of concentration, into the blood. Alcohol even has been recommended as an antiphlogistic, on the ground that it lowers the temperature in health. But even this is not constant, and there is no good reason for thinking that it has this effect in fevers, still less that it checks the inflamma- tory process. If alcohol be given, it must be on other grounds. Salicylic acid, carbolic acid, and thymol are lauded as destroying fever-germs ; but, as -with quinine, we cannot get them into the blood in sufficient concentration, and if we could, it is probable that other more serious disturb- ances would be produced. The conclusion must be that there is no one drug which is capable of controlling local pro- cesses of inflammation, though the resulting con- dition of fever may be modified. The use of mercurials andantimonials seems to have been affected by the same considerations as blood-letting. Tlie action formerly attributed to them is now doubted, and it is further thought they do harm in other ways. But no adequate explanation has been given of the difference in this respect between the practice of this and the last generation. Purgatives remain as a harmless, unquestionable, but not very potent antiphlogistic method. In the general treatment of chronic inflamma- tions we have more satisfactory principles. It is in cachectic persons, or persons with an in- nerited proclivity (perhaps not yet manifest) to cachectic diseases, that inflammations most tend to become chronic. Hence, the first rule is to improve the nutrition. Many patients with chronic inflammations get well at once when placed in good quarters, and on good food. Next in importance come nutrient tonics, of which cod- liver oil is the chief. There are few chronic in- flammations in which it does not do good. Iron is very often valuable ; and, if it fail or is con- tra-indicated, arsenic may be employed. In chronic inflammations of fibrous tissues, iodide of potassium has a real value, not easily ex- plained. In treating other inflammations, either acute or chronic, there are many specific remedies, but these are remedies for the disease, not for its inflammatory features only. For this reason, we do not here speak of mercury, colehicum, salicylate of soda, and other agents. Finally a most important means of treating indirectly accessible inflammations must be men- tioned, namely that by counter-irritants, or setting up a rival inflammation. In order to relieve an inflammation, for instance, of the knee-joint, we produce a superficial inflammation cf the skin. This is most used in chronic, but applies to some 'cute inflammations also. Various explanations lave been given of the undoubted efficacy of this reatment. Some believe the action is trans- nitted through the nerves ; others that blood is Irawn away ; others that the lymphatics are timulated. The writer’s belief is that in the most 45 INFLUENZA. 706 marked cases of benefit from counter-irritation, there is a continuity of tissue between the in- flamed organ and the part where the counter-ir- ritant is applied, and that the action may some- times consist in drawing away blood; but gene- rally this is not possible, and the benefit results from setting up currents of plasma through the lymphatics and the connective-tissue spaces. It should be noted that in some inflammations, where oedema is a marked feature, simple puncture has an unquestionable efficacy which may perhaps be explained in the same way. The substances used for counter-irritation are either vesicants, such as cantharides or ammonia; or rubefacients, as mustard and iodino. Dry heat at different tem- peratures mayproduce the effect of either of these classes. When redness is produced on the skin, it does not follow that hypersemia alone result-. In fact the desquamation often shows that a low form of inflammation has been established. We have here endeavoured to give the principles onlv of the treatment of inflammation. For the treat- ment of inflammations of special parts, the ar- ticles on these subjects, as well as the article? on Blood, Abstraction of ; Counter-irritation ; and Heat, Therapeutics of, must be consulted. J. F. Payne. INFLATION ( inflo , I blow into). — A term applied, therapeutically, to the method of blowing air or gas into any hollow space. It is employed particularly in connection with the lungs in the process of artificial respiration {sec Artificial Respiration). It is also used for the purpose of dilating the bowel in cases of obstruction {see Intestinal Obstruction). The term inflation was formerly used, pathologically, as a synonym for emphysema of the lungs, but is now moro strictly limited to the condition in which the alveoli are temporarily distended with air, from any obstruction in the air-passages. See Lungs, Emphysema of. INFLUENZA. — Synon. : Epidemic Catarrh ; F’r. Grippe ; Ger. Influenza ; Epidemischer Scknupfenfieber. The term Influenza is said to have been first introduced in 1711, when the disease was pre- vailing in the North of Italy, and it has been generally adopted in this country ; though the more scientific term — Epidemic Catarrhal Fever — is often used in systematic works. Df.finition. — This disease is not to be re- garded as simply an unusually prevalent common catarrh, but must be considered as a specific affection, which appears occasionally over wide districts, and at or about the same time ; is characterised by marked febrile symptoms ; is often attended by serious complications ; and causes great and prolonged prostration of strength. Occurrence. — Various epidemics of influenza are on record from the middle ages down to more recent times, and those which have oc- curred in the last and present centuries have been fully described. The disease is reported to have prevailed in 1729, 1732-33, 1737, 1742 1758, 1762, 1767, 1775, and 1782, and iu 1803, 1833, 1837, and 1847. The following account is chiefly founded upon the disease as it prevailed INFLUENZA. roe in 1847, but the description given of its pecu- liarities corresponds with the accounts of previous epidemics. The disease may be described as assuming three distinct forms: — 1st. That in which it is simple, or unattended with any serious complication. 2nd. When it is complicated by serious affec- tion of the aiirial mucous membrane, and espe- cially with bronchitis and pneumonia ; and 3rd. When the disorder of the digestive organs , which generally exists to some degree in the disease, becomes a more prominent character • while there are marked rheumatic symptoms, and a tendency to assume a remittent form. The description would also be imperfect without reference being made to the modifying influence which the epidemic exerts over other diseases prevailing at the same time, and especially over the specific fevers. 1. Simple Catarrhal Fewer. — Symptoms. — In this form of the disease the attack is most com- monly sudden. The patient experiences a sense of cold down the back and between the shoulders, lapsing into general chilliness or complete rigors, and succeeded by flushes of heat and dryness of the skin, pain in the head, chest, and extremities, find prostration of strength. Generally these symptoms follow some exposure to cold and damp, but occasionally they appear without being traceable to any immediately exciting cause, and more rarely the attack comps on gradually, with a general feeling of indisposition of two or three days’ duration. At first there is dryness of the nostrils and soreness of the throat, wfith a sense of tightness or constriction of the chest, and a dry, hard cough. As the disease advances, copious de- fluxioc from the nostrils takes place; the throat is often seriously affected ; and the cough is more frequent. The expectoration is at first scanty, and consists of a pale glairy fluid ; but at a later period there is more copious discharge of opaque mucus. At the same time some degree of diffi- culty of breathing and soreness at the chest are experienced. The respiration is in most in- stances accelerated ; and, on auscultation, the inspiratory sounds are dry and harsh, especially in the posterior and inferior parts of the chest, and sibilant and sonorous rhonchi may be audible on forced inspiration. In some cases no marked sounds are heard, but the vesicular murmur is very indistinct. A sense of chilli- ness. alternating with flushes of hea.t, is a general symptom throughout the progress of the attack ; and there is distressing headache, particularly in the forehead, across one or both eyebrows, as well as pain in the balls of the eyes. These symp- toms often undergo considerable remission during the day, and become much increased in severity towards night. There is also commonly much mental depression, listlessness, inability for in- tellectual exertion, and nocturnal restlessness. The tongue is usually moist, and covered with a white creamy fur; but occasionally it is mor- bidly red at the tip and edges, and thickly coated with a whity-brown fur towards the centre and root ; more rarely, and especially in the morning, it is dry. In the greater number of cases, entire loss of appetite, with some nausea, and a confined state of the bowels, are present from the com- mencement; but occasionally diarrhoea is observed at an early period, and not unfrequently it comes on during the progress of the disease. Sense of weight, tenderness, and pain in the right hypo- chondrium are frequently experienced; and there is often some icteroid tinging of the conjunctiva or of the general complexion. The urine ij scanty and high-coloured at first, but subse- quently becomes more free, and deposits some sediment. Prostration of strength is throughout one of the most marked and distressing features of ike complaint, and there is a general feeling cl soreness, with dull aching pains in the chest, back, and limbs. The pulse is but little varied in frequency, generally ranging from eighty to ninety, and rarely exceeding a hundrel beats in the minute. Though occasionally full, it is uni- formly very compressible, and, after the first day or two, feeble. The skin is seldom hot or very dry, or, if so, it is only at the commence- ment of the attack, and it soon becomes cool and moist ; the complaint usually subsides with free perspiration. The ordinary duration of the indisposition in this form of the epidemic may be stated at from three to five days in the milder cases, tind from seven to ten in those of a more severe description. The disease, however, on its sub- sidence usually leaves the patient for some time much prostrated, and suffering from loss of appe- tite, inaptitude for bodily or mental exertion, and a troublesome cough. There is a great tendency to relapse. Not unfrequently towards the termination of the attack the transient pains, which are trouble- some during its course, increase in severity, and rheumatic affections of an obstinate and painful character supervene. These often assume a re- mittent or intermittent form, returning regularly at the same hour for several days in succession, and not unfrequently affecting one side of the head, or one eyebrow or eyeball, and occasionally the intercostal muscles of one side of the chest. 2. Epidemic Catarrhal Fever with pre- dominant Pulmonary Affection. — Symptoms. It has already been noticed that some amount of soreness of the throat, and uneasiness or pain in the chest, with cough and expectoration and slight bronchitic signs, are observed in the cases of the epidemic which might be considered as assuming the simple form. Not unfrequently. however, the symptoms of affection of the aerial mucous membrane are more marked, there being decided quinsy, laryngeal symptoms, croup, bronchitis, or pneumonia. Of these, however, the most frequent and important are the bron- chitic and pneumonic complications. The bronchitis has especially the tendency to assume the acute capillary form. In cases of acute capillary bronchitis occurring as a compli- cation of influenza, there is usually in the early stage increased frequency and some difficulty ot breathing, constriction of the chest, and sore- ness or stiffness of the throat. The cough, though slight, is troublesome from its frequency. The expectoration, if there be any, is scanty and of a glairv character. The tongue is usually red at the tip and edges, and covered at the Jersnn INFLUENZA. with a creamy mucus or with a whity-brown fur ; occasionally it is morbidly red throughout. The pulse is accelerated, heating generally 110 to 112 or 1 1 G in the minute, and occasionally more. The skin is not usually hot, except it be at the commencement of the attack, and if so it usually becomes cooler in two or three days. With these symptoms there are the marked prostration of strength, the severe frontal headache, the general soreness of the body, and the pain in the back and limbs, which characterise the ordinary cases .f influenza. When the chest is examined in this stage if the disease, the only morbid signs detected are a roughness of the inspiratory sound, par- ticularly when a forced inspiration is drawn ; some slight crepitation, audible more especially towards the lower part of each dorsal region; feebleness of the vesicular murmur; and per- haps slight sibilant rhonehus in front. The respiration is, however, quicker and shorter than natural, averaging 28, 32, or 40 in the minute ; the dvspnoea is greater than is explained by the obvious physical signs ; and most generally there is some lividity of the face. In the second stage all these symptoms are much aggravated. The respiratory acts are per- formed quickly and imperfectly, the respirations in the minute varying from 30 to 40 or 50. The cheeks are much flushed, and the lips of a somewhat purple colour. Generally there is not acute pain in the chest, but rather a sense of constriction and soreness ; the cough, though frequent and occurring in paroxysms, is not usually severe. The expectoration still con- tinues scanty, and consists of small yellowish- white pellets, forming tenacious masses of a peculiar nodulated orbotryoidal form, very much resembling, when floating in water, fragments of •some of the large oolitic limestones. The tongue is mostly covered with a thick whity-brown fur, i and somewhat dry and often red at the tip and i edges ; or morbidly red and glazed. The pulse is much accelerated, beating 120, 130, or 140 times in the minute, but it is generally small and very compressible. In some instances, after being low and feeble at the outset of the disease, it acquires a more sthenic character in the second stage. The skin is rarely dry, or much above the natural temperature ; and the hands and feet are generally cool. The skin of the extremities is also much congested, so that when blanched by pressure, the colour does not readily return. The prostration of strength also be- comes greater ; and there is much headache, and often transient delirium, especially during the night. On percussion, the chest does not present any marked alteration of resonance, unless there exists some other disease of the lung; and on lauscultation, crepitation of a more or less fine character is audible with the inspiration, first in the inferior part of one or both dorsal regions, then spreading rapidly higher up in the back and toward the bases of the lungs in front, whilst ubilant rhonehus is heard in other parts of -the ■hest. The third stage of the disease is marked by he dyspnoea becoming so severe that the patients re compelled to sit constantly upright inhed.or to jean forwards, resting on their arms and elbows ; 707 whilst at intervals the respiration becomes very laborious. The lividity of the cheeks, lips, and hands is increased; the eyes become prominent ; and the expression of countenance is extremely anxious. The cough is frequent, and of a short abortive character, giving the impression of viscid secretion in the lung, which the patient has not power to expectorate ; whilst it is aggra- vated by paroxysms, which cause pain in the head, and increased lividity. The sputum now becomes large in quantity; it is of a greenish- yellow colour, very viscid, contains little air, and is occasionally streaked with blood. The re- spirations are very frequent, 50 to 60, or even more ; and expiration is very laboured and pro- longed. The pulse is very feeble, and either extremely quick — 140, 150, or 160 in the minute — or intermittent, so as to number only 100 or 1 20 beats. The tongue is covered with a thick yellowish-white or brown fur, and is generally dry ; sordes also form upon the teeth. Tho general surface of the body becomes cool and bathed in perspiration ; and the hands and feet decidedly cold. The delirium is more constant ; with the decaying strength the cough declines; the expectoration ceases or becomes slight; and the patient sinks. With the progress of the disease the physical signs change. The chest in front yields a uni- formly clear sound on permission, while behind there is a general impairment of the resonance. The crepitation gradually extends over larger portions of the lungs, being of a finer character in the parts more recently involved ; giving place to subcrepitant and mucous rhonehi in the situation in which it was first heard; and finally becoming of a gurgling character in the neigh- bourhood of the larger bronchial tubes. The subcrepitant rhonehus also towards the end ot the attack is heard with the expiration as well as with the inspiration; and if there is some local condensation, bronchial respiration may be developed. Tn the cases which terminate favourably, the amendment is marked by the respiration becom- ing less hurried and laborious ; by the expression of countenance being less anxious, and the face less livid; and by the prostration of strength de- creasing. The pulse becomes less frequent, the cough less severe, and the sputum less viscid - — more of a muco-purulent character with a ten- dency to form a homogeneous mass, containing large air-bells. At a later period it becomes thinner, and declines in amount. The mucous and subcrepitant rhonehi are replaced by finer sounds, and the space over which the morbid signs are heard diminishes— these disappearing first in the upper part of the chest, then at the front and sides, and lastly in the dorsal regions. The clearness of the sound on percussion on the front of the chest also passes away, and is often succeeded by a somewhat dull sound ; and tho respirator)’ sounds become indistinct. The con- valescence is, however, generally protracted ; the patient is liable to returns of dyspnoea at intervals; and the cough continues troublesome. After the subsidence of the pulmonary symptoms, the rheumatic pains, if previously present, may become aggravated, or may then first appear and become troublesome, affecting the head, face, or INFLUENZA. 708 intercostal muscles, and being aggravated to- wards night. Anatomical Characters. — On examination after death, one of the peculiar features of this form of disease is the extremely inflated con- dition of the lungs, which in lieu of collapsing when the chest is laid open, in some cases protrude from the cavity. This condition is not limited to certain parts in which there are larger or smaller bullse, but consists in a gene- ral inflation of large portions of the lung. The mucous membrane of the bronchi is reddened, and the injection increases towards the smaller tubes, where the membrane may be intensely red and have a villous appearance. The lung- tissue in the cases proving fatal at an early period has a peculiar dry appearance, but in the later stages it is oedematous. There is also more or less lobular condensation, the condensed parts being depressed below the adjacent inflated tissue, and having a deep purple colour. At a later period the condensed tissue may soften from the presence of pus, and small cavities may be formed in this manner. The bronchial glands are enlarged and softened. The cavities of the heart, especially on the right side, are distended with firm and more or less decolorised coagula. Prognosis and DURATION. — The cases of in- fluenza complicated by acute capillary bronchi- tis are always very serious in their character; and when the disease occurs in persons who have before been out of health, and especially if there be any previous disease of the lungs or heart, or if the subjects be very young or elderly, they prove fatal in a large proportion of cases. The duration of the disease in the cases which prove fatal is from about ten to fourteon days ; and when recovery occurs, the patient is ill from a fortnight to three weeks, or longer. Pneumonia . — In the cases of pneumonia which were seen during the prevalence of the last epidemic of influenza, the disease was very generally combined with bronchitis, either af- fecting the larger or smaller tubes, yet the cases were less serious than those in which the disease assumed the form of acute capillary bronchitis alone. This is the more remarkable as they were more frequently combined with serious disorder of the abdominal organs, and with rheumatic symptoms, and were attended with great prostration of strength. Of the symptoms in these cases, cough is one of the most trouble- some ; the expectoration is peculiar, partaking both of the glassy, transparent, or opaque charac- ter of the sputum of bronchitis, and of the brownish viscid expectoration of pneumonia, with the usual small air-bells. In some cases, how- ever, when there is great prostration, there may be no expectoration. Pain in the chest is gene- rally experienced at the invasion of the disease, of a more or less severe character, but after- wards it is not present to any marked extent, or is only experienced when the patient has a severe paroxysm of coughing. The dyspnoea also is not severe, and there is not much lividity of the face, unless in cases in which there is also considerable bronchitis. The breathing is not usually very rapid, the respirations not ex- ceeding 28 or 32 in the minute. The pulse also is comparatively quiet, -beating 80, 90, or 100, and it is usually soft and compressible, or de- cidedly small and weak. The skin, as in the other forms of influenza, is not generally hot or dry ; or, if so at the commencement of the attack, it soon becomes cool and moist. The tongue has usually the whitv-brown covering which has before been described, and is not dry: but sometimes it does become dry and brown. There is often very marked disorder of the diges- tive organs — sickness and vomiting and diarrhea; and usually some slight jaundiced tinge of the skin is observed. There is also not unfrequently some delirium and stupor of mind ; and the pros- tration of strength is often extreme. On ex- amining the chest, in addition to the signs of bronchitis, which are always present to a greater or less degree, there are the usual indications of pneumonia. At first fine crepitation is perceived in the seat of the disease ; to this moro or less marked dulness on percussion, bronchial respi- ration, and increased resonance of the voice and cough succeed ; and these signs, though gene- rally found in one or both dorsal regions, may be more widely diffused. Notwithstanding, how- ever, the threatening character of the symptoms, it was observed in the epidemic of 1847 that the disease was not very fatal, and the signs of consolidation disappeared more readily than in most ordinary cases of pneumonia. The reso- lution was shown by the return of crepitation, though of a coarser character, in the seat of consolidation; and by the gradual diminution of the bronchial respiration, and of the dulness on percussion. After a time the natural vesicular breathing again became audible. The duration of the disease was very similar to that in the cases of acute capillary bronchitis. In this, as ia the other forms of influenza, the convalescence was often very protracted; there was the same tendency to recurrence of the symptoms on any slight exciting cause ; and the rheumatic pains often long continued to distress the patient. 3. Catarrhal Fever, complicated with gastro- intestinal affections and rheumatism, and of a remittent character. It has already been stated that in the last epidemic of influenza, there were very generally present more or less marked symptoms of gastro- intestinal and hepatic disorder; and that rheu- matic pains, having a more or less decidedly remittent character, were very usually observed. It has further been said that in the cases in which the pulmonary complication assumed the pneumonic form, these symptoms were generally more marked than in the cases of acute capillary bronchitis. In some cases, however, the latter symptoms were, throughout, the predominant feature ; and as similar observations have been made as to former epidemics, cases of this kind may fairly be regarded as constituting a special form of the disease. In this form of the epidemic, nausea and sick- ness generally occurred at an early period of the attack, and often became very urgent symptoms. The matters vomited often had a bilious tinge ; and there was generally a marked bilious tinge of the conjunctive and general surface of the body, amounting in some cases to decided jauc INFLUENZA. dice. There was often diarrhoea ; and sometimes blend was passed in the stools. The pains in the head, back, loins, aud extremities, which are present with more or less severity in all forms of influenza, wero from the first of a severe charac- ter, or increased with the progress of the disease till they constituted a predominant feature. The pain was usually most distressing in the head, especially in the forehead, and in some cases was limited to one temple, one eyebrow, or one eye- ball. This was generally of an intermittent or re- mittent character, coming on at night after more or less distinct remission during the day ; and was attended with singing in the ears, distress- ing restlessness, agitation, and inability to sleep, whilst delirium generally increased during the exacerbation. In some cases it only amounted to a little excitement and incoherence, but in ethers it was so urgent as to require the employ- ment of restraint to retain the patient in bed, and sometimes it continued without intermission for some hours. It was, however, remarkable how completely it subsided, as a rule, in the morniDg. With these symptoms there was usually much tremor of the extremities ; and the eye was pale and glassy, though the pupil was frequently contracted. Early in the attack the pulse was quick and feeble, and of a peculiarly' vibratory character, though sometimes it was but little accelerated. At a later period it often became very rapid and feeble, or fell below the natural standard cf frequency, being very soft and compressible, and occasionally intermittent. The tongue was at first moist, covered with the usual wkltv-brown fur, and red at the tip ; subse- quently it hid a tendency to become dry. The breath had a peculiar, offensive, acid odour. Epistaxis occasionally occurred, and sometimes to an alarming amount. The skin was generally moist; and the perspiration had tho usual sour , rheumatic smell. The urine was at first scanty, but afterwards increased in quantity, and de- posited much sediment of urates. Occasionally' it was slightly albuminous. With these symptoms there were evidences of some pulmonary disorder — bronchitis or pneu- monia ; and very frequently murmurs were heard at the heart, which were not, however, generally persistent. After the exacerbations the sweating was often very profuse, so that in the morning the patient was found completely bathed in it, and the bedclothes were quite wet. The prostration of strength also was often extreme, so that the hands and feet became livid and cold, and the patient resembled a person in the algide stage of rholera. Notwithstanding their severity, the cases of 'his third form of influenza generally did well, hough the patients long sufferod from the rheu- matic symptoms, and only very slowly recovered heir strength. As seen from the Kegistrar- leneral's reports, there was a great increase in he deaths from ‘ rheumatism’ during the pre- alenco of the epidemic, which probably referred o cases of this kind. I. Modifying Influence of the Presence fi Influenza on other Diseases. — In allvisit- tions of influenza of which we have detailed 709 accounts, the epidemic has been attended by an unusual prevalence of other forms of disease, and especially of the specific fevers — and the features of such diseases have been much modified by the epidemic influenza. To this rule the influenza of 1817 affords no exception. As shown by the re- ports of the deaths in London and the country generally, there was a great increase in the total mortality; this especially showed itself in tho zymotic class of diseases, but obtained also as to diseases of the heart, brain, and digestive organs. An unusual number of deaths were re- corded from ‘ typhus,’ under which head were then included the fevers which we now discrimi- nate into typhus, typhoid, and relapsing fever. Of all these forms of disease, cases occurred during tho time, though the chief prevalence was apparently of typhoid and relapsing fever. Tho features of these diseases were generally so much modified by the epidemic influence, and they were so constantly attended by pulmonary complications, that it was often difficult to de- cide whether any given case was to he regarded as a case of specific fever or of influenza. Various forms of local disease were also preva- lent at the time, both as distinct affections, and as complications of specific fever, such as diph- theria, parotitis, otitis, stomatitis, and quinsy, with erysipelas, abscesses, &e. ; and these were often attended by great prostration of strength, and added greatly to the danger of the various other forms of disease with which they were combined. Pathology. — Every phenomenon of influenza points conclusively to the influence of some powerful depressing agent, operating on the nervous system, or entering the blood. The sudden seizure of a large proportion of cases ; the extreme prostration of strength from the commencement, and to a degree disproportionod to the amount of local disturbance ; the symptoms of disorder of all organs, and especially of the cerebro-spinal system ; and the debility which so often succeeds even simple cases of the disease, can on no other supposition be explained. It seems probable also that the affection of the respiratory mucous membrane may be due to the morbific influence, whatever it may be, ope- rating more specifically upon it ; but it is ex- tremely difficult to offer even a probable sugges- tion as to the naturo of that influence. The almost simultaneous outbreak of the epidemic in places widely apart ; the seizure of a large proportion of the population of a town or district within the course of a few hours ; and the sudden illness of in- dividuals or bodies of men visiting a locality where influenza is, or has very recently been, prevailing, and previous to direct intercourse with any per- sons actually suffering — are all circumstances op- posed to the notion of the disease being dependent on infection in the ordinarily understood sense; and might seem to point to the operation of atmospheric influence as the cause. The con- ditions, however, under which the disease has presented itself in different epidemics, render such an explanation impossible. It has travelled over districts without reference to season or climate, and has prevailed in the same locality in all seasons and in almost every variety of weather. It is true that it has often broken out ?10 INFLUENZA, after great meteorological changes, as in the last two epidemics after sudden and remarkable falls from a comparatively high to a very low temperature; but, on the other hand, epidemics have arisen under other circumstances, and such alternations of temperature frequently occur without the occurrence of an epidemic of influ- enza. The disease has also broken out at the same time at different places in which the same atmospheric conditions did not exist, so that the operation of the sudden change can scarcely be regarded as acting even as an exciting cause. There can, however, be no doubt that the more common predisponants to disease, such as de- fective drainage, overcrowding, impure air, de- ficient clothing, and insufficient or unsuitable food, powerfully conduce to the prevalence and fatality of the epidemic. Treatment. — Of the treatment of the simpler forms of influenza it is not necessary to say much. The patient should be confined to bed; have a footbath; take some form of diaphoretic medicine; and be allowed a mild, unstimulating diet. If the cough becomes troublesome, or if there bo pains in the chest, sinapisms may bo applied, and some anodyne may be added to the medicine; and for the relief of the subsequent debility, stimulants, tonics, and a nutritious diet may be enjoined. In the cases complicated with pulmonary affections, the same measures may bo used, in combination with expectorants and anodynes; and more decided counter-irrita- tion maybe applied to the chpst. When there is very copious secretion, and the patient cannot expectorate froely, the greatest benefit is often derived from the use of emetics, and they may be employed with advantage in cases in which the patient’s strength is too much depressed to allow of nauseating doses of medicine being given. To the use of emetics, the stimulating expectorants — squills, ammonia, &c. — should succeed. For the relief of the cases :n which there is nausea and sickness or vomiting, effer- vescents with morphia, or hydrocyanic acid, may be given. W T hen there is more or less jaun- dice, small doses of calomel or grey powder, in combination with Dover’s powder, are very bene- ficial ; and when there is diarrhoea the Dover's powder or decided astringents — such as acetate of lead, or lannic acid — may be employed. When (he rheumatic symptoms are severe, the greatest relief is obtained by the administration of small doses of eolehieum with carbonate of potash and opiates; and when the prostration of strength is great, ammonia, in combination with bark, should be given. In the cases in which there is a decided tendency to remissions and exacer- bations, bark also may be prescribed, or, in the more severe cases, quinine; and quinine and other tonics should be freely given during con- valescence. In all cases of influenza all depressing treat- ment should he avoided. The cases do not require it, and the patients are too much pros- trated to admit of its employment. In all the dif- ferent forms of influenza it is necessary to admin- ister support very freely, and sooner or later to exhibit stimulants. In the cases in which there is pulmonary or othor local complication, the strength becomes more rapidly and more INHALATIONS, THERAPEUTIC USES Of. seriously depressed, and stimulants and support are still more urgently needed ; and indeed it is necessary to have recourse to them at an earlier period, to exhibit them more f-eely, and toper- severe in their use for a longer period in such affections, when occurring during an attack of in- fluenza than when arising as idiopathic diseases. In the management also of the other forms of febrile affections which are seen during an epi- demic of influenza, a more restorative and stimu- lating treatment is required than under ordinaiy circumstances, for all such diseases partake of the peculiarly asthenic type of the epidemic. • Thomas B. Peacock. INHALATION, lEtiology of. — See Dis- ease, Causes of. INHALATIONS, Therapeutic Uses of ( inhalo , I breathe in). — Inhalation is a method of applying remedial agents to the respiratory tract, whereby these substances in a gaseous or atomized form are brought into contact with tbe mucous membrane of the nos?, mouth, pharynx, larynx, and bronchi, and may even penetrate to the epithelium of the air-cells. Inhalation dates from the days of Hippocrates and Galen, and has been more or less in vogue in all ages ; but onlv lately has it been proved that theinhaled material passed through the finest ramifications of the bronchi into the pulmonary alveoli and in some instances became absorbed by the capillaries, thus entering the general circulation. The examina- tion of the lungs of colliers, grinders, and others engaged in dusty occupations has shown that the inhaled dust can be detected in the lung-tissue, where it induces chronic pneumonia. The ex- periments at the Academie de Medeeine proved that medical sprays are equally penetratitg. Methods. — The modes of inhalation vary with the drug used, depending mainly on the tempera- ture at which ic volatilizes, and also on the medicinal effects aimed at. Chloroform, ether, bichloride of methylene, and nitrite of amyl evaporate at ordinary tempera- tures, and only need to be diluted with air to be safely inhaled. Calomel and sulphur are sub- limed at high temperatures in special appara- tuses ; but the majority of drugs are best vapo- rized through the medium of hot water or steam, or reduced to fine spray by passing compressed air through their solutions. Many forms of inhaler are in use, but in select- ing one for warm inhalations the requisites are:— (1) that it can be used without difficulty by the patient; (2) that a temperature of 1 3l) r V' 15IFF. can be steadily maintained ; (3) that the steam bo thoroughly impregnated with the medicament: and (4) that the inhaling tube be fitted to the nostrils as well as to the mouth, so as to ensure a sufficient supply of the inhaled vapour. When no inhaler is at hand, a jug with a wide mouth and half filled with hot water may be used, a towel being placed round between the mouth and nose of the patient and the opening of the jug, to prevent the escape of the vapour into the air. Varieties and Uses. — Inhalations are em- ployed chiefly in diseases of the pharynx, larynx, and air-passages, and may be classed as sedative, stimulant , and antiseptic. Sedative. —Steam is soothing to the throat INHALATIONS, THERAPEUTIC USES OF. when this part is dry, inflamed, or irritable. In incipient laryngitis and croup, as well as in irri- table bronchitis, the inspiration of steam from specially arranged kettles is very grateful, the moist vapour promoting secretion and expecto- ration. Jets of steam are used in hospitals and bath establishments as vehicles for the inhaled drugs, and are directed into the patient's mouth. As sedatives the vapor conii and the vapor acidi hydrocyanici are recommended in cases of laryngeal or pulmonary irritation A sedative inhalation made of equal parts of chloroform and rectified spirit — of which one teaspoonful may be added to a pint of water, at 60° to 100 D F. — is much commended in hay-fever and laryngeal spasm. A combination of chloroform and conium, in the proportion of 15 minims of the former to 1 drachm of the succus conii, in half a pint of boiling water, is useful in phthisis and some forms of asthma. Stimulant. — Stimulating moist inhalations can be prepared with various volatile oils. Oils of pine and of cubebs are useful stimulants in cases where there is much secretion from the throat and air-tubes. Thus 2 drachms of oil of pine or oil of cubebs may bo mixed with 60 grains of light carbonate of magnesia in 3 ounces of water ; and of this mixture 1 drachm may be used in a pint of water at each inhalation. One drachm of the compound tincture of benzoin, in half a pint of hot water, is often useful in chronic bronchitis and laryngitis. Oil of turpentine or of pinus silvestris (1 drachm to the half- pint of hot water) makes excellent stimulant inhalations in cases of dilated bronchi. Antiseptic . — Antiseptic inhalations are used where the object is to correct a feetid secretion, as well as to stimulate the secreting membrane to fresh action. In foetid bronchorrhoea, in gan- grene of the lung, in feetid abscess, and in pyo- pneumothorax, benefit is derived from the vapor creasoti, the vapor iodi, or from glycerine of car- bolic acid (from 2 to 3 drachms to the pint of boiling water), or again from oil of thymol, pre- pared like the other essential oil vapours, with light magnesia and hot water (10 grains to the 3 ounces). The fumes of nitre paper are employed as inhalations in cases of pure spasmodic asthma uncomplicated with bronchitis. The paper — pre- paredly soaking white blotting-paper in solution of nitrate of potash — is sometimes washed over with tincture of benzoin, and this, in certain cases, may be an improvement ; but in ordinary forms of asthma the nitre paper (30 or 40 grains of nitrate of potash to 1 ounce of water to form the solution for soaking the paper) burnt till the patient is enveloped in smoke, will usually relieve the asthmatic paroxysm. The fume of a grain of powdered opium volatilised on hot metal has been praised as a remedy to cut short nasal catarrh ; as well as smoking solid opium in the Chinese fashion through a pipe, in spasmodic asthma. Cigarettes and pastilles containing stra- monium and other antispasmodics, are sometimes i used with benefit. Atomised inhalations of spray havo of late I years come into deserved repute as valuable aids to the treatment of chronic diseases of the throat end lungs. The principle of the hand-ball and INJECTION. 71 1 steam-spray atomisers is, that if two capillary tubes are placed at a certain angle to each other, one dipping into a fluid, while through the other a stream of air is driven by heat or compression, a vacuum is formed in the first, causing the liquid to pass out in the form of fine spray. In using tlieso instruments, the operator should seek to blow the spray into the patient’s throat at the time when an inspiration is being taken, as thus the spray will obtain a free entrance through the larynx into the trachea. It is doubtful if much spray enters the air-tubes ; some certainly does, as has been stated above, but the cold sprays do not appear to afford so much relief to affections of the lungs as the warm inhalations. In cases of tumidity of the larynx, a spray containing 10 grains of alum to 1 ounco of distilled water may be used. In place of alum, 2 grains of sulphate of iron, 5 grains of sulphate of zinc, or 5 grains of dry chloride of iron, in 1 ounce of water, may be employed. For antiseptic purposes, 5 minims of sulphurous acid, or 1 minim of carbolic acid, to 1 ounce of water, or a like quantity of liquor iodi may be used. In putrid sore-throat and diphtheria the writer has seen excellent results from iodine, either inhaled in vapour or applied in solution. Three and a half drachms of lactic acid in 10 ounces of water form a solution which, thrown as spray into the throat, is of use in diphtheria ; it seems to dissolve the exudation. As a styptic and hremostatic spray 50 to 200 grains of tannic acid are em- ployed, dissolved in 10 ounces of water, but for relaxed throat a weaker solution is useful. For sedative purposes a solution of bromide of am- monium, or one containing half a grain of acetate of morphia to 1 ounce of water, may be employed. Diluted ipecacuanha wine spray is said to be very efficacious in relieving the dyspnoea of chronic bronchitis and emphysema. This spray in a few instances may induce vomiting, but this accident may be obviated by diluting the wine with a considerable proportion of water. At the Continental spas it is usual to medicate large chambers by means of sprays and vapours, in which patients can sit for hours breathing the artificial atmospheres; and in this way various mineral waters, such as those of La Bourboule, Aix-les-Bainc, and Cauterets arc locally applied. John C. Thorowgood. IHJECTION ( injicio , I throw in). — Synon. : Fr. Injection; Ger. Einspritzung. Definition. — Injection is the act of introduc- ing a fluid into any part of the body, by means of a syringe or similar apparatus. The word is also employed to designate the fluid so introduced. Varieties. — Injections are chiefly used in the treatment of disease; but reference must also be made to the method as it is practised by anatomists for the preservation of ‘ subjects’ for dissection; and for the purpose of filling the blood-vessels, lymphatics, duets, cavities, spaces, &c., preparatory to microscopical examination. The therapeutical application of injections comprehends the following measures : — 1. Hypodermic or subcutaneous injection, in which the fluid is injected under the skin. See Hypodermic Injection. 2. Injections into the natural canals or open 712 INJECTION. cavities of tho body ; for example, the external ear, the Eustachian tube, the nose, the nasal duct, the stomach, the rectum (see Enema). the urethra, the bladder, and tho vagina and uterus. The various forms of injections just indicated will be found fully discussed under the diseases of the several organs. 3. Injections intosA«i sacs, normal or morbid ; such as the tunica vaginalis, the serous cavities, the synovial cavities, the sheaths of tendons, and jysts and chronic abscesses. Tho fluids used in this class of injections are generally stimulant, such as a solution of iodine. See Hydrocele. 4. Intravenous injections, the fluid introduced into the circulation being either blood (trans- fusion), milk, or some kind of nutritive solution. See Transfusion. J. Mitchell Bruce. INOCULATION ( in . , into, and oculus, a bud, a graft). — As usually understood, inocula- tion is either an operative procedure or an acci- dental occurrence, by means of which morbid materials are brought into direct contact witli the minute vessels of the skin or of a mucous membrane, or with those of the subcutaneous or submucous tissue, so that they are readily and speedily absorbed, the result being that they originate certain definite and specific diseases, varying with tho nature of the mate- rial employed. In short, inoculation, as com- monly practised or observed, is a mode by which the contagia of certain specific diseases are con- veyed from one animal or individual to another; and some of these affections can only be thus transmitted, while others are capable of being communicated in other ways, but in th»j way most effectually and with the greatest degree of certainty. The most familiar examples of dis- eases thus transmitted are vaccinia, small-pox. syphilis, and hydrophobia. It need hardly be mentioned that vaccinia can only be conveyed by inoculation, and it is for the purpose of inducing this disease that the method is ordinarily inten- tionally practised, so that the terms vaccination and inoculation have come to be popularly re- garded as synonymous (sec Vaccination). Under certain exceptional circumstances inoculation of tho contagious matter of syphilis, small-pox, or anthrax is employed, with the deliberate pur- pose of originating these affections ( see Small- pox ; Syphilis ; and Pustule, Malignant). This plan has also been practised of late years in ex- perimental pathology, by which the effects of the inoculation of septic liquids upon the system have been demonstrated; while it has also been shown that the introduction of certain solid morbid products iu this way may orkinate an infective process, leading to definite pathological results. See Contagion. With regard to the modes by which inoculation is effected, it need only he said hero that when it is practised as an operation, the material is usually introduced into the subcutaneous or submucous tissue, by means of a lancet or other pointed instrument. Sometimes the surface of the skin is merely scarified, so that the epi- dermis is more or less destroyed; or this is removed by somo blistering agent, and the con- tagious substance then applied to the exposed antis. Accidental inoculation may take place in INSANITY. connection with any abrasion, wounl, or ulcer on the skin or on a mucous surface ; or by tho bites of animals, as in the case of hydrophobia. Frederick T. Roberts. INSANITY. - Synon.: Fr. Folk ; Gcr. Geisteskrankheit ; Geistesstoruiig. Insanity is popularly known as disorder of mind : as physicians, we know it to be disorder of the highest organs of the nervous system which unite in the performance of that function recognised and spoken of as mind. There can be no disorder of mind without disorder of braiu : as physiologists and pathologists we have to study and treat the latter, and for this reason the legislature enacts that certificates of insanity shall be given by medical men, and by them alone, and that to their care shall be committed those who are insane. As a preparation, then, for the study of insane mind, the learner ought to acquire a knowledge of healthy mind — the healthy function of a healthy brain. Ho must know what are the structures which combine to make up that which we call the cerebrum, and contribute to its healthy work- ing, and must trace the growth and development of this working from the earliest days of infancy to the time of adult life. He will perceive that the growth of mental function is as gradual as that of bodily power; that in some it may be more rapid than in others, like that of the body; that it may be arrested in its development, or stunted and deformed; and that it may by imperfection of the organs, as blindness or deaf- ness, be impeded or stopped. In all particulars it will be found subject to the laws which regu- late the growth of the body generally. Before examining brain-function, it will be necessary to become acquainted with the various structures which form the cerebrum. The brain of man, and indeed of all vertebrates, is made up of nerve-cells and nerve-fibres ; of a substance or stroma in which the cells are imbedded, called neuroglia ; and of blood-vessels and lymphatics. The nerve-cells are gathered into convolutions or centres ; and by means of the nerve-fibres com- municate with the organs of special sense, with the sensory ganglia and spinal cord, with each other, and with the convolutions of the other hemisphere. Modern science is endeavouring to throw light upon tho nature and uses of these convolutions. The seats of the highest intelli- gence, they at the same time appear to he cen- tres of voluntary motion, and of the outward manifestation of intellectual action. Concerning the physiology of the blood-supply of the brain there is still great doubt and con- troversy. Anatomically we know that from the internal carotid and vertebral arteries, combining in the circle of Willis, there pass to the brain-sub- stance the anterior, middle, and posterior cere- bral arteries. The terminations of these ramify in the pia mater, and thence send many small vessels to the grey matter, and fewer, but larger ones to the white, the supply of blood to the former being much the more plentiful. That, however, which chiefly concerns the student of insanity is the vaso-motor system of nerves which controls and regulates the blood-supply. Modern research appears to render it more and INSANITY. more certain that the condition of insanity, at any rate in its early and acute stage, is mainly one of increased blood-supply. On what does this depend ? To this question no precise an- swer can as yet be given. Investigations are still being made as to the nerves which dilate and contract the vessels ; but with regard to this subject, and the so-called inhibition of nervous influence, much more must be ascertained before the pathology of insanity can be definitely fixed. The lymphatics of the brain are also, according to some observers, largely concerned with the disturbance of mental function, if it should hap- pen that by being blocked up or impeded they fail to carry off the waste products of the organ. They are contained in perivascular lymph-spaces, lying between the outer fibrous coat of the blood- vessels and a hyaline membrane or sheath of pia mater which separates them from the brain- Bubstance . 1 Even concerning the neuroglia, controversy exists. Is it merely connective-tissue, or is it nerve-structure ? Authorities lean to the former view, and the increase of it in diseased brains seems to point to a growth of lower structure at the oxpense of higher. Passing to the functions of the brain, the phenomena comprised under this name are of two kinds. There are the various movements excited by the stimulation of the different brain- centres, on which the experiments of Dr. Ferrier have thrown new and interesting light. But these are not the phenomena of mind. The latter can only be studied by observation of a totally different character. For mind implies sensation, feeling, consciousness ; and as we have no consciousness of any feelings but our own, it is evident that here objective observation is insufficient, however unwilling physiologists may be to admit it. Yet the subjective exami- nation of ourselves is as inadequate by itself to explain the phenomena of diseased mind, as ob- jective observation is to make known the nature of mind in general. We must use the subjective method as our key, and by means of it open up and interpret the phenomena of mind : we may then objectively examine the mental characteris- tics, the growth and development, the diseases and decay of mind in all human beings, children or adults, idiots or insane, and by tracing thus the effects of injuries and disease, we arrive at a knowledge of the differences between sound and unsound mind. By observation of the movements brought about by nerve-function, we perceive that they follow the application of a stimulus, and that many actions take place in response to stimuli which we call reflex, instinctive, or automatic, before those begin that are the product of - mind in its highest sense. For mind grows slowly | and gradually. The first movements of the child, reflex or instinctive, are the result of sti- mulation of nerve-centres, but are only slightly, if at all, attended by consciousness. This be- ! comes appreciable later, and with it the com- mencement of memory and ideas, as the feelings roused by stimulation are stored away in the nimd, to be reproduced as some new stimulus is 1 Dr. Batty Tuke. Morisonian Lectures. Edinb. Med. fount., Dec. 1874. 713 presented to them, The various brain-centres are in this manner stored with ideas, the result of experiences derived from without, and by means of the nerve-fibres they are united in groups till a most complex system is evolved. The sensations are developed into more and more complex feelings, till the highest emotions of civilised man are reached ; and in a similar manner the intellectual processes grow from mere perceptions and cognitions to the highest trains of thought. Mind may be said to be made up of feelings and the relations between feelings, for the intellectual element of mind is the rela- tional element, and it will be found that we can- not locate in two parts of the brain the emotions and the intellect, as some physiologists have proposed; for no kind of feeling, sensational or emotional, can be wholly free from the intellec- tual element; and on the other hand ic very rarely happens that any act of cognition can bo absolutely free from emotion . 2 For the growth of healthy brain and mind all the conditions of physical health are necessary. If at birth there is inherited defector accidental injury, or if at any subsequent period develop ment is arrested or perverted, idiocy or imbecility is the result. There will be an imperfect re- cording of the experiences of life, an inability to learn, and a deficient power of bringing into re- lation one with another the various groups of nerve-centres which make up the brain, and are the seat of mind. If, however, growth and development have proceeded normally, and normal mind is the re- sult, what are the conditions of insanity, or dis- order of mind ? What are the conditions of heal- thy and unhealthy brain-function ? I. We know by experiment on nerves and nerve-centres, and by observation of the objec- tive phenomena of motion, that a discharge of nerve-force or nervous fluid — call it what W6 will — is liberated when a centre is stimulated, and that this ramifies according to its quantity in various directions throughout the system. When there is health and vigour the supply will be large, and every channel both in the brain and body will be duly supplied. But in the healthiest nervous system there must in time be a cessation of this discharge, for in time the sup- ply will be exhausted, and repair and replenish- ing must take place. And unless this is done, nerve-function will be impaired or cease. For the repair of the higher nerve-centres sleep is necessary, for only during sleep is the repair of the waste effected, and we commonly, nay, con- stantly find, that mental disturbance is preceded by loss of sleep. In some cases want of sleep may depend on the actual time allowed for it being insufficient. Though not a very common cause of insanity, yet it sometimes is found in persons who aro very hard-worked, or who, by religious exercises and services, deprive themselves of sleep. In tho great majority, however, want of sleep is the result of a pathological condition of the brain, a condition which by appropriate treat- ment the physician seeks to remedy as the first step towards the cure of the insanity. 2 Herbert Spencer, Principles of Psychology, vol. i. pi INSANITY. 714 Not only may there bo a want of repair and replenishing of the nerve-force expended, but there may be also a defective generation and supply of it. Through anaemia or exhaustion from acute diseases or long-continued illness, the nerve-centres fail to generate from the blood the power necessary fur their due operation. The discharge liberated does not ramify throughout the nervous system, calling into action every part of the brain, and penetrating to every por- tion of the muscular structures ; thus the tailing supply is manifested in the gloom of melancholia and the slow and torpid movements which ac- company it; and when it is reduced to a still lower ebb, there may be not enough to carry on oven the semblance of mind ; the patient pre- sents the appearance of utter fatuity seen in de- mentia. , whether primary or secondary, and either sits motionless and lost in the condition termed melancholia cum stupors [Fr. melancolic avec stn- pear ; Ger. Schwcrmuth mit Stumpfsinn] or exe- cutes the purposeless and automatic movements of acute dementia [Fr. Demence aigue\. The defect of nerve-force may bring about in- sanity in more than one way. A sudden strain or shock may make an unwonted demand upon the nervous supply. Incessant thought, especi- ally of a painful kind, may use up the reserve of force : this is not renewed, and insanity is the result, the increased moleeular discharge not being duly compensated by an increased supply from the nutritive sources. Secondly, the sup- ply may fall so far below the standard that it is not sufficient for the ordinary demands of every- day life, and so, without any mental cause, but simply from nerve-inanition, the stage of depres- sion appears. In both of these cases, however, as in all recent, insanity, the brain is in a state of hyperuemia, as evidenced by heat of head, want of sleep, and often pain and congested appearance of face. The hyperemia impedes healthy nutrition and causes sleep to be absent, but it is erroneous to say that the brain irr such patients is in a state of anaemia, even if the general bodily condition deserves that name. II. It may be, however, that there is not so much a defect of nerve-force, as an unstable con- dition of the cerebral centres, which is mani- fested by a rapid and continuous discharge. Such a discharge in a more sudden and violent form we are familiar with in the phenomena of epilepsy. In insanity it may vary from undue hilarity and excitement up to the incessant move- ments and vociferation of acute delirium ; and tike epilepsy it may terminate in exhaustion, coma, and death. The supply of nerve-force in such cases is often abundant. The patient goes without sleep for days and nights, and yet re- covers. The higher brain-centres lose the power of control, owing to the violence of the dis- charge, and the lower and more automatic cen- tres thus liberated are stimulated to overaction, which is manifested in noisy and violent delu- sions, and so on to mere delirious incoherence. And after the discharge has ceased, there may be a period of dementia and complete obliteration cf mind, before the exhausted brain begins to recover. Persons who are in this condition of un- stable nerve- equilibrium may be thrown off their balance by mental causes — by shock, or grief, or losses. Their brain may also be affected by disorder of the other organs of the body sympa- thetically. In all such patients there is a predispo- sition, often inherited, to nervous instability and rapid discharge, and such ‘ causes ’ as puberty, pregnancy, or child-birth bring about an explo sion. Here, too, there is marked cerebral hy- peremia, producing an abnormal nutrition and corresponding abnormal function. III. Disturbance 6v defect of mind may bn caused by incomplete development of any part concerned in mental action, or by the presence of anything within the cranium which interferes with the healthy life of the various organs, There may be tumours of different kinds, or ab- scess. Insanity also follows blows oa the head; and deterioration of brain is frequently caused by the action of alcohol and other poisons. In all these cases we have not a functional disturb- ance which may suddenly arise and as suddenly pass away, but a gradually organized lesion which usually advances, producing serious and permanent results. The degeneration of the organ and tissues through age will also produce corresponding results. Symptoms. — What are the symptoms of in- sanity, and how far do they correspond to the pathology of brain-disturbance as set forth in the above remarks? The first symptom usually noticed in a per- son becoming insane is an alteration in his emotional condition. Either he is more quiet and dull than usual, or, on the contrary, more restless, irritable, excitable, or hilarious. The dulness may vary from a mere disposition to sit still, and neglect his work or amusements, to actual gloom and despondency. The restlessness and excitement may also vary in degree, and be accompanied by gaiety or outbursts of anger and violence. The change may be more or less concealed, according as the patient can or can- not control himself. Those of his own family or people about him may notice it long before others, and this stage will vary in duration, often lasting some time before delusions or other marked symptoms are discoverable. The acts of the patient will correspond to his altered feelings. His relations towards the outer world will be altered. In bis torpor or gloom he will look on everything despondingly ; will be unable to perform his duties, will not care for amusements, will sit at home inactive, or take up morbid fancies about his health. Con- versely, he will act rashly iu matters of busi- ness, embark in foolish speculations, take no heed of time or appointments, spend money recklessly, indulge in debauchery or frivolous pursuits, show causeless anger to those about him, or exhibit silly' and childish hilarity when matters of grave moment are pending. Here we have a slight insanity. The higher brain-centres are but slightly disturbed, and stiil exercise a considerable amount of control oTer the lower and less specialised centres. It may be difficult to say that any one act or feeling is of itself indicative of insanity, but the patient is a changed man, and the term moral insanity is specially applicable to this condition. Such an insanity may remain and l e perma nent : more frequently, however, it either passes INSANITY. off, tho patient recovering, or advances in one or other of the directions already indicated. The gloom will increase ; corresponding delusions will present themselves with appropriate acts and conduct; and the patient will drift into melancholia. Or he will become more and more hilarious, angry, excited, or suspicious, and a state will arise to which for want of a better' wo give the name of mania. Though delusions are not usually found in the stage of alteration, they are seldom absent in the second and more advanced period, and generally correspond to the feeling of the sufferer, so much so that the appearance and humour frequently enable us, without previous information, to arrive at the de- lusions under which he is labouring. This stage is often called intellectual insanity , or insanity with delusions. Patients labouring under one or other of these forms vary in the degree of insanity, from a condition in which they are able to talk coherently on many topics to one of complete incoherence or delirium. To the former the name of partial insanity is often applied. Another condition is ths.t of fatuity or child- ishness in various degrees. It may come on rapidly, the patient passing at once into this state, which is then called acute or primary dementia-, or it may be the result of years of insanity or brain-disease, and is termed chronic or secondary dementia. In such people we find loss of memory, inability to revive the relations of feelings and ideas — not emotional disturbance, but rather an absence of all emotion. As regards the bodily symptoms, almost every variety of insanity is ushered in by sleeplessness, sleep being deficient or altogether absent, per- haps for days, according to the acuteness of the attack. This indicates a disturbance of the brain- circulation, which is also shown by heat and pain of head, injection of the eonjunctivse, and throb- bing of the carotids. There may be excessive vascular action even when the insanity is the reverse of what is sometimes termed sthenic,’ and the general condition of the patient is one of anaemia rather than hyperemia. It has been said that the mental symptoms of insanity are accidental, that they do not indicate the pathological conditions, but depend on the state of the body, and that no classification of the forms of the disorder ought to be based on them. But it is perfectly certain that the brain of a man suffering from melancholia differs alto- gether from that of one in acute mania. In the former there is a scanty generation of nerve- force, which is insufficient to reach the remote channels and plexuses of the brain. There is not a general incoherence and confusion of ideas, and the patient can converse rationally on many topics. His feelings are those of pain and not of pleasure, because pains in general are more in- tense than pleasures in general , 1 and the former are evoked into consciousness by the feeble nerve-currents, while the latter are not. In what is termed mania we may have every shade of feeling displayed, from gloomy and suspicious irascibility to great hilarity. Heelings of anger and resentment are called up without the con- trolling power of reflection and judgment, such 1 See Herbert Spencer, Principles of Psychology, vol. L p. 602 . 715 as would prevail were the whole brain at work, and tho higher faculties and feelings co-opera- ting and in relation with the lower. This, again, may be due to a want of nerve-force, or more frequently to an undue expenditure of it, as may be seen in the irritability of an over-tired child. What we may call the more automatic and less complex feelings of fear and self-love are evoked, while there is not force aud pressure enough to supply the rarer and more remote qualities of comparison and reasoning which require the combination and union of the highest portions of the brain. If there is an increased and accelerated blood-tlow, great hilarity and self- satisfaction may be the result, yet with perfect incoherence of ideas, owing to all the rela- tions of the brain-plexuses being interrupted by the tumultuous or impeded circulation, and the excessive nervous discharge. And in dementia the very opposite may be witnessed. The supply of force is reduced so low that, there is an ab- sence of all ideas ; memory, at any rate of re- cent events, is lost, and only the well-marked occurrences of earlier life are recalled. That the mental symptoms are to be by the pathologist altogether disregarded, and that they are of no assistance in the -appreciation of the pathological condition, seems a most extraordi- nary assertion. These symptoms do not depend on the state of the body generally, but on that of the brain, and as accurately indicate the con- dition of the latter as the breathing indicates that of a lung. The brain in insanity is the 2>ars affecta, the insanity is the symptom, and when we see in the same individual at one time mania and at another melancholia, we may be sure that the condition of brain at the one period is not the same as at the other, though originally one cause may have lighted up the malady. Diagnosis. — Accuracy of diagnosis is specially important in insanity, owing to the legal and social results which flow from it, and because the restrictions on liberty which may be neces- sary for proper treatment cannot be resorted to until a diagnosis has been conclusively estab- lished. The direction of the investigation will be different, according as the condition may be the result either cf incomplete development, or of disablement or perversion by disease. Where imbecility is in question, it may often he neces- sary to take several opportunities of examin- ing the patient. This condition always implies intellectual defect, though great moral depra- vity is often the predominant symptom. It is therefore necessary to ascertain whether any or what kind of occupation has been attempted, and what amount of incapacity has been shown, and whether the individual has proved capa- ble of profiting by such education as he has received. Adults in ordinary circumstances ought at least to be able to read, write, an l count. The decision rests on whether such capacity has been shown as is required in the ordinary conduct of life. To form a correct opinion in cases of acquired insanity is often a very difficult matter. The relatives of the patient often obstruct rather than aid the en- quiry. They are generally divided in opinion, and this may be partly an aid and partly au INSANITY. 716 obstruction ; but great care is required to avoid taking part at first with either side. Before seeing the patient it is proper to make what inquiry is possible into the hereditary history of the family, the nature of the diseases or in- juries from which the patient may have suffered, including any previous attacks of insanity. The ordinary habits, disposition, tastes, and occupa- tions must be ascertained, and also the present habits, disposition, tastes, occupations, amount of sleep, and general bodily health. The mental symptoms, such as suspicions, delusions, or loss of memory, which have suggested the allegation of insanity, must also be inquired into ; and special attention must be paid to any indication of the change of conduct or disposition which is so characteristic of the advent of mental disease. A reference to the articles descriptive of the forms of insanity will show the importance of all these points. In the whole investigation care must he taken to avoid accepting mere ex parte statements, and as much information as possible should be obtained by the inspection of letters or other documents written by the patient. Sometimes the conduct of the patient renders it difficult to obtain an interview', and care must be taken not to overstep legal limits in the attempt. If the physician has to see the patient in the presence of other persons, it is a necessary procaution to make certain that he clearly under- stands whom he is to examine. In obtaining the interview a certain amount of stratagem may sometimes be resorted to ; but it is best that the physician should be introduced by a friend in his true character as a doctor, and on no account should, any false statement be made. As a mere matter of expediency it will be found that any deviation from this produces more evil than good. If the interview takes place in the pa- tient's home, valuable information may fre- quently be obtained by observation of the order or disorder which prevails. The condition of the furniture, the state of the patient’s clothing, the manner of the patient towards the rest of the household and their hearing towards the patient, ought to be noted. The patient’s physiognomy, the condition of the pupils, and any gesticulations or convulsive or tremulous movements, must he observed. In conversation it is well to get as soon as possible to the sub- ject of the patient’s health, as it relieves many necessary questions of their offensive character. Eccentric ideas ought not to be combated more than may aid in making the patient disclose them fully; and everything tending to show the presence or absence of delusions, irrational sus- picions, or loss of memory, ought to be elicited. Many other points will probably be suggested by the course of each inquiry; and the importance to be attached to them, as well as to those just mentioned, must be decided by a careful study of how far they are included or excluded by the known symptoms of any cf the various forms of insanity. -33tiolosy. — We now pass to the causes of insanity, which are usually spoken of as pre- disposing or exciting: in many cases both com- bino in the causation of the disorder. The great predisposing cause is an inherited disposition to neurotic disorder— one difficult to estimate and, indeed, to discover, owing to the care with which it is concealed, but the impor- tance of which cannot be questioned. It has been adverted to in the second section of the pathological conditions, and will again be noticed. See Insanity, Varieties of. When we speak of such predisposing causes as sex, age, and condition of life, it is evident 'that they can only be called causes in the sense of being concurrent conditions, in some of which a man or woman is more likely to become insane than in others. Has sex anything to do with insanity? Re- ferring to statistical tables we find that in the Report of the English Commissioners in Lunacy for theyear 1871 there were under treatment in asylums at the end of theyear 1873, 18,872males and 20,74-1 females. There were admitted during the year (not reckoning re-admissions or trans- fers) 6,261 males and 6,317 females, while in the same period there died 2,288 males and 1,705 females. The preponderating number of females under treatment is probably due to the fact that the mortality among them is far less than among males, and consequently they accumulate in asylums. The difference in the number of the two sexes who become insane is probably not material, but it seems that tho males are the larger number, or, looking at the difference in the mortality, they would fall below the number of the females further than they do. With regard to age, we find that the tendency to insanity increases with the development of brain and mind. In the first decade of life it is rare. In the second, which includes the period of puberty, it is more common, but not so much so as in the next. The period between 25 and 40 years is that in which the greatest number of cases arises, and is that of the highest de- velopment and working power. After this the number declines in each decade, as before it rose. With the age the character of the insanity varies. In youth it is displayed in violent and paroxysmal mania, sometimes in acute de- mentia, and cataleptoid states. There is great motor disturbance and emotional rather than intellectual aberration. Rarely are the young melancholic. In the prime of life there is active mania with delusions and intellectual insanity, and at this period we meet with the most acute forms. Later, melancholia prevails ; while in old age weakness of mind, passing into fatuity and second childhood, indicates the general decay of the brain and nervous system. As to the condition of life in which insanity is most frequently found, there is not much to be said. That it occurs more frequently in civilised than in barbarous countries may be assumed without recourse to figures, because in the former mind and brain are more complex, and therefore more prone to disorder. It is, however, the failures and vices of civilisation that bring about the great mass of insanity. And of these the chief is poverty, with all its attendant physical evils of insufficient food and wretched dwellings, and moral evils of anxie'y and degradation. Next to poverty, and closely bound up with it, is drinKing, which among tho working classes plays a fearful part in the causation of the disease. Among the predispos- ing causes of insanity included by the Interna- INSANITY. tional Congress of alienist physicians in 1867 arc, besides those already enumerated, consan- guinity ; great difference in the age of the parents ; influence of the soil and surroundings ; convulsions or emotions of tne mother during gestation ; epilepsy and other nervous affections ; pregnancy, lactation, menstrual periods, critical age, puberty, venereal excess, or onanism. We may add to these, damage received at birth owing to difficult parturition. The exciting causes of insanity are usually divided into moral and physical. Among tne former vve may reckon domestic trouble and anxiety, mental shock, overwork, religious ex- citement, political excitement and war, and disap- pointment. Concerning such little need be said. They may vary in duration, some quickly bring- ing about insanity, others persisting for years before that result is reached. For the most part those who are affected by such causes are already predisposed by hereditary taint, by a neurotic temperament, or by being at one or other of the critical periods of life. Among the physical exciting causes are some which are both exciting and predisposing — for example, intemperance and epilepsy. These may be the immediate precursors of an attack ; as well as agents causing a predisposition to the disorder, by being repeated through a series of years. Other physical causes are parturition, menor- rhagia, amenorrhcea, and various other ovarian and uterine ailments; diseases and injuries of the head ; acute febrile diseases and chronic illness, producing exhaustion ; constitutional dis- eases, as gout, ague, or syphilis ; disease of heart and vessels ; exposure to great heat or cold ; lead and other poisons ; anaemia ; blows on the head, and organic affections of the bones of the cranium, or the various parts contained therein. Classification. — Almost every writer on in- sanity has suggested a special classification of its forms, andthe majority have founded their sugges- i tions either on the aetiology or symptomatology of the disease. Of those based on symptoms none is simpler than Griesinger’s : — (1) states of mental depression-, (2) states of mental exaltation ; (3) j states of mental weakness. He placed general paralysis and epilepsy apart as mere complica- tions of insanity. His groups, therefore, corre- spond broadly with the old divisions of Melan- cholia, Mania, and Dementia. The aetiological classification most widely known is that of Morel. He divides the forms into six: — (1) Hereditary insanity, including congenital nervous tempera- ment, moral and impulsive insanitjq imbecility, and idiocy; (2) Toxic insanity, including con- ditions caused by insufficient or injurious food, poisons, or noxious air or water ; (3) Hyste- | rical, epileptic, and hypochondriacal insanity ; (4) Idiopathic insanity, dependent on disease of the brain or its membranes ; (5) Sympa- thetic insanity ; and (6) Dementia, or the condition ' °f terminative enfeeblement. For any systematic study of the subject, it is obvious that some Bymptomatological grouping, based on the cha- racters of the mental manifestations, must be necessary. It has, however, been maintained that it is impossible, either on this cr on a purely •etiological basis, to found groups which have 717 more than an artificial relationship to one another. And there is some truth in this criticism. Hut, though the ties which bind the psychological groups together may be in a sense regarded as artificial, it is found in practice that the asso ciated conditions exhibit a considerable amount of intimate natural connection. At the International Congress of Alienists in 1867 the following classification was laid down, intended to combine the setiological and symp- tomatological methods: — 1. Simple Insanity, comprehending mania, melancholia, monomania, circular insanity, moral insanity, and the demen- tia following these forms. 2. Epileptic Insanity. 3. Paralytic Insanity. 4. Senile Dementia. 5. Organic Dementia. 6. Idiocy. 7. Cretinism. The first class, it will be observed, comprises all the varieties which may be regarded as merely functional ; the others are mostly associated with permanent structural lesions. No classification which has been proposed can be regarded as altogether satisfactory. This is partly owing to the fact that the true nature and limits of insanity itself have been very imper- fectly recognised. The essence of the condition is, of course, the manifestation of disease through some deviation from the healthy standard of mental action. It is a condition of mental uu- health analogous to bodily unhealth. Hut we must not allow ourselves to imagine that there is a class of morbid mental manifestations which are independent of the condition of the physical frame. The truth is that there is no pathological condition of the individual in which both mind and body are not affected ; but in some diseases the mental symptoms come into prominence, in others the physical. The notion, not yet alto- gether exploded, that there is something in in- sanity altogether distinct from bodily disease, arose from the belief so long prevalent that mental action is independent of physical condi- tions, and from the fact that the study of insanity has been and still is too much dissociated from the study of the rest of cerebral pathology. Acting upon the broader and truer views, at- tempts have been made by Schroeder van der Hoik, and others, to introduce a more natural system of classification. Such attempts have proceeded on the recognition of all mental symp- toms as phenomena whose nature cannot be ascertained without a full consideration of the physical symptoms of disease by which they may he accompanied. Dr. Slcae proposed a clas-ifi- cation based on the belief that every mental dis- order bears a relation to some bodily disease — acuto or chronic — analogous to what the delirium of fever does to the fever in whose course it is manifested. The detailed list which he offered was, however, admittedly imperfect; and it is likely that any satisfactory classification on this principle will only be arrived at after a much closer study of the mental symptoms of disease than has yet been given to them. But Skae de- serves the credit of having given the most power- ful impulse to the purely medical, as opposed to the metaphysical, mode of studying insanity. In furtherance of this, some progress has been made by Clouston, Batty Tuke, and others, who have published careful monographs of some of the more prominent forms. If by such means we INSANITY. 718 can group together conditions which are similar, not only in their mental but also in their physi- cal characters, we obtain units which may ulti- mately contribute to the building up of a more perfect system, and which can never be altogether disregarded by classifiers in future. Most of the attempts which have been made to describe such groups must at present be regarded rather as valuable suggestions than as well-established clinical and pathological species. For the pur- poses of this work it has been considered best to describe in the present article, the various phases of insanity which have been regarded as of special importance, without regard to the prin- ciples which underlie their conception; and afterwards to discuss the various well-marked forms of the disease under their several heads, alphabetically arranged. Prognosis. — The general prognosis of in- sanity will depend (1) on the duration of the existing disorder. Perhaps the best established fact of all is, that the chances of recovery diminish in direct proportion to the duration of the malady, and that it is consequently of the utmost importance to place a patient early under adequate and appropriate treatment. If a twelve- month elapses without appreciable improvement, the chances are decidedly unfavourable. If de- lusions or hallucinations remain fixed and un- changed at the end of a year, especially if there he hallucinations of hearing, the prognosis is bad. The chiof exception is where there is marked melancholia. Patients will recover from this after long periods ; whereas such recoveries are seldom found in insanity when depression is absent. (2) When the cause of the insanity has been of long duration, the prognosis is less fa- vourable than when it is a passing or accidental cause. (3) Is the prognosis unfavourable in hereditary insanity ? So much of the so-called simple insanity is hereditary, that we must admit that recoveries from it are not infrequent, for it is from this simple insanity that recoveries chiefly take place. Hereditary insanity is brought about by very slight exciting causes, and thus the prognosis is often favourable, and recovery takes place ; but relapse is to be feared, and the prognosis in a second or third attack is not nearly so good. In this hereditary insanity, too, we frequently meet with the cases of recurring and ‘ circular ’ insanity, the progress of which is most unfavourable. Both Kay and Griesinger have remarked that the prognosis in hereditary insanity is favourable only where the individual has previously been of normal mind. When he has always been eccentric or semi-insana, and undoubted insanity at last manifests itself, the prognosis is very bad. (4) The more acute the symptoms, the greater the cerebral disturbance and insomnia, the more favourable is the pro- gnosis, if the case is recent. Conversely, the prognosis is bad when there is little bodily dis- turbance, where sleep is present, the appetite normal, and the secretions unaffected, especially if persistent delusions or an entire moral change are found. (5) As all deviation from the ordi- nary mental state and disposition is indicative of insanity, so any return to it is a favourable sign, however trifling the circumstances may be. (6) Improvement, however slow, is a good sign if it he progressive. So long as this goes on. recovery may take place ; but many patients improve up to a certain point, and then go no farther. (7) The age of the patient must be considered. Young people recover in greater numbers than those advanced in life. The latter recover if their insanity be melancholia ; but, if it be mania, with hallucinations and delusions, and obscene conduct and ideas, recovery is rare, especially if the memory is impaired, and signs of approaching dementia are present. (8) All periodicity in the disease, such as exacerbations and remissions on alternate days, is unfavour- able. Treatment.- — Only a few general remarks on treatment will be offered here. Our objects should be to restore to health the disordered brain, to cause the incessant waste to cease, to promote a storing and not an expenditure of nerve-force. The brain must be nourished by healthy blood. The quantity of the latter when in defect must be increased; when its quality is in fault it must he improved ; and when the blood-flow is in excess it must be checked; while all causes of disturbance reacting upon the brain from other organs of the body must bo removed. It is not to be forgotten that powerful effects are produced throughout the nervous system, both in the lower and higher centres, bv what has been termed ‘ inhibition.’ By the diversion of nervous action from one channel to another, considerable influence may be exercised. 1 Emo- tional excitement may be diverted into motor or intellectual channels ; or, by other emotional stimuli, may be counteracted or arrested. Intel- lectual or ideational troubles may be diverted by emotional longings, or by counteracting intellec- tual pursuits. And for all this certain adjuncts are necessary. Painful emotional distress, with the idea of impending ruin, is perpetually fos- tered by the sight of the loved faces of wife and children : the patient must therefore he removed from them. Outbursts of anger are constantly directed against those most familiar, and delu- sions correspond. These must be abolished by his being placed among strangers. Great as is the need in many cases of medicinal treatment, it is not so universally demanded as is the re- moval of the sufferer to fresh surroundings. W e try agtiin and again, in apparently the most pro- mising cases, to effect a cure at home, and we fail. The necessity for early treatment in in- sanity is dwelt upon by every writer ; and the treatment, when insanity is once fairlv estab- lished, only begins after the patient is removed. The first questions to be solved are how the removal is to be effected ; and to what place the patient is to be removed. In the majority of cases, especially in the case of the urban poor, no doubt cau arise — an asylum is the only place open to them, because either the friends are poor and cannot afford any other plan of treat- ment, or are compelled to have recourse to the public asylums of the land. For many an asylum is necessary because the patient is danger- us to himself or others, or would incessantly struggle to escape from a less guarded dwelling. But 1 Dr. Lauder Brunton, on Inhibition. RidW Reports , iv. 179. INSANITY. there are some patients who may be cured out of an asylum. Some recover from acute but transitory attacks of delirious mania very rapidly, much as do the sufferers from delirium tremens, and, if measures of safety can be taken, we may watch such for a few days and perchance they may recover without removal. Many persons at the very outset of insanity may by removal and judicious treatment be cured, if their friends will only 'pen their eyes and acknow- ledge the threatening evil, and not wait, as they so often do, till compelled by circumstances to interfere. Such patients must not be sent abroad or out of reach, must not go alone, or without able or skilled companions. They may go from place to place, or to a friend’s or medical man’s house. Fresh scenes and faces, and the cessation cf work or wcrry, will often effect a cure. But they must be people able to walk out in public thoroughfares, and to live in houses under ordinary precautions. Where they cannot walk in public, and cannot live in a house without its being converted into a prison, they ought to go to an asylum, where there are grounds for exercise, and where facili- ties for escape are not always suggesting attempts. Patients' friends constantly make a mistake : they keep the patient out of an asylum at the time asylum treatment would cure him, and send him there when all hope of cure is over, and when, as a chronic lunatic, he would be just as well off out of one. With regard to medicinal treatment little need here be said. The drugs chiefly used in insanity nre sedatives and narcotics. The writer ha3 little faith in these, except for the purpose of obtaining sleep, and gives them only at night, except in the happily rare cases where life is in danger from want of sleep. To procure sleep no drug iu his experience approaches chloral in value ; and few are the cases where it is totally ■ inefficacious. He has failed to observe the per- nicious effects attributed to it by some writers, and the results both in severe and slight cases have been most satisfactory. In the melancholic and non-exeited cases the preparations of opium are of great service, alone, or in combination with chloral. Iu excitement, bromide of potas- sium is valuable, alone, or in combination with chloral, Indian hemp, or henbane. Digitalis, alone, or with morphia, is highly spoken of by Drs. Robertson and Williams. Ergot, of rye is efficacious, according to Dr. Crichton Browne, in recurrent and chronic mania ; and the same physician extols the virtues of calabar bean in general paralysis. Good and abundant food is an essential in the treatment of the insane: stimulants are re- quired in many cases, particularly the depressed and anaemic forms, but in the opposite, though often useful, they in some cases produce or in- crease excitement, especially in the early stage. With the food tonics should be given, and those best suited are, in the writer's experience, the mineral rather than the vegetable, and chief of all the preparations of iron. G. F. Blaxdford. INSANITY, Morbid Histology of. — Up to the present time do definite and distinct INSANITY, MORBID HISTOLOGY OF'. 719 lesion has been shown to accompany invariably any definite and distinct form of insanity, with the exception of general paralysis ; it may, how- ever, be considered an established fact that in every case, whether recent or chronic, a marked departure, or departures, from healthy condi- tions may be observed if properly sought for ; but in what manner these lesions have influenced the character of the case in respect of its leading symptoms, mania, melancholia, or dementia, little as yet has been elucidated. Nevertheless, the nature of the morbid appearances is sufficient to account for perversion of functional activity, although we are unable to account for the pecu- liar nature of the perversion. One great difficulty which presents itself to the mind of the cerebral pathologist is to deter- mine whether the morbidities which are apparent on microscopic examination are of a primary or se- condary nature, whether they have been efficient causes of insanity, or whether they are mcrely the results of mail-nutrition of the brain, and as such efficient causes of chronic lunacy. There exists an undetermined point in anatomy which, until settled, must leave the question to a cer- tain extent open — that point is the presence or absence of cerebral lymphatics. When it is considered that the brain is an exceedingly active organ, performing many and various functions, and when it is further considered that it can obtain no vicarious aid in the performance of those functions —that it cannot, like the lungs, seek assistance from other systems — it must be at once apparent that the question of its posses- sion of an overflow for getting rid of super- fluous plasm and waste products is of paramount importance. Fohmann and Arnold demonstrated to their own satisfaction the existence of a sys- tem of lymphatics in the pia mater; and His, Obersteiner. and Boll believe that the pia-rratral envelope of the cerebral arteries (hyaline mem- brane) exercises the function of a lymphatic duct. The very existence of such a sheath or envelope has been called in qrrestion, hut, com- paratively slight study is needed to make its demonstration certain. Although differences of opinion exist as to its relations and manner of debouchement, we believe that it terminates by funnel-shaped openings into the spaces which exist over the sulei between the pia mater and the so-called arachnoid membrane. Kolliker 1 has pointed out that the connection between the pia mater and the arachnoid over the convolu- tions is so complete and perfect that only at parts, namely over the sulci, a distinct space can be shown to exist. It is questionable whether the arachnoid should not he considered to he merely the outer layer of the pia mater. The bearings of this point on pathological histology will be considered under the head of cerebral congestion ; it would not have been alluded to were it not that it assists somewhat in the dif- ferentiation between primary and secondary lesions of the cerebral tissues. In prosecuting the study of the morbid histo- logy of the brain and spinal cord, two methods of investigation should be adopted: — I The exami- nation of the tissues in the fresh state ; 2. The examination of the parts in situ by means of ’ Kolliker’? Histology, Old Syd. See. vol. i j . lie. INSANITY, MORBID HISTOLOGY OF. 720 sections made after submission of portions of nervous tissue to hardening agents. The con- dition of the constituents of the recent brain can best be observed by colouring small speci- mens with rosaniline. The modern method of freezing, and section by means of the microtome designed by Mr. Reran Lewis, has rendered the investigation of histological brain-chaDges a comparatively easy task. The Membranes. — The dura mater is, com- paratively rarely, thickened by proliferation of its elements ; the vessels are foun 1 to be irre- gularly dilated and tortuous, with thickening of their walls. The arachnoid and pia mater are in such close anatomical relation on the convexity of the hemi- spheres, that they can be best described to- gether. Between them, supported by a delicate connective tissue, lie the blood-vessels which dip into the sulci, carrying with them an investment of pia mater, which gives prolongations to ac- company them when they pierce the cerebral substance, and forms the so-called hyaline mem- brane. Over the sulci are the spaces usually termed sub-arachnoid, which communicate with one another by conduits accompanying the ves- sels. The microscopic appearances of ‘ milky arachnoid’ have not beeu thoroughly described; both membranes are often thickened, presenting a laminated appearance, and the connective tis- sue supporting the blood-vessels is considerably increased, as well as the pia-matral prolonga- tions accompanying the blood-vessels into the cerebral substance, which loses its hyaline cha- racter, and becomes distinctly fibrous. Exten- sive but thin blood-clots are occasionally found between the arachnoid and pia mater, while more rarely extravasations of blood ar-e found between the pia mater and the cerebral sub- stance. Deposits of hsematoidiu often surround the vessels, and their coats are frequently hyper- trophied. Crystals of triple phosphate have been seen on the visceral surface of the pia mater. Lymph has been found between tho pia mater and the spinal cord ; the membrane was thick- ened, and internal to it were numerous distinct laminae of a finely fibrillated material, in some places of an inch in breadth. In one case there was long-standing epilepsy, in the other chorea, both being complicated by insanity. The Epithelium. — The ground-glass ap- pearance frequently seen in the ependyma of the ventricles is due to three different morbid conditions, which are, in the order of their fre- quency, proliferated epithelium, lymph-exuda- tions, and crystalline deposits. When change in the epithelium is the cause of the granulations, a vertical section shows simply a proliferation of cells projecting into the ventricle, like villi. When lymph-exudations have pushed the ependyma upwards, it presents the appearance of rough, irregular, bullse-like nodules, consist- ing of the layer of proliferated epithelial cells, and a greenish homogeneous stroma, which to- gether overlie the pia mater ; the same ma- terial can be frequently seen infiltrating the subjacent cerebral tissues. Deposits of phos- phate of lime have been recorded as occurring beneath the ependyma of the lateral ventricles in general paralysis, and Bergmann discovered a formation of pretty large crystals of ‘ double phosphate ’ in both plexus choroidei in a case of ‘mania with mental weakness* (Griesinger, New Syd. Soc. Trans., p. 429). A proliferation of the columnar epithelium of the central canal of the medulla oblongata is not unfrequent, causing its occlusion. The Nerve-cells. — The changes in the nerve- cells are most marked in the anterior two-thirds and superior parts of the hemispheres, as in this situation they are usually most numerous and large in size. In the depending portions of the hemispheres and the occipital lobe few, if any, changes have been noticed. The special morbid conditions of the neive- cells are : — a. Atrophy ; or pigmentary, granu- lar, or fuscous degeneration. £. Hypertrophy. y. Calcification. Pigmentary, fuscous, or granular degeneration is a very common condition in many forms of insanity, particularly senile insanity and general paralysis, and is probably to some extent a nor- mal senile change. Dr. Major distinguishes three stages : — 1st. The cells lose their sharply defined triangular contour, and become swollen or inflated in appearance ; the process running towards the periphery of the convolution usually remains distinct, but the other processes dis- appear, and the cell becomes rounded off; the nucleus becomes swollen and more or less round or oval, and the nucleoli are seen with great dis- tinctness. 2nd. A deposit of granules takes place, either external to the cell and pressing upon it, or in its interior, until it becomes more and more yellow and opaque ; or both these con- ditions may occur together. 3rd. The cell goes on to destruction, breaking down and shrink'ng, leaving the nucleus surrounded only by a mass of granules, and forming a gap in the cerebral tissue formerly occupied by the swollen cell ; still later tho granules entirely disappear, leaving the nucleus free. He has not observed the nucleus actually undergoing disintegration, but often no trace of it is to be found in the mass of granules left by the degenerated cell. Hypertrophy of the large pyramidal cells of the inner layers has been observed in senile atrophy and general paralysis : as the name implies, they are large, abnormally distinct and swollen in apperance, often presenting granular masses in their interior ; the processes are in- creased both in size and number; and the angles of the. cells may be greatly prolonged or swollen and stunted. Calcification of the cells by the deposit of phosphate of lime within their walls has been observed, according to Blandford. The Nerve-fibres. — The chief changes in nerve-fibres, apart from their disintegration l y apoplexies, softenings, &e., are coarseness, irre- gularity and twisting of outline, and their power in the fresh state of resisting pressure under a covering glass, some becoming readily ampul- lated. They may be affected by a pigmentary degeneration similar to that occurring in the cells ; and finally they may present fusiform or oval swellings, which tint strongly with car- mine, and give rise to the appearances knowr as amyloid bodies. INSANITY, NI0RI3ID HISTOLOGY OF. 721 Special Morbid Conditions of the Grey Mattel’. — In many subjects when the pia mater is thickened and hyperaemic, a condition of the grey matter closely resembling grey degeneration in the whito matter is often found; it differs from the latter by the absence of proliferated nuclei, and is strongly suggestive of lymph-infil- tration, which has gradually caused atrophy and absorption of the normal structures. Circum- scribed spots of yellow softening show under the microscope ragged fibres, colloid bodies, and granular corpuscles at the base of the diseased tract. Local atrophies of the convolutions are pretty common ; under the microscope a thin layer of indurated grey matter, presenting no trace of normal structure, may be found ; in other cases there is simple absence of the grey matter, the white matter in both being unaffected. The Neuroglia. — This substance undergoes inflammatory changes of a sub-acute or chronic nature, with the results of which we are fami- liar as more or less diffused sclerosis. Together with the other elements of the cerebral tissues, it undergoes atrophy in the brain-wasting of senility, and especially of senile dementia ; it is also liable to special forms of degeneration, which have been called miliary sclerosis and colloid degeneration, though those terms are somewhat misleading, as the changes in question differ entirely from those generally described by these names. General sclerosis has only been observed in one case, which is fully detailed in the Journal of Anatomy and Physiology, May, 1873. In a hy- drocephalic epileptic idiot (whose brain weighed sixty ounces) the hemispheres varied in weight; the left being 23J ounces, the right 30J ounces. In the heavier or hypertrophied side, the nerve- fibres were found lying in fasciculi consisting of from four to six strands ; these fasciculi were separated from one another by a clear, finely- fibrillar plasm in which nuclei existed, somewhat larger than normal. j. Disseminated or •partied sclerosis, or grey degeneration, is a lesion frequently met with in the brains of old-standing cases of insanity, especially in general paralysis. Its most fre- quent seat is the white matter of the motor tract ; less frequently it is met with in the hemispheres. In the pons varolii, medulla iblongata, and spinal cord of epileptics, patches >f this disease are of common occurrence and n an extrome degree. When a fino section of lerve-tissue affected by this disease is examined |’V the naked eye, circumscribed opaque patches an be seen ; in coloured sections these tracts re strongly tinted; as a rule, they are found ontiguous to a vessel whose nuclei are much pro- ferated, and around which considerable prolifer- don of the nuclei of the neuroglia exists, nder the microscope, the nerve-fibres, are seen 1 be partially or completely atrophied; the vis-cylinders and sheaths are destroyed ; and ie field is occupied by a finely molecular and orillated material, imbedded in a cloudy homo- rneous plasm. In this matrix the proliferated iclei exist, somewhat enlarged, sometimes Shjty granular in appearance ; but around the mlicated spot they are to be seen in much 46 greater quantity, and not actively diseased. The atrophied nerve-fibres occasionally project rag gedly into the grey matter, where they are lost Rokitansky believes this to be essentially a pri- mary increase of the neuroglia. Leyden thinks it occurs secondarily to the atrophy of nerve- fibres ; while Rindfleisch and others are of opinion that the first stage is marked by pro- liferation of the nuclei of the vessels, which i» followed by an increase of the neuroglia, and the development of a morbid plasm, which is, in all probability, modified neuroglia. Miliary sclerosis. — For the full details of t hi- remarkable lesion the reader is referred to the Edinburgh Medical Journal for September, 1863. and to the British and Foreign Medico- Chirm- gical Review, July, 1873. The following is 1 short account of its principrd features. It is not confined to any one class of mental disease, but has been found best marked in cases accompanied by paralysis or epilepsy. It differs from a 1 other lesions termed sclerosis in not being pre- ceded, attended, or followed by proliferation of the nuclei; it is a circumscribed lesion, occurring in patches from M to of an inch in length, not involving surrounding tissues, except by dis- placement, diffusing no morbid plasm beyond its own area, and not connected with the blood- vessels. It is essentially a disease of the nuclei of the neuroglia, and its progress is marked by three stages : — 1st. A nucleus becomes enlarged, and throws out a homogeneous plasm, of a milky colour and apparently of a highly viscid con- sistence, forming a semi-opaque oval spot, usually unilocular ; but by aggregation the spots may be bilocular, or, more rarely, multilocular. In the centre of these spots a cell-like body containing a nucleus is discernible — the original dilated nucleus of the neuroglia. 2nd. The morbid plasm becomes distinctly molecular, and per- meated by fine fibrils ; as it advances, the plasm round the periphery of the spot becomes more dense, and a degree of absorption of the nerve- fibres around it takes place. 3rd. The molecu- lar matter contracts on itself, becomes more opaque, and .often falls out of the section, leaving ragged holes. Colloid degeneration may be either a primary or a secondary product, that is to say, there i? reason for believing that in certain forms of in- sanity it is the primary pathological change, and that it is also to be met with in the brains of chronic cases as a result of long-continued per- verted vascular action. It has been produced arti- ficially in the brains of pigeons by incising them and allowing the wound to heal. This degener- ation should be searched for in recent specimens. It consists of round or oval bodies, from to of an inch in diameter, bounded by a distinct wall containing a homogeneous, transparent, and colourless plasm ; sometimes it is somewhat granular. The general appearance of a section may be compared to a slice of cold sago-pudding; it cannot be coloured by carmine. The condition may be regarded as a degeneration of the nuclei of the neuroglia, and is found in both grey aD'i white matter. The Blood-vessels. — When we examine an injected preparation of the substance of a cere- bral convolution, and witness the perfection and l ,'22 INS ATS IT Y, MORBID HISTOLOGY OF: AND VARIETIES OF. delicacy of its circulatory apparatus ; and when we reflect on the results of the phenomena of con- gestion, stasis, and anaemia on the functions of other organs; we have little difficulty in compre- hending the influence such conditions must have upon the highly complex elements which make up the organ of the mind. It is certain that in most cases of recent insanity, disturbance of the cerebral circulation is one, if not the essential, pathological factor ; and if such disturbance is of long continuance, permanent lesions of cells, fibres, and nuclei, and, as a consequence, chronic insanity in some form, must result. The examination therefore of the cerebral vessels is of primary importance. The following is the method of examination adopted by the writers; — After noting the degree of engorgement or anaemia in the centrum ovale, and whether on section the vessels are dragged out by the knife, vessels of moderato size should be dissected out and carefully washed with camel’s-hair brushes, and then submitted to the microscope. By this mode of procedure the fol- lowing changes may be discovered — (a) Thick- ening or degeneration of one or other of the coats. ( b ) Thickening of the sheath or hyaline membrane, (c) Deposits between the adventitia and the sheath, (d) Proliferation of the nuclei. (a) Thickening nr degeneration of the coats . — The inner fibrous coat has been found thickened and more fibrous than in health. The muscular coat is often hypertrophied, especially the circu- lar fibres; it is best; marked in general paralysis and epilepsy. The adventitia is occasionally thickened. The whole of the coats sometimes undergo a hyaloid or vitreous change, which is probably allied to lardaceous disease. ( b ) The hyaline membrane or sheath is ofton thickened and fibroid, enveloping the artery in a loosely sacculated manner. (c) Deposits between the adventitia and the sheath are of t wo kinds ; but neither is peculiar to insanity, being found in the brains of persons who have died offerer or Bright’s disease with cerebral symptoms. The first is a finely molecular material of a pale yellow tint, or more often colourless, closely resembling in appearance the spores of the Favus fungus, and refracting light highly ; it undergoes no change when treated with the ordi- nary oil-tests, and is found on the smallest capil- laries. The particles vary in size from to T of an inch. The second form of deposit consists of irregular crystals of haematoidin distributed pretty equally over the vessels, except at the bifurcations, where they are aggregated. ( d ) Proliferation of the nuclei usually accom pauies proliferation of the nuclei of the neuro- glia ; they do not seem to increase to the same size, as those of the neuroglia, but become oval or irregular in shape. Fine sections of hardened tissues are necessary for the demonstration of the following vascular changes: — (c) Abnormalities in direction. (/) Dilatation, microscopic aneurisms, and apo- plexies. (g ) Perivascular spaces. (A) Syphi- loma. (e) Abnormalities in direction may take the form of extremo tortuosity or actual thickening; these are usually evidences of congestion, but may under certain circumstances be produced artificially. (/) Dilatation , microscopic aneurisms, and apo- plexies . — Ecker, Romaer, and Major have found a general dilatation of the small vessels in mama and ‘brain-wasting.’ MM. Bouchard and Charcot have carefully described the appearances of mi- croscopic aneurisms ; they are usually fusiform, more rarely sacculated, measuring Y to Y of aD inch in length, their breadth being one- fourth of their length. These authors describe a thick- ening of the fibrous coats, with proliferation of the nuclei, and atrophy of the transverse mus- cular striae. Drs. Bastian and Blandford have described a thrombosis of the minute vessels by masses of white corpuscles occurring in maria and delirium. (g) Perivascular spaces. — In subjects who have been liable to cerebral congestion the vascular canals are often distinctly dilated, to an extent several times the calibre of the vessels; the brain- substance bounding them is condensed. (A) Syphiloma of the cerebral arterioles is cha- racterised by the formation of a plastic deposit around their walls, which becomes converted into fibrous tissue, and gives to their transverse sections an enormously hypertrophied and con- centric appearance, going on to almost complete occlusion of the canals. Tumours. — Tumours have been met with in some cases of insanity, but as no growth pecu- liar to insanity has been described, it is unneces- sary to enter into their description. The Spinal Cord. — Microscopic examination of the spinal cord has not revealed any lesion peculiar to the various forms of insanity, except- ing general paralysis. Drs. Westphal, Meredith Clymer, Boyd, and others are of opinion that in this disease well-marked departures from health are to be found. The first-named patholo- gist describes an atrophied condition of the cells of the posterior columns, with increase of their connective tissue, commencing externally and extending inwards ; he also believes in a chronic myelitis affecting the posterior columns and the posterior sections of the lateral columns. As for as the writers have been able to observe, this is by no means an invariable accompaniment of this disease, although in one case it was undoubtedly present. The cells of the cord were in most instances undergoing fuscous granular degenera- tion, like these of the hemispheres. The Sympathetic System. — The sympa- thetic ganglia undergo a pigmentary degenera- tion in various forms of cerebral disease. J. Batty Tcke. Robert Saundbt. INSANITY, Varieties of.— Iu this article various forms of insanity will be described under separate heads. Dkmextia, General Paralysis of the Insane, Mania, and Melancholia will be found in other parts of the work. 1. Alcoholic Insanity. — The conditions in- cluded under this head must not he confounded with what is called dipsomania. In the latter affection the indulgence in alcohol is asvmptom. and not necessarily a cause ; while here the in- sanity is always a direct result of some form of alcoholic poisoning. It is met with in three forms, namely, acute alcoholic insanity. chre.'UC alcoholic insanity, and delirium tremens. INSANITY, Y; Acute alcoholic insanity seldom occurs except when there is a strong hereditary tendency to mental disturbance, or when the cerebral ener- gies have been notably impaired by excesses or overwork. Where all these predisposing causes exist, it may not require a large dose of alcohol to bring on an attack. The most frequent form of the affection is violent maniacal delirium, known as mania a potu, with a tendency to homi- cidal acts. In some cases the mental disorder takes the melancholic form, and it becomes neces- sary to guard specially against the strong sui- cidal tendency which generally characterises it. Unless the brain has been weakened by repeated attacks, both forms are curable and generally of short duration. The treatment is the nourish- ing, non-stimulating regimen detailed in the articles on Mania and Melancholia. Chronic alcoholic insanity is one of the results of chronic alcoholism, and there is no condition which better illustrates the ‘solidarity of the psychical and somatic functions of the nervous system’ and the interdependence of their morbid manifestations. The physical symptoms are fully described in the article on Alcoholism; the mental symptoms are generally present from the beginning, though not always prominent enough to attract special attention. The sleeplessness, so characteristic of commencing mental disorder, is an early symptom ; then restlessness and depression, with suicidal tendency, sometimes passing rapidly into complete dementia, but generally passing gradually through a course of moral and mental degradation, which progresses step by step with tile symptoms of failure of physical nervous power. The affection presents many points of resemblance to general paralysis of the insane, and is in some cases only to be distinguished from it by obtaining evidence of alcoholic poisoning, and by the persistence of the mental depression, which is seldom more than a transitory symptom in the general paralytic. Delirium tremens is described fully under the . .leading of Alcoholism; but it is proper to note here that after the acute symptoms of that disease have passed away, there is sometimes . left behind a state of subacute insanity of a ' characteristic nature. At first suicidal symp- toms are apt to appear. Suspicions of poisoning, fear of impending evil, and hallucinations of hearing are also frequent. The treatment re- quired is constant companionship of a trust- worthy attendant, exercise, fresh air, and change of scene, with attention to every ordinary means of restoring the functions to a healthy stato. Under proper treatment the prognosis is favour- able. John Sibbaid. 2. Amenorrb.ee al Insanity. — Mental de- rangement is often accompanied in females by sup- ires.-ion of the menses. Butin many such cases he insanity cannot be called amenorrheeal, as he cerebral and uterine disorders may only be i ssociated as both symptomatic of some debili- atiug cause affecting the whole system. Then lie mental condition is usually the depression 1 reduced by amemia. But there is a mental de- ^ mgement directly resulting from sudden suppres- on of the catamenia, to which this distinctive lme is not inaptly applied. Here the insanity ARIETIE3 OF. 72S takes the maniacal form. It is sometimes ushered in with urgent febrile symptoms, in which case the mania assumes the acutely delirious charac- ter. Where general febrile disturbance is not prominent, the mental condition is more simply maniacal, and sometimes does not get beyond mere irritability with delusions. The patholo* gical condition must in either case be regarded as mainly a hyperaemia of the brain. Treatment. — This must be directed towards the restoration of the arrested discharge. If the patient be seen at the commencement of the attack, the hip-bath and a gentle purgative may recall it. If the menstrual period has passed, the attention of the practitioner must bo devoted to the relief of the more urgent symp- toms. If the symptoms of cerebral congestion are distinct, leeches will probably be found use- ful. Regular action of the bowels should be secured, but active purgation should be avoided. The food ought to bo easy of digestion, and caro should be taken not to let it be deficient in quan- tity. If the mental excitement is great and long- continued, it will necessarily produce consider- able exhaustion, and the condition of the patient after recovery from the mental excitement will depend very much on the extent to which the strength has been supported during the continu- ance of this strain. The re-appearance of the catamenia generally implies recovery of mental health; but cases occur where prolonged amenor rhcea leads to a chronic maniacal condition, ultimately passing into hopeless dementia. John Sibbald. 3. Choreic Insanity. — There appears to bo an intimate connection between the pathological basis of chorea and a certain disturbance of tlm mental functions. The physical and the merit;. I symptoms however do not necessarily correspond in intensity. Sometimes where the convulsive symptoms are very severe, the mental condition is merely one of dulness, apathy, or irritability. In children it shows itself generally in a mania cal restlessness, accompanied by delirium of a peculiarly automatic character. It is frequently associated at all periods of life with the rheu- matic condition, and hence it has by some author." been called rheumatic insanity. It generally commences with sleeplessness and delirious ex citement of a remittent character, which is some- times accompanied by violent convulsive effoit. As the excitement passes off, delusions of sus- picion are apt to arise, and these are strangely associated with an apathetic mental condition. In the acute form the prognosis is favourable, recovery generally taking place in from four to eight weeks. The chronic form is apt to pass into dementia. John Sibbald. I. Epileptic Insanity. See Epileptic In- sanity. 5. Feigned Insanity. — Insanity may bo feigned in order to escape the obligation of duty, or the consequences of crime. If manifested at a time when its recognition might be a benefit to the individual, it becomes necessary to test i ts real! ty. It must not be rashly inferred in any case thai insanity is feigned; for it sometimes results from the excitement consequent on a sense of guilt oi INSANITY, VARIETIES OF. m the shock of a false aecusation ; cr it may arise roineidontly but independently of such conditions. The best preparation for making a satisfactory examination in such a case is a familiar acquaint- ance with the appearance and conduct of persons undoubtedly insane. A person feigning insanity must, to be successful, simulate some known form of the disease ; and as each form presents a more or less definite group of symptoms, an impostor is apt to reveal the truth by omissions or by additions inconsistent with the part that he attempts to play ; but the mistake generally made by the impostor is to over-act the part. The inquiry may, of course, assume various as- pects. A person may pretend to have been insane at the time a certain act was committed. Here it is to be remembered that the insanity, if real, would not probably have been confined to the time of the commission of the crime ; and some evi- dence of premonitory symptoms previous to the act would probably be found. In such cases it is proper to regard want of motive as so far an in- dication of insanity ; but when the supposition of a sudden mental perturbation is put forward, some reason would have to be shown for its oc- currence ; and some history of the occurrence of cerebral injury, or of previous attacks of insanity, epilepsy, or other cerebral affection ought to be forthcoming. A person feigning to be insane at the time he- is examined must endeavour to present symptoms of either mania, melancholia, mono- mania, dementia, or imbecility. When the symp- toms arise suddenly, simulation of the maniacal condition is generally attempted. The exertion which this entails will, however, generally com- pel an impostor to exhibit symptoms of fatigue, and even to sleep, when the true maniac would exhibit persistent excitement. The raving also when feigned may be recognised as hesitating and premeditated. Forgetfulness, which is generally assumed by the impostor, is an unfrequent symp- tom of mania, except when it occurs in the course of general paralysis, and this is a disease whose other symptoms could scarcely be simulated. If melancholia or monomania be feigned, the chief facts to be borne in mind are that such con- ditions, when real, are very unlikely to arise suddenly where there are no symptoms of bodily disease to account for them ; and that they are usually characterised by a tendency to conceal peculiarities, or at least not to push them osten- tatiously forward. Dementia never occurs sud- denly without evident cause. A class of cases occur in which insanity is only partially feigned. Young criminals frequently try to exaggerate the signs of the intellectual weakness which is so generally mingled with their moral depravity, in hopes of obtaining a relaxation of discipline, or a transference from a prison to an asylum. Such cases are often full of difficulty. The principle which ought to regjdate our action is to avoid the continuance of punishment when disease or deficiency renders it useless. Before deciding upon the reality of any doubtful case of insanity, all the physical conditions of the individual, such as the amount of sleep, the state of the pulse, skin, tongue, and digestive system generally, the conduct and the state of health immediately pre- ceding the signs of insanity, should be ascertained. The effect of remarks made within hoaring of the suspected person should be observed ; one who proclaims his own insanity should be distrusted. And the medical history of the family and of the individual should be inquired into, with a view to disclose anything which might have caused insanity or predisposed to it. Joint SlBBALD. 6. Gastro-Enterio Insanity. — The emo tional condition is well known to be to an appre- ciable extent dependent on the state of the 'prime vice ; and where the nervous system is predisposi-d to derangement, certain affections of the stomach and bowels seem sufficient to produce insanitv. and to stamp it with a special melancholic character. In addition to the mere depression caused by anaemia, there is associated with such affections a peculiar anguish of mind, and ten- dency to self-accusation, which is often of the most distressing nature. Refusal of food is fre- quently a prominent symptom. The intellectual perversion is often slight, and seldom so promi- nent. as in other acute insanities. Relief of the bodily symptoms is generally accompanied by a return to sanity. The affections which have been most frequently observed to produce this form of melancholia, are irritation and catarrh of the mucous membrane, constipation, stricture or other causes of distension of the viscera, ami pressure upon the stomach or intestines bv tumours in the epigastric region. Schroeder van der Kolk described the mental symptoms as being always due to affections of the colon; but disease of other portions of the canal — as the rectum and anus— seems also to produce them. John Sibbald. 7. Hereditary Insanity. — Srxox. : Fr. Folic hereditaire ; Ger. ErblicheGeisteskrankheit . — This implies insanity symptomatic of hereditary weak- ness of the nervous system, generally coming on without the intervention of appreciable exciting cause. The nervous system seems to be peculiarly liable to be involved in the effects of heredi- tary degeneracy, and this is frequently evinced by the occurrence of mental symptoms. The ages at which these are developed, and the character which they exhibit, depend both on the nature and on the strength of the hereditary disposition. The forms of insanity, however, which seem to be most directly the result ot hereditary influence, generally make their ap- pearance at those periods of life when either rapid structural development takes place, special functional activity is first exhibited or is ulti- mately arrested, or upon the advent of senile decay. The ordinary exciting causes of insanitv may also affect persons at these periods, and in such cases the resulting disorder will be stampel more or less distinctly with the impress of it* origin. But where these forces do not come powerfully into play, it is found that hereditary insanity exhibits a special character according to the period at which it is developed. We have thus an insanity of pubescence, a climacteric insanity, and a senile insanity. Idiocy and im- becility (which will be found discussed under their respective heads) are also frequent results of hereditary weakness, showing itself during foetal life, or during the period of dentition; and the INSANITY, VARIETIES OF. 725 mental derangements which often affect women at parturition, and during the processes which precede or follow it, seem to occupy a position in the pathological scale intermediate between the hereditary and the accidental form of insanity. Insanity of pubescence is a condition not un- frequently met with, and one which it is very important to recognise early in its true character. Much unintentional injury is frequently done by the patient being at first regarded as a de- linquent and treated accordingly, instead of re- ceiving the careful management suitable to the disease. The affection is characterised by great disorder of the emotional and moral nature, which is evinced by restless though seldom violent excitement, eroticism, acts of purposeless mis- chief, and exhibitions of inordinate vanity. Any marked changeof disposition during the passage from youth to adult life ought to be regarded as probably pathological in its nature, and must be carefully watched. Persistent sleeplessness at such a time must also be regarded as significant of danger to the mental functions. The physical condition is indicated by capricious appetite, and symptoms of anaemia. The treatment required is rest to the mind, both in its intel- lectual and emotional energies, with cultiva- tion of everything likely to develop physical vigour. If the hereditary tendency is not ex- ceptionally strong, or aggravated by accidental causes, the prognosis is not unfavourable. Climacteric insanity occurs in males between the ages of fifty and sixty, and in females be- tween forty and fifty'. Its general character is a form of melancholia, gradual in its develop- ment, manifesting itself in loss of sleep, fear of undefined evil, religious despondency, hal- lucinations of the senses, refusal of food, and frequently in a suicidal tendency. Excitement and exaltation occur rarely', and are generally off short duration. The mental disorder is fre- quently accompanied by very marked emaciation, ind the t endency is always to anaemia. The treat- ment required at the commencement is cessation of mental labour and change of scene. During the whole progress of the disease the diet should bo full and nourishing, and the digestive func- tions often require to be stimulated to healthy action. In the majority of cases the prognosis is unfavourable, and where recovery does not take place within one or at most two years the course is generally towards dementia. Senile insanity is essentially a form of de- mentia, which comes on gradually in persons who have passed through the earlier periods of life without disturbance of their mental health, but who break down in old age. Its principal features are loss of memory, slight excite- ments, whimsical likings and dislikings, queru- lousness, and a gradual decadence into fatuity. It is subject to occasional remissions, which are sometimes very short, as when caused by the stimulus of acute febrile conditions. But they are sometimes so prolonged as to amount prac- tically to recovery. Not infrequently the break- down of the nervous system pursues a rapid , course, aud in such cases there is often a marked similarity in the symptoms to those of general paralysis. Both mental and physical conditions m the advanced stages of each are sometimes practically indistinguishable. The diagnosis will depend on whether the characteristic first stage of general paralysis has been observed at the commencement, or only a gradual loss of physical and mental power. Paralytics, moreover, are seldom of advanced age. John Sibbaxd. 8. Impulsive Insanity. — Violent acts are committed under an insane impulse by numerous patients whose insanity is plain and acknow- ledged. They may be done under the influence of delusions or hallucinations, but the term im- pulsive insanity is commonly applied to a dis- order manifested, not by delusions and similar symptoms, but by acts of violence to which a patient is driven by blind, uncontrollable, and morbid impulse, whereby the will and the reason are overpowered for a longer or shorter time. These are for the most part acts of suicide or homicide ; and in connection with the latter, great controversy has arisen as to the responsibility of persons committing them. Here, as in moral insanity, there are no delusions ; frequently no change will have been detected in the individual prior to tho act, nor will there be observers of it. And it is a fact that the impulse may be satisfied and exploded in the act, and having thus found a vent may be felt no longer, at any rate for a time. It may be as sudden as an epileptic fit, and may, like the latter, bring relief to the brain. Indeed, there is a strong connection as well as analogy between the two disorders, and, as Dr. Maudsley says, instead of a convulsive movement there is a convulsive idea. In estimating such acts as these we must not only consider the act itself and the manner of its performance, but must also closely inquire into the past history of the perpetrator and his pro- genitors. For all this we may or may not have op- portunity. If the act is one of attempted suicide, and the individual is kept under observation, we may have no difficulty in diagnosing insanity. If it is one of homicide, and the criminal is in prison for, perhaps, only a week or two, op- portunity of ascertaining the history of his family may fail, nor will he himself be under skilled observation. Moreover the period just after the committal of an impulsive homicide will very probably be the one in which fewest symptoms of insanity will be noticeable. The period immediately preceding it will be that which most closely demands a scrutiny, but we may be able to get no information if the accused has been moving from place to place, has been among strangers, or has had those about him who were obtuse and unobservant. Many an act of sui- cide and homicide would be prevented if the friends would not shut their eyes with such per- tinacity to the strange and altered looks and con- duct of the patient. But in this impulsive form, although there may not have been enough to warn those about a man to restrain him, there may have been symptoms which are sufficient subsequently to indicate to a physician the presence of mental disorder. There may have been attacks of grand mal or petit mal : there may have been former attacks of insanity, periods of, it may be, slight depression, which, though they may have attracted little notice at the timev INSANITY, VARIETIES OF. 126 may indicate an insane diathesis. The sufferer may hare been sleeping badly or hare taken less nourishment than usual. The medical witness will, in the case of homi- cide, carefully examine and pay special attention to the following points : — (a) The nature and character of the act must be noted. The presence or absence of motive may often assist us. When the victim is near of kin and dearly loved, suspicion of insanity will at once arise. AVhen, on the other hand, it is a perfect stranger, never before seen, where there has been no previous meeting or quarrel, the same suspicion will arise. The method of the act may guide us somewhat, but not so much. There may be premeditation, though generally there is not. ( b ) The demeanour of the prisoner after the act may assist us. Were there, or were there not, attempts to conceal it, or to escape detection and arrest? What was said in explanation? It sometimes happens that there is complete un- consciousness or forgetfulness of what has oc- curred, and we may then strongly suspect the presence of epilepsy. (o) We must closely inquire into the family history, and shall often find that in cases of im- pulsive homicide, the family of the accused is saturated with insanity. And where this is so, we may also find that from youth the accused has been deficient and weak in intellect, or odd and eccentric. The weak-minded, in fact, may be grouped in a special class of homicides. As there is a weak-minded moral insanity, so there is a weak-minded impulsive homicidal insanity the sufferers from which have not unfrequently been hanged, their insanity not having been sufficiently marked to absolve them from legal responsibility. Fits in childhood may contribute to this state. And throughout, at the age of ppberty, or ; n adult life, there may be slight but sure indications of the insane blood that has been inherited, which are displayed in an im- pulse to homicide or suicide, even as in others the tendency is shown in ordinary attacks of insanity. (d) We must look very closely for symptoms or a history of epilepsy. Such indications as nocturnal micturition or a bitten tongue may guide us to the truth, while in acknowledged epileptics it may happen that the homicidal at- tack takes the place of the ordinary convulsion, and without the occurrence of the latter there may be a period of unconsciousness and uncon- scious action lasting, perhaps, for days. See Epileptic Insanity. The occurrence of one homicidal attack of a strange or anomalous character may make us fear its recurrence, and when we have to examine a criminal who has committed one act of this kind, it is important to inquire whether he has ever at any former time done any sudden act of violence of a similar description. For this reason such patients should not be released from an asylum, except under great and special precautions. G. F. JIlandfoed. 9. Legal Insanity. — Lawyers regard insanity from a different point of view from medical men. A medical man applies his mind to its study so as to ascertain how far he may infer from the evidences of mental action the existence of mor- bid conditions which he may hope to alleviate or remove. It is therefore hisduty to be acquainted with such symptoms as give the earliest indica- tion of the approach or development of these morbid processes. For it is during their initia- tory stages that he may most successfully inter- vene with the resources of his art, to check their progress or to ward them off. He there- fore identifies with the existence of disease, every deviation from the healthy mental standard which indicates the necessity for medical treat- ment or advice. A lawyer, on the other hand, takes note of insanity only in so far as it affects the safety of person or the preservation of pro- perty. The question which he seeks to deter- mine is whether a person is justly responsible for certain acts which he has committed, or is competent to perform certain acts which he mav be called on to perform. It is evident, therefore, that the legal view of insanity must naturally be much more limited than the medical. ■ A lawyer, when speaking of insanity,’ says Mr. Justice Stephen, ‘ means conduct of a certaiu character; a physician means a certain disease one of the effects of which is to produce such conduce ; ' an t though this has been adversely criticised it seems to show correctly the directions in which the two views diverge. They might perhaps be as fairly indicated in other words ifwe say that the lawyer has to deal with the naturo or quality of certain acts, while the physician has to deal with the condition of certain persons. No satisfactory general definition of legal insanity has been given. In the earlier ages of our legal system none but the most outrageous cases of insanity were recog- nised. Bracton in the thirteenth century defined a madman as ‘one who does not understand what he is doing, and, wanting mind and reason, differs little from brutes.’ Sir Edward Coke, though he recognises different classes, according as the insanity is congenital, permanent, or temporary, only admits that a person is insane when he is non compos mentis, or has wholly lost his memory and understanding. Sir Matthew Hale, in the seventeenth century, was the first to recognise the existence of less extreme forms of insanity. ‘ Some persons,’ he said, * that have a competent use of reason in respect of some subjects, are yet under a particular dementia in respect of some particular discourses, subjects, or applica- tions; or else it is partial in respect of degrees, and does not excuse persons who commit capital acts in this state.’ He also said that it is ‘very difficult to define the invisible line that divides perfect and partial insanity,’ and ‘ that most persons that are felons, of themselves or others, are under a degree of partial insanity when they commit these offences.’ The recognition of these gradations, reaching even to the mutual overlap- ping of crime and insanity, indicates as much breadth of view as could be expected at a time when the very judge who recognises them passed sentence of death on persons convicted of witch- craft. Wo cannot doubt, indeed, that at that period the ignorance of the nature of insanity was such that many lunatics were executed for this offence. The recognition of the necessity of takiug legal account of minor degrees of insanitv INSANITY, VARIETIES OE. 727 than ‘ furious madness ’ or idiocy may be said to commence at the beginning of the present cen- tury. The mode in which unsoundness of mind comes into relation with law at present, may be looked at most conveniently from three points of view: — 1. Where a person suffers from such unsoundness of mind that it is necessary for his welfare, or the safety of the public, that his liberty should be restricted by his being placed in an asylum or subjected to similar restraint. 2. Where a person suffers from such unsound- ness of mind that he is incapable of managing himself or Ins affairs. 3. Where irresponsibility for crime, on account of insanity, is pleaded in a court of law. It will be found more convenient to consider these three relations of insanity and jurisprudence separately. The reader is conse- quently referred to the articles specially devoted to them, which will be found under the heads of Lunacy, Law of ; Civil Incapacity ; and Cri- minal Ihresponsibility. John Sibbald. 10. Moral Insanity. — Synon.: Fr. Manie sans dilire ; Folie raisonnantc ; Monomanic affec- tive-, Ger. Gcmuthsxvaknsmn. Under the names of moral insanity , emo- tional insanity, impulsive insanity, affective insanity, has been described the disorder of certain patients, which is manifested by insane actions and conduct rather than by in- sane ideas, delusions, or hallucinations. Such persons are sometimes said to be of whole and perfect intellect, though unsound in the moral and emotional part of their brain. They come under the notice of medical men, not so much for purposesof treatmentasfordiagnosis. Their con- duct being chiefly displayed in foolish or violent acts, they require to bo restrained, and the ques- tion arises : Is this conduct badness or madness? are they responsible for it or not ? Dr. Maudsley gives moral insanity and impul- sive insanity as two subdivisions of emotional or affective insanity ; and, as the symptoms are certainly different, wo cannot do better than con- sider them under separate heads. But certain observations are applicable to both. In neither will there be found delusions, and as delusions are, in the opinion of some, especially lawyers, necessary to the establishment of legal insanity and irresponsibility, these patients are notlegally insane. Another remark is that this moral or impulsive insanity does not constitute a definite and well-marked disease, like acute delirium or general paralysis. Every patient may at one time or other bo ‘morally insane,’ that is, may not have reached the stage of delusions, or may have recovered from it, and every patient may commit ‘ impulsive ’ acts of violence, whether his insanity is displayed in other ways or not. By moral insanity is to be understood a dis- order of mind shown by an entire change of character and habits, by extraordinary acts and conduct, extravagance or parsimony, false asser- tions and false views concerning those nearest and dearest, but without absolute delusion. Such a change may be noticed after any of the ordinary causes of insanity. It may follow epilep- tic or apoplectic seizures, or may be seen after a poriod of drinking. Its approach is gradual, as a rule, rather than sudden, and the extraordinary character of the acts may not at first be so marked as subsequently. Friends wonder that a man should say this or that, or should do things so foreign to his nature and habits, but some time may elapse before they can convince themselves that such conduct is the result of disease, and the acts may be such that many will look upon them even to the last as signs merely of depravity. Such insanity of course varies in degree. When it is well marked, and the conduct is outrageous, there will be no diffi- culty in the diagnosis. But it may be loss marked ; it may consist of false and malevolent assertions concerning people, even the nearest, of little plots and traps to annoy others, in which great ingenuity and cunning may be displayed. And there will be the greatest plausibility in the story by which all such acts and all other acts will be explained away and excused. It would seem sometimes as if a universal badness had taken possession of the individual, yet a badness so inexplicable that it can only be looked upon as madness. Where we can ascertain that this condition of things is something which has come over the patient, being formerly absent, and that he is altogether changed, we may suspect insanity. But much examination and opportunity for ex- amination may be needful before wo can sign a certificate, for such people are often very acute, and quite on the alert. They have no scruples about falsehood, and will deny or justify every- thing with which they are taxed ; and where the insanity is manifested in conduct, the medical man may never be a witness of it, and is obliged to receive on hearsay that which the patient strenuously denies. Careful inquiry, however, will probably reveal the origin and cause of the change ; there may have been a period, though short, of acute insanity — as acute mania or me- lancholia — which passed away and left this as a permanent condition; or it maybe the precursor of a more advanced stage of the disorder, one marked by the ordinary symptoms, as delusions and hallucinations. If the change has been rapid and progressive, if the sufferer has become more and more outrageous and eccentric, it is likely that in a short time unmistakable in- sanity will be displayed ; but some cases pro- gress slowly, and steps for restraint have to be taken before anything like delusion is to be found. It may be necessary to prevent a man from squandering all his property — a common symptom in this variety — or from wandering from home and absenting himseif no one knows where, or keeping low company. And when a man previously quite sober suddenly takes to drinking, the question may arise whether this is not the effect of insanity. Great diffi- culty may be found in proving the latter, but unquestionably it is often the case. Here, how- ever, if the habit is indulged in, the patient will most likely get rapidly worse, and then restraint will be more easily enforced. Moral insanity may be the precursor of general paralysis ; it may also be the sequel and result of a more severe insanity ; it may be the outcome of apoplexy, or of a blow or other damage to the brain. It may be one of the alternating states of the 6o-called Folie circulaire. Here a period INSANITY, VARIETIES OF. , 7 28 >f depression alternates with one of excitement, gaiety, self-glorification, ot irascibility, and the latter may be one closely resembling that usually called moral insanity, and evidenced by exag- gerated conduct and absurd acts. It may follow a simple attack of epilepsy, or may be the pre- cursor of such attacks, being a part of that epi- leptic condition known as masked epilepsy. See Epileptic Insanity. The one constant and marked feature of this insanity is the absence of delusion ; but we are not on this account to argue that the intellect is sound. There is often great acuteness and cunning displayed by such patients, yet along with the cunning there may be the most silly and foolish conduct. Often there is great acute- ness shown by those who have delusions, but because of the latter we say their intellect is disordered. Yet it is proof of disorder of the intellect if a patient spends his capital as though it were income, defends and justifies the most outrageous acts, and cannot be made to see that they are outrageous. Close examination will probably reveal the fact that there is very con- siderable intellectual lesion in these cases. There is a want of the power of attention and concen- tration of ideas on a subject. A patient com- mences a story of his grievances, and in two minutes is far away from his theme, and is boast- ing of his virtues or conduct, and no amount of bringing back will enable him to give a definite and succinct account of what he has to complain of. Such rambling is a marked symptom of this insanity, and a strong indication of a weakened intellect. There is one more form of moral insanity which is, perhaps, the hardest of all to diagnose and estimate. It is the congenital moral defect occasionally met with in persons who have been from birth odd and peculiar, and incapable of acting and behaving like other people. They can hardly be called idiots or imbeciles, for they may exhibit a considerable amount of intellect and even genius in certain special directions. We shall generally find that they are the offspring of parents strongly tainted with insanity, epi- lepsy, or alcoholism, and many in childhood are tire subject of fits, chorea, or other neuroses. They are incapable of being instructed like other boys aud girls, are often frightfully cruel towards animals or their brothers and sisters, and seem utterly incapable of telling the truth or under- standing why they should do so. Here there is no change ; we cannot compare the individual’s condition with a former one, but we can only estimate him by the average of mankind. These are the persons who commit crimes and become the chronic inmates of prisons, and it is most difficultboth for medical and otherprison-officials to say how far they are responsible, and how far not. Careful and special education is needful for them, and this they may obtain if they are born of well-to-do parents, but a vast number are to be found amongst the ranks of the lower classes; the offspring of intemperance and poverty, they swell the numbers of the criminal classes in no inconsiderable degree. G. F. Biandfobd. 1 1. Pellagrous Insanity. — This is a form of insanity associated with pellagra, and not n:e( with in Britain. It is characterised by mental symptoms usually indicative of anaemia — great depression, frequently with tendency to suicide, passing on to chronic dementia. It is most fre- quently met with in Italy. 12. Phthisical Insanity. — It has been gene- rally observed that there is a special mental cha- racter associated with pulmonary tuberculosis. This consists frequently in a peculiar cheerful hopefulness, which has received the name of spet phthisica, and which seems strangely out of har- mony with the unmistakable signs of an inevit- able doom by which it is accompanied. But there is also a state of mental depression which has been observed in intimate association with the disease. Tho peculiar hopefulness is most frequently met with in the acute and active f orms of phthisis, and it is often so irrational and per- sistent us to amount to an insane delusion, grow- ing as it does in strength while the evidences of its baselessness accumulate. In the last stages of the malady the religious and general emotional exaltation is often extreme, and actual delirium is not infrequent. An opposite mental condition is met with in chronic phthisis, more especially in that form of it which has been called latent. All through the course of the disease there is a prevailing depression and distrustfulness, though the physical symptoms are neither so distressing nor so obvious as in the acuter forms. The men- tal symptoms sometimes precede the physical. Languor and depression, mingled with wayward- ness. are characteristic of the initial stage. This is usually accompanied by general functional debility, which is often attributed to mere dis- turbance of digestion and nutrition. The skin is habitually pale, and the circulation feeble. In many cases the physical signs of pulmonary dis- ease when present are apt to be overlooked, and occasionally they escape observation for years. Where the mind is much affected the ordinary symptomatic cough, expectoration, and dyspnoea are often absent ; and this is the case sometimes where physical exploration reveals the existence of extensive vomicae and other characteristics of advanced disease. The mental condition as the further stages are reached becomes less one of depression and more one of distinct enfeeble- ment. Occasional fits of considerable irritability and excitement occur. Dr. Clonston, who first drew special attention to this condition, says of the patients that ‘ there is a want of fixity in their mental condition. There is a disinclination to enter into any kind of amusement or con- tinuous work; and if this is overcome there is no interest manifested in the employment. It might be called a mixture of subacute mania and dementia, being sometimes the one and sometimes the other. As the case advances, the symptoms of dementia come to predominate ; hut it is seldom of that kind in which the mental faculties are entirely obscured, with no gleam of intelligence or any tendency to excitement. If there is any tendency to periodicity in the symp- toms at all, the remissions are not so regular, nor so complete, nor so long as in ordinary periodical insanity. If there is depression it is accompanied with irritability and the want oi INSANITY, VARIETIES OF. an}' fixed depressing idea or delusion. If there is any single tendency that characterises these eases, ir. is to be suspicious.’ Where any chronic form of insanity is associated with phthisis the chance of complete restoration to sanity is very small. In the affection distinguished by emo- tional exaltation no special treatment is called for. The only indication of treatment in the other type of disease is the necessity of keeping up a full supply of nourishment to the brain ; and this sometimes requires that forcible feeding should be resorted to. Where the mental con- dition is much disturbed, a trustworthy attend- ant ought to be employed, and the general treat- ment should always be tonic and stimulating. Removal to an asylum ought in most cases to be avoided. John Sibbald. 13. Puerperal Insanity. — Synon. : Insania gravidarum; Insania puerperarum ; Insania lac- tantium ; Fr. Folie puerperale ; Ger. Puerperal- manie. Definition. — Insanity developed during preg- nancy, parturition, or lactation. It has been the custom of authors, till a recent period, to include under this heading the forms of insanity which occur in females during the periods of utero-gestation, the puerperal state, and lactation. It is now frequent to find the term ‘ puerperal’ restricted to the derangements which come on at the time of delivery, or within a short period thereafter. Whatever names we adopt, it is impossible to consider the insanity occurring at these different periods quite inde- pendently. The condition of the woman during tlie whole process, from the time of conception till the child is weaned, represents one of those physiological crises during which congenital or acquired weakness of constitution tends to show itself. The insanity of pregnancy generally takes the melancholic form, and seems to be due in some cases chiefly to a gradually developed anaemia, and in others to disturbance of the abdominal viscera, both of which conditions are frequently associated with mental depression. The delusions which characterise the disorder are generally exaggerations of the anxieties and , whims so frequent in pregnancy. In the severer ■ forms the suicidal impulse is frequently developed. ; The prognosis is generally favourable; but re- covery seldom occurs till the termination of the gestation. It may sometimes be expedient to resort to the induction of premature labour. In all cases a torpid condition of the digestive func- tions should be carefully corrected. Puerperal insanity in its more restricted mean- ng is frequently understood to include all de- rangements occurring at parturition, or within six or eight weeks after it. Rut it is better to imit the term to what occurs during the first hree weeks, as the form of disorder which com- nences after that period is generally different in haracter. ■(Etiology. — Prominent among the causes of merperal mania are all states of debility, either nduced before parturition by want, intemperance, isorders of nutrition, or rapid succession of preg- ancies, especially if lactations and pregnancies le carried on simultaneously ; or it may be the 723 result of weakness induced during parturition by hsmorrhage or exhaustion. It is liable to occur in primipar®, when the subjects are either exceptionally young or exceptionally advanced in life. Irritation arising in the pelvic organs, intestines, or mammae also tends to produce it. Any inordinate mental excitement or depression is apt to bring it on. Where any of these causes are superimposed on hereditary tendency, the danger is of course greatly augmented. Symptoms. — Attacks of maniacal excitement sometimes occur during actual parturition. They are usually of very short duration, and seem to be directly dependent on the intense suffering which may accompany the pains. The most fre- quent period of their occurrence is when the head of the child is passing either the os internum or externum. The more serious phase of the dis- order is in its acute stage a variety of acute maniacal delirium. It usually commences with- in a week or ten days after delivery. Gen- erally it is preceded by sleeplessness, and the patient manifests more or less apprehension of coming evil. Sometimes, however, she awakes delirious from what had been regarded as a healthy slumber. When the attack has com- menced, sleep is always either very imperfectly obtained, or is altogether absent. The pulse is quick ; the skin often, but not always, dry and hot ; and the head throbbing. The eyes are bright, and the face generally pale, with occasional flushing. The expression is generally indicative of alarm or suspicion on the part of the patient. The tongue is dry and furred, and the secretions of milk and lochia are either suppressed or diminished. The bowels are sometimes loose, but constipation is the usual condition. The appetite is uncertain ; sometimes it is impaired, but more frequently it is abnormally large. Not infrequently the sense of taste is perverted, and the patient suspects the presence of poison in her food, and persistently refuses it. The breath is often offensive in odour. Sometimes the men- tal excitement does not reveal itself in language, and the patient may be obstinately taciturn from the commencement. But there is usually a great increase of loquacity, gradually increasing from the beginning, and passing into incoherent raving. Sudden impulsive acts of violence fre- quently manifest themselves in this disorder, and in these the patient often attempts to destroy herself, her child, or persons for whom she has usually the most affectionate regard. She generally appears to be dissatisfied with those in attendance on her, and often entertains delusions as to their identity. In many cases the mental condition bears a strong resemblance to that of delirium tremens, especially when the patient has undergone privations, or has been intem- perate during pregnancy. Diagnosis. — The only conditions for which puerperal insanity may be mistaken are the typhoid delirium of puerperal fever or pyaemia ; and the violent excitement frequently sympto- matic of meningitis. In these cases the febrile condition precedes the development of the deli- rium, while in puerperal mania the mental symptoms show themselves from the first. In meningitis the pupils are generally contracted, ] and the headache is peculiarly intense; ■while in 730 INSANITY, 1 puerperal mania the pupils are usually dilated, and the h eadache i s n ot a very prominent symptom. Pkoqnosis. — According to the published sta- tistics of this disease, recovery may he expected in about 70 per cent, cf the cases, and a fatal termination need not be anticipated in more than 5 per cent. But as these figures are in a great measure obtained from asylum statistics, and other sources in which only the severer and more persistent forms have been taken into account, it may be fairly assumed that the true estimate would be much more favourable. The duration of the insanity may vary from a few days to a year, after which time the proportion of recoveries becomes extrenjely small. The great proportion of recoveries takes place during the first six months. The most favourable symp- toms, in addition to amelioration of the mental symptoms, are increase of bodily weight, and re- storation of the catamenia. Treatment. — The transitory mania which sometimes accompanies tho severer pains of labour does not require special treatment ; but anaesthetics may be given as a preventive measure in cases where there is a known liability to such excitement. Special care ought also to be taken after such attacks, until the strength is fully restored, to avoid injury by premature bodily exertion, unnecessary social intercourse, disquiet- ing news, or any kind of mental or moral strain. In the treatment of the graver form of puerperal mania, the chief objects are to remove all sources of irritation, to restore the patient’s strength, and to obtain repose. If there is any accumulation of faeces, a smart purgative should he at once ad- ministered. If the locbial discharge is scanty, an injection of warm water, containing carbolic acid or some other antiseptic remedy, should be given per vaginam. The condition of the bladder should be ascertained, and this organ should he relieved, if necessary ; care should also bo taken not to allow the breasts to be over-distended. In those cases in which violent excitement does not come on suddenly, an attack may sometimes be warded off or cut short by relieving the sleepless- ness which is one of the early symptoms. As a hypnotic about thirty grains of chloral is the best. Opium ought to be avoided, and hyoscya- mus and belladonna cannot be relied on. In every case the patient should receive from the first as much light and nourishing food as her digestive powers can properly hear ; for it must always be remembered that we have to deal with a condition of ansemia. Both in the first stage, and when the disease is more advanced, everything must be done to promote tranquil- lity. The room should he darkened, and still- ness maintained as' far as possible, for the at- tention of the patient is very easily excited, and both vision and hearing are preternatu- rally acute. Constant supervision is necessary, however, on account of the tendency to sudden impulsive violence ; and the patient should see her infant as seldom as possible. After the maniacal condition has fairly declared itself, the child should be removed altogether, as its pre- sence is sometimes productive of great excite- ment in the patient, and must always be regarded as attended with risk to itself. In cases where the excitement is somewhat of a hysterical VARIETIES OF. character, bromide of potassium, given in twenty, grain doses at intervals of four Lours, may pro- duce good results. Cooling applications to the bead sometimes soothe irritation, and induce sleep. Digitalis in small doses, and warm baths, have proved useful. Alcoholic stimulauts should generally be given with the food ; their effects being carefully watched, and the quantity varied accordingly. Bleeding and every kind of deple- tion should be avoided. The nursing and attendance should, if possible, be entirely en- trusted to strangers, and the patient should not be permitted to see any members of her family. It will sometimes be necessary, especially in the case of poor persons, to resort to asylum treat- ment ; but this ought not to be done if it can be avoided ; and with patients in good circumstances it ought never to be necessary in the acute stage of the disease. When the disease becomes chronic, tonics, such as quinine and iron, ought to be given, and a plentiful supply of nourish- ment should then, as all through the illness, b» carefully administered. Patients liable to this disorder should not be allowed without consider- ation to nurse their children. The insanity of lactation is symptomatic of causes which come into play after the puerperal period, and it ought perhaps to be looked on as symptomatic merely’ of prolonged ansemia. Acute maniacal symptoms of short duration may occur; but the characteristic condition is melancholia, ushered in by headache, tinnitus aurium, flashes of light before the eyes, and other signs of debility. A suicidal tendency sometimes appears. The treatment required is to wean the child, and generally to save and increase the strength of the patient. The prognosis is favourable in the majority of eases. John Si.ibald. 14. Syphilitic Insanity. — Amonsthe results of constitutional syphilis, affections of the nervous system are not uncommon ; and when the disease affects the brain, the mental symptoms that arise are found in the majority of cases to present a marked similarity in their character. In such cases the mental disorder is generally preceded, as in so many forms of insanity, by distressing sleeplessness. This is followed gradually by in- creasing depression of mind. Religious anxiety of a peculiarly hopeless character frequently shows itself. Exaggerated self-accusings are earnestly uttered by those who have previously been unusually callous as to the results of their actions. Hypochondriacal delusions are not un- common, and are frequently associated, in the mind of the patient, with the fact of the syphi- litic infection. The feeling of alarm which ac- companies these symptoms sometimes developes into a violent excitement, which may be called maniacal. If the symptoms he associated with any of the ordinary signs of syphilitic poisoning — the dry, scaly skin, and the sallow lean face ; and especially if any of tho characteristic erup- tions are present, the mental disease may. he expected to yield to treatment by mercurials and iodide of potassium. The mental symptoms which have been here described seem to occur without the existence of any important structural lesions in the encephalon. The development oi gummy products within the cranium is frequently INSANITY, VARIETIES OF. evinced by symptoms similar to those of general paralysis. Headache of very persistent character, giddiness, vertigo, and epileptoid fits occur, accompanied at first with mental depression. During the progress of the disease attacks of acute delirium are not unusual. Sometimes extravagant delusions, such as are frequent in general paralysis, are exhibited ; but generally the progress of the disease is characterised by a gradual falling into dementia. The prognosis in such cases must be regarded as unfavourable, but considerable improvement frequently follows the administration of antisypliilitic remedies. John Sibbald. INSECT PARASITES. — Insect parasites are of two kinds, external and internal. The former are described under several affections of the skin (see Pediculi ; Scabies ; &e.) ; the latter are classed with the entozoa. See (Estrus ; Chigoe ; and Demodex. INSENSIBILITY (in, not, and sentio, I perceive). — This word signifies either loss of con- sciousness ; or merely loss of sensation in a part. See Consciousness, Disorders of; and Sensation, Disorders of. INSOL ATIO (in, in, and sol, the sun). — A synonym for sunstroke (see Sunstroke). Inso- lation is also used to designate a method of treat- ment, which consists in exposing the patient to the rays of the sun. INSOMNIA (in, not, and somnus, sleep). Want of sleep, or sleeplessness. See Sleep, Disorders of. INSPECTION (inspicio, I look upon).— The technical name for the examination of a patient by the sense of sight. See Physical Examina- tion. INSTILLATION (in, into, and stilla, a drop). — The method of applying remedies to a part in the form of drops. Instillation is chiefly employed in connection with the eye. INSUFFICIENCY (in, not, and sufficio, I am sufficient). — A synonym for incompetence. See Incompetence. INSUFFLATION (in, into, and sufflo, I bloiv). — This term is used in the same sense as inflation (see Inflation). It is also a name given to a method of applying remedies in the form of powder to the throat and respiratory passages, by blowing them through a tube into these parts. See Inhalations, Therapeutic Uses of. INTEGUMENTS, Diseases of. See Skin, Diseases of. INTELLECTUAL INSANITY. See In- sanity. INTEMPERANCE, Effects of. See Al- coholism ; and Disease, Causes of. INTERCOSTAL NEURALGIA. —Any of the dorsal nerves may be the seat of neuralgia, not differing materially in its symptoms from neuralgia affecting other mixed nerves, but espe- cially important from a diagnostic point of view. The pains are paroxysmal ; usually affect the region of distribution of the anterior division of , INTERCOSTAL NEURALGIA. 731 one or two of the dorsal nerves ; and are confined to one side, most frequently the left. ^Etiology. — The female sex, neurotic heri- tage, and weak general health predispose to in- tercostal neuralgia. As determining causes may be mentioned blows ; the action of cold ; local injury to the nerves from the growtli of thoracic aneurism ; and disease of the vertebrse. Ex- haustion from oversuckling, menorrhagia, or leucorrhcea; irritation from cracked nipples; and pregnancy are all occasional but.imporlant causes of this form of neuralgia. The pain met with in the chest in early cases of phthisis is not un- frequently due to intercostal neuralgia. Symptoms. — Pain is complained of at some part of one side of.the thorax or abdomen, most often in the region innervated by the sixth, seventh, eighth, or ninth intercostal nerves, and much more frequently in the front or side than behind. It is occasionally found in the axilla and inner side of the arm. The pain may be intermittent, occurring in paroxysms, varying in number from a recurrence every few minutos to only two or three such during the twenty-four hours ; or there may be persistent pain of a dull character, interrupted at varying intervals by darts of a very sharp kind, which may sometimes be'referred with precision to the course of the neighbouring nerve. The pain is described as ‘tearing,’ or resembling such injuries as a ‘stab of a knife,’ or ‘ boring with a red-hot iron.’ The acts of coughing or sneezing, as well as any rapid movements of the body, are apt to increase the distress, but the pain is also independent of these disturbances, and will attack without any such provocation. The pain is sometimes more of a wearing than acute character, and tho rest will often be destroyed by it. Painful points are sometimes to be discovered in the following situations: — 1. Over a spinous process corre- sponding to the emergence of the affected dorsal nerve from the intervertebral foramen. 2. At the side of the chest or abdomen, where the lateral branch becomes subcutaneous. 3. Near the sternum or at the margin of the rectus abdo- minalis muscle, at any part down to the pubes, where the termination of tho nerve supplies the skin. The skin in the neighbourhood of the tender points is sometimes so hyperaesthesie that the pressure of the clothes is painful. In epileptics and other highly neurotic patients, intercostal neuralgia is often associated with palpitation of the heart, and the pain is usually referred in a vague manner to that organ. Close examination will show that it is in the chest-wall, and tender points may generally be discovered. The affec- tion is not accompanied by fever. Tho paroxysms of pain may produce fainting and vomiting. They often cause dyspnoea, ■with an anxious expression of face, from the inability to draw a full breath without starting the pain. Complications. — Intercostal neuralgia is some- times accompanied by herpes zoster. The pain usually precedes the appearance of the eruption, but it is occasionally coincident only, and some- times comes after it ; more often than not it out- lasts the eruption, it may be for a long period. In certain cases actual pain lasts but a few days, but is succeeded by an intolerable itching, which is described as being under, not in the skin. This 132 INTERCOSTAL NEURALGIA, sensation is said to be felt less in walking than when at rest. Not unfrequentlv neuralgia of some other nerves, either at a distance, as the fifth, or ana- tomically near, as the brachial plexus, occurs as a complication of intercostal neuralgia. This is especially likely in cases happening in the period of bodily decay. It is then too, that the affection may occasionally be accompanied by attacks of angina pectoris. Diagnosis. — Absence of pyrexia, as shown by the use of the thermometer ; the intermittence of pain, and its occurrence irrespective of respira- tory movements, although liable to be precipi- tated by them ; and the results of physical examination, serve to distinguish intercostal neu- ralgia from pleurisy, a condition with which, on account of resemblance in the stabbing character of the pain, it is very apt to be confounded. from muscular rheumatism it maybe discrimi- nated by the presence of the small and charac- teristic tender points ; tenderness of the spinous processes on pressure ; and by the pain being found to be not dependent upon movements. The same features serve to distinguish it from myalgia, especially that form which often comes from long-continued use in an unaccustomed manner of some muscle attached to the ribs, as when a person unused to carpentering handles i he saw energetically for a loug time. Physical examination and the presence of py- rexia, will preserve from the error of confounding the dull pain often noted in pneumonia with that of intercostal neuralgia. Pains of a stabbing, plunging, or electric- shock-like character are often experienced in the intercostal spaces in the course of locomotor ataxia, and it is important not to confound this disease with a simple attack of intercostal neu- ralgia. The distinguishing points are the occur- rence of similar pains coincidently or alternately in other parts of the body, especially in the lower extremities; the absence of patellar tendon re- flex ; and the characteristic gait (if present) — all which mark locomotor ataxia. Prognosis. — As in the case of other forms of neuralgia, thatof the intercostal nerve can hardly be said to be attended with danger, though it must be allowed that in some very rare instances the severity of the pain appears to have actually destroyed life. It is apt, however, to be of trouble- some duration, lasting for periods of weeks or months, and liable to recurrence. Treatment.— Search should be made in other branches of the same nerve, and in the distribu- tion of neighbouring nerves, for any source of irritation which it is possible to remove. Consti- pation of the bowels should be treated by 3 grains of pilula hydrargyri, followed by some Fried- richshall or Hunyadi Janos water, repeated for two or three days. Quinine should be given in doses of from five to ten grains twice a day ; and if there should be a state of antemia, steel should be added. Exposure to cold and damp must be avoided; whilst the surroundings generally should be favourable to improving the nutrition and tone. If the pain be very acute, and sleep pre- vented, morphia may be injected hypodermically in the neighbourhood of the affected nerve, com- mencing with a dose of an eighth of a grain, and in- INTERMITTENT FEVER. creasing this, if necessary, to a quarter of a grain in the twenty-four hours. This dose should not be repeated, however ; and it is better to be satisfied with a repetition of the smaller dose, if required. Small blisters (size of half-a-erown) may be applied to the neighbourhood of the spinal column, near the point of emergence of the affected nerve, one succeeding another as it heals. The continuous voltaic current, from about 10 to 20 cells, Leelanche or Stohrer, may be ap- plied, one sponge on the spine and the other upon the painful points, in turn. There is no better application than collodion flexile for the herpes zoster which sometimes complicates in- tercostal neuralgia. See Neuralgia. T. Buzzard. INTERLOB U LAK (inter, between, and lobulus, a little lobe). — Situated in the tissue between the lobules of any organ. A good illus- tration is interlobular emphysema, in which air occupies the parts between the lobules of the luDgs. INTERMITTENT ( intermitto , I leave off for a time). — A temporary cessation or sus- pension. either of a function, for example, of the action of the heart, when the pulse is said to intermit ; or of a disease, such as neuralgia or ague, when the symptoms cease for a certain time. See Pulse ; and Intermittent Fever. INTERMITTENT FEVER. — Synos. : Ague ; Fr. Fievrc Intermitiente ; Ger. Katies Ficber. Definition. — A fever of malarial origin, cha- racterised by the sudden rise of temperature during the paroxysm ; by the equally sudden fall at its termination ; and by the regularity of the times of accession and apyrexia. .Etiology. — Intermittent fever belongs to the class of malarial or paroxysmal fevers. It is the most typical, and the most common of the class. The human system once subjected to the pheno- mena of a regular attack of ague in any of its forms, is for the remainder of the life of the per- son so affected liable to a repetition of the attack, without his necessarily having been exposed afresh to the action of its cause. This tendency is very commonly shown in those who, after long residence in hot and malarial climates, are ex- posed to the influence of cold, and especially easterly' winds, on their return to temperate cli- mates in the spring time of the year. The more the person has suffered from tlie blood-changer and visceral degenerations described in the ar tide Malaria, the more prone is he to such recurring attacks. Anatomical Characters. — In the article Malaria the pathology of intermittent fever is fully discussed, including its probable depen- dence on the presence of the liacillus malaria in the body. The spleen is enlarged, and in pernicious agues proving rapidly fatal, it is found in a state of softening, often reduced to a state of deeply pigmented pulp. Death is common in malarious countries from rupture of the spleen, the result of blows or kicks, ofte.i of no great severity. The liver is usually lounJ somewhat congested aud pigmented, and in cases of long standing it enlarges like the spleen, with INTERMITTENT FEVER. the same increase in the connective tissue. In the algide cases hereafter described, when blood is driven in large quantity into the abdominal viscera, the digestive mucous membrane of the stomach and duodenum is congested and softened. The heart is invariably soft and flaccid, pale, sometimes of a dirty yellowish colour— degenera- tive changes induced by the combined action of diseased blood and high temperature. Blood-changes. — Blood-changes sometimes take place both in intermittent and remittent fevers with astonishing rapidity. Army medical officers serving in the Mauritius during tho epidemics of malarial fever which prevailed there some years ago. noted that the sufferers were often reduced to a state of complete anoemia in a few hours ; the same is tho case in Algeria {see Malaria). In such cases dropsical affections supervene, often rapidly, and military medical officers there record cases 1 proving suddenly fatal from oedema of the glottis.’ The blood is changed before any of the usual symptoms of an attack are present— it becomes dark in colour; the serum which separates has a dark brown colour ; and when exposed to the air, the coagulum, which is large and loose, does not assume its usual bright- red colour. The white corpuscles are immensely increased in number ; and tho red corpuscles do not evince their usual tendency to run together in rouleaux. State of the urine. — The urine contains a large amount of free acid, and retains a highly acid reaction for many days in the hottest weather. In tile intervals it is often alkaline. When the paroxysms cease, the watery part of the urine diminishes ; and it assumes a deep orange colour, depositing also an abundant sediment of urate of ammonia. This change is often observed by intelligent patients, who learn to appreciate its favourable significance. The late Dr. Parkes has shown that at the first elevation of temperature the urea increases ; this lasts during the cold and hot stages ; then it decreases, falling below the healthy average. Colin and other French authors note the enormous excretion of urea in malarial fevers both in Italy and Algeria. Symptoms. — Three forms of ague have long been recognised, namely, the quotidian, which re- curs in twenty -four hours ; the tertian in forty- eight hours ; and the quartan in seventy hours. The term double tertian is used when the paroxysm recurs regularly on alternate days, the attacks being alike in severity and duration. Other more rare forms of the irregular type have been de- scribed, as the triple tertian, with two paroxysms in one day, and one the next; the double quartan, with a regular fit one day, a slight one the next, and a complete intermission on the third day. The quotidian is the most common ; the quartan the rarest of all — a rule which seems to hold good wherever malarial fevers prevail. The quartan type has been noted from early times for the te- nacity with which it clings to its victims. Premonitory symptoms. — These are much the same as in all febrile disorders, namely pain in the back and lower extremities, languor, lassitude, gastric irritation, loss of appetite, nausea, and Bometimes vomiting ; with occasionally frequent calls to micturate, tho urine being pale and highly acid. Then follow in succession the three 733 stages, the cold, the hot, and the sweating ; succeeded by what is technically known as the interval or apyrexial period, which lasts i'or a number of hours, varying according to the typo of the disease. Cold stage. — Tho patient experiences a sense of coldness in the back; then rigors set in, at first faintly, becoming quickly more distinct, until tho teeth chatter, and the patient feels cold all over, and demands to have clothes heaped on him ; the skin shrivels, the nails become blue, and ho ex- periences a sensation of intense discomfort. This feeling of cold is, however, only a ‘subjective symptom,’ for if a clinical thermometer be placed in the mouth or rectum, even beforo distinct rigors set in, it will indicate a rise in the tem- perature of from two to three degrees. The skin, from contraction of the superficial vessels, is in- deed colder than natural, but from the first tho temperature of the blood is above the normal. The phenomena of the cold stage are gastric irri- tation, a foul tongue, a rapid pulse, and quickened respiration, with a feeling of coldness not cou firmed by the thermometer. Hot stage. — As this sets in, the patient grow' warm all over, the face flushes, the pulse rises in frequency and volume, the skin grows hot, and the patient becomes restless, seeking ease to hie aching head, back, and limbs in frequent change of posture. The tongue in this stago is usuallj dry, often bilo-tinted; and the bowels are consti- pated. Sweating stage. — At first beads of perspira- tion appear on tho brow and face, and the hands become moist; and soon, to the immense relief of the patient, his whole body sweats freely, the temperature begins to decline, and the paroxysm is at an end. The average duration of the parox- ysm is from five to six hours, but in severe cases it may last for twelve hours. When sufferers have been exposed to malaria in such places as the mangrove swamps of Africa, ‘ they will be re- minded of what their systems have imbibed in the way of surroundings by the sickly scent of the swamps thrown off in the secretion through the skin.’ (Waller.) Both officers and soldiers who came under the care of the writer on their return from the late expedition to the Gold Coast, observed tho same fact in their own persons ; some were severely nauseated by the unpleasant smell, recalling the stench of the places where the poison was probably taken into their systems. Temperature. — The rapidity with which the temperaturo in ague rises to 105°, 106°, and sometimes 107° Fahr., and the equally sudden manner in which it falls when the sweating stage begins, is a very notable and characteristic fact of great diagnostic value. According to Wunder- lich, nothing like this is to be seen in.any other disease, with the exception of cases of relapse in typhoid, the febrile paroxysms in acute tuber- culosis, and pyremia. As soon as the sweating stage begins, the temperature declines, at first slowly, then as rapidly as it rose ; when the de- fervescence is complete, it will be found one or two points of a degree below the normal, where it remains during the period of apyrexia. If tho paroxysms he cut short by quinine, wo may still I detect at the hour of expected attack a distinct INTERMITTENT FEVER. 1 34 rise in the temperature, although none of the other symptoms of a paroxysm may occur, and the patient may be hardly sensible of it. Pernicious agues. - — This term is much used both by French and Italian authors, who apply it to cases both of intermittent and remittent fevers, in which certain symptoms are developed, such as delirium, coma, an algide condition ; in a word, any serious complication placing the life of the patient in peril. So far at least as intermittent fever is concerned, this pernicious form appears to bo more common in the intensely malarious regions of Italy than in India. Such was the experience of the writer, in whose large sphere of observation such grave complications were almost entirely confined to the worst forms of remittent fever, contracted in places notori- ously dangerous. The writer is strongly im- pressed with the belief that the ‘ pernicious ’ symptoms, the mental incoherence' and delirium, the coma, and the ‘algide condition’ so much dwelt on by some Italian physicians of the old school, were often the result, not so much of the disease, as of the lowering treatment to which they subjected their patients. The algide form of ‘pernicious’ intermittent is sometimes described by writers on the diseases of India as ‘ ague of adynamic type,’ and it was frequently seen and well described by the French military surgeons both in Algeria and in Rome, during the long occupation of that city by the French army. The surface is cold, but, unlike the cold stage of an ordinary ague, the patient is unconscious of the low temperature of the surface. The internal temperature is high, and of this lie is aware. There is an immense accumulation cf blood in the abdominal viscera, with great thirst. Hie expression of the patient is tranquil, and his intelligence is intact. ‘ II se sent mourir,’ says Maillot, ‘et l’abattement est tel qu’il se complait dans cet etat de repos ; son physionomie est sans mobility ; Impassibility la plus grande estpeinte sur la visage.’ (Maillot, Coliu.) Complications. — Intermittents may be compli- cated by attacks of various diseases of greater or less severity — attacks often governed by cli- matic causes, by the habits of the individual patient, or by the fact that he has suffered from one orotlierof such diseases on previous occasions, such as pneumonia, bronchitis, asthma, dysen- tery, diarrhoea, or epilepsy. It is an old observa- tion that the last-named disease, even in so-called ‘confirmed epileptics,’ sometimes disappears when the victim becomes the subject of an attack of ague. One very striking examplo of this kind the writer has seen. Pneumonia is certainly the most formidable complication met with in intermittent fever. In- valids returning from India or from other hot and malarial climates to high latitudes, unless they are carefully protected by suitable clothing, are prone to suffer from this disease. The ra- pidity with which consolidation of the lungs takes place in such cases is very remarkable. It is not an uncommon thing to see five or six cases of this kind out of one party of invalids landed at Netley from India, if, on entering the Chan- nel, they have been exposed to cold weather. The pneumonia is generally double, and recovery is rare. the patients either sinking at once, or dying after a longer or shorter illness from pneu- monic phthisis. Pneumonia of this type is a common and fatal disease among the malaria- poisoned civil population of Rome during the winter months; and the French military surgeons record its prevalence in the French garrison there at the same season, and also among malarial in- valids sent back to France both from Algeria and Rome ( Recueil des Memoir es Med. MU. t. ii. 2* Sirie, p. 268). "When pneumonia occurs as a com plication of any form of malarial fever, it is one of the gravest import. There is no difficulty in making the diagnosis by the ordinary means. Diagnosis. — An ordinary intermittent presents no difficulties. The well-marked nature of the paroxysms ; the sudden rise of temperature and its equally sudden decline; the splenic enlargement ; the discolouration of the skin; the urinary changes described above ; together with considerations re- lating to the place where the disease was con- tracted ; and, above all, the therapeutic test, that is, the power of quinine in preventing the recur- rence of the attacks, ought to clear up all doubts. Prognosis. — This, in ordinary agues, so far as immediate danger is concerned, is highly favour- able; death from uncomplicated ague is very rare. The direct mortality from ague, at all events among the European races affected by it. is small; the indirect mortality' from the malarial cachexia, occurring either per se or as a com- plication of other diseases, is very great. In complicated or so-called pernicious agues, the prognosis will depend on the extent to which important organs are involved — cerebral, pul- monary, or gastric ; much on the stage the dis- ease has reached before the patient comes under treatment ; and much, very much, on the nature of that treatment. Treatment. — Keeping in view the fact that every’ paroxysm of intermittent fever, particu- larly in a hot climate, is a step, however short, on the road to the cachectic condition described above and in the article on Malaria, the impor- tance of breaking the recurrence of the paroxysms will be apparent. This, then, is the first indication of treatment ; the second is hardly less important, namely, to improve the condition tf the blood, and by judicious treatment. — therapeutic, dietetic, and climatic — to prevent further degeneration of organs, and, so far as may be, to restore affected tissues to their normal condition. If. as the writer firmly believes, there be such a thing as a specific disease, intermittent fever is specific. Like all such, it has a certain definite series of phenomena to pass through, which we may assume to be needful for the purpose of destroying, altering, or in some way expelling the poison, or at least such portion of it as may at the time be acting on the system. There is no drug known to science capable of arresting tho stages of a true malarial fever once it has entered on the first or cold stage. This doctrine, as Sir William Jenner has admirably stated it in bis Address on the JEtiology o f Acute Spccifi ■ Diseases, has been taught by the wri’er. as regards malarial fevers and cholera, in liislectures at Netley for the last twenty years. There is little, therefore, to be said as to the treatment of the stages of ague ; they must take their course, the only in- terference being to supply the patient with the INTERMITTENT FEVER. warm covering so much desired during the cold stage : if this be protracted unduly, to giro him draughts of warm tea; and should symptoms of collapse appear in any of the more ‘pernicious’ forms at the end of the hot stage, to administer such restoratives and stimulants as the case may demand. Excepting in cases where the stomach is oppressed by a recently taken meal, the time-honoured practice of administering an emetic may be safely omitted. The lamented traveller Livingstone, whose experience of mala- rial fevers was immense, began the treatment of rearly all cases with the following combination : Resin of jalap and of rhubarb, from 6 to 8 grains, with 4 grains of calomel and a like quantity of ciuinine. According to the great traveller and his hardly less experienced companion, the Rev. Horace AValler, this combination was found very efficacious as the commencement of treatment both in intermittent and remittent fever. In Livingstone’s camp his pills were known as ‘ rousers,’ and as such were at once administered to men who, ‘ from premonitory symptoms, be- came idle and lethargic.’ In about five hours copious dark coloured motions followed ; if these were delayed, recourse was had to a brisk pur- gative enema. Quinine was then given in 4-grain doses every four hours, until twelve grains were administered in the twelve hours succeeding the purgative medicine. Livingstone and his followers deemed any other mode of dealing with the fevers of Africa to be ‘ mere trifling.’ Common sense points to the necessity of caution in the use of such active purging in men much debilitated by disease or climate, or both, or when the patients are delicate women, or Asiatics, often calling for as delicate handling. It is hardly necessary to add that this sharp treatment is notapplicable to those who are labouring, or have previously la- boured under dysentery, or any other form of bowel-complaint. In the ‘ interval,’ energetic efforts must be made to bring the patient under the influence of quinine. At once the most effective and the most economical plan is to administer quinine, ia solu- tion, in a ten-grain dose at the end of the sweat- ing stage, and to repeat it in from four to six hours. At least a scruple of the remedy should be given during the interval. If obstinate vomiting interferes wi:h the retention of the quinine, which will rarely happen if the bowels have been well relieved, the quinine must be ad- ministered either by enema or by the hypodermic method. The first plan is very efficacious, and is safe ; ihe latter is the most effective, but is not without risk of inconvenience from troublesome ulceration round the site of injection, if a mineral acid has been used to dissolve the quinine ; this in urgent circumstances, such as in per- , nicions agues dangerous to life, or in remittents | (as will be explained under the head of that type j rf fever), might be disregarded were it not that tetanus followed the operation in five cases in one year in the Bengal Presidency, all of them proving fatal. In the face of such a fact, this operation, trivial as it seems, should not be per- . formed on light grounds. The neutral sulphate of quinine, which dissolves freely in water at a temperature of 99° F., does not, so far as the writer's experience goes, cause ulceration. The 736 syringe used for this purpose should be a little larger than that for operations with morphia, and should have a platinum hollow needle. Quinine, in one or other of the methods advised, should be used until the paroxysms are broken. The remedy should be continued da : ly, so long as the clinical thermometer indicates a rise in temperature at the time of expected attack, even if there be no sign of a regular cold stage ; and within a lunar month from the time of first attack, the patient should be again brought under the influence of quinine for some days. In per- nicious agues, or in cases where complications arise, it is in a high degree dangerous to pause in the administration of quinine. to use remedies of a depressing kind for this or that set of symp- toms. Those who so act will have little success in practice until taught by bitter experience the daDger of departing from the golden rule of trusting to quinine. In this way, epi'epsy, pneu- monia. asthma, bronchitis may liavo to be met, aided by stimulation of the skin, support from proper food, and stimulants when called for. For many years the writer has urged this doctrine on the attention of young practitioners, and lie is glad to see that it is even more strongly insisted on by Trousseau in his well-known lectures. It is in such cases, and in grave remittents, that the Tinctura Warburgi has been found so useful as to warrant a strong recommendation. The active ingredient in this febrifuge is quinine, in combination with a variety of aromatic drugs, which either are now, or were formerly officinal. It is the most powerful sudorific known, and has been found in the writer’s hands, and in the practice of many medical officers in Southern India, a remedy of great power in all malarial fevers. After opening the bowels, half an ounce of tincture is administered, undiluted, all drink being withheld ; a second dose is given in three hours. It soon produces free action of the skm, the perspiration often having an aromatic odour. It is rare to see another paroxysm follow the use of the tincture. In adynamic cases it should be used in smaller doses, and with some caution, lest its excessive sudorific action should be too depressing. 1 Substitutes for quinine . — The officers in charge of the Government cinchona plantations in India now prepare from the red cinchona bark, by a very simple and economical process, a preparation known as ‘cinchona alkaloid,’ which, in some- what larger doses than quinine, is found to be effectual in checking malarial fever, but this pre- paration, although very cheap, has fallen into disrepute from the distressing nausea, and even vomiting, it often causes. Salicylic acid is now largely used as an anti- pyretic. 1 Dr. Warburg has communicated to the wrEer the formula for the preparation of this tincture, which at Dr. Warburg's des re was publishidin the Lancet, and Medical Times and Gazelle. (See Medical Times and Gazette , 1875, vol. ii. page 540 ) As stated in the text, quinine proved to be the active ingredient, in combination with a number of aromatic drugs common to ancient and mo- dern pharmacy. It is consistent, with the writer's know- ledge that this tincture has maintained its high reputa- tion in the treatment of malarial fevers of the most danererous type, in the hands of Colonel Gordon, in the pestilential regions traversed by him and his cfSor.n, while carrying out the policy of the Khedive of "Egypt along the head-waters of the hide. 7Sfi INTERMITTENT FEVER. Arsenic has been used for ages, particularly in the East, in the treatment of agues. There is no doubt that it possesses considerable power as a so- called antiperiodic. TheFrenehmilitary surgeons, who are obliged to study economy, use it largely, and in doses much larger than are commonly given by British. practitioners. They seek, as Boudin expresses it, to oppose an arsenical to a malarial diathesis. In the brow-aches and other neuralgic sequels of malarial fever it is an effective remedy, either alone or in combination with quinine. The alkaline sulphites, so much lauded by Professor Polli. have hitherto disappointed the expectations of British medical officers who have fried them. In the late epidemic outbreak of malarial fever in the Mauritius they were found useless. The sulphate of cinchonine in scruple doses is much praised by Dr. Paul Turner. Biberine was largely tried by the writer in India, and found to be inert. Of late, various preparations of Eucalyptus globulus, the blue gum tree of Australia, have been much praised in the cure of ague, and more particularly in the treatment of its sequels. The writer is inclined to fear that this remedy, like many others, has been unduly vaunted. It certainly is often useful in the malarial cachexia, with occasional attacks of ague, but in the acute forms of the disease it is, in the experience of the writer, far below quinine. The best form is that of tincture. Both in France and Germany it is much used for the reduction of enlarged spleens. Diet. — This should be nutritious and easy of digestion. Dr. Cornish has pointed out how much the mortality from malarial fevers is in- creased amongst the natives of India by ‘starva- tion treatment.’ Treatment of malarial cachexia. — On the first signs of this condition appearing, the sufferer should be sent to a non-malarial climate. If by sea- voyage, care must be taken so to regulate the diet as to avoid the risk of ingrafting the scor- butic on the malarial cachexia. Remembering also the danger of exposure to cold insisted on al- ready, scrupulous attention to clothing is a point of cardinal importance. According to the writer’s experience, one of the most effective means of reviving the action of the skin, improving the condition of the blood, and restoring the spleen and liver to a more healthy condition, is to send those whose circumstances admit of it to Carls- bad or Homburg, where, under proper local medical advice, they may drink the waters and use the baths. The good effects of this treatment are often very marked and lasting. It should be supplemented by a course of the syrup of the triple phosphates of iron, quinine, and strychnia, in half-drachm doses three times a day; which after a time should give way to iron in some more direct form. The Carlsbad water, in com- bination with that of Friedriehshall, if con- tinued for a sufficient length of time, is often most useful in improving the condition of the abdo- minal organs, even when the patient can only use them in this country; and the action of the skin may be stimulated with profit by the occa- sional use of a Turkish bath, or by a wet sheet packing. The writer has long used the ointment of the biniodide of mercury in reducing enlarged spleens, and often with great success. The strength of the ointment is 13 grains to an ounce INTERTRIGO. of lard. Of this a piece as large as a walnut is to be well rubbed in before a good fire. The pro- cess is repeated on the afternoon of the samedav_ and again, if need be, in a fortnight. If ordinary care be taken to watch the effects, and not to use the remedy too often, no ill consequences need be feared. The writer has in this way again and again reduced spleens, extending even into the pelvis, to almost normal dimensions, without pro- ducing any of the inconveniences either of the mercurial or iodine ingredients of the ointment. It is a point of great importance that patients should be placed under the most favourable hygienic conditions, and breathe the purest air available. W. C. Maclean. INTERNAL EAR, Diseases of. See Eab, Diseases of, INTERSTITIAL (inter, between, and sto, I stand). — Relating to the interstices of an organ. The term is applied in physiology to the tissue which exists between the proper elements of any structure, namely, some form of connective tissue. In pathology the word is used in con- nection with absorption, when a part is gradually removed without any obvious breaking off; and also to indicate the implication of the interstitial tissues in morbid processes, or their infiltration with morbid products, as interstitial pneumonia, interstitial hepatitis, &c. INTERTRIGO (inter, between, and tero, I rub). — Definition'. — A slight inflammation of the skin occurring in the hollows of folds of tho integument or joints, where two surfaces lie in contact with each other. Aetiology. — The cause of intertrigo is not, as might be implied by its name, friction alone; but rather moisture and heat associated with contact and pressure, acting on a sensitive skin. In certain situations the amount of inflammation is liable to be aggravated by the addition ol irritant discharges, such as excessive perspira- tion, urine, and faecal matter. Intertrigo is common in infants, in whom it is favoured by abundance of integument, and sensi- tiveness of skin. For a similar reason it is met with in corpulent persons ; but it is not wanting in the emaciated, when there exists a tendency to eczema, or an eczematous diathesis. In in- fants it is seen in the perineum, extending froir the anal fossa behind to the groins in front, and likewise in any other of the deep folds of the integument. Among adults, in addition to these situations it occurs in the axillae, in the groove be- neath the mammae, and in the flexures of joints. Description. — The term intertrigo points tu a rubbing together cr chafing, fretting, or gall- ing of the skin by friction, and no doubt friction may have some share in producing the inflam- mation ; but it is also certain that intertrigo re- sults most frequently from irritation caused by the heat and moisture of the part. Intertrigo has been adopted as an erythema under the name of erythema intertrigo, but it very rarely remains at the erythematous stage, having a natural tendency to run on to exudation with the discharge of a muco-purulent fluid, and to be further complicated with excoriations and chaps. In this condition it becomes an eczema and i= INTERTRIGO. rery properly treated as such. Indeed, it is more consistent with, the genius of modern der- matology to consider it, even from the begin- ning, as an eczema, under the name of eczema crythematosum. Prognosis. — The prognosis of this affection is favourable as to cure, but uncertain as to time, and in adults it is very apt to degenerate into chronic eczema. Treatment. — The removal of the cause is the first indication to be attonded to in the treat- ment of intertrigo. This may be effected by careful ablution with soap. The part should then be kept as dry and cool as possible, and dusted with fuller’s earth, or any unirritating desiccative powder. Where powder is unsuitable, a lotion of lime-water inspissated with oxide of zinc will be found useful ; and if this should provo irritating, zinc ointment, with the addition of a drachm of spirits of wine to the ounce, should be kept constantly applied. Where there is much exudation, it is desirable, as in eczema, to avoid ablution, and confine the treatment to wiping with a soft cloth previously to each repetition of the zinc ointment. Constitutional symptoms are rarely present in intertrigo, but should such arise, the indications to be considered are regu- lation of the digestive organs and associated functions ; a suitable diet ; and tonic regimen. Erasmus Wilson. INTESTINAL OBSTRUCTION. — Sy- non. : Ileus ; Er. Occlusion intestinalc ; Ger. Darm verschliessung. Definition. — Under this term are included all those cases in which the contents of the in- testinal canal are obstructed in their onward , passage, by causes or conditions occurring with- in the abdomen or pelvis. Cases in which ob- struction is due to causes or conditions affecting protruding or protruded bpwel are included | under the head of Hernia. General Remarks. — The subject of intestinal obstruction will be best treated by first discuss- ing the condition in general, and afterwards re- ferring to its various pathological causes under separate and distinct heads. Frequency.— The comparative frequency with which intestinal obstruction occurs is difficult to estimate. It is by no means a common affec- tion, though less rare, perhaps, than is sometimes supposed or asserted. It is always fraught with clanger, and in a very large proportion of cases more or less speedily proves fatal. Brinton esti- mates 1 out of every 280 deaths from all causes .0 be due to some form or other of intestinal ibstruction. Leichtenstern gives 1 out of every TOO to 500. Brinton’s estimate, founded on the ■csults of 12,000 post-mortem examinations, is probably somewhat too high, inasmuch as a larger Proportion of cases of intestinal obstruction are ikely to have been inspected than of cases of lore common and less obscure affections. IEtiology and Pathology. — Most forms of atestinal obstruction are more often met with i the male than iu the female subject. Out of a >tal of 1,806 sufferers, 1,018 were males and 788 males. But women are more liable than men 1 suffer from certain forms, as, for example, cose which depend upon impaction of gall- 47 INTESTINAL OBSTRUCTION. 737 stones or faecal matter; upon compression <■ the intestine by tumours or displaced viscera ; oi upon constrictions by peritoneal or other adhe- sions. Some forms, esjiecially intussusception and volvulus, most frequently occur during in- fancy or childhood ; others, as strictures, at comparatively advanced periods of life. The causes, or anatomico-pathological condi- tions which may give rise to intestinal obstruc- tion, vary in nature, in mode of action, ani ir acuteness and severity of effect. Some are Con genital, depending upon developmental abnor- malities ; others are Acquired, resulting from accident, disease, or physiological incapacity Some act by compression of the bowel from with- out; some by constriction of the bowel within and others by blocking its canal. Some com. into play suddenly or almost suddenly’, am! without warning, and at once lead to complett occlusion ; the symptoms are most acute, and in the absence of relief, fatal results speedily follow. Some coming into play with almost equal sud- denness, and accompanied by almost equally severe symptoms, do not, however, so immediately lead to complete occlusion ; some degree of per- meability remains for a time ; and the chances of relief are somewhat better. Other causes, again, seem to develop slowly ; the symptoms in the earlier stages, at any rate, are not acute ; the malady takes a chronic course ; better oppor- tunities for consideration and treatment are afforded; and fatal results, though they may ultimately ensue, can be longer averted. The causes of intestinal obstruction may be enumerated as follows, in order as nearly as possible corresponding to the acuteness and urgency of the symptoms, and the imminence of danger to life to which they’ give rise ; and the relative frequency with which they occur may be approximate vely estimated by the numbers ap- pended, representing the results of an analysis of 1,839 fatal eases recorded or observed : — 1. Congenital malformations. 2. Internal strangulation (546). («) By peritoneal false ligaments or bands, the result of previous inflammatory mischief, either under such bands, or by loops or knots, or in button-hole slits, or by kinking caused by traction, or by the margins of slits or rings pro duced by adhesions of parts or organs to one another, or to some part of the parietes (219). (6) By the omentum or mesentery (in associa- tion with some abnormal peculiarity) by bands or in slits (65). (c) By diverticula or diverticular appendages, as the obliterated omphalo-mesenteric vessels, or by diverticular knots (To). (d) By the appendix vermiformis (42). (e) By twisting or knotting (volvulus) and consequent compression of the bowel by itself, or by its mesentery (106). (f) By the margins of peritoneal pouches (retro-peritoneal hernia, hernia through foramen of Winslow, and other forms of internal hernia) (39). 3. Impaction of gall-stones (51). 4. Intussusception or invagination (537). 5. Constriction (511). (a) By cicatricial contractions of the ’>owel itself, resulting from injury or ulcerative disease. i INTESTINAL OBSTRUCTION. 738 (i) By peritoneal thickening and contraction, with sometimes matting together of the bowel, from strumous or other form of peritonitis(138). (c) By new growths, innocent cr malignant, in the bowel itself (373). 6. Compression. ( 7 44 sucked with advantage from time to time; but it is worse than useless to attempt to introduce food or medicine in bulk into the stomach, only to be again speedily vomited. Abdominal taxis . — After one, two, or at most perhaps three days (according to the circum- stances and conditions of the particular case) have elapsed, without abatement, or with probable in- crease in the severity of the symptoms, when the nature of the case is clearly pronounced, and espe- cially if the seat and cause of the obstruction are indicated, surgical operation appears to the writer imperative ; and the earlier this is done, the better is the chance of success. “ The writer cannot forbear expressing in this place the strong feeling and conviction, after long consideration and some experience, that he entertains on this matter. Before proceeding, however, to the use of the knife, it may be well under chloroform to try the effect of changes in the position of the body, and of ‘ abdominal taxis ’ by gentle, firm, unstained manual compression of the part of bowel presumably strangulated and distended, and by attempts at movement in one direction or another. The good effects of sustained compression, with the view of emptying the distended bowel of its contents, rather than of pushing it back, in the reduction of external hernia, are not sufficiently generally appreciated and systematically attempted. And further, every surgeon of experience has met with cases of external hernia in which the movements or joltings of a journey to the hospital have re- sulted in reduction. So it may bo with some rases of internal strangulation. Abdominal section . — If such attempts fail, an incision should be made in the middle line down- wards or upwards (as the indication may be) from the umbilicus into the abdomen, of sufficient ex- tent to permit the introduction of the fingers, and the seat and cause of the obstruction sought for. As a rule, it may be better to extend the incision so far as to afford a clear view of the strangulated bowel ; but it must be borne in mind that the longer the incision the more, probably, will the distended bowels protrude, and the greater will be the difficulty in replacing and retaining them. Any constricting band that may be dis- covered may then be divided, and the bowel re- leased, or a twisted portion may be restored to position. The chief difficulties likely to occur arise from the protrusion of distended bowel, which is apt to hinder proceedings. Punctures may be made by a fine trocar and canula; but all such punctures should be carefully closed by ligature or suture. The chief immediate danger is that of giving way of the bowel at the seat of strangulation at the momentof release, and extra- vasation of its contents; but in cases in which this happens, it is almost certain that similar rupture would have speedily occurred if matters had been allowed to take their course. Any such opening in the bowel should be at once closed by suture, and every effort made to pre- vent extravasation into the peritoneal cavity. It has sometimes been found desirable to attach the edges of the ruptured portion to the abdo- minal pariotes, with the view of establishing an artificial opening. In cases in which there has been an external hernia, it maybe preferable to make the incision in the groin, and to extend it upwards as far as may be needful. In several such cases (four in the writer’s own experience) the cause of strangulation has been found to be omentum adherent to the sac of the old hernia, division of which up in the abdomen has resulted in release of the strangulated bowel. After the operation the abdominal incision should be care- fully closed, and the patient kept for sometime thoroughly under the influence of opium. It must be admitted that the statistics of operations for internal strangulation do not seem encouraging. In 61 out of 95 recorded or observed cases death followed more or less speedily, and in 34 only did recovery take place. But the causes of failure are obvious. In most cases there has been either some error in diagnosis, or the operation has been per- formed too late, and at a period when recovery under any circumstances would have been hope- less. Increased accuracy in diagnosis ; earlier resort to operation ; and the adoption of im- proved surgical methods, among which must t*“ especially urged the use of antiseptic precautions, may be confidently expected to yield better re- sults in the future. Colotomy . — In cases in which it appears that the lower part of the colon or sigmoid flexure i= strangulated by twisting or doubling over, and in which it is deemed inexpedient to perform abdominal section, temporary relief at any rate may be afforded by lumbar colotomy — right or left. Or simple puncture of the colon by a fine trocar and canula may give relief, temporary or permanent, by affording escape for the flatus. Enterotomy . — -The operation of enterotomy is applicable to cases of chronic, rather than of acute strangulation, and will be subsequently referred to. III. Obstruction from Impaction of Gall- stones. — Gall-stones may enter the intestine, either after passing down the gradually dilated duct, or after a process of inflammatory adhe- sion and ulceration between the gall-bladder and the duodenum or colon. It is in this latter way probably that gall-stones large enough to block its canal get into the bowel ; and hence in such cases, though there is usually a previous history of more or less suffering in the hypochondriac region (which may assist the diagnosis), yet those paroxysms of pain and the jaundice which accompany the passage of gall-stones down the duct have not been experienced. Having entered the intestine, gull-stones may either pass along until they escape by the anus — sometimes giving but little trouble during their passage, sometime- being temporarily arrested, or damaging the bowel at one point or other, and giving rise to pain, vomiting, deranged action of the bowels. &c. ; or they may become firmly impacted, and completely- obstruct the intestinal canal. Ob- struction from such cause, however, is com- paratively rare, occurring in only about 8 per cent, of the cases of acute obstruction. It is met with about four times as often in the female as in the male subject ; and almost without exception, or with very few- exceptions, after late middle life — most frequently after the age of sixty. INTESTINAL OBSTRUCTION. 745 The gall-stones which have been found to ;ause obstruction have been from one to two inches or more in longest diameter. As a rule they have been single, in some instances con- glomerate. In a large proportion of cases they have been impacted in the duodenum or upper- part of the jejunum; in some few instances about the middle of the ileum ; and, again, in somewhat more cases, in the ileum near the ilco-csecal valve. Impaction in the large intes- tine very rarely occurs, and has scarcely ever led to a fatal result, but in some instances it has been attended by very severe symptoms. Impaction is favoured by natural or accidental narrowing of the bowel, and doubtless is aided or maintained by swelling of the mucous mem- brane and spasmodic contraction round the stone, as well as by a more or less persistently con- tracted condition of the bowel beyond it. Symptoms. — The symptoms following impac- tion often come on suddenly, and are usually very acute ; and death, preceded by all the in- dications of intense enteritis conjoined with those j of acute obstruction, as a rule occurs in five or i 6ix days, if it have not occurred earlier as the result of shock. Recovery rarely takes place. In some few exceptional cases, however, relief has come about even after periods of severest suffering, by the release and onward passage of the stone; in some, the bowel has become stretched into a kind of diverticulum, in which the stone has remained lodged, a way by it beingleft; in some, after adhesion and ulceration, an opening has been formed between the small intestine and the neighbouring part of the colon 1 through which the stone has escaped; and in some, again, after similar processes between the bowel and abdominal wall, the stone has escaped externally, or has been removed by operation. Diagnosis. — The diagnosis of obstruction by gall-stone is aided by consideration of the age, sex, and previous history of the patient ; the character and acuteness of the symptoms ; the localisation of the earliest pain ; and sometimes I by the recognition on examination of a more or less distinct hard lump, corresponding to the obstructing gall-stone. - Treatment. — None other than palliative ^measures can as a rule be recommended; but having regard to the extreme danger of the con- dition, and the severe suffering of the patient, the operation of enterotomy would seem to the writer to be justifiable. IV. Intussusception or Invagination. — By intussusception or invagination is understood the passage of one portion of intestine into the immediately adjoining portion. Intussusceptions that have given rise to no symptoms during life are not infrequently found pn post mortem examination, especially of the bodies of children, and those who have died of irain-disease. Such intussusceptions occur in '’.rticulo mortis , or immediately after death ; hey are easily reduced, are almost equally . asily reproduced or imitated, and are accom- 'anied by no sign of inflammation. They are f no practical import. But their possible ccurrcnce should be borne in mind, lest, when let with, they should lead to false conclusions S to the cause of death or previous suffering. .(Etiology. — Intussusceptions occurring dur- ing life, and causing intestinal obstruction, are most frequently met with during infancy or early childhood. About one fourth of the cases on record have occurred during the first year, and more than one half during the first seven years of life. The male subject appears to be more liable than the female, in the proportion of about two to one. The occurrence of intussusception w-ould appear to be brought about, in the first place, by some irregular or disorderly peristaltic action of one portion of bowel, conjoined with inaction or paresis of another, dependent upon some ill- defined or unaseertainable cause or other of derangement. Sometimes it follows diarrhoea or violent straining ; sometimes it is associated with the presence of worms, or of masses of imperfectly digested food ; and sometimes with the pressure or dragging of some new growth. Having once commenced, the intussusception goes on increasing, more or less continuously, as the result of peristaltic action. The portion of bowel first invaginated, as a rule, advances at the expense of the receiving portion, which turns in to form the middle layer. The length of bowel involved varies greatly in different cases, as a matter of course. But the process may go on until the portions first involved, having traversed the whole length of the colon, may reach, or even protrude or be expelled from the anus. Anatomical Characters. — As a rule, with but very few exceptions, it is the upper portion of the bowel that passes into the lower. In ordinary cases the intussusception is complete and single, and thus a transverse section shows three rings of bowel ; a longitudinal section, three layers of bowel on each side; the outer and middlo layers having mucous surfaces in mutual contact, and the middle and inner hav- ing serous surfaces in mutual contact. In some rare cases, however, the intussusception is said to be incomplete-, in such a funnel-shaped pro- cess is drawn down, usually by the dragging of a pedunculated tumour, from some part of the intestinal wall into the canal. In some casos, again also rare, the intussusception is double, the whole intussusception-mass being received into another portion of bowel; under such cir- cumstances four rings or layers are shown on section. Between the middle and inner layers the mesentery, or mesocolon, or both, as the case may be, are also received, and these determine, from the first, peculiarities in the conformation of the intussusception ; and the consequent com- pression of their vessels, and arrest of the cir- culation through them, bring about complications and more or less characteristic effects, such as congestion and swelling, ecchymosis, and even considerable haemorrhage. Almost any part of the intestinal tract may be involved, but some parts are involved much more frequently than others. Thus in upwards of 50 per cent, of the cases, the ileum and caecum have been found passing into the colon ( Intus ■ susccptio ileo-ccecalis) ; in about 30 per cent, the small intestine has alone been involved — the ileum in most of those (J. ilcalis), the jejunum INTESTINAL OBSTRUCTION. Ji 8 iu a few (/. jejanaUs), the duodenum in still fewer (/. duodeualis). In some a portion of iloum invaginated in another portion has passed on through the ileo-eaecal valve into the colon (/. ileo-colica). In about 12 per cent, of the cases the colon only has been involved (/. colica ). The rectum, though it constantly forms the receiving layer of an extended intussusception, is very seldom primarily affected, except as the result of the dragging of, or pressure upon some new growth. Symptoms. — The symptoms of intussusception usually appear suddenly and are very severe. First, there is pain, often most intense and agonising, sometimes like that of colic, some- times ‘straining and tearing’ in character, felt most distinctly at a spot corresponding to the commencing lesion. In children convulsions sometimes occur. Vomiting speedily super- venes, and the vomited material is often streaked or mixed with blood, and, sooner or later, usually becomes fseeulent. Diarrhoea soon sets in, and, accompanied by severe strain- ing and tenesmus, recurs at frequent intervals. The evacuations, at first fsecal, very early are ptaioecl with blood, and soon consist of little more than blood and mucus, with only a slight admixture of faecal matter, or none at all. The occlusion of the bowel is often not complete at first, but it speedily becomes so from congestion and swelling. After a variable period, some re- mission in the severity of the symptoms takes place, to be again followed by paroxysmal exa- cerbation. On examination of the abdomen, a firm, cylindrical, ‘sausage-like’ swelling, of greater or less length, can be distinctly felt, and recog- nised as the intussusception-mass, in almost all cases of ileo-caecal or colic invagination. In eases in which the small intestine alone is 'in- volved, such swelling is much less distinct and smaller, and often cannot he made out at all. When the intussusception has reached the lower part of the rectum, which it may do even by the second day, it can be readily felt, and its cha- racter can often be determined on examination per anum. Diagnosis. — The diagnosis of intussusception of the intestine is generally established without difficulty, by the recognition of the signs and symptoms thus indicated, at any rate during childhood, and in the more acute cases. In some of the more chronic cases occurring in adult life, however, it is not always easy. Course and Progress. — The course and pro- gress of a case of intussusception may he (1) acute. Unless relief is obtained, the case will then terminate fatally, either speedily from shock, or within four or five days- in children, or within a week or ten days iii the adult from peritonitis or exhaustion. Or (2) the case maybe sub-acute ; death occurring within three or four weeks. Or (3) the case may become, or may be from the first, more or less chronic , and terminate in death only after a period of weeks or months, from peritonitis, or enteritis, followed or not by perforation ; or from wasting and exhaustion. Lastly, recovery may take place after sloughing, separation, and evacuation of the invaginated bowel. The last event, which is of great interest, and, in regard to prognosis, of great importance, very rarely takes place during childhood. It follows peritonitic adhesion between the invagi- nated and receiving portions of bowel, and death of more or less of the former from deprivation of blood-supply. Numerous cases of this nature are on record, varying in detail. In most of them it has been some portion or other of small in- testine that has come away. In some, how- ever, the caecum with its appendix and portions of the colon have been found. Sometimes the sloughed intestine is evacuated in shreds or frag- ments, sometimes in its entirety. Such separa- tion and evacuation take place, as a rule, in from eleven or twelve days to three or four weeks, and much earlier in the case of the small than of the large intestine. In some instances the adhesions have giveaway at or immediately after the separation of the slough, and fatal extrava- sation of faeces has occurred ; and in some a permanent stricture has resulted after fair pros- pect of recovery had been afforded. Treatment. — Acute intussusception, espe- cially in the child or infant, demands prompt and active measures for its relief. Purgatives can only increase the mischief ; palliatives are, as a rule, of little or no permanent avail, though opium and belladonna may sometimes do good by relieving pain, checking undue peristaltic action, and thus hindering the progress of the lesion, and affording a possible chance of re- covery, or, at least, by rendering the remaining hours of life comparatively free from suffering. When once the diagnosis is established, resort should be had without delay to mechanical or operative treatment, for in such measures, accord- ing to the results of experience, lie the best pros- pects of complete and permanent relief, first, a copious enema of oil, or oil and thin gruel, should be gently and slowly injected, the body being inverted, and moved from one position to another, abdominal taxis and manipulation being, meanwhile, carefully and systematically carried out; or, in place of liquid injection, insufflation of air by means of bellows may he employed. If the intussusception have pro- truded from the anus, it should, of course, be first replaced, and if felt in the rectum pushed up as high as may be practicable. Numerous cases are on record in w hich such means haTe been attended by success. But should they fail after full and fair trial — and more than three or four attempts should not be made unless signs of improvement in the condition are manifest ; then surgical operation — laparotomy — becomes justi- fiable, and increasing experience encourages its adoption. Laparotomy should be undertaken be- fore there has been time for the formation of adhe- sions, or the supervention of general peritonitis. The abdomen having been opened, with all due precaution, by median incision of requisite ex- tent, the intussusception is usually found with- out difficulty, and may he traced upward and downward. Reduction may generally be effected with comparative ease by gentle traction upon the upper part of the invaginated portion, com- bined with gradual working up of the lower part by manipulative pressure from below up- wards upon the receiving portion (Hutchinson). After the operation, the wound must be carefull* INTESTINAL OBSTRUCTION. closed, an abdominal bandage applied, perfect rest secured, and after-treatment on general principles carried out. In 15 out of 58 recorded cases this opera- tion has resulted in recovery; in 43 it has been followed by death, although in most of these reduction was effected. It is probable, however, that a much larger proportion of suc- cessful than of unsuccessful cases have been published, and the figures must therefore be taken for what they may be worth ; they suffice, however, to justify the more frequent and earlier adoption of such means of relief, espe- cially under the protection of antiseptic pre- cautions. In the more chronic forms of intussusception, and especially in the adult, resort to operation is not so urgently called for. Palliative measures, and particularly the administration of opium and belladonna, with enemata from time to time, are often of the greatest service ; and, as already indicated, recovery after sloughing of the intus- suscepted bowel, or portions of it, not infre- quently takes place, although consecutive and dangerous complications may sooner or later arise. V. Obstruction from Constrictions. — The anatomico-pathological conditions involving some portion or other of the intestinal wall, which may give rise to obstruction, have been already enumerated or indicated. Regarding them the following further statements may bo made. 1. Simple cicatricial stenoses may result from the effects of in juries inflicted by caustic poisons or foreign bodies ; such are most likely to ho found in the upper part of the small intestine ; they are, however, very rare. Similar stenoses may follow the sloughing of intussusceptions ; or the ulceration produced by temporarily impacted gall-stones, fecal masses, or foreign bodies ; or dysenteric, tubercular, or syphilitic ulceration of considerable extent and long standing. The dysenteric stenoses are most frequently found about the flexures of the colon ; the tubercular in the lower part of the ileum or caecum ; and the syphilitic in the rectum or lower part of the colon. Typhoid ulceration is very rarely fol- lowed by stenosis. 2. Peritonitic thickening and contraction , with more or less matting together and constriction of the bowel, most frequently involves the small intestine or the flexures of the colon. 3. New growths of innocent character — fibro- mata, myomata, lipomata, and papillomata (benign villous growths) — are from time to time met with, connected with some part or other of the intestinal wall, anil causing more or less obstruction, either by themselves blocking the canal, or by leading to dragging down of the part to which they are attached. Such growths 1 often become polypoid. They are (with the ex- ception of myomata and lipomata) most fre- quently met with in the rectum, sometimes in other parts of the large intestine, very rarely in the small intestine. 4. New growths of -malignant character — fibrous I cancer, forming hard, narrow constrictions, slow to ulcerate, scirrhus, encephaloma, colloid can- cer, epithelioma, cylindroma, and sarcoma— are much more common; and from the readiness with which they involve the whole circumference of the bowel, much more rapidly load to serious ob- struction than do those of au innocent character In about 80 per cent, of the eases such growths have been found affecting the rectum ; in about 15 per cent, the colon and caecum; and in only about 5 per cent, some part or other of the small intestine. Symptoms. — The various conditions thus de- scribed, develop more or less gradually; and tho symptoms to which they give rise are chronic in character, and in their earlier stages by no means well marked. Disordered, irregular, and imperfect action of the bowels, and general dis- comfort occurring from time to time, with inter- vals of comparative ease, constitute the earliest indications. Later, and after a very variable period, as the constriction increases, the trouble becomes greater and more constant, and the symptoms of obstruction become more pronounced. In most cases abdominal distension (meteorism) — localised or general, and accompanied by sensa- tions of fulness, feetid eructations, shortness of breath, and pains in the back, varying in degree from time to time — comes on sooner or later ; and except when the seat of obstruction is in the rectum, the peristaltic movements of the intes- tines at intervals become very manifest through the abdominal wall. The pain experienced is very variable in character and severity, and is often paroxysmal, with periods of complete intermis- sion. As the case progresses towards a fatal ter- mination, the distress becomes extreme. Absolute occlusion, as a rule, comes about slowly. In some cases it is never completely established ; hut in other cases it occurs suddenly, from impaction of hardened feces or undigested food, or from other cause ; and in such tho symptoms at once correspondingly increase in severity. It is worthy of note that even in cases in which tho seat of constriction is in the sigmoid flexure or rectum, the greatest fecal accumulation and corresponding discomfort are observed in the caecum. Diagnosis. — The general diagnosis of obstruc- tion from constriction, as a rule, is not difficult ; hut the differential diagnosis as to the. precise nature of the constriction is often very obscure, except in those cases (the large majority) in which a stricture, or the presence of some new- growth, can be discovered on examination per anuin. The previous history often supplies important indications, and should therefore bo thoroughly investigated. Course and Terminations. — The course of all such cases, though very variable in duration, is progressively unfavourable, and sooner or later death supervenes, usually from peritonitis with or without perforatiou, or from exhaustion from prolonged suffering. Treatment. — The treatment must ho deter- mined and varied in accordance with the symp- toms and indications presented from time to time. In the earlier stages, soothing and palliative measures should be adopted during periods of exacerbation of suffering; and during periods of comparative relief laxatives may often be given with great advantage. In all cases in which there is reason to suspect the existence of some causa of constriction, the most careful attention to diet. INTESTINAL OBSTRUCTION. 148 and the administration from time to time of such medicines as favour a soft, semi-solid condition of the faeces, should be insisted upon. Operation.— In the later stages resort must be had to surgical operation, and the greatest relief may often be afforded, and life prolonged, by the establishment of an artificial anus by opening the bowel above the seat of constriction, either by incision through the peritoneum— enterotomy ; or by post-peritoneal incision — lumbar colotomy, right or left. Laparotomy is altogether out ot' the question. In cases in which there is reason to believe that the constriction affects the small intestines , en- terotomy should be adopted. An oblique incision in the right iliac region, more or less parallel with and above Poupart’s ligament, having been made and cautiously carried down through the various structures, the peritoneum is to be opened to a limited extent, and the first protruding portion of distended small intestine is to be seized, and being well pulled out, opened by very limited incision. In the case of the small intestine, it is needless, on account of the semi-fluid nature of the contents, to make a large opening, and it is obviously disadvantageous to do so. The mar- gins of the opening in the intestine are then to be sutured to the margins of the external wound. This operation, especially advocated by Nelaton, has proved successful in affording relief and prolonging life in a considerable number of cases (10 out of 16). One great drawback to it, in the event of prolongation of life, lies in the extreme inconvenience and annoyance the patient suffers from the continual escape of liquid faeces in the part of the body operated upon — an escape which there is the greatest practical difficulty in restraining. In cases in which the seat of constriction is in the colon or rectum, lumbar colotomy (post- peritoneal enterotomy) is to be performed, on the right or left side according to the indications afforded. The merits of this operation in reliev- ing suffering and prolonging life in such cases, can scarcely be esteemed too highly. After the establishment of an artificial anus, and the rest from constant irritation thereby afforded, the constricted bowel may recover to a certain extent its permeability. VI. Obstruction from Compression from without. — Various viscera, enlarged and dis- placed as the result of disease — especially the uterus and ovaries, and in rare instances the 6pleen, the pancreas, and even the kidney ; tuber- cular or cancerous glands ; tumours of the omen- tum or other parts of the peritoneum ; tumours growing from one part or other of the abdominal or pelvic parietes, or from the contained viscera ; hydatid cysts, &c., may so compress a neigh- bouring portion of bowel as to lead to obstruc- tion, which either may be brought about gra- dually, or from some accidental cause may be suddenly determined. Symptoms. — The symptoms more or less closety resemble those of obstruction, chronic or acute, arising from other causes. Diagnosis. — Careful examination of the abdo- men, including thorough examination per vagi- nam and per anum (sometimes the introduction uf the whole hand into the rectum is especially likely to be useful), together with the history or the case, and the consideration of the collateral signs and symptoms, will generally suffice to establish, approximafively at any rate, the diagnosis of obstruction of the bowel from ex- ternal compression. Treatment. — The treatment of this condition consists, first, in the removal of the cause, if practicable ; secondly, if this should be imprac- ticable, in relieving the obstruction. By altering the position oi the body, the displaced viscera may sometimes be so moved as to cease to com- press tho bowel; tumours, uterine and ovarian especially, may be taken away by operation; hydatid cysts may be tapped; and thus relief may be afforded. Or again, by manipulation or by the effects of copious enemata, the bowel itself may be so moved as to be no longer compressed ; or after a period of rest, under the influence of sedatives, it may release itself. But if none of these measures should be applicable or successful, and if the symptoms of obstruction be severe, resort to one or other of the operations (la farce tomy, enterotomy. or colotomy) already discussed, may become needful. In some cases, of this class especially, relief lias been afforded, and the bowel has recovered itself, after puncture by fine trocar and canula and aspiration. The ultimate prospects must depend upon how far the com- pressing cause can be removed. VII. Obstruction from Impaction of Fo- reign Bodies, Intestinal Concretions (Ente- roliths) &c. a. Foreign bodies in bull-, such as bones, coins, buttons, knives, forks, pins, needles, &c., acciden- tally or intentionally swallowed, occasionally find their way on from the stomach into the intes- tines. In a considerable proportion of cases they pass on, and are evacuated per anum without very much inconvenience ; in some cases they give rise to enteritis and various other intestinal troubles ; in some rare cases they lead to more or less complete occlusion, with acute or sub- acute symptoms. Symptoms. — The symptoms of impaction of foreign bodies in the bowels vary with the ex- tent of injury inflicted, and the degree of obstruc- tion occasioned. Diagnosis. — The diagnosis of such cases rests on the history, and on the recognition of the presence of the foreign body on palpation of the abdomen, or examination per rectum. Treatment. — The treatment of this condition must be determined by the general circum- stances and urgency of the case. As a rule, purgatives can only do mischief. Soothing re- medies give temporary relief, and favour the gradual onward passage and ultimate expulsion of the foreign body. If absolute impaction has clearly taken place, and the symptoms are urgent, enterotomy and extraction may be justi- fiable, or even imperative. The wound in the intestine may either be carefully closed by suture, and the bowel returned ; or its edg-s may be attached to those of the external wound, and an artificial anus temporarily established. In some instances, such procedures have been encouraged and favoured by the previous for- mation of inflammatory adhesions between the bowel and the parietes. INTESTINAL OBSTRUCTION. b. Foreign bodies — as hair, &c. ; indigestible constituents of the food— as the skins, seeds, and stones of fruit (the husks of cereals, and. oats especially), orange-pulp, and the curd of milk in young children ; and some medicinal substances us macnesia, chalk, oxide of iron, Ac., swal- lowed bit by bit from time to time, may accu- mulate in some part or other of the bowel. Be- coming matted or felted together, and aggluti- nated by the intestinal mucus and other secre- tions. these bodies may form rounded masses, which sooner or later may give rise to more or less complete obstruction. Such masses consti- tute the large proportion of the so-called ‘ intes- tinal concretions’ in the human subject. c. In some rare instances, however, hard stony concretions ( enteroliths ), consisting for the most part of phosphates of lime and magnesia with organic material, and resembling those not in- frequently found in some of the lower animals, have been met with. These usually have as a nucleus some foreign body, or portion of har- dened altered faeces. Intestinal concretions are almost invariably found either in the caecum or in the rectum. Their presence may commonly be recognised on examination. They are, as a rule, slowly formed, and only give rise to complete occlusion after a considerable period, during which repeated at- tacks of more or less persistent abdominal dis- comfort and distress have occurred. Death may be brought about by gradual exhaustion, or by the effects of inflammation with or without per- foration ; or recovery may follow the evacuation of the concretion, either per vias naturales, or through an ulcerated or artificial opening. Foreign bodies introduced into the rectum, or which have passed down and there become im- pacted, and concretions similarly situated, may be removed per anum. VIII. Obstruction from Impaction of Faces. — Habitual or accidentally prolonged constipation may lead to definitive obstruction by impaction of faecal masses, conjoined with paralysis and inaction of the bowel from disten- sion, and contraction of the empty portion below. Sometimes the occlusion is rendered more abso- lute and irremediable by the doubling or dragging clown of the bowel by the weight of its contents. The seat of the obstructing faecal mass is usually the sigmoid flexure or the rectum, but corre- sponding accumulation is at the same time often found in the caecum. This cause of obstruction is most frequently met with in advanced life, and especially among lunatics or idiots. Symptoms. — The symptoms of faecal impac- tion are characterised by their chronicity; and complete occlusion as a rule comes about slowl v. There is little or no actual pain during the early stages, and even during the later stages, in the absence of complications, it rarely becomes acute. Vomiting is altogether absent at first, or slight and rare ; towards the end, however, there may be faecal vomiting. Abdominal distension only comes about gradually. Absolute constipa- tion is only slowly established, and somotimes is preceded by more or less frequent scanty diar- rhoea-like evacuations. The faecal mass can sometimes be felt on abdominal examination, and tench more often on rectal exploration, which in INTESTINES, DISEASES OF. 749 such cases should always be thoroughly carried out. Diagnosis. — The diagnosis of such cases is determined generally without difficulty by the history ; by the absence of acute symptoms ; by the process of exclusion of other causes of ob- struction ; and by the aid afforded by physical examination. Course. — In a considerable proportion of case* of this kind relief may be afforded by appro- priate treatment. In some cases, however, death ensues from gradual exhaustion ; in others from chronic peritonitis ; and in others from ulcera- tion of the bowel, followed or not by perforation and acute peritonitis. Treatment. — In this form of obstruction of the bowels, very copious enemata, administered through a long, soft tube, carefully introduced and insinuated onwards as far as practicable, are especially useful. Such enemata— consisting of thin gruel, soap and water, oil, with or with- out turpentine, to the extent of two or three pints or more, should be given and repeated at intervals as indicated. Or a stream of warm water from a vessel raised to a height, through a long tube, may be advantageously made to play upon and wash away, portion by portion, the faecal mass (Gay). Sometimes the mass may be cleared out of the rectum by the finger or a spoon. In some cases galvanism to the abdo- minal wall, in some t.he application of an ice- bag, in others hot fomentations or immersion in the hot bath, may bo useful. In the earlier stages, laxatives or even purga- tives, as calomel in a full dose, or castor oil, may often be given with safety and advantage. A teaspoonful of Rochelle salts in a cupful of mutton broth, is an old but often efficacious re- medy. In the later stages, and when purgatives have been found to fail or to increase distross, opiates are indicated ; and belladonna in large doses seems often to exert a peculiar and bene- ficial influence. When relief has been obtained, the greatest care as to diet and after-management is neces- sary, in order to prevent that recurrence of trouble to which the patient remains liable. Sec Constipation. Arthur E. Durham. INTESTINAL WORMS.— This combined term was formerly much employed in medical literature, as an equivalent for the simpler ex- pression entozoa , which latter title is far better, more comprehensive, and now in general use. To be sure, nearly all the internal parasites of mac, at some time or other during the course of their development, play the part of intestinal worms, within either the human or animal host ; but since this particular residence frequently consti- tutes neither the only locality they occupy, nor the principal feature of their life-record, it is well that the use of these possibly misleading words should be discontinued. See Entozoa; Para- sites; Worms; and Vermes. T. S. CoBBOi.n. INTESTINES, Diseases of. — G eneral Rejiarks. — Morbid affections of the intestinal tract are of very frequent occurrence at all ages ; some being limited to certain periods of life, others presenting no such restriction. 75 0 INTESTINES. DISEASES OF. The direct exposure that the canal offers to external influences, in the form of ingesta, will account for the causes of a large proportion of cases. So many irritants to disease have thus the opportunity to exert their immediate in- fluence, and produce what may be termed ■primary affections of the canal. On the other hand, since much of the normal physiological work of the tract depends for its performance on a healthy condition of other functions, espe- cially of the blood-circulation and nervous sys- tem, any disturbances of these processes will tend to influence injuriously intestinal digestion, and thus give rise to secondary diseases of the bowel. And it is evident that an improper preparation of the food in the intestine must in its turn affect the nutrition of the tissues gene- rally, and among others those of the canal itself. In no case is the interdependence of the functions on one another seen more completely than in af- fections of the digestive apparatus. For this same reason it is that the symptoms essentially due to any disease of the intestines may be considerably masked by more prominent signs of mischief elsewhere, though secondary to the intestinal affection ; whilst in other cases the disease we may be called upon to treat is but an expression on the part of the bowels of a morbid state, primarily connected with some other organ. Besides the direct nutritive disturbance of all organs and tissues of the body that must ob- viously follow any morbid condition of the intes- tinal function, there is a most close sympathy between the processes of digestion and the ner- vous system ; or, in other words, a dyspepsia which may be so slight as practically to produce no ap- parent alteration in the general state of the body, may yet distinctly affect the mental condition, and all degrees of disturbance, from a mere irritability of temper to a complete hypochondriasis, may result. The frequent association of headache with dyspeptic symptoms is a further illustration of the connection ; in reference to which we can- not avoid noticing the very extensive nervous supply that is provided by the sympathetic sys- tem to the chylopoietie viscera. Although structurally continuous with the stomach, and closely associated with it in its working, the intestine nevertheless is exceed- ingly prone to be diseased independently of that organ, while at other times both suffer together. Certain spots in the course of the tract favour the development of certain diseased states, and it is rare to find the entire length of the canal involved ; whilst one portion of the tube, the jejunum, is probably less liable to disease than any other organ of the body. The indications of intestinal disease are fre- quently extremely vague and uncertain. The subjective symptoms, such as pain, may be com- pletely wanting in some of the most serious condi :ions, or out of all proportion to the severity of the case. An ulcer may proceed to perforation, and a fatal result happen, with but a minimum of discomfort, whilst an attack of simple colic may be agonising. Nor is physical examination so fruitful in its results in the case of intestinal disease as it is in the affections of many other organs, the ugh perhaps in no other region is the tactus cniditus so valuable. Many ot' the states to be considered below undoubt- edly pass through their whole course without giving the slightest indication of their exist- ence that can be recognised by physical exami- nation. An investigation of the evacuations at present furnishes information within the narrowest limits. From all these circumstances, a diagnosis of many diseases of the intestines is almost a matter of pure inference and conjecture, based upon a careful consideration of all cir- cumstances, with due regard to the value of ex- perience. In respect to treatment, very much may be done with the means at our command. The re- moval of causes is in a large proportion of cases easy, and a complete cure may bo effected. .And whilst some of the remaining cases admit of little or nothing being done for them, a greater number can be partially relieved by palliative remedies. The several diseased conditions of the intes- tines may now be discussed, for the sake of con venience, in alphabetical order. 1. Intestines, Abscess in "Walls of. — In the course of severe cases of enteritis — phleg- monous — where the inflammatory process affects all the coats of the bowel, and the products in- filtrate the different tissues, collections of pyoid cells may be met with, but with no well-defined limit, which may be regarded as abscesses. Such bodies may burst into the intestine, leaving small ulcers ; or through the peritoneal coat, and so conceivably cause perforation. In the chronic enteritis so often met with in scrofulous subjects, the solitary and agminated glands may undergo slow suppuration, and form abscesses which end by bursting into the lumen of the gut. Such morbid products are rather of post-mor- tem interest, since they give rise to no sym- ptoms during life which will permit of their formation being diagnosed, apart from the gene- ral existing enteritis, and are practically inca- pable of treatment. 2. Intestines. Albuminoid disease of.— The intestines appear to be affected with albu- minoid disease next in frequency to the spleen, liver, kidneys, and lymphatic glands, and it is rare for the alimentary canal to show si;:ns of this degeneration until it has become far ad- vanced in the above-named organs. It is stated that the intestines are affected in 42 per cent, of all cases (Habershon). Anatomical Characters. — As in other or- gans, the inner coat of the arteries, particularly of those surrounding the solitary and agminated glands, appears to be the starting point of the albuminoid change, from which it gradually ex- tends to adjacent tissues, until the whole thick- ness of the bowel may be replaced by this ma- terial. In milder cases it is limited to the mueons and submucous coats, which in all cases are the first to suffer. Considering the exceeding prone- ness of tho Malpighian corpuscles of the spleen to undergo this change, it is noticeable that the solitary and agminated glands of the intestine, which are of similar structure, should long resis 1 INTESTINES, DISEASES OF. tho degeneration, and in many cases may be quite unaffected. Sooner or later, however, the albuminoid granules appear in these structures, until the whole gland is involved. The mesen- teric lymphatic glands are usually implicated ; and in severe cases the mesenteric and peri- toneal vessels, and even the appendices epiploic® (Hayem). The naked-eye appearance of the mucous membrane is that of a pale, thickened, leathery- layer, often of a ‘peculiar glistening aspect’ (Friedreich). The pallor is very striking. When the degenerative process has become extreme, the surface is ulcerated, especially over the fol- licles, from fatty degeneration and breaking down of the new material, the diminished blood- supply by the constricted vessels leading to this result. The small intestine, and particularly the lower part of the ileum, is the favourite seat of the dis- ease, which sometimes extends upwards to the duodenum and stomach ; the colon is sometimes affected. Symptoms. — The most prominent symptoms which this condition gives rise to, so far as the alimentary canal is concerned, are diarrhoea and hmmorrhage. Since the other important viscera are always simultaneously affected, other symp- toms coexist. The diarrhoea is rather characterised by fluid- ity than undue frequency of the stools, though the latter does occur: the evacuations'are often greenish from altered blood. It is rare to find either pain or tenderness ; and the diarrhoea when once established rarely ceases. Dr. Grainger Stewart has shown that h®mor- rhage from the surface of the mucous membrane, independently of any ulceration, is of frequent occurrence, and he considers it as due to rup- ture of the diseased vessels. Treatment. — Enemata of starch and opium are the most efficacious, though their effect is at best but temporary. The writer, however, has seen a case, where extreme degeneration of all the abdominal viscera was present, almost com- pletely recover on removal of the cause, namely, a suppurating joint. 3. Intestines, Atrophy of. — A general atrophy of the intestines accompanies a wasting of the entire body from any serious cause of malnutrition, such as starvation, where the or- gans are estimated in fatal cases to lose 42 per cent, of their weight, becoming extremely thin and transparent. Intestinal catarrh, particularly in children, may lead to atrophy of the bowels, even to an extreme degree. Wasting of parts of the canal are of more frequent occurrence from disease. This is well seen in cases where an artificial anus has been made, the gut below the opening becoming thin and shrivelled. In all cases where any consider- able stricture of the intestine exists, the portion beyond the obstruction atrophies more or less. This subject will be found fully discussed by Nothnagel, in the Zeitschrift f. Klin. Medicin, IV., 1832, p. 422. 4. Intestines, Catarrh of. — This is a mild ' form of iutestiual inflammation in which, how- 751 ever, the essentials of that morbid process aro present, though in a slight degree ( see Intes- tines, Inflammation of). 5. Intestines, Contraction of. — The calibre of the intestinal canal may be diminished by the pressure of tumours; by structural changes in the walls ; or by displacements of portions of the bowels in invagination, &c. Such causes of stricture are more properly described under in- testinal obstructions. See Intestinal Odstnuo tion. The term contraction may be applied to that state of shrinking which the gut is liable to pre- sent below the seat of any permanent stricture, whatever its nature, just as the portion of the canal above the obstruction tends to dilate. It is a condition that calls for no interference, being of no practical importance. A spurious contraction of part of the intes- tines may be occasionally seen post mortem , due to extreme spasm of the muscular coat. Congenital malformations, producing contraction of the canal, may be met with. 6. Intestines, Dilatation of. — The normal diameter of the small intestine may be taken as 1 i inch throughout ; and that of the large in- testine as gradually diminishing from 2.1 inches at the emeum. to 11 inches at the upper part of the rectum. But the canal is evidently capable of distension much beyond these limits, as may be recognised when large accumulations of flatus exist. Such conditions, however, may disappear after death, the bowel returning to its proper capacity. These dilatations, therefore, may be regarded as temporary, and it is impossible to say what may he the extreme limit reached and recovered from. Other forms of distension of a more perma- nent nature are frequently observed. Cases have been placed on record by Peacock, Crisp, and others (see Path. Soc. Trans.) where extreme distension occurred without an- obvious cause, but associated with marked constipation. In one case the colon was uniformly distended to a diameter of six to eight inches ; and in an- other the average diameter of the small intestine was twice the normal. In this case the stomach shared in the distension: and the person had been a large eater, and extremely fat. In the greater number of cases the dilatation is attributable to the existence of some stricture in the course of the canal. It is rare for any distension tr follow' an acute obstruction, though it is not absolutely unknown ; but a chronic stricture is almost invariably associated with more or less dilatation of the tube immediately above. The length to which this may extend is largely dependent on the duration of the case; and inasmuch as a persistent obstruction is usually located somewhere in the large intestine, it is the colon that is most frequently distended, and this may be so excessive as practically to obliterate the ileo-cmcal valve. The mere accu- mulation of the contents above the obstruction is doubtless one factor in causingthe di-tension . but a diminished resisting power on the part of the gut probably co-exists, brought about by malnutrition of its textures. The muscular coi>t of the dilated portions is usually hypertrophied. INTESTINES, DISEASES OF. 752 while the mucous membrane is thinned and peculiarly liable to ulceration, the decomposing contents furnishing an exciting cause for this result. The existence of any extreme dilatation may be recognised by mspection or manipula- tion of the abdomen, especially if the parietes be thin and wasted, as they frequently are in such cases. Faecal vomiting may of course occur in connection with the existence of a dilated intestine, but this is rather to be attri- buted to the primary obstructing cause, in the symptoms of which the few indications peculiar to this condition are merged. Paralysis of the muscular coats, by diminishing the resistance of the bowel, allows of its disten- sion. This is well exemplified in the extreme dilatation from flatus which so frequently accom- panies acute peritonitis. 7. Intestines, Gangrene of. iETionoGY. — The immediate cause of the com- plete death of a portion of the intestine is the complete arrest of the flow of blood through the part affected. This obstruction may be produced by : — (i.) Embolus of the superior mesenteric artery. Several cases of this condition have been re- corded, the emboli originating from the heart. (ii.) Thrombus of the mesenteric veins. The perfect stasis induced by this cause is of very rare occurrence, but it has been seen to fol- low invasion of the portal vein by malignant disease. (iii.) Local constrictions of the bowel. This is by far the commonest cause of gangrene, and is the probable sequence of an invagination or ileus. In these states the vessels are pressed upon by the altered position of the gut, which, with the continuously increasing pressure of the oedema that follows the venous obstruction, leads to complete stasis. (iv.) The more gradual obstruction to the blood-flow, from constriction of the vessels by diseases of their walls, leads to sloughing, which frequently tends to occur in albuminoid disease of the intestines. (v.) Sloughing also occurs as a sequence of the inflammatory state, when the process is of such intensity that complete cessation of the circu- lation takes place in localised spots, usually affecting the mucous membrane only, though occasionally penetrating deeper, ulcers remaining after separation of the sloughs. Anatomical Characters. — From the nature of the constructive tissues of the intestine, the- gangrene which is met with is of the moist variety. The portion of bowel which is affected is at first of an intense red colour, gradually increasing, and becoming purple, even to black. The extreme congestion of the vessels leads to effusion of blood into the tissues, which, however, are uniformly coloured ; decomposition rapidly takes place in the stagnant blood, and the pro- ducts acted on by the sulphuretted hydrogen of the intestines become black, all traces of red colour being soon lost. Meanwhile the mucous membrane and muscular coats are swollen and soddened by the serum and blood with which they are infiltrated, and a dark-black to ash- grey, soft, pulpy mass is finally thrown off from the healthy tissue. The extent of substance which may under"o this necrosis and be separated is extremely variable, from a mere slough of half an inch in diameter or smaller, to portions of bowel several feet in length. Dr. Peacock records a case where 12 feet were passed in eight portions during a period of three years. Symptoms. — The occurrence of symptoms whereby mortification of the bowels can le diag- nosed is not to be expected. The signs resolve themselves into those of the existing inflamma- tory state. It is not until the sphacelus has been passed, or that signs of ulceration are manifest, that the existence of gangrene can be ascer- tained. A very few hours suffice to produce this condition when once the causo is established, and it cannot be either arrested or cured; the sepa- ration of the slough is to be desired, though fatal haemorrhage may be associated with this process. The circumstances of this state pre- clude any treatment being specially directed to- wards it. 8. Intestines, Haemorrhage from. — An es- cape of blood from the intestines is a sign of certain morbid conditions rather than an actual disease itself, hence the cause of the haemorrhage must be sought for. ./Etiology. — The causes of intestinal haemor- rhage may be thus indicated : — o. Increased blood-pressure. Intense hyperaemia or extreme congestion. /3. Affections of the intestinal walls. 1. Injuries of the bowels. 2. Ulceration. 3. Vascular growths, haemorrhoids. 4. Amyloid disease of the walls. y. Primarily altered blood-states — 1. Purpura haemorrhagica. 2. Leucoeythaemia. 3. Yellow fever and severe intermittent fever. 8. Occasional causes— Kupture of aneurism into intestine. Vicarious menstruation. The mere enumeration of the causes must here suffice. It is obvious that the relative frequency of these conditions differs considerably, and in many cases the cause is at once apparent, whilst occasionally the source of the blood may be more obscure. It would seem from statistics that in- testinal hsemorrhage is of more frequent occur- rence in males, as gastric haemorrhage is more common in -women ; the latter fact being ex- plained by the greater liability of females to ulcer of the stomach, as the former appears to he by the preponderance of males suffering from the determining causes of haemorrhage, and not that the sex per sc predisposes to such a result. Symptoms. — Associated with the symptoms special to the loss of blood, and which are in the main similar to bleeding from any other organ, there are the signs and symptoms of the causal disease. The extent of the haemorrhage will necessarily largely determine the symptoms, many bleedings being so trivial as to give rise to no appreciable effects, and in extreme cases the loss being so great and sudden as to lead to rapid INTESTINES, DISEASES OF. collapse and death. Between these extremes all degrees of anaemia, faintness, pallor, giddiness, and. failing pulse may be observed. A sensation as of a warm fluid flowing into the abdomen is occasionally complained of, but otherwise haemor- rhage in this situation is possessed of no charac- teristic feature. The occurrence of the above- mentioned indications in the course of a disease liable to lead to this condition, would point to hc'emorrhage, especially if there be a fall in tem- perature from a previous pyrexial state. Occasionally the escape of blood is beneficial. This is particularly the case where the cause is a congestion of the intestinal tract, with or without haemorrhoids. Thereby the fulness of the bowels is relieved, and a more equable circulation is established. In some cases ot typhoid fever, contrary to what might be supposed, improvement has been noticed to follow a moderate loss of blood. (Trousseau.) Except in such cases as when the effusion of blood is so excessive that death takes place be- fore any escapes from the bowel, intestinal haemorrhage reveals itself sooner dr later in the character of the evacuations. Unless the cause be such as an ulceration immediately within the anus, or that the blood be sufficient in amount to escape alteration, when the bright red colour is retained, the fluid is always altered in appearance. The haematin is readily affected by the sulphur- etted hydrogen in the canal, and converted into a blackened material, sulphide of iron being formed, which stains the feces ; or a black tarry substance is evacuated, being the altered clotted blood (see Melina). As a rule, when the blood has undergone this change, the source of it is in the small intestine ; blood from the colon — where it is usually due to ulceration — being passed ad- herent to the feces. The height of the source, and the duration of its stay in the canal, largely de- termine the extent of alteration in the effusion. Diagnosis. — The history of the case ; the con- dition of the patient ; and the character of the oided blood, are the points upon which a dia- rnosis of the cause of intestiual haemorrhage is o be based. Prognosis. — The amount of blood evacuated ■5 not a sure guide to forming an opinion of the asult. It is difficult to estimate the actual uantity lost, since much may be retained in the owel. The general condition of the patient, specially the state of the pulse, is of far more nportance ; whilst allowance must he made for ae nature of the cause, not forgetting the oeca- onal favourable import of a flux. Treatment. — In a certain number of cases 'ceding from the bowel is quite uncontrollable ; others it is capable of cure ; whilst in a third ■oup it is rather to be encouraged. When arrest the htemorrhage is desired, rest, both general ‘id local, is essential ; the patient should be kept the recumbent position, as thereby the liability syncope is averted ; and the canal is to be kept jijet by abstinence from food, and the use of ium, to prevent peristalsis. The active treatment is to be directed to with- jawing the blood as much as possible from the ectedregion, by means of heat, sinapisms, dry- oping, &c., to other parts of the body ; and to ) application of styptics to the bleeding surfaces, 48 or the administration of such remedies as arrest bleeding after their absorption into the blood. Among the agents which, administered by the mouth or rectum, act locally, may be mentioned turpentine in 30 to GO minim doses, with two or three ounces of starch as an enema. Injections of equal parts of tincture of perchloride of iron and water may be given ; or acetate of lead in combination with opium. Tannic acid and the vegetable astringents are usually too slow in their effects to be of much avail. Probably the most effective remedy is ergotin, administered subcutaneously in 2-grain doses dissolved in gly- cerine, and repeated if necessary. This acts not only by constricting the vessels, but by dimi- nishing the blood-pressure. Bi tartrate of potash in doses of two drachms, and the local applica- tion of a saturated solution of perchloride of iron in glycerine, are of great benefit in arresting the bleeding of piles; for wliich purpose also, as well as for vicarious hemorrhage from the lower bowel, the writer has found frequently repeated doses (.n\v. to viii.) of tincture of hamamelis of much advantage. When the haemorrhage is d stinetly the result of engorged vessels, its occurrence should not be checked, provided it be not excessive. Sulphate of magnesia in full doses, with a few minims of dilute sulphuric acid, is then of great service ; by determining an effusion of the watery part of the blood, the congestion is relieved and the htemorrhage is arrested, the patient meanwhile refraining as far as possible from taking fluids. The giving of stimulants is a procedure that involves careful judgment. Whilst undoubtedly the tendency of loss of blood is to produce death by .syncope, it is also true that faintness itself favours the cessation of the bleeding, and, so far as a general direction can he given, stimulants should be avoided, unless there be reason to fear, from the condition of the patient, character of the pulse, &c., that the syncope is excessive. Short of that, alcohol, by temporarily increasing the heart’s power, increases the bleeding. Transfusion of blood, when practicable, should be resorted to in extreme cases. 9. Intestines, Hyperasmia and Congestion of. — The former term is here applied to those conditions of vascular engorgement where the excess of blood is, primarily at least, on the ar- terial side of the capillaries (active congestion, fluxion, determination of blood); whilst the latter term is restricted to cases where the fulness is caused by some obstruction to the venous flow (passive congestion). Doubtless cither of these conditions may lead to the establishment of the other, hut it is desirable to consider them sepa- rately, not so much for the difference in the causes producing them, as for the great differ- ence in their results. It should be remembered that even within the limits of health a considerable variation is met with in the degree of vascularity of the alimen- tary canal. The fluctuating periods of rest and activity undergone by the tube are associated of necessity with alternations of comparative hyper- semia and ansemia, as during the digestion of a meal or during fasting. It is impossible, there- fore, to draw any line beyond which the vascu INTESTINES, DISEASES OF. T54 lar fulness can be said to be abnormal ; as it is equally impossible to say exactly where hyper- aemia and normal gland-change end, and catarrh begins. Anatomical Characters. — The appearances seen post mortem are far from being always in- dicative of what existed during life. For an ex- treme arterial fulness may completely disappear after death, from contraction of the vessels ; whilst venous engorgement more or less com- pletely remains. ^Etiology. — The causes of intestinal hyperse- mia are as follows : — (a) Mechanical and chemical irritants, foreign bodies, and poisonous drugs. Spices and highly seasoned food, and alcohol ; any substance, in fact, which may be swallowed, and at all exceeds the blandest nature, may bring about an abnormal degree of hyperaemia of the whole or part of the canal. These causes act locally and directly upon the vessels. (/3) Vnso-motor paralysis of tho splanchnic area. If from any cause the normal tone of the mesenteric vessels is diminished, by inhibition or removal of the tonic influence excited by the sympathetic, tho vessels dilate and hyperaemia ensues. It isin this way that diarrhoea following certain emotional states is to he explained. Tho intimate relation which has been shown experi- mentally to exist between the splanchnic nerves and the vaso motor system generally, but especi- ally with the cardiac innervation by means of the ‘depressor nerve,’ whereby any considerable peri- pheral resistance in the systemic capillary area which impedes tho action of the heart is com- pensated for by a dilatation of the mesenteric vessels, renders it probable that an undue hy- peraemia of the intestines is of very frequent occurrence. ( 7 ) Collateral hyperaemia, or the fulness of tho vessels of one region caused by contraction of the vessels of another, as in the shrinking of tho cutaneous vessels from cold, extensive burns, &e. In such cases the blood, remaining constant in amount, must distend other vessels : and those of tho abdominal viscera, including the intestines, are peculiarly liable to become engorged, as ex- plained by what may be called their compen- sating paralysis. The causes of passive congestion are the fol- lowing': — (a) A general congestion of the entire intestinal tract will bo produced by any of those causes which lead to universal congestion of the tissues, as dilatation of the right heart from lung- disease. Pressure by tumours or othor conditions on the inferior vena cava above the liver, or on the portal vein, will bring about the same result. So also will any obstruction to the portal circula- tion in the liver. This is by far the commonest cause of intestinal congestion, since cirrhosis of tho liver, however produced, directly tends to it. (A) A congestion of a portion of the tube occurs when any obstruction exists to the venous flow of that part, as is marked in cases of in- vagination and strangulation of the bowel. The rarer conditions of embolism of branches of the mesenteric arteries, or thrombosis of the veins, will induce intense congestion. This state also forma a part of the vascular changes undergone by any inflamed part. Symptoms and Effects. — These conditions may of themselves give no evidence of their ex- istence. But tho following results may ensue: From hyperaemia, an increased secretion of mucus and other intestinal fluids, often more watery than normal, which with an increased peristalsis, induced by the same irritant that led to hyperaemia, produces a diarrhoea. Provided this over-functional activity be limited to the production of the normal secretions of the part, and increased healthy action only, the condition of hyperaemia is not exceeded ; hut. the passage into catarrh is easy, and persistently sustained ar- terial fulness will sooner or later pass into that state. The increased blood-pressure maybe sufficient to induce diapedcsis of the red corpuscles, or rupture of the capillaries, leading to capillary haemorrhage, submucous petechia-, &c. As regards congestion, the more complete the obstruction to the flow, the greater vail he the pressure in the veins, whose thin walls favour the transudation of the serous part of the blood, and so produce an oedema of the mucous mem- brane and entire thickness of the bowel, with a transudation onhoth surfaces, into the canal itself and info the peritoneal cavity, the latter being more marked. The fluid ethision in this ease is dependent entirely on mechanical conditions, whilst the flow in hyperaemia is mainly the result of increased secreting activity. Ibemorrhago from rupture of the smaller vessels is of frequent occurrence, and may ho very considerable. A prolonged stateof congestion — and asa rule the cause is such as to determine a permanent state — leads to certain structural alterations in the tissues of the bowel, from the imperfect nutrition that a chronic venous fulness permits of. The nature of the change is chiefly the infil- tration of tho mucous and submucous coats with an imperfectly formed connective tissue, which causes a thickening and toughness of the bowels, almost identical with the results of chronic in- flammation. Treatment. — It is seldom that these con- ditions are such as call for treatment. The hyperaemia is usually of a transient nature; and the cause of congestion is generally irremovable. Aperients, such as jalap, gamboge. &c.. are some- times beneficial, by inducing watery evacuations and so relieving the vessels, but they demand constant repetition. The treatment of haemorrhage has been con- sidered ; but this and diarrhoea, when due to congestion, are, unless excessive, often benefi cial, and are not to he checked. 10. Intestines, Hypertrophy of. — This is always of local occurrence, a general hypertrophy, involving the entire length of the bowel, being practically unknown. In chronic enteritis the mucous, submucous, and even muscular coats are apt to become' much thickened, and though this is partly due to an excessive formation of connective tissue, there is also some actual hyperplasia of the normal textures. In portions of the intestines above an 1 bstruc- tion. a true hypertrophy of the gut, parthulsrly of the muscular layers, is to be found ; uu*.. as INTESTINES. DISEASES OF. 756 already said, this is usually associated with dila- tatiou of the tube. It is rare for this condition to he other than inferred during life ; it gives rise to no symptoms and calls for no treatment ; and when established is rather of the nature of a compensatory lesion. 11. Intestines, Inflammation of.— Synon. : Enteritis ; Fr. Enter it e ; Ger. Darmentzundung. Under this term are included all those struc- tural changes in the mucous membrane of the intestinal tract which primarily follow the ap- plication of an abnormal irritant, provided that the irritant be not of sufficient intensity to pro- duce absolute destruction of tissue. Such changes will involve more or less all the tissue-elements of the mucous membrane, and may extend to the muscular, or even the peritoneal coat. They are essentially characterised by productive, coinci- dent with destructive features, the former leading to the formation of new material, as pus or con- nective tissue, the latter to ulceration or gangrene. The inflammatory process may present consider- able variety in type. The simplest form, to which the term ‘ catarrh ’ may be applied, passes, by almost insensible gradations, from the tissue- changes met with in the course of normal diges- tion, to a distinct condition of disease. Or it may be that, superadded to the above-named , characters of inflammation, are certain specifle . characters due either to the nature of the cause, or to t he predisposition of the tissue affected, or to both, which determine the conditions known ifts diphtheritic, phlegmonous, dysenteric, &c. There are thus differences in the severity with which enteritis may occur, both as regards the extent of departure from normal structure, ,and in respect to the symptoms which arise. But in all cases the essential characters of in- flammation are present, which may be regarded as the results of the irritant, phis the efforts at repair on the part of the affected tissue. The morbid process may affect the intestine throughout ils entire length, either in common with or independently of the stomach — general enteritis ; or it may be distinctly limited to cer- tain parts of the canal — local enteritis, including duodenitis, ileitis, typhlitis, colitis, proctitis. As i rule the term enteritis is restricted to inflam- mation of the small intestines. In respect to duration and intensity, enteritis nay be acute or chronic. (4) Acute Enteritis. — Acute enteritis is lometimes culled gastric remittent, or infantile ;emittcnt fever — terms it is advisable to discard ntirely, since they are frequently applied to ery different diseases. Acute enteritis is meant r include all those cases where the essential fea- i.ires of an inflammation are present, varying in ^verity from a simple catarrh or muco-enteritis, p those severer forms possessed of special fea- iires, such as phlegmonous or diphtheritic. The tore severe cases, especially in children, are imetimes called simple or English cholera, or flora infantum. AStioi.ooy. — It is doubtful whether an idio- ithic enteritis is ever met with; some cause is 'nerally to be found. 1 Predisposing causes. — (a) The exposed situa- m of the intestinal tract to irritating sub- stances swallowed, causes this disease to be one of frequent occurrence. (/3) The structure of the intestinal mucous membrane, with its delicate and susceptible epi- thelial cells, and slightly protected blood-capil- laries, favours the occurrence of those changes which constitute inflammation. (y) Age especially 7 predisposes to enteritis. Foi although itmay occur at any period of life, infante and children during the period of dentition are peculiarly susceptible. A moderate intestinal catarrh may almost be regarded as a normal ac- companiment of dentition, like to the increased activity of the salivary and other glands at that period. From the moderate it may easily pass into the serious or even fatal degree. (5) The season of the year appears to exercise an influence, for during the summer this disease is certainly much more frequent; and particularly so when there is extreme difference between day and night temperatures, or when the heat is as- sociated with much moisture. (e) Occasionally this malady would appear to be epidemic. Exciting causes. — These, whatever their nature, would appear to act by inducing a hyperaemia of the tissues, which thence pass into a state of in- flammation. 1. Irritating ingesta of the most varied kind, such as abnormal, ilL-cooked, or improperly di- gested food, and irritant drugs or poisons, often cause enteritis. Of these, improper food is by far the most common, especially during the first year of life. Cow’s milk alone may be at that time sufficient to produce it, and it is rare for infants to escape an attack. An excessive flow of bile into the intestine is an occasional cause. i. Exposure to cold may be followed by in- flammation of the intestines, as it may be by inflammation of the lungs, kidneys, or pleura; the factor which determines the particular organ involved is unknown. There would seem to be some other factor than the mere determination to the viscera of an excess of cooled blood from the contracted cutaneous capillaries, which probably affects the nutrition of the tissue-elements via the nervous system. The occurrence of inflammation and ulceration of the duodenum which follows extensive super- ficial burns, cannot bo altogether explained by the hyperaemia of the intestines, which is said to follow the superficial injury. 3. Wounds, new-growths, and the mechanical results of intussusception, hernia, impaction of faeces, gall-stones, parasites, and other condi- tions, will lead to enteritis. 4. Inflammation of neighbouring parts may involve the intestines by extension, as from the stomach, peritoneum, or bile-ducts. 5. The specifle poison of diphtheria not in- frequently leads to enteritis of a characteristic nature. An inflammatory state of the intes- tinal mucous membrane is said to accompany or follow the exanthemata, and more especially s< arlet fever; and it sometimes complicates sep- ticaemia, particularly when this is of puerperal origin. In such cases the disease would seem to be set up, at least sometimes, by extension from the uterus along the peritoneum. Anatomical Cuabacters. — It probably novel INTESTINES, DISEASES OF. f56 occurs that the whole length of intestine is the seat of inflammation, and it is not often that even the entire small intestine is so affected. It is far more frequent to find certain tracts, of a few inches or a few feet, involved. Speaking generally, the colon, caecum, rectum, duodenum, ileum, and jejunum are affected, as regards fre- quency, in that order. In some situations special features are present, but the essential characters of inflammation always exist, whatever be the site. Owing to the physical properties of the in- testinal tissues, tlie appearances seen after death by no means necessarily correspond to what actually exists during life. Thus, the hyper- cemic state of the mucous membrane, with the increased redness, varying from a more intense pink than normal up to a deep dark red, may leave but a trace ‘post mortem , the vessels having become considerably emptied from the constriction of the vessels in rigor mortis. An increased vascularity, however, is one of the im- portant features of the state under consider- ation, and it may sometimes be so intense as to lead to capillary rupture and formation of pe- techise in the mucous membrane. The tissue- elements of the gut, as a result of the irritant causing the inflammation, and with the accom- paniment of an increased vascular supply, under- go changes in their appearance and behaviour. Thus the epithelial cells are in a state of cloudy swelling and increased activity in multiplica- tion, each successive progeny approaching nearer and nearer to the embryonic type ; the connec- tive-tissue elements are similarly affected, and leucocytes transude into the tissues from the vessels. These new-formed cells constitute pus- corpuseles, which are thrown off from the surface of the mucous membrane, and crowd to a vari- able depth the tissues of the different coats. If the primary irritant to the inflammation be of a specific character, such as the poison of diphthe- ria, or of an extremely severe nature, such as an intussusception or hernia, then the new'-formed cells become entangled in a fibrinous coagulable exudation from the blood, and form patches of membrane more or less adherent to the surface of the bowel, depending on the depth of tissue involved. In all cases there is some cedema of the intestinal walls from serous effusion, and the free surface of the membrane is covered with a glairy mucus, containing pus-cells, and frequently crystals of triple phosphates. The epithelium of the follicles of Lieberkiihn becomes extremely granular, and proliferates extensively, with the frequent result of blocking up the lumen of the gland, which thus becomes very prominent. The solitary and agminated glands are invariably much swollen, and very often the process of inflammation is most in- tense in their vicinity. Occasionally the mesen- teric glands are similarly affected. How this inflammation may terminate very much depends on the course ; it may subside, and the bowel gradually assume its normal characters with no impairment of function ; it may lapse into a chronic state; or it may pass on into ulceration, or even sloughing and gangrene. To these various degrees of the inflammatory state different terms have been applied in no very definite way. Thus, when the mucous membrane alone is affected, a catarrh or muco- enteritis is said to exist ; whilst the severer form, affecting all the coats, and attended with sup- puration, such as occurs in the neighbourhood of an intussusception, is known as phlegmonous. When a membranous exudation is found in asso- ciation with diphtheria, we have a true diph- theritic enteritis ; and the expression pellicular may be more fitly applied to those cases where a similar membrane is formed, though not in connection with the diphtheria poison. Such a state is of not infrequent occurrence on the prominent edges of the valvul® conniventes, and still oftener of the saccules of the colon, due to the presence of hardened faeces or impacted calculi. Both these latter forms are invariably associated with ulceration. The term dysenteric is very indifferently applied to more than one form of enteritis or colitis : the writer thinks it better limited to that form of inflammation due to the specific poison of dysentery, although the morbid appearances of such cases are almost or quite identical with some of the varieties enume- rated above, the differences in the cases being dependent on their clinical history. An enteritis associated with aphthae is of common occurrence in children. Symptoms. — That a considerable variation is met with in the kind and severity of the symp- toms presented in cases of enteritis, is only to be expected when the great difference in degree and extent of morbid change that is met with is re- membered. “Whilst the pathological changes that take place in a limited part of the canal are iden- tical with those that may be found in another, to a very large extent the symptoms that arise in the two cases may be widely' different. For whereas one patient may suffer from an attack of intes- tinal catarrh, with but a trifling array of symp- toms, another may succumb within a few days. There is no one symptom or even group of symptoms that is absolutely' characteristic of the disease ; even the general condition of the patient is not constant. In the milder forms of intestinal catarrh there may be slight pyrexia with thirst and quickened pulse, but these symp- toms may' bo scarcely noticeable ; while, on tha other hand, in the severe phlegmonous enteritis they are extreme, and the patient is in a stats of considerable prostration. I The following symptoms, more or less marked occur in different cases. ; Stools .— Diarrhoea is in some respects th most constant symptom, though, when the affec tion is limited to the higher part of the cam and space is given for the reabsorption of th excessive exudation, it may' not only be wantin; but there may be actual constipation. The lowi down the gut is inflamed, the greater theliab lity to diarrhoea, which hence becomes a markf character of colitis and proctitis. In the seve forms of the affection a more or less comple constipation may be due to the paralysis of t inflamed bowel, arresting the peristalsis, a allowing of the accumulation of the intestir contents above the lesion ; this is obviou: more complete when the enteritis is associate with any state producing mechanical obstructi such as intussusception, or ileus. INTESTINES. DISEASES OF. 757 The character of the evacuations is very vari- able. As a rule they are semi-fluid when diar- rhoea exists ; or they may consist chiefly of a liquid with a few feculent flakes ; but, when time has permitted a partial re-absorption of the fluid part, the stools become more consistent, and in cases of enteritis which are chiefly duo to faecal accumulation, solid, hard masses are passed. Mucus, in greater or less quantity, is con- stantly present — being especially abundant in affections of the large intestine and rectum, when it is often discharged as complete tubular casts of the bowel. Flood is not usual except in proctitis, or un- less there be ulceration or haemorrhoids; and pus is seldom noticed unless the rectum be in- flamed. Owing to the imperfect performance of diges- tion or absorption, the motions are liable to con- tain many abnormal constituents — as fat, when the duodenum and upper part of the jejunum are involved, or even masses of food scarcely changed ; and the altered character of the intestinal con- tents, with the products of decomposition, are in themselves important features in maintaining a diarrhoea. As a rule, the discharges are paler than normal, or may be even colourless ; the greenish tint so often seen in the enteritis of children is due to altered bile or blood-pigment. The odour is usually extremely offensive or even putrid; though sometimes, when the evacuations vre very liquid and colourless, smell may be alto- gether absent. Owing to a large production of gases, discharges if flatus are of very frequent occurrence. Vomiting, except in the severe forms, is not a .:ommon symptom of enteritis, unless the stomach tie involved. In phlegmonous enteritis, however, ■omiting may be persistent, and even stercora- eous; and it is relatively more frequent in chil- ren than in adults. Short of actual vomiting, nausea is frequently complained of. Pain and tenderness . — Pain in itself is a most neertain symptom, perhaps being scarcely no- iceable in the milder forms of catarrh ; whilst in plitis, the colicky, griping pains, which may or lay not be relieved by pressure, are character- tic. Still more is this the case when the rectum affected, when the straining and tenesmus con- itute one of the most distressing symptoms of le malady. When the peritoneum is involved, lie pain and tenderness are marked and charac- ristic. Both may be generally diffused over ue abdomen, or may be local in character, as over .e caecum ; in a large number of cases the pain referred to the umbilical region. General symptoms . — Among the more general mptoms, or those associated with inflammation special regions, are the phenomena of the fe- i he state in a more or less marked degree. The aperature may reach 104° F., or even higher; 1 in some cases it may be scarcely elevated. The j petite may be unaffected, especially if the upper jrt of the tract be free from the disease; whilst hromay be complete anorexia when the reverse -he case. Thirst is of usual occurrence, and it homes very marked when the evacuations are i andant and fluid. The tongue indicates rather ’ general state of the patient, and is a less re- ble index of the actual state of the intestinal mucous membrane, than in corresponding affec- tions of the stomach. It may be red, irritable, and glazed ; or coated with a thick fur, witn the edges and papillae bright and prominent ; in milder cases it can often scarcely be said to be affected. The character of the pulse varies with the general state. Provided that the pyrexia be extreme, there is the usual dry skin and con- centrated urine, with a tendency towards the production of the typhoid state, which usually is reached in fatal cases. In many cases the pros- tration is excessive, though the mind is usually unaffected to the end, and in a large number of cases there is a very marked irritability of temper. Notwithstanding the intimate sym- pathy between the alimentary tract and the brain, headache is of rare occurrence in enteritis. A persistent hiccough, presumably of nervous origin, is met with sometimes. In children the disease readily leads to a condition of collapse. The child lies in a languid, almost torpid, state ; with the skin of the abdomen intensely hot and dry ; whilst the extremities are cold and blue, the face is pinched, and the body generally appears shrunken. Frequently this state is interrupted by attacks of convulsions, especially if dentition be in progress. The child, too, is usually ex- tremely fretful, and maintains an almost con- stant, short, feeble cry, evidently accompanied with pain. When the disease affects the duodenum, jaun- dice, due to closure of the bile-duct, very often occurs. The intimate nervous relation between the rectum and base of the bladder explains tho frequency of micturition, so commonly associated with proctitis. Diagnosis. — The variability and oftentimes vagueness of the symptoms frequently admits of a diagnosis of enteritis being made only by a process of exclusion. The history of improper feeding, whether temporary or prolonged, often indicates the nature of the disease ; though it cannot be denied that all rules of a rational dietary are frequently violated, both by children and adults, with apparent impunity. Diarrhoea alone can by no means be taken to indicate the existoneeof intestinal inflammation, it being due to many causes which leave the in- testines unaffected ; and the same may be said of constipation, pain, vomiting, and other symp- toms. It is rather to a group of symptoms, with the previous history, that the observer must look. The character of the stools, as already described, often indicates the region of gut affected ; and tho existence of extreme tenderness and pain, with a hard, quick pulse, and the abdominal decubitus together, point to the involvement of the peri- toneum, which an exacerbation of temperature tends to confirm. The distinctive features of typhlitis, colitis, and proctitis have been already described sufficiently to form material for dia- gnosis in most cases. To distinguish between in- flammation of the jejunum and ileum is usually impossible, nor, practically, is it a matter of im- portance. The history of the case, the course of the temperature, and the characteristic rash and headache, should serve to separate acute enteritin from typhoid fever, for which it is sometimes mistaken. INTESTINES, DISEASES 01' 758 Prognosis. — This -will clearly depend on the degree of severity of the affection, no less than on its seat and extent. Best, which is of prime necessity to an inflamed organ, is almost incom- patible with maintaining the due nutrition of the patient, and this fact renders the prognosis very uncertain. A simple intestinal catarrh occurring in a healthy subject certainly tends, after a few days, to complete cure; but occurring, as it frequently does, in persons in ill-health, it is far more liable to pass into an obstinate chronic condition. In children, the opinion should be very guarded ; for whilst in a large number of cases perfect re- covery follows removal of cause and suitable treatment, others, for no very apparent reason, will, in spite of everything, progress to a fatal termination ; and this is, of course, more likely to be the case where a strumous or tubercular diathesis exists. Enteritis in different degrees of severity constitutes one of the most, if not the most, important cause of infantile mortality. In the severer forms, as they affect adults, opinion must be guided by the nature of the cause, and the general state of the patient. Re- cognising that the unfavourable tendencies of the patient are towards extreme prostration, to per- foration with fatal collapse, or to chronic ulcer- ation — according as these conditions are threat- ened, so may the prognosis be fairly made. The duration of extreme cases rarely extends beyond a few days, when, if death do not occur, the symptoms abate, and recovery, with oftentimes a tedious convalescence, follows, or a chronic con- dition of disease is established. Treatment. — Although great variety exists in the degree of severity of the symptoms of acute enteritis, and a corresponding difference obtains in the treatment to be pursued, yet certain gene- ral principles may be first laid down, and the more special details adapted to certain condi- tions afterwards indicated. Inasmuch as tho disease is one of a febrile nature, where, among other things, the tissue-waste is out of propor- tion to the repair, and at the same time the or- gans concerned with the preparation of the food are those mainly at fault, every effort should be made to minimise the bodily waste. This is best attained by keeping the patient in bed, which also offers tho additional advantage of providing a uniform warmth. As regards diet, in the greater number of cases of acute intestinal inflammation, the appe- tite is much impaired, even to complete anorexia. Providing the person attacked have been pre- viously in good health, no harm is done by com- plete abstinencefrom food for twenty -four or even forty-eight hours. This gives a much better chance of rest to the intestine, and abetter oppor- tunity for the removal of any irritant ingesta which may have been the cause of the inflamma- tion. The thirst during this period may be re- lieved by ice-cold water, with or without a little lemon-juice. It must not be forgotten that, with the mucous membrane and its glands inflamed, the conditions of normal digestion and absorption are materially interfered with, and articles of diet that ordinarily are most nutritious and easily digested, may and do become, under these altered circumstances, positively harmful. The aim in feeding the patient should be to give those materials which are most quickly absorbed, and leave the smallest amount of indigestible resi- due. Provided that the stomach be implicated and it is rare that it is not so. either directly or indirectly — meat foods are badly borne ; instead of the proteid constituents being digested in the stomach, they remain there and undergo putre- factive decomposition, and thus a ‘d fresh irri- tants to the canal lower down. If. however, as is largely shown by the state of the tongue, the stomach be tolerably free, then meat essences, made thin and allowed to stand till cold, may be given. The nausea or vomiting which is usually present is more easily overcome by giving the nourishment cold ; and a few drops of lemon- juice are of great service if added to the beef-tea. Milk is very uncertain in the way it is tolerated by such patients. Ocasionally it is impossible to give it, tho vomiting or diarrhoea being increased by it ; but equal parts of milk and soda-water may constitute sufficient nourishment to last for seve- ral days in extreme cases, and may be well borne. Lime-water maybe substituted for the soda-water, but, as a rule, effervescing fluids are more grate- ful. The milk should be as free as possible from cream, for fats in all forms are to be avoided, since the products of their decomposition are extremely irritating. A similar objection, though not to such an extent, may be made to farina- ceous foods, for the lactic and butyric acids to which they give rise in the process of pancreatic digestion will further increase any existing in- flammation. If given at all, it should be only in small quantities at a time; a remark which equally applies to all other food. Nutrient ene- mata may be of much use in some cases. A very great deal may be done for the patient J with drugs, both in the relief of symptoms, and in aiding the cure. It is seldom advisable to check the diarrhoea in acute enteritis; and an aperient to begin with.ei- cept evidence exist of there being any peritonitis, i or that the caecum be impacted with faeces, is a rational treatment. Thereby the irritant, what- ever it may be, is removed, and a better chance for recovery is given. Improper food is so com- monly the cause, that the majority of cases are benefited by a preliminary purgation. This it’ may be necessary to repeat, especially if irrita- ting results follow the nourishment that is given. Probably the best aperient in this case is calomel, in doses of two to four grains, given as powder. This undoubtedly cleans out the upper pint of the small intestine, and it will be necessary ml follow it up after a few hours with a quickly acting aperient of a saline character, or, better still, senna, if the latter can be borne. If the inflammation be confined to the colon, where, as already said, accumulations of feces are the common cause, copious simple enemata, repeated every six or eight hours, are of great advantage and this plan may be pursued in comunction wit! the aperient given by the mouth. The object ha been to clear out the alimentary canal, ant provided that this has been done, abstinent from food for twelve hours, and some bismuth r an effervescing form, are frequently sufficient i. milder cases to put the attack on the road i cure. The writer places great reliance on bismut. INTESTINES, DISEASES OF. 7W eilher in the form of solution with an effervescing cicrate of potash, and tlireo or four minims of diluto hydrocyanic acid; or granular effervescing lime-juice and bismuth. The nausea or vomiting are best relieved by this treatment. Pain is of course a pressing symptom. Besides external applications of poultices or poppy-head fomen- tations, the internal administration of opium is very effective — five or ten drops of t-he tincture everv four hours : the opium in these cases does not seem to interfere with the action of the aperi- ents. Should there be peritonitis the opium must be increased in amount, to the end of giving complete rest to the gut. Several leeches applied to the anus, with the view of relieving the hy- peremia of the intestinal tract, are occasionally necessary in extreme cases. When the attack is distinctly attributable to cold, a profuse sweating induced by hot baths, and ten grains of Dover’s powder, is often of great benefit. In those cases ■where, from the duration, character of stools, and previous treatment, there is reason to believe that the irritating causes are got rid of, the diarrhoea may then require special treatment, especially when the patient has been in ill-health, or is constitutionally debilitated, in which cases an ulceration of the bowel is more likely to follow. In such cases a powder, consisting of Dover's powder, 5 grains, and carbonate of bismuth, 10 grains, given every six hours, is very efficacious. Sulphate of copper, nitrate of silver, and vege- table astringents, are frequently used for the same purpose. So soon as the more acute symptoms have subsided, the bismuth may he still continued and gradually given with a vegetable bitter, such as calumba. But ten to fifteen minims of the dilute hydrochloric acid in an ounce of water is almost an essential to the recovery of the digestive power of the stomach. Inconsequence of the great liability to a second attack which this disease engenders, avoidance of well-known harmful articles of diet, and the use of warm clothing or flannel belts, arc de- manded as a prophylaxis. In infants and ,'ottng children the great lia- bility to collapse, often rapidly fata], must be borne in mind. Stimulants in some form are almost a necessity. The following prescription is usually used by the writer: — Liquoris Bis- ranthi wij-iij, Spiritus Ammcniae Aromatici "l'j-v, Tincture Cardamomi Composite in i j- v ; Aquae Jj-Jij according to age. Brandy in small quantities is often the means of saving life in these cases. When the collapse is not threaten- ing, two or three drops of solution of corrosive sublimate, with syrup, ”ss. and water, 5iss., every two or three hours, is of great service. It is a more convenient mode of giving mercury than in the form of grey powder. But in one form or another the writer believes mercury to bo of prime necessity. Corrections of diet on the lines indicated above are of course essential. Hot baths and other means to keep the child Warm must be followed. In the severer cases, which are lapsing into the ■yphoid state, the general principles for that londition must be followed ; but, except in srrch k state, alcoholic stimulants are rarely called or. (A) Chronic Enteritis. ^Etiology. — 1. A certain proportion c.f trv acute cases lapse into chronic when the original cause persists ; or when the structural changes resulting from an acute attack are permanent. 2. Those conditions which lead to a chronic state of congestion of the intestinal tract will thereby so affect the constitution of the tissues, with a consequent disturbance of function, as to constitute a chronic inflammation. The most important of these conditions is obstruction, either at the right side of the heart, or affecting the portal circulation in the liver. 3. Chronic enteritis is the occasional accom- paniment of some general chronic disease, such as Bright’s disease, when the altered nature of the arterioles, and circulation of a deteriorated blood, may readily be regarded as leading to a chronic inflammation. 4. Residence in tropical climates is a not in- frequent cause of inflammatory disease of the bowels. Anatomical Chakactees. — The intestinal mucous membrane, when it has been the seat of inflammation for any prolonged time, is thick- ened, tough, and of a grey or almost black colour, from a deposition of pigment, due to the chronic congestion. The epithelial cells are cloudy and ill-defined, and there is an infiltration of the mu- cous and submucous layers with new round-celled tissue, passing into the stage of connective tissue ; hence the thickness and toughness. The lymph- oid follicles are prominent and hard, and the intestinal glands are frequently blocked with cells and secretion, and form minute solid, though perceptible masses. The surface of the mem- brane will be more or less covered with a viscid glairy mucus, containing pus and imperfectly- formed epithelial cells ; not unfrequentlv such mucus may bo voided in the form of complete casts of the tube, and this is particularly the case in the pellicular form of colitis. Sometimes the muscular coat is thickened from connective- tissue formation. As a rule, therefore, the bowel is increased in thickness ; but in children it net unfrequently happens that a chronic en- teritis is associated with an atrophy of all the coats and the contained glands. It is unusual for a chronic inflammation of the intestine to exist in adults without coincident ulceration; but in children the disease may proceed to a fatal termination, and show no such condition after death. Symptoms. — Whilst many cases with a persis- tent cause may be said to be chronic from their outset, it is not always easy to say exactly when an acute case has lapsed into a chronic state, very much the same symptoms being continued. In such affections of the small intestine, the diarrhoea may be wholly wanting, and the bowels may be very confined. This is due to the dimi- nished peristalsis, from cedema of the muscular coat and impaired irritability. “When, however, ulceration is extreme, and especially if it be the coion or rectum that is mainly affected, chronic diarrhoea is an invariable symptom. The re- marks made on the character of the stools in acute enteritis are equally applicable to the chronic state, with the addition, that solid and liquid evacuations frequently alternate. Lasting INTESTINES, DISEASES OF. J 60 is the disease does often for many months or even years, a general impairment of nutrition results; the function concerned in the elaboration of the food, as -well as that by which the digested products are absorbed, are necessarily perverted, from the structural alteration of the organs con- cerned in their performance ; and as a result the entire body suffers. The marasmus is speedily noticed in infants and children, whose growing tissues the less readily withstand malnutrition. Apart from the general ill-health produced, there would seem to be a special inclination for the mental qualities to become affected, so that the intellect may become dulled and sluggish, the temper irritable, and the patient may fall into a condition of marked hypochondriasis ; this is particularly liable to be the case when the colon s the seat of the disease. The emaciated appear- mce; the dirty, muddy complexion; complicated >ften with a short, dry cough, dependent on reflex i uuses from the stomach, frequently lead a su- perficial observer to suspect the existence of phthisis. Diagnosis. — The grounds on which a dia- gnosis can be made are sufficiently obvious from a consideration of the foregoing remarks. Prognosis. — Chronic enteritis almost invari- ably tends towards a fatal termination, though this may be long delayed. As already said, it is, at least in adults, the colon that is chiefly the seat of this malady, and where it is almost always associated with ulceration, obstinately re- sisting all treatment, which at best is only pal- liative; the general nutrition is more and more deranged; and death from inanition finally ter- minates an existence of prolonged suffering and discomfort. Treatment. — Owing to the unfavourable ten- dency of this disease, the treatment can be rarely more than palliative. The debilitating and wearying character of the malady emphati- cally calls for good feeding. The diet should he abundant, no less than nutritious. When the disease affects the large intestine, the ordinary digestive changes in the food have taken place, and the contents of the canal reach the colon in the normal semi-fluid condition ; in this state they may be passed ; but owing to the impaired movements of the affected bowel the feeces are apt to accumulate, and constipation results. This should be guarded against by simple ene- mata, and the soothing effect of injection of warm water only is often very marked. In those cases where the enteritis is a sequence of a congestion of the intestine, the treatment must be directed to i-elievo if possible the cause of that congestion. Since this is usually some such in- tractable condition as Bright’s disease, cardiac dilatation, or cirrhosis of the liver, it is not very much that can be done. Tonics — such as quinine, iron, bark, with sea nir — are of undoubted benefit ; and, so far as pos- sible, causes of mental worry should be removed. 12. Intestines, Malformations of. — These may be {a) congenital ; or ( h ) acquired. (a) Congenital. — Though seldom of much cli- nical importance, congenital malformations of the intestines are often of great interest from a developmental point of view. The malformation may be of the nature of an excessive develop- ment. Thus certain parts of the canal — duo- denum, colon, and appendix vermiformis — have very rarely been found double. The commonest of all these malformations are certain diverticula of the ileum, which may be found protruding from the free margin of the ileum anywhere within ten inches above the ileo-cfecal valve. The eaecal ex- tremities of such processes may be connected with the umbilicus by thin fibrous cords, showing them to be unobliterated portions of the vitelline duct. They vary in length from half an inch to six inches, or even more ; their structure is exactly that of the ileum ; and they have been found the seat of typhoid ulcerat ion, or of perforation from the irritation of foreign bodies that have become lodged in them. The vermiform appendix may vary from half to twice the natural size. Deficiencies of development may affect the whole alimentary canal, or only certain parte. Andral records a case where only a straight tube joined the rectum and (Esophagus. The ileum may open upon an ectopic bladder. The lower extremity of the canal is frequently imperforate. Thus the rectum may end in a cloaca common to the urino-genital organs ; or the bowel may ter- minate in a closed extremity anywhere between the brim of the pelvis and immediately beneath the skin ; the anal pouch, which develops from without inwards, is in the latter case absolutely wanting ; and all degrees between this and a pouch that has just failed to establish a junction with the rectum maybe met with, producing the lesion known as imper forate anus. The valvulte conniventes are sometimes wanting, or very im- perfect, over varying areas of the small intestines. Congenital constrictions of different parts of the canal are occasionally met with — in the duodenum, either close to the opening of the common bile- duct or at the junction with the jejunum; in the lower end of the ileum, where some abnor- mality in the closure of the vitelline duct ap- pears to be the cause ; or in the sigmoid flexure. Such constrictions maybe multiple, of very short extent, the canal being much dilated above, and extremely narrowed and shrunken below. The ileo-csecal orifice has been seen contracted to the diameter of a small cedar pencil. The cause of these lesions is very obscure, but at present they are ascribed to a prenatal peritonitis or enteritis, though they may be occasionally accounted for by the existence of prominent valve-like folds of the mucous membrane. Hernial protrusions of the mucous membrane through the other coats, often very numerous, and varying in size from a pin to a walnut, have been seen in the colon, sometimes extending into the appendices epiploic®. They are very liable to become developed in cases of long- standing constipation. ( b ) Acquired. — The acquired malformations include the dilatations and contractions that are associated with stenosis ; and the adhesions and abnormal communications established by ulcera- tion and peritonitis, which have been already re- ferred to. When any symptoms are produced by malfor motion of the intestines they are usually those of obstruction ; and the only condition that mar be amenable to treatment is imperforate anas. INTESTINES, 13. Intestines, Malignant Disease of. Tho new growths which are met with in con- nection with the intestine may, for the present purpose, most conveniently be divided into malig- nant and non-maliqnant — a clinical distinction irrespective of their minute structure. We will here discuss the former class, in which there are included those neoplasms which tend to produce a fatal result, as a rule, rapidly ; and that are accompanied with a marked general perversion of nutrition. ^Etiology. — Malignant growths of the intes- tine, as in other situations, whilst not wholly unknown in the earlier periods of life, are rarely met with before the age of forty. From an examination of 9,000 fatal cases of cancer, the relative frequency of intestinal cancer to that of other organs was found to be as 1 to £G (Tanchou). Cancer of the intestine is nearly always primary, and very frequently runs its course without any secondary formations elsewhere. Occasionally the bowels are affected by exten- sion from neighbouring parts, and this is espe- cially liable to be the case in the rectum, when the uterus or vagina are the seat of tho disease, and in the duodenum, which may become in- volved in an extension from the pancreas, liver, or stomach. Primary cancer of the duodenum is very uncommon. Very rarely small nodules are found in tho solitary and agminated glands secondary to carcinoma existing elsewhere. Anatomical Characters. — Malignant disease may occur at any spot throughout the entire length of both small and large intestine, but is infinitely more often to be met with at certain special parts, notably the rectum, sigmoid flexure, caecum, colon generally, and duodenum; the jeju- num and ileum being rarely affected. There is undoubtedly a predilection for those spots where any delay may occur in the passage of the in- testinal contents, such as the flexures of the large intestine ; and this favours the idea that me- chanical irritation is largely concerned in the causation of malignant growths. The greater number of the growths included in the category of malignant are comprised in the group of carcinomata, and present the following varieties : — Schirrus, encephaloid, scirrho-ence- phaloid, and colloid. Others belong to the epi- theliomata, and not a few to the adenomata and lymphadenomata. The former are perverted growths of the epithelial tissue; but sometimes tu- mours of the sarcomatousorconnective-tissuetype are met with, following a malignant course, and presenting many points of similarity to encepha- loid. The microscopic characters of these new growths present no special features. See Can- cer; and Tumours. As a rule, malignant growths would appear to commence in the mucous and submucous coats of the bowel, and then gradually involve the other issues; but the colloid form usually begins in the peritoneum, and extends inwards. I The mesenteric glands are invariably affected, .lid may come to form large tumours. Following the general course of these neo- ilasms when found elsewhere, they may undergo egeneration and ulceration, thus suffering a iminution in bulk at one spot whil-t they extend DISEASES OF. • 7(51 in other directions, and this is especially the case in the more rapidly growing varieties, as the encephaloid, adenoid, and malignant sarcomata. In tho course of their development they may set up adhesions between the bowel and other parts, as the abdominal wall or uterus, and two or more coils of intestine may be thus involved. The new-formed tissue may constitute an irre- gular mass of a very variable size and extent, of a nodulated or of a villous appearance, perhaps partially ulcerated, and extending into tho passage of the canal, producing an obstruction. The scirrlius and encephaloid growths are liable to develop in an annular manner, involving the whole circumference of the bowel ; the obstruct ion produced in such circumstances may be extreme, even to narrowing the lumen of the tube to barely the size of a probe. Occasionally, how- ever, annular encephaloid growths occur with no stenosis, but rather a dilatation of the canal. The extent of obstruction may be altered by partial destruction of the new growth by slough- ing, though the subsequent cicatrices that may result, will again constrict the gut. Symptoms. — For a varying time beforo this disease definitely and unmistakably asserts itself, the patient complains of vague dyspeptic symp- toms ; a sense of uneasiness in the abdomen, not amounting to pain, and usually increased after meals ; and marked irregularity in the action of the bowels, with or without flatulent distension. The persistent and gradual increase of these symptoms, especially if there be any loss of flesh, is very significant, and should excite suspicion. Sooner or later, according to the duration of the case, the usual cachexia is established; and in the greater number of cases the patient rapidly emaciates, especially towards the end, though in cases of very short duration the wasting may not be so excessive. The emaciation depends not only on the general perversion of nutrition caused by the development of the cancer, but also on the direct influence it exerts on organs concerned in the digestion of nutriment. The local signs and symptoms referable to the new growth itself are very variable in their occur- rence, and often aro singularly slight in comparison with the gravity of the cause. Thus pain may bo completely wanting, and perhaps there is but little tenderness on pressure; when present the pain is usually of a dull character, and quite localised. When the rectum is affected, the pain is apt to be rather of a burning character, and to- radiate into neighbouring parts ; not infrequently in this situation the pain may be extreme, and with tenesmus may amount to a degree of suffer- ing which is very rarely the case elsewhere. The indications of the tumour produced by the new growth are very uncertain, being often little more than an ill-defined fulness in one region ; at other times presenting a distinct hard irregu- lar mass, of variable size, this last quality being partly dependent on faeces. Should the growth happen to be situated on the aorta or iliac arteries, an indistinct pulsation may be communicated to it. The percussion-note over the tumour is usually imperfectly tympanitic, from the existence of coils of intestines between it and the abdominal wall, the thickness of which will of necessity considerably modify the signs of the existence of 762 INTESTINES, tho growth. The mass may present all degrees from free mobility to complete fixity, dependent on the nature of its sea.t, and also on the exist- ence of adhesions 1 to neighbouring parts. Symptoms of intestinal obstruction are rarely wanting ; though, as already said, in exceptional cases the bowels may be dilated at the seat of the growth. Vomiting, constipation of increas- ing severity, with signs of intestinal distension above the lesion, are among the most constant ; occasional diarrhoea, determined by the chronic enteritis which exists, may alternate with the constipation ; and rupture of the intestines has been met with. Sec Intestinal Obstruction. The stools are usually characteristic of the obstruction, consisting of small separate masses, frequently hard and round, and often mixed with sloughed-off portions of the new-growth, or with blood, that has escaped from the ulcerated surface. The nearer to the anus the growth is situated, the less change will there be in the blood, which sometimes maybe considerable in amount. If the peritoneum be involved, peritonitis is likely to arise ; and ascites, often considerable, is usually developed with colloid cancer. Super- added to these symptoms will be those caused by tho morbid condition of any other organ that may be affected, such as the liver, bladder, or uterus. Course and Terminations. — Malignant dis- ease of the intestines in the majority of cases progresses continuously from its commencement to a fatal ending. It is difficult to state even an average duration, owing to the insidious onset and vagueness of the first symptoms; but the greater number of cases rarely go beyond twelve to eighteen months from the time when the dis- ease is clearly established, whilst some may be fatal in a few weeks, and a few may last for years. Death may result as the direct consequence of tliecachexia ; or from haemorrhage, peritonitis, or other effects of the growth. Diagnosis. — An exact diagnosis is often not to be made, and the nature of the case remains throughout uncertain, if not actually as to the existence of a malignant growth, at least as to che seat of it. The insidious and ill-defined character of the earliest symptoms presents nothing diagnostic, though their progressive character and resistance to treatment would cause a suspicion, especially in a person over middle age, and in whom a gradual even though slight loss of weight is noticed. Even in the later stages, the symptoms are almost identical with those of chronic enteritis, which really co-exists with the new-growth to a greater or less extent ; and in the not unfrequent cases in which a tumour is not to be felt, or is uncertain in its indications, the diagnosis becomes extremely difficult. Some cases also in which the new-growth is unrecogni- sable to palpation, and at the same time causes little or no obstruction, closely simulate in their course diseases of the supra-renal capsule ; for the latter are not invariably accompanied by cutaneous pigmentation, and the rapid and pro- gressive emaciation, with more or less persistent vomiting, may be common to both. It is true that the malignant cachexia is frequently pro- ductive of a characteristic, facies, but this would equally occur in cancer of the capsules. DISEASES OF. Supposing that the existence of an abdominal tumour be clearly ascertained, it is not always easy to determine its connection with the intestine, since the variability in position, in mobility, and in size (due to tho accumulation, or the reverse, of feces), precludes any diagnostic sign, although this very variability is regarded bv some as almost indicative of intestinal cancer, lii distinguishing between an intestinal tumour and one connected with the liver, pancreas, kidney, mesenteric glands, uterus, abdominal wall, or the inflammatory new-growths following a perityph- litis, an aneurism, or a simple fecal accumula- tion, the history of the case, age, progressive na- ture of the condition, existence of tumour, signs of obstruction, and character of the stools, are the points to be considered in forming a diagno- sis. Any one or even two of these points might equally indicate other lesions, but taken collec- tively, they will usually justify the formation of an opinion. A rectal cancer, that is accessible to the touch or oven to inspection, need offer no difficulty, but it is otherwise where it comes to distinguishing a duodenal growth from one strictly limited to the pylorus. The vomiting in the latter case is more persistent than in the former, and there is a greater liability to hsema- temesis ; but these are most uncertain signs, as also is the existence of jattndice, which oftener complicates the duodenal affection, from the greater chance of involving or pressing on the bile-duct ; but jaundice is not a necessary ac- companiment. A firm epigastric tumour, felt close )o the margin of the thorax, and associated with distinct dyspeptic symptoms, may also be due to primary cancer of the head of the pan- creas. The symptoms of obstruction are less marked at first, but the growth will probably involve the gut in its progress, and cause more complete stenosis. Owing to the destruction of the gland-tissue, the pancreatic juice is not se- creted, and undigested fat may be found in the stools. Similar difficulties may surround the investi- gation o! a tumour situated in the right iliac fossa. Emaciation, constipation, and melana might equally indicate a scirrho-cncephaloid tu- mour of the caecum, or the remains of a chronic perityphlitis. The history may help a little, but frequently the case remains throughout in doubt. Treatment. — The extremely rare cases of re- puted natural cure of malignant disease of the intestines, brought about by sloughing of the growth and subsequent cicatrisation of its site, afford no hope of our being able to artificially imitate the process, and the treatment remains at the best symptomatic and palliative. The diet should be so arranged as to contain the minimum of indigestible residue, and permit the chief digestion and absorption in the stomach, if it be the upper part of the tube that is affected. But in the majority of such cases the utmost disinclination for food exists, even apart from any vomiting or pain its ingestion may produce, and hence, whatever the directions, the patient in the later stages practically takes nothing. The anorexia is frequently as marked even when the mischief is seated in the colon, and the area for digestion and absorption is un- it) terfered with. INTESTINES, In the earlier stages it may be advisable to insist upon as much nutritious food as possible by the mouth or in the form of enema, so as to offer the most prolonged resistance to the inevit- able end ; but at the same time there is no slight cause for thinking that the same course favours the speedier development of the new- growth. Preparations of iron may be given with the same view. The symptoms dependent upon the obstruction we can do next to nothing to relieve ; only the mildest aperients are permissible, to combat the constipation ; while the vomiting is as a rule uncontrollable, and, indeed, is often a relief. Hannorrhage may require special attention, and the pain may be so severe as to necessitate free administration of morphia subcutaneously ; in other cases belladonna is of value in alleviat- ing the local discomfort, and acts favourably by allaying any spasm. But our best remedies offer no resistance to the progress of the disease, and but too often very little relief. The special characteristics of cancer of the rectum, sigmoid flexure, or caecum occasionally permit of operative interference — such as co- lotomy. See Intestinal Obstruction; and Rectum, Diseases of. 14. Intestines, Malpositions of.- — ’Dis- placements of the intestines, like malformations, are both congenital and acquired. Among the former may be mentioned complete transposition of the viscera, the ciecum and as- cending colon being on the left side, and the sigmoid flexure and descending colon on the right, the liver, spleen, stomach, &c.. sharing in the change. Certain parts only of the intes- tinal canal may occupy an abnormal situation, as seen in the various congenital herni® ; or the displacement may be due to unusual length of the mesenteries, the caecum and sigmoid flexure being the parts that present the most usual alteration from this cause. Thus the caecum may occupy the left hypochondrium or left iliac fossa, or be found in the pelvic cavity, and, of course, other parts of the canal must correspond to these malpositions. The sigmoid flexure has been seen lying to the right side of the left kidney, which was situated immediately below the bifurcation of the aorta. Similar displacements are referable to adhesions, de- termined by intra-uterine peritonitis, which is frequently associated with syphilis. The malpositions which the intestines may come to present from changes set up after birth are so variable as scarcely to admit of classification. Hernia, both external and in- ternal, volvulus, and intussusception are among the well-recognised displacements ; but there is scarcely any limit to the changes in position which the traction and pressure of tumours and the effects of peritonitis may produce. Many of these conditions give rise to no symptoms, and may even fail to be recognised during life. The acquired malpositions lead to obstruction in varying degrees. Nee Intestinal Obstruction ; and Hf.rnia. 15. Intestines, Morbid Growths of. — Owing to the variety of tissues that enter into DISEASES OF, 768 the formation of the intestine, no less than to the origin of these tissues from two of the three pri- mary layers of the blastoderm, the new-growths that may develop are exceedingly numerous. It will be most convenient here to consider them from their clinical rather than from their genetic or histological point of view, and to di- vide them into malignant and non-malignant growths. The former have already been treatod of, and the special neoplasms of tubercular and syphilitic origin are more conveniently referred to separately. Varieties. — 1. Filrromata. These growths, which are developed from the connective tissue of the submucous coat, are usually of small size, fre- quently pedunculated, though sometimes appear- ing as sessile, flattened nodules, of half the siso of a pea projecting into the canal. The smaller ones may be scattered throughout the length of the bowel, whilst the larger ones (up to the size of a walnut) are fewer in number or single, and are usually found in the rectum. They present the ordinary microscopic characters of fibrous tissue. 2 . Lipomata. — Polypoid growths of adipose tissue, springing from the submucous coat, are not of uncommon occurrence in any part of the intestines. Less often they are sessile and of small size. 3. Myomata. — Very rarely small growths are met with, chiefly composed of contractile fibre- cells, with a variable amount of connective tissue. 4. Vascular tumours — Angiomata. — Besides hoemorrhoids, other vascular growths are some- times found, of an erectile character, similar to naevi of the skin. 5. Mucous. — It is to these growths that the term polypi is oftenest applied. They essentially consist of all tho tissues of the mucous membrane, though differing in their vascularity, and also in their glandular elements. When these latter are excessive in amount, they are liable to present characters which connect them with malignant forms of new-growth, especially if their surface assume a villous character. Polypi are not limited to any one part of the canal, though undoubtedly they are most common in the rectum. Sometimes they are distinctively pigmented. They are oc- casionally multiple ; and have been met with at all ages. 6. Lymphoid growths — Lymph adenomata . — Neoplasms whose structures correspond to that of the solitary or agminated glands, or of the lym- phoid layer of the submucosa, are met with in association with theso normal constituents of the intestinal wall, and quite independently of any leucoeythmmia. 7. Cysts. — These have been rarely met with, and the contrast to their comparative frequency in the uterine mucous membrane is remarkable. Dr. Dickinson (TV. Path. See. vol. xii. p. 138) re- cords the occurrence of a colloid cyst of the size of an orange, between the muscular and mucous coats of the c®cum in a patient aged 75, so placed as to give rise to no obstruction or other symp- toms. The contents were gelatinous and oily, and there were no cysts elsewhere. Effects and Symptoms. — As a rule, tho growths mentioned above present very little in- terest, unless they be situated just within the 764 INTESTINES, rectum, and accessible to digital examination. They cannot be diagnosed, though they may give rise to certain symptoms, as, for instance, haemorrhage from the vascular polypi and erec- tile tumours, or partial obstruction if they attain any size ; but such symptoms are not diagnostic. One of their most interesting effects appears to be the liability that the polypoid forms, occur- ring in the small intestine, have of inducing in- tussusception, from interfering with the due pro- gress of peristalsis. Prolapse of the rectum is similarly found to be occasionally due to polypi. Treatment. — No treatment can be attempted, beyond that of the symptoms which may arise; or the removal of growths within reach of the anus. 16. Intestines, Paralysis of. — The peris- talsis of the intestinal tube is normally depen- dent on automatic nerve-impulses, originating in the intrinsic ganglia of the canal, controlled by both reflex and direct impressions from the cerebro-spinal and sympathetic systems, the former acting via the vagus in an accelerating manner, the latter via the splanchnics in an in- hibitory direction. The integrity of the involun- tary muscular fibre is assumed. ^Etiology and Pathology. — A paresis of the intestinal movements may be brought about by ( 1 ) causes acting through the nervous system ; or (2) through imperfection of the muscular tissue. (1) Nervous.— Whilst it is possible that the intrinsic ganglia and nerves of the intestinal mus- cular coat may be the seat of degeneration, no known observations are recorded. Certain lesions of the brain are accompanied by symptoms of intestinal paralysis, but with no hitherto recog- nised regularity, and it is assumed that such lesions act by interfering with the function of the vagi. It is doubtful how far disease of the spinal cord produces actual paralysis of the in- testines, though constipation may result, a cir- cumstance that may be explained by assuming an interference with the centre that controls de- fecation. See Pieces, Retention of. (2) Muscular. — The irritability of the mus- cular tissue may be much weakened by degene- ration (cloudy, fatty, or amyloid). Inflammation of the mucous or serous coat, especially the latter, is liable to determine granular change in the muscular fibres, which, aided by a coexistent oedema, largely impairs the contractile power of the tissue. The irritability is also liable to suffer from the over-stimulation of too powerful and too frequent purgative medicines ; and the muscular fibres of a much dilated portion of the bowel are apt to become paralysed from distension and stretching. The general want of tone that the muscular and nervous systems manifest subse- quent to debilitating diseases, want of food, hy- steria, and other conditions, also finds expression in the alimentary canal, in diminished peristaltic action. The modus opcrandi of certain astringent drugs upon the bowel is quite unknown, possibly through the nervous system, as appears to be Hie case with opium, and perhaps by affecting t he muscular fibres or nerve-terminals. Lead, which would seem to cause both paralysis and spasm of the muscular coat, may act in this way. DISEASES OF. Symptoms. — The prominent symptom of ictea- tinal paralysis is constipation, though other signs of obstruction, such as vomiting, meteorisra. &c„ may be superadded. See Constipation; and Intestinal Obstruction. Treatment. — As a rule this is directed to the primary cause, but great benefit has undoubtedly followed the special application of electricity to the abdominal parietes. Friction applied on systematic principles is of undoubted service. 17. Intestines, Perforation and Rupture of. — Aetiology. — The causes of perforation or rupture of the intestines may be arranged thus : — 1. External injuries, such as blows, being run over, &c., though more liable to rupture the solid abdominal viscera, frequently cause the intestines to burst, especially the ileum or jejunum. 2. Corrosive poisons, when swallowed in any considerable amount, may destroy not only the walls of the stomach, but also of the upper part of the intestines. 3. Extreme distension byjlaius above the site of a constriction may cause the bowel to burst. 4. Ulcerations, pre-eminently the so-called peptic ulceration, and less commonly typhoid and catarrhal ulceration, are liable to lead to perfora- tion. 5. Perforations may be produced ab extra, by the bursting of abscesses or aneurisms into the canal. Symptoms. — The most striking symptom which perforation of the bowel presents is collapse, and it is a noticeable fact that rupture of the hollow abdominal viscera is more liable to induce this condition than a similar lesion of such organs as the liver or spleen. The exact explanation of this collapse is not apparent. Should the patient live twenty-four hours after the establishment of a perforation, signs of peri- tonitis will assert themselves — severe abdominal pain and tenderness, pyrexia, vomiting, and other symptoms. Supposing that the perforation follow an ulceration in the course of a previously high temperature, such as enteric fever, there will be a sudden and usually considerable fall in the body- heat ; this may be the first indication that per- foration has taken place. Perforation or rupture of the intestines usually proves fatal within forty-eight hours of its oc- currence, although cases are recorded which have lasted for weeks ; very rarely recovery has taken place. There are no reliable signs whereby rupture of the stomach may be distinguished from that of the intestines, nor is it of any practical im- portance. But the collapse and fall in tempera- ture, with the history of the case, are quite suf- ficient to warrant the diagnosis of perforation of some part of the canal. Treatment. — Rest is of primary importance, both in regard to the whole body, and the bowels themselves. This object is best attained by flic free use of opium, commencing with a grain, and repeating it in a few hours until its influence is fully established. It is also desirable to cut off all food, except an occasional teaspoonful of meat essence; to give ice to suck; to administer nu- trient enemata, and brandy and ether if the col- INTESTINES, DISEASES OF. lapse be profound ; and to apply warmth to the extremities. 18. Intestines, Spasm of. — The irregular and forcible movements of the bowels, usually accompanied with pain, are known as colic. Under ordinary circumstances we are uncon- scious of the peristaltic action, but when the contractions of the muscular coats bfcome violent, more or less pain is likely to occur. JEtiology.' — The determining causes of intes- tinal spasm are : — 1. The direct irritation of indigestible ingesta. 2. Exposure to cold. 3. Certain poisons— lead, strychnia, &c. — which probably affect the mus- cular fibres through the nervous system. It is difficult to ascertain the exact condition of the contracted bowel, since the appearances seen after death are not an index of what existed during life ; but it would seem that the spasm may start from several points in the course of the canal, and, after persisting for a variable time, either yield or travel on as a wave of spasmodic contraction. For how long a portion of bowel may remain contracted is quite conjectural. Symptoms. — The existence of a painless spasm of the intestines is very doubtful; as a rule it is the pain which indicates this condition, and ex- cept the contraction be maintained, no further symptoms may occur. Constipation, vomiting, meteorism, may all be present in varying degrees, dependent upon the extent of obstruction which is produced. Not infrequently fever, collapse, and prostration may co-exist, leading to the belief that a more serious condition is calling for treat- ment. The specially painful spasm of the anal sphinc- ters and lower portion of the rectum termed tenesmus, is associated with gouty congestion, with ulceration, and with most other lesions in that locality. Treatment. — The external application of moist heat in the form of poultices or fomentations, preferably of poppy-head or other opiates, is of great value, for relaxing the spasm or removing the pain. Since an irritant is so frequently the cause, an aperient, such as castor oil or calomel, combined with opium, is essential. The collapse may be so severe as to call for energetic stimula- tion by brandy, ammonia, or ether. 19. Intestines, Syphilitic Disease of. — The intestinal canal is rarely the seat of the specific lesions of syphilis, except at the lower end of the rectum, and margin of the anus. Small gummata have been found in the submucous tissue of various parts of the bowel, but more often the ulcers to which these growths give rise by their degeneration and breaking down ; radiating fibrous cicatrices of the mucous membrane have also been seen, produced by these syphilomata. It is doubtful whether there be any specific ulcer- ation of the intestine which is not preceded by gummata, although small ulcers do occur in new- born children, the subjects of congenital syphilis. Syphilitic ulceration and stricture of the rec- tum is not of infrequent occurrence. See .Rectum, Diseases of. 20. Intestines, Tubercular Disease of. — The specific lesions cf the tubercular diathesis, 765 namely, grey granulations or miliary tubercles, are of frequent occurrence throughout the intes- tinal canal. Regarding them as local developments of lymphoid tissue, the opportunity for their for- mation is most favourable, owing to the extensive distribution of this tissue throughout the sub- mucous coat, and the special aggregations of it which form the solitary and agminated glands. The abundant supply of lymphatic vessels in the thickness of the walls of the canal, and the close connection of the serous surface with the lym- phatic system, all predispose to the development, and spread of a tubercular growth which may have become established in a subject of the diathesis. jEtiology, — As a primary growth tubercle very rarely attacks the intestines in adults, though it is of very frequent occurrence in chil- dren as piart of a general tuberculosis. In adults, on the contrary, tubercular disease of the intes- tines is very commonly developed secondary to a similar affection of the lungs. Anatomical Characters. — The submucous layer and the peritoneal coat are the structures in which the tubercle originates; in the former situation it especially favours the ileum and cse- cum, although it may develop throughout the entire length of the tube, whilst the peritoneal tubercle is about equally distributed. The me- senteric glands are always considerably involved. The rareness with which the stomach is affected by tubercle is in marked contrast to the fre- quency of the intestinal lesion. In extreme cases of tuberculosis in children, death may take place before any changes in the tu- berculous formation have taken place, and count- less grey granulations, from the size of a pin's head to bodies microscopic, are to be found in the submucosa, and in the solitary and agminated glands. Later on, however, these non-vascular new-growths coalesce, and form distinct masses, which from lack of nutrition undergo caseous degeneration and break down, thus forming the tubercular ulcers. The ulcers tend to spread, and rarely to heal, and whilst they may be at first limited to the glands, they invade the ad- jacent mucous membrane, especially in a direc- tion round the bowel, their extension being preceded by the development of fresh tubercles, to the progressive formation and destruction of which the spread of the ulcer is really due. Large masses of the mucous surface may be thus destroyed, leaving a ragged, flocculent surface, formed of the muscular fibres, or even of deeper structures, which lesions rarely proceed to per- foration into the peritoneal cavity, adhesive peri- tonitis having established attachments to adja- cent parts. The thickened, congested, irregular edges of the ulcers, with miliary tubercles close to the margin, are very distinctive ; apart from the granulations, the ulcers themselves are not unlike those of dysenteric origin, or chronic fol- licular ulceration. Symptoms. — Until ulceration be established, there will be no symptoms of tubercular disease referable to the intestinal canal, and even when this stage is reached, there is nothing to distin- guish it from ulceration due to other causes. There is the same pain and tenderness, often but little marked ; usually an obstinate diarrhoea, 766 INTESTINES, characteristic stools -with occasional blood ; and progressive emaciation. Added to these are the symptoms due to implication of other organs — lungs, brain, &c. — since tubercular ulceration of the bowels scarcely ever occurs alone. Treatment. — Little can be done for intestinal tuberculosis. The course of the disease is almost invariably to a fatal end, and it is very rare for healing and cicatrisation to take place. The necessity for feeding the patient is almost contra- indicated by the existence of a destroyed digesting and absorbent surface, whereby the food becomes a positive irritant. Such nourishment as is taken should therefore he in the most digestible and concentrated form, that as much as possible may be taken up from the stomach. Starch and opium enemata may do a little to check the diarrhoea, but their efficacy is soon lost. Hemorrhage, should it set in, is scarcely amenable to treatment, though astringent enemata may be of some use, combined with the internal administration of ace- tate of lead and opium. No treatment, has as yet been effectual in arresting the spread of t.uborcle, and until that be gained, there is nothing we can do that will permanently benefit the affected intestines; even .palliative measures afford but little relief, 21. Intestines, Ulceration of. — - Ulcera- tion of the intestinal wall, from one cause or another, is of extremely common occurrence. The morbid processes involved in the production of the ulcers are in all cases essentially the same, namely, a molecular death and disintegration of the tissue, leaving a solution in continuity, of varying extent. The severe disturbance of tissue- nutrition which leads to ulceration, may he one of the later stages of inflammation: — (1), affecting previously healthy tissues ; or (2), as a means for the removal of necrosed tissue ; or (3), de- veloped in new-growths. Varieties: 1. Primary inflammatory ulcers.— Any enteritis, whether of the mildest character, or of a specific type such as diphtheritic, may lead to ulceration of the bewols. As a rule, the more severe the cause of the inflammation, the greater the liability to this complication ; and the same holds in respect of any intestinal catarrh, developed in the course of any serious state, such as typhus fever or Bright’s disease. The ulcer may appear either as a small abrasion of the epithelial layer, which gradually extends and deepens until the whole mucous coat is involved ; or the first indication may be a thin glairy pellicle, adherent to the mucous membrane, which in time is thrown off, leaving a breach in the subjacent tissue. In other cases the destructive process commences in the thickness of the bowel, either from the rupture of small collections of inflammatory products, resulting from an enteritis, or from inflammation of the Soilicles. The escape of these products into the tube leaves behind an ulcer. These lesions may be found anywhere through- out the bowels, although they are much more frequent in the large than in the small in- testine, and one form of follicular ulceration, associated with the specific poison of dysentery, is practically limited to the latter situation. At those places where any delay is likely to arise in DISEASES OF. the passage of the feces — the caecum, sigmoid flexure, and rectum — and at those spots which are most prominent, such as the edges of the valvulae eonniventes, and the sacculus of the colon, where an enteritis is most likely to he produced, there will be the probable site of these inflammatory ulcers. 2. Ulcers resulting from the separation oj necrosed tissue. — The process of molecular dis- integration which takes place in the adjacent bodies of living and dead tissue, resulting in the separation of a slough and the leaving of an ulcer, takes place in the intestines as elsewhere. The causes leading to the death of circumscribed areas cf tissue are various. Sometimes the vitality of a portion of the mucous membrane is destroyed by degeneration, such as amyloid, and an ulcer marks the spot of the removed patch. More frequently the local death is induced by cessation of blood-flowthrough a limited area; the cause of this stasis is not very apparent, though believed to be due to emboli. Under such circumstances the solvent power of the digestive juices may be exerted on the non-living tissues, which are thus removed, and an ulcer is left. To such ulcers the term peptic has been applied, and identical lesions are met with in the stomach. They almost invariably occur in the first part of the duodenum, above the point of entrance of the alkaline bile and pancreatic juices, although very rarely they have been seen in the jejunum. Ulcers of this character appear to be connected with large superficial burns, but how the relationship is established is not known. It is a singular fact in regard to them, that they are ten times more common in men than in women, which is quite the reverse of what obtains in the stomach, although the relative frequency of gastric and duodenal ulcers is estimated as thirty to one. Both the ileum and colon have been found ulcerated in amyloid degeneration. 3. Ulceration of new-growths. — Almost any neoplasm of the intestinal wall may ulcerate, though as a rule the more rapidly developed forms are more liable. Tubercular and typhoid growths primarily connected with the solitary and agminated glands, invariably end in this man- ner. Syphilitic gummata and malignant growths are especially prone to ulceration. Characters.— The appearances presented by the various ulcers differ with the cause and the duration. They may he single, as is generally the case with the duodenal ulcers ; or innumerable, as the follicular ulcers of the colon. Typhoid and tubercular ulcers are as a rule multiple, and are most numerous at the lower end of the ileum, where the agminated glands are most abundant. Occasionally large surfaces of the mucous membrane are destroyed, with here and there small isolated spots of the membrane left, due to the spread and coalescence of many separately arising ulcers. In dysentery and chronic tuber- cular ulceration this is especially liable to happen. Many of the catarrhal and follicular ulcers are extremely small, not more than a line in di tmeter. The peptic ulcers are distinguished by their very definite, ‘clean-punched’ appearance ; the edges are slightly sloping, and but very little, INTESTINES, DISEASES OF. 7C7 if at all, thickened ; whilst the mucous membrane immediately adjacent has a perfectly healthy appearance. In most of the other varieties the edges are thickened, irregular, and shaggy, fre- quently excavated and overhanging the base ; the ulcerative process extending beneath the mucous membrane, which gradually dies and sloughs away as its nutrition is cut off. De- pendent upon the depth and course of the ulcer will be the nature of its base, which may be formed of the muscular coat, of the peritoneum much thickened, or of adjacent structures with which adhesion has been established, such as the liver or abdominal wall. The floor of the ulcerated tubercular and malignant new-growths usually presents small nodules of the neoplasm, which are being developed coincidently with the ulceration. The buif or ash-grey pigmented sloughs, partially separated, give a characteristic appearance to the old-standing ulcers of dysentery and tubercle. The tubercular and typhoid ulcers of Peyer's patches present a certain difference in the direction in which they extend ; whilst at first both are limited to the patch, the former tend to spread in an annular manner, whilst the latter have usually their long axis correspond- ing to the length of the bowel. This difference depends rather on the duration of the ulcer, than on any specific distinction due to the two diseases ; for the more acute enteric lesion rarely spreads much beyond the area of the patch, which is in the long axis of the bowel, whilst the chronic tubercular ulcer follows the distribution of the lymphoid tissue outside the patches, and par- ticularly along the course of the blood-vessels and lymphatics. Couese. — The course of an intestinal ulcer may be acute or chronic, lasting a few days or for years. Some of the simple ulcers of an acute intestinal catarrh belong to the former group ; whilst the ulceration that accompanies chronic enteritis may be of indefinite duration. The acute forms may either heal or go on to perforation ; in the former case their existence can only be inferred, and catarrhal and follicular and enteric ulcers belong to this category. The peptic and typhoid tilcers are those most liable to perforate the gut, their duration being too short to allow of the formation of adhesions to neighbouring structures, as is very apt to be the case in the more chronic forms. Occasion- ally the perforation may lead to communication between one coil of intestine and another, be- tween the duodenum and stomach, or between the bowel and bladder, without any rupture into the peritoneal cavity, which is the com- monest end of a perforating typhoid ulcer. In chronic ulcers, where no adhesion or communi- cation takes place, the base is thickened by a new- I formed connective tissue, which is developed as fast as or even faster than the destructive process proceeds, and hence the intestinal wall adjacent to, and involved in such ulcers, is usually much I thickened and indurated. Short of actual per- foration or adhesion to other parts, the site of the ulceration most frequently is marked on the external surface of the bowel by a sub-acute peritonitis, which may produce a partial matting together of the intestines. In the course of the healing of the larger ulcers, by the formation of a contracting cicatricial tissue, the gut may be considerably constricted, and a most formidable obstruction may be established. But this does not neces- sarily follow even large ulcers, such as those of typhoid fever; and the extent of depth of the destruction would seem to influence this result; when the superficial portion of the mu- cous membrane only is destroyed very little contraction follows, but when the deeper parts of the wall are involved the subsequently de- veloped cicatrix tends to shrink considerably. Similar differences are seen in destructions of the skin and subcutaneous tissues. Sy.mptosis. — The greatest diversity is met with in the symptoms of intestinal ulceration, and few, if any, can be regarded as characteristic. Inas- much as the lesion may occur without producing any symptoms ; or those that do exist may be determined by the course of, or by the conditions associated with the ulceration ; or lastly, the re- sults of this condition, such as perforation, may entirely obscure the actual ulceration itself : it frequently happens that the existence of an ulcer is not recognised. Nor may the severity of the symptoms be taken as a measure of the extent of the ulceration, for the most marked pain, tender- ness, diarrhoea, and other symptoms may be pro- duced by an area of typhoid ulceration that heals; whilst a perforating duodenal ulcer may’ give scarcely any indication of its existence, until within a few hours of a fatal ending. This course appears to be very characteristic of duodenal ulcers ; and the writer has recorded a case of a young man who was suddenly attacked with all the symptoms of apparently intestinal colic, after constipation of a week’s duration, no vomiting and no tenderness, the pain beingrelieved by pressure on the abdomen. Collapse set in, and death re- sulted in less than twenty-four hours from the commencement of the attack. The autopsy showed a perforating duodenal ulcer. Such a case is not singular, and may be preceded, as this case was by nothing beyond an occasional feeling of dis- comfort at the epigastrium, not serious enough to call for advice or treatment. Such symptoms as diarrhoea, vomiting, pain, tenderness, and pyrexia are as much dependent on a co-existent enteritis or r.ew-growth, as they are upon the ulcer. Doubtless the exposed surface of an ulcer offers the opportunity for increased peristalsis being induced, but this is not of necessity', for constipation may be present. AVhere the area of ulceration is extensive, the absorbing surface is by so much diminished, and thus while the general nutrition suffers, the unabsorbed products of d'gestion are liable to decompose and induce diarrhoea. Vomiting may arise from a duodenal ulcer, but not always, and when present it may' be due to perito- nitis; icterus may also complicate an ulcer in this situation, by involving the opening of the bile-duct, or by extension of the duodenal ca- tarrh. Pain may be quite absent or quite insignificant, unless the rectum be the seat oi the disease, when the pain and tenesmus are excruciating. The passage of blood in the stools, especially if bright, is probably a most characteristic indication of ulceration, but it does not always 768 INTESTINES, DISEASES OF. occur, and it may be due to general venous congestion from partial obstruction. See Stools. The symptoms due to perforation have been already described. See Intestines, Perforation and Bupture of. Diagnosis. — From what has been said, the formation of a diagnosis of intestinal ulceration is frequently impossible, and an ulcer is assumed rather than proved to exist. In enteric fever ulcerat ion is taken for granted as existing, though no special symptoms may indicate its presence. But if a severe and persistent diarrhoea, with liquid stools and shreds of mucus, and much pain and tenderness over the abdomen, supervene in a case of tubercular phthisis, it is a fair inference to assume ulceration of the intestines. In dysentery, like enteric fever, the ulceration is a specific part of the disease, and the diarrhoea, pain, and cha- racteristic stools are in this case directly de- pendent upon the ulceration. Since there are no constant distinctive symptoms of ulceration, the ground for a diagnosis must remain uncertain. Prognosis. — This largely depends upon the cause. Except through perforation or fatal haemorrhage by erosion of vessels, death does not take place from the ulceration itself. But a tubercular ulceration is not to bo expected to heal, and it may by its development hasten the end of a phthisical patient. The prognosis in typhoid ulceration will almost entirely be founded on the general state of the patient, since the indications of the ulceration itself may be so slight. The ulceration of malignant new-growtlis may be of actual benefit, by removing portions of the mass, and so diminishing obstruction. In all cases the liability to stenosis must be remem- bered; and the impaired health of body and mind in chronic ulceration may continue throughout life. Treatment. — Since ulcers of the intestine are inaccessible to direct treatment, little can be done for them apart from the general conditions which they may complicate, or the treatment of the symp- toms to which they may give rise. Becognising that an ulcer, when it exists, may lead to perforation, the object will be to avoid all undue movements of the intestines, and hence aperients are forbidden, and opiates are indicated. The astringents that are likely to bo used for the diarrhoea or haemorrhage may exert a local action on the lesion, and for that purpose bismuth, sul- phate of copper, and similar agents, are recom- mended. But rest is probably the only element of treatment that can affect the ulcerative process directly ; whilst any improvement of the general condition will necessarily favour the healing — objects which can he best accomplished by the use of diet of the most bland description, or of nutrient enemata. In the preceding article the diseases to which the intestines are 'liable have been treated of as affecting the canal as a whole : but it will be ob- served that when the structure and functions of particular regions of the bowel modify the cha- racter of the disease, special reference is made thereto ; and, further, that when the affections of any portion require detailed description — as of the caecum or rectum, the reader is referred to articles under those headings. "William Henry Allchin. INUNCTION. INTRA-THORACIC TUMOURS.— Un- der this general term are included all growdia and diseases within the chest, which give rise to tumours or swellings, offering more or less me- chanical interference with the functions of the thoracic organs, and for the most part manifest- ing themselves by external swellings. Aneur- isms would thus be comprised in this general definition. The general features and pathology of aneurismal tumours are, however, so distinct as to require separate consideration ( see Thoracic Aneurism). Other intra-thoraeic tumours will be found described under the headings Lung, Malignant Disease of ; and Mediastinum, Dis- eases of. J. Bisdon Bennett. INTUSSUSCEPTION ( intus , within, and suscipio, I receive).— Aform of intestinal obstruc- tion, in which one portion of the bowel passes infi. another portion. Sec Intestinal Obstruction. INUNCTION (ill, on. and unrjuo. I anoint). Synon. : Anointing. — This is a method of ap- plying certain substances to the cutaneous sur- face, the object being to promote their absorption, either for the purpose of producing local effects, or of influencing the system generally. Inunc- tion implies more or less friction, the substance employed being rubbed with the hand into some part of the skin. When used for local purposes, the part to be anointed must be chosen accord- ingly ; but if it is intended to affect the system, a region must be selected where the cutaneous tissues are thin, such as the inside of the thighs, or the axillae, so that absorption may take place more rapidly and easily. The rubbing must be carried on gently, and for a variable time accor- ding to circumstances; it may be aided by heat, being performed before the fire, or the part mav be previously fomented. Application and Uses. — The pharmaceutical preparations which are employed for inunction include glycerines, liniments, oils, ointments, oleates, and compounds made with vaseline, ozo- kerine, and other materials of a like nature re- cently introduced. If these are used for local purposes, they may be employed simply on ac- count of the oleaginous ingredients, or to allow friction to be more easily carried on ; but active ingredients are often combined in the preparations mentioned above, varying according to the object sought to he obtained, such as to produce a stimu- lant or an anodyne effect. Inunction for procuring absorption in order to affect the system, is almost entirely confined to the use of mercury, and on this subject the following observations were writ- ten for this work by the late Mr. Gascoyen:— ‘ Inunction is an old but very effectual plan of introducing mercury into the system by the skin. Although objected to as a dirty method, and therefore less practised than fumigation, it is often much more convenient, and can be used in many eases where the mercurial bath is im- practicable. ‘From half a drachm to one drachm of strong mercurial ointment, mixed with an equal quan- tity of lard, should be rubbed into the skin on the inside of the thighs, legs, and arms, before a fire at bedtime, using the different limbs on successive nights. The friction should be gent A INUNCTION. and continued for a quarter of an hour to half an hour, -when most of the ointment Trill have disappeared; the surface must not be washed, and the patient should wear the same flannel under-clothing night and day. The ointment may be used every night until the gums give evidence of its action, when the quantity and frequency of application must be diminished. Sometimes it will produce an irritation of the skin, especially in fair or hairy persons. If this occur, the surface must be washed clean, and the rubbing discontinued. ‘ Inunction is a most convenient way of treat- ing syphilis in young children. The ointment should be spread upon a flannel roller, and the body of the child swathed therein ; occasionally the skin should be washed, and fresh ointment applied. ‘Although but little practised now in this country, inunction is still largely employed on the Continent, and pu'ticularlv in conjunction with the natural sulpbur waters, for cases of old- standing syphilis.’ Frederick T. Roberts. INVAGINATION" (in, in, and vagina, a sheath). — A synonym for intussusception. See Intussusception ; and Intestinal Obstruction. INVASION, Modes of. — This expression oignifios the manner in which a disease sets in or commences, and the mode of onset of an ill- ness is frequently an important factor in forming a diagnosis as to the nature of the complaint. The following are the variations noticed in this respect: — 1. The invasion may be absolutely or almost sudden, although slight symptoms may have been previously observed, indicating the presence of some morbid condition, but not suf- Sciently marked to attract attention. Or there nay be distinct indications of some disease, but l secondary lesion suddenly occurs in its course, [“his mode of onset is exemplified by the im- aediate effects of injuries, apoplexy, syncope, upture of the heart, cholera, many cases of aemorrhage, and most forms of colic. Certain iseases of a paroxysmal type are also charac- arised by the occurrence of attacks, which come i more or less suddenly, such as asthma, ague, nd epilepsy. Some cases of fevers, especially ’phus and relapsing fever, as W'ell as of in- immatory diseases, begin in a sudden manner. Frequently the onset is acute, the symptoms ming on rapidly, and becoming speedily severe, ough often preceded for a variable time by pre- onitory symptoms. This is illustrated by most ses of the various fevers, and the different forms acute inflammation. 3. A subacute mode of vasion is not uncommonly noticed, this being ; s rapid, and the symptoms less marked than here it is acute. 4. Most affections are chronic ■ their onset, setting in gradually, and often perceptibly, so that it may be a long time ore the patient is aware that there is any de- tion from health. Frederick T. Roberts. ODISM. — Definition. — Iodism is the term hin which we include a variety of painful ‘ inconvenient effects, following, under certain t i circumstances, the administration of iodine a its salts, but more especially the iodide of P issium. 49 IODISM. 7(5!) Description.— Iodide of potassium being in part, at least, decomposed in the presence of ozone by the acids of the b:ood, we shall en- deavour, in considering the symptoms of iodism to determine which are due to the iodine, nn-l for which, the potash must be held responsible. The physiological action of iodine is mainly di- rected to the nutritive and glandular functions, to the skin and mucous membranes ; whilst tilt- salts of potash are not only diuretic and purga tive, but, experimentally at least, powerfully de press the heart and spinal cord. Killiet, the most exhaustive writer on th» subject, makes three forms of iodic intoxica- tion : the first consisting of gastric irritation : the second, where nervous troubles come ir.t- more special prominence: whilst cachexia and rapid emaciation characterise the. third. But the most orderly and convenient plan to pursue, will be to take into consideration, in regular order, the effects produced by iodine salts on the va- rious organs and functions of the body, under various conditions of idiosyncrasy or retarded elimination. 1. On the nervous system. — Mental depression and diminution of muscular energy are not in- frequently noted in patients taking iodide of potassium ; whilst neuralgia, tinnitus aurium, and convulsive movements have also been de- scribed. It is probable that the potash is here the active agent. 2. On mucous membranes. — Much mucous irri- tation is occasionally observed; conjunctivitis, lachrymation, sneezing and running from the nose, frontal headache, and puffy swelling of the oye- lids, closely simulating coryza, being the most common symptoms of iodism, and sometimes following a single small or moderate dose. Pharyngeal congestion, and irritable redness of gums and tongue, have also been described. These symptoms are doubtless due to the iodine. 3. On the skin. — The eruptions produced by iodide of potassium have recently attracted much attention, and they appear under several forms. Erythema has been observed ; and most practi- tioners of experience must have seen the small round petechial spots, situated between the knees and ankles. These do not as a rule cause any inconvenience, and are usually accidentally dis- covered; but Dr. Stephen Mackenzie records the case of an infant of five months old, suffering from hereditary syphilis, who died of purpura after taking two and a half grains of iodide of potassium in a single dose. Some further points of interest, in connection with a case of this kind, reported by Dr. G. F. Duffey, will be found in the British Medical Journal, 1880, vol. i. p. 626. A papular and pustular eruption resembling acne, and occasionally appearing in so great pro- fusion as to excite the suspicion of small-pox. is not very uncommon. The late Dr. Tilbury Fox has noted ‘a quasi-bullous disease,’ sum- ming up the description of his cases as follows : ‘In some parts they resembled acne simplex ; in others they vesiculated and subsequently simu- lated variolous pustules ; at a later stage ecthy- ma ; finally bullae filled with milky contents, or discharging smegma; and these bullae possessed I peculiar solid bases wholly unlike true bullsp, 770 IODISM. aud answering rather to large molluscum eonta- giosum tumours with semi-fluid instead of more solid contents. ’ Dr. Fox believed this condition to be essenti- ally distinct from hydroa, but Mr. Hutchinson has brought forward good evidence to show that the rare skin-affection going under that name must usually be looked upon as one of the symptoms of iodism. The same author mentions a case of deep and unhealthy ulceration of the legs follow- ing the prolonged use of iodide of potassium. It seems probable that the iodine rather than the potash must be held responsible for these symp- toms. tiea Archives of Dermatology, 1880. 4. On the nutritive and glandular systems . — Patients taking iodide of potassium sometimes complain of nausea, anorexia, and a bitter taste in the mouth ; but where cachectic symptoms supervene, indicated by rapid emaciation, nervous palpitation, insommia, and hypochondriasis, a ra- venous desire for food has been observed. Vo- miting, diarrhoea, and diuresis have also been described. Salivation is not an uncommon symp- tom. A time-honoured accusation against iodine is its supposed tendency to cause atrophy of the mammae and testicles ; of this, fortunately, there is no real proof, the disappearance of the testicle, which occasionally accompanies the absorption of inflammatory products in its substance, being sometimes unjustly attributed to the treatment pursued. Pathology. — The only reason for the occur- rence of many cases of iodism seems to be an in- dividual peculiarity on the part of the patient, or iu other words, that idiosyncrasy which so fre- quently interferes with our efforts for the treat- ment of disease. But now and then a more plausible explanation may be given, when we find cardiac or renal disease coinciding with the pustular rash of iodide of potassium. Retarded capillary cir- culation would naturally detain the drug within i the blood ; whilst the blocking of its usual means of exit from the system might be supposed to throw the onus of elimination on the glandular structures of the skin. Hence has been derived the plausible theory that iodine-acne is produced by direct local stimulation of the sebaceous structures; but, however true this may be in the slighter cases, Dr. Thin’s careful examination of the skin of a. patient suffering from a bullous rash, has shown the true pathological condition to be one of rupture of blood-vessels at certain localised points, with blocking by coagula, and escape of some of the constituents of the blood into the sui'rounding tissues. The sebaceous ele- ments and sweat-glands were quite unaffected, and he believes the iodic papule, the so-called acne, the bulla, and the purpuric spot, to repre- sent different stages of vascular injury. Drs. Duckworth and Vineent-Harris were unable in their observations to detect any rupture of ves- sels, but confirm Dr. Thin's report in all other essential respects. Diagnosis. — Coryza, or any skin-eruption, suddenly occurring in a patient taking iodide of potassium, ought to be looked upon with sus- picion, and treated by the immediate suspension of the drug. The slighter varieties of iodism are by no means uncommon, and may appear after a single small dose ; but although ammonia has IRRITATIVE FEVER. been confidently vaunted as a specific against such irregular manifestations of physiological activity, experience has been unableto confirm this, and we should place more faith in encourag- ing prompt elimination by very free dilution of the remedy. Fortunately, the graver symptoms of iodism are decidedly rare, and we may all the more con- gratulate ourselves on this, when we remember how powerless we are to recognise the idiosyn- crasy on which they depend. Trousseau, how- ever, pointed out that iodine is always badly borne in exophthalmic goitre; and Dr." Stephen Mackenzie is inclined to credit syphilis with some share in producing the purpura which proved fatal to his patient. Robert Fauqvhabson. IRELAND, South, of. See Queenstown. Glengariff is also deserving of notice. IRITIS.~-Inflammation of the iris. See Eye and its Appendages, Diseases of. IRREGULAR. — This term is applied to cases of disease which do not run their regular or typical course, such as gout (see Gout); or to functions when they are disturbed with respect to time or rhythm— as the pulse, the bowels, or menstruation. IRRIGATION ( irrigo , I water). — A method of applying cold water as a therapeutical agent, which consists in causing it to fall drop by drop on one spot. See Cold, Therapeutics of. IRRITABILITY ( irrito , I provoke).-In physiology this word signifies the power of re- sponding to a stimulus, as exemplified by the contractility of muscular tissue. In medicine irritability implies an undue excitability of an organ or tissue, from disease or disorder, sucli I as of the brain, spinal cord, stomach, eye, or bladder. IRRITATIVE FEVER. — The nervous disturbance consequent upon fretting of the sys- tem by r various sources of irritation, gives rise > to a pyrexia which is often called ' Irritative fever.’ The febrile excitement so familiar to the surgeon as a consequence of wounds and in- juries may be classed under this head. It may, however, be provoked by any kind of irritation, especially irritation applied to the mucous membrane of the aliment ary canal. The rise of tempei’ature which often accompanies irritation of the bowels by scybalse or acrid secretions, aud the febrile phenomena attendant upon den- tition, may be quoted as familiar examples of irritative fever which must be within the experience of all. The readiness with which pyrexia can be , induced by these and similar causes must vary according to the intensity of the irritant, and the constitutional peculiarities of the individual upon whom it operates. As a rule, men are less susceptible than women, and women than chil- dren. In children, indeed, with their exalted nervous sensibility, feverishness from thiscausc is a common symptom. In young subjects mental emotion alone will often produce a rise of temperature, which may be a source of per- plexity. In children's hoq itals it is a common IRRITATIVE FEVER. observation that the bodily temperature on the night of admission is high, even although the illness affecting the -child is one not in itself usually accompanied by fever. Dentition in young children is so frequent a cause of pyrexia, that the state of the gums should never be overlooked in any case where feverishness is a prominent symptom. Neglect of this precaution may cause some obscurity in the diagnosis. Thus, if a child, while cutting a tooth, have an attack of pulmonary catarrh, the temperature will almost certainly be high. In such a case the cough, combined with fever, rapid breathing, and a quick pulse, might natu- rally suggest the presence of pneumonia. On examination, however, it will be found that the pulse-respiration ratio is little perverted, the cough is loose and not hacking, and the history of the attack is not the history of pneumonia. On searching further for a cause of the pyrexia, tension and swelling of the gums will be noticed, and the difficulty will be at once explained. Irritation of the stomach and bowels by icrid secretions or indigestible food is another common cause of irritative fever in children. The intense nervous disturbance excited in young babies by an improper meal induces a rapid rise of temperature, and may culminate in an attack of convulsions. Fsecal accumulation, or the irritation of worms in the bowels, may also, in children and delicate women, produce sufficient disturbance to give rise to fever. In children the sensitiveness of the system to irritants varies according to the age of the child, according to the natural impressionability of its nervous system, and also according to the state of its general health. Thus, as a rule, the younger the child, the more sensitive is its ner- vous system; but even in young babies differ- ences will be found in this respect, some being affected much less easily than others by reflex stimuli. In all, however, slow reduction of the strength, such as is produced by progressive ichronie disease, gradually reduces nervous sen- jhibility ; and a child, enfeebled by an illness of ong standing, may show a complete insensi- nlity to all nervous impressions. In voung sub- JAUNDICE. 771 jects irritative fever, like other forms of pyrexia, is usually remittent; but its remissions are not always found at the same period of the twenty - j four hours. There is not, for instance, always a fall of temperature in the morning and a rise at night. One of the peculiarities of this form of febrile disturbance is the irregularity of the fever. A high morning temperature in a young- child should always suggest a reflex cause for the pyrexia. Treatment. — The treatment of irritative fever must be directed to the relief or to the removal of the irritating source from which the fever pro- ceeds. The use of febrifuge remedies may be also called for, if constitutional symptoms be marked or persistent. Eustace Smith. ISCHEMIA (iVxw, I restrain, and aT,ua, tho blood). — Deficiency of blood in a part, short ol complete cessation of tho circulation : partial anaemia. See Circulation, Disorders of. ISCHIALGIA ( l(rx'‘ov , the haunch, and pain). — A synonym for sciatica. See Sciatica. ISCHL, in the Saltzkammergut, Austria. A sheltered, bracing, mild, rather moist cli- mate. Altitude 1,560 feet. Thermal common saline baths. See Climate, Treatment of Disease- by ; and Mineral Waters. ISCHURIA (lex", I restrain, and oOpov, t in urine). — This word properly signifies the arrest of the secretion of urine (see Urine, Suppres- sion of). It is also applied to mere retention ot urine. ISSUES. See Counter-irritation. ITALY. See Climate, Treatment of Dis- ease by; and Naples, Pisa, Rome, and San Remo. ITCH. A popular name for scabies. See Scabies. ITCHING. See Pruritus. -ITIS. A terminal syllable used to indicate an inflammatory disease of a tissue, or organ ; for example, Pleuritis, Hepatitis, or Cystitis. J JACTATIOHh or JACTITATION (jae- ,tio, a tossing about of the body, or marked btlessuess). — This is a condition mostly asso- ited with certain severe febrile diseases, but so with some nervous affections, with severe ii-iearditis, or as a sequence of copious uterine other haemorrhages. A restlessness amounting jactation may likewise be met with in some 1 tents, when suffering from severe or long- ' tinned pain. It must not be confounded ' h certain forms of chorea, in which a some- Vit similar tossing about of the body may be < ountered. The absence of pain and of marked febrile disturbance, together with the history of the patient, will, even in the cases where the general resemblance is closest, speedily enable the latter condition to be recognised. JAUNDICE. — Syxox. : Icterus; Morbus regius ; Morbus arquatus (Celsus) ; Pr. Ictere ; Jaunisse ; Ger. Gelbsuclit. Definition. — Jaundice may be defined as a yellowness of the integuments and conjunetivae, and of the tissues and secretions generally, from impregnation with bile-pigment. vEtioi.ogy and Pathology. — All cases -># JAUNDICE. 772 jaundiee may be referred to one of two classes : — 1. Cases in which there is a mechanical im- pediment to the flow of bile into the duodenum, and where the bile is in consequence retained in the biliary passages, and thence absorbed into the blood. 2. Cases in which there is no impediment to the flow of bile from the liver into the bowel. These two forms of jaundice have long been recognised ; but there is much difference of opinion as to the mode of production of the jaun- dice in the second class of cases, although these are, perhaps, the most common in practice. When there is any obstruction to the flow of bile through the hepatic or common duct, the way in which jaundice arises is sufficiently clear. The bile-ducts and the gall-bladder become dis- tended with bile, which is absorbed into the blood by the lymphatics and the veins. If the hepatic duct of a dog be ligatured, and the animal killed after two hours, the lymphatics in the walls of the bile-ducts are seen to be distended with yellow fluid; the fluid in the thoracic duct is also yellow, and so likewise are the intervening lymphatic glands. In patients also who die of obstruction of the bile-duct, the lymphatics of the liver are often found to contain bile. On the other hand, two hours after ligature of the common duct, the serum of blood taken from the hepatic vein contains much more bile-pigment than that of blood taken from the jugular vein, which shows that in cases of obstruction of the bile-duct, bile is also directly absorbed by the veins. But in a large proportion of cases there is no mechanical impediment to the escape of bile from the liver, and then an explanation of the jaundice is less obvious. Boerhaave and Morgagni long ago suggested that the jaundice in these cases was the result of a suspended secretion. They taught that the function of the liver was merely to separate the elements of bile which were already formed in the blood, and that when anything interfered with the function of the liver, the elements of bile accumulated in the blood, and the result was jaundice of the skin and other tissues. Although this view has been strenuously opposed by several excellent authorities, it is, in this country at all events, still generally accepted. It is advocated, for example, by Dr. George Budd, in his valuable treatise on diseases of the liver, although it is but right to add that Dr. Budd makes a special exception with regard to the biliary acids. ‘ The most skilful chemists,’ he says, ‘ who have recently analysed the portal blood, have failed to detect the biliary acids in it, and have come to the conclusion that these at least are formed in the liver.’ This opinion, that the liver manufactures the bile-acids, while it merely excretes the bile-pigment, was adopted by Dr. G. Harley, in his essay on jaundice. There are, however, weighty objections to this view, some of which may bo mentioned. 1. Although bile-pigment appears to be de- rived from the colouring matter of the blood, it has not yet been satisfactorily shown that bile- pigment, as such, exists ready formed in the blood of persons who have not jaundice. Frerichs denies that it ever has. Lehmann, who has in- vestigated with great care the changes which the blood undergoes in passing through the liver, has never been able to detect tho colouring matter of bile in portal blood, and infers that this, as well as the bile-acids, must be formed in the liver itself. The blood of the hepatic artery has been examined with a like result. It is obvious that if bile-pigment exists in healthy blood at all, its quantity must be very minute ; and when we consider that the quantity of bile secreted by the human liver daiiy is about two pints, and yet that jaundice is not a normal condition, it seems impossible that all the bile- pigment secreted by the liver can be formed in the blood, and it is not probable that part is formed in the blood and part in the liver. The discovery by a few observers of a small quantity of bile-pigment in what appeared normal blood does not prove that it was formed in the blood. It is quite conceivable that it may have been formed in the liver, and have become subse- quently absorbed. 2. The secreting tissue of the liver is often for the most part or entirely destroyed, so that bile is no longer secreted, and yet no jaundice results. If bile-pigment be formed in the circu- lating blood, it is difficult to explain what be- comes of it in these cases. 3. If the constituents of bile are formed in tho blood, intense jaundice ought at once to follow the extirpation of the liver in any of the lower animals, in like manner as urea accumulates in the blood after removal of tho kidneys. But Muller, Kunde, Lehmann, and Moleschott have repeatedly extirpated the liver of frogs, and haTe invariably failed to find a trace of the biliary acids, or of bile-pigment, in the blood, the urine, or the muscular tissue. These and other considerations make it very doubtful if any case of jaundice can with pro- priety be attributed to a suppression of the hepatic functions ; and it is therefore necessary to seek for some other explanation of those cases of jaundice in which there is no obstruction in the bile-duct. A solution of tho difficulty has been proposed by Professor Frerichs, of Berlin. According to this distinguished observer, a large proportion of the colourless bile-acids found in the liver is either directly taken up by the blood in the hepatic vein, or is absorbed from the bowel. Under ordinary circumstances, these bile-acids become oxydised and assist in forming tho large quantity of taurin found in healthy lung and the pigments voided in the urine; but it these normal metamorphoses are interrupted by nervous agencies, or by poisons in the blood, the bile-acids, not being sufficiently oxydised, are converted into bile-pigment in the blood, an! the result is jaundice. This view has been sup- ported by two experiments intended to show first, that bile-pigment can be produced artifi- cially from the bile-acids, by the action of con- centrated sulphuric acid ; and, secondly, that colourless biliary acids, whon injected into the veins of dogs, are converted in the blood of theso animals into bile-pigment. There is, however far from being unanimity among different obser- vers as to the results of these experiments; ana a decision of the points at issue does not appear JAUNDICE. (obe of material importance for explaining those eases of jaundice in which there is no obstruc- tion of the bile-duct, inasmuch as there are good grounds for believing that not only in jaundice, but in health, a portion of the bile-pigment, as well as of the bile-acids, formed in the liver, is absorbed into the blood. Although the amount of bile secreted daily must vary in different persons, and in the same person under different circumstances, being modi- fied by the quantity and quality of the food, the activity of respiration, and other conditions, there can be little doubt that but a small portion of that which is ordinarily secreted is discharged from the bowel. Observations on the lower animals and on man himself have shown that the quantity of bile secreted by the liver of a nealtby adult averages forty ounces. It is gener- ally admitted that the faeces contain but a frac- tion of the bile-acids (altered) corresponding to this quantity of bile, and it seems equally clear that much of the bile-pigment must also dis- lppear in the bowel. There are grounds for relieving that the bile-pigment which so dis- appears goes to form urinary pigment ; while the fact familiar to all clinical observers, that '.he bile-pigment discharged from the bowel is greatly increased by calomel and other purga- tives, without any corresponding increase of secretion of bile by the liver, seems to show that under ordinary circumstances much of the "bile— |i pigment secreted by the liver is not discharged with the faeces. It may bo added that in carni- vorous animals and in snakes, although bile- pigment is secreted in abundance by the liver, the quantity discharged with the feces is even relatively less than in man. The question as to what becomes of the bile which is not discharged from the bowel has an important bearing on the pathology of the cases of jaundice now under consideration. A large proportion of it is again absorbed, either by the biliary passages, or by the mucous membrane of the bowel. From what is now known of the dif- fusibility of fluids through animal membranes, it is impossible to conceive bile long in contact with the lining membrane of the gall-bladder, bile-ducts, and intestine, without a large portion of it passing into the circulating blood. The constant secretion and roabsorption of bile is, in fact, merely part of that osmotic circulation constantly taking place between the fluid con- ents of the bowel and the blood, the existence if which is too little heeded in our pathological peculations and in therapeutics. The quantity 'f fluid which is being thus constantly poured ut from the gastric and intestinal glands, the iver, pancreas, &e., and then reabsorbed is normous ; in twenty-four hours it probably far jxceeds tho whole amount of blood and fluid in lie body. The effect of this continual outpour- ig is supposed to be to aid metamorphosis ; the ime substance, more or less changed, seems to e thrown out and reabsorbed, until it is adapted >r the repair of tissue or becomes effete. How I'any times this cycle of movement is repeated, cfore the bile is extruded from the system, we ive no means of knowing; but in the course of ['is osmotic circulation, much of the bile appears become transformed into products which are 773 eliminated by tho lungs and kidneys, while at the same time this circulation assists in the assimilation of the nutritive materials derived from the food. Here, then, we have an explanation of those cases of jaundice where there is no impediment to the flow of bile from the liver. Under nor- mal conditions, the whole of the bile that is ab- sorbed is at once transformed, so that neither bile-acids nor bile-pigment can be discovered in the blood or in the urine, and there is no jaun dice. But in certain morbid states, the absorbed bile does not undergo tho normal metamorphoses ; it circulates in the blood and stains the skin and other tissues, and in this way we have jaundice without any obstruction of the bile-duct. The morbid states which, so far as we know, conduce mainly to this result are, for the most part, pre- cisely those in which we might expect abnormal blood-metamorphoses, namely:— 1. Certain poisons, such as those of yellow- fever, relapsing fever, pyaemia, and more rarely those of remittent fever, typhus, and scarlatina; also snake-poison, chloroform, &c. 2. Nervous influences, such as a sudden fright, violent rage, great or protracted anxiety, and concussion of the brain. 3. A deficient supply of oxygen, as happens in certain cases of pneumonia, or in persons living in confined and crowded dwellings. 4. An excessive secretion of bile, especially when conjoined with constipation. In this case, unless the bile he removed by purging, tho quantity absorbed may be too great to undergo the normal metamorphoses, and tho presence in the blood of the untransformed bile causes jaundice. According to this view, the only pathological difference between jaundice from obstruction and jaundice independent of obstruction of tho common bile-duct is that, in the former case, little or none of the bile secreted by the liver can escape from the body with the feces, and con- sequently all that is secreted is absorbed into the blood, and the quantity thus absorbed is far too great to undergo the normal metamorphoses ; while, in the latter case, bile passes into, and is discharged from the bowel, as usual, but that which is absorbed, which in quantity may not exceed what is absorbed in health, remains un- changed in the blood. As might be expected, the jaundice in the former case is usually much more intense than in tho latter, although, when an obstruction of the bile-duct has lasted long, the jaundice often becomes paler, not from any diminution of the obstruction, but from the secreting tissue of the liver becoming destroyed, and comparatively little bile being secreted ; while in cases where there is no obstruction of the bile-duct, the intensity of the jaundice will vary according to the amount of bile which ie absorbed, and the degree of derangement of the blood-metamorphosis. With these preliminary remarks on the pa- thology of jaundice, we may now proceed to enumerate its different causes, which may ho classified according to the following tabular form :— A. Jaundice from Mechanical Obstruction of the Bile-duct. JAUNDICE. 774 I. Obstruction by foreign bodies within the luct. 1. Gall-stones and inspissated bile. 2. Hydatids and distomata. S. Foreign bodies from the intestines. II. Obstruction by inflammatory tumefaction if the duodenum, or of the lining membrane of the duct, with exudation into its interior. III. Obstruction by stricture or obliteration of 'hr duct. 1 . Congenital deficiency of the duct. 2. Stricture from perihepatitis. 3. Closure of orifice of duct in consequence of an ulcer in the duodenum. 4. Stricture from cicatrization of ulcers in the bile-ducts. 5. Spasmodic stricture. IV. Obstruction by tumours closing the orifice of the duct, or growing in its interior. V. Obstruction by pressure on the duct from without, by : — 1. Tumours projecting from the liver itself. 2. Enlarged glands in the fissure of the liver. 3. Tumour of the stomach. 4. Tumour of duodenum or pancreas. 5. Tumour of the kidney. 6. Post-peritoneal, or omental tumour. 7. An abdominal aneurism. 8. Accumulation of fasces in the bowels. 9. A pregnant uterus. 10. Ovarian and uterine tumours. B. Jaundice independent of Mechanical Obstruction of the Bile-duct. I. Poisons in the blood interfering with the normal metamorphosis of bile. 1. The poisons of the various specific fevers. a. Yellow fever. b. Remittent and inter- mittent fevers, c. Relapsing fever, d. Typhus. e. Enteric fever, f. Scarlatina, g. Epidemic Jaundice. 2. Animal poisons, a. Pyaemia, b. Snake- poi son. 3. Mineral poisons, a. Phosphorus, b. Mer- cury. c. Copper, d. Antimony. 4. Chloroform and ether. 5. Acute atrophy of the liver ? 11. Impaired or deranged innervation interfer- ing with the normal metamorphosis of bile. '1 . Severe mental emotions, fright, anxiety, & c. 2. Concussion of the brain. III. Deficient oxygenation of the blood, inter- fering with the normal metamorphosis of bile. IV. Excessive secretion of bile, more of which is absorbed than can undergo the normal metamor- phosis. 1. Congestion of the liver, a. Mechanical, b. Active, c. Passive. V. Undue absorption of bile into the blood, from habitual or protracted constipation. Symptoms. — Prom what has been stated in the preceding section, it is obvious that jaundice is not a disease, hut is a sj'mptom of many different diseases. This view of the matter cannot he too strongly impressed upon the student and practitioner, whose efforts must in every case be directed to discover the fundamental malady. There are, however, certain phenomena con- nected with jaundice, independent of its cause, which deserve to be mentioned. 1 . Intensity of the jaundice. Next to the liver itself, the skin is the tissue of the body which becomes most deeply jaunliced: but before it becomes affected a yellow tint is usually observed in the conjunctiva. There must be a certain concentration of bile-pigment to produce a yellow colour of the skin ; in the slighter and more temporary cases, the conjunctiva only mav bo affected. Although after ligature of the com- mon bile-duct in the lower animals it has been sometimes found that even the conjunctiva do not become jaundiced for two or three days; ic the human subject jaundice of both skin and conjunctive is usually observed within twenty four hours of closure of the duct. The colour of the skin varies from a pile sul- phur or lemon-yellow, through a citron yellow, to a deep olive or bronzed hue. The tint varies according to the cause and its duration. When the cause is obstruction of the bile-duct, it is light at first, and increases in depth the longer the disease lasts; although in advanced cases, as already stated, the colour sometimes becomes paler, not from the obstruction yielding, but from the tissue of the liver becoming destroyed, and very little bile being secreted. Iu jaundice from obstruction also, the depth of tint often varies from day to day, not from any variation in the degree of obstruction, hut according to the amount of bile secreted by the liver, and the eliminative activity of the kidneys. It iswellto remember that what is called ‘ black jaundice ’ may result from any cause of obstruction — from gall-stone as well as from cancer. In these cases the greenish or almost black hue is due to the absorbed bile-pigment being vitiated and dark, or to the visage being also d arkened from imper- fect arterialization of the blood, the dark colour resulting from a mimrling of the lividity with the colour of bile. When the jaundice is inde- pendent of obstruction to the flow of bile, the colour is rarely very deep, and yet these are often the most serious cases. The colour also varies with the age, the natural complexion, and the amount of fat in the individual. It is deeper in the old, the wrinkled, and the dark-complexioned than in young persons of fair complexion, and with plenty of fat. Lastly, it is important to remember that the colour often remains in the skin for some time after the cause of the jaundice has been removed, and that then its departure may be expedited by diaphoretics and warm baths. 2. The secretions are tinged with bile-pigment, but some much more so than others. This is notably the case with the urine, by which the greater part of the bile-pigment is eliminated from the body, aud which acquires a saffron- yellow, greenish-brown. or brownish-black hue, according to the amount of pigment which it contains. The urine usually becomes yellow before the skin, or even the conjunctivas; and when the cause of the jaundice is transient, it j may happen that the whole of the pigment is eliminated by the urine, without any jaundice appearing in the skin. On the other hand, when once the skin has become yellow, it may remain so for some time after bile-pigment has quite or nearly disappeared from the urine. Other secretions may contain bile-pigment well as the urine. The cutaneous glands some- .JAUNDICE. tiines eliminate it in such quantity as to stain the linen yellow, but the amount discharged in this way is never great. Instances have been recorded where the secretion of the mammary glands has been tinged with bile-pigment, but they are not very common. Still rarer instances have been noticed where the saliva or the tears have been tinged. It is not a little remarkable that bile-pigment is not eliminated in cases of jaundice by the mucous membrane of the respi- ratory passages, or of the digestive tube. This is a matter of some practical importance, for, were it otherwise, the stools might contain bile-pig- ment even when theie was complete obstruction of the gall-duct. Still, when either of these mucous membranes is inflamed, and throws off an albuminous or fibrinous exudation, the altered secretions may contain bile-pigment. Thus, when pneumonia coexists with jaundice, there is often bile-pigment in the sputa, which may be distinguished by the nitric-acid test from the greenish or yellow colour often presented by pneumonic sputa, owing to changes in the blood- pigment independent of bile. Indeed, in cases of jaundice bile-pigment may be detected in inflammatory exudations, as in the serum of a blister, before it appears in either the skin or even in the urine. It is probable that those rare cases where the saliva lias been noticed to be yellow admit of a similar explanation; in many of them there has been mercurial salivation, a condition in which the saliva is not normal, but contains much albumen. 3. A bitter taste is notnnfrequently complained of by persons who are the subjects of jaundice. It may denote the presence in the blood of the biliary acids, for taurocholie acid is intensely bitter. It is at all events not due to bile-pig- ments, which are tasteless. Moreover it is a common symptom in biliary derangements where there is no jaundice. f. Dercaigements of digestion, such as flatu- lence, constipation, and an altered character of the motions, may be due to the absence of bile from the motions. Bile is an antiseptic, and when it is absent the intestinal contents undergo fermentation, gases accumulate in the bowels, the motions become putrid, and from the absence of bile they present a pale-drab or clay colour. Bile is also the natural stimulant of the peri- staltic action of the gut, and consequently when the supply is cut off, the bowels are usually constipated ; but in some cases the putrid faeces act as an irritant and excite diarrhoea. In those casps of jaundice where there is no obstruction if the common bile-duct, the motions may be but ittle altered. When bile does not enter the bowel, the diges- ion of fat is interfered with. Jaundiced patients dislike fat, and do not assimilate it, and the fatty natter in the ingesta may sometimes be detected n the stools. Hence, whatever be the cause of ibstruetion of the bile-duct, the nutrition of the >ody suffers : the emaciation may be slow, but it [ s progressive, until all the fat disappears, and hen the weight of the body may remain station- ry for many months. "With the emaciation bore is always more or less muscular debility. 5 . Tneritus, without any eruption, is a very betinate and distressing symptom in many cases of jaundice. It is usually worse at night, and by preventing sleep, may wear out the patient. It is chiefly observed in cases of jaundice due to obstruction of the bile-duct. It is not due to the presence of bile-pigment in the blood, for in some cases it precedes the jaundice, and in others it comes and goes during the persistence of the jaundice. Moreover, in many cases of jaundice it is absent throughout, while it is not uncom- mon in biliary derangements where there is no- jaundice. 6. Cutaneous eruptions. Urticaria, lichen, beds, or carbuncles are occasionally observed in connection with jaundice; and likewise that re- markable affection of the skin known as Xanthe- lasma or Vitiligoidea, the more severe forms of which are in fact almost invariably associated with persistent jaundice. 7. The temperature is not altered in jaundice, except when this occurs as a complication of some acute febrile disease, or when there is in- flammatory action in the liver itself. 8. Slowness of pulse. A common result of non-febrile jaundice is retardation of the heart's action, and diminution of arterial tension. The pulse may fall to 50, 40, or even 20, and some- times it is also irregular. This slowness of pulse is particularly noticeable when the patient is recumbent. When there has been antecedent pyrexia, the pulse usually falls on the superven- tion of jaundice. Siowness and irregularity of the pulse are chiefly observed in jaundice from obstruction of the bile-duct, and particularly in those common cases known as catarrhal jaundice; and accordingly they are not unfavourable symp- toms, as might have been supposed. So far as the writer's experience goes, patients with this symptom invariably recover. It has not yet been explained why this condition of circulation should be present in some cases of jaundice, and absent in others. The natural explanation would be that it is due to some ingredient of the bile, which does not exist in the blood in all cases of jaundice. Some experiments of Eohrig have shown that the biliary acid salts paralyse the heart, and retard its action, while bile-pigment has no such effect. Slowness of the pulse, there- fore, in jaundice may indicate the presence in the blood of unchanged biliary acids ; but so far there are no observations to show that bile-acidy are present in the urine in these more than in other cases of jaundice. 9. Hemorrhages . — In many cases of jaundice the blood seems to become impoverished, by a diminution in the proportion of red corpuscles and fibrine ; and haemorrhages take place from the various mucous membranes, and into the sub- stance of the skin. This haemorrhagic tendency is particularly observed in conjunction with cerebral sj'mptoms in cases of jaundice, where there is no obstruction of the bile-duct, but it also occurs in cases of mechanical jaundice of loDg standing, from any cause, when the secreting tissue of the liver has in a great measure disap- peared. 10. Xanthopsy or Yellow Vision . — In rare cases of jaundice, all white objects appear to the patient yellow. The administration of santonin internally has also sometimes been followed by yellow vision, which has ceased as soon eu tlui JAUNDICE. 776 lolouring matter has been eliminated by the kid- neys. This fact, as well as the observation that in several cases of jaundice, with xanthopsy, the conjunctival vessels have been pretematu- rally distended with blood, has led to the belief that the symptom is due to a tinging -with bile- igment of the humours of the eye. On the other and, the circumstances that the xanthopsy may intermit, without any change in the jaundice ; that it is usually absent when there is intense jaundice of the cornea and other tissues of the eye; and the statement that it may occur in ty- phus fever and in certain derangements of vision, such as night-blindness, when there is no jaun- dice, have led some authorities to regard it as a purely nervous symptom. 11. Cerebral symptoms, and the Typhoid, state. Patients with jaundice are often irritable in their temper and hypochondriacal ; aud occasion- ally they are attacked with acute deliri-um, stupor, coma, convulsions, muscular tremors, subsultus, carphology, paralysis of the sphinc- ters, a dry and brown tongue, and other indica- tions of the typhoid state. These symptoms are most common in cases where there is no obstruc- tion of the ducts, but they also occur in cases of obstruction, usually of long standing, where all or the greater part of the secreting tissue of the liver has been destroyed. Different opinions are held as to their cause. After death no lesion is found of the brain or its membranes, and they are, therefore, most probably due to somo alter- ation of the blood. They are commonly attri- buted to poisoning of the blood with bile, either from suppression or re-absorption of the secre- tion. But the assumption that the elements of the bile are preformed in the blood has been al- ready shown to be probably erroneous : and there is equally little evidence that bile is possessed of poisonous qualities, or that its presence in the blood, even to saturation, will give rise to cere- bral symptoms. Many experiments have been performed on animals to show that bile is a deadly poison ; but, there is reason for believing that the bad results observed have been due to the injection into the areolar tissue of decom- posing mucus contained in the bile. Bile, from which the mucus has been removed, has been repeatedly injected by Frerichs and other obser- vers into the largo veins of dogs, without cere- bral symptoms or any bad results ensuing, ex- cept that death has in some instances been caused by the entrance of air into the veins. But it is scarcely necessary to turn to experimental en- quiries on the lower animals for ovidence on the matter, and in all these experiments there are sources of fallacy. There is ample proof that the blood of the human subject may be satu- rated with bile for months, or even years, with- out any cerebral symptoms resulting. Dr. Aus- tin Flint, jun., is of opinion that the cerebral symptoms of jaundice are due to the retention of cholesterine in the blood, or to what he has designated Cholcstcrcemia. Cholesterine is one of the constituents of bile, and Dr. Flint regards it as an excrementitious product of nervous tis- sue. the elimination of which from the body is one of the functions of the liver, and the reten- tion of which in the blood he believes to act as a poison like urea. But if the non-excretion of all the elements of bile docs not give rise to cerebral symptoms, it is difficult to understand how they can result from the retention of choles- terine alone. In eases, for instance, of perma- nent closure of tho bile-duct, cholesterine is not discharged from the liver into the bowel, nor does it accumulate in the biliary passages, and yet, if it be retained in the blood, cerebral symp- toms rarely occur. The cerebral symptoms in jaundice are often most severe when the jaundice is slight, and they may occur in diseases of the liver when there is no jaundice. They aro best explained by the knowledge which we now possess of the function performed by the liver in disintegrating albumi- nous matter into less complex substances, such as urea and uric acid, which are eliminated by the kidneys. When this function of the liver is arrested or seriously impaired, urea is no longer eliminated in sufficient quantity by the kidneys ; lithic acid and deleterious products of disintegra- ting albumen even less oxydised, such as lencin and tyrosin, and perhaps others with which we are as yet imperfectly acquainted, accumulate it the blood and tissues ; the result is the develop- ment of symptoms of blood-poisoning similar to those which arise when the kidneys are unable to eliminate the products of albumen-disintc gration, owing to disease of their own structure, or to an excessive formation of urea and other products, as happens in many febrile diseases. In acute atrophy, for example, the structure of the liver is destroyed, and its functions are arrested ; leucin and tyrosin take the place of urea in the urine, and are also found in large quantity in the liver, spleen, and kidnevs; while cerebral symptoms and the typhoid state are prominent features of the disease. Diagnosis. — There is rarely much difficulty in the diagnosis of jaundice, but it is well to re- member that certain conditions are sometimes mistaken for it, such as chlorosis; the anaemic aspect resulting from organic visceral disease (and particularly from contracted kidneys), from cancer, from exposure to malaria, from Addison's disease, or from lead-poisoning; an undue amount of sub-eonjunctival fat; or an unusually dark colour of the ordinary urinary pigment, or the presence in the urine of abnormal pigments, such as those of santonin, turmeric, rhubarb, Ac. In ever} - case where there is the slightest doubt, it will be removed by resorting to the nitric acid test for bile-pigment in the urine. If this gives no result, the case is not one of jaundice. But it is a more difficult matter to determine the cause of the jaundice, and yet this should in- variably be the aim of the medical attendant, before forming a prognosis or proceeding to treat- ment. The scope of this article does not per- mit a lengthened analysis of the characters distinguishing the different forms of jaundice according to its cause, but the following remarks may be of some service. 1 . In the first place it is always well to deter- mine whether or not the jaundice be due to ob- struction of the bile-duct. According to Dr. G. Harley this can be done by determining the pre- sence or absence of bile-acids in the urine. Adop- ting the view that bile-acids are f rmed by the 1 liver, while bile-pigment isprefbrmcd in tho blond JAUNDICE. JOINTS, DISEASES OF. 777 he contends that in jaundice from ‘ suppression ’ (or independent of obstruction) the liver does not secrete bile, and consequently no bile-acids heiuo’ formed, none can enter the circulation or be detected in the urine; -whereas in jaundice from obstruction,, bile is secreted and absorbed into the blood, and a portion of the bile-acids not transformed in the circulation appears in the urine. But in addition to the strong improba- bility already urged that any form of jaundice is due to a suppressed secretion of bile, clinical experience is entirely opposed to the practical value of the test in question for throwing light on the cause ot' jaundice. Bile-acids have been found in the urine in cases of acute atrophy of the liver, where there is no obstruction of the bile- duct, and in very many cases of mechanical jaun- dice they are certainly absent. A more reliable indication of obstruction of the common bile-duct is furnished by the stools. When there is no obstruction, the, stools almost invariably contain bile ; but when the duct is obstructed, they are clay-coloured. The rule is not without excep- tions, and there are several sources of fallacy. The jaundice usually persists for sometime after the duct has become pervious, and thus bilious motions may co-exist with jaundice which has resulted from obstruction ; or, if the motions be thin and watery, they may appear to contain bile from the admixture of jaundiced urine ; or, not unfrequently, when the bile-duct is quite impervious, the motions are of a brownish tinge, owing to the presence of altered blood, which may closely resemble dark bile. A tumour corresponding to the region of the gall-bladder will favour the view that jaundice is due to obstruction of the bile-duct. Lastly, jaundice which persists and is yet slight, is most probably independent of obstruction, for jaundice from persistent obstruction speedily becomes intense. 2. It is always important to note the mode of commencement of jaundice. That which appears suddenly in a person whose previous health has been good, is most probably the result of obstruc- tion of the duct by a foreign body, or it has a nervous origin. The former cause will be dis- tinguished by biliary colic, vomiting, and clav- ’.oloured stools. On the other hand jaundice toming on slowly, but ultimately becoming in- ense, with clay-coloured stools, points to pres- ure on the duct from without, or to a growth in ts interior. 3. A history of previous attacks of jaundice if a similar nature is in favour of a catarrhal rigin or of gall-stones. 4. Pain in severe paroxysms concurring with inndice points generally to gall-stones or can- er; more rarely to hydatids, or to an aneurism f the hepatic artery. Cancer is distinguished j.-om gall-stones by there being usually a history f failing health and emaciation before either the ; ain or the jaundice. 5. Jaundice concurring with enlargement of ie liver is most probably due to cancer or cir- ;iosis; more rarely to'pysemic abscesses, or to axv liver, with large glands in the portal ssure. C. Jaundice concurring with ascites points to mcer or cirrhosis. The diagnosis of the latter ill usually be assisted by the physiognomy, the slightness of the jaundice, the previous habits, and a history of alcoholic dyspepsia ; while in cancer there are often darting pains, and the jaundice is usually- intense. 7. Jaundice concurring with pyrexia is either secondary to some acute febrile disease ; or is due to suppurative pylephlebitis, a suppurating hy- datid tumour opening into a bile-duct, or inflam- mation of the bile-ducts. Temporary pyrexia may also occur during the passage of a gall- stone. 8. Cerebral symptoms associated with jaun- dice suggest acute atrophy of the liver, poisoning by- phosphorus, some specific fever, pneumonia, or nervous shock. 9. Jaundice in a young person, preceded by symptoms of gastric catarrh, is most probably catarrhal. Treatment. — There is no special treatment for jaundice ; in all cases the treatment must have reference to what is believed to be its cause. The appropriate treatment will therefore be dis- cussed under the head of the several diseases which give rise to it. Here it is only necessary to observe, that in all cases of jaundice from ob- struction it is important to maintain the action of the kidneys, which are the main channel for the elimination of the bile ; while portal conges- tion is obviated by appropriate purgatives. The part which the bile plays in assisting assimila- tion of nutriment may to some extent be sup- plied by ox-gall; and creasote will often check the diarrhcea excited by the putrefying feces. Patients suffering from jaundice ought also to partake sparingly of fatty or saccharine food, or of alcoholic drinks. Charles Murchison. JEJUNUM, Diseases of. See Intestines, Diseases of. JIGGER. — A popular term employed to designate the sand-worm or sand-flea. See Chigoe. JOINTS, Diseases of. — Diseases of the joints are classified according to the structure primarily or chiefly involved. They may com- mence in the synovial membrane, in the bone, or in the cartilage. Primary disease of the liga- ments is rare, and is not clinically demonstrable. No form of joint-disease remains long confined to one tissue, so that when the disease is of some duration it will be found to implicate, more or less, every element of the joint-apparatus. In this article the diseases of joints will first be generally discussed ; and tho individual diseases will then be considered separately. .(Etiology and Pathology. — The larger arti- culations, those in constant use, and more espe- cially the joints of the lower extremity, are the most frequently diseased. Thus the knee is more often the seat of disease than any other joint; the hip-joint comes next in order; and then the ankle and elbow. All kinds of joint- diseases are frequent in children and young persons. The first year of life appears, how- ever, to be nearly exempt from these affections, and during the second year they are compa- ratively rare, perhaps because movement and risk of injury are at that period at a minimum. JOINTS, DISEASES OF. 778 Acute arthritis, however, is occasionally wit- nessed during the first year of life — during even the first six months. It is unconnected with syphilis or injury; very sudden in its appear- ance, and rapid in course ; dangerous to life ; and destructive to the articular ends of the hones by suppurative disorganisation. The causes of joint-disease in general are connected either with disordered nutrition, in which case it usually assumes an inflammatory type ; or with disordered function. The latter may depend on the former, or be unconnected with it. Again, the cause may be local in its origin, or arise from some constitutional defect. AmoDgst the exciting causes, injury is liy far the most fre- quent. This being often slight, and not followed by any immediate consequences, the connec- tion is frequently overlooked. A blow, or a fall against the edge of a table or down stairs, may readily bruise the synovial membrane, in such exposed joints as the knee or elbow, without causing any external sign. A slight haemorrhage takes place into the synovial cavity or the sub- synovial areolar tissue, and serous effusion may speedily supervene ; in this manner a common variety of acute or traumatic serous synovitis is produced. But although injury is the most fer- tile cause of joint-disease, the articulations may sustain most severe injury without becoming inflamed. It is rare to find any serious conse- quences result from dislocation; the joint usu- ally perfectly recovering itself. Penetrating wounds of the joints are always serious injuries ; they often occasion acute synovitis, and if septic changes occur, are followed inevitably by suppu- ration in the articulation, and danger both to the limb and life of the individual. Fractures often implicate the joint-surfaces, and prove a fre- quent source of stiff-joint. Plastic synovitis may be thus set up, causing adhesions ; or sup- puration takes place ; or the callus formed for the repair of the fracture may interfere with the joint motion. Gunshot wounds often produce the severest form of inflammation of joints, sup- puration being the usual result. When joint- disease follows an injury it is usually confined to one joint ; but when joint disease originates from constitutional causes, more than one joint is often affected ; or when only one, the constitu- tional nature of the cause is manifested in dis- eased conditions present elsewhere, or by traces of inflammation in other joints, due to the same cause. The deposit of tubercle in the synovial membrane and hone is a frequent cause of chronic joinl>disease. Joint-inflammations are of common occur- rence in all kinds of fever ; and also as se- quelae of the exanthemata. The great frequency of polyarticular serous synovitis in acute rheu- matism is well known, as also in purpura and haemophilia, w r here it is complicated with blood- extravasations. In pyaemia the joints are fre- quently the seat of sero-purulent and purulent effusions ; as they also occasionally are in scar- latina. Puerperal synovitis is a variety of the pyaemic. In typhus monarticular arthritis is frequently met with, and the hip is the joint oftenest affected. Endocarditis and polyarth- ritis are very often associated together, and the endocarditis may precede and give rise to the joint-disorder by embolism. The fact that multiple joint-affections are met with both in pyaemia and in rheumatism suggests a connec- tion, but what its nature may be is not clear. Although in articular rheumatism p s-formation is rare, we sometimes witness joint-suppuration in such cases ; whilst pyaemia and metastatic abscess may originate from ulcerative endocar- ditis. In chronic synovitis, affecting two or more joints, the heart should always he ex- amined, for traces of endocarditis will sometimes he found. In the exanthemata, typhus, and diphtheria, metastases in the shape of joint-in- flammations more or less frequently take place. Joint-inflammation is of frequent occurrence in dysentery. With gonorrhoea a form of arthritis is associated which is called ‘ gonorrhoeal.’ Syphilis in the later stages frequently attacks a joint, the knee by preference, syphilitic deposits taking place in the bone or the subsynovial con- nective tissue, but synovial effusion is not com- mon. A suppurative inflammation of the ends of the bone is not rare in children the subjects of inherited syphilis. In gout the joint-struc- tures are affected ; as a rule the perisynovial tissue becomes inflamed owing to deposits of urates. Similar deposits even occur in cartilages of encrustation. The great toe is most often affected, but the other tarsal, digital, and larger joints are frequently diseased. Some ilL-understood form of vaso-motor or trophic irritation appears to occasion arthritis, in locomotor ataxy. Effusion into the joint is preceded by pain, and the knee and shoulder joints are those generally affected. In some cases of the disease changes similar to those in rheumatoid arthritis have been observed, gene- rally in the knee, shoulder, elbow, or hip. They occur early in the disease ; arise suddenly ; aro often monarticular; and not rarely give rise to dislocation, especially in the shoulder. These characters distinguish the disease from ordinary rheumatoid arthritis. Severe inflammation of the joints of the paralysed limbs has been ob- served in cases of hemiplegia. The occurrence of joint-disorder, usually synovial inflammation, is frequent in chronic disease of the spine ; and it also occasionally happens in acute myelitis, in the form of suppurative arthritis. In both cases the knee is most frequently affected. Axatoxiicai, Characters. — Joint-disease may begin as an inflammation of the synovial mem- brane, of the bone, or of the cartilage. Fibrous tissue having but slight tendency to inflame, it is improbable that primary disease affecting the ligaments can be otherwise than most excep- tional ; but these textures very soon become secondarily affected, from their intimate connec- tion with the synovial membrane. The synovia' membrane is perhaps more ready’ to inflame than any other tissue in the body, and in many joints it is much exposed to injury from without, while excessive joint-movement alone is sometimes sufficient to excite synovitis. Primary disease of the hone comes next in order of frequency. Cartilage is least likely to take on primary u •- ease. Each of these tissues, however, becom. - speedily affected by disease which has invaded or commenced in the other. SnrPTOMS and Diagnosis. — The local syrnp JOINTS. DISEASES OF. toms of joint-disease have reference to impair- ment of function, and change in form-, together with pain, both local and sympathetic ; and cer- tain physical signs. Impaired function. — Usually this is great in proportion to the natural mobility aud import- ance of the joint, and most evident in the ex- I remities. The earliest symptom in hip-joint- disease is a slight limp or halt, whilst in other joints mere stiffness occurs; the full range of movement is simply curtailed, before actual pain or swelling takes place. The position of maxi- mum relaxation, namely, that intermediate be- tween flexion and extension, is commonly as- sumed by diseased joints. Even in the earliest Btages of disease, the interference with move- ment is often very great, amounting to a sort of vital anchylosis, produced by the action of the muscles, whoso tension prevents the joint-sur- faces movingupon each other — an effort to avert pain. This form of anchylosis disappears during narcosis. Muscular or vital anchylosis must be distinguished from the rigidity produced by structural changes. Both synovial effusion and peri-synovial infiltration mechanically hinder free joint-movement. Changes in form. — Changes in form are due to the alterations in shape and texture of the joint>structures, and to effusions within its ca- vity. These changes may be best appreciated by careful measurements, and a comparison with the opposite joint. No true estimate of the amount of departure from the normal is other- wise possible. The practitioner is thus better able to diagnose the special character of the swelling, whether it be due to synovial effusion, and con- fined to the limits of the capsule, causing it to bulge at the least protected parts ; or to chronic thickening of the synovial membrane, recognised on palpation by its elasticity and general diffu- sion; or to disease of the bone and periosteum, when the swelling is deep-seated and hard. By accurate comparison a fluid collection outside the joint, either an abscess or a bursal tumour, may be distinguished from intra-articular swell- ing. Pain. — The character of the pain is an im- portant symptom in diseases of the joints. In .acute synovitis it is severe and lancinating. In bone-inflammation it is a dull aching pain, with marked local tenderness, liable to periodic exa- cerbations of an intense kind. Often the pain is of a shooting, starting character, wakening the sufferer from sleep. The pain is of this charac- ter and most severe in subarticular ostitis. Pytemic suppuration and chronic synovitis are ‘generally painless. Physical signs. — "When one band is laid flat upon a diseased joint while the other moves it, certain sensations or sounds are often distin- guishable. A peculiar soft crepitation due to the presence of blood-clot, must not be mistaken for he rougher sensations which adhesions afford, he friction-sounds of movable joint-bodies, or he grating of exposed bone. The rubbing of one ganulation-surface upon another may be likened o that of two pieces of velvet. Abnormal move- nts, such as lateral motion in a ginglymoid oint, usually imply extensive joint-disorder, lisplaeement or partial dislocation, and altera- tion in form of the joint-surfaces occur as the disease progresses. A notable increase of local heat may be felt in all inflamed joints. When fistulous tracks exist around a diseased joint, they do not often afford direct evidence on being probed of the condition of the joint, but they generally prove the existence of articular sup- puration, and disease of the bone. With respect to the general symptoms of dis- eases of the joints, it need only be said here that the amount of pain or constitutional dis- turbance in acute cases varies according to the extent and acuteness of the disease, and the pre- sence and amount of suppuration. In chronic disorders the associated constitutional condition should be investigated. Complication's aud Sequel®. — The complica- tions which occur in joint-disease are generally connected with long-continued suppuration. Amyloid degeneration of the viscera is pretty certain to be present when suppuration has existed for a year or more in young people ; less certainly in adults. Hectic fever, tuberculosis, or pyaemia may occur at any period. In the ab- sence or failure of treatment, the patient, should he survive, will suffer from contraction, defor- mity-, and imperfect growth of the limb, together with more or less complete loss of function. Prognosis. — The prognosis in diseases of the joints will depend on many circumstances, and must be considered both as regards life and as regards function. First, with respect to life, the gravity of joint-diseases increases with the size of the joint affected. They are more serious in the lower than in the upper limb. Pyaemia is comparatively rare in acute joint-suppurations — why, it is impossible to say. When pus escapes from the interior of a joint into the surrounding tissues, pyaemia may occur. A continuous high temperature, or a large evening increase asso- ciated with hectic, are bad signs'; the exhaus- tion, which depends on profuse suppuration with its attendant hectic fever, amyloid degene- ration, and tuberculosis, being the most frequent causes of death in joint-disease. The prognosis as regards function is often difficult to determine. After an attack of simple acute or subacute serous synovitis, recovery is generally complete. Joint-function is usually completely lost after suppuration of traumatic origin, recovery being quite exceptional. When the suppuration is of a pyaemic nature, and the patient survives, the effu- sion may become absorbed, and the joint-motion bo preserved. Chronic synovitis with thickening of the subsynovial tissue, due to infiltration with granulation-material, can seldom he cured except by operation, especially after suppuration has taken place. If recovery should ensue, the joint- function is lost, and deformity is always present. Increased mobility — ‘ flail joint’ — is a very rare sequence of joint-disease. It is occasionally seen in the shoulder, and also in the knee. Treatment. — The treatment of diseases of the joints must be directed to preserve the life of the individual ; and, as far as possible, the functions of the limb. Of the first and greatest impor- tance among remedial measures is rest, which is best secured by fixation of the joint and limb in an appropriate apparatus. This is of cardinal importance to a diseased articulation, just a» JOINTS, DISEASES OF. 160 motion is a necessity for a healthy one. Immo- bilisation should not be continued longer than necessary ; it "will sometimes seriously damage even a previously healthy joint, immobilised on account of fracture of the limb ; and a continu- ance of rest after all diseased action has sub- sided often exerts a very prejudicial influence. Best, however, should be continued so long as pain and increased temperature persist. Position . — The same means adopted to secure immobility must be utilised to obtain the best available position for the future function of the part, should anchylosis become inevitable. In the ankle the foot should be maintained at a right angle ; the hip and knee must be extended in the axis of the body ; the elbow is generally flexed to a right angle, the position in which the limb is most useful. Splints of various forms are used, and we possess in plaster-of-Paris and starch ready and invaluable means of producing an apparatus, which gives uniform and equable support of a simple and very perfect kind. Extension exerts a beneficial influence, as well by immobilising the joint, as by its power to remove contraction and deformity. It relieves pain and abates the symptoms rather by keeping the joint at rest, and changing the surfaces of contact, than by any actual distraction of the joint-surfaces. A much greater weight than a patient could tolerate must be used before any such separation could occur. Extension often even increases the intra-articular pressure. By straightening the limb it removes the joint from its position of maximum relaxation, and puts the skin and tendons on the flexor aspect on the stretch, and alters the mutual accommodation of the joint-surfaces. As there is almost invariably an increase of temperature in the affected joint, the application of coll, by means of ice-bags or coils of cold water tubing, is indicated. Cold acts most bene- ficially in all acute, and many subacute inflam- mations. Even in deep-seated joints like the hip, it will often soothe the pain and abate the symptoms, but it is more applicable to the superficial joints. Cold is both anaesthetic and prophylactic in its action. The sensations of the patient in respect of the continuance of cold applications must be consulted. In most cases they are grateful. In chronic joint-affections when an acute attack supervenes, threatening suppuration, cold should also be applied. Cold applications may in some cases be continued for weeks or months with advantage. When the acute symptoms have passed off, and it is de- sirable ” to encourage lymphatic activity and absorption, the cold must be discontinued, and compression, together with friction and warmth, substituted. Cold is not applicable to purely chronic cases without much pain or tenderness. In some instances of acute and subacute ar- thritis local depletion by means of leeches or scarification is very useful, and this may be combined with hot fomentations in cases where cold is not well borne. In chronic inflammation of the bone the actual cautery sometimes procures .mmediate abatement of the pain, and, after a time, the subsidence of the inflammation. The Dutton cautery may be used, or, still better, linear cauterisation, over the most sensitive points. Or an issue may be employed in- stead. Compression by strapping, or with a thick layer of cotton-wool and a tightly applied ban- dage over it, is applicable to the chronic stages of joint-disease. It must be discontinued if it occasion pain. It is better calculated to remove fluid effusions than the plastic material poured out into the perisynovial tissue. For these cases the more continuous compression of a properly applied elastic bandage will prove more efficient; or the strapping known as ‘ Scott’s dressing.’ Massage is a most valuable local means for the dispersion of chronic swellings of joints. It both removes the results of diseased action in the joint, and helps to restore its function. It is well suited to disperse serous effusions when the acute stage is over ; for cases of plastic sy- novitis it is also useful, but not for cases of the type known as tumor albus. It produces a diminution of the sensibility of the part, and a local increase of temperature, and the lymphatics are stimulated to increased activity. There are several modes of employing massage. The first is centripetal stroking with the palm of the hand from the periphery of the affected part to wards the centre of the body, called effkurage, one hand following the other in immediate suc- cession. The amount of pressure varies with the circumstances of the case. This will readily dis- perse fluid effusions both of blood and serum. Friction-massage is another useful method, and is practised by pressing the palm firmly upon the surface, and then rotating it. This plan may be combined alternately with the last method, massage proper — petrissage — which is done by raising up the soft parts vertically from the bone with both hands, and compressing them, always in a centripetal direction. Forcible movements. — Forcible movements, which break-down adhesions, are often most use- ful in cases of stiff joint arising after protracted immobilisation, after fracture in the vicinity of a joint, or after a severe sprain. Pain will be relieved in this way, and mobility restored in some instances, in a degree quite remarkable. Constitutional treatment . — Where any general taint exists, this must be treated at the same time. A tendency to tubercle must be met by iron, tonics, good food, and fresh pure air. Gout, syphilis, or rheumatism must, when pre- sent as a diathesis, be appropriately treated. Operative treatment . — Puncture alone, or com- bined with antiseptic washing-out of the articu- lation, may often be performed with advantage, to evacuate the fluid in a distended joint or to diagnose the presence of pus and evacuate it when suppuration has taken place. Sufficiently free incisions, however, and the insertion of drainage tubes are generally to be preferred m cases of joint-suppuration ; and with these should be combined the washing-out the joint-cavity with a three- or five-per-cent, solution of carbolic acid, or other adequate antiseptic. It has been, pro- posed to substitute free incisions and drainage for excision of the joint, in certain chrome forms of disease, such as white-swelling, but excision is probably in most respects preferable. Ex- cision is practised for chronic joint-disease not amenable to other means ; it is not a substitute JOINTS, DISEASES OF. for amputation, but is intended to obviate its necessity. Subperiosteal resection, where practic- able, possesses many advantages, especially in cases of traumatic origin. The attachments of the muscles and tendons, and the cellular inter- faces between them, are thus left undisturbed. The chances of perisynovial suppuration are diminished, and the bleeding is reduced to a minimum. There is more complete bony repro- duction of the joinGsurfaees, and in young per- sons a new joint very similar to the normal is in some instances formed, while in all cases there is a probability of better subsequent function and position. The operation thus performed requires time and skill. It is scarcely applicable to the knee or even the hip, and is unstated for cases of chronic synovial disease, where it is of the last importance to excise all the diseased granula- tion-material. The after-treatment of excisions is of great importance. Plaster-of-Paris ban- dages supply one of the most useful means of immobilisation, especially in those cases where anchylosis is sought for, as in the knee ; and the splint should be unchanged, if possible, fcr four or five weeks. In the elbow, shoulder, and wrist, where mobility is the end aimed at, passive movement should be commenced as soon as the i condition of the wound admits of it, namely in about a week or ten days. Galvanism must be used at a later period to restore the wasted mus- cular apparatus. Amputation is only performed as a last resort. It is very rarely needed for joint-diseases in the upper limb, except perhaps the wrist, when the hand is permanently crippled. In the lower limb, amputation must be performed in those cases in which the patient has lost all strength and healing power, from the drain of a long- 1 continued discharge. It is advisable where amyloid degeneration or incipient tuberculosis exists, or in any case, in short, in which the power of the patient is inadequate to furnish the amount of repair required in the expectant form of treatment, or in case of excision, always a more serious operation than mere amputation. Amputation should also be adopted in those eases in which the local disease, especially of the bone, is too extensive to admit of a good func- 'tional result after excision. In the very young excision is very undesirable, since the epiphysis is almost of necessity sacrificed, and the growth of the limb checked. Resection in some joints is practised to avert anchylosis, or to restore the lost function of the joint, as in the shoulder, slbow, and wrist. Various congenital and other deformities of the joints may be removed by osteotomy of the bones concerned. The chief diseases of joints will now be sepa- rately considered in alphabetical order as fol- ows : — ] . Cartilages, Diseases of ; 2. Congenital Dislocation ; 3. Immobility ; 4. Inflammation, Vcute, of the Synovial Membrane : 5. Inflamma- ion, Chronic, of the same ; 6. Gonorrhoeal In- lammation ; 7. Gouty Inflammation ; 8. Stru- ious Inflammation ; 9. Loose Cartilages in oints; 10. Nervous Affections; 11. Bheumatic arthritis, Chronic; 12. Serous Effnsions; and 3. Syphilitic Disease. Rheumatism in its svarai forms will be considered separately. 781 1. Joints, Cartilages of, Diseases of. — Primary chondritis as a form of joint-disease is neither clinically nor pathologically established. The cartilage has little tendency to active in- flammation ; it is not sensitive to pain; chronic changes take place in it as the result of impaired nutrition, rather than inflammation. The car- tilages of encrustation are the residue, which does not ossify, of the mass of fcetal cartilage forming the bone-ends. We meet in the joints of the aged with depressions and fibrous scars, caused by partial atrophy of the cartilage ; these changes do not occasion symptoms during life, beyond sensations of creaking and roughness in the joint when moved. Almost all the changes which occur in the articular cartilages are secondary to synovitis and ostitis, and more or less passive. In serous synovitis the cartilage is softened and swollen, and becomes to a certain extent cedematous. In suppurative synovitis it becomes rough, sodden, and yellow ; its cells burst ; the intercellular substance fibrillates ; and portions may necrose. The cartilage-changes in chronic synovitis have been already discussed, and others will be re- ferred to later. Young growing bones, like the periosteum covering them, readily inflame ; and as soon as the inflammation invades the articular surface of the bone, the cartilage becomes loosened and necrosed, or invaded by the granulation-tissue springing from the bone. The cartilage is soft- ened ; its capsules burst ; fibrillation occurs ; and at different places it becomes thinned. Per- forations occur in it, leading to the bone, giving it a sieve-liko appearance. Where the inflam- matory process is more acute, the whole of tLe encrusting cartilage may become .at once de- tached from the bone beneath. In these cases the pain, especially at night, is very severe. Involuntary starting of the limb causes intense suffering, wakening the patient from sleep with a scream. This symptom was formerly considered distinctive of ulceration of cartilage, a process which is wholly painless when it occurs without other disease in the joint, but it is probable the pain is due to pres- sure upon the inflamed bone, and it will some- times greatly abate when the cartilage wholly disappears. Disease commencing near the epi- physeal cartilage often extends to the adjacent joint. Those joints in which the epiphyseal junction is within the capsule, as, for instance, the hip, run a double risk from bone-inflamma- tion. 2. Joints, Congenital Dislocation of.— Description. — This is a curious and ill-under- stood affection of the joints. It is almost exclu- sively confined to the female sex. The liip-joint is nearly always the one affected, and the dis- placement is generally double. It has often been erroneously mistaken for morbus coxae, and treated accordingly. It probably occurs in early fcetal life from defective formation of the joint-surfaces. It is not discovered until the child begins to walk, which it generally only commences to do at a late period. When the hips are affected, the gait is accompanied by a most ungainly swaying ul JOINTS, DISEASES OF. ?&2 the body from side to side like the waddling of a duck. All that can be done is to supply a 'well- contrived artificial support to the pelvis and limbs. Genu valgum and genu varum (knock-knee and bow-knee) are two forms of disabling and un- sightly deformity of the lower limbs. They are often due to an abnormal development of the condyles or shaft of the femur, or the tuberosities of the tibia, and to changes of a rickety character at the epiphyseal junction. In extreme eases progression is greatly interfered with. The symptoms are painfully obvious. Treatment. — Treatment of the limb by splints and apparatus and forcible straightening in plaster- of-l’aris bandages succeeds in the milder cases, but in those of a severe type, or in persons of ten years or upwards, this plan is most tedious, and is usually attended by com- plete failure. The subcutaneous division of the internal or external condyle, according to the nature of the deformity, restores the joint-sur- faces of the femur to their normal level, and is attended by the happiest results both to the form and function of the limb and joint. It is an easier and in many ways a more successful operation to divide the shaft of the bone with a chisel near its articular extremity, and thus procure the rectification of the limb. 3. Joints, Immobility of. — S ynon. : Anchy- losis ; Fr. AnJcylose ; G-er. Gelenkverwachsung. .ZEtiology. — This condition may be due to changes in the structures of the articulation — true anchylosis ; or in those surrounding the joint — false anchylosis. It may be fibrous and incomplete, or bony and complete. False or spurious anchylosis — extra-articular — may de- pend on muscular spasm or rigidity; on cicatri- cial contractions ; on paralytic or spasmodic affections; or upon prolonged disuse of the ioint. It is often difficult, even under chloro- *form, to distinguish the presence of absolute bony anchylosis, as the fibrous form may be so strong and extensive as almost wholly to prevent movement. The two varieties are but degrees of the same process. Both may result from pre- vious inflammatory changes in the joint, either of the nature of plastic synovitis, or of granu- lations springing from the bone and other joint- tissues, becoming further organised. Fibro-car- tilaginous anchylosis is a common form in young persons. In time it usually becomes converted into true bony anchylosis. The marked anchylosis which tonic spasm and rigidity of the muscles produce in the early stages of some joint-diseases, as in the hip-joint and knee, may be called vital or physiological. It is induced by an effort to avert pain ; it disap- Dears entirely during narcosis. A joint may be- come stiff and anehylosed by long fixation on account of some injury or disease elsewhere, es- pecially if it be retained in a flexed position, as the muscles of the flexor side actually shorten when their points of origin and insertion per- manently approach one another. The same thing may also happen in the myogenic affections due to paralysis : in which the cartilages and bones atrophy at the san e time. Treatment. — The treatment of diseases of joints should, in all cases where it is possible, bo prophylactic against the occurrence of anchy- losis. When this has taken place in an incomplete degree, an attempt to restore the function of the limb must be made by breaking down the adhe- sions by forcible or gradual extension, by pas- sive motion, by massage, and by tenotomy of the tense tendons. Excision is indicated to restore motion in complete anchylosis of such joints as the wrist, the elbow, and the shoulder. In other cases of complete anchylosis, especially in the lower limb, surgical interference should be confined to an attempt to rectify a faulty position either by tenotomy, extension, forcible straightening, excision, or osteotomy. Amputa- tion can only be needed in extreme and other- wise irremediable deformity. 4. Joints, Inflammation, Acute, of the Synovial Membrane of. — Synox. : Acute Sy- novitis ; Fr. Synovite ; Ger. Synovitis. This i3 one of the most common of all joint- affections. Probably in half the total number of chronic joint-diseases the synovial membrane is first affected. The synovial membrane is very rich in vessels and cells ; and much exposed to injury, and to the effects of joint-movement. Au inflammation beginning at one point soon spreads over the whole synovial sac. Description. — A cute synovitis is a Tery com- mon Tesult of injury; it also occurs in rheu- matism, gout, pyaemia, and other diseases. It may be serous, sero-fibrinous, or purulent. Se- rous synovitis is the simplest and most common variety. Even a slight external injury’ is often sufficient to produce it; a sprain of the joint, or even excessive movement, may cause it, as well as the constitutional disorders already men- tioned. The knee is very often affected, from its exposed position and the large area of the serous membrane lining it. The synovial mem- brane becomes injected and thickened, with oedema of the subsynovial tissue. The natural secretion is increased in quantity, and many cells are shed into the joint cavity, the capsule becoming swollen, tense, fluctuating, or elas- tic. The least protected parts bulge, from the pressure of the effused fluid, and the normal contour of the joint is lost. It is usually semi- flexed. A severe burning, cutting pain is ex- perienced in it. It is exceedingly sensitive to pressure, and painful on the slightest movement. There is usually considerable fever. When the inflammation is more intense, the synovitis be- comes sero-fibrinous. Flakes of lymph are min- gled with the synovia ; layers of false membrane cover the synovial membrane, which is consider- ably thickened and dull red in colour ; and the constitutional disturbance is greater. Finally, it is but a short step from this to suppurative sy- novitis. If the irritant cause continue its action, the leucocytes filling the meshes of the synovial membrane are shed in larger quantity ; the fluid becomes turbid and puriform ; the fever and local symptoms increase very much in severity; the external parts become implicated in the inflam- mation within; and joint-suppuration or abscess is the result. Treatment. — The treatment of the first two stages of synovitis is directed primarily to check JOINTS, DISEASES OF. 783 I | i the progress of the inflammation ; and then to procure resolution, and absorption of the effused fluid. Fortunately the synovial membrane pos- sesses very active absorbent powers ; and early and efficient treatment, conjoined with removal of the source of irritation, will generally ensure a cure, with complete restoration of function. The chief means are cold applications ; immobili- sation till the acute stage is over; and then com- pression and friction, or in suitable cases counter- irritation. Gout, rheumatism, or other diathesis, must be appropriately treated at the same time. In those cases in which the inflammation has persisted for some time, and plastic effusion has taken place on the surface and in the substance of the synovial tissue, the joint will remain for a long time stiff and thickened, and its function impaired, after all acute symptoms have sub- sided ; whilst in those cases where the inflamma- tion has continued long enough to invade the other joint-structures, a perfect cure may not be possible. When suppuration occurs, the joint must be deait with as any other abscess-cavity. Free incisions must be made into it, and it should be thoroughly washed out with some antiseptic solution, free subsequent drainage being pro- vided for. In tho more favourable cases, an- chylosis in a convenient position will be obtained. Recovery of function is very rare. In other cases the suppuration continues ; the cartilages of encrustation become necrosed and detached ; the bone becomes exposed and carious ; and either excision or amputation must be performed to save the patient's life or limb. 5. Joints, Inflammation, Chronic, of the Synovial Membrane of. — - Synon. : Chronic Synovitis. Chronic synovitis may arise as the sequel of the acute disease ; or, as is more frequent, it may depend on some constitutional dyscrasia, or at least some continuously acting irritant, al- though in the first instance it is generally ex- cited by an accidental injury. Vabieties. — There are three chief varieties of this disease which are often co-existent, namely : —Pannus Synovitis, Granulation Synovitis, and Pa-pillomatous Synovitis. a. Pannus Synovitis. — In this variety a deli- cate membrane will be found, stretching from the inflamed and thickened synovial margins more or less over the surface of the cartilage, to which it may be in whole or in part ad- herent. b. Granulation Synovitis. — Tho second, or granulation-form, is a more advanced stage of the disease. In it the synovial membrane is often completely replaced by granulation-mate- ' rial, which encroaches on the margins of the cartilages, and, as the disease progresses, in- vades them, and coalesces after a time with granulations springing from the inflamed bone. These granulations are pink or greyish-red, not 10 vascular as those in an ordinary wound. They have little tendency to cicatricial change, md are prone to soften down and form abscesses. The synovial membrane often becomes enor- uously thickened from the granulation-material accumulated in it, and this form of disease is frequently associated with the tuberculous dia- thesis. Bodies identical with miliary tubercles are very often found in the semi -gelatinous or pulpy synovial membrane ; the whole constitut- ing what is known as tumor a/bus, or ‘ white- swelling.’ Sv r MProMS. — The more prominent symptom associated with the form of chronic synovitis just described is the presence of a uniform semi-elastic swelling, caused by the sero-fibri- nous infiltration of the synovial membrane. The skin is whitish, tense and smooth, whence the name tumor albus. The amount of- synovial effu- sion into the joint is usually limited; the pain is seldom severe ; the amount of joint-movement is diminished ; and there is usually contraction of the limb, and sometimes partial dislocation. When suppuration occurs, there is more pain and fever. The progress of the disease is gene- rally very chronic, extending over months or years, and allowing the patient at intervals to take moderate exerei-e. Exacerbations take place, however, from slight causes, or without cause ; attacks of subacute or acute inflammation supervene ; and sooner or later abscesses form, communicating both with the cavity of the joint, which becomes totally disorganised, and with the surface. Brodie’s ‘pulpy disease of the synovial mem- brane ’ is simply an exaggerated degree of gra- nulation synovitis, in which the subsynovial tissue becomes enormously thickened by succes- sive attacks cf inflammation, Treatment. — The disease is most rebellious to treatment, and scarcely curable amongst the poorer classes without operation. Sometimes the diseased tissue is got rid of by suppuration ; and, if the patient’s strength suffice, a cure by anchylosis, probably accompanied by consider- able deformity, will ensue. Generally, however, the symptoms become worse; the aeneral health gives way from the drain of the continuous dis- charge ; or amyloid or some other intt-reum-nt disease kills the patient. At any time, as in a suppurating wound, pyaemic symptoms or hectic may set in. c. Papillomatous Synovitis. — Synon. : Fim- briated disease of the synovial membrane ; Pa- pilloma, or Papillary Fibroma of the synovial membrane ; Ger. Gchnlrzottcn. This is a peculiar form of joint-disease depen- dent on chronic synovitis, in which numerous pedunculated bodies, cylindrical or fusiform, varying in size from a pin’s-head to a large pea, project from the membrane, generally near the cartilage margins, or they may cover the entire surface. They are identical in minute structure with the synovial fringes. Some become de- tached, and fall into the cavity of the joint. The disease is essentially a hyperplasia of the sy- novial adventitia ; and there may be dozens or hundreds of these bodies present in one joint. Occasionally they contain cartilage-cells, or osseous particles. The joints in the lower limb are most, often affected. Treatment. — The disease is scarcely reme- diable except by excision of the joint, which may be practised in those cases in which there is serious loss of function. 784 JOINTS, DISEASES OF. 6. Joints, Inflammation of, Gonorrhoeal. This disease is often called ■' gonorrhoeal rheu- matism.’ It is almost always observed in the male, very rarely affecting the female. Generally one joint, usually in the lower limb, is involved, as the knee or the ankle. It is not so common in the upper extremity. It may affect several joints in succession. It may occur at any period of a gonorrhoeal or even a gleety discharge, of which the patient himself is possibly unaware. The fibrous tissues of the joint seem to be primarily engaged. Sclerotitis and inflammation of the internal layer of the cornea often coexist, but never either endo- or pericarditis. Symptoms. — The joint affected is exquisitely tender on pressure ; it is swollen rather from sub- cutaneous oedema than by intra-artieular effu- sion, which is usually inconsiderable ; and one side of the joint is often more affected than the other. The fever is not in proportion to the in- tensity of the local symptoms, the rise of tempe- rature being slight. The course of the disease is sloyv and obstinate ; but when cured it is not liable to return, except with a fresh attack of gonorrhoea. These characters distinguish it from ordinary rheumatism. Treatment. — Best, cold applications, and the internal exhibition of iodide of potassium consti- tute the best treatment for gonorrhoeal inflam- mation of joint. See Rheumatism, Gonorrhoeal. 7. Joints, Inflammation of, Gouty. — Gout frequently occasions synovitis, by the deposit of urate of soda in the perisynovial tissue, which excites a synovial effusion. The attacks are very acute and painful ; and as they recur, the joint becomes more and more disorganised, horn permanent deposits of urates in the cartilages and bone, as well as in the perisynovial tissue. The use of the joint is lost; and the ‘chalk- stone,’ as it is called, acting as a foreign body, sometimes produces an abscess, or an ulceration very troublesome to heal. When the collection is quite superficial, it may often be evacuated by incision with great relief. See Gout. 8. Joints, Inflammation of, Strumous. — - Scrofula and tubercle are often associated with joint-diseases. Scrofulous or strumous inflam- mation of a joint is a vague term, but we are without a better. It is a form of chronic inflam- mation in ill-nourished persons — nearly always children — who live under had hygienic condi- tions, and are prone to deposits of tubercle. It is observed most frequently in the knee- and hip- joints. Anatomicau Characters.-— This disease gene- rally commences in the synovial membrane, which becomes thickened, and by degrees con- verted into a semi-gelatinous mass of granulation- tissue, yellowish-white or pink in colour ; or the disease may originate in osteomyelitis of the end of the bone. After it has existed for some time, it is difficult to determine in what tissue it may have originated, and it is of no clinical impor- tance to do so, for in any case the later stages of the malady present similar features. The cartilages are encroached upon from their mar- gins and from their deep surfaces by the gra- nulations, whilst active changes occur simul- taneously in their substance, similar to those already described. The ligaments soften, and nil the structures of the joint become involved. Frequently small masses of necrosed Lone will be found in the cancellated structure, and the granulations have a great tendency to suppurate. In the thickened synovial membrane, and also in the ends of the bones, miliary bodies, identical with tubercles, may very frequently be detected. Symptoms. — In strumous inflammation the joint is uniformly swollen, tense, elastic, with a white glistening surface, and enlarged veins shining through the skin. The patient can usually move about until suppuration has taken place, as the pain is never very severe in the intervals of the acute attacks of inflammation which supervene from time to time. Enlarge- ment of the lymphatic glands, or marks of strumous ulceration elsewhere are seldom want- ing ; whilst sooner or later a large proportion of the individuals affected by this form of joint-dis- ease show signs of general tuberculosis. Some- times this state precedes, but generally it fol- lows, the local joint-affection. Inherited syphilis appears to be a predisposing cause of strumous arthritis. Treatment. — This must be mainly directed to improving the patient's general condition. A purely local treatment, short of a complete remo- val of the diseased structures, is not of the least use. When the joint has become disorganised, as before described, excision should be performed before the viscera become implicated. If other organs be involved, or the local disease be too extensive, then amputation becomes imperative. When not relieved, fresh foci of suppuration form ; the patient becomes more and more ex- hausted ; or some intercurrent disease sets in. It is rare for spontaneous cure to happen. 9. Joints, Loose Cartilages in. — S txon. : Fr. Corps flottunts ariiculaires; Ger. Gclenk- maiise. Description. — * Loose cartilages ’ in joints may originate either from chronic inflammation, or from traumatic causes. They may be single or multiple. The knee-joint is most frequently affected, and in it the most serious symptoms are produced. These bodies may be fibrous lipomatous, chondromatous. or osteo-chondm matous. They may be produced from polypoid growths springing from the synovial membrane in certain forms of chronic synovitis, and in arthritis deformans ; and they are then usually of the fibrous or osteoid variety. Lipomatous free bodies are rare, and are derived from the sub- synovial fatty tissue, being produced in a fashion analogous to the appendiese of the great intestine. The chondromatous and osteo-chondromatous are the largest and most important varieties of these bodies ; hence the common term ‘ loose car- tilage.’ Portions of the joint-surface may some- times become detached, as the consequence of an injury, by a process of quiet necrosis. They thus become loose in the joint. There is good reason to believe that some of these bodies may obtain nourishment from the surrounding syno- vial fluid, and that cartilage and even bone can be developed in them subsequently to their do tachment. JOINTS, DISEASES OF. Symptoms and Diagnosis. — T he symptoms of loose cartilages in a joint vary very much. In some instances these bodies cause no inconveni- ence. In others they produce repeated attacks of excruciating pain, followed by synovitis, lay- ing the patient up for weeks ; whilst in the most severe cases the limb may become almost use- less. When the knee is the joint alfected, the patient experiences great insecurity in walking, the loose body from time to time becoming wedged between the joint-surfaces. The joint is thus ‘ locked.’ The patient may suddenly fall, or faint with pain ; an attack of synovitis follows ; and with a frequent repetition of this process joint-disorganisation may finally result. The prognosis as regards function is always bad. Tbeatment. — The treatment of loose carti- lages may be either palliative or radical. The former method consists in applying support to the joint; limiting its movements ; and fixing the loose body in some synovial pouch where it can- not interfere with the articular surfaces. The radical method consists in excising the body — an operation, with few exceptions, almost exclusively practised upon the knee-joint. The body may be removed by a free direct incision into the joint, and squeezing the body through the wound at once. Or the indirect manner of operating may be adopted. This consists in subcutaneously incising the capsule of the joint with a long, narrow- bladed knife introduced at some distance from the articulation ; forcing the body through this incision into the cellular tissue outside ; and then closing the small ex- ternal puncture in the skin. Three or four weeks later the ‘ cartilago ’ may be removed by a superficial incision, or left undisturbed, when it often becomes absorbed. In appreciating the comparative value of these -wo plans, it may be said that the former has litherto proved more uniformly successful quoad extracting the body, but that it has been more langerous to limb and life — a danger, however, vhich antiseptic precautions will in future re- use to a minimum. The indirect method has ■een attended by a considerable number of fail- res in the extraction of the loose cartilage, specially if it be pedunculated ; but it has jitherto proved a much less dangerous opera- on. The extremity should be immobilised fterwards for two or three weeks. When some dozens of these bodies are present . a joint, many of them free, many attached, icision of the articulation is often the only medy. This is a severe measure, and not to be ,;htly undertaken, in the joints of the lower ib at all events. 10. Joints, Uervous Affections of. — ‘Non.: Hysterical joint ; Neuralgia of Joints; •jthralgia; Fr . Art.hralgie hysterique-, Ger. Ge- i kneurose. Ieschiption. — Hysterical affections present f lptoms simulating real joint-disease so closely, I t the strongest therapeutic measures havo c n been exerted, though in vain, for thoir c P* Prolonged immobilisation, blistering, the Mai cautery, resection, and even amputation, h 3 been practised upon joints in which there 1* not a trace of organic disease, 50 786 The existence of hysterical affections of joints is denied by some ; but assuredly they do occur . and most often in young women, well-to-do in life, with disordered catamenia. The same thing occurs, but less frequently, in young men. The disease is not witnessed under the age of pu- berty. The hip and knee are the joints princi- pally complained of — most frequently the latter. An all-important feature of a hysterical joint is that, while the local symptoms may be intense, the general symptoms are either absent, or in no sort of proportion to the local. A special character of this disease is that deep pressure is often less painful than super- ficial pressure; and that the pain and tenderness are vague, shift from one point to another, and will disappear at a given spot when the patient's attention is directed elsewhere. There is pain on movement, but of an indefinite character, and not so limited or localised as in real disease. Nocturnal startings do not occur ; the patient may enjoy uninterrupted sleep for hours. There is never a continuous rise of temperature, either general or local ; the co-relation of the symp- toms is not the usual one ; the function of the joint is much more interfered with than the other features of the disease present would ap- pear to justify. There is an exaggerated fear of examination; and the facies hysterica is often well-marked. There may be thickening around the joint, and even marked synovial effusion into it; but these conditions are passive in character, and generally due to the treatment employed. The limb is wasted and consequently weak, but never to the same extent as in real joint-disease. Exacerbations occur at the menstrual period. A careful inquiry should be made into the history and antecedents of the case. An examination under chloroform will often afford important evidence ; and the patient’s symptoms will be ■ improved afterwards by the movements then practised on the joint. Neuralgic pain in the articulations may arise under different circumstances. It may be the referred pain, unattended by local lesion, which is so frequent in the knee in cases of hip-joint disease. Neuralgic pains in various joints are observed in the preliminary or early stages of chronic myelitis. In the first stage of locomotor ataxy the knee may be affected by severe neu- ralgia when the disease is low down in the cord ; or the shoulders when it is at a higher point. Lastly, so called neuralgia of a joint may really indicate some obscure lesion, as chronic inflam- mation of the bones entering into the formation of the articulation. Treatment. — The methodical exercise of an hysterical joint is as plainly indicated as rest is imperative in a case of organic disease. Tilt- bowels should be regulated, as also the men- strual flow. Assafcetida, iron, and quinine are most important remedies; and healthy mental and moral influences are valuable adjuncts. ‘Get up and walk’ is a good prescription in many such cases. Very careful and repeated ex- amination should always bo made, to exclude any possible form of chronic inflammation, before pronouncing a joint to be hysterical. It must not be forgotten, however, that after slight in- juries which produce some inflammatory symp- 786 JOINTS, DISEASES OF. toms, those of hysterical joint may supervene, and persist long after all traces of organic dis- ease have disappeared. The treatment of neuralgia connected with a joint will necessarily vary with its cause. See Neuralgia. 11. Joints, Rheumatic Arthritis of. Chronic. — Synon. : Osteoarthritis ; T'r. Arthrite avec usvre des cartilages ; Artlirite sechc ; Ger. Altersabschleifung. ^Etiology and Pathology, — The number of names that have been applied to this disease be- trays the obscurity enveloping its pathology. In nature it is, however, essentially a senile dege- neration, preceded by chronic inflammation ; and is, in part, perhaps the result of wear and tear of the joint. It is most common in hard-work- ing people, exposed to the influence of wet and cold, and in the aged. One or many joints may be affected ; generally the fingers, the toes, the hip, and the knee. It may be set up by injury, such as a sprain, dislocation, or fracture ; or it may arise without known cause. It is difficult to say which tissue is primarily at fault, but sooner or later all become involved. The syno- vial membrane inflames ; papillary outgrowths form upon it ; the cartilage swells ; and the ends of the bones enlarge. After atime the quantity of synovial fluid diminishes; the joint-friction in- creases; the cartilages are rubbed away at the surfaces of contact ; and afterwards the bone it- self, which becomes denser by interstitial deposit, disappears. The surface is ebumated, and marked with striae produced by friction ; whilst deposits of new bone, which may often be felt externally, form around the margins of the joints, so that the area of its surfaces becomes greatly increased. Symptoms. — The symptoms of ohronic rheu- matic arthritis chiefly consist in constant pain, of a dull aching character, and worse at night, Motion becomes more and more difficult and painful as the disease advances; but anchylosis uever occurs. Rough crepitus is felt both by the patient and the surgeon when the joint is moved. See Rheumatic Arthritis. Treatment. — The treatment of rheumatic arthritis can only be palliative, and consists in the use of warm douches and other warm appli- KKLOID. cations, and the administration of iodide of po- tassium internally. The disease is incurable. 12. Joints, Serous Effusion into. — Synon. : Hydrops articuli-, Hydarthrosis\ I'r. Hydarthrose 1 , Ger. GelenJcwassersucht. This is a form of chronic serous synovitis, in which there are no obvious inflammatoiy symp- toms. The joint sometimes becomes greatly distended : the ligaments are stretched ; and in consequence there is a sensation of tension and feebleness in the articulation. The knee and elbow are most frequently attacked ; and the dis- ease is often associated with a gouty or rheu- matic diathesis, or with rheumatoid arthritis. It is very difficult to cure. The joint may be punc- tured and the fluid drawn off, or, still better, it may be injected and thoroughly washed out with iodine (equal parts of the compound tincture and water) or a carbolic acid ( 2-t to 5 per cent.) so lution ; but relapses are common. 13. Joints, Syphilitic Disease of. — This disease maj r originate in children, in the form of a suppurative ostitis at the junction of the epi- physis and diaphysis. Other signs of congenital syphilis will help to establish the diagnosis. The disease runs a rapid course, and the joint is frequently destroyed. In the adult a chronic plastic synovitis, due to gummatous infiltration of the perisynovial tissue, or of the bone and periosteum, is the more common form. There is very little fluid effusion within the joint, but considerable impairment of mobility is produced by the thickening outside it. The progress of the disease is slow and painless, except at night or on motion. The history of the case; the presence of traces of syphilis elsewhere; and the effects of treatment, will help in establishing the diagnosis. The internal administration of mercury and iodide of potassium, combined with local pressure by means of strapping with mer- curial plaster, speedily effects a marked im- provement and cure. "William MacCormac, JUGULAR VEINS, Physical Signs in connexion with. — The principal physical signs in connexion with the jugular veins are distension, pulsation, and venous hum. See Physical Examination. K KELOID. — Stnon. : Fr. Childide, Keloide ; (tor. Keloid .- — Keloid and cheloid are two words reAAiabling each other in sound, and sometimes used indiscriminately, but differing altogether in origin and signification. Keloid is derived from kt]\U, a mark or blemish; whilst cheloid derives its origin from xv^-b, a crab’s claw. The disease which we now recognise as cheloid was first described by Alibert under the name of he Us, with the synonyms, cheloide and caneroidc, aud is therefore sometimes referred to as the * kelis of Alibert ’ (see Cheloid). The term keloid ha*, however, been applied by Addison to a blemish of the skin, resulting from a fibrous degeneration of the derma allied with scleriasis; hence the use of the term kelis Addisonii. Both diseases are. really fibromata ; but one, namely cheloid, is a tumour, while the other, kelis, is flat, and offer resembles a cicatrix. There is another obvious difference between them: cheloid is restricted ti the derma, whilst kelis follows the subeutaneom connective-tissue to the deeper parts of the boat KELOID. The early dermatologists described kelis under the name of morphoea , and by that name it is still distinguished by some modern writers. Erasmus Wilson. KERATITIS, or KERATODEITIS (nepas, a horn, the cornea). — Inflammation of the cornea. See Eye and its Appendages, Diseases of. KERION (xriptov, a honeycomb). — A term applied to a pustular folliculitis of the scalp. The inflamed skin occurs in the form of one or several blotches of a deep red colour, prominent, and dotted over with yellow spots— the apertures of the follicles, from which the hair has been ex- pelled, and which exude a copious muco-purulent fluid. The yellow spots are converted into hol- lows by the tumefaction of the framework of inflamed skin, and, no doubt, thereby suggested the idea of a honeycomb, whilst the muco- purulent secretion might in like manner be compared to honey. Another feature of the disease is the elimination of the hair from the inflamed follicles, and the subsequent baldness , of the affected part. Kerion is sometimes as- sociated with tinea capitis. See Skin, Diseases j of ; and Tinea. Erasmus Wilson. KIDNEYS, Diseases of. — Synon. : Er. Maladies des Reins-, Ger. Mierenkrankhciten .— The kidney is subject to a number of diseases, which will be considered in the following pages in alphabetical order. At the outset, however, jt will be convenient to present an outline of the abnormal phenomena to which these affections nay give rise. Summary of Symptoms. — The facts upon which the diagnosis in diseases of the kidneys is ounded, are of three classes, namely A. Ab- lormal local conditions ; B. Abnormalities f the urinary secretion ; C. Abnormalities u other parts of the system, secondary to he local phenomena. A. Abnormal local phenomena. — These juiy be : — a. Subjective. The patient may experience ain or uneasiness in the region of the kidney, lone or both sides; and abnormal sensations ay be also referred to the ureter, the bladder, the urethra. The pain may be influenced by titude or by exertion ; and be either constant, roxysmal, or periodic. It may be aggravated, lieved, or unaffected by pressure. b. Objective. Examination of the abdomen and jvis, by means of palpation and percussion, ly reveal the presence of a tumour connected th the kidney. The tumour may be solid or id; uniform or lobulated. Tumours of the Iney may generally be made out by palpa- n, and especially by tilting with the one ■ id the mass forwards from the lumbar region, ■>n the fingers of the other hand applied iu tut. In some cases the absence of the kidney ijin its normal position may be ascertained by 1 cussion in the lumbar region. By careful ob- i ration of the relative form of the two sides at t back and in front, either the presence of tu- t tr, orthe absence of the organ, may be rendered I inct. KIDNEYS, DISEASES OF. 787 B. Abnormalities of the urinary secre- tion. — a. The urine may be altered iu quantity. It may be increased, as in waxy degeneration of the kidney, or in advanced stages of cirrhotic and inflammatory Bright’s disease ; or diminished, either from obstruction to its escape, or from failure of secretion. The conditions leading to obstruction to outflow are certain diseases of tho urethra, prostate, bladder, or ureters : the last- named inducing suppression only where both the ducts are simultaneously occluded, or where one kidney having been previously destroyed, the ureter of the other side subsequently becomes affected. The impaction of calculi, and the pres- sure of new-formations are the chief causes of these obstructions. The conditions leading to diminution or failure of secretion are the py- rexial state ; obstruction of uriniferous tubules, as by inflammatory products ; long-standing passive congestion, as in cardiac disease ; and probabiy some forms of altered innervation. b. The urine may be altered in colour, as from the presence of blood, pus, bile, purpurin ; or of substances introduced into the system, such as logwood, rhubarb, senna, tar, and carbolic acid. c. The specific gravity may be altered, being much raised when the proportion of water is small, or when an excessive amount of sugar or of urea is being eliminated, or when a large pro- portion of blood or of albumin is present. It is diminished whenever the proportion of water is excessive, or the elimination of urea diminished. It is thus an important feature of renal disease. In determining the specific gravity it is impor- tant to remember that, when the specimen has stood for some time, it may vary in different parts of the same column of fluid ; that it varies with the temperature, being lower iu warm than in cold fluid; and further that it varies at dif- ferent times of the day, in relation to the stale of the digestion. d. The reaction of urine varies from the slightly acid standard of health, by being either too acid or alkaline. The acidity may be excessive when the urine is passed, or may become increased after it has been voided, in consequence of the acid fermentation. It may be alkaline when passed, from the presence either of fixed alkali or of ammonia. The ammonia results from de- composition of urea, and this change constantly occurs in urine which has been kept and allowed to decompose. e. Albumin is a common morbid constituent ot urine, either temporary or permanent. Tempo- rary albuminuria may be artificially produced by the ingestion into the stomach, or by subcutaneous injection, of raw albumin of egg; and it some- times results from derangement of the digestion, due to the use of indigestible articles of food. It occurs iu certain blood-diseases, such as scarlet fever, erysipelas, diphtheria, and acute yellow atrophy of the liver, and is probably due to the irritation of the kidneys by the poisons proper to these maladies. It also occurs in some cases where fever is high and persistent, and is then to be explained by alteration of the condition either of the vascular walls, of the renal cells, or of the innervation of the kidneys. It also occasionally results from the use of certain drugs, such as turpentine and cantharides ; certainly sometimes KIDNEYS, DISEASES OF. 788 from nervous affections, such as exophthalmic goitre, epilepsy, and injuries to or organic dis- ease of the brain. Permanent albuminuria is met with in all the forms of Bright’s disease ; most abundantly in the inflammatory form ; to a less extent, but constantly, in the albuminoid ; to a still less extent, and sometimes altogether abstnt, in the cirrhotic variety. It also re- sults from passive congestion of the kidneys, due to cardiac disease or other cause ; as well as from suppurative nephritis and other diseases of the kidney, and from pyelitis. The ordinary albu- min of the blood-serum is the form which usually appears in the urine. Now and then it is found, especially in the course of or after acute febrile diseases, that a variety of albumin occurs in the urine which is unaffected by heat and nitric acid, but which becomes coagulated by alcohol. This may either be from alteration of the sub- stance itself, or from the presence of some mate- rial which interferes with the ordinary chemical reaction. See Albuminueia. f. Urea is diminished in quantity wherever there is destruction of the renal epithelium, as in the different forms of Bright's disease, especi- ally the cirrhotic and inflammatory varieties. g. The physical and chemical characters of the urine are often much modified by conditions other than diseases of the kidneys themselves, and abnormal ingredients may be present, such as sugar or bile, but these alterations do not come within the scope of the present article. h. Deposits are also frequently present in the urine, which are due to various causes apart from renal disease, namely, urates and uric acid, oxalate of lime, phosphates, cystine, xanthine, tyrosine, and leucine. Organic deposits are im- portant in many affections of the kidney or its pelvis. In the first place the epithelium from the latter may be present in more or less abundance. Pus appears as a fine granular yellowish de- posit, which becomes viscid and transparent on the addition of liquor potass*. In ammoniacal urine it is sometimes found that the pus-cells have undergone this change within the bladder. Pus may be derived from the pelvis of the kidney, or from the kidney-substance itself. Deposits very similar in general appearance to pus are sometimes seen in cases of scrofulous kidney, but the microscopic appearances are different, the corpuscles being altered, and often associated with fibrous tissue. Cancerous deposits, showing distinct cancer-cells, are also sometimes met with. The presence of blood gives the urine a smoky, pinkish, or actually bloody appearance. See Hematuria. Tube-casts are sometimes so numerous as to constitute a deposit quite visible to the naked eye. These casts are solid moulds of the urini- ferous tubules, sometimes formed within the free lumen of the tube, but far more frequently with- in the basement-membrane, thus including the more or less altered epithelium. The simplest form of tube-cast is the hyaline, a clear structure- less cast, Blood-casts are common, containing distinct red corpuscles. Epithelial and desqua- mative casts are opaque and granular, the granu- larity being due for the most part to the abundance of altered epithelium in their substance. Fatty casts are those which exhibit evidences of fatty degeneration of the epithelium. See Bbight's Disease ; Casts ; and Urine, Morbid Conditions of. C. Symptoms occurring in other parts of the body. — Very important symptoms occur in connection with renal diseases, affecting the or- gans of circulation and of digestion, the nervous system, and the skin ; but these are for the most part associated with Bright’s disease. Set Bright’s Disease ; and Uraemia. The several diseases of the kidney will now be indicated, and those will be discussed which are not described under special headings in other parts of the work. 1. Kidney, Abscess of. — Synox. : Benal ab- scess. — This is often used as a generic term in- cluding any accumulation of pus in connection with the kidney, whether in the substance of the organ, in its pelvis, or even around it. Strictly, it applies only to a collection of matter resulting from suppuration in the kidney-structure itself. See Kidney, Inflammation of Pelvis of; Kidney, Suppurative Inflammation of; Perinephritis ; and Surgical Kidney. 2. Kidney, Acute Atrophy of. — D eftnition. This is a rare disease of the kidney, consisting in rapid exudation into the cells of the organ, followed by fatty degeneration and disinte- gration ; caused by unknown conditions ; cha racterised by sudden occurrence of copious albuminuria, with very numerous tube-casts, and frequently marked uraemic symptoms; and resulting apparently invariably in death. ./Etiology. — The causes of this affection are unknown, but it appears probablo that it depends upon some form of blood-poison, the disease being frequently associated with acute atrophy of the liver. In most cases it would appear to fol- low the hepatic disease ; in some it precedes it. It is much more common in the female sex than in the male; and is most frequent during preg- nancy and after childbirth. Anatomical Characters. — There are two stages in the progress of this disease, namely, (1) that of exudative infiltration and enlarge- ment ; (21 that of disintegration and atrophy. In the first stage the organ is enlarged, not markedly congested, the capsule strips off readily, the substance is flaccid, the cortical substance is swollen, the individual tubules are enlarged and white. On section the vessels are found mostly empty of blood, being compressed by the diseased tubules. The tubules are oceu pied by dense opaque material ; and the individual cells are swollen and granular, their nuclei being hidden by molecular cell-contents. The tubules of the cones, as well as those of the cortical substance, are frequently affected. Many of the cells also are in a state of fatty degeneration, or broken down even at this stage. In the more advanced stage the organ is smaller than natu- ral, and its capsule appears wrinkled. The kid- dey is pale and flaccid. When cut into there escapes a quantity of debris, often containing oil- globules, quite visible to the naked eye. The stroma is intact, and sections can easily be made with a Valentin’s knife. The sections show that many of the tubules are denuded of epithe- lium, and that the shrinking of the organ result* KIDNEYS, DISEASES OF. 789 from this disintegration. It is easy to find dif- ferent tubules and cells in various stages of transformation, some showing the early stage of cloudy swelling, others the stage of fatty trans- formation, and others the disintegrating, almost deliquescent condition. The friability of the cells is quite extraordinary, the weight of a thin covering glass often sufficing to reduce them to molecular debris. It will be observed that the changes, both in the organ and the individual cells, exactly cor- respond to those met with in acute atrophy of the liver. Symptoms. — The symptoms characterising this affection have not yet been very fully studied. Diminution of urine, copious albuminuria, with deposit of casts corresponding to the changes in the kidney, are probably the chief renal symp- toms. A tendency to haemorrhages, jaundice, and uraemic nervous affections, and the series of symptoms proper to acute atrophy of tho liver, ire also observed. Diagnosis. — There is probably no disease with which this is very liable to be confounded. Prognosis and Treatment. — The prognosis must be unfavourable ; and no treatment can be of any avail. 3. Kidney, Albuminoid Disease of. See Bright’s Disease. 4. Kidney, Anomalies of. — The kidneys may present three kinds of anomaly, namely: — 1. In number. 2. In form. 3. In situation. Only the first of these will be referred to here. Anomalies in Number. — Sometimes one kid- ney, with the corresponding ureter, is entirely rbsent. In such cases the organ which is present is muchabove the normal size. There is generally jno symptom present during life, but diseases of he pelvis of the kidney or the ureter are made nore formidable in persons so affected, than in hose normally developed. Occasionally one or nore supernumerary kidneys are present. See fidney, Malformation of ; and Kidney, Malposi- ions of. 5. Kidney, Calculus in. See Renal Cal- DI.US. 6. Kidney, Cancerous Disease of. See lidney, Malignant Disease of. 7. Kidney, Chronic Atrophy of.— This con- ition of the kidney arises under a variety of rcumstances, hut specially as a consequence of ydronephrosis, and of the different forms of right’s disease. In hydronephrosis the atrophy immences in the cones, and spreads to the cor- ral substance. In all the forms of Bright’s dis- use it commences at the surface and spreads in- Ards. In hydronephrosis atrophy is a result of ;e pressure of the renal secretion, as it aecumu- tes in the dilated pelvis and within the tu- lles. In inflammatory Bright’s disease it is due interstitial changes, and the gradual absorp- m of the contents of the occluded uriniferous bules. In cirrhotic Bright’s disease it is a con- duce of the contraction of the hypertrophied rous stroma, and the consequent destruction vessels and secreting structures. In the waxy albuminoid form it is due to the molecu- lar absorption of the hyaline material and al- tered cells which occupy the uriniferous tubules, as a consequence of the degeneration proper to the vessels. Anatomical Characters. — Although really atrophied, the hydronephrotic kidney appears large, and may form a mass several times the size of the normal kidney. It is lobulated on the surface, and may often be seen to be little more than a group of cysts containing watery fluid. In the earlier stages no change is ob- served, except flattening of the cones ; in the later the cortical substance also is more or less wasted. This condition is usually seen only on one side, the other kidney being natural, or some- what hypertrophied. Atrophy from inflammatory Bright’s disease is rarely far advanced when tho fatal result occurs. Both kidneys are affected, and usually to the same extent. The capsule strips off readily. The surface presents a finely granular appear- ance. On section, the cortical substance is found relatively diminished. Many of the tubules are occupied by sebaceous-looking material. Many of them are diminished in size, and irregular in outline from absorption of their contents. The stroma is relatively increased; the vessels are little altered. In the cirrhotic form the atrophy is often more advanced, and is commonly equal, or nearly so, on the two sides. The capsule is adherent, the surface granular and uneven. On section, the cortical substance is diminished, and it often contains many cysts. On microscopic examina- tion the fibrous stroma is found markedly in- creased, many of tho tubules and vessels arc destroyed, while the smaller arteries are thick- ened. In the albuminoid form the kidneys have in some cases been found greatly and nearly equally diminished in size. The capsule strips oft readily; the surface is finely granular. On sec- tion the cortical substance is found diminished, the degenerated Malpighian bodies remaining sin- gularly prominent, especially towards the sur- face, the stroma appearing relatively somewhat increased, and the hyaline contents of the tubules in process of absorption. Symptoms. — No definite group of symptoms indicate the existence of atrophy. Those met with in the atrophic stages of tho different affections are described under each disease. Partial Atrophy of the Kidney results from embolism, new-formations, and other like causes; and is in many instances unattended by symptoms. 8. Kidney, Cirrhotic. See Bright’s Disease. 9. Kidney, Congestion of. See Kidney, Hyper* mia of. 10. Kidney, Cystic Disease of. — Defini- tion. — A chronic morbid state of the kidney, caused by conditions not fully ascertained ; cha- racterised in some cases by no symptoms, in others by the presence of tumours, and by symp- toms resembling those of the cirrhotic form of Bright’s disease ; resulting in permanent change; and not amenable to treatment. The formation of cysts in the kidney may he unim- KIDNEYS, DISEASES OF. 790 portant, either from the small number of cysts, or from the co-existence of much graver disease of the kidney ; but it may constitute a serious disease. -ZEtiolosy. — N othing is known as to the causes of cystic degeneration. It may be con- genital, or may come on during adult life. The mode of origin of the cysts appears to be from the dilatation above obstructed points in the course of uriniferous tubules, or at their points of origin in the Malpighian bodies. Sometimes the cysts are new formations in connection with epithelium ; and sometimes they arise from the fibrous stroma of the organ. Anatomical Characters. — Renal cysts vary greatly in size, from minute, almost microscopic, cavities, to spaces capable of holding several pints of fluid. The true cystic kidney is large ; its surface is uneven, and in colour resembles a piece of conglomerate. The capsule strips off, but often with some difficulty. On section its substance is found replaced by multitudes of cysts, scarcely any proper tissues remaining. The contents are sometimes watery, sometimes contain urinary constituents, sometimes are tinged with blood, and sometimes are gelatinous or colloid. Symptoms. — In many cases cystic disease of the kidneys is unattended by any symptoms ; and even when thedisease is extensive and severe there are, as a rule, no constitutional symptoms until the case draws near its termination. Among local signs the most important is enlargement of the organs, which may sometimes be made out by means of palpation and percussion, in cases which are advanced, and in emaciated sub- jects. Both organs are generally equally enlarged. The urine is secreted in natural or in excessive quantity ; its specific gravity is low ; and it con- tains albumin, and sometimes blood. The ter- mination of these cases is not unfrequently abrupt, with uraemic convulsions and coma. Diagnosis. — The points which are of impor- tance are the presence of bilateral tumour; with copious discharge of urine of low specific gravity, or containing albumin. Prognosis. — T he prognosis is always un- favourable. Treatment. — Treatment can be directed only to the relief of symptoms. 11. Kidney, Dropsy of. — This is a synonym for hydronephrosis, in which urine, more or less altered, accumulates in the renal pelvis, as the result of obstruction of the ureter. See Hydro- nephrosis. 12. Kidney, Embolism of. — The impaction of emboli in the branches of the renal arteries gives rise to various lesions, of which the most common is the haemorrhagic infarction ; next to this inflammation and secondary abscesses ; and more rarely gangrenous inflammation. These affections often do not manifest themselves dur- ing life by any distinct, symptoms ; or their exist- ence may be revealed by sudden albuminuria and hoematuria, and sometimes by general constitu- tional disturbance and local pain. JEtiolooy. — T he chief cause of reual embo- lism is disease of the valves of the heart. The emboli may be composed of coagulated fibrin ; or of fragments of the tissue of the valve, which have been separated by ulceration. More rarely embolism is caused by fibrin which has coagu- lated between the meshes of the fleshy columns of the heart, or by coagula which have formed on the roughened inner coat of arteries. Among the remoter causes are those of endocarditis and endarteritis. This, in so far, vindicates the name which Ray er applied to these infarctions — ‘rheu- matismal nephritis.’ Anatomical Characters. — 1. Of hemorrhagic infarction. — This may, for convenience, he de- scribed as passing through three stages: — (1) that of red consolidation; (2) that of fawn- coloured transformation ; and (3) that of absorp- tion or atrophy. The form of the masses is usually conical, or, as seen on section, wedge- shaped, the base being towards the surface. At first a patch is deeply congested, and presents a dark red colour. On microscopic examination the vessels are found congested, many ruptured; and blood is extravasated into the tubules. In the second stage this redness has passed away; a buff or fawn-coloured mass represents the red patch of the earlier stage. On microscopic examination the cells of the tubules are found to be destroyed, and within them, as well as in the stroma, blood-pigment may he found. In the third stage there is commonly a depression of the surface of the organ ; and, on section, what had been the conical patch is represented by a fibrous cicatrix. 2. Of the abscesses. — In certain cases, espe- cially in the course of pyaemia, emboli lead to abscesses. Throughout the organ such abscesses exist, and may be traced in various stages, which might be described as those of red con solidation, of ashy-gray consolidation, and of sup- puration. In this condition the clot is not to he found at the apex of the cone of disease, but imbedded within it. Between the simple infarc- tion and the abscess there is an intermediate form — a certain degree of suppuration occurring at tho margin of the affected area. 3. Of gangrenous patches. — Very rarely it ap- pears that, in consequence of the impaction of an embolus, gangrene of the affected district occurs, with more or less suppuration. Symptoms. — The symptoms of the embolic infarction are often very indistinct, hut the con- dition may sometimes be diagnosed. When valvular disease of the heart or extensive cal- careous affection of the arteries exists, and when in addition to this sudden albuminuria or hsemu- turia appears, with some degree of fever, and pain in the region of the kidneys, there is every reason to conclude that an embolus has been ini pacted. This condition is rarely one of impor tance in the case, for much graver maladies co- exist with it. The occurrence of abscess in the kidney' may sometimes be surmised when sudden albuminuria or haematuria becomes superadded to the other symptoms of pyaemia. Gangrene ot the kidney or a portion of it is not likely to he, capable of diagnosis during life. Diagnosis. — The diagnosis of renal infarction turns upon the points above referred to. _ It is important to distinguish it from Brialit s dis- ease, and from passive congestion. From t ie former it is distinguished by tho suddenness o KIDNEYS, DISEASES OF. the onset, the shortness of its duration, the ab- jouee of dropsy, and tho presence of cardiac or vascular disease ; from the latter by the sudden- ness of its development, and by the absence of signs of stasis in other organs. Pbognosis. — The prognosis in cases of infarc- tion is favourable so far as the kidneys and their functions are concerned, but unfavourable in this respect that there is a tendency to the impaction of emboli in other more important parts, par- ticularly in the brain. Treatment. — No special or particular treat- ment can be directed in this condition. 13. Kidney, Fatty Disease of. — D efinition. A chronic affection of the kidney, consisting in simple fatty degeneration of, or infiltration into, the renal epithelium, without inflammation ; characterised by no symptoms as yet clearly ascertained. ^Etiology. — Fatty kidney results in some cases from long-continued exhausting disorders ; from senile marasmus ; from starvation ; from poisoning with phosphorus ; and perhaps from excessive indulgence in fatty food. Anatomical Characters .— 1 The organs are of about the natural size, their surface is smooth, and the capsule strips off readily. There is no congestion, and scarcely any stellate veins are visible. The organ is more soft and flexible than natural, and the surface is mottled with numer- ous deposits of sebaceous-looking material. On section the relative size of the cortical substance and the cones is seen to be preserved ; and be- yond a general pallor there is no change except the abundant deposition of sebaceous-looking material, mostly in the tubules of the cortical substance, but also in those of the cones. On examining a section with a low power of the microscope, the characteristic fatty opacity is well-marked, and by careful scrutiny it may be generally made out that the fatty material is not in the canal of the tubule, but within the epithelial cells. The Malpighian bodies, the ves- sels, and the stroma, under a higher power, appear natural ; and in transverse section of the tubules, a clear lumen may be made out. It will thus be observed that there is no inflammatory desqua- mation of the, cells, nor exudation filling up the lumen of the tube. Symptoms. — Little is known of the clinical features of this affection. But the quantity of the urine appears to be diminished. There is cer- tainly no albuminuria, and apparently no other important change in its composition. Dr. Lang, of Dorpat, has shown that a little free oil is sometimes found in the urine. Diagnosis. — It is scarcely possible to diagnose this affection with certainty; but diminution of .he urine, without albuminuria, and with the pre- sence of oil in the urine, especially if associated vith the signs of fatty liver, and with any of the mown causes of fatty degeneration, may lead to he establishment of the diagnosis. Prognosis. — The renal affection is not gener- ■lly an important element in the prognosis, other ouditions of more importance being present. Treatment. — General tonic treatment, and he removal of the cause when known, are the nly indications. 791 14. Kidney, Gouty. — This is a form of con- tracted granular kidney, occurring in gouty sub. jeets, and attended with the deposit of urates in the renal tubules. See Bright's Disease; and Gout. 15. Kidney, Granular. — A synonym for a chronic form of Bright's disease, where the kidney presents a granular appearance. See Bright’s Disease. 16. Kidney, Haemorrhage in connection with. — Blood may escape into the substance of the kidney, as the result of embolism or injury ; into the tubules, giving rise to blood-casts; or into the renal pelvis, especially from injury to the mucous lining by calculi. The only diag- nostic indication of this event is the presence of blood in the urine, intimately mixed with it, or sometimes in clots. A coagulum of blood may block up the ureter. See H-Hhatinuria , Paroxysmal ; and Hematuria. 17. Kidney, Hydatid Disease of. — Defi- nition. — A chronic parasitic disease of the kidney, caused by the reception into the system of the ova of the Tsenia echinococcus, and the development in the kidney of the corresponding cystic form ; consisting in the formation of hy- datid cysts — ‘ echinococcus hominis ’ — in the sub- stance of the organ ; characterised in some cases by no symptoms, in others by renal tumour, or by the discharge of cysts with the urine, after symptoms resembling those of renal calculus ; and resulting sometimes in recovery, sometimes in death, either by perforation into the lung, in- testine, or other part, or by suppuration. PEtiology. — 'The tape-worm form is the Tsenia echinococcus, which inhabits the intestine of the dog. The frequency of hydatid-disease is deter- mined by the frequency of the occurrence of the tape-worm in the dogs, and by the habits of the people. It is common in Iceland, in Egypt and in South Australia. In England it is not com- mon; in Scotland it is very rare. See Hydatids. Anatomical Characters. — The affected organ is enlarged, sometimes greatly. It is often con- nected by adhesions to neighbouring parts. A globular tumour projects from the surface, and extends into the substance of the kidney, in- ducing corresponding atrophy. The cyst has an outer covering of fibrous tissue derived from the organ ; and an inner coat — the cyst proper, which may be barren, that is, devoid of daugh- ter-cysts, or may contain within it numerous smaller cj-sts and processes growing inwards from the walls, containing scolices which may give origin to the corresponding tape-worm. In either case the cyst-wall is somewhat tensely expanded by a clear liquid, rich in chloride of sodium. Tho cyst enlarges gradually, and may burst in various directions, but most frequently into the pelvis of the kidney, or into the lungs and bronchi. Sometimes suppuration of the cyst occurs, and accordingly one finds on post-mortem examination the remains of a shrivelled and sunken cyst, with caseated contents, in which are imbedded remains of daughter-cysts and hooklets from the scolices. Symptoms. — The course of hydatid-disease cl the kidney is always chronic. It may be pro- KIDNEYS, DISEASES OF. 792 longed for many years. The advance is insidious. Attention is sometimes drawn, first to the pre- sence of a tumour, sometimes to the evidences of its rupture. When rupture takes place into the pelvis of the kidney, daughter-cysts passing along the ureter give rise to symptoms resem- bling those of renal colic ; but the discharge of the cysts, and the results of the microscopic examination, reveal the true cause of the irrita- tion. After such a discharge the cyst may atrophy ; sometimes it happens that a second or even a third discharge occurs after a shorter or longer interval. When the discharge is by the lung, pain and cough occur, due to irritation of the pleura. Then the expulsion of the hydatids takes place ; sometimes this also results quite favourably. The special features of a hydatid tumour are its globular form and its elasticity. When suppuration occurs, fever super- venes, attended with local pain. Diagnosis. — The diagnosis of hydatid of the kidney depends upon the presence of a tumour of a special kind; and is made certain by the discharge of cysts or booklets. Prognosis. — -The prognosis is always doubtful. Treatment. — Medicine is of no avail. The best treatment is the removal of the fluid con- tents of the cyst by aspiration. When such re- moval is effected the parasites die, and the cyst shrivels up. 18. Kidney, Hyperaemia of — D efinition. An acute or chronic affection of the kidney, consisting in active or passive congestion of its vessels, with secondary changes ; characterised bv the appearance of albumin, and sometimes of blood and of hyaline tube-casts in the urine, the quantity of urine being generally diminished, and its specific gravity natural ; resulting in re- covery if the cause be removed, but in the passive form commonly continuing or recurring till the fatal result is induced, partly by the original, and partly by other causes. TEtiolosy. — Active congestion, that is conges- tion due to increased influx of arterial blood, may be caused by inflammation; by various blood- poisons, such as those of scarlet fever, measles, typhus ; and by some medicinal substances, such as cantharides, turpentine, cubebs ; also probably by agencies which paralyse the muscular fibres of the small arteries — as is sometimes seen ip the course of exophthalmic goitre — or which increase the blood-pressure in the renal arteries. Pas- sive congestion, which implies congestion due to hindrance to the efflux of venous blood from the organ, may be caused by any obstruction to the circulation. It is most commonly met with in cases of cardiac disease, where the right chambers of the heart are dilated. It also results from such diseases of the lungs as are followed by dilatation of the right side of the _ heart— for example, emphysema. It also sometimes arises, though much more rarely, from obstruction in the course of the inferior vena cava, or in the renal veins, as from pressure of aneurismal or other tumours, or from the formation of a thrombus. Anatomical Characters. — Iu the active form of renal hyperaemia, the anatomical changes are probably less marked after death than during life. The kidneys are generally of fully the nor. mal size ; the capsule strips off readily ; and the surface is smooth. On section tiie vessels are found congested; the Malpighian bodies fre- quently standing out prominently, being dis- tended with blood. The vessels of the cones are also overfilled. More or less evidence of inflam- matory change is to be found in the tubules, the epithelium being granular and opaque, and the lumen of the tubules, especially those of the coues, being filled up with coagulated fibrin. Blood is sometimes found extra vasated into the convoluted tubules. The stroma is unaltered. Sometimes there is congestion of, or even extra- vasation into the mucous membrane of the pelvis of the kidney and of the ureter. In passive congestion the anatomical changes are more marked, and vary with the duration and inten- sity of the affection. In the slighter forms, or in those of short continuance, the kidney is of fully the natural size ; its capsule strips off readily ; the surface of the organ is smooth ; and there is evidence of congestion. On section, the congestion is seen to occupy the veins and the Malpighian bodies ; sometimes there lire evi- dences of extravasation of blood ; and sometimes fibrinous coagula are found in the tubules. Iu the more chronic forms, although the cap- sule strips off readily, the surface is somewhat uneven ; congestion is still marked on the sur- face, but scarccdy so distinctly as in the earlier stage. On section the organ feels firmer than natural ; it is in a condition which may be best described by the term induration. Its small veins and Malpighian bodies are dilated and full of blood ; the fibrous stroma is relatively increased, especially towards the surface of the organ ; some of the tubules are wasted, some are blocked up with exuded material, and some exhibit evi- dence of disintegration and fatty degeneration of the epithelium. The condition of the stroma thus approaches that of cirrhosis of the kidney ; the condition of the tubules approaches that of inflammation. There is no definite boundary line between the conditions anatomically; still the combination of the changes confirms the infer- ence which must be drawn from the study of the clinical history, that these hypersemic changes, though approaching to, are not identical with the processes properly included under the term • Bright’s disease.’ Symptoms. — The symptoms of active conges - tion are the presence of albumin in the urine, occasionally accompanied by hyaline tube-easts, and sometimes by blood in greater or less quantity. It occurs commonly as a transient, or occasionally, as a recurring condition, and unless when it betokens a commencing inflammatory action, is rarely of much practical importance. In passive congestion albuminuria is again the leading symptom ; the urine is generally some- what reduced in quantity, of about normal spe- cific gravity, often of acid reaction, depositing urates. The amount of urea is little below the normal. Tube-casts are usually scanty, and may be wanting ; when present they are hyaline or sometimes bloody, and occasionally contain altered epithelium. The other symptoms are those of obstruction to the circulation ; occlu- sion of, or pressure on, the veins ; disease of the KIDNEYS, DISEASES OF. heart; emphysema of the lungs; and general dropsy. Diagnosis. — The question relating to diagno- sis, -which is of most practical importance, lies between hypersemia and inflammatory Bright’s disease. In making this distinction, the points to which we havo to attend are the general con- dition of the patient, in respect to the possible causes of such an affection, the presence of car- diac or pulmonary disease, or of venous obstruc- tion. Incongestive affections the urine is scanty, as it often is in Bright’s disease, but it is of high colour, of natural specific gravity, and rarely deposits blood, renal epithelium, or tube- casts. Prognosis. — The prognosis depends entirely upon the conditions inducing the congestion. In the active form it usually rapidly subsides ; in the passive form, it is persistent, or at best, if temporarily got rid of, is almost sure to recur. Treatment. — When the renal congestion is very intense, dry cupping, local blood-letting, the hot air or the warm vapour bath, or warm applications over the kidneys, may be indicated ; but the treatment is mostly that of the diseases which are inducing the congestion. Thus, in the case of cardiac disease digitalis and iron, in the case of pulmonary disease digitalis with squill, and if necessary, a little blue pill or carbonate of ammonia, are indicated. The general manage- ment should be that proper to the obstructive disease which has induced the congestion. 19 . Kidney, Hypertrophy of. — True hyper- trophy, that is to say, increase of all the elements, or of the essential elements of the kidney, occurs only in one organ as a rule, and that by way of compensation for atrophy of the other. Simple increase of bulk of the kidneys often results to a certain extent from congestion, inflam- mation, the various forms of Bright’s disease, new formations, and accumulation of the secre- tion. Anatomical Characters. — These present no peculiarity beyond the enlargement, the organ weighing sometimes eight or nine ounces, the renal artery and vein being proportionately en- larged, with a corresponding coarseness of struc- ture. Symptoms. — Hypertrophy of the kidney is without symptoms, but it might so happen that the enlargement of the organ could be detected on physical examination. 20. Kidney, Infarction in. — See Kidney, Embolism of. 21 . Kidney, Inflammations of.- — Inflam- nation of the kidneys and their pelves presents aany varieties. The kidneys themselves exhibit, ; irst, tubular inflammation, acute or chronic ; econd, inflammation of the stroma, acute or nronie ; third, suppurative inflammation of the ubstance of the organ, septic or non-septie. The ;nal pelvis is also liable to acute or chronic iflammation. It will serve no useful purpose to iscuss these in a general article, and therefore le reader is referred to the several special arti- es. See Bright’s Disease ; Kidney, Suppura- ve Inflammation of; and Kidney, Inflammation ' Pelvis of. 793 22. Kidney, Inflammation of Pelvis of. Synon. : Pyelitis; Fr. Fyelite ; Ger. Nieren- bcckenentzundung . Definition. — An acute or chronic disease of the pelvis of the kidney, caused by extension of inflammation or of irritation from the neigh- bouring parts, by renal calculus, by cold, or by blood-poisoning; consisting in inflammation of the mucous membrane, frequently associated with changes in the other coats and in neigh- bouring parts ; characterised by the presence of mucus or pus in the secretion, with local pain, and more or less constitutional disturbance ; sometimes resulting in recovery, sometimes in long-continued illness, and occasionally in death. .-Etiology. — -Pyelitis is caused by: — (1) ex- tension of inflammation from neighbouring parts of the urinary tract sometimes from the kid- neys, sometimes from the bladder ; (2) stagna- tion and decomposition of the urine in the renal pelvis; (3) mechanical irritation, as from calculi and gravel; (4) exposure to cold; (5) certain blood-poisons, such as those of pyaemia, diph- theria, and typhus ; (6) the action of certain other poisons. Anatomical Characters. — • Three typps of pyelitis may bo recognised, namely: — (1) the acute-, (2) the chronic ; and (3) the calculous. (1) Acute. — The mucous membrane is con- gested, and its surface coated with mucus, some- times with a bloody, sometimes with a diph- theritic layer. The membrane itself may be more or less extensively destroyed ; and the cha- racteristic tailed cells of the pelvis of the kidney may be thrown off in excessive quantity. Be- sides these cells, the cavity contains mucus or muco-purulent material in quantity. (2) Chronic.— In this condition the mneoua membrane is much thickened, ofren of a slate- grey colour, with ecchymoses, and sometimes with ulcerative abrasions of the surface. The other coats of the pelvis and ureter may also be distinctly thickened, and the lumen of the ureter may be more or less narrowed, The cavity con- tains purulent material, with debris of broken- down mucous membrane; and sometimes, the ureter being obstructed, great accumulation of pus takes place, so as to expand the pelvis and lead to partial atrophy of the kidney ( pyo- nephrosis). (3) Calculous. — In this form the mucous membrane may present either of the conditions above described, but one always finds mingled with the other materials calculi of greater or less size. Symptoms. — The symptoms of acute pyelitis may be either well-defined, or masked. There may bo uneasiness or acute pain in the loins and along the line of the ureter ; sometimes distinct rigors, with other febrile symptoms, occur ; and the urine is cloudy, depositing mucus or muco- purulent material, or sometimes blood. The most characteristic feature is the presence in the urine of the angular tailed cells which line the pelvis of the kidney. The condition may gradu- ally subside, or may become chronic ; or in rare cases, and where important complications exist, it may prove fatal. In chronic pyelitis there is often an aching feeling, or well-defined pain in the region of the KIDNEYS, DISEASES OF. 794 ureters. There is constitutional disturbance, debility, fever, hectic ; the urine is opaque, and deposits pus — generally grey, sometimes tinged with blood. This condition may go on for long periods, sometimes terminating in recovery, but often persisting and proving fatal by exhaustion, by extension to the kidney-substance or to the cellular tissue, or by concomitant complications. The calculous form differs from the others in respect of its cause ; and in being attended by more pain, by more tendency to haemorrhage, and sometimes by thepresence of crystals, gravel, or calculi in the deposit. If the escape of the pus should be prevented in any of the three forms of pyelitis, owing to obstruction of the ureter, and pyonephrosis result, a fulness or fluctuating tumour may be detected in the renal region, and this in some ' instances subsides at intervals, with a copious discharge of pus in the urine. Diagnosis. — From cystitis, pyelitis is distin- guished by the absence of vesical pain, and of frequent calls to micturition; and by the pres- ence of the lumbar uneasiness, and the more in- timate admixture of the foreign materials with the secretion. From renal inflammation it is distinguished by the absence of tube-casts; the seat of the pain ; and the presence of the charac- teristic cells of the renal pelvis. From strumous kidney it is sometimes almost impossible to dif- ferentiate simple pyelitis. Indeed the two con- ditions are not unfrequently associated together, but the presence of other evidences of strumous disease, the enlargement of one or both kidneys, and the presence of copious debris, in addition to the pus, often suffice to distinguish the one from the other. Prognosis. — In the slighter and acute forms of pyelitis, the prognosis is generally favour- able. In the chronic variety 7 it must always be guarded, the amount of danger being determined in some measure by the cause, the constitutional conditions, and the complications. Treatment. — Tho first essential is that the patient shou'd have rest, and that the urinary secretion should be copious and bland. In order to secure this a diet largely composed of milk and simple diluents, or in some cases exclusively of milk, and the avoidance of stimulating foods and drinks, are to be insisted on. As to medi- cine, if the urine be excessively acid, alkalies should be administered ; if it be alkaline, mine- ral acids should be given. Various remedies which appear to diminish irritation, such as tho uva ursi, pareira brava, buchu, triticum repens, copaiva, aud sandal-wood oil, ought to be em- ployed. In the acuter cases the application of poultices to the loins, and the internal administra- tion of henbane or opium, are to be recommended. In the chronic forms of pyelitis a similar lino of treatment should be perseveringly followed ; and in cases which owe their origin to the pres- ence of calculi, the remedies appropriate to the diathetic condition should be employed. Astrin- gents may possibly be useful in checking too copious a discharge of pus, 23. Kidney, Malformations of. — The commonest malformation of the kidneys is lobu- lation, which is a relic of the fcetal condition. Next comes the undue development of one organ. Sometimes there are two pelves belonging to each kidney, or two ureters. A not very rare anomaly is the horseshoe kidney, which consists simply in the union of the two kidneys, by a band of renal tissue, at either end, usually the lower. This abnormality is often attended bv anomalies in the arrangement of the ureters anil vessels. A very rare condition is that in which there is a central union between the two organs, owing to the development of supplementary renal structure opposite their pelves. None cf these malformations lead to any important symptoms, except by pressure upon the i.uct or vessels, under superadded abnormal conditions of the organs themselves, or of neighbouring parts. 24. Kidney, Malignant Disease of— De- finition. — A chronic disease of the kidney, caused by the circumstances which induce cancer elsewhere ; consisting in the formation of no- dules of cancer, or the infiltration of the organ with the new formation ; characterised by a renal tumour, cachexia, and frequently by altera- tion of the urine ; and resulting in death. tEtiology. — Primary renal cancer arises from causes not yet ascertained. It occurs at two epochs of life, namely, in early childhood and in adult age. Children under four years appear specially liable. The male sex is more fre- quently affected than the female ; the right kidney 7 more commonly than the left. Secondary cancer of the kidney is most fre- quently associated with carcinoma of the liver, the stomach, the mamma, the testicle, or the uterus ; sometimes of the supra-renal bodies, or the mesenteric glands. Anatomical Characters. — All the varieties of cancer have been met with in the kidney, but the medullary is by far the most common. It is sometimes primary, sometimes secondary. The primary affects usually one kidney, most com- monly the right; the organ is often much en- larged, weighing sometimes as much as sixteen or seventeen pounds, and this even in young chil- dren. In ten children Dr. Eoberts found the aver age weight 8f lbs. : in ten adults hefound it 9| lbs. Such large tumours occupy a great part of the abdomen, and push the colon forward. The cancer is in some cases scattered in separate nodules ; in others it is infiltrated through the mass. It commences always in the cortical sub- stance, and is developed from the fibrous stroma. In the scattered cases the remaining portions oi the kidney 7 are quite sound. The cancer may involve the sub-mucous tissue of the mucous membrane of the pelvis, the ureters, and tho veins. The lymphatic vessels and glands also become secondarily affected. Sometimes it at- fects the peritoneum, colon, and it has even involved the skin. When the renal affection is secondary, it con- stantly affects both organs, and rarely leads to such enlargement as is seen in the primary dis- ease. It occurs in the form of numerous nodules, developed in the stroma or along the vessels. The remaining renal tissue is commonly healthy, but it may be inflamed or otherwise altered. Symptoms. — The symptoms of primary cancer generally become quite distinct when the disease KIDNEYS, DISEASES OF. advances, but in the earlier stages they are very indistinct. The urine itself is, as a rule, natural in quantity, of acid reaction, normal specific gravity and colour; but from time to time blood appears, its amount varying from a mere trace to a very serious haemorrhage. Sometimes the blood is in clots, and this bleeding may be the earliestsymptom; and it occasionally happens that carcinomatous elements may be discovered in the urinary deposit, but it is very difficult to be sure of their presence. Examination of the abdomen reveals the pre- sence of a tumour, occupying and extending from the region of the kidney. The tumour is generally nodulated, of tolerably firm consist- ence, and dull on percussion. The colon lies in front of the mass, which is capable of being tilted forward by pressure on the renal region. When the left kidney is affected, the spleen is displaced upwards. As a rule, there is persistent consti- pation, and some pain, together with the general symptoms of the carcinomatous cachexia. Diagnosis. — Carcinoma of the left kidney may be confounded with enlargement of the spleen ; with perinephric abscess ; perhaps sometimes with disease of the mesenteric glands ; or with obstruction of the colon, and retention of feces. From splenic tumour it is distinguished by its lower position, and the absence of the splenic notch ; the normal condition of the blood ; and the presence of blood in the urine ; also by the nodulated character of the tumour itself, and by the position of the colon. From perinephric abscess it is distinguished by the absence of fever, and of fluctuation ; as well as by the less rapid advance of the disease. From tumours of the mesenteric glands renal cancer is distinguished by its situation, being more towards the side and the lumbar region. The mass also is less nodular than in mesenteric growths, which are composed of groups of glands. From carcinoma of the intestine, with accumu- lation of faeces above it, it is distinguished by the position of the mass, and by its characters on palpation; as well as by absence of the signs proper to the intestinal disease. Carcinoma of the right kidney may be con- founded witli tumour of the liver, especially in children ; but the presence of a space of clear per- cussion, more or less extended between the liver and the tumour, should remove all doubt. If the diseased kidney touches the liver, reliance must be placed on the symptoms proper to renal or to hepatic disease. Cancer of the kidney is to be distinguished from tumour of the ovary, by its more fixed con- . dition, and the h'story of its growth. Prognosis. — The prognosis is in all cases unfavourable ; the duration varies with the form of cancer. Dr. Walshe thinks eight months tho average, but that probably is too short. Treatment. — Treatment is, of course, merely palliative — morphia, belladonna, henbane, applied externally or injected subcutaneously to relieve pain ; ergotine and other preparations of ergot, jeetste ot lead, and gallic acid to check haemor- rhage ; and iron as an astringent and blood-tonic. Hie bowels require careful attention; and some- imes there may be so much ascites as to warrant apping. 795 25. Kidney, Malpositions of. — The kidney may be congenitally displaced, but the impor- tant anomaly coming under this head is the movable kidney, which demands special consider- ation. Definition.— The movable kidney is a con- dition especially affecting women; consisting in the undue mobility of one, or rarely of both kid- neys ; characterised in some cases by no symp- toms, in others by uneasiness or pain and general nervous disturbance, and by the presence of a tender reniform tumour, with clear note on per- cussion in the renal region of the affected side ; resulting, as a rule, in frequent recurrence of the symptoms without danger to life. ^Etiology. — Movable kidney is more common in the female sex, and especially in those who have passed through many pregnancies, but it is not exclusively associated with women, for it, occurs (although rarely) in males, and also in children. The right kidney is much more fre- quently affected — 65 out of 91 cases (Ebstein). Its occurrence is probably mainly due to laxity of the abdominal parietes, and utfusual length, or irregular distribution, of the renal vessels. Anatomical Characters. — The kidney is not necessarily changed in its structure, but its posi- tion may be altered in any direction. Symptoms. — In many cases no symptoms oc- cur in movable kidney. But in some, whenever the displacement occurs, much uneasiness or even considerable pain is experienced. Tho writer has known a man unable to work in con- sequence of the pain induced by the displace- ment, and losing a day’s work regularly once a week or once a fortnight. The sensations are generally rather of the nature of vague uneasi- ness than of actual pain, except when tho organ is touched, and then there is pain of a peculiar and sickening kind. On percussion over the renal region posteriorly a clear note may be elicited on the affected side, and sometimes a flattening may be made out at the part. The urine some- times becomes altered during the attacks, de- positing mucus and in one case in the writer’s practice a little blood. Careful palpation re- veals a tumour, of characteristic renal form ; and now and then pulsation of the renal artery may be felt. The morbid condition may recur at intervals during many years, and is in some cases apparent for a time, and then absent fur a very long period. It is liable to be brought on by effort, but often appears without discoverable cause. Occasionally it is found that the dis- placed kidney owes its position to the existence of carcinoma or other disease of the organ. Diagnosis. — The malady may be confounded with tumour of a malignant nature, originating either in the abdomen or the pelvis. The diag- nostic points are, the fever ; the peculiar tender- ness ; the mobility ; the occasional disappear- ance ; the unchanging character of the tumour ; and the occurrence of a clear percussion-note and flattening in the renal region of the affected side. Prognosis. — The prognosis is favourable. Treatment. — The treatment should be by means of bandages or trusses, to support the ab- dominal walls, and keep up a pressure upon tho kidney, so as to retain it in its normal situation. In the case of the working man above referred /90 KIDNEYS, DISEASES OF. to, complete immunity from the displacement was obtained by the use of a bandage with a pad bo arranged as to keep up a pressure upon the organ. 26. Kidney, Morbid Growths of. — The only really important morbid growths of the kidney are cancer and tubercle. Syphilitic new formations occasionally occur, but give rise to no characteristic symptoms. Growths of fibrous, fatty, bony, muscular, and glandular tissue have all been met with in a few cases. Hydatid disease may also be mentioned. 27. Kidney, Parasites of. — The parasites which have been described as existing in the human kidneys are Hydatids, Strongylus gigas, Pentastoma denticulatum, and Bilharzia hsema- tobia. The Strongylus gigas is a large nematode worm, and is extremely rare in man. The Pen- tastoma denticulatum is the larval form of P. tsenioides, one of the Arachnida. It was found in one case by AVagner. Bilharzia liaematobia is a trematode worm, about three or four lines in leDgth ; and inhabits the branches of the portal system, and the minute veins of the pelvis of the kidney, ureter, and bladder. The parasite also affects these structures themselves. So com- mon is it in Egypt, that out of 363 post-mortem examinations, Griesinger found it 117 times. Symptoms. — Hydatid-disease gives rise to a tumour. The symptoms produced by the pres- ence of Bilharzia in the kidney are hsematuria, with irritation of the urinary tract. This para- site is the cause of the endemic hmmaturia of certain regions. The other parasites do not originate any definite symptoms. Treatment. — In the treatment of patients affected with Bilharzia haematobia, the internal use of oil of turpentine, and of the extract of the male shield fern, is recommended. It is stated that when the bladder is affected, injections of iodide of potassium, twenty or thirty grains dis- solved in tepid water, repeated every second or third day, have been found useful. Sec Kidney, Hydatid Disease of; Strongylus gigas, &c. 28. Kidney, Suppurative Inflammation of. — Definition*. — An acute or sub-acute disease of the kidneys ; caused by injuries, extension of disease from the bladder, and perhaps exposure ; consisting in inflammation and suppuration in the kidney ; characterised by constitutional dis- turbance, with local pain or tenderness, and va- rious alterations of secretion ; and usually result- ing in death. -Etiology. — The commonest causes of this disease are renal calculus, leading to inflamma- tion of the pelvis of the kidney; or inflamma- tion of this part, propagated upwards from the bladder or urethra. Next in frequency is pyse- mia, which induces metastatic abscesses. Com- paratively rarely the inflammation is a result of embolism of the renal arteries ; of injuries ; and perhaps of exposure to cold. Anatomical Characters. — The affected or- gans are generally above the natural size. The capsule may strip off readily, but often, as it is being stripped, leads to tearing of the substance, and liberation of pus. The surface is frequently discoloured in patches. The abscesses mav be described as passing through several stages. There is first the stage of congestion, with exu- dation into the stroma of the organ ; secondly, the stage of grey consolidation ; and thirdly that cf suppuration. Occasionally sloughing occurs. Sometimes perinephric abscess results, from perforation of the capsule. Drying up of the pus, with shrivelling of the affected area, is some- times met with. Microscopic examination reveals in some cases at an early stage the presence of colonies of bac- teria in certain districts within the tubules, causing irritation first in them, then in the stroma, and thus inducing suppuration. Stmttoms. — The most important clinical fea- tures of suppurative nephritis are the constitu- tional disturbance, accompanied by pain in the region of the kidneys, and tenderness on pres- sure, with scantiness of secretion ; the urine being albuminous or bloody, or sometimes purulent, and depositing tube-casts. Diagnosis. — From pyelitis, suppurative in- flammation of the kidneys is distinguished by the presence of tube-casts, and the absence of the characteristic angular cells of the calices of the pelvis. From perinephritis, it is diagnosed by the absence of distinct tumour, and by the his- tory of the case. Prognosis. — The prognosis is generally grave. Treatment. — The strength should be sup- ported by suitable food, by tonics, and stimu- lants when necessary ; and in some cases benefit may be derived from poulticing, fomentation, or from the application of leeches. Under suitable conditions it might be desirable to open a renai abscess, and evacuate the pus. 29. Kidney, Syphilitio Disease of. — Sy- philis may produce in the kidney, as in other organs, congestion, inflammation — either simple or gummatous, with the cicatrices and nodules resulting therefrom, and waxy or amyloid de- generation. -Etiology. — Nothing is known as to the con- ditions which determine the action of the syphi- litic poison upon the kidney. Anatomical Characters. — There is scarcely ever an opportunity of studying the appearances of the kidney in cases of congestion — probably over-filling of the vessels, with slight inflamma- tory conditions of the tubules, is all that would be found. The simple interstitial inflammation is characterised by thickening and swelling of the fibrous stroma, in patches here and there. Gummatous inflammation is rare, but when it does occur, it forms masses of the ordinary gummy character. Either of these conditions may lead to the formation of syphilitic cicatrices, which may appear on the surface of the orcan. or be imbedded in the cortical substance. Their formation is attended by the destruction of tubules in the affected parts. Stmttoms. — Albuminuria, slight in amount and of temporary duration, occurring along wi:h other syphilitic congestive affections, has ap- peared to the writer to indicate renal conges- tion. Various slight cases of inflammatory Bright’s disease, have appeared to be due to the syphilitic poison. The symptoms of the inter- KIDNEYS, DISEASES OF. stitiiil and gummy inflammations are not ascer- tained, although probably albuminuria attends them also. The symptoms of waxy degenera- tion are described under Bright’s Disease. Diagnosis. — The diagnosis of syphilitic dis- ease of the kidney depends upon the co-existence of renal symptoms with evidences of syphilis, while other diseases of the kidney are excluded. Prognosis. — This is favourable so far as dan- ger is concerned, except in the case of severe waxy degeneration. Treatment. — Iodide of potassium has been found to be useful in this as in other syphilitic affections, at least in the congestive and inflam- matory conditions. Should it fail to give relief, the bichloride of mercury may be given in moderate doses, and continued cautiously even when albuminuria is present. 30. Kidney, Tuberculosis of. — D efinition. A chronic disease of the kidneys and ureters ; caused ,by tubercular infection, or by strumous inflammation of the structures involved; con- sisting in the formation of nodules of tubercle, or in strumous inflammation of the substance of the gland, and of the mucous membrane ; charac- terised by some constitutional disturbance, some- times by renal tumour, and by various alterations of the urine, particularly deposit of caseous puru- lent debris- and resulting usually in death. JEtiology. — The direct causes of tubercular disease of the kidney are unknown. It is more common in children and young people than in those more advanced in life, but it — especially the scrofulous form — may occur later on. Men are decidedly more frequently affected than women. The kidneys are rarely equally involved ; the right is commonly worse than the left. One organ may be quite free from disease. Anatomical Characters. — Under this term are included both tubercle proper, and strumous inflammation. Tubercle proper occurs in the form of minute miliary nodules scattered throughout the substance of the organ, as a local manifes- tation of a general true tuberculosis. Strumous inflammation leads to the formation of larger masses, involving either the mucous membrane of the pelvis of the kidney, or the cortical sub- stance. When the former is its seat, it leads to a thickening of the mucous membrane, commenc- ing in patches which gradually extend, and ulti- mately undergo ulceration. When the cortical substance is affected, the organ becomes en- 'arged ; presents a markedly lobulated surface ; md on section conical masses of altered tissue ire found to correspond to the prominences of he lobules. Some of them are solid and cheesy ; ithers are softened in the centre ; while others ire completely softened, so that on section a mantity of puriform debris flows out, leaving a avity with white walls, rendered shaggy by the hreds of fibrous tissue which project from hem. Sometimes scarcely any renal struc- ure is loft. Occasionally what remains shows lie characters of waxy degeneration. The dis- use commences in the stroma of the organ ; the ! ibules are compressed, but are rarely the seat f inflammatory changes. ’When uie mucous lembrane of the pelvis of the kidney and the retor is affected, the membrane is thickened at ■ IUE3TINE. 707 certain parts, and afterwards becomes ulcerated ; and the lumen is diminished, or completely choked up by granular debris. Frequently both the mu- cous membrane and the substance of the kidney are affected. It occasionally happens, when one kidney is exclusively affected, that shrinking of the gland takes place; and a putty-like material, rich in cholesterine, or perhaps even calcareous nodules are found, occupying the smooth-walled cavities produced by the disease. Tuberculosis of the ureters, prostate, vesiculoe seminales, blad- der, and testicle not unfrequently co-exists. Symptoms. — When tubercle occurs in small no- dules it produces no symptoms, and even in the inflammatory form the constitutional symptoms are, in the earlier stages, not very well-marked ; but as the disease advances, fever, passing gra dually into the hectic type, is developed. The local symptoms may be negative, but there is frequently pain in the affected organ, with tenderness on pressure ; and in some cases a tumour may be felt in front, or percussion may reveal an increased area of dulness in one or both renal regions. The secretion may be nor mal, or even sometimes excessive in quantity, when the disease is not far advanced. It may bo acid or alkaline, of fair specific gravity, albumi- nous, and sometimes bloody. It often contains a puriform material, with debris of renal tissue. Sometimes there are masses of cheesy material, which are eminently characteristic, occurring in no other form of disease of the urinary tract. Occasionally the urine becomes suppressed, and symptoms of uraemia precede the fatal termina- tion. Sometimes a tumour may bo felt ; and on percussion behind, it may be found that the renal dulness is more extensive on one side than the other. Diagnosis. — The evidences on which we rely in the diagnosis of tubercular disease of the kid- ney aro the presence of pyelitis, combined with those of tubercular disease in other parts, and above all the deposit in the urine of the character- istic fragments of cheesy tissuo above described. Prognosis. — The prognosis is very unfavour- able, on account both of the local and of the constitutional conditions. Treatment. — The treatment is merely pallia- tive, to relieve pain or uneasiness ; and to seek to improve the general health, by administering remedies which are useful in strumous affections. 31. Kidney, Tumour of.— Any enlargement connected with the kidney, which reveals itself on clinical examination, is regarded as a renal tumour. This may be due to mere hypertrophy of the organ ; any form of cystic disease ; accu- mulation of any fluid in the renal pelvis, or in the kidney itself; or a solid new-growth, espe- cially malignant disease. For a description of the signs of these several conditions, the reader is referred to their respective headings in this article. T. Grainger Stewart. KIESTINE (kvid, I am pregnant ; and a pellicle). — Synon. : Fr. Kyestiine\ Ger. Kyestein. — -This substance was formerly be- lieved to be peculiar to, and always present in, the urine of women in pregnancy, and it was held, therefore, to be significant of that condition. 198 KIESTINE. Recent investigations show that it may be absent all through pregnancy, or present only during certain months, usually from the second to the seventh ; that it may be present in the urine of anaemic persons, male as well as female ; and therefore that it has not the diagnostic value which was formerly attached to it. Kiestine is a nitrogenised body allied to caseine ; and, according to Dr. Braxton Hicks, the amount deposited from urine containing it can be aug- mented by the addition of rennet. Chemically and microscopically it is a variable body. Fat, mucus, crystals of the phosphates, infusoria, and granu- lar matter have been found in it. If urine capable of yielding kiestine be set aside in a tall glass, a cloud, apparently of mucus, becomes visible in the middle of it on the second or third day. This soon rises to the top, and an iridescent pellicle is seen forming on the surface. When this has fully formed, it begins to fall through the fluid in the form of flocculi, until the whole is deposited at the bottom in a whitish layer. Another pellicle containing triple phosphates succeeds this, and putrefaetivo changes proceed. No reliance can be placed upon the presence of kiestine as a proof of pregnancy. Alfred Wii.tshire. KINAESTHESIS (tcivtu, I move, and al(rdT]7Ls, sensation). — The sense of movement. In view of the conclusion that the term ‘ mus- cular sense ’ ought to be abolished, as being in several respects misleading, when applied, as it often is (see Muscular Sense) by diflferent writers with totally different significations, partly referring to some and partly to all the impressions which we derive from our moving members, or from movements generally, the writer (The Brain as an Organ of Mind, p. 543, : and Appendix ) has proposed to employ the above term as the designation of an important but confessedly complex sense-endowment. He re- gards it as a form of sense, ‘ whereby we are made acquainted with the position and movements of our limbs, whereby we judge of “ weight” and “ resistance,” and by means of which the brain also derives much unconscious guidance in the performance of movements generally, but espe- cially in those of the automatic type.’ In re- gard t o the various components of this endow- ment he adds: — ‘ Impressions of various kinds combine fur the perfection of this “sense of movement,” and in part its cerebral seat or area coincides with that of the sense of touch. There are included under it, as its several components, cutaneous impressions, impressions from mus- cles and other deep textures of the Jimbs (such as fasciae, tendons, and articular surfaces), all of which yield conscious impressions of different degrees of definiteness ; and in addition there KYPHOSIS. seems to be a highly important set of “unfelt” impressions, which guide the motor activity of the brain by automatically bringing it into rela- tion with the different degrees of contraction of all muscles that may be in a state of action.’ Kinsesthetic centres or mechanisms would, therefore, in accordance with this view, exist in the brain, just as visual or auditory centres also exist. The cerebral seat or locus pertaining to the movement-sense would perhaps be more dif- fused, though it would otherwise hold much th6 same relative rank as the several cortical me- chanisms for the more special senses. Disorders of Kinjesthesis.— In certain cere- bral and spinal diseases the sense of movement is known to be blunted, or actually abolished, in some parts of the body ; and that in regard either to the whole, or only to some of its com- ponent impressions. Concerning perversions or exaltations of this endowment, however, we as yet know almost nothing. Total abolition of the endowment in the limbs, on one side of the body, exists in certain rare cases of hemianssthesia, where there is also complete loss of tactile sensibility. On the other hand, it is partially impaired in both lower extremities, not unfrequently, in cases of locomotor ataxy ; whilst in another class of cases, without coexisting anaesthesia, there would seem to be an absence of the ordinary unconscious impressions emanating from muscles in action, and as a consequence motor defects of an ataxic order, so long as the movements at- tempted are not guided by sight impressions. Incoordinate movements pertaining to this latter category are decidedly rare, and stand in need of further investigation. H. Charlton Bastian. KIN-COUGH (Dutch, Kienhhoef). Also Chin-cough, Both of these words are synonyms for whooping cough. See Whooping Cough. KING’S EVIL. — A popular name for scrofula, originating in an idea formerly held that the disease could be cured by the king’s touch. See Scrofula. KISSINGEN, in Bavaria.— Common salt waters. Sec Mineral Waters. KLEPTOMANIA. — Insanity characterised by an irresistible impulse to steal. See Insanity, Legal ; and Criminal Irresponsibility. KRETZNAC5, in Germany. — Common salt waters containing Iodine. See Mineral Waters. KYPHOSIS (Kuhs, bent). — A synonym lor angular deformity of the spine. See St ine. Diseases of. L LABIO GLOSS 0-LAET5TGEAL PA- RALYSIS ( labium , a lip ; y\w sibly to congenital malformation of die lies. J paralytic lagophthalmos, the treatment is. it. of facial paralysis. Where there is contra, t LAGOPHTHALMOS. Or deformity, each case must be considered on its own merits, with regard to the possibility of obtaining relief from a surgical operation. R. Brudeneix Carter. LARDACEOUS DISEASE ( lardum , ba- con). — A synonym for albuminoid disease, which is so called from the resemblance of the cut surface of an affected organ to raw bacon. See Albuminoid Disease. LARVALIS (larva, a mask). — A term usually associated with porrigo. The thick in- crustation which is sometimes seen covering the face of children affected with eczema, and con- stituting a hideous mask to the features, is an example of porrigo larvalis, or rather eczema lar- > >alc , as likewise is ordinary milk-crust. LARVATED (larva, a mask). — A term ap- plied to certain diseases, when their ordinary characters are masked or concealed ; as, for ex- ample, typhoid fever. See Typhoid Fever. LARYNGEAL PHTHISIS. — A morbid condition of the larynx, supposed to be of a i tubercular nature, and either associated or not ! with pulmonary phthisis. See Larynx, Diseases of ; and Phthisis. LARYNGISMUS STRIDULUS (larynx, fthe windpipe; stridor, a noise). — A form of obstructed breathing, attended with a peculiar stridor or crowdng sound during inspiration, and .dependent on spasm of the muscles of the glottis. See Larynx, Diseases of ; 9. Spasm. LARYNGITIS. — Inflammation of the la- ynx. See Larynx, Diseases of ; 3. Inflammation. LARYNGOSCOPE, The. (AdpiryL the arynx, and okow4w, I look.) — Definition. — An nstrument- for illuminating the interior of the arynx and trachea, and reflecting those parts o as to present their image to the eye of the bserver. Description.— The apparatus for laryngoscopy onsist of a small round plane mirror, set on a letal stem and fixed in a wooden handle, for itroduction into the throat; and, for concen- ■atingand reflecting the light into the throat, a incave reflector to be worn in front of the fore- iiad, or perforated for wearing in front of the re of the observer. With this throat-mirror and Hector, any lamp, or even a candle, is available.; it brilliant illumination contributes so much the distinctness of the image that some appa- tus to condense the light is also desirable. : tiler a special apparatus with a bull’s-eye lens, a globe of water, such as a plain round de- bater, forms a powerful condenser, and with it j? concave reflector may be dispensed with, the lit be ng concentrated directly by the globe of ter on the tbroat of the patient. Appl ication. — In practising laryngoscopy, the >t object is to throw a brilliant light into the i irynx. Sunlight falling directly, or reflected -in an ordinary looking-glass, through the ' uth into the throat of the patient ; bright ((’light; or the concentrated light, of a lamp ^candle, are each of them available for this I pose. 'he patient being placed beside and a little LARYNGOSCOPE. 803 in front of the lamp, when the reflector is used; or opposite the window, or lamp and concen- trator, if direct light is employed, the operator seats himself opposite him, and adjusts the re- flector which he is wearing, or the concentrator in front of the lamp, so that wheu the patient sits upright, with his head inclined slightly back, his mouth widely open, and the tongue put out, the light shall be concentrated on the back ol the pharynx and velum palati. The first object being thus attained, the nexi is to throw the light into the larynx. While the patient breathes deeply and quietly, his pro- truded tongue, protected by a napkin or hand- kerchief to prevent its slipping, is held steadily but gently forward, either by his own hand, or by the disengaged hand of the operator ; and the throat-mirror, previously warmed to prevent the condensation of moisture on its surface, held like a pen, is passed into the patient’s throat, and held with its back steadily pressing against and rais- ing the soft palate and uvula at such an angle that it throws the light into the larynx. This angle will vary according to the position of the patient and the part of the larynx which we wish especially to examine ; and the inclination of the mirror must be altered, it must be raised or lowered, brought forward or advanced further in the pharynx, as may be necessary ; the operator observing what part is reflected in the mirror, and in moving it being guided by his knowledge of the relation of the various parts of the larynx to each other. Unless the tonsils are enlarged, no part of the fauces or pharynx, except the soft palate and uvula, should be touched ; and the operator must be specially careful that the lower edge of the mirror does not come in contact with the back of the pharynx. He must remember also that, while steady pressure can be borne, titillation of any part of the fauces will induce retching. If a patient’s nervousness induces retching, or if a spasmodic action of the muscles of the tongue makes it rise, his nervousness must be calmed, he must be induced to take a deep inspiration through the mouth, to accomplish which he will raise the soft palate and depress the tongue, the traction on which must also lie slackened. Enlarged tonsils may present an in- superable obstacle to successful examination ; in slighter cases either a very large round mirror which presses the tonsils on one side, or a small ovate mirror, should then be used. More fre- quently a pendulous epiglottis banging back over the upper part of the larynx impedes the view ; in such a case the patient must utter, or try to utter, in a high falsetto tone, a prolonged ‘eh,’ or he must force a laugh or a cough, and the mirror must bo held lower in the pharynx, in a more vertical position. For the topical treatment of laryngeal diseases, in addition to the laryngoscope the practitioner requires a laryngeal probe or sound, brushes on whalebone or stout wire handles, curved at a suitable angle, for applying solutions ; a caustic- holder, similarly curved, for applying solid sub- stances; an injector to apply a shower of fluid or spray; and a scarifying instrument. For tilt operative treatment of polypus, &c., a set oi special forceps, a laryngeal ecraseur, special knives, and other instruments are necessary ■ 304 LARYNGOSCOPE. while, for use by the patient, a spray-producer ur atomiser, and a simple inhaler will be required. Thomas James Walker. LARYNX, Diseases of. — The functions and peculiar anatomical position of the larynx give to its diseases a special importance ; and in addition to such objective and subjective symp- toms as are common to affections of other organs, we find here modifications of respiration, vocali- sation, and deglutition. The principal diseases and disorders which affect the larynx may be conveniently enume- rated and described in the following order: — - 1. Aphonia; 2. Disorders of circulation; 3. In- flammation ; 4. Lepra ; 5. Lupus ; 6. Malignant disease ; 7. Paralysis ; 8. Polypus ; 9. Spasm ; and 10. Syphilitic disease. See also Croup ; Diphtheria ; and Trachea, Diseases of. 1. Aphonia. — Synon. : Fr. Aphonic; Ger. Stimmlosiglceit. Definition.— S peaking in a whisper, the sound being produced without closure of the vocal cords. Various modifications of the note, tone, and quality of the laryngeal voice result from changes in the larynx ; and if no air passes through the larynx or mouth, as when a patient breathing through a tracheotomy tube attempts to speak, all sound is abolished, the movements of the lips alone being used in the endeavour to form words. Aphonia is the term applied to the voice produced in the mouth when the laryn- geal note is withdrawn from it; and this symptom occurs not only as a result of disease, but as a common functional disorder constitut- ing functional hysterical aphonia. In these cases there is no morbid change in the larynx, no affection of its nerves or muscles. The word paralysis should never be applied to this or other similar affections without the prefix simulated ; the power to exercise the voice exists, but the patient holds it in abeyance. The affection is much more frequent in women than in men. It commonly originates • in an attack of catarrh, when, owing to the relaxation and congestion of the laryngeal mucous membrane, vocalisation is inconvenient and requires an effort, and the patient whispers to rest his voice, precisely as an exhausted phthisical patient does, even when there is no laryngeal complication. The habit thus originated is maintained for months or years, as long as t.he unhealthy mental, emotional, and physical condition which we term hysteria lasts ; and this may be the only phenomenon of that condition. Like other nervous and hysterical symptoms, nervous aphonia may lead us to sup- pose the existence of more serious disease; but the patient suffering from nervous aphonia fre- quently closes the vocal cords in laughing and coughing, while in speaking she never emits even a husky uncertain laryngeal sound. The laryn- goscope is of the greatest value for the diag- nosis. The interior of the larynx is seen to bo free from disease; the vocal cords move during respiration ; but when the patient is asked to say Ah or Eh, they remain apart, or are brought to- gether for an instant (showing that there is no loss of power) and again separated and allowed LARYNX, DISEASES OF. to remain open, while an apparent effort is made to utter the sound. Sec Voice, Disorders of. Treatment. — Well-regulated and interesting employment, or amusement and remedies adapted to the general condition of the patient, must be employed; and the patient must be convinced that she has the power to speak, a power which she does not exercise, usually under the belief that she has it not. The mere expression of aconfident opinion, or fhe promise of a successful result to some system of using the voice may suffice; but usually some measure directed to the part is necessary to induce the patient to exercise her will upon the laryngeal muscles, and to speak, and of those which may be used none is so effective as, or more innocent than, electricity, especially when applied to the interior of the larynx. Frequently one application of electricity, particularly when accompanied by the circumstance of a laryngo- sccpic examination in a dark chamber, makes a sufficiently profound impression on the mind of the patient to restore the voice ; the slight pain of the operation occasionally inducing her to ex- claim Oh! while her attention is diverted from her supposed inability to speak. In using this remedy in these cases, no practitioner can de- ceive himself into the belief that he is restoring power to a paralysed part and it is to be re- gretted that, in describing the treatment of theso cases, this belief should be implied, and should have led to a distrust of those who merit the confidence of the public and the profession, from their special skill in the diagnosis and treatment of laryngeal diseases. 2. Larynx, Disorders of Circulation of.— Ancemia of the larynx does not exist as a separate disease. Like the pallor of the gums, it is arts. Lead Colic . — Synon. : Colica Saturnina ; Fr. Udiquede Plomb; Ger. ISleikoUk . — Following the 813 symptoms just described, but sometimes without marked prodromata, a very characteristic affec- tion occurs, namely, lead colic. This is known by many other synonyms, of which the more com- mon are Painter's colic, Devonshire colic, Colica Pictonum, the last being derived from the inhabi- tants of Poictou, among whom in modern times it was first extensively prevalent, owing to adulter ■ ation of wine with lead-salts. Patients affected with lead colic oxhibit a cachectic look, earthy hue, blue line on the gums, coated tongue, and fetid breath ; and suffer from nausea and, occasionally, vomiting. The bowels are obstinately confined, cr scanty hard motions are passed with difficulty. Paroxysms of excru- ciating pain occur in the abdomen, which feels hard, and is retracted in tho region of the um- bilicus. The pain is of a truly colicky nature, and is relieved by pressure. The countenance is anxious, and the skin is covered with cold per- spiration. The respiration is shallow, and the pulse generally slow and hard, though this is not always tho case. The urine is not unfrequently almost or entirely suppressed. Lead Palsy. — Synon. : Fr. Paralysie satur- nine ; Ger. Bleildhmung. After repeated attacks of lead colic, or it may be after one, and some- times without antecedent colic, various other affections occur. One of the most common of these is a form of paralysis termed lead palsy, or, from its special features, ‘dropped wrist.’ The paralysis shows itself more particularly in the extensor muscles of tho forearm, or region of distribution of the musculo-spiral nerve ; and in consequence, when the arm is raised, the hand drops by its own weight. The paralysis generally commences in the extensor digitorum communis, and gradually extends to the other muscles sup- plied by the musculo-spiral, with the remarkable exception of the supinator longus. The paralysis does not necessarily confine itselfto the forearm, for in advanced cases it may attack other muscles in the arm, the muscles of the leg, and the dorsal muscles ; showing itself by preference in the ex- tensor muscles of the body, and giving rise to a peculiar stooping, tottering gait. Aphonia occa- sionally results. The paralysed muscles undergo atrophy, and ultimately cease to react to fara- disation or galvanisation, the faradic excitability being lost before the galvanic, as in peripheral paralysis generally. Other 'phenomena . — Tendinous swellings of an oval or elongated shape frequently form on the tendons at the back of the wrist, and contrast prominently with the atrophied muscles. Neu- ralgic pains in the muscles and joints are often complained of. In the more advanced cases various forms of encephalopathies occur. Epileptiform convulsions are common ; and psychical affections are not unfrequent, in the form of delirium, mania, or melancholia. Appa- rently in causal relation with lead-poisoning, dis- ease of the kidneys and albuminuria may occur ; and gout is frequently seen among those who work in lead. Abortion occurs to a large extent among women employed at white-lead works ; according to Paul, in the proportion of sixty per cent, of those so employed. The tendency is to recovery, if the cause of the symptoms is removed; but if not, the paralytic S 1 4 LEAD, POISONING BY. and other affections become incurable, and death occurs in a miserable state of cachexia. Anatomical Characters. — There are no very characteristic appearances of chroniclead-poison- ing. Lead is found in almost every organ and tissue in the body, the greatest quantity, accord- ing to Heubel, being found in the bones ; next in the kidneys, liver, brain, and spinal cord ; and to a less extent in the muscles. Among the appearances which nave been de- scribed are constriction and apparent thickening of the muscular coats of the large intestine ; and an atrophic condition of the intestinal mucous mem- brane has been found by some authors (Kussmaul and Maier). These authors have also found an increase of the connective tissue, and atrophy of the nervous tissue in the abdominal ganglia of the sympathetic. The paralysed muscles exhibit atrophic degeneration, with hyperplasia of the connective tissue, and disappearance of the striie, and the nerve-trunks likewise exhibit various stages of atrophy. We possess, as yet, no very reliable knowledge of the condition of the nerve- centres. The subject is one still requiring much investigation. Pathology. — The mode of action of lead, and the causation of its characteristic symptoms are subjects still under discussion. Henleis of opinion that lead acts primarily on the non-voluntary muscular fibres throughout the body , while Heubel thinks that the primary action is on the nerve- centres. From this, as secondary consequences, are deduced the colic, due to irritation by com- pression of the intestinal nerves, and the consti- pation from cessation of the intestinal secretion by contraction of the blood-vessels. To the arterial ischaemia so produced the paralysis is attributed (BUrwinkel). Hitzig thinks that the paralysis of the extensors is due to a peculiar disposition of the veins, which favours the deposition of lead there. This is a mechanical theory which has little to support it except a dilated-condition of the veins, and is utterly insufficient to account for the occurrence of paralysis in other regions, besides being in contradiction to the fact that lead is not specially deposited in the muscles, as this theory would necessitate. That the paralysis is due to degeneration of the nerves is in harmony with the symptoms and electrical reactions of the muscles, and is supported by the post-mortem appearances ; but whether the peripheral degene- ration is primary, or secondary to central de- generation in the anterior horns of the spinal cord, is not as yet satisfactorily determined. Treatment. — In acute lead-poisoning from any cause the stomach must be emptied by the stomach-pump, or by emetics — of which sulphate of zinc is to be preferred. Solutions of the alka- line or earthy sulphates — of which the best is sulphate of magnesia — are indicated, with the view of forming the comparatively insoluble sul- phateof lead, and expelling it from the intestines. As regards chronic poisoning by lead, prophy- laxis is the most important consideration. The great principles in lead-works are the inculcation of cleanliness ; avoiding eating with unwashed hands, or in working clothes, or in workshops; moist grinding ; free ventilation ; precautions against dust rising, or wearing of flannel respi- rators where it is unavoidable ; and occasional LEPEA. doses of sulphate of magnesia, acidulated with sulphuric acid. Sulphuric acid lemonade has been recommended as a drink. Workmen who begin to show signs of lead- poisoning should at once give up the work, and take to some other employment. As regards water-contamination, what has already been said on this subject will suffice to indicate the pro- phylactic measures. In the treatment of lead colic, purgatives are indicated, and opium may be necessary to allay the excruciating pain. The sulphate of magnesia is the best purgative. Iodide of potassium is generally given with the object of removing the lead from the system, and is on the whole satis- factory in its results. A combination of the iodide with sulphate of magnesia is very beneficial. Sul- phur baths are also recommended. The local paralytic affections require local, in addition to the general treatment.. Unless the muscles are in an advanced state of atrophy, and give no response to electrical stimulation, good results may be obtained by the use of the galvanic current applied to the muscles and to the mus- culo-spiral nerve. Faradisation has also been found beneficial, and is recommended by Dn- chenne, but the preference is to be given to the continuous cuiTent, D. Fere; an. LEAMINGTON, in Warwickshire. — Sul- phated common salt waters. See Mineuai. Waters. LEECHING. — The local abstraction of blood, by means of leeches. See Blood, Abstrac- tion of. LENS, Diseases of. See Cataract. LENTIGO. — A synonym for freckle. See Freckles. LEPIDOSIS (Xeirls or Aeaos, a scale). — A term adopted by Mason Good to distinguish the group of squamous affections of the skin ; amongst which is included lepra vulgaris or lepriasis. The term is now obsolete. LEPOTHRIX (Acaly or AeVos, a scale, and Splf, a hair). — Definition. — A term applied to a hair in which there is loosening and partial detachment of the overlapping edges of the scales cf its cuticle. Such hairs are usually met with in the axilla, and their peculiar conformation is attributable to the heat and dampuess of that region, which causes maceration of the hair, particularly when it is of feeble structure. Sometimes the scales completely surround the hair ; very commonly one side of the shaft is more affected than the rest, and presents the appearance of a fringe; and not uufrequently the scales are roughened with earthy and saline crusts deposited by the sweat. Treatment. — The treatment most suitable for this evil is saponaceous ablution, followed by the use cf a lotion compose! of two to four drachms of oxide of zinc to half a pint of lime- water. Eeasmcs Wilson. LEPRA ( Aeirls or XeVoy. a scale). — The term lepra was used in the plural, \cvpai, by Hippo- crates, to imply its constitution of mmtiplc LEPEA. patches. ’Willan adopted the term as significative of a squamous eruption, and in this sense it has been regarded as the lepra Gnecorum. The foreign schools, however, prefer to name it psoriasis, a term now commonly associated with it in Great Britain ; whilst they assign the word ‘ lepra ’ to the elephantiasis of the Greeks, the so-called • true leprosy.’ Hence whilst the operation of time has transferred the word ‘ psoriasis ’ to the lepra of tho Greeks, : t has conveyed the term ‘elephantiasis’ of the Greeks to the lepra of the Arabs ; and common consent reserves the word lepra or leprosy for the elephantiasis of the Greeks. Thus, the terms, lepra, psoriasis, ele- phantiasis graecorum, and leprosy are somewhat confusedly intermingled, and cne mode of extri- cation from the dilemma would appear to be to consider lepra as synonymous with leprosy, and to abandon its upe in connexion with the lepra of the Greeks, now termed psoriasis; although the adoption of Mason Good’s term ‘ lepriasis ’ would no doubt be the better alternative. For himself, however, the writer prefers the more classical courso of retaining the term ‘lepra,’ the type of roughness, for the lepra Grsecorum and the lepra vulgaris of Willan.; giving to genuine leprosy, the great disease, its Greek designation, elephan- tiasis ; and attaching psoriasis to squamous eczema, the ‘psora’ of the ancients, to which it properly belongs. The elephantiasis Arabum or ‘elephant leg,’ must be left out of consideration, as being an error of nomenclature, taking its origin in a blunder of translation of the Greek writings by the Arabian authors. See Elephan- tiasis Arabum. Erasmus Wilson. LEPROSY (Xeirpbs, rough). — Derivation and Synonyms. — The term leprosy had its origin at a time when diseases of ‘roughness’ compre- hended a large majority of affections of the skin; and it was, in fact, a generic name for ‘skin diseases.’ Hence the indefiniteness of the word as we meet with it in the Bible, where ‘leprosy’ in one connexion represents a trivial disorder, and in another a serious dis- ease ; and in a similar sense, a leper, in many instances, was nothing more than a person afflicted with a cutaneous complaint. In mo- dern times leprosy has been found a convenient designation for that terrible disease described by the Greek fathers of medicine as elephan- tiasis — a disease widely spread over the world, j and, according to the saying of Aretteus, so much greater than tho rest of diseases as the elephant is bigger than ail other animals — a I disease which is universal in its diffusion through the frame, and in which all the tissues of the Body are implicated to a greater or less extent. The terms leprosy and lepra are consequently .quite distinct from each other; leprosy and ele- phantiasis being synonymous ; whereas the term lepra, or rather \ewpal, in tho plural, was ap- plied by the Greeks to scaly white spots of the skin, a disease of roughness as in elephantiasis, although a disease of roughness in a very dif- ferent sense. But the analogy of the two words, both in derivation and sound, has given rise to some confusion, and the contusion is increased by a misapplieaticn of the term elephantiasis, l’hus we find that whilst the elephantiasis of the LEPEOSY. 815 Greeks has the signification of leprosy, the lepra of the Greeks is a trivial affection, sometimes styled lepra vulgaris, and very commonly, although erroneously, ps riasis. The word elephantiasis has aiso been applied to a local disease of hypertrophic growth known as ele- phantiasis Arabum , whilst the Arabians, amongst whom leprosy is also found, call that disease lepra. It therefore follows that leprosy, ele- phantiasis Graecorum, and lepra Arabum are synonymous terms. The synonyms of leprosy are numerous, as may be inferred from the extensive distribution of the disease throughout the world, and its identification in different countries by different names. Amongst the most important of its syno- ny^msare: — Elephantiasis ; Lepra; Lepraelephan- tia ; Black Leprosy; Bed Leprosy ; Elephantiasis tuberosa, ancesthetica, nodosa, mutilans, leontina, satyria; Joint-evil; the Myckle Ail or Great Disease, its English name in ancient times ; la Lepre in France; dcr Aussatz in Germany; Spedalskshcd, throughout Scandinavia; Lik.pra in Norway ; and so forth. Geographical Distribution.— The countries in which leprosy prevails most extensively are: — Hindostan, China, the islands ot' the Indian Ocean, some of the Polynesian Islands, Madagascar, Africa, the West Indies, parts of South America, Norway, Sweden, and parts of Canada. Therefore, although most abundant in hot climates, it is likewise frequently met with in the North. For thirteen centuries it was endemic in Great Britain ; the last case still lin- gered on the borders of Scotland so late as the beginning of the nineteenth century ; now an indigenous example is nowhere to be found in the British Islands. ^Etiology'. — The cause of leprosy is endemic. The disease has been mi t with from time imme- morial in certain countries and localities; there- fore the cause must be one which will be capable of abiding in different countries and in different climates — climates as various in character us the northern regions and the tropics. Time was when leprosy prevailed in Great Britain, and it took up its abode there for thirteen centuries ; but the disease has gone, and therefore we may presume that the cause lias ceased. Whether it has ceased in consequence of drainage and more general cultivation of the soil, is a question to be carefully considered. Hitherto indigenous leprosy has been unknown in the Australian colonies; but a well-marked ease of elephantia- sis tuberosa has recently come under the wri- ter's attention, having its origin in New Zealand. The patient was a man of distinguished note in Australia; he had been draining very extensively in New Zealand, and he had lived for several years amidst the exhalations of the fresh-opened soil of the marshes. The example is not soli- tary. An English lad was born and brought up on the verge of a marsh in the West Indies. He was sent to Lond-m on account of debility ; tho diagnosis was elephantiasis. A few years after- wards, his father, an officer of police, followed him home, a victim of the same disease, which had become developed since the departure of Iris son. The writer could multiply cases of this kind considerably, and has had the conviction LEPROSV 816 forcibly borne in upon him, that the cause of leprosy is miasma. No other cause is of such general distribution, suiting every climate and every part of the world, uuless it be such coun- tries as have been relieved of the cause by land- culture and improvement. Leprosy has been as- sumed to be caused by bad food, and by a fish diet. There can be no doubt that an improper diet may be quite equal to the production of debility and disease, and might predispose, like aDy other lowering course, to the invasion of a miasma ; but the disease prevails amongst the well-nourished as well as amongst the ill-nourished, and in countries where fish is rarely or never eaten ; whilst fish in moderation must be regarded as a most healthful and nutritious article of diet. Leprosy is now believed to be hereditary, and it has the character of being non-contagious. Nevertheless there are some curious histories on record of the first appearance of leprosy in a population after the immigration of foreigners from a leprous country, as in the example of the importation of negroes into the district of Surinam in South America, and the origin and spread of the disease among the Sandwich Islanders after an immigration of the Chinese. This and other questions of cause must still remain unsettled until further information is obtainable. A specific form of bacillus has re- cently been found in leprosy, the lymphatics being believed to be the channels of infection. See Lancet, July 30, 1881. Axatomicai. Characters. — The morbid ana- tomy of leprosy centres chiefly in the integument and in the nervous system. Danielssen and Boeck found the sheaths of the cutaneous nerves thickened and distended with exudative deposits, and similar changes were seen in the spinal cord. They also discovered tubercular matter in seve- ral of the internal organs, glands, and viscera. Virchow is of opinion that the pathological ele- ment of elephantiasis differs in no essential re- spect from that of the gummata of syphilis, nor indeed from that of lupus and glanders. Granu- lation-tissue is the characteristic element of all the three; the granulation tumour of elephan- tiasis is, however, more permanent than others of the same class, and tends in a less degree to degeneration and softening. Dr. Moxon, in a well-marked case of elephantiasis tuberosa that fell under his examination in Guy’s Hos- pital, regarded the pathology of the disease as especially evinced by the integument, which he found atrophic and disorganised, the nerves apparently healthy, but the cutaneous nerves and veins alike involved in dyscrasic degenera- tion. ‘ We are struck,’ he observes, ‘with the small amount of morbid change proper to ele- phantiasis. The immediate cause of death was amvloid or lardaceous disease of the alimentary canal, liver, kidneys, and spleen, with marasmus in the most extreme degree. The amyloid change occurs in the same places as in other lingering but not otherwise mortal maladies.’ Symptoms. — Leprosy makes its beginning so lightly and so unobtrusively, that it is perhaps rarely detected in its earliest stage. At that period there might, after close examination, be discovered a few symptoms of debility, such as weariness, chilliness, failure of appetite, sleepi- ness, and lassitude. But these symptoms subside after a while, and the patient "recovers his wonted energy and power ; some months later similar symptoms return, but somewhat inten- sified ; and several such recurrences may be experienced before any more obvious symptoms are made evident. The symptoms resemble those produced by malarious poison, and may be regarded as indicating the incubation of the leprous virus. These premonitory symptoms of leprosy ac- quire force after repeated recurrence ; and then two other symptoms make their, appearance, namely, a hyperaemia of the skin, and a defective sensibility of the peripheral branches of the spinal nerves. The hyperaemia of the skin ge- nerally assumes the form of circular spots, some- times of uniform size, at other times of blotches of irregular shape and varied extent. The iso- lated spots appear commonly on the trunk of the body and fleshy parts of the limbs, whilst on the face and neck, and on the hands and feet there is an uniformly diffused redness. What has already been said with regard to the pro- gressive development of the constitutional symp- toms must be repeated with respect to the local signs of the disease. At first only the face, hands, and feet may he congested, with a few spots on the trunk of the body. Then the hyperaemic congestion will subside and remain quiescent until another exacerbation of the lep- rous fever is imminent, when the spots will be increased in number and deepened in colour. The redness of leprosy is dull coppery or purplish in tint ; as it subsides it leaves on the skin a pigmentary stain; the affected integument is puffy with serous infiltration; the pores are dilated as if from hypertrophy of the follicles ; and in general appearance the skin resembles the rind of an orange. At a more advanced stage of the cutaneous disorder the hyperaemic congestion becomes centrifugal, and the circular spot is developed into a ring ; even the pigment d ; s- appears from the centre of the blotch, leaving a bleached centre surrounded by a belt which is slightly tumid, of a dull red hue, and deeply pig- mented. Eventually the whole of the affected part may be represented ljy a white blotch. Blotches of all the three kinds may be seen at the same time dispersed over the body, some being red only, some melasmic, some leucasmic, according to their age ; and others of irregular figure, arising from the blending of the circular spots, or spread out into rings of various extent. The distribution of the maculse or blotches of leprosy on the surface of the body corresponds with the nerve-territories of the integument, and the same may be said with regard to the face, and the extremities below the elbows and knees. On the face the parts specially affected are the superciliary regions, the nose, and the ears ; and on the arms the territory of the ulnar nerve. In all these regions the blotches soon become blended ; and the redness, pigmentation, and infil- tration are more general than elsewhere. The suffused redness of the skin has suggested the term elephantiasis erythematosa ; and tins state of congestion is frequently accompanied by pro- minence of the follicles, and more or less des- quamation and exfoliation of cuticle. In some LEPROSY. aituations the hypereemic blotches are moistened by a greasy exudation ; in others they are dry, parched, and rough. In all the affected parts of the skin there exists a certain degree of numbness or anaes- thesia. In the early stages of the disease there is scarcely any pain ; nevertheless, if the ulnar i nerre be pressed against the inner condyle, the pain is frequently acute, and the same occurs trom pressure on the peroneal nerve. As a con- sequence of imperfect innervation, the fingers are frequently slender and benumbed ; they are brown from pigmentation ; and the metacarpal space between the forefinger and thumb is hol- lowed, from defective nutrition of the abductor muscle. Varieties. — Starting with one uniform series of premonitory symptoms, leprosy after a while evinces a remarkable tendency to pursue an [elective course. In the great majority of cases die prime seat of manifestation of the disease is lie integument and mucous membrane; this constitutes the form of the disease known as •lephantiasis tuberosa. In a smaller number of uses the affection of the nervous system, and lartieularly loss of sensation, are most conspi- uous ; and this constitutes the group called ele- ihantiasis anasthetica: whilst a sub-group of lephantiasis anasthetica is remarkable for dis- ocation and amputation of the members at the lints; constituting elephantiasis nodosa, juint- vil, or elephantiasis mutilans. In the tegumentary or tuberous group, the inspicuous symptom is the development and radual growth of solid papules or tubercles in le skin. These originate in the centre of the (•persemic spots already mentioned, and do not ake their appearance until after the disease has fisted for several months. At first they are ddish in colour ; afterwards they differ little tint from the surrounding skin. They range in :efrom two lines to half an inch in diameter; d are slightly convex at the summit, and hard the touch. Their development follows the igressive exacerbations of the leprous fever ; ;y grow while the febrile process continues, • i become stationary when it abates ; each ucerbation, however, adds to their bulk, and ices them on to maturity. Having reached I mature stage, they soften and break up ; an 1 8r is formed, which discharges for a while ; c l then the ulcer heals. A common seat of the t ercles is the region of the eyebrows, which t y denude of hair ; they also give a frowning a set to the countenance, and when of large size a a leonine fierceness to the expression, which h suggested the term elephantiasis leontina. S ilar phenomena to those already described ifest themselves in the fauces, the nasal c. ties, and the larynx — at first hypersmic ®ul», then tuberous prominences, and next ul ration, so that the symptoms in this region 81 usually severe. The voice is hoarse ; the ml passages are clogged; occasionally the se un ulcerates ; and sometimes the nasal bones H n. Tubercles likewise form along the edges °l e eyelids ; the conjunctiva is inflamed and th ened; the cornea becomes opaque; and 80 i times the eyeball is destroyed. The lips art andered protuberant by the tubercles, and 52 817 ulcerate like the rest. The external ear is like- wise enlarged and studded with tubercles, and the lobule of the pinna is remarkably elongated, suggesting, with the large tubercles on the fore- head, the features of the typical satyr. Finally, the leprous congestion extends to the scalp ; the hair falls off, as it does on the eyebrows ; and the term elephantiasis alopcciata receives some corroboration. On the trunk of the body the ulcers are frequently of considerable extent ; and occasionally the limbs have the appearance ol being stripped of integument from the shoulders to the hands. The ulceration of elephantiasis is not, how- ever, restricted to the softening of tubercles ; in- stead of, as in this instance, beginning from without, it starts inits most extensive formsfrom within. There is at first a general swelling of a part, such as the heel or the joint of a great-toe ; a blister is raised on the skin covering the swell- ing; the cuticle is rubbed off; and an ulcer is quickly established. All this may occur with- out pain and almost without the knowledge of the patient. A large quantity of a glairy, colourless fluid is poured out by the ulcer ; the sore is asthenic and sluggish ; in the case of a joint the bone may be exposed, and very pro- bably the end of a phalanx will be forced through the opening, to be followed in due time by the rest of the bone ; then the ulcer contracts ; the cavity closes up ; and the integument heals. After a time a similar process commences in tho great>toe of the opposite foot, or in the joint of a thumb, and runs the same course — either tho extrusion of a bone or the healing up of an asthenic sore, after a continuance of several weeks or months. The joints of the phalanges of the feet and hands are similarly attacked from time to time, and a considerable amount of deformity of these members results. But it is worthy of note that while these morbid processes are all of them subject to the periodical canon of the disease, they alternate in their occurrence ; and it is to be further noted that an excessive discharge from one of these ulcers has a deriva- tive influence, and communicates a sense of re- lief to the whole system. Elephantiasis ansstlietica differs from ele- phantiasis tuberosa in the more decided mani- festation of disorder of the nervous system. There are the same premonitory symptoms, the same hyperaemic spots and blotches on the skin, the same pigmentary maculae ; but there is an absence of tubercles and ulceration, the numb- ness and anmsthesia are more decided, a general state of atrophy creeps through the system, and the sufferer is prostrated by exhaustion. Neuralgic pains, which are not wholly absent in elephantiasis tuberosa, are more obtrusive in ele- phantiasis anaesthetics. A sense of dulness and heat pervades the surface; and there are sensations of tingling and prickling, and of burning heat. Whilst the integument is insensible, there are deep-seated burning pains, sometimes of a bone or joint, and sometimes of the vertebral column. These pains are greatest at night ; they prevent sleep, and give rise to restlessness and frightful dreams. Moreover, the skin, robbed of its sensa- tion, is prone to vesication and excoriation, and the latter frequently ends in ulceration. The LEPROSY. SIS anaesthesia is often so great that the contact of fire or of the severest caustics occasions no sensation. Elephantiasis mutilans is more local in its characters than either of the preceding; it is wanting in the tegumentary manifestations of elephantiasis tuberosa, and although essentially anaesthetic in its nature, the anaesthesia is local, and affects chiefly the limbs. In this form of the disease loss of the bones of the hands and feet is a conspicuous symptom ; and not unfrequently the limb is lopped off painlessly at the ankle or knee, or at the wrist or elbow. When the pha- langes and metacarpal or metatarsal bones are alone attacked, the last phalanx, probably from its higher vascular organisation, is generally spared ; this may be the case even when the bones of the wrist are eliminated ; ’and the hand or foot in this case is crumpled up, re- sembling a confused bunch of tips of fingers or toes. Often the bones are ejected; in these cases the integument heals in the most complete man- ner, and it is in similar cases, where consider- able reparative power is obviously present, that spontaneous cure is most likoly to occur. In elephantiasis anaesthetics the nervous system is too deeply and seriously implicated to admit of spontaneous cure ; and in elephantiasis tuberosa the tegumentary system, both cutaneous and mucous, is likewise too extensively damaged to render cure a rational expectancy. Prognosis. — The prognosis of leprosy is essentially unfavourable. A disease which tends to the continuous degeneration of the skin and mucous membrane, with general dyscrasia of the entire organism ; which is impelled onwards by a law of periodic progression ; and which has no tendency to spontaneous resolution, must necessarily be fatal, the only question being one of duration. A very few instances are on record in which individuals afflicted with this disease have survived, and these principally from amongst the cases of elephantiasis muti- lans; hut such instances must be regarded as the rare exception, rather than the rule. The tuberous form of the disease is more rapid in its termina- tion than the anaesthetic form ; and the duration of life in both ranges from about ten to twenty years. Treatment. — The treatment of leprosy re- solves itself into, first, the employment of means intended to promote improvement in the general health; and, secondly, the adoption of such em- pirical remedies as have acquired a favourable reputation for the cure of the disease. In the first category we must place the removal of the patient from the locality wherein the disease has been engendered, and possibly to one where the disease is unknown. Next would follow a liberal and generous diet, such as animal food nnd beer; with active exercise. Thirdly, tonic mid nutritive remedies, such as cod-liver oil, iron, quinine, strychnine, bitters, and phos- phates, should he given. Nitric acid has been praised by one physician, and acetic acid in com- bination with carbolic acid by another. There can be no doubt that under a generous regimen the patient will improve in health and strength; the periodical exacerbations of fever will be less frequent, and hope will gleam in the mind, both of the physician and the patient; but cure, alas! is as distant as ever. Specific alteratives hare been exhausted with equal want of success. Iodine has failed. Daniels- sen and Boeck administered arsenic largely; and the perchloride of mercury has been exten- sively used by Beauperthuy. When these and other remedies are employed judiciously, in com- bination with a generous diet, moderate exerdre, and thorough stimulation and inunction cf the skin, the symptoms invariably improve for a time ; but the disease as certainly falls back into chronic sluggishness and smouldering inactivity when they are relinquished or neglected. The principal empirical remedies which have been recommended in this disease are; — tLo asclepias gigantea; hydrocotyle asiatica; ve- ronica quinquefolia ; cliaoulmoogra oil, and gurjun balsam. The asclepias or rumex gi- gantea, the mudar of Hindostan, has received the name of vegetable mercury. The part of the plant employed medicinally is the root-bark, reduced to powder ; and the dose of the latter is half a drachm daily. The hydrocotyle asiatica. in the form of powder of t he dried plant, is given in doses ranging between one and six grains daily, and is also administered as an infusion, a syrup, and an extract; its active principle is vellarine. The medicinal part of the veronica quinquefolia is its root, and ten ounces of the root has been menlioned as a quantity sufficient | to cure a leprosy. The cliaoulmoogra oil is! procured from the seed of an Indian tree, the chaoul moogra or gynoeardia odorata. It is ad- ministered both internally and externally, the dose for the former purpose being six to twelve minims, three times a day. A tincture of the plumbago rosea has also been found serviceable! in cases of anaesthetic leprosy; the dose being one drachm three times a day. More recently Dr. Joseph Dougall lias recom- mended gurjun balsam or wood oil ai a very promising and successful remedy. It is ail oleo-resin, obtained from one of the species "t the dipterocarpus tree of India ; and is given in the form of an emulsion, in combination with ar equal proportion of lime-water, the dose of the emulsion ranging between two and four drachm: twice a day. Or it may very conveniently be adj ministered in capsules, each containing a drachm The local treatment of leprosy consists 1 stimulation of the skin by means of hot-ail baths, followed by frictions and inunction witj bland and stimulating oils. Ointments and hnj ments of the specific remedies already mentioned namely', mudar, hydrocoty'le, and gurjun, hav been used for this purpose, as well as for dres: ing the ulcers. Danielssen and Boeck employe counter-irritants in the course of nerves pr sunied to be affected, with cupping and mox to the spine in anaesthetic leprosy; whilst t!» treated the tubercles of tubercular leprosy wi the acid nitrate of mercury, and with a strongs lution of potassa fusa. Beauperthuy found bene result from the acrid irritating oil of the shell the cashew nut ( Anacardium orientate) used a; blister to the tuberous skin ; a copious exudati followed the application, and relieved both || local and the constitutional symptoms. Thegnrj treatment is accompanied by energetic trie:. with a liniment composed of equal parts oi • I a satu and lime-water, the same as the emuisi LEPROSY. taken internally ; and asthenic ulcers are pen- | cilled with a solution of chloride of zinc. A review of these various methods of treat- ment, and a consideration of the personal atten- tion required by the patient suffering under this terrible disease, are suggestive of the observation that it can only be effectually treated in an in- stitution devoted especially to the purpose. Eras u us Wilson. LEPTOMENINGITIS (Aejr rbs, delicate ; or thin, and meningitis). — A term signifying in- flammation of the pia mater. By its use, in association- with arachnitis and pachymeningitis, we are enabled accurately to indicate the precise teat of inflammation involving the meninges of the brain or spinal cord. There is a practical convenience, warranted by pathological facts, in retaining the term arachnitis, although anato- mists are not now disposed, as they were for- merly, to believe in the existence of an arach- noid membrane, distinct, externally from the dura mater, and internally from the pia mater. 'iee Meninges, Diseases of. LEPTOTHRIX. (AeirrAs, delicate or slender, .nid a filament or hair). — Lcptothrix buccalis is a name assigned by Robin to certain vege- table parasites or minute filaments, which can be recognised by means of the microscope, amongst the epithelial scales of the tongue or other parts of the mouth ; and especially between the teeth, or in the hollows of decayed teeth. They occur in healthy persons, as well as in the sick, and have in this situation really no pathological signification. Organisms of the same kind are, however, now 'Commonly named bacilli, and have during the fast two or three years been recognised as ex - j’eedingly common in many organic solutions, ind also within the blood and tissues of animals and of man suffering from splenic fever ( see Pus- fULH, Malignant). Some regard them as con tituting a distinct genus, whilst others believe 'hem to be only one of the multitudinous forms .hat may be assumed by bacteria, when growing a certain kinds of media. See Bacteria ; and Ticrococci. Dermatologists also employ the term lepto- ihrix to indicate a morbid thinness and weak- ess of the hair. LESION ( ledo , I hurt.) — This word ori- inally signified a hurt or an injury ; but its use now extended to comprehend all organic langes of a morbid character, affecting an ■gan or tissue. LETHARGY (Ai j(b), oblivion, and apyla, Teness). — A disorder of consciousness, which nsists of prolonged and profound sleep, from i'aich the patient may be momentarily aroused, it into which he falls off again immediately, j e Consciousness, Disorders of ; and Trance. LEUCE (Afu/cbs; white). — This term has been i plied to blotches in the skin of a white colour; 1 hence it has alternately been confounded with lira alphoides, with vitiligo, and with the leuco- Irmic blotches of leprosy. It seems, however, are than probable that the pathological eon- i m intended to be signified by this word, is a jcumscribed scleriasis, namely, that which we ■ present term morphea alba. See Morphcea. Erasmus Wilson. LEUCOCYTHzEMIA. 313 LEUCIN (\evichs, white). — Leucin, the che- mical composition of which is C 12 H l3 NO', is a product of decomposition of albuminous bodies. It may be obtained from them by the action of caustic alkalies, or by long boiling with sul- phuric acid. It is found in the secretion and substance of the pancreas, in the spleen, thy- mus, thyroid, suprarenal bodies, lymphatic glands, salivary glands, liver, kidneys, and brain. It is also found in old scales of the epidermis, and in ichthyosis, old toe-nails, and sebaceous cysts. Pathologically it occurs in abundance in the urine and liver of those who die of acuic yellow atrophy; and, it is said, in the urine of those suffering from severe typhoid and variola, although thereisno chemical proof of this. Leucin is thought by some physiologists to be a stage in the decomposition of albuminous matters into urea. Under the microscope it is seen as round balls, having some resemblance to drops of oil, sometimes hyaline, sometimes with radiating marks, sometimes with concentric rings. The test for leucin with the microscope is very untrust- worthy taken alone. Nearly every urine can be made to give this evidence. If leucin is to be looked for, it must be separated by the following process. The urine is precipitated with acetate of lead, filtered, and the excess of lead removed from the filtrate with sulphuretted hydrogen. The filtrate must bo next evaporated to dryness ; the residue extracted with boiling alcohol and fil- tered ; and the filtrate evaporated to a syrup. If leucin be present, it separates in the form of the crystals described above. Chemical tests must now be applied to the crystals. A small portion is evaporated to dryness in a platinum crucible with nitric acid ; and if leucin be present, a colourless, almost invisible, residue is left, which becomes yellow or brown when warmed with a few drops of soda solution. Leucin is almost always found associated with tyrosin. See Tyrosin. J. Wickham Legg. LEUCOCYTHAEMIA (Aewc&j, white, Kbros, a cell, and ol/ict, blood). — Synon. ; Leukemia (Virchow) ; Splenopathia leucocythemia (Huss) ; Er. Leucocythemie ; Diatfiese lymphogene a forme leucemique (Jaccoud ); Ger. Lcucocythamie. Definition. — A chronic disease, in which there is a considerable and permanent increase in the number of the pale blood-corpuscles ; usually associated with enlargement of the spleen, some- times also with that of the lymphatic glands, and with disease of the medulla of bone. The term leucocythaemia proposed by the late Dr. Hughes Bennett is a convenient and signifi- cant designation, the essential feature of the dis- ease being the excessive proportion of leucocytes in the blood. The term leukemia, proposed by Virchow, is less obviously accurate, since the blood (as Parkes urged) although appreciably paler than normal, is not white. Excess of leucocytes in the blood, slight or transient, is known as leucocytosis, and is met with in many morbid states. Permanent excess, some- times considerable, but rarely very great, also occurs, associated with a primary enlargement of the lymphatic glands — ‘lymphatic leucocy- thaemia.’ These cases differ in many important respects from the cases of leucocythaemia a3St> LEUCOCYTILEMIA. 820 mated with primary enlargement of the spleen ; so that it is most convenient to describe them in connection with lymphadenoma, and to consider here only cases of splenic leucocythaemia. See Lymphadenoma. History. — Pallor of the blood, as if pus were mixed with it, was noted by Bichat in the be- ginning of this century ; and the combination of this appearance with enlargement of the spleen, was observed by Velpeau in 1827. The de- pendence of this alteration in the blood on an excess of pale corpuscles was described by Donn6 iD 1844, and interpreted by him as due to imperfect transformation of white into red corpuscles. In 1845, two cases of the disease were published together, the one by Dr. Craigie, the other by Dr. Hughes Bennett ; and to the latter appears to belong the credit of recognising the salient features of the affection as a distinct malady. A month later, however, Virchow pub- lished another case, independently and admirably worked out. In all these cases the change in the blood was only recognised after death. It was first observed during life in 1846, by Dr. H. W. Fuller, and subsequently by Dr. Walshe. In Germany the first case was diagnosed during life, by Vogel, in 1848. Since then numerous cases and descriptions of the disease have been pub- lished, of which the more important are those of Virchow, Hughes Bennett, Vidal, Huss, Ehrlich, and Mosler. .Etiology. — In only a small proportion of cases of leueocythmmia can any causation be traced. Race, as such, seems to be without influence. Heredity has only been traced, as a history of splenic disease in ancestors or collaterals, in one or two isolated instances. The disease is twice as frequent in men as in women. It may oecur at all ages. It is very rare under the age of ten, and the numbers gradually rise, taking both sexes, to the decade between thirty and forty, when nearly one-third of the total occur (46 out of 154 cases). After forty they fall in each decennial period. In females, however, the maximum is reached in the period between forty and fifty ; and of eleven cases over sixty collected by the writer, only one was in a woman. Position in life appears to exercise no influence on the occurrence of the disease. Depressing influences, inanition, over-exertion, and especially depressing mental emotion, are antecedents which have been occasionally noted. Sexual processes, in women, appear to have a dis - tinct influence. The disease has been seen to be most frequent, in them, during the climac- teric decade, and practically to cease when the menstrual epoch is over. In some cases the disease has commenced during pregnancy ; in a larger number it has succeeded parturition. Injury to the spleen seemed, in one or two recorded cases, to be the cause of the disease. Small-pox, typhoid fever, acute rheumatism, pneumonia, and syphilis, have been supposed to be causes of the affection, but the aetiological re- lation is doubtful. Of all antecedent conditions, intermittent fever is incomparably the most frequent. In one-fourth of the total num- ber of cases (150) analysed by the writer, there was a history either of ague or of residence in an aguo district. The interval between the malarial affections and the disease varied from a few months to thirty years. The fact that, in many cases, a long period elapses, and that the attacks of ague, in some instances, were trifling makes it probable that, in the cases in which th» patients had merely lived in an ague district, the malarial influence, which did not cause ague led to morbid changes which eventuated in the leucocythaemia. One patient under the writer’s care, amiddle-aged woman, had lived in amalarial district only during the first few years of her life, but, shortly before her birth, her mother had suffered from an attack of ague. Anatomical Characters. — Blood. — The blood, as seen after death or during life, is paler than normal, and may even be greyish-red in colour. In extreme cases coagulation is imper- fect ; a grumous chocolate-brown mass results. After defibrination three layers form — red cor- puscles, pale corpuscles, and liquor sanguinis. Under the microscope the pale corpuscles are seen to he in great excess : instead of two or three per field, as in the normal, there may be several hundreds. Enumeration (see H hemacytometer) shows that not only are the white corpuscles in- creased, but the red are lessened out of propor- tion to the increase in the white, so that the total number of corpuscles is always diminished. In- stead of the normal 5,000,000 per cubic milli- metre, there may be only 2,500,000 or even 1,150,000 (50 and 23 per cent, of the normal). The proportion between the white and red varies, being 1-20, 1-10, 1-5, 1-2, or 1-1; or the white may be the more numerous. The apparent is greater than the real excess of white, in con- sequence of the closer contact of the red. It was proposed by Magnus Huss to regard as leuco- cythaemia only' those cases in which the propor- tion is greater than 1 to 20, and the rule has been largely followed ; but it must be remem- bered that in commencing cases the proportion may be smaller than this. The greatest change hitherto recorded was a reduction of the red from 5,000,000 to 470,000 per cubic millimetre (9 per cent, of the normal), and an increase or the white to 680,000 per cubic millimetre in- stead of 15,000, the normal average. The pale corpuscles may be of normal size ; but usually some are large ; and often many are smaller than normal (the globulins of Donne), especially when the lymphatic glands are affected. Re- agents bring into view one to four nuclei. Some of the corpuscles present obvious fatty degenera- tion. The red corpuscles are usually normal in appearance, sometimes unduly pale. Nucleated coloured corpuscles have been seen in a few cases, believed to be intermediate forms between the white and red corpuscles. The specific gravity of the blood is lessened from 1,055, the mean in health, to an average of 1,042 ; the change being due to an increased proportion of water, from 790 parts per 1.000 in health, to 840 in leucocythaemia. The fat and fibrin are increased, and the latter sometimes presents a pe- culiar granularappearance. The iron is lessened. Abnormal constituents have also been found in the blood, such as the albukalin of Reichardt, mucin, a substance analagous to glutin, hypo- xanthin, lactic and formic acids. Minute octa- hedral crystals have been found in the blood ana in many organs after death, about '016 mm. in length. Their nature is uncertain. _ have been found only after death, it is conjec- tured that the substance of which they consist is held dissolved during life. They are not pecu- liar to this disease. Organs.— The.spleen is always enlarged, some- times extremely. Its weight varies from twice to fifty times the normal — 1 lb. to 18 lbs. The average of 72 cases analysed was about 6 lbs. The average length is nearly 12 inches. The en- largement is commonly uniform; the shape of the orme reason to believe, that as the spleen alone ay be diseased, so, in some rare cases, the arrow of bones may alone be diseased, and j a y give rise to a primary ‘ myelogenic leuco- j'thsemia,’ but this is not yet proved. That e disease may be primary in both the marrow '.dthe spleen, is highly probable, from recorded TIIjEMIA . 823 facts. It is certain, however, that the marrow is, in most cases, not affected primarily, and may bo unaffected throughout, or may suffer second- arily, as do the glands. The same is true of the collections of lymphatic tissue elsewhere in •the body. The cases in which the lymphatic glands enlarge early — ‘ lymphatico-splenic leuco- cythsemia’— are, for the most part, if not entirely, cases of composite nature. The spleen presents a double change — growths in the follicles, such as are associated with the glandular growths in lymphadenoma (Hodgkins’ disease), and increase in the splenic pulp, as in pure splenic leucoey- thaimia. In such cases there may be a large increase in the pale corpuscles of the blood. Diagnosis. — The diagnosis of leucocythaemia rests on the existence of enlargement of the spleen, and a considerable excess of leucocytes in the blood. In all cases of splenic tumour, the blood should he examined ; if the proportion of white corpuscles to the red is greater than 1 to 20, the case is certainly one of leucoeythsemia. But if the proportion is less than this, leucocythaemia cannot with certainty be excluded, because it is probable that, in all cases, the splenic tumour and anremia precede the leucocytal excess, and the latter may he in process of development. To ascertain the actual state of the blood, it is always desirable to enumerate the corpuscles with the hsemaeytometer. Repeated examina- tion, to ascertain that the proportion of pale cor- puscles is not increasing, is necessary before impending leucoeythsemia can he excluded. In cases in which the lymphatic glands enlarge early, the question arises whether the case is one of splenic leucoeythsemia, or of Hodgkins' disease. In the latter, as just stated, the enlarge- ment of the spleen depends, not on an increase of the splenic pulp, hut on overgrowth of the Mal- pighian follicles; the splenic enlargement is less than in leucocythaemia, and is less uniform. In the composite cases alluded to above, in which, witli enlargement of the glands and splenic follicles (lymphadenoma), there exists also over- growth of the splenic pulp, and a considerable leucocytal excess in the blood, the two morbid processes are conjoined, and the affection may- be termed lymphadeno-splenic leucocythaemia. These cases are distinguished from the simple splenic affection by the early enlargement and firmness cf the glands. In simple- splenic leueo- cythaemia the affection of the glands is usually late, and rarely considerable. The diagnosis of the disease from conditions in which a consider- able excess of pale corpuscles exists, without enlargement of the spleen, is usually easy, be- cause such excess is transient, soon passes away, and is not associated with a splenic tumour. Prognosis. — The prognosis of a disease which depends on a primary affection of theblood-form- ingorgnnsis necessarily most grave. No means of arresting the progress of the developed disease has yet been discovered. The immediate prognosis is less serious in proportion as the evidence of organic changes in the blood-forming organs is slight, and in proportion to the early stage of the disease. Neither age, sex, nor causation affords prognostic information. The greater the number of white corpuscles and the deficiency of red, as ascertained by counting, the worse the 324 LEU COC YTHiEMI A. prognosis. The size of the spleen, alone, affords little information. Hemorrhages are of grave augury, but epistaxis least so. Treatment. — The knowledge of the causes of leueocythasmia, slight though it is, suggests im- portant prophylactic measures — the prevention of ague, and the careful treatment of all who have been exposed to malarial influences. Splenic tumours resulting from such exposure should be systematically treated ; the subjects of them should exercise great care to avoid exposure to cold, injuries, and all causes of portal congestion. These precautions are especially necessary in women at the menstrual periods ; and if such women bear children, their state during preg- nancy and after parturition should be carefully supervised, and lactation prohibited. Whether there is simple anaemia or leucocythcemia, every effort should be made to reduce the size of the splenic tumour, by quinine, cold affusion, ergo- tine, and especially by voltaic electricity, a most powerful agent. By obtaining contraction of the spleen, expelling retained leucocytes, and per- haps stimulating directly its functional action, we render its condition less abnormal. In a caso of anaemia splenica no remedies improved the blood-state till the spleen was galvanised, when the red corpuscles at once began to increase. Remedies which do good in ordinary anaemia have slight influence in this disease. Iron is almost useless; cod-liver oil, however, has seemed to do some good. Arsenic has been largely tried, but without benefit in pronounced cases. Its undoubted value in lymphadenoma suggests its further trial in early cases ; it should be given in tho largest doses that can be borne. Phos- phorus has been recommended, but in almost every case of pronounced leueocythaemia it has been powerless for good. Nevertheless, its in- fluence in improving the blood-state in lympha- denoma warrants further trial in the early stage of the disease. Iodides, bromides, and mercury are useless. Change of air may slightly improve the patient’s state, but has no influence on the disease. Transfusion has been tried, but the results are not encouraging. Excision of the spleen has been suggested. The operation has been performed with success in cases of anaemia splenica, but in actual leueocythaemia the opera- tion has been invariably fatal— in most cases from uncontrollable loss of blood, the result of the haemorrhagic tendency. Further trial of it, in such cases, is not justifiable. In early cases, where there is no considerable excess of pale corpuscles, and the red are not reduced below sixty per cent, of the normal, it might be suc- cessful; but it is questionable whether, in such cases, the ultimate issue without interference is sufficiently certain to justify the performance of so grave an operation. Special symptoms may require treatment. Haemorrhage must be checked by the usual methods, and crystals of perchloride of iron may be applied to accessible places (Jon- ner). For vomiting, a posture which will relieve the stomach from pressure, and counter-irrita- tion, are usoful. Aperients should be employed with caution ; and under no circumstances should the yellow tint of the skin lead to the use of mercurials. For the oedema, digitalis and other diuretics are best. For the splenic pain, counter i LEUCORRHCEA. irritation, sedative liniments, and hypodermic injections of morphia may be used. In propor- tion to the anaemia, physical rest is important that the diminished supply of oxygen may not be rendered inadequate for the need of the tissues, by muscular exertion. W. R. Gowers. LEUCOCVTOSIS (Aeiocis, white, andici/Toi, a cell). — A condition of the blood, in which the white corpuscles are appreciably but mode- rately increased. See Blood, Morbid Condi- tions of. LEUCODEEMA (A.eu/d>s, white, and 5q>/±o, the skin). — White or aehromatous integument. See Pigmentary Skin-Diseases. LEUCOMA (\evubs, white) A white opa- city of the cornea, generally referable to in- flammation or ulceration of that structure. Set Eye and its Appendages, Diseases of. LEUCOPATHIA (\evKbs, white, and vd&n a disease). — Synon. : Albinism, Achroma, Leni-o- derma, Leuce, Leucasmus. This disease is sometimes general, but fre- quently partial ; in the latter form constituting cutis variegata and ‘ piebald skin.’ The -white- ness is referable to absence of pigment, which may be simply due to an arrest of function of tho rete mucosum, or to an organic alteration of the integument. See Pigmentary Skin-Dis- eases. LETTCO-PHLEGMATIC TEMPERA- MENT. See Temperament. LEtTCORRHCEA (Aeuxos, white, and |Ss», I flow). — S ynon.: Fr. Leucorrhee; Ger. Weisser Flues; Lat. Fluor All/us; Pop. ‘ The 'Whites ’ ; ‘ White Discharge.’ Definition. — A non-hsmorrhagic discharge, of pale colour, escaping from the female genital fissure. -Etiology. — Leucorrhcea is a symptom rather than a distinct disease ; and is found resulting from all the morbid processes that lead to hy- per-secretion from the genital mucous surfaces, or from the glands opening upon them, whether tho mucous membranes be injured or entire. It is, however, a source of much discomfort and deterioration of health, and so demands special treatment. Symptoms. — Leucorrhcea presents several dis- tinct varieties according to the seat of its cause ; and the symptoms of each variety require sepa- rate consideration. 1. Vulvar Leucorrhcea. — In this variety a glairy viscid secretion is found bathing the ap- posed surfaces of the pudenda, stiffening into a crust on the surface of the labia majors or on the insides of the thighs, and sometimes glueing the lips more or less firmly together at their margins. It is usually derived from the mnei parous glands covering the internal surfaces of the labia majora and the nymphs ; but in cases of special eruptions and general vulvitis it m37 come from the vestibular surface ; and in still rarer cases it is poured out from the glands of Bartholin. Vulvar leucorrhcea is met with al any period of life, hut is most common in the young, infantile leucorrhcea almost always being of this variety. In cases of gonorrhoeal infection LEUCORRHCEA. in the female, the vulva is usually the seat of a profuse discharge that is apt to become puru- lent, but it is rarely confined to this situation, spreading both into the urethra, and upwards into the higher spheres of the genital mucosa. 2. Vaginal Leucorrhcea. — The discharge in cases of vaginal leucorrhcea is most frequently white in appearance, of acid reaction, and due to a secretion from the general surface of the vaginal mucous membrane. Its whiteness, on microscopic examination, is found to be owing to the presence of quantities of scaly epithelial cells, many of which are crowded with fatty par- ticles, whilst others have been quite dissolved in consequence of the fatty degeneration. Some- times the discharge has a more yellowish tint, and then it is found to contain quantities of pus-cells among the epithelial scales. In the former group of cases we have to do with a simple catarrhal condition of the vaginal mucosa ; in the latter there are red granulation-like spots scattered over the membrane, which has here lest its epi- thelial covering. Vaginal leucorrhcea is a com- plaint to which women are specially liable during their reproductive life. The catarrhal form is extremely common in young married females ; whilst the other form occurs rather about the menopause, or. if occurring earlier, is complicated with some of the other varieties of leucorrhoea. Apart from specific causes, it may be brought on by sexual excesses ; by the presence of a foreign body, such as a pessary ; by a displaced uterus; by a chill; or by any condition that interferes with the circulation in the pelvis. In a large proportion of cases it is secondary to the next variety of leucorrhcea. 3. Cervical Leucorrhoea. — The discharge that comes from the canal of the cervix uteri is transparent, like unboiled white of egg, very tenacious, and of alkaline reaction. It may still present these characters as it escapes from the pudenda ; but it generally becomes somewhat clouded as it passes through the vaginal canal, . and gets acted upon by the acid secretion from the vaginal walls. Independently of this change in the vagina, it is sometimes found already more or less opaque as it lies within the cervical canal, and may he seen of a yellowish or greenish or reddish tint in various cases. The clear cervical leucorrhoea is seen under the microscope to be made up of a viscid magma, having entangled jin it large numbers of columnar epithelial cells, which have a tendency to arrange themselves in tows. These are easily seen to be the ciliated ipithclial cells that cover the normal mucous uembrane, but deprived for the most part of heir cilia. They are accompanied by smaller ounded cells like mucous corpuscles or wander- ng cells, partly derived from the interior of the ;rypts, and partly shed from the general surface rom which the epithelium has been removed, n almost all cases some of the epithelial cells nd mucous corpuscles are charged with fatty articles, and surrounded with granules, resulting •om the breaking down of some of their number, he more turbid the fluid, the more the cells re found to have undergone such degeneration ; id where the discharge is profuse, fluid, and of dlowish colour, it has more the characters of a indent fluid in which the relatively few cylin- 825 drical cells are changed in form, becoming oval or rounded, and nearly all reduced to a compound granular mass. The more deeply tinted dis- charges owe their discoloration to the admix- ture of blood, the rod corpuscles of which can easily be recognised. Apart from the leucorrhceas of specific origin, this is the commonest of all the varieties. It maybe found in females of any age, but specially affects women during their reproductive history, and more especially those who have been mothers. We can understand the special liability of the cervix to catarrhal affec- tions, when we remember that all intra-uterine discharges pass through and may irritate it ; that it is exposed to damage during the transit of the foetus in parturition; thatvaginalaffeetionseasily pass into it by continuity of structure ; and that it may readily be injured by foreign bodies in the vaginal canal, or even by fretting of its orifice against the vaginal wall in cases of displacement or excessive mobility. 4. Intra-uterine Leucorrhoea. — Here also the discharge is transparent, like white of egg, and alkaline in its reaction, but it is more fluid than the secretion from the cervical canal, and may escape as a clear liquid from the genital fissure. In cases of long standing, more particu- larly where there exists some organic disease in the uterine parietes, the fluid becomes turbid, purulent, and more frequently than in any other variety of leucorrhcea tinged with blood, even alternating with irregular discharges of blood. Under the microscope we see many cylindrical epithelial cells, not infrequently ciliated; along with groups of smaller cells, partly cylindrical, partly rounded, that have been discharged from the uterine follicles ; all imbedded in a mucous fluid. Where the discharge is more turbid, tho epithelial cells are seen to be undergoing fatty degeneration, and to be accompanied with wan- dering cells, pus-globules, and crowds of free fatty particles. This uterine leucorrhoea may be found at any period of life, but as an indepen- dent affection it is found almost exclusively in virgins or your.g married women, or in women who are ceasing, or have ceased, to menstruate. In the last-named class of cases the cervix is often atrophied, and its orifices narrowed ; and tho intra-utorine secretion may accumulate for a time, and be expelled with some degree of suf- fering. Most frequently it is found associated with cervical leucorrhoea, the endo-cervical affec- tion having passed up to the endometrium, or, more rarely, vice versa. Perhaps the most fre- quent form of it is found in women who are subject to a leucorrhoeal discharge before or after the menstrual periods ; and in the cases of amenorrhea where a pale discharge escapes at the usual menstrual periods, this has its source in the interior of the uterus proper. o. Tubal Leucorrhoea. — ■ Doubtless some small portion of the fluid that escapes in certain eases of leucorrhcea is furnished by the Fallopian tubes ; but despite the elaborate attempts of Hen- nig and others to establish a distinction between it and the other varieties, it remains rather as a subject of pathological interest than of clinical importance, and need not occupy us further here. Diagnosis. — The statements of a patient in regard to a lencorrhosal discharge cannot be re« R23 L E U CORRHQE A. lied on in establishing a diagnosis as to its source. If it be white and flaky we may judge that it is vaginal ; if more transparent, and escaping in half- coagulated flocculi, we may conclude that it is cervical ; whilst a clear and more continuous and fluid discharge would be more justly referred to the uterus proper. But it is never safe to trust merely to the appearance of the discharge as it escapes from the vulva, for it may have become modified as it lay in or traversed some part of the canal, or may be compounded of fluids derived from different surfaces. The seat of the dis- charge must therefore be exposed. In the vul- var variety it suffices to separate the labia and occasionally to expose the navicular fossa and the orifices of the Bartholinian ducts, bypassing the finger into the anus. The vaginal form of leucorrhcea requires for its detection the use of a speculum, duck-bill or tubular ; and the cervical, one of these or a bi-valve speculum. For the diagnosis of intra-uterine leucorrhcea it is some- times helpful to remove some of the fluid for microscopic examination by means of a fine syringe. Unless a clear history of infection can be obtained, it is almost impossible to establish a distinction between a gonorrheal discharge and the simpler catarrhal leucorrhoea. In the former there is a very notable tendency to spread through all the contiguous mucous surfaces, though the vulva may he predominantly affected. In chil- dren suffering from the infectious discharge, traces of the injuries that are usually inflicted at the period of infection should be sought for. Treatment. — In instituting our treatment of leucorrhoea it is of the first importance to have in view the constitutional condition of the patient ; to use means to counteract any diathetic ten- dency — tuberculous, strumous, or syphilitic; and to raise as far as possible the general stan- dard of the patient's health, by tho administra- tion of tonics, and the enforcement of a suitable diet and regimen. It is partly in this way that a change of residence is often useful; and in making a change, it is well for the patient to go to some of tho spas, such as Ems or Kissingen, the waters of which are helpful in reducing con- gestions and catarrhs of the pelvic viscera. In young women of relaxed habit of body, it mav be enough to prescribe quinine and iron or arsenic, and the daily use of a cold sponge bath; and in infantile leucorrhcea, cod-liver oil aud iodide of iron should be administered. In the great majority of cases of leucorrhoea, 6ome kind of local treatment becomes an absolute necessity. Sometimes it is enough to pay strict attention to cleanliness, washing the pudendal surfaces with a soft sponge, or syringing the va- ginal canal with tepid water; and even when as- tringent applications are to be made, the surfaces should first be subjected to a detergent stream of water. Where there is marked congestion of tho uterus it is best to make the injections with hot water, and to keep the stream passing through the vagina for at least five minutes at a time ; the immediate relaxation of the blood-vessels and hyperaemia being followed by contraction of their walls, which favours the cessation of the dis- charge. The astringents most serviceable for checkinguidiwmnd leucorrhceas are alum, Illuminated iron, acetate of lead, sulphate of cop- I LICHEN. per, sulphate of zinc, borax, and infcsiont of oak-bark, matico, and other vegetables charged with tannin. They are best applied in the form of an injection with a Higginson’s tyringe. having a vaginal nozzle attached to it ; or of a douche through a long india-rubber tube, with a stop-cock for regulating the flow fitted clos« to the vaginal nozzle, and the other extremiw opening into a wide receptacle, or fitted to a filler into which the fluid is poured. Where there is a difficulty in using the injection, and where it is desirable to keep np a more prolonged ap- plicationof the medicament, it maybe introduced into the vagina in the form of pessaries made with cacao-butter or with gelatine. Topical appli- cations to tne canal of the cervix and cavity of the uterus ought always to be made tlirough the speculum, and without such applications it is a hopeless task to undertake the cure of cervical leucorrhcea. Here, more concentrated or more powerful astringents or escharotics become necessary. Nitrate of silver in the form of a stick of caustic is easily applied, but its repeated application may lead to mischief. Zinc-alum, dried sulphate of zinc, sulphate of copper, per- chloride of iron, or tannin may be introduced in the form of rods or arrows made with starch and giun. If a uterine sound or stiletto be dipped in water and a thin film of cotton wadding wrapped round the point to the length of about two inches, the adherent mucus can be cleared away, and the same or another sound mounted with wadding can be charged with fuming nitric acid, or the acid nitrate of mercury, or strong carbolic acid, or a solution of perchloride of iron, or tincture of iodine, and carried through the speculum along the cervical canal. In intra- uterine leucorrhoea it becomes necessary to carry the application right up in the same way to the interior of the uterus. It is usually best to be- gin with one of the stronger liquids, apply it a few days after a menstrual period, and folio" it up with applications of iodine. So long as the stiletteor sound with the dry waddingpasses easily through the os internum, it is usually necessary to continue from time to time the intra-nterine application. Alexander Bussell Simpson. LEUKAEMIA. See Leccoctthxmia. LEUTERBAD (Locite), in Switzerland. Thermal earthy waters. See Mineral Waters. LICE, Diseases due to. See Pedicclus. LICHEN (AeixV, an eruption). — This term was originally assigned to lichens of the vege- table kingdom from the idea, which is by them suggested, of adhesion to the bark of a tree. Subsequently the term became transferred to a diseased state of the skin, but the precise nature of that disease is unknown at the present day. The affection which most nearly realises the signification of the term is lepra vulgaris, r '~ possibly a centrifugal cluster of papulae. In the latter sense the term was adopted by Willan, and since his time it has been generally accepted ns the type of a papular eruption of the skin. TVitl this acceptation lichen is a folliculitis attended with prominence in the form of a minute pimple and may be associated with eczema — as in ibi LICHENS instance of lichen simplex, lichen circumscriptus, lichen agrius, and lichen tropicus ; or with urti- caria — as in lichen urticatus. It may, however, be independent of these, as in lichen pilaris, lichen planus, and the eruption described by Hebra, under the name of lichen scrofulosorum. See Appendix. Erasmus Wilson. LIENTERIC (\e~Los, smooth, and tvr epov, the intestine). — A form of diarrhoea in which the stools contain much undigested food, in con- sequence of its having passed rapidly along the alimentary canal. See Diarrhcea ; and Stools. LIGHTNING, Effects of. — The effects produced by lightning differ only in degree from those produced by the discharge of static electri- city, generated in the laboratory. With a Leyden jar of sufficient size a small animal may be killed, and in larger animals the effects of shock and local injury may be produced. By lightning a person may be killed outright, and a post-mortem examination may reveal no lesion whatever. The mode of death in these eases seems to be by the shock to the brain and nervous system generally. Effects not distinguishable from ordinary con- cussion of the brain may be observed, and the person struck may remain insensible, with slow respiration, scarcely pereeptible pulse, and dilated pupils, for periods varying from a few minutes to more than an hour. This may be followed by complete recovery; or there may remain paralysis of the limbs, usually the lower, or occasionally derangements of the special senses — blindness, a metallic taste in the mouth, noises in the ears, and an odour in the nose. The brain may be more or less permanently affected, and we read of delirium, mania, and loss of memory as results of the lightning-stroke. Various objective phe- nomena have also been observed. The electricity .on its way through the body may produce a number of mechanical effects. Wounds like those produced by a blunt stabbing instrument may nark the points of entry and of exit ; bones have oven been broken, the membrana tympani has been ruptured, and internal viscera have suffered n a similar way. Patches of erythema, urticaria, 'mperficial ecehymoses, and scorchings of the urface having a curious tree-like and branched .rrangement, have all been described ; and this ast phenomenon has apparently given rise to the ssertion that delineations of trees standing in he neighbourhood of the accident have been .raced photographically on the body of the vic- im. Lightning is apt to be attracted by any betal w orn about the body. Watch-chains are ■equently broken and fused, and by the intense eating of these metallic conductors the clothing .as been set on fire. Watches have been broken 'ad partially fused, and have forcibly burst trough the pockets in which they were con- ined. Steel articles, such as pocket-knives, have ten rendered magnetic. The clothing is some- mes burnt and torn to a great extent, and strong tots have been found burst open, or thrown off e feet to a distance, or nails in the soles have en driven out of them. The remote effects of ;htning are due to the mechanical injuries pro- ved by it: permanent paralyses may result >m injury to the nerves, and inflammatory LITHONTRIPTICS. 827 action may be set up by the injury inflicted on internal or external parts. One ease is recorded in which the whole of the hair on the head and body, as well as the nails of both hands, came off after a lightning stroke. It has been asserted that rigor mortis does not occur in persons killed by lightning, and that the blood remains fluid for a very long time after death, but neither of these facts has been substantiated. Treatment. — The treatment of those who have been struck by lightning consists in first rousing and keeping up the respiration and circulation. The cold douche is often of great value, and this, combined with friction of the limbs, warmth to the extremities, and the administration of stimu- lants, either by the mouth or in the form of enemata, would seem to be the measures best calculated to restore the suspended animation. Secondly, special injuries must be subsequently treated according to their nature. G. V. Poore. LINE^l ATROPHIC2E (Lat. Atrophic lines). — A form of scleroderma. See SCLERO- DERMA. LIPOMA (Aliros, fat). — A fatty tumour. See Tumours. LIPPSPRINGE, in Germany. — Earthy waters. See Mineral Waters. LISBON, West Coast of Portugal. — - Warm, moist climate, with very variable tem- perature. Mean temperature in winter. 51° Fahr. Prevailing winds, N.E.-S.E. in spring; S.W, rainy. See Climate, Treatment of Disease by. LISDOONVARNA. in Ireland.— Sulphur waters. See Mineral Waters. LITHIASIS. LITHIC ACID DIA- THESIS (\ldcs, a stone). See Gout ; and Uric Acid Calculus and Diathesis. LITHONTRIPTICS (\l0os, a stone, and Tpiipis, friction). — Synon. : Fr. Lithontriptiques ; Ger. Steinaufloscnde Mittel. Definition. — Lithontriptics are therapeutical measures used for the purpose of dissolving cal- culi in the urinary tract. Enumeration. — The chief lithontriptics are : Water, Potash, Lithia, Borax, Phosphate of Soda, Soap, Lime-water, Nitric Acid, Phosphoric Acid, Hydrochloric Acid, Sulphuric Acid, and Mineral Waters, such as those of Wildungen. Action. - — • Lithontriptics dissolve stone in various ways. Some of them possess a simple solvent action, as in the case of water. Others unite with the calculi so as to form a more soluble compound, as in the case of the union of potash or lithia with the uric acid of a calculus, producing urate of potash or lithia, which is more soluble than uric acid itself. In the case of phosphatie calculi dilute nitric acid combines with the bases of which they are composed to form a more soluble compound. Uses. — Lithontriptics may be employed for tlio purpose of dissolving calculi either in the kidney or in the bladder. They may either be taken internally, so as to act upon the calculi through the medium of the urine ; or be injected directly into the bladder. This latter treatment can only be adopted in the case of a vesical cal- 828 LITHONTEIPTICS. cuius, and is inapplicable in the case of a renal calculus. The most useful of all lithontriptics is water, and especially distilled water. When this is taken in large quantities, the urine be- comes very dilute^ and small calculi may be partially dissolved, so as to be reduced in size and ejected through the natural passages. If the calculus is composed of uric acid, potash or lithia is the best remedy for internal adminis- tration, the urates of these bases being mere soluble than the urate of soda. In the case of phosphatic calculi, acid remedies are employed instead of alkaline; but it is exceedingly difficult to render the urine acid by means of acids given by the mouth, unless they are administered in quantities likely to derange the digestion. In place of mineral acids, benzoic acid and benzoate of ammonia have been employed, as benzoic acid passes out of the body in the form of hippuric acid, giving an acid reaction to the urine. On account of this difficulty, acids have been di- rectly injected into the bladder, in order to act directly upon the stone; for which purpose nitric acid, largely diluted, is the one which has been most generally employed. This procedure, how- ever, is now rarely had recourse to, as it is much easier to crush the stone by mechanical means. T. Laud sr Brunton. LITH UKIA (\i6os, a stone, and olpov, the urine). — A condition in which a deposit of uric acid or urates takes place in the urine. See Uric Acid Calculus and Diathesis ; and Urine, Morbid Conditions of. LIVEE, Diseases of. — Synon. : Fr. Mala- dies dn Foie ; Ger. Krankhcitcn Fr Leber. The liver is an organ which has always occu- pied a prominent place, both with the pro- fession and the public, as being the seat of important diseases, as well as the origin and source of numerous symptoms and ailments. Not only is it concerned in the formation of one of the principal secretions, namely, the bile, but, according to most physiologists, it has a peculiar glycogenic function ; and some autho- rities now maintain that it is in this organ that urea is formed. Moreover, a large quantity of blood passes through it, in connection with the portal circulation, by means of which the blood returning from the stomach, intestines, pancreas, and spleen is distributed throughout the liver, and thence conveyed to the inferior vena cava. Hence, hepatic affections, by interfering more or less with the physiological functions or anato- mical arrangements of the organ, may give rise to diverse phenomena, not only of a local cha- racter, but associated also with the general system. Summary of Diseases. — The individual affec- tions of the liver will be treated of separately, in alphabetical order, but it may be well to in- dicate here beforehand their general nature. The first great division is that into functional and or- ganic. Functional hepatic disorders are regarded by many eminent physicians as being of peculiar significance, and as demanding special attention, particularly with reference to those disorders which influence the secretion of the bile. The main organic diseases of the liver, in which there is some more or less obvious anatomical change, LIVEE, DISEASES OF. may be summarised thus ; — 1 . Congestion, either active or mechanical. 2. Hemorrhage into the organ, or so-called apoplexy. 3. Acute inflam motion, usually terminating in abscess, rarely in actual gangrene. 4. Chronic inflammation, end- ing in the condition termed cirrhosis . in which the liver is hardened, granular, and usually contracted. 5. Hypertrophy. 6. Atrophy, either acute — which is a very fatal disease ; or chronic, the latter being of different kinds. 7. Biliary accumidation. 8. Malpositions and uialfo*ma tions. 9. Infiltrations, including fatty and al- buminoid disease. 10. Few growths, especially hydatids, syphilitic formations, and cancer. Tubercle is occasionally found in the liver. ^Etiology and Pathology. — Taking a gen- eral survey of the causes which originate hepatic diseases, and of the circumstances under which they arise, the most important may be indicated thus: — 1. An affection of the liver may be merely a local manifestation of some constitu- tional or general malady, as in the case of cancer, tubercle, syphilis, or albuminoid disease. The last-mentioned is remotely due to causes which need not be discussed here ; but it may be men- tioned that the liver is an organ very liable to suffer from albuminoid change. 2. Some local injury or irritation may originate hepatic dis- ease, either from without, as a blow or stab; or from within, as sometimes happens in the case of biliary calculi. 3. Certain animal parasites entering the body are prone to lodge in the liver. This applies especially to hydatids, originatingfrom the Tania echinococcus. 4. From the intimate connection of the liver with the alimentary canal, and the existence of the por- tal circulation, hepatic disorders are very liable to arise from improper diet, as well as from digestive derangements in the stomach and bowels, and constipation. 5. Abuse of alcohol, and especially indulgence in ardent spirits, oc- cupies an important position in the aetiology of disorders and certain diseases of the liver. Un- due use of hot condiments is also regarded as an element of some consequence. 6. Long-continued •exposure to a high temperature in tropical cli- mates is a powerful cause of hepatic derange- ment and disease, particularly if accompanied with too free indulgence in alcoholic stimulants. 7. Diseases of the liver may arise by extension from neighbouring structures ; or by the convec- tion of morbid materials from more or less dis- tant parts. The latter may be best illustrated by pyaemia; and secondary affections of this kind aro believed to be particularly frequent in the liver, when the morbid products are conveyed directly from the alimentary tube, in conse- quence of some disease of its walls, such as ulceration. 8. Obstruction to the circulation, due to certain forms of cardiac disease, is an important cause of some hepatic affections. 9. Disorders of the liver are often attributed to various hygienic errors, exposure to cold, and other causes, but how far this conclusion is jus- tified in particular cases is a matter of question. Clinical Signs. — So far as the actual diseases.'! the liver are concerned, it is unnecessary here la regard any symptoms resulting from disturbance of the glycogenic functions, as these belong to a difforent category. The clinical phenomena to LIVER, ABSCESS OF. 829 be looked for lie -within a limited range, and may he grouped under the following heads : — X. Morbid sensations, referred to the hepatic region, or to the shoulder, such as pain of various kinds, tenderness, sense of weight, throbbing. 2. Symptoms due to interference with the biliary functions, particularly jaundice and Its accom- panying phenomena. 3. Symptoms resulting from more or less obstruction to the portal circulation. These include digestive disorders, due to con- gestion or catarrh of the mucous membrane lining the stomach and intestines ; hemorrhage from this membrane in some cases ; ascites, which is a most important symptom ; enlarge- ment of the spleen ; congestion of the womb in women ; haemorrhoids ; and, in certain condi- tions, dilatation of the veins of the abdominal wall. 4. Symptoms produced by the pressure, or interference with neighbouring structures, of an . enlarged liver. Thus, it not uncommonly ex- tends upwards, checking the movements of the diaphragm, and pressing upon the lung, hence causing dyspnoea. Or it may compress vessels and olher structures ; or in some cases it even ■ interferes with the heart’s movement. 5. Phy- i sical signs. — These indicate enlargement or con- traction of the liver; changes in situation or isliape; or changes in physical characters. 6. General symptoms. These maybe more or less ■ independent of the hepatic disease, this being merely a part of a general malady ; or the liver- ■affeetion may give rise to pyrexia, wasting, and other symptoms. Hepatic derangements are sup- posed to originate many general symptoms, not obviously connected with this organ; and they have even been made accountable for the goaty ;tate. The individual diseases of the liver will now oe discussed in alphabetical order. Frederick T. Roberts. LIVER, Abscess of. — Synon. ; Hepatic .bscess ; Fr. Abces du Foie-, Her. Leberabscess. Though of such importance as to require a eparate notice, abscess of the liver is not an ndependent affection, but is only the consequence f inflammatory action set up in that organ. .Etiology. — As abscess of the liver is com- aratively rare in temperate climates and fre- dent among Europeans in tropical ones, it has aturally been attributed to the effects of heat, or ' alternations of heat and cold. Being occasion- lly associated with malarious fever, and fre- lently with dysentery, it is supposed that it may s induced by the same causes as those diseases, he opinion has been often advanced that ab- ess of the liver is always secondary to dysen- ry, or to ulceration of the bowels. That it may easionally be so it would be difficult to deny, th reference to what is known of its occasional usal connection with operations on the rectum, it although dysentery and hepatic abscess are iquently associated, this association is very re except in the tropics ; nor is it there very istant. Thus dysentery is extremely common children, while abscess of the liver is equally •e among them ; indeed, abscess of the liver is ry unusual under the age of twenty, and is re common after the age of twenty-five than ow it. The proportion of cases in which liver-abscess and dysentery are associated is extremely variable ; it is more frequent in one year than in another, and also at one period of the year than at another. Although dysen- tery is the commoner affection, yet occasionally the number of cases of hepatitis, with a certain proportion of deaths from abscess, may greatly exceed the number of cases of dysentery. There are many fatal cases of abscess in which the towels have been found perfectly healthy ; ab- scess of the liver, on the other hand, can scarcely be considered to be very frequent in dysentery. Yet dysentery and abscess of the liver seem to arise in the tropics from very much the same causes ; and something is there impressed on the constitution which seems to render the system, even for some years after a return to Europe, somewhat inclined to liver-abscess. Abscess of the liver is an occasional result of pytemia, and connected at times with surgical operations, especially with those performed on the rectum. It has been induced by falls or by direct violence ; or by the impaction of a gall- stone, especially where it has been rough and spicular. The predisposing causes are the same as those of hepatitis — drinking, irregular life, exposure, and residence in the tropics. Anatomical Characters. — The course of for- mation of hepatic abscess seems to be the follow- ing ; — The liver is first loaded in some portion or portions with an excess of blood ; then fol- lows exudation of lymph and pus, forming small deposits, of which two or throe coa- lesce, while the liver-substance breaks down. The abscess extends in this mode. It is usually lined by a membranous cyst, which is very thin when the formation of the abscess has been rapid, and of greater consistence when the abscess is old. The abscess may be of almost any size, from that of a small orange up to a huge cyst containing ten or twelve pints of pus. Six hundred ounces of pus have been withdrawn from an abscess in five months. Most commonly the abscess is single, but frequently there are several abscesses. They are most common in the right lobe. They may have reached the surface or havo burst, or they may be only discoverable on making an incision into the organ after death. In the great majority of cases, if the abscess has not been exposed to the air, its contents are laud- able or healthy, inodorous pus. In some cases the pus is of the colour of chocolate. It is said that streaks of bile have sometimes been ob- served. Slight pinkish streaks are not so rare. An abscess may open through various channels. Sometimes it finds its way to the surface, and discharges itself through the skin. This usually happens lower down than tho ribs. The abscess may open into the peritoneal cavity, and has done so into the pericardium. In such cases the result is fatal. It passes occasionally into some portion of the bowels, and as this causes the least constitutional disturbance, it is a favourable mode of discharge. Very frequently, when the abscess is near the convex side of the liver, the diaphragm and the surface of the liver become adherent— as in this case the abscess has not usually been very deep-seated — and the abscess opens itself through the lung. This offers a fair LIVER, AESCESS OF. 830 chance of recovery. There are still other possible points of exit, but these are chiefly matters of curiosity. When the abscess has burst, cicatrisation commences, and has sometimes been traced when the case has terminated fatally. But it is remarkable that well-marked cases of complete cicatrisation have not often been recorded— various membranous formations and slight de- pressions in the liver being new considered to be the results of syphilitic hepatitis. There is a strong presumption that liver-abscess is occa- sionally absorbed without having ruptured, and also that it may remain latent for a long period. In cases where the abscess has been partially absorbed, a white fibrous sac has been found, containing a little pus and sometimes cheesy matter ; and in some cases in which there has been strong presumption that the abscess had existed for four or five years, the walls of the abscess have been found much thickened, and almost cretaceous. Although a portion of the liver has been converted into abscess, the remaining portion of it may be healthy, or some- what indurated from former attacks of con- gestion ; and it is wonderful how in favourable cases, where the contents of an abscess have been absorbed or evacuated, the remaining healthy portion of the liver executes its work. In addition to the formation of ordinary he- patic abscesses, suppuration may take place ex- tensively throughout the liver, after lobular hepatitis, as in a case recorded by Dr. Quain (Path. See. Trans. 1853) ; and also in the portal canals, or beneath the investing capsule of the liver. Symptoms. — These are more urgent when acute hepatitis runs into abscess, than when abscess is the consequence of repeated attacks of illness, as Is most commonly the case. The general symp- toms are a pale, muddy complexion ; a look of anxiety, and a state of low, irregular feverish- ness, the pulse being generally about 100, and the temperature increased by a degree or two. There may be one or two shivering fits, or accesses of fever simulating ague. The appetite is im- paired,- there is vomiting, with irritability of the stomach ; the tongue has generally a white coating, but in some cases is almost clean. The throbbing pain which usually accompanies the formation of pus is scarcely ever present. There is occasionally pain in the shoulder or shoulder- blade, but this is uncertain. A certain amount of pain, usually dull, is felt in the liver, often in- creased on pressure ; attended with more or less, and sometimes with very considerable, enlarge- ment of the organ. There is also fulness or bulg- ing of the right side; and at the last, possibly, fluctuation. If abscess form on the upper side of the liver, there is more or less pressure on the diaphragm, causing shortness of breath, and occa- sionally leading to local inflammation, attended with acute pain. But such symptoms, which are more valuable taken collectively than indi- vidually, may not be present in a marked degree. The state of the biliary secretion is very often normal, or nearly so ; and the condition of the urine offers no certain indication, although bile- pigment is sometimes present in it.. Jaundice is comparatively rare. In some of its more in- sidious forms, hepatic abscess may come on with- out being preceded by fever or ushered in by sbiverings; but even in such cases a general falling off of the health is always observable. As has been already pointed out. the abscess may burst in various directions; or it maybe opened by a surgical operation. As a general rule the result is more favourable — probablv because the opening being small the pus escapes gradually — when the abscess finds an opening for itself, than when it is evacuated artificially. In the latter case the discharge usually la-ts for some months — nay, for more than a year in some instances ; and although the patient im- proves up to a certain point, he is very likely to sink in the end. When the patient sinks, it is usually from general exhaustion of the system. Pyaemia is of extremely rare occurrence. Complications. — Abscess of the liver is often complicated with dysentery, or with diarrhoea : and less frequently with malarious fever. Some- times there is a certain amount of pleurisy or pneumonia. This is more frequent in acute cases than when the formation of abscess has been slow. Diagnosis. — A positive diagnosis is difficult to make in the early, and sometimes in the later, stages of hepatic abscess. The writer has known an iron-worker burst an abscess through his lungs when at work, the presence of which was not suspected; also a medical man sub- mit his side to examination by several of his brethren, bear any amount of pressure, and yet die two days after choked by the bursting of an abscess. Nevertheless, an experienced physician will from the symptoms be able to guess the pre- sence of abscess of the liver before any palpable , signs appear. These are, first, the general aspect of the patient ; then the enlargement of the side. It is only in a more advanced stage that fluctua- tion can he made out. As to the diagnosis after the abscess has burst, if it breaks through the lung the peculiar chocolate- colour expec'oration is at once characteristic. If the absepss bursts into the pleura or peritoneum, the diagnosis is not so positive, but the sudden collapse usually shows what has happened. When the abscess bursts through the bowels, especially in small amounts at a time, the fact is rarely recognisable, except by the gradual improvement of the patient. It seems to be certain that hepatic abscess has sometimes been confounded with a distended gall-bladder ; with care, however, such a mistake can scarcely happen. It may be confounded with cancer or with hydatids of the liver - but in these affections — and particularly in the last — there is very little constitutional disturbance, and in cancer a nodular protuberance may very generally be recognised. The only other mistake that is occasionally- made is, that of confounding abscess and the effects consequent on its pre- sence, when it points upwards, with pneumonia or pleurisy near the baso of the raht lung; but with careful auscultation the affection of the lung or pleura ought to be made out by then physical signs. Prognosis. — This is generally very unfavour able. Yet there is always a char.ce of recover if the pus finds for itself an exit, as throughthi bowels or lungs, or even if exit to it is fT 1 ' reJ LIVER, ALBUMINOID DISEASE OF. artificially. The statistics of the results of mak- ing artificial openings are not very encouraging. The operation, however, frequently appears to prolonglife. The most favourable mode of exit is through the lungs. The discharge of pus may continue for six months, and yet recovery take place. Absorption of the abscess probably sometimes occurs, though this is a very rare termination. Such absorption is, obviously, chiefly a matter of inference. If a patient re- covers from an attack of liver-abscess, his health may return to its usual standard. There is reason to believe that individuals have lived thirty or forty years after the occurrence of abscess ; and the writer knew a man of 7*, who had had abscess forty-five years before. Treatment. — To avert the formation of ab- scess. t h e ordinary treatment for hepatitis is the only one that can be adopted. When abscess has" once formed, or evenwhekevcr there is good ground for suspecting this, the time for all active treatment has gone by. The patient must have his strength supported by mild nutritious diet and wine. He must be treated symptoma- tically. Usually it is sufficient to secure regular action of the bowels, and thus help the sound remaining portion of the liver to perform its function. Mineral acids, quinine, and other tonics, may all be useful. Counter-irritation over the liver is often tried, but it may be doubted whether in this condition of things it is a mea- sure of any importance, although some think that it may help to limit the extent of the ab- scess. The course of the disease must be watched. The only mode of interference that, we can pursue is that of helping to give exit to the contents of the abscess. Towards expediting this little can be done until fluctuation becomes evident, and then interference is to be delayed as long as possible, as nature will probably select the most convenient spot for the exit of the pus, and, after all, the presence of other undetected abscesses in the liver may make operative procedure useless. The abscess may point in an intercostal space, below the edee of the ribs, at the epigastrium, and even as low down as the umbilicus. A great deal has been written about modes of opening the abscess, and of ascertaining first whether it has formed adhesions, and various modes have been suggested for ensuring adhesions. However these are not matters of much practical impor- tance. It is usual to make an opening whenever there is distinct bulging between the ribs; but it is better, when it is at all possible, to wait and operate, if it can be managed, below the ribs. However near the surface the abscess may appear to be, a lancet is seldom sufficient, and a good- sized trochar and' canula should be employed. The aspirator, and everything that will help to ; prevent the introduction of air, should be taken advantage of. and the precautions of the anti- septic method most strictly observed. For there is always a chance of gangrene after a time supervening round the opening, and the risk of this seems to be greater the higher up the opening is made. The evacuation of an abscess i usually produces amelioration of the general condition, whether it be permanent or not. Change of climate may operate favourably when the patient is suffering from the long- 831 continued drain of an open abscess; and if we are to .judge by the number of patients suspected of having liver-abscess who have been sent to sea and who have arrived in Europe with their symptoms relieved, we may almost venture to say that a long sea-voyage under favourable circumstances assists absorption. In favourable cases the sequelae of liver-abscess must be treated like those of hepatitis. J. Macphebson. LIVER, Albuminoid Disease of. — Stnon. : Fr. Degencrcsccnce amylo'ide da Foie; Ger. Amy- loide Kntartung der Leber. Definition. — A disease characterised by pain- less, more or less considerable, enlargement of the liver ; due to the existence in i*s structure of a peculiar homogeneous substance, the exact nature of which is not known, but which has a marked relation to certain cachexias and consti- tutional maladies. ./Etiology. — Albuminoid disease of the liver occurs in association with certain cachexias, especially those of constitutional syphilis, scro- fula, rickets, scrofulous diseases of bones and joints, and other diseases attended with pro- tracted suppuration. It has been noticed in connection with chronic dysentery, but the re- cords of the Seamen’s Hospital do not confirm such association. In many cases of chronic ague, with marked cachexia, which have been admitted into the hospital just named, there was an enlarged, hard liver, pointing to albu- minoid change; but there was probably in these cases the superaddition of syphilitic taint. Rokitansky speaks of the disease as congenital in children born of syphilitic parents. Anatomical Characters. — The liver has its normal shape; is more or less enlarged, some- times to such an extent as to fill the greater part of the abdominal cavity; and is hard, resistant, and inelastic, with a smooth glistening surface. The organ cuts like bacon, hence the name ‘ larda- ceous.’ The cut surface is grey, or fawn-colour, or pale red; but sometimes it is yellowish, and this appearance, in conjunction with the con- sistence of the organ, has led to the name ‘ waxy.’ From the incised veins a little pale blood usually oozes. The application of solution of iodine to the cut. surface causes change of colour, which has been described as blood-red, reddish-brown, mahogany brown, walnut, by different observers. The addition of sulphuric acid induces a blue colour, best seen in a deli- cate section placed under the microscope. Sup- posing a lobule of the liver to be divided into three zones, the characteristic iodine stain will be seen, in less advanced stages of the disease, to be limited to the middle zone, where the hepatic artery is distributed; the vessels and cells here being filled with the new material, which afterwards may extend so as to implicate the entire lobule. The structures invaded by the new material have, in a section examined microscopically, a lustrous, transparent, and somewhat swollen appearance. "When the entire lobule is affected, the aspect is homogeneous. The appearance of an albuminoid liver may be modified by the co-existence of fatty change, or cirrhosis, or syphilitic disease. The spleen is generally, and the kidneys are occasionally. in>- LIVEE, ACUTE YELLOW ATROPHY OF. 832 plicated. Corral has used some new colouring matters, namely, two methyl-anilin violets, dis- covered by Lauth, and a violet discovered by Hoffman, as tests of albuminoid degeneration. The normal tissues of the liver and other organs do not decompose the violets, but when amy- loid degeneration is present, the affected parts become of a violet-red, the normal structures assuming a violet-blue tint. In the examinations of specimens by Cornil the hepatic cells were unaffected, a result in opposition to generally received views, as just stated, and to his own previous investigations. In all cases the walls of the capillaries, or of the hepatic arteries and veins, were affected. Methyl-green has been more recently used for the same purpose. Symptoms. — Palpation, in marked cases of albuminoid disease of the liver, will readily detect a large, hard, resistant tumour, having the normal outlines of the liver ; the smoothness of its surface; and the extent to which it en- croaches upon the abdominal cavity. Pressure doesnot elicit any tenderness, nor is there usually any pain ; at most, in advanced cases, there isonly a sense of tension and fulness, as in other hepatic enlargements. The painless nature of the tumour is distinctive. The disease does not interfere with the portal circulation, and does not there- fore directly cause ascites. When this occurs it is the result of general cachexia, induced by the constitutional malady, and perhaps by associated ronal complication. The dropsy generally affects the legs in the first instance, and afterwards the serous cavities, and is not a prominent symptom unless the kidneys are implicated. In this case the urine is usually of low specific gravity and albuminous, and the anaemia very marked. The system of bile-ducts not being obstructed by the disease, there is no jaundice; or if this occur, which is a rare event, it is from pressure on the duct externally by enlarged lymphatic glands. The evacuations are, however, frequently ot a pale yellow, and at times of a clayey, colour, which may be accounted for by the extensive impair- ment of secreting structure, and the consequent secretion of a poor, colourless bile. A lardaceous state of the spleen is a frequent accompaniment of the liver affection, and gives rise to increased volume and hardness of the organ, which may be detected by palpation in the left jhypochon- drium. Vomiting, without the usual indications of gastric derangement, as furred tongue, &c., and diarrhoea, are symptoms not uncommon in ad- vanced cases, and are due, according to Frerichs, to the implication in the disease of the vessels and villi of the stomach and intestines. Diagnosis. — The peculiar features of the en- largement, its painless character, the concurrence of the constitutional maladies already noticed, especially if with implication of spleen and kid- neys, will distinguish this from othei hepatic enlargements. If there be associated cirrhosis or syphilitic disease, the diagnosis will be diffi- cult ; but, as Bamberger remarks, an error will not be of moment as regards prognosis and treatment. Prognosis and Duration. — The disease may run on for months or even years, but it generally proves fatal, either by intercurrent affections, or by ansemia, general dropsy, and exhaustion, such result being more rapidly deter- mined when the kidneys are involved, In the early stage of the malady an arrest of mischief, if not a cure, may possibly be effected. Treatment. — It is only in the earlier stages of albuminoid disease of the liver that treat- ment can avail, and then it must be directed especially to the associated cachexia. Whether this be syphilitic or strumous, the preparations of iodine are indicated ; the iodide of potassium, the tincture of iodine, or, where the ansemia is marked, iodine in combination with iron. The syrup of iodide of iron in drachm doses, three times a day, has proved useful, if not in reducing the tumour, at least in improving the general condition of the patient. The iodine mineral springs, as Woodhall Spa, Kreuznach, Adelheids- quelle, &c., are indicated, although they contain but infinitesimal doses of iodine and bromine. The baths of Aix-la-Chapelle, Ems, and Weil- bach have each had their supporters in the treatment of this malady. Hydrochlorate of ammonia, in ten to twenty grain doses, three times a day, continued for some time, has been found to be efficacious in reducing large, hard livers (Budd, Begbie). The general therapeutical indications are pure air ; plain, nourishing diet; the regulated use of alcoholic stimulants ; and adequate protection of the skin by warm clothing and other measures. Stephen H. Ward. LIVER, Apoplexy of. — By this is meant haemorrhage in the liver, in the form either of isolated patches of extravasation or of general effusion, the whole of the hepatic parenchyma be- ing converted into a dark-red pulpy mass. This affection is rarely met with in this country, but has been often observed abroad in warm climates and malarious districts, as a result of disease of the liver, or prolonged and intense congestion It occurs also in some cases of scurvy. Aber- crombie believed that the puerperal condition predisposed to hepatic apoplexy. It has been observed also, according to Frerichs, in some Dew-born infants after loDg labours, and in cases of this kind it is usually associated with pulmonary atelectasis. A rapidly fatal case of hepatic apoplexy was reported by Andral, in which there were no indications of any efficient cause of the haemorrhage. (Clin. Med., 3 ed., t. ii., p. 259.) Extravasation of blood into the substance of the liver, together with a pulpy condition of more or less of the parenchyma, may he produced by the application of violence to the hepatic region. Symptoms. — The symptoms that have been observed in cases of hepatic apoplexy are pain in the right hypochondriac region, and excessive tenderness; jaundice ; bilious vomiting; melanin; a cold and bloodless condition of the skin of i he face and limbs ; and in some cases syncope. This affection is almost invariably fatal when due to prevailing disease of the liver, or to ex- tensive laceration. W. Johnson Smith. LIVER, Atrophy of, Acuta Yellow.— Sv non.: Fr. Atrophie jaune aigue du Fcic ; Ict'crt grave ; Ger. Acute Atrophie dcr Leber. Definition, — This is a general disease, iikened by Trousseau to a pyrexia. The jaundice, bcinc LIVER. BILIARY prominent a symptom, formerly drew attention too exclusively to the liver ; but the same de- generation which seizes upon the liver, likewise attacks all the glandular and muscular organs of the body. The morbid change is a parenchy- matous degeneration, called by Virchow and his schoola parenchymatous inflammation. It con- sists in a filling of the cells of a gland with albu- minous granules, iu such numbers as altogether to hide the nucleus ; the albuminous granules are quickly followed by oily particles and drops. In the muscular tissue, the striation is lost, and its place taken by granules, placed irregularly or running lengthwise. These morbid appear- ances are found in poisoning by phosphorus, arsenic, antimony, alcohol, and other agents, and in all fevers, though in a less degree than in acute yellow atrophy. Buhl was the first to point out that the pyrexial changes were the be- ginuings of acute yellow atrophy. .Etiology. — Acute yellow atrophy is perhaps the rarest of all the diseases common to this cli- mate. Of its causes, next to nothing is known. It seems to be more common in women than in men; and in pregnant women than iu others. It has been shown that in pregnant and suck- ling quadrupeds and laying hens, the liver and kidneys often show cells infiltrated with fat, a fact which may throw some light on the dispo- sition of pregnant women to acute yellow atro- phy. Emotional disturbances, such as grief and ;roublo, and bad hygienic conditions, have been bought by some to predispose to this disease. Dthers believe that all cases may be traced to I'hosphorus-poisoning. Anatomical Characters. — After death it is tot uncommon to find the liver of natural size, r even enlarged, in the early stages of acute trophy. Later on the organ shrinks, so that in xtreme cases it may' weigh as little as nineteen unces. It decreases in all diameters, but the ;ft lobe is especially shrunken. The capsule is ften wrinkled. On section, there is no longer ny appearance of lobules, but an ochre-coloured irface without definite structure, but often iddened. Under the microscope, the liver-cells •e found, in the early stages, to be filled with •anules, so as completely to hide the nucleus ; vrt of these granules are soluble in acetic acid, hers are not. Later on, all trace of liver-cells ay be lost, nothing but a granular and oily de- itus and pigment being seen under the miero- jpe. If the organ be set aside, it often he- mes covered with crystals, stated by Frerichs consist of leucin and tyrosin. The spleen is enlarged and soft in the great i jority of cases. The stomach and alimentary ual are filled with dark-red or tarry contents, t • outcome of haemorrhage ; the tubular glands i the stomach are filled with fattily degene- tsd epithelium. The muscular tissue of the 1 rt shows likewise fatty degeneration ; and t tubules of the kidneys are filled with epithe- 1 n in various stages of fatty degeneration. tmptoms. — Acute yellow atrophy is com- u fly preceded for some days or weeks by a s pie jaundice, in which nothing peculiar can b nade out. Delirium and convulsions then ti lenly set in, followed by deep coma, sterto- n i breathing, and dilated pupils. During the 53 ACCUMULATION IN. 833 first part of the disease the pulse is natural in frequency, but with the appearance of the con vulsions and delirium it rises to 120 or 130. The skin is always yellow, rarely deeply coloured. The urine is natural in quantity, bilious, contain- ing leucin and tyrosin, and towards the end of the disorder, containing no urea, chlorides, or phosphatic earthy salts; a kind of peptone is present. There is almost always constipation ; the stools being at first pale, afterwards black from admixture of blood. Vomiting is very con- stantly present ; at the end of the disease, of a black coffee-ground matter. The right hypo- chondriac and epigastric regions are painful and tender. The liver, at first natural in 6ize, or even largor than natural, decreases daily in dimensions, so that at last percussion may give no liver-dulness at all. With the decrease of the liver, the spleen increases in size. A hmmor- rhagic diathesis likewise sets in, as shown by petechise on the skin, epistaxis, haematemesis, and melaena. The temperature is commonly low, until just before death. Diagnosis. — The diagnosis is beset with diffi- culties, and may remain -doubtful even after death. Poisoning by phosphorus can hardly be distinguished from acute yellow atrophy, unless the patient own to having taken the drug. The prodromal stage cannot be distinguished from simple jaundice. Prognosis. — The prognosis is extremely bad : only a very few suspected cases are known to have recovered. Treatment. — The treatment must be con- ducted upon general principles. A few eases, in which the diagnosis of acute yellow atrophy has been thought justifiable, have recovered, and these have been treated with the mineral acids and purgatives, aconite, quinine, and camphor. These are therefore the remedies which may be recommended to be used. Local symptoms, such as vomiting or bleeding, must be treated as in other diseases. J. Wickham Legg. LIVER, Atrophy of, Chronic. — Chronic atrophy of the liver is seen in many wasting diseases, and in old age ; the liver then often shrinks, becoming tougher in consistence, but rarely granular on the surface. The cut surface is dark red or pale brown ; the acini are either invisible, or else smaller than natural. Frerichs thinks that the blood-vessels are all dilated. The increased toughness seems due to the atrophy of the liver-cells, the meshes of the connective- tissue network being thus brought nearer to each other. The symptoms of chronic atrophy are merged in those of the primary disease, against which all treatment must be directed. J. Wickham Legg. LIVER, Biliary Accumulation in. — Anatomical Characters. — When a permanent obstruction to the flow of bile into the duodenum has been set up, serious changes take place in the gall-ducts and the liver itself (see Gall- Bladder and Gall-Ducts, Diseases of). At first the liver swells, apparently from the pent-up secretion. It becomes of a deep bilious or olive- green colour, tne central parts of the acini being the deeper coloured ; on section the dilated LIVER, CIRRHOSIS OF. S34 ducts are seen, and bile or a colourless fluid wells out of them. Increase in the consistence of the liver commences ; and if the obstruction continue, the organ wastes, becomes much tougher, and shows a granular surface. This increase in consistence is due to an overgrowth of the con- nective-tissue of the liver, as in cirrhosis, only to a less degree. The amount of over-growth de- pends upon the kind of obstruction. It is greater when a rough angular gall-stone is the cause, than when an hydatid tumour with its smooth walls presses upon the gall-ducts. This over- growth springs at first from the gall-ducts, which are greatly thickened, and thence spreads over the connective tissue of the portal canals. The liver-cells atrophy, as in cirrhosis. They vary much in size. Their contents seem to be chiefly fat and pigment-granules, though neither is of very great amount as a rule. The arrange- ment in rays around the hepatic venule is quite lost. One of the most important functions of the liver is the preparation of glycogen, and this function seems to be abolished in long-continued jaundice. In animals whose bile-ducts were tied, the writer found the glycogen to disappear not many hours after the ligature was applied ; and after puncture of the fourth ventricle, no sugar appeared in the urine. In some cases of complete obstruction to the bile-ducts, the liver-cells have been found alto- gether destroyed, nothing hut a fatty detritus being seen under the microscope. This is not owing simply to post-morton, changes in the liver ; but is possibly due to the long-continued action of the bile-acids circulating in the blood upon the liver-cells themselves, as Leyden has pointed out. It is not owing to the simple solu- tion of the liver, -cells in the bile, for the bile has not the power of dissolving these cells, as Th. von Duscii has asserted. Symptoms. — As regards the clinical pheno- mena of biliary accumulation in the liver, theie are, of course, all the symptoms of jaundice and of the disease which leads to it. In ad- dition, the liver at first swells, and may be detected bolow the ribs for two or three fingers’ breadth, but rarely more; it is often painful on palpation. Later on, the liver retreats within the boundaries of the chest. Ascites often shows itself, owing to the disturbance of the circula- tion in the liver; and the spleen often swells. All these symptoms are, however, liable to be interfered with by the primary disease. Treatment. — The treatment must be directed to the cause of the obstruction of the ducts. J. Wickham Legg. LIVER, Cirrhosis of. — Synon. : Granular liver ; Hobnailed liver ; Gin-drinker's liver ; In- terstitial hepatitis; Fr. Cirrhose du Foie; Ger. Girrhose der Leber. Definition. — A chronic disease of the liver, in which the organ becomes hardened, and usu- ally more or less diminished in size, at the same time assuming a granular or hob-nailed appeannee ; these changes resulting from an in- crease in the connective-tissue, usually caused by ab'-.se of spirituous liquors. The name cir- rhosti was first given by Laennec to the hardened and shrunken liver, on account of the yellow colour of the granulations in this disease. -ZEtiology. — The most common cause of cir- rhosis is, undoubtedly, the abuse of spirituous liquors. Spirits, unmixed with water, seem to be more potent in causing cirrhosis than wine or malt liquors. Next after these, but at a great distance, come syphilis, aud the immoderate use, it is said, of spices — such as curry, or of coffee. In some rare cases no cause is apparent. The disease is far more common among men than women ; it is very rare indeed amongst children. In one of these cases, the child asked the nurse for gin soon after admission into the hospital. Cirrhosis has also been seen among the lower animals, a proof that alcohol is not the sole cause. Anatomical Characters. — The seat of the disease in cirrhosis is the capsule of Glisson. The connective-tissue, which accompanies the vessels entering at the portal fissure, and which forms a covering for the liver beneath the peritoneum, takes on a very active overgrowth. One result of this overgrowth is a compression and atrophy of the secreting cells of the liver. Another is a hindrance to the flow of blood through the liver ; for, although new vessels do indeed form in the new connective-tissue, yet these are by no mea-us enough to carry on the circulation, in the place of those obliterated or destroyed by ihe advancing overgrowth of connective-tissue. There are several varieties of cirrhosis. In the first — that which is most common — the liver is shrunken, it may be to one-half or one-third i.f its natural size. This shrinking is often greatest in the left lobe, so that th:s may become a mere appendage to the right. At the sharp edge < t the liver, there is often nothing left but a semi- transparent tissue, containing noneof theelemen.'s of the gland. False membranes often join the I surface of the liver with the diaphragm or other neighbouring parts. The surface itself is greatly roughened. It shows numberless granulations, varying in size from a poppy-seed to a hazel-nut. The fibrous investment of the liver is greatly ! thickened; and the peritoneum tears off either in I layers, or leaving a granular surface bi hind. The liver is exceedingly hard and tough; and on section, the cut surface is seen to be made up of I yellow islets, imbedded in a white translucent tissue. These yellow bodies are the representa- tives of the granulations seen on the outer surface, and they are the remains of the natural liver- tissue, separated from one another by the new white connective-tissue. This is by far the com- monest variety of cirrhosis, but there are others. One form is hypertrophous cirrhosis, in which the liver is greatly increased in size, sometimes more than double its natural weight; but tin surface is smooth, and the capsule, though thick ened, leaves a smooth surface when torn oft There is toughening of the liver, though not ti so great a degree, and the same appearance o the cut surface as in ordinary cirrhosis. In an other variety the organ is shrunken, but thesur face is smooth, and or. section are seen or.l pins'-points of yellow tissue in the white trait lucent overgrowth. Whether the hypertrophou variety ever becomes shrunken is still undecid.ec A third variety is fatty irrhosis, which may V LIVER, CIRRHOSIS OF. mistaken at first sight for fatty liver, but the touch shows how tough it is. It sometimes floats in water. There is no everted edge, and on section no acini are to be made out; but the cut surface is indistinct, pale, and yellow. The sur- face of the liver is smooth. Under the microscope, using a low power, the tissue of the cirrhosed liver is seen to be broken np into islets, separated by broad bands of what looks like a highly nucleated connective-tissue. The separation between the two appears sharply defined. In some cases the liver-cells may be | seen infiltrated with fat. With higher powers, the most striking object in the field is the great abundance of what were once called nuclei, but now lymphatic corpuscles, in the new-formed connective-tissue: these vary little in size or shape, being nearly all round or roundish. The prevailing opinion now is that they are emi- grated leucocytes. They are arranged sometimes in clusters, sometimes in lines, and sometimes indefinitely. The origin of the clusters is uncer- tain ; but it sepms tolerably clear that the linear disposition arises from the obliteration of vessels carrying bile or blood. The connective-tissue itself is highly fibrous ; sometimes homogeneous or granular. The liver-cells themselves undergo great changes. They lose their natural polyhe- dral shape, and become oblong, oval, or spindle- ■ shaped. Between them the new connective- tissue gradually insinuates itself, and the cells -become lost in the advancing overgrowth. These changes in the liver-cells are of course best seen at the spot where the liver-tissue and the con- -neetive-tissue join. Symptoms. — The first approaches of cirrhosis are commonly very insidious. Often one of the first symptoms is a dull pain in the neighbour- hood of the liver. This is accompanied by signs if a chronic gastric catarrh, of which morning tickness is, for the diagnosis of intemperance, of lie greatest importance. The patients are com- nonly of a sallow, often almost jaundiced, com- ilaxion. They grow thinner, and their strength Jails. Some patients suffer from piles : in others .iarrhasa occurs. Later on the belly begins to well, and ascites appears; the legs may become idematous. from the pressure of the fluid in the f elly on the anterior wall of the inferior vena java. The urine is high-coloured ; of- en deposits rates; and sometimes contains albumin from mtr, acted kidneys. An important point in the diagnosis is to -termine whether the liver is of small size, lid growing smaller. This is often difficult, on count of the ascites; the difficulty may some- nes be overcome by laying the patient on his :t side. In the earlier stages the hard edge of je liver may at times he felt, and even though ,e ascites be great, by suddenly depressing the P 11s of the belly with the fingers. The percus- n-dulness of t he liver in the nipple line may be luced to two inches or even one inch in height. [Although in the new-formed connective-tissue ' cirrhosis fresh vessels form to take the place 1 hose obliterated, yet these by no means suffice 1 carry on the circulation through the liver, ■tal obstruction therefore arises, which relieves 1 If in various ways ; most commonly fluid is bred out into the cavity of the peritoneum, 835 causing an ascites, or into tlio cavity cf the in- testines, causing a diarrhoea, which should not be lightly checked. In other cases it is relieved by hsmatemesis, or by hasmorrhoidal discharge. That which is most fortunate for the patient ia the formation of a varicose communication be- tween some radicles of the portal system and the general veins ; as between the htemorrhoidal and the hypogastric, the veins of the stomach and the oesophageal. Most important of all, however, is a vein discovered by Sappey. It arises from the left branch of the portal vein, and passes up the falciform ligament close to tho ligamentum teres to join the epigastric and in- ternal mammary veins. It is by no means tho same as. the old obliterated umbilical vein, although so near to it. The vein just mentioned will often be found dilated after death. As a rule the spleen is enlarged in cirrhosis. The enlargement may be very great, but tho organ is commonly about twice or three times the natural size. After death the spleen is found of softer consistence than natural, sometimes pulpy. Tho cause is obscure ; the reason com- monly civen is the hindrance to the flow of blood through the liver acting on the splenic vein. The spleen, however, does not always swell when there is obstruction to the portal cir- culation, for example, in nutmeg-liver. Ascries is a symptom which sooner or later is sure to come on. It appears to arise from the venous stasis in the subperitoneal tissues. Fluctuation, and the movement of the fluid on change of posture are very clear. The fluid, like all other dropsical effusions, contains albr.miD, salts, sometimes urea, sometimes sugar ; and in jaundice bile-pigment. After the ascites has set in, the feet may begin to swell, from the pressure of the fluid on the vena cava. The upper limbs and face are free from oedema. In some cases albumin is present in the urine, from coincident Bright’s disease. The patients often complain greatly of flatu- lence, which adds much to their distress, and dyspnoea. Haematemesis and piles are of fre- quent occurrence. Diarrhoea when it comes is, as above mentioned, salutary, and should not be checked unless extreme. The urine is scanty and high-co'oured ; often turbid from urates ; and bile-pigment is present when jaundice sets in. Jaundice may or may not be seen, according as the pressure of the new connective-tissue does or does not involve the bile-ducts. Diagnosis. — The diagnosis depends upon tho history of intemperance ; the size and consist- ence of the liver; the size of the spleen; and the appearance of ascites and other dropsies. Of importance also is the peculiar sallow earthy complexion ; and the occurrence of haemorrhages from the stomach or intestines The diagnosis is often easy ; while at other times it is very hard or well-nigh impossible to make. Cirrhosis may be confounded with portal thrombosis ; ob- literation of the hepatic duct; nutmeg-liver, syphilitic disease, cancer, or hydatids of thp liver; and chronic peritonitis. Phognosis. — It is rare for a patient suffering from cirrhosis of the liver to live longer than a twelvemonth after the symptoms have become so pronounced as t< allow a diagnosis to bo marie LIVER, ENLARGEMENTS OF. i3G Death is in nearly all cases the end of the dis- ease. . Treatment. — In the early stages of cirrhosis it is most important to induce the patient to give up his habits of intemperance, for without this, treatment will be of little avail. Next the use of alkaline purgatives, with or without vege- table bitters, such as chiretta or calumba. will be very useful. A course of the waters of Carls- bad is often most useful, or other alkaline or iodised waters. The diet must be mild ; and exercise on horseback or on foot should be re- commended. In the later stages of the disease the great object will be to keep up the strength of the patient. For the ascites, which often becomes the patient’s great trouble, diuretics, especially copaiba, and mercurial alteratives may be em- ployed. Paracentesis should be put off as long as possible, as the end of the disease often arrives soon after the tapping, though in some cases the ascites is cured by this operation. The flatulence should be combated by regulation of diet, charcoal, small doses of hydrochloric acid, and carminatives. The bowels must be kept open, but not severely acted on. J. Wickham Leoq. LIVER, Congestion of. Sea Liver, Hy- persemia of. LIVER, Contraction of. — -A .small liver is met with in cirrhosis, in nutmeg-liver, and in long-continued obstruction to the gall-ducts, in all of which an over-growth of the connective- tissue of the capsule of Glisson is seen. Any kind of pressure on the liver from neighbouring organs will likewise beget wasting. A small liver is seen in old age, and in the marasmus of wasting diseases. The liver likewise wastes if the portal vein be obstructed, or the capillaries in the liver be obstructed, as in pigmented liver. A shrunken liver cannot be looked upon as a disease by itself. J. Wickham Legg. LIVER, Enlargements of. — Anatomical Relations. — In proceeding to determine ■whether the liver is enlarged or not, the following points must be remembered. Normally, the dull sound yielded by percussion extends upwards in front, in a line drawn towards the nipple, to about the sixth rib ; laterally, in the axillary region, to the eighth rib ; and by the side of the spine, to the eleventh rib. The lower border of the liver corresponds in front and at the side to the lower border of the ribs; and the dulness behind merges into that caused by the right kidney. The left lobe of the liver extends across the epigastrium to the left of the mesial line; the dull sound caused by its upper border merging in that produced by the heart. The upper part of the convexity of the liver rises to a little more than an inch above the sixth rib, the lung dipping down in front, and giving rise to a modi- fied percussion sound; but for practical clinical investigation it is better to take the line of abso- lute dulness. The extent of the dull sound from above downwards in the right mammary line is nearly four inches, and at the side about four inches and a half. In the middle line in front it extends from the base of the ensiform cartilage to about two fingers’ breadth below its point. It should be remembered that the limits of the liver present, compatibly with health, consider- able variation ; that the organ is relatively larger in early than in adult life ; that it is depressed in inspiration, and ascends in expiration ; that it is somewhat lower down in the erect than in the recumbent position ; and that there is temporary distension during digestion. Diagnosis. — There are various sources of fal- lacy which may lead to an erroneous conclusion as to the size of the organ. Thus, an intestine distended with flatus may get in front of the anterior border of the organ, and lead to the supposition that there is contraction, when the contrary is the case. When there is ascites to any extent, it is difficult to make out the boun- daries of the liver. In this case, however, by placing the patient on the left side, so as to let the fluid gravitate in this direction, a diagnosis may often be effected ; also, by suddenly pressing the finger down below the ribs, and thus dis- placing the fluid, one may sometimes detect the enlarged organ. A rigid right rectus muscle is liable to be taken for a tumour ; to obviate this source of fallacy, the patient should lie on his back with his thighs drawn up, and his attention should be diverted by conversation whilst the examination is being made. Sources of fallacy may exist in the liver itself, as in malformations or malpositions of the organ ; or they maybe outside it, either in the abdomen or chest. Malignant disease of the stomach, omen- tum, or pancreas ; a kidney greatly enlarged by cancerous deposit : or faecal accumulations in the colon, maybe mistaken for hepatic enlargement. The following considerations will assist in arriv- ing at a correct diagnosis — (a) enlargements of| the liver, however much they may extend beyond,: generally occupy the normal site of the organ, and however irregular the surface, the usual outline may be traced ; (6) such enlargements usually follow the movements of the diaphragm in full respiration. Effusion into the right pleura may be mistaken for enlarged liver, especially a: this organ may be depressed by it, and so appea. to extend beyond its limits in the downward a well as in the upward direction. In pleuritic effu sion, however, the dulness on percussion will var with the position of the patient, and the upper lin of dulness will in' effusion be straight, in hepati enlargement convex. Pleuritic effusion and hep; : tie enlargement may, however, co-exist. Pnei mothorax, emphysema of the right lung, thorac tumours, and even extreme pericardial effus-o may depress the liver, and affect the diagnosis. Enumeration.- -Dr. Bright arranged enlarg ments of liver under two heads, according to t surface of the organ, namely, smooth and irreg lar. Dr. Murchison considered this elassificati open to the objection that an enlargement usua. smooth is at times irregular, and vice versa, a he proposed the division into painless and pa ful enlargements ; but to this similar object may be taken. The principal enlargements- the liver are associated with the following d eases of the organ. | 1. Hypcra-mia or Congestion. — The enlar- ment is not usually, particularly in aente cas- very great ; but in chronic cases, and in cong LIVER, FATTY DISEASE OF. non from obstruction to the circulation, it is often considerable, the organ extending down- wards nearly to the umbilicus, and across into the left bypochondrium. The normal contour of the liver is preserved ; the surface is smooth ; and the resistance is increased. Pain and tenderness are often present, especially in acute congestion. 2. Obstruction of the bile-ducts. — Obstruction of the bile-ducts, whether temporary from in- flammation or impaction of gall-stones, or per- sistent, will be attended with some enlargement, ' smooth and normal in shape, of the liver ; with, perhaps, also, distension of the gall-bladder, causing a pyriform tumour, which projects down- wards from the anterior border of the liver, and . is, in! some cases, of considerable size. 3. Abscess. — The presence of numerous pysemic abscesses in the liver will give rise to an en- largement of the organ, with tenderness on pres- sure over the right hypochondrium. Tropical abscess, when deep-seated, may give rise to like results ; but when large and near the surface will, if under the ribs, cause prominence of the right hypochondrium, with obliteration of the intercostal spaces; or when pointing below or to the left of the ribs, will present an elastic, fluctuating tumour, with, perhaps, redness of surface. 4. Hydatid disease. — Hydatid of the liver is marked by nearly the same physical signs as abscess ; a large hydatid cyst causing, according o its site, cither bulging of the right hypo- hondrium, or an elastic tumour either below or o the left of the right lower ribs. The tumour n some cases gives a sense of fluctuation, and ho peculiar vibratory tremor known as hydatid- i-emitus. A hydatid cyst may attain much Teater magnitude than is ever reached by ab- eess, and may occupy the greater part of the j Women. Unlike abscess, hydatid disease, un- less the cyst is suppurating, is unattended by lain or constitutional disturbance. 5. Simple hypertrophy. — Simple hypertrophy f the liver, resulting from an increase of the ize or number of the secreting cells, causes a ainless enlargement, having the normal shape f the organ, but attaining at times to twice its ormal size. 6. Hatty degeneration. — This morbid condition " the liver causes a painless enlargement, not sually very great ; with preservation of the nor- ; al outline and smooth surface of liver ; but with minished resistance. 7. Albuminoid degeneration. — In albuminoid sease the liver preserves its shape ; is large ; ually has a quite smooth surface ; and is hard d resistant to the touch. Enlargement from is cause is sometimes very great, and second ly to that which results from malignant ;sease. The surface in albuminoid disease is metimes irregular, from co-existence of cir- osis or syphilitic cicatrices. The spleen is ually enlarged. 8. Malignant disease.— In malignant disease j liver is not always enlarged; and in the iltrated form, the surface may be smooth, ually, however, especially when the disease is ranced, there is enlargement, with loss of nor- 1 shape ; and the surface is hard and resist- . and coverel with nodules, or large knobs 837 and protuberances. The greatest enlargement — sometimes such as to occupy the greater part of the abdominal cavity, is attained in this disease. Pain, varying in character and intensity, seated in the liver or distal, is also generally present. 9. Cirrhosis . — In some cases of cirrhosis the liver may be found enlarged, as in the so-called ‘ hvpertrophous ’ form. See Liver, Cirrhosis of. Stephen H. Wabd. LIVER, Eatty Disease of. — D efinition. A disease attended with painless enlargement and diminished consistence of the liver ; due to the presence of a large quantity of fat or oil in the secreting structure ; and occurring in connection with phthisis and other wasting diseases, or in persons of luxurious and indolent habits, in whom there is usually an abundant development of fat in the tissues and other organs. ^Etiology. — Fatty liver may either be due to degeneration of cell-structure through faulty nutrition, or it may result from infiltration of the cells with fat, transmitted through the portal vessels from without (fatty infiltration.) Fatty degeneration is met with in association with other hepatic diseases, as albuminoid disease and cancer. The fatty liver which results from poisoning by phosphorus would, according to the experiments of Voit and Bauer, appear to be due to degeneration, as the dogs upon which they experimented had been kept without food previously, and were starved during the time phosphorus was administered ; showing that tho fat could not have come from other parts of tho body, or been introduced in food, but must havo resulted from the metamorphosis of tissue-ma- terial. It is with fatty infiltration that we are more particularly concerned. The fat may come either from within or from without the body. The former case is illustrated when the greater part of the fat of the tissues and organs is ab- sorbed, as in the emaciation of advanced phthisis. Louis, who first established the association of fatty liver with phthisis, found it to. exist in about one-third of the cases of this disease, and met with it much more frequently in phthisical females than in males. His observations have been amply confirmed by subsequent observers. Fatty infiltration of the liver also occurs in con- nection with other wasting diseases, and is not infrequent in patients who have been long bed- ridden. From a therapeutical point of view, the medical practitioner is more interested in tho disease under consideration, when fat is intro- duced from without the body. The affection of the liver is then associated with development of fat in other organs and in the tissues generally. Persons thus affected are usually given to undue indulgence in eating and drinking; to eating not only too much food, but food rich in oil and fat, and drinking beer, but especially spirits to excess. Want of exercise of mind and body, a heated atmosphere, and general luxurious habits, mate- rially assist in determining the affection. In illustration of this cause may be adduced tho oft-cited experiments of Magendie, who induced very fatty livers in dogs by feeding them exclu- sively on butter; and also in the production of the foie gras in geese, by penning them up in a heated atmosphere and cramming them. LIVER, FUNCTIONAL DISORDERS OF. 538 Anatomical Characters. — In fatty disease the liver is more or less enlarged, but seldom to any great extent; the surface is smooth; the borders are rounded ; the substance pits on pres- sure ; and the organ is either of pale yellow or drab colour, or, when partially affected, has a mottled appearance. A portion placed in water floats, showing a diminished specific gravity. On cutting into the organ, the knife is greased ; and a greasy stain is imparted to blotting paper applied to the cut surface. A portion when held in the flame of a lamp or candle, will, when the water is driven off, burn. It is, however, as Frerichs remarks, only by the microscope that the degree to which the liver is implicated can be determined. In slighter grades, fat-granules and globules are seen to be limited to the outer zone of the lobules in the vicinity of the portal vessels ; but in advanced cases the whole of the cells will be found to be filled either with separate globules, or with a single large drop of fat. In less extensive infiltration the liver may be marked by red spots, corresponding to the hepatic veins. Fat in limited quantity is always present in the human liver, so that the term fatty can only be applied when it is in excess. Symptoms.— In the lessei grades of the disease, there are scarcely any distinctive symptoms, either objective or subjective. When the affec- tion is more pironounced, percussion will indicate more or less enlargement, usually in the down- ward direction ; and palpation may detect a rounded border and diminished consistence, and will, at any rate, determine that the organ is not unduly hard, has no irregularity of surface, and does not differ materially in shape from the healthy liver. There is seldom, if ever, any pain ; at most, in marked cases, a sense of tension and of uneasiness on lying on tne leftside. Jaun- dice is a rare event; and ascites and enlarge- ment of the spleen cannot be classed as symptoms of the disease. In cases of fatty infiltration, de- pendent on luxurious habits, as regards diet, &c., there is usually more or less development of fat in other organs, as well as in the omentum and sub- cutaneous cellular tissue. There is also a greasy condition of skin, with peculiar odour, resulting from abnormal oily secretion from the sebaceous follicles. Dr. Addison considered a peculiar con- dition of the skin — presenting to the eye a blood- less, almost semi-transparent, and waxy appear- ance, and to the touch a feeling of smoothness, looseness, and flabbiness — as indicative, if not pathognomonic, of fatty degeneration of the liver. In cases where the liver is much enlarged, and there is much abdominal fat, the upward pressure may interfere with the action of the diaphragm, and cause, especially after meals, embarrassment of breathing. The functional symptoms likely to be present in advanced cases are irregularity, generally sluggishness, of the bowels ; more or less dyspepsia ; and, perhaps, loss of appetite. In some cases a weak or irre- gular, or intermitting action of the heart, with tendency to faintness or giddiness, points to impli- cation of this organ, and is indicative of possible fatal consequences. Diagnosis. — The enlargement of the liver, with preservation of its normal shape, without hard- ness or irregularity ; the absence of pain, j atm . dice, ascites, or enlargement of the splewi; and its association either with the emaciation of phthisis or other wasting diseases, or with the habits of the gourmand and general development of fat in the body, will usually enable us to dis- tinguish fatty from other hepatic enlargements. Prognosis. — The prognosis of fatty disease of the liver is affected by the associated general condition of the patient, and will, of course, le unfavourable in phthisis. Treatment. — The general therapeutical indi- cations in fatty liver resulting from luxurious habits of living, point to reform in the direction of diet, air, exercise, &c. Rich, oily, and fatty articles of food are to be avoided ; whilst sugar and starch should be taken in moderation. Beer, in all forms, is objectionable, and so also is alcohol, unless well-diluted, and taken only at meals. Champagne is objectionable, hut other light French wines are admissible. Exercise, either on foot or horseback, should be had recourse to daily, but must be regulated accord- ing to the soundness of the heart and cir- culation. Free exposure to pure air, and avoid- ance of heated rooms, are desirable. The func- tions of the skin must be promoted by adequate clothing, and by the use of the hath, or by sponging with soap and warm water. The bowels must be attended to, and dyspepsia met by antacids and vegetable bitters. The Carlsbad waters — the warm Sprudel especially — are indicated, being supposed to act upon the redundant fat. Stephen H. Ward. LIVER, Functional Disorders of.— In- troductory Remarks. — The late Dr. Copland, in his Dictionary of Practical Medicine, arranged these disorders under three heads, according to; the nature of the biliary secretion. 1. Diminished; secretion of bile; 2. Excessive secretion of bile; and 3. Vitiated biliary secretion. Dr.Budd, whilst recognising the functions of the liver ail threefold, namely, as to changes effected in the blood, the formation of sugar, and the seere tion of bile, almost restricts what he says upon the subject of functional disorders to abnormal conditions of the secretion — excessive, defective or unhealthy bile. The late Dr. Murchison, in his lectures on P'unctional Derange nents of tin. Liver, showed that the classification lieretofon adopted, does not represent the present state oi knowledge of the functions of the organ. Hi summarises these functions under three heads 1. The formation of glycogen, which contribute to the maintenauee of animal heat, and to U nutrition of the blood and tissues. 2. The de structive metamorpdiosis of albuminoid mattei and the formation of urea and other nitrq genous products, which are subsequently elimi nated by the kidneys ; these changes also main taining the animal heat. 3. The secretion r a communication to have been effected be- ween them and the cysts. When at the surface j'f the organ, the cysts as they enlaree may nduce inflammation and thickening of the peri- ;oneum, and adhesion to neighbouring struc- ures. Symptoms. — A hydatid cyst, when sufficiently irge and near the surface, generally exhibits •self as a tumour of variable size, situated either i the right hypochondrium or in the epigastric igion ; evenly globular in its early stages ; cm, resisting, yet elastic, and, at times, with a ■nsation of fluctuation. Briancon and Piorry noticed a vibration or trembling — hydatid fremi- tus — which is felt when the surface is compressed gently by three fingers of the left hand, and sharp percussion made with the right hand over the middle finger. Prerichs does not consider this sign of much importance, it having been present in only one-half of his cases. If the tumour is situated behind the liver, it will, as it develops, push this organ forwards, flatten it, and increase the area of dulness. The tumour may last for a considerable time, and go on increasing to some extent, and yet the patient remain free from constitutional disturbance, perform all his functions well, and keep in good condition as regards flesh and strength. When, however, it has attained a very large size, it will give rise to various symptoms ; to a feeling of tightness and distension ; if it press upwards, to embarrassed breathing, cough, and palpitation ; if upon the abdominal viscera, to interference with their functions. Pain is not generally present, but in some cases there is a gnawing pain, either at the epigastrium, or extending forwards from the lumbar region. (Edema of the lower extremities may occur when the tumour presses upon the inferior cava. Diagnosis. — Hydatid tumour of the liver is not always easily diagnosed ; but the charac- teristic features already noticed, and its com- patibility (in many cases up to an advanced stage) with a good state of health, will generally point to its nature. Abscess of the liver will he distinguished by local and remote pain ; the fre- quent antecedence or co-existenee of dysentery; and severe constitutionalsymptoms.suchasheetic fever, rigors, &c. It must, however, be remem- bered that hydatid cysts are liable to become inflamed and to suppurate, when the diagnosia will not be so readily made. Cancer of the liver will generally he marked by irregularity of sur- face ; the presence of pain ; the cachectic aspect ; and the rapidity of progress. Aneurism of the abdominal aorta may form an epigastric tumour, of even, spherical shape; hut the pulsations, frequently very forcible, coupled, probably, with bruit, audible along the course of the vessel before and behind, will determine the diagnosis. The site, the pyriform shape and uniform size, and the usual accompaniment of jaundice, will distinguish from hydatid disease the tumour caused by a distended gall-bladder. Prerichs thinks that hydatid disease of the liver is more frequently confounded with localised pleuritic effusion at the base of the chest than with any other affection. He remarks that the same signs — dulness on percussion, absence of vocal thrill, intercostal fluctuation — would be present in both cases. He rests the diagnosis on the fact that the line of dulness would present a curve which would look upwards in the one case, downwards in the other. Prognosis and Terminations. — Hydatid tumour of the liver may last for years, and he compatible with an average state of health; or at an early or advanced period of its existence, it may terminate in one of the following ways ; — 1. It may, from its bulk and position, press upon and interfere with the functions of different organs. Pressuro on the large venous trunks may induce ascites and dropsy of the lower ex- 342 LIVER. HYPEREMIA OF. tremities ; pressure upon the stomach and intes- tinal canal may obstruct functions connected with the assimilation of food, and induce failure of flesh and strength, and ultimately death from exhaustion. 2. The tumour may contract ad- hesions with the diaphragm ; ulcerative action through this may be set up, and either (a) dis- charge of the contents of the sac may take place into the pleura, and fatal pleuritis result ; or ( b ) further adhesions and ulceration may effect com- munication with the lung, pneumonic symptoms ensue, and the contents of the sac, mixed with the products of inflammation, be expectorated. 3. A rare result is adhesion to, and ulceration into the pericardium, with escape of contents, and rapidly fatal results. 4. Adhesion may be effected with some part of the alimentary canal, and the contents of the sac be discharged by vomiting or by stool. 5. Rupture of the sac may be caused by a blow or otherwise ; the con- tents be discharged into the peritoneum ; and fatal peritonitis result. 6. The tumour may contract adhesions with the parietes ; point ex- ternally ; and be opened or effect an opening by natural process, inflammation and suppuration having been previously set up in the sac. 7. Budd and Ererichs notice a possible cure from the obliteration of the sac by the formation within it of a putty-like matter, which involves or perhaps results from destruction of the cysts. 8. Communication may be effected between a cyst and one of the bile-ducts, and then the result will usually be fatal, although there are one or two cases recorded of recovery. 9. Similar cysts may be formed in other parts or organs of the body. 10. As a possible rare event may be mentioned communication of the sac with the ascending vena cava, escape of the contents into this, transfer of the contents to the right side of the heart, impaction in the pulmonary artery, and fatal asphyxia. Treatment. — So long as a hydatid tumour induces no distressing symptoms, and does not affect the functions of any organs, there is no pressing cause for interference. When, how- ever, it is rapidly increasing, is accompanied with pain or distressing distension, and espe- cially if by upward pressure it is causing diffi- culty of breathing, and other symptoms, it will be well to have recourse to tapping. If there be any doubt about the nature of the tumour, the exploratory needle may be first introduced, and should a clear fluid, free from albumen, escape, the case may be fairly pronounced to be one of hydatid disease. It is now, indeed, considered the best treatment not to wait for urgent symp- toms : but when the disease is well developed, the cyst yet perhaps single, and the walls elastic, to let out the contents. This is best and most safely effected by puncturing with a fine trochar or with an aspirator. Certain precau- tionary measures must, however, be attended to. Prior to tapping, a broad flannel roller should be firmly applied round the abdomen, commencing from below and carrying the bandage np to the tumour, so as to assist in fixing this. It is con- sidered desirable not to quite empty- the cyst, as by doing so the chance of air entering the cyst is increased. This result may also be further prevented, and adhesion of the cyst to the parietes promoted, by applying a compress of lint over the wound and fixing it firmly with the remainder of the bandage which has been already partially applied. The patient should be kept quiet in bed for a day or two, and rest should be further ensured by the administration of morphia. Tho late Hr. Murchison discoun- tenanced the use of chloroform for this operation, as the pain is but trifling, and the chloroform may induce vomiting, which would interfere with the subsequent rest of parts, so desirable to ensure a successful result. It is not necessarv to wait for the adhesion of the cyst' to the parietes before puncturing, as the use of a fino trochar diminishes the risk of escape of the con- tents of the sac into the peritoneum ; and, more- over, the escape of a certain amount of fluid will not usually induce peritonitis. A large propor- tion of cases thus treated have been successful "When a hydatid cyst has suppurated, it should be opened with a large trochar or a bistoury, and kept open. Puncture and subsequent injection of the cyst with some stimulating fluid ; gradual opening of the cyst by applications of caustic potash, so as to ensure adhesion with the pa- rietes ; and a large incision with a view to effective removal of contents, are methods of treatment which have been practised, but cannot be re- commended in comparison with simple puncture with a fine trochar. Dr. Ililton Eagge and Mr. Durham treated several cases successfully by acupuncture, and by passing a galvanic current through the contents of the cyst ; hut it seemed probable that the result was due to the acu- puncture, and not to the galvanic influence. Treatment by special medicinal agents, adminis- tered internally, has been fairly tried. Of these, common salt and iodide of potassium in large doses may he mentioned. They have, however, proved useless. Stephen II. "Ward. LIVER, Hypersemia of. — Synon. : Conges- tion of the Liver. Definition. — Uniform enlargement of the liver, with preservation of its normal shape; caused by over-distension with blood, the result of mechanical obstruction to the return of bicod to the heart, or of direct afflux of blood through the portal vessels ; attended with a sense of ful- ness and oppression in the right hypochondrium and in the epigastric region, a dusky and some- times jaundiced complexion ; and terminating, if not relieved, in organic changes in the hepitio parenchyma. JEtiology. — Congestion of the liver may he | either active or passive. Niemeyer limits tho | term ‘ congestion ’ to the latter, and applies the 1 term ‘ fluxion’ to the former. Active hyperamiaA or congestion, results from — 1. Excess iu eat- ing and drinking, especially in persons efse’en- tarv and indolent habits. Determination derate saline aperients, or of iodide of potassium — in short, the ordinary treatment for congested liver, should be adopted. Counter- irritants and blistering, or the application of tincture of iodine over the liver, aro of more use in this than in the earlier stages. The nitro- muriatic acid bath has long been a popular re- medy in the chronic stage of hepatitis. The body may be immersed, but a bath for the feet, or sponging the side with a solution of the acid, will usually he found as efficacious. The in- ternal use of the mineral acids the writer believes to be more effective. Change of climate exer- cises a singularly beneficial effect ; especially that obtained by a sea -voyage. Sudden exposure to cold, however, after a return from a "arm climate, must be particularly guarded against LIVER. MALIGNANT DISEASE OF. 847 The treatment of the sequelae of hepatitis be- comes practically that of congestion of the liver. The steady use of saline aperients, or a resort to the saline-alkaline, or to alkaline baths, as Carlsbad, Marienbad, Elster, Vichy and others, will be found beneficial. Jn the acute stage the diet must be low, and limited chiefly to fluids. Great attention must be paid to diet during con- valescence also ; attention to this will help mate- rially in preventing the disease from becoming chronic; and, indeed, there is no better prophy- lactic against hepatitis than a carefully regu- lated diet, with abstinence from spirituous dTinks. J. Macpherson. LIVER, Inflammation of, Chronic. — This is usually only another name for cirrhosis. Some- times the name is given to a perihepatitis, a thickening and opacity of the capsule enclosing the liver, and beneath which the liver-substance is found hardened and tough, due to an over- growth of the connective tissue from the capsule. Most pathologists, however, look upon cirrhosis as a chronic inflammation of the liver, and the name is usually restricted to this state. Sec Liver, Cirrhosis of. J. AVickham Lecg. LIVER, Malformations of. — Abnormali- ties in the form of the liver are not common, and are more often acquired than congenital. The following are some of the most frequently observed malformations that are congenital , and due to some original defect : — A more or less quadrangular liver ; a rounded liver ; reduced ( proportions or total absence of left lobe ; pro- longation of the left lobe in the form of a narrow tongue-like process towards the region of the spleen ; abnormal grooving of the surfaces of the liver; extremo depth of normal fissures. Another occasional variety of hepatic malformation con- sists in extensive lobulation, and tho existence of one or more additional small lobes — a con- dition met with in the livers of rodent animals. An extreme instance of this extensive lobulation was observed by Dr. Dickinson, and is recorded in the Transactions of the Pathological Society (vol. xvii.,p. 160). Acquired malformation may be due to hepatic abscess ; to hydatids of the diver; to new-growths; to some form of chronic nflammation (cirrhosis, syphilitic disease) ; or, inallv, to compression of the organ by tight- acing and other means. AV. Johnson Smith. LIVER, Malignant Disease of. — Defini- ion. — D evelopment in the liver of cancerous or arcomatous growths, either primary, or secondary i similar growths elsewhere ; causing, generally, nlargemeut of the organ, with irregularity of its urface; attended with pain, often with jaundice ;ud ascites, with marked cachexia and progressive naciation ; and having usually a rapidly fatal ■rmination. AiTtOLOGT. — Sex has no influence in the cau- ition of hepatic cancer; the disease occurs as i ten in males as in females. It is very rare early life, but cases are recorded. Of eighty- ree cases analysed by I'rerichs, forty-one were tween forty and sixty years of age, and the mainder in nearly equal proportions above and low that period. Climate, habits of life, over- indulgence in the use of spirituous liquors, do not seem to play any part in determining the malady. The influence of hereditary tendency to cancer must not, however, be overlooked. Anatomical Characters. - — The malignant growths which affect the liver are usually the carcinomata — the true cancers; and of these, in nearly all cases, tho sehirrous and medullary or encephaloid forms ; the colloid being rarely met with, and then only as a secondary deposit. Of the sarcomata, the melanotic and round-celled or medullary sarcomata are met with occasionally. Cancer may occur as an infiltration of the liver- tissue, when large masses of the liver are uni- formly affected, and little or no irregularity of surface results. It usually, however, occurs in circumscribed masses, smaller nodules or larger protuberances, varying in size, to use a familiar comparison, from that of a pea to that of achild's head. These masses are more or less numerous, and usually distinct; or they may encroach upon one another, and give an appearance of coales- cence. AVhen near the surface, they give rise to the marked irregularity which is very charac- teristic of the disease ; and when lar-re and numerous, cause considerable increase in the size of the liver. The masses on the surface are sometimes flattened, arid have a central depression which has been designated as ‘ cancer navel.’ The growths may be firm and of brawny or even cartilaginous consistence, as when scirrhus prevails ; or thpy may be of medullary softness, when an incision will yield freely the so-called cancer-juice. The cut surface is either white, or reddish-white, or darker red when blood has been recently extra vasated, or of vary- ing colour, from altered blood-p>igment, when the extravasation of blood has been of longer date. The portal ard hepatic veins are some- times invaded by the cancer, and a clot is formed in them, which becomes cancerous. Colloid cancer of the liver occurs rarely as a secondary invasion from the stomach or peritoneum. Me- lanotic sarcoma or melanosis exists occasionally in conjunction with the disease in other parts of the body. Malignant disease of the liver is primary in about one-fourth of all eases ; se- condary in the remainder ; and in about onp-half of the cases in which it is so, the primary disease has been seated in structures connected with the portal system. Symptoms.--Li the earlier stage of this disease, the symptoms may be merely subjective, and then diagnosis will be difficult. AVhen the dis- ease, however, is far advanced, a prominent irregular swelling may be seen, raising tho ab- dominal parietes, and occupying often a lartre portion of the abdominal cavity. Lesser grades of the disease may be detected by palpation and percussion. The liver will be found to extend more or less beyond its normal limits ; to be hard and resisting ; and, in a uirge proportion of eases, irregular, in a few cases, however, when tho disease is infiltrated, the surface will perhaps be smooth throughout. At times there is no enlargement of the organ, and the portion af fected lies under (he ribs, so that physical exa- mination does not help us. There is often tenderness on pressure, especial'y when the peri- toneal coat is inflamed. Usually, hut not always, 848 LIVER. MALIGNANT DISEASE OF. there is pain in the liver itself; sometimes merely a feeling of tightness and fulness ; at other times a gnawing, aching pain; and some patients have described the pain as ‘ burning.’ There is frequently also pain shooting back to the spine, over the sacrum, or about the angle of the right scapula. A sensation as of a cord drawn round the right hypochondrium has been complained of. There is sometimes pain radia- ting down to the lower part of the abdomen ; and occasionally wandering pains in the extremities and body generally are complained of. When the stomach is intact, there may be no material dis- turbance of its functions, but usually derangement is manifested by loss of appetite, nausea, vomit- ing, and other symptoms, which will be intensi- fied if the stomach is implicated in the disease. The bowels are, as a rule, constipated in the earlier stage, but towards the close there is often dysenteric diarrhoea. Jaundice occurs in nearly one-half of the cases of malignant disease of the liver, and is due to compression of the bile-ducts by cancerous masses within the organ, or by an enlarged lymphatic gland in the portal fissure. When once established it is permanent, and the colour of the patient varies, being pale yellow, or deep olive-yellow, or greenish, or sometimes of the dark hue which has given rise to the term ‘black jaundice.’ The stools in such cases are white or clayey in appearance; and the urine deep-coloured from bile-pigment. The condition of urine, when there is no jaundice, is variable ; in the earlier stages of the disease it is generally scanty and pigmented, and loaded with lithates; in the last stage, according to Dr. Parkes, copi- ous, pale, and deficient in urea. This condition he attributes to the utter failure of digestive and nutritive power. Ascites is present in more than half of the cases, and is due either to com- pression of the portal vessels, or to inflamma- tion of the peritoneum. Sometimes the large size of the tumour, especially if ascites to any extent be present, may cause much pressure up- wards, and give rise to distressing chest-symp- toms, such as embarrassed breathing, or palpi- tation. Haemorrhage not unfrequently occurs in advanced cases. The blood may come from the stomach or bowels, and be duo to portal obstruc- tion ; or may be of passive character, as in scurvy or purpura ; and the bleeding may take place beneath the skin, or come from the stomach or bowels. In the latter case the haemorrhage is accompanied, according to Frerichs’ experience, by intense jaundice, and usually by somnolence and delirium. The complexion of patients suffer- ing from the disease under consideration, when there is no jaundice, is usually sallow, anaemic, earth-coloured. There is, in a large majority of cases, progressive, and towards the close, often extreme emaciation. Generally there is no fever, but a sort of hectic may occur when the can- cerous development goes on rapidly, and involves several organs. When the disease of the liver is secondary to, and complicated with cancerous affections of other organs, as the stomach — which occurs in a considerable proportion of cases — pancreas, uterus, or mammary gland, symptoms will exist indicating such complications, but need not be specially dealt with here. Diagnosis.- -When hepatic cancer is somewhat advanced, and the liver large and irregular ou its surface, the diagnosis will be easily effecied. In the early stage, on the contrary, and in cases in which, throughout, the liver is not perceptibly enlarged, one must be cautious in giving a hasty or too decided opinion. Inherited tendency to cancer; the age of the patient; in women the period of ‘change of life;’ a sallow, earthy aspect; progressive emaciation ; and pain in the right hypochondrium, point with fair probability to the disease. But nearly the same conditions and symptoms maybe associated with aggravated hypochondriasis, or chronic tendency to gall- stones ; and in the latter case, the difficulty of diagnosis is increased, as gall-stones are often associated with cancer. Permanent closure of the bile-duct from other causes gives rise to persistent jaundice and other symptoms, as in the case of closure by pressure from a cancerous mass. Enlargement of the liver from malignant disease may be confounded with the following hepatic enlargements and malignant tumours 1. Albuminoid or lardaeeous disease. In this affection the hard, perfectly smooth surface, with preservation of normal shape of the liver, absence of pain in the tumour, and of jaundice, will lit sufficiently distinctive, unless the liver is ren- dered nomewhat uneven by other associated affections. 2. In a not very advanced stage of cirrhosis, as also of malignant disease, the liver may be enlarged, and its surface uneven, and in both diseases there is great resemblance in the aspect and general cachectic state of the patient, and similar disturbance of gastric and hepatic function. In cancer, however, the ascites is generally but slight, and the liver, instead of contracting, as it usually does in cirrhosis as the disease progresses, continues to increase, and is marked by large nodules and protuberances, which contrast with the smaller elevations in cirrhosis. In cancer the skin is often perspiring ; in cirrhosis it is harsh and dry. Intemperance is not an element in the aetiology of cancer, as it is in cirrhosis. In the latter disease, as also in lar- daceous liver, the spleen is frequently enlarged. 3. Hydatid tumour is to be distinguished from a localised cancerous mass by the presence of more or less distinct fluctuation ; and the absence of pain, and of serious functional and constitu- tional symptoms. 4. A tumour caused by hepa- tic abscess would probably give evidence of fluctuation ; be associated with or consecutive j upon dysentery ; and often attended by rigors, hectic fever, and characteristic shoulder-tip pam. o. Malformations and malpositions of the liver have been mistaken for cancerous enlargement, especially in females about the period of ‘ change of life.’ 6. A highly-distended gall- bladder has been mistaken for a cancerous pro- jection from the liver; but the smooth, oval swelling, and the site of the enlargement, arc distinctive, and, as Frerichs says, a practitioner who made an erroneous diagnosis in such case would be wanting in the tactus cruditus. 7 . Cancer of the omentum would present a movable tumour, separable, probably, from the liver by a slight area of tympanitic resonance. S. Cancerous de- posits in the left lobe of the liver may be readdv mistaken for cancerous affections of the stomach Tha following points will assist in diagnosis:- LIVER, MORBID GROWTHS 05. 84'/ ' a ) Percussion in the greatest thickening of the stomach-walls gives a tolerably clear, tympa- nitic sound; m cancer of the leftlobe of the liver, the sound is much more deadened, and is only somewhat tympanitic on stronger percussion stroke ; (4) careful examination of the liver, and of the stomach, when full and when empty, will also lead to a correct conclusion ; (e) even when the liver and stomach are both affected, careful examination may often make out the boundaries of disease in each. 9. Malignant tumour of the right lobe may be mistaken for malignant enlargement of the right kidney. Percussion will generally give a tympanitic sound, from the presence of intestine between the kidney and liver. The hepatic tumour is also distinguished from this and other abdominal tumours by its following the movements of the diaphragm in respiration. But when the renal enlargement is very great, diagnosis is not easy. Three or four years ago a sailor was brought into the Seamen’s Hospital with an immense tumour occupying the greater part of the abdomen. This was diagnosed by all who saw it as malignant disease of the liver. After death, however, it was found that the liver was quite healthy, much com- . pressed and narrowed, and spread out over the upper part of an enormous, cancerous kidney. 10. Malignant disease of the ascending or trans- verse colon will constitute a movable, and gene- rally somewhat tympanitic swelling; and faecal accumulations in the colon may be removed, but not always readily, by aperients and injections. Percussion, too, will often elicit a resonant space between the enlarged intestine and the liver. Proonosis. — The prognosis is always unfa- vourable. The disease when once fully pro- lounced runs its course rapidly, the fatal ter- nination being seldom deferred beyond a year, ichirrus has usually a longer duration than nedullary cancer. Treatment. — This can be but palliative, and irected to rendering the inevitably fatal course s smooth as possible, by' relieving distressing ymptoms. Remedies which in other hepatic Sections are valuable, such as cholagogues, or lineral waters, are here useless, if not worse, he diet should be plain and nourishing ; and te moderate use of wine and alcohol is not con- j'a-indicated, as in other disorders of the liver, trious gastric and other derangements must be et by appropriate remedies; it being always irne in mind that we have to soothe the patient, id not add to his distress by the exhibition of .useous drugs. For the relief of pain, the various eparations of opium are indicated, and, as a le, morphia acts the best. It may be adminis- ted either internally, or by the hypodermic :thod,and must be repeated when pain demands Local applications over the liver, as poul- es, spongio-piline, &c., with solution of opium •inkled over the surface, are useful, especially en the peritoneal coat is inflamed. Tapping mid not be had recourse to for the relief of : ites, unless this becomes so great as to inter- • e by upward pressure with the functions of I ^ lungs or heart. The fluid soon reaccumulates, I I the effect of the operation is to hasten the 1 d termination. Stephen H. Ward. LIVEK, Malpositions of. —Abnormalities in the position of the liver are much less rare than abnormalities in its form. The more fre- quent forms of congenital displacement are these : Lateral transposition, the liver being found on the left instead of the right side of the abdomen ; eventration, the organ being exposed in front of the abdomen of a fcetus ; the presence of more or less of the liver in the chest, through con- genital deficiency of the diaphragm. In acquired displacement the liver may be either depressed or elevated, some rotation of the organ on ils transverse axis taking place in an opposite direc tion in each case. Depression may be caused by pressure from above, as by effusion in the right pleural cavity, and probably to some slight ex- tent by considerable pericardial effusion, or car- diac hypertrophy. Elevation of the liver, which takes place more frequently, may be due to preg- nancy, ascites, or the presence of some large ab- dominal tumour. Curvature of the spine, whether lateral or angular, usually gives rise to some change in the position of the liver. In Potts’ disease the organ is often forced downwards towards the crest of the right ilium. By tight-lacing both the position and the form of the liver may he altered. The organ may be forced downwards, and at the same time so twisted on its transverse axis that its convex surface looks directly forwards, and its concave surface directly backwards. When tightly compressed the upper surface of the right lobe becomes marked by' the ribs, and presents transverse puckerings. At the same time tho right lobe is bent upon itself, the concavity of its lower surface beiDg much increased. The hepatic tissue corresponding to the summit of the arch thus formed gradually wastes, until at last the lobe is divided into two portions by a deep transverse groove, which portions are connected merely by a membranous band, com- posed of thickened serous membrane, and the corresponding portion of the hepatic capsule. AV. Johnson Smith. LIVER, Morbid Growths of. — Several morbid growths have been met with in the liver, of which the following are the most import- ant t 1. Simple Cysts. — These formations are not often met with in the liver. There may be a single cyst, which is usually large ; or a number of small cysts scattered throughout the organ. In tho latter case the condition is analogous to that of the so-called cystic disease of the kidney, and indeed is sometimes associated with this affection. The cyst-wall consists of a fibrous membrane projecting in folds into the cavity of the sac, and lined on its inner surface by pave- ment-epithelium. The cyst almost always con- tains thin clear fluid, and is net connected with any bile-duct or vessel. 2. Dermoid Cysts. — Mr. Hulke has recorded an instance in which several dermoid cysts in a withered condition were found attached to the surface of the liver. 3. Erectile Tumours. — An hepatic erectile or cavernous tumour consists of it small red or bluish-red formation, of a more or less globular shape, of reticulated structure, and containing 54 350 LIVER, PIGMENTATION OF. fluid blood or soft coagula. Growths of this nature are often multiple, and each of about the size of a filbert ; they are usually found either along the anterior margin of the liver, or on the upper surface of the organ, near the attachment of the suspensory ligament. Each tumour is enclosed in a capsule of delicate con- nective-tissue. Though seated at the periphery of the liver, an erectile tumour seldom projects beyond the surface of the organ. Much remains to be made out as to the pathological signifi- cance of these tumours, especially with regard to their relation to malignant disease. There is some difference of opinion as to their connection w ith the hepatic vascular system. Virchow and Wilks hold that they are in communication with minute branches of the hepatic artery ; whilst Frerichs states that they cannot be injected through this vessel or through the hepatic veins, but only through branches of the portal vein. 4. Lymphatic Formations. — The liver is sometimes found studded in all parts with minute patches of tissue of soft consistence, each patch being made up of an aggregation of lymphoid cells disposed in the meshes of a deli- cate reticulum. These patches of tissue are in close connection with small vessels, from the walls of which, according to Frerichs, they are developed. This condition is associated with leukaemia. 5. Tubercle. — Tubercle, as met with in the liver, occurs only in the form of minute miliary granulations, scattered throughout the whole organ, but accumulated more especially on the surface. These growths have been rarely observed in the liver, and in most of the in- stances in association with acute general tu- berculosis. 6. Cancer. — Different forms of cancer are liable to affect the liver ; but this class of diseases is so important that they require sepa- rate consideration. See Liver, Malignant Dis- ease of. 7. Hydatids. — This is an important disease affecting the liver, -which demands notice in this connection, but it is discussed in a separate article. See Liver, Hydatids of. 8. Benign Growths. —Fibrous and other growths have been iu rare instances found in the liver, but they do not give rise to any clinical signs. W. Johnson Smith. LIVES, Nutmeg. — Sr non. : Fr. Foie noix da muscade ; Ger. Mascatnussleber. — N utmeg-li ver consists in a chronic passive congestion of the organ, a state which may always be brought about when there exists any impediment to the circu- lation of the blood through the heart or lungs. The radicles of the hepatic vein become filled with blood, and thus the centre of each acinus shows a deep red, while the outer parts are either yellow or of natural tint. A nutmeg appearance is thus given to the liver, which is often shrunken and tough, with adherent capsule, and granular surface. Under the microscope the centre of the acinus is seen to be filled with dilated blood- vessels, which, pressing on the liver-cells, cause them to atrophy, so that in advanced stages of the disease they disappear altogether, and the centre of t ho acinus is made up of blood-vessels only, but there is no increase of the connective tissue in the same situation. The capsule of Glisson now and then takes on an overgrowth, just as in cirrhosis ; and the connective tissue between the lobule and around the vessels is considerably increased. It is to this overgrowth of the connective tissue that the shrinking and hardening of the liver are due. Symptoms. — The liver may sometimes be felt during life under the ribs, more often net. Slight jaundice is often present. The spleen is not en- larged, hut is small — the opposite condition to that found in cirrhosis. Treatment.— T his must be directed to the condition of the heart or lung upon which the obstruction to the circulation depends. Nutmeg- liver may always be suspected when there exists any impediment to the return of blood from the hepatic veins. J. Wickham Lego. LIVEK, Pigmentation of. — In subjects who have succumbed to intense malarious fever, and in some who during life had suffered from fre- quent attacks of intermittent or remittent fever in hot climates, the liver may he found to be stained by pigment, either diffused throughout the whole organ, or dispersed here and there in irregular patches. This pigmentation of the liver is always associated with a similar condi- tion of the spleen, and frequently with staining of the nervous centres, the lungs, the kidneys, and the lymph-glands. Hepatic pigmentation is one of the chief post-mortem phenomena of the condition known as ‘ melanaemia,’ in which the blood, especially that of the portal system, is per- vaded by granules of pigment of a black or deep- brown colour, some of which are free and isolated, some held together in irregular masses by a pale jelly, and others enclosed in cells. In the pig- mented liver these granules are to bo found in the portal blood, in the walls of the capillaries, and outside the vessels, scattered amongst the hepatic cells, but not within these cells. In an early stage of the hepatic pigmentation the stain- ing affects only the periphery of each lobule, hut, as the disease progresses, the deposit gra- dually extends to the centre of the lobules, and attacks the hepatic venous system. The arterial capillaries also contain similar pigment-granules. Symptoms.- — The size of the affected livci varies in different cases, and according to the severity and the stage of the disease. Th( organ is. sometimes congested and swoHen: i often remains of normal size ; in some fev instances it finally becomes atrophied. Tli main symptoms of this condition of the live are occasional intestinal haemorrhage, diarrhtE.- and ascites. These symptoms in well-marke cases of melanaemia are usually associated wit albuminuria, due to pigmentary affection of tl kidneys, and with more severe symptoms due t cerebral complications, such as delirium, com and paralysis. Melanaemia has been met wit mostly in warm climates, and occasionally dmur severe epidemics of intermittent and remitte: fever in some parts of the North of Europe. . this country it lias been very rarely observe See Blood, Morbid Conditions of. W. Johnson Smith. LIVES. Syphilitic Disease of.— The liv LIVER, SYPHILITIC DISEASE OF. occasionally becomes diseased during the tertiary fctao-e of syphilis, or the period of gummy deposits, the hepatic affection being associated at some period with osseous and cutaneous lesions, and with syphilitic cachexia. Anatomical Characters. — Syphilitic hepatitis may attack both the capsule ( perihepatitis ) and the internal prolongations or septa of the capsule ( parenchymatous hepatitis, syphilitic cirrhosis). In some cases a small portion, in others a greater part or the whole of the organ, is affected. In the milder form and less adranced stages of the disease the capsule is slightly thickened, and marked by a few isolated white patches, while the surface of the liver is here and there slightly grooved and indented. After prolonged inflam- matory action the liver becomes much deformed, and is made up of a number of small lobes oounded by deep depressions, the parenchyma on section beingfound to be traversed by well-marked bands of tough and retractile connective-tissue. The secretory structures of the liver do not under- go very much change in this disease, and notwith- standing the retractile properties of the fibrous tissue forming the white bands, the vessels and facts usually remain permeable. The liver-cells occasionally become loaded with fatty elements, and in some rare instances undergo albuminoid degeneration. In cases of syphilitic hepatitis, the liver is almost always bound to the diaphragm, and sometimes to the adjacent viscera, by firm adhesions. Deposition of gummy tummirs — ‘ the encysted knotty tumours of the liver,’ as they were named by Dr. Budd— occurs more frequently than syphilitic hepatitis, with which condition, however, it is often associated. In this form of syphilitic disease, the liver presents on sec- tion, especially in its deoper parts, a number of globular growths, more or less firm in consist- ence, of a yellowish-white colour, and varying from the size of a pin's head to that of a large walnut. A large deposit of this kind is usu- ally soft or cheesy at its centre, and becomes more and more firm towards its periphery, where it is surrounded by a greyish and trans- lucent zone of incipient connective-tissue, which passes gradually into apparently healthy paren- chyma. A full description of the minute struc- ure of these hepatic gummy tumours will be bund in a report by Dr. Payne on three speci- nens shown before the Pathological Society in 870 ( Transactions of the Pathological Society , 'ol. xxi. p. 207). In each tumour it was found hat the soft central portion was composed of ranular and almost amorphous material, in ■hich were imbedded certain round or irregular ranslueent bodies of large size, which probably ^presented collections of degenerated liver-cells, i lie soft central portion passed imperceptibly ito fibro-nueleated structure. The surrounding |brous zone was found to be composed of dense innective-tissue, in crescentic and irregularly- jtaped interspaces, containing masses of fatty obules or granular matter. This fibrous struc- re was not strictly defined fromthe structure of e mure central parts of the tumour, and on the tsivle passed into the interstitial connective- 's™ of the liver, and became converted into isses of nucleated tissue, each of which masses 851 appeared to be formed around a small branch of the portal vein or hepatic artery. Dr. Payne supports the view held by Virchow concerning the pathogenesis of hepatic gummy tumours, and holds that the amorphous central portion is to bo regarded, not as a deposit of tissue lowly organised from the first, but as fibrous tissue in a more or less advanced stage of involution and decay. Whether true hepatic cirrhosis may be caused by syphilis is open to doubt, since in most cases supposed to be of syphilitic origin it has been found impossible to exclude with confidence the idea of a probable alcoholic origin. Albuminoid degeneration of the liver has not unfrequently been observed in the subjects both of acquired and of inherited syphilis, and very often in syphilitic subjects who had not been pre- viously affected with caries or necrosis of bone, with cutaneons ulceration, or with profound or prolonged suppuration. This condition of the liver, when associated with syphilis, is probably due rather to cachexia and debility, than to any essentially syphilitic influences. The almost if not quite obsolete views that the amyloid dis- ease is to be attributed to the action of mercury, or to the combined action of this medicinal agent and syphilis, are opposed by the facts that this condition of the liver has often been ob- served in a syphilitic foetus, and also in adults who had not previously been treated with mercury, and never in non-syphilitic subjects of mercurial poisoning. Symptoms.— The symptoms of syphilitic hepa- titis and gummy tumours in the liver are in most instances obscure, so that these complications of advanced syphilis are often overlooked. The liver in some cases is enlarged, in other cases reduced in size. In the former instance it will often bo found on abdominal percussion that the relative proportions of the right and left lobes have been much altered, and that there » considerablo deformity of the whole organ. Firm globular elevations on the surface of the liver may some- times be felt through the anterior abdominal wall. Advanced syphilitic hepatitis is usually associated with slight and slowly increasing ascites, and sometimes with oedema of the lower extremities. There is seldom any well-marked jaundice. The patient often complains of a sense of weight and uneasiness in the right hypo- ehondrium, or, in some few cases, of severe pain. In almost all cases there is some hepatic tenderness. The most constant symptoms are of a dyspeptic character ; the abdomen often be- comes painful and distended ; and there is very often, at an advanced stage of the disease, obsti- nate and profuse diarrhoea. Diagnosis. — The slow progress of the disease : the absence of any severe pain in the region of the liver ; aclear history of syphilis, and the presence of syphilitic lesions at some part of the body; no history of cancer ; and the absence of any indica- tions of malignant disease, whether on the surface of the body or in the abdominal cavity, all serve to support the diagnosis of syphilitic, as opposed to cancerous disease -of the liver. In ordinary cirrhosis of the liver the progress of the disease is more rapid ; the dyspeptic symptoms more severe; the ascites more abundant; and the indi- cations of alcoholism are generally well marked 352 LIVER, TUBERCULAR DISEASE OF. Treatment. — The treatment of syphilitic disease of the liver is that usually carried out in cases of tertiary syphilis. W. Johnson Smith. LIVER, Tubercular Disease of. See Liver, Morbid Growths of. LIVER-FLUKE. — A common name for the Fasciola. See Distoma. LLANDRINDOD, in Radnorshire, South Wales. — Saline, sulphated, and chalybeate waters. See Mineral Waters. LOBULAR ( lobulus , a little lobe). — Of or belonging to a lobule. A term generally ap- plied to morbid conditions affecting indivi- dual lobules of organs which are thus constituted, euch as lobular pneumonia, lobular pulmonary collapse, and lobular hepatitis. LOCAL. — This term is used in contradistinc- tion to the word general. Thus, in connection with morbid conditions, it is applied to those which are confined to, or seem specially to affect, a par- ticular part. Again, local causes are such as act upon a limited portion only of the body, such as a blow or a burn. Local treatment implies the application of remedies in the same sense. LOCK-JAW. — A popular synonym for teta- nus. See Tetanus. LOCOMOTOR ATAXY (locus, a place, and moto, I move ; a, priv. and ra(ts, order). — Synon. : Tabes dorsalis ; Fr. Ataxie locomotrice ; Ger. Graue Degeneration der Hinterstrange des Ruck- enmarJcs. Definition. — A disease of the spinal cord, characterised by a peculiar unsteadiness in the performance of voluntary movements ; or a loss, to a greater or less extent, of the power to control and co-ordinate the action of muscles necessary’ for the steady performance of these movements. Aetiology. — The causes of locomotor ataxy are so various, that in persons who are predisposed to it, almost anything that seriously depresses the nervous power, especially of the spinal cord, will become an exciting cause. Such are cold, wet, excessivefatigue, bad or insufficient diet, depress- ing emotions of the mind, and, as the writer thinks, onanism, or the long continuance of other forms of sexual excess. Suppression of habitual perspirations, particularly of the feet, and the removal of haemorrhoids, have in many instances immediately preceded the disease. But pro- longed exposure to cold and wet appears to be one of its most common causes. Syphilis is regarded by some as the chief predisposing cause ; and the disease is certainly very much more frequent in males than in females. Anatomical Characters. — The spinal cord is invariably altered in structure. Generally, the membranes are much congested, and the writer has often found them thickened posteriorly by exudations, and adherent to each other and to the posterior columns. The posterior columns, especially in their outer regions, and the nerve- roots are the parts that are chiefly affected. The morbid change consists of atrophy and disinte- gration of the nerve-fibres, to a variable extent ; with hypertrophy of the connective tissue. Oil- LOCOMOTOR ATAXY, globules surround many of the blood-vessels The posterior nerve-roots undergo the same kind of degeneration, which sometimes extends to the surfaces of the lateral columns, and even along the edges of the anterior. Sometimes the write t has found the extremities of the posterior cornua, and even the central grey substance, more or less damaged by disintegration. 1 The pathological change seems to travel from the centre to the periphery— from the spinal cord to the posterior roots. In the cerebral nerves, however, the mor- bid change takes an opposite direction— from the periphery towards the centres. Sometimes it extends as far as the corpora geniculata, hut seldom as far as the corpora quadrigemina. Symptoms. — In most cases the unsteadiness begins in the lower extremities ; hut generally — after a certain bnt variable time — it involves the upper extremities, the hands and arms being the parts most affected. As the writer has pointed out, this un- steadiness, or muscular inco-ordination, occurs under two consecutive forms. It first makes its appearance as a simple unsteadiness of gait; the patient walks like a person partially intoxicated. He likewise frequently complains of heaviness in his logs ; and of fatigue after walking or after standing. With his legs close together, and his eyes shut, he sways about and would fall if not supported. Later on he finds that he cannot walk without looking at his feet. When the upper extremities become affected, the patient is unable to dress himself, to button his clothes, to write, or to pick up a pin. After a time a second kind of disorderly move- ment supervenes. This arises from a spasmodic and jerking action of the muscles, which the will quits in motion, but is unable to control; the patient cannot regulate the degree of their con- traction. When put in motion the muscles con- tract beyond the degree intended, and flex or extend the limb with an uncontrollable jerk. All the voluntary movements are hurried and precipitate. The patient seems to be walking upon springs ; he proceeds with a kind of pranc- ing gait, and brings his heels to the ground with a kind of kick. If he attempts to take hold of an object he probably will thrust it from him by a spasmodic jerk of his arm. The disease is progressive. At ail advanced stage the patient cannot walk or stand -without assistance, and even then, if he attempts to advance, he jerks his legs about in the most disorderly manner. The ataxy or disorderly movement is accom- panied by some of the following symptoms, namely : — Strabismus, diplopia, amblyopia, am- aurosis, ptosis, contraction of both pupils or only of one ; shifting pains in different parts of the body, but chiefly in the extremities ; cutaneous and muscular anaesthesia, and loss of the sense of temperature; incontinence of urine, and dy- suria; loss of electro-muscular contractility, in a variable degree ; abolition of the patellar-ten- don reflex ; spermatorrhoea, with loss of sexual power and desire ; occasionally, hut not often paralysis of the first, fifth, seventh, eight, ant ninth cerebral nerves; (edematous swelling o the joints, chiefly of the knees; and cardiac ar.i gastric disturbance. * See Lancet , June 10, 1SG5. LOCOMOTOR ATAXY. All these symptoms are never found together in any one case of locomotor ataxy, but occur in different groups in different cases, as the follow- ing examples will show. The symptoms made their appearance in the order of time in which they are mentioned. Case 1.— Strabismus and diplopia; pains in the legs, with numbness of toes ; ataxy, or un- steadiness of gait; numbness of fingers, followed by pains in the arms, with unsteadiness of mus- cular movements; incontinence of urine; both pupils contracted to the size of pins’-heads. Case 2— Darting and shifting pains in legs, with numbness and heaviness; pains in abdo- men and chest ; ataxy ; pains and numbness in hands and arms, followed by ataxy ; analgesia ; incontinence of urine, alternating with dysuria ; haemorrhoids ; loss of sexual power. Very frequently the pains in the limbs are, for a variable period, the only precursors of the other symptoms. They are of two kinds — the irst is of an aching, gnawing character, and is often mistaken by the patient for rheumatism. The other kinds of pains are acute and lancinat- ing, like electric shocks, shifting from one part of the body to another. They recur in paroxysms, lasting for a few hours or a few days, and suddenly disappear for a variable period. In other cases the ocular disturbances are the first symptoms that make their appearance. They consist of strabismus, or amblyopia, ending frequently in amaurosis. In a large proportion of cases, paralysis of either the third or the sixth cerebral nerve, with diplopia, is found during the first stage of the disease. The peculiarity of this paralysis is its periodicity. It may last for a few days, or a few weeks or months, and then iisappear as suddenly as it came ; or it may con- tinue uninterruptedly throughout the disease. Sometimes the strabismus is double, but more frequently it is limited to one eye. Even when there is no perceptible strabismus, there is some- times double vision, when the patient turns his ayes in a particular direction. Ptosis and dila- .ation of the pupil are also frequently present. In some cases one pupil is dilated, while the >tker is contracted. Amblyopia sometimes ap- pears at a very early period, and increases till it erminates in amaurosis. Cutaneous anaesthesia usually accompanies the ■taxy, and affects chiefly the arms, fingers, legs, nd toes. The patient says that he seems to be talking on something soft, and does not feel the Tound properly ; unless he looks at his feet, he careely knows that they have reached it. Some- mes he feels as if he were ‘ walking on air,’ on is ankle-joints, or on his hip-joints, when the umbness extends up the legs and thighs. Anal- Issia, or loss of sensibility to pain, in a greater t less degree, is very common; or painful im- tessions are felt with unusual slowness. The riter has known cases in which several minutes ive elapsed before the prick of a needle has ^en felt. Disorders of the urinary organs are generally termittent in their attacks. Usually the suria and incontinence recur alternately in e same stage of the disease. Spermatorrhoea commonly one of the early symptoms in ■omotor ataxy. It is followed by loss of 853 sexual power, with or without loss of sexual desire. Affection of the joints in locomotor ataxy was first described by M. Charcot, of Paris. The knee- joint is almost always the seat of the disease, which appears suddenly as an elastic oedematous swelling. Like the diplopia, strabismus, and urinary troubles, it may be intermittent — may remain only for a short time, or continue unin- terruptedly and result in permanent deformities, with disease of the bones and cartilages of the joint. The strabismus, amblyopia, and shifting in- termittent pains were considered by Duchenne as the first stage of ataxy, which may last for months or years. The next stage is when the ataxy or unsteadiness of gait makes its appear- ance, either accompanied with or soon followed by anaesthesia or analgesia, generally in the lower extremities. In the third stage many of the symptoms become more marked and more general, the ataxy or muscular inco-ordination extending to the upper extremities. This divi- sion into three distinct stages does not, however, apply to all cases. Diagnosis. — In the early stages of the disease, especially before the muscular ataxy has made its appearance, and when only two or three other symptoms are present, the diagnosis is extremely difficult, even to those who have great practical experience of the disease. Several of the symp- toms, such as strabismus, amblyopia, anaesthesia, and the so-called ‘ rheumatic ’ pains, which precede frequently for a long time the motor ataxy, may be found in other disorders which differ essen- tially from this malady. But there is often in some of these symptoms a certain peculiarity which may assist us in the diagnosis. For instance, in a great many cases the strabismus is accompanied by amblyopia ; and when it is single, the amblyopia is on the corresponding side. Moreover, the sudden attacks and equally sudden cessation of the pains, their rapid shifting from one place to another, or their remarkable proneness to fix, sometimes for hours, on some particular spot, are not without their signifi- cance. Prognosis and Treatment. — The prognosis is generally very unfavourable. An early diag- nosis is of the greatest importance, as it is chiefly at the first invasion of the disease that the patient is most benefited by treatment. An important object is to protect the patient from cold and wet, and keep him in an equable temperature. The whole of the body should therefore be enveloped in flannel. A good and generous diet, with 11106 or beer, seems best suited for the patient. Of the different medicines that have been used, nitrate of silver seems to have the most specific influence on locomotor ataxy. One-eighth of a grain gradually increased to one grain three times a day, after meals, is the best mode of exhibition. If it should irritate the bowels or the bladder, it may be combined with morphia, cannabis indica, or belladonna. The oxide of silver is a useful substitute for the nitrate, when the latter dis- agrees. Dry-cupping along the spine has been found useful. For the relief of the severe limb- pains there is nothing so efficacious as the sub- cutaneous injection of morphia. The writer haa 854 LOCOMOTOR ATAXY. always found that constipation aggravates the pains. Sulphur baths have been used with some relief. Cod-liver oil and phosphorus may also be prescribed. Rest has been strongly recom- mended ; and the constant galvanic current is certainly sometimes beneficial. J. Lockhart Clarkk. LORDOSIS ( \opS'os , bent). — A term ap- plied to abnormal curvature of the spine for- wards. See Spine, Diseases of. LUCID INTERVALS.— No better defini- tion of this state has been given than that of Lord Thurlotv, who calls it ‘ an interval in which the mind having thrown off the disease had recovered its general habit.’ It must be regarded as ex- tremely unlikely that a perfect restoration to reason can take place in the course of any long- continued insanity, without full opportunity having been afforded of testing its nature. The law more readily recognises the restoration of the mind to a state of civil capacity such as will render testamentary acts valid, than such tem- porary recovery as would restore responsibility for crime. If a civil act be rationally performed, the law accepts that as vrimd-facie proof of the capacity of the agent; but juries very seldom convict the accused of a crime if insanity is proved to have existed within a short period of its com- mission. John Sibb.ald. LUHATSCHOWITZ, in Moravia— Mu- riated alkaline waters. See Mineral Waters. LUMBAGO ( lumbi , the loins). — Synon. : Fr. Lumbago ; Ger. Lcndcnweh. — Muscular rheu- matism, affecting the muscles and fasciae of the lumbar region. Sec Rheumatism, Muscular. LUMBAR ABSCESS. —Definition. — A variety of spinal abscess, usually due to caries of the upper lumbar or lower dorsal vertebrae ; in which the pus, instead of taking the course followed in psoas abscess, becomes envelopied by the muscles and fasciae of the lumbar region, and usually points in this situation ; or by infiltrating the cellular interspaces of the abdominal muscles, gains the front of the abdomen, and descends above Poupart’s ligament. The last-named feature is a diagnostic point of some moment, since psoas abscess, although commencing in the same man- ner, is usually characterised by making its way below Poupart’s ligament. JEtiology.— The origin of lumbar abscess is often ascribed by the patient to a wrench or a blow — statements which must be taken with some caution, since it will be noticed that the patient rarely remembers any injury having hap- pened, until long after well-marked symptoms have arisen. Curvature of the spine is almost invariably present. In children it is almost always the result of scrofulous osteitis ; and it has been by some ascribed, in adults, to sexual excesses. Description. — Lumbar abscess may commence in the soft parts, but when dependent on spinal caries is preceded by the usual symptoms of Rotts’ disease, which have been coming on slowly and insidiously for a period varying from three to six months. Owing to the numerous tendinous expansions, LUMBAR REGION. and dense aponeurotic structures and fasciae of the lumbar region, the pus, which has formed in connection with the spine, meets with many ob- structions, resulting in singular deflections, before it gains the surface (see Lumbar Region). Most frequently it perforates the quadratus lumbornm muscle, and points at the edge of the sacro- lumbalis. Here it shows itself as a broad, flat, slightly elevated, fluctuating tumour; bavin*' a somewhat irregular surface, owing to the tendi- nous structures which traverse its cavity. Occa- sionally the pus of a lumbar abscess makes its way downwards and forwards above Poupart’s liga- ment, or between the abdominal muscles, and points at the outer edge of the rectus abdominis muscle; and indeed there would seem to be no intermuscular or interaponeurotic space which it may not permeate. In other instances, it may be first observed by palpation of the abdominal walls ; may simulate caecal abscess, a malignant growth, an intestinal collection, an aneurysm, or other abdominal tumour ; or may burst into the cellular tissue of the abdominal cavity. In chil- dren, owing to the relatively small size of the pelvis, there is a chance of the pus mounting over the iliac crest, or sidewaysover the glutsi muscles. Prognosis. — The prognosis is precisely the same as that mentioned in the article on psoas abscess. See Psoas Abscess. Treatment. — The treatment is the same as that indicated in psoas abscess, namely, free an- tiseptic incision. There are, however, cases where spontaneous evacuation of the pus, and treat- ment by the prone couch have led to good re- sults ; and, moreover, there are casts of spon- taneous cure. Edward Bellamy. LUMBAR REGION. — This rogion, to which it is somewhat, difficult to assign precise limits, may conveniently be described, for practical purposes, as bounded(with reference to the surface of the body) superiorly by the last rib, below by the posterior half of the upper edge of the crest of the ilium, and externally by the posterior margin of the external oblique muscle. The series of lumbar spines would thus superficially separate the right from the left lumbar region. All the structures lying between the skin and such abdominal viscera as are in relation with the parietes, enter into the formation of the lum- bar region, the symmetry’ of the two sides being broken by the fact that the right kidney lies lower than the left. These structures are met with in the following order from the surface: — 1. the skin; 2. the cellular tissue ; 3. the lum- bar aponeurosis ; 4. the museulo-aponeurotic layer; 5. the bones; and 6. tbe visceral layer. The blood-vessels and nerves are distributed amongst these tissues. 1. The s/cin. — The skin of the lumbar region is remarkable for its extreme thickness, and want of sensibility and mobility, being firmly fixed to the spines of the vertebrae. 2. The cellular tissue. — The cellular tissue consists of two laminae, a superficial and a deep the former very’ adherent to the skin, whilst tbe deepor is strengthened by several processes, do rived from the aponeurotic layer. 3. The lumbar aponeurosis. — The lumbar apo neurosis, the strongest in the whole body, deier LUMBAR REGION. mines in a gieat measure the form of the region. | It is attached firmly' to the spinous process of the lumbar vertebrae, and its anterior surface gives origin to, and binds down the erectores spiD® muscles. The aponeurosis of the transver- ' salis is here divisible into three vertical laminae, namely, the posterior, which assists in the for- mation of the lumbar aponeurosis ; the middle lamina, attached to the tips of the transverse processes of the lumbar vertebrae, and forming with the preceding a sheath for the erectores spin®; and the anterior, attached to the bases of the transverse processes of the vertebrae, and forming, with the middle lamina, the sheath of the quadrates lumborum. The aponeurosis is limited by the posterior border of the external oblique muscle. 4. The musculo-aponeurotic layer. — The mus- culo-aponeurotic layer consists, on either side of the mesial line, of the mass of the erector spin® muscle and the transverso-spinales internal to and below it; whilst between these muscles are the branches of the lumbar vessels and nerves. Beneath these lie the transverse processes of the lumbar vertebr®, the inter-transversales mus- cles, the lamins of the vertebrae, with the liga- menta subflava ; and, in a plane anterior, the quadrati lumborum, and ilio-lumbar ligaments. The psoas muscle enters the lumbar region. 5. The bones. — These consist of the lumbar vertebr®, with the inter-vertebral discs and liga- ments, enclosing the cauda equina with its in- vestments. 6. Visceral layer. — In front of the bones lie the pillars of the diaphragm ; the inferior vena cava to the left, and the aorta to the right ; on either side, the chain of the sympathetic, the lumbar glands, and the receptaculum chyli, and the commencement of the thoracic duet ; and the commencement of the azygos major vein. In front of the quadratus is a space occupied in its superior third by the kidney, and its lower two-thirds by the colon. About half the kidney lies in this space, of which the right is rather the lower of the two. The right colon is entirely enclosed in the peritoneum, whilst the left has only apartial investment of that membrane. The kidney lies external to the psoas, and upon the quadratus, corresponding with the outer side of die sacro-lumbar muscular mass. Certain anom- ilies in the relation of die kidneys are sometimes net with : they occasionally descend into the iliac ’osss, or they may float, owing to extreme length if the blood-vessels, which penetrate the hilum, nd may then be felt loosely situated amongst he other abdominal viscera. On the psoas lie : -the ureter internally ; obliquely the spermatic r ovarian vessels, and the sympathetic ; and xternally the genito-crural nerve. Blood-vessels. — The arteries which perforate nd supply this region are the lumbar arteries, 'he veins correspond with the arteries ; they aastomose, however, with the renal veins. Berves. — The nerves of the region are derived om the lumbar plexus, formed by the five lum- ir nerves and last dorsal ; whilst the sympa- etic system is derived from the solar, renal, ’■pogastric, and lumbo-aortic plexuses. Pathological and Clinical Relations. — The mbar region is of great surgical importance, LUNACY, LAW OF. 855 from the relation to its anterior aspect of certain abdominal viscera ; from the numerous fasci® which enter into its formation, and their relatior to abscesses, growths, and bloody or urinary effusions ; and from the fact that the operations of colotomy, nephrotomy, nephrectomy, and ths opening of perinephritic abscesses are performed within its boundaries. Spina bifida has a great predilection for this region. Penetrating wounds in the lumbar region are liable to involve the cauda equina, owing to the wide separation which exists between the lamin® of the lumbar verte- br®. ‘With regard to abscesses, connected with caries of the lumbar vertebr®, their situation is generally determined by their origin. When the posterior portion of the bodies or spines are af- fected, the pus is conducted backwards, beingcon- fined by the fascia lumborum. If the transverse processes or the anterior portion of the bones be the seat of disease, the pus will point anteriorly on the abdominal wall, being either bound down by the fascia transversalis, or conducted forwards between the abdominal muscles, in which case the pointing always takes place above Poupart’s ligament. Renal or perinephritic abscesses often point at the border of the quadratus lumborum muscle, and may there be opened. Lumbar hernia protrudes at the so-called * triangle of Petit. ’ The operations practised in the lumbar region are lumbar colotomy, Dephrotomy, and nephrectomy. Of lumbar colotomy there are several modifications, but it is generally per- formed in the descending colon, which is usually uncovered by peritoneum posteriorly. Other pathological andclinical relations of this region, which have many points in common with those of the iliac region, are referred to under that heading. Edward Bellamy. LUMBRICUS. — By many practitioners this term is still employed to designate the large round-worm ( Ascaris lumbricoides ). The title is entirely a misnomer, having originated with Tyson (Phil. Trans. 1683) who called the com- mon species Lumbricus teres liominis. All the larger round- worms infesting man and animals are apt to be called lumbricoids. Notwithstand- ing their general resemblance to ordinary earth- worms, their organisation is totally different. Occasionally, in practice, patients seek to deceive the medical attendant, by placing one or more earth-worms in the night-stool or chamber-pot. Quite recently the writer encountered an instance where a large garden lobworm (L. terrestris ), about a foot in length, had been carefully selected for this purpose. The practitioner should not only be familiar with the differences of character presented by true and false worms of this kind, but should bear in mind that earth-worms can- not live in the human bladder and intestines. See Ascarides; and Round- worms. T S. Cobbold. LUNACY, Law of. — The medical practi- tioner is frequently required to perform duties in connexion with lunacy, the satisfactory discharge of which requires that he should have somo acquaintance with the legal enactments by which they are regulated. Tbo statutes differ slightly in the three divisions of the kingdom. It will therefore be necessary, after describing what is LUNACY, LAW OF. 566 required under the law in England, to show where its requirements differ from those which exist in Scotland and Ireland. The details to be given here will only include what is necessary for the information of the general practitioner. Anyone who intends to devote himself specially to the treatment of the insane, or to receive one or more persons of unsound mind into his house, must comply with regulations which we cannot here set forth, but which are fully described in works upon the subject. When a person living in his own homo is under treatment for insanity, t he medical attendant is justified by the common law, in adopting any measures of restraint which may be necessary for safety or the proper treat- ment of the malady. This has been decided by the courts of law in recent cases. If, however, it is proposed to place the patient in an asylum, or to remove him to the charge of any person who is to derive profit either directly or indi- rectly from the proceeding, it is necessary that certain forms should be carefully observed. In the case of a Chancery lunatic, an order by the ‘ Committee of the Person,’ having annexed to it an office copy of the appointment of the Committee, is sufficient authority for the recep- tion of the lunatic either into an asylum ora pri- vate house. In the case of other private patients, it is necessary to have what is called an ‘ order’ and two medical certificates, as in the annexed form. 1 The order may be signed by anyone having a reasonable right to interfere, provided he is neither of the medical men signing the i MEDICAL CERTIFICATE. Sched. (A.) No. 2, Sects. 4, 5, 8, 10, 11, 12, 13. /, the undersigned, William Haney , being a (*) Mem- ber of the Royal College of Physicians of London, and being in actual practice as a ('>) Physician, hereby certify, that I, on the third day of March 1875, at ( c ) number 8 Kent Street, Norwich, in tbe county of Norfolk, separately from any other Medical practitioner personally examined Edward Harris of ( d ) number 8, Kent Street , Norwich, Grocer, aud that the said Edward Hands is a ( e ) person of unsound mind and a proper person to be taken charge of and detained under Care and Treatment, and that I have formed this opinion upon the following grounds ; viz. 1. Facts indicating Insanity observed by myself tf) He states that his daughter, who has lived in his house for years, is a person unknown to him, who has been placed in the house as a spy, and made to look like his daughter. He states also that he believes Parliament intends to ruin him. 2. Other facts (if any) indicating Insanity communi- cated to me by others (e) If is daughter, Mary Harris, informs me that he has been sleepless and restless and much depressed in mind for the last week, and that he has on that account been unable to attend to his business. Signed, N ame, William Harvey Place of abode, 31. Chapel Street, Norwich. Haled this third day of March One Thousand Eight Hundred and Eighty. (“) Here set forth the qualification entitling the person certif ying to practise as a physician, surgeon, or apothecary, for example:— Fellow' of the Royal College of Physicians of London, Member of the Royal College of Surgeons of England, Licentiate of the Apothecaries’ Society, or as the case may be. ( b ) Physician, surgeon, or apothecary, as the case may be. (') Here insert the street and number of the house (if any) or other like particulars. ( d ) Insert tvsidence and profession, or occupation (if any) of the patient. (•) Lunatic, or an idiot, or a person of unsound mind. < f ) Here state the facts. fs) Here state the information, and from whom. certificates, nor father, son, brother, partner, or assistant to either of them, nor professionally or pecuniarily connected, or to be connected in anv way, with the person under whose charge the patient is to be placed. The person signing the order must have seen the patient within a month of the date of the order ; and the order con- tinues available for one month from the day of its date. The medical certificates must be signed by registered practitioners in actual practice in England. They must have no interest, directly or indirectly, in the patient, in the establishment or house to which he is to be sent, or in his subsequent treatment ; and they must not be in partnership with one another, nor otherwise pro- fessionally connected. A certificate when granted remains valid for seven days from the date of examination. The necessary form is here given. The words in italics describe a supposititious case, and are introduced merely to illustrate the manner in which the blanks must be filled up. This document may he altogether in writing; but it is both desirable and convenient for all concerned that the regular printed forms should be used. 1 Great care must he taken to have every detail of these documents complete and accurate ; for it frequently happens that what may appear to many a trifling error renders a certificate invalid, and thus entails much inconvenience and some- times distress. The foot notes attached to the certificate will be found sufficient as guides in the more important details, but the following hints will also be found useful : — 1. The medical quali- fication must he given in full ; 2. The house at which the examination was made must he accu- rately named, giving the name of the street, if there be any, and the number of the house ; 3. The residence of the patient must be described with similar precision ; and 4, The name of the person must be given, from whom the ‘other facts ’ are obtained. The opinions at which the medical man must arrive before signing a certi- ficate are two, and they are quite distinct. He has first to determine whether the patient is of unsound mind, and next whether it would be proper to place him under restraint. The deter- mination that a person is insane does net neces- sarily imply that it is proper to place him under restraint. In stating the facts upon which the certificates are founded it must he borne in mind that' they must be such as will appear to the Commissioners in Lunacy to be sufficient evi- dence of insanity ; and great care must be taken to state them both intelligibly and accurately. There must be sufficient in the facts observed by the medical man himself to justify the opinion to which he certifies, the facts communicated by others being only accepted in corroboration of it; these may indeed he altogether omitted with- out invalidating the document. On this point tho Commissioners have laid it down that the Legislature has been careful to guard against the facts communicated by ethers exercising 1 These forms can he obtained at. the law-stationers. As they are frequently wanted with the least possible delay, we mention the names of Messrs. Shaw and Sons, Fetter Lane, and of Messrs. Knight and Co., 90 Fieri Street, as fir-ms in the habit of supplying them. LUNACY, LAW OF. undue influence upon the mind of the medical man in granting his certificate, ‘ by requiring that this certificate shall be directly dedncible from examination on a particular day and at a specified place, and that the opinion expressed therein as having been formed on such particular day shall be set forth as the result of his having observed at that time in the person under ex- amination some specific fact indicating insanity.’ In the statement of the facts observed, it is therefore necessary that at least one such fact or combination of facts, should be mentioned as could not be affirmed of a person of sound mind. A frequent error is the stating of facts in such an imperfect manner that, though they may have been real indications of insanity as observed, the manner in ■which they are recorded makes them appear insufficient. It is sometimes stated, for example, that a patient ‘ believes himself to be possessed of great wealth;’ but it is necessary that we should also state whether this is or is not a well-founded belief. And it is not infre- quent to find this necessary adjunct absent from the statement. One actual statement of facts, for instance, was 1 his appearance, manner, mode of speaking, as well as his conduct,’ a detail of circumstances which had probably proved con- clusively enough to the writer that the patient was insane, but which afforded no substantial information to those who merely read the state- ment. When the case is urgent, and it is found impracticable to obtain certificates from two medical men, the patient may be received into he asylum or house upon a single certificate. But this entails the necessity of obtaining two ldditional certificates from ether medical men vithin three clear days after the reception of the jatient. A private patient may be discharged from the sylum or house in which he has been detained, ■a the written authority of the person who igned the order for his admission. If a patient herald die while under detention it is necessary 3 give notice of the death to the Coroner and to le Commissioners in Lunacy. In the case of pauper lunatics the procedure i somewhat different from what is required for rivate patients. Anyone aware of the exist- ■ice of an insane pauper in a parish, ought, if lie case is a proper one for asylum treatment, i give notice to the relieving officer or the ■erseer. When a district medical officer under e poor law becomes aware of such a circum- ance it becomes his statutory duty to give this 'ticein writing within three days after obtaining i ch knowledge. The relieving officer or over- ir may then place the patient in an asylum upon e medical certificate, accompanied either by e order of a justice of the peace, or by an order i;ued conjointly by himself and an officiating Tgyman of the parish. In order to place a patient in an asylum in utland, a petition accompanied by a statement |1 two medical certificates has to be presented the sheriff, 1 In the case of a private patient ■ person signing the petition must state the ;ree of kinship or other relation in which he The regular printed forms for Scotland may be ob- Gf t from Messrs. T. and A. Constable, 11 Thistle ' iet, Edinburgh. LUNATIC. 857 stands to the patient. In the case of a pauper the petition must be signed by the inspector of the poor. In either case, if there be reasonable ground for so doing, the patient may be placed in the asylum on what is called a ‘ certificate of emer- gency,’ signed by one medical man. If, however, the order of the sheriff is not obtained within three days thereafter, the patient must be dis- charged. In the case of a patient placed for profit in a private house in Scotland, the fact must be reported to the General Board of Lunacy for Scotland, and the sanction of the Board obtained. The procedure required for placing a patient in an asylum in Ireland is generally similar to what is required in England. For admission to a private asylum, an order and two medical cer- tificates must be filled up and signed, subject to regulations resembling those already described as enforced in England ; but the facts indicating insanity do not require to be stated in the certi- ficates. Pauper patients are placed in district asylums, and are admitted to these institutions on application being made at the asylum of the district in which the patient resides. The neces- sary form is obtained at the asylum. It consists of (1) a declaration to be made before a magis- trate, that the patient is insane and destitute, and has no friend able or willing to pay for his board in an asylum ; and to this is annexed a statement descriptive of the patient ; (2), a certificate by a magistrate, and a clergyman or poor law guardian, in corroboration of the declaration ; and (3), a medical certificate of insanity. When these forms have been filled up, it is necessary to wait until it is notified to some of the friends of the lunatic that there is room for him at the asylum. The procedure specially designed for the committal of dangerous luna- tics is, however, frequently adopted in placing paupers in asylums. As this necessitates the lodgment of the patient in an ordinary prison, it is evidently a course which ought to he avoided, and which the medical practitioner ought specially to discourage. According to this procedure the patient requires to be appre- hended by the police, and brought before two justices of the peace. They call to their aid the medical officer of the Dispensary District, and either discharge the patient or order his removal to the asylum. Patients who are not destitute, but whose friends are unable to pay the rate3 of board charged in private asylums, are received into district asylums at low rates, upon appli- cation being made at the asylum in a similar manner to that already described for paupers. The chief difference between the two forms is that in the case of patients not destitute, the medical certificate requires to be signed by two medical men instead of only by one. John Sibbai.d. LUNATIC (tuna, the moon). — Synon. : Fr. Lunatique ; Ger. Mondsiichtig . — A designation given to persons suffering from mental disorder, because such subjects were formerly believed to be peculiarly affected by lunar influences. The term is used popularly as synonymous with in- sane. In medical literature it is seldom em- ployed, but the legal relations of the word are important. The adjective lunatic is also used 858 LUNATIC, to signify that the object with which it is asso- ciated is connected with insanity, as lunatic asy- lum. See Insanity. LUNGS, Diseases of. — Synon. : Fr. Mala- dies du Ponrnon ; Ger. Krankheiten dcr Lungen. Under this title there will be described in the following pages, with certain exceptions, the various morbid conditions which affect the pul- monary organs. Pulmonary phthisis is so com- mon a disease, so complex and variable in its pathology, and so closely associated in its aetio- logy and symptoms with the entire organism, that it will, be most conveniently described apart from tho other diseases of the lungs (see Phthisis). Certain other diseases which in- volve the lungs, if not the lung-tissue proper, and which in some nosological systems are de- scribed as pulmonary diseases — namely, asthma, diseases of the bronchi, and diseases of the pleura, will also be found described apart from the present connection, and under their several headings. Again, disorders of respiration, such as dyspnoea, orthopnoea, and ‘ Cheyne-Stokes re- spiration,’ although frequently associated with diseases of the lungs, are in other instances referable to some morbid condition of other parts, such as the blood, the heart and circulation, or the nervous apparatus of breathing, and they will therefore be discussed in a distinct article ( see Respiration, Disorders of). The more im- portant special clinical phenomena of disease of the lungs — namely, cough, expectoration, haemop- tysis, and the various physical signs, also de- mand more detailed and complete consideration than can be devoted to them in connection with the various pathological conditions to which they are due. See Cough ; Expectoration ; Haemoptysis ; and Physical Examination. After the separation of these subjects from that of diseases of the lungs, there remain for consideration under this head a large number of morbid conditions, which rank of the very first importance in practical medicine, and which will now be enumerated. The morbid processes which affect the lungs may be readily divided into two great groups — namely, first, those which are not essentially different from similar processes in other parts of the body ; and, secondly, those which arc quite peculiar to these organs. First, -with respect to the former group, the lungs, like the other great viscera, may present any of the ordinary morbid conditions, which affect either entire organs, or the several tissues of which they are composed. Thus the lungs maybe the subject of various injuries, leading to perforation or rupture, and may present certain malformations and misplacements. They may undergo such alterations of nutrition as end iu atrophy, hypertrophy, or certain degenerations. Disturbances of circulation give rise to well- defined pathological conditions, such as anosmia, congestion, hyperemia, ‘ apoplexy embolism, in- farction, oedema, and hesmorrhage. The inflam- matory process leads to a greater variety of pathological changes in the lungs than in per- haps any other organ, and which are known as catarrhal, croupous, and chronic pneumomia, abscess, cirrhosis, gangrene, and some forms of phthisis. Morbid growths of all kinds, including LUNGS, AUS CESS OF. malignant disease, may involve the lurgs, whether primarily or secondarily. Syphilis, besides actu- ally involving the lungs, occasionally determines or modifies the occurrence of other pathological processes within them. Various parasites, espe- cially hydatids , are occasionally tenants of the pulmonary organs. Secondly, the morbid conditions which are peculiar to the lungs are such as depend upon their special structure, relations, and functions. Thus the relation between the pulmonary tissue and the pressure within and around the lungs may he so disturbed as to lead, on the one hand to collapse or compression, or on the other hand to emphysema. Their communication with the atmosphere, and the constant interchange that is going on between the contents of the lungs and the external air, have an important influ- ence upon the origin, distribution, progress, and treatment of many of the diseases which affect them ; whilst the length and complexity of the respiratory passages and their liability to dis- ease, lead to many disturbances of the pres- sure, the circulation, and the nutrition within the lungs, and thus to collapse, hypenemia, inflammation, and even destructive disease. The relation of tho lungs to the circulation has an equally important influence upon them from a pathological point of view. Constituting as they do the channel of communication between the right and the left sides of the heart, the pulmonary’ vessels are involved in all the dis- turbances which affect the cardiac circulation, whether due to actual disease of the valves or of the walls, or to simple functional derangement of that organ. Congestion, oedema, embolism, infarction, htemorrhage, and some forms of in- flammation of the lungs, are the ordinary results of such circulatory disturbance of a temporary kind ; and when it is more protracted, brown induration, as well as diseases of the bronchi and pleura, are likely to result. Such are the principal conditions which deter- mine and influence diseases of the lungs; and wo shall here enumerate these in the alphabetical order in which they will be found referred to in the following pages ; — 1. Abscess. 2. Albu- minoid Disease. 3. Anaemia. 4. Apoplexy. 5. Atrophy. 6. Brown Induration. 7. Cancer. 8. Cirrhosis. 9. Collapse. 10. Compression. 11. Congestion. 12. Consumption. 13. Degenera- tions. 14. Embolism. 15. Emphysema. 16. Gangrene. 17. Haemorrhage. 18. Hydatids. 19. Hyperemia. 20. Hypertrophy. 21. Indura- tion. 22. Infarction. 23. Infiltrations. 24. In- flammation — Croupous, Secondary, Catarrhal and Chronic. 25. Inflation. 26. Malformations 27. Malignant Diseases. 28. Malpositions. 29 Morbid Growths. 30. Gxdema. 31. Perforation 32. Rupture. 33. Syphilitic Disease ; and 34 Tuberculosis. LUNGS, Abscess of.— Synon. : Fr. Abet du Poumon ; Ger. Lungenabscess. Definition. — Circumscribed suppuration c the pulmonary tissues. -Etiology and Pathology. — An acute pri mary inflammation of the lungs may oecasior ally lead to the formation of abscess. Muej more commonly, however, pulmonarr abseesst LUNGS, ABSCESS OF. are the result of secondary or infective inflam- mations, and they are then, for the most part, associated with pyaemia. Of acute primary inflammations of the lung, as causes of abscess, we have to csnsider those due to mechanical injuries, and those associated with acute pneumonia and with gangrene. With regard to the former it is only neces- sary to remark that mechanical injuries, as frac- tured ribs, penetrating wounds of the thorax, the lodgment of foreign bodies, &e., may cause suppuration, and so occasionally lead to the for- mation of abscess. That acute pneumonia may, in rare cases, terminate in abscess of the lung, has already been stated. Such a result appears to be favoured by a bad constitution, and by any circumstances which tend to impair the general health, either before or during the disease. The ' abscess is more common in the upper than in the lower lobes. Lastly, circumscribed gangrene of the lung occasionally terminates in abscess. This takes place by the evacuation of the ne- , erotic tissue through the bronchi, and the for- mation of a pyogenic membrane from the walls of the cavity, which generates pus. The cavity may ultimately close by granulation and cicatri- sation. Abscesses of primary origin are usually single. Secondary or infective abscesses of the lung owe their origin to the dissemination of infective substances, derived from some focus of primary inflammation, by means of the blood-vessels or lymphatics. They are usually due to a general pyaemie process ; and consequently the blood- vessels are the channels by means of which the ■ufective substances are conveyed to the lungs. These substances are sometimes sufficiently arge to block the pulmonary vessels, the for- nation of the abscess being preceded by a pro- ’ess of haemorrhagic infarction. In other cases he suppuration occurs without any evidence of I'.ueh infarction taking place. These abscesses re almost invariably multiple. They vary in ize from a pin’s head to a walnut, and are sually most abundant near the surface. They' are ommonly surrounded by a thin zone of dark red onsolidation ; and when adjacent to the pleura, his membrane over them is always inflamed. Symptoms and Physical Signs. — The forma- ion of abscess in the lung is rarely attended by ny marked clinical phenomena, the symptoms f the disease, in the course of which the localised ippuration takes place being, for the most part, ut little modified by its occurrence. When acute pneumonia terminates in abscess, ther the rapid fall of the temperature which 'institutes crisis does not occur, or, what is more mmon, its occurrence is followed by pyrexia an irregular type. The physical signs of msolidation also persist, and there is usually 'eat prostration. Sometimes, owing to the s ening of the abscess into a bronchus, pus is ughed up ; and then, if the communication th the bronchus remain free, signs of cavity 3 discoverable. Before such partial evacuation its contents, the detection of the abscess by ysical examination is usually impossible. The 'Peetoration of sputa containing large quan- ta of pus, and often a little blood, may con- ue for some weeks ; the signs of prostration LUNGS, ANiEMLh OF. 859 may gradually increase ; and death may ensue in the course of from two to three months, and often earlier. Partial or complete recovery may, how- ever, take place, the cavity becoming quiescent and secreting only small quantities of pus ; and complete cicatrisation may ultimately occur. In exceptional cases the abscess opens into the pleural cavity. Abscesses of the lungs occurring in the course of pyaemia rarely give rise to any special symp- toms or physical signs. They are usually much smaller than primary abscesses ; and death com- monly ensues before any of them have attained sufficient magnitude to influence the general phenomena of the disease. Diagnosis. — The diagnosis of abscess, occur- ring in the course of pneumonia, rests mainly upon the persistence and characters of the pyrexia ; upon the physical signs of excavation supervening on those of pulmonary consolidation; and upon the expectoration of sputa containing pus. Pyaemie abscesses rarely admit of diagnosis. Their existence may be suspected if, in cases of pyaemia, pleural friction-sounds are audible over different portions of the chest. Prognosis. — Abscess resulting from pneu- monia very commonly proves fatal in from one to three months ; it may, however, as already stated, ultimatelyterminate in partial or even complete recovery. The development of abscesses in the lungs in the course of pyaemia does not appear to influence the general prognosis. Treatment. — Abscesses of the lungs rarely admit of any special treatment. Their occur- rence, however, indicates the importance of doing all that is possible to maintain the strength of the patient. T. Henry Green. LUNGS, Albuminoid Disease of. — In advanced eases of albuminoid disease, the lung- tissues may present more or less of this morbid change; but it is of no practical importance, for it does not give rise to any evident symptoms, nor does it have any specially injurious effect upon the patient. LTJN GS, Anaemia of. — Synon. ; Pr. Animie du poumon ; Ger. Lungenanamie. Definition. — A deficiency of blood in the lungs. Anaemia of the lung may be general or local. IEtiology. — Besides haemorrhage and the other causes of general bloodlessness, there are certain local causes which produce amentia of the lung. In senile atrophy, and in pulmonary vesi- cular emphysema, anaemia is associated with destruction of capillaries. Local or partial anaemia of the lung is the immediate result of embolism of the branches of the pulmonary artery. It rarely happens that the main vessel is entirely obstructed by an embolus ; but it, or more commonly one of its main divisions, may be compressed or obliterated by the invasion of a malignant growth or aneurism. Aneurism of a branch of the pulmonary artery within the luns usually causes anaemia of the portion to which the vessel is distributed. Anatomical Characters. — In extreme anae- mia, as after death from haemorrhage, the lungs and the bronchial mucous membrane are ex- SCO LUNGS. ANAEMIA OF. coedingly pale from absence of blood. They are of coarse lighter in weight than natural, but in other respects unchanged. In the general disease known as anaemia, the lung partakes with other organs of the general deficiency of red blood ; but in this condition, it being not so much in bulk as in quality that the blood is deficient, the lungs are of normal weight, but paler and more moist than natural, sometimes slightly (edematous. Effects. — The consequences of pulmonary anaemia, when long-continued, are atrophy of its texture, as in senile atrophy and vesicular em- physema, and in local deficiency of blood from partial obstruction of a large branch of the pulmonary artery. In complete obstruction of vessels from embolism, death and sloughing of the deprived area of lung is the consequence. The . sudden arrest of circulation through a limited portion of the lung, gives rise to stress on the collateral circulation, the result of which is often haemorrhage. Symptoms. — The dyspnoea and palpitation observed in anaemia are traceable to the anaemic condition of the lungs, and have their rationale in the necessity for an increased diligence of respiration, to enable the diluted blood to gather sufficient oxygen for carrying on the various combustion-processes of life. The remarkable gasping and restlessness seen in cases of fatal haemorrhage, are really the signs of asphyxia from pulmonary deprivation of blood. The symptoms of general or local pulmonary anaemia dependent upon emphysema, embolism, &c., are lost in those of the more important diseases. Treatment. — There is no special treatment for pulmonary anaemia. B. Douglas Powell. LUNGS, Apoplexy of. — A synonym for extravasation of blood into the lungs. See Lungs, Haemorrhage into. LUNGS, Atrophy of. — Synon. : Senile em- physema; Fr. Atrophie du Poumon ; Ger . Lun- genatrophie. Definition. — A wasting of the constituent elements of the lungs, from defective nutrition. Varieties. — Atrophy of the lung may be : — (a) general, in which all the tissues of the whole of both lungs are wasted, as in senile atrophy ; or it may he ( h ) local, in which all the tissues of a portion of the lung are wasted, as in the atrophy that results from a local diminution of blood- supply; or (c) it may be partial, in which some of the tissues are atrophied coincidently with increased growth of other tissues, as in some cases of so-called ‘ hypertrophous emphysema,’ and in ‘cirrhosis’ of the lung. .Etiology. — The cause of simple atrophy of the lungs is that general failure of nutrition which is natural to advanced age. Hereditary predisposition may determine an earlier failure of nutritive change in the lungs. The strongly- marked tendoney of vesicular emphysema to re- cur in successive generations is certainly in favour of such a tendency to premature impairment of tissue being inherited. Over-stretching of the walls of the air-cells in emphysema, with the consequent impediment to circulation, is an important cause of subsequent atrophy in this disease. Collapse and anaemia LUNGS, ATEOPHY OF. of lung from pressure from without, or from the pressure of a growth or aneurism upon one of the pulmonary vessels, cutting off the blood- supply, or on a large bronchus, diminishing the respiratory function, may cause atrophy of the whole or of a part of ono lung. Anatomical Characters. — The appearance of an atrophied lung may be best seen in a case of natural or senile atrophy. The lung is small, light, anaemic, more or less deeply pigmented, drier in texture and less firm and resisting than natural, pitting on pressure from want of elastic resilience, and capable of being squeezed into a very small compass. The air-cells appear to be increased in size; and at some portions, if the lung be inflated and dried, large cells may be seen, evidently resulting from the coalescence of two or moro infundibula. Across such cells fila- ments, the remnants of small bronchi and blood- vessels, may extend. The pulmonary arterv and its branches are diminishedin size, and the bron- chial tubes are also thinned. Microscopical characters. — The atrophic pro- cess commences at the vesicular septa, which project inwards to subdivide the infundibula, or alveolar spaces of the lung, into true air-cells, or alveoli. The process is one of simple withering and obliteration of capillaries, dependent on di- minished respiratory function and blood-volume. The septa dwindle down to mere ridees upon the infundibular walls; and these walls in their turn become thinned even to perforation and coalescence of several air-spaces. Thus, without any corresponding enlargement of lung, there is an apparent enlargement of air-cells from the simplification of structure. A certain degree of fatty degeneration, affecting especially the mi- nute vessels and the nuclear remains of the pul- monary epithelium, is associated with this simple atrophy, as with all other atrophic processes. When atrophy of the lung is associated with, or the result of, other diseases, as emphysema or forcible collapse, the process is essentially the same, but is combined in the former case with over-stretching of the air-cells, and more or less thickening of the fibrous tissues derived from the bronchial and perivascular sheaths, from re- peated congestions. Thus we have a larger and heavier lung; and, in the later stages, more marked fatty degeneration of its fibrous texture. In cases of atrophy from the long-continued pressure of fluid in the pleura, the pleura is always thickened from the original inflammation, and fibrous processes are directed inwards from it between the lobules, so as to render difficult any subsequent expansion of the lung. In the case of atrophy from compression of the lung by fibrous growth or fluid effusion, we have again often a heavier lung from increase o; fibrous tissue. It is obvious that the increast in weight must always be due to attendant often determining, disease. Effects and Symptoms. — The consequence of the partial atrophy of lung which aceom panies the ‘ large-lunged’ emphysema of advancr< middle life are very grave. Extensive obliter.i tion of tlie pulmonary capillaries, without corresponding diminution in the blood-volum( induces a stress of circulation, a mechanics congestion, which ultimately tells back throng LUNGS, ATROPHY OF. the right heart upon the whole venous system. The damaged elasticity of the lung impairs the mechanism, as the atrophy of the alveoli impairs the function of respiration. In senile emphy- sema, however, the lung-atrophy, being but a part of a general atrophy of all the tissues and of the blood, causes no discomfort, provided no extra effort is attempted and no bronchitis super- vene. Local atrophy of the lung has its symp- toms merged in those of the predominant disease. Physical signs . — In senile atrophy of the lungs the chest-capacity is diminished in all directions to accommodate the small lungs. The lower ribs are approximated and their obliquity greatly increased ; the upper intercostal spaces aro de- pressed. The chest-movements are very limited. The percussion resonance is generally increased over the chest, except over the prsecordial re- gion, which is less covered by lung than natural. The respiratory murmurs are simply enfeebled, not altered, unless there be some bronchitis pre- sent. It has been said that there may be some effusion into the pleura in atrophy of the lung, to fill up the space vacated by the shrunken organ, fhe mechanism of such an effusion is, how- ever, quite inconceivable. Complications. — There are no complications necessarily incident to senile atrophy of the ung. Bronchitis not uncommonly, however, supervenes, and proves fatal to the patient. Treatment. — The treatment of senile atrophy if the lungs simply consists in shielding the aged lerson from the causes of bronchitis. R. Douglas Powell, LUNGS, Brown Induration of. — The ondition recognised by this name by Virchow Ind Laennec, is one which is sometimes ob- erved after prolonged congestion of the lungs, ■articularly that which results from disease con- ected with the mitral orifice. The morbid change insists mainly in excessive pigmentation, the pig- lent accumulating not only in the interlobular ssue, but also in the alveoli and minute bronchi, here it is enclosed in enlarged epithelial and .ranular cells. At the same time the capil- iries are dilated, the interstitial tissue is iicreased, and probably the alveolar walls are lickened. The pigment is granular, and of a bllowish colour; it is derived from the blood; id seems to be of the nature of haematoidin. . may become brownish, reddish, or even black ; id ultimately may bo found free. The extent id degree of brown induration vary much in fferent cases. When the change is marked, e lungs are enlarged, heavy, firm, incompres- jhle, and inelastic, not collapsing on exposure, ley present various tints, from yellowish to ■ ddish-brown. This alteration in colour is also ; ident on section, and red spots are often seen, ading into black, while a brownish fluid may expressed. Brown induration is associated th congestion of other parts of the lungs, and en with infarctions. It cannot be clinically cognised apart from these conditions, unless i affected organs should present physical signs consolidation in cases of known pulmonary igestion from mitral disease. No special treat- 'Dt is called for. Frederick T. Roberts. LUNGS, COLLAPSE OF. 861 LUNGS, Cancer of. — See Lungs, Malignant Disease of. LUNGS, Cirrhosis of. — A synonym for chronic pneumonia, See Lungs, Inflammation of. LUN GS, Collapse of. — Synon. : Apneuma- tosis; Fr. Affaissenient pulmonaire; Ger. Lungcn- collapsus. Definition. — Simple diminution in size of the whole or of a part of a lung, with reduction of the volume of the contained air, and caused by interference with its free entrance in inspiration. -Dtiology. — -The causes of collapse of the lung are either intrinsic or extrinsic ; and fre- quently the two classes of causes are combined. The intrinsic causes present actual obstruction of the respiratory passages, and include all diseases of the larynx, trachea, and bronchi, attended with inspiratory dyspnoea, whether due to the pressure of external tumours, to af- fections of the passages themselves, or to the presence of inflammatory products, blood, and foreign bodies within them. To this class of cases belongs the collapse of the lung which is apt to follow infantile bronchitis, when the tubes become obstructed, and there is no power to ex- pectorate. All causes that interfere with respi- ratory efficiency favour the occurrence of the condition named. A plug of mucus may be drawn, in inspiration, deeper and deeper into the bronchial tubes, which it obstructs, and act- inglike a ‘ ball plug,’ allows the expulsion of air in expiration, but interferes with inspiration ; the air not being replaced, apneumatosis is de- veloped; and as there is no air behind the plug of mucus, cough is powerless to expel it. In children, bronchial inflammation is exceedingly common, and the smaller tubes being propor- tionately smaller in the child than in the adult, the danger of collapse is increased. When chil- dren under five years of age die of bronchitis and allied affections, apneumatosis is almost invari- ably present ; and 2opercent. of the total mortality of infants may be safely set down to this cause. Partial collapse of the lung from pressure on the respiratory passages will be found described in the article Mediastinum, Diseases of. The extrinsic causes of pulmonary collapse are cer- tain conditions of the walls of the chest, which diminish the force of the inspiratory act, such as paralysis or debility of the inspiratory muscles, and softness of their bony attachments. Muscular paralysis is seen in injuries to the cord. Debility of the respiratory muscles may often be observed before death. Collapse of the lung is sometimes, although rarely, met with in adult life, when great prostration occurs in the course of fever, and respiration is impeded by pulmonary congestion. Asssociated as it is with softness and weakness of the ribs, rickets is one of the most frequent causes of collapse of the lungs. The action of the inspiratory muscles may be still further interfered with by abdominal distension, or by the binding up of the abdomen of the infant with tight bandages. The danger of collapse is lessened when the ribs have gained firmness and fixity, and when, raised by the respiratory muscles, the thoracic cavity is enlarged, and the lungs are consequently expanded. 362 LUNGS, COLLAPSE OF. Anatomical Characters. — The whole of one lung or of one lobe may be affected, but a lobule or a part only of the lung is usually involved, the affected lobules being abruptly separated from those adjoining. As a rule several patches of collapse occur in each lung, having a darker colour and more depressed surface than the healthy parts. The lower margins of the left lower lobe are most frequently affected. The collapsed portions of lung are similar to the liver in consistence ; they resist pressure, are non-crepitant, are smooth on section, and sink in water. The bronchi are filled with mucous fluid ; there is an entire absence of air in the collapsed parts. On inflation the affected portion assumes a natural appearance, unless considerable con- gestion exists ; whereas in pneumonia inflation cannot restore the lung to its natural appearance. In pneumonia pleurisy is rarely absent ; but in collapse, uncomplicated with diathetic disease, the pleura is invariably healthy. Symptoms. — The symptoms of collapse of the lung vary greatly with the cause, rapidity, and extent of the morbid condition. In severe cases, for example, in the collapse that follows bron- chitis in very young subjects, the symptoms are peculiar. There is great prostration, debi- lity, restlessness, and sleeplessness. The tem- perature falls ; the surface becomes cold, blue, or dusky ; the eyes become shrunken ; and the pulse is quick and small. There is a constant feeble whining cry. Respiration is very quick and shallow, as high as 70 to 80 or even 100 per minute. The rhythm is changed, the interval being between inspiration and expiration, in- stead of after expiration. There is no pain as in pleurisy. The cough is constant and impotent ; is often followed by a cry of impatience; and differs much from the suffocative cough of bron- chitis. On examining the chest, the lower part is found retracted and diminished in diameter. The intercostal spaces sink in inspiration, and move outwards slightly in expiration. When the collapse is extensive the percussion is dull and resistant, unless the affected lobules are in- terspersed among the healthy ones. The respi- ratory murmur is lost over the affected parts, though conducted breath-sounds, of a bronchial character, and rhonehi are generally audible almost universally. In the simpler cases of col- lapse of the lungs, such as occur in pertussis during the severe fits of coughing, some of these symptoms and signs may be suddenly developed, and again speedily disappear. Diagnosis. — -Apneumatosis may be distin- guished from croupous pneumonia by the com- parative rarity of the latter disease in infancy ; and by absence of the great heat of skin, and of fine crepitation on auscultation. From extensive miliary tuberculosis it is diagnosed by the ab- sence of advancing symptoms of constitutional disorder, though the two conditions may co-exist. In pleurisy the dulness on percussion, and the absence of respiratory sounds at the base, are much more marked than in apneumatosis. Con- genital collapse or atelectasis, is a condition which has to be diagnosed from infantile collapse or apneumatosis. Readily separable by symptoms, these two conditions may be indistinguishable by LUNGS, COMPRESSION OF. physical signs. In atelectasis the lung retains, in whole or in part, its foetal condition, nature having failed to establish respiration and fit the child for its new mode of existence. In apneu- matosis the once permeable lungs cease to admit air, and thus death from apncea occurs without any apparent structural change being discover- able, save that the respiratory organs bear the appearance of foetal, unexpanded lungs. Prognosis. — The prognosis in collapse of the lung is favourable if the affection is recent, and the child healthy, with fair muscular power, and under favourable hygienic conditions. On the contrary, the disease is generally fatal if it involve a considerable extent of lung, es- pecially if it supervene on atelectasis. Death usually occurs from slow asphyxia, the effect being the same as if the size of the lung were reduced by the removal of the affected parts. As much as half of the entire lungs has been found involved, thus fully accounting for the quickened respiration, the distress, and the dyspncea, andfor the bloodlessness and extreme pallor, with cold, blue extremities. The fatality of whooping-cough in infants is mainly due to the ready collapse of the lungs, specially when the child is badly nourished and breathing impure air. The natu- ral course of the disease is from bad to worse ; more lung is involved each day; and death occurs after two or three weeks from slow as- phyxia. If collapse follows acute bronchitis death often ensues rapidly, but if recovery takes place the lungs are slow to regain activity, and the seeds of future mischief remain. After an attack of pneumonia complete absence of breath- sounds may exist for a time, and then suddenly — after a blow, shock, or violent cough — air en- ters the collapsed portion of lung, and the respi- rator}' sounds assume a normal character. Treatment. — When this affection was looked upon as a form of pneumonia it was treated by depletion. Now that we realise that it is not of an inflammatory character, our object must he not to lower vitality but to diminish excessive secretion. Slight counter-irritation, by means of stimulating embrocations, is useful. An emetic of ipecacuanha will help to remove accu- mulation if the patient is not too weak. Expec- toration may be promoted by small doses of the same drug. When the lungs are extensively in- volved, vital power must be kept up by the help of ammonia, steel, phosphates of iron, port wine, and beef-tea ; and the food must he so designed as to be digestible by the stomach of the in fant. E. Symes Thompson. LUNGS, Compression of. — S ynon. : Fr. Compression dn l’oumon ; Ger. Lunyencom- pression. Definition. — Diminution in size of the whoh or of a part of a lung, associated with reduetioi of the volume of the contained air, and causes by pressure on the pleural surface. ^Etiology. — Compression of the lung roa; arise in the course of numerous diseases or in juries affecting the chest, the compiressing in fluence being either gaseous, liquid, or solid. First, the admission of air to the pleura fron without, through a perforating wound, as from : sword or bayonet thrust ; or from withm, as b LUNGS, COMPRESSION OF. rupture of an air-cell, or the extension of pulmo- nary ulceration through the pleura, produces in either case compression. If no previous pleu- risy has existed the compression is complete ; hut if, on the other hand, long-standing pleurisy has caused udhesion, compression cannot take place, or will be but partial. Pneumothorax arising without perforation may be due to the evolution of gas from gangrene, or to the decom- position of pleuritic fluid ; or the gas may be directly secreted within the pleura, taking the place of serum absorbed after pleuritic effusion. Resides the causes named, perforation may arise from fractured ribs with pulmonary laceration, or from contusion of the lung without frac- ture; from ulcerative perforation of lunar, either tuberculous or gangrenous ; from pulmonary apoplexv, hydatids, cancer, empysema, abscess ; from rupture of the lung in whooping-cough ; from perforation of the lung from without, by diseased and suppurating bronchial glands open- ing into the pleura and bronchi ; and from rup- ture or ulceration bf the oesophagus, opening into the pleura. Of this long list, omitting the surgical cases, nine out of ten aro due to phthisis. Secondly, compression may arise from the presence of fluid, such as pleuritic effusion, acute or chronic; passive, non-inflammatory effusion, as in hydrothorax ; or blood, as in hsemato- thorax. Thirdly, compression of the lung by solids is teen in the case of various tumours of the- chest, whether originating in the mediastinal struc- ures, in the lungs, or in the thoracic parietes. In a fourth class of cases compression of the ung is the result of the enlargement of neigh- bouring parts, other than the thoracic viscera ; md especially of the abdomen, as in ascites, and umours of the liver, spleen, or ovaries. Anatomical Characters. — Compression of ho lung may he either general or local, eom- lete or partial. A lung compressed by pleuritic ffusion is found to be reduced in volume, non- repitant. dense, and quite insusceptible of in- jation. The blood is coagulated in the affected jibes, the clot being often decolourised and ad- ierent to the walls of the vessels, many of Rich are impervious, or altogether obliterated ; jhile the pervious vessels and the air-cells of le adjacent parts are distended, and eniphy- ■ma is produced. In other cases, the compressed ng proves to be anaemic, tough, and dry. In cases of slow recovery from chronic em- ■a?ma the lung is often found bound down and Tokened, having very little normal pulmonary istie remaining. The thoracic cavity vacated the shrunken lung is occupied by the dis- iced heart, and sometimes by the extension of b sound lung across the middle line. When perforation occurs with admission of from the bronchi to the pleural cavity, the nospheric pressure distends the pleura, and ds to displace the mediastinum and the other g. The heart, too, being unsupported, is ; ssed against the healthy lung, and may he i placed to a very considerable extent. Symptoms and Phvsicai. Signs. — The symp- l.is of compression of the lung vary greatly in '• .irdance with its causes, the rapidity of onset, LUNGS, DEGENERATIONS OF. 863 and the extent and degree of compression. If pleuritic effusion be very rapid, the dyspnoea may be exceedingly urgent. After perforation of the pleura with sudden collapse of the lung, there also occur acute pain, dry cough, and painful spasms of the intercostal muscles. The pulse is frequent, feeble, and often irregular. Symptoms, more or less acute, of inflammation may follow. In other instances the symptoms are those of hydrothorax, or of intrathoracic tumour. The physical signs of compression of the lung are chiefly those of the associated cause, such as pmeumothorax, pleurisy, hydrothorax, or intra- thoracic tumour ; and part y certain phenomena characteristic of the physical condition of the lung itseif. The latter vary considerably with the degree and extent of compression, but they may be described in general terms as follows: — Either increased clearness of the percussion sound over the area of compressed lung, with tubular or rarely even tympanitic quality, espe- cially in children, or in extreme eases of com- pression complete loss of resonance ; indefinite, weak, but occasionally rather blowing or tubular respiratory sound, sometimes mixed with scanty, dry, subcrepit.ant rhonchus ; and exaggerated loudness and ringing quality of vocal resonance. A further description of these symptoms and signs will be found under the headings of the various causes of compression referred to. Diagnosis. — The diagnosis of compression of the lung is in general simply the diagnosis of the condition on which it depends. Prognosis. — The prognosis depends on the cause of the compression. Thus in pneumothorax it is unfavourable, though recovery may take place. In liydrothi >rax the prognosis is unfavour- able, as it is usually an evidence of formidable, if not incurable, organic disease. In pleurisy, if the effusion has been rapid, met by prompt treat- ment, and uncomplicated with hectic, complete recovery may take place without much compres- sion of lung or distortion of chest; but incom- pletely-cured pleurisy is too frequently the first incident in the history of phthisical disease. In empysema the prognosis is more favourable than in pneumothorax or hydrothorax. Treatment. — Little need be said as to the treatment of lung-compression. It resolves it- self into that of the intercurrent or causative diseases. Bearing in mind the injury done to the lung by compression, eff >rts should be made to relieve the lung before it has been irremediably bound down. The early adoption of paracentesis thoracis is the most practical means of gaining this end in pleuritic effusion. Remedies calcu- lated to remove effusion and thus relieve the lung should be given, remembering that the more speedy the relief given to the lung the more complete will be the cure. Suitable movements of the chest might bp ordered subsequently, with the view of promoting expansion of its walls and of the lung. E. Symes Thompson. LUNGS, Congestion of. — See Lungs, Ily- peraemia of. LUNGS, Consumption of. — See PnTHisis. LUNGS, Degenerations of. — Changes of 8G4 LUNGS, DEGENERATIONS OF. a degenerative cliaracter in connection with the lungs constitute an important element in some pulmonary diseases, or they may he the sole morbid condition present. They are of the fol- lowing nature : — 1. Albuminoid. — This is only occasionally noticed, in marked cases of general albuminoid disease. 2. Fibroid.- — Changes leading to a more or less fibroid condition of the pulmonary tissue are of common occurrence, but it is not always easy to determine whether they should be regarded as due to a chronic inflammatory process, or to degeneration, and pathologists differ in their views on this point. As a degeneration, the fibroid change may bo considered as most im- portant in connection with emphysema, and it is regarded by some authorities as an element of much consequence in the causation of many cases of this disease. It also follows long-continued congestion, and collapse or compression of the lung from any cause. Of course much fibroid or fibrous tissue is found in the lungs in many cases of phthisis, and in connection with pleu- ritic adhesions and other conditions, but this state must be looked upon mainly as of inflammatory origin. The effects of these changes are to make the lung-tissue firmer and tougher, but at the same time to diminish or destroy its elasticity, the elastic tissue being more or less displaced. Hence, if the lungs be exposed to any distend- ing force, they cannot recover themselves pro- perly, and the air-vesicles remain more or less permanently dilated. 3. Fatty. — This degeneration is also regarded by some pathologists as one of the main ele- ments in originating many cases of emphysema of the lungs, and also as one of the actual con- ditions in this disease. Here, again, the lung- tissue is impaired in its elasticity and resisting power to distension, but it is not tough. Granu- lar fat may be visible under the microscope. 4. Figmentary. — The lungs become the seat of more or less pigmentation with increasing age. They are also markedly affected in certain occupations in which carbonaceous matters are inhaled. In so-called brown induration of the lungs there is an abundance of pigment. 5. Senile. — The lung-tissue undergoes atrophy, with more or less less of elasticity, owing to wasting of the elastic tissue with increasing age, and even a fatty degeneration may take place. Hence, in such subjects emphysema is readily set up by causes which would have no effect on younger persons. 6. Secondary. — Under this head may be in- cluded those degenerative changes which take place in morbid formations in the lungs, such as inflammatory deposits, tubercle, or cancer. These belong mainly to the fatty or caseous variety of degeneration, but calcification may also occur. Frederick T. Roberts. LUNGS, Embolism of. — See Lungs, Anmmia of ; and Lungs, Haemorrhage into. LUNGS, Emphysema of. — Synon. : Fr. Emphyseme du poumon ; Ger. Lungencmphyscm. Definition. — An excess of air in the lungs, whether due to a dilated condition of the air- LUNGS, EMPHYSEMA OF. sacs, or to the presence of air in the interlobular tissue. Varieties. — There are two kinds of empty sema of the lungs, namely : — A. Vesicular Emphysema. B. Interlobular Emphysema. A. Vesicular Emphysema. — Pulmonary ve- sicular emphysema exists in three forms, namely, 1. partial lobular ; 2. lobular; and 3. lobar. The last form involves the whole of a lobe, or the whole of one or both lungs. The first form is rarely seen alone, butis generally associated with the second form, which is very common, and is found in connection with diseases, such as bron- chitis, which are attended with violent or long- standing cough. The third form is by far the most important, and will be more especially re- ferred to in the present article. It more fre- quently attacks both lungs than one, and the lower as well as the upper lobes. It is a serious malady, and sometimes destroys life at an early period. Its features are characteristic : the lung- substance has a peculiar deughy feel; pits on pressure ; is wanting in healthy crepitation ; and has a colour very closely resembling that of a calf’s lung. It has been described as ‘large- lunged vesicular emphysema.’ .-Etiology . — Determining causes and mechan- ism. — With reference to the determining causes of emphysema there are two theories, namely, the inspiratory theory, and the expiratory theory. On the first view the dilatation and rup- ture of the air-sacs are accounted for by the over-distension of the lungs in inspiration. On the second view these changes are considered to | be caused by the strain to which the lung-tissue is subjected in violent expiratory efforts, espe- cially the act of coughing. It has been thought by others that emphysema must be looked upon i as a eomplemental lesion, arising in consequence of the over-distension to which the healthy por- tions of the lungs are subjected in cases of pul- monary collapse. Without entering into any critical examination of the theories as to the mechanical causes of emphysema, it may per- haps be sufficient to say- that there can be little, if any, doubt that the lobular forms of the dis- ease are mainly produced bv expiratory efforts.; such as violent cough, or blowing wind instru- ments. They have their seat in those parts of the lungs which become most distended by such acts. With regard to the lobar form of the dis- ease, however, this explanation cf its mechanism does not suffice. In this affection the inspiratory power is that which distends the lungs. The pulmonary tissue has lost a portion of its elasti city r , it yields to distension, and no longer re-act; perfectly when the distending power ceases Further distension follows ; reaction diminWic still more ; until at length in some instances th lungs become greatly enlarged. In senile cases the loss of elasticity of th chest-walls aids in preventing the pulmonary re action. Anatomical Characters and Pathology.-I In the early stages of emphysema there is siir ply a dilatation of the air-sacs ; an increase i the size of the alveoli; and a diminution in tlj height of the alveolar walls, which yieldir with the distending cavities, become partial LUNGS, EMPHYSEMA OF. obliterated. As the disease progresses the air- bucs become more distended, and the -walls of the alveoli sometimos completely obliterated, so that the air-sacs are quite smooth, instead of honeycombed. Then follows perforation of the air-sacs— at . first slight, here and there an oval opening being discoverable ; afterwards the openings become more numerous and larger. The subsequent progress of the disease is attended with further distension of the air-sacs, and rup- ture of the fibres of their walls. The openings thus caused coalesce, until at length the walls are simply represented by membranous shreds, and even large vesicles may form. These changes, varying in degree, characterise all the forms of emphysema. In the lobar form, however, perforation takes place to a much greater extent quoad the amount of dilatation, than in the lo- bular or partial lobular form. The emphysematous lung is ansemic, its blood- vessels become widely separated, and often rup- tured and atrophied. The bronchial tubes are sometimes dilated, -especially in old-standing cases, and in these there is frequently found an increased development of the circular muscular fibres. The pathology of emphysema involves some important points for consideration. The great question is whether there is any degeneration of tissue preceding or attending the affection. When the disease is partial, and has followed or s attended by bronchitis, or some other affec- ion in which there has been violent or long- itanding cough, the emphysema may be the re- ult of mechanical violence, without pre-existing .egeneration of the lung-tissue. When, however, t is of the lobar form, degeneration is probably he primary step in the affection. The facts dlieh tend to confirm this view are: — (1) the isidious manner in which the disease sometimes tines on, and the development which it attains, ''ithout any previous history of violent or long- anding cough ; (2) the frequency with which attacks the whole of both lungs; and (3) its jreditary character. The exact nature of the generation has not been satisfactorily made jit. Fatty matter has been found in a few in- ances, but not in all cases. The degeneration probably one primarily involving the elastic 'res and other structures of the walls of the '-sacs. Whatever be the nature of the degene- ion, there can be no doubt that lobar emphy- na is a malady resulting from some form of 1-nutrition of the lung-tissue. There is reason believe too that this form of emphysema is netimes associated with gout. There is a form of lobar emphysema which is ■ t with in old age, and which differs in some i pects from that already described. The lungs not so large ; they are universally distended, 1 rever, to a greater or less extent; and they I sent a somewhat atrophied appearance. The t rations, of which they are the seat, are pro- 1 ly the result of those changes which age pro- i es in the chest- walls, impairing their elasti- c . This loss of elasticity may also affect the 1 ;-tissue. See Lungs, Atrophy of. knowledge of the changes produced by em- P sema affords an explanation of the peculiar C, 'acter of the respiratory movements and 55 860 sounds, as well as of the other pnysical signs and symptoms of the disease. The lungs being the seat of general expansion, the thorax is kept abnormally distended. Thus it can undergo but little enlargement at each inspiration. As there is no impediment to the passage of air to the air-sacs, inspiration is accomplished rapidly. Not so, however, with expiration. The lung- tissue has in great measure lost its elasticity, and reacts slowly after distension ; and this results in laboured, slow, and ineffectual efforts to expel the air. Further, as the lungs art- more or less riddled with perforations, their aerating surface is diminished, and this neces- sarily causes dyspncea, whenever any increased demand is made on the respiratory function The quantity of blood circulating through the lungs, even from the earliest stages of the af- fection, is also diminished ; and the destruction of the capillary vessels, which ensues when the disease is more developed, further decreases the vascularity of the pulmonary tissue. Hence its pale, anaemic appearance after death, a circum- stance which serves to explain how rarely it is the seat of pneumonic inflammation. Symptoms. — A constant and generally gradu- ally increasing dyspnoea is one of the most im- portantand most frequent of the symptomsof em- physema. Cough with expectoration is generally more or less present. Haemoptysis is rare, and when it does occur, is slight. The patient usually complainsof no pain, butof afeeling of oppression, or a 1 smothering in the chest.’ In severe cases of lobar emphysema this last symptom and the dyspnoea are often the only circumstances which attract the attention of the sufferer to his malady. In other instances, however, and especially when the disease is only partial, a close examination will elicit the fact that there have been bronchitic symptoms. Few cases of emphysema exist for any length of time without the occurrence of asthmatic seizures. In advanced cases the aspect is peculiar. The countenance is dusky, leaden, and puffy. The nostrils are dilated, and expand widely on inspiration, whilst the angles of the mouth are drawn down. The voice is feeble. The whole body has a cachectic appearance, and is sometimes much wasted. General dropsy often ensues. Physical Signs. — Amongst the most important of the physical signs of emphysema are the fol- lowing The upper part of the chest and the clavicles are prominent ; the neck seems short- ened ; the fosste above the clavicles are deepened ; there is increased curvature of the dorsal spine • and the sternum is arched. The gait is stooping: the ribs are prominent; and the intercostal spaces are depressed. There is indeed a general increase in the size of the chest, usually most marked at the upper part. These are the fea- tures of the disease when it is extensive. If par- tial, or confined to one lung or part of a lung, the prominence of the chest exists on one side only, and the other symptoms and signs are less marked. The movements of the chest in respi- ration are peculiar. The breathing is for the most part superior thoracic, but the chest is not much expanded on inspiration, for the lungs are already inordinately distended. The lower end I of the sternum and the lower ribs are drawn ir 566 LUNG3, EMPHYSEMA OF. luring inspiration. In some cases during in- spiration there is marked protrusion of the abdomen. The respiration presents other fea- tures. The inspiration is short and quick, and is followed by a prolonged and often wheezing expiration. Coughing is performed feebly, and expectoration is attended with difficulty. Per- cussion and auscultation elicit important diag- nostic marks of the disease. When it is gene- ral there is increased, and in some instances almost tympanitic, resonance over the whole of the chest, most marked towards the apices of the lungs, and along their anterior borders ; and in partial cases almost confined to these spots, or to one side. The prsecordial region is generally resonant, owing to the distended lungs coming between the heart and the wall of the chest; and the cardiac impulse can often be felt beneath the lower end of the sternum. The respiratory murmur is faint, and characterised by peculiarities which a knowledge of the anatomical condition of the lungs and of the chest-walls enables us to explain. The in- spiratory murmur is short, and is followed by a prolonged expiratory murmur. This latter is unlike the sound heard in any other affection, and is, in fact, pathognomonic of emphysema. In some advanced cases the respiratory sounds are scarcely audible, if the bronchial tubes are free from mucus, and no spasm exist. Laennec de- scribed a rale which he thought was peculiar to emphysema. He called it ‘ rale crepitant sec a grosses bulles.’ A rale such as Laennec described is often heard in emphysema, but it is not a dry rdle. It is probably produced in the finest bronchial tubes, and is a modification of the sub- crepitant rale of bronchitis. Although valuable in aiding diagnosis when present, yet from its frequent absence and the difficulty of distinguish- ing it from the ordinary sup-crepitant rale , it loses much of its diagnostic import. Complications and Sequels:. — Bronchitis is one of the most frequent of the diseases asso- ciated with emphysema of the lungs. It is rare for the latter affection to exist for any length of time without the supervention of the former. Bronchitis presents some peculiarities when it affects an emphysematous lung. It is rather the result of congestion than of inflammation. It often attacks the finer bronchial tubes ; and when severe, is attended with profuse secretion; a circumstance which, coupled with the fact that expectoration is less easily accomplished than when the lungs are healthy, seriously compli- cates the affection, and increases the danger of death from apnoea. The inflammation some- times runs on very rapidly, and copious puru- lent or purit'orm expectoration occurs. Even when this is the case, an examination of the tubes after death may reveal but little vascularity of the mucous membrane. These severe bron- chitic attacks are very apt to be attended by the formation of fibrinous clots in the heart and the large vessels arising therefrom. Bronchitis, in a sub-acute or chronic form, is a very constant cause of winter cough in emphysematous patients. Asthma, occurring with greater or less seve- rity, is a frequent attendant on emphysema. The attacks come on for the most part during the night, and may possibly be due to the congestion of the lungs which takes place during sleep, or when the body is long in the recumbent posture. This congestion probably sets up an irritation, which gives rise to reflex spasm of the bronchial muscular fibres. Secondary affections of the heart are constantly met with in advanced cases of emphysema. Many pathologists have believed that the right cavities alone become affected ; but more recent obser- vations have shown that the cardiac disease is not confined to one side. There is, in exten- sive emphysema, a general hypertrophy of the heart, with dilatation of all the cavities, especially of the ventricles. But hypertrophy is not the only change which takes place; valvular dis- ease is frequently found. The deposits and thickening which occur about the valves are no doubt secondary to the changes in the muscular walls, and must be attributed to the general mal-nutrition produced by the disease. It is not difficult to understand how it happens that in emphysema there is general cardiac hypertro- phy. The impediment which exists to the cir- culation of the blood through the lungs neces- sarily gives rise to an overloaded state of the right side of the heart ; hence results increased action of the right cavities, and hypertrophy of their walls. Again, the overloaded state of the venous system, and the consequent impediment to the capillary and arterial circula'ion. call for increased action of the left ventricle ; and this is followed bv its dilatation and thickening. There exists also another cause, which probably has some influence in producing this cardiac hyper- trophy, namely’, the altered position of the heart. This organ is pushed downwards and towards the median line, and its impulse is often felt strongly’ in the epigastrium. The position of '.1 e ventricles is therefore changed, and the direction of the axis of their cavities is altered with re- ference to that of their great vessels This must lead to embarrassment of the circulation. As a consequence of the changes in the heart and venous system in emphysema, dropsy often results. Many’ cases go on for a long time with- out any dropsical symptoms, whilst in others there is only slight oedema of the legs. In advanced cases, however, there is frequently general dropsy. General emphysema is attended in its progress with symptoms of cachexia and antemia. It some cases there is much wasting of the mus- cular system, even before dropsic.il effusion: occur. Further, the patients often have a sallov and anaemic appearance, not unlike that me with in renal and other serious organic disease^ There has been an impression that emphysem and phthisis are incompatible diseases, bn recent researches have shown that this view ; not correct. Indeed, in a large proportion d cases of death from phthisis, patches of emphy sema, lobular or partial lobular, are met with and doubtless have been produced by the fits < coughing so common in the disease. But tl great question is whether tubercular depos ever takes place in lungs which are the seat lobar emphysema ; and this question must 1 answered in the affirmative, although the co currence of the two diseases is rare. Tne monic consolidation is 'cry uncommon in ■' LUNGS, GANGRENE OF, emphysematous lung, and probably acute so- 1 called sthenic pneumonia never attacks the organ in such a condition. Pleurisy not unfrequently exists in connection with emphysema ; pleuritic adhesions being often found after death. The occurrence of pleurisy must, however, be considered as an accidental circumstance. In the most extensive cases of emphysema pleuritic adhesions may not lie found. Treatment. — This must be referred to under two heads, namely (1) the treatment of the dis- ease : and (2) that of the secondary affections, which follow or are associated with it. (1) Treatment of the disease. — Too little at- tention has been paid to emphysema of the lungs as a substantive disease. Considered in the main as the result of bronchitic affections, the treatment has been chiefly directed to the con- trol of these attacks; and in regard to the partial forms of emphysema, this is a most im- portant object. But in reference to lobar em- physema, if we recognise the fact that it is pri- marily due to some degeneration of tissue, it is ihvious that the treatment should be directed to check, if possible, this process. It can scarcely be expected that when once perforation and rup- ture of the air-sacs have taken place, the normal condition of the lung can be restored. But whilst we admit this, it is by no means implied that the disease is beyond control. That condi- tion of lung-tissue which precedes the perfora- tions — the simple distension of the air-sacs — admits of great amelioration, and further dege- nerative changes may be, if not prevented, at east much retarded. The main principles of treatment should be •uch as guide us in the management of other iionstitutional diseases attended with degenera- ion. All measures which tend to invigorate ,he system, to give tone to the heart, and im- prove the condition of the blood, should be esorted to. Amongst the remedies for internal administration the most useful is iron. It should e given in small and continued doses. Quinine !> valuable, as are also the various bitters and , flier reme lies for dyspepsia, from which emphy- :matous patients often suffer. Cod-liver oil is jery useful in some cases. Strychnia has been 'commended with the view of improving the ■ne of the muscular fibres of the bronchial tbes. It has not been found useful in this re- ject ; nor need we wonder at this, for tile disease one primarily of the air-sacs, and not of the '/onch.al tubes, and if the muscles of the latter anterior and inferior margins are thick and unded, and are found to extend beyond their rmal thoracic limits both laterally and infe- irly. The texture of the lung is firmer and ire resilient than usual; and it is plentifully pplied with blood. The air-cells are slightly larged, but not obviously dilated ; and on mi- pscopic examination the nutrition of the alve- r walls and capillaries is found to be perfect; ■re being neither the thinning of the alveoli, " tile excessive growth of fibrous tissue met 873 with at different stages of so-called ‘ hypertro- phous emphysema.’ Nor are the capillaries tortuous and dilated as in the indurative ‘ hypertrophy ’ of the lung from heart-disease. Extent of lung affected . — W e have considered, for the sake of simplicity of description, those cases in which the whole of one lung is hypertrophied, and such cases are very common. Hut a single lobe of a lung may become hypertrophied, the seat of the hypertrophy depending upon the seat of the disease to which it is compensatory. But, except when the pulmonary destruction is limitedand circumscribed, other conditions come into play, and we are more apt to get em- physema than hypertrophy. It may be said then that hypertrophy of the lung is (at least so far as we can appreciate it clinically) a one- sided affection, except in those cases in which it has been occasioned by some general external cause, as rarefied air. Physical Signs. — The side on which is the hypertrophied lung is expanded, both relatively (tho opposite side being usually flattened and contracted) and absolutely. The nipple-level is raised. There is increased percussion-reso- nance over the side, extending across the median line, so that sometimes the line of resonance indicating the inner margin of the enlarged lung will reach the mid-clavicular vertical line of the opposite side. The lower limits of resonance are also extended in front and behind. The respiratory murmur has that peculiar coarse vesicular character, with somewhat prolonged expiration, which is known as ‘puerile’ or ‘ exaggerated ’ respiration. The heart is more or less displaced towards the contracted side, and tho displacement is often apparently in- creased by the heart becoming on the one side covered by the expanded lung, and on the other side unduly exposed by the recession of the diseased lung. This is especially the case when the hypertrophy affects the left lung. There are no morbid sounds heard over the enlarged lung unless (as in many cases of phthisis) it becomes or has been affected by disease. With the ex- pansion of the lung the general symptoms im- prove, and the dyspnoea lessens. Diagnosis. — The diagnosis lias to be made between hypertrophy of the lung; hypertro- phous emphysema ; and mere dilatation. The unilateralness of the hypertrophy ; its arising secondarily to some disablement of the opposite lung ; the absence of precedent or present general bronchitis or asthma; together with the observa- tion of its occurrence being commensurate with improvement in the condition of the patient, are the main features distinguishing it from large-lunged or hypertrophous emphysema. Nor could the puerile breathing of hypertrophy be easily confounded with the short, weak, or inaudible inspiration, and wheezy prolonged expiration of emphysema. In persons of broken constitution, with contractile disease of one lung, tho opposite lung may become dilated and assume the shape and dimensions of hypertrophy ; but the breathing of the patient does not improve, the respiratory sounds are enfeebled, and it is clear that the condition present is one of em- physema rather than true hypertrophy. Prognosis. — The prognosis is always prt LUNGS, INFLAMMATION OF. 174 tanto favourable to the patient, the hypertrophy beingan important element of his recovery. Treatment. — (Compensatory hypertrophy of the lung is a condition carefully to be encouraged, when all active symptoms attendant upon the original disease are past. Mild courses of calisthenics, and a temporary sojourn at some elevated health-resort during the warm season, are most valuable, if not attempted too soon. Abundanco of fresh air throughout the year, with the careful avoidance of fresh catarrhs, such as may be obtained by spending a winter and spring or two seasons at the South of France, in Italy, or at Madeira; or a well-planned sea-voy- age to Australia, are excellent ways of spending months of convalescence. A generous unstimula- ting diet is indicated, and tonic remedies and cod- liver oil are useful, more especially in the early stages of the wished-for hypertrophic develop- ment. E. Douglas Powell. LUNGS, Induration of. — See Lungs, In- flammation of. LUNGS, Infarction of. — See Lungs, Hre- morrhage into. LUNGS, Infiltrations of. — Certain morbid formations in the luog assume the arrangement of an infiltration, the tissues, especially the in- terlobular cellular tissue, being permeated with the morbid material. In some instances itinvolves even the epithelial cells. The best examples of this arrangement are observed in connection with certain cases of the fibroid change; iu infiltrated cancer ; and in those forms of pulmonary disease where the lung-tissue is the seat of a deposit of substances introduced from without, being in- haled in various occupations, such as particles of carbonaceous matter and cnal-dust, stone-grit, iron-filings, particles of cotton or wool, and other materials. Albuminoid disease, and some forms of pigmentary change also present a kind of in- filtrated arrangement. These conditions need not be further considered here, as they are dis- cussed it their several appropriate articles. Frederick T. Koberts. LUNGS, Inflammation of.— Synon. : Pneu- monia; Fr. Pneumonie', Gar, Lung client ziindung. Definition. — The tern: 1 pneumonia ’ has been employed simply to designate inflammation of the lung-tissue. Inflammatory processes in the lungs, however, occur under such diverse circumstances, and are accompanied by such diverse clinical phenomena and histological changes, that ‘ pneu- monia’ used in this sense includes widely differ- ent diseases. Varieties. — Pneumonias are divisible into the following varieties; — A. Acute Pneumonia; B. Secondary Pneumonias ; C. Broncho, Catarrhal, or Lobular Pneumonia; and D. Chronic or Interstitial Pneumonia. In addi- tion to these there are those intense and concen- trated forms of pulmonary inflammation which lead to the formation of abscess. There are certain other forms of lung-consolida- tion which have sometimes been described as pneumonic, but which are really, for the most part, non-inflammatory in their nature, arid will, therefore, be only briefly alluded to in the present article. These are: — (1) tlat condition rf col- lapse and hypersemia, mainly due to weak inspi- ratory power, feeble circulation, and gravita- tion, which is so common in the more dependent portion of the lungs in many acute and chronic diseases {see Hypostasis). (2) Consolidations of the lung resulting from mechanical congestion and embolism, such as are met with in certain diseases of the heart, &c. See Lungs, Hyper- aemia of. The several varieties of pulmonary inflamma- tion must now be considered separately in tha order just indicated. A. Acute Pneumonia. — Synon. : Fr. Pueu. monie aigue ; Ger. Croupose Pneumonie. — This is pneumonia par excellence. It is the disease to which some would be inclined to restrict the ap- plication of the term. It is often termed croupous pneumonia, from the supposed resemblance of the histological process to that of croup. It is also known as lobar pneumonia, inasmuch as a large area of the lung is usually involved in the inflam- mation. Definition. — Pneumonia may be described generally as an acute disease, characterised clinically by sudden onset, severe febrile symp- toms, cough, expectoration, and dyspnoea; by the physical signs of pulmonary consolidation ; and by a rapid abatement of the eeneral symp- toms between the fourth and teDth days. Anatomically it is characterised by an acute inflammation of the lung-tissue, and by the accumulation of the inflammatory products within the alveoli, which products consist in the main, of a fibrinous exudation and leucocytes. .Etiology. — Atmospheric influences. — Condi- tions of weather and climate are probably the most important of all known agencies in the causation of pneumonia. The influence of cold and damp in increasing the liability to acute in- flammatory diseases of the chest is well known. This influence is marked in pneumonia, although to a much less extent than in bronchitis. Pneu- monia is more common in temperate climates than in those regions which are characterised by great heat or extreme cold. Climates and sea- sons which are liable to sudden changes of tem- perature, and winds from the north and north- east, appear to be especially favourable to this disease. Age. — Acute pneumonia is met with betweer the ages of one and five years. Here, however it is liable to be confounded with broncho-pncu monia and with collapse of the lung, so that the results of statistics are less reliable at this that in the subsequent periods of life. It may b stated notwithstanding, that acute pneumonia i less common during infancy than has been gene rally supposed, and that amongst the pneu monias which are so frequent during this pen. 1 of life the broncho-catarrhal forms preponderate After the age of five years the liability to pnev monia diminishes, but it again becomes exceet ingly frequent between the ages of twenty an forty', during which period the liability to tl disease reaches its maximum. It is also qui common in old age. Sex. — In adults more males than feraal suffer. This is probably owing to the foim LUNGS. INFLAMMATION OF. 875 being more exposed to atmospheric influences. In early life this difference does not obtain. Social position, §c. — Pneumonia is more com- mon amongst the poor and badly fed, and amongst those whose occupation necessitates an irregular mode of life and great exposure, than amongst the upper classes of society. Constitution, and health. — Those who arc ■ constitutionally weak, and those whose general health has been impaired by some temporary cause, are more prone to the disease than the strong and vigorous. ) Previous diseases. — True pneumonia, as is well known, sometimes occurs in those who are the subjects of other disease. It is impossible to speak with certainty as to the relation which subsists between the pneumonia and the disease in the course of which it supervenes. In some cases it may be merely an accidental complica- tion; whilst in others the previous disease may exercise more or less influence in the causation of the pneumonia. Most of the pulmonary con- solidations, however, which occur in the course of other diseases do not belong to the category of true pneumonia, but are either local inflam- mations, caused by some abnormal state which the pre-existing disease has induced ; or conditions of hyperaemia and collapse, in which an inflam- matory process plays but little part. Exciting causes. — In many cases of acute (pneumonia evidence of the existence of any ex- isting cause is ent irely wanting. Of discoverable causes, that which is most common is a sudden chill, or less frequently, more prolonged exposure to cold and damp. Excluding cold, no conditions can be mentioned which have any marked in- lluenee in determining the disease. Anatomical Characters. — The changes oc- curring in the lungs in acute pneumonia are tommonly described under the three following heads : — 1. Stage of engorgement. — This is the stage if inflammatory hyperaemia and oedema, and it is characterised microscopically by overfulness and flight tortuosity of the pulmonary capillaries, and by swelling of the alveolar epithelium. The ung is of a dark red colour ; it is heavier and ess crepitant than natural ; it pits on pressure; •ndits cut surface y ields a reddish, frothy, tena- ious liquid. 2. Red hepa/isation. — Here there is an exu- ation of liquor sanguinis and blood-corpuscles, he exuded liquids coagulate within the alveoli nd terminal bronchioles, the coagulum enclosing umerous white and a few red blood-corpuscles, 'he alveolar epithelium is swollen and granu- ir. It is stated by some German patholo- ists that the coagulum is in part produced by langes in the epithelium. The lung is now jiueh heavier than in the preceding stage, and is icreasod in size, so ns to be often marked by is ribs. It is quite solid ; sinks in water ; and mnotbe artificially inflated. It is remarkably iable, breaking down with a soft granular frac- . re. The cut surface has a markedly granular ipearance, seen especially when the tissue is rn, and due to the plugs of coagulated exuda- }n matter which fill the alveoli. The colour is a dark reddish-brown, often hero and there ssing into grey. This admixture with grey sometimes gives a marb’ed appearance. The pleura covering the solid lung always partici- pates more or less in the inflammatory process. It is opaque, hypersemic, and coated w ith lymph. 3. Grey kepatisation . — This stage is charac- terised by a continuance of the process of inflam- matory cell-emigration, and by cell-proliferation. The white blood-corpuscles continue to escape from the vessels, and the alveolar epithelium multiplies. The alveoli thus become more com- pletely filled with young cell-forms, so that the fibrinous exudation is no longer visible as an in- dependent material. Many of these cells, espe- cially those in the vicinity of the alveolar walls, are larger than leucocytes and nucleated. These are evidently the offspring of the alveolar epi- thelium. The fibrinous exudation now disinte- grates, and the young cells rapidly undergo fatty metamorphosis. The alveolar walls themselves, with few exceptions, remain throughout the pro- cess unaltered; although very occasionally, when this stage is untisually advanced, they may be found here and there partially destroyed. Owing to these changes, the reddish-brown colour of the lung becomes altered to a greyish or yel- lowish white. The granular appearance is much less marked ; the solid tissue is much softer and more pulpy in consistence; and a puriform liquid exudes from the cut surface of the organ. This stage, when advanced, has been termed ‘suppu- ration ’ of the lung. Although these three stages of the pneumonic process have been described as succeeding one another in orderly succession, it must be remem- bered that each stage does not occur simul- taneously throughout the whole of the affected area of the lung. The changes advance unequally, so that whilst one portion of the lung is in the stage of red hepatisation, another may be in the grey stage — hence the mottled, marble appear- anceof the consolidation. Therapidity with which the several stages succeed one another is also subject to marked variations. In some cases the pneumonic consolidation very rapidly becomes grey, whilst in others the time occupied in the transition is much longer. These differences will be again alluded to when considering the clinical history of the disease. Resolution . — The natural and almost invari- able termination of the histological process is in resolution — the lung gradually returning to its normal condition. This is effected by the fatty and mucoid degeneration, and consequent liquefac- tion, of the inflammatory products which have ac- cumulated within the alveoli. As the liquefac- tion proceeds, the circulation in the alveolar walls is gradually restored ; the softened products are removed by absorption, and to a much less extent by expectoration ; and the lung ultimately re- gains its normal characters. The other excep- tional modes of termination in gangrene, abscess, and chronic pneumonia will be alluded to subse- quently. Site . — The local lesion in acute pneumonia is in the majority of cases limited to one lung. When double, one lung is usually involved before the other. The right lung is more commonly af- fected than the left. The part of the lung usually involved is the lower lobe (about 75 per cent.) Tho consolidation may extend upwards and implicat* LUNGS, INFLAMMATION OF. 376 the -whole lung. Pneumonia of the upper lobes is more frequently double than basic disease. It is quite rare for the pneumonic process to com- mence in two different portions of the lung. When the consolidation is met with in both lungs, or commencing in the upper and middle lobes, the pneumonia is often either a secondary affection, and has supervened in one whose health has been previously injured, as by alcohol ; and such distributions of the local lesion should always make the physician look carefully for evidence of some pre-existing disease. Pathology.— Acute pneumonia is undoubtedly to be regarded as a general disease, of which the pulmonary inflammation is the prominent local lesion. The view that it is a strictly local affec- tion of the lung, to which the pyrexia and other symptoms are secondary, is altogether untenable. The truth of this statement becomes obvious from a study of its natural history. The disease, as will be seen subsequently, runs a typical course. The pyrexia bears no definite relation to the lung-affection. It frequently precedes it by a considerable interval, and commonly disap- pears suddenly, and long before the resolution of the pulmonary consolidation. Respecting the exact nature of the disease, however, we are at present unable to speak definitely. It is maintained by some observers that, like tho specific fevers, it is due to a specific cause. Pneumonia, whilst differing from these fevers in not being contagious, resembles them in the typieal character of its clinical phenomena, and to a less extent, of its local lesion. The changes in the lung occurring in pneumonia cannot be induced by artificial in- jury of the organ, and it must therefore be ad- mitted that there is something special in the inflammatory process. Pneumonia appears to be most closely allied to tonsillitis and acute rheumatism, and like these diseases the circum- stances under which it originates are certainly exceedingly diverse. Symptoms. — The onset of acute pneumonia is in the majority of cases sudden, not being ac- companied by any premonitory symptoms. Much less frequently certain premonitory symptoms precede the more severe phenomena which characterise the invasion of the disease. These symptoms include general malaise, headache, chilliness, pains in the back, and loss of appetite. Invasion . — The invasion in adults is, in almost all cases, announced by a rigor. This rigor is more marked in pneumonia than in almost any other disease. The rigor is usually single, and is »*cely repeated, either at the commencement or in *hecourseof the illness. In very old subjects the i gor is very frequently absent, and in children il s place is often taken by convulsions or vomit- ing. The rigors or other phenomena marking the invasion of the disease, together with the attendant pyrexia, are usually quickly followed by symptoms pointing to the lung-affection. These symptoms commonly supervene in the course of from twelve to twenty-four hours, al- though in exceptional cases not until after the lapse of two or three days. The earliest of them are pain in the side, dyspnoea, and cough. These more local symptoms, together with the pyrexia, acceleration of pulse, thirst, and prostration, gradually develop up to tho second day of the dis- ease, by which time (and sometimes before this) the pulmonary lesion is usually sufficiently far advanced to yield unequivocal physical signs. The general aspect and symptoms of the patient are now tolerably characteristic. The flushed and sometimesdusky face, anxious expression, hurried breathing, hot skin, rapid pulse, short frequent cough, and marked prostration, supervening quickly upon the well-marked initial rigor, indi- cate pretty clearly the nature of the disease. Pain . — The pain in the side, which is increased by deep inspiration and by cough, usually corre- sponds in situation with that of the affected lung, although it is occasionally experienced in other parts. This symptom may occur coincidently with, although it more commonly succeeds, the rigor. In quite exceptional cases it precedes it, being the first symptom noticed. Respecting its cause — it is probably due to the implication of the pleura in the inflammatory process. Respiratory phenomena . — Increased frequency of respiration, dyspnoea, and cough, are early and prominent symptoms. The respiration— usually regular — ranges from 30 to 60, and in children reaches even to 70, whilst the pulse may be only from 90 to 120. This perversion in the pulse-respiration ratio is important in diagnosis. The breathing is shallow; inspira- tion is abrupt; and when the pain in the side is severe, respiration is sometimes irregular. The accelerated respiration is accompanied by marked expansion of the alee nasi, and by more or less dyspnoea. There is. however, no definite relation between the last-named symptom and the frequency of the respiratory act. Owing to the pain, and to the frequency and difficulty of breathing, speech is interfered with and often rendered exceedingly difficult. Cough is an almost constant symptom, except in the very old. It is short and hacking, rarely paroxysmal like that of bronchitis. It is usually in the early stages attended with severe pain iu the side, so that the patient endeavours to repress it. The cough, except in children, and often in the old, is attended by expectoration. The sputa of pneumonia are very characteristic. They are viscid, glairy, and remarkably tenacious, so that they cling to the mouth of the patient, and adhere closely to the sides of the vessel contain- ing them. In colour, they present various shades of red, brown, and yellow, owing to the admixture of blood. The appearance so well known ns ‘rusty,’ is that most commonly met with. Sometimes they are much more diffluent, and of a dark purple colour, somewhat resem- bling prune-juice. The characteristic sputa are usually met with on the first or second day of the disease, but their appearance is otren preceded by a frothy aerated expectoration like that of bronchitis. The amount expectorated is small, and sometimes the pneumonic is asso- ciated with more or less of the frothy catarrha, sputa throughout the whole of the disease During the period of resolution the sputa bi come less viscid and more catarrhal in diameter and they usually contain small particles of hlac* pigment. The histological elements met wit! in the sputa are leucocytes, red blood-cells, an( altered epithelium from the alveoli and air-pas LUNGS, INFLAMMATION OF. Bages ; and towards the decline of the disease, I fat-grannies, pigment, and occasionally fibrinous masses, which are casts of the alveoli and ter- minal bronchioles. Pulse. — The pulse m adults usually ranges from 90 to 1 20, and it may be even more frequent. It is commonly much more rapid in children, and less so in the old. In the early stage of the disease it is often full and strong, but it soon becomes smaller and easily compressible. It may be irre- gular, intermittent, or diehrotous. The small- ness of the pulse is probably due partly to diminished cardiac power, and partly to the diminished amount of blood which is propelled from the left ventricle, owing to the overloading of the right cardiac cavities which results from the obstructed circulation in the lungs. Pyrexia. — The pyrexia of pneumonia is con- tinuous, with slight morning remissions and even- ing exacerbations. The temperature rises very suddenly with the invasion of the disease, to from 102° to 105° Fahr. ; and this high temperature is maintained until the period of crisis. This sudden rise and maintenance of a high tempera- ture is very characteristic. The amount of elevation varies in different cases. As a rule it does not exceed about 1 01° or 1 05° Fahr., but tem- peratures of 107° have been known to terminate favourably. In fatal cases it may reach 109° shortly before death. The maximum tempera- ture is usually met with on the second or third lay of the disease, but it occasionally occurs mmediately before the crisis. The daily varia- ions are usually as follows : — The temperature ,s lowest about 7 or S a.m. In the forenoon, >r somewhat later, it commences to rise, and attains its maximum in the early evening. It , hen falls, but a slight exacerbation occasionally iccurs again at midnight, after which it gradually alls. The difference between the highest and owest temperatures is usually not more than 0 Fahr. The pyrexia runs, for the most part, uniform course until the period of crisis, when he temperature falls rapidly, in the manner to ■a hereafter described. Nervous system. — Headache, restlessness, and leeplessness are almost always prominent ymptoms. Slight delirium is also common, 'specially towards evening, when the pyrexia is t its maximum. Sometimes the delirium is tore marked and violent. It constitutes a tore prominent symptom in the old, and in the lebilitated and intemperate. In drunkards it ■ constantly present, and here it often assumes ue character of delirium tremens. Convulsions [•e common in children, especially at the period invasion. They are rare in the adult. These ■rvous symptoms are sometimes so prominent ; to mask the nature of the disease. Digestive organs. — The symptoms of acute jieumonia referable to the digestive system are nilar to those met with in other severe febrile seases. There is loss of appetite and thirst. le tongue is more or less thickly coated with white fur, and it tends in severe cases to oomc dry and brown. Herpes often appear lout the lips, and sometimes on other parts of 8 face, about the third or fourth day of the lease. \ omiting, which is a common symptom invasion in the child, is an occasional compli- 877 cation, as is also diarrhoea; constipation, how- ever, is the rule. Urine. — The quantity of urine is considerably diminished, and its specific gravity increased, so that abundant urates are deposited. The excretion of urea is greatly increased, and it may amount to as much as seventy-five grammes in the twenty-four hours. The uric acid is likewise augmented. The chloride of sodium is much diminished, and during the height of the disease it may entirely disappear. Slight temporary albuminuria is perhaps more co mm on in pneumonia than in almost any other acuto febrile affection. The amount is usually in direct proportion to the severity of the disease. Bile-pigment is occasionally met with. Course and Terminations. — The symptoms which have been described continue with often increasing severity up to about theendof the first- week of the disease, sometimes longer, when an improvement usually occurs. This improvement may tqke place quite suddenly, and the disease rapidly terminate in health — termination by crisis ; or the recovery may be more gradual — termination by lysis. In other cases death occurs either before or after the crisis. The disease may also terminate in gangrene of the lung ; in pulmonary abscess ; or in chronic pneumonia. These several modes of termination must be considered separately. Complete recovery. — This is the most common termination of acute pneumonia in young and healthy adults, and the improvement usually occurs quite suddenly — by crisis. The time at which this crisis takes place, as indicated by the sadden fall of temperature, varies from the third to the twelfth day. In the majority of cases it is on the fifth, sixth, or seventh day; it is occasionally as early as the third day ; and sometimes it is prolonged into the middle of the second week. The old doctrine that the crisis always occurs on the odd days is untenable. The supervention of the crisis is sometimes indicated by a change in the pulse, which be- comes softer, and somewhat irregular in force and rhythm. The most marked phenomenon attending it is the abrupt fall of the bodily temperature. This fall may commence either during the morning remission or the afternoon exacerbation. It appears to be most eommor late in the afternoon. The temperature very often reaches the normal standard in from six- teen to twenty-four hours, usually within forty- eight hours ; the morning remission and evening exacerbation occurring during the period of de- fervescence. The temperature not unfrequent ly falls to 1° or 2° Fahr. below normal, and may remain so for two or three days. Occasionally a marked increase in the pyrexia is observed immediately before the commencement of defer- vescence. With the fall of temperature all the symp- toms rapidly improve. The skin becomes moist and often perspires profusely. The amount of urine increases. The respiration falls in fre- quency; and, to a less extent, the pulse. The cough becomes looser, and the expectoration more copious ; the sputa gradually losing their tenacity and rusty colour, and becoming more bronchitic in character. They are now usually 878 LUNGS, INFLAMMATION OF. mingled with more or less black pigment. An improvement in the physical signs is sometimes observed at the same time ; more commonly, However, this does not take place till one or two days later. The patient often falls into a deep sleep, and on waking, with the exception of great weakness, declares himself pretty well and be- gins to ask for food. In some cases, however, the amount of prostration following the crisis is so great that the return to health is more gra- dual, and a condition of collapse may ensue which may even terminate in death. Iu the majority of cases acute pneumonia terminates abruptly in the manner above de- scribed. Sometimes, however, recovery is more protracted, and defervescence may not be com- plete till the end of the second week, the tem- perature falling more gradually — by lysis. The critical fall of temperature is occasionally in- terrupted by more or less marked exacerbations, due either to the implication of fresh portions of the lung, or to the supervention of one of the complications to bo hereafter alluded to. In some cases, again, after the occurrence of the crisis, the temperature assumes a hectic type, and does not quite reach the normal stan- dard for perhaps two or three weeks : the irregu- lar fever being due probably to the contamina- tion of the blood by the absorbed pneumonic products (Parkes). Lastly, a distinct relapse may occur after the completion of crisis ; but the relapse is in most cases shorter and less severe than the primary attack. Death . — When pneumonia terminates fatally, it usually does so towards the end of the first, or quite at the beginning of the second week. Death is commonly due partly to failure of cardiac power, and partly to apncea. Apnoea is the least important element in the causation of dissolution. The danger from it increases with the extent of lung involved, and it is consequently usually greater in double than in unilateral disease. Failure of cardiac power is undoubtedly the most important means by which pneumonia destroys life (Juergensen). There are several conditions in the disease which tend to damage the contractile power of the heart. First, and foremost of these is the pyrexia. The severe pyrexia of pneumonia, like that cf other acute febrile diseases, produces more or less granular degeneration of the cardiac muscular fibres. It also necessitates increased frequency of the cardiac contractions, in order to supply the increas- l demand for oxygen, and to remove the excess of carbonic acid. Owing to this increased frequency, the length of diastole — the period during which the heart rests and is nourished — is shortened. The condition of the lung itself constitutes another important ele- ment tending to damage the contractile power of the heart, and especially of the right ventricle (Juergensen). The lung-consolidation not only presents more or less obstruction to the pulmonary circulation, and hence necessitates increased action on the part of the right ven- tricle ; but owing to the diminished respiratory surface, this ventricle is obliged to do more work in order that the proper interchange of gases may be effected in the lungs. Such being the modes by which pneumonia tends to destroy life, it will he readily understood that the earliest and most important signs of unfavourable augury are on the 6ide of the circulation. The pulse becomes more frequent, small, irregular, and often dichrotous. The frequency of the respiration, the dyspnoea, and the cyanosis increase. The cough becomes feeble and ineffectual. Owing to the engorgement and failure of power of the right ventricle general pulmonary cedema usually supervenes, so that moist rales are audible at both bases. The ex- tremities become cold, and there is often profuse perspiration. The mind wanders, and a condi- tion of partial coma supervenes before the close. In some cases a rapid rise of temperature takes place before the fatal termination, whilst in others there may he a considerable fall in the thermometer. Pneumonia may also terminate fatally from the state of collapse which follows the crisis. Lastly, in those exceptional eases in which the pneumonia tends to become more or less chronic, death may occur during the third or fourth week. Death may also result from the com- plications. Gangrene . — This is quite rare. It is most common in chronic drunkards, and in those of de- bilitated constitution. Its occurrence appears to he due partly to blocking of vessels, and partly to the septic influence of altered inflammatory pro- ducts. It is usually limited to a small area of the pneumonic lung ; and is either diffuse, or becomes limited by a zone of inflamed tissue. It commonly’ supervenes late in the disease; and the most reliable signs of its occurrence are marked feetor of the expectoration, and great prostration. Portions of lung-tissue are occa- sionally found in the sputa. It is almost invaria- bly, hut not necessarily, fatal. Abscess . — This is somewhat more common than the preceding. See Lungs, Abscess of. Chronic pneumonia .— Acute pneumonia in very exceptional cases becomes chronic, and leads to induration of the lung. See D. Chronic Pneu- monia. Physical Sign’s. — The earliest physical signs of acute pneumonia are usually discoverable within forty-eight hours of the invasion cf the disease. They often appear within twelve or twenty-four hours ; hut occasionally, when the local lesion is deeply seated, nothing abnormal is to be detected until the third or fourth day. It will be well to describe them in the order in which they commonly make their appearance. The time occupied in their evolution will vary according to the rapidity with which the several stages of the pneumonic process succeed one another. _ The earliest abnormal physical signs are due to the pain caused by the movement of the affected side ; to the hypersemia of the pulmo- nary capillaries; and to the commencing exu- dation into the air-vesicles. The respiratory movements of the side are more or less im- paired. This is partly’ owing to pain, and partly to diminished elasticity of the lung-tissue. The breath-sounds are usually somewhat weak an harsh, but not distant; although, an stated by Stokes, they are occasionally in the earnest stage harsher and louder than natural. Pei^ LUNGS, INFLAMMATION OF. mission during this stage is usually not mark- edly altered. The resonance, however, is some- times quite appreciably tympanitic, but as the disease progresses the tone becomes impaired. The tympanitic quality of the resonance is caused by the diminished elasticity of the still air-containing lung. The vocal fremitus is in- creased. The most important sign, however, of th^ congestive stage is fine crepitation. This rale consists of a number of fine, dry, crackling sounds, following one another in rapid succession, which have been aptly compared by Dr. C. J. B. Williams to the sounds produced by rubbing the hair between the fingers close to the ear. It occurs during the later period cf this stage, when the process of exudation from the pulmonary capillaries is commencing to take place. Its production is probably due to the partial agglu- tination of the walls of the air-vesicles and their forcible separation during the inspiratory act. The rale is almost exclusively limited to inspiration. It is intensified by deep inspira- tion and also by cough, and it is sometimes necessary to make the patient cough in order that it may be produced. A precisely similar j rale is often heard with deep inspiration in portions of the lung which have been imper- fectly expanded. Such imperfect expansion is common in the posterior parts of the lungs of patients who have been confined to bed from .acute or chronic disease, and in whom, owing to muscular weakness, inspiration is incompletely .performed. The rale produced under these circumstances is distinguished from pneumonic crepitation inasmuch as it completely disappears After a few deep inspirations, whereas the pneu- monic rale when once established persists until the consolidation of the lung is tolerably com- plete. The physical signs of the stage of hepatisa- ion are due to the more or less complete eon- ■olidation of the lung. The fine crepitation which characterised the later periods of the ■receding stage continues during the process f consolidation, but ceases as the filling of he air-vesieles becomes complete ; although it tay often still be heard at the confines of the ■ore firmly consolidated lung. It occasion- tly happens, however, when the consolidation very rapidly induced, that no crepitation is eard throughout the course of the disease until le period of resolution. When the lung has ;icome consolidated, the expansivo movement ' the corresponding portion of the chest, which as before diminished, ceases. The intercos- 1 spaces, although sometimes slightly more •ominent than in the healthy side, are still pressed and not obliterated as in pleural effu- >n. AVhen the amount of exudation is very insiderable, slight enlargement of the side is ‘cessarily produced. The situation of the car- te impulse is not altered. The vocal fre- ! 'tus is usually increased. To this general rule, wever, there are exceptions, and it not un- quently happens that it is unaltered, and it •y even be completely absent,. This diminu- ,n in the vocal fremitus is sometimes due to * blocking of the smaller bronchi with the lammatory exudation, but more frequently i appears to result from an accumulation of 879 mucus. In the latter case it may sometimes be restored by cough. Coincidently with the increase of vocal fremitus there is usually in- creased vocal resonance, and sometimes whisper- ing pectoriloquy (Walshe and AVilson Fox). The percussion-sound now is much more deficient iD tone, and it is often more or less amphoric. This amphoric quality is probably obtained from the columns of air in the larger bronchi and trachea. There is also a great increase in the sense of resistance, but neither the dulness nor the resistance are so marked as in pleural effusion. In basic disease percussion under the clavicle often yields a distinctly amphoric note, whilst the lower portions of the chest may be almost absolutely dull. The auscultatory sign of this stage is bronchial breathing This is usually remarkably superficial, high-pitched, and metallic in quality (tubular breathing). Some- times, however, it is less metallic and softer (diffused blowing — AValshe). These- respiratory phenomena, like the vocal resonance and fremi- tus, may be ab-ent over larger or smaller areas of the consolidated lung, owing to the obstruction of the bronchi by catarrhal secretion. The slight pleurisy which constantly accompanies the pneumonia is rarely susceptible of physical demonstration during this stage. This is prob- ably owing to the immobility of the solid lung. During the period of resolution, as expansive power returns, friction-sounds are occasionally audible. Resolution usually commences in those por- tions of the lung which were the last to become consolidated. The most important and the earliest of the signs of resolution is the return of crepitation. The crepitation, however, differs from that met with in the earlier stages of the disease. It is larger, coarser, and more liquid in character — redux crepitation ; audits liquid cha- racter gradually increases until it may become distinctly bubbling. AVhen resolution is very rapid, redux crepitation may be absent (Wilson Fox). The bronchial breathing now loses its metallic ringing quality ; the pcrcussion-dulness gradually disappears ; and the respiration regains to a great extent its normal characters. The commencement of resolution and of the improvement in the physical signs occasionally takes place, as already stated, coincidently with the establishment of crisis ; but more commonly it is not observed until from twenty-lour to forty-eight hours after the temperature has reached the normal standard. The time occu- pied in the completion of resolution varies. Sometimes all physical signs almost completely disappear in twenty-four hours. L'sually, how- ever, resolution is less rapid, and marked signs of consolidation remain for periods varying from two or three days to two weeks. A slight amount of dulness and some weakness of respira- tion often persist at the posterior and inferior portions of the lung for even still longer periods. This is especially the case if the pneumonia is complicated with pleurisy. AA T hen marked signs of consolidation exist after the third week, there always exists more or less probability that the pneumonic process may become chronic. A'ahieties. — The three following varieties of pneumonia present clinical phenomena some- 880 LUNGS, INFL, what different from those which have been de- scribed. a. Latent •pneumonia . — Pneumonia has been termed latent when the characteristic symptoms of the disease are absent, or but little pro- nounced ; or when they are masked by some other clinical phenomena. It is in the pneu- monia of the aged that marked latency is so often observed. Here invasion may be unat- tended by rigor or other prominent symptoms. Cough, expectoration, pain, and dyspnoea may be completely wanting. If cough be present the sputa often do not present the rusty tinge, but are simply transparent or muco-purulent. Pyrexia, some increased frequency of breathing, great prostration, and mote or less muttering delirium, are the principal symptoms. The fever, however, is usually much less than in adults. This latent course of pneumonia it is important to bear in mind, as it indicates the necessity of making a most careful physical examination of the chest in all severo acute illnesses of the aged. In the pneumonia of drunkards and of young children, also, the accompanying nervous pheno- mena may be so prominent as to mask the nature of the disease. b. Asthenic ( typhoid ) pneumonia. — When pneumonia occurs in those who are debilitated by previous disease, by the abuse of alcohol, by age, by privation, or other causes, the pheno- mena of invasion are usually not pronounced, and symptoms of intense prostration occur early. In many respects the course of the disease closely resembles that which has been just de- scribed as so common in the aged. The initial rigor and pain in the side are often observed; but cough is slight ; and the expectoration, instead of the rusty-brown tint, may present a dirty brown or prune-juice appearance. Various symptoms of an asthenic type soon become pro- minent ; the most important of which are low delirium, alternating with stupor; tremors ; and paralysis of the sphincters. The tongue is brown and dry ; sordes form ou the teeth ; the pulse is exceedingly rapid and feeble ; and there is often slight jaundice and albuminuria. Death usually supervenes some time during the second week of the disease. After death the lung is usually found to be less firmly consolidated and less granular than in sthenic forms of pneu- monia. The stage of grey hepatisation in some cases is exceedingly advanced, constituting what has been termed ‘suppuration’ of the lung (Sturges). c. Intermittent pneumonia . — An intermittent variety of pneumonia is sometimes met with in malarial districts, which appears to be one of the results of malarial infection. According to Grisolle it occurs in intermittent and remittent forms. The former is characterised mainly by the complete intermissions which occur in the pyrexia. The temperature falls suddenly at the end of twenty-four hours ; profuse sweating oc- curs ; and the physical signs of the pneumonia almost entirely disappear. A return of the pyrexia and physical signs takes place at the expiration of twenty-four or forty-eight hours, followed by another intermission, and this by a third or fourth, the disease presenting either a quotidian or a tertian type. Both lungs are MMATION OF. liable to be involved. In tne remittent form there is a much less complete disappearance of the physical signs during the remission. Complications. — Pleurisy. —Pleurisy of slight intensity and unaccompanied by effusion is, as already stated, almost invariably met with in acute pneumonia over those portions of the lun» which are consolidated. This is natural to the disease, and cannot he regarded as a complicaticr. Pleurisy of greater intensity, and atten !ed*'l,y effusion, occurs in from five to fifteen per cent, of the cases. Signs of effusion are not usually discoverable before the third or fourth day of the disease. The amount of liquid varies xvith the extent of the lung-consolidation. When this is considerable, involving nearly the whole lung, there is but little room for effusion. The super' vention of pleurisy does not commonly mate rially modify the course of the disease. It may, however, protract the period of defervescence.' Its influence in interfering with the disappear- ance of the physical signs has been already alluded to. When pleurisy occurs on the side opposite to the pneumonia it constitutes a more dangorous complication. Bronchitis . — This is also a common complica- tion, especially in the aged and in young chil- dren. Many cases, however, which have been described as acute pneumonia associated with bronchitis, have doubtless been eases of broncho- pneumonia. The bronchitis almost invariably affects both lungs. Its supervention is attended by an increase in the cough and in the amount of expectoration. When it involves the smaller tubes generally, it constitutes a serious compli- cation. Pericarditis . — This is less frequent. It may result from the direct extension of the inflam- matory process from the pleura, or it may be a part ot the general disease. It is a grave com- plication, and greatly increases the mortality. Jaundice . — A slight yellowish tinge of the conjunctiva, and even of the skin, is not unfre- quent in pneumonia, and has no clinical signi- ficance. It is probably in most eases owing to the congestion of the liver which results from the impeded pulmonary circulation — the dis- tended portal veins pressing upon the bile-duets. Much more extensive jaundice is also occasionally met with, which appears usually to be due tc duodenal catarrh, and is attended by gastru symptoms. In other cases, especially in asthenii forms of the disease, a non-obstructive jaundici sometimes occurs, resulting from changes in th< red blood-corpuscles. This is commonly asso dated with nervous symptoms, such as stupor delirium, and a tendency to collapse, which ar of grave prognostic import. Parotitis . — This is a very rare and exceeding! serious complication. According to Grisolh it is usually unilateral ; the inflammatory pr cess is very acute ; and commonly leads to suj puration or gangrene. Diagnosis. — The diagnosis of acute pneum' nia, although usually easy, is sometimes attend; with difficulty. It cannot be made with abs lute certainty before the appearance of tl physical signs of pulmonary consolidate, although some of the phenomena of invasion a so characteristic, that the nature of the disea LUNGS, INFLAMMATION OF. 851 # often tolerably evident before abnormal phy- sical signs are discoverable. The phenomena which are of the most diagnostic value at this early stage of the disease are the pyrexia, the altered pulse-respiration ratio, the pain in the side, and the cough. The sudden and rapid rise of the bodily temperature, which usually reaches its maximum in forty-eight hours, is very cha- .racteristic; such a rapid attainment and main- tenance of a high temperature being perhaps more common in pneumonia than in any other disease (Wilson Fox). Of the other symptoms, the increased frequency of respiration, and espe- cially the alteration in the pulse-respiration ratio, are of the most valuable diagnostic import AValshe). When physical signs of pulmonary lonsolidation are discoverable, which they usually ire within forty-eight hours, the diagnosis be- •omes certain. Difficulties in diagnosis may arise in those ■ases in which the local process in its earlier tages is deeply seated. Here, characteristic ihysical signs may be wanting for four or five lays, during which time some doubt may exist s to the nature of the disease. Then, again, n those latent forms of pneumonia which have een already described the disease may be easily verlooked, unless a careful examination be made f the chest. The diagnosis of pneumonia from other dis- uses of the lungs is rarely difficult. The isease with which it is most liable to be con- iiinded is pleurisy. In pleurisy, however, there not, as a rule, such a sudden aud rapid attain- ent of a high temperature as in acute pneu- onia ; and when effusion has taken place, the lysical signs are in most cases sufficiently stinctive. In pleural effusion the bulging of e side; the obliteration of the intercostal aces ; the displacement of the heart ; the abso- tedulness and sense of resistance on percussion; 'e weak and distant character of the respiration ; d the diminished vocal fremitus and resonance, ntrast with the signs of pulmonary consola- tion. Another disease with which pneumonia may confounded is that somewhat rare form of very ■ ite phthisis, in which a large area of the lung 1 tomes rapidiy consolidated — the consolidation 1 ug often in the main indistinguishable histo- 1 ically from that met with in acute pneu- r ha. Here, however, although the whole lung r ; be involved, the disease usually commences n;he upper lobes, so that abnormal physical 8 .s are more marked at the apex. The onset o he disease also is commonly much less sud- d and its course is more protracted. Then, n > the rapid consolidation of the lower por- t> > of the lungs which sometimes supervenes ii pore chronic forms of phthisis, might be mis- ta n for the consolidation of acute pneumonia ; b' the history of the case, a careful examina- j" of the upper lobes of the lungs, the irregu- jf 'ourse of the pyrexia, and the protracted notion of the disease, will easily serve to dis- ! u ' s h them. It may be stated generally that, ln 1 acute consolidations of the lung, a pro- tn 3d course of the pyrexia, and the occur- 18' of marked exacerbations and of remissions °t 3 fever at irregular intervals, afford grounds 56 for the supposition that the consolidation is phthisical. The diagnosis of acute pneumonia from broncho-pneumonia and collapse of the lung, will be considered when treating of broncho-pneu- monia. See Broncho-Pneumonia. Prognosis. — The mortality from acute pneu- monia varies at different periods, the diseasa being more fatal in some years than in others. This is probably partly owing to variations ir what is called ‘ epidemic influence.’ Of all the circumstances which influence the prognosis of pneumonia, that which is perhaps the most important is the state of the general health. In weakly subjects, and in those whose constitutions have been damaged by previous disease, by privation, or by their mode of life, acute pneumonia is exceedingly dangerous. The prognosis is, however, especially grave in those injured by the long-continued abuse of alcohol, the mortality being, according to Huss, from 20 to 25 per cent. In healthy children the mortality from pneu- monia is comparatively small. The fatality for- merly ascribed to the disease at this period of life was probably owing in great measure to the inclusion of cases of collapse and broncho- pneumonia in the statistics ; the latter disease being exceedingly fatal. Healthy young adults rarely die ; after the age of thirty the mortality increases considerably ; and in the old pneu- monia is an exceedingly fatal disease. Pneumonia is more fatal in females than males, the mortality being in the proportion of three to two. Pregnancy renders the disease more dangerous. The danger of pneumonia increases somewhat with the extent of lung implicated. It is, how- ever, the implication of both lungs which ren- ders the prognosis especially grave. With re- gard to the situation of the consolidation it may, perhaps, be stated generally that pneu- monias commencing in the upper lobes are rather more serious than basic disease. The gra- dual extension of the consolidation late in the disease, and the spreading of the inflammatory process from one centre to another, constitute elements of gravity. When resolution is much protracted, the fact that the disease in very ex- ceptional cases terminates in an indurative con- solidation of the lung is not to be forgotten. The mortality of pneumonia is greatly in- creased by the existence of complications. The prognostic importance of these has already been considered. Of individual symptoms the pulse is of chief importance. A pulse which in the adult is persistently over 120, and in the child over 140. is of grave significance. Marked irregularity in force and rhythm is also unfavourable, es- pecially in the young. Dichrotism may occur temporarily in quite favourable cases, but if it persists it indicates danger. The variations in respiration are of less import. An extreme quickness of breathing, marked dyspnoea, and cyanosis are not uncommon in cases which ter- minate in recovery; at the same time such symptoms must have more or less unfavourable significance. Sputa of a dark prune-juice colour are of somewhat evil augury; as is also ac LUNGS, INFLAMMATION OF. iH‘2 Abundant liquid puriform expectoration. The indications from the pyrexia are of less prognos- tic value in pneumonia than in most other acute diseases. A temperature of 105° or 106° Fahr. does not in itself indicate danger. Greater eleva- tion is grave. In many fatal cases the tempera- ture never attains 102°. The significance of a protracted defervescence has already been al- luded to. On the side of the nervous system, it is to be remembered that slight delirium is not uncommon ; but when it is marked, and espe- cially when it occurs late in the disease, it is most grave. It is of greater significance in adults than in children. Tremors and a ten- dency to coma are also unfavourable. A dry, brown tongue is unfavourable, especially when associated with only a moderate degree of py- rexia. Gastric catarrh and diarrhoea add to the danger. A slight amount of jaundice is not of bad impoTt. The existence of albuminuria, or the appearance of albumen in the urine early in the disease, is unfavourable. Tkkatment. — In considering the treatment of acute pneumonia, it is of the utmost importance to bear in mind the true nature of the disease. All rational and successful therapeutics must be based upon the recognition of the fact, that it is a general, and not a local, affection which we wish to influence. The ‘heroic’ methods of treatment by venesection, tartar emetic, &c., so much in vogue in the past, had for their object the controlling or cutting short of a local affec- tion of the lung ; hence the unfavourable results which attended them. As these methods have been abandoned, and there has existed a more correct appreciation of the pathology of the disease, the mortality attending it has dimi- nished. ■When discussing the pathology of pneumonia, reasons were adduced for the belief that it owes its origin to a specific cause. Whether this be so or no, the disease is so closely allied to the specific fevers, that in attempting to influence its course by treatment, we must be guided by the same general principles. As in these fevers, our object must be to endeavour to conduct the pneumonia to a favourable termination. We cannot arrest its progress, but we can often do very much both to maintain the strength of the patient, and to modify those elements in the disease which tend to destroy life. The modes by which pneumonia tends to destroy life have been already considered. Failure of cardiac power is the. great source of danger. The causes of this failure it is impor- tant to bear in mind when treating the disease, and the reader is referred to what has been already stated respecting it. The natural course of the disease is also to be remembered. In the strong and robust pneumonia usually terminates in health. It is in those who are debilitated by age, privation, mode of life, the abuse of alcohol, or pre-existing disease, that such great morta- lity attends it. It is a question of the intensity of the disease on the one hand, and of the resisting power of the individual on the other. Such con- siderations as these not only indicate the impor- tance of doing all that is possible to husband and support the strength of the patient, but also | af not interfering too actively with the disease, 1 unless circumstances arise which, if uninfluenced by treatment, would tend to rapidly prove latil. Such being the general principles which should guide the practitioner in the treatment of acute pneumonia, the manner in which they are to be best carried out may now he indicated. The patient should he kept in bed. The room should be large and airy ; and the temperature about 60° to 62° Fahr. It should be well-ven- tilated : a plentiful supply of fresh air is most important, and although due care should be ex- ercised in the ventilation, there is not the same necessity to keep the patient scrupulously pro- tected from draughts, as in the treatment of acute bronchitis. The diet should he carefully regulated, nutri- tious, and easily digestible, consisting of milk, milk with the white of egg, beef-tea, meat es- sence, and such-like articles, given in varying quantities and at varying intervals, according to the condition of the patient. With the object of promoting the appetite, it is well to keep the mouth cleansed with glycerine and lemon- juice. Small quantities of wine, as hock, dry sherry, champagne, or burgundy, given occa- sionally with food, are often useful as stimu- lants to the appetite and digestive process. Some acid and bitter, as hydrochloric acid and orange-peel, may also he prescribed for the same purpose. If in the early stage of the disease there is great constipation, loaded tongue nausea, or other gastric symptoms, the adminis- tration of a small dose of calomel, or of blue pill and colocynth, is often followed by marke' improvement, both in the power to take food, anc in the general condition of the patient. Tin exhibition of purgatives, however, requires grea care, as they occasionally set up a catarrhs condition of the intestine, and consequent diar rhcea, which may prove more or less persistent It is important, therefore, except in such case as those above indicated, to procure all neeessar evacuation of the bowels either by a small dos of castor oil, or of colocynth and hyoscyamus, c by simple enemata. Everything should he done to husband ti strength of the patient, and the services of s efficient nurse will often do very much towar; the attainment of this object. Perfect rest mu be enjoined, and all unnecessary speaking 1 forbidden. There are two circumstances whi> often tend greatly to interfere with rest— tl pain in the side, and the cough. The former these may usually be relieved by the appliq tion of large hot linseed poultices, or of b fomentations to the side. These must be f> quently changed, and great care should exercised in their renewal not to disturb or : convenience the patient. If these means do i succeed, from one-eighth to one-sixth grain acetate of morphia may be administered hy] dermicallv ; or a small blister or three or fc leeches may be applied to the seat of the pa and the hot applications then renewed. Cou. is not usually a troublesome symptom, and less it greatly disturbs the patient, it is bet? not to interfere with it. If necessary, a linet, containing from two to four minims of liq- morphi* hydrochloratis and a similar quanta of vinum ipecacuanhas, given occasionally^ ! LUNGS, INFLAMMATION OF. 88S often beneficial. By means of the treatment above indicated, and by keeping the room quiet and darkened, the patient will often procure a sufficient amount of sleep. This can very frequently be promoted by carefully sponging the whole surface of the body, a portion at a time, with tepid water, the last thing at night. Should it be necessary, some narcotic must also be administered, but with great caution, so as not to interfere with freedom of expectoration ; and it should only be had recourse to when other means have failed, and in the absence of contra- indications. Hyoscyamus and bromide of potas- sium may be safely used for this purpose ; and should these fail, opium may also be given. This should be prescribed in a sufficiently large dose to ensure sleep, and is perhaps best administered hypodermically, as acetate of morphia. Chloral is usually contraindicated, on account of its de- nressing effect upon the circulation. A very large number of cases of pneumonia erminate in health without the necessity of any further interference on the part of the physician i ban has been described. Frequently, on the ither hand, circumstances arise indicative of '.anger, which require to be met by more active treatment. The chief source of danger, as al- ready stated, is failure of cardiac power, and onsequently all symptoms of such failure must Jo carefully watched for. Apncea is less impor- tant, excnpt in those cases where both lungs are xtensively involved. Any sign of cardiac failure will in the first lace suggest the advisability of administering Icohol. The exhibition of small quantities of ;ine with food has been already recommended •> sometimes useful in stimulating the appe- |te and assisting digestion, in cases where there ■e no symptoms of asthenia; but when such ■mptoms arise, alcohol must be employed in rger quantities. It may be stated generally at a pulse of over 120 or 130 calls for the lployment of stimulants. Brandy appears in }st cases to answer best. The amount admin- ered must depend upon its effects ; and al- Dtigh in most cases from four to eight ounces the twenty-four hours will be sufficient, if the licnia persist it must be given in very much ■ ger quantities. Baik and camphor have also jin employed as stimulants, and in some cases diminished temporarily by venesection, and at the present day this is probably the only symp- tom for the relief of which the practice of bleed- ing would be considered at all justifiable. In S84 LUNGS, INFLAMMATION OF. considering the advisability of removing blood in those cases in which dyspnoea constitutes an urgent symptom, it must, however, be borne in mind not only that the relief is merely temporary, but that the loss of blood must tend more or less to weaken the patient, and hence to favour that condition of asthenia which is of all things the most to be feared. Bleeding is certainly only to be thought of when the dyspnoea threatens life, and when at the same time the strength, as in- dicated by the pulse, is good ; and it should not exceed the removal of eight or ten ounces of blood. Such cases are certainly not common; and when they do occur, it is a question whether i t would not be safer practice to endeavour to relieve the dyspnoea by reducing the tempera- ture (either by the cautious application of cold or by quinine), than to have recourse to the lancet. Of the complications delirium sometimes calls for treatment. Active delirium is not com- mon in pneumonia, except in those who have been intemperate. When marked it is always indicative of danger. In its management the practitioner must be guided by the general con- dition of the patient. It is usually accompanied by asthenia, and hence calls for the exhibition of stimulants. The influence of an experienced nurse is most important. If the pyrexia is con- siderable, the advisability of wet packing or of the cold bath should be considered. In many cases simply sponging the surface of the body with cold water produces a soothing effect. The application of ice to the head for a short time may also be tried. If these means fail in quiet- ing the patient, and the delirium is very violent and prevents sleep, it may in some cases be ad- visable to administer an opiate. This should only be done, however, as a last resource, and when there is marked asthenia it is quite unad- visable. The opiate should be given in one full dose sufficient to procure sleep. Morphia admi- nistered hypodermically, or given with ammonia or brandy by the mouth, is perhaps the best form of exhibiting it. Of the management of other complications occurring in the course of pneumonia there is nothing special to be remarked; they must be treated on general principles. The existence of bronchial catarrh often requires small doses of ipecacuanha, ammonia, and. salines. Diarrhoea and gastric symptoms are to be met by careful dieting, chalk, bismuth, and, if necessary, other astringent remedies. In pneumonia, as in other acute diseases, the administration of an opiate enema is an efficient and safe means of checking diarrhoea. Pericarditis rarely admits of any special interference. Convalescence.— During the period which im- mediately succeeds the crisis, the utmost care is required to support the patient, and to prevent any serious amount of prostration, which at this time sometimes supervenes. Stimulants are usually required for some days after the temperature has attained the normal standard. Convalescence in most cases is quickly established. Solid diet is soon desired, and may be safely given. Tonics — such as quinine, iron, and cod-liver oil — and change of air are useful in assisting the restora- tion to health. B. Secondary Pneumonia. — DErurmos.— Secondary pneumonia is a local affection, not a general disease. It is an inflammation of the lung occurring in those who are the subjects of some other disease ; the pneumonic process standing in more or less causal relation to the disease in the course of which it supervenes. Intercurrent Pneumonia. — Before proceeding to consider secondary pneumonia as thus defined, it is to be remarked that the general disease- acute pneumonia — occasionally occurs in the course of other diseases as an accidental com- plication, its occurrence not being influenced Lv the pre-existingcondition. Such pneumonias may be termed intercurrent , and they are to be dis- tinguished from the local secondary affections. They often closely resemble, in their clinical features, the acute disease as it has been already described ; although in some cases they arc more or less modified by the disease in the course of which they occur. Hypostatic Pneumonia. — There is also a class of consolidations of the lung very common in those who are the subjects of other diseases, which are often described as secondary' pneu- monias, but which are really for the most part non-inflammatory in their nature; and will, therefore, be very briefly alluded to in the present article. These are those consolida- tions so often met with at the bases and more dependent portions of the lungs, in the course of both chronic and acute diseases, and also in the aged and cachectic. They have been termed hypostatic pneumonias, and consist, in the main, of collapse, hyperoemia, andeedemaof the lung- tissue, resulting from weak inspiratory power, feeble circulation, and gravitation. The con- solidation thus mechanically induced is in- creased by more or less exudation of liquor sanguinis and blood-corpuscles into the alveoli : which exudation is due to the damage to the walls of the capillaries caused by the blood- stasis (Cohnheim). There is also some swelling and proliferation of the alveolar epithelium. The frequent occurrence of this epithelial activity in collapsed and oedematons lung-tissue is discussed at greater length under the head of broncho- pneumonia. -ZEtiologt. — Secondary pneumonias, as already stated, bear a causal relation to the disease it the course of which they supervene. Theywoulc seem to owe their origin almost exclusively t< some abnormal condition which the pre-existin: disease has induced. They occur in the cours of many diseases, and sometimes appear to cop stitute the acute affection which determines dis solution. There is one disease in which sue pneumonias are especially frequent — namel; Bright’s disease. Pneumonia occurring in tfc course of Bright's disease, however, sometime closely resembles the acute primary affectio. and the Bright's disease is probably merely oi of the elements concerned in its causation : b more frequently it is simply the local affeeti about to be described. Anatomical Characters. — The changes c curring in the lung in secondary pneumon are, for the most part, precisely similar to tho of the acute primary disease. In many caS' however, the consolidation is less dense; a LUNGS, INFLAMMATION OF. epithelial activity sometimes constitutes a more orominent feature in its production. The pleura is usually implicated, but not so invariably so as in primary pneumonia. When associated with Bright's disease, the consolidation often passes rapidly into the stage of grey hepatisation. With regard to the situation of the consolidation, it :'s more frequently situated in the upper and middle lobes, and is more often double, than is that of the primary disease. Symptoms. — - The clinical phenomena of secondary pneumonia differ from those of the acute primary disease, the symptoms so charac- teristic of the latter being almost entirely want- ing. The symptoms which do exist are often but little pronounced, and the disease may even run an almost latent course. This latency of symptoms is often partly due to their being masked and modified by those of the disease to which the pneumonia is secondary. The onset of the pneumonic process is usually unattended by rigors or other marked pheno- mena. Cough, expectoration, pain, and dyspncea are often slight, and they may even escape obser- vation. If cough be present, the sputa may be free from blood, and simply watery or muco- purulent. The pjmexia is moderate, the tempe- rature often not being more than 100° Fahr. Not unfrequently slightly increased frequency of :he respiration, with occasional cough, and symp- toms of increased illness, are all that exist to in- dicate that pneumonia has supervened. Diagnosis. — Owing to the frequent latency of he symptoms of secondary pneumonia, the liagnosis often rests, for the most part, upon lie existence of physical signs of pulmonary onsolidation. When the consolidation occupies he posterior and inferior portions of the lung, t may be impossible to distinguish it from iraple hypostasis. See Hypostasis. PnoGNosis. — The supervention of pneumonia n the course of a chronic disease usually, but y no means invariably, indicates that the isease will shortly terminate in death. The nlmonary inflammation appears to determine issolution. Pneumonia occurring in acute iseases materially increases the gravity of the rognosis. Treatment. — The treatment of secondary leumonia usually resolves itself into that of ,ie disease in the course of which it occurs, 'arm applications to the chest, small doses of nmonia, and alcoholic stimulants may some- mes favourably influence the pneumonic ocess. C. Broncho-Pneumonia. — Synox. : Catar- al inflammation of the lungs ; Lobular pneu- i>nia; Fr. Pneunionie lobulaire ; Broncho-jmeu- \nie ; Ger. Bronchopneumonie. Definition. — Broncho-, catarrhal, or lobular ’eumonia is inflammation of the lung-tissue iociated with, and usually secondary to, in- timation of the bronchial mucous membrane. ■ the earlier stage the pulmonary inflammation commonly limited to scattered groups of air- icles, hence the term lobular which is applied 'bis form cf pneumonia. As the process ad- 1 ices, the inflammatory nodules may gradually i lesce so as to produce larger tracts of consoli- 883 dation. The inflammatory products which fill the alveoli consist principally of cells, derived from the epithelium of the alveoli, and from the bronchial mucous membrane ; exudation and emigration play a much less prominent part in the process than they do in acute pneumonia. Owing to this preponderance of epithelial pro- ducts, and to the association of the pulmonary with the bronchial inflammation, the process is also known as catarrhal- pneumonia. -(Etiology. — Broncho-pneumonia, as already stated, is invariably associated with bronchial catarrh. In some eases it would appear that the injury which produces the bronchial inflamma- tion produces at the same time inflammation of the alveolar walls, but much more frequently the bronchitis precedes the pneumonia, and gives rise to it in a manner to be hereafter described. Whatever causes inflammation of the bronchial mucous membrane may thus be a cause of broncho-pneumonia. Bronchitis is frequently followed by broncho- pneumonia, especially in childhood and in old age. All those conditions which favour the occurrence of bronchitis must therefore he enumerated amongst the causes of this form of pneumonia. Of these conditions it will be suf- ficient to mention here the marked influence of cold and damp, and, to a less extent, of heart- disease and emphysema ; also the inhalation of irritating gases, and of an atmosphere contain- ing irritating particles of solid matter. It is the bronchitis associated with certain infectious diseases which is most liable to he followed by broncho-pneumonia. This is espe- cially the case with that accompanying measles and whooping-cough. In both these diseases this form of lung-complication is exceedingly fre- quent. It also sometimes occurs in connexion with the bronchial catarrh of influenza and diph- theria. All conditions which tend to impair the gene- ral health favour the occurrence of broncho- pneumonia. The weakly and debilitated suffer most. Bad air and insufficient food are most important predisposing causes. A state of mal- nutrition not only renders the bronchial mucous membrane abnormally liable to become inflamed, but also diminishes the power of the respiratory muscles, and thus aids in the production of pul- monary collapse, a condition which, as will ho seen presently, is especially favourable to the pneumonic process. Owing to the general debi- lity and weakness of the thoracic parietes in rickets, bronchitis in the subjects of this disease is exceedingly liable to be followed by broncho- pneumonia. Broncho-pneumonia is most common during the first four years of life — the period when bronchial catarrh, measles, and whooping-cough are so frequent. It is also common in old age. In young adults it is comparatively rare. Sex has no influence. Anatomical Characters. — The appearances presented by the lungs after death vary. The bronchi always exhibit signs of more or less bronchial catarrh. This may involve the whole of the bronchial mucous membrane, but it is usually most marked in the smaller tubes. These are found containing a thick, tenacious, and often *86 LUNGS, INFLAMMATION OF. puriform secretion, ■which is occasionally here and there drier or inspissated. The mucous mem- brane of these tubes is more or less softened, swollen, red, and thickened, and often presents irregular superficial erosions. Owing to this in- flammatory swelling the tubes stand out pro- minently on section of the lung. Cylindrical dilatations of the tubes are also frequently met jrth. The lung-tissue itself exhibits, associated in various degrees, collapse, congestion, oedema, emphysema, and pneumonic consolidation. The bluish, non-crepitant, depressed portions of col- lapse, which become darker and more friable with age, are usually most abundant in the lower lobes and margins of the lungs. The collapse sometimes involves the whole of one lobe, but more commonly it is limited to much smaller areas of the lung. When scattered and limited in its distribution, there is usually more or less emphysema of the intervening portions of the lung ; when very extensive in the lower lobes, the emphysema is most marked in the upper. Those portions of the lung in which the pneu- monic process has supervened most commonly appear as scattered nodules of consolidation, varying in size from a small pea to a hazel nut. These are ill-defined and pass insensibly into the surrounding tissue, which is variously altered by congestion, collapse, and emphysema. They are of a reddish-grey colour, slightly elevated, smooth, or very faintly granular, and soft and friable in consistence. As they increase in size they may become confluent, and thus are pro- duced larger tracts of consolidation. In a more advanced stage, the nodular and more diffuso consolidation becomes palor, firmer, and drier, and somewhat resembles in colour the greyish- yellow hepatisation of acute pneumonia. The cut ends of dilated bronchi, filled with pus, are occasionally seen in the centres of the pneumonic nodules. Microscopical characters. — When examined microscopically this consolidation is seen to con- sist of an accumulation within the alveoli of a gelatinous mucoid-looking substance, small cells resembling leucocytes, and epithelial ele- ments. In many cases much of this accumu- lation is precisely similar to that contained in the smaller bronchi ; aud it is evidently the inflammatory and richly cellular bronchial se- cretion which has been inhaled. At the same time it is in the highest degree probable that it is partly the result of exudation and emi- gration from the pulmonary capillaries ; such exudation and emigration, however, do not play nearly such a prominent part in the process as they do in acute pneumonia, and a fibrinous coagulum is rarely met with. Associated with this material are large epithelial elements, pro- bably the offspring of the alveolar epithelium. These vary considerably in number. In some portions of the consolidation they may be very few, whilst in others they may constitute the predominant change. These differences probably depend upon how far the inhalation of the bron- chial secretion constitutes a part of the process. The epithelium covering the alveolar walls is more or less swollen and granular, and is often loosened from its attachment. - Many of the nodules of consolidation met witli in the lungs after death from bronchopneu- monia, differ somewhat from those which have been described. They are smaller and softer, cf a more yellow colour, les3 prominent, and less granular; and on scraping, a puriform liquid is obtained from them. These consist almost ex- clusively of puriform secretion inhaled from the bronchi ; and there is an almost complete absence of epithelial elements, and of other evidence of alveolar inflammation. Some of these nodules are merely the cut ends of dilated bronchi tilled with pus. The pleura is usually more or less injected, and a little lymph with small ceehymoses aro commonly met with. These appearances are most marked in the vicinity of the sub-pleural pneumonic nodules. The subsequent changes which take place in the lungs vary. When the disease dots not end in death, resolution is the most common termina- tion. The contents of the alveoli undergo fatty degeneration, and are removed by expectoration and absorption, the lung gradually regaining its normal characters. This process, however, is less readily effected than in the consolidation of acute pneumonia ; and it often occupies such a lengthened period that some thickening of the bronchial aud alveolar walls, and dilatation of I the smaller bronchi remain. In still more chronic cases the fibroid thickening is much more marked, and considerable irregularly-dis- tributed pigmented induration and bronchial j dilatation may be produced (see Chronic Pneu- monia). In these chronic forms the contents of the alveoli sometimes caseate, and the caseous products and thickened alveoli may, in excep- tional cases, disintegrate, and thus lead to the destruction of the lung. Such a result comes under the category of phthisis, and will there- fore not be described in the present article. Pathology. — The inflammation of the bron- chial mucous membrane, which is invariablyasso- ciated with broncho-pneumonia, in the great ma joritv of cases precedes and is the principal caus* of the pneumonic process. In exceptional case it. would appear probable that the same injur; which produces the bronchial inflammation pro duces at tho same time the inflammation of th air-vesicles. Inflammation of the bronchial mu cous membrane may give rise to broncho-pneu monia in two ways — ( 1 ) By causing, in the firs place, collapse of the lung-tissue ; and (2) by th direct extension of the inflammation from th bronchi to the air-vesicles. The pneumonic pr< cess being the result of the bronchitis almo: invariably involves simultaneously both lungs. 1. Broncho-pneumonia consecutive to collajt Collapse cf the lung-tissue greatly favours tl occurrence of broncho-pneumonia, and usual tho pneumonic process is principally confined those portions of the lung in which collapse h taken place. This is particularly the case young children. Although it would be beyo the scope of the piresent article to discuss length the relation which subsists betwe bronchial catarrh and pulmonary collapse, t mode of production of the latter may be brie indicated. There tire two circumstances prin pally concerned in the production of the collap LUNGS, INFLAMMATION OF. which is consecutivo to bronchitis— the narrow- ing of the bronchial tubes, and the weakness of the inspiratory power. The mucous membrane of the bronchi becomes considerably swollen as the result of the inflammatory process, often being thrown into folds ; and its surface is covered with thick tenacious mucus. These conditions may cause so much narrowing of the smaller tubes as to render the entrance of air exceedingly difficult, and they may even completelyprevent it. In addition to the bronchial narrowing the power of inflating the lungs is usually diminished. This is due partly to tne general debility which so often exists prior to the bronchitis, and partly to the damage to the respiratory muscles caused by the febrile process. The superficial charac- ter of the respiration due to the fever also aids in the production of the collapse, as does also any weakness of the osseous structures of the thorax, such as exists in rickets. The collapse thus induced is especially frequent in the pos- terior and inferior portions of the lungs — those portions in which normally the inflation of the lung is the least complete. Commencing here the process may gradually extend upwards till large areas of both lungs become involved. In Other cases, owing to a more irregular distribu- tion of the bronchial obstruction, the collapse is limited to small isolated portions of the lung. These portions vary in size from a hemp-seed to i walnut. They are commonly more or less wedge-shaped, with their apices towards the jronchus leading to the group of collapsed obules ; and the lung-tissue around them usually Presents various degrees of congestion and em- thysema. The tendency of the pneumonic process to iccur in the collapsed portions of the lung is lue partly to the hypersemia which is induced >y the collapse, and partly to the irritation of nhaled bronchial secretion. Collapse of the ung-tissue invariably induces more or less con- estion. This is owing to the absence of the ex- ansion and contraction of the air-vesicles, which ormallyaid the pulmonary circulation, and also 3 the impediment to the blood-flow resulting ■om imperfect aeration. This congestion is uickly followed by oedema, and the bluish- urple collapsed portions of the lung become eeper in colour, less resistant, and more friable i consistence. In lung-tissue thus altered an iflammatory process, characterised partly by nidation and partly by epithelial activity, is •one to supervene. Another circumstance which often appears to ay a prominent part in the causation of the leumonie process, is the presence within the reoli of the inflammatory products cf the onehial mucous membrane. Such products are | squently found in the lungs in cases of broncho- eumonia. They occur in scattered groups of ■-vesicles, and are evidently inhaled. They are ind both in the air-containing and in the coi- ned portions of the lung, but especially in the ter, the presence of collapse necessarily inter- ing with their removal by expectoration or ab- ption. These inhaled products are often found ing small groups of alveoli without any evi- ' ice of sv.bsiquent inflammation, and there can 1 no doubt that many of the patches of consoli- 887 dation which are usually described as pneumonic are in reality non-inflammatory in their nature, and are thus produced. At the same time, owing to the irritation of the inhaled secretion, it tends to induce inflammatory changes within the alveoli, and these changes are frequently largely owing to its presence. Juergensen accounts for the pneumonic process occurring in isolated spots in the collapsed lung by regarding the inflam- mation as being determined by the inhaled bron- chial secretion. 2. Broncho-pneumonia independent of collapse . Although the pneumonic process is usually con- secutive to collapse it may occur independently. This maybe owing either to the direct extension of the inflammation from the bronchi to the air- vesicles, or to the influence of inflammatory pro- ducts inhaled from the bronchi. In other cases it is possible that the injury which causes the bronchitis causes at the same time the inflam- mation of the pulmonary alveoli. Symptoms. — The symptoms of broncho-pueu monia are, to a great extent, those of capillary bronchitis. They vary according to the severity of the bronchitis, aod according as this is asso- ciated or not with other disease. In the severe forms of capillary bronchitis of childhood, and in that associated with measles, the implication of the lung usually gives rise to early and marked symptoms, and the disease runs a comparatively acute course. In the less severe forms of bronchial catarrh, on the other hand, and in that associated with whooping-cougli, the supervention of a pneumonic process commonly occurs later; the symptoms are less pronounced; ami the course of the disease is much more chronic. Although various gradations are met with between these more acute and the chronic forms, it will be advisable, for the sake of de- scription, to consider them separately. Acute hroncho-pncumonia — The more acute forms of broncho-pneumonia occur especially as a complication of measles, and in the simple capillary bronchitis of childhood. In measles the pneumonic process commonly supervenes towards the end of the first, or beginning of the second week, but it may be much later. The early symptoms are those of severe catarrh of the smaller bronchi — pyrexia, fre- quent cough, accelerated respiration, slight action of the nares, &c. Such symptoms precede, for a varying length of time, those clue to the implication of the lung-tissue. The earliest symptoms of the pneumonic process are by no means well-defined, and consequently the time at which the lung becomes involved cannot be fixed with certainty. Rigors and vomiting are but rarely observed. Usually an increase in the acceleration of the respiration, or in the dyspnoea, are the first signs of the pulmonary implication. The breathing becomes very rapid, and commonly causes much distress, the child tossing about and being ex- ceedingly restless. This dyspnoea is more marked at some times than at others, and is occasionally more or less distinctly paroxysmal. The respiration is superficial, inspiration being short, and the expansion of the thorax imper- fect. There is marked action of the accessory respiratory muscles, and the upper portions ri 388 LUNGS, INFLAMMATION OF. the thorax are raised, whilst the lower are retracted during the inspiratory act ; the action of the nares is very pronounced. An increase in the pyrexia which attended the pre-existing bronchitis is, with few excep- tions, observed as the lungs become involved, and such increase is to he regarded as one of the most valuable indications of the existence of a pneumonic process. The maximum temperature af acute simple bronchitis is seldom higher than 102°Fahr., whereas that of the secondary pneumonic process is often 10f° or 105°. This i ncrease usually occurs more or less gradually ; — there is rarely the sudden rise of temperature met with in acute pneumonia. Unlike the temperature of this disease also, the fever of broncho-pneumonia runs no definite course. It varies with the extent of the lung-implication, and with the rapidity with which this implication is effected. There is no regular diurnal variation; the remissions and exacerbations are often con- siderable ; and they occur at irregular times, the temperature being sometimes higher in the morning than at night. The cough, which beforo the implication of the lung was paroxysmal in character, gradually becomes less and less so, and it now often causes much pain to the pa- tient. The sputa are bronchitic in character, usually very tenacious, and occasionally streaked with blood; as, however, expectoration rarely occurs in the child, they are not often seen. The pulse is much increased in frequency, in children under five years often being 150. It may in the earliest stage of the disease be moderately full and strong, but it quickly becomes soft, small, and feeble. In addition to the above, there are often symptoms referable to the digestive organs. Of these diarrhoea is the most important. This is quite frequent, especially when the disease follows measles. It is very readily induced by medicines and by improper feeding; and as it greatly weakens the patient, it is important that this liability to it should be kept in mind. Vomiting, as already stated, is very rare as an initial symptom ; it is, however, common in the course of the disease, especially as a result of cough, the bronchial secretion, together with the contents of the stomach, often being expelled. As the implication of the lungs increases, the breathing becomes still more rapid and super- ficial ; the dyspnoea is more marked ; the expres- sion is auxious ; the face is pale ; and symptoms of carbonic-acid-poisoning become evident. Strength now fails; the face and lips become cyanotic; and the extreme restlessness ' gives place to apathy and a semi-comatose condition, which is interrupted from time to time by in- effectual efforts to cough. With the rapid failure of strength and increasing cyanosis, cough almost ceases ; the pulse becomes exceed- ingly feeble; and the child, often extremely emaciated, may die exhausted, and in a condition of more or less profound coma. Sometimes death occurs suddenly during a paroxysm of cough, or with convulsions. Chronic broncho-pneumonia . — The symptoms of the more chronic forms of broncho-pneu- monia, such as occur especially after whooping- cough, and also after bronchial catarrh of mo- derate severity, differ somewhat from those of the acute disease. The pneumonic process com- monly supervenes later, and the course of the disease is much more protracted. As in the acute forms, pyrexia and increased frequency of respiration are the earliest indications of" the pulmonary implication. In these cases, how- ever, there is usually but little if aDy fever prior to the pneumonia ; it comes on very gradually ; and the maximum temperature is much lower than iu the more acute forms, commonly not being more than 102°Fahr. The course oftho pyrexia also is still more irregular, lengthened periods of very slight fever being interrupted from time to time by slight exacerbations. Loss of appetite, great emaciation, increasing diffi- culty of breathing, and loss of strength, charac- terise the disease. Such symptoms may con- tinue for months, and the child ultimately die or recover with more or less damaged lungs. AVhen broncho-pneumonia occurs in adults and in the aged, the symptoms are for the most part much less pronounced than in the child. In strong adults the disease is perhaps most common after diphtheria, and here the pulmonary symptoms may be well-marked ; but in the debili- tated, and especially in the old, the course of the disease is much more latent, very slight pyrexia (100° Fahr.), slight cough and dyspnoea, and marked debility being the principal symptoms observable. In the aged and feeble, broncho-pneumonia is very frequently associated with that form of lung-consolidation which results from weak in- spiratory power, feeble circulation, and gravita- tion (hypostatic pneumonia). It has already been stated that this consolidation, which con- sists mainly of collapse, hyperaemia, and oedema of the lung-tissue, favours a catarrhal swelling and proliferation of the alveolar epithelium. Hypostatic consolidation may exist quite inde- pendently of bronchial catarrh ; but when such catarrh occurs in the aged and feeble, gravita- tion often determines the supervention of tile pneumonic process, which under such circum- stances is consequently not infrequently unila- teral. When the more acute varieties of broncho- pneumonia terminate fatally, they usually do go from the tenth to the fourteenth day of the disease. Death, unlike that from acute pneumonia, is mainly due to the interference with the respiratory function and, to a much less extent, to failure of cardiac power (Juergen- sen). The interference with the respiration if much greater than in acute pneumonia, for, in addition to the diminution of the respirator! area, due to the pulmonary consolidation anc collapse, there is the much more -importan cause of interference — namely, the impedimen to the entrance of air, caused by the swelling o the bronchial mucous membrane, and the aceu mulation of secretion in the bronchial tubes These interferences with respiration necessitat increased action of the respiratory muscles; bu with the progress of the disease these muscle become weakened, partly by the fever, and parti from the imperfect supply of oxygen. With thi failure of respiratory power the incompletencs of oxygenation necessarily increases, until th supply of oxygen may become so small as te lea LUNGS. INFLAMMATION OF. to complete muscular paralysis. The damage to the heart, as in acute pneumonia, is due partly to the diminished respiratory area, and partly to the fever; but this damage is a much less im- portant element in the causation of dissolution m broncho-pneumonia, than it is in the general disease. (Juergensen). In chronic broncho- pneumonia death may not occur for some months, and then it results as much from general failure of strength as from interference with the respi- ratory function. When the disease does not terminate in death, improvement in the symptoms is always gra- dual. The temperature falls slowly, several days, and occasionally some weeks, being occu- pied in the completion of defervescence; and this gradual decline is usually interrupted by more or less marked and frequent exacerba- tions and remissions of the fever. The cough and dyspnoea diminish, and the appotite gradu- ally returns ; but restoration to health is always protracted ; and the child remains for some time especially liable to repetition of the bronchial symptoms. Sometimes recovery from the broncho-pneumo- Jnia is not complete, andthe disease leads to indu- ration of the lung, dilatation of the bronchi, &c. ? (see Chronic Pneumonia). Emphysema and acute tuberculosis are occasional sequelae. That the disease sometimes terminates in phthisis, espe- cially in children and in those who inherit weak ungs, appears to the writer to be indisputable. Physical signs . — The physical signs of broncho- ineumonia are in the main those of capillary bronchitis. Imperfect expansion of the thorax, deration of the upper portions, and recession if the lower, during the inspiratory act ; moist jiud dry rales, audible over both sides ; and the ibsence of any marked alterations in perctission- esonance, are the principal signs observable, not nly in the earlier stages, but throughout the (thole course of the disease. The recession of he chest-walls is increased by collapse. The iaporvention of the pulmonary implication is lidicated rather by the symptoms — increase in te pyrexia and in the dyspnoea — than by any larked alteration in tho physical signs. The iffieulty of detecting the lung-consolidation is ne to its usually being limited, in the earlier ages, at all events, to small areas, which are irrounded by healthy or emphysematous lung, ' that resonance on percussion is but little im- lired. It is only when these small areas have lalesced into larger areas of consolidation, that y marked alterations in percussion-resonance ie discoverable. The impaired resonance due to lapse is not to be distinguished from that duo pneumonic consolidation ; and, inasmuch as the llapse is so often symmetrical, involving both ;=>es posteriorly, the difficulty of appreciating is increased. Much more valuable aid in ysical diagnosis is in most cases to be ob- ned from auscultation. Over those portions the lung where consolidation has taken place ' moist bronchitic rules tend to assume a some- at metallic quality; they also becomo finer, mgh not so fine as true pneumonic crepitation ; 1 1 they are more superficial. The detection of 1 so superficial, somewhat metallic fine moist 1 heard with inspiration, and often with 889 expiration, over small areas of the lungs, is a most valuable and often the only physical sign of the pulmonary implication. If large areas become consolidated, there is, in addition to this, some impairment of rosonance on percussion. Complications. — These are few. It is scarcely necessary again to state that bronchial catarrh is always present. Pleurisy is less common than in acute pneumonia. Slight inflammation of the pleura is, however, usually found post mortem , over those portions of the lung which are con- solidated. Pleuritic effusion is rare. Intestinal catarrh is a very important and common com- plication. Tho liability to this in the child, and the mechanical congestion resulting from tho ob- structed pulmonary circulation, must be borne in mind in explaining its frequency. Convulsions occasionally occur, and are of un- favourable augury. The nervous phenomena in some few cases have been described as simulating those of tubercular meningitis. Catarrhal laryn- gitis, associated with much spasm and laryngeal stenosis, is sometimes observed, especially after measles. Diagnosis. — The diagnosis of broncho-pneu- monia is occasionally difficult. This difficulty is mainly owing to the co-existence of capil- lary bronchitis. The recognition of the pulmo- nary implication in its earlier stages is often impossible. The increase in the pyrexia, and in the frequency of respiration, are the symptoms of the most diagnostic value. Owing to the small areas of lung involved, any alteration in the physical signs of tho capillary bronchitis may be entirely wanting. The occurrence of exten- sive collapse in the earlier stages gives more marked physical signs of consolidation, and hence renders the diagnosis more easy. It is almost impossible to diagnose certainly, either by symp- toms or by physical signs, between the collapse and the pneumonic consolidation. This, how- ever, is of but little practical importance, inas- much as the collapse is usually associated with, and often the immediate precursor of, the pneu- monic process. The diagnosis of broncho-pneumonia from the pulmonary consolidation of acute pneumonia may occasionally be difficult in the later stages of the former, when an extensive area of the lung has become consolidated. The history of the case, and especially the course of the pyrexia, will usually suffice to distinguish them. The distinction from acute tuberculosis some- times presents much difficulty, as does also the recognition of tuborculosis and phthisis as an occasional result of the disease. A careful con- sideration of the earlier symptoms, and the ex- istence or not of marked predisposition, are here most important. Slight and irregular pyrexia, existing before the supervention of lung-symp- toms, is greatly in favour of tuberculosis. In some cases, however, tbe phenomena of these diseases are so analogous that a certain diagnosis is impossible. Prognosis. — Broncho-pneumonia is much more dangerous than the acute primary disease, and the mortality from it is much greater. The more chronic forms are more fatal than the acute. Tho two circumstances which have an especial influence upon prognosis are the age oi 390 LUNGS, INFLAMMATION OF. the patient, and the general health. Before puberty, the younger the patient the graver the prognosis. In children under five years, the mortality is exeeedintrly great (probably about 20 per cent.) I'he disease is also especially fatal in weakly children, and in all those who are constitutionally feeble, or debilitated by previous illness. The existence of rickets materially in- creases the gravity of prognosis. The daDger also increases greatly with the extent of lung involved, much more so than is the case in acute pneumonia Of the value of the several symp- toms as influencing prognosis, alter the descrip- tion which has been given of the disease and of the modes in which it tends to cause death, it is hardly necessary to speak further. Symptoms of imperfect aeration of the blood are those most to be feared. Treatment. — In the treatment of broncho- pneumonia, it is important to bear in mind: — 1st, that the disease is invariably associated with, and is in the main induced by bronchial catarrh, and by its so frequently attendant col- lapse ; 2ndly, that its occurrence is especially favoured by everything that weakens the patient ; and 3riily, that it tends to destroy life prin- cipally by interfering with the function of respi- ration, which interference necessarily increases with the consequent weakening of the respira- tory power. Such being the facts, it is obvious that the main object of treatment will be, first, to control bronchial catarrh, and endeavour so to modify it as to prevent the occurrence of collapse; and, secondly, to support as much as possible tho strength of the patient, with the object of preventing not only collapse, but also that increased interference with the function of respiration which results from weakening of the respiratoiv muscles. It wonfd be out of place in the present ar- ticle to enter into a detailed description of the management of acute bronchitis (stc Bronchi, Diseases of). It will be sufficient to indicate the more important means of controlling the dis- ease, with especial reference to the prevention of the so frequently attendant collapse. The patient should be kept in a warm room, the temperature of which should never be allowed to fall below 60° Falir. The room should be well, but carefully ventilated ; and protection from draughts is important, much more so than in the treatment of aeuto pneu- monia. It is also advisable to keep the air moist by means of a steam kettle, as the exhalation of water from the lungs is thus diminished, and the bronchial secretion consequently ren- dered less tenacious, and more easily removed by cough. The diet, which must be regulated according to the age of the patient, should be nutritious and easily digestible, the importance of supporting the strength being kept in mind. When the disease follows measles, the liabi- lity to gastro-intostinal catarrh must not be for- gotten. Small doses of ipecacuanha with salines should be administered frequently. The chest should be enveloped in lightly made linseed and mustard poultices ; or, what in the case of very young children answers better, it should be rubbed three or four times daily with some Stimulating liniment, and kept wrapped in cotton- wool covered with oil-silk. When the secretion in the tubes is abundant, its removal may be much aided by small doees of carbonate of ammonia. This may be either combined with the ipecacuanha and saline mixture, or given separately in a little milk. Sen ga, as an in- fusion, and chloride of ammonium may also be given with the same object. The last-named drug appears to have the effect Dot only of rendering the secretion less tenacious and more easily removable, but also of diminishing its formation. An occasional emetic dose of ipeca- cuanha often materially relieves the patient, when numerous rales audible over the chest, and increased dyspnoea, indicate an accumula- tion of the secretion. This, however, must not be given when there is marked exhaustion present. The exhibition of opiates is as a rule contraindicated. When the cough is feeble, and the secretion abundant, they do much harm. In the more chronic forms of the disease, however, and especially when following whooping-cough, where the cough is often violent, and there is but little bronchial secretion, opiates may he cautiously given with advantage, as may alto bromide of ammonium. With the object of reducing the temperature, and also of increasing the expansion of the lungs, much may be done by the external applica- tion of cold. This method of treatment appears to be especially valuable in increasing the depth and force of respiration, and thus in preventing the occurrence of collapse. Its utility has been strongly advocated by both Bartels and Ziemssee. The method recommended by these physicians consists in the application of cold wet compresses round the chest, which treatment may he con- tinued from half to three or four hours. It is often necessary to repeat the application at intervals for some days, as the beneficial effect is only temporary. This treatment produces a marked reduction of the temperature, and also a diminution in the frequency, but an in- crease in the depth, of the respirations; the distress being thus considerably relieved, and the patient often falling into a sound sleep. Owing to the depression produced by the cold if too long continued, its effects require to be watched, and when symptoms of exhaustion appear, the cold should be discontinued, to be renewed again subsequently. Another method of treatment by cold is that recommended by Juergenscn, and considered by him very preferable to the preceding, as being more effectual and causing less discomfort. This is a treatment by baths and cold affusion. The child is first placed in a bath at a tem- perature of from 77° to SO 0 Falir. for twenty minutes; and then from 10 to 20 quarts of water at 36° Fahr. are to he quickly thrown over the hack and chest. This causes severed deep respirations, and thus is valuable in pre- venting collapse ; hut it appears to have less effect in reducing temperature than the treat- ment by cold compresses. Whilst these various means are being em ployed, it is all-important to support tin strength of the patient. Brandy is here mos valuable, and it is to he remembered tha: children hear stimulation well. The brandy if LUNGS, INFLAMMATION OF. test given in milk, the quantity being pro- portioned to the age of the patient. An infant may begin with from five to ten drops every two or three hours. Under its influence the pulse usually improves, the respirations become less frequent, and the distress and cyanosis diminish. The administration of brandy is usually advis- able before and during the treatment by cold. When prostration is extreme, or deglutition difficult, both the brandy and other nutriment may be administered by the rectum. In the chronic forms of broncho-pneumonia these more active methods of treatment are but rarely called for. Here attention to nutrition is most important, and small doses of cod-liver oil in the later stages, even before the complete disappearance of the pyrexia, are often useful. When the disease leads to induration of the lungs and dilatation of the bronchi, the treatment re- solves itself into that of chronic pneumonia. Convalescence, it must be remembered, is al- ways slow, and there is a tendency to relapse. Great care is consequently requisite during this period. All causes of catarrh must be carefully guarded against ; and the restoration to health assisted by nutritious diet, cod-liver oil, and iron. A change of air is especially valuable. D. Chronic Pneumonia.— Synon. : Chronic Inflammation of the Lungs ; Cirrhosis of the Lung; Fr. Pneumonic interstitielle ; Ger. Lun- jencirrhose. Definition.— Chronic pneumonia is a compa- ratively rare disease, characterised by a gradual increase in the connective tissue of the lung, which leads to an induration of the pulmonary texture, and to progressive obliteration of the alveolar cavities. It is commonly associated with catarrh and dilatation of the bronchi, and often with ulceration of the bronchial walls, and excavation of the indurated lung. Cough, ex- pectoration — often abundant, but varying with the bronchial catarrh — -dyspnoea, gradual impair- ment of nutrition, and occasional accessions of slight pyrexia, are the most prominent clinical phenomena accompanying the disease, which runs an exceedingly chronic course, often subject to long periods of quiescence, but tending to terminate fatally in from five to fifteen years. Chronic pneumonia is also known as intersti- tial pneumonia. In its most marked form it constitutes the disease which received from Cor- rigan the name of cirrhosis. The term ‘ fibroid phthisis,’ which is sometimes applied to it, is iltogether inapplicable. ./Etiology and Pathology. — It is exceed- ngly doubtful if chronic pneumonia is ever a irimary aud independent disease. It probably n all cases owes its origin to some antecedent nflammation of the pulmonary or bronchial extures, or of the pleura. It may be stated generally that all inflammatory processes in the ungs, as in other organs, which become chronic, cad to an increase of the connective-tissue ele- ments, and consequently to fibroid induration f the organ. In the lungs by far the most . ommon cause of such induration is pulmonary hthisis. In all cases of phthisis, excepting hose which are the most acute, there is more r less fibroid growth; and the extent of this 891 growth is, for the most part, in direct propor- tion to the ehronicity of the disease. Those forms of phthisis which are the most chronic, and in which the fibrosis reaches its maximum, have been termed ‘fibroid phthisis.’ The most chronic cases of phthisis are, it must be ad- mitted, somewhat closely allied to some forms of chronic pneumonia. The two diseases, how- ever, differ pathologically in this respect — that whereas much of the pulmonary consolidation of phthisis tends to undergo molecular death and disintegration, that of chronic pneumonia exhibits no such tendency ; but any destruction and excavation of the indurated lung which may take place, is due to secondaiy inflammation and ulceration commencing in the bronchial walls. In considering the pathology of chronic pneu- monia, therefore, it is necessary to exclude in the first place the pulmonary induration of phthisis. Chronic pneumonia must also be separated from that form of pulmonary induration which is produced by long-continued mechanical conges- tion, namely, brown induration; and from those more localised indurations due to bronchitis, peri-bronchitis, old infarctions, and syphilis. There appear to be four conditions which may give rise to chronic pneumonia, namely: — 1. Acute pneumonia. 2. Broncho-pneumonia. 3. Pleurisy. 4. The inhalation of irritating par- ticles of solid matter. Each of these must be considered separately. 1. Acute pneumonia . — Chronic pneumonia is an occasional, though quite rare, result of the acute primary disease. The pulmonary consoli dation of acute pneumonia almost invariably undergoes complete resolution. This resolution is usually effected rapidly, in from seven to fourteen days. Occasionally, however, the course of the disease is more protracted, and the con- solidation persists beyond the third week. When thus protracted, the hepatissd lung tends to be- come slightly indurated, owing mainly to thick- ening of the walls of the alveoli. This indurated hepatisation differs but little in its physical cha- racters from ordinary red and grey hepatisation ; it is simply somewhat firmer and more resistant. In very exceptional cases this small amount of induration commencing in the alveolar walls may gradually increase, so as ultimately to give rise to that extensive fibrosis of the lung which con- stitutes what is known as chronic pneumonia. 2. Brmicho-pneumonia. — Broncho-pneumonia appears to be a somewhat more frequent cause of the disease than the preceding (Wilson Fox). The greater liability of this form of pneumonia to lead to pulmonary induration is to ho ac- counted for partly by its longer duration and greater tendency to become chronic, and partly by the existence of bronchial dilatation with which it is so frequently associated. That bronchial dilatation is favourable to an in- durative pneumonic process has been espe- cially insisted upon by Dr. Wilson Fox. Dila- tation of the bronchi is exceed ugly common in the simple bronchitis of childhood, and espe- cially in that associated with whcoping-cough and measles ; it is also a direct result of pul- monary fibrosis. In whatever way originating, its existence favours the persistence of tha catarrhal and pneumonic processes. The removal LUNGS, INFLAMMATION OF. S92 of secretion is rendered more difficult ; the retained secretion tends to increase and keep up the irritative process, both in the dilated bronchi and also in the pulmonary alveoli ; and this persistence of the bronchial and pulmonary inflammation leads to fibroid thickening of the bronchial and alveolar walls. In this way more or less disseminated patches of indurative con- solidation are produced, which as the process proceeds gradually increase, so that ultimately they may involve large areas of the lung. The progressive tendency of the process is probably partly to be explained by the fact, already stated, that pulmonary fibrosis is a cause of bronchial dilatation, so that fibrosis once esta- blished, by inducing further dilatation of the bronchi, favours the extension of the bronchial and pulmonary inflammation. 3. Pleurisy . — Pleurisy in very exceptional cases leads to the development of a chronic pneumonia. It appears to be in those cases of pleurisy which are more or less chronic, and in which the lung remains long collapsed from the effusion, that such a result is most liable to oc- cur. The induration of the lung thus induced is often, however, exceedingly partial, consist- ing merely in some increase of the interlobular connective tissue originating and extending in- wards as dense bands from the thickened vis- ceral pleura. In other cases pleurisy probably gives rise to a much more general fibrosis. -1. Inhalation . — The inhalation of irritating particles, such as occurs in the trades of miners, potters, stone-masons, grinders, &e., is the cause of the fibrosis of the lungs common amongst persons so employed. The continuous irritation of the inhaled particles induces a bronchial and alveolar inflammation, and ultimately fibrous growth in the bronchial and alveolar walls, which, gradually extending, may involve large areas or even the whole of the lungs. Anatomical CiiAHACTEns. — The histological changes met with in the lungs in chronic pneu- monia may be described generally as consisting in the development of a fibro-nucleated tissue from the walls of the alveoli, from those of the bronchi, and from the interlobular connective tissue ; which new growth, as it increases, and from its tendency to contract, gradually replaces and obliterates the alveolar structure. The character of these changes, however, varies somewhat according to the inflammatory ante- cedents in which they originate. When chronic pneumonia is the result of acute pneumonia, the principal change takes place in the walls of the alveoli. These become thickened by the growth of a small-celled tissue, in which, associated with the spheroidal cellular elements, there are sometimes elongated fusiform cells, such as are found in embryonic tissue which is in process of forming a fibrous structure. This new growth, in its earlier stages, usually contains new blood- vessels ; but later the tissue contracts, and the vessels become to a great extent obliterated. The growth differs from the non- vascular growth rf phthisis, inasmuch as it has but little ten- iency to undergo molecular death and disin- tegration. The alveolar cavities, where not obliterated, are either empty, or contain exuda- li on-products and a few epithelial cells. When secondary to ordinary broncho-pneu. monia, or to that induced by the inhalation of irritating particles, the new fibroid growth also originates principally from the alveolar walk. Here, however, the growth in the earlier stages is less uniform, and the peri-bronchial and inter- lobular connective tissues play a more promi- nent part in the process. The new peri-bronchial tissue invades the walls of the adjacent alveoli, and materially increases the fibrosis. In the chronic pneumonia resulting from pleurisy, the change, as already stated, Is often more localised, consisting in the development of dense fibreus bands passing inwards from the thickened pleura. Those are developed from the interlobular tissue. In other cases the fibrosis is more general. In whichever of the pulmonary structures the new fibroid growth originates, as it increases, all the connective tissue of the lung may become involved, and the alveolar cavities be completely obliterated. The new growth, like that met with in the inflammatory indurations of other organs, although in the earlier stages of its develop- ment it may be richly cellular and contain new blood-vessels, tends gradually to become less cellular, denser, and more contractile. In its more advanced state it often consists either of closely packed wavy fibres, or more frequently of a dense homogeneous or obscurely fibrillated material, associated with which are a few s mal l round or fusiform cells. Sometimes the new growth is found richly cellular, even in the most advanced stages of the disease. The macroscopical appearances of the lung vary with the extent of the fibroid change. In the earliest stages of the induration resulting from acute pneumonia, where there is merely a slight thickening of the walls of the alveoli, the consolidation very much resembles that of red or grey hepatisation. It differs in being firmer and less friable in consistence, and is somewhat less granular. In the later stages, and in all cases where the fibrosis is extensive and general, the lung is diminished in size, den-e. firm, fibrous, and even cartilaginous in consistence. The cut surface is smooth ; and the large amount of irregularly distributed black-pigment usually present, gives to it a peculiar grey, marbled appearance. Numerous dilated bronchi traverse it in all directions. When the disease is secondary to broncho- pneumonia the fibrosis in the earlier stages is much less general, as it usually is also when the result of pleurisy. Sometimes dense tracts of fibrous tissue are found intersecting the lung in various directions. As the disease advances, however, a large area, or even the whole lung, may become involved. The bronchi are almost invariably found dilated in those portions of the lung where the induration is advanced. In some cases some dilatation of the tubes is observed in parts which are not involved in the induration. This dilatation is often very considerable, and the dilated tubes sometimes form large cavities, which may occupy a large portion of the indu- rated lung. The walls of the tubes are much thickened, and the mucous membrane is olten ulcerated. This secondary inflammation and LUNGS, INFLAMMATION OF. olceration of the bronchi occurs especially in the dilated portions, and it appears here to be induced by the irritation of the retained and putrid secretion. It may extend into and in- volve the indurated lung, and so lead to more or less excavation. The mucous membrane some- times sloughs, and the gangrenous process may involve ths lung. The large cavities so common in these lungs are in the main, however, dilated bronchi. See Bronchi, Diseases of. The pleura of the affected lung, except in the earliest stages of the disease, is much thickened and adherent. Site . — Chronic pneumonia is in the majority of cases unilateral. The whole lung may be involved or only a portion. In the latter case the base is much more commonly affected than the apex. When due to the inhalation of irri- tating solid particles, both lungs are usually im- plicated. Symptoms. — In the earlier stages of chronic pneumonia the symptoms are often very obscure, and it is not uncommon to meet with advanced aud extensive fibrosis in which the lung-affection must presumably have been of much longer duration than the symptoms accompanying it. In some cases the symptoms are directly con- tinuous with those of some more acute pulmo- nary inflammation — an acute or a broncho- pneumonia. Under these circumstances a pro- longation of some of the phenomena of the original disease indicates the supervention of the pulmonary fibrosis. The pyrexia does not entirely disappear. There may be merely slight elevation of temperature towards evening, or the course of the fever may be very irregular. The cough usually persists, as does also some increase in tho frequency of the respiration and pulse; and the patient, instead of improving, gradually loses strength and flesh. At the same time the physical signs of the pulmonary consolidation remain, and gradually give place to those of pulmonary induration. Where thronic pneumonia is secondary to pleurisy, a ;ontinuous sequence in the symptoms is less commonly observed. When the result of the nhalation of irritating solid particles, thesymp- ■oms of bronchial catarrh are predominant. When the fibrosis is fully established the ymptoms are usually more pronounced. They •ary considerably, however, according to the xtent of the lung involved, the quiescence or ctivity of the indurating process, and the pre- ence or absence of bronchial catarrh. When ronchial catarrh is absent, and the disease is erfectly quiescent, a considerable area, or even he whole of the lung, may be involved without roducing any marked pulmonary symptoms, ad slight dyspnoea, with some general impair- ment of nutrition and failure of strength, may be most the only phenomena present. Such qui- cence and immunity from symptoms, however, though common in the course of the disease, rarely observed over very lengthened periods. With the existence of catarrh of the bronchi, ueh more marked symptoms are observable, fiammation of the bronchi is especially fa- ured by the dilatation of the tubes, and it is Most invariably present, to a greater or less tent, during the course of the disease ; with it S93 is usually associated activity of the indurating process. The dilatation of the bronchi and secondary ulceration of their walls, which are so frequent, are also most important factors in accounting for the symptoms. The courso of the disease now often simulates that of chronic phthisis, but it is for the most part more chronic, less regularly progressive, aud more frequently interrupted by periods of quiescence. The dyspnoea is now more marked, and cough be- comes a troublesome symptom. The cough may be more or less constant, and it is usually at- tended by expectoration. Its characters vary, however, according to the extent of bronchial dilatation and excavation. Wlien there are numerous dilated bronchi in the lower portions of the lung, the secretion accumulates within them, and its removal by expectoration becomes exceedingly difficult. Under these circumstances the cough is violent and paroxysmal. The patient may remain for several hours with but little or no cough, and then occurs a violent paroxysm, which results in the expectoration of large quantities of muco-purulent secretion. This violent paroxysmal cough and copious expectora- tion, occurring at long intervals, are exceedingly characteristic of bronchial dilatation in the lower portion of a lung. According to Niemeyer, the paroxysm occurs when the secretion which accu- mulates in the lower portions of the lung reaches and irritates the more healthy bronchi which retain their sensibility, the dilated tubes being so altered as to be completely insensible. The sputum may be simply puriform, but when there is much bronchial dilatation, owing to its accu- mulation and retention in the tubes, it usually undergoes putrefaction. It then often has a greyish or greenish-black colour, and is usually more or less feetid. This feetor exists quite independently of gangrene, although it is more marked when gangrene is present. Haemoptysis is not unfrequent, but it is usually small in quantity. It is probably in most cases due to ulceration of the bronchial walls. Pyrexia is usually present to a greater or less extent in the course of the disease. The fever, however, is exceedingly irregular, and there are often long periods of perfect immunity. During the pyrexial periods the maximum evening tem- perature is rarely more than 101° or 102° Fahr., and it may be only 100°. The morning tempe- rature is often normal. The pyrexia appears in most cases to be due to inflammation and ulcera- tion of the bronchi, and to the activity of the indurating process. With the progress of the disease the patient gradually emaciates. The digestion becomes impaired, and diarrhoea is often present. Dropsy is a common symptom, although it is rarely ex- tensive, and is, for the most part, confined to the lower extremities. It appears in most cases to be due to the anaemia and impeded pulmonary cir- culation. The pulmonary obstruction may also give rise to some enlargement of the right side of the heart, and cyanosis. Lardaeeous disease of the viscera is occasionally met with. Death usually results from the general failure of strength, or from some intercurrent affection nf the opposite lung. Physical signs. — In the earliest stage of 304 LUNGS. INFLAMMATION OF. chronic pneumonia, when it is the result of a more acute pneumonic process, the physical signs are, in the main, those met with during the acute consolidation. It is the persistence of the signs of the pulmonary consolidation after the acute attack which indicates the possibility that the disease may become chronic. Dulness on percussion ; increased vocal fremitus ; bron- chial breathing; and the existence of rales, which are larger, moister, and more metallic in quality than those of fine crepitation, are ob- servable during this stage. When the induration is fully established, the physical signs are those of contraction and consolidation, with usually those of more or less dilatation of the bronchi, of a whole or a portion of the lung. The re- traction is well-marked, and commonly affects the whole side, although when the lung is not universally involved it may be more limited. Expansion is exceedingly deficient, or com- pletely absent. The heart is much displaced towards the affected side ; the diaphragm and the abdominal viscera are drawn up ; and the opposite lung encroaches considerably across the middle line in front. Percussion is hard, wooden, and high-pitched, sometimes more or less amphoric. The vocal fremitus is usually increased ; and there is often bronchophony or pectoriloquy. The respiratory sounds will vary according to the extent of the bronchial dilata- tion and excavation, and the amount of secretion. They are for the most part bronchial; usually large and loud ; and often distinctly cavernous. When there is much secretion in the dilated bronchi, high-pitched bubbling rales are heard, which are often amphoric and cavernous. These may be audible only after cough. The opposite lung is usually hyper-resonant, and the respira- tion exaggerated. Diagnosis. — The diagnosis of chronic pneu- monia rests mainly on the physical signs. The diseases with which it is most liable to be con- founded are chronic phthisis, and retraction from pleurisy. In the most chronic forms of phthisis, where the fibrosis of the lung is con- siderable, the diagnosis from non-phthisical consolidation may present some difficulty. This difficulty, however, rarely exists except in those eases in which the chronic pneumonia involves only the upper portions of the lung. Here the situation of the consolidation is very greatly in favour of its phthisical nature. This proba- bility is infinitely increased if the other lung be affected. In unilateral basic disease, and in induration of the whole of one lung, the other lung being healthy, the question of phthisis can rarely present itself. Disease of the larynx is in favour of the phthisical, fostidity of the sputa of the non-phthisical nature of the consolidation. The retraction resulting from pleurisy with effusion may also be occasionally confounded with chronic pneumonia. Here, however, there are rarely the physical signs of dilatation of the bronchi, and the vocal fremitus is more commonly diminished. The presence of abundant foetid sputa, of pyrexia, emaciation, &c., in chronic pneumonia will also in most cases render the diagnosis easy. Prognosis. — Chronic pneumonia, when it in- volves a considerable area of the lung, usually tends ultimately to terminate in death, although under favourable circumstances life may be pro- longed for many years. When the induration is more limited, and remains quiescent, the general health and duration of life may sometimes be but little affected. The most important element in the prognosis is the condition of the bronchi. The existence of bronchial inflammation, as evi- denced by profuse expectoration, is always un- favourable, as it not only weakens the patient, but is usually attended by extension of the in- duration, and ultimately leads, in the dilated tubes, to ulceration of the bronchial walls and surrounding tissue, and occasionally to gangrene. Pyrexia, as another evidence of inflammation of the bronchi and indurated lung, is likewise un- favourable, as is also haemoptysis. The latter indicates deep ulceration, and it may in excep- tional cases endanger life. The general condition of the patient must also be taken into account in making a prognosis. Failure of strength and of digestive power, diarrhoea, and dropsy, are all of unfavourable augury. Treatment. — In considering the treatment of chronic pneumonia, it is in the first place im- portant to bear in mind that the usual origin of the disease is some more acute pulmonary inflammation. Hence the necessity for the most careful management and supervision of such in- flammations in their later stages, with the object of procuring a complete resolution of the pneu- monic products. When the fibrosis of the lung is established, it is hardly necessary to remark that the new growth is incapable of removal, and by treat- ment we can only hope to influence the extension of the disease, and control the bronchial catarrh with which it is so frequently associated. The frequency and gravity of bronchial catarrh has been already insisted upon, and its management, in the majority of cases, constitutes the most important element in the treatment. In that class of cases in which the disease owes its origin to the inhalation of irritating particles of solid matter, the removal of the patient from the source of irritation is obviously called for. In the attempt to prevent and control bron- chial catarrh, the question of climate must ne- cessarily present itself, an4 very much may usually be done by residence at some suitable station. One not subject to vicissitudes of tem- perature, and at the same time dry and mode- rately bracing, is most likely to be beneficial. The patient should he warmly clad, and every- thing should be done, by means of diet and medicine, to improve the general health, inas- much as the better the state of nutrition, the less is the liability to bronchial inflammation. Cod-liver oil and iron are often useful for this purpose. If an attack of acute bronchial catarrh supervenes it should be treated at once, and the importance of quickly controlling it should not be forgotten. In the medicinal treatment of the more chronic catarrhal process, which is so often associated with profuse secretion, much may usually be gained by the use of inhalations, o which turpentine, creosote, iodine, and carbolu acid are, perhaps, the most generally useful These not only tend to diminish the amount o LUNGS. MALIGNANT DISEASE OF. 895 socrefion. bat induce coughing, and so assist in its evacuation. They also materially lessen fcetor. Turpentine may be administered inter- nally with the same object. When the cough is excessive and prevents sleep, opium and chloral are most valuable. Counter-irritation, especially inunctions with iodine, appear some- times to be serviceable. Gastric disturbance, diarrhoea, haemoptysis, &e., must be treated, as they arise, on general principles. T. Henry Green. LUNGS, Inflation of. — This term is used somewhat ambiguously. It is sometimes em- ployed as synonymous with emphysema in its general sense. More correctly it has been limited to that condition in which the lungs are acutely and temporarily distended more or le>s with air from various causes, such as plugging of the bronchial tubes, a condition which is usually called ‘acute emphysema.’ It cannot be said to give rise in itself -to any definite symp- toms ; but it can be made out by physical ex- amination, the signs being those indicating excess of air in the lungs. When this condition exists, the aim in treat- ment should be to get rid of any obstruction leading to the imprisonment of the air, and to help the lungs in expelling it. It must be remembered that, even after a considerable degree of distension, the lungs may return to their normal dimensions. Inflation is also a term applied to that expan- sion of the lungs with air, which is aimed at in the practice of artificial respiration. Frederick T. Roberts. LUNGS, Malformations of. — There are no malformations of the lungs which can 1 e re- garded as of much importance from a clinical point of view. As anatomical peculiarities, the shape of these organs, or the arrangement of their lobes, may be abnormal. In a case which came under the notice of tho writer, one of the lungs was improperly developed and unexpanded, in connection with the almost complete absence of one of the divisions of the pulmonarj - artery. The form of the lungs is frequently more or less altered, as the result of various organic diseases if these organs. Frederick T. Koberts. LUNGS, Malignant Disease of. — Synon. : i'r. Carcinome du Poumon ; Ger. Lungenkrebs. Definition. — Malignant disease affecting the mlmonary tissues. .(Etiology. — Malignant disease of the lungs is jf more frequent occurrence than was at one ime supposed. But there are not sufficient rustworthy statistics to enable us to determine s relative frequency to other forms of thoracic jrganic disease. It has been met with in per- ms of all ages, from childhood to extreme old ;e; but the middle periods of life, from ‘20 i 60, are the most liable; and the two sexes ■e about equally obnoxious to the disease. As primary disease, originating in the lungs, can- r is undoubtedly rare, though much less rare first manifesting its presence in those organs, jlhsr by local or general symptoms. In by far c larger number of eases the disease in the lgs is a secondary affection, consequent on the transmission of cancer-cells, or blastema, from other parts ; and in this way. with the exception of the liver, the lungs are more frequently im- plicated than any other internal organ. Thus, after the removal of an external cancer, pulmo- nary symptoms are among the most frequent and earliest indicate ns that the disease has in- vaded internal organs. Anatomical Characters. — The right lung has been considered to be more frequently affected with malignant disease than the left. This, however, does not accord with the writer’s experience. Of thirty-nine cases tabulated by him, the left lung was the principal seat in four- teen, and the right in nine only, whilst of the remainder either both lungs were affected, or the disease was confined to the mediastinum. Of the several varieties of cancer encephaloid is by far the most common in the lungs ; colloid and epithelioma are the rarest ; and scirrhus holds a middle place. The intermediate varieties of these leading forms are also occasionally seen. Symptoms and Diagnosis. — In proceeding now to describe the various aspects under which these several varieties are presented to the clinical observer, their natural history and diagnosis, it is not pr< posed to maintain any precise distinction between primary and secon- dary forms, nor to discuss the minute anatomy or general pathology of the several species, such questions h iving been considered in other parts of this work. The object of the writer is to treat the subject from a clinical p nnt of view. It is important, however, to observe, in limine, that cancer may either commence in, or eventually implicate any or all i f the pulmonary textures; although undoubtedly both the primary localisa- tion and the spread of the disease are influenced by the particular species. Both the early symp- toms and the subsequent progress of the case will often be materially nr dified bv the parlieular tissue that is mainly implicated. If the disease first manifests itself in ihe form of sui>-p!cural growths, both tho early symptoms and the sub- sequent phenomena will differ from those which present themselves when the disease commences in the deeper tissues of the lungs. And it is observable, that when the disease commences as disseminated deposits in the lungs, these depo- sits are frequently most numerous in the vicinity of the pleura, so that this membrane is very early implicated, in many cases, when it is net the primary seat of disease. For clinical purposes we cannot do better than divide intra-thoracic cancerous growths into three groups. 1. Where the disease is dissemi- nated through the lungs, either in the form of isolated scattered nodules of varying magnitude, or as spreading along the mucous membrane and sides of the bronchial rubes and vessels, through a greater or less extent of the lung. 2. Cases where the growth is more localised, occurring, tor the most part, in large masses. 3. Medias- tinal tumours involving the various stru turesat the root of the lungs, and eventually giving rise to symptoms of pressure and distress of a moro or less seiious character. 1. Disseminated Malignant Disease. — In the disseminated form of pulmonary cancer the symptoms vary considerably, according to the 896 LUNGS, MALIGNANT DISEASE OF. seat of the growths. When the pleural sur- face is chiefly implicated, both the symptoms and the physical signs are essentially those of pleurisy, though the degree of febrile dis- turbance is usually very slight, and but little or perhaps no false membrane may be effused. The exudation is generally clear serum, or serum mixed ■with blood; and it may have a greenish or brown colour, but is rarely purulent or even semi-purulent. As the effusion increases in amount, the ordinary consequences of compres- sion of the lung ensue, but dilatation of the side is generally much less marked than in simple pleurisy with effusion, in consequence of there being less giving way of the intercostals. The fluid generally returns speedily after paracen- tesis. When the mucous and submucous membranes of the bronchi and the surrounding connective tissue are the chief seats of the disease, the physical signs are those of bronchial irritation and emphysema, which, however, may, for some time, be quite disproportionate to the dyspnoea and other symptoms of ordinary bronchitis. The expectoration is, for the most part, scanty, and either simply mucous or mixed with blood ; or small bronchial casts may be expectorated. Examination with the microscope vyill occasion- ally reveal characteristic cancer-cells. The resonance of the chest may remain normal, when auscultation proves that there is a diminution of air entering the lung. But there will not be the hyper-resonance of emphysema. AVheezing and dry and moist sounds vary much with the amount of constriction of the tubes, and the amount and character of the secretion. But in advanced cases of this kind, by the spread of the disease along the interlobular septa and through the lung, its condition becomes similar to that of a cirrhotic lung, and the clinical aspects of the case may be greatly altered. Perhaps the most characteristic symptom of this class of cases is dyspncea insidiously increasing, especially on exertion, without corresponding symptoms of either congestion of lung or compression. Of the general symptoms the most characteristic is that of steadily-advancing debility, which is common to other forms of cancer. And it is from asthenia, or from general cachexia, that the patient usually dies, before much or any disintegration of tissue takes place. It is the scirrhous variety of cancer which most often Ihus follows and implicates the bronchi. In the distributive form, characterized by nu- merous masses, varying from the size of a millet- seed to that of a pea, scattered throughout the lungs, the clinical phenomena, both local and general, may very closely simulate those of tubercle, with recurrent attacks of bronchial irritation and congestion, and febrile disturb- ance. But as a rule, to which, however, some remarkable exceptions have been met with, there is little if any increase of temperature, nor is there the quickened breath and frequent dry cough of tubercle. The dyspncea is chiefly on exertion, and seems more due to feeble circula- tion and general debility than to either pulmon- ary disease or febrile disturbance. Indeed the absence of local signs of inflammation, or symp- toms of functional disturbance, are frequently remarkable. Signs of bronchial irritation in some of these cases have been early noted and prominent symptoms ; in others they have been slight and variable. The apices of the lungs, though often implicated, are not specially and early invaded as in tubercle, but rather the bases. If the cancerous growths are TaDidly developed and extensively distributed through the lungs, both the signs and general symptoms become greatly modified, and the case proves speedily fatal. The similarity to acute tuber- culosis is sometimes very close, especially in those instances in which there is marked febrile disturbance, and recurring slight haemoptysis. 2. Localised Malignant Disease. — The second class of cases of malignant disease of the lungs, in which the disease manifests itself in the form of isolated masses of larger size, is the most common. There may be one such tumour or several, at first assuming a rounded form, but as they gradually invade the luDg, acquiring an indefinite shape, and involving a large portion or even the whole of the lung. Such tumours, being most frequently of the encephaloid varie ties of malignant disease, often grow rapidly, and as rapidly disintegrate, giving rise to haemor rhage and destruction, not only of the mass itself, but also of the surrounding tissues. In this way vomicae may be formed, or portions of lung may become gangrenous. The symptoms and progress of these cases necessarily vary much. If the growth or growths have attained any considerable size, there is dulness on percussion, and an absence of respiratory murmur over the affected portion of lung. The presence and character of other physical signs depend very much on the patency or occlusion of the bronchi. When, as is often the case, these are completely occluded, nothing whatever may be detected on auscultation, aud all vocal fremitus may be absent ; the implicated portion being completely shut off from the rest of the lung, and from all communication with the trachea. If, however, the bronchi remain patent, or— as the result of breaking down of the cancer- ous mass — if communication with the larger bronchi lias been re-established, we have evi- dence of abundant secretion, and the ordinary phenomena associated with a cavity. In such circumstances microscopic examination of the expectorated matters may give decisive evidence of the nature of the case. On the other hand, before any such consequences have arisen, we may have in the case of a large tumour involv- ing the whole or the greater part of one lung, auscultatory signs which are witli difficulty dis- tinguishable from those of extensive pleuritic effusion. In other instances, where the portion of lung implicated in the cancerous growth is; limited and well-defined, the physical signs may so closely resemble those of phthisis as to lead astray the most expert. Thus we may have limited dulness on percussion, with absence of respiration ; followed by signs of surrounding irritation, slight haemoptysis, cough, expecto- ration, and indications of a cavity. In some rare instances there have been limited flattening and altered form of the chest-walls, such a; characterise chronic phthisis. Copious haemop- tysis, except in connection with extorsive >r less diminution of the amount of air in the ungs, as in cases of compression or collapso ; rom excess of the same, as in emphysema and ypertrophy; or from diseases which affect their tructure. The lung may also be displaced y the pressure of tumours, in addition to being impressed. The most important malposition c the lung, however, is that known as hernia, which a portion of the organ projects into the ;ck, or through some part of the chest-walls, through the diaphragm into the abdominal vity. If the hernia passes towards the surface the body, it may be made out clinically, being licated by a soft and compressible swelling, :alised, resonant on percussion, and rendered >re prominent by a cough. Pulmonary symp- qs might possibly be present. It is imprac- iblo to detect a hernia of the lungs through diaphragm. Frederick T. Roberts. TONGS, Morbid Growths in. — The for- i dons in the lungs which belong to the class < morbid growths may be thus enumerated, l the order of their importance : — 1. Tubercle. * Cancer. 3. Syphilitic gummata. 4. Hydatids, t Hare formations, such as sarcoma, enchon- 57 GROWTHS IN. , 897 droma, osteoid and myeloid growths, haema- toma, lymphatic formations. &c. Most cf these are discussed under their appropriate heading.-, and it is unnecessary to allude to them any further here. Those belonging to the last group are usually rather of pathological interesi than of clinical importance, as they rarely give rise to any local symptoms or physical signs during life, and are merely discovered, as a rule, at the post-mortem examination. It is a questiot how far some of these growths are to be re- garded as being of a malignant nature. In some cases they are secondary to similar growths else- where, or the lung may be involved by extensi i. Lymphatic formations in the lungs are sum times observed in cases of Hodgkin's disease. Effects. — It maybe useful to indicato i he effects, if any, which morbid growths may p o- duce in connection with the lungs. 1. l ilt lung-tissues may merely be more or less d s- placed ana compressed; or, in course of time become absorbed or atrophied, in proportior as the growth progresses. 2. The distribu- tion of air in the lungs may be modified by the mere presence of a growth, so that in one pail it is in excess, and in another part deficient. 3. Similarly, the circulation of blood may be dis- turbed, leading to congestion in one part, and anaemia in another. 4. Morbid formations are very liable to cause local irritation. Hence they may induce bronchial congestion and ca tarrh, localised acute pneumonia and its con- sequences, or chronic interstitial pneumonic, which may lead to the formation of a fibrou: capsule around a growth. 5. Certain formations are liable to undergo degenerative and destruc- tive processes, either in themselves, or along with the pulmonary tissues. In this way they originate ulcerations or cavities, and may give rise to products, which are not only injurious to the lungs, but also infect distant parts to which they may be conveyed. After destruction re- parative processes not unfrequently take plac-v with loss, however, of the involved portions oi the lung-structures. It must be remarked here that some morbid growths seem to become in- filtrated through the pulmonary tissues without destroying them ; and under appropriate treat- ment the growth is absorbed, leaving the in- volved portion of the lung intact. This applies, for instance, to some cases of syphilitic infil- tration. 6. Growths in the lungs sometimes extend beyond these organs, so as to interfere with neighbouring structures, causing irritation, pressure, or destructive effects. Thus, local pleurisy, pressuro on vessels or nerves, destruc- tion of bones, and other consequences may ensue. In short, the growths become then practically in- tro-thoracic tumours, and produce similar effects Symptoms. — What has been stated as to the effects of morbid growths in theluDgs will readily explain the clinical signs which they tend te originate. They may be of such little conse- quence that they produce no sign whatever during life, not interfering in any way with the respiratory functions, or being themselves in in- sufficient amount to be discoverable by physical examination. Indeed, some formations may in- vade the lungs to a considerable extent so insi- diously that no evident symptoms are induced. 898 LUNGS, (EDEMA OF. The writer has known cases in which the lungs were extensively implicated in secondary cancer without any symptoms, except some feeling of shortness of breath on exertion. Usually, however, various degrees and combinations of the ordinary pulmonary symptoms may be antici- pated— namely, pain in some part of the chest, cough, expectoration, the sputum sometimes containing fragments of the growth, haemoptysis, and dyspooea. Pressure-symptoms in connection with other structures are induced in some cases. Physical examination may detect the disease when there are no symptoms ; or these may co- exist with physical signs, which either reveal the presence of the morbid formation itself — such as alteration in the shape and size of the chest, deficient expansion, dulness, bronchial or other abnormal breath-sounds, modified vocal fremitus and resonance; of its effects on the lungs; of the formation of cavities; or of its effects on neighbouring parts. The particulars relating to these points are discussed in other articles. Definite general symptoms are asso- ciated with many forms of morbid growth in the lungs. Treatment The principles of treatment of morbid growths in the lungs are, first, to get rid of them, if possible, by medicinal means, as in the case of syphilis ; secondly, to treat their effects ; thirdly', to treat local symptoms which may arise ; and fourthly, to treat the general sj'mptoms. Frederick T. Roberts. LUNGS, (Edema of. — S ynon. ; Fr. (Edeme du Poumon ; Ger. Lungenbdem. Definition. — Infiltration of the pulmonary tissue with serous fluid. The serous fluid is effused from the pulmonary capillaries into the pulmonary textures, and into the alveolar and bronchial spaces. JEtiology. — The causes of this exudation are manifold, but of two sorts : — ( a ) Disordered cir- culation:— 1. active congestion, attendant upon inflammatory conditions of the lungs and bron- chi ; 2. passive congestion ; 3. mechanical con- gestion — in heart-diseases, emphysema, or pres- sure upon the pulmonary veins ; 4. want of tone of vessels after inflammatory' conditions, as pneumonia or bronchitis, or pressure upon the vagus nerve or pulmonary plexus ; 5. afflux of blood to the lungs in croup, and during the asthmatic paroxysms determined by the ineffec- tual efforts at inspiration. ( b ) Morbid conditions of the blood'. — in albuminuria, and to a less de- gree in other diseases in which the condition of the blood is altered or impaired — for example, scurvy, purpura, ansemia, hydraemia — the lungs partaking of the general disposition to dropsy. Anatomical Characthrs. — In cases of oedema pulmonum, the lungs are usually large, filling the thoracic cavity, and sometimes indented by' the ribs. They are heavy; their pleural sur- faces are wet; and the pleural cavities contain an excess of serum. Both lungs are as a rule affected, their lower and most dependent por- tions chiefly; and one lung, on the side to which the patient has last inclined, is more highly [edematous than the other. The higher the legi'ee of oedema, the lees crepitant the lung icd tbe more distinctly the surface pits on pres- sure. A portion cut from a simply oedematoag lung will, however, almost always float in water; but at the base of the lung there is usually some collapse iu addition to the oedema, and a por- tion removed therefrom sinks. On section the lung exudes abundant thin serum, and more or less frothy fluid, with which the bronchial tubes are also occupied. On first making a section, the succulent tissue will break down easily under the finger; but, after the excess of fluid has been squeezed out, the lung feels toughened. (Edema may be found at any por- tion of the lung — at the apex, for instance, determined there by the inflammatory process. The transition between oedema and inflammatory consolidation is very gradual (Edema is also very apt to pass into, or to be complicated with, a certain degree of inflammation. The degree of friability', and of compressibility, and the applica- tion of the water test, are the readiest methods of distinguishing between the two. If a por- tion of cedematous lung be examined under the microscope, tbe alveoli are found to contain more or less numerous large gTanular cells, but these are never so numerous as to occupy entirely the alveoli. Symptoms. — The symptoms of oedema of the lungs are — in addition to those of the disease which has produced it — dyspnoea, which may amount to orthopnoea ; troublesome • retching’ cough; and difficult, yet tolerably abundant, frothy, serous expectoration. The percussion note is deadened at both bases, although the dulness is usually more extensive at one base than the other ; the vocal fremitus is diminished; the re- spiratory murmur is enfeebled or lost; and a fin* bubbling crepitation is heard. Diagnosis. — The diagnosis of pulmonary aide ma is not usually difficult. The absence of pleuri tic pains and offerer, and the double-sidednes of the disease, together with the absence of an; true bronchial breathing or aegophonv, will ex elude pneumonia or pleurisy. The presence c dulness will also distinguish the condition froi simple capillary bronchitis, with a certain dt gree of which, however, it is often combine! The general condition of the patient, and tf presence or absence of those diseases or circun stances which are known to produce oedema the lungs, must be carefully taken into conside ation. If, for instance, after an asthmatic p roxysm we hear some fine bubbling rales oter tl bases of the lungs, and find tho patient expect rating an unusual quantity of frothy serous flui we may suspect pulmonary oedema rather th; bronchitis. Prognosis.— The prognosis in oedema of t lungs depends mainly upon the general or lo- conditions with which it is associated. It is very grave purport in chronic Bright s disease, in heart-disease. It is also a grave complieati in chronic bronchitis, showing failure of hen- power. It is, however, often a transient h unimportant affection when it succeeds to act chest-affections, as pneumonia or bronchitis.' to asthma. As a complication of acute che- affectiuns. it is rarely recognised clinicallv. Treatment. — The treatment of pulmonj cedema is, in all important cases, derivat* Poultices are to be applied to the chest, LUNGS, PERFORATION OF. 899 rofficient mustard to produce redness. Dry- cupping will often give great relief. Blisters should be avoided. Watery purgatives should be administered, according to the strength o‘ the patient. Diuretics are useful in some eases, especially the vegetable diuretics, such as digi- talis. juniper, and scoparium, as also nitric ether: and the same is to be said of diaphor- etics, fur example, acetate of ammonia, -warmth, air baths. Moderate stimulation and support must b“ kept up. Kidney or heart-disease if . present will mainly determine the exact treat- ment. If there be failure of cardiac power, sether, ammonia, and alcoholic stimulants are required; and if the heart’s action continues hurried or irregular, digitalis is especially in- dicated. When we suspect a loss of tone of vessels, as after bronchitis or pneumonia and n anaemic states, perchloride of iron with some mineral acid is to be recommended. In all cases rest in bed or on a couch is neces- sary. R. Douglas Powell. LUNG, Perforation of.— Synon. : The term pneumothorax is almost equivalent. Definition. — The formation of an opening through the pulmonary pleura, communicating with the interior of the lung. .Etiology.— Perforation of the lung may irise in many ways. Its causes may be classified inder the three following headings : — 1. Penetrating wounds; for example, gunshot round, punctured wound, or laceration by a iroken rib. 2. Dis uses affecting the pleural cavity or e : gkhouring organs-, such as empyema, hepatic bscess nr hydatid, or suppuration of the bron- hial glands. 3. Disease affecting the lung itself ; for in- :ance, phthisis, emphysema, gangrene, hydatids, r cancer. Of all the causes of perforation of the lung, hthisis is infinitely the most common. It is te rule in phthisis for pleuritic adhesions to rm part passu with the pulmonary lesion, and aese adhesions are usually very firm and diffi- lt to break down. In neither respect, how- er, does this rule always hold good. In some re cases in the earliest stage of the disease a lall tubercular nodule situated immediately der the pleura softens, and the pleura gives y. Again, at any stage of the disease an out- ng tubercular mass, situated below the point which the pleural adhesions have extended, y soften and rupture into the pleural cavity. In the more acute pneumonic varieties of ; :hisis there is often a singular indisposition ' the formation of pleural adhesions. The ] mcnary pleura in such cases becomes covered ha thin, smooth, translucent layer of lymph, t ning through which can be seen at several Ints opaqne yellow spots. These spots are 1 id to correspond with underlying masses of 6 ened cheesy material, by which the pleura I been undermined and deprived of its vascular * ply. Pneumothorax has its most frequent o in in rupture of the pleura at one of these r ow points. mally, sinuses are sometimes found leading I I old cavities within the lung to the pleural surface. Occasionally these sinuses, the pleura being adherent, penetrate through the thoracic wall and point externally. In other cases, of which the writer has seen two examples, they may open into the opposite pleural cavity. Anatomical Characters. — The affected lung is in all cases collapsed, and in cases of old standing may be so completely so, and covered by such thick layers of lymph, as to be found only with difficulty. The opening may have closed. It is sometimes difficult to discern. It may consist of a small slit, communicating with a cavity by a slanting sinus, so as to form a com- plete valve ; or it may be of considerable size, and communicate widely with a cavity or bron- chus. All degrees of patency between these two extremes occur. The position of the open- ing is very variable ; it is most commonly situa- ted somewhere on the lateral or convex side ef the lung. The rupture is almost always into the pleural cavity on the same side. It may, however, take place into the opposite pleural cavity, through the mediastinal fold of pleura. The pleura is inflamed, and covered with lymph; and its cavity contains air, and a greater or less quantity of purulent fluid. The heart is dis- placed, unless in some rare ease it be held by a strong adhesion. Someyears ago the writer tested the degree of air-pressure present in ten eases of pneumothorax by means of a water-pressure gauge. In two eases it was nil; in one case it was equal to 125 inch; in two cases 2 inches; in one case 3'75 inches ; in two cases 4 inches ; in one case 5'3 inches; and in a double case il equalled 3’5 inches in one pleura, and 2'7 in the other. The gas effused approximates in com- position to that of expired air, containing frem 8 to 16 per cent, of carbonic acid. Sometimes sulphuretted hydrogen also is found in fetid cases. Symptoms and Signs. — The symptoms and signs of perforation of the pleura are those of pneumothorax and of hydro-pneumothorax. At the moment of attack sudden acute pain is felt in the chest, at the seat of rupture, and is im- mediately followed by great dyspnoea and shock. In a well-marked case the expression of face is peculiarly agonized and terror-stricken; the ex- tremities are cold ; damp sweats break out , the pulse is quick and small ; and the respirations are exceedingly rapid. The position of the patieDt is that of orthopnoea. with an inclination forwards, and to the sound side ; it is, however, frequently changed in the endeavour to gain breath. The voice is feeble and whispering. The urgency of the shock and dyspnoea depends upon the amount of useful lung suddenly disabled. If the patient survive the attack, after two or three days fever of a hectic ebara ter, with sweats, supervenes. In some cases, however, the symptoms of pneu- mothorax come on very insidiously. Physical signs. - The physical signs are very characteristic. There is enlargement of the side affected, and effacement or bulging of the inter- costal spaces. The heart is displaced towards the s und side. The percussion-note is hyper- resonant or tympanitic over the siae affected, except where i at the apex) the lung may perhaps be still adherent; and on auscultation either r.o respiration at all is audible, or amphoric breathing of a peculiar character may be hear,: 930 LUNGS, SYPHILITIC DISEASE OF. at one or more points, sometimes accompanied with the characteristic metallic tinkle. A pecu- liar metallic echo is heard if the patient coughs. If, whilst the ear is applied, a coin placed on the diseased side is struck with another coin, a characteristic bell-note is heard. The vocal fremi- tus is diminished or lost. At a later stage, when more or less effusion has taken place, the signs of hydro-pneumothorax present themselves, namely, dulness below and liyper-resonance above — in varying proportions and shifting in relative posi- tion with the posture of the patient. If the amount of fluid be moderate, a splash or succus- sion-sound may be elicited. This sound may be audible to the ear applied to the chest, or to bystanders. If the fluid effusion be consider- able, intercostal fluctuation may be felt ; and this fluctuation gives to the finger, on percussion at the level of junction of. air and fluid, a peculiar sensation of thrill. The position usually assumed by the patient now is with the head raised, and leaning towards the diseased side. Diagnosis. — The diagnosis of perforation of the lung is to be made from other diseases; and also with respect to the probable nature of the opening, and the degree of pressure pre- sent. If the three essential signs of pneu- mothorax be remembered, namely, displacement of heart, tympanitie percussion-note, and either absence of respiration or amphoric breathing, there can scarcely be any difficulty in mak- ing the diagnosis. It cannot be confounded with a. bilateral disease like emphysema. The shift- ing resonance and dulness, the succussiou-splash, with 1 perhaps metallic tinkle and amphoric breath-sound, are signs abundantly sufficient to distinguish hydro-pneumothorax from ordinary empyema. Respecting the nature of the opening —whether valvular or free, careful auscultation will usually gain the desired information. If amphoric breathing be well-marked, it may be assumed that the opening is a free and tolerably direct one ; if, on the other hand, no respiratory sound be audible, the communication with the pleura is indirect and more or less completely valvular. In the latter case the pressure-symp- toms become more urgent. Prognosis. — Of course the prognosis in every case of tubercular pneumothorax is necessarily very grave, but by no means equally .grave in all cases. The following considerations will guide to a correct prognosis, (a) Nature of opening. If the communication with the pleura be valvular, signified by the entire absence of breath-sound, and the increasing urgency of dyspnoea, the patient will die in a few hours, unless relieved by paracentesis. ( b ) State of the opposite lung. If the effusion of air have" occurred on the side least affected by previous disease, the case is correspondingly hopeless. If, on the other hand, we know that the lung now collapsed was previously much diseased, and if the other lung be but little affected, the duration of life may not be greatly shortened by the accident. Life is then gradually extinguished bj r hectic fever, and progressive disease in the opposite lung. It is by no means impossible, and probably hap- pens more frequently than is supposed, that the opening in the pleura may close, the air become absorbed, and the case converted into one of simple empyema. In pneumothorax arisingfrom accidental wound or injury to the lung, the prog- nosis depends upon the visceral injury. Theair in the pleura is absorbedwith considerablereadiness. Treatment. — In all cases in which death ia threatened by asphyxia, in consequence of air accumulating in the pleura, paracentesis with a fine trochar must be performed. This will Id such cases give great relief, and may be repeated if necessary. There is a tendency for an opin- ing at first completely valvular to become at a later period more patent or possibly to close so that it is better to operate when necessary with a fine trochar than to make a permanent open- ing. Rest to the affected side should be secured, as far as possible, by the application of a broad piece of strapping extending round the side to beyond the middle line in front and behind. The shock and dyspnoea are best treated by opium in repeated small doses. Stimulants may also be necessary, but opium is far more useful. R. Douglas Powell. LUNG, Rupture of.— Rupture of the lung is an extremely rare occurrence. Cases of so- called rupture of the lung from external violence are, for the most part, really produced by per- foration or laceration of the pleura by a fractured rib. It is said that rupture of the lung may occur in whooping-cough. LUNGS, Syphilitic Disease of. — There is still much uncertainty as to the effects which syphilis may produce in connection with the lungs, but there can be no doubt that it does sometimes originate specific lesions in these organs, though much less frequently than in most of the other viscera. They are generally only met with in advanced cases of acquired syphilis, when the signs of the disease are markedly developed in other parts. Occasion- ally the lungs are involved in congenital syphilis. The. presence of a tubercular or scrofulous dia- thesis has been supposed to predispose to the implication of the lungs in syphilitic disease. Anatomical Characters. — Gummata consti- tute the most certain and unquestionable lesioDs of a syphilitic nature in the lungs, but they are rare. When present, they vary in number from one to many. In the latter case they an disseminated, but are stated to have a predi lection for the deeper parts of the organs. Ii size these growths usually vary from a pea t< a walnut, but may reach the dimensions of ; large egg. Thoy are generally well-defined rounded in shape, and often surrounded wit' a fibrous capsule. In their early condition gum mata in the lungs appear on section greyis or brownish-red, homogeneous, firm, and dryis in consistence. Subsequently they tend to do generate, becoming more or less caseous, ye : low, and less consistent; and they may eve break down in the centre, so as to form cavitie The structure of these gummata is found c microscopical examination to be made up of nj perfect fibres, abortive nuclei, and a few fibr cells, infiltrating the pulmonary tissues, ai thickening the alveoli. Afterwards these a mixed with granular matter and other produc of degeneration and disintegration. There has been much discussion regarding t LUNGS, SYPHILITIC DISEASE OF. relation of syphilis to another form of lesion affecting the lung-tissues, namely, a variety of chronic interstitial pneumonia. There seems every reason to believe that this morbid condition is in some instances due to syphilis. The result is a fibroid infiltration of the pulmonary tissue, which in its general and microscopic characters cannot be distinguished from a similar condition due to interstitial pneumonia from other causes, but the new tissue is said to be more vascular in its early stages. The affected parts are much indurated ; and any bronchi which are im- plicated tend to become more or less dilated. The morbid condition may be distributed in various parts of the lungs, but appears to have a preference for their bases and the vicinity of their roots. It frequently originates at the sur- face, and penetrates thence into the interior of the lungs in the form of fibrous bands, the pleura being generally thickened or adherent, and super- ficial puckerings and depressions being visible. In other instances the new growth commences around gummata; or from a chronic contracting peri-bronchitis, associated with ulcerative inflam- mation (Pye-Smith). Dr. Green states that it originates mainly around the small interlobular blood-vessels. Syphilitic fibroid infiltration has 10 tendency to caseation ; but it may become the seat of ulceration or gangrene. In connection with congenital syphilis, a pecu- liar condition has been described as affecting the ungs in new-born or very young infants, under carious names, such as syphilitic pneumonia, white hepatization, and epithelioma of the lungs, t assumes a more or less diffuse or infiltrated .rrangement, but is of variable extent, and may ivolve one or both organs. One lung may be ffected throughout, while the other is quite free :om disease. The more obvious characters are s follows : — The pleura is usually unaffected, he lung is enlarged, and may be in a state of ill expansion, so that its surface is marked by te ribs ; it feels remarkably heavy ; and at the ;at of the disease is dense, firm, hard, and ,ually resistant, not breaking down under pres- re. On section it presents a white or yellow- h-white colour, being more or less bloodless ; uniform and smooth; and little or no fluid can expressed or scraped from the cut surface, refill examination reveals minute bands of rous tissue running in all directions. Miero- ipically the change seems to consist mainly in ickening of the alveolar walls and minute inchi, due to an imperfectly fibrillated and fieated tissue, which undergoes degenerative 1 inges. Most observers further describe an i rease in the epithelial cells, which fill the : -vesicles and minute air-tubes, but Wagner i ies this. The vessels also become thickened ! . ultimately obliterated. t maybe remarked that the bronchial tubes o-heir divisions may be affected with syphi- 1 ‘ disease, their submucuous tissue, or occa- 6 ' a lly their deeper structures, becoming in- fi ated with a fibro-nuclear growth. Ulceration n ' take place, followed by cicatrization, and h ing to thickening of their walls, and narrow- u or even complete closure of their channel. tstPTOMS.— In the present state of knowledge ■t mpossibleto write with anything like definite- LUNGS, TUBERCULOSIS OF. 901 ness respecting the clinical history of syphilitic disease of the lungs. As a matter of fact, in the majority of cases the lesions have only been discovered after death, no symptoms having occurred during life pointing to the lungs ; or, these having been obscured by symptoms affect- ing other parts. In a case of recognised consti- tutional syphilis, attention should be paid to the lungs as well as to other organs, and it would be advisable to examine them from time to time, as physical signs might occur without any obvious symptoms to attract the patient's attention. If pulmonary symptoms should arise in a person undoubtedly syphilitic, or who had had syphilis, the possibility of the lungs being affected should specially be borne in mind. Among these symp- toms haemoptysis at an early period is said to be important. Physical examination might pos- sibly reveal the presence of gummata, as evi- denced by localised dulness, bronchial breath- ing, increased vocal fremitus and resonance, and other signs of consolidation. The most signifi- cant signs, however, are those indicating marked induration of the lung from fibroid infiltration, especially if unilateral, and confined to the base or middle portion of the organ. In course of time signs of cavities might become evident, due to breaking-down of gummata, or to dilated bronchi. The general symptoms are those of constitutional syphilis, combined with those of phthisis. There is but little or no pyrexia accompanying the pulmonary lesions ; and the progress of the case is essentially chronic. The effects of treatment may be of peculiar signi- ficance in the diagnosis of syphilitic disease of the lungs. If such symptoms and physical signs connected with these organs as have been in- dicated above should disappear under the use of anti-syphilitic remedies, a diagnosis of this disease might fairly be made. Indeed some ob- servers think that they frequently discover and cure it, but this is somewhat doubtful. Treatment.— If syphilitic disease of the lungs be recognised or suspected, the appropriate treatment in most cases is to administer iodide of potassium freely and continuously. In some cases a mercurial course of treatment answers best ; or perchloride of mercury might be com- bined with the iodide. It may be necessary to employ internal remedies or local applications for the relief cf pulmonary symptoms. Cod- liver oil and tonics may be given with advantage for the amelioration of the general condition, in cases where such medicines are needed. Frederick T. Roberts. LUNGS, Tuberculosis of. — Tubercle is the most important morbid growth affecting the lung, but it is by no means a settled point what should be included under this term. Many pathologists only recognise as tubercle the so-called grey gra- nulations ; others regard the various masses and infiltrations noticed in cases of phthisis as of this nature, and they look upon tubercle in these or- gans as divisible into grey and yellow varieties, and arranged either in granules or as an infil- tration. It is unnecessary in this place to discuss this subject further, as it is considered fully in other appropriate articles. See Phthisis ; and Tuberculosis. Frederick T. Roberts. 002 LUPUS ERYTHEMATOSUS. LUPUS ERYTHEMATOSUS {lupus, a wolf, or a rodent disease; and erythematosus, re- lated to erythema). — Synon. : Seborrhasa, con - f the face. The non-ulcerative form chiefly elects the cheeks, and afterwards, in order of requeney, the nose, ears, legs, arms, and trunk, 'he ulcerative form — lupus exedens — begins lmost exclusively on the nose, attacking chiefly is anterior portion, either the tip or the odges f the alae. Sometimes it begins within the ostril. Unless proper treatment is at hand the ose may be entirely destroyed, and severe in- mds made into the tissues of the cheeks, lips, ad other neighbouring parts. Complications and Seqtjeuj. — Lupus may i-exist with enlarged and suppurating glands the neck and elsewhere; with various scrofu- us affections; with phthisis; and with chronic right’s disease. Great deformity may result em tho coutraction of the scars which it leaves, r example, ectropion, stricture of the nares, d distortion of the mouth. About a dozen ses have been recorded in which epithelioma veloped on a patch of lupus of many years’ mding, or on a lupus scar. We may regard -h cases as arising from the stimulus of the aliferative processes in the cutis on the neigh- aring epithelium. Diagnosis. — Theduration and position of lupus garis, and the absence of thick scaliness and 903 itching, will generally render it easy to distin- guish this disease from circumscribed forms of psoriasis and eczema ; and its commencement in early life will clearly separate it from epitheliul cancer and rodent ulcer. It is with syphilis that it is most apt to be confounded, and the diagnosis between lupus exedens on the nose, and an ulce- rating 6yphilide, is sometimes extremely diffi- cult, or at first sight impossible. In these cases, after carefully considering the history, we must examine other parts of the body for traces cf syphilis, and an inspection of the mouth and pharynx will often materially assist us ; and lastly, the greater chronicity and slower exten- sion of lupus, as well as its resistance to specific treatment, will generally lead to a correct opinion. Indolence is a character of special value in deciding between lupus and syphilis, particularly as affecting the mucous membranes. Syphilis has also more tendency to suppuration than lupus. Prognosis.— Lupus is never fatal per se, but it can never be looked on in a favourable light, owing to its tendency to relapse under treat- ment, and its invariable termination in a con- tracting cicatrix. Treatment — Internal .— Internal treatment is only of use in lupus vulgaris where the patient's general health is bad, or where well-marked symptoms of scrofula are present. In these cases great benefit may be derived from tonics, especially the iodide of iron, and from cod-liver oil in as large doses as can be tolerated. Nu- tritious food should be freely given ; and the patient should take plenty of outdoor exercise in a bracing climate. External . — The real cure for all forms of lupus must always consist in the destruction of tho new tissue forming it, by caustic agents of various strengths. A number of such remedies have been proposed, but the successful applica- tion of each seems often to depend more on individual experience of its use, than on the superiority of any one caustic over the rest. The caustics most generally used are caustic potash, nitrate of silver, and acid nitrate of mercury. Equal parts of caustic potash and dis- tilled water may be applied with a tiny piece of sponge, so as to limit the action as much as pos- sible. The pain which follows is not of long duration — a point of much importance where a caustic must be repeatedly used. Solid nitrate of silver should be bored freely into all ulcerated parts or soft tubercles. The lupus-tissue offers but slight resistance to it, whereas it will not penetrate or injure healthy parts. Acid nitrate of mercury may be painted on with a glass brush. The crusts which form after any of these agents, fall off in ten days or a fortnight, and it is not advisable to repeat the application at shorter intervals. As a rule no dressing except zinc ointment is required. Some authorities prefer the actual or else the galvanic cautery, but both these measures have the disadvantage of disfiguring the parts, so that it is difficult to determine when healthy tissues are reached. Others advise multiple scarification, with one or more fine-bladed knives, so as to obliterate blood-vessels, and produce absorption by starv- ing the lupus tissue and exciting inflammation 904 LUPUS VULGARIS. (Volkmann, Veiel). For a more detailed descrip- tion of the mechanical methods of treatment, including that by ‘ scraping,’ see Appendix. In the treatment of the superficial patches of lupus non-exedens, the repeated application of mercurial plaster during several months has sometimes been followed by absorption of the growth. Pyrogallic acid ointment (1 to 10) has been used by Hebra and others with much suc- cess. In other cases painting with tincture or liniment of iodine, and coating with gutta-percha foil, produces slow improvement ; and where no uleoration exists, demanding active interference, these milder remedies deserve a trial. See Ap- pendix. Edward I. Sparks. LYMPH (rvfitpTi, a nymph, water). — Physio- logically, lymph signifies the fluid which circu- lates in the lymphatic system. Pathologically, the term is applied to the coagulable exudation which escapes from the vessels in inflammation. The name ‘ vaccine lymph,’ or ‘ lymph,’ is also given to the fluid contained in the vaccine- vesicle. See Inflammation ; and Vaccinia. LYMPHADENITIS ( lympha , lymph, and adenitis, inflammation of a gland). — Inflamma- tion of lymphatic glands. See Lymphatic System, Diseases of. LYMPH ADENOMA.— Synon. : Hodgkin's Disease ; Antenna Lymphatica (Wilks) ; Fr. Ade- nie (Trousseau) ; Lymphadenic (Ranvier) ; Ger. Pseudoleukdmie (W underlich). Definition. — A disease characterised by more or less widely-spread enlargement of the lymph- atic glands, accompanied frequently by enlarge- ment of the spleen, and by progressive anaemia. History. — Cases of coincident enlargement of the lymphatic glands and spleen were noted by Malpighi (1669) and Morgagni (1752). The nature of the glandular change was first care- fully described by Craigie, (1828); and the gen- eral clinical history of the affection was pointed out by Hodgkin (1832), and by Wilks (1856). The most important subsequent observations are those of Virchow (1864), Wilks (1865), Trousseau (1865), Wunderlich (1858 and 1866), and Mur- chison (1870). Nature. — The enlargement of the lymphatic glands, which consists at first of mere hyper- plasia, and subsequently of fibroid induration, varies much in its extent. A few glands only may suffer, or every gland in the body may be enlarged. The former cases have the characters of a local growth ; the latter is distinctly a general disease, for which the term lymphade- nosis seems the most exact. The glands vary in consistence : when soft there may a considerable excess of leucocytes in the blood ; when hard there may be simple anaemia. This difference does not afford sufficient ground for separation. The enlargement of the spleen is usually due to disseminated growths, arising in the Malpighian bodies : sometimes there is also hyperplasia of the splenic pulp, as in splenic leueocythoemia. ^Etiology. — In two-thirds of the cases of lymphadenoma, no cause can be traced, and the ascertainable antecedents of the disease, in most of the remaining cases, evidently constitute oniy a small part of the influences tc which it is duo. Hereditary transmission has not been distinctly LYMPHADEN OMA. proved. The disease is three times as frequent in males as in females. It is met with at all ages, but is most frequent in early and late adult life! 1 1 occurs, but is not specially frequent, in chil- dren under ten years, and, having regard to the numbers living, it is least frequent between the ages of forty and fifty years. Intemperance, mental depression, insufficient food, and over-' exertion have been noted, in rare cases, as ante- cedents. Exposure to cold, in several instances, has appeared to be the exciting cause of tho affection. It is doubtful whether the disease has any relation to constitutional syphilis. In several cases the symptoms have first appeared after child-birth. Various febrile affections have, in a few instances, preceded the affection. The exciting cause which has been noted most fre- quently is some local irritation, as of a decayed tooth, discharge from the ear, sore-throat, in- flammation of the lachrymal sac, or eczema. In these cases the glands nearest the source of irri- tation first enlarged, and then more distant oDes became affected. Anatomical Characters.-— The several groups of glands are affected in the following order of frequency, beginning with those most commonly diseased: cervical, axillary, inguinal, retro-peri- toneal, bronchial, mediastinal, mesenteric. Sub- sidiary adjacent glands are often enlarged together with the chief groups, and nodular growths, similar to enlarged glands, arise in the course of the lymphatics in places in which the existence of glands is not usually recognised, so that continuous chains of nodules connect the various groups. The size attained by the glands i n lymphadeuoma varies from that of a bean to that of a hen’s egg. At first the individual glands are separate and movable one on another. Ulti- mately they often unite to form a conglomerate mass, in consequence, in most cases, of the per- foration of tho capsules of the glands by growth, which may also invade adjacent parts. The cervical glands are usually enlarged iu both the anterior aud posterior triangle.; and the sub- maxillary glands may encircle tho neck beneath the lower jaw. They may press on the trachea or larynx, displace the latter, compress the internal jugular vein, and cause paralysis of the recur- rent laryngeal uerve. The occipital glands are usually also enlarged. The axillary glands often form a mass of rery large size, and pro- longations may extend beneath the pectoral muscle. The glands in the anterior mediasti- num frequently suffer, and the growth may extend to adjacent structures, such as the peri- cardium, which may be perforated. The thymus may be involved, secondarily or primarily, or may escape. The bronchial glands are diseased more frequently than the cardiac glands, and the trachea and bronchi may be pressed upon, or the lung invaded. The retro-peritoneal glands often form a mass of large size, which may surround and compress the solar plexus causing symptoms similar to those of Addison"; disease. Enlargement of the mesenteric gland; is neither common nor considerable. The in guinal group is frequently diseased, and tin femoral vessels and craral nerves may be th-rc- by compressed. The consistence ofthoenlar®* glands maybe either soft or very hard. Usually LYMPHADENOMA. the longer the enlargement has existed, the firmer are the glands. Their section is more uni- form than in health. The colour is yellowish or whitish-grey. In the firmer glands dense tracts of fibrous tissue are seen to pass in different directions. Barely the follicles have a dif- ferent appearance, being opaque and yellowish from fatty degeneration, whilst the septa are white and conspicuous, from fibroid thickening. ( hiseation is, however, rare, and when it occurs is commonly confined to one or two glands. When caseation is general, the cases are of a form intermediate between lymphadenoma and scrofula. The softer glands yield a juice on scraping; the firmer glands yield no juice. In the former, the only histological change is an enormous increase in the cellular elements — the lymph-corpuscles of the reticulum ; but the relations of the septa and follicles often remain normal. Sometimes the cell-growth invades the septa, which become split up and disappear ; and it may even, in a similar manner, perforate the capsule. The firmer glands present much fibrous tissue, which may be confined to the ; septa, or invade also the delicate network in the substance of the gland ; and then the cells gradually disappear, and the whole substance of the gland may be transformed into a fibrous mass. The tracts of fibrous tissue may have under the microscope a peculiar vitreous aspect, especially around the arteries. The spleen is diseased in at least four-fifths of the cases, usually in consequence of disse- minated growths, often irregular in shape, arising from the Malpighian corpuscles, yellow- ishor greyish white, rarely caseating. and usually corresponding in consistence, and resembling in structure, the glands in the same case. The splenic pulp may be normal in quantity, or nay be compressed and atrophied. In some cases it is also increased in quantity, and this • ncrease may even be the sole change. In such ases the morbid changes of lymphadenoma and plenic leucocythasmia coexist, and there is ■ften a much greater increase in the white orpuscles of the blood, than when the spleen s the seat of simple growths. The size at- uued, in the cases of nodular growths, is not reat, the weight being from ten to thirty ounces, /hen the splenic pulp is increased, the size stained is rather greater. In the latter case le enlargement is uniform, while it may be regular when there are growths. The medulla ' bones has been found, in rare cases, to pre- nt a change similar to that met with in splenic acocythsmia and pernicious anaemia. Col- htions of adenoid tissue elsewhere often under- changes similar to that of the lymphatic inds. The tonsils, the mucous membrane of ,e pharynx, the oesophagus, the stomach, and 3 large and small intestines, may all be the •t of growths, originating in the follicular nds, and sometimes ulcerating. The liver is en the seat of scattered lymphoid growths, lally minute, varying in size from a small pea ! a pin’s-head. They occupy the interlobular 1 ces. Barely larger nodular growths are I nd. In other cases the liver is simply fgested. Similar minute growths are often l ad in the kidneys, chiefly in the cortex ; and 90.3 these organs may also be the seat of parenchy- matous degeneration. The peritoneum may he inflamed over enlarged glands, or may be the seat of growths. Growths have also been found in the testicles ; and frequently in the lungs, where they may break down and form cavities. SrarpTOirs. — The most important symptoms of lymphadenoma are due to the altered blood-state, and to the enlarged glands. The latter .cause the earliest symptoms, and the cervical glands are commonly the first to enlarge. When the internal glands are primarily affected, pain and pressure-signs may precede other symptoms. Occasionally the signs of anoemia precede those of the local change; and, in rare instances, irre- gular febrile disturbance may occur before the glandular enlargement. The affected glands are smooth, and present, at first, a peculiar mobility, which may disappear when they become adher- ent, and constitute an irregular lobular tumour of some size. They are usually painless, except during periods of rapid growth. A diminution in size has been observed before death. The enlarge- ment of the cervical glands may cause the neck to equal, or even exceed, the head in circum- ference. The pressure on the veins may cause ■ symptoms of passive cerebral congestion. The larynx may be displaced ; and the movements of the lower jaw may be interfered with. Pressure on the trachea, by the glands in the neck and in the posterior mediastinum, may cause dyspnera and even death by suffocation. That on the pharynx and oesophagus may obstruct deglu- tition, and cause death by starvation. The enlargement of the axillary and inguinal glands may interfere with the movement of the limbs, and impede the circulation. Various and serious pressure-effects result from the enlargement of the thoracic and abdominal glands, obstruction in veins, pressure on nerves, &c. The enlarge- ment of the spleen can usually readily be felt, but does not commonly give rise to symp- toms. Anaemia is one of the conspicuous symp- toms, and may precede, or succeed, obtrusive affection of the glands. The red corpuscles may be reduced to fifty, thirty, and even twenty-five per cent, of the normal. In mest cases there is no marked excess of white cor- puscles, but occasionally they are much more numerous than normal. In almost all cases in which their excess is comparable to that met with in splenic leucocythaemia, the splenic pulp is increased in quantity, and the lesions of splenic leucocythaemia and of lymphadenoma are conjoined. The liver may he enlarged from the disseminated growths, and from congestion. Jaundice only occurs from the pressure of en- larged portal glands upon the bile-ducts. Ascites may he due to similar pressure, or to the blood- state, being then part of general dropsy. The function of the kidneys is rarely affected. Sto- matitis, sometimes ulcerating, results from the lymphoid growth in the mucous membrane; and a similar change in the stomach causes interference with digestion and vomiting — symptoms which are increased by the ansemia. Slight dyspnoea results from the blood-state, while intense diffi- culty of breathing, and even actual suffocation, may occur from the pressure of enlarged glands on the trachea or bronchi. The functions of ths LYMPHADENOMA. JOG nervous system are variously deranged Ly the ill-nourished blood. Towards the end there may be convulsions, delirium, and coma. Pyrexia is a frequent, but not invariable symptom. It is almost always present in early life, much less common at advanced ages. The temperature may be considerably raised, even when the glandular enlargement is slight ; the elevation varies from two to six degrees, and may be continuous, or with daily remissions, or periods of considerable elevation may alternate with periods in which it is only slightly raised. Complications. — The pressure-effects of the enlarged glands, already mentioned, are some- times so considerable as to give rise to com- plications, as thrombosis in vessels, pleural and pericardial effusions, and bronzing of the skin from disease of the solar plexus. Inter- current affections, occasionally met with, are Bright’s disease, pneumonia, fatty degeneration of the heart and liver, erysipelas, pemphigus, boils, and other effects. . Course and Duration. — The disease may remain local for a long time, even years, affect- ing one group of glands only, and subsequently slowly becoming general. When the general enlargement of glands is established, the disease rarely lasts more than two years. It usually terminates fatally by asthenia ; but not rarely by some secondary effect of the morbid process, ns asphyxia, starvation, diarrhoea ; or by a com- plication, especially by pneumonia. Pathology. — The changes in the glands in lymphadenoma resemble, in the early stage, those which result from simple irritation; and, as has been seen, the first enlargement often appears to be excited by local irritation. Clinically, how- ever, the disease has a semi-malignant aspect. Dr. Wilks therefore assigned to it a position be- tween cancer and tubercle. Its history suggests that it is due to both constitutional and local causes, and that the extent of these two elements varies in different cases. The constitutional predisposition apparently affects chiefly the Lymphatic structures. The assumption of such a predisposition is necessary to explain the general affection of the glands which charac- terises some cases in the beginning, and also the persistence of the affection when it begins locally, as well as its subsequent extension. In the hitter easo, however, a process of secondary infection may be at work, the lymphatic tissues, already predisposed, becoming affected by the circulation in the blood of a matcries morbi derived from the structures first diseased. Some cases present characters intermediate between lymphadenoma and scrofula — the low tissue- vitality of the latter leading to wide fatty degeneration and caseation of the new growth, instead of its fibroid transformation. The ex- istence of an excess of white corpuscles in the blood does not present valid ground for separa- ting certain cases from the rest, and calling them ‘ lymphatic leucocythaemia.’ Most of such cases are, as has been said, forms of mixed disease. In simple lymphadenosis the Mal- pighian follicles of the spleen are diseased, and when there is a considerable excess of leu- cocytes in the blood, the splenic pulp is usually also increased in quantity. The anatomical lesions of splenic leucocythaemia and lymphade- nosis are conjoined, and to the increase in th« pulp the leucocytal excess is due. Occasionally, however, when the diseased glands are soft, lymphoid corpuscles, changed in character, pass from them into the blood, and persist there, leading to an excess of the pale cells. When the glands are hard, the production of lymphoid cells, and their passage into the blood, seem in- terfered with, and thus simple anaemia results. Diagnosis. — Local glandular growths cannot he sharply separated from cases of generalised lymphadenoma, although they may be clinically distinguished. Generalisation may ultimately occur, even though one group of glands hai alone been diseased for many years. In splenic leucocythaemia the glands are only affected late in the disease, after considerable enlargement of the spleen has existed alone for a long time. When the spleen presents great enlargement, and the glands are affected early, the case is usually of the mixed form above described, both splenic pulp and follicles being diseased. In scrofulous enlargement of the glands, the diaeaso is commonly confined to a single group of glands which have been subjected to local irritation ; some of the glands often soften and suppurate ; the affection occurs chiefly in early life ; and the other constitutional signs of scrofula are present Cancer of tho glands differs widely in its micro- scopical characters from lymphadenoma, but clinically the distinction from a local lymphoma may be difficult, and turns chiefly on the slow extension of cancer to neighbouring glands, and in its subsequent localisation in organs rather than in lymphatic structures. Prognosis. — When the disease is widely spread, or the local growths considerable in size, a fatal termination is almost certain. The duration, however, in each case, varies much. Tho younger the patient, tho better the pre- ceding health, the longer is the duration of the disease. The consistence of the glands has little prognostic value. The softer they are, the more rapid is the course of the disease; but. on the other hand, if it is influenced by remedial agents, the soft glands can be restored to a better func- tional condition than the hard. The prognosis is worse the more profound the ansemia. Eleva- tion of temperature as a rule indicates a rapid course, but to this there are some striking ex ceptions, as in one ease under the writer's care in which the glandular enlargement continue! slight, although the temperature for twelve months was always above the normal. Treatment. — The possibly infecting influene of the primary glandular enlargements has let to their extirpation. Where other glands, o the spleen, has been enlarged, the operatio has done no good ; and, in such cases, surgiaj interference is only justified by impending deat from the local pressure. But where the affectio has been confined to one group of glands, tb progress of the disease has been retarded h their removal, and in some cases, the malad has even been cured. The degree of ansemia of great importance as influencing the prospe of benefit, and even of survival from the oper tion, and the actual proportion of corpusd should, in all cases, be estimated by the haemac LYMPHADENOMA. tometer. An operation should never be per- formed if the proportion of red corpuscles is less than 60 per cent, of the normal. A slight excess of white corpuscles does not militate against the success of an operation. Other methods of local treatment have been employed, with some benefit, especially rubbing and sham- pooing, the alternate application of heat and cold, compression, and blistering. Galvano- puncture is useless. Various substances have been injected into the glands— iodine, nitrate of silver, carbolic acid, arsenic. The last has alone appeared useful (Winiwarter), but it was, in all cases, given internally at the same time. Of internal remedies arsenic is incomparably the most potent. It should be pushed to the largest doses the patient can bear, as n\.xv. of liquor arsenicalis three times daily. It often causes some pain in the glands, followed by their diminution in size, and even, in a few re- corded cases, by their complete disappearance. Although such a favourable result has not come under the writer's personal observation, he has seen a marked diminution obtained in the size of glands which were before steadily enlarging, a diminution which has been maintained for years. Phosphorus has been given in the disease (first by Verneuil), but it is far less useful than arsenic. Iodine and iodide of potassium are of littlo service. Cod-liver oil is useful when there is any indication of a scrofulous diathesis. Mercury and carbolic acid have been given in- ternally without success. Iron, useless alone, has sometimes appeared to do good when given in conjunction with other remedies. Change of air, general tonics, and careful diet are often of considerable sendee, especially when employed along with other measures. W. R. Gowers. LYMPHAH GEITIS ( vvfjupr j, water, or lymph, and iyyuov, a vessel). — Inflammation of lymphatic vessels. See Lymphatic System, Dis- eases of. LYMPH AN GIECT ASIS ( lympha , lymph, md angiectasis, vascular dilatation). — Lymph- itic varix, or varicose dilatation of lymphatic -essels. See Lymphatic System, Diseases of. LYMPHATIC SYSTEM, Diseases of.— Iynon. : I'r. Maladies du Systems Lymphatique ; ler. Krankheiten dcs Lymphsy stems. There is no essential difference between the emphatic and lacteal systems, which together onstitute the absorbent system. In this article ttention will be briefly directed to those diseases f the lymphatic vessels and glands which are lore or less of a local nature ; and what is ated with regard to the former will apply merally to the lacteals, but attention will be rected to any points connected with these issels calling for special notice. Some of the lections involving these structures are con- lered in separate articles, and need, therefore, erely be mentioned here ; while the mesen- ■ric glands are discussed independently (sec esenteric Glands, Diseases of). It may be marked that recent pathological investigations mt to the existence of important relations tween the absorbent system and certain dis- ses, namely, some of those belonging to the nolle class, and those depending upon septic Ll'MPHATIC SYSTEM. 901 conditions, such as plague, typhus and typhoid fever, diphtheria, erysipelas, glanders, malignant pustule, snake-bite, dissection or post-mortem wounds, and certain forms of serous inflara mation, such as puerperal peritonitis. Moreover, the lymphatic vessels seem to bo materially affected in some skin-diseases, such as erythema and elephantiasis ; while there are structures which consist mainly of lymphatic follicles, and their diseases principally affect these follicles. The absorbent system is also concerned in an important degree in conveying morbid products from one part of the body to another, such as cancerous elements, tubercle, or the syphilitic poison, and thus of disseminating these diseases through the system. These points are more fully dwelt upon in their appropriate articles, and now the individual diseases of the lymphatic system will be discussed in their appropriate order. 1. Acute Inflammation. — According to the structures involved, acute inflammation, con- nected with the lymphatic system, presents threo varieties, namely : — (a) where the vessels are alone affected — lymphangeitis or angcioleucitis ; ( 'b ) where the condition is limited to the glands — adenitis ; or (c) where both vessels and glands are involved. It will be convenient to consider these varieties together. As a rule the disease is localized, but under certain circumstances the lymphatic system is more or less widely im- plicated, especially if the inflammation is of a septic character. It may be set up and extend with great rapidity. .(Etiology and Pathology. — The causes of acute inflammation of the lymphatic vessels or glands may be thus indicated; — 1. Traumatic, including such injuries as wounds, contusions, or a severe strain. 2. Irritation from without. Strong heat, as that of the sun, may set up inflammation of the superficial lymphatics. Pressure or friction may also produce this effect upon the vessels or glands. It is not an uncommon practice to excite inflammation arti- ficially in the glands, for the cure of certain of their diseases, by injecting irritants into their substance. 3. Irritation from within. This may be due to inflammation in the vicinity, sup- puration, ulcerat ion, diseases of joints or bones, and other causes. In medical practice the im- plication of the glands under the jaw, in cases of diphtheria and scarlatina, is a familiar illustra- tion of this class of cases ; or the inflammation of the glands behind the ear in cases of im- petigo of the head. It may also be noticed here that the lymphatic vessels are more or less in- volved in phlegmasia dolens. 4. Specific irrita- tions. These deserve separate recognition, and include syphilis, gonorrhoea, and various septic poisons, which frequently affect the lymphatic structures. Inflammation of the absorbent glands is also an important feature in plague, glanders, and other diseases. With regard to the modes in which the inflam- mation is set up, this may happen in several ways. In the first place, the cause may act directly upon the lymphatic vessels or glands, as in the case of injury. Secondly, these struc- tures may be involved by extension from neigh- bouring parts. Glands are frequently affected in this way ; and lymphatic vessels may be 908 LYMPHATIC SYSTEM. DISEASES OF. involved by continuous extension of irritation from inflamed organs, serous membranes, or other structures with which they are connected. Thirdly, the cause of the inflammation is often more or less remote from the situation in which 'it appears, especially in the case of the glands. This may arise from the condition passing con- tinuously along the vessels from some seat of irritation to the glands in their course; or mor- bid products may be carried by the current of lymph to the glands, the vessels themselves be- ing unaffected, when the inflammation thus set up is said to bo sympathetic. In other instances pus has been found within the lymphatic vessels, having made its way from some seat of inflam- mation. It may also be mentioned that lymphatic inflammation may originate a similar condition in other structures, such as the joints, and this may be of a purulent character. ' Inflammation is much more readily excited in the lymphatic structures in some persons than in others, and especially in those who are of a strumous habit. The glands are more liable to ■be affected in the early periods of life. A low state of the general health may predispose to inflammation of these structures from slight causes. Glands which are chronically enlarged, as the result of inflammation, are very liable to become the seat of acute inflammation from slight causes. Anatomical Chakacters. — Inflammation af- fecting the lymphatic vessels presents two forms, but they may be met with together. When the minute capillary network is involved, the con- dition is termed reticular lymphangeitis ; the skin and its capillaries are generally affocted at the same time, so that there is more or less diffused redness, but it may present a reticulated arrangement. Tubular lymphangeitis signifies that the main vessels are implicated. They are visible on the surface as red lines, straight or wavy, passing to the gftnds. They become dilated, and their walls thickened. Their in- ternal coat is opaque and uneven, and the endothelium often disappears. Coagulation of the lymph within the vessels takes place, closing tip their channel. The coagulum may become organised, so that they are permanently ob- literated; or it may soften and even suppurate at the centre, and the products may enter into the general circulation, and thus cause septi- caemia or pytemia. The inflammation is liable to extend to the surrounding cellular tissue, leading to exudation, hyperplasia of cells, and consequent swelling and thickening. Inflammation of lymphatic glands is charac- terised in the early stage by swelling, congestion, and increased firmness. The lymph accumu- lates, exudation takes place, and abundant cells are present. The inflammatory process may soon subside, terminating in resolution. In many cases, however, suppuration ensues, especially in certain forms of inflammation, this com- mencing in the centre of the glands, the cavities of which become more or less speedily filled with pus. The inflammation spreads to the surrounding cellular tissue, and, an abscess be- ing formed, the pus makes its way to the sur- face. If the glands are internal, they may burst, there, and lead to serious consequences; or by merely setting up irritation in adjacent struc- tures, they may produce similar results. Some- times the glands remain permanently enlarged and indurated, especially after repeated attacks of inflammation ; and they may become adherent to the parts around. A single gland may be in- flamed, but it is common for a cluster or a chain of glands to be involved. In some cases the in- flammation assumes a more or less sub-acute character, and the progress of events is slower. Symptoms. — These are local and general. The local phenomena consist of subjective sensations, and objective signs. Pain is felt at the seat of inflammation, which may be very severe, often accompanied with a sense of heat or burning, and stiffness or tension. There is usually marked tenderness, and this may be present when little or no spontaneous pain is complained of, while it is often remarkably limited to the line of an affected lymphatic vessel. Movement also increases the pain. The subjective sensa- tions are more severe as a rule when the glands are involved. When suppuration takes place, the pain tends to assume a shooting and throb- bing character. As regards objective signs, inflamed lymphatic vessels, if superficial, are usually visible as red lines, either straight or wavy, running in the direction of the glands; or there may be separate red patches. Should they be deeply situated, however, the vessels cannot be seen. The larger trunks may be felt by the fingers, being cord-like, firm, and knotted. The surrounding tissues are seen and felt to be more or less swollen and indurated. If the cir- culation of the lymph is much interfered with, a limb may be considerably enlarged, and presents a feeling of firmness and solidity, owing to the occurrence of lymphatic oedema. When the lymphatic glands become inflamed their enlargement can be detected, and the sur- rounding tissues may also be swollen. At first they feel firm, but if suppuration takes place they become more and more soft, and at last present a sensation of fluctuation. The over- lying skin is markedly red, and there is often subcutaneous cedema. Suppurative inflammation of tymphatic glands constitutes the condition known as ‘ bubo.’ If not opened artificially, the abscess ultimately bursts externally, but it may burrow considerably before doing so, and the opening is often imperfect. Sec Bubo. The general symptoms accompanying inflam- mation of the lymphatic structures vary in their intensity in different cases, according to its seve- rity, extent, and results. In the slighter cases there is no obvious constitutional disturbance. As a rule, however, more or less fever, with its accompanying symptoms, sets in, preceded often by shivering or even distinct rigors. II suppuration occurs the rigors may he repeated ; the pyrexia increases; and more or less wasting follows, if there should be prolonged discharge of pus. Where the inflammation is of a septic character from the first, or when septic matters are conveyed into the circulation, the genera, symptoms are exceedingly grave, being similar tc those indicative of septicaemia from other causes such as repeated rigors, high and erratic fever great weakness and prostration, low nervna symptoms, weak and rapid cardiac action asx LYMPHATIC SYSTEM, DISEASES OF. »09 pulse, and other typhoid phenomena. The ter- mination is then usually fatal. Treatment. — In the management of any acute inflammation affecting the lymphatic vessels or ■ glands, the first indication is to get rid of its cause, if this be practicable. In the next place rest is of essential importance, and the affected part should be so placed as to avoid all pressure er tension. As regards local treatment, the ap- plication of heat and moisture, by means of fomentations and poultices, usually answers best. To these anodynes may be added, if necessary, especially belladonna; and the latter may be often applied with advantage in the form of ex- tract, mixed with glycerine. Itis not uncommonly advisable to take away blood locally from the neighbourhood of inflamed glands, by means of leeches. Some authorities maintain that sup- juration may sometimes be prevented by counter- rritation around the glands, effected by applying jlistering-fluid or strong iodine. If suppuration take place, the progress of the pus towards the mrface must be encouraged by the usual means, md the abscess opened at the appropriate time. Should general treatment be required, at first it s usually necessary to keep the patient on low diet, to open the bowels well, and perhaps to .dminister some simple saline mixture. When uppuration occurs, a more or less supporting onic and stimulant treatment is called for. In eptie cases the free use of alcoholic stimu- ints, with the administration of full doses of uinine or salicine, constitutes the appropriate treatment. 2. Chronic Inflammation. — It is only the mphatic glands which can be said to be liable < this affection — chronic adenitis. They may main in a condition of chronic inflammation 'ter one or more acute or sub-acute attacks ; or iis is set up as a chronic affection from some ■ntinued or repeated irritation. Formerly a W form of chronic inflammation was regarded the primary lesion in scrofulous or tubercular inds, and some pathologists still hold this view, le affected glands are enlarged and firm, and uallv somewhat painful and tender. These anges may be due partly to a hyperplasia of le gland-structures, partly to an exudation into rir midst. Frequently they continue in this idition for a long time, without undergoing y obvious change, hut they are liable to acute icerbations from slight causes. They may ulti- tely become the seat of caseous degeneration, -pf suppuration, even though there is no evident i ofulous diathesis. The circulation of the lymph t ough the involved glands is prevented to a later or less degree. Usually there is no con- * utional disturbance, unless a considerable tuber of glauds are implicated, or they dege- tate or suppurate. Treatment. — It is not desirable to allow t onic adenitis to continue, as unpleasant or c n serious consequences may ensue, and there- I ■ it should be subjected to proper treatment v rout delay. Any source of irritation must be tjoved at the outset. Gentle friction over the e irged glands, with some simple oleaginous o reasy material, may be effectual in reducing t n, or ;t may be necessary to rub in weak II n e ointment, or to paint the surface with tincture of iodine. Counter-irritation by blisters may be sometimes useful. Internally cod-liver oil and quinine are frequently of much value ; preparations of iron are also often very service- able, especially the syrup of the iodide. 3. Scrofulous or Tubercular Disease. — The morbid condition of the lymphatic glands thus named may be conveniently discussed here, as the ultimate effects produced are very similar to those which result from chronic inflammatiol in certain cases. This affection, however, is sup- posed to be one of the manifestations of a par- ticular diathesis — the scrofulous or tubercular — in which the absorbent glands are very prom 1 to become the seat of certain changes of a de- structive character. It will be discussed at greater length in other articles, and here it will suffice to offer a few general remarks on the subject. HStiologv. — Scrofulous disease of the glands often occurs in those who present obvious cha- racteristics of the diathesis ; but this is by no means always the case, for the subjects of the glandular affection may be apparently strong and healthy. Children and young persons are by far most frequently affected. The glandular change may originally be set up by some irritation, which seems to give it a start, but in many instances there is no such obvious cause, and it appears to cco-nmence spontaneously. Once an absorbent gland becomes the seat of scrofulous changes, others in connection with it, or even at a distance, are very liable to become secondarily implicated. Anatomical Characters. — Scrofulous disease may involve the lacteal as well as the lymphatic glands, and of the latter those within the body may be affected, as well as those which are external. This disease of the lacteal glands is separately discussed (see Mesentejhc Glands, Diseases of); and also that of certain lymphatic glands within the chest (see Bronchial Glands, Diseases of). Of the external glands, those in the neck and under the jaw are most com- monly involved. The changes always go through a more or less chronic course. At first the glands become enlarged and firm, and, accord- ing to most observers, this seems to be merely due to a hyperplasia of the lymphatic elements. These, however, possess but a very low de- gree of vitality, and have a marked tendency to degenerate and disintegrate, so that the tissues become destroyed. Ordinarily caseation takes place, the substance of the glands becoming yel- low and softened ; then a slow process of un- healthy suppuration generally ensues, leading to the formation of chronic abscesses. The skiD over them presents a congested appearance, and is often undermined for some distance, the sub- cutaneous tissues being involved in the suppura- tive process. If the abscesses are not properly opened, they are liable to cause much destruction of the skin, and to leave unhealthy sinuses and ulcers when they burst of their own accord. If they subsequently heal, this is often attended by extensive scarring, and the scars are permanent, but become less marked in course of time. In some cases the glands do not suppurate, but. after caseation they become calcified and inert; it appears that this result may take place even after the formation of pus, which then becomes in- spissated, and mixed up with calcareous matter. LYMPHATIC SYSTEM, DISEASES OF. 010 Symptoms. — In the case of the external glands, with which we are now concerned, the changes above described can be observed clinically. They are attended with little or no pain, but there is usually more or less tenderLess. Constitutional symptoms are usually prominent, when the glands become to any extent the seat of scrofulous disease. There may bo the symptoms of the diathesis ; but the glandular affection Itself also tends to produce wasting, anaemia, general weak- ness, and more or less pyrexia, which, if there should be abundant suppuration, is apt tc assume a hectic type. If the glandular disease is limited, however, the system may suffer but little or not at all ; and even alter it has been extensive and severe, so as to lower the patient very much, recovery may take place under appropriate treat- ment, the patient ultimately becoming strong and robust. When the internal glands are affected, they may give rise to symptoms from their mere mechanical presence, such as those indicative of pressure or irritation ; and if destructive changes occur in them, very serious results are liable to be produced. The general symptoms are also usually more marked in these cases, and may become extreme in degree. It must be remarked that it is highly probable that phthisis may be set up by an infective process, in connection with suppurating or caseous scrofulous glands. Tkeatme.nt. — General treatment is of essen- tial consequence in the treatment of scrofulous disease of glands. The patient should be placod under the most satisfactory sanitary conditions that can be obtained ; but in many cases this is a very difficult matter, and it is of great im- portance, if possible, to remove from their un- healthy and often wretched homes those suffer- ing from this affection, and to treat them in suitable sanatoriums or hospitals. They should be as much as possible in the open air, and a change of air will often prove of decided benefit to those suffering from scrofulous glands. Resi- dence at the seaside, with sea-bathing, is also of much service, or a sea voyage may be desirable. The digestive functions require careful attention and regulation ; and the food must be nutritious, including abundance of good milk, fresh eggs, and such articles of diet. As regards medicines, those which are usually indicated are cod-liver oil, quinine, and preparations of iron, especially the syrup of the iodide, steel-wine, or Parrish’s syrup. Where there is much suppuration, marked benefit has been found to result from the adminis- tration of minute doses of sulphide of calcium, and from chloride of calcium. Local treatment is usually called for. In the early stages attempts may be made to cause ab- sorption of the enlarged glands, but these must be cautiously conducted. Gentle friction, the application of preparations containing iodine or certain iodides, and the use of poultices or fo- mentation of sea-weeds, arc the measures usually adopted. In some cases it certainly seems the best plan of treatment to try to encourage sup- puration in glands which are in a torpid state, and which cannot be absorbed. For this purpose they have been injected with irritants. Suppura- tion ant its consequences must be treated on ordinary principles ; but it should be remarked that abscesses should not be allowed to burst of their own accord, but need surgical interference, as otherwise they may lead to much destruction of the skin and subcutaneous tissues. 4. Hypertrophy and Atrophy of Glands. The lymphatic glands become hypertrophied un- der different circumstances. In some cases there is a mere local hypertrophy, which shows no tendency to progress towards other parts, and which may be due to some obvious irritation, or independent of any known cause. As has been already pointed out, hypertrophy is the earlv condition of scrofulous glands. This morbid change is most important, however, in connec- tion with the disease termed lymphadenoma, or Hodgkin’s disease, in which there is a progres- sive enlargement of the lymphatic glands ; and with one form of leucocythimia. These affec- tions are discussed in separate articles. Without entering upon any lengthy description, therefore, it will suffice to remark that in these affections the enlargement varies much in degree and ex- tent in different cases ; that it is due simply to an increase of the normal lymphatic structures; and that the glands usually show no tendency towards any degenerati ve or destructive change. Clinically they are recognised by their obvious physical characters when superficial; or by phy- sical signs when situated in internal cavities. As a rule they are painless ; but may give rise to various symptoms by their mechanical pres- sure, irritation, or destructive effects. In many cases more or less severe general symptoms are present. See Leucocyth.emia; and Lymphadb- noma. Atrophy of lymphatic glands may occur after inflammation; as a senile change; after the re- moval of a limb, or its long-continued want of use ; or from other causes. No definite effects can be referred to this condition, but if there should be extensive glandular atrophy it might obviously interfere with the due nutrition of the blood and general system. 6. Morbid Formations and Deposits in Glands. — Under this heading the following may be considered : — a. Caitccr . — The various forms of malignant growth frequently involve lymphatic glands. In most cases the disease is secondary to cancer in some neighbouring part, and the glands are very prone to become involved, owing to the cancer- elements being directly conveyed to them by the lymphatics. This is well exemplified by the implication of the axillary glands when the breast is the seat of cancer. Not uncommonly, however, the formation is primary in the glands, and then involves other structures by direct ex- tension or convection. All forms of malignanl disease are met with, but the encephaloid variety is most common. When secondary, however, i> generally approximates in characters to tlu primary formation, and hence may be of a scir rhous or melanotic nature. It may also be men tioned here that secondary sarcoma occurs ii the lymphatic glands. The growth may attain i considerable size, and it is more or less node lated. The consistence will depend on th variety of the cancer ; often it is soft, and milky juice escapes on pressure. If eancerou glands aro external, they can be recognised o examination, and are usually painful and tende LYMPHATIC SYSTEM, DISEASES OF. 911 ■When situated internally they give rise to physi- cal signs of their presence, either in the chest or the abdomen; and to more or less pressure- symptoms ; -which may be combined with the con- stitutional symptoms of malignant disease. It may be very difficult to distinguish clinically between cancerous glands and lymphadenoma- tous growths situated internally. b. Albuminoid, disease. — The glands are liable to be involved in conditions which give rise to albuminoid degeneration. On section they pre- sent the peculiar waxy, pale, translucent, homo- geneous appearance characteristic of tissues which are the seat of this change. The glands may be enlarged; but when they attain a consi- derable size, this is partly due to hypertrophy. In other cases they are small and firm. This condition may give rise to symptoms by pres- sure, as sometimes happens in the case of albu- minoid glands in the portal fissure, which may cause ascites or jaundice. c. Pigmentation. — The bronchial glands may be the seat of a deposit of black particles in cases where the lungs are thus affected, as in miners, colliers, &c. They are enlarged to some extent, and black ; and a black liquid escapes on pressure. This condition does not give rise to any obvious symptoms. More or less pigmen- tation of these glands is often observed with advancing age. d. Syphilitic growths. — The glands in the groin are affected from the irritation of the primary syphilitic sore, and others are often involved in connection with its secondary and tertiary effects ; but no doubt they are also liable to become the seat of special syphilitic formations. e. Tubercle. — The condition of glands usually termed ‘tuberculous’ has been already con- sidered, but sometimes distinct grey granulations ure found in connection with acute tuberculosis. They originate in the follicles of the glands. Treatment. — Practically the treatment of the morbid formations in glands just considered, if iny be called for, consists in measures directed igainst the constitutional condition of which they ire a manifestation. In the case of cancer, opera- ive interference may be demanded. Symptoms, specially those resulting from pressure, may Iso require special treatment. 6. Chronic Changes affecting Lympha- ic8. — The lymphatic vessels are subject to two rincipal classes of chronic changes, namely (a) dilatation and hypertrophy ; and ( b ) Obstruc- on. a. Dilatation and hypertrophy — Lymphangiec- sis. — Leaving out of consideration the thoracic ict and receptaculum chyli, the lymphatics, '.her superficial or deep, and also the lacteals, ly become more or less dilated and hypertro- ied. Even the vessels of internal mucous or •ous membranes may be thus affected. In most les the larger trunks are implicated, but the Hilary plexuses are sometimes chiefly or alone •olved. With regard to the causes of this con- ' ion, it is often congenital, and has then been i ributedto a want of specialisation in the lvm- 1 itic system of certain parts. In other cases it 1 vidently due to some obstruction to the circu- 1 on of the lymph, and consequent, enlargement 0 ho vessels behind the impediment. Such ob- struction may be seated in the glands or vessels, and in the latter case may be due to internal plug- ging or to external pressure. In some instances the enlargement of the lymphatics partakes of the character of a primary hypertrophy, either alone, or along with other tissues, as in connec- tion with elephantiasis and other growths, of which enlarged lymphatics constitute an im- portant element. Dilatation has been also attri- buted to a supposed paralysis of the muscular coat of the lymphatic vessels. Lymphangiectasia is most common in warm and moist climates. There, are various forms which enlarged lym- phatics assume. Thus, there may be simply a localised dilatation of the capillaries, consti- tuting a visible freely-anastomosing reticulum or network. More commonly the trunks are enlarged, assuming a tubular, fusiform, vari- cose, saecnlar, or cirsoid form. Or a distinct growth may be produced, which has been speci- ally termed lymphangiectasis, and has been divi- ded by Wagner into three varieties — (i.) simple ; (ii.) cavernous ; (iii.) cystoid — names which sufficiently indicate their several peculiarities. The walls of the vessels are often more or less thickened from hypertrophy. Dilated lymphatics are liable ultimately to give way, with conse- quent escape of the lymph. Clinically the conditions now under considera- tion are visible when superficial, or when occur- ring on a surface which can be inspected. The appearances will differ according to the par- ticular morbid chaDge present. There nmy lie a distinct tumour; or the enlarged lymphatic- may only' form one element in certain growths. Cystic formations originating in the lymphatic system are said to be most common in connection with the upper lip, tongue, and neck. I is beyond the province of this article to describe these conditions in anv detail. Enlargement of the superficial lymphatics is chiefly observed pn the inner side of the thigh, the sides of the ab- domen, and the scrotum and penis; they appear in the form of vesicles like grains of sago, grouped regularly or irregularly Sometimes only am- pullse are formed, which are generally soft and painless. These conditions have been mistaken for hernia, abscess, scro ulous glands, and other diseases. Should the dilated lymphatics rup- ture subeutane usly, vesicles containing a clear or milky fluid appear. They may rupture on the surface of the skin, the lymph being dis- charged externally, which is an important ele- ment in the diagnosis of doubtful cases. When dilated absorbents are situated internally, they cannot be recognised unless they should happen to runture, with the escape of their contents by some outlet This applies mainly to the lacteals, the contents of which may pass out with the stools, and to the urinary mucous membrane, it being supposed by some pathologists that the condition termed shyluria is merely due to the rupture of dilated lymphatic vessels in this membrane. b. Obstruction . — As in the case of dilatation, the capillary plexuses or larger lymphatics may be obstructed. This may arise chiefly from pluggingof their channels by coagulated lymph; inflammation of the vessels: pressure by enlargod glands, aneurisms, or other tumours, or tnoruly 912 LYMPHATIC SYSTEM. as a result of inflammation of the cellular tissue around the vessels. It may he remarked here that lymphatic tissues, similar to those observed in the glands, sometimes form here and there in the course of the lymphatics in cases of lympha- denoma. The lymphatics of the urinary mucous membrane are also supposed by some pathologists to become the seat of aggregation of the animal parasites named filaria, and they consider that this is the cause of chyluria. The effects liable to be produced by obstruc- tion of lymphatic vessels are swelling, from so- called lymphatic oedema ; and dilatation of the vessels behind the obstruction, which may lead to their rupture. It is by these effects alone that this condition can be recognised clinically. Treatment. — But little can be done for the chronic changes now under consideration affect- ing lymphatic vessels. Proper bandaging, or the use of some elastic support, may be of use in treating dilated vessels, if they happen to be con- veniently situated. Friction and kneading may assist in removing lymphatic oedema due to ob- struction. Growths come under the treatment of the surgeon, and do not call for any special remark here. Frederick T. Roberts. LYMPHATIC TEMPERAMENT. Sec Temperament. LYMPHOMA. — A synonym for lymphade- noma. See Ly.mphadenoma. LYMPHORRHAGIA or LYMPHOR- RHCEA ( lympha , lymph, from vvfitprj, water ; and frfiyvv/xt, I burst forth, or pea, I flow). Definition. — These terms literally signify a flow of lymph, but they are used to indicate an abnormal discharge from any part of the ab- sorbent system, whether it be of lymph or of chyle. .Ft 10 logy and Pathoeosy. — L ymphorrhagia may take place from the lymphatic capillaries or trunks; from the lacteals ; from the absorbent glands; or from the receptaculum chyli or tho- racic duct. Cases in which this condition occurs are usually divided into traumatic and idiopathic , according to their apparent causation. In the former the cause is a wound, which generally affects either the thoracic duct, the larger ly 7 m- phatic trunks, or the glands. A discharge of lymph has in rare instances followed even a slight wound, particularly in the neighbourhood of joints, and this was attributed by the late Mr. Messenger Bradley to a constitutional defect — a lymphorrhagic diathesis, corresponding to the haemorrhagic diathesis. Idiopathic lymphorrhrea is almost always the result of dilatation of a ves- sel or vessels, which ultimately rupture. They lire often greatly distended before they give way. Allusion may again be made here to the supposed relation of chyluria to the presence of filaria in the lymphatic vessels of the urinary organs, these 1 LYSIS. parasites causing them to rupture, and the lymph consequently being discharged with the urine. Symptoms and Effects. — Should an escape of lymph take place upon any part of the surface of the body, it differs much in its quantity and characters in different cases. It may be less than an ounce, or amount to five and even ten pounds within the twenty-four hours; while in the same case its quantity is liable to variation from time to time, and the flow has even been known to assume a periodic character, increasing during the period of digestion. In traumatic cases the discharge either presents the ordinary appearance of lymph, being clear and limpid, or it is mixed more or less with blood or with in- flammatory products. 'When rupture takes place spontaneously after dilatation of the vessels, the fluid is more like chyle, being more or less milky and white, from the presence of particles of fat, but its characters are liable to alter from time to time. It contains a variable quantity of fibrino- genous elements, and is proportionately disposed to coagulate spontaneously 7 . Internal lymphor- rhagia causes different results. In the case of the intestines and urinary 7 organs, the fluid is discharged with the feces and urine respectively, in the former case being supposed to give rise to fatty stools, and in the latter to chyluria. The late Mr. Bradley attributed some cases of effusion into serous cavities, such as certain forms of hydrocele, hydrocephalus, pleuritic effusion, and ascites, to a lymphorrhagia into the respective cavities ; and the writer has met with a case of ascites which seemed to support this view. Fatal peritonitis has resulted from the entrance of chyle into the peritoneum, owing to the rupture of a dilated receptaculum chyli. The escape of lymph or chyle out of the system tends to affect the general health, and if it is in large amount, this is likely to lead to marked emaciation, debility, and anaemia. Treatment. — In external lymphorrhagia all that can be done is to check the flow of lymph by pressure of bandages, and the application of astringents. In cases where it takes place into internal passages, tincture of iron in full doses may be of service. The general condition must be attended to, and improved by nutrients and tonics, if required. Frederick T. Roberts. LYPEMANIA (Aihnj, grief, and panto , mad- ness). — The name applied by Esquirol to the form of insanity characterised by mental depres- sion, usually 7 called melancholia. See Melax cholia. LYSIS (\0w, I dissolve).— This word hai formerly various significations, but is now ge nerally applied to the gradual decline of an disease or pathological process, especially fevei I See Fever. M MACUTjJE ( macula , a spot or stain). — Synon.: Fr. Macules ; Ger. FlecTce. Description. — Willan’s definition of macula is ‘a permanent discoloration of some portion of the skin;’ and that author adopted the term as the title of his, eighth ordor of cutaneous affec- tions, including sunburn, naevus, and spilus. The term macula is likewise applied to a hyperaemic Btate of the skin, which may be simply chronic without being permanent, such as those which hare received the name of macula syphilitica. Maculs, therefore, may be merely pigmentary, and located in the rete mucosum alone ; or they may be haemostatic or haemorrhagic, and be seated in the derma and subcutaneous tissues. Sunburn, freckles, liver-spot, bronzed and melas- mic spots, and the stains left on the skin after the dispersion of certain cutaneous eruptions, such as lepra vulgaris, acne, lichen planus, syphilis, and elephantiasis, are examples of pig- mentary maculae, whilst leucosmic spots and blotches represent an absence of pigment. The maculae resulting from a permanent hyperaemia >f the blood-vessels of the skin, such as flat vas- mlar naeviand the claret-stain naevus, are haemo- static and disappear under pressure; whilst the lsemorrhagic maculae are represented by the scape of the red corpuscles of the blood from the •essels, and their diffusion in the connective tis- ues, such as occurs in purpura and in bruises. Treatment. — The therapeutics of maculae will e found treated of under the heads of pigmen- iry affections of the skin, and of the respective iseases with which they are associated. Erasmus Wilson. MADEIRA ; North Atlantic Ocean. — foist, mild, equable, relaxing climate. Mean imperature in winter, 60’6° Fahr. Prevailing indN.E. See Climate, Treatment of Disease by. MADNESS. See Insanity. MADURA-POOT. — A synonym forfungus- ot of India. See Fungus-Disease cf India. MAGGOTS. — A popular term for tho para- de larvae of various insects, including hots. See Istrus. MAGNETISM, ANIMAL.— This name is formerly applied to the imaginary new force principle, supposed to be akin to magnetism, d to be in operation when individuals were esmerised.’ This hypothetical new force was 'might to be called into play by the mesme- er ; and it was deemed to be by virtue of its luence that the will, thoughts, and actions of ' ( ‘medium,’ or person mesmerised, are capable ‘ being influenced in the so-called mesmeric 1 nee or sleep. This view as to the nature of 1 causal conditions is now regarded as alto- [ her erroneous, although certain remarkable < cts appear to have been produced on many 1 sons by so-called ‘ mesmeric passes,’ or other 58 means, owing to the induction in such persons under physiological conditions, of some at pre- sent impprfeetly understood state or modification of cerebral activity (sea Mesmerism). This state is now generally spoken of as the ‘ hypnotic condition.’ 1 hypnotic sleep,’ or ‘hypnotism’; or more rarely as ‘ induced somnambulism.’ On the other hand, when such a state is induced, as a therapeutic means or agency, it has been spoken of as ‘ Braidism.’ See Braidism. H. Charlton Bastian. MALACOSIS (y-aXaubs, soft).- — A term for the morbid softening ofstructures. See Softening. MALACOSTEONf/uaAasbs, soft, and omlov, a bone). — A peculiar disease of bone, charac- terised by softening. See Mollities Ossium. MALAGA, in South of Spain. — Dry, mild, bracing, equable climate. Mean temperature in winter, 55° Fahr. Winds; N.W. ( Tcrral), dry and dusty; E. (Lcvante), cold and damp. Draw- backs : bad drainage and cookery. See Climate, Treatment of Disease by. MALAISE (Fr.) — Synon. : Indisposition; Ger. Missbefinden. — In cases of simple digestive derangement, in ague, and in the stage of inva- sion of many acute diseases, the patient very commonly first becomes aware that his health is disturbed by a feeling of general illness, which is known as malaise. Description. — Under tho circumstances just mentioned, the ordinarily unconscious feeling of being well, or bien-etre , which accompanies perfect health, is replaced by a painful and depressing feeling, which the patient probably cannot describe otherwise than as a sense of being weak, languid, listless, and disinclined to bodily or mental exertion. Malaise is commonly associated with bodily debility, chilliness or actual rigors, moderate pyrexia, general pains or aches, giddiness, headache, and anorexia. In the course of the more serious diseases in which it occurs, malaise either passes off or soon gives place to more urgent symptoms — such as depres- sion, apathy, delirium, or stupor ; but in other instances it persists, and constitutes the chief subjective phenomenon of the disease, as in some cases of typhoid fever. Treatment. — The treatment of malaise will depend upon the nature of the cause of the feel- ings just described, and should be directed to its removal or remedy. J. Mitchell Bruce. MALARIA (Itah). — Synon.: Marsh Miasm. ; Fr. Mauvais Air; Intoxication dcs Marais; In- toxication Tellurique ; Ger. Malaria. Definition. — An earthborn poison, generated in soils the energies of which are not expended in the growth and sustenance of healthy vegeta- tion. By almost universal consent this poison is the cause of all the types of intermittent and MALARIA. )14 remittent fevers, commonly called malarial, and of the degeneration of the blood and tissues re- sulting from long residence in places where this poison is generated. The Italian word malaria is now employed to convey the meaning expressed in the above defi- nition. It is certainly preferable to the term marsh miasm, which implies that marshes are the sole source of the poison. M. L6on Colin, Pro- fessor of Military Medicine in the Val-de-Grace, who has written an instructive work on malarial lovers, does not use the term malaria to distin- guish the agent that causes them ; he prefers the term telluric poison, intoxication tellurique, pro- ceeding from the energy of the soil, when that energy is not absorbed by its natural consumers, crops or plants — in a word, healthy vegetation. This telluric influence or poison is, however, after all, a malaria, a bad or poisonous air under another name. Essential Nature. — Chemists have not been ablo to demonstrate the presence of a malaria — a fever-generating agent — in the air of marshes, any more than they have been able so to do in other places where the same fevers prevail. Much light has. however, been thrown upon the intimate nature of the malarial poison, by the researches of Professors Tommasi Crudeli, of Rome, and Elebs, of Prague, who made the physical cause or poison t.o which malarial fevers are due the sub- jectof careful investigation in the Agro Romaiw, in the spring season of 1879. They examined minutely the lower strata of the atmosphere of the district in question, as well as its soil and stagnant waters; and in the two former they discovered ‘ a microscopic fungus, consisting of numerous movable shining spores, of a longish oval shape, and nine micromillimetres in diameter. This fungus was afterwards artificially generated in various kinds of soil; the fluid matter thus obtained was filtered, and repeatedly washed; and the residuum left after filtration was intro- duced under the skin of healthy dogs. The same iliing was done with the microscopical particles obtained by washing large quantities of the sur- face soil. All the animals experimented upon had the fever, with the regular typical course, show- ing free intervals, lasting various lengths of time up to sixty hours, and an increase of thetempera- turo of the blood during the shivering fits up to nearly 42° C.; the normal temperature in healthy dogs beingfrom38°to39 3 centigrade. The animals affected by intermittent fever showed precisely the same acute enlargementof the spleen ashuman patients who had caught the disease in the usual way; and in the spleens of these animals a large quantity of the characteristic form of fungus was present.’ Tommasi Crudeli andKlebs have given to this organism the name of Bacillus mnlarue. Doctors Marchiafava and Valenti, of Rome, af- firm that they have detected the Bacillus mala- ria in human patients, in a more advanced stage than in the animals operated upon by Crudeli and Klebs. Dr. Crudeli still more recently states, as the result of further pathological investiga- tions, that the bacilli may always be found in the blood during the period of i vasion of the fever; hut that during the acme they disappear, and spores only can he discovered. The bacilli have been found chiefly in the spleen of the human subject ; and in the marrow of bones in animate experimented on. The bacillus has not yet been found in Bengal. According to the researches of Laveran, extended and corrected by Richard, the blood in malarial fever contai ns, duri ng the acces- sion, spherical organisms, developed in connexion with the red corpuscles, and furnished with fila- ments; also certain curved and pointed bodies, w-hich are only infected and deformed corpuscles. The pigment granules of malarial blood are pro- duced in the red corpuscles during the growth of the organisms. Lancet, 1882, vol. i. p. 993. Should future investigations by independent observers in other malarial regions confirm these conclusions, it would be difficult to overrate their importance. Genetic Relations. — When we consider that in many regions of the globe two-thirds of the mortality is caused by the fevers, and their sequels, to which this poison gives rise, we can understand why all that relates to malaria is important to the statesman, the soldier, the sani- tarian, and the physician. ‘Fevers,’ savs Dr. Cornish, the Sanitary Commissioner of Madras, ‘one year with another destroy twice as many people in India as small-pox, cholera, and ail other epidemic causes put together.’ Dr. Partes has well said ‘that when a climate is called “unhealthy,” it is simply meant that it is mala- rious.’ This remark is especially true of tropical climates. Malaria has generally been said to be the product of heat, moisture, and vegetable decomposition. The terms marsh miasm, and paludal fevers, long employed to distinguish the poison and the fevers to which it gives rise, mark the almost universal belief that the air of marshes alone is endowed with the power of generating them. That low, moist, and warm localities are generally noted as malarious is indisputable. Marshes are not, as a rule, dangerous when abundantly covered with water; it is when the water level is lowered, and the saturated soil is exposed to the drying influence of a high tem- perature and the direct rays of the sun, that this poison is evolved in abundance. The pro- duction of malaria on a great scale in this way was seen in the district of Burdwan, in Bengal The soil is alluvial, but dry ; and, until withii the last few years, Burdwan was more salubriom than the central or eastern districts of the Lowe Gangetic delta. The drainage of the district be came obstructed bythe silting up of its naturalam artificial outlets, the result being a waterloggw condition of the soil, the development of malaria and an alarming increase in the death-rate. Malaria is, however, generated under condition apparently widely different, from the above. Whe the British Army under Wellington was operat ing in Estremadura, the country was so arid an dry far want of rain, that the rivers and sma streams were reduced to mere lines of widely d( tached pools ; yet it was assailed by a remitter fever of such destructive malignity ‘ that,’ say Ferguson, who records the fact. ‘ the enemy an all Europe believed that the British host was e: tirpated.’ A fever of like malignity scourged tl same army in the bare open country by whic Ciudad Rodrigo is approached from the side • Portugal, at a time when, says the same autho ‘ the vegetation was so burned up that tl whole country resembled a brick-ground- MALARIA. must, however, be kept in mind that both dis- tricts are in the rainy season flooded with water, at which time they are healthy, until the drying process begins under the action of a powerful sun. Malaria is notoriously rife in soils the upper strata of which are rich in organic matter, and are from any cause left to nature and the influ- ence of the sun. The Roman Campagna 1 is a well-known example of this kind. M. Leon Co- lin lias explored this tract of country in search of rhe commonly recognised sources of malaria, arid reports it everywhere dry and free from stagnant water. But the cultivating hand of man has long been withdrawn from this once fer- tile region, and the energies of its rich soil, in- stead of being directed to food-producing ends, are wholly given up to the development of mala- ria, for which it is notorious. It is well known that so-called malarial fevers prevail in some of the most sterile regions of the earth. Here, it is often said, ‘ there is no or- ganic matter, no vegetative energy running waste, on which to fall back for an explanation.’ Yet many of those desert places, to all appearance mder the curse of perpetual barrenness, do con- tain organic matter, and are in reality so full of vegetative energy, that water only is wanted to fit them for the productive labour of the husband- man. There are millions of acres in India, now supplying abundant harvests, which, if water was withdrawn, and the cultivating hand of man withheld, would quickly relapse into deserts ruitful only in malaria. We need not go to tropical countries in search >f examples of this kind : our own country can 'urnish them in abundance. So late as the •eign of the sister of Elizabeth, * to whose name . horrible epithet adheres,’ large tracts of country him political causes fell out of cereal cultivation, ml forthwith malarial fevers became epidemic, itended with a heavy mortality. The disturbance of soil that has long been fal- low is often followed, both in hot and temperate limatos, by the evolution of malaria. A familiar sample was the prevalence of intermittent fever 1 Paris during the construction of the Canal t. Martin ; also during the excavations for tho unifications of the same city, in the reign of ouis Philippe ; and on a larger scale in dif- uent parts of France when tho railways were i process of construction. Malaria is freely generated at the bases of ountain ranges in tropical climates. The strip land extending along the base of the Himalaya, lied the terrai, is a notable example of this nd. The soil of this region is immensely rich, ill supplied with water, and covered with dense rests, which with the vast mountain range ■ikes free perflation of air impossible. At .rticular seasons of the year it is almost certain ath to enter this region. Some rocks in a state of disintegration, when icly exposed to the drying action of the sun d air, are in tropical countries often highly ilarious, and give rise to severe forms of fever. 1 Every sanitarian must wish success to the gigantic ernes suggested by Garibaldi to make Rome fit in a itary point of view for the capital of Italy, and to ffy the pestilential Agro Romano. In the present te of matters Rome is unsuitable for a capital, except reasons purely sentimental. 91A The example most familiar to the writer from personal knowledge is the island of IIong-Kong. The soil, according to Dr. Parkes, contains only about 2 per cent, of organic matter ; but like all granitic rocks it is highly absorbent of water ; and Friedell, quoted by the same authority, affirms that it is permeated by fungi. The writer was encamped on this island before it was ceded to the British Government. At this time the soil was but little disturbed, and the troops did not suffer. But when excavations were made at a subsequent time, for the construction of the city of Victoria, on the side of the island facing the harbour, a fatal form of remittent fever appeared, which caused great mortality among both tho civil and the military population. Parkes (Practical Hygiene) thus sums up his account of the soils with the largest organic emanations: ‘1. Alluvial soils, old estuaries, deltas. Peaty soils are much less malarious. Marshes overflowed regularly by the sea are often healthy, while the occasional admixture of salt water increases the emanations. 2. Sands, if there is an impermiahle clay or marly subsoil. Old watercourses. 3. The lower parts of tho chalk, where there is a subsoil of ganlt or clay. 4. Weathered granitic or trap rocks, if vegetable matter has become intermixed ; such soils absorb both heat and water. 5. Rich vegetable soils at the foot of hills.’ When malarial fevers appear in ships return- ing from unhealthy climates, tho explanation is to be looked for under one or other of the follow- ing causes : — (a) the sufferers may have had their systems charged with malaria before embarka- tion, as is constantly seen in the case of invalids returning from India ; (b) they may have used water on board drawn from a malarious locality ; (c) tho source of tho malaria may ho in the ship, from decayed vegetable matter mingling with the bilge water, in ships under a bad sanitary regime ; 1 or (d) it may be derived from mala- rious mud, as in the case of H.M. ship ‘ Power- ful,’ returning from India, when a severe out- break of fever was traced to this cause. There is, however, reason to believe that when fever has been observed to follow the consumption of unwholesome water at sea, it has sometimes been not malarial but enteric, from the unsuspected presence in it of the specific germs of that disease. Instances are also recorded, in which symp- toms having aperiodic character, and yielding to the treatment which is effective in malarial dis- eases, have resulted from exposure to decaying vegetable matter, a connection of which with a special marsh poison could not well be traced. Attributes. — Malaria, however generated, possesses certain properties well known to those who live in malarial localities. Temperature exercises great influence over its development and activity ; many places can be visited with impunity in winter which are dangerous in summer and autumn. Wenzel made observations on the effect of temperature in the development 1 The writer is indebted to the late Dr. Mansfield, R.N., for an instructive example of a fatal form of yellow ma- larial fever on board H.M. ship ‘ Egmont,’ long used as a storeship at Rio. The ship was found to be in a stato of decay ; the timbers were permeated by fungi of a white or cream colour, giving otf a sickening and o fta»* sive odour. MALARIA. J16 of malaria during the construction of the fortified port of Jahde ; he observed that the increase of attacks of malarial fever was coincident with a rise in the temperature. In the charts con- structed by him to illustrate the point, a constant precedence of the temperature curve by twenty or twenty-five days of the sickness curve of attacks is to be seen ; so that in a temperate climate like that of Jahde, threo weeks of increased tempera- ture appeared to be necessary for the genesis of the malarial poison, and the outbreak of sick- ness. When in any year the medium summer temperature did not reach 12° R. (59° F.) the sickness remained at its minimum. Malaria drifts along plains to a considerable distance from its source, when aided by winds sufficiently strong to propel, but not to dispel it. Under the influence of currents of heated air it can ascend, in dangerous concentration, far above its source, and buildings elevated some hundreds of feet above a malarious plain are often more under its influence than those on the plain itself. When favoured by ravines and currents of heated air, it can scale mountains to a height which appears to differ in different climates, varying from four or five hundred to two or three thousand feet. It is unsafe to place human habitations on the edge of such ravines on moun- tain tracts generally considered above ‘ fever- range.’ A belt of forest, interposed between any malarial place and human habitations affords considerable protection, and a sheet of water similarly placed exercises an absorbing power — facts long familiar to sanitarians. Soils protected from the sun’s rays by forest trees are generally healthy ; but when exposed to the sun after the forests have been cleared away, malaria is evolved until the land is brought under cultivation. 1 Pathological Relations. —The physician can demonstrate the existence of malaria by the best of all tests, namely, its pathological action. This action has been recognised for ages in the pro- perty it possesses of producing a class of fevers distinct from all others in their symptoms and sequels, to which the name of malarial or pa- roxysmal has been given ; the latter term from the almost clock-like regularity of the periods of apyrexia and recurrence. Pathologists have also recognised its power of impressing on other dis- orders, in a lesser degree, the same stamp of periodicity, and its more insidious but not less dangerous endowment of inducing that ‘slow blight of the constitutional powers’ to which the term malarial cachexia is now applied. The most striking features of this condition are easily recognised. The sufferers appear much older than they are; the 6kin assumes a brownish ‘ A popular belief has arisen that the blue gum tree of Australia, Eucalyptus Globulus, is particularly effica- cious in this way. This tree is now popularly known as the ‘ fever tree,’ and is being extensively planted for pro- tective purposes in the malarious parts of Italy. Its supposed virtues are said to be due to the camphoracious constitution of the leaves of this •■cnie, gigantic, and rapidly-growing tree. It is a notable fact that the ex- tensive pasture lands of Australia are very free from malaria, and the fact is there attributed to the existence of vast forests of the blue gum tree. All the species of eucalyptus grow with amazing ra- pidity ; wherever they are planted they are great con- sumers of moisture, and thus exercise a drying influence on the subsoil, which must have a considerable effect on the climate where they exist in large numbers. yellow tint, of various shades, according to the natural complexion of the person and length of residence in an unhealthy climate. Thi-y become anaemic, with an immense increase in the white corpuscles of tlio blood. The rapidity with which this ansemia is developed is surprising. Pro- fessor Kelsch has shown by carefully conducted observations made by Malassez’s method, that in twenty-four hours a man affected with in- termittent fever lost more than a million of globules per millimetre cube. This condition of the blood often gives rise to murmurs, not confined to the cardiac region, but heard also in the large vessels, misleading unwafy observers into a false diagnosis of organic disease. Persons whose blood is thus so affected are prone to attacks of a f,-.tal form of pneumonia, if exposed to cold when not protected by sufficiently warm clothing. Their digestive and h at-generating powers are impaired, and they are liable to diarrhoea from slight causes, often of an intrac- table kind. The liver is generally enlarged, bat the most characteristic lesion is enlargement of the spleen, which often attains such a size aj to occupy a large part of the abdominal cavity. There is in the pathological museum at Netley a preparation of the section of a spleen taken from the body of a small drummer bov, who had been under the caro of the writer. This lad had spent some years of his brief life in the Pesliawnr Valley. The weight of the spleen was 10 lbs. 15 oz., that of the liver 9 lbs. 10 ozs. The con- dition was alike in both organs, an immense de- velopment of connective tissue having taken place. These two organs made up one quarter of the total body-weight of the boy. Roth spleen and liver, and sometimes even the brain and spinal card, are deeply pigmented. The urine is sometimes albu- minous, with oedema of the lower extremities— symptoms suggestive of Bright’s disease, leading to a grave prognosis, often ill-founded, as the above symptoms usually’ disappear under good climatic and therapeutic means. Neuralgic affections, varied and numerous, are common sequels of malarial poisoning; ‘brow ache ’ is a familiar example. To the above may be added palpitation of the heart, rheumatic pains in limbs and joints, and amenorrhoea ; and if, as often happens, scurvy be engra'ted on the malarial cachexia, such of the above affectionsas may be present are at once seriously aggravated. Tropical dysentery prevails in its worst forms in malarial localities ; the same is true ot sup- purative inflammation of the liver. It seems probable that when malaria acts as a predisposing cause of dy’sentery, it is taken into the system through the medium of water. It is a significam fact, elsewhere insisted on by the writer, tha- exactly in proportion as we have banished ma laria from the soil of the British Islands, so ha dysentery disappeared as an endemic disease. The late Dr. Cutchliffe, of the Bengal annv noticed that in some very malarious districts h the Bengal Presidency, large numbers of male were impotent, the women proving fruitful wit males from other non-malarious regions. I such localities, also, the children of those affee.e are often born, not only with the external signs c the malarial cachexia, but also with the viscen changes and pigmented organs described above MALARIA. Since we cannot yet affirm that the essential | nature of the malarial poison has been discovered, we may notice two other theories that have j oeen advanced. It need only be said of the few who maintain that the grave pathological changes attributed to malaria are ail explicable either on the hypothesis of ‘ chill,’ according to Dr. Oldham. or ‘certain electrical conditions,’ according to Dr. Munro, that they have a difficult thesis to support. If ‘chill’ will account for the loss of 10,000 men at Walcheren, for the frightful disaster of a like kind at Carthagena, for the terrible visitation of paroxysmal fevers in the Mauritius, and countless examples of the same kind, and for the yearly loss of life in India from fevers— the country in which Dr. Oldham serves, why, seeing that mankind are exposed to ‘chill’ everywhere, are not such fevers with their sequels universal in their prevalence, instead of being . unfilled to places under one or other of the con- ditions described in this article ? Why, above all, in a country like Great Britain, where vast nultitudes of the population are hourly exposed ‘.o every variety of atmospheric change, have paroxysmal fevers, once endemic there, disap- peared, save in such exceptional places as are j still under one or other of the conditions de- scribed above? No satisfactory answer has been given to this question. As for the ‘ electrical mnditions ’ of the other hypothesis, when its author can explain what these conditions are, and why they no longer exist in the British Islands, or do not produce their usual effects, we shall be prepared to discuss their value from a pathological point of view. W. C. Maclean. MALARIAL.— Pertaining to or connected withmalariajfor example, malarial fever , malarial region, malarial poison. See Malaria. MALFORMATIONS (male, amiss, and formo, I fashion). — Synon.: Fr. Malformations- Ger. Nisshildungen. Definition. — Deviations from the normal standard, in the size, form, number, or situation if any part or organ of the body. Varieties and ^Etiology. — The malforma- ions of the human body may be conveniently ■onsidered under two distinct heads, namely — A) Acquired malformations, more commonly ailed deformities ; and (B) Congenital mal- ormations. A. Acquired Deformities. — Acquired deformi- ies may be the result of disease, affecting, for istance, the spine, which may become curved, or le joints, or the tendons. Similarly, the bones my tie the seat of deformity, as in rickets, mol- ties ossium, or osteitis. Certain injuries and ■‘cidents, such as burns, scalds, fractures, and islocations, lead also to a great number and ir.ety of deformities. Various habits, customs, id occupations, by giving rise to pressure on rtain parts of the body, by altering the amount blood circulating through them, or by inter- ring with their due innervation, bring about inges in the relative size and shape of the bony 1 soft textures, and so lead to malformations, is thus that the brow is flattened by certain bes of American Indians ; the waist deformed, d the corresponding viscera compressed and MALFORMATIONS. 917 dislocated, by means of the tight-lacing practised by more civilized peoples ; and the feet dis- torted by many nations, especially the Chinese. Not only is such a striking example as the com- mon depression of the lower part of the sternum in shoemakers a deformity, but the huge develop- ment of certain groups of muscles at the expense of others induced by some occupations, must bo looked upon in the same light, lor these, too, aro deviations from the normal outline of the hu- man figure. Besides these cases, which may bo termed primary malformations, many others ol a secondary character, that is, dependent on somo antecedent change or lesion, are frequently seen. These may occur in organs correlated in growth, as the absence of hair on the face and pubes, and the increase of subcutaneous fat, if from any cause the testicles waste, or if they are removed before puberty. Absence of, or disease in, any part which causes the disuse of other parts, also induces a secondary deformity, as the atrophy and degeneration of a group of muscles, or ol a limb, when the nervous supply is in any way interrupted either at the centre or the periphery. The brief reference which has been made to these acquired malformations will suffice, and this arti- cle will be devoted to a consideration of the largo class of congenital deformities, and of these to such only as are of a general character Special malformations of organs will be noticed with the diseases of those organs, such as the brain, heart, and liver. Deformities of the chest, which are a subject of the greatest interest to the practi- tioner, are also separately discussed. See Defou- MITIES OF THE CHEST. B. Congenital Malformations . — Since the ap- pearance of the classic work of Bid. Gcoffroy St. Hilaire, congenital malformations have been grouped and classified, and their causes deter- mined with such approximate accuracy, that, in place of the superstitious beliefs and incredible absurdities which formerly prevailed, a distinct branch of pathological anatomy has been estab- lished, namely, that of Teratology. Instead of considering a monstrosity as a presaee of somo misfortune, a proof of divino vengeance, an effect of witchcraft, the result of intercourse with the lower animals, with demons, or even with women during menstruation or pregnancy, we now trace it either to a malformation of the original germ, or to somo cause interfering with its development, and inducing either an excess or a deficiency of parts or organs. Starting from the normal stan- dard, we find varieties in development of all kinds in two complete series, namely, an ascending series, from a mere supernumerary digit to double or even triple monsters ; and a descending series, from the mere default of a digit or organ, or the union of digits, to monsters with scarcely a traco of human structure, forming an almost shape- less mass Besides these, we may have excess or defect in the size and development of various organs and parts, or of the body cn masse, lead- ing to the formation of giants and of dwarfs. In other cases, development and size are normal, but the viscera are transposed, and this, too, may be either general or partial. From the moment of fecundation the ovum is exposed to various influences, which may alter its normal development ; and it depends on whether it i ? MALFORMATIONS. P18 subjected to these /it an early or a late stage, as to whether complex or simple anomalies result. 1. Malformations by Excess. — Reference will first be made to the formation of mon- sters by excess. Two ova may be formed in one Graafian vesicle, for double-yelked eggs are well known ; but there is no evidence to show that these would form a double monster. In- deed, Professor Allen Thomson found on incu- bating a dozen of such eggs, that not one pro- duced a double embryo ; whilst Wolff observed two completely separate foetuses developed upon a single yelk. The arrival of two impregnated ova in the uterus at the same time will probably give rise, not to double monsters, but to twins, and their fusion seems almost impossible. We are thus led to the opinion that monsters by excess depend on an error of development taking place in a single germ ; and this idea is more readily tenable since Allen Thomson has shown that, in birds, two primitive grooves may be formed on one yelk and in one area germina- tiva, for in this way the most complete cases of double monstrosity can be explained. In con- firmation of this theory, the researches of Le- reboullet may be quoted. This observer has seen, instead of the single budding of the blas- toderma, which is ordinarily developed into the embryo of the fish, two or even three buds marked off; and these, during the process of development would meet at some point, and in this manner produce parts of distinct embryos where they are separate, whilst a corresponding region . of a single organism only would be formed at the point of junction. According to the mode and extent of the junction of the blas- todermic buds, the monsters would vary ; and so would be derived all the different varieties, from a duplicity of the face or head, the upper or lower extremities, to such extreme cases as the Hungarian sisters, and the Siamese twins, who were joined by the xiphoid cartilage only, and the twin negresses (Millie and Christine) who are united by their lower lumbar vertebrae, sacrum and coccyx. In these cases all the viscera are not completely isolated and double, for in the Siamese twins three peritoneal prolongations were found in the connecting band, and there was a vascular communication between their two livers. In the case of Millie and Christine, there is a single anus and a single vulva, but two hymens, two clitorides, and very probably two vaginae and uteri. The Hungarian sisters, Helen and Judith, had but one vaginal orifice, although the upper part of that organ was divided into two, and the two intestines met in a single anus, placed between the four thighs. The Bohemian sisters Rosalie and Josepha, more recently exhibited, in whom there is a junction of the posterior wall of the pelvis, present ap- parently a single urethra and a single anus, but a double vagina. Still more curious are the mon- strosities which are only united by their vertex, as the cephalopages. where the two foetuses are placed end to end ; and the metopages, where they are placed parallel, face to face, and sternum to Sternum. In one of these cases, two normal brains, Completely separated by their membranes, were found on dissection. These compound monsters always have a single chorion, a single amnion, and a single placenta, though the umbilical cori may be double. They are always of the same sex, and their capability of living depends on tlieir having an almost completely double organisation, or on one individual being reduced to such a state of atrophy as to be a mere appendage to the other, who is almost normal in other ro- spects. The condition of the brain and of the heart are the most important factors with re- gard to their viability. They have never trans- mitted their peculiarities to their offspring. 2. Parasitic Monsters. — The parasitic fa- mily of monsters are characterised by a more or less rudimentary individual being implanted on, and growing at the expense of, another who is fully formed. This parasite may either exist as a supernumerary head, or limbs, or may be almost complete ; it may grow from the head, maxillae, or lower part of the trunk ; and when the genitals exist, it is found to be of the 6ame sex as the chief individual. Some of these cases attain to adult life, and if they have any children, these are well-formed. From such instances the transi- tion is easy to those monsters in which the para- site is either included under the skin, or even, during the approximation of the visceral laminae, becomes implanted inside the abdominal cavity, as is well seen in a specimen in the Hunterian Museum of the College of Surgeons. In these an arm, a leg, or a hand may be found; fragments of bone are common ; and even nervous, muscu- lar, or glandular structures may occur. A fibrous capsule is formed around these vestiges, and if they are sufficiently nourished from without, they may live a kind of vegetative life ; but more frequently they degenerate or decompose by contact with the air, and so causo the death of their host. 3. Malformations by Deficiency. — In the case of monstrosities by deficiency, we again have every grade, from those almost without human form, to the simplest malformation due to a non-development or defective union of some parts of the embryo. The acardiac monsters are always products of a twin conception; and the amount of their development depends on the period of its arrest, and on the degreo of anastomosis between their umbilical vessels and those of the normal foetus. Slighter malforma- tions are caused by physical or mechanical influ- ences acting on a single individual, or by some pathological lesion. Panum and Dareste, by experiments on this subject, have shown that different degrees of heat, and mechanical shocks always lead to some malformation, and that the same agency always produces the same malfor- mation. Lesions of the amnion and placenta, and twisting of the funis around the foetus, are fertile causes of deformity. On dissection a large number of deviations are found to bo dependent on inflammatory processes, causing morbid adhesions and serous effusions. These interfere with nutrition, and so lead to an arrest of development. Again, as in after-life so in the embryo, a primary lesion may induce a secondary one, as when club-feet are caused bv a defect in the nervous centres. In the produc- tion of malformations, causes of a general nature affecting the parents must not be left out o! consideration; for syphilis, chronic nlcohdism MALFORMATIONS. and hereditary influences are undoubtedly very potent factors. The writer attaches but very little importance to Demeaux’s suggestion — un- supported as it is by any valid evidence — that copulation in a state of drunkenness may en- gender malformations ; but he is inclined to give more credit to maternal impressions during pregnancy as an agent in some of these cases. Many examples which are ascribed to such influences are undoubtedly due to other causes ; but the numerous well-attested instances in physiological treatises, which prove the effects of "both prolonged, and sudden, but intense, emotion on the process of secretion, must make one pause before dogmatically asserting that the nutrition and development of the embryo cannot be interfered with in a similar manner. 4. Transpositions. — Transposition may af- fect the entire organism in some of the lower classes of animals, as in certain fishes and mol- luscs, but in man this is limited to the tho- racic and abdominal viscera. The organs nor- mally situated on the right side are placed on the left, and vice versa; whilst those which occupy the median plane are so rotated that the parts which should be found on one side of the mesial line are displaced to the other. Such transposition varies in degree in different cases, sometimes affecting all the viscera, at ether times merely one or two organs. The ■more general cases are stated by Dareste to be lue to the embryo-heart taking a turn in its sarly development to the left instead of to the •ight, which is its normal change. lie has arti- icially produced similar deformities by incuba- ingeggs placed obliquely, so as to subject their xtremities to unequal degrees cf heat, and ause an excess of development on one side, lischoff, however, attributes them to an altera- ion in the normal position of the umbilical esicle and allantois, so that the former turns e the left and the latter to the right, and uggests that this might possibly influence the te of the internal organs. A variety of malformations, such as hare-lip, .eft palate, imperforate anus or vagina, club-foot, id webbed fingers, are subjects which belong i surgery, and do not require further notice here. Tbbatment. — Many malformations, especially ich as belong to the ciass of acquired deformi- bs, admit of benefit by treatment, but as such Batment is of a purely surgical kind, it does j't require to be discussed in the present work. John Curnow. MALIGNANT CHOLERA. A synonym ’ Asiatic cholera. See Cholera. MALIGNANT DISEASES.— This term is plied to certain diseases or types of a disease ich tend towards a fatal issue. First, it is ap- ed to such diseases as cancer, which essentially dto the destruction of life ; and secondly, to i tain varieties of fevers and other acute affec- ’ as, such as typhoid fever, scarlet fever, small- 1 :, and cholera, which present peculiarly grave v aggravated symptoms, and generally end in t th. See Cancer; Smallpox; &c. IALIGNANT PUSTULE. See Pustcle, 1 UQNANT. .MALINGERING. 91i> MALINGERING. — Malingering, in the sense of an elaborate and carefully-planned attempt to deceive the medical man, is not very frequently met with in private practice ; and although the simulation of various morbid con- ditions is a common complication of hysteria, the consideration of this branch of the subject w:L find its more natural place under the heading of Feigned Diseases. The army or prison surgeon however, must be on his guard against imposture and must exercise all his diagnostic skill. For his guidance many elaborate works have been written and much information collected regarding th. nefarious way in which soldiers have often oiu witted their medical attendants. In our ou • country, under the present conditions of voli i tary service, the men seldom attempt to do mot\ than plead the excuse of some slight and tem- porary ailment to obtain remission from guard, or drills. Headaches, rheumatism, colic, diar- rhoea, and other affections of a more or less ‘subjective’ order, are naturally difficult of de- tection ; but the surgeon learns gradually by experience, and seldom fails to acquire a pret t \ shrewd knowledgeof the habitual schemer’s some what narrow range of imposture ; and hence it is that, with all its faults, the regimental system of military practice has always worked well, and enabled a sharp look-out to be kept on tht troublesome malingerer, whose ingenuity is so unprofitably expended on attempts to shirk his own duties at the expense of his more indus- trious comrades. Occasionally, however, when the soldier urgently wishes his discharge, he is induced to lay hisplans with greater decision, ami to resort either to mutilation or to the imitation of chronic disease, and in Continental armies in- stances of this sort are comparatively common. To avoid the grievous burden of conscription, aD infinite variety of artifices have been employed with greater or less success, and the ample lite- rature of the subject bears amusing record to the ingenuity with which these inventions have been carried out. In dealing, however, with the minor degrees of malingering met with at home, we must be very careful not to be over-suspicious, and not to do injustice to a real sufferer whose symptoms seem somewhat vague and incomprehensible. Numerous eases are on record in which the mystery surrounding a fixed and obstinate pain in the back has been cleared up by the rupture of an abdominal aneurism ; and Dr. Spry records, in the nineteenth volume of the Pathological So- ciety's Transactions, a most instructive case in point, A typically healthy trooper of the Second Life Guards presented himself at hospital, com- plaining of very uncomfortable sensations in the oesophagus and stomach, following the swallowing of a bone. Some suspicion of malingering was entertained at the time ; but Dr. Spry, impressed by a certain anxiety of aspect, retained the man under treatment, and three days later death sud- denly ensued, and the post-mortem examination revealed perforation of the aorta, caused by a small spiculum of beef-bone. Facts like this are abundantly suggestive of caution, and of the happy medium between excessive sharpness and undue credulity, which a wide and intelligently used experience can alone confer. Far better ia it for us to be deceived twenty times, than foi 020 MALINGERING-, unjust suspicion to be directed to the victim of some painful and depressing disease, -whose only fault may consist in his inability to supply a sufficiently clear and convincing scheme of suffer- ings which may be only too real. Robert Farqtjharson. MALPOSITION OF ORGANS. See Organs, Displacement of. MALTA. — Warm, rather moist, and very variable winter climate. See Climate, Treat- ment of Disease by. MAMMARY GLAND, Diseases of. See Breast, Diseases of. MANIA (/xavla, fury, madness). — Synon. : Fr . Manie suraigue ; Dclire aic/ue ; Fiuretor ; Ger. Tobsucht ; Wuth. Under the term mania, very distinet disorders or degrees of disorder have been described, which we shall speak of as Acute Delirious Mania ; Acute Mania ; and Mania. I. Acute Delirious Mania. — Acute delirious mania, or maniacal delirium — whichever we pre- fer to call it — is something quite distinct from that ordinarily known as acute mania. The symptoms are much graver, the course is briefer and more defined, and the treatment of the one would be quite inappropriate to the other. An outburst of delirious mania may take place after very few and very short premonitory symptoms. Quite suddenly, after a few days or even hours, the patient will display the most violent excitement, whieh may as suddenly subside, or rnn a well-marked course of a few weeks ; and if it does not terminate fatally will gradually 'decline, recovery usually taking place. Such an attack may have its origin in some sudden mental shock, as the death ©f a friend, a violent quarrel, a disappointment or -suddenly announced misfortune ; or it may arise in the course or decline of an acute disease, as pneu- monia or measles. It may also come on during rheumatism ; or after great fatigue, an epileptic seizure, or child-birth. We cannot tell at first whether theattack will j be transient or prolonged. We may try to cut it short by a brisk purgative, and by such medicines as chloral and bromide of potassium, and these not unfrequontly answer the purpose. Sleep i s procured, and perfect recovery may take place in a few days. There are patients whose organisation is so unstable that it is thrown off its balance by a eause perhaps trifling, but which produces a tremendous nerve-discharge, a com- plete disturbance of the whole mental functions. But so transient may this be, that one sleep restores the normal equilibrium, and the patient is cured. This condition in females is often called hysterical — hysterical mania. There is no special connection between it and the uterine functions, and it is better to retain the name hysterical mania for a variety to which it may be more appropriately given. The delirium, however, does not always ter- minate quickly. If sleep becomes less and less, the mind more and more confused, and quiet and lucid intervals rarer and rarer, we may be > sure that the attack will be serious and pro- longed, and that careful and efficient nursing | MANIA. for some time will be necessary. Where a quiet and airy room can be provided, and where a patient’s means are sufficient to allow him an adequate staff of attendants, an asylum is not indispensable. He will not require to take exercise in a garden ; he will not be dangerous, as some are, to himself or others, though he may be violent and excited. He may be noisy, and therefore may not be able to remain unless the house is detached. The room should be lofty and cool, the windows protected and darkened; all furniture must be removed, aud the bed made on mattresses placed on the floor, for he will not lie on a bedstead, and attempts to keep him there will end in bruises or more 6erious injury. Clothes will be torn off ; but if the weather is very hot, as is so often the case during these attacks, this will be of little con- sequence. If it is cold, a strong suit laced up the back may be put on, and underneath it the requisite body-clothes ; or a blanket may be placed round the patient, and fastened up the back. These patients are in incessant motion, singing, shouting, and talking in a string of incoherent utterances, often repeating the same sentence again and again, or a snatch of a song or text, or a rhyme of their own composition. As a rale they are not violent, and do not attack those about them, though they may resist that which is done for them. They may be hilarious and full of glee and mischief, which is a good sign ; or terror - stricken, with visions of horrible objects, which is unfavourable. They are wet and dirty ; and the urine will be high-coloured, and often retained for a long period. We shall derive valuable information if we are able t" take the temperature, but often that is a diffi- cult task. A high temperature is a bad sign: and so is a rapid pulse, if it continues persis- tently' when the patient has not been using violent exertion for some time. The tongue will often become thickly coated, dry, and brown. If it does not, but remains moist and comparatively clean, this is of good omen. Prognosis. — The prognosis in these cases is upon the whole favourable. The terminations are almost always either recovery or death. The patients are mostly young persons, who recover unless weakened by previous attacks, other disease, or child-birth. Many of the fatal cases, in the writer's experience, have been com- plicated by tuberculosis. Treatment. — Sleep in such attacks is gener- ally absent, sometimes for many days. M omen can last longer without sleep than men, and die much less frequently in acute delirium. If sleep does not come the patient dies, and our great effort must be to promote sleep by various methods. The first question will be whether we are to give drugs to accomplish this ; and it so, what drugs ? Opium must not be given ; it will not procure sleep, whether given by the mouth or subcutaneously'. It may produce a slight narcotism for half-an-hour or so, and if we increase the dose, will cause narcotic poison- ing and death ; but in the height of the attack it will not procure sleep. Chloral we may try in combination with bromide of potassium, giving balf-drachm doses of each and watching tbi MANIA. 92 i effect. In all bat the most acute cases, sleep of longer or shorter duration will be caused by these drugs ; and although it may be short, it may bo sufficient to save the patient’s life, and enable him to battle successfully with the dis- order. In the writer’s experience, many more of these acutely delirious patients died before the introduction of chloral than have done since. Yet it must not be given in enormous or repeated doses, and a considerable interval should elapse between them. It may be ad- ministered easily in stout or ale, and often in wine. Next to sleep, the most important matter is food. To enable the sufferer to withstand the exhaustion, which is the cause of death when a case ends fatally, he must be fed frequently and liberally. These patients rarely refuse food, but require careful coaxing and feeding ; and a skilful attendant will give something every two or three hours — minced meat and vegetables, or bread and milk, beef-tea, eggs, and the like. Brandy often produces great excitement at the onset and height of an attack, and stout or ale s more suitable, and more likely to bring about sleep. We may give also plenty of lemonade, oarley-water, and such drinks, if there be great leat and thirst. Although this unconscious or semi-conscious leliriuni may continue for many days, yet in ihnost every case the violence and excitement re paroxysmal, with intervals of comparative ■aim, even if there be no sleep. Judicious .ttendants will avail themselves of these quiet Intervals to administer food, and to keep the atient in the recumbent posture, thus ensuring est, instead of letting him be continually on is legs wandering about the room, and so ex- austing his strength. And when held down in his way, with cold cloths applied to the head, r his face fanned by the nurse, he is not n'ikely to drop off to sleep. Can sleep be procured by other means ? The 'rench have advocated prolonged hot baths, ut they are attended with considerable danger, /e may try a bath of half-an-hour at GO 1 or 1°, allowing it to become cooler, but it is of ) use attempting this unless the patient sub- mits to it without a desperate struggle. Cold > the head may be applied, because it is sooth- |.g and grateful to the sufferer, though it is a testion whether the circulation in the brain is uch affected thereby. The bowels maybe kept open by a few grains calomel administered in the food, or half- grain of podophyllin. Active purgation is admissible except at the very outset, and emata cannot easily be given in the violent ages. It is somewhat the fashion to apply l.sters to the nape or calves. This is most idvisable, for such parts may become very re. owing to the restlessness of the patient, d thus deprive him of sleep. Neither is it itessary to cut all the hair off, which in the je of a lady may be a very grievous matter, very long, it may he shortened without being close to the head. II. Acute Mania. — Quite different from the Conscious raving of maniacal delirium is the 1 scions but violent excitement to which we give the name of acute mania. The former is a disorder dangerous to life, running a rapid course to death or amendment in a week or two. The latter may goon for weeks or months with little danger to life, but with excitement so trouble some that the sufferers require the restraint and discipline of an asylum. Though most insane, full of delusions and insane habits of every kind, they know what they are about, and are all the more mischievous in consequence. They can take every advantage of an opportunity, and know how to exasperate those about them. They generally eat well, and sleep ii, differently, but. sufficiently to support life; and their bodily health often remains wonderfully good consider- ing what they go through. They will destroy clothes, windows, bedding, and deny or justify all they have done. The termination is nr. Ransome, of Manchester, obtained particles ■•om the breath of two persons suffering from leasles. Drs. Braidwood and Vacher have since imfirmtd this observation. Glycerine, on which lildren with measles respired during any of the ciptive days, exhibited numerous highly refrac- le bodies, larger than those seen in vaccine- mph ; others wero elongated, with sharp-cut uls, sparkling and colourless ; they were most mndant in the two days of greatest eruption ; icy were not found in the breath during jalth, nor in the course of scarlet fever and phus. After death from measles, on the ghth day, they were found in the true skin in •oups below the rete mucosum, by the lymph- iaces and sweat-ducts, but not deeper than e level of these glands ; sparkling, spindle- aped, rod-like, or canoe-shaped bodies were so seen, which did not take the carmine tinge, lese bodies were not seen in the lymph-spaces, r in the sweat-ducts and glands, nor in the ■ir-follicles. In the lung both forms were found some exudation filling the alveoli. The sphe- ■al forms have a dark, smooth outline, and not readily take the carmine stain. Near ese were rod-like, fusiform, or ovate bodies, ghtly tinged with carmine. These are quite itinguishable from the particles seen in other ms of pneumonia. With a high power, similar firkling, staff-shaped bodies were seen scattered : md the bile-ducts. None were found in the * ineys, spleen, or mesenteric glands. ;.n the blood some increase of white and a ( at decrease of red corpuscles occur during the 1 er. Numerous moving microzymes have been i n during the eruption, decreasing rapidly, i.l disappearing in three weeks ; but temoo- J ily reappearing with any febrile disturbance. Ixatomical Characters. — The mucous mem- 1 ne of the larynx and trachea is always red > measles, often with punctiform congeries of ' 3els; and not unfrequently thin films of lymph 8 found loosely adherent. The bronchi are con- ned, sometimes with exudation on the lining t nbrane, more frequently covered with muco- 1 or plugged with catarrhal mucus ; capillary ichitis with broncho-pneumonia is frequent. Lobules of the lung are often collapsed or in- flamed : the pneumonic exudation, whether the result of occluded bronchioles, or of direct conges- tion, fills or breaks down the alveoli, and invades the parenchyma. Lobar pneumonia, if extend- ing to the surface, is accompanied by pleurisy, often limited to the part of the lung affected. Fluid may be found effused into the pleura or pericardium, without any traces of inflamma- tion. Petechia are often found on the pleural surfaces. Any inflammatory signs, either cardiac or articular, in the serous membranes are so rare as to be quite exceptional. Dark, soft coagula are found in the right side of the heart, in the venae cavae, and in the cranial venous sinuses. The meninges are congested; there is injection and hypersemia of the brain-substance, and in- creased fluid in the ventricles and subarachnoid space ; more rarely recent lymph is seen on the surface of the hemispheres ; deposits at the base belong to later consequences of the disease. Congestion of the digestive tract is most marked near the ileum and colon ; externally the distended veins of the submucous coat are seen ; internally there is deep redness of the surface, the solitary glands are distended and elevated, the agmi- nated to a less degree, but there is little or no enlargement of the mesenteric glands ; the follicles of Lieberkiihn and the tubular glands of the large intestine are more distinct than usual ; a chronic ileo-colitis may result. The liver is mottled ; both the portal and hepatic veins are full; and the lobules are ill-detined and granular in appearance, with fatty particles interspersed. The bronchial glands are often enlarged, and sometimes softened ; suppuration from them extended up behind the (Esophagus in one instance. The lymphatic glands of the neck are always congested and enlarged, and often those elsewhere, as in the axilla or groin. The spleen is swollen and friable, or very little altered. The kidneys show no distinctive changes; they are hyperaemic in the earlier stages of the disease, and the tubules may then be full of epithelium and cell-debris ; the degree of after- congestion depends much on the degree of pul- monary obstruction, or on early exposure to cold or fatigue ; no albumen or casts of renal tubes are found in the urine, unless a secondary nephri- tis have been thus occasioned. Symptoms. — The symptoms of measles seldom occur until eight days after exposure to infection. They may begin suddenly, with high fever, aching pains, and vomiting, the initial fever subsiding next day, but not completely, when there may be little feeling of illness, but some signs of coryza, cough and sneezing, with enlargement of the lymphatic glands in the neck. On the third day the coryza is more marked, the cough often very troublesome, and the fever increased. Some few spots of eruption are now visible on the forehead and sides of the face. The conjunctivas are in- jected, thetonsils full and smooth, the soft palate mottled, the tongue furred, the pulse quickened. On the fourth day the eruption appears more fully, with rapid pulse and sudden elevation of temperature, often to 104° by night, with de- lirium. On the fifth day, with full rash, there is marked alleviation of all the symptoms : the cough is quiet ; the pulse is less full and fre- MEASLES. 326 quent; the tongue cleans; and the temperature, already fallen by 3° or even 4°, often reaches the normal by the sixth day, leaving the skin still deeply stained by the fading rash, and the patient ■weak. Luring the next week or ten days there is a tendency, not only to depression, but to sud- den rises of temperature, with various complica- tions that retard or endanger convalescence. We notice three stages : — the ingress ; the eruption , and the decline. The ingress . — The ingress of measles is not always with marked initial fever. Coryza and spots of the rash may be observed before illness is complained of, though some elevation of tempe- rature can be traced by the thermometer for three days before the full eruption. This febrile movement has been preceded in some cases, where thermometric observations were made throughout tlie period of incubation, by a well-marked de- pression of short duration. Before this, fatigue, headache, vertigo, chorea, and other irregular symptoms may occur. Often some slight dis- turbances of health, and even cough, have been observed all through the incubation-period ; sometimes an intercurrent disease has delayed the regular march of the invasion to seven or eight days, or the latent stage has been prolonged to ten or twelve days ; more frequently this is reduced to three days, and even these days may In- febrile from a concurrent influenza or herpetic catarrh. The eruptive fever always occupies four days. As this approaches the crisis, many symp- toms are aggravated. Incessant cough occurs, often in children with croup of the catarrhal kind; bronchial irritation with rales and rhon- chal fremitus, or possibly submucous rhonchus, may be heard at the pulmonary bases ; the re- spirations, hurried and shallow, are 30 to 40 in tlie minute ; the pulse is quickened to 130 or 140. Both the respiration and the pulse, especially the former, are more accelerated in young children ; and with them convulsions may at this period retard the eruption or prove fatal. Death before the rash is thrown out, though rare, has also hap- pened in adults.- The urine is scanty, yellow or dark-coloured, and deposits lithates ; in extreme cases it has been suppressed. Abdominal pain or diarrhoea may occur, and the latter may become a serious symptom. Thirst is great; the bps are dry; the tongue is moist, with red papillae show- ing through a thick white fur; the palate and fauces are red, from many punctiform congeries of vessels; the deep injection and swelling of the pharynx may extend to the Eustachian orifices, and cause deafness ; deglutition is painful, and sometimes difficult, from the imperfect closing of the turgid epiglottis, as well as from fulness of the tonsils. With these throat-symptoms the gland at the angle of the jaw is somewhat en- larged and tender ; but there is not much swell- ing or oedema of the overlying integument. The lymphatic glands of the neck are palpably enlarged before there is much or any rash on the skin, those of the axilla and groin afterwards. Kpistaxis is not rare. The eyelids are swollen, tlie conjunctiva being inflamed and purulent ; there is intolerance of light; there is fear of the eye being permanently injured. The noc- turnal delirium and most of the other symptoms abate when the eruption is complete. The rash . — The rash first shows itself in dis- tinct, red, and nearly circular spots, much scat- tered; fresh spots soon show in the clear skin. They begin as red points, which are raised, and feel rough or ‘ shotty,’ especially on the face, and early in the eruption; they then form crescentic groups, which coalesce into patches of irregular outline on the body. The face, disfigured by the swelbng, is first covered; then the neck and chest. The rash is also well-marked in the scapular region, extending to the rest of the trunk and to the extremities on the second day, becoming more sparse as it descends. A peculiar and offensive odour from the sick is recognisable during the whole eruptive period. The rash de- clines in the order of its invasion. Within twenty- four hours the swelling of the face subsides ; the red spots, no longer raised, become pale under pressure, and leave a yellowish discolouration. or on the shoulders marks of a dusky red. Conside- rable irritation attends tlie rash, con tinning win it to the third day or longer. At this time fine desquamation is noticed on the face; small scales of cuticle are detached from the top of the enlarged papillae, so that most of the surface is furfuraceous ; this disappears with the irritation by the second week, or may persist a week longer ; it does not occur when the eruption has been slight, hardly ever on the fingers and feet, and never in large shreds. A coppery, mottled discolouration remains on the more vascular parts of the skin, or where the rash has been most marked, for eight or ten days, and some- times continues visible three weeks from the commencement of the illness. The eruption may begin on other parts of the body than the face, as at the seat of any injury to the skin. The disease may run its course safely with very little, possibly without any eruption. An imperfectly developed dusky or livid rash is met with in severe cases. With serious lung-complication a full rash may recede. Petechial specks may accompany a mode- rate eruption, or haemorrhagic spots complicate the irregular forms. Some of the earlier spots may not only be raised and acuminate, but minutely vesicular at their apices. In the dark races the erupt ion is yellowish, raised above, but somewhat lighter in colour than the surrounding integu- ment ; in the mulatto it varies from a yellowisi to a dusky brown ; but all other signs cf thi eruptive period are well marked. The decline. Complications and sequela.— The pulmonary lesions of the febrile stage, capillary bronchitis or broncho-pneumonia, may delay defervescence, or rapidly prove fatal. Witt moderate lung-mischief the fall of temperature following the rash is often very marked, and with extrema depression further congestion c: the lung will occur. The liability to depression o: temperature which follows many acute fevers, ii specially marked in this one, and requires to be guarded against. A tendency to sudden eleva tions of temperature is also noticeable for ten o twelve days after the eruptive fever subsides rarely this has been accompanied by a recrudes cenee and reappearance of the rash, someumc- by no definite changes, possibly by some tha are obscure, of the nervous centres. The commo accidents of this period are — first, 3 return c cough in children ; this may becroupy, beginnm MEASLES. the very day of the first decline of temperature. The temperature again rises suddenly, perhaps to 103°, with greatly excited pulse and respiration. Next day there is tracheal rhonchus, but no in- creased size of the cervical glands. The cough then becomes looser, and thin shreds of false membrane are expelled. This form of membra- nous croup is as common from three to six days ifter the rash, as catarrhal croup is the day before he rash. It rarely attacks more than one child r. a family ; this is sometimes the same child who pad laryngeal symptoms in the catarrhal period, in some epidemics laryngitis and subsequent loarseness have often followed. More frequently i return of cough indicates the commencement of .ironchitis or ot broncho-pneumonia. In the lat- er a sharp elevation of the temperature of no oug duration occurs. Lobar pneumonia, less fre- ;uent, maintains a higher range of temperature ; t may be mistaken for meningitis. Pleurisy, xcept in connection with lobar pneumonia, is are. Otitis may cause a high temperature of hort duration. Three or four such inter- uptions may happen in a single convalescence, erious complications, not attended with much emperature-disturbance, are found in diarrhoea, yseutery, and passive haemorrhages. Enteritis, nth diarrhoea and dysentery, is as fatal and 'equent a complication of this disease in hot imates as are pulmonary affections with us. In mvalescence, after a critical increase ot urine, ■ie kidneys act more freely ; if during pulmonary ^struction the chlorides were diminished, they m reappear, the excretion of urea is increased, id uric acid may be eliminated in excess. Al- lminuria, unless determined by extreme neglect id exposure, is not a consequence of measles. Impairment of health results as often from is as from other specific fevors. Nerve-waste ay lead to imbecility and dementia. Acute berculosis is started, or tubercular deposits gin after measles. The strumous diathesis evoked, and may set up a troublesome oph- almia, with danger to the cornea; or a fatal torative stomatitis. Abrasions of the nares or s may persist or extend, eczema or ecthyma pear, and glandular enlargements increase or :ome chronic. Even in the. robust acute pul- inary disease is readily induced by exposure want of care during convalescence ; a liabi- . r to this, to pustular eruptions, and to irre- ( lar febrile disturbance, may persist for three ' eks. It has happened that some nervous dis- fciers, such as chorea or mania, have been nested during an attack of measles, even with ] manent benefit. Measles not infrequently ( sxists with mumps and with whooping-cough, i re rarely with varicella and vaccinia. Either t hese, taken with measles, is delayed or inter- tted, resuming its course when the eruption c ueasles is over. Whooping-cough, established 1 trehand, is temporarily interrupted by an a ,ck of measles. Scarlet fever may complicate n ,sles, also erysipelas ; or measles may be e racted in the course of typhoid fever. Diph- tl ‘ia is not so frequent a complication of measles a it is of scarlet fever. After any of these d ases the liability to suffer infoction from the o rs seems to be increased. The exemption ft, l a second attack of measles is not universal, 927 but the exceptions to the rule are so few as to be rarely observed. In two instances observed by the writer, at intervals of fifteen and twenty-five years respectively from the primary attack, the rash was preceded by the usual catarrhal fever, and was but slightly, if at all, modified. Out of numberless mistaken eases, no other has come un- der his notice. An allied form of rubeola {sine ca- tarrho ), essentially distinct, iscommonly mistaken for measles ; hence the belief in second measles. Diagnosis. — The first spots of measles, if scattered, raised, and hard, may be mistaken for those of small-pox; or the small-pox eruption may begin with some measles-like roseola. The temperature curve for the two diseases is similar. In the small-pox curve a sudden rise begins only two days before the eruption, whilst in measles there is a gradual rise for three or four days ; this iu small-pox is evidenced by a history of sudden and severe illness only on the day but one before the eruption, whilst in measles there is no such symptom on that day, the illness dating from a day or two earlier, usually with distinc tive catarrhal symptoms. The declining rash of measles leaves a mot tling of the skin, not unliko the mulberry eruption of typhus ; the latter seldom appears before the fifth day of the disease, the fever continuing high for several days after. In measles, at this stage of the rash, the fever has already begun to decline, the temperature falling suddenly, often to below the normal. The rash of rubeola sine catarrho, Eotheln, or rubella, closety resembles the erup- tion of measles ; the spots, brighter in colour and even more discrete, are preceded by only one day of headache or slight sore-throat. The incuba- tion-period generally is longer than in measles. In scarlet fever the ingress is sudden ; there is the characteristic sore-throat ; and there is the early appearance on many parts of the body of the finely diffused, comparatively smooth, bright scarlet redness of the rash. The incubation-period has been short. In erysipelas the redness appears at one part only, and extends from that, whether it be the face or other parts of the body. Roseola from irritating articles of food has very little fever, and no enlargement of the cervical glands, otherwise it might look like measles. Urticaria and erythema, with differing aspect, cause hut slight thermometric disturbance. Prognosis. — This is mostly favourable in measles ; the tendency of the febrile action is to recovery. Favourable progress may be endan- gered by — 1. The bad health of the sufferer. 2. Wantofcare. 3. Insanitary surroundings. Under either of these conditions the simplest kind of measles in a healthy subject may give rise to the worst forms of the disease. Morbilli mitiores and graviores are not essentially distinct. High fever with the eruption is not in itself unfavourable ; at this time a temperature of 105° in children, and 104° in adults, or half a degree beyond, is safely reached ; with precautions at its sud- den decline, the progress afterwards is most satisfactory. High temperature during the after- course is a sign of greater import ; it guides to various complications, and subsides as they are relieved ; occurring irregularly it is a cause for anxiety; if steadily maintained, or recurring regularly at short intervals, with wasting ns a MEASLES. 928 result, there is little hope of recovery, and none if acute tuberculosis of lung or of brain is evidenced. The latter danger makes convulsions of worse augury in the decline than during the ingress of measles in young children ; convulsions, taking the place of delirium in older persons, cease after the eruption. Recession of the rash is not alarm- ing when the attack is slight, or the temperature is low at the crisis; when there i3 pulmonary or other local congestion, and at the same time sud- den depression, it becomes an additional sign of danger. A dark rash, interspersed with fine red specks, may occur early in cases of moderate seventy ; a dusky or livid colour subsequently marks cases of considerable intensity ; petechial or haemorrhagic blotches at this time are of grave import, as indicative of scorbutus, which state ranks next to impaired nutrition in infants, as the most unfavourable concomitant of measles. Black or haemorrhagic measles, without scor- butus, is more rare than is haemorrhagic or black small-pox. Some dangerous haemorrhages may follow measles where no scorbutic condition exists. Among insanitary conditions, though the presence of sewer-gas has in isolated in- stances determined a fatal result, the most dis- astrous is overcrowding. The great mortality from measles is due to lung-disease, not at the height of the fever, but in the second week ; the frequency and severity of pulmonary complica- tions being less a direct effect of low temperature than of tainted air in which the poor are pent up for the sake of warmth. During the ingress of measles exposure to cold may occasion a highly dangerous suffocative catarrh, with capil- lary bronchitis ; after or during the rash a chill is as likely to conduce to serious diarrhcea as to pulmonary congestion, especially in hot weather. Equally depressing in their effects, these are direct results of the disease independently of weather or season. Measles contracted during acute or prolonged illness is a grave addition to the danger. In the puerperal state infinitely less mischief is produced by this disease than by scar- let fever; delivery has been hastened without mischance, or abortion has resulted, not without risk of fatal results; there are times when young married women who have not had measles should Keep from risk of infection. It would seem that the child can go through the disease in ittsro, with after-immunity. There is an instance on re- cord of a mother with measles giving birth to a child ‘full of measles,’ both doing well; others of infants having the rash three, five, and eight days after birth, when the mother was herself ill. Infants escape measles while suckling, in- somuch as they are less exposed to infection ; they suffer no less severely than others. In adolescence a body-heat of 107° has been safely passed, during the decline of measles, with no marked complication. In children of all ages a warning is given of some danger closely fol- lowing the eruption, when the normal fall of temperature at the crisis is delayed or pre- vented. In advanced convalescence sudden rise of temperature, with delirium, often marks an attack of pneumonia ; this, if of limited extent, may be hoped to end favourably in a week by resolution, without much cough, but with steady high temperature till near the end. Treatment. — Rest, pure air, equable warmth, diluents, and nourishment, are tUo chief requi- sites in the treatment of measles. All risks from exposure or fatigue should b« avoided while the disease may be only latent The first catarrhal signs demand confinement to the room ; the initial fever, rest in bed. The usual meals, moderate in quantity, can be taken; if not, milk, broth, or meat-jelly will be require!. Extra liquids, as barley-water, lem onade, or even cold water, and small pieces of ice, are pleasant and necessary. Simple salines, as potash in the lemonade, or citrate of ammonia, are useful; dilute acetate of ammonia, coloured with syrupus croci, is an old and good form ; to this a few drops of ipecacuanha wine may be added, bat neither expectorants nor diaphoretics have any influence on the cough until after the eruption. The bowels must be gently regulated; a furred tongue is not a reason for giving purgative me- dicine. No diminution of the expected critical fever, if this were desirable, will be brought about by the action of emetics and aperients; where either of such evacuations have troubled the ingress, the eruption is delayed with no after- benefit. The froe use of cold, so speedy and potent an antipyretic in scarlet and other fevers, is not required in the early stages of measles, and would be injurious until after the eruption is out. In the fever of measles a certain pro- gressive rise of temperature is necessary to its favourable termination ; where this is inter- rupted, as by debility or chill, sometimes by convulsions in infants, the warm bath is to bt used. At this stage of the disease wine is rarely necessary ; it may be required after epistaxis o for sudden depression, where food has not beei taken. The room should bo kept quiet, ant perhaps dark, so that sleep may be favoured Tepid sponging of the surface, part at a time relieves the feeling of heat and tension ; irri tation is soothed by applying cold cream to tk face, and carbolated oil to the body, or by rut bing with snot in some places. The bed-clotke should not be too heavy. An attendant may b required during the night. Good ventilatio admits fresh air without draught or chill to tfc patient. A spray of ozonised water or aromat vinegar freshens the air of the room. In thiswa; with previous good health, the danger of pulmi nary complications is lessened. AYhen sever cases have to be treated in a ward, each patiei should have a space screened off from draught and kept sweet. Directly the rash is out, tl fever falls, the tongue cleans, the appetite r turns, and the patient seems cheerful and we! ordinary food can again be taken, sleep rcturr and no alcoholic stimulant is required. On t other hand, with dislike of food, languor, or ret lessness at nights, stimulants should be givt before the dry tongue, small and rapid puli receding rash, or signs of pulmonary congestu render free and frequent stimulation indispt sable. There is, perhaps, no condition wh< wine produces such marked and immediate her fit as in the depression following upon the cri of measles ; it seems to give life, certainly is a direct means of saving it. enabling st nourishment to be taken as will soon sup altogether the needed support. Sedative* i’ MEASLES. not often required ; a small dose of Dover’s powder moderates any tendency to diarrhoea; this is always to be guarded against, and never provoked. Where, without complication, the fe- brile crisis is delayed, a dose of quinine with Dover’s powder at night has been useful. After the crisis cold bathing, with great precaution, aids sleep, and gives tone to the cutaneous, bron- chial, and pulmonary circulations ; cold affusions may be necessary for hyperpyrexia at a later stage, when, if head-symptoms threaten, ice should be applied to the head. Croupy symptoms and bronchial catarrh in children after the eruption, ire to be treated on general principles, as de- scribed in the articles having reference to these liseases. Diarrhoea at the close of measles may ake the place of pneumonic symptoms, and need jot be suddenly checked. Best in bed, carefully ’egulated diet, and stimulants, with opiate epi- hems, or an opiate enema, will generally relieve, the mineral acids, with or without a bitter, aid igestion, and can either be given very dilute as a rink at any time, or in a definite dose with food, 'or the irregular febrile disturbance noticed in le weakly, they are useful adjuncts to the quinine ■ cod-liver oil that are then essential. Some cal troubles must he treated; earache needs a )se of croton-chloral, or a warm poultice with little opium in the ear gives relief ; otorrhcea quires tepid syringing ; for ophthalmia, lead cion, and the topical use of belladonua or atro- ,i if there be photophobia, a7e necessary; the 'cllen eyelids should be raised to sea that no ury to the eye occurs while other severe symp- us may be attracting most attention. Ulcers in i ) mouth or elsewhere may have to be touched Ah nitrate of silver or boracic acid, where ; ringent washes are ineffective. After-treat- intis always important and necessary. For the f smia which attends convalescence some form c ron is to be taken with meals two or three t es a day. Cod-liver oil should be given an 1 r after meals, at least twice a day, to the s imous or delicate. Often the mineral acids " i a hitter are of service, especially when the r l has been livid or petechial. The clothing 6l ild be warm, with flannel next the skin. Cold baling rapidly performed, or with salt-water, » ) £* e recommended ; and when the weather is ne the patient should go out of doors once or vice a day, avoiding chill or fatigue. Chil- dr are the better for an afternoon sleep ; adults sh Id avoid full work, or exposure at night, for on >r two months after measles. Convalescents *h' d have a change of room in the second week of le illness ; means should then be taken to po v and disinfect the sick chamber, as by hui ng sulphur or the bisulphide of carbon in it donning ; this does not interfere with oft rooms in the house to which convalescents are moved. Change of air or place is not so nee ary ns is often supposed. Homo is the best k. ^ or cure, not only until all danger of infec- j>or i passed, but that the dangers of conva- lesc ee and the possible development of any coni utional defect may be watched, and receive ■he diest and best attention. William Squire. ^ MS U KEMEKT. — A method of physical 59 MEDIASTINUM, DISEASES OF. 92P examination, in which tape-measures and othei instruments are used to ascertain accurately the shape, dimensions, and movements of different parts of the body. See Physical Examination. MEDIASTINUM, Diseases of. — Synon. : Fr. Maladies du Mediastin ; Ger. Krankheitcn des Mediastinum. — The principal morbid condi- tions which occur in connection with that regior of the chest which is known as the mediastinum, are (1) aneurism of the thoracic aorta ; (2) in flammation of the tissues or textures within the cavity ; and (3) new growths involving the same space. Of theso conditions, aortic aneurism is by far the most common ; hut it possesses so many special features that it will be described separately in this work ( see Aorta, Diseases of and Thoracic Aneurism). The remaining pa- thological conditions involving the mediastinum will be discussed in the following pages. 1. Mediastinum, Inflammation of. — Sy- non.; Mediastinisis ; Fr. Mediastinite ; Ger. Mediastinitis. Definition. — This term has been employed by writers to denote inflammation ofihe serous sur face of the duplicature of the pleura separating the pleural from the mediastinal cavity, and also: inflammation originating in the cellular tissue or other tbxtures of the mediastinal space. In the former sense mediastinitis is but a variety of pleurisy, which, though it may he characterised by special symptoms, must be very difficult, if not impossible, to diagnose during life. We confine our attention here to inflammation and its result s in the mediastinal cavity. ^Etiology and Anatomical Characters. — There are very few trustworthy observations or record of simple acute inflammation of the me- diastinum, terminating either in resolution or in effusion of plastic lymph. An example of the latter detailed by Wildemann is probably unique. In this instance the anterior mediastinum was filled with layers of solid exudation ; the peri- cardium inflamed; and its cavity distended by six ounces of pus. The mediastinal effusion appeared to have been occasioned by long-con- tinued pressure on the sternal region. On the other hand, we have numerous examples re- corded, in which mediastinal abscesses have re suited both from primary or idiopathic, and froir secondary or symptomatic inflammation. Primary abscess, thongh rare, is occasionally met with produced either by local injury or simply cold Gunther (in Oesterreich . Zeitschr. f. prak. Heilk 1859,) and others have recorded cases of medias tinal abscess originating simply in cold. It may however, be suspected that some forgotten pliy sical injury had in some of these cases been received, as in the only case of the kind that has fallen under the writer’s notice. Dr. Goodhart in the Pathological Transactions, vol. xxviii., re- cords a case of acute mediastinal abscess, result- ing apparently from injury produced by tin. sticking of a piece of meat in the oesophagus. But by far the most frequent cause is suppura- tion of the lymphatic glands in scrofulous sub- jects, as in a remarkable instance recorded by Dr. Bristowe, in the Pathological Transactions, vol. ix. p. 46. Secondary or symptomatic ab- M EDIASTINTJM, DISEASES OF. 930 scesses, in the form of purulent depots , are not infrequently met with in the anterior medias- tinum, either in connection with operations, such as tracheotomy, or as the result of general py- aemia. Symptoms.- — The only instance of primary ab- scess of the anterior mediastinum that has fallen under the writer's observation presented the following symptoms : — A middle-aged lady, pre- viously in good health, fell on going up-stairs and struck the sternum against the stone edge of the stairs. A few weeks afterwards she complained of uneasiness about the chest, and of pains in the left shoulder and about the scapula and neck. They were not severe, and had more the charac- ter of neuralgia or rheumatism than of anything more serious. After a time there was some general derangement of the health, attended by dyspeptic symptoms, a certain degree of febrile disturb- ance, some dyspnoea, and inability to lie down except in certain positions. Two months after the accident, which had been forgotten, there was a distinct prominence over the upper part of the sternum of an oval shape, and rather less in cir- cumference than the palm of the hand, not red, but tender on pressure, and to which was referred a sense of uneasiness and pressure. The aspect of the patient was indicative of some anxiety, but not distress. The breathing was quiet; the pulse was quickened ; but there was little or no febrile heat. There was some cough, attended by mucous expectoration sometimes streaked with blf cases commence in tlie lymphatic glands of he posterior mediastinum, or in the anterior nediastinum, from, as some believe, remains of he thymus gland. They sometimes attain to in enormous size, and may ultimately involve .11 the structures within the thorax, including he heart and pericardium. In other instances, ommencing probably in the connective tissue, be disease spreads along the roots of the lungs nd sides of the bronchi, extensively involving le adjacent tissues and the lungs themselves, ithout, for a long time, giving rise to any con- derable tumour. In other cases several distinct imours are developed at some distance apart, he period at which pleuritic effusion, or oedema 1 tho external parts occurs, also varies greatly, bus, too, it happens that alterations in the ex- rnal form of the chest are early manifest in me cases, and not till later in others. In some stances these alterations of form are limited, in ,hers they implicate the whole of one side, or en the whole contour of the thorax. In not few instances, whilst the growth is still of lited extent, and confined to the posterior me- jistinum, the symptoms so closely resemble those aneurism as to make the diagnosis extremely ■iScult and uncertain. The more prominent inptoms are indeed in some instances, and i a long time, mainly cardiac. In the most i lignant types of disease, and where, as in far t greater number of instances is the case, the 1 iphatic glands of the thorax have become i >licated by extension of disease from other o ms, the local thoracic symptoms are from the f ; assoc.ated with those general symptoms Well are characteristic of malignant disease, a pass under the term of cancerous cachexia. S omatous tumours, on tho other hand, at- h a considerable size without constitutional syptoms of any special character. As a rule ithay he said that all intra-thoracic growths te to develop inwards rather than outwards; ar thus often overlap the limgs and heart, P 8 ) along the great vessels and nerves, and P r i on those parts that offer- least resistance. It only in very rare instances that the chest- Wi 1 become eroded by the outward pressure of th umour, as in so many cases of aneurism. T1 is the more remarkable because in many in- stsies the presence of the growth is distinctly in- dicated by external tumour, arising from outward pressure of portions of the chest-wal Is. Thisis of course especially the case when the growth is in immediate proximity to the walls of the chest. In the case of large tumours the external form of the chest may be rendered unsymmetrical by displacement of the heart, and downward pres- sure on the diaphragm and liver. There is, how- ever, another and very distinct mode by which the symmetry of the chest is affected, and that is by collapse of the lung and sinking of the chest- wall, in consequence of the pressure exercised on the root of the lung, by the progressive advance of the tumour. The effect of this is sometimes rendered still more apparent by the corresponding expansion of the opposite lung, either from con- gestion or induced emphysema. The deformity of the chest attains its maximum in many cases by the outgrowth of tumours above the clavicle and along the neck. It may be well, however, at the risk of some repetition, to classify, under different heads, the most characteristic of the multifarious phenomena that have been observed in connection with the different varieties of mediastinal growths. Derangements of tlie circulation . — Derange- ments of the circulation, which are necessarily induced, in all cases, to a greater or less degree, give rise to phenomena which are of special dia- gnostic importance in mediastinal tumours. The return of blood through the vena cava superior and its affluents is early impeded, more or less, in the majority of cases, and sometimes to such n.n extent as to give a special aspect to the case It is not, however, simply by pressure on the venous trunks that the indications of pulmonary conges- tion, oedema, and cyanosis areinduced. In many cases the veins themselves, although seldom the arteries, are involved in the cancerous disease : and when this is not the case, there is often a special tendency to thrombosis and obliteration both of the large veins and of their radicles. Cancerous deposit has, in some cases, been traced into the jugular and subclavian veins, entirely occluding them; in other cases these vessels have been enormously distended. Thus we h ive in many instances great tumefaction of the face- neck, and upper extremities, from oedema and general serous infiltration. In like manner the circulation through certain portions of the lungs may give rise either to haemorrhage in the form of haemoptysis, or to sanguineous effusion into tile plpura, or to large apoplectic clots, that is, infarcts. In this latter way the physical signs of consolida- tion are sometimes suddenly induced, or increased.; and after death the pleural cavity has been found occupied by large protuberances from the pleura, consisting simply of blood-tumours, due to extra- vasation into the pulmonary tissues. Although the arteries are much less liable to become im- plicated in cancerous disease than the veins, they are subject, like all the other contents of the thorax, to pressure. The force of the current o' blood through them may thus be diminished, ami there may be a marked difference in the radial and carotid arteries of the two sides, just as tiler is in aneurism of the aorta. It is needless t say that the symptoms arising from mechanical influences acting on the heart must be ver various. This organ may either be dragged fro c MEDIASTINUM, DISEASES OF. 032 its natural situation, or surrounded, more or less completely, by the advancing disease, and its situation and action concealed from all observa- tion ; or its very substance may become involved in the spread of the disease, and the pericardium may be largely distended by serous and bloody effusion. Apart from those disturbances of the heart’s action arising from interrupted circula- tion through the lungs, its innervation may be seriously affected, as will be subsequently noted. And it is evident that the sounds, rhythm, and impulse will be affected in more ways than one ; even when neither the valvular apparatus nor any other structure is the actual seat of disease. In the malignant forms of disease the muscular power of the heart is generally impaired, and there is a consequent tendency to palpitation and faintness, often associated with nausea and vomit- ing. Such symptoms have been observed in rare cases, where the heart has become implicated by disease extending from the mamma through the thoracic walls. Febrile symptoms . — Mediastinal tumours are not as a rule characterised by febrile disturbance, at any period of their course. Several examples of tumours having the character of lympha- denoma have, however, exhibited striking excep- tions to this rule. The writer has recorded a re- markable instance, and others have been recorded by the late Dr. Murchison and Dr. Church, in which there was persistent elevation of tempera- ture, and rapidity of pulse and respiration, but with daily alternations of rise and fall. And in these instances it is remarkable that the pyrexia declined with the advance of the disease to its fatal termination. Intercurrent inflammatory affections, whether of the pulmonary tissue or of the pleura, may in any case occasion correspond- ing symptoms of fever. These, however, are seldom very pronounced. Disturbances of innervation . — Disturbances of innervation occur at all stages, and in connection with every variety of growth. They vary, how- ever, greatly in their character and severity. Although pain may be said to be present in most instances, it is often, all through the case, by no means a prominent symptom. The patient’s dis- tress, often very great, is more frequently due to dyspncea and interrupted circulation, than to direct implication of the nerves. Nevertheless neuralgic pains are among the most frequent of the early subjective symptoms, and are some- times severe in the later stages. When from the situation of the growth the recurrent laryngeal nerve is early implicated, we sometimes get paralysis of the vocal cords and aphonia, at other times spasmodic paroxysms of dyspncea, and ur- gent laryngeal symptoms. In rare cases cancerous disease of the posterior mediastinum has invaded the spine, and given rise to paralysis of the limbs and trunk. The cough, which is generally due to more or less bronchial irritation and secretion, sometimes arises from purely nervous reflex ir- ritation, and may occur in paroxysms like those of whooping cough. The innervation of the heart may be so disturbed as to occasion symp- toms of angina, as well as various irregularities of action and tendency to fainting. The immediate cause of death is not infrequently to be attributed to sudden interruption of the heart’s action. Bespiratory phenomena . — The respiratory phe nomena, although presenting the utmost diver- sities, have nevertheless certain special charac- teristics. When the patient is at rest, there is often nothing to denote any impediment to the respiratory function — no quickened movement, nc alteration of aspect, no expression of anxiety; but on the least exertion, dyspncea is at once manifested. Mere change of position may induce a paroxysm of dyspncea. With advancing dis- ease implicating at length the contents of the thorax to a great extent, there may be no corre- sponding increase of dyspnoea, especially if the progress be slow. In other cases, with physical signs of a very questionable and limited charac- ter, there may be great distress in breathing. Absence of apparent dyspnoea is sometimes the more remarkable from the manifestly diminished movement of the chest-walls, or even com- plete immobility perhaps of one side. Nor in many cases does the dyspnoea correspond with the evidence of pressure, and the absence of respira- tory sounds on auscultation. The want of cor- respondence between the physical signs and the functional symptoms is indeed often most striking. In one case there will be persistent difficulty of breathing, amounting to orthopnoea of the most urgent character, in another merely a little quick- ened respiration — lividity and turgescence of features in one case, in another an anaemic aspect. Physical signs . — So long as a mediastinal tu- mour remains of but small size, it will, of course, not be recognisable by external physical signs, except such as are due to mechanical derange- ments of the circulation, generally denoted by enlargement of the external superficial veins. Comparatively small tumours will, however, sometimes manifest themselves by circumscribed alterations in the external aspect of the chest. This of course will depend much on the site of the tumour. Tumours of the anterior medias- tinum may very early manifest themselves, bv throwing forward the sternum and the sternal attachments of one or more of the ribs, and ulti- mately rendering the two sides of the chest asymmetrical. It is in these cases, when, with the growth of the tumour, the heart and aorta become overlapped and pressed on, that we have evidence of pulsation and vibration, simulating closely the signs of aneurism, and sometimes attended by a cardiac bruit. In other cases the growth, extending upwards, shows itself by tu- mefaction and swelling above the sternum and clavicles, being then often attended by signs or pressure on the trachea or bronchi. When the posterior mediastinum is the chief seat of dis- ease, this may attain to very considerable deve- lopment before any very decided alteration is seen in the form of the chest, unless one or other pleura have become distended by fluid effusion. The diagnosis of these latter cases often present- the utmost difficulty, the physical signs being simply those of pleuritic effusion, and the symp- toms such only as may be fairly referred to mechanical effects of fluid pressure. When tie tumour is of any considerable size, the motion- of those parts of the chest-walls which are m immediate proximity to the growth are almo always impeded, and there is evidence of dimiu ished expansion. This is also the case when t MEDIASTINUM, DISEASES OP. 933 pleura ia occupied by secondary growths, when there may he obliteration of the intercostal spaces, as in pleurisy. But as collapse of the lung sometimes takes place with little or no pleuritic effusion, there may be falling in of one side of the chest, appreciable by the eye, as well as by measurement. As, however, the tumour usually extends more to one side than the other, the measurements of the two sides will generally differ, from this cause alone. By percussion and palpation the ordinary signs of solidification will of course be detected, whenever the tumour ap- proaches the chest-walls and attains to any size, or whenever any considerable portion of the lung has been rendered solid, either by invasion of the growth, by pneumonic consolidation, or by hae- moptic engorgement. Signs of displacement are often manifest comparatively early, and later on may be of the most unmistakable character. The heart may be dragged away from its natural situation in various directions ; the diaphragm thrust down ; the lower ribs thrown out ; and the leformity of the anterior part of the chest, and .lie physical signs on auscultation and percussion, may be greatly modified, by distension of the pericardium from effusion. It will at once, therefore, be seen that the cardiac signs will be of very variable and diverse character — so much so that any detailed description would be of little practical use. It should also always be remembered, that the lung undergoes very various and opposite changes as the result simply of pressure on the bronchi, and interruption to the entrance and egress of air from the air-cells. Thus in the early stages there may be more or less of emphysema, and corresponding physical signs on the affected side; and in more advanced cases a certain amount of emphysema of the opposite side. As the bronchi become occluded, we have at first the stethoscopic signs of accumu- lation of secretion, soon to be followed by signs of consolidation and absence of respiration, when the lung is undergoing those destructive changes by which it becomes converted into a solid mass broken up by irregular abscesses or pockets of pus, produced in part by actual pulmonary disinte- gration, and partly by dilatation of the bronchi. In the latter condition there may be enlargement of the lung and distension of the side, rather than collapse. Hyper-resonance from emphysema, followed by signs of consolidation and absence , of all respiratory phenomena, associated with or preceded by other indications of pressure, would be tolerably decisive of the existence of a me- diastinal tumour, but whether aneurismal or some form of malignant disease might still be a question. Diagnosis. — From the preceding remarks it will be evident that there are no symptoms or physical signs, nor any precise order of pheno- mena, that can be said to be peculiar to, or diagnostic of, an intra-thoracie growth. No two leases will he found to be precisely alike. Never- theless, the want of correspondence with the irdinary forms of thoracic disease; the very general presence of signs of pressure and me- ■haoical derangement ; and the varying aspects f these signs are, in the majority of cases, when onsi lered in conjunction with the history of the ase, sufficient to lead, if not to a positive, at least to a probable diagnosis. In the early stages of a mediastinal tumour, when the growth is still small, it will be easily seen, if we reflect on the anatomical relations of the mediastinum, that an accurate diagnosis must often be impos- sible. And even when formidable symptoms arise from the peculiar relations of a small growth, it must often be extremely difficult to avoid error. Both retro- and antero-stemal nodes will some- times closely resemble both aneurism on the one side, and mediastinal tumours on the other. For further remarks on the physical diagnosis, the reader is referred to the articles Lungs, Malig- nant Disease of ; Mediastinum, Inflammation of ; and Thoracic Aneurism. Treatment. — There is but little that can he said as to the treatment of mediastinal tumours, except as regards the palliation of urgent symp- toms, or the relief of some of the chief secondary effects of the original diseases. All forms of intra-thoracic growths of a malignant character are steadily progressive to their fatal termina- tion. Some of the less malignant in character — for example, lymphadenomatous tumours — may last a long time, and appear for a while to be stationary, and unattended by any serious im- pairment of the general health. Even these, how- ever, are exceptional cases. Bodily rest, freedom from causes of moral disturbance, maintenance of the general nutrition, change of air, and every available hygienic means, are essential in all cases. Chalybeates and other tonics may be of more or less service. Special symptoms often admit of considerable relief; for instance, local pains by external soothing applications, or counter-irritants, such as sinapisms and small blisters. The latter are often of signal benefit. Pain, sleeplessness, and harassing unrelieving cough may all he alleviated by opium and other narcotics, such as chloral or bromide of potas- sium, and sometimes by minute doses of anti- mony. For the distressing paroxysmal attacks of (^jspncea and laryngeal spasm, opium and its preparations require to he given with caution ; but chlorodyne, Hoffman’s ether, and the in- halation of chloroform are often useful. The distress arising from dyspnoea and inability to lie down will often tax the resources of the physician to the utmost, depending as they do on a variety of complex causes. When they ap- pear to be mainly referrible to accumulation of fluid in the pleura, paracentesis must he resorted to. and will often be followed by great temporary relief. At one time the writer was averse to this procedure, but further experience has led him to believe that it is productive of little if any mischief, and that life may sometimes be much prolonged by even repeated evacuation of the pleural effusion. In proportion as symptoms of pleurisy, bronchitis, or pneumonia predominate, they must be met by the ordinary therapeutic resources. It remains to be seen whether our further knowledge of the natural history of lym- phadenoma may advance our therapeutic re- sources. Certainly the slower progress of such cases affords more time for the trial of iodine, chalybeates, or other constitutional remedies. It should ever be borne in mind that severe attacks of dyspncea, with stridulous breathing and other indications of intra-thoracic pressure, may all 334 MEDIASTINUM, DISEASES OF. be due to nerve-irritation alone, and often be greatly alleviated by small doses of morphia combined -with antispasmodics. J. Risdon Bennett. MEDIATE (medius, a means). — -A term ap- plied to auscultation and percussion, when some medium is interposed between the surface of the body of the patient and the ear or finger of the physician, such as the stethoscope in the one case, or a pleximeter in the other. See Physical Examination. MEDITERRANEAN, The.— Moderately dry and warm, and very sunny winter climate. See Algiers; Cannes; Hyeres; Nice; Men- tone ; Malaga ; San Remo, &c. ; and Climate, Treatment of Disease by. MEDULLA OBLONGATA, Lesions of. Synon. ; Fr. Maladies de la Moelle allongee ; Ger. Krankkeiten des verldngerten Marks. Introduction. — The pathology of the medulla oblongata is more than usually complex. Not merely is it liable to injuries, and diseases such as haemorrhages, softenings — necrobiotic and in- flammatory, tumours, &c., having their primary seat here, as in other nerve-centres; hut also, and more frequently, the medulla is implicated in diseases of the pons and cerebellum, and affected indirectly by intracranial diseases in general. Being the connecting link between the brain and spinal cord, it is subject to ascending or descending degenerative processes, secondary to lesions in the cerebral or spinal sensory and motor tracts. Further, it is the seat of a special form of degeneration, characterised by a very doflnite group of symptoms, differentiated under the term bulbar or labio-glosso-laryngeal para- lysis. With the indirect affections of the medulla oblongata, in connection with the various forms of intracranial disease, degenerations of the sensory or motor tracts secondary to cerebral or spinal disease, or the pathology and symptom- atology of bulbar paralysis, this article does not profess to deal, as these subjects will be found fully discussed under other headings. Attention will be directed mainly to the data which serve to establish, so far as this is possible, the regional diagnosis of medullary lesions. Summary op Pathological Conditions. — Traumatic lesions. — Injuries of the medulla ob- longata are not uncommon in consequence of fracture or dislocation of the atlas and axis, as in falls, hanging, twisting of the neck, or as the re- sult of diseased vertebra. In such cases death is instantaneous, owiug to the sudden cessation of the circulation and respiration, from lesion of the centres of these vital functions, which are situated in the medulla (Flourens’ ncetid vital). To commotion or contusion, with punctiform extravasations in the medullary centres (Duret, Sur les Traumatismes Cerchraux, 187S), is also to be attributed sudden death from blows on the head. Not unfrequently lesions of the fourth ventricle, the result of cranial injuries, not proving fatal, give rise to diabetes mellitus or insipidus, along with other symptoms indica- tive of chronic lesion of the pons or medulla. MEDULLA OBLONGATA, LESION'S OK. Effusions of blood into the fourth ventricle, whether arising from the medulla itself, the pons, or the cerebellum, or gaining access from the la- teral ventricles by the aqueduct of Sylvius, are, as a rule, suddenly fatal from paralysis of the circulation and respiration. Death may occur with or without convulsions. Tumours. — Tumours implicating the medulla oblongata may have their seat primarily in tiie medulla ; but more commonly the tumours are situated at the base of the skull, in the cerebellum or pons, and invade the medulla in their growth. Apart from the general symptoms of cerebral tumour — headache, sickness, optic neuritis, &c., the special indications of implication of the me- dulla oblongata are one or more of the symptoms mentioned below. Here also, however, some remarkable cases have been put on record, in which, notwithstanding the existence of tumours actually in the substance of the medulla itself, the symptoms during life have presented nothing striking or characteristic. (See a case by Dr. Wiiks, Diseases of the Nervous System, 1878.) Hemorrhage. — Haemorrhage into the substance of the medulla oblongata, and limited to this, is comparatively rare. More commonly the pons and medulla are affected together. Hemorrhages here of any extent are very rapidly fatal. Insome cases death is instantaneous. In others a few hours may elapse, death occurring in profound coma with stertorous respiration, and occasionally con- vulsions. Whether the haemorrhage is primarily in the medulla or in the pons cannot be diagnosed with certainty. The other causes of sudden death, such as affections of the heart, must be excluded before haemorrhage into the medulla can be diagnosed, and this is in many circum- stances obviously impossible. Haemorrhage into the medulla oblongata is usually fatal, and rarely gives rise to ehronie stationary lesions. These are usually the result of thrombosis or embolism, or, more rarely, acute myelitis. Thrombosis. — Thrombosis of the vertebral arteries is the most common origin of softening limited to the medulla oblongata. The onset is frequently sudden, as in haemorrhage, but the course is more slow. The more chronic nature of the affection is an important diagnostic featuro of softening. The symptoms of softening of the medulla thus arising are in many respects like those of progressive bulbar paralysis, but there are also important differences. They are some- times generalised under the head of ‘acute’ or ‘ apoplectiform ’ bulbar paralysis, in contra- distinction to the classic form of this affection described by Duchcnne. See Labio-Glosso- Laryngeal Paralysis. Localising Phenomena. — The symptoms met with in the affection just named are the most reliable clinical data on which to found a regional diagnosis of lesions of the medulla oblongata. The characteristic symptoms are a conjoint affection of the extremities and one or more of the bulbar cranial nerves, with im- pairment of speech and deglutition, and cardio- respiratory disturbances. Sometimes all foul extremities are paretic or paralysed; some- times the lower extremities alone; anJ occa- sionally the paralysis is of the hemiplegic order MEGRIM. 93a MEDULLA OBLONGATA, LESIONS OE. [t the paralysis affects only the extremities, n thout implication of the bulbar nerves, as ' sometimes occurs a diagnosis of the medullary I -eat of the lesion cannot be made with certainty. Anaesthesia has not been recorded, but occa- sionally paraesthesiae have been observed. Ataxic affections of the extremities have also been met jvith by Leyden and Prevost. Of the cranial nerves the hypoglossal is most commonly involved. The symptoms are im- paired mobility of the tongue, with more or less pronounced dysarthria. This is not absolutely characteristic of bulbar disease, however, as a similar affection of the hypoglossal may occur in disease of the pons. The tongue and speech are rarely, if ever, so affected as iu the classic or progressive bulbar paralysis, nor has the atrophy of the muscles of the tongue, with altered electrical reactions, been noted. Of more importance as a diagnostic mark is dysphagia, or paralysis of deglutition. This, in the absence of general cerebral symptoms, points to affection of the medulla. Paralysis of the soft palate, on one or both sides, is also a fre- quent, if not constant, symptom. Occasionally also aphonia occurs, and, taken with the other eymptoms. points conclusively to affection of the medulla oblongata. Irregularity of the heart ; acceleration or re- tardation of the pulse ; and sighing and laboured respiration, often amounting to orthopncea, in the absence of general cerebral symptoms, are also important indications of disease of the me- dulla oblongata. Among other symptoms have been noted coughing, and vomiting, explicable by affection of the respiratory centres. Trismus has been mentioned by Joffroy as a charac- teristic symptom of acute bulbar paralysis, but Nothnagel, on good grounds, disputes the accu- racy of this statement. Albuminuria and glycosuria have also been observed in connection with bulbar lesions, the latter more particularly after injuries affecting the floor of the fourth ventricle; but the occurrence of these symptoms in connection with acute bulbar paralysis requires further investigation, as they cannot as yet be regarded as constant. An affection simulating disease of the medulla oblongata results from bilateral lesion of the an- terior third of the internal capsule (Lepine), or of the cortex in the region of the lower extremity of the ascending frontal and posterior extremity of the third frontal convolution (Barlow). Such a bilateral lesion causes paralysis of articulation, and also true aphasia if the lesion is cortical, along with a greater or less degree of double • hemiplegia. The diagnosis must depend on the truly volitional character of tho paralysis in such cases, the reflex mechanism of deglutition being unimpaired. There will also be absence of af- fection of sensibility and of trophic degeneration of the muscles, and absence also of disturbances of the cardiac and respiratory rhythm. Defective comprehension of speech, and obvious aphasia — - the movements of articulation not being abso- lutely paralysed, and also agraphia — the hand not being completely powerless — will differen- tiate cerebral from bulbar paralysis. D. Fkekier. MEDULLA OP BONES, Diseases of.— Sy.nox. : Fr. Maladies de la Moelle cks Os ; Ger. Krankheiten des Knochenmarks. — The mor- bid conditions of the medulla of bones are most conveniently described under the head of the several diseases of which they almost invariably form but a part. Thus, injuries, acute and chronic inflammation or osteomyelitis, and the majority of new growths involving the marrow, affect the bone as a whole, and are accordingly discussed in the article upon these subjects (sc« Bonk, Diseases of). Myeloid tumour, which is peculiarly connected with the medulla, is also described and figured in the article on Tumours. The medulla of bones is also the seat of important pathological changes in several chronic constitutional diseases. For instance, ii is affected in some cases of leucocythsemia, and of lymphadenoma ; in mollities ossium ; and in rickets. The reader is referred to the descrip- tion of the anatomical characters of these con- ditions in the articles bearing their several names. MEDULLA SPINALIS, Diseases of. See Spinal Cord, Diseases of. MEDULLARY CANCEB.-A synonym for encephaloid cancer. See Cancer. MEGBIM. — Synon. : Migraine; Sick Head- ache ; Nervous Headache ; Hemicrania ; Fr. Migraine ; Ger. Migr'dne. Definition. — Headache of a periodical cha- racter; generally ushered in by some piremoni- tory symptoms ; more or less unilateral ; and frequently associated with nausea and bilious vomiting. fEnoLonY. — The chief predisposing causes of attacks of migraine are hereditary tendency; anaemia ; a general want of tone in the system ; and the nervous temperament Among tho ex- citing causes may be included all those of a depressing or exhausting nature, whether physical or mental, such as prolonged mental work, men- tal excitement, grief, anxiety, bodily fatigue, late hours, sexual excesses, breathing the impure aii of a crowded room, and improper food. Symptoms. — This complaint seems to have two more or less well-defined stages, the head- ache being preceded for a variable period by certain disorders of sensation. In some persons the malady stops short here, and is not followed by headache; in others the headache appears to be developed without any premonitory symptoms, until careful inquiry reveals the contrary'. The two stages therefore are, first, the stage of dis- ordered sensation ; second, the stage of head- ache, with other symptoms. The most striking of the disordered sensa- tions is a transient disturbance of vision which sometimes takes place. It commences with a wavy glimmering near the outside corner of the field of vision, and spreads all over the visual area with a zigzag outline, in a straight-lined angular pattern, and with or without lines of colour between the darker lines. Or it may commence by the appearance of a blind spot close to the centre of vision, which soon begins to spread, showing a serrated margin, and present- ing a tremor or wavy glimmering in its interior MEGRIM. )30 This condition is often associated with a feeling, of chilliness, coldness of the hands and feet, or other symptoms ; it may last from five to thirty minutes or longer, and then be succeeded by the stage of headache. On the other hand, the headache may be, and in many individuals always is, developed without the ocular disturbance, but other sensations are substituted for it. The patient has a feeling of chilliness, and the feet are cold. There is mental depression, with a dread of impending evil ; the patient is restless and uneasy; ‘cannot quite tell,’ as he says, ‘ what he would be at ; ’ and has what is expressively called ‘ the fidgets.’ This condition may continue half an hour cr more, and then the slight boring pierciDg pain is felt in the head, with which the aching begins; and the disorder runs its course, as will ho presently described. In other cases, this feeling of depression or uneasiness lasts for several hours, the patient goes to bed, and in the early morning wakes with the headache' fully deve- loped. The headache, when preceded by ocular distur- bance, shows itself as follows : — When the vibra- tory movement is at its height, a little aching is felt in the head, on the side opposite to that on which the glimmering first appeared : it is slight at first, but gradually increases in intensity. Some persons have said that the sensation was as though a point in the temple were being bored with a gimlet, and the gimlet slowly increasing in size. The pain gradually spreads from this point, which may be covered with the finger, and pressure upon which affords relief, first over one side of the head ; and then, but not always, it ex- tends to the other. As the headache increases, the ocular disturbance declines ; nausea is felt, which increases with the headache ; retch- ing and vomiting occur, the latter sometimes, though rarely, giving relief; the head throbs; the slightest movement increases the pain, and any attempt to move from the recumbent posture increases the gastric uneasiness ; the mouth feels clammy ; the eyeballs ache, and are tender on pressure, one more so than the other ; the pupils are rather contracted, and generally unequally so ; and the patient lies apparently more dead than alive, his face pale, and the head hot. After a varying number of hourslie is somewhat relieved bv troubled sleep ; he wakes up next morning free perhaps from headache ; but he is listless ; his brain is weary; and he feels as if he had undergone a hard mental struggle. There may be now an interval of a few days, weeks, or years, before the disorder again shows itself. The headache varies much in character, degree, and duration. In some persons the pain is not localised in any particular spot, but seems generally diffused over the head ; others have not noticed that there is more pain on one side of the head than the other, or that the aching radiates from one painful spot, until their attention has been directed to the fact, and then I hey distinctly recognise it ; others, again, have neither vomiting nor nausea ; and lastly, the duration of the headache may be very short, or not extend over more than two or three hours, or this symptom may be entirely absent. The disorder may even stop short at the vibratory stage, the vision be restored, and no farther inconvenience felt. In a certain proportion of cases during the vibratory stage a tingling is felt in some" por- tion of the body — the partis ‘asleep.’ Sometimes it is felt in one arm or in the side of the toDgne, or on the side of the face, and it is on the same side as that on which the glimmering in the eye begins. Sometimes the hearing, speech, or memory is affected. The age at which the attacks generally com- mence is from twelve to twenty-five. Females are more liable to them than males. After a cer- tain period, with advancing age the attacks, as s rule, are less easily developed, and become much less frequent. They cease generally after fifty or sixty, and in women not uncommonly at the change of life. Pathology. — Considerable diversity of opinion exists as to the nature of megrim. Formerly it was regarded as ' being dependent upon gas- tric or hepatic derangement, a view, howerer. which now finds few supporters. Some patho- logists hold it to he a form of neuralgia; but though it has a great resemblance to neuralgia, it ‘causes much greater disturbance of the sen- sorium, it spreads much more generally over the head, and is not unfrequently accompanied with nausea and vomiting. After the attack there may be an intermission of weeks or months, and the attack itself runs a more uniform or con- tinuous course ’ (Lebert). The view which the writer has advanced is that the affection is to be referred to the sympathetic nervous system. If by fatigue, anxiety, or other depressing cause, the general tone of the body be lowered, and with it the regulating or inhibitory power of the cerehro-spinal over the sympathetic ner- vous system impaired, then uncontrolled action or excitement of one or more portions of the latter takes place, causing contraction of the blood-vessels under the influence of the affected portions, and so producing the disorders of sen- sation which precede the headache; this excite- ment is followed by exhaustion or paralysis of the sympathetic, and is associated (just as would be the case after section of the nerve) with dilatation of the vessels, and with headache. Dr. Edward Liveing, in his classical and exhaustive work on megrim, combats this view, and main- tains that the phenomena are those of ‘a nerve- storm traversing more or less of the sensory tract from the optic thalami to the ganglia of the vagus, or else radiating in the same tract from a focus in the neighbourhood of the quadriga- minal bodies.’ Treatment. — By careful management very great relief can be afforded to the sufferers from , this malady, not only by diminishing the inten- sity of the attacks, but also by considerably lengthening the intervals between them. Me may consider separately the remedial measures to be employed (1) during the intervals between the attacks; (2) during the premonitory stage or stage of disordered sensation ; and (3) during the stage of headache. 1. During the intervals between the attacks.— It is to the treatment during this period that the greatest consideration must be given. The cause, if possible, must l»- discovered, and in a MEGRIM. 937 very large majority of eases, careful inquiry -will reveal the fact that a distinct cause does exist. Overwork, prolonged anxiety, over-fatigue, dis- appointed hopes or affections, sexual irregulari- ties, and impoverished nutrition of the body, are among the chief causes ; and while these are in operation medicine will prove of little avail. Remove the causo, and then endeavour to brace up the bodily and nervous systems. The chief remedies for this purpose are the vegetable bitters, iron, strychnine, and cod-liver oil. But the success following their use very much de- pends upon the way in which they are adminis- tered. For a day or two after a headache the 6tomaeh and bowels may possibly be disordered, and not in a fit state to tolerate iron or cod-liver oil. This condition must be corrected, and for this purpose the simple vegetable bitters, such as gentian with small doses of henbane and some aromatic, may be of service ; and if necessary one or two grains of blue pill, with four or five of compound rhubarb pill, may be given at night, but strong purgation must be avoided. Iron may then be given, either in the form of the ammonio- citrate alone, or combined with two or three grains of iodide of potassium ; and according to circum- stances fifteen or twenty minims of tincture of henbane, or twenty or thirty minims of aromatic spirit of ammonia, may be added to each dose. Or the iron may be given in the form of the mistnra ferri composita of the Pharmacopccia ; the mixture answering better, however, in some cases without the myrrh. Strychnine is, in the writer's opinion, a very important remedial agent n many forms of this disorder, and may be given with the remedies previously mentioned in the form of liquor strychnine or tinctura nucis romicse, or may be combined with infusion of •luassia or ealumba. Where iron is contra-in- jicatedfrom any cause, or when it is not readily ■"roe, the administration of nux vomica with quassia has seemed to act beneficially. In 'eniales with a distinct hysterical temperament iux vomica does not answer so well, and better ■esults will be obtained by giving the vegetable litters with ten-grain doses of bromide of potas- ium, and fifteen or twenty of tincture of henbane, wice or three times a day. As a rule, however, he bromide is of more use administered during he headache than in the intervals. Cod-liver il often acts beneficially, especially when there i much nervous exhaustion. It may be given ■nee a day immediately after breakfast, beginning ith a small teaspoonful, and gradually increasing le quantity to a tablespoonful, but not beyond, nless in exceptional cases. Ifthe bowels are con- dpated, five grains or so of the socotrine aloes ill may be given at night ; or ifthe constipation 3 habitual, five grains of the aloes-and-iron pill, ven twice a day before meals, will generally duce greater regularity in the action of the )wels. Other remedies have been recommended, and a sometimes of service, especially arsenic and unine. In persons of feeble bodily power, rest is of e greatest importance, and it is often advisable at such patients should remain in bed at least ■ elve hours out of the twenty-four, and take cir breakfast an hour and a half or two hours before rising in the morning. Whenever the headaches recur frequently, this rule should be enforced. In many cases a tumblorful of new milk, to which two teaspoonfuls of brandy, rum, or whisky have been added, may be taken with advantage before breakfast, directly on waking in the morning. The diet should be liberal ; the food plain and easily digestible ; and two or three glasses of wine, beer, or porter per diem, may generally be taken with benefit. The more exercise the patient can take in the open air, without fatigue, the better. 2. During the 'premonitory stage, or stage of disturbed sensation. — In the forms attended by disturbance of vision, the longer this lasts the greater will be the headache, and we must en- deavour therefore to shorten this stage as much as possible. Directly the glimmering appears the patient should lie down, with the head low ; and if the glimmering be on the right or left of the field of vision, he should lie on the opposite side. Let him take at once some alco- holic stimulant, a full-sized glass of sherry, a large tablespoonful of brandy diluted, or a glass of champagne. If alcoholic stimulants be ob- jected to, or if it be not advisable to recommend them, then a teaspoonful of sal volatile in water may be prescribed instead. If the patient be chilly, or his feet cold, the couch should be drawn near the fire, and a hot bottle applied to the feet By these means the heart is enabled to drive the blood with greater force to the brain, and the duration of the vibratory movement is thereby materially lessened. After the glimmering has passed off, the patient should lie still for a time, so that it may not return. This injunction will only be necessary when the headache is slight ; if it be severe, attended with much nausea or vomiting, the patient will be little disposed, or little able, to leave the recumbent position. If, instead of the disturbance of vision pre- ceding the headache, there be a feeling of depression or irritability, fidgets, and similar phenomena, the administration of such cerebro- spinal stimulants as henbane, valerian, assa- foetida, spirit of chloroform, or ether, will often cut short the attack. Fifteen or twenty drops of the tincture of henbane, with the same quan- tity of spirit of chloroform, will soothe the nervous irritability in the slighter forms, and may be repeated in three or four hours if neces- sary. If there be great mental depression, then valerian or assafoetida should be tried. Half a drachm to a drachm of the ammoniated tincture of valerian, or the same quantity of the fetid spirit of ammonia may be given. As a rule, in such cases as these, alcoholic stimulants are not advisable at this stage. A small quantity will cause flushing, heaviness, and slight confusion of thought, without relieving the depression ; and though the severe headache may be averted, alcoholic stimulants do not answer so well as the remedies previously mentioned. 3. During the stage of headache. — If the head- ache be slight, and the patient soon able to sit up, there is little to be done. A cup of coffee or tea, cheerful conversation, a walk, drive, or ride, may often help to remove the pain. If, how- ever. the symptoms be severe, then the ad minis- 93S MEGRIM, tration of fu>ther remedies is called for. The patient should keep perfectly still and quiet, ■with the room darkened ; for every sound or sight causes pain, and the slightest movement is sufficient to produce gastric uneasiness. Some- times free evacuation of the contents of the stomach, especially if it contain undigested food, is followed by relief; but, as a rule, it is better to try to relieve and check the vomiting. Iced soda-water, with or without two or three drops of dilute hydrocyanic acid or spirit of chloroform ; cold tea ; or the effervescing citrate of potash with hydrocyanic acid, may often afford marked relief. The headache may be lessened byapplying cloths dipped in cold water or evaporating lotions to the head. If the extremities be cold, and the headache severe, a warm stimulating foot-bath can be tried, so soon as the nausea will allow the patient to sit up. If the attacks occur in the early part of the day, as soon as the pain has subsided it is generally better for the patient to sit up or move about, or even to take exercise in the open air. During the attack the appetite is diminished, the idea even of taking food provoking disgust. Still, after the nausea has passed away, a plate of soup, or some easily digested food, will often have a good effect in equalising the cerebral cir- culation, and in relieving the headache. If the headache be severe, bromide of potassium is a remedy which will often prove of great service. It may be given in doses of fifteen or twenty grains, with fifteen or twenty minims of tincture of henbane, and to these may be added thirty or forty minims of the aromatic spirit of ammonia, in some cases with advantage. If necessary, the dose may be repeated after an interval of two hours or so. In other cases chloride of ammonium in doses of fifteen grains produces marked relief, and may be sometimes advantageously combined with spirit of chloroform and compound tincture of lavender. Guarana powder is a remedy which is used, often with happy results. The sick- headaches which it seems te reLeve are those in which distinct premonitory symptoms usher in the attack, and particularly those preceded by disturbance of vision. It may be given in such cases in doses of fifteen grains, with the same quantity of sugar, and repeated in from half an hour to two hours. In those individuals, however, in whom the headache is developed suddenly, where the attacks come on without any or with very indefinite premonitory symp- toms, guarana appears to have little effect. As a rule, the use of purgatives in this stage is decidedly objectionable, but occasionally a saline purgative at the commencement of an attack is indicated, and is of service. P. W. Latham. MELJ3NA (/xe'Aas, black). — Syxox. : Dysen- teria splenica-, Fr. Milena; Ger. Schwarze Ruhr. This term is used to denote black tar-like evacuations that are passed from the bowel. The colour and appearance are due to altered blood, and the expression is not properly appli- cable to simple haemorrhage from the alimentary canal, when blood of a normal appearance is voided. In order that the blood should have undergone the change which produces the characteristic MELANCHOLIA. evacuations, it must have been effused high up in the canal, and in some quantity. When haemorrhage takes place in the lower part of the small intestine, or in the colon or rectum, ths blood is passed in a scarcely altered state, or at most renders the faeces dark, without producing the black, viscid motions now referred to. Blood that is passed into the stomach, from any cause, is subjected to the action of the gastric juice, and undergoes a partial digestion. The acid of the secretion converts the htemoglobin into haematin, a blackish-brown substance, and the exposure of this to the sulphuretted hydro --ea produced in the lower part of the intestine con- verts the iron it contains into a black sulphide. The tar-like consistency is due to the serum, digested clot, and mucus ; and the discharged material is usually free from remains of food, being simply altered blood. When the haemor- rhage takes place into the upper part of the intestine, the change is not so completely effected. In place of being submitted to pro- longed action of an acid secretion, with consider- able power of digesting, the blood is acted upon by alkaline secretions, the officacv of which is les6, unless the ingesta have been previously affected by the gastric juice. The result is that, although the blood is to a great extent altered, and the same black sulphide of iron is formed, it be- comes more or less mixed with the contents of the tube, and is not voided in lumpy clots, but almost uniformly incorporated with the faeces, which may be solid, semi-solid, or fluid. The faeces may be blackened by iron, bismuth, and other agents, taken as drugs, but they do not pro- duce the viscid matter like semi- digested blood. Melsena is the mere expression of a condition brought about by many causes, and these have to be sought for and treated. See F.eces, Exa- mination of ; ILhmatemesis ; Intestines, Hae- morrhage from ; and Stools. W. H. Allchin. MELAN^IMIA (geAas, black, and cl/m, the blood). — A morbid condition of the blood, in which it contains black and brown pigment-particles. See Blood, Morbid Conditions of. MELANCHOLIA (jueAos, black; and xoAlj, bile). — Stxon. : Fr. Lypemanie ; Melancolie ; Ger. Sckwcrmuth ; Melancholic. — This name is now usuaUy applied to a form of insanity characterised by great mental depression, but formerly it was U6ed by writers to denote par- tial insanity, or monomania. The sufferer in this disorder feels his whole existence, mental and bodily, overwhelmed and oppressed by gloom, anxiety, and foreboding. At first it may be only a feeling which takes no definite shape, and there may be no delusions. Sometimes, though rarely, there are none throughout; the morbid feeling constitutes the disorder, which in this form has been called simple melancholia. Its access is almost always gradual, and though we may attribute it to grief, overwork, or worry it often happens that no mental or moral cause can be found, and we are obliged to set it dowi to inherited predisposition, to some debilitating illness, to declining strength, or to advancing age. Some are aware that there is no real grounc MELANCHOLIA. for their sorrow and sadness, and are able to look on it as an illness; others feel that there must be some real cause for their despondency, that something terrible is impending, though they know not what. The majority can argue and ■converse rationally on subjects unconnected with their feeling of misery. The bodily health, even if at first it appears good, soon participates in the disturbance. The digestion is disordered, the urine loaded with lithates, the skin dry, the bowels are constipated, the pulse is slow rather than quick, the conjunc- tiva dull and yellow. The patient will complain of various uneasy feelings in the prsecordial or epigasciie region, and this, with the state of the excretions, will confirm the notion, so prevalent amongst many, that the whole misehiof is in the liver. Such simple depression may continue for a longer or shorter space of time. It may pass away suddenly or gradually, or the individual will grow worse in one of two ways. The depres- sion becomes greater, and delusions of various kinds present themselves ; or it is replaced by the excitement of mania. Melancholia with delusions is far more common than simple melancholia , and is that which most frequently we are called upon to treat. The patient feels utterly changed, and attributes it. to carious causes, and. deduces various results from ;t. He has all manner of diseases— syphilis, ‘eprosy, lice ; his stomach is gone, and therefore ae cannot eat. He cannot attend to business, tnd therefore is ruined. He is so wretched that ■ie must have committed sins unpardonable in his world or the next. The bodily symptoms, ike the mental, are aggravated. Sleep is absent ir scanty, and there is rapid wasting. The bowels re loaded, and resist strong purgatives ; the ongue is white and furred; the breath offensive. Ihe patients are for the most part elderly ; limacteric insanity is almost always melancholia. )f 338 melancholic patients admitted into St. rake’s Hospital only 9 were below the age of wen t v. | It cannot be too strongly impressed upon tedical men that all melancholic patients, ven those whose disorder seems simple and light, are, especially in the early stage, vpry apt ) commit suicide. We read accounts almost laily in the newspapers of suicides committed by Lis class of persons, and most lamentable they re, for it is a class which above all others is menable to treatment. An asylum is not absolutely requisite for ach, if their means allow of proper companions, 'ouse, and exercise. They must not be left alone y night or day; must not he left to attendants aly; and must have some amusement or diver- on. If all this cannot be provided, to an asy- im they must go ; for if they are resolutely and instantly bent on suicide, it is most difficult to uard against it in an ordinary house. Whether they are sent to an asylum or not, it found to be almost invariably necessary to re- ove them from. home. We may think the case slight one, and may hope that amusement id cessation from work, with medical treatment id good living, will remove the depression, gain and again we are disappointed. The sight - home ar.d home scenes, of family and friends, 939 and the contrast between past happiness and present gloom, perpetuate the melancholy and prevent its dispersion. After valuable time is lost, we are compelled to send away the patient to an asylum or quasi-asylum. Prognosis. — The prognosis in cases of melan- cholia is favourable, and patients get well in great numbers, even at an advanced age. It is also important to remember that recovery may take place from this form of insanity after con- siderable periods of time. The writer has in the second volume of the St. George s Hospital Reports recorded three cases of melancholia in which recovery took place after five, six, and seven years’ residence in an asylum ; and he has since treated a lady who recovered from a most suicidal attack of the disorder after nine years. In deal- ing with property it is often necessary to con- sider the question of probable recovery, and it is well to keep in view the chance of it here, although in perhaps every other form of insanity recovery after such periods would be out of the question. Treatment.— On examination of a melan- cholic patient, it is generally found that there has been a considerable loss of flesh. This may be due to the mental care and sorrow, but it is often caused by an insufficient quantity of food, which has been scanty, either because all appetite has been lost owing to the prevailing wretchedness, or because, from various delusions, there has been an unwillingness to take food. Moreover, there is almost always considerable disorder of the digestive apparatus, the result and not the cause of the depressed nervous condition. Tho first thing to be done is to correct this disorder ; and then to restore the defective nutrition of the brain. One symptom is obstinate constipation. It may be necessary in the first instance to relieve the loaded and obstructed bowel by means of turpentine enemata; after which it will be of advantage to give a daily dinner pill of the ex- tracts of aloes and nux vomica, or a daily tea- Bpoonful of castor-oil, following it up if necessary by an enema, but ensuring an action every, or every other day, and so habituating the bowels to act. Many of these patients, especially women, will be found to be persons who have been accustomed to go for long periods without the bowels acting, or who never had relief with out medicine. Food must be given to melan- cholic patients in large quantities. It constantly happens that it is withheld from them under the impression that their malady is essentially dys- pepsia, and that the stomach must not be allied upon for much exertion. Many, as has been said, refuse it for one reason or other. In either case the melancholia increases, and the patient gets thinner and weaker. Food must be given with no sparing hand, not merely beef-tea and invalid diet, but solid food, bread, meat, and eggs, with a liberal allowance of wine or malt liquor. Some may require forcible feeding, and this can hardly be carried out except in an asylum, but many by coaxing or threats will take what is given to them with a spoon, and they must be fed _ frequently till they will take the meals of their own accord. Under this augmented diet the tongue will become clean, the bowels will ad 940 M ELANOHOLIA. without/ physic, and the patient’s appearance ■will soon testify to the efficacy of the treatment. Sleep, though not entirely absent here, trill be in defect. To procure it opium has teen long looked upon as of the greatest value. In melan- cholia, of all the various forms of insanity, this drug is most useful, and its benefit consists not merely in the procuring of sleep, but in alleviating the feeling of wretchedness. It may be given ei tlier by the mouth or by subcutaneous injection. It is of importance that we do not give a prepa- ration which shall cause sickness or constipation : the ordinary preparations of morphia, the acetate and hydroclilorate, are apt to do this if given in full doses, and it is better to substitute the liquor morphiae bimoconatis, Dover's powder, Battley’s solution, or solid opium, if we can be sure that pills will be swallowed. Chloral will procure sleep here as in other cases, and may be combined with opium to bring about more speedy action of the latter, but chloral has not such a lasting influence on the malady; when its sleep- producing effect has passed away, the patient does not feel any benefit from the medicine. When the secretions have been corrected, and digestion is re-established, tonics may be useful, especially the preparations of iron. G. F. Blandford. MELANCHOLIA, Varieties of.— 1. Me- lancholia, Acute. — Although the prognosis in simple melancholia, and that which may be called sub-acute, is so favourable, there is an advanced stage which truly merits the name of acute, and generally terminates fatally. The patients are not silent, gloomy, and depressed, but panic- stricken; and in violent frenzy and terror they try to escape from those about them, to tear off their clothes, gouge out their eyes, and injure themselves in overy way. They will not lie on a bed unless forced to do so, but will prefer the floor, or incessantly pace the room. Food they resist with all their power, thinking that it is poisoned, or that they will be punished for taking it. Such patients must be fed by force, and fed early, but it often happens that our feeding here is of no avail, and they sink from the exhaustion of this acute disorder. For it is constantly found in those who are already broken and debilitated in health, and it is but the last stage of a series of disorders. The incessant agitation, violence, and sleeplessness produce rapid wasting and sinking; the food administered is not assimilated, and fails to restore the wasted force. This form runs a rapid course, in contradistinction to the last, which is tedious, hut nevertheless tends to recovery in the majority of cases. We may ad- minister opium here with or without chloral; other drugs are of little use. Cod-liver oil may be added to the food. Warmth and stimulants are demanded ; and clothes must be kept on by means of a strong suit which cannot be removed by the patient. 2. Melancolie aveo Stupeur (Fr.) Synox. : Her. Schwermuth mit Stumpfsinn . — A more ex- treme form of melancholia is thus named, where the patient sits or stands, speechless and motion- less, and requires to be fed, washed, and dressed. Though such a one will not speak or do anything for himself, he may bo watching every opportunity MEMORY, DEFECTS OF. of committing suicide, and refusu food with the same motive. The vital powers in these persona are greatly depressed, and they require much food and stimulant. This form has been confounded by some with that variety of insanity termed acute dementia (see Dementia) ; but the latter occurs only in young people, whereas melancholia as a rule does not; and the early symptoms are quite different, acutedemeutia coming on rapidly, and without the depression and gloomy delusions which mark the other complaint. G. F. Blandford, MELANOMA (jtteAas, black). — Any morbid growth in which the presence of black pigment is a leading character. See Tumours. MELANOPATHIA (geAar, black, and ndeos, a disease). — An excess of black pigment in the skin, due to abnormal function of the rete mucosum. Melanopathia is rarely general, more frequently partial. In certain instances, as in the ‘bronzed skin ’ of Addison’s disease, it is asso- ciated with anaemia. See Pigmentary Sein- Diseases. MELANOSIS (yueAas, black). — A ecording to the present doctrines of pathology, melanosis signifies the condition of system associated with the presence of pigmented tumours. See Canceb ; and Tumours. MELASMA (fit\as, black). — A term usually applied to excess of pigment in the skin, from abnormal function of the rete mucosum. See Pigmentary Skin-Diseases. MELLITURIA (jue'Ai, honey, and oupov, urine). — A synonym for saccharine urine. See Diabetes. MEMBEANA TYMPANI, Diseases of. See Ear, Diseases of. MEMBRANES OP BRAIN AND CORD, Diseases of. Meninges, Diseases of. MEMORY, Defects of. — There are so many different kinds of memory, and so many different degrees of excellence of each variety in different individuals in health, that it is not always easy to say in regard to any particular person how far his memory is defective. In other cases the degree of impairment is so great as to make its existence perfectly obvious. Between such ex- tremes, all intermediate grades of defect m3v at times be met -with. The nature and causes of the various defects of memory cannot possibly he set forth withont giving some account of the different physiological processes involved in its exercise ; and also of the several fundamental modes in which this is brought about. The Component Processes in Memort. — What is commonly known as ‘memory’ is de- pendent upon two kinds of processes. The first of these is a vital, molecular, or organic process of some kind, taking place in various parts of the brain simultaneously, on the occurrence of some ‘ perceptive act ’ or thought-process. In a healthy and properly-nourished brain certain neural pro- cesses, in different regions of the organ, are sup- posed to coincide with each act of perception and apprehension. Similarly, in ‘ ideation’ or reflec- tion, molecular processes of a closely -related kind are presumed to take place, partly in the arene MEMORY, DEFECTS OF. f the brain concerned witn perceptions and ortlyin other regions, and these several changes ave the same kind of relation to our thoughts hat the others have to our perceptions ; in eacli ase they, in fact, constitute the organic basis of he respective processes. These initial organic hanges of all kinds -were referred to by Lay- ock, and comprised under the name ‘ synesis.’ ihe first essential, therefore, for the exercise of lemory is that these synetic processes should ave been properly accomplished. If they have ■eeu imperfectly performed, memory will be ither defective or non-existent. Yet these processes constitute the foundations or memory, rather than memory itself. Memory essentially consists in a repetition or reak revival of such molecular movements and processes in nerve-tissues, and of the conscious tates associated with them. They are similar a kind, and take place in all such parts of the rain as were concerned with the original con- cious realisation of the objects, relations, or recesses which now recur as ‘remembered’ im- ressions or thoughts. This, therefore, is the tcond of the processes above referred to, as ssential to the exercise of memory. Modes of Exercise of Memory. — The repe- tion or weak revival of foregone processes, and f their associated conscious states, is brought ■bout in three modes fairly distinct from one nother. The first mode of exercise of memory i ) is found in acts of perception, when, on the resentation of some object to the sense of !ght, hearing, toueh, smell, or taste, or to any ,vo of them, the remaining qualities of this bject become nascent or revived in memory, so rat the object itself is perceived or recognised j being of such and such a nature. This kind of process is only impaired where id nutrition of the brain as a whole is gravely iterfered with. Special parts of such a process re, however, not unfrequently interfered with y local brain-disease, as when, for instance, le sight of a written or printed word does not mse its appropriate related memories; or when spoken word remains unrealised or unappre- ;nded, because its mere sound does not excite 1 the memories which should cluster round ; in the one case we have what has been .ther inappropriately termed ‘ word-blindness,’ id in the other ‘ word-deafness.’ The one set persons exhibiting such defects may be per- ctly well able to recognise natural objects or rsons by sight; just as the others maybe able appreciate different kinds of natural sounds, differences in emotional intonations of the ice, although particular words may not call to eir mind any distinct apprehension of the ing, idea, or relation which they are usually iployed to designate. The second, or most common mode in which smory is exercised is ( b ) during the ordinary irse of thought, when by natural processes of ;3sociation’ the ideas of objects, of persons, of ents. and of their relations one with another i with ideas, recur to consciousness, with or shout a simultaneous full realisation of the rds suitable for the expression of all these ises of our thoughts — according as we are rely thinking to ourselves, or as we at the 94 ) same time give expression to our thoughts whilst conversing with another person. These, together with the kinds of exercise first referred to, constitute by far the most frequent modes in which memory is called into play. It here manifests itself in a purely automatic manner, without sense of effort on our part (other than that which is concerned with the direction of our thoughts), owing to the fact that present cerebral activities tend to recur in the manner and order which have been most frequently re- peated in the race and in the individual— such manner and order necessarily varying according to the particular direction and nature of their or his education, natural or acquired. The study of this order corresponds with the study of the order of mental phenomena, and has resulted in the establishment of certain so-called Taws of association.’ The process by which language incorporates itself with all our perceptions and thoughts is not different from that which associates percep- tions and thoughts among themselves. It is, however, a more special association; and con- sequently a weak or failing memory — whether resulting from old age, brain-shock, or malnu- trition — is peculiarly apt to show itself in this direction, and that more especially by' an ina- bility to revive the cerebral processes conneeced with the names of persons, places, or things ( see Aphasia). But this kind of defect has to be dis- tinguished from the inability to utter or to write words which are nevertheless remembered, that is, where the cerebral processes associated with the word as a mental symbol may be revived, in the main, in some portions of the brain con- cerned with the reception of auditory impres- sions, though incitations may not be able to pass over from these centres so as to revive nerve-processes in other centres of the motor type, by which the word is either spoken or written, according as the one or other effect is desired ( see Aphasia). The loss of verbal me- mory is in these latter cases not so real as it seems to be, and such defects may, moreover, be induced by quite limited cerebral lesions. In the third mode of exercise of memory (c) there is no longer the easy flowing mechanical revival of foregone processes, together with the simultaneous recurrence of copies of foregone phases of consciousness, which should charac- terise the modes of exercise above alluded to. Now there is a delay in the process of automatic revival ; a vague sense of effort intervenes at some stage of the thought-processes, similar to that of which we are conscious when we attempt to ‘guide our thoughts’ into particular chan- nels ; we strive ‘ by way of association ’ to find some new molecular channel by means of which the cerebral processes concerned with the for- gotten name, event, idea, or relation, may be roused anew, in order that we may ‘ recollect,’ or recall by voluntary effort, what may be needful for the continued expression of our thoughts. This latter process of ‘recollection ’ is, there- fore, that which is rendered necessary by the first stage of faultiness of memory, a condition which may obviously be brought about in alto- gether different modes, to some of which w: are now about to refer. 242 MEMORY, DEFECTS OF. ./Etiology of Defective Memory. — It seems clear, on the one hand, that for memory to be good (cr) the preliminary process of synesis must have been well accomplished. Yet this first and essential condition may be defective from va- rious causes. (1) The original plasticity or re- ceptive potency of the nerve-tissue may have been inferior from birth; or it may have been temporarily lowered by conditions of mal-nurri- tion, such as are not unfrequently met with in porsons who have suffered from severe fevers or from other exhausting diseases. On the other hand, the potency of the nerve-tissue may be good, and yet the processes of synesis may have been badly effected, owing (2) to the individual s lack of attention at the time when what is now to be remembered originally engaged his con- sciousness ; for no truth is more obvious in regard to memory than that of its dependence upon the degree of attention bestowed upon the original impressions or ideas. Those which have been vividly attended to at the time, from what- ever cause, tend to become indelibly ‘stamped upon the memory,’ and all the more so because such impressions or ideas are prone to be often thought of, and thereby strengthened by each revival of the cerebral process; whilst those that have slightly engage.d our attention are apt not to be revived, and to be after a time effaced, though it is in this respect especially that so much of individual difference is met with. Greatly diminished power of attention is, moreover, com- monly met with in exhausting diseases, and in multitudinous brain-affections. Rut, on the other hand, however well the pro- cess of synesis may have been accomplished originally, this will be altogether unavailing if (i) the avenues are damaged or impaired by which associated processes transmit their sti- muli. The automatic excitation of memory is then hindered. Thus, to take only one ex- amplj, if certain commissural connections be severed between what we may term the visual and the auditory word-centres, a person may be able to read so as to understand the words which he sees, and yet not be able to pronounce one of them, because the associational stimulus cannot pass to the corresponding part of the auditory word-centre, so as to rouse this particular memory or idea of the word, from the molecular processes concerned with which the motor stimuli issue for its pronunciation. (See Brain as an Organ of Mind, p. 640.) Again, however well the process of synesis may have been originally performed, if (c) the whole nutrition of the brain becomes lowered by ex- hausting disease or old age, failure of memory may present itself because attention cannot be adequately roused, and the cerebral processes generally are too feeble to propagate them- selves, as they would have done formerly, into the various collateral channels or molecular paths, so as to rouse the activity of all such previously associated brain-regions as are neces- sary for the full realisation of the thoughts of the moment. From what has been already said, it will be boeu taat defects of memory may result from very various causes, acting as an impediment to one or other of the successive processes upon MENINGES, DISEASES OF. which memory depends — namely, either (a) from synetic defects; (6) from associational defects; or (c) from expressional defects. Pathology. — In all those cases in which we may presume that synesis is impaired, we may expect also to find evidence of a greatly weak- ened power of attention, and there may in addi- tion be an impaired perceptive power. Such defects are mostly dependent upon general causes affecting the nutrition of the brain as a whole. A condition of this kind may be only temporary, and then, whilst recent events are speedily for- gotten, it may happen that the memory of old impressions remains fairly good, or may even be marvellously intensified, so that long-forgotten occurrences or knowledge become revived. At other times the patient's mind may for a time be reduced to a perfect blank, old and recent know- ledge, familiar and unfamiliar, is alike blotted out ; though after a time recovery of memory may take place, either slowly or with compara- tive suddenness. In cases of epileptic mania, and in many instances of brain-shock from blows upon the head, the patient may lose all memory of immediately preceding events. Where the secondary process of revival is that which is interfered with, the loss of memory is generally most manifest in regard to words. The processes of association by which these are re- called to memory, are either impaired or dis- turbed, so that we get one or other variety of amnesia induced, either of tho paralytic, or of the incoordinate type ( see Aphasia). Such de- fects are, in the opinion of the writer, specially prone to be induced by lesions of the convolu- tions contiguous to the posterior extremity of the Sylvian fissure. (See Brain as an Organ cf Mind, pp. 682-7.) Where there is mere loss of power to express thoughts, the loss of memory is often more appa- rent than real, and is due to a mere paralysis affecting speech and writing as motor acts ( set Aphasia). And these conditions, either singly or in combination, are also apt to be induced by lesions in the third left frontal convolution, or of regions between this gyrus and those bordering upon the posterior extremity of the Sylvian fissure. T rkatment. — The treatment of these various defects of memory, so far as they are amenable to therapeutic influence, naturally resolves itself into the treatment of tho various general or local merbid conditions upon which they depend. In some cases we can do little or nothing ; but in other instances much good may be effected under the influence of a tonic and restorative regimen, ai led by stimulant, sedative, or hypno- tic remedies. H. Chaei.ton Bastian. MENIDROSIS (mV, a month, and iSpusJ sweat). — A term applied to vicarious menstrua- tion by the skin. Set Perspiration, Disorders of MEBTIERE’S DISEASE. Ses Vertigo. MENINGES, Diseases of.— The treatmeD 1 of this subject is naturally divisible into two mail heads. We have to consider (1) the morbid cun ditions resulting from disease of tile Cerebra Meninges; (2) those of the Spinal Meninges Though most frequently affected separately meninges, diseases of. etill it happens on some occasions that these two main divisions of the membranes surround- ing the great nerve-centres are simultaneously diseased.^ This is the case, for instance, in Epidemic Cercbro- Spinal Meningitis , an impor- tant general disease, which is considered in a i B eparate article (see Epidemic Cerebro-Spinal Meningitis). A similar diffusion of inflammation also occurs, but more rarely, in cases of Sporadic Cerebro-Spinal Meningitis, which may be some- times • simple,’ and sometimes of the 1 tuber- cular’ order. In the articles that follow, the several diseases of the Cerebral Meninge3 and of the Spinal Meninges will be separately discussed. MENINGES, CEHEBEAL, Diseases of. — Synon. : Fr. Maladies des Meninges Cere- drrales ; Ger. Krankkeiten der Himhdute. — The following morbid conditions, and varieties of such conditions, have to be considered under this heading : — 1. Inflammation — of several varieties. 2. Hemorrhage into. 3. Hematoma of. 4. New growths and Adventitious products. — Under this head are included, besides the different kind of tumours originating in the meninges, other bodies of quasi-accidental origin, which may be met with in the cavity of the arachnoid, in the meshes of the pia mater, or in connection with the vessels of these parts. ■5. Malformations. See Brain, Malforma- tions of. Inflammation of the cerebral meninges occurs ’rom various causes, and also affects various jarts of the membranes, so that the subjoined •arieties of the disease will have to be separately icnsidered : — , ,, . ... f a. Idiopathic. ”■ Simple Meningitis h. Tubercular Meningitis. The simple meningitis of traumatic origin iccurs under three pretty distinct forms, aecord- ng as it affects the dura mater — Pachymenin- gitis ; the surfaces of the arachnoid — Arachnitis ; r the meshes of the pia mater beneath this oembrane — Leptomeningitis. Both the idiopathic imple meningitis and tubercular meningitis are orms ot' leptomeningitis. All are acute diseases. Concerning chronic meningitis we have more f pathological than of clinical knowledge, though ren as regards the former side we are bound 'i say that much of the thickening and opacity f the arachnoid, formerly regarded as duo to ihronic inflammation,’ is rather a mere result of egenerative overgrowth — partly brought about 5 an appanage of advancing age, and partly as a ^sequence of frequent or long-continued eon- jjstions. Still, such conditions may at times be iiupled with more distinctive evidences of actual ironic inflammation, for example, in some cases : chronic mania, and also iu general paralysis the insane. . Good reasons, moreover, exist for believing in te frequent clinical existence of local chronic flammation of the meninges, as evidenced by e presence more especially of localised pain id of tenderness on slight percussion, coupled th other head-symptoms. Fortunately for e patient, however, we have often no oppor- MENINGES, INFLAMMATION OF. 943 tunity of verifying this diagnosis, because such a condition is of itself not likely to lead to fatal results. It may follow a blow ; it may occur as one of the consequences of constitutional svphilis, or it may manifest itself independently of either of these causes. Chronic syphilitic meningitis is the best known of these varieties. Its associated morbid conditions are, however, most closely related to another set of changes, which will be described, and in which wo have to do with new growths or ‘ gummata.’ Two other varieties of meningitis are occa- sionally met with as rare events ; first, an in- flammation limited to the envelopes of the cerebellum, or extending from it only to the pons varolii ; and, secondly, an inflammatory condition of the lining membrane of the lateral, and .perhaps the third ventricles. The natural history of these states is at present so little known as not to admit of systematic treatment. Their aetiology and symptomatology have still to be established. H. Charlton Bastlan. MENINGES, CEREBRAL, Inflamma- tion of. Simple Idiopathic. — Synon. : Simple Idiopathic Cerebral Leptomeningitis ; Lepto- meningitis infantum (in part). Fr. Meningite Simple ; Ger. Acute Himhautentcundung. Definition. — A simple non-tubercular inflam- mation of the cerebral pia mater, which may be either limited to the convexiiy, general, or con- fined to the base of the brain. It is associated with very variable symptoms in different cases , and is probably caused in many different ways. yEtiology and Pathology. — Our knowledge of the aetiology and pathology of acute idio- pathic cerebral meningitis is only vague and in- definite, so that little but unconnected statements or mere suggestions can be here set down. It appears that sex exercises an influence in the production of idiopathic meningitis, and that the disease occurs much more frequently in males than in females. In regard to age. it is met with almost as frequently in individuals from ten to twenty as in those below the tenth year. In individuals over twenty the disease is much more rare. Meningitis is apt to occur during, or as a sequence of, some acute febrile disease, such as measles, scarlet fever, small-pox. and rheumatic fever. It may complicate erysipelas of the head and face ; or may occur in the course of pneumonia or pleuro-pneumonia. Sometimes it is met with in miserably cachectic subjects, who have not previously been suffering from any acute disease. It has been known to follow prolonged exposure to the sun; to ensue after the occurrence of severe moral perturbations ; and likewise to fol- low a shock or blow, even when this has not been complicated with an external wound, or with a fracture of one of the bones of the skull. But how do these various predisposing or exciting causes operate, so as actually to bring about the inflammation ot the meninges, with which we are now concerned? Here some hints only can be offered by way of explanation. In part the problem does not difier from that as to the actual cause of inflammation in other internal parts of the body. Setting aside ttaumatic influences, or the sudden operation of 944 MENINGES, CEREBRAL, excessive heat or excessive cold, how does in- flammation start from mere altered nutritive processes ? It is difficult to believe in a primary alteration in themode of activity of cell-elements originating of and by itself, independently of altered nervous or of altered vascular conditions within the texture. Again, altered nervous in- fluence (whether vaso-motor or other) may be a real factor in the initiation of a meningitis, even though we know nothing of it as a fact, and consequently can say nothing as to the kind or cause of altered nervous influence which might be operative. We are thrown back, therefore, necessarily upon a consideration of those altered influences that may arise in or upon the side of the vascular system, for the elucidation of the other probable cause or starting-point of the in- flammation with which we may have to deal. We shall do well to bear in mind, also, that tn certain states of the system, or in certain constitutions, conditions exist (partly febrile, partly cachectic, and partly of the nature of blood-poisoning) which are inimical to the localisation of an inflammatory process (how- soever initiated), and just as favourable to its extension, especially in a tissue like that of the pia mater. And in just such conditions of the system we should also find that some simple accident on the side of the vascular system, such as the rupture of some vessel or vessels and the occurrence of a slight haemorrhage into the tissue, or the occlusion of one or more vessels either by embolism or thrombosis (events which might not on other occasions lead to the setting up of any- thing like inflammation), may, under the par- ticular constitutional conditions existing in the patient, be capable of exciting an inflammatory process. 1. In the acute diseases, or during convales- cence from them, as well as in extremely cachectic subjects, altered blood-states sometimes exist favourable to the occurrence of thrombosis ; and this may occur either in one of the veins return- ing blood to the longitudinal sinus, or in the sinus itself. The condition of the sinuses should therefore be always investigated in cases of meningitis. In many instances hcemorrhages have been found beneath the arachnoid in meningitis, and these may, like the meningitis itself, have been immediately consequent upon thrombosis in the longitudinal sinus, although this, the primary process, has escaped observation. 2. In erysipelas of the head and face, as a cause, we have the type of a mode of origin of meningitis such as may occur also in other cases — for example, in some of those instances where, in the course of rheumatic fever symptoms of meningitis (other than those which are occasioned by hyperpyrexia) set in with great severity, and cause the death of the patient just as rapidly as when they supervene in the course of erysipelas of the head and face. In both these cases no products of inflammation may be met with in the membranes post mortem , but only a very minute injection of the pia mater in all regions basal, as well as lateral, or vertical. The ten- dency here, therefore, is to set up a general menin- gitis, just as in the previous category of causes the tendency would be to the establishment of a meningitis affecting the convexity. On micro- INELAMMATION OE. scopical examination, in one such case, the writer found the minute vessels blocked with concretions of an albuminoid or fibrinous nature, which seem to have separated from the blood. (See Path. Trans, vol. xx. p. 8.) It is difficult to say in what acute conditions some such cause as this may not have been opera- tive in settingup the inflammation, where menin- gitis occurs in the absence of other easily recog- nisable causes. 3. Multiple embolisms of the vessels of the pia mater in certain cases of endocarditis are another possible initiating cause of idiopathic meningitis — which, moreover, seemed almost cer- tainly to have been the actual cause, in a case that came under the writer’s observation a few years ago. 4. Meningitis may take its origin in a slight lacerating lesion of the surface of the braiH or of its membranes, with or without notable extra- vasation of blood, as a result of a fall or blow, even in cases where there is no fracture of the skull or external wound. 5. In other cases, also, a meningitis really secondary may appear to be primary and idio- pathic, as when (a) it extends from some focus of syphilitic disease of the meninges, or (b) when i; occurs as a sequence of some unrecognised chronic inflammation involving the middle ear and por- tions of the temporal bone. Anatomical Characters. — Simple idiopathic inflammation of the cerebral meninges is a con- dition which varies much in severity in different cases. In its earliest or initial stage, nothing more than a minute and more or less uniform injection of small vessels and capillaries in cer- tain regions of the cortex maybe met with. Bat later on, definite products of inflammation are to be seen ; these are for the most part situated beneath the arachnoid, in the meshes of the pia mater. They consist, according to the stage of the morbid process, either of a gelatinous white or yellow lymph-like matter, of actual pus, or of more coherent yellow lymph, in the form of mem- branous layers. In regard to the area involved considerable differences also exist. The inflam- mation — (1) may be limited to the convexity and to the lateral regions of both hemispheres : (2) it may be general, that is. involve the parts above-mentioned, and also the base; cr (3) it may be limited to the basal regions of the brain. In both the latter eases the ventricles are apt to contain fluid, and the central parts of the brain to'be softened, as they are in tuber- cular meningitis, which also affects the base in a special manner. Of these varieties as to seat, the first, in which the convexity is involved, is decidedly the most typical, and in this respect simple idiopathic meningitis contrasts in a salient manner with tubercular meningitis, in which the tendency is no less marked to implicate the base of the brain. In' the second variety, the inflammation beginning above probably extends to the base by mere continuity, in eases where the condition of the patient, or the intensity of the inflammatory process itself, favours its spread from the original site; or, in certain cases, the inflammation may be from the first general in seat. In regard to the third variety MENINGES, CEREBRAL, INFLAMMATION OF. much doubt may be said to exist. It is by no means clearly established that a simple idio- pathic inflammation ever begins to manifest itself at the base, and there only — though no good reason can be assigned why such a distri- bution should not occasionally exist, except that experience shows it to be at least very rare. If, moreover, such an inflammation be not of unsuspected traumatic origin, there are still two other modes of accounting for its exist- 'euce, which should be excluded before regard- ing it as an idiopathic cerebral meningitis of unusual site. Thus, it may be an extension up- wards from the spinal meninges of an inflamma- tion beginning there — a case, in fact, of cerebro- spinal meningitis, either sporadic or epidemic. Or, on the other hand, it may be one of those cases of tubercular meningitis where the general disease manifests itself on tho side of the brain irst, and in which the patient dies before the ocal process is at all fully developed. In such i case tho inflammation may be really of the ubercular variety, and yet to superficial obser- vation not recognisable as such. Although not ikely to occur often when the autopsy is made >y a competent observer, the case may be other- rise, and either of such misapprehensions as to he real nature of the affection is more especially pt to occur where the head only is examined. In all these cases, too, the inflammation may e limited to the meninges themselves, or the irface of the brain may also bo manifestly lvolved in the inflammatory process, so that e then have to do with a meningo-cercbritis of drying seat and extent. Symptoms. — In no disease is the symptoma- >logy more various than it is in acute menin- tis— a fact partly due to the varying intensity the inflammatory process, partly dependent >onthe process being localised or more general, id partly according as there is or is not the -existence of dropsy of the ventricles with flammation of their walls. Sometimes the sease is almost latent, accompanied only with ,ght symptoms, merging into stupor and coma lay or two before death. Or tho symptoms iy be marked and quite tragic in their severity ; hered in either by frightful pains in the head, well-marked delirium, or by convulsions ; sub- ing eventually into a condition of stupor or na; and followed by death within eight or 1 days, though this may be delayed till the i liration of three weeks or a month. Recovery, ' ich sometimes occurs, must be regarded as a i e event. nasmuch as it is not practicable, within the 1 its of this article, to give a detailed account c :he various groupings of symptoms that may 1 met with in different cases, we must confine qselves to an enumeration of the symptoms t nselves, most apt to occur — (1) in the early a ;es of the disease, and (2) in its later phases. . Cephalalgia of an intense character, either {ioral, or localised in some particular region or r ons of the head, may be complained of again a again where the patient is old enough, or, d e he too young, is indicated by cries, by ap- P ition of the hands to the head, or by other 81 s. Sometimes, however, this symptom may be «t absent, or it may come on at a later date. 60 94£ Delirium, occasionally furious, at other times more quiet and of a simply loquacious type, i.- another symptom; or extreme restlessness. Mere insomnia, too, sometimes exists from the com- mencement ; whilst at other times a semi-coma- tose condition, gradually deepening into actual coma, may exist from tho first, especially in children, or it may succeed a transitory de- lirious condition. Nausea and vomiting, and also convulsions, either local or general, may be met with in the early stages of the disease, and sometimes as initial symptoms. With them will go general pyrexia and sometimes rigors ; also heat of head, rapid pulse, a furre i and often thickly-coated tongue, constipation, perhaps some intolerance of light and of loud sounds, together with an easily obtainable tail" cerebrate. 2. As later symptoms we may have localised convulsions, or spasms, often of the tonic order, affecting perhaps the head and neck, which are frequently drawn backwards, or one or both arms ; or a condition of trismus may exist. Tho eyes, too, are sometimes drawn upwards. The pupils may be at first contracted, or if not. they may be of medium size, unequal and insen- sitive ; whilst later on they are most frequently widely dilated and insensitive. The conjunctivee are often injected. Paralysis of one arm, or sometimes of an arm and a leg. may occur. The sensibility of the skin may be either exalted or deadened. The abdomen is often hollow and boat-shaped. The tongue becomes thickly coated, or dry and brown. Difficulty of deglutition is frequently well marked towards the end ; and there is incontinence of faeces and urine as soon as the stupor becomes marked. Sometimes the pulse is unnaturally slow and infrequent from the first ; at other times, and especially towards the end, it is very frequent and irregular. The respiration, too, becomes much disturbed, being often sighing and of very irregular rhythm, tending to become stertorous at last. The tem- perature is frequently high, but pursues a mark- edly irregular course. Remissions of the py- rexial condition may take place from time to time. The skin is generally hot and dry, though occasionally there may be copious sweats. Stu- por and coma almost invariably occur at the last, if not present at an earlier stage. Prognosis. — A large number of deaths take place within the first week of acute meningitis ; a much smaller number survive till the end of the second week ; fewer still reach the end of the third ; and only a very few survive to the fourth week. It is difficult to say what the percentage of recoveries may be ; but probably less than ten would survive out of a hundred cases of acute idiopathic cerebral meningitis. Diagnosis. — The diagnosis of idiopathic me- ningitis involves considerations very similar to those arising in the diagnosis of tubercular meningitis, and need not therefore now be dis- cussed. See Meninges, Cerebral, Inflammation of, Tubercular. The diagnosis of simple from tubercular menin- gitis must oftentimes be a matter of extreme difficulty. Whether the condition of the blood, as recognised by the aid of the microscope is the same in simple meningitis as it is in tubercular 346 MENINGES, CEREBRAL, INFLAMMATION OF. meningitis the ■writer is unable to say. Should it not be so, some help might be obtained in this direction. The conditions under whichthe disease seems to develop may throw some light upon the problem. In regard to special symptoms, the possible range is so great in each variety, that it becomes difficult to fix upon any that are positively distinctive of one or of the other. Delirium is, however, rarely so violent in tuber- cular as it may be in simple meningitis. Re- traction of the head is also not so frequent in the tubercular variety. On the other hand the tem- perature much more frequently rises over 101° Fh. in simple than it does in tubercular meningitis. Finally, it must be borne in mind that the former is an extremely rare disease, the latter unfortunately only too common ; and that whilst in tubercular meningitis the two sexes fall vic- tims with about equal frequency 7 , in the simple variety, t-wo out of three are likely to be males. Treatment. — In the early stages of acute simple meningitis aperients may be freely ad- ministered. A leech or two might be applied to the temples, in cases where pain is greatly com- plained of ; or under the same conditions the head may be shaved and an ice-bag applied, should it not be deemed useless on account of the extreme restlessness of the patient. The writer believes that little or nothing is to be expected from drug treatment towards the cure of this disease, although some alleviation of the more distressing symptoms may at times be brought about by special attention to them. The patient requires to be carefully fed, and assidu- ously nursed and kept quiet throughout, in the hope that the end may be favourable. H. Ch.vbi.ton Bastian. MENTNC+ES, CEREBRAL, Inflam- mation of, Simple Traumatic. — Several dis- tinct forms of meningitis, of traumatic origin, have to be carefully distinguished from each other. We have a meningitis in which the outer surface of the dura mater is the part chiefly affected — Pachymeningitis-, one in which the cavity of the arachnoid is the seat of the effu- sion —Arachnitis ; and one in which both these escape, and the subarachnoid spaces, or, it may bo, the structure of the pia mater, is primarily iuvolved — Leptomeningitis or Subarachnoid Me- ningitis. For the most part, it is possible to dis- tinguish these forms at the bedside, as well as in the post-mortem room. Sometimes the case is of a mixed form ; especially is it not uncommon for an inflammation which had begun between dura mater and bone to extend through the fibrous membrane, and involve the arachnoid beneath it; but it is still a remarkable fact in pathology that very frequently the delicate arachnoid suf- fices to restrict an extensive inflammatory pro- cess to one or the other side of it. Of the inflammation between the dura mater and bone it is possibly true that it occurs only in association with disease of the bone. If there be any exceptions to this latter statement they occur probably in connection with syphilis. Oc- casionally cases are met with in which the ar- achnoid cavity itself contains puro-lymph, the surface of one hemisphere, for instance, being covered, and yet there is no history of injury or of prior inflammation of the scalp or bone. Such cases are, however, rare, and their possible causes need further investigation. In a general way, children may be deemed more liable to meningitis after injuries than adults, and in them not very unfrequently severe and fatal complications ensue after injuries not attended by fracture. 1. Pachymeningitis. — Inflammation of the meninges secondary to inflammation of the bone is one of the commonest of the dangers which attach to injuries to the head. The hone is con- tused, and in most cases there is some stripping off of the pericranium. Symptoms. • — For a week or ten days the patient does well ; and then he begins perhaps to complain of headache, feels chilly and uncom- fortable, and cannot eat. These symptoms in- crease, and drowsiness and semi-stupor mav come on. If the ophthalmoscope be used, very possibly at this stage the discs may be found hazy and swollen ; aDd this may occur without any evident defect of sight, or with but little. If the I trephine be now used, the bone will be found discoloured, its diploe greenish, and beneath it a collection of pus. The pus is rarely in large quantity, and is usually discoloured, whilst all around the collection of fluid there is much cohe- rent and sticky lymph, which loosens the mem- brane from the bone. It is very rare to find ;:i large abscess, such as those described in the cele- brated cases given by Pott. Usually the termi- nation of such cases is that the substance of the dura mater inflames ; that the arachnoid is im- plicated ; and that a layer of puro-lymph line: that membrane, and coats the hemisphere. With this state special symptoms are associated, th< most noteworthy being hemiplegia of the oppo site side. Very commonly, however, anothe event cuts short the case. In mentioning th early symptoms nothing has been said as t rigors, r.or do they, as a rule, occur, unless th complication just hinted at is developed. Th;: complication is pyaemia. This pytemia has n essential connection with the meningitis. 1 depends upon the inflammation of bone, whic is the common cause of both, and which may V the parent of either singly, or of the two as twin With the gangrenous osteitis occurs gangrenoi phlebitis of the veins of the diploe ; from the; the process extends to the proximal sinus of t) brain (more commonly the superior longitudinal infectivo emboli of decomposing material ga access to the circulation ; aDd all thewell-knov phenomena of pyaemia iollow. It is most it portant to distinguish the symptoms whi; belong to the pyaemia, if we would rightly e- s mate those due to the meningitis, for very i? quently they are met with together. Especia must we remember that a severe rigor probat denotes pyaemia; and that, if it be repeated, t diagnosis of this affection is almost certain, t is the almost constant complication with pl- bitic pvaemia, which so almost invariably dis- points the surgeon of any benefit from the nst t the trephine in this group of cases. If pvten does not occur, then probably arachnitis is the, and thus it conies to pass that a recovery a i secondary trephining is almost unknown. Treatment. — But little is to be doneS MENINGES, CEREBRAL regards treatment for this form of osteitic menin- gitis ; the main thing is to adopt measures for its prevention. The careful management of the wound, either by Lister’s plan or by the constant use of the lead and spirit lotion, and the exemp- tion of the patient from all risk of contagion, are the matters which will chiefly claim atten- tion. In cases of depressed compound fracture without symptoms, one of the objects of primary trephining is to prevent meningitis, by removing displaced fragments, and by affording free exit i for secretions. 2. Arachnitis. — The form of meningitis to which the term arachnitis is applicable is a frequent consequence both of inflammation of ?ontused bone and of wounds of the membranes. ' Suough has already been said as to the circum- stances under which it occurs after contusions of bono, and we have chiefly now to examine its pathology and special symptoms. Anatomical Characters. — In the post- mortem, room arachnitis may be easily distin- guished from inflammation in tho subarachnoid spaces, and tho distinction ought always to be 'carefully made. In arachnitis tho puro-lymph covers the cerebral convolutions in an even layer, and does not dip into the sulci, to which, indeed, it has no access; whereas when the spaces are affected, the sulci are filled, and the convexities of the convolutions remain free. In the latter Tone of the effusion can be peeled or sponged iway, nor does any adhere to the parietal arach- noid. In true arachnitis both the parietal and fiscerai layers are smeared over. Symptoms. — Many cases of compound fracture if the skull, with laceration of the dura mater, , fiord us good opportunities for the study of acute raumaticaraclmitis; but, unfortunately, in many >f these cases the brain-substance is also punc- tured, and it becomes at least possible that the ondition described as diffuse encephalitis may e present, and may complicate the symptoms. Ve are helped, however, as regards the avoid- nca of fallacious inferences by the other set f arachnitis cases, in which the arachnitis is scondary to osteitis, in which, there having ;en no injury to the brain, there is no proba- lity of encephalitis. Speaking, then, from |o result of observation of both classes, it may ||) stated that whenever evidences of arachnitis e found widely spread over a whole hemisphere, ere has been during life hemiplegia of the op- ■ site limbs. Exceptions, apparent or real, occur this, but they are rare, and probably most of dm are apparent and not real. The risk of •or lies in the ease in which, in a patient who j very ill, hemiplegia, which supervened gra- ally during the last day or two of life, may re been overlooked. The hemiplegia is rarely nplete, and unless the limbs be carefully I ced at each visit, both patient and surgeon >y be unaware of its presence. Its degree is I portionate to the extent of the arachnitis; if the latter pass under the falx and involve t opposite hemisphere also, there may be f cral weakness of all the limbs, which may pin to some extent mask tho hemiplegia. It 1 Imost certain that the hemiplegia has little jj nothing to do with pressure from effused " l l°r the latter is rarely in large quantity. INFLAMMATION OF. 947 Its immediate cause is, indeed, not very obvious, but as the grey matter of the cortex is almost always discoloured, and changed from a pink tint to a greenish-slate hue, it may be conjectured that this in some way has to do with tho symptoms. The other symptoms which attend acute diffuse arachnitis are — wandering delirium, rarely violent ; increased temperature ; inconti- nence of urine and faeces (part of the hemiplegia) ; and occasionally unilateral sweating. It should be remarked that the hemiplegia involves both sensation and motion. As, however, it is in- complete, the defect in sensation is almost cer- tain to escape notice. Patients who are obliged to admit that they cannot move their limbs forcibly, will deny that there is any defect in feeling, and it is often impossible to confute them. In well-pronounced cases, however, sen- sation always fails as well as motion. Treatment. — It is doubtful whether recovery ever takes place after this form of arachnitis has become well established ; and here, again, we have to think rather of prevention than of cure. Cold to the head — spirit lotions being the most convenient form — and very early and efficient resort to mercury, are the chief measures where the dura mater is known to have been lacerated. Strong spirit lotions should be used from the first, and mercury also given. It is too late tu commence the exhibition of mercury after the symptoms of arachnitis have set in. Amongst the measures of treatment of more doubtful value are aconite, in small doses frequently re- peated, leeches, blisters, and fomentations. If blisters are used, they should be applied to the neck, or back, or shoulder. 3. Leptomeningitis. — This form of trau- matic meningitis, which occurs in the sub- arachnoid spaces, is an exceedingly interesting malady. ^Etiology. — Leptomeningitis may ho encoun- tered after any form of injury to the skull in- volving laceration or puncture of the visceral arachnoid, but its most typical illustrations arc witnessed after fracture through the petrous portion of the temporal bone. This fracture although usually counting as a simple one, is in reality compound, in that it opens up access to au air-containing cavity. It is possible that air may reach the injured bone either through the external ear or the Eustachian tube. It is a matter of some interest to determine whether arachnitis of these spaces often, if ever results from severe concussion without any frac- ture, or after simple fracture without any pos- sibility of admission of air. It is impossible, however, to speak clearly on this point. Anatomical Characters. — Results which are scarcely ever witnessed after simple fractures in other regions of the skull may occur here, a fact which can only be explained on the supposition that we hive to encounter tho risks incident to compound lesions. Amongst the results re- ferred to is the frequent development, sonx- days after the accident, of inflammation in the large subarachnoid spaces at t.he base of the brain. It is .probable that the inflammatory process travels along the course of the nerve- trunks (seventh nerve), and thus gains access tu tho spaces. Affecting first the parts adjacent MENINGES, CEREBRAL, INFLAMMATION OF. 118 to the roots of the nerves, the inflammation may spread downwards on the medulla and eord, or upwards through the posterior fissures into the ventricles, cr C7er the surface of the hemispheres. Usually it is almost confined to the base of the brain and medulla oblongata. These parts are coated with serous lymph, which invests them closely and adheres to all the nerve-roots passing from them. The layers of arachnoid which cover in and confine the exu- dation remain quite transparent, and show no traces of lym-ph on their inner surface. It is only when these layers are cut or torn that access to the inflammatory effusion is gained. In performing the autopsy it is needful to use care lest this laceration be made by accident, and the characteristic appearance somewhat spoiled. Symptoms. — Patients suffering from this form of basal subarachnoid inflammation may become delirious and die very quickly in the first access of the morbid action; but., on the other hand, and more usually, they may live for several days, or a week or two, and show only compara- tively mild symptoms. Absolute sleeplessness, with occasional wandering, but without any degree of paralysis, was the most prominent symptom in one very well-marked caso. It is probable, though not as yet established, that optic neuritis often attends this form of menin- gitis. Its peculiarities as regards increase of temperature have not as yet been ascertained. That the subarachnoid spaces are affected may be plausibly suspected whenever, after supposed injury to the base of the skull, vague cerebral symptoms, unattended by definite paralysis, supervene ; and if there have been bleeding from the ear and deafness, with facial paralysis in the first instance — a triad pathognomonic of fractured petrous bone — then this is the form of meningitis certain to follow, if any. Prognosis. — As regards recovery from trau- matic meningitis of the base, what has been said on the difficulties in forming a confident opinion as to its presence will sufficiently explain the im- possibility, in any given ease in which recovery has resulted, of feeling sure that the inflammation in question had really existed. Many patients, however, recover more or less, often perfectly, after prolonged and severe symptoms following fractured base. Some of these are doubtless recoveries from severe contusion, but others, espe- cially those in which serous fluid has drained away from the ear, may be plausibly conjectured to be recoveries from meningitis of the base. Treatment. — The measures of treatment likely to conduce to recovery in such cases are the same as those for other forms of meningitis. Mercury to ptyalism is the chief agent, and so impressed has the writer for long been as to the danger of the malady, and the value and harm- lessness of the drug, that ho has been in the habit of giving it from the first in all cases in which fracture of the petrous bone has been diagnosed. Jonathan Hutchinson. MENINGES, CEREBRAL, Inflam- mation of, Tubercular. — Synon. : Granular Meningitis ; Acute Hydrocephalus ; Hydro- cephalus intemus ; Brain Fever (in part) ; Tuber- cular Leptomeningitis ; Fr. Fie ire cerebrate, Meningite granideuse ; Meningite tubercukuu- Ger. Tubercvlose Hirnhoutentzundung. Definition. — An acute and extremely fatal febrile disease, with a predominance of head- symptoms ; terminating in stupor and coma, with or without convulsions ; and characterised after death by a ‘ granular ’ meningitis affecting the pia mater at the base of the brain, with the frequent accompaniment of dropsy of the lateral ventricles, and softening of the parts around them. The inflammation of the membranes at the base of the brain is often found to be asso- ciated with a spinal meningitis. Tubercular meningitis is not an independent affection; it constitutes one important phase of a maDy-sided general disease commonly known as Acute Tuberculosis, and marked anatomically by the presence of ‘grey granulations’ within the thorax and abdomen, as well as in the mem- branes of the brain. In certain rare cases death takes place from granular meningitis, before the anatomical marks of the general disease have had time to develop within the chest Of abdo- men. More frequently, however, the manifes- tations of the general disease are already well developed in one or other, or in both, of these situations, at the time that they reveal them- selves also on the side of the brain. In the latter, and by far the most common class of cases, the symptoms met with will he in part those of the general affection, and in part (but in a predominant degree) those due to that im- plication of the brain and its membranes with which we are now specially concerned. See Tuberculosis, Acute. .(Etiology. — The aetiology of tubercular men- ingitis of course resolves itself into the fetiolcgy of the general disease, acute tuberculosis, of which it forms part. This affection is one which occurs with special frequency in young children, between two and six years old, though it is also met with in infants, in older children, in young adults, and even in persons beyond middle age. In adults it is most apt to manifest itself as an occasional complication in the course of chronic phthisis. In children a proclivity to the disease seems often to he inherited, so that two or more in the samo family may be carried off by it. But in what proportion of cases any such proclivity exists can scarcely he said to be known. The central brain-changes — namely, the dropsy and the central softening — are not, in the opin:o: of the writer, necessary accompaniments of tuber cular meningitis, although they most frequentl. coexist — just as they are also most frequentl concomitants of simple or non-tubercular mer ingitis when it affects the base of the braii These central brain-changes were, howeror, th part of the disease that first attracted tlj attention of physicians, so that the affectic with which we are now concerned was knov as Acute Hydrocephalus long before the mo modern designations of Granular or Tubercul Meningitis came into use. Anatomical Characters. — "When the calvar is removed the dura mater is found to be tight stretched over the brain. On stripping hack tl membrane, the arachnoid presents a dull appet MENINGES, CEREBRAL, ance, and it is slightly sticky when touched. The convolutions of the vertex and lateral regions of the brain are seen to be more or less flattened from pressure, and the sulci are cor- respondingly indistinct. No lymph may be seen ; or at most a small quantity, in the lower parietal regions along some of the branches of the middle cerebral arteries. When the brain is removed, however, and its under surface is examined, a more or less opaque white or a yellowish lymph- like matter may be seen (beneath the arachnoid, in the meshes of the pia mater) extending from the optic commissure backwards over the central portions of the base and onwards over the pons. In certain cases lymph and evidences of recent inflammation are found round the medulla, and even along the whole length of the spinal cord. More or less lymph also extends on each side into the sylvian fissures. A minute inspection mil likewise show that the tip of the temporo- sphenoidal lobe, and the orbital surface of the frontal lobe, are flecked with a number of translucent granulations, as though the parts had been sprinkled with fine sand ; and on open- ing up the Sylvian fissure on each side, similar granulations, with others more opaque and of larger size, may be seen amongst the lymph in this situation. Translucent granulations also sometimes exist, scattered more sparingly over the lateral aspects of the hemispheres, especially along the sides of the vessels. Examination with the microscope shows that the granulations are composed of overgrowths of tissue-elements immediately surrounding the smaller vessels, and within their perivascular sheaths. In these situations the tissue over- growths may cause a local bulging of the sheath, either all round, or merely on one side of the vessel ; and when such growths become opaque from incipient fatty degeneration, they are then more easily visible as minute white specks. A close examination of the prolongations of the pia mater dipping between the convolutions, with the aid of lens or microscope, will often show minute granulations not otherwise recog- nisable — and that, too, in many regions of the brain. And in cases of incipient tubercular meningitis, where the amount of lymph about lie base is extremely slight, the lens or micro- icope may show the presence of granulations, iot otherwise recognisable, in and around the ower part of the Sylvian fissures — that is in the ■cgions where they are most prone first to mani- fest themselves. The pia mater is generally unduly adherent o the surface of the convolutions, so that it an only be removed in small shreds, and then ot without tearing the superficial grey matter, 'his condition of things is the very opposite f what may be met with in some cases of imple meningitis affecting the vertex, in which he thickened pia mater, with all its prolon- ations, may sometimes be easily stripped off ;om the greater portion of a hemisphere in one iece. The substance of the brain is commonly much lore vascular than natural. The lateral ven- 'icles are usually moderately dilated, containing ■om 2 to 4 or 6 ounces of not very clear serum, he veins on their surface are then engorged, ,, INFLAMMATION OF. 949 and the fornix and other adjacent parts may b© more or less softened, or actually diffluent. Mi- croscopical examination of such softened tissue will reveal the presence of an abundance of granulation-corpuscles; and its specific gravity, if estimated, will be found to be diminished — both these characteristics being marks of a patho- logical softening which has occurred during life, and not of a softening due to mere post-mortem maceration. Some have erroneously supposed that such mere maceration would be adequate to produce the softening. Sometimes the above-described changes aro more fully developed in one than in the other hemisphere ; and occasionally also in some parts of the brain small nodular growths of a ‘ tuber- cular’ nature may be met with, varying in size from a small pea to an almond. These growths are most apt to occur in the substance of some of the cerebral convolutions, or near the surface of the cerebellum, or even, as the writer has seen, within the substance of the corpus striatum. In many such cases the small nodular tumours will be found to be in intimate relations with the vessels of the part, and, in fact, to be composed of a mere aggregate of the smaller ‘granulations’ more or less fused into a single mass. Pathology. — The granulations begin to ap- pear first in the meninges of the base under those influences, whatever they may be, that lead to the development of similar grey granu- lations in other organs of the body. These primary changes excite a common inflammation of the membranes around, and thus entail the production of the lymph, which covers the base of the brain, and extends on either side into the Sylvian fissures. Why the grey granulations should tend to develop first, and specially about the vessels at the base of the brain, cannot at present be explained. This inflammation of the basal meninges also extends, by direct continuity of tissue, over and around the cerebral peduncles to the velum in- terpositum, and to the connective tissue at the upper and anterior extremity of the middle lobe of the cerebellum. In one or other, and often in both, situations the tissues are thickened by lymph. The writer has seen the velum inter- positum thick and leather-like in consistence, and the vense magn® Galeni which run through it blocked by thrombosis; and this he believes to be an occasional cause of the central soften- ing and dropsy, previously referred to as com- ponent parts of the disease (see Edinburgh Medical Journal , April 1867). In other cases, where no such thickening or thrombosis is to be detected, there is great swelling of the connec- tive tissue, from development of lymph, opposite the termination of these great veins which re- turn the blood from the surface of the ventricles and from the central parts of the brain — at the point, that is, where the veins of Galen empty themselves into the straight sinus. In this way the very common association of the central ventricular changes with the basal meningitis may be accounted for, and also the occasional absence of such changes, in instances where the inflammation, apt to be setup through mere continuity of tissue, does not attain sufficient proportions to interfere with the return of blood, MENINGES, CEREBRAL, INFLAMMATION OF. 950 either through the veins of Galen, or from them into the straight sinus. It is of course possible that the central softening may also be favoured by an independent affection of the small vessels situated in the walls of tho ventricles, and a de- velopment of granulations around them — though this has not hitherto been recognised. It is, however, well known that thrombosis is ex- tremely apt to occur in those minute vessels in various parts of the brain which are enveloped by granulations — a fact that goes far to account for the extreme gravity of the symptoms in many cases of tubercular meningitis, in which naked-eye changes appear to be slight and alto- gether disproportionate in amount. Symptoms. — The symptoms presented in dif- ferent cases of tubercular meningitis often vary very widely from one another, although amongst them all there is an underlying bond of similarity. The variation may be easily understood from a consideration of the fact that such symptoms form part of those pertaining to a febrile affec- tion characterised by other local manifestations, of varying importance in different cases ; and also from the fact of the differences constantly met with in the relative and absolute develop- ment of the different kinds of changes encountered within the cranium itself in this disease — espe- cially in regard to the amount of ventricular effusion and central softening existing in con- junction with the meningeal inflammation, which itself varies much in intensity and in regard to the area involved in different cases. It is, therefore, usual and most convenient to enumerate the possible signs and symptoms of this disease as they occur in three stages— artificial and often ill-marked from one another as they are — namely, (1) those of the invasion stage ; (2) those of the developed disease ; and (3) those of its closing phases. (1) Stage of Invasion. — Amongst the initial symptoms of tubercular meningitis may be men- tioned obstinate and recurrent vomiting, often associated with constipation ; coming on fre- quently after a period of previous malaise ; and associated with fretfulness, slight wasting, in- disposition to play, and disturbed sleep. Soon after, or simultaneously, there may be more or loss marked indications of cephalalgia. Young children who cannot speak are fretful and con- stantly cry ; they often also put their hands to their head. Such children start and cry out in their sleep. The temperature may ba as yet scarcely, if at all elevated ; or there may be rigors from time to time, with temporary feverishness, recurring daily about the same hour. The child often cries out when touched, and a more or less general exalted sensibility to painful impressions seems to exist. (2) Developed Disease.— In the second stage any feverishness that may have existed often itbates. There may be less restlessness, so that tho child even sleeps more than natural. Tho pupils are often insensitive to light, and unequal. There is frequently also some slight or perhaps marked strabismus. The pulse is apt to be much less frequent than natural (56-70 per minute perhaps), and decidedly irregular. The hyper- sensitiveness of skin may havo disappeared, but a peculiar vaso-motor irritability exists, bo that when the nail of the fore-finger is drawn ones across the skin of the abdomen or other part, a deep red linear mark comes out slowly, and per- sists a long time. This so-called ‘ tache cere- brale,’ whilst also met with in other affections is, as Trousseau rightly enough insists, rarely absent in tubercular meningitis. Frequent plain- tive cries may be uttered, though the child is generally more quiet and drowsy ; it is apathetic also in regard to food, not asking or 'crying for it, but still talcing it, perhaps well, whenever it is administered. Convulsions may occur during this stage, or weakness of one or more limbs may be noticed, especially where larger tubercular nodules occur in one or other portion of the brain-substance. Sometimes, too, the paralysis is of a shifting and transitory nature, varying in degree or even in situation in the course of a few days. (3) Closing Phases . — In the closing stages of the disease the drowsiness may gradually deepen into stupor or actual coma ; though in conditions short of the latter, the child may still more or less fre- quently utter plaintive cries. The pulse, instead of being less frequent than natural, now becomes preternaturally frequent; whilst the respiration often assumes a slow, sighing, and markedly irregular type. The face, frequently pale and clammy, flushes at times. The head is hot, and the temperature generally raised, though often not more than to 100°, and rarely beyond 102°, until quite to the close of the disease. The fontanelle is raised, and there may be unnatural pulsation. The eyes, when examined with the ophthalmo- scope. may show evidences of grey granulations in the choroid. The pupils may be unequal, but are generally dilated and insensitive. In one remarkable case the writer has seen a rhyth- mical contraction and dilatation go on, especially on exposing them to light. In this stage, when the patient is sufficiently conscious, it may be found thatsight is notably impaired oralmost lost. The patient may take the food which is given, up to the last; though at other times there seems to be an actual inability to swallow it, even when it is placed in the mouth, owing to paralysis of the muscles of the tongue and pharynx. The abdomen is often boat-shaped and retracted: and an obstinate constipation stiil continues. Even in this last stage of the disease a temporary and delusive lull may take place ; the child may seem to revive a little, but only too soon to lapse again into a state as bad as or even worse than before. Frequent and long-continued convulsive seizures are especially apt to occur during this stage of the disease ; and death may take place during or immediately after one of these attacks At other times the end is brought about more gradually, through progressing failure in tin heart’s action, combined with disturbance o respiration. In the latter class of cases thi temperature may gradually fall, during the las few hours before death takes place, to severs degrees below the normal ; though in otherease of tubercular meningitis there is a slow an< steady rise of temperature up to 105°, or eve 106°, before the patient expires. Diagnosis. — -In the early stages the diagnosi of tubercular meningitis may present extsem difficulties. "We must wait, before expressing MENINGES, CEREBRAL, INFLAMMATION OF. definite opinion in one of these doubtful cases, till the patient has been seen and examined two or three times. The premonitory symptoms and those of the first stage are often far from distinc- tive. They may, it is true, represent the begin- ning of tubercular meningitis, but, on the other hand, they may also represent something less serious — for instance, a mere failure of health from various causes, complicated by some gastro- intestinal irritation, or perhaps the commencing outbreak of some one or other of the specific fevers. Details as to the child’s condition during the last two or three weeks, comprising the order of evolution of the several symptoms, may, how- ever, throw some light upon the real nature of the case at an early stage of the disease. A contributory cause of the difficulties beset- ting the early diagnosis of tubercular meningitis is to bo found in the fact that acute tuberculosis is itself extremely difficult to recognise. We cannot, therefore, readily fall back upon a diagnosis of the general condition in order to strengthen our diagnosis of tubercular meningitis. As a matter of fact it is just the reverse. Of all the local manifestations of this disease, those within the head produce by far the most definite set of symptoms ; so that we can always most safely infer the probable existence of acute tuberculosis with grey granulations throughout the body, from the presence of the developed symptoms of tubercular meningitis. The symp- toms produced by grey granulations within the thorax or within tho abdomen, are 'far less distinctive or, in fact, not distinctive at all. The existence of a particular habit or build of body in all cases of acute tuberculosis to any ap- preciable extent, or certainly to such an extent as to make it possible to use the recognition of it as an aid to diagnosis in a case otherwise obscure, is very improbable. Our notions as to the existence and nature of a tubercular habit of body need revision ; it must not thoughtlessly be confounded with the mere phthisical habit of body; and it seems probable, from more than one point of view, that acute tuberculosis is a quasi- accidental disease, occurring at times in in- dividuals of any build of body whatsoever — with no more limitations, that is, than may exist in regard to the incidence upon persons of different lodily types of one of tho common acute specific diseases. The symptoms of the established disease are therefore alone distinctive, to any really trust- worthy extent, of the existence of tubercular meningitis, and through it of the presence of its general underlying condition. We may have 3ur suspicions before, but these can only trans- form themselves into certainties as the disease ictually develops, and as it passes, moreover, nto the incurable stage. At this phasis of the disease the alternative ■onditions to be thought of are in the main hese — typhoid fever on the one hand, or else iome form of intracranial disease other than ubercular meningitis. Here, as in almost all uses of brain-disease, we have to look not to any me or two signs or symptoms which can be re- :arded as pathognomonic, but ra iher to the sum otal of symptoms, and to the way in which they ie grouped. With the possible existence of some 95 1 or all of the premonitory and initial symptoms already enumerated, if the patient becomes more somnolent; if the pulse falls much below par in frequency, and is at the same time irregular; if with a condition of fever still existing, the child does not constantly crave for drink ; and especially if there is also the combination of obstinate con- stipation and a retracted abdomen, together with an irregular and suspirious form of respiration, we may feel more and more certain that we have not to do with even one of the most anomalous forms of typhoid fever associated with head- symptoms — or, indeed, with any form of intra- cranial disease other than tubercular meningitis. An examination of the temperature chart may considerably aid us in the same direction, and so also may a microscopical examination of the blood. Some years ago, tho writer made observations upon this latter point, tending to show that ir tubercular meningitis there are, in a large pro- portion of the cases, distinctive alterations in the blood — as drawn by a needle-prick from the tip of the fore-finger and examined at once upon an ordinary microscope-slide — capable of affording very material aid in the diagnosis of tubercular meningitis from typhoid fever, as well as from other brain-affections (such as a new-growth im- plicating the pons and contiguous parts, throm- bosis in some of the cranial sinuses, or perhaps one of the simple forms of meningitis). The characters of the blood met with in tubercular meningitis are these ; — The white corpuscles are decidedly more numerous than natural, and speedily (that is, within ten to fifteen minutes after the blood has been drawn) show signs of great amoeboid activity, by tbe development of vacuoles within them, and of numerous projec- tions from their outer surface ; groups of proto- plasmic particles of various sizes are also to b® seen interspersed amongst the blood-corpuscles, as well as here and there a small pigment-granule or an irregular block of pigment of reddish or reddish-black colour. Tho red corpuscles usually run together into irregular masses, rather than into definite rouleaux, though they present ws very distinctive changes. This increase in num- ber with exalted amoeboid activity of white corpuscles, in conjunction with the other blood- characters above-mentioned, are not met with- in typhoid fever, or in the great majority, at least, of other cerebral affections. F’or the diagnosis of tubercular from the simple form of meningitis, see Meninges, Cerebral, Inflammation of, Simple Idiopathic. Prognosis. — Death is well-nigh certain within three weeks, or at most a month, from the date of the invasion-symptoms of tubercular meningitis. When the disease has arrived at a stage permit- ting of pretty certain diagnosis, hope rather than rational expectation may still hold out a chance of recovery. Although instances of this have occurred, they are of extreme rarity. If the courso of the disease is to be modified by treat- ment, it must be during those early stages when we are capable of forming only a provisional or tentative diagnosis. In these stages, however, the writer — and many good observers share this opinion — is inclined to think that under judicious treatment the development of the disease mav MENINGES, CEREBRAL, H.EMOKRHAGE INTO. 96‘2 be arrested. Still this view may, quite possibly, be an erroneous one. Proof of such a position, or of its opposite, is, from the nature of the ease, impossible. Treatment. — From what has just been said, it will be seen that anything like curative treat- ment must be directed to the early or premoni- tory symptoms of the disease. Here the writer thinks he has seen decidedly good results from one to six grains of iodide of potassium, accord- ing to the 'age of the child, administered three times a day, with small doses of cod-liver oil; at the same time attending to the state of the bowels, and giving suitable doses of bromide of potassium at night, till the restless condition with disturbed sleep has passed away. When the disease is further advanced, we may perhaps be able to diminish pain by the appli- cation of cold to the head ; but we only aggra- vate the sufferings of the patient by the use of blisters, tartar emetic ointment, or other irrita- ting applications. Bromide of potassium may do something to keep convulsions in check, though at other times it seems to be quite powerless. Chloral is probably a dangerous drug for a patient, the action of whose heart is already so seriously interfered with ; though chloroform inhalations may be had recourse to in an extreme case, where persistent convulsions cannot other- wise be checked. Beyond this, the child needs the most careful nursing, and to be well sup- ported with strong beef-tea and milk, and occa- sionally with stimulants, so long as it is capable of taking food, whilst attention is paid to the bowels. In this way, if the patient’s case is to prove one of those rare and exceptional instances in which recovery is possible, we, at all events do nothing to thwart the course of natural processes which have a chance, however small, of terminating in recovery. H. Charlton Bastian. MENINGES, CEREBRAL, Haemor- rliago into. — S ynon. ; Fr. Apoplerie meningee \ Hemorrhagic meningec ; Ger. Hirnhautblutungen. ' Definition. — Effusion of blood in one or other of the following situations; — (1) Between the bone and the dura mater ; (2) Between the dura mater and the arachnoid (into the so-called ‘ arachnoid sac ’) ; or (3) beneath the arachnoid and into the meshes of the pia mater. ■^Etiology. — The first of these varieties of meningeal haemorrhage has an almost exclusively traumatic origin ; being a result of falls or blows which occasion the rupture of one of the meningeal arteries, lying between the bone and the dura mater. Still, caries of the bone may in very rare cases lead to such a haemorrhage, by causing erosion of one of the meningeal arteries. The other two varieties are not so distinctly separated from one another, since a haemorrhage occurring in the pia mater, if large, is very apt to break through the arachnoid, and thus lead to effusion of biood into the ‘arachnoid sac’; and this whether t lie primary effusion has been the result, of a traumatic injury, or is a sequela of some gclier. 1 or local disease. Effusion into the arachnoid may also occur as a result of rupture of some vessel on the inner surface of the dura mater; this being probably a rare consequence of injury, though it is a frequent result of disease in this situation ( pachymeningitis interna). Effusions of blood are occasionally found be- neath the arachnoid which have not originate i there, but which have come to the surface, hr laceration of brain-substance, from some intra- cerebral haemorrhage ; or they may have been caused by intraventricular haemorrhages, finding their way into the fourth ventricle, and thence into the sub-arachnoid tissue. In very young children, whose vessels are presumably healthy, bleeding into the arach- noid may occur from any unusual amount of strain. This occasionally takes place at the time of birth, especially during prolonged labours. Indeed, according to Cruveilhier, arachnoid haemorrhage is the cause of the death of about one-third of those infants who die almost imme- diately after birth. A little later on in life, a similar accident may occur during paroxysms of whooping-cough, or during other spasmodic respiratory conditions, in which the return of venous blood from the head is impeded. Later still, an arachnoid haemorrhage not unfrequently follows a fall or blow upon the head, or it mav result from the rupture of an aneurism on one of the larger vessels about the base of the brain — especially the basilar or one of the middle cere- brals. Small subarachoid haemorrhages, often multiple, are not unfrequently produced by the occurrence of thrombosis in the longitudinal sinus. They may also occur in persons suffering from scurvy or leucocythemia. Lastly, they may be met with as ooe out of the many forms of lesion occurring in men suffering from general paralysis of the insane. Meningeal haemorrhages are decidedly more common in males than in females — in the pro- portion of about three to one. They do not like cerebral haemorrhages, occur with progressiro frequency as age advances, but are much more uniformly distributed through the different de- cades of life. Anatomical Characters. — When death takes place soon after blood has been effused into the arachnoid, as well as in the other situations, it is found in an easily recognisable condition. This is by no means the case, however, after the lapse of montns or years ; then, in the case of small haemorrhages, we may meet with mere yellowish or rust-coloured stains ; whilst where they have been of larger size, we may meet with decolorised cyst-like bodies, either free or ad- herent — or else there may be decolorised mem- branous masses, adhering mostly to the parietal arachnoid. "Where the size of the clot has been large, the surface of the brain is more or less pressed upon, so that some atrophy of its sub- stance follows. Many of these latter points are well exemplified in a case recorded by Dr. Quain in the Path. Trans., vol. vi. page 8. Sometimes the layers of altered blood are neithei adherent to the arachnoid, nor do they lie freeot its surface ; they may be attached to the surfaci of the dura mater, or lie between new growth; arising from its inner layers, and thus produci a condition which often goes by the name o heematoma. Prolonged discussions have take! place on the question whether these change are results of a primary haemorrhage oi whethe MENINGES, CEREBRAL, HAEMORRHAGE INTO: AND HEMATOMA OF. 953 we have not rather to do with a ’pachymeningitis interna hemorrhagica, where an inflammation is the first event, during which effusion of blood takes place into the innermost layers of the altered and inflamed membrane. See Meninges, Cebebbal, Haematoma of. Simptoms. — The symptoms attendant upon meningeal haemorrhage will necessarily vary a i great deal in severity, according to the amount and suddenness of the effusion. These symptoms are, moreover, in the great majority of the traumatic cases obscured by those depending .upon the mere shock and concussion of the brain, which the original accident or blow occa- sions. Where subarachnoid haemorrhages occur in the course of thrombosis of the longitudinal sinus, no distinctive symptoms are as a rule produced ; and those of the primary affection are them- iselves only too variable, and difficult of recog- nition. Again, where subarachnoid haemorrhages occur in the course of purpura, leukaemia, or allied affections, the amount of blood effused is usually too small to produce definite or recog- nisable symptoms. At most, the abrupt onset nfpainin the head, vertigo, or mental confusion, may give rise to a suspicion that such an event has occurred. Where a large haemorrhage takes place be- neath and into the arachnoid sac, over one hemi- iphere, or over both, either as the result of a all or blow, or from the bursting of an aneurism in one of the large arteries at the base of the irain, a profound coma is produced which may irove rapidly fatal — that is, in the course of a 'ew minutes or a few hours. Where the amount if blood effused is less, and where it is poured ■ut more gradually at first, there may be pre- aonitory symptoms, in the form of sudden head- cke, vertigo, mental confusion, vomiting, or onvulsions, rapidly followed by unconsciousness, it first there js generally complete relaxation f all the limbs ; but later — after some hours or ays — the weakness may be distinctly unilateral, iat is, of hemiplegic type — though sometimes •ith very slight implication of the face. There iay also be twitchings or rigidity of the limbs a one or both sides. On recovery of conscious- ess there may be no distinct loss of sensibility, fly numbness, in the limbs ; and the paralysis .ay after a time grow less up to a certain point, • gradually disappear. Diagnosis. — In many of the slighter forms of emorrhage into the cerebral meninges diagnosis for the reasons specified, almost impossible. In the more severe cases a sudden apoplectic tack is produced, agreeing very closely with at occasioned by some of the most serious 'ms of intra-cerebral haemorrhage. Causal nditions, especially when they have been trau- itic, together with the possible youth of the tient, may in some cases help us to diag- se a large arachnoid haemorrhage, from a oious bleeding into the lateral ventricles, or ■m a sudden haemorrhage into the middle of s pons Varolii ; though it should bo borne in ad that in the former of these two conditions pupils are almost always widely dilated, list in the latter they are as constantly cou- rted and insensitive, whereas they are likely, so far as the writer’s observations have gone, to be in a more intermediate condition in arach- noid haemorrhage. Prognosis. — In the case of arachnoid haemor- rhages, whether large or of only moderate volume, should the patient survive the first effects of the effusion, and, it may be, of the injury which caused it, danger to life is no longer to be feared. The only question, then, is as to the amount of paralysis, mental impairment, or of irritability with cephalalgia, which may remain ; or whether or not a tendency to convulsions may be set up, as a consequence of the original injury and lesion. Treatment. — The treatment of a case of meningeal haemorrhage does not differ from that appropriate for cerebral haemorrhage. Perfect rest in the recumbent position, with the head slightly raised, is essential. Cold to the head may be conjoined with hot applications and mustard plasters to the lower extremities. For other indications and details of treatment we must be guided by the varying conditions of the patient. During convalescence in the more fa- vourable cases we must pay great attention to the general health of the patient, and above all protect him from overwork or excitement of any kind. H. Charlton Bastian. MENINGES, CEREBRAL, Heematoma of. — Synon. : Pachymeningitis interna hemor- rhagica-, Fr. Pachymeningitc ; Ger. Pachymenin- gitis. Definition. — Inflammation of the inner sur- face of the dura mater, attended with the forma- tion of a membranous vascular tissue, into which hcemorrhage takes place. .Etiology. — This affection is met with at all ages, but is most common in advanced life and early childhood. Males are said to suffer more frequently than females. It is rarely primary ; most of the recorded cases have followed, at some interval, an injury, or occurred in the subjects of insanity, or chronic alcoholism. Other cases have appeared consequent on acute rheumatism and other pyrexial affections, especially pneumonia and small-pox. Anatomical Characters. — According to Vir- chow, in the early stage, before haemorrhage has taken place, a delicate reticulated membrane exists on the inner surface of the dura mater in one or many layers — even twenty. It varies in consistence according to its age. The colour is usually reddish, from the number of new-formed vessels ; but it is often rust-coloured from de- generated blood extravasatedin minute quantity. The position of the membrane is always over the convexity, commonly near the middle line; and it is often symmetrical on the two siRes. In the second stage, that of haemorrhage, blood in con- siderable quantity is effused between the layers in one or several places, and may extend as far as the limits of the false membrane, thus con- stituting one or more simple or loculated cysts. These cysts are, of course, adherent externally to the dura mater, and internally rest on the arachnoid membrane and convolutions, which they compress and even depress. Their con- tents are blood — liquid, coagulated, or in every stage of degener ition. Ultimately only coloured J54 MENINGES, CEREBRAL, NEW GROWTHS AXI) PRODUCTS IN. serositv may remain. The thin delicate wall of the cyst was formerly regarded as organised fibrin from a blood-clot, or as the separated parietal layer of the arachnoid; and some pa- thologists are still of opinion that the haemor- rhage precedes the formation of ihe membrane. Sec Meninges, Cerebral, Haemorrhage into. Symptoms. — Two periods may often be recog- nised, corresponding to the anatomical stages of hsematoma of the dura mater just described. In the first, circumscribed headache is the chief symptom, often felt at the vertex. It may be asso- ciated with giddiness, uncertainty of movement, lowered mental power, and contraction of pupils. In children, in whom the whole disease commonly lasts only a few days, there is often fever. In adults this stage may last for weeks or months. The second stage, that, of blood-effusion, is at- tended by an increase of the mental dulness to distinct somnolence, at first intermitting, but deepening to actual coma with a rapidity that depends on the rapidity of effusion. The pupils continue contracted, but that on the side of the mischief may become the smaller. Hemiplegic paralysis or contraction may occur when the haematoma is unilateral. In children convul- sions are common. The duration of this stage in the adult may be weeks or months ; and death occurs in coma. In children it usually lasts only a few days. Diagnosis. — The diagnosis of haematoma of the dura mater is often difficult, and depends on the slow onset of coma, after a period of liead- uche, without symptoms to indicate a localised lesion of the brain. In the child the disease may be mistaken for tubercular meningitis, but the course of infantile haematoma is usually more rapid, vomiting is rare, and muscular contractions and convulsions are common. Prognosis. — The prognosis is very unfavour- able, but not absolutely fatal in the adult ; in several cases in which the symptoms of hsema- toma have been present, recovery has taken place. In children there is little hope. Treatment. — In the child one or two leeches may be applied behind the ears: and cold to the head, and counter-irritation to the skin of the neck and limbs, are likely to be useful. In the adult, if by rest, cold to the head, and counter-irritation the effusion can be arrested, absorption of the blood will slowly take place ; and this may be furthered by moderate purga- tion, by diuresis, as well as, perhaps, by the administration of iodide of potassium. W. R. Gowers. MENINGES, CEREBRAL, New Growths and Adventitious Products in. — The clinical aspects of the several pathological conditions composing the set of changes included under these heads, are comparatively meagre and ill-defined, as compared with what we know of them pathologically. For this various reasons exist, some of which will he presently in- dicated. Anatomical Characters. — In the present article it will suffice to enumerate the new growths and adventitious products met with in the cerebral meninges, referring to special arti- cles on the several bodies for a fuller description of them. Symptoms and Diagnosis. — Intracranial new growths or adventitious products are, as a class, accompanied by the most diverse sets of symp- toms. The new growths or products vaiy in dif- ferent eases within very wide limits, from the point of view of the suddenness of their onset or increase, as well as of their actual bulk or num- ber, and also as regards the particular intra- cranial region or regions which they implicate. We may therefore in some measure understand what happens, that some growths or products may be unaccompanied by appreciable symptoms during life ; that others may be associated only with vague symptoms of a general order, deno:’- ing the existence of some kind of intracranial mischief ; whilst, on the other band, some may be associated with such comparatively definite groups of symptoms as to make it reasonably easy to arrive at a pretty certain diagrosis, both as to the situation and as to the nature of the intracranial growth or morbid product. But, it may be said, why use the broader term ‘ intracranial ’ when we are here only con- cerned with morbid conditions of the meninges? This brings us to the second of the reasons above referred to, namely, that it is often, and, for the most part, impossible to distinguish cli- nically between mere meningeal new growths or products, and those which arise from or within some portions of the encephalon. The reasons for our impotency in this direction are also not! difficult to find. First, wc may cite the general one, of the frequent vagueness or even absence of any appreciable symptoms attendant upoi intracranial growths or products; and, secondly the more special reason, that growtlis starting from the meninges will often press upon ant implicate the surface of the brain in differen regions, in much the same manner as if the; sprang from the surface of the brain itself i' such regions. And. thirdly, there is the furthe consideration that intracranial growths or pre ducts are frequently multiple in the same indi vidual, and then may partly spring from th meninges, and partly in the substance of tb brain itself. Eor these various reasons it happens that the diagnosis of a purely meningeal new growt or adventitious product could ever he arrive at, it would be effected through the medium t a previous pathological diagnosis. But ho limited are the possibilities in this direction mf be gathered from the following consideration Certain personal or family characteristics pr sented by a patient may make it highly pr bable that syphilitic intracranial disease, < that scrofulous intracranial growths exist. St- more rarely the signs and symptoms may i dicate that cancerous intracranial growths, that growths similar to some multiple tumou already existing in other parts of the body, mt be the causes also of co-existing head-symptotr Yet these are almost the only cases in which may be possible for us to arrive at anythit like a positive diagnosis as to the nature of supposed intracranial growth or product. At of these the first only, namely, syphilitic d;sesj could with any degree of certainty be diagnos MENINGES, CEREBRAL, NEW as a change limited to the meninges ; the others would be just as likely to take origin within the cerebral substance as from the meninges. For these reasons no good purpose would be attained by enteringat. length into the groups of symptoms that may be produced by meningeal growths or adventitious products. They are apt ciosely to resemble some of those co-existing with growths within the brain, which have been already considered. See Bbain, Tumours and New Growths of. A. New Growths — (a) Syphilitic growths or thickenings of the meninges. — These products are met with principally in the form of yellowish lymph-like masses, connecting the dura mater to the arachnoid, and this with the pia mater to the surface of the cerebral hemispheres in some region (often the parietal), of irregular area and variable extent. This yellow ‘ gummatous ’ material probably takes its origin, for the most part, in or on the surface of the dura mater, while it may extend inwardly so as to infiltrate or press upon the surface of the brain, and also outwardly, so as to cause erosion of the cranial bones. The membranes around may be thickened, or more or less obviously inflamed. This form of disease does not occur in congenital syphilis ; when it exists, therefore, it is invariably met with in persons beyond the age of puberty. Similar growths taking origin completely within the brain-substance are extremely rare. (h) Scrofulous tumours. — -These are often spoken of as ‘tubercular’ growths. They, un- like the last, are much more frequently met with in children than in adults, and especially in young children between the ages of two and seven years. They are yellowish nodular masses, 'varying in size from a small pea to a walnut. Whilst some of them may obviously spring from ,ke pia mater, others (and this much more fre- quently) are met with within the substance of some portion of the cerebrum or cerebellum, is in the last case, these growths are presumed :o be in the main dependent upon the existence )f a special constitutional state — one which carries with it proclivities to certain kinds of tissue iver-growth. (c) Cancer.— Cancer not unfrequently affects he dura mater, wdience it may extend outwards ■r inwards, and thus implicate other parts second- ■rily — either eroding and perforating the bone, >r greatly depressing the surface of the brain s it grows inwards. Although more frequent n the second half of life, meningeal cancer may ecur also in youth, or even in childhood. (d) Other growths. — Other growths of less fre- uent occurrence, and therefore of less importance, iso start from the meninges. We may havo the showing : — Sarcomata ; Fibromata ; Fibro-en- hondromata ; Stcatomatous or cholesteatoniatous rowths ; and Structureless or wax-like tumours, aving the so-called ‘ amyloid ’ reaction. Such amours as these may give rise to more or less efinite head-symptoms during life. They spring, >r the most part, from the dura mater rather tan from the arachnoid. Other smaller, and mostly rare, growths may a met with quite unexpectedly after death, be- mse of their occurrence in the form of flat plates, hich do not interfere by pressure or otherwise GROWTHS AND PRODUCTS IN. 955 with the subjacent cerebral substance, and there- fore give rise to no obvious symptoms. They are: — Osteomata, which occur either iu the falx, in the walls of the lateral sinuses, or much more rarely in the substance of the arachnoid, in the form of osseous plaques ; aud Calcareous deposi- tions (belonging, perhaps, more strictly to the next than to this section) which vary in size trom a mustard seed to a small nut, and which may be found in or beneath the arachnoid, or also on the inner surface of the dura mater. Sometimes a number of such minute concretions miy be met with in connection with the pia mater or arachnoid (especially when these membranes are thickened or otherwise diseased), in the form of minute granules closely resembling the so-called ‘brain sand,’ each of which may present traces of several concentric layers. B. Adventitious Products. — (a) Parasites. These may be of two kinJs, both of them being larval states of tape-worms. Cysticerci are larval conditions of Tenia solium, having the form of small bladders, which vary in size from that of a pea to a horse-bean. They often exist in large numbers in the meninges, and within the brain of the same individual, and are very rarely solitary. As many as 100 may be found within the cranium ; and when they are thus numerous many of them will almost certainly be met with in the pia mater, merely pressing upon and slightly indenting the surface of the convolutions, though others will be situated within the substance of both cerebral and cerebellar convolutions. They are not confined to persons of any age or either sex, though they occur rather more frequently in those representing the second than the first half of life. Infection is brought about by the eating of raw, or insufficiently cooked ‘ measly ’ pork. See Cysticercus. Hydatids are larval forms of Teenia echinococ- cus, a very small four-jointed tape-worm com- monly infesting the alimentary canal of the dog. The hydatids met with in the brain are always barren cysts (aeephaloeysts), and the outer en- closing membrane is generally very thin. They are usually solitary; may vary in size from that of a marble up to a large orange; are rare even in the brain-substance, and still more rare in th# pia mater. Sometimes two, three, or more hy- datid cysts exist within the cranium of the same individual, but they are then usually of small size. Davaine refers to an instance in which many hydatids were found in the meninges and at the surface of the brain, as well as within its substance. Out of twenty-fuur recorded cases, in which the age was stated, the writer has found that no less than eighteen of them were persons between the ages of ten and thirty years, three of the remainder being above and three below these extremes. Infection may well be brought about by means of the dog’s tongue, which is at times only too quickly transferred from parts liable to be contaminated by ova of its own tape-worms, to the hands or even the lips of his master or mistress. Besides this more direct method, the ova of the Taenia echinococcus voided by the dog may be blown about, or other- wise get by accidencal means into water or foo 1 taken by man. See Hydatids. (4) Aneurisms. — These, situated either on ona 066 MENINGES, CEREBRAL, NEW GROWTHS AND PRODUCTS IN of the vessels composing the circle of Willis, or on some one or more of its primary branches, may vary in size from a small pea to that of a walnut. Those of larger size, which are usually single, may give rise to distinct head-symptoms ; but at other times, and especially when the aneurism is very small, there may have been no reason to suspect its existence, or that of any other intracranial disease, till, perhaps, the rup- ture of such an aneurism may lead to the super- vention of serious symptoms, speedily terminating in death. These aneurisms may occur, possibly as a sequence of a previous embolism (Church), even in early youth as in adult age. (c) Thrombi in the cerebral sinuses. — The process of thrombosis is known principally as it occurs in three of the sinuses contained within the cere- bral meninges, namely, in the longitudinal sinus, or in one or other of the two lateral sinuses. (1) The formation of a thrombus in the lon- gitudinal sinus is usually a primary phenomenon, dependent in the main upon the operation of general causes, such as some alteration in the quality of the blood, combined with slow, feeble, and irregular action of the heart. The opera- t ion of these causes has, however, been known. In have been favoured in certain cases by local conditions, such as the great development of Pacchionian bodies, and their projection into the sinus — an event most likely to occur in elderly persons. Thrombosis of the longitudinal sinus may, however, be met with also in the early as well as in the middle periods of life. The ori- ginal thrombus frequently prolongs itself through the straight sinus to the * torcular Herophili,’ and thence on either side into the lateral sinuses. And in this latter class of cases ventricular effu- sions and superficial cerebral softenings are apt to be associated with the thrombosis. The soft- enings are of a peculiar and characteristic kind, consisting generally of a number of small red patches, occupying principally the grey matter on each side of the upper surface of the brain. Occasionally softening of a portion of brain of considerable extent has been produced. Besides the ventricular effusion, there may also be an excess of serum beneath the arachnoid, or more rarely small effusions of blood in these situa- tions, together with minute patches of haemor- rhage in the convolutional grey matter, such as havo been described by Cruveilhier under the name of apoplexie capillaire. The actual combi- nation of these conditions will depend upon tho seat of the obstruction, the rapidity with which it is brought about, and the existence or not of marked pathological conditions of the vessels generally. The variation in the symptomatology of this affection in different cases is, therefore, also extreme ; the symptoms are sometimes of an excessively grave order, and sometimes almost nil. Strange as it may seem, Dr. Gee says: — ‘ I have known a decolorised softening thrombus to occupy the whole bore of the upper longitudinal sinus, to be attended by large sub-arachnoid haemorrhages, and to have caused no symptoms during life.’ (2) Just as frequent, however, as the event abovo referred to, is the formation of a thrombus in one or other of the lateral sinuses ; only then the process is almost invariably secondary to in- flammation of the scalp or cranial bones, whethei induced by traumatic conditions or by disease. Caries of the cranial bones is the principal pre- disposing condition ; indeed, in three-fourths of the recorded cases the temporal bone was the part affected, and that as a result of internal otitis. In these cases there is often evidence of a more or less circumscribed inflammation of the meninges, but cerebral softenings and sub- arachnoid extravasations of blood rarely occur. This, according to Yon Dusch, is explicable by the fact that in these cases the thrombosis starts from tho veins in communication with tho in- flamed spot, and reaches the lateral sinus only after the collateral circulation has had time to establish itself ; instead of forming primarily in the sinus, and before a collateral circulation has been set up. (d) Serum, — This fluid may be met with in excess in two situations. It occurs (1) beneath the arachnoid, in cases in which one or both cerebral hemispheres have become wasted or atrophied. After fifty or sixty years of age, therefore, it is common to find an excess of sub- arachnoid serum. This fluid transudes from the vessels as pressure outside them diminishes, owing to brain-atrophy. It is absurd to suppose that it has any other, or at least any important, pathological significance. To speak, as some do, of ‘ serous apoplexy ’ as a cause of death, when no very obvious reason can by such persons he assigned for it, is a mischievous assumption of knowledge where aconfession of ignorance would be better. But serum is sometimes found in excess (2) within the cavity of the arachnoid, when it constitutes the condition occasionally spoken of as ‘ external hydrocephalus.' It seems probable that the majority of such cases are in- stances in which the fluid of an ordinary internal hydrocephalus has, at some period before or after death, in part escaped from the ventricles into the cavity of the arachnoid (see Hydrocepha- lus, Chronic). Still, there may be a narrow margin of cases not capable of being thus ac- counted for, iu which the cause of the presence of fluid in this situation is very uncertain, when it is not, as it may be sometimes, an appanage of meningeal inflammation. Prognosis. — Some of tho smaller and more slowly growing tumours may give rise to no symptoms during life, and may not appreciably! tend to shorten its duration. The accumu- lation of serum beneath the aiachnoid is, more- over, only a non-disturbing effect of other causes. The case is, however, of much graver import whore we have to do with syphilitic, scrofulous, cancerous, or other growths having a tendency to more or less rapid increase ; also where the patient is suffering from tho existence of intra- cranial cysticerci or hydatids, or from the occur- rence of thrombosis in the longitudinal or lateral sinuses. In all such instances we may, for the most part, look for a steady increase in the gravity of the patient's symptoms, and, except in the case of the first kind of growth nndti the influence of proper treatment, for death at no very distant date. Treatment. — Drug treatment can be looiec forward to as curative, or nearly so, in only out MENINGES. SPINAL, DISEASES OF. judicious use of drugs, modify the course of ' | inflammation. Also by suitable feeding and i 'icious nursing we should endeavour to tide 11 patient through the disease. And if, hap- ly, the activity of the inflammatory process f isides, the most unremitting attention will U be required to protect the patient against a Apse. Should his condition otherwise admit c it, the absorption of inflammatory products ' Adi i n this stage, be likely to be promoted by t use of a small dose of bichloride of mercury ( ih as one-sixteenth of a grain for an adult), ■ ombination with increasing doses of iodidoof P issium. At the same time, every effort must 61 be made to restore the patient’s general health, and to combat the emaciation which the disease itself usually involves. 2. Meninges, Spinal, Hsemorrhage inti or upon. — Synon. ; H-rac/iis; Meningea Apoplexy (Spinal). Effusions of blood upon, between or beneatl the spinal meninges are altogether rare events contrasting notably in this respect with the com- parative frequency of parallel conditions on th< side of the cerebral meninges. AEtiology. — Among the causes of meningea! haemorrhages, stabs, blows, or falls will hold a first rank. After these causes we should have to cite impediments to the circulation of blood occasioned by various respiratory or museulai spasms, occurring either in the course of whoop- ing-cough, or during some more than usually violent convulsive attack, epileptic, tetanic, oi other. The lifting of heavy weights, or other great voluntary muscular exertions, may like- wise at times prove causes of spinal meningea] hiemorrhage. Occasionally, however, it occurs independently of any such, or of other readily assignable causes. Anatomical Characters. — Fluid blood or blood-clots may exist in relation with the spinal meninges in three different situations. The most frequent site of such hsmorrhago is (1) outside the dura mater, between it and the vertebral arches. Here large clots arc sometimes found, wholly, or more frequently in part, surrounding the dura mater in the region in which tho hsemorrhage has occurred. Where the effusion is large, the cord itself may he dis- tinctly compressed, but even smaller effusions may produce some amount of compiession of nerve-roots. A clot in this situation, as in oilier sites, will, of course, become much modified in appearance with age. Clots and more or less fluid blood may also, but more rarely, be met with (2) inside the dura mater, within the so-called arachnoid sac. This occurs perhaps most frequently as a mere sequence of a similar hsemorrhage taking place in the cerebral meninges, the blood simply gravi- tating into the spinal canal. Sometimes, however, especially in cases of spinal pachymeningitis, blood is actually effused in this situation — and that where the internal surface of the dura mater is much more vascular than natural. The open- ing of a thoracic or abdominal aneurism may also occasionally take place into the spinal canal, and thus produce sudden and grave compression of the spinal cord. Much smaller extravasations of blood are also met with (3) beneath the arachnoid and within the meshes of the pia mater, over areas perhaps small in extent longitudinally, but more or less embracing the cord in one or more regions. The cord or nerve-roots may, however, he decidedly compressed by such haemorrhages, even when they are small in amount, owing to the space into which the effusion takes place being com- paratively shallow. Symptoms. — The symptoms of these affections are in a large proportion of the cases vague and ill-defined. They may be much obscured by the causal conditions. In other cases they will vary 362 MENINGES, SPINAL, NEW GROWTHS AND PRODUCTS OF. in distinctness according to the amount and abruptness of the haemorrhage. As a rule, the onset of symptoms is sudden. Pain in the region of the spine, in which the haemorrhage exists, or radiating thence along the nerves emanating from this region, may be the first symptom. More rarely, muscular twitchings or spasms may exist, either alone or with pains. These symptoms, dependent upon irritation and compression of sensory and motor nerve-roots, are at other times almost wholly' absent. There may then be as abiding symptoms mere numbness or tingling in the parts affected, together with a sense of weight and paresis in the limbs. Actual paralysis is rare ; and even when it is present, the rectum and bladder mostly escape. Where pain exists, there is often stiffness of rhe spine; and these botli together greatly inter- fere with movement. Febrile reaction is usually absent or very slight. The severity of the symptoms may abate after a day or two, leaving only more or less paresis. In the case of large haemorrhages, however, with extensive compres- sion of the spinal cord, death may bo rapid, occurring in the course of some hours or of a day or two. The symptoms will vary as the effused blood presses upon the cord in the cervical, the dorsal, or the lumbar region. Where the effusion is in the cervical region in a traumatic case, in which there is obvious head-injury with a condition of stupor, it is almost certain not to be diagnosed. The patient is not sensible enough to complain of pain ; and the irregular respiration and small disordered pulse, with slight tremor or rigidity of one or both upper extremities, may with more probability be ascribed to multiple head- lesions — as actually happened in a case which recently came under the writer’s notice. Diagnosis. — It maybe impossible to diagnose haemorrhage into the spinal meninges in cases where it occurs as a concomitant of other grave diseases — such as tetanus, eclampsia, or cerebral haemorrhage; and also in cases where it merely complicates a traumatic injury of the spinal cord itself. In other cases, the presence of certain causal conditions, together with the ab- rupt commencement of spinal symptoms in such combinations as have been above referred to, is sufficient to enable U9 to diagnose it from haemorrhage into the substance of the cord, as well as from meningitis, or acute softening (see Spinal Cord, Diseases of). The gradual onset of the symptoms arising from tumours of the spinal cord, or of the spinal meninges, make it more easy to separate theso affections from meningeal haemorrhages. Prognosis. — Meningeal haemorrhages are as a class decidedly less grave than meningeal tu- mours. They are unlike the latter, moreover, inasmuch as the worst symptoms attendant upon them are produced at once, instead of being only very slowly evolved ; so that after a short time, unless the blood effused happen to have pro- duced a certain amount of compression of the spinal cord, the symptoms gradually diminish in severity. Large extra-meningeal haemorrhages, compressing the cervical region of the cord, are by far tne most serious forms of this affection. Treatment. — In the treatment of spinal me- ningeal haemorrhage the patient must, of course, be kept perfectly quiet and in the recumbent position. Spoon diet should be administered for a few days ; and vascular sedatives, such as aco- nite, may be given with advantage. Some re- commend active purgation, and the aDstraction of blood from the neighbourhood of the spinal column by cupping or leeches. These measures, however, are of questionable utility, and the fir- mer especially might easily do positive ham. 3. Meninges, Spinal, New Growths and Adventitious Products of. — This subject re- quires no very lengthy discussion. As was said in regard to such growths and products spring- ing from or connected with the cerebral menin- ges, the symptoms to which they give rise are in the main referable to irritation and pressure upon adjacent portions of the nerve-centres or upon certain nerve-roots. The symptoms, therefore, of meningeal growths or adventitious products are almost, if not quite, indistinguishable from those produced by similar bodies in the spinal cord. The sections on special symptoms and diagnosis which might otherwise have appeared here maj be suppressed; and the reader be referred foi their equivalents to what he will find under the bead of Spinal Cord, Tumours of. We shall now merely give a few details con cerning the aetiology, nature, and precise sites o. the various new growths and adventitious pro ducts that may be met with in connection with th spinal meninges, and shall supplement these de tails with some few general remarks bearingupo; the prognosis and treatment of such affections. -Etiology. — In accounting for certain tu mours, such as those of a syphilitic, of a sere fulous, or of a cancerous type, we may fall bae upon the existence of a general ‘predisposition though what determines the appearance of sne tumours in this or that particular situatiq generally remains as much a matter of unce tainty as when the growths are solitary or < non-diathetic origin. Amongst such determinir or exciting causes only one of those usually cit< seems to be of real potency, namely, the occu rence of blows or injuries of various kind Theso certainly appear at times to be — in tl spinal meninges as in other situations — t immediately exciting causes of certain nt growths. Parasites, such as cystieerci and hydatic gain entry to the system in the way mention in the articles on these subjects; butsomethi so indefinite or accidental as to be spoken of us as ‘ chance,’ will determine their appearance this or that particular tissue or organ. A. New Growths. — (a) Cancer. — Cancer' curs most frequently in the spinal meninges, i: as a primary affection, but by extending to thi from a previous cancerous growth in one of o adjacent vertebrae. The space within the spi 1 canal being very limited, such a tumour s i begins to press injuriously upon nerve-roots u upon the cord itself. In rare cases, howeve® cancerous new growth may start from the sp •* dura mater. (A) Scrofulous growths . — These masses are » meninges, spinal. with principally incases of scrofulous disease of the spinal column, and especially where angular curvature is produced, though they are not con- fined to these more severe forms of vertebral caries. Caseating growths are in such cases apt to extend from the vertebrae, so as to infiltrate the dura mater, and then produce fungating ex- crescences on its inner surface. Small isolated scrofulous tumours, the so-called ‘ tubercular ’ growths, may also he met with, though more rarely than in the cerebrum, springing from the [spinal pia mater, and more or less imbedding themselves in the substance of the spinal cord. (c) Syphilomata. — Syphilitic growths are also decidedly less frequent in connection with the spinal than with the cerebral meninges. Small tumours may, however, spring either from the dura matcror from the arachnoid and pia mater. Or. instead of well-defined tumours, there may be thickenings of the membranes in some part of their extent, and adhesions between one another and the surface of the cord, by means of opaque, yellowish-white, gummatous growths. (d) Sarcomata. — Sarcomatous tumours of all kinds may be met with in connection with the Spinal meninges, springing occasionally from the iura mater, hut more commonly from the arach- noid and pia mater. Instead of being distinctly circumscribed, such growths may exist in the ! orm of diffuse infiltrations, invading the pia nater all round the cord for a variable extent. In one remarkable case the writer met with a growth of this kind involving the pia mater liroughout the whole length of the spinal cord, rliich was most developed on its lateral and tosterior aspects. Here in some places the layer *f new growth was about one-third of an inch in iepth, and the cord was notably compressed in ts postero-lateral aspects ( Lancet , June 26, 880, p. 988). j ( e ) Myxomata. — Myxomata are met with in he form of small circumscribed tumours, spring- ig mostly from the pia mater. The writer has Ten one about the size of a very large almond ituated on, and greatly compressing, the pos- hrior columns of the cord. Its presence was ssociated with very obscure and ill-defined .■mptoms during life. If) Tubercle . — Tubercles in the form of 1 grey ranulations’ have already been referred to in le description of Spinal Leptomeningitis. (y) Fibromata, ( h ) Lipomata, and (i) Enckon- •omata. — These various kinds of new-growth ivebeen met with occasionally, but principally connection with the outer aspect of the dura ater. ' (£') Osteomata.—' These formations are here of 1 clinical significance, though they are much Jre common in persons of all ages on the spinal an on the cerebral meninges. They are apt occur in the form of small bony plates scat- red over the surface of the arachnoid. Some- nes a limited ‘ ossification ’ of the dura mater also met with. B. Advontitious Products. — Parasites The ne two kinds of parasites may he found connection with the spinal meninges as we ve already had to refer to in connection with >se of the cerebrum — namely, the small and en numerous cysticerci, as well as the more MENINGO-MYE LITIS. 963 solitary and larger hydatids. The latter may be found within the dura mater, but they have been met with much more frequently outside this membrane, often forming large tumours con- tiguous to the spinal canal. These are the only adventitious products of any importance which occur in, or in relation with, the spinal me- ninges. Prognosis. — As a class these affections are grave, tending to produce, with some exceptions, various irregular forms of paralysis, and ulti- mately death, though this latter may take place only after the expiration of two, three, or more years. The symptoms produced by tumours and parasites, as a rule, go on increasing in severity; and the gravity of the prognosis will depend much upon their rapidity of growth, as evidenced by the increase of signs of severe compression of the cord or of its nerve-roots, in connexion with the state of other organs. The supervention of obstinate bed-sores, and para- lysis with inflammation of the bladder, may at List greatly hasten the fatal termination. Treatment. — In the treatment of tumours or parasites within the spinal canal, our efforts must be in the main directed to restoring or improving the general health of the patient, and to com- bating the more urgent symptoms that may arise— such as pain, spasms, paralysis, sleepless- ness, bed-sores, and cystitis. Where, however, we have to deal with growths of syphilitic origin, we can attack the disease itself by means of drugs. Under the influence of small doses of mercury and increasing doses of iodide of potas- sium, the patient's condition may often be mar- vellously improved, though the relief is perhaps not so striking as in cases where syphilis affects the cerebral meninges, because in this latter dis- ease the symptoms are more varied in nature, and more dependent upon added functional com- plications. H. Charlton' Bastian. MENTNGOCELE. — See Brain, Malforma- tions of; and Skull, Diseases of. MENINGO - CEREBRITIS. — A name given to a pathological condition in which in- flammation of the pia mater extends in some regions of the cerebrum so as to implicate the subjacent cortical substance. The fact of such an extension is much less capable of being diagnosed during life than of being discovered after death, but it may then be recognised by the existence of superficial softening of the brain-substance, to- gether with a more or less marked increase of vascularity. This condition probably always exists to a certain extent in meningitis, and might reveal itself on careful microscopical ex- amination — although the inflammatory changes may not have advanced far enough to produce an easily appreciable amount of softening. MENIN GO-MYELITIS is a term used to indicate a condition in which inflammation of the spinal meninges has extended to the surface of the spinal cord. The evidence of such an exten- sion has usually been supposed to depend upon the existence of an appreciable amount of super- ficial softening. But minor changes of an in- flammatory type, capable of recognition by the 064 MENING O-MYELITIS. microscope, may also here exist -with frequency, as F. Schultze has shown, although they may fall short of entailing actual softening. MENOPAUSE {pyres, the menses, and i rav- en, a cessation). — The natural cessation of the menstrual flow, or ‘ change of life ’ in the female. See Change of Life. MENORRHAGIA (gyv, a month, and pi j- ■yvvfj.1,1 burst forth). — Over-abundant menstrua- tion, whether due to excessive quantity, or to undue frequency. See Menses or Menstruation, Disorders of. MENSES or MENSTRUATION, Dis- orders of. — Synon. : Fr. Troubles dc la Men- struation ; Ger. Storungcn des Monatsflusses ; Storungen der Menstruation. Menstruation is the periodic discharge of a sanguineous fluid from the female generative organs. The discharge continues each time for from three to eight days. It varies in quantity in different subjects. The estimation of this is surrounded by great difficulties ; usually, how- ever, the quantity is from four to six or eight ounces. It takes place monthly; that is, a period of twenty-eight days intervenes from the appear- ance of one flow to the appearance of the next following. In many cases, however, this interval is less than twenty-eight, and may be as short as twenty-one days ; on the other hand, it may he prolonged to thirty-one days, and the function he still performed normally. The discharge does not appear during childhood or old age. It usually appears for the first time between' the twelfth and fifteenth years, and for the last time between the forty-third and forty-eighth; hut it may appear as early as the ninth, and continue to appear regularly afterwards up to the fifty-third or fifty-fifth year. The function is suspended during pregnancy, and, as a rule, during lacta- tion. The source of the discharge is the body of tho uterus. It is not due to a congestion or an erection of that organ, as has been supposed, hut to the degeneration, disintegration, and removal of the so-called mucous membrane of the uterus — the decidua menstrualis. In conse- quence of this degeneration and disintegration, the vessels on the inner surface of the uterus aro opened, and haemorrhage follows. The ultimate cause of the discharge is said to be the separation of ova ; such, however, is not the case in every instance, for menstruation may take place without the discharge of an ovum, and, on the other hand, ova may be separated from the ovary without the occurrence of menstrua- tion. It can hardly be doubted, however, that the function is in some manner dependent cn the ovaries, for when tho latter have been removed menstruation ceases. The fluid is not in all eases sanguineous ; indeed its bloody character may he regarded as accidental, though present in tho infinite majority of cases. It may, however, be easily under- stood that the disintegration and removal of the ‘ decidua menstrualis,’ which is the essential factor in menstruation, may be effected without the occurrence of haemorrhage, and there is MENSES, DISORDERS OF. reason to believe that in so-called ‘ white met struation ’ such is the case. For the due performance of the function two conditions are essential, namely, sound general health, and normally developed organs of gene- ration. Disorders of the menstrua) process mav be brought about by very many conditions. These disorders are generally divided into : — I. Amenorrhcea, where the discharge is ab- sent, or deficient in quantity. II. Dysmenorrhoea, where the function is performed with difficulty and pain. III. Menorrhagia, where the discharge is profuse. I. Amenorrhcea. — Synon.: Fr. Amenorrhk; Ger. Amenorrhoe. ^Etiology and Symptoms. — Amenorrhcea is dependent either on general states ; or on local pathological conditions — that is, on lesions of the uterus and ovaries. 1. All conditions or influences which tend to deteriorate the blood, or which act unfavourably on nutrition, may be causes of amenorrhoea. The most common of these is the demand made on the' system in the development of the aptitude for! aonception, the growth and separation of ova, and ► tjie performance of the menstrual function. At this time the breasts develop, the ovaries and uterus enlarge, the pelvis grows, and the whole form becomes altered. Many women who dim ing childhood have enjoyed apparently perfect health, as they approach puberty become gra- dually or suddenly anaemic or chlorotic, without! any assignable cause other than the demand made on nutrition by the process of develop- ment through which they at the time pass Nutrition becomes impaired, tastes perverted pains of a neuralgic character are felt in variou; parts of the body, the menstrual discharge does not appear, or it may appear once scantily and then at irregular intervals, or it may disap pear for months or even years. All the symp toms of anaemia are present, and the patient i languid, listless, lacks energy, and is in more o less constant suffering. The above may tab place in cases where the surroundings may b favourable to healthy development. Hygieni conditions, however, play a most important par in the proper development of the female func tions, and when the surroundings are unfavour able, evil is sure to follow. Want of food, o improper food, want of fresh air. impure ail want of exercise, foul gases, malaria, are prolifi causes of failure or imperfection in the growt and development of the young girl, and at common causes of amenorrhcea. Disease also i a by no means infrequent cause of the conditio: under consideration, as phthisis, Bright's diseas- diseases of tho liver, stomach, and nervous sy: tern. Emotion, fright, or grief, change of a and food (as when girls go from the country 1 London), and cold, may- arrest or suspend tl monthly discharge. 2. But amenorrhcea may he due to local coi ditions. These are absence cr disease of tl ovaries, of the uterus, or of both; and imperfe< development of one or both organs. In cases where the ovaries are absent, tl change in form, from girl io woman, which tak place at puberty, does not occur. The gi MENSES, DISORDERS OF. grows but does not develop. A masculine ap- pearance supervenes, the breasts remain small, the pelvis narrow, the voice becomes manly and harsh, a beard may grow on the face, sexual passion is absent, and the health remains good. When the uterus alone is wanting, there may he no indication of the condition in the state of the general health or development, and local examination is necessary in order to detect the circumstance. In theso cases the vagina termi- nates in a cul de sac, and the uterus cannot be felt on examination. On introducing a finger into the rectum and a sound into tho bladder, it is found that the two organs are in i contact, and that there is no uterus between them. There are, however, as a rule, one or two small fibrous masses representing the uterus. Certain diseases, as scrofulous abscess and atrophy, which involve the whole substance of the ovaries, and also atrophy of the womb, may tause amenorrhcea. Amenorrhcea from retention . — In these cases the sanguineous discharge is separated, but does not appear externally, owing to atresia of the genital tanal. The closure may occur at any point between the os uteri and the vaginal orifice. •A, membrane may close the os tine®; the hymej may be imperforate ; the vagina may be absent, - or its walls may be adherent at any part of its course, or along the whole of it. The occlusion may be congenital, or may arise from inflamma- tion during childhood, or after severe labours. In these cases the menstrual molimina are periodically present, but the catamenia do not appear. The molimina increase in severity from month to month ; the patient has pain in the back, a sense of weight in the pelvis, and becomes pale and sallow ; the abdomen after a ;ime begins to enlarge, and continues to increase. Dn examination a tumour having the shape of the enlarged uterus maybe felt rising from he pelvis. It is smooth, elastic, and dull on oercussion. If the condition be not discovered, the intension of the uterus may go on to rupture, le tonics, iron, iodine, or other appropriate uedies. No efforts should be made to act es- | 'ally upon the uterus, and this is particularly 965 binding when the amenorrhcea is dependent on phthisis, Bright’s disease, or such-like conditions. The second form is often incurable. In those cases where the uterus and ovaries are absent, nothing can be done. If the uterus be present, but imperfectly developed, means should be used to promote its growth. With this view stem pessaries, galvanic pessaries, and irritants have been advised. Galvanism will probably prove a useful agent in these cases. It should be tried first externally, one pole being applied to the spine and one over the uterus and ovaries. Should this fail, one pole should be applied to the uterus direct, and tho other above the pubes, and to the ovarian regions. These means, which are not free from danger, should, however, never be tried where the amenorrhoea is not associated with suffering of some kind. Indeed, amenor- rhoea in many instances requires no treatment at all. In cases of retention from atresia of the genital canal, an outlet must be made for the flow. If the hymen be imperforate it should be divided, and the fluid allowed to run out. In cases of . absence of the vagina, a canal has in some in- stances been successfully mado. In atresia of the os uteri the offending structure should be divided by the trochar or knife. These opera- tions aro accompanied by a considerable amount of danger. Patients not infrequently die after them from peritonitis or shock. It should not be forgotten, however, that it is imperative to remove the menstrual fluid retained, for unless this be accomplished death is inevitable. II. Dysmenorrhcen. — Synon. : Fr. Dysme- norrhee ; Ger. Dysmenorrhoii. In dj'smenorrhoea, menstruation is accompanied by pain. In some women the menstrual function is performed without pain or discomfort of any kind ; as a rule, however, they suffer more or less from backache, headache, languor, and lassitude during the catamenial flow. When the dull aching amounts to sharp pain, the function is performed abnormally, and the woman is said to suffer from dysmenorrhoea. ^Etiology and Symptoms. — -This symptom has been referred to five different conditions, upon one or more of which it is supposed to de- pend, and hence there are five kinds of dysme- norrhoea recognised, namely: — - 1 . Mechanical or obstructive. 2. Congestive or inflammatory. 3. Neuralgic, sympathetic , or spasmodic. 4. Membranous. 5. Ovarian. 1. Mechanical dysmenorrhoea. — Mechanical dysmenorrhoea is doubtless the most common of the above forms. Indeed, it has been said that dysmenorrhoea cannot exist without ob- struction to the flow of blood from the uterus. Opinions, however, differ greatly with regard to the seat of obstruction. It may exist in the vagina or in the uterus. Dr. Robert Barnes believes it to be usually situated at the os tine®, and to be frequently accompanied by conical cervix. Dr. Marion Sims thinks its most frequent seat is the os internum uteri. Dr. Graily Hewitt refers the obstruction to flexion of the uterus in the great majority of cases. That the outer orifice of the uterus is occasionally so small as to cause ob- MENSES, DISORD EES OF. 366 Btruction to tho catamenial flow has been proved beyond question, but there is no evidence of the great frequency of this condition. Still less evi- dence is found of the existence of obstruction at the inner orifico. Flexions ot the uterus need be acute to present obstruction to the flow ; in such cases, at the point of flexion the canal of the uterus is flattened, and its walls are not easily separated. Retroflexion is a more fre- quent cause of dysmenorrhcea than antiflexion, because, as a rule, the aDgle of flexion is more acute in the former than in the latter. It should, however, be borne in mind that a very fine channel, even a pinhole os, may suffice to permit a fatal haemorrhage, and it is probable that a very narrow canal would prove capable of the painless passage through it of the menstrual discharge when the latter is in a healthy state — that is, when it contains neither clots of blood nor fragments of membrane. There are reasons for believing that in the great majority of cases of painful menstruation, tho cause of the ob- struction does not lie in the genital passage, but in the menstrual fluid itself, because the latter, instead of being a homogeneous mixture of blood, mucus, and the molecularly disintegrated deci- dua, contains small fragments of the inner sur- face of the uterus, clots, and masses of viscid mucus ; and that while the orifices of the uterus would easily permit the passage of healthy menses, they do not suffice for the painless expulsion of such particles as have been enume- rated. This form of dysmenorrhcea is very common. It is frequently accompanied by inflammation or congestion of the body of the uterus, as well as by inflammation and abrasion of the lining membrane of the cervix. That these complica- tions contribute to enhance the pain caused by the obstruction present during menstruation cannot be doubted. At the same time it should be borne in mind that the complications are probably secondary. Indeed, primary inflamma- tion of the unimpregnated uterus is of infinite rarity ; it depends on the obstruction which had been at work for years before the inflammation set in. The symptom of this variety is pain of vary- ing intensity; in some cases it is of a very severe character. It begins in the pelvis, and radiates to tho groin, sacrum, and thighs. It is often said to be all round the pelvis or lower part of the trunk. It may come on a little before, with, or a little after the appearance of the discharge, and may cease with or soon after the same; or it may continue more or less severe, but always paroxysmal, until the end of the flow. There is often tenderness of the skin of the hypogastriura and groins ; vomiting, hic- cough, headache, hysteria, and even delirium may be present. The flow may be scanty or profuse, and in the former case it is often followed by an abundant yellow discharge for a few days. There may be leucorrhoea throughout the inter-men- strual interval, Micturition is often painful. 2. Congestive or inflammatory . — This name has been given to those cases of painful menstruation in which the uterus is enlarged, and heavier than natural. It is met with in the married and in the single ; but it is probable that it never occurs as a primary affection, but is the result of obstruc- tion, abortion, or labour. The symptoms are those of mechanical dysmenorrhcea. The state of enlargement can be diagnosed by digital ex- amination only. 3. Neuralgic . — This variety at one time in- cluded a very large number of the cases of painful menstruation which came under notice; but since more efficient means have been employed for learning the condition of the uterus, the number of cases referred to this category has greatly diminished. At present it is limited to the cases of young girls, in whom it is not desirable to make a vaginal examination; and to those cases in which no pelvic lesion can be found to account for the suffering. It cannot be said that neu- ralgia of the uterus never exists ; at the same time it is of such rarity that it should be diag- nosed with the greatest hesitation. The symptoms are similar to those of the ob- structive variety. 4. Membranous . — In this form a membranous sac, having the shape of the cavity of the body of the uterus, is expelled with the catamenia. The sac has three orifices, corresponding to the orifices of tho Fallopian tubes, and the inner orifice of the neck of the uterus. It has an inter- nal smooth, punctated, and an external flocculent surface. Occasionally during expulsion the sae is turned inside out. It may be passed with every, or with every other, menstruation, or only occasionally. Instead of being passed in the form of a complete sac, the membrane may be broken up, and expelled as shreds of various sizes. Micro- scopic examination shows that the membrane possesses a structure identical with the lining of the body of the uterus. It contains glands and blood-vessels, and is, in fact, the decidua. It has been said that it is always the result of concep- tion, but ample evidence has been published to refute this statement. As a rule the uterus is enlarged ; this, however, is not always the case. The enlargement is probably a condition secon- dary to the dysmenorrhtea, or to previous gesta- tion. There is commonly tenderness of the pelvic tissues around the uterus, probably of the peri- toneum; ovaritis is frequently present. All these conditions are probably secondary. Displacement of the uterus is also not an un- common complication — an anteflexion or retro- flexion : an affection of another mucous mem- brane may also co-exist. The symptoms are usually very severe, the pain being most intense, of a bearing-down cha racter, and often compared to labour-pains. I reaches its acme just before the membrane i. expelled. If the membrane be passed in frag ments, the pain recurs with the passage of each The pain accompanying the expulsion may hi slight, or even absent. In the latter case the uteru is large, and the os patulous. The passage of thj membrane takes place often on the third day c menstruation, but may occur later; frequentl shreds are passed from the first or second da at intervals to the end of the flow. With tl: expulsion of the membrane, there is generally gush of blood, after which the flow proceec normally. The catamenial discharge may 1 normal in amount, considerably increased, < even scanty. MENSES, DISORDERS OF. 967 The pathology of this affection is unknown. It has been said, to be the result of conception. Cases of abortion may probably hare been mis- taken for this affection, but that it occurs inde- pendently of sexual connection is amply proved. It has also been said that it is due to inflam- mation ; that the membrane expelled is an in- flammatory exudation. The evidence in favour of this view is very scanty. Inflammation or congestion of the uterus is frequently met with in cases of membranous dysmenorrhoea, but not (always. Indeed, cases of this affection occur in which no trace of inflammation of the uterus could be found either before or after death. More recently it has been stated that it is due to amyloid degeneration of the lining membrane of the uterus. If this be the fact in some cases, jt certainly is not in all. It is more probably due to malnutrition, which in some cases has oxisted ah initio. It has been met with also in gouty and rheumatic subjects, but what rela- tion it holds to these diatheses is unknown. 5. Ovarian . — This does not deserve the name of dysmenorrhoea, for it is not due to menstruation —that is, to the discharge of the sanguineous fluid from the uterus — but to the growth and rupture of the Graafian follicles. The Graafian 'ollicles develop gradually, and take a long time o arrive at maturity. It is not a sudden pro- :ess. It is, however, towards the end of their growth, as they approach the time of rupture, hat they become painful. They usually burst ome time before the appearance of the men- trual flow, but this may happen during the atamenia, or after their cessation. The pain sually comes on before the catamenia, a few ays or a week, an 1 may cease with the appear- nee of the menses, or several days before that vent. The suffering may, however, come on at ny time during the flow or during the interval, is situated usually in the left ovarian region, )r the left ovary is more frequently affected lan the right. The pain extends down the lighs, and to the sacro-iliac joint of the same de. Not infrequently the corresponding kidney tender. Pain may occur in the left and right de at. alternate periods, or a period may pass ithout pain. Vomiting and hysteria are often ■esent. There is superficial and deop tender- ss over the painful part. Patients often say at they have a swelling in the side, and on animation a diffused fulness is found in the arian region, which is tympanitic, and due idently to local distension of the intestine by s. Examination per vaginam and per rectum 11 often detect a small tumour, tender, mov- ie in the early periods, later on fixed, on the e affected, and a little behind the uterus, essure on the tumour calls forth severe pain 1 a feeling of sickness. Later on the uterus :omes less movable, and drawn to the affected ■ e. This is doubtless due to contraction of > :ammatory products, and not to distension of i broad ligaments, for it occurs in long stand - i cases only. Micturition is frequent and ] nful. fhe pathological lesion is inflammation of the < lafian follicles, of the stroma, or surfaces < the ovary, extending to the neighbouring tis- f s. This, again, is rarely primary. In women who have had children, it is often due to par- turition and abortion. In tho unmarried it is the result of long-standing dysmenorrhoea. In the latter cases true dysmenorrhoea is always primary, and ovaritis secondary. It may, how- ever, be the result of exposure to cold during menstruation. Many diseases of the uterus, as fibroid tumours, polypi, cancer, &c., cause dysmenorrhoea. Treatment. — Dysmenorrhoea is often very obstinate under treatment, and its course is very protracted. In many cases much may be done by attention to the general health, and to the stomach, liver, and bowels. During an attack rest in bed should be en- joined, and hot baths, anodynes — opium, morphia, chloral, or chloroform — be administered for the relief of the pain. Saline aperients, iron, arsenic, and bismuth, are of service during the intervals. If there be a gouty or rheumatic tendency, this must bo treated. But recourse must be had in the great majority of cases to local treatment, and the plan adopted will depend much on the view taken, not of the individual case, but of dysmenorrhoea generally. Should displacement be found, it should be corrected. Frequently, however, when this has been accomplished, the suffering continues. Clots are commonly found in the discharge, and the cervical canal is not capacious enough to permit their passage. In these cases the channel must be enlarged. This may bo done in several ways : — 1. By graduated bougies, similar to those in use for dilating stricture of the urethra. One or more of them are passed at intervals of several days, until the necessary dilatation has been accomplished. 2. A dilator, such as Priestley’s or Ellinger’s, may be introduced into the uterus, and the ori- fices forcibly and suddenly dilated. 3. Tents of compressed sponge, or of lami- naria digitate, may be passed into the canal, and allowed to remain there for six or ten hours, until it has been well dilated. These means, however, are unsatisfactory, for the orifices regain their original state — the dila- tation is not permanent. To obviate this con- traction, recourse has been had to incision of tho supposed contracted part. The best method is that first proposed by Dr. Marion Sims, that is, the division of the external orifico by scissors, and of the internal, if necessary, by means of a blunt pointed knife. The operation is performed as follows : — The patient is placed on a table on the left side, with the knees drawn up. Sims’s duck-bill speculum is introduced, so as to bring the cervix uteri to view. It is then given to an assistant to maintain it in position. The cervix is fixed by a sharp hook, and the lips of the uterus divided laterally by scissors. Sims’s knife is then introduced through the inner orifice, and as it is withdrawn is made to incise the os in- ternum as well as the angle of the wound made by the scissors near the same orifice; the knife is again introduced, and the opposite side incised in a similar manner. Marion Sims re- commends incision of the inner and outer orifices ; Dr. Robert Barnes the outer orifice only. When the cutting is completed, a strip of lint, m MENSES, DISORDERS OF. moistened in a solution of perchloride of iron in glycerine, should bo introduced into the wound, and a plug of lint into the vagina, and the patient put to bed. The haemorrhage accompanying the operation is usually slight ; sometimes, however, it is profuse, but it can generally be controlled by pressure made against the cervix fixed by a sharp hcok, by means of sponge probangs. Rest in bed for one week should be enjoined. The vaginal plug should be renewed every day until the third or fourth day, when the intra- cervical dressing may be removed. The sound should then be introduced daily, to prevent union of the edges of the wound, or an intra-uterine stem may be worn with a similar object. Instru- ments called hysterotomes have been invented for incising the orifices of the uterus. They are single or doublo-bladed. The blade or blades are concealed in a sheath during their introduc- tion into the uterus ; when this has been done, the blade or blades are made to spring out and incise the cervix as the instrument is withdrawn. The operation is better performed by knife or scissors. III. Menorrhagia, and Metrorrhagia.— Syjsox. : Vulg. Flooding; Fr. Menorrkagie ; Metrorrhagie ; Ger. Mutterblutfluss. The former term is used to denote profuse menstruation ; the latter, haemorrhage from the uterus at any other time than the catamenial epoch. The two symptoms are frequently met with. Menorrhagia often exists alone. When metrorrhagia is present during menstrual life, the ci.tamenia are, as a rule, also profuse. These haemorrhages may be called forth by many lesions. Indeed, they may accompany the majority of the pathological conditions to which the pelvic organs are liable. They may also arise from general states — as scurvy, the haemor- rhagic diathesis, Bright’s disease, phthisis, cir- rhosis of the liver, and the acute specific diseases. . The most common cases are, however, met with in the form of distinct alterations of structure in the polvic organs, as sub-involution of the uterus, polypus, fibroid tumour, cancer, displace- ments, retained portions of placenta, moles — - fleshy or vesicular, fungous degeneration of the mucous membrane of the uterus, mucous polypi, ulcerations of the cervix, haematocele, inversion of the uterus, and congestion of the uterus, duo to obstruction to the circulation through the heart and lungs or liver. Profuse haemorrhages of an irregular character occur also in young girls before the advent of re- gular menstruation. This form of uterine haemor- rhage is not common, hut it is sometimes of very serious import, for occasionally it has proved fatal. More frequent is the occurrence of irre- gular bleeding from the uterus during the menopause. The causes of these climacteric hsmorrhages are really not known. They have been said to be due to congestion, but on in- sufficient evidence. Treatment. — The treatment of haemorrhage from the uterus resolves itself into the imme- diate treatment of the attack, and the treatment of the condition leading to it. The treatment of the attack, or the means of arresting the bleeding, consists in great part in securing abso- lute rest. The patient should remain in bed in MENSURATION. the recumbent position, and avoid all exert, on mental and physical. At the same time, internal remedies which tend to check haemorrhage should be given. Of these, those most commonly used are ergot of rye, gallic acid, the mineral'acids, and acetate of lead. Mineral acids, in combi- nation with sulphate of magnesia or soda, often act welL Should acetate of lead be adminis- tered, the patient should be carefully watched, as some persons are very sensitive to the action of the drug, and manifest symptoms of acute lead-poisoning after the administration of a small quantity of it. Should these means fail, recourse should be had to plugging the vagina or uterus. The vagina is plugged in the follow- ing manner : — The patient is placed on her left side and a speculum is introduced, and the canal is firmly packed with pledgets of cotton-wool or strips of lint, tied on a string for convenience of removal. This will arrest the haemorrhage for a time, hut it can only prove a temporary expedient. The plug is liable to become ex- tremely offensive, from decomposition of blood! and of the secretions in the vagina, and shonld consequently he changed every eight or twelve, hours. A more efficient means of arresting haemorrhage is plugging the uterus itself. This is done by means of tents of sponge or laminaria and with a twofold object. The first object i.“ the immediate arrest of the bleeding; but tilt chief object usually is to dilate the canal o the uterus so as to permit its exploration by the finger, and the discovery of the cause of th> bleeding. This means will not only check tin bleeding temporarily, but will in many case effect a permanent cure. To facilitate the intro duction of a tent a Sims’s speculum should b used, and the cervix of the uterus should be fixe’ by a sharp hook. In many cases, however, tent will not be necessary. The hsmerrhage wall b controlled by the other means enumerated, c the cause of the haemorrhage will be made od without the use of tents. In all cases, howeve: in which the haemorrhage is uncontrollable, d so profuse as to threaten life, or in which th cause of the bleeding is obscure, tents shou! be had recourse to, both to check the flow an complete the diagnosis. When the cause h; been discovered, it should, if possible, be n moved. But even after the uterine canal has bee dilated no definite cause may be found for tl bleeding. In these cases, styptics, or evf caustics, may be applied to the inner surface the organ. Those chiefly used are nitric aci chromic acid, carbolic acid, a solution of iodic or a solution of perchloride of iron. The are best applied through a uterine speculr of platinum or vulcanite, on a probe similar material. While using these mea it should be borne in mind that interi uterine medication is not free from gra danger. The remainder of the treatment of mem rhagia consists in attention to the gene state. MENSURATION ( mensura , a measure) A synonym for measurement. See Measuj went ; and Physical Examination. MENTAGRA. MENTAGRA ( mentum , the chin, and &ypa , in attack).— A name for affections of the chin, more general than sycosis, and therefore some- times convenient. See Skis, Diseases of ; and Sycosis. MEUTAGEOPHYTON ( mentagra , and yirrov, a plant).— The fungus-plant of mentagra, in reality a trichophyton, discovered by. Gruby in the hair-follicles and hair in sycosis. See Epiphytic Skin-Diseases; Sycosis; and Tinea. MENTAL DISORDERS. See Insanity. MENTIGO. See Mentagra. MENTONE, on extreme east of French Riviera.— Moderately warm, bracing, sheltered, and dry -winter climate. Mean temperature in winter," 48° Fahr. Winds: E. SE., and NW. Soil, sandstone. See Climate, Treatment of Disease by. MERCURY, Diseases arising from. — Synon. : Fr. Hydrargyrie ; Intoxication mercu- rielle; Ger. Quecksilbervergiftung . Though considerable discrepancies of opinion have existed as to the poisonous or innocent properties of the metal mercury itself when ■swallowed, there can be no doubt as to the poisonous character of its soluble and volatile compounds, nor even as to the insidious nature of the vapours of metallic mercury. Metallic mercury has occasionally been administered in enormous quantities without producing any de- cided physiological effects ; whilst in other in- duces, salivation and other specific effects lave resulted. These differences are doubtless lue to the fact, that in those cases where effects fare resulted from the administration, oxidation nd solution of a portion of the metal had taken dace. Mercurial poisoning may be either (A) acute, r (B) chronic ; the former resulting from the dministration of one or several large doses at hort intervals, the latter form of mereurialism rising from the repeated exhibition of small oses of the less active preparations of the letal. There is also a peculiar form of mer- irialism, which is the effect of the inhalation : the vapours, either of the metal or of its ilatile compounds, and is characterised by iralysis. A. Acute mercurial poisoning. — Descrip- on. — The effects produced by a considerable 'se, say a drachm, of one of the more soluble mpounds of mercury, such as corrosive sub- aate, or the nitrate, are those of a corro- "e and irritant poison. The effects are im- idiate. In the act of swallowing an intense rning sensation is experienced in the mouth I throat, followed by excruciating piain in ') stomach, and extending to the abdomen, ie local effects of the poison are frequently ;ible, as a whitening of the tongue and j.ces. There is vomiting, tenesmus, and pur- i g, often of a bloody character. Colic and I at tenderness and swelling of the abdomen, i also symptomatic. Not unfrequently there ■ oppression of the urine. The gustatory sen- tion is perverted; there is dryness of the ' nth ; and a brassy or metallic taste is generally MERCURY, DISEASES FROM. 960 experienced after the first local corrosive action of the poison has somewhat abated. The coun- tenance is anxious ; the skin is pale, cold, and clammy ; and the pulse is small, weak, and rapid. Salivation may supervene, accompanied by foetor of the breath. Should recovery not take place, death may occur within a few hours, or may be delayed for one or more days ; or the patient may more rarely succumb to some of tho ordinary sequelfe of corrosive poisoning. When death supervenes speedily after the administra - tion of the poison, the fatal result is usually due to collapse. Most of the effects of acute mercurial poison- ing may result from the application of a concen- trated solution of corrosive sublimate to the un- broken skin. Anatomical Charactf.rs. — The -post-mortem appearances seen after acute mercurial poison- ing are inflammation, and even erosion of the mucous membrane of the stomach, and extrava- sation of blood beneath this membrane. Ulcera- tion is rare. The intestinal tract also exhibits signs of extensive inflammation, and this has been noticed especially in the large intestine. The rectum is usually much inflamed, and its surface covered with shreds of bloody mucus. A peculiar slaty appearance of the mucous mem- brane of the stomach and intestines, where not highly inflamed, has been thought to be charac- teristic of corrosive sublimate poisoning. Diagnosis.— Though the symptoms of poison- ing by corrosive sublimate, and other corrosive preparations of mercury, greatly resemble thos6 produced by arsepic, the diagnosis is generally not difficult. The effects following almost imme- diately on administration, the metallic taste in the mouth, and the greater frequency of bloody stools in mercurial poisoning, serve to differen- tiate between the poisons. Where doubt exists, an analysis of the secretions may be made ; arsenic is most readily detected in the urine, and mercury in the saliva. The existence of saliva- tion and feetor of the breath — though not always present — may also be valuable aids in completing the diagnosis. Treatment. — In acute poisoning by corrosive sublimate, the best antidote is albumen, or the albuminoids in any soluble form. The white of one or more eggs should be beaten up with water, and swallowed as quickly as possible. Failing an egg, flour made into a thin paste may be ad- ministered. Albumen combines directly with cor- rosive sublimate to form an insoluble compound. On account of the powerful local action of the poison on the stomach, the use of the stomach- pump is not advisable ; but if the vomiting be not free, emetics of as simple character as pos- sible may be administered. The rest of the treatment consists in alleviating pain by means of opiates, and the general treatment applicable for irritant poisons. Thirst must be alleviated by demulcent drinks. For this purpose milk, mixed with once or twice its bulk of lime-water, is excellent ; the casein of the milk and the lims both tending to render the mercury insoluble, and so to act as antidotes. B. Chronic mercurial poisoning. Synon. : Mereurialism. Description. — The repeated ingestion of small 970 MERCURY, DISEASES FROM, doses of the more soluble and active prepara- tions of mercury, such as the bichloride and the bicyanide, may give rise to chronic symptoms ; but these more frequently result from the ad- ministration of one or more doses of the more insoluble preparations of the metal, such as calomel or the oxides. When chronic symptoms follow the administration of one dose of a mer- curial preparation, this is not altogether due to the peculiar idiosyncrasy of the patient, but is attributable in no small degree to the slow- ness with which mercury is eliminated from the system. There appears also to be a remarkable difference, not altogether dependent upon their differing solubilities, between mercuric or per- salts, and mercurous or proto-salts, in respect to their toxic properties. Mercuric compounds are greatly more potent than mercurous salts. By far the most common result of the continued ad- ministration of mercury compounds is salivation. This consists in a profuse discharge from the salivary glands ; swelling and tenderness of the gums ; and foetor of the breath. In children, and more rarely in adults, salivation may pass into sloughing and gangrene of the cheeks ; and a fatal result may ensue. Other symptoms are nausea, colicky pains, depression, and those ner- vous symptoms to which the term ‘ mercurial palsy ’ has been applied ; but this last group of symptoms, which is most commonly met with after inhalation of the vapours of mercury, must be described more in detail. Mercurial Paralysis . — Workers in mercury, such as water-gilders, looking-glass makers, and the makers of barometers 'and thermometers, are apt to suffer from a peculiar form of shaking palsy, kr.own either as ‘ the trembles,’ mercurial tremors or metallic tremors, and tremblemcnt metallique by the French. This disease affects those who handle the oxides of the metal, but more frequently those who aro exposed to mercu- rial fumes. Mercury exhibits a small vapour- tension, and consequently is vapourisable at all ordinary temperatures, but the tension of it3 vapour below 60° Fahr. is very small. The metallic tremors may come on suddenly or gra- dually, and they may be unaccompanied with salivation. The upper Embs are first affected, and then by degrees the whole muscular system. The patient is affected with tremors when an endeavour is made to exert the muscles, so that he is unable to guide, for instance, a glass of water steadily to the lips ; he cannot put his feet steadily to the ground ; and when he tries to walk he breaks into a dancing trot. The muscles of mastication and deglutition are affected in advanced cases. Delirium, mania, and idiocy have occasionally followed the continued inhala- tion of mercury fumes. Diagnosis. — The diagnosis of mercurial tre- mors is usually not difficult. It must be ad- mitted, however, that in some cases the tremors produced by mercury are in no way distinguish- able from those due to the now well-recognised disease known as disseminated, multiple, or in- sular sclerosis. The former are less readily confounded with ordinary shaking palsy (para- lysis agitans) and the convulsive movements of chorea. The history of exposure to mercury will seldom be absent. In paralysis agitans the MESENTERIC GLANDS, tremors occur when the patient is at rest ; and the peculiar forward gait, as if the patient were endeavouring to pass from a walking to a running pace, is characteristic. The metallic tremors come on only when the muscles are exerted, and usually they entirely cease when the patient is lying at rest, or is asleep. The same may be said of the tremors of disseminated sclerosis ; but here we have the peculiar con- sensual rotation of the eyes known as nystag- mus. In paralysis agitans, when told to raioo the affected hand, or to protrude the tongue, the patient performs both actions steadily. In mercurial tremors, and in disseminated sclerosis, the case is different — the tongue when volun- tarily protruded is tremulous, and the patient cannot raise his hand when requested to do 60 , without shaking. In both mercurial tremors and the tremors of insular sclerosis, the muscular agitation ceases for the most part during sleep. In one form of metallic tremors the movements approach in character the convulsive movements of chorea. Tbeatment. — In chronic mercurial poisonine. it is obvious that the patient must at once be removed from the further influence of the metal. Masks worn over the mouth aro not of much use. In mercurial tremors cessation from working with the metal, and mild tonics of iron, usually suffice for the speedy restoration to health; but the shaking occasionally persists throughout life. For salivation and the more formidable gangrene of the mouth, besides cessation of the administration of the metal, and the exhibition of tonics, iodide of potassium may be given. Astringent gargles and active local treatment may perhaps be necessary. Thomas Stevenson, MESENTERIC GLANDS, Diseases of. Of the lacteal glands, which lie in the folds of the peritoneum connected with the intestines, the mesenteric — which are connected with the small intestines — may be ranked as the most important, and what is described with regard to these will apply to the rest of the lacteal glands. They are all really of the same nature as the lymphatic glands, and are subject to similar diseases. The statements made, therefore, with reference to these structures, will also apply in the main to the lacteal glands (see Lymphatic System, Diseases of) ; but the latter are likewise liable to certain special morbid changes, whilst these changes present some peculiarities as re- gards their effects and symptoms. Thus, when the lacteal glands are diseased, the general nutritior tends to bo markedly impaired, owing to the in- terference with the transmission and due elabo ration of the chyle, and if they are extensive! involved the entire system suffers gravely Owing to their situation and anatomical rela dons, these glands, in certain forms of diseasf may originate secondary effects of consider able importance. For instance, peritonitis ma be excited by their irritation or rupture; c by their pressure on vessels or other structure 1 ascites and other conditions more or less senou may result. The enlarged mesenteric glands ma be felt, in certain diseases, through the abdomim walls. With these preliminary remarks, the pa MESENTElttC GLANDS, DISEASES OF. icular diseases of the mesenteric glands will now ie considered, so far as they may require special omment. 1. Acute Congestion and Inflammation, 'he lacteal glands are very liable to become lore or less congested or inflamed in connection nth any inflammatory condition affecting the ntestinal canal. The situation and number of lands implicated will correspond mainly with he portion of bowel involved. They become nlarged, but the changes are seldom such as 0 give rise to any evident symptoms, and they ubside as the cause of the irritation ceases to perate. In rare instances the inflammatory rocess may go on to suppuration, and then there 1 great danger of serious consequences ; in one ase which came under the writer's notice, fatal eritonitis appeared to have been set up by the rotation of a suppurating mesenteric gland. Attention may be directed here to the changes hich o;cur in the lacteal glands in certain pecial acute diseases, namely, typhoid fever and ysentery. In typhoid fever the mesenteric iands are usually involved, corresponding with le part of the small bowel affected in this dis- use; but if the colon is implicated themesocolic lands also suffer. The changes in the glands innot be looked upon as merely secondary i> intestinal irritation, for they commence from ie outset, and go on simultaneously with the rogress of the intestinal lesions. The glands ecome enlarged, from a hyperplasia of their lym- hatic elements, and this enlargement increases util from about the tenth to the fourteenth ly of the disease. They are of a red or purplish ilour, and moderately firm. On section small, jaque, pale-yellow, friable collections are some- mes seen. As a rule the glands subsequently icome gradually softer, and diminish in size, suming in favourable cases their normal con- tion; not uncommonly, however, they become ore or less shrivelled and contracted, tough and le, or of a grey or bluish colour, and they may en calcify. In exceptional instances the glands pidly soften in their interior, a purulent fluid iug formed, mingled with sloughs ; and very cely they have ruptured into the peritoneum, us setting up fatal peritonitis. It cannot be monstrated how far the implication of the sorbent glands accounts for the symptoms of phoid fever, but it is highly probable that they ye more or less influence over them. Dysentery is another special disease in which '■ \ lacteal glands are involved, but the changes i ’e seem to be merely the effects of irritation 1 m the intestinal lesion. The mesocolic glands ; mainly affected, but if the disease implicates t small intestines, the mesenteric also suffer. 1 ;y become enlarged, red, and softened; and if t dysentery assumes a chronic form, the glands 6 also permanently changed. . Scrofulous or Tubercular Disease. — - ies mcsenterica. — The nature of this affection 1 been already discussed in relation to the s orbent glands generally (see Lymphatic 1 tem, Diseases of), and it will suffice to indi- c i here the special points which require to be r ced in connection with the lacteal glands. £ )fulous or tuberculous disease of the me- * glands constitutes a most important 971 disease in children and your.g persons. It may exist independently, but is usually associated with so-called tubercular ulceration of the in- testines, to which it is then probably secondary. It is not improbable that the mesenteric disease may be primarily set up as the result of mere long-continued chronic intestinal catarrh. The patient may be evidently scrofulous or tuber- cular, but this is by no means constant, and there may' be no signs whatever of any such diathesie. The disease may also be accompanied with pul- monary phthisis, although this is comparatively rare in children, and the lung-affection is almost always secondary. In adults, on the other hand, tuberculous disease of the lacteal glands, when it does occur, is in tho large majority of cases a complication of pulmonary phthisis, intestinal ulceration being present at the same time. The changes in the glands are similar to those characteristic of the scrofulous process in the lymphatic glands, namely, a hyperplasia of the cellular structures, of low vitality, followed by caseation, and ultimately by calcification, if tho case last sufficiently long ; and it is usual in fatal cases to find these conditions more or less combined in different glands. Should recovery take place, all the involved glands may be con- verted into inert, chalky masses, in which con- dition they remain permanently. A case came under the writer's notice some years ago, in which the patient having died from an independent acute illness, the mesenteric glands were found to be universally calcified, this being associated with scarring of the external glands, and other signs of past scrofulous disease, from which the patient had quite recovered ; the condition of the glandg was unattended with any symptoms whatever. The individual glands in mesenteric disease may attain a considerable size, and when they aro agglomerated a distinct tumour is formed. Symptoms. — It is frequently impossible to recognise definitely the symptoms, either local or general, due to scrofulous disease of the mesenteric glands, as they are combined with, and masked by those resulting from intestinal ulceration and catarrh, or from the implication of other structures. The digestive organs are usu- ally disordered, and, even if there should Dot be intestinal ulceration, children who suffer from mesenteric disease are very liable to enteric catarrh. Hence diarrhoea, with unhealthy stools, is a common symptom, and it is often difficult to check, or it returns from very slight causes. In other cases the bowels are constipated. Scrofu- lous mesenteric glands do not seem to be painful in themselves, but colicky pains in connection with the bowels are of frequent occurrence, and the diseases of the glands may have some influence in exciting these. The abdomen is almost always dis- tended and prominent, owing to the accumulation of flatus, and it may be distinctly tympanitic. Hence, even when the glands are much enlarged, it is often impossible to feel them, but they may sometimes be made out by deep pressure with the fingers over the abdomen. In some instances the abdomen is retracted, and then the glands may be more readily felt. They may produce symptoms by their mechanical effects, and the writer has met with a case in which extreme ascites was probably due to tubercular mesenteric 972 MESENTERIC GLANDS, lisease. By irritation of the peritoneum, or, in rery rare instances, fcy the glands bursting into its cavity, peritonitis may be set up. The general symptoms are usually very prominent, as evi- aenced by wasting, which may reach extreme emaciation, anaemia, debility, and pyrexia, marked heetic fever ultimately supervening in some cases. How far, however, the mesenteric lesion originates these symptoms is a matter of doubt and dispute, but it is highly probable that it is in some measure accountable for them. Oases in which mesenteric glands are tho. seat of scrofulous disease differ much in their seve- rity, and it may be quite impossible to make any positive diagnosis. A large number of cases prove fatal, but it mustbe remembered that even after severe symptoms recovery may take place, the glands becoming calcareous and harmless. When the glandular affection is secondary to pulmonary phthisis, it helps to hasten the fatal termination. Treatment. — This mainly consists in the treatment required for scrofulous disease in gene- ral, such as the administration of cod-liver oil, preparations of iron, quinine, and other tonics ; favourable hygienic conditions and surroundings ; change of air, especially to tho country or to the sea-side ; and other appropriate measures. The diet needs particularly careful attention. It should be nutritious and digestible, but has often to be modified so as to render it suitable for the condition of the alimentary canal. Re- medies directed to the improvement of the state of this canal, or to the relief of symptoms con- nected with it, are also often required. No local application can possibly have any effect upon scrofulous mesenteric glands ; but symp- toms might be benefited by friction with some liniment, the application of a flannel bandage, or the use of dry heat, fomentations, or poul- tices in connection with the abdomen, should occasion call for them. Any secondary morbid conditions which may arise must be attended to. In the case already alluded to, paracentesis was urgently demanded, on account of extreme ascites ; the fluid re-accumulated almost to the same amount, but it afterwards gradually dis- appeared entirely by absorption, and the patient recovered. 3. Hypertrophy. — It will merely be needful to remark under this head that the lacteal glands are liable to be more or less hypertrophied in cases of lymphadenoma, and in the form of len- cocythsemia attended with glandular enlargement. The writer has met with instances where the growth was very considerable. They might pos- sibly be detected during life by physical exami- nation, or they might cause symptoms by their mechanical effects ; but, as a rule, their existence is only ascertained at the post-mortevi examina- tion. 4. Atrophy and Degeneration. — The me- senteric glands atrophy in old age, and they may also become wasted and withered after previous disease, such as typhoid fever. The caseous and calcareous changes which they undergo in con- nection with scrofulous disease have been already indicated. It may happen that atrophic or de- generative changes in these glands affect the general condition ; but it is certain that they MESMERISM. may be extensively calcified, and yet the patient remain apparently in excellent health. o. Morbid Formations. — The mesenteric glands may be the seat of albuminoid disease. It is said that they can then be felt through the abdominal walls, firm, distinct, and easily mov- able ; but thi3 is by no means always the case. Cancer is chiefly met with as a secondary de- posit, the lacteal glands being particularly liable to become affected if the intestine is the seat of malignant disease, and the localisation being de- termined by that of the intestinal lesion. It may, occur, however, as a primary affection. The cancer is usually of the softer variety, but it will de- pend to some extent on the nature of any primary deposit. A considerable tumour may be formed, firm and nodulated ; or the glands may remain separate. Physical examination often revealsthe presence of the disease ; and this, together with localised pain, and symptoms due to pressure,! should any such be present, as well as signs of the cancerous cachexia, or of the implication oil other organs, especially the intestines, constitute] the clinical phenomena associated with malignant disease of the lacteal glands. No treatment can be of any service. Frederick T. Roberts. MESENTERY, Diseases of. See Perito- neum, Diseases of. MESMERISM — Definition. — The name oi the process by which, rather more than a century ago, Anthony Mesmer, the deluded (or at all events the deluding) promulgator of the doctrine of ‘animal magnetism,’ induced the so-called mesmeric trance or sleep. See Magnetism Animal. This mesmeric trance is identical with the condition now known as ‘ induced somr.am bulistn,’ or still more commonly as ‘ hypnotism or the ‘ hypnotic state.’ The condition itsel is one which presents to the observer many highly interesting phenomena, and it, togethc; with the means of inducing it, were first investi gated in a full and scientific manner by Jam*- Braid of Manchester (1843). In this place it is not intended to speak o the subject from its old point of view. Tin reader who desires to gain some notion of tht errors, deceptions, and vain pretensions witl which tho whole subject was enveloped by thos, who have been content to style themselvc] ‘ mesmerists,’ may with advantage consult th article on ‘ Mesmensme,’ by Deschambre (Die' Ency. dcs Sc. Med., tome vii.), at the close o which they will also find a valuable bibliography Here the proceedings of Mesmer and his fol lowers in France are fully exposed. As a sort of transition between this old statj of things, with its erroneous theory and vai pretensions, and the scientific standpoint take, by Braid in regard to the more correct linn tation of the phenomena observable and thei altogether intrinsic mode of production, cam the observations of Elliotson in London, as con ducted in the years 1837-3S, when he sought t inform himself and others as to the phenomen and curative virtues of mesmerism. He er countered a storm of opposition, principally o account of his mode of dealing with the subjee He was unquestionably honest and enthusiast! I MESMERISM. to Iij 3 search for what he believe'd to be truth ; ,'but, he unfortunately did not, as Braid by his keener insight was enabled to do, reject and otherwise explain the so-called phenomena of clairvoyance, of transposition of the senses, and ot prediction or prophecy. It is to be regretted, however, that Braid did not also reject all the so-called phenomena of phreno-hypnotism. An independent practical study of the subject jnd of its therapeutic applications was shortly after the date of Braid's labours commenced by Esdaile in India (1846), as well as by J. K. Mitchell in the United States. They have more recently been succeeded by other investigators, Lmongst whom may be mentioned Girard Teulon md Demarquay (1860); Ch. Richet (1875); Charcot (1878); and also Weinhold, Beard, Pre- fer, Berger, Griitzner, and Heidenhain (1880). The induction of the hypnotic state or sleep las hitherto been possible in only a certain, but Variable percentage of the persons with whom rial has been made, though a successful result ias been much more frequent with women than with men. According to Richet, however, the Operator should not be discouraged by the failure >f his first attempts with the same person ; as iersons may succumb on the fourth or fifth rial, and subsequently prove thoroughly good ubjects for experimentation. Persons who have nee been hypnotised can in general be again rought with comparative ease into the same ondition, and the facility of hypnotising such -ersons goes on increasing after each operation, wing to the existence of a predisposing mental Vate. A condition of excited expectancy is in- feed a decidedly favouring mental state, though ne which is not essential, since, according to '■raid, Heidenhain, and others, even male adults ho have heard nothing on the subject, and do jpt know for what purpose they are being ex- irimented with, can often be hypnotised. In persons who are favourably disposed for issing into the hypnotic state, the condition is sily induced by weak, long-continued, and uni- rm stimulation, either of the nerves of sight, touch, or of hearing. This state is, on the utrary, almost always easily capable of being ruptly terminated by some strong or suddenly rying stimulation of the same nerves. Many of the lower animals, such as frogs and .vis, cau be thrown into an extremely similar iidition as a result of certain sudden and werful sensorial impressions. Preyer distin- ishes the state into which they are thrown by different name, namely, ‘ cataplexy,’ because ’ i mode, or physiological process, by which it induced, seems to be different from that by ’ ich hypnotism is caused. Che hypnotic state or sleep is one which Vies much in intensity in different persons, tin the same person at different times. The ficipal phenomena that are exhibited or t ;ch can be detected in hypnotized persons are I. following: — (1) Imitation movements; (2) 1 iltations of special sense ; (3) Illusions and lilucinations ; (4) Analgesia, general or uni- 1 ral, or even a condition of hemianaesthesia, geral and special; (5) Increased reflex irrita- t l.y and tonic spasms of the voluntary muscles ; ftj (6) Other miscellaneous phenomena, such MESOLOGY. 973 as spasm of the accommodation apparatus in the eye, dilatation of the pupils, increased rapidity of respiration and of the pulse, together with profuse perspiration. A discussion of the mode of production of these several phenomena, or of the nature of the hypnotic condition itself, would lead us info details too purely physiological for our present purpose — suffice it to say that the hypnotic state, in one or other of its stages, seems to be akin to that met with in some sleeping persons, as well as to the states known as somnam- bulism and catalepsy, and that its physiological cause is presumed by Heidenhain to be some inhibitory arrest of activity of the ganglion-cells of the cerebral cortex, or, as the writor would rather put it, of certain tracts of these ganglion- cells. (See Animal Magnetism: Physiological Observations, by R. Heidenhain, 1880.) The scientific study of the phenomena pre- sented by hypnotized persons is unquestionably of great interest and importance, from the point of view of the higher cerebral physiology. But whether the systematic induction of such a state can ever be used as a legitimate or potent means for curing disease, or even for the alle- viation of certain distressing symptoms, must be left for the future to decide. The good use to which it was put by Esdaile in India, as a means of inducing insensibility during sur- gical operations before the general introduction of chloroform, ought, however, never to be for- gotten. (See his Mesmerism in India, and its Prac- tical Application in Surgery and Medicine.) The whole subject is one of great interest for the practitioner of medicine, now that the absurd theories have been got rid of. We must be care- ful, however, to pursue the study of the con- dition itself in a strictly scientific manner, and watch lest the too-ready adoption of hypnosis or Braidism as a curative agent may do harm rather than good — and that not to the patient only, but also to the practitioner. Tile state- ments of the results obtained by Braid (see his Neurypnology, 1843) are little less than mar- vellous ; and there can be. no doubt that the therapeutic uses of hypnotism ought to receive a new and thorough investigation by some in- structed and well-trained observers. The pit- falls besetting such an investigation are by no means few ; but, on the other hand, the gains to the science of medicine and to therapeutics might be great. See Braidism. H. Chaklton Bastian. MESOLOGY (jue'croj, a medium; aDd Xiyos, a discourse). This term, recently introduced by Bertillon, conveniently expresses the investigation of the mutual relationships existing between liv : ng be- ings and their surroundings. The physiological life of any organism may be regarded as the resultant on the part of the tissues of two sets of influences — intrinsic or hereditary, and extrinsic. To the former are due those structural, and consequently functional characteristics, which are common to ancestors and progeny alike, whilst the fluctuating nature of the environment determines those variation® which distinguish different species. Within cer- 074 MESOLOGY. MICRCCOCCI. tam assumed limits these stimuli are regarded as normal, and the resulting manifestations of the tissues aro said to be healthy; -whilst dis- turbances in either of these groups of influences constitute the causes of disease — that is, abnormal function dependent on abnormal structure, which in its turn has been brought about by a change in the usual conditions under which it exists. Mesology, therefore, may be looked upon in a restricted sense as a branch of setiology, dealing, as it does, with such factors as temperature, atmosphere, climate, locality, food, clothing, and i ha more subtle agencies of habit, profession, domesticity, mental states of depression, excite- ment, or irritation; in short, with any and every circumstance, whether material or psychical, which acts upon the body. W. H. Allchin. METALLIC. — A peculiar quality of sound, which the name suggests, either elicited by per- cussion or heard on auscultation, especially in connection with certain adventitious sounds in pulmonary cavities. See Physical Examination - . METaMORPHOSIS (jueTci, a particle sig- nifying change, and p.ep grossest character, the theories of disease re limited only by fancy and empiricism. ■It as the great truth which established the 1 nection of physiology, and hence of pathology, ' h anatomy came more and more to be recog- i ad, the principles of morbid action, the ex- 1 nation of symptoms, and the suggestion of r onal treatment followed on truly scientific Kinds. It was in establishing, and is now in Retaining and following this truth, that the n loscope ranks highest among our instru- m.its of research. as Instrument.— In face of the many and e .llent instruments that are offered, it would be id lious to recommend any particular one ; but ‘bellowing remarks are intended to be a guide as the kind of microscope that is sufficient for th irdinary requirements of the practitioner, it M ; assumed that the optical principles of a >ouud microscope are understood. 62 Obviously the first point to keep in view is the magnifying power, inasmuch as it is to bring within the rango of vision invisible objects that the instrument is valuable. For all ordinary practical purposes a power that will magnify 300 to 400 diameters is sufficient ; higher de- grees require specially skilled manipulation, and are out of the category of present consideration. But at the same time it is almost an essential that a much lower power be available, such as one of 60 diameters, in order that a more general view may be had of the object under examina- tion, since it is thus that an idea may be ob- tained of the plan and arrangement of the object, the details of which are resolved by the higher power. Scarcely secondary in consideration is the ‘defining power,’ by which ‘a clear and distinct image of all well-marked features of an object, especially of its boundaries,’ is ob- tained (Carpenter). Subordinate to these quali- fications, but yet of great importance, are ‘ flat- ness of field,’ ‘achromatism,’ ‘penetration,’ and ‘ sufficient light.’ Excellence in these various points is to be aimed at in the selection of a glass. The whole field of vision should he flat, that is, the circumference and the centre should be in focus at the same time ; and the margins of the object viewed should not be fringed with coloured bands. Errors in these directions, known as spherical and chromatic aberrations, are corrected by the employment of ‘combinations’ of lenses, of varying degrees of convexity, and manufactured of different kinds of glass. It is clearly of great import- ance to have the field well illuminated, or that there be as much light as possible, but it is equally obvious that this necessarily varies with the focal length of the object-glass — the higher the power the less the light that can he ad- mitted. Still, however, a considerable difference exists in respect to the illumination among glasses of the same magnifying power, and it is highly desirable to keep this point in view in choosing an objective. Certain aids to this end are given by reflectors, achromatic condensers, &c. With the degree of ‘ illuminating power ’ of the glass must be considered its ‘ penetrating power or focal depth, by which the observer is enabled to look into the structure of objects’ (Carpenter). The latter quality is of the utmost importance in the microscope of the medical practitioner and histologist, as by it a know- ledge is afforded of the relative disposition of the constituent parts of the object under inves- tigation. All these properties are closely asso- ciated with what is known as the * angular aper- ture’ of the objective, that is, ‘the angle formed between the most external rays that can pene- trate the entire system of lenses of an objective, from a luminous point placed in the focus.’ Now the degree of angular aperture will depend on the distance of the object, when in focus, from the front lens of the objective, and the size of the ‘ actual aperture,’ or width of the front lens of the combination. The illumination of the object must be directly proportionate to the latter, since upon the actual size of the lens must depend the amount of light admitted ; but since the cir- cumferential and central rays tend to come to a focus at different points, to the manifest detri- MICROSCOPE IN MEDICINE. ?78 ment of the distinctness of the image, the defin- ing power of the glass will be improved as the outside rays are cut off by diminishing the field, or, in other words, by diminishing the amount of light. Within certain limits, therefore, the definition improves in inverse proportion to the illumination, always assuming a complete correc- tion of chromatic and spherical aberration. Now the ‘ penetrating power,’ within certain limits, va- ries in inverse proportion to the extent of angle of aperture of the objective, which, as already said, in part depends on the size of the actual aperture. Hence also the penetration up to a certain point improves in inverse proportion to the illumination. Since it is impossible to recon- cile these very opposite qualities, the observer must be prepared to lose somewhat in light what he gains in distinctness and depth of his image; and, as a rule, the angular aperture of the J should not exceed 75°, nor of the Ath or^th, 90°. The so-called ‘ resolving power ' of a glass, ‘ by which closely-approximated markings may be distinguished,’ is of but little value to the medi- cal practitioner. Keeping in mind these points, it is possible tc obtain a microscope for a very moderate cost (£6 to £7), which shall fulfil all the ordinary requirements of the medical man. The stand should be small and perfectly steady, on the tripod or horseshoe (Hartnack) model. The stage should be tolerably large (a common fault is its small size), and its aperture of moderate size and provided with a wheel of diaphragms ; whilst the addition of an achromatic condenser is most desirable. The mirror itself should be double, concave on one side and flat on the other, attached to the body by a j ointed arm, and not too small — another fault in cheap instruments. The body of the microscope should be so attached to the stand as to permit of inclination to any angle between the vertical and horizontal positions, and should be provided with a ‘draw tube.’ In order that the tube carrying the optical arrange- ments, eye-piece and objective, may he brought into proper position to focus the object, it is usually provided with ‘coarse’ and ‘fine’ ad- justments, though these are not always both present in the cheaper instruments, and are really not absolutely necessary for the powers here recommended, being moreover worse than useless unless they are exceedingly well made, which adds considerably to the expense, whilst a little practice will render the observer indepen- dent of them ; if one only be available, the finer should be preferred. Lastly with respect to the glasses, a great diversity of opinion exists, very much determined by what the individual is accus- tomed to ; familiarity with a special instrument and its parts going a great way to ensure success in its employment. Whilst probably the A ery best glasses, and those of the highest power (l-25th and l-50th inch) are made in England, excellent objectives are made in Germany and France, are amply sufficient for medical practice, and give a nearly equivalent result at a much lower cost. The cheapest English glasses should certainly be avoided. For a low power a 1-inch or f-inch is sufficient, and anything lower is of little use ; whilst for a high power opinions differ in regard to a J, or | (or the foreign equivalents), depending much on the quality and maker of the glass. The writer believes that for all ordinary purposes the English J-incli is sufficient, if used with a No. 2 or B eye-piece, giving a magnifying power of about 32(1 diameters, whilst it has the great advantage of permitting considerable illu- mination, the want of which is especially felt by the occasional observer, whilst to one more familiar with the instrument the loss of light is hut little felt, as magnifying power and defi- nition are increased. For testing the optical properties of theglasses, nothing is better than a drop of fresh blood and a piece of muscular fibre ; and both the A and B eye-pieces should be tried with each objective. Drawing. — It is frequently necessary that an accurate drawing should be made of the object seen, and this may be doDe by means of the camera lucida prism, attached to the eye-piece of the microscope, which is then placed horizontally. The rays of light proceeding from the object along the tube to the eye-piece are then pro- jected downwards by the prism, on to the paper beneath, forming an image which may be traced over. An arrangement with a piece of neutra tint glass is supplied, which answers all the pur- poses of a camera lucida, and is much cheaper Considerable practice is, however, needed in the use of these instruments. Measuring.— For purposes of measuring mi- croscopical objects various forms of micrometers are employed. One kind fits into the eye-piece ; I and another consists of a ruled glass slip, a drawing of the lines on which is made by the I aid of the camera lucida with each objective- such drawing being afterwards used as a measure to be applied to the outlines previously made by the prism. Binocular Microscope. — The binocular ar- rangement of the microscope, though undoubtedly possessing great advantages as regards pene- trating power, is not of such value for ordinary clinical purposes; and, necessitating as it docs the very best construction, is only applicable to the larger and more expensive instruments. A very convenient accessory when well made is the ‘ nose-piece,’ which carries the two objectives and thereby saves much trouble. For power; higher than the J, it is not satisfactory with th< smaller microscopes. Apparatus and Reagents. — Bearing in mini that it is for tho clinical use of the instrument rather than as a means of histological research that the microscope is here considered, the ae tual reagents and apparatus required are ver few. The following are requisites: — A pair c small curved scissors ; a pair of fine pointed foi ceps ; a few sharp needles, mounted in handle: those with cutting edge being preferable ; slid? and cover-glasses, which latter cannot be :c thin ; several camel’s-hair brushes ; one or t\v glass rods ; and pipettes. Except for the ex; ruination of tumours and new growths, whitj may require hardening and staining, tho medic, man chiefly wants a microscope to ascertain tl nature of various secretions and discharge which are mostly of a fluid nature, and do a require the addition of any medium ; but shou any such be needed, it is desirable that should be inert, and as nearly as possible of t MICROSCOPE IN MEDICINE. 979 density of the blood-serum with which the tis- sues are normally moistened. For that purpose a g or 4 per cent, solution of chloride of sodium, or a 3 per cent, solution of glycerine in distilled water, to which a few crystals of carbolic acid have been added to prevent the growth of fungi, is most convenient. For hardening portions of i tissue to allow of cutting sections, solutions of iehromic acid (| to 1 per cent.) ; of bichromate of potash of the same strength ; of chromic acid Lid spirit (| per cent, to 90 per cent.), dis- frilled water to 100 ; and Muller’s fluid — a solu- tion of bichromate of potash (2£), sulphate of Lda (1), distilled water (to 100); are the most effective, and are easily made. It is necessary to (remember that a very considerable quantity of Inch fluid is required, and that it requires re- aewing daily for the first three days. For a liece of tissue of tho size of a filbert, at least 'our ounces of either of the above is requisite. Jndcr favourable circumstances the hardening s complete in 14 to 21 days. By means of the reezing microtome perfectly fresh tissue may |e cut and examined. Among the very many methods recommended pr hardening and staining portions of tissue, jie following is given as an extremely ready nd, on the whole, easy plan. Small pieces of tie substance, of about the size of a large pea, (re placed in spirit for at least twelve hours to pt rid of the water ; they are then transferred j> a solution of magenta in oil of cloves, to lain. The time required for staining varies jith the tissue, the size of the piece, and the 'rength of the solution; but usually twenty- fur hours is sufficient. The pieces are then moved to a bottle containing melted cocoa- .tter, and kept there for twelve hours. The (at of the chimney-piece suffices to keep the tter melted. One of the portions is now put the end of a small cork, to which it becomes ached by the setting of the cocoa-butter in out a couple of hours, and may then be cut :h a razor, wetted with spirit in the ordinary y. The sections are floated on to a slide, the i lerfluous spirit removed by blotting-paper ; and ! rop of oil of cloves let fall on the specimen ; \ichis covered with acovering-glass, and finally t tly warmed for a minute over a spirit-lamp t| lissolve out the butter. Such a specimen may tjbreserved by the addition of a little chloro- f n-balsam to the edge of the cover-glass. linical Uses.— The microscope may be ap- p d to the investigation of the various dis- ci ’ges and secretions from the body, with the Hit of obtaining information, which though oli of but imperfect value, may on other oeca- 6i 3 be of the most positive and precise cha- ra F, determining a diagnosis which without it w id be uncertain. ) Urine. — It may be taken as a fundamen- ta rinciple that perfectly healthy, fresh urine 6hld have no visible deposits. A small (putity of flocculent mucus, entangling a few e P dial cells, is, however, of such frequent ociiTence and of such trifling importance as pn ically to come within the limits of health. Me than that is abnormal, and such deposits je | n d investigation. It may he that they are result of changes in the urine after it is passed, or, on the contrary, they may have been voided as such. Occasionally absolutely clear- looking urine may contain tube-casts, which the microscope only can detect. It is important, therefore, to know the age of any sample of urine that is examined, and when possible, a portion of the whole twenty-four hours’ quantity should be taken. Where this cannot be done, what is passed in the morning on rising should be chosen, since it is in such a specimen that certain matters are most likely to be present. Frequently an examination for seve- ral successive days may be necessary, for there are some conditions of kidney-disease in which but very few casts are passed, and would most probably escape one examination of a haphazard specimen. The urine should be collected in coni- cal glasses, holding about four ounces, which must he scrupulously clean, and, if in frequent use, are best kept in a closed vessel of water, since thereby dust is prevented from accumulating at the bottom ; and it is well to pour a little strong nitric acid into such glasses occasionally, to effectually remove all dust and deposits, sub- sequently, of course, thoroughly washing them in cold water. Tho urine should be allowed to stand six or eight hours at least, and be covered by a plate of glass ora paper cap, to prevent the entrance of dust. With a clean glass pipette a few drops of the lowest portion of the fluid may he removed. A collecting-glass has been recently invented whereby the lower strata of urine may- be drawn off from the bottom by a tap ; but a pipette answers all ordinary purposes. It is con- venient to have the glass slide to which tho drops are transferred provided with a cell, made by a very thin circle of gold size, sinco not infre- quently large casts are crushed by the pressure of the cover-glass. The cell also answers the. purpose of confining the fluid, any excess of which can he removed with blotting paper. Such an arrangement is not suitable when it is re- quired to add any reagents to the specimen. A preliminary examination with the lower power is occasionally desirable, but it is with the higher power that a knowledge of the nature of any deposit that may be present is obtained. The following objects may occur, the clinical significance of which is treated of elsewhere : — 1. Adventitious matter, dust, — Even with the greatest care in collecting and preparation, foreign bodies are extremely apt to be met with, the commonest of which are hairs, wool, cotton and flax fibres, minute particles of wood, starch-granules, sand, and oil-globules. Besides these, a number of extraneous substances may occur, such as sputum and faeces, the source of which is obvious, whilst occasionally substances are purposely added to deceive the observer. It is absolutely essential that an acquaintance with the microscopic appearance of all such objects be possessed by the medical man. 2. Mums . — This material presents itself as finely granular streaks and smears of every variety 7 of size and shape, often mistaken for casts, and occasionally simulated by scratches on the slide or cover-glass. 3. Epithelial cells . — These may be derived from all parts of the urinary tract ; and they include glandular spheroidal or polyhedral Celia 980 MICROSCOPE from the kidney, especially the convoluted tu- bules ; columnar cells from the ureter and the greater portion of the urethra ; and flattened tesselated scales from the pelvis of the kidneys, and the orifice of the urethra. Very large cells of the same variety come from the vagina. The vesical epithelium is very variable in appear- ance, but is generally either flattened or pyri- form, of large size, and not always to be distin- guished from the scales from other parts. 4. Spermatozoa. — Spermatozoa occasionally occur in the urine, without being of serious importance. Their characteristic appearance is not easily recognised under a magnifying power of less than 300 diameters. 5. Blood.— Blood-corpuscles in the urine differ considerably from their normal biconcave disc shape, and usually shrink into irregularly-shaped particles, but they may swell up and become globular in appearance, these changes being due to alterations in the density of the fluid. Under such circumstances the corpuscles are not very easy of detection, and if but very few in number, may not always bo recognised with certainty, especially as there are many other objects, such as spores of fungi, which closely resemble them. If the blood be present in moderate quantity, it gives a characteristic colour to the urine, which suggests the presence of corpuscles. The discs more rapidly disappear in alkaline than acid urine, remaining in the latter for a considerable time. 6. Leucocytes. — Bodies identical with white blood-corpuscles are sometimes seen entangled in the shreds of mucus (mucous corpuscles), or may be derived from the epithelial surface ; and, if present in large amount, constitute pus- corpuscles, originating from pyelitis, cystitis, urethritis, leucorrboea, rupture of an abscess into the urinary tract, and other conditions. 7. Portions of new growths. — Cells, fibres, and other elements, from cancerous and other neo- plasms of the urinary organs or adjacent struc- tures, such as the uterus and the rectum, may be detected in the urine; but it is very seldom that the diagnosis of the existence of these new growths rests upon their recognition under such circumstances. . 8. Penal tube-casts. — The appearances, nature, and origin of these bodies have been fully treated of in the article Casts. 9. Living organisms. — The urine after standing, at the onset of the alkaline fermentation, con- tains bacteria and vibriones, with their charac- teristic vibrating movements ; sometimes, also, various forms of torula and even sarcinre, the former often in association with diabetes in acid urine ( Torula ccrevisies ; Penicillium glaucum). Certain entozoa are found in the urine, the most important of which is the Bilharzia hcemotobia, a trematode worm, which causes a peculiar form of endemic haematuria. The ova are about .tMM inch in length, of oval form, and terminating in a spine: empty egg-shells and flask-shaped cili- ated embryos are present in large quantities in the urine of patients suffering from this affec- tion, together with blood and pus. Booklets and fragments of echinococci from rupture of hydatid cysts into the urinary passages may sometimes be detected in the urine. IN MEDICINE. 10. Fat. — In the condition known aschyluria, large quantities of fat in a state of fine mole- cules and minute globules, with a few leucocytes and red blood-corpuscles, are seen by the aid of the microscope. 11. Salts — (a) Amorphous. — During the so- called ‘ acid fermentation,’ which takes place within a few hours after the passage of normal urine, urates of soda, potash , and ammonia, and occasionally of lime and magnesia, are thrown down as a granular amorphous deposit of a brick- dust appearance ; and later, during the ‘ alkaline fermentation,’ phosphate of lime is precipitated in a similar condition, but of a white colour. Microscopic examination is useless to distinguish such substances, which require treatment with heat or reagents for their detection. (#) Crystalline . — Uric acid, which in excess forms the cayenne-pepper-like grains, or gravel, is multiform in its microscopic appearances, presenting as it does typically six-sided plates, and four-sided rhombs, but often ovoid, barrel- or comb-sbaped. Owing, to the affinity of the urinary pigments for uric acid and its salts, such crystals are usually slightly tinted— straw colour to pale brown ; and they are verv fre- quently aggregated into masses, and of the greatest diversity in size. Oxalate of lime, found in both acid and alka- line urine, especially after tho ingestion of rhubarb, tomatoes, and certain other articles of food, occurs as octahedra, or more rarely as very perfect dumb-bells, the former being com- posed of two four-sided pyramids placed base to base, appearing when seen in the short dia- meter as a square marked by two bright cross lines. Triple or ammonio-magnesian phosphites ar- deposited in alkaline urine as triangular prism: with bevelled ends, and differing in length; whei very short simulating the oxalate of lime octa hedra. Stellate crystals of the same substanc- have been seen. Phosphate of lime, though usually amorphous occurs sometimes as crystals arranged iu ver characteristic rosettes. Carbonate of lime, of very rare occurrenei appears as small spheres. Lcucin occurs as yellowish, highly refractia spheres, almost like oil-globules, and as needh like scales. Tyrosin assumes the form of tuf of very fine neodles. Cystin appears as reguh hexagonal tablets of various size, frequently la one on the other. Ha-matin, derived from tl blood-pigment-, has been found in minute acic lar crystals in the urine of cases of hsmai nuria. For the simple detection of most of the abov mentioned objects no reagents are necessary, t urine itself being sufficient ; but the more trai parent bodies, such as casts and epithelial cel are often rendered easier of detection by sligh tinting the field with a drop of magenta soluti- or tincture of iodine. The crystalline depos- may be preserved by mounting in Canada b- Si'.m, subsequent to washing in spirit and t- pentine ; but attempts to keep for any tu casts, or epithelium, are usually very unsatisf- tory, though occasionally successful in very w glycerine solution. M10K0SC0FE IN MEDICINE. (B) Faeces. — It is not often that the matters passed by the bowel are submitted to micro- scopic examination — not so often perhaps as they should be. The greater part of the motions ap- jpears to consist microscopically of amorphous granular flakes of no special character ; these are lor the most part the degenerated dead epithelial cells shed from the mucous membrane. Amongst the distinctly recognisable normal pbjects are starch-granules, oil-globules, shreds hid fibres cf vegetable tissue, and also of yellow dastie tissue, and not infrequently leucin, tyrosin, ind eholesterine crystals. Various fungi, blood- ,ind pus-corpuscles, crystals of triple phosphates, nd ova of entozoa, are among the most impor- tant abnormal objects that may be met with. To investigate these it is merely sufficient to fatten out, by means of slight pressure on the 'over-glass, a small portion of the motion, in a rop of dilute glycerine. Both powers should |e employed, since many of the fragments are asily recognised when magnified sixty or eighty .iameters. (C) Vomit. — This should be examined as soon 'is possible after expulsion, and the liability to the ■resenceof all kinds of extraneous matter should je borno in mind. Small portions may be spread iit in dilute glycerine; or it may be necessary i shake up the matter with distilled water, and Ike up a few drops of the mixture with a pipette. It is impossible to give any accurate descrip- pn of theappearaneesofthe various kinds of par- filly digested food; hut besides the characteristic arch-granules and the gastric epithelial cells, ere are certain bodies which it is often of im- rtance to be able to recognise, such as torulse d sarcinse, blood-corpuscles, and cancer-cells. (D) Sputum. — In the examination of the ex- ctoration the microscope is often of great I ue, as thereby the exact nature of the con- ion of the lungs may be declared. Small reds of the sputum should he separated and read out on the slide, and covered at once ; netimes a drop of dilute glycerine is required. . is obvious that the expectoration is liable contain all kinds of objects that have not ne from the lungs — fragments of food, epi- :lial scales from the tongue and mouth, hairs, ■ . — but, excluding all such bodies, the sputum lisists of a menstruum of viscid mucus, which . hardly recognisable under the microscope, ■ '■ept as a very finely granular film, entangled if which are innumerable air-bubbles of all t is, with a few leucocytes (mucous corpuscles), : i occasionally a few ciliated epithelium-cells 1 n the air-passages. If a drop of acetic a 1 be floated in beneath the cover-glass, the mus assumes a finely striated appearance, it the nuclei of the colls are rendered very dlinct. With all degrees of catarrh and in- timation of the mucous tract the number of h ocytes becomes more and more abundant, "|i occasional red blood-corpuscles and oil- gjiules, the latter often aggregated into sphe- re al masses. Black particles, due to inhaled ev, or coal or metallic dust, or else derived h i the pigment of the lung-tissue, are present st' trying amounts. When the lung is actually t» king down, fragments of pulmonic tissue uj be readily recognised under the microscope 981 by the characteristic elastic fibres, which are rendered especially distinct by the addition of acetic acid, or by previously boiling the sputum with solution of caustic soda (20 grains to the ounce), which clears up other matter, leaving the elastic tissue untouched. Vegetable fibres derived from the food, and which also resist tho action of the alkali, must not be mistaken for the lung-tissue. Among other objects which an examination of the sputum may reveal are crystals of eholes- terine from caseous matter, blood-crystals, por- tions of new growths, as cancer-cells, bacilli, and hooklets of echinococcus. (E) Blood. — By an examination of a drop of blood under the high power, the relative and actual numbers of the red and white corpuscles, their character, and the presence of abnormal objects, may he ascertained. The method of estimating the number of corpuscles is fully detailed under the heading Hemacytometer. The recognition of leucoeythtemia to a great extent depends upon the microscope, by which the excess of white corpuscles is at once mani fested. The red corpuscles are apt to undergo altera- tion in shape, such as shrinking, or crenation, but it is not always easy to determine how far such may be the result of the preparation of the specimen. Living organisms are occasionally found in the blood— bacillus, spirilla, &c. — associated with certain septic states, such as malignant pustule and relapsing fever. For their detection a higher power is needed, and no satisfactory investi- gation of such bodies can he made without a power of 700 diameters. A small nematoid worm, the Filaria sanguinis-hominis, about yh inch long and ^Jjg-inch broad, has also been found in the blood. See Filaria Sanguinis- Hominis. To examine the blood it is sufficient to prick the finger, apply with the small forceps a clean, dry cover-glass to the wound, and gently place it on the slide, interposing a hair at the edge to prevent the corpuscles from being crushed. It is necessary to have enough blood to form a com- plete film, as otherwise it dries very quickly and alters in appearance, whilst if there be sufficient, the edge alone will dry, and prevent the central part from evaporating. (F) Milk. — A drop of milk placed on a slide and covered with a thin glass, discloses on exa- mination fatty granules and globules of all sizes, with sharply-defined outlines, and kept separate from one another by being surrounded by invisi- ble films of transparent casein. In the milk secreted immediately after delivery will he seen colostrum corpuscles. (G) Morbid Discharges. — The microscope is frequently of value in examining discharges from surfaces — for instance, in leucorrhcea; or from abscesses which may have hurst. In the latter cases, besides the pus-cells, fragments of tissue may be seen, indicating the situation of the abscess ; or the existence of a new growth may be manifested by the escape of small por- tions in the discharge. (H) Contents of Cysts. — These are for the most part fluid or gelatinous, and leave -cry 082 MICROSCOPE IN MEDICINE. little for microscopic examination. Exception must bo made to the echinococcus hooklets of hydatid cysts, the fatty matter of sebaceous cysts, and cholesterine crystals, so commonly met with in ovarian, and indeed in all forms of cysts. (I) Hew Growths. — The microscopical cha- racters of tumours are fully described under the heads of Cancer and Tumours. (K) Adulterations of Food, Drugs, &e. — By means of the microscope many impurities and adulterations may be discovered, which would otherwise remain unrecognised. The fol- lowing substances which are extensively used — namely, starch of various kinds, improperly added to cocoa and mustard ; leaves of willow or plum, substituted for tea; chicory, a root of a species of dandelion, mixed with coffee ; sand with sugar ; red lead with cayenne pepper; and many pigments — indigo, Venetian red, umber, turmeric ; as well as different salts, sulphate and carbonate of lime— are at once detected under the microscope, and many of them in this way only. (L) Medico-Legal Inquiries. — Stains of blood, semen, &c., on clothing. The spots should be moistened with a few drops of distilled water, or, better still, a per cent, solution of chloride of sodium, and scraped with a sharp knife ; and the fluid then transferred to a glass slide, and examined in the usual manner. The micro- scopical characters of spermatozoa and blood have been already referred to. (Consult The Microscope, by Dr. Carpenter ; How to work with the Microscope, and The Micro- scope in Clinical Medicine, by Dr. Beale ; Prac- tical Histology, by Professor Rutherford ; and A Course of Practical Histology, by Professor Schitfer.) DESCRIPTION OF FIGURES. Fig. 28.— Bed blood-corpuscles— human : x 350. a. Normal, singly and in rouleaux, b. Shrunk from treatment with concentrated fluid, c. Distended and globular from absorption of water. It is in this condition that the red corpuscles are most apt to appear when mixed with various fluids of the body. Fig. 29.— Scaly epithelial cells from mouth, vagina, &c. x 200. Fig. 30. — Leucocytes. Pus, mucous or white blood-cor- puscles. x 350. a. Normal, b. After treatment with acetic acid; nuclei very apparent, c. Distended and rendered transparent by water. Fig. 31.— Ciliated epithelial cells from air-passages, x 200. Fig. 32. — Cotton fibres, showing characteristic twist, x 100. Fig. 33.— Milk showing colostrum corpuscles and oil-glo- bules, the latter very variable in size, and with a sharply defined outline, x 200. Fig. 34. — Particles of vomited matter, x 250. a. Starch granules, showing characteristic concentric lines, b. Fragments of partially digested muscular fibre. Fig. 35.— Epithelium from urinary tracts, x 200. a. From renal tubules ; glandular, b. From ureter and urethra ; columnar, c. "Vesical. Fig. 36.— Spermatozoa ; human, x 350. Fig. 37.— Fragments of hair, x 100. a. Cortex, b. Epidermis, c. Medulla. Fig. 38.— Sarcina ventriculi. x 250. Fig. 39. — Hooklets of Echinococcus, x 250. Fig. 40.— From phthisical sputum, showing elastic fibres of lung-tissue and leucooytes. x 350. Fig 41.— Hsemin crystals from old blood-clot, x 250. Pig, 42.— Cubes of chloride of sodium, x 200. Fig. 43.— Leucin. x 120. Fig. 44.— Tyrosiu. x 120. MICTURITION, DISORDERS OF. Fig. 45. — Erie acid, various forms, x 120. Fig. 46.— Cholesterin plates, x 120. Fig. 47 — Cystin. x 120. Fig. 48.— Oxalate of lime ; dumb-bells and oetahedii x 120. Fig. 49. — Triple or ammoniaco-magnesian pliosnlate. x 120. Fig. 50.— Torula cerevisim ; yeast fungns. x 350. Fig. 51. — Sputum of early pneumonia, showing red blood- corpuscles and leucocytes, x 300. Fig. 52.— Shreds of elastic tissue in sputum of phthhis x 300. Fig. 53. — Oidium albicaus ; thrush, x 300. Fig. 54. — Penicilliiun glaucum. x 300. W. H. Allchw. i MICRO SPORON ( ixiKpos , small, and avlpos, a spore). — The fungus-plant of phytosis or tinea versicolor ; also named epidermophyton. Set Epiphytic Skin-diseases; and Skin, Diseases of. : MICTURITION", Disorders of. — Under this term will be considered those conditions which interfere "with the normal performance of micturition, regarded as a physical act. Thus suppression of urine is not included in this cate- gory, for in the state so described, the urine is not secreted by the kidney, and the absence of: the secretion is not due to any physical cause in the bladder or urethra. The following will he treated of as disorders of micturition: — 1. Irritability of the bladder in the adult. 2. Diminished size of stream. 3. Retention of urine, partial and complete. 4. Urine passing by an abnormal channel. 5. Incontinence and overflow of urine in the adult. 6. Incontinence of urine in the child. 1 . Irritability of the bladder. — This term if never to be employed as defining any morbic condition of the bladder, since it is too vague t denote anything else than a symptom, of whicll the practitioner has to discover the cause. It il commonly used iu widely differing senses, and con veys therefore no definite meaning to the hearei As denoting a symptom, it may be held to impij the simple fact of unduly frequent micturition, am should never be used, either in writing or other wise, in any other sense. Whenever, therefore, tin phenomenon is present, instead of regarding : as due to ‘ irritability of the bladder ’ as so fre quently happens, the problem to be solved i what is the cause of that irritability ? In a! maladies of the bladder, and in most that affec the kidney also, unnaturally frequent micturitio is present. It may vary in degree, and exi: alone as a single symptom ; or it may, as is mne more usually the case, be accompanied by otke symptoms, which aid the diagnosis. Thus it present in all the inflammatory conditions of tl bladder, and whenever foreign bodies ortumou. exist there. Also when the bladder is full, a: either habitually does not empty itself, or wh< absolute retention is present, in either ease tl wants to pass water are frequent and press in It is often present in stricture of the urethr and in inflammations of that passage ; also j chronic pyelitis, simple or calculous, in chrou nephritis, ,n Bright's disease, and in diabet^ as a result of the increased quantity of urn It is present likewise during hysterical stau and under emotional excitements iu many p>" sons of either sex ; and whenever the watery t! ( face page 982 . MICROSCOPE IN' MEDICINE. Drawings Illustrating Common Objects seen with the Microscope in Medicme. MICTURITION, meats of the urine are rapidly and abundantly eecreted. 2. Diminished size of stream. — This may occur either with or without organic obstruction in the passage. It is always present, of course, in con- genital narrowing of the prepuce or of the exter- nal meatus ; in organic stricture of the urethra ; and mostly in enlarged prostate. It may be occasioned by inflammation of the urethra and prostate; and by impaired power in the bladder to expel its contents, from partial paralysis, atony, or other cause. Occasionally the channel 1 is narrowed by irregular actions of the sur- rounding muscles, and thus ‘ spasmodic stricture’ (not a good term) is spoken of as producing a diminution of the stream. 3. Retention of urine. — Retention of urine, partial or complete, is not to be confounded with ‘suppression,’ the latter being of course defective action of the socreting organ, so that no urine is produced, and the bladder remains .empty. Retention is the product in almost all cases of mechanical obstruction, such as enlarged prostate from hypertrophy, tumour, or inflam- mation, or stricture of the urethra. Impacted calculus is sometimes the cause ; sometimes also, but most rarely, the spasmodic action referred to above. Treatment. — As the cause is a purely me- chanical one in the great majority of instances, the remedy which should be applied is also a nechanical one, namely, a catheter of appro- priate size and kind. The instrument, however, s not always at hand, and medicinal agents .ire valuable until it can be obtained. At the lead of these no doubt is opium, which allays nvoluntary straining, and sometimes thus en- ibles the patient to relievo himself by the latural method, at all events to some extent. It hould be given in full doses, for the purpose ither of relieving the patient’s suffering and .nxiety, or of acting favourably on the func- ion; and the error in practice which has been nost common is to give doses of 10 to 15 linims of laudanum orliquor opii, when 30 to 40 r more were necessary, and would have been ighly useful. Of course the form of opiate may e varied, according to the habits of the patient, r the views of the attendant. Simple opium is lerely mentioned here as the type. Local bath- rig, as hot as it can bo borne, is also a valuable djunct. Diuretics, often given, are for the most art injurious ; that is to say, when the cause is mechanical one ; the same must bo said, in ich circumstances, of the tincture of the per- iloriile of iron, once in some repute in retention ’ urine. As a general principle also, it is not to i forgotten that purgation commonly promotes is expulsive action of the bladder, often ma- rially so, and tends to afford relief. 4. Urine passing by abnormal passages. — The ■ine may escape by abnormal channels, such fistul®. This condition is necessarily named one of the ‘ disorders of micturition,’ but its '.ture and treatment bring it solely under the .nds of the surgeon. 5. Incontinence and overflow of urine in the 'ult. — The conditions so denoted are among ose disorders of micturition which it is most iportant to understand. Nothing is commoner DISORDERS OF. 983 than to find a man, probably in advanced yearr, passing urine with increased frequency, even sometimes passing it without his will or know- ledge, during sleep ; and it is unfortunately not uncommon also, that he is told that this is a com- mon weakness among elderly men, inseparable from the fact of age, and either not amenable to treatment, or not worthy of serious notice. Many a life has been endangered most certainly, and some even lost by such counsel. This condition is often loosely spoken of as ‘ incontinence ’ of urine ; of which, however, it is not only not an example, but on the contrary indicates a condition of a precisely opposite character. The confounding of these opposite states is a matter of extreme im- portance. AVhat does produce frequent micturi- tion and so-called incontinence, is a bladder un- able to empty itself, consequently always partially if not completely filled, from which the surplus must be either frequently discharged, or runs off ‘ incontinently.’ The important point, then, is never to lose sight of the fact that frequent micturition, and above all urine involuntarily passed by elderly men, in nineteen cases out of twenty indicates retention (requiring the cathe- ter), and not incontinence. True incontinence, which means inability to retain, on the part of the bladder, is a very rare occurrence, and is present almost invariably only in cases of disease in the nervotfe centres pro- ducing paralysis in other parts of the body, as well as the bladder. AVhen the bladder-symptoms alone are present, and no signs of paralysis else- where exist, it maybe held as almost absolutely certain that the bladder itself is not paralysed. It may be over-distended with fluid from en- larged prostate ; or its coats may be thinned and atonied, and so unable to contract on their con- tents ; but there is no true paralysis of the bladder (commonly as that term is often em- ployed) without central lesions of the kind above referred to, and affecting other functions also besides that of micturition. Treatment.— In these partial retentions of urine, producing its overflow and involuntary discharge, the remedy is the catheter, and the case is mainly surgical. There are some in- stances in which restoration of the power of tho bladder may be attempted by medicinal agents, such as strychnia, iron, and electricity, but their effect is little or none, apart from the habitual emptying of the organ by artificial means. In some cases perhaps they may be advantageously associated with the surgical treatment. 6. Juvenile incontinence . — A brief sketch of this common and well-known affection is all that our limits will admit. Nevertheless it is one relative to which much might be written, without exhausting a subject the pathology of which has wide and manifold relations. In the earliest periods of childhood an undue frequency of passing water is often to be observed among individuals of both sexes, more com- monly in boys than in girls. As age advances the infirmity usually lessens, and then disappears; whilst in exceptional instances it continues, with- out change, to puberty, and even for some years after that period has arrived. But the pecu- liarity of the case is that the urine is passed unconsciously during sleep, and this forms thi 9S1 MICTURITION. DISORDERS Or. most serious symptom. In spite of all precau- tions a quantity of urine is discharged every night during deep sleep, an occurrence of which the child is quite unaware, and which as he advances in age he is wholly unable to control, however strong may be his disposition to do so. On the bladder becoming distended reflex action of the vesical muscular coats takes place, and the contents are discharged. The flow of urine is de- termined, as it would appear, not by inability on the part of the bladder to retain a small quantity of urine, but by its undue excitability or readi- ness to contract, so that the act of micturition can be exerted while the will is in abeyance through sleep. There appears to be something analogous between this condition and that which determines in after-life seminal emissions under similar circumstances. In a few instances, cer- tain aberrations from a good standard of health seem to favour the production of these phenomena, especially sources of irritation in the rectum, which produce activity in that muscular apparatus, involving also the kindred muscles of the bladder, which are so closely associated. Thus the presence of ascaridos or other foreign agents may suffice to occasion expulsive action in the bladder. During the period of infancy and early childhood the nervous system is highly impressionable, and the habit in question being accidentally set up, its persistence may result solely from repetition through the force of cus- tom. long after ths original cause has disap- peared. Sometimes slight malformations of the male organ favour the occurrence of incontinence ; such as a narrow meatus, or a long prepuce which is never retracted, and is consequently in an unhealthy state. Precocious development, and extreme activity of the mental faculties, producing disturbed sleep, seem to favour the occurrence of incontinence. On the other hand, it is sometimes associated with a morbid deficiency of intelligence. Treatment .— 1 The treatment ordinarily neces- sary may be to some extent inferred, when ex- amination of the patient has determined the oresence or absence of the conditions named. This done, the next indication is to subdue the ictivity of the expulsive function of the bladder by some agent which possesses that power. The most powerful for this purpose is undoubtedly belladonna; one of the most notable qualities of this drug is its temporary influence to pro- duce a paralysed condition of the vesical mus- cles. Thus, if administered to an adult whose powers of expelling urine are feeble, such, for example, as are commonly met with in ad- vancing years, complete retention of urine is often produced. Of this the writer has seen many marked illustrations. Now, as has already' been observed, in not a few of the cases of so- ralled ‘juvenile incontinence,’ its existence is due solely to persisting habit after the original occasion of it has long ceased ; and these are certainly and rapidly cured by administering the agent in question. We have only to induce a partial paralysis of the bladder for a week or two, or for a few weeks at most, and by this means not only to destroy the old habit, but to develop a new one, namely, a habit of retention, and the annoyance disappears entirely and for ever. On meeting, therefore, with a case, whether in childhood or youth, the first indication is to correct any 7 manifest deviation from the ordi- nary standard of general health; and secondly, to administer belladonna persistently. Small doses, suited to the age of the patient, suffice at first, and may be given every afternoon and evening only — say from eight to fifteen minims of the tincture on each occasion during the first week. In the second week of treatment, the dose may be augmented one half; and in the third week the original dose is doubled ; meantime some improvement will almost certainly now he manifest. Since the ability to bear belladonna in- creases rapidly as the system becomes habituated to it, a large dose may be given during another term of three successive weeks, by which time the involuntary discharge of urine probably ceases. After this the dose may be gradually diminished, and at a rate more rapid than it was augmented: the habit of retention has probably been formed by this time, and when cessation from medicine takes place, no recurrence of the symptoms will be observed. Such is the writer's experience in a considerable proportion of the cases which have fallen in his way. But it must be confessed that a troublesome minority is met with in which the belladonna has had little or no useful in- fluence. It generally exerts some, however, and it is worth while to be careful that the drug has been well prepared. Thus the writer has been successful with the belladonna of one chemist after failure with that of another. Now, in regard of these obstinate and exceptional cases, what remains to be done ? It may be assumed that an exhaustive observation has been made of all the functions, especially of those which perform digestion, and that it is unnecessary to insist further on this score, or to suggest the numerous details which such consideration gives rise to. All this done, there still remain modes of treat- ment of a local character, which ultimately almost always prove successful in these cases. These do not include blisters on ihe sacrum: apparatus to prevent the patient lying on his back, when asleep ; arrangements to arouse him during the night once or twice to pass watei voluntarily, and such measures — all of which are palliative means, and do little towards a radical cure, and which constituted the chief agencies employed some years age. Superior to all these in the writer's hands ha: been the application of a solution of nitrate o silver to the urethra, whether in the male o: female. Even the use of a flexible bougie, smal of course for children, passed daily, and removei in the course of a minute or so, is sometime' successful. But if this fails, the injection bj means of a sufficiently long tube of the solutio named to the prostatic portion of the urethra am neck of the bladder, is a remedy of no mean value Eqr young women up to the age of eighteen o twenty in whom this unfortunate infirmity stii exists, the writer has found it almost, if nc invariably, successful. It should be apphe immediately after the bladder is emptied. ■ quantity, say, of a drachm, and of a minimui strength of ten grains to the ounce, up to trebi that strength if necessary for subsequent appl MICTURITION, DISORDERS OR. cations. Enough should be employed to produce decided smarting, which shall continue for a day or two. A week or two should be permitted to elapse between each application. It would not be right to omit the mention of other remedies besides belladonna, which may be used either alone or in combination with it. Such are the tincture of the perchloride of iron ; strychnia ; tincture of cantharides ; and bromide of potassium. The latter, given at night only, has sometimes a manifestly beneficial effect. Henry Thompson. MIGRAINE. — A synonym for megrim. See Megrim. MIGRATION OF CORPUSCLES.— The iseape of blood-corpuscles through the walls of ninute vessels, and their passage into the sur- rounding tissues. The process is chiefly seen in nflammation. See Inflammation. MILIARIA ( milium , a grain). — Synon. : iudatoria ( sudamina ) ; Fr. Miliaire ; Ger. 't'riesel. Definition. — A vesicular eruption of the kin, generally associated with profuse sweating, nd sometimes with pyrexia. Description. — The proximate cause of milia- ia is reduction of the vitality of the skin, under he influence of extreme heat and sweating, 'he vesicles have the bulk of millet-seeds ; are eveloped close to the pores of the skin ; are enerally discrete ; and are dispersed irregularly ver the surface. They are thin, and contain at rst a pellucid serum, which by magnifying the ypewemic base on which they are developed, lives them a red appearance — miliaria rubra ; in more advanced stage the serum becomes milky id opaque, and then the eruption is called Maria alba. When left, to themselves the isicles subside and dry up into an extremely jlin scale. Treatment. — The treatment of miliaria con- its in subduing whatever feverish symptoms ay be present; in lightening the clothing and - verings ; in the use of tepid baths and tepid onging; and after the bath, dusting the skin th some absorbent powder, such as fuller's jrth. Sponging with lime-water is also use- 1 ; and the use of a lotion in which oxide of ic is suspended in lime-water, in the propor- ® of two scruples to an ounce. This should painted on the affected parts of the skin, and owed to dessicate thereon. Erasmus Wilson. MILIARY ANEURISMS.— Minute dila- tions in connection with the small blood-ves- ts; especially met with in the brain. See ■ ain, Vessels of, Diseases of. MILIARY NEVER.- — A febrile condition i ended with the eruption of miliaria. See 1 MARIA. MILIARY TUBERCLES.— True tuber- jk which appear in the form of minute granu- i ons. See Tubercle. ULIUM (Latin). — A term suggestive of - d size and roundness, resembling a millet- 8 l ; a synonym of grutum. See Grutum. MINERAL WATERS. 9S5 MILK FEVER. — Synon.: Ephemeral Fever; Fr. Fievre laiteuse-, Ger. Milchfieber. Definition. — A certain amount of constitu- tional disturbance, accompanying the flow of milk to the breasts, on the second or third day following delivery. ■/Etiology. — This condition appears to affect chiefly those who are in a feeble state, from want of nourisnment, loss of blood, or other cause ; or to occur when the child has not been put to the breasts sufficiently early to free the milk-tubes. Symptoms. — The symptoms of milk-fever are sometimes slight, and pass off very quickly, in which case the term ‘ ephemeral’ is appropriate ; but not infrequently the fever runs high, the temperature reaching beyond 102° Fahr., and the pulse beating 140 in the minute, from which state recovery is less rapid. The patient is generally seized suddenly with severe rigors ; her teeth chatter, there is a sensation of cold water running down her spine, and she calls for blankets and hot-water bottles. At this time the breasts are swollen and sensitive. This chill soon gives way to a hot stage, which may last from two to twelve hours ; the head aches fear- fully ; there is pain in the limbs, restlessness, a dry tongue, thirst, and sometimes delirium. The breasts now become hard and knotty, and very painful when touched. Then follows the sweat- ing stage, from which great relief is experienced ; as a rule the breasts become softer, and milk commences to flow from the nipples ; the tem- perature falls; and all the symptoms abate. Sometimes, however, the breasts remain hard, and an abscess forms in one of them, in which case the temperature still remains high, though the other feverish symptoms subside. Treatment. — During the cold stage the desire of the patient for hot-water bottles and blan- kets should be gratified ; and care should be taken not to diminish the amount of clothing too rapidly during the hot stage. The bowels should be evacuated. A diaphoretic mixture should be administered ; and the child should be put to the breasts as soon as the sweating stage sets in. Clement Godson. MILFHOSIS (fii\ T er used, and only for a very few minutes. The 'Tacts vary also considerably, according to the uration of the immersion. Uses. — The drinking courses of these waters l‘.ay assist iu the treatment of irritable forms of factions of the throat, stomach, and intestines, ith spasmodic cough, cardialgia, constipation ;om sluggish secretion of bile and intestinal dees ; and by increasing the tissue-change, they •e useful in chronic rheumatism and gout. One of the main uses of the simple thermal iths is to allay over-excitability and hyper- nsibility of the nervous system in its various iheres; thus they often act beneficially in ses of neuralgia, hypercesthesia, painful men- ruation, and hysterical tendency. Their re- lation in painful wounds and cicatrices is statical. In these cases, as well as in chronic eumatism in its various forms, and sciatica, 'e hotter are more useful than the tepid baths. ! some forms of paralysis and loss of muscular tver depending on peripheral changes, such as udations on nerve-sheaths, good effects are oduced ; but if they are caused by changes the centres of the nervous system, not much to be expected. In gout the internal use of aer mineral waters is generally required, but second courses the simple thermal waters are en useful ; and in many delicate gouty per- is the balneotherapeutic treatment ought to restricted to courses of tepid baths, aided by mata and diet. Most of these conditions can also treated with other waters. 987 Enumeration', and Selection. — The choice of a simple thermal spa is to be guided, not by the name of the disease alone, but also by the state of constitution, and many concomitant cir- cumstances. The simple thermal waters deserve, catcris paribus, the preference, when gentle management is required — when it is desirable to make as slight demands as possible on the powers of the constitution. Their action is in this respect greatly assisted by the mountainous climate enjoyed by the majority of these baths. The selection of a special spa in a given case depends on the nature of the case in the widest sense ; on the degree of elevation which is desi- rable ; on the means of treatment obtainable and customary at the different spas, including the most important agent — the spa physician ; on the accommodation, the food, manner of living, and social conditions ; on the distance and means of reaching the spa; and on many other circum- stances. Information on these subjects can only be obtained by the study of larger works ( see the English edition of Braun's Work on Baths, pp. 123 to 192), and by personal visits. We can give here only the names of the principal spas of thi s class arranged according to their elevation Elevation Tempera- Name. Country. (approxi- mative). Feet. lure of springs Fahren heit. Panticosa Lenkerbad ) (Loeche j- Spain (Pyrenees) 5000 77°-02° Switzerland 4600 102°-122° les Bains) ) Bormio Italy 4300 90°-104° Gastein Austrian Alp3 3300 95°-114-8 c Pfaffcrs Switzerland 2115 100 4° Jokannisbad Bohemia 2000 86° Bagneres de ) Bigorre J France (PjTenees) 1850 90°-95° Ragatz Switzerland 1570 96° Badenweiler Baden 1425 8G°-90 5° Landeck Silesia (Prussia) 1400 Getes; uric acid diathesis, and its results — rravel and litbiasis ; some forms of gout ; and specially chronic catarrhal affections of the mil- ieus membranes of the respiratory, digestive, ,nd genital organs. Enumeration, and Selection. — Where it ; s i.ecessary to improve the stato of the blood, or to void emaciation, the muriated alkaline are pre- erahle to the simple alkaline waters. 1. The principal spas with simple olkaline haters are:— a. Hot: — Vichy, Neuenahr, Mont lore, Chaudes Aigues, and Neris, the three last eing feebly minoralised ; b. Cold: — Apollinaris, fals, Salzbrunn. le Boulou, Evian, Bilin, Facliin- len, Geilnau, Wilhelmsquelle, Taunus, Giess- iibel, Soulzmatt, and Marcolo. 2. The chief muriated alkaline waters are — i) Ems, Royat, and La Bourboule, which repre- tntthe^of springs; whilst ( b ) Luhatschowitz, alters, Gleiehenberg, Roisdorf, Kosbach, Vic- ar-Cere, and Toennistein are cold. We ought to remark that several of the waters i this class, especially la Bourboule and Mont ore, contain arsenic in appreciable quantities. IV. Sulphated waters. — Composition. — We elude under this term those springs which are laracterised by a preponderating amount of the dphates of soda or magnesia, or both sulphates gether. They may be subdivided into (1) tuple sulphated waters or bitter waters ; and (2) kaline sulphated waters , which latter contain so carbonate of soda and chloride of sodium. Action. — The bitter salts can scarcely be said , be constituents of the organism ; they seem act by stimulating, and in larger doses irrita- ig the mucous membrane of the stomach and .mentary canal, causing thin watery secretion, d in large doses diarrhoea. Sulphate of soda is is irritating than sulphate of magnesia. The ristaltic action of the bowels is likewise in- cased by them. Their continued employment apt to cause emaciation. By the presence of rbonate of soda and chloride of sodium, the bion of tho bitter salts is modified. Uses. — The bitter waters are useful in habits | constipation with sluggish portal circulation, hsmorrlioidal tendencies, in congestion and .argement of the liver and spleen, in some ,'ms of dyspepsia, in gallstones and allied af- tions, in gouty conditions, lithiasis, and din- es ; and, ceeteris paribus, have in stout and in i; called plethoric persons, the preference over ' ! muriated saline waters. 2numeeation, and Selection. — Where pro- ged courses are required the weaker sulphated ' ters, and especially the alkaline sulphated ’ cers, are to be preferred ; whilst the stronger Her waters, are more frequently selected for .asional purging doses. 1. The principal sim- i sulphated or bitter waters are: — Galthof, - llna, Saidschutz, Sedlitz, Birmensdorf, Ivanda, 1 nyadi Janos and other springs near Ofen, . 10 m, Aranjuez, Friedrichshall, and Mergen- I im, ths two latter being also rich in chlo- 1 58. Weaker springs of a similar nature are WATERS. 989 at Leamington and Cheltenham — both with a large amount of common salt, at Scarborough, and at the Purton Spa. 2. The principal alka- line sulphated waters are Carlsbad, Marienbad, Tarasp-Schuls, Franzensbad, Elster, and Ber- trich. The constitution and the action of the waters of Carlsbad and Bertrich are modified by their thermal nature. . V. Iron or chalybeate waters. — Composi- tion. — Iron is contained iu the majority of mineral waters ; hut we regard as iron waters only those where the quantity of iron is, in pro- portion to the other constituents, so far predo- minant as to give a therapeutic character to the springs. Action. — The formation of blood-globules, the contractility of the blood-vessels, the oxidation and the production of heat, and the general nutrition of tissues seem to be favoured by the use of iron waters. A small quantity only of iron seems to be absorbed by the stomach, none through the skin ; the action of chalybeate baths seemingly being due to the influence of the water and carbonic acid only. TIses. — The conditions most benefited by chalybeate waters are the various forms of anae- mia, or poverty of blood and particularly of red corpuscles, especially when caused by actual loss of blood, suppuration, or previous acute oi chronic disease. The liver and digestive organs, however, must be in healthy working order , whilst in cases of anaemia accompanied by con- gestion of the liver and spleen, chalybeates alone are rarely useful, but must be preceded or modi- fied in their action by the use of saline waters ; and this is often the case not only in anaemia ot Indian and malarious cachexia, hut also in chlo- rosis. Neuralgia, sterility and impoteney, and general debility are often benefited through im- provement of the general health. Those iron waters are most useful which contain the iron in the form of the bicarbonate of the protoxide, kept in solution by free carbonic acid. Enumeration, and Selection. — Iron springs are (1) comparatively pure, that is containing only a few grains of other substances in 16 ounces of water : — Schwalbach, Spa, Briickenau, Schandau, Liebwerda, Flinsberg, Freienwalde, Recoaro, Koenigswarth, Liebenstein, Altwasser, Alexisbad, Muskau, Tunbridge "Wells, and one spring at Harrogate : (2) compound iron springs, that is, which contain, in addition to iron and carbonic acid, a moderate quantity of other salts, especially the carbonates of soda, lime, and mag- nesia, the sulphates of soda, magnesia, and lime, and common salt : — Aratapak, Orezza, Pyrmont, Driburg, Rippoldsau, Griesbach, Antogast, Pe- tersthal, Booklet, St. Moritz, Reinerz, Godes- berg, Cndowa, Imnau, and Santa Catarina. VI. Sulphur waters. — Composition. — Amongst sulphur waters we class those springs which contain either sulphuret of hydrogen, or the sulphuret of sodium, calcium, potassium, or magnesium, in an appreciable and constant pro- portion. They are partly thermal, partly cold ; and some of them, especially Aix-la-Chapelle, Uriage, and Baden in Switzerland, contain a considerable proportion of common salt and other solids, which are to be taken into consideration in the appreciation of their effects. 990 MINERAL Action. — It is difficult to describe the physio- logical effects of the sulphur "waters, as far as they depend on such minute quantities of sul- phur as are contained in them. Sulphur "water baths seem to act in the same manner as simple baths. If the "waters are taken internally, some sulphuretted hydrogen is probably absorbed, entering the circulation through the portal vein. The pure sulphur waters exercise a constipating rather than an aperient effect. The faeces become mostly blackened from sulphuret of iron. The protracted use of these waters is apt to lead to a certain degree of anaemia, possibly from the action of the sulphur on the iron of the blood- globules. Uses. — Sulphur waters are mostly used in combined bathing and drinking courses, as also by inhalation, in cases of metallic poisoning ; in congestion of the liver ; piles ; bronchial, laryn- geal and pharyngeal catarrh ; in early chronic phthisis ; in numerous cutaneous affections, espe- cially the herpetic dyscrasia of the French ; in rheumatism and gout ; and in constitutional syphilis. Enumeration, and Selection. — The best known thermal sulphur waters are : — Eaux Bonnes, Eaux Ohaudes, Cauterets, Saint Sau- veup, Bareges, Bagneres de Luchon, Ax, Escal- des, Lo Vornet, Amelie-les-Bains, Ullage, Alle- vurd, Aix-les-Bains, Aix-la-Chapelle, Baden in Austria, Baden in Switzerland, Lavey, Schinz- nach, Battaglia and Abano in the Euganean Mountains; Panticosa ; Mehadia, and other springs in Hungary ; and Helouan or Helwan, near Cairo. Gold sulphur springs are : — Eilsen, Nenndorf, Langenbriicken, Weilbach, Meinberg, Reutlingen,Enghien,Challes, Stachelberg, Heus- tri cli, Gurnigel, some Harrogate springs, Llan- drindod and Builtli in Wales, Moffat andStrath- peffer in Scotland, and Lisdunvarna in Ireland. VII. Earthy and calcareous waters. — Com- position. — As earthy and calcareous waters we designate those springs in which the earthy substances, especially carbonate and sulphate of lime and carbonate of magnesia, form the pro- minent constituents. Action.- — In the shape of baths, the earthy waters act almost in the same way as ordinary water baths. Internally taken, the carbonate of lime exercises an antacid and a soothing effect on the mucous membrane of the stomach and intestines, and together with the sulphate of lime is slightly astringent and constipating. If lime is absorbed, it may possibly assist in the formation of cells and of bone, and may exercise also a soothing effect on other mucous mem- branes ; this point, however, can scarcely bo regarded as settled. Uses. — These waters, according to their com- position, are useful in digestive troubles with tendency to acidity, diarrhoea, and undue irrita- bility of the mucous membrane. They are em- ployed also in osteomalacia, rhachitis, and tuber- culosis ; and further, in some skin-diseases, especially in eczema and psoriasis, where, how- ever, the long continuation of the warm bath, that is the soaking of the skin, is of more impor- tance than the nature of the solid constituents contained in the water. Some of these waters possess a great reputation in chronic catarrh of , WATERS. the bladder, and in tendency to gravel and stone ; but probably the large quantity of water con- sumed, as for instance, at Contrexeville, and the consequent dilution of the urine and the washing out of renal tubules, are here to be regarded as the principal causes of the useful effect. The best known earthy or calcareous waters are Wildungen, Lippspringe, with the Inselbad, Weissenburg, Contrexeville, Bagnere-de-Bigorre, St. Arnaud, and Cransac ; and amongst the table waters : — Couzan, St. Galmier, and the Taunts water. Many of the waters mentioned in other classes might also be mentioned here, such as Bormio, Leuk, Bath, and Lucca, named under the simple thermal waters ; and Baden in Austria, Baden in Switzerland, Schinznach, Battaglia, Abano, and others enumerated under the sulphur waters. On prescribing mineral waters and baths. In every case we must first settle the ques-- tion whether the treatment hy mineral waters and baths offers advantages over ordinary treat- ment. If the question is answered in the affirm- ative, we have to consider not only the nature of the disease, but quite as much the nature of . the individual in whom it occurs ; the amount of vital forces in general ; the power of reaction;! the state of the different organs ; and whether they can assist in relieving the diseased parti of the organism, or whether they are unable to| respond to any unusual demand made on them.. Thus we shall be enabled to decide whether stronger therapeutic influences can be employed; whether longer and rougher journeys are permit- ted, and colder climates and seasons ; or whether delicate treatment is essential, comprising the; simple thermal baths, summer temperature, moun- tain climates of moderate elovation, and easyj journeys. The baths and waters are not to bq selected according to the chemical constitution of their springs alone, but the means and appli- ances in use, and the accustomed methods of treatment at certain places, the qualities of the local physician, the accommodation, the fool the cooking, and the social conditions, the faei lity of reaching a place, the climate and othet elements of ‘ change,’ are each and every on to be taken into consideration. It must he evi- dent already from these remarks, that the same morbid affection can occasionally be treated wit. advantage by different classes of mineral waters and at different spas, and that apparently widely different diseases may be benefited by the sami spa ; not only because many mineral waters an composed of different active elements, but alsc becausothe internal and external administratiot of the same water may be so much varied as ti produce a great variety of effects. In mam instances the disease itself cannot be directly attacked, but our efforts must be directed to: wards improving the general constitution, am through this influencing the diseased portion d the organism. We cannot do more here thau give some hint regarding the groups of diseased conditions i which mineral waters may be prescribed. 1. Anemia . — In cases of anaemia it is essenti; to consider whether the condition is caused, fir; I bv direct loss of blood and its component part; I secondly, indirectly by acuto or chronic diseas MINERAL (sleeplessness, neuralgia, and inability to take up food; thirdly, by congestion of the pelvic or- gans, with loss of blood and albuminous juices ; or, lastly, by lymphatic diseases, or visceral affections resulting from warm climates. The 'more the first cause preponderates, the more we may expect from the direct use of iron ; and v.'e have then to consider whether pharmaceutical preparations, or iron waters with or without chango of climate, with or without baths, are to bo preferred, or whether iron springs are to bo recommended. In the indirect forms of anaemia the mildest thermal treatment, with mountainous idimates of moderate elevation, or the latter [alone, are often the only beneficial courses in de- licate constitutions ; whilst in others somewhat less feeble according to individual conditions, common salt waters and baths with or without iron, or the gaseous tepid salt baths of Nauheim [and Rehme, or the much stronger influences of jea air and of sea baths, are useful. In the ;hird group the common salt waters with a certain jimount of iron, and occasionally the sulphated -aline waters, must generally precede every other lttempt at strengthening ; for the acceleration of [he portal circulation, the regular emptying of he different branches of the portal vein, and the Increased tissue-change are essential to the im- provement of the nutrition and sanguification ; ;.nd only after such a preliminary course the purer iron waters and the higher alpine air are ikely to become useful. 2. Sluggish portal circulation. — A sluggish tradition of the portal system forms a frequent implication, not only of anaemia, but of a great fany ailments of the different systems of the Body ; and is often only a part of a general want ,f tone in the organic muscular fibre, especially if the right ventricle and of the whole venous ’stem. It is difficult to find a name for these, by p means, rare constitutional defects, which form to main characteristics of what the old German lysicians called ‘abdominal plethora.’ If we [lly know what we mean by the terms, we may 11 these conditions portal venosity and general nosity according to the extent of the defect, toy form tho principal complications and in any cases the main cause of the most varied [gestive troubles, as aciditjq sickness, flatu- icy, constipation, and intestinal catarrh. They lie also at the root of congestion of the htemor- ioiaal vessels and piles, of varicosity of the ;s, of congestion of the womb and ovaries and rastrual anomalies, of congestion of the liver d imperfect secretion of bile, and of chronic rachial catarrh, with dilatation and imperfect ' ■ i traction of the right ventricle. Gravel and |ht are likewise often associated with slug- i;h portal circulation. In the treatment of jse very numerous complaints, widely different tiugh they appear to be, we have therefore • ’ays to ask in how far they are complicated [portal venosity, and in how far diet, regimen, yirmaceutical and balneotherapeutic treatment Gcted against this venosity may relieve the t cial case before us. If this portal venosity jar in lean and delicate persons, the common H -waters as Ivissingen, Homburg, Soden, &e., [jell increase the tissue-change without impair- 1 the nutrition, internally and in the form of WATERS. SOI baths, or the simple thermal baths in sub-alpina situations, assisted by the internal use of salt waters, are often useful. If the individual be stout and inclined to costiveness, the sulphated saline waters with soda and common salt, such as Carlsbad, Marienbad, Franzensbad. Elster, and Tarasp, are the most effective; while again in others of this class the simple alkaline waters, such as Vichy, are preferable. In all these cases, however, the treatment by waters and baths ought to be assisted by regulation of diet and exercise. 3. Gravel. — Gravel, especially uric acid gravel, is usually complicated with portal venosity, and is to be treated accordingly. As a symptom- atic treatment, the alkaline mineral waters have a more lasting effect than the administration of pharmaceutical preparations ; but more effec- tive are alkaline waters containing sulphates, and especially the less concentrated and hot springs of Carlsbad. Most useful of all, espe- cially for home treatment, are the waters of Luhatschowitz, with their peculiar combination of carbonates and chlorides. 4. Gout. — Gout is likewise often complicated with and aggravated by portal venosity, and we must always endeavour to facilitate the removal of the products of the retrogressive tissue- change ; but gout occurs in the most widely dif- ferent constitutions. If gout and its allied forms be met with in so-called strong constitutions, with a good primary digestion, ability to sustain a long morning fast, accompanied perhaps by a tendency to stoutness, and an acid urine of toler- ably high specific gravity, becoming iridescent with nitric acid, the alkaline sulphated waters of Carlsbad, and sometimes those of Marienbad. Franzensbad, Elster, and Tarasp are most useful, though they cannot altogether remove the gouty disposition. If the time be short, and a long rest after the course not permitted, the simple alkaline waters of Vichy may be selected, and in more delicate constitutions the muriated alka- line waters of Royat, Ems, or Baden-Baden. In lean and decrepit gouty patients the common salt-waters of Homburg, Kissingen, Harrogate and Leamington, the arsenical salt-waters of La Bourboule, tho waters of "Wiesbaden, the muriated sulphur waters of Aix-la-Chapelle, or, again, weak muriated alkaline waters like Baden-Baden, deserve a trial. In many delicate persons the simple thermal waters of Buxton, Schlangenbad, Wildbad, Ragatz, Gastein, and Bath, and the sulphur waters of Aix-les-Bains and Bagn&res-de-Luchon, offer great advantages ; but numerous cases may be regarded as quite intractable by baths, waters, and medicines, and in these diet and climate are the only means of management. 5. Chronic Bheumatism. — In chronic rheuma- tism, associated with exudation round the joints, the hot thermal treatment, either at the hotter simple thermal spas, as Bath, Teplitz, the Eiiga- nean baths, or the natural vapour baths of the cave of Monsummano, at the weaker hot salt- waters of Wiesbaden and Baden-Baden, or at the thermal sulphur waters, such as Aix-la-Cha- pelle, Aix-les-Bains, Bareges, Bagneres-de-Lu- chon, Eaux Chaudes, &c., are the most useful ; oi in more delicate cases, tho gaseous thermal salt 992 MINERAL WATERS, waters of Rehme and Nauheim. In the muscular varieties, -with stiffness, the hotter waters, assisted by douches and shampooing, are specially indi- cated. In many instances, however, the cause of constantly recurring rheumatism is weakness of the skin, and here the tonic forms of the cold water-cure and sea-baths promise more perma- nent good than hot baths. It is impossible, in .a short treatise, to enter into all the morbid conditions suitable for balneo- therapeutic treatment; but the preceding remarks may show that the physician, in prescribing waters, ought to base his advice on the teach- ings of physiology, pathology, climatology, and general therapeutics, in the widest sense. We might be expected to give a few hints on diet, during mineral-water courses, but no general rules can be laid down. Every individual re- quires rules for his own case, and rules 'which may be necessary during the use of muriatie saline, or sulphated saline waters, are not neces- sary in other courses— for instance, of simple thermal or of iron waters. The bath physician ought to guide every in- valid, according to his or her individual con- dition, as well with regard to diet, as to the internal or external use of waters, and with regard to exercise and other hygienic and thera- peutic aids. The result of a course of waters often depends entirely on this guidance. It is important, therefore, to supply the bath physician with a statement as to the ailments and tho con- stitution of the invalid. Length of Treatment. — It is a general belief that three or four weeks is the term for a course of waters or baths ; but it is impossible to fix a definite time. As courses of iodide of potassium, of iron, of quinine, or of mercury must be of dif- ferent duration in different individuals, exactly so we find it with mineral waters ; and as two or three courses of a remedy may have to be taken in the same year, so it is often desirable to give two or three courses of Vichy, of Carls- bad, or of Spa waters, in one year, though not all of them need be taken at the spring. In many cases preparatory courses are advisable, climatic, medicinal, and balneotherapeutic, and in as large a number secondary courses. Most invalids would do well not to return imme- diately after a course of baths to their usual abodes and accustomed ways of living. In many instances, however, it is imperatively necessary to abstain from work, and to keep to a simple diet for about a month or more after the course of waters, and this is especially the case with the more powerful waters like Carlsbad and Marienbad. Season. — As to tho period of the year, there is no time when the different waters might not he drunk, if it were necessary. Most spas are open only from May till October, some longer, some only from June till September ; but some few localities are partially open also during winter, especially Aix-la-Chapelle, Aix-les -Bains, Baden- Baden, and Wiesbaden. Many waters can be taken at home, and at any time of the year ; hut the elements of change are wanting, and the strict adherence to regimen and diet is often difficult. During the summer months the de- mands on the human body are diminished, by the external warmth and the greater equability MISCARRIAGE. of the meteorological influences ; nature is more exhilarating, and invites to outdoor life and exercise, without much risk of chills and their consequences ; and delicate persons, therefore, ought to select the summer months for courses at the spas. The later parts of the spring and the autumn, however, offer advantages to the more robust, who at those times find the baths and the hotels less crowded, and who can then receive more attention from the bath physician. And. besides, those who are unable to bear heat have in the earlier and later parts of the season the benefit of cooler air, which is to the average visitor a real advantage at some c.f the hotter localities, like Aix-les-Bains, Aix-la-Chapelle, Ems, Creuznach. Soden, Baden-Baden, and Ra- gatz. Hermann Webeu. MIS CARE IAGE. — Stxon.: Abortion; Pr. Avortcment; Faussc Couchc ; Ger. Fehlgcburt. Definition. — Miscarriage is the interruption of gestation before the foetus has become viable. Frequency. — The relative frequency of mis- carriages, of premature labours (between th“ ! seventh and ninth months), and of full-time 1 births, cannot be very closely estimated. Early abortions are often unnoticed or forgotten. The ' statement of Dr. Whitehead is very striking, that of sixty-four women who had lived in wed- lock till the menopause, there were only eighth who had not at some time had a miscarriage. His statistics show that the period at which abortions most frequently occur is about the third month. .(Etiology. — The causes of abortion may be found either: — (1) on the part of the ovum o: foetus ; or (2) on the part of the mother. 1. Foetal. — The causes of miscarriage on the part of the ovum are : — (a) all the diseases of the feetus itself which compromise its life, surf as acute fevers and chronic diseases — chiefly of syphilitic origin ; and (6) many of the morbid changes in the foetal appendages. Of the latte) the most noteworthy are, first, diseases of th< chorion, the more familiar of which is the hyda tidiform degeneration ; secondly, abnormal condi tions of the umbilical cord, such as excessive tor sion with constriction of the vessels, convolution! of it simultaneously round the neck and lowe extremities, and the formation of tight knot upon it ; and thirdly, abnormal relations am morbid conditions of the placenta. Where th placental area, for example, is of too limited ex tent, the ovum easily becomes detached from th uterus ; where it is too large, extravasations c blood easily take place in the lobules. Whe the placenta is planted low down in the cavit of the uterus, it is liable to partial detacl ments ; and thus in a great many cases abortio takes place at an early stage in patients wh would have been subject to the greater dange) of unavoidable hsemorrhage, had the pregnane gone on towards the usual term. Again, tl morbid processes which occur in the placent inflammatory, degenerative, or apoplectic, whethc duo to a syphilitic taint, or to other cause lead to death of the embryo or feetus, and th' in many instances to the early casting of t! ovum. It is worth while to note that death the embryo, and morbid changes in its appe MISCARRIAGE. y 03 Jages, do not necessarily at once cause abortion. Three or four weeks usually elapse after the 'death of the foetus ero its expulsion is effected ; the decidual membrane having in the interval indergone retrogressive changes. It is only |vhen such an extravasation of blood takes place is leads to sudden distension of the uterus, or vhen the membranes burst and such escape of liquor amnii occurs as leads to its sudden col- lapse, that the organ is stimulated to the im- mediate evacuation of its contents. Hence, while lie ultimate cause of abortion is often enough traceable to the ovum, the immediate occasion is 'tore frequently due to some maternal condition, 2. Maternal. — The causes of miscarriage on re part of the mother are either («) general ; or >) local. ( a ) Amongst the general or constitu- onal conditions that favour the occurrence of jortion we note, first, all the causes that lead ) depression of a woman's health. Abortions re frequent, for instance, in times of famine; nongst women who yield themselves to ex- sses ; in anaemic women ; and in those tainted 'tli the syphilitic poison. Often enough, espe- illy in the last class, the cause of the abortion jn be traced to som# morbid change in the iternal portion of the placenta ; but sometimes, seems to be due simply to the impure or poverished condition of the patient's blood.* ■ condly, fevers, such as the zymotic fevers, and j'ute inflammations, more particularly of impor- |t viscera, such as pneumonia, occurring in livid women, very frequently become compli- (|ed by abortion. Thirdly, shock may bring on tiscarriage, whether operating simply through It! nervous system, of which we meet occa- taal examples ; or, as is more frequently the ee, by producing a more direct physical impres- 6 1 upon the uterus, as in cases where the patient l'is or steps suddenly down from a height, lifts weight, stretches her arms above the head, or '■',‘xposed to any sudden jar or more protracted j'ing. Though many cases of abortion are a ibuted to such a cause, it is always to be lie in mind that in some of these, at least, t! supposed cause would not have led to the d ster unloss there had already existed a p lisposition in some morbid condition of the ufus or its contents. mongst ( b ) the local causes we find, first, and m . frequently, diseased conditions of the deci- < l , Commonly in these cases the patient had Pfiously been the subject of chronic endome- tr J 3 > though occasionally cases are met with wl , 0 there have been no marked symptoms pt lously, and the degenerative process may a t either the vera or reflexa or serotina, se - ately or simultaneously. Second in fre- .y under this head we have the abortions due 0 'placements of the uterus, these being com- mc y either descents or retroversions. Thirdly, «e : asms of the uterus, such as cancers or fib- toi amours, sometimes permit the occurrence •' . Qce ption, but prevent gestation running to usjatural term.. Fourthly, the presence of w us in the neighbouring organs, or inflam- y adhesions a,mong them, may prevent the nil , rom attf dning its full growth, and com- P to early evacuation of its contents. 1 moms and Diagnosis.— In dealing with a 63 case of suspected miscarriage, we have to de- termine first that the patient is pregnant. This we do by a careful inquiry into the patient's history, and a complete physical diagnosis. Supposing that, by the usual investigation into the signs and symptoms of pregnancy, we are satisfied that gestation had begun, we have next to ascertain whether miscarriage is only threatening to come on, has fairly set in, or has already been completed. The symptom that, in the great run of cases, first attracts attention, which usually goes on till the process is completed, and which continues for some hours or days subsequently, is haemor- rhage. The amount of blood lost varies indefi- nitely; and so does the manner of its escape. Ix certain cases the onset of pelvic pains, with the regular intermissions that betray their origin in the muscular contractions of the uterine walls, alarms the patient and attracts her attention before any escape of blood has taken place. These cases are exceptional. Usually the haemor- rhage precedes — and it may be for days or weeks — the expulsive action of the uterus. The cases, however, are rare unless they be instances of very early abortion, where the process is com- pleted without the accession of appreciably pain- ful contractions. Occasionally there occur dis- charges of liquor amnii or other watery fluid, or of fragments of the degenerated membranes, or of the disintegrated fcetus. These symptoms call for physical exploration of the uterus. If we find the uterus gravid, with the os undilated and tile cervical canal above it unexpanded, the haemorrhage being slight and the pains controllable, we regard and treat the case as one simply of threatened abortion. But if the pains are persistent, if the os uteri opens to admit the finger, or the canal of the cervix above it is becoming expanded; still more, if the uterine contents are being pressed down within reach of the exploring finger, we have to do with an actual abortion which it is useless to seek to avert. The treatment of actual abortion is often enough called for, even with quiescent uterus and closed canals, when the haemorrhage is profuse. In trying to determine whether the miscar- riage is completed, we have first to examine the mole or mass that has been expelled. This consists sometimes of the ovum alone ; of the ovum and decidua reflexa ; or of the ovum with all the uterine deciduae. Where the uterine contents escape in broken-down fragments, and cannot be satisfactorily pieced together, it be- comes necessary to examine the uterus, and even to explore the interior of that organ with the finger ; and in these and other cases where the diagnosis is doubtful, it may be requisite some- times to dilate the cervix with a carbolized sponge-tent, in order ta get full access to the uterine cavity. Treatment. — The treatment of miscarriage varies according as wo have to do with a case of (1) threatening abortion ; or (2) abortion in ac- tual progress. Treatment of threatening abortion . — The treat- ment in a case where abortion is merely threat- ening is largely expectant. The patient is put to bed and kept at rest in the recumbent position 904 MISCARRIAGE. All exercise or excitement, physical or psychical, must be forbidden A light, non-stimulating diet, with fluids for the most part cold, is to be enjoined ; and any tendency either to constipa- tion or to diarrhoea is to be combated. Where the haemorrhage is continuous and the uterus atonic or flaccid, small doses of ergot — twenty drops, every six or eight hours, of the extractum ergotso liquidum— are useful. Dilute sulphuric acid or gallic acid, either alone or in com- bination with digitalis, may be administered. Where there are occasional pains accompanying the discharge, the best effects are obtained from the administration of opiates, which may be prescribed in the form of the acetate of lead and opium pill. Where the pains constitute the more urgent symptom, and the haemorrhage is less, it may be well to check the uterine action at once by the use of an anaesthetic fol- lowed by opiates, or the administration of a dose of chloral ; and the astringent may then be dis- pensed with. The opiates in such eases are best administered hypodermically ox per rectum. Treatment of actual abortion . — Where the stage of expectancy is clearly over, and the patency of the os internum, the persistence of the pains, or the profusion of the haemorrhage, calls for active interference, there are two main indications to be fulfilled, namely, to restrain the haemorrhage ; and to ensure the complete evacuation of the uterus. To restrain the haemorrhage we compel the uterus to more energetic contraction, first, by the administration of large repeated doses of ergot. A drachm of the liquid extract may bo given every three or four hours ; but the effect of the drug can be most speedily and safely ensured by the hypodermic injection of ergotin -according to some such a formula as this: — ije Ergotin. 5ij ; chloral hydratis, css ; Aquae destil- lataj, 5vi — 16 drops to be injected into the gluteal muscle. The dialysed solution of ergotin is said to produce less irritation. Secondly, the, geni- tal canal must be plugged. Where we have no other means at command of checking the dis- charge, a carefully applied vaginal tampon may be trusted ; or the vaginal plug may be used where the haemorrhage is going on, but there is still some hope that the abortion may be ar- rested. Where the indication is more urgent, the introduction of a sponge-tent into the cer- vical canal is very much more satisfactory, and in every way more efficacious. It arrests the hcemorrhage immediately and inevitably; it excites the uterus to more energetic action ; and it at the same time expands the cervical canal in all its length. The complete evacuation of the uterus may take place by the unaided efforts of its muscu- lar walls. On visiting a patient in the morning, who had a sponge tent passed into the cervix uteri, and a hypodermic injection of ergotin over night, we may find sponge and ovum and all expelled. Where the ovum is still in utcro, if it be loose and the cervix dilated, compres- sion of the uterus from above the pubes may suffice to make it expel its contents. Usually, however, it becomes necessary to get at the interior of the uterine cavity with a finger or fingers passed through the vaginal canal. In MITRAL VALVE. most cases it greatly facilitates the operation to anaesthetize the patient, and in some cases the previous administration of chloroform is abso- lutely necessary. To render the uterus accessible to the exploring fingers, it must either be pushed down from above or dragged down from below. The patient lying unconscious on her back, the fundus uteri may be depressed by the left hand pushed firmly and steadily down through the pelvic brim. The depression may be effected by I an assistant, but never so satisfactorily as by the operator himself. Not less than two fin^er- of the right hand should be used for the intern:.! manipulation; the middle finger being folded i; the fornix vaginae, whilst the index passes throuci the os to the fundus uteri, and sweeps round tin entire ovum, detaching it at any adherent points! Sometimes the middle finger more convenient! enters the uterine cavity ; and in most cases c miscarriage in the fourth month, the whole ham. except the thumb, may require to be passed inti the vagina, and two or more fingers into the util ri n e cavity. Even where the vagi nal orifice is ntj at first very wide, if the hand be carefully warms and soaped, and the interstices of the finger filled up on their palmar aspect with a quantity - half-melted soap, sufficient dilatation is speedi effected. Occasionally the smaller left hand mt 'be employed for internal manipulation, while t! stronger right is engaged in making the exte nal pressure on the fundus uteri. Access the interior of the uterus may in most cases gained more easily by dragging the uterus doy from below. One or other of the lips of t uterus — usually the anterior— is seized with! vulsellum, double or triple pronged, and sligh curved. One of the blades grasps the vagi, aspect of the front lip of the cervix as high ap' the roof of the vagina, the other at a eorrespo - ing level within the cervical canal. The ute : is capable of being drawn far down without : ' injury to its ligaments, or aoy laceration by ’ bite of the vulsellum. It may be pulled down wi the right hand and kept fixed by it, whilst h fingers of the left pass into the cavity, andexple and evacuate it. Or the vulsellum may be helm the left hand, or given to an assistant, to keepje uterus depressed, whilst the more familiar rig- hand fingers do the intra-uterine work, ie finger or fingers that have detached the oyn commonly succeed in extracting it, aided sce- times by pressure with the other hand fin without. If not, there is no objection to lajg hold of the loosened body with a pair of ;tg dressing forceps, or a Lyon's or polypus forws, and so withdrawing it; but no such instruirit, even though it bear the name of abortion» ceps, ought to be trusted to for the detachmt of a retained ovum or fragment of adherenta- qenta. The separation should always be effied by the direct action of the living finger. After-treatment. — The uterus having pen completely emptied, the patient should be ep : at absolute rest in bed, and subjected to the me treatment as an ordinary puerperal female.; Alexander Russell Suits'. MITRAL VALVE AND ORIFlE. Diseases of. See Heaet, I alves 0F,li* eases of. MODIFIED. MODIFIED. — A term applied to a disease, >r to any of the phenomena of a disease, such as in eruption, when, as the result of a recognised I’.ause, they present unusual characters, or run an inusual course. Thus, small-pox is modified by Vaccination. See Small-pox. MOFFAT, in Scotland. — Sulphur and also jhalybeate waters. See Mineral Waters. MOGIGRAPHIA {p-6-yis, with difficulty, nd ypacpu, I write).— A synonym for writer's ramp. See Writer’s Cramp. MOLE.— MOLAR PREGNANCY.— The Lies that are met with in obstetrical practice lay be conveniently divided into two classes, ft) the false ; and (B) the true moles. The false ; oles maybe briefly dismissed, but it is desirable |at they should be discussed, in order to clear ie ground for the consideration of the more iportant variety. A. False moles. — False moles are not the re- llt of conception. Substances discharged from Ie virgin passages are occasionally so called ; r example, shreds of vaginal mucous mem- ;me, which the microscope should recognise, fere is more difficulty, however, with the mem- knes of membranous dysmenorrhcea, where |e discharged tissues may be mistaken for true pidual membranes. The circumstances attend - t each case must he nicely weighed, such as b history of previous attacks, the absence of | signs or symptoms of pregnancy, and so on. fain, if the discharged membrane happen to I complete, the two openings of the Fallopian lies and that of the cervix will be found, a con- ilion which does not obtain in true deciduae, ilproscopieal examination will also aid in the clgnosis, by proving the presence or absence structures belonging to the fecundated ovum, lod-clots, variously altered, may also be dis- crged by the non-pregnant, and give rise to dbt and difficulty ; especially those partially dplourised clots, which consist mainly of filin, the serum and red blood-corpuscles having t< . great extent escaped. The blood is probably hlierinotic in these cases. Careful examina- ti is necessary to determine the true nature ofthe expelled product. Nothing should be pjkounced to bo a true mole which does not pfent structures known to occur only in the felndated ovum. Polypi and small fibroid tinurs, or portions of large ones, are not diffi- cii of recognition by naked-eye and micro- scjical examination. True moles. — True moles are always the re t of impregnation. The embryo may speedily disipear in the early stages, and then we meet onjwith the membranes or appendages ; these, Mver, are characteristic. 0 chief varieties of true mole are at present rec nised, namely, (1) the fleshy, and (2) the vesldar or hydatidiform mole. 1 Fleshy mole. — ^Etiology and Pathology. Ex ivasation of blood between the maternal andntal structures of the fecundated ovum, or inb he tissues of the latter, appears to be the act agent in the production of the fleshy mole ; “ 10 |h it is difficult to determine the agencies ■*hi by this condition is brought about. A MOLE— MOLAR PREGNANCY. 995 diseased state of the decidiue may doubtless re- sult when pregnancy supervenes upon chronic endo-metritis ; or effusion of blood into the ma- ternal structures may occur from cardiac disease. Again, syphilitic and other hlood-dyscrasiae ap- pear to exert an influence; and perhaps the same may be said of acute specific diseases when they fail to excite abortion. It seems probable that degeneration of the embryonic appendages takes place as the initial lesion in some cases, it may be from syphilis. The pathology of the subject is still, however, shrouded in considerable ob- scurity. Description. — Whatever may be the excit- ing causes, when once blood has been effused into or between the foetal and maternal struc- tures, the vitality of the embryo is speedily compromised. The common result of this is abortion ; but when the whole ovum is not thrown off, growth may take place in the remaining tis- sues, while the effused blood becomes organised and gives bulk to the mole. Notunfrequently a considerable effusion of blood takes place imme- diately beneath the amnion, encroaching greatly upon, and sometimes rupturing, the amnionic sac. The inner aspect of this cavity then pre- sents an irregularly nodular appearance, and is of deep, almost black, colour. When the nodule* are incised they are seen to be composed of firm blood-clot. If not immediately thrown off, growth may continue in the tissues, and a bulky, fleshy mole may result. The connection between the ovum and the womb being most intimate at the placental site, changes go on most actively at that spot ; and when blood is largely effused here it constitutes what is called ‘apoplexy of the ovum.’ Examination of carneous moles seems to show that, under certain circumstances, the decidua vera is the chief scat of degenerative changes ; but it appears that in all cases chorion villi may be found, though much altered by the presence of fatty and molecular matter. The growth of fleshy moles may be rapid, but ordinarily it is not excessively so; such, at least, is the experience of the writer. Fatty degeneration may be extremely marked, and in rare cases cal- careous degeneration may be met with, forming what the Germans call the Steinmole ; but it must never be forgotten that similar degenera- tion of other uterine bodies may occur, for ex- ample, of fibroids, so that calcareous bodies are not to be looked upon as true moles unless other clear evidence exists of conception having taken place. Blood-polypi are occasionally met with, arising after miscarriage or delivery at full term, in which, organisation having taken place, and communication being established between the clot and the uterus, degenerative changes go on to the extent of calcification, whereby a so-called Steinmole may be produced. 2. Vesicular mole . — The vesicular, hydatid, or hydatidiform is the better understood, if not more important, variety of true mole. Description. — It is necessary to state at the outset that the name ‘ hydatid ’ mole is erroneous and misleading. There are no true hydatids or ecchinococci in it. The physical arrangement of the vesicles is different. True hydatids are closed sacs, contained one within another, while the vesicular mole is formed by saccules growing 096 MOLE— MOLAR PREGNANCY, from one another. It was formerly supposed that they grew from a common stalk, and they were likened to a hunch of grapes or currants ; but, for the reason given above, that simile was imperfect. The vesicles vary in size from a chestnut to a pin’s head, or less ; usually they are about the size of small currants ; and as a few may from time to time escape, accompanied by more or less sanguineous discharge, Gooch’s simile of ‘ white currants floating in red-currant juice ’ is a very apt one. All authorities agree that the vesicles grow from the chorionic villi. There is no new for- mation, but excessive and erratic development. Mettenheimer, Paget, Barnes, Virchow, and others concur in this view. Whether the chango is the cause or consequence of the death of the embryo is unsettled. Leishman points out that the period within which degeneration of the chorionic villi may originate does not extend probably beyond the tenth week, that being the period of greatest activity in the growth and multiplication of the villi. Later on, when blood-vessels have occupied the bulk of the villi, this kind of degeneration seems incapable of formation. The probabilities, therefore, are in favour of the formation taking place in the first chorion, or vitelline membrane. In re- ference to this portion of the subject it may be well to remark that recurrence of vesicular growths has occasionally, though rarely, been met with after apparent removal of vesicular moles from the uterus. Probably some portion escaped detection in those cases, and growth went on therein. Dr. McClintock mentioned this many years ago, and several cases are on record. The connection between the vesicular mole and the uterus may be extremely intimate, some vesicles penetrating the uterine wall even to the peritoneum. Barnes states this, and Schroeder refers to a case by Volkmann and oneby Jarotsky and Waldeyer, in which it occurred. The occa- sional recurrence of this variety of mole may be explained by portions imbedded in the uterine wall escaping removal, or resisting expulsion. The penetration of the uterine parietes may also favour rupture of the organ during the expulsion of a vesicular mole, as in a case recorded by the late Dr. Tyler-Smith. The vesicular mole belongs to the class of pathological products known as myxomata. According to Gscheidlen the cyst-fluid contains albumen, mucin, phosphates, and other inorganic salts, leuein and tyrosin in small quantities, but no trace of fibrinogenous substance, paralbumen, cr sugar. An analogous degeneration of the placenta has been described by Virchow and Hildebrandt as 1 fibrous myxoma’ of the placenta. Schroeder quotes cases of ‘ diffuse myxoma ’ of the placenta, by Breslau and Ebertli, and Spaeth and Wedl. A case of myxoma, or hyperplasia of the cho- rionic villi, is related by Dr. Sinclair in vol. i. of the Publications of the Massachusetts Medical Society. StmptOms. — The symptoms of vesicular molar pregnancy are at first usually those of ordinary- pregnancy, but patients often complain of ma- laise. The bulk of the uterus increases with HOLIMEN. great and disproportionate rapidity. There is a tendency to the loss of the ovoid form, and the assumption of the globular or more transversely wide shape. Generally there is early evidence of the presence of some derangement, hy the ap- pearance of watery and sanguineous disebarse. When vesicles come away the diagnosis is clear : but in their absence the practitioner may bej puzzled. In other cases there may be high tem perature, quick pulse, an icteric tint of skin, arP a dry or glazed tongue. Physical examination often yields important information. Palpation may give, as Leishman remarks, a significant sensation of bogginess with absence of the irregular foetal hardness Hardening under manipulation is very significan | of the uterine nature of the tumour. On vaginv examination a doughy sensation may be expe rienced in the lower segment of the uterus 1 Should the os be open, vesicles may be felt. T ! the touch they somewhat resemble recent blood) clots. In all suspicious cases discharged mate rials should be carefully examined. Treatment. — The treatment of all these casej of mole pregnancy consists in the complete ra moval, whenever practicable, of all the disease tissues. Dilatation of the uterus may be nece.- sary for this purpose, either by the fmger or b means of tents, or Barnes's bags; and erect and other oxytocics may be called for to aid i the expulsion of the offending product in son cases. The diseased tissues should, if possible, 1 completely removed. Portions may beretaine after the bulk has been removed or expelled, at give rise to grave and exhausting discharges, to recurrence, as has been mentioned above, is important to remember, in this connection, th| twin pregnancies may occur in which vesieul degeneration affects the membranes of but o ovum. It is well, therefore, to bear in mind t possibility of this ; and that the sound ovum m proceed to full development. This state of thi is said to have occurred on the occasion of birth of the celebrated anatomist Bedard. Ai-fbf.d Wiltshire MOLE, in Skin-Diseases (A.S. mal).- term applied to certain permanent out-grows of the skin. They are usually congenital, and.- termed navi or ‘ mother-marks.’ When coved with hair they are called ‘ hairy moles,’ or n t pilosi ; and when of a dark colour, ‘ pigmentk moles,’ navi pigmentosi. Another synonynH the pigmentary mole is spiltis. I Treatment. — The most convenient modgt treatment of all these kinds of mole is the c; - ful application of a strong solution of pot; a fusa, two parts to one of water. They are tk > - by converted, in the course of a few minutes, - j a transparent gelatinous mass, which dritdp into a black scab ; and they are rarely rep- duced when removed in this manner. Erasmus Wilso MOLIMEN ( molior , I move or stir).-- 1 impulse or effort. The word is chiefly use-; - connection with menstruation, to indicated effort which appears to be made by the sy n to perform this function. See Menses, oe -*• steuation, Disorders of. MOLLITIES OSSIUM. . MOLLITIES OSSIUM (Lat.).— Synon. : Isteomalacia ; Malacosteon ; Fr. RamoUissement L Os; Ger. Knochenerweichung. Definition. — A condition in which the bones ' the skeleton become by degrees decalcified, so lat they can no longer sustain the weight of the |dy, but bend or break on slight provocation. [Mollities ossium has been called an excentrie rophy; but the minute changes which occur re not those of atrophy, but rather of active calcification of the bone. /Etiology and Pathology. — The causes of Wlities ossium are unknown. It affects the jnale sex almost exclusively ; only occurs in iults, and during the period of child-bearing. ;iere is some intimate connection between the c'tbr'eak of mollities ossium and the gravid i.te; and repeated pregnancies appear to pre- ,..pose to its occurrence. It also, but very :-ely, is observed in the male sex. The disease t ms to occur in the lower classes cf the people, are exposed to hardship and have inade- Jtte food. In certain localities it would seem be endemic. It has been ascribed to changes i the nutrition of the bone. ; to a process akin tjchronie osteitis, or osteomyelitis ; and to the p.'ion of an excess of lactic acid in the. blood, jis acid is said to have been found in the bones si urine of persons affected by the disease. Anatomical Characters. — The bone in mol- lies ossium becomes gradually decalcified, the amge spreading from within outwards, until ipere shell of external compact tissue rs left, it this cortical layer never wholly disappears. r -e medullar}’ cavity enlarges in all directions, ( upying the epiphysis, and invading the cor- til substance, until the interior becomes a pitiniform mass, enclosed in a periosteal shell. jb bone can be cut into layers with a knife, (Indented with the pressure of the finger. n the stage of acuta progress the medulla is vjy vascular, the vessels are enlarged, and here a. there extravasations of blood occur. The r> lullary spaces are filled with nucleated mar- r ’-corpuscles ; the trabeculae give way; the olous particles disappear; the fat-cells dim- ii h, and gradually disappear ; and finally the wile interior is filled with a pale or yellowish g.tinous substance, resembling the vitreous bijy. In extreme cases the external covering u be solely the fibrous periosteum, with a ft plates of bone in its interior. ntPTOMs. — One of the earliest symptoms iciollities ossium is aching rheumatoid pains idlhe affected bones, generally aggravated at n t. The vertebral column, the ribs, and tl pelvis are the parts first affected; and in tl e serious deformity shortly becomes mani- fcj The weight of the body causes extreme liyal and angular curvatures. The ribs are hi; and broken ; one series of fractures taking pie in the axillary line, usually directed inirds, is produced by external pressure ; m st a second and third row of fractures take pi i by more indirect force — the one near the jjjjj of the ribs, the other outside the sternum. Ti arms often lie in a trough-shaped hollow on tlij ides of the body. The sternum gives way njveral places, and. is displaced forwards. I r,>|! gh the weight of the body acting from MOLLUSCUM. 997 above, the promontory of the sacrum is projected forwards, whilst the lateral pressure of the head of the femur, against the acetabulum, causes the transverse diameter of the pelvic outlet to diminish. It thus assumes a trifoliate shape, the pubic symphysis often projecting forwards at right angles to its normal position, with its two horizontal rami in contact. The floor of one acetabulum may even touch the other. The bones of the extremities suffer from multiple fractures and bending from the most triflin'? causes ; and these are very imperfectly repaired in the later stages of the disease, although in the earlier they unite readily by bony callus. As the disease progresses, the body becomes more and more misshapen ; the patient more perfectly helpless and bedridden ; and death usually ensues from exhaustion, after a more or less protracted interval, or the sufferer is carried oft' by inter- current disease. Female subjects frequently die in consequence of severe instrumental interference required during pregnancy. There is no consti- tutional cachexia. Diagnosis. — The diagnosis of mollities ossium is at first very obscure. The pains resemble those of rheumatism. The character of the deformity will, however, settle any doubts. The disease should not be confounded with rickets, which is a disease of infancy or childhood, due to delayed ossification, and producing prominent curvatures of the shafts of the bone, and en- largements near the epiphyses, very distinct in type from the infractions and extravagant dis- tortions of the osteomalacic skeleton. Nor does mollities resemble the fatty atrophy of bones due to senile changes, in which condition, though fracture be common, there is no general de- formity involving different parts of the skeleton. Prognosis. — The prognosis in most cases is unfavourable. In some well-marked cases of softening, the bones appear to have afterwards recovered their normal consistence, but this is very unusual. Treatment. — No remedial measures, as yet discovered, have either arrested the progress of mollities ossium or promoted its cure. Women affected in this way should be restrained, if possible, from further childbearing, not only to avert increase of the disease, but to avoid the dangers attending childbirth in cases of de- formed pelvis. Otherwise, an ample supply of nourishing food, rest in the recumbent position, and abundance of fresh air, are, combined with iron and quinine internally, the principal means of treatment at our disposal. Willi am Mac Cormac. MOLLUSCUM ( mollis , soft). — Defini- tion. — A term applied to soft tumours of the skin. Structurally, molluscum is an overgrowth of the connective tissue, and therefore a fibroma ; hence it is named by Virchow fibroma molluscum. But there is another tumour of small size, rarely larger than a pea, which has been described as an overgrowth of the sebaceous glands, but re- cently as a specific degeneration of the cells of the reto Malpighii. In England observation proves the contagiousness of this affection — molluscum contagiosum. Description. — Pathologically the fibromatoue 39U MOLLUSCUM. molluscum is an hypertrophy of the connective tissue of the superficial stratum of the inte- gument, infiltrated "with serum, which renders the tumour more or less mdematous, and gives it its character of softness. It may range in size from that of a millet-seed to that of an oraDge or large melon. Occasionally even, as in a remarkable case illustrated by Virchow, small mollusea were protruded from the surface of one of very large size. The molluscum will also vary in density, in proportion to the firmness or relaxation of the connective tissue, and the quantity of fluid contained within its meshes. Sometimes the molluscous growth is not re- stricted to the form of a tumour, but occupies a large extent of the integument, such as the whole cii’cumference of a limb, and gives rise to immense folds and lobes which overhang each other in festoons, suggesting the term ‘ derma- tolysis,’ applied to this variety by Alibert. At other times the tumour grows in length, expand- ing as it proceeds, until, issuing from a narrow base, it develops into a mass resembling distended intestines. The blood-vessels of molluscous tumours are always large, particularly the veins; but in the exaggerated forms of the disease, the latter are prodigious in size, and may be seen through the tikin twining around the base of the lobes. Treatment. — The treatment of molluscum consists in the removal of the tumour. When the latter is of small size this may be accomplished with the scissors, hut when it assumes the gigantic proportions already mentioned the operation is a serious one. Mr. Pollock, in a case of this kind, secured the large vessels by means of a ligature before proceeding to the employment of the knife. To treat molluscum contagiosum we must slightly enlarge the opening with a lancet, and press out its contents. The capsule then contracts or dies. Erasmus Wilson. MONOMANIA. — Svnon. : Fr. Monomanic ; Ger. Wahnsinn . — This term is falling into disuse on account of its vagueness, and because it has been employed by various writers to denote different kinds of insanity. Some have used it to denote an insanity which is indicated by some one particular delusion, the mind remain- ing clear on every other point. Others mean by it an insanity without delusion, an affective or impulsive insanity, the essence of which is the absence of delusion, and the so-called in- tegrity of tho intellectual portion of the mind. Esquirol thought it a disorder of the faculties limited to a few subjects, with excitement, and gay and expensive passion ; while according to others, melancholia without delusion would be an instance of affective monomania. We may take it, however, that all authors are agreed in using the term monomania to indicate a partial insanity, which enables the patient to converse and act rationally to a considerable degree, and therefore renders his responsibility a matter of question. Such cases form the grounds of forensic contests, whether criminal or civil; but it is better to affix to them some more precise term, and to indicate symptomatologically and pathologically the exact nature of the mental and bodily condition of the alleged lunatic. G. F. Blanbford. MOKBIFIC. MONSUMM.ANA, Cave of; in Uppe Italy. — Natural vapour baths. See Mixeha Waters. MONT DOEE, in France. — Simple thei mal water, containing arsenic and soda. & Mineral Waters. MONTPELLIER, in South of Franci Variable, fairly warm, winter climate. Hie winds from N.E. and N.W. See Climate, Trts ment of Disease by. MORAL INSANITY. See Insanity, yJ rieties of. MORBID (morbus, a disease). — This won merely signifies diseased, and is used, in its sever applications, as a technical or scientific term. : contradistinction to the term healthy. Amoi the most common examples of these applicatio: may be mentioned morbid anatomy and histolcg which imply the anatomy and histology of d: eased conditions ; morbid sensations or fedim as distinguished from healthy sensations, wheth connected with either of the ordinary senses, with some particular organ, such as appetit morbid actions ; morbid secretions or discharge and morbid growths. The word is employed it somewhat special sense, in relation to individn: who are mentally low in spirits and despondei without any obvious cause to account for tH condition; such individuals are often spoken! as being in a morbid state. MORBIDITY ( morbus , a disease). — II term, which is of recent introduction, is ei ployed to denote the amount of illness exist! in a given community; and, as 1 mortality ’ s! presses the death-rate, so ‘ morbidity’ indica; the sick-rate, whether the diseases be fatal or nl Since health is an extremely ill-defined sta- marked out by no absolute boundaries, and sit many people suffer from diseases that are e. cealed intentionally or through ignorance, it comes a matter of considerable difficulty to ■ press with certainty the amount of illness tk may exist at any time. Some information m, however, be obtained from the records of sit- clubs and benefit societies, on which statists may he based of the average time their s;- scribers arc ill during the year, in relations employment, age, locality, and other circc- stances. _ 'Ll By an investigation of this subject the rate.-f mortality come to possess an extended sigi|- cance, for they thus indicate not merely the p- portion between tho living and tho dead, but r tween tho latter and the two classes of the liv;. namely, the healthy and the diseased; and-s a branch of State medicine, must doubtless cfe to take a prominent place. As further kn- ledge provides accurate facts and figures, >e subject will have a distinct practical beariosn estimating the value of men for work, if average liabilitv to disease and the total amc - .. of illness an individual may expect to suffer-’ known ; while it is reasonable to believe thais the ‘ aptitudes to disease’ are further conditio- the means for prevention mav be extended. : W. H. Allchi: MORBIFIC ( morbus , disease, and fan 1 make). — This word is properly applied toot MORBIFIC. juso that produces a disease. Such a cause is ften spoken of as a morbific agent. MORBILLI (dim. of morbus, a disease). — A ynonym for measles. See Measles. MORBUS. — This is the Latin word for isease. Formerly it was frequently employed, ■,ut is not much in vogue at the present day. Vhen applied to particular diseases, it is asso- rted with some qualifying adjective or noun, idicating the nature or seat of such disease, ome peculiarity by which it is characterised, or te name of some renowned authority upon it. |b would not serve any useful purpose to give a st of the diseases with which the word is con- ected, and it will sufiico to cite, as examples, ime of its more common applications, such as '/>rbus cordis, disease of the heart; morbus ■ixce or coxarius, disease of the hip-joint; morbus rcalis, ergotism ; morbus Brightii, Bright’s isease ; morbus cceruleus, blue disease. MOROCCO, in. North Africa. — Warm, ealthy winter climate. Tangiers is exposed to lid, damp S.W. winds in autumn and spring, !ad to E. winds. Living superior to Malaga. ,cc Climate, Treatment of Disease by. MORPHIA, Poisoning by. See Opium, oisoning by. MORPHCEA ( morphcea , a blotch).- — This ord has been used at various times as a synonym ' lepra alphoides or alphos, and leuce, and is .Tied in meaning with vitiligo. More recently it |s served to distinguish a circumscribed form of leroderma. Four varieties of morphcea have ■en recognised — namely, morphcea o.lba, nigra, berosa, and atrophica ; but a better knowledge the pathology of the disease will probably erge the whole of these varieties in sclero- ma. See ScLEKODEitMA. Erasmus Wilson. MORTALITY. — Synon.: Ratcof Mortality ; •wth-rate; Fr. Mortality ; Ger. Sterblichkdt. Definition. — The proportion of persons dying those surviving under given circumstances ; more usually, the proportion borneby the per- is who die to the whole number of those sub- , ted to the given circumstances. Thus we may have to do with the annual •.rtality of the population of a country, a dis- t it, or a city ; or of a body of men similarly < mmstanced, as of clergymen or of lead-miners ; ( of bodies of men otherwise alike, but sub- j ;ed to different conditions of climate, Sec., as t British army ; or of the population, or any stion of the population, at special ages, as of ihnts in factory towns. Or we may be concerned with the propor- t is of deaths to survivors, or to the whole paher of entrants, during and after exposure t . special cause or causes of death, operating e ier speedily or during a protracted period, b'eunder come, for example, the mortality sus- t .ed by the population of Rio Janeiro, or New leans, during an epidemic of yellow fever ; or I ; suffered by a number of persons in passing t iugh an attack of enteric fever or pneu- n, ia. stdiation of Mortalitt. — The annual mor- ■' j of a population is reckoned, not on the MORTALITY. 999 numbers in existence at. the beginning of a year, but on the average number in existence on the several days of the year, or, what is nearly the same thing, on the mean population of the year. The necessity of this becomes evident., when we consider that in our own country the large towns are mostly increasing an a very rapid rate, while some agricultural parishes and unprosperous places actually' decline in population. In the towns, therefore, the death-rate, if reckoned oo the last census, or even on the number be- lieved or estimated to exist at the beginning c: the given year, would come out higher than it ought to be, while in declining parishes it would be somewhat too low. Similarly the annual mortality of bodies of troops is calculated on the mean strength. Two formulae are in use for specifying death- rates. In the first the proportion of deaths is takenas unity ; thus, the mortality in England and Wales in 1873 would be stated as 1 in 46. In the second, which is more convenient and is now generally employed, the number of lives at risk is taken as 100 or 1,000 : thus the mortality of 1878 would come out 21;7. Either formula is convertible into the other by simplo division: thus 1,000 -=-46 = 21-7 ; and 1,000^-21-7 = 46. The death-rates of large civilised countries, in which registration is strictly carried out, give a pretty fair representation of the viability of the population. So much may he said for England, Wales, and Scotland, and for most of the European States, but not, unfortunately, for Ireland, where the weakness of the registration laws makes the record defective. Mortality of Nations. — The following are the death-rates per 1,000 of most of the prin- cipal States of Europe : — Norway Sweden Denmark England and Yales Scotland Belgium Switzerland France Or excluding two years of war Netherlands Herman Empire Italy Spain Austria Hungary Or excluding two cholera years The death-rate of Russia, except in the ex- treme north, is high. It was stated at 35'9 ir 1842. That of Portugal the writer has not been able to obtain. Those of Turkey, of Ireland, and of Greece are unknown. In maDv of the British colonies it is lower than everf in Norway. Thus the average mortality during the ten years, 1866-75, was in 1 Victoria, 15-8 | South Australia, 13-3 New South Yales, 15-3 Tasmania, 14-8 Queensland, 17-7 | New Zealand, 12-4 Mortality of Cities. — T he mortality of cities is in this country almost invariably higher than that of the. open country. But this rule does not apply to all other countries ; the exceptions occur mostly where endemic fevers are prevalent 1 Hayter, Australian Statistics. In years. Per 1000 living. 1846-55 .. 17*9 1869-78 .. 18*9 ,, .. 19*2 .. 21*8 „ . . 22*1 . . 22*6 1S70-78 . . 23*5 1869-78 . . 24*3 22*5 1869-78 . . 24*4 1872-78 . . 27*2 1869-78 . . 29*5 1861-70 .. 29*7 1869-73 .. 31-1 1868-77 . . 39*6 . . 36*1 MORTALITY. 1000 in the country. Thus the mortality rate in 1878 was in London, 23 - o ; in Edinburgh, 22T, and in Dublin, 29 6 ; and in 20 other large towns in the United Kingdom it varied between 19‘ in Portsmouth, and 29'4 in Liverpool ; while in 50 towns of the second class the extremes were 16 2 at Dover, and 1ST at Rochester; 30’4 at Blackburn, and 30'8 at Preston ; the average of the 23 towns being 24'4 per 1,000, and of the 50 towns 23'. In the same year the rural dis- tricts and small towns of England yielded an average rate of 19' only. There are a consider- able number of districts, almost all rural, which year after year fall below 17 ; and 17 was accord- ingly fixed upon by the late registrar-general for England as a kind of standard to be aimed at by sanitarians. And there are districts in England, and entire small counties in Scotland, where the rate occasionally falls below even 15. The following table exhibits the death-rates experienced in 1878 in a number of foreign and colonial cities : — Calcutta 37-7 Paris . 24-6 Madras 48-8 Brussels . 28-0 Bombay 41-8 Amsterdam. . 24-4 New York . 24-8 Rotterdam . . 27-3 Brooklyn . 20*1 The Hague . . 26*4 Philadelphia 1 8-0 Copenhagen . 22-0 Montreal 30-9 Stockholm . . 22-4 Alexandria . 4o"4 Christiania . . 18-5 Melbourne, 1873 and St. Petersburg . . 47-1 1875. 22*8 Berlin . . 29*9 Borne (1878) 2.9-8 Hamburg . . 26*9 Naples 33-1 Dresden . 24-7 Turin .... 31*1 Munich . 34-G Venice 28-7 Breslau . 29-9 Trieste 36-2 Vienna . 29-G Geneva 23-G Budapest . . 40-3 Analysis of Results. — -These tables awaken, by the enormous differences between the several cities and countries, a curiosity respecting the causes of such differences, which, however, the figures themselves go far towards satisfying. It is at once evident that, whatever may be the case in the open country, cities suffer to a con- siderable extent in the ratio of their ignorance and neglect of sanitary laws, and of the poverty and squalor, or barbarism of their populations. Mark, for example, the contrast between Phila- delphia and St. Petersburg ! Cities having a steadily warm climate, or a climate of extremes, are more unhealthy than those which enjoy a temperate one. By this consideration, combined with that of their superior civilisation, may be explained the favourable position of the cities of "Western as compared with those of Eastern Europe. The short, hot summers are very fatal in the latter region, and even in Southern Ger- many and at Stockholm ; while in Western Europe generally, and especially in Scotland, winter and spring are the deadly seasons. It is noteworthy that in most of the large cities of Italy the short, sharp, and changeable winter is not less deadly than the hot summer and mala- rious autumn; in fact good winter climates for poitrinairqs are exceptional even in Italy. In Great Britain the inriuenee of climat e per se on the annual mortality of the several cities and districts is not very great ; and its effects are obscured by those of other agencies. But if we confine our attention to the rural districts, where the disturbing factors are less important, we shall find that the rates of mortality are on the whole slightly more favourable in the north than in the south. Of all the counties in Great Britain Orkney-and-Shetland stands best, with an annual mortality, on an average of 10 years, 1 of 15" 13 ; and Shetland, the more northern divi- sion, stands better than Orkney. Great Britain is, therefore, no exception to tho rule that in Europe mortality decreases from south to north. This is in no way inconsistent with the fact that throughout Great Britain winter is the deadly season, and cold is more fatal than heat, thoracic than abdominal diseases. Influence of Seasons. — The following were the death-rates of the four seasons in England and Wales, in 1868-77 : — Win- ter. Spring. Sum- mer. Au- tumn. Year. In the chief towns . 25-8 22-5 23-1 24-9 23-7 In the small towns and rural districts 21-7 19*3 17-2 18-5 19-0 In Scotland the seasonal mortality, owin 2 . doubtless, to the less intensity of the summer heat, follows pretty nearly the order of the English small towns and rural districts. Thus in 1878: winter, 25'2; spring, 23'2 ; summer 19'8 ; autumn, 204 ; year, 22 - 3. It would seem, however, that in London, ir the early part of the seventeenth century, wher the death-rate, owing to the closeness anc filthiness of the city, was fearfully high, tin maximum was attained in summer, the figure: standing as follows in 1606-10, during whic! years the plague was absent. Average mortalit percent.: — winter (J. F. M.), 1'4; spring, 1'5 summer, 2'7 ; autumn, 2’0 : — total, 7'0. Influence of Density of Population.— 1 accordance with a principle already laid dowr that in communities sufficiently' advanced to fm nish mortality statistics, the death-rate dim' nishes with the progress of civilisation, th mortality of London has since the seventect century' gradually and greatly diminished. ^ the beginning of this nineteenth century it ha sunk to 29, in 1840-49 it was 25'3, and i 1870-78 only 23. The death-rate is also diminishing in Franc Belgium, the Netherlands, Sweden, and Ge many, in all of which countries the populatic is believed to be advancing in comfort and gen ral well-being, but in southern and easte Europe, where comparatively little advance h taken place in these respects, no such diminuth can be demonstrated. Nor, though evident in London and in sevei other great towns, can a diminution of t death-rate be positively affirmed of Great Brita generally. In Scotland, indeed, there was a c cided increase from 1S55 until 1S76, when decline, which may' prove transient only, set And in England no improvement could he she for many years before 1S7L since which ds> there has been an almost unbroken success: of years of low mortality, concurring with- generally low temperature and excessive fill/ rain. 1 1S66-76. MORTALITY. IO01 The great antagonistic influence in Great Britain may bo found in Dr. Farr’s principle, That mortality increases with density of popu- lation.’ And ‘urbanisation’ advances so rapidly in Great Britain, that all the efforts and de- vices of sanitary and medical science are scarcely lable to do more than neutralise its evil effects. ■ SotmcES of Fallacy. — It may he as well to advert to some of the principal sources of fallacy, uhich hamper us in appreciating national and local death-rates. One of these is the varying number of births. This ranges in the Conti- nental States of Europe from about 40 in Ger- nany and Austria, and even more in Russia and Hungary, down to 25 in France; and in Britain ’rom 48 or 50 in some coal and iron districts, jlown to 22 in the county of Sutherland. The ate Dr. Letheby maintained that a high birth- ate was a direct cause of a high death-rate, >wing to the great mortality among infants. This was an error ; the two often concur, but he former is not a cause of the latter, unless vhere the infants perish in enormous propor- ion. The usual result in this country of a large ,nd especially of an increasing birth-rate, is to ..ugment in the community the proportion of ihhdren beyond infancy, and of young persons, rho ordinarily suffer a very low death-rate as ompared with old or even middle-aged per- .ons. The favourable rates prevailing among nese young persons overpowering the unfavour- ite ones of the infants, and of the comparatively nail number of old people, the apparent death- ate is actually diminished, instead of being lereasedas Letheby supposed. And this points ) the true reason why the death-rate of France ; higher than that of England, whereas the ex- 'octatiou of life in the two countries is about le same at most ages, the birth-rate of France ling exceedingly low (Bertillon). The lower \e average age of the population the lower the nth-rate. A considerable amount of emigration or immi- •ation affects the death-rate in proportion to te average age of the migrants. Thus the ortality of most great and growing towns ould stand worse than it does, were it not for e large numbers of young and healthy persons im the country who settle in them. Watering- ices and residential towns appear somewhat althier than they really are, by reason of the .mbers of young domestic servants who form a rge portion of their population. But it is in r colonies that the effect of migration on the ath-rate can best be studied. The unexampled ith-rate of New Zealand, quoted above, is the suit of two kinds of causes, one set of which I 1 may call real, the other factitious or apparent, e former are the cool, equable climate, and the lerly and prosperous condition of the popula- n ; the latter are the constant stream of ■stly youtliful immigrants, and the very high th-rate. Influence of Age and Sex. — The influence age and of sex on the mortality in England and lies may be best shown in a tabular form. Mortality per 1,000 at twelve groups of i’S in males and females in the 41 years IS— 78 : — All Ages 0- 5- 10- 15- 20- 25- ^rales 71 3 4 G 8 9 Females .... 21-2 G2 s 4 3 9 35- 45- 55— 65- 75— 85- ■Males 23-3 13 IS 32 67 147 311 Females .... 21-2 12 15 2S 53 134 287 The superiority of the women is here well- marked, except during childhood and the years of early married life and much child-bearing. Influence of Race. — The influence of race is usually difficult to separate from that of habits of life. In Europe the Jews offer the most notable example. It may be sufficient to quote from Oesterlen Neufville’s statistics of Frank- fort-on-the-Maine, who found that there the aver- age age of Christians at death was 36'9 years, but that of Jews was 48‘7 ; and from Hoffman, the death-rate of the Jews of Prussia, which was only 21'6 per 1,000, against 29'G among the Christians. Influence of Station and Occupation. — The influence of station and occupation on mor- tality is very great. The subject has been care- fully handled by Dr. Farr in the Supplement to the Registrar-General for England's thirty-fifth Report. Briefly, it may be said that of all trades or professions that can be isolated, clergymen, barristers, farmers, agricultural labourers, game- keepers. grocers, seem to stand best in this re- spect. Booksellers, paper-makers, wheelwrights, and carpenters also suffer but a small mortality. Schoolmasters and teachers go on well up to fifty-five. Solicitors, domestic servants, watch- makers, shoemakers, blacksmiths, range not far from the average rates ; so do bakers (though such is not the current opinion), and the whole tribe of weavers. The workers in iron, as a rule, experience but a low mortality in early life, but a high one as they grow older ; the same may be said of millers, and, somewhat strangely, and no doubt for very different reasons, of Roman Catholic priests. Tailors begin very ill, and end fairly. Medical men, alas 1 perish frequently in early life, and only attain a respectable position after fifty-five. Chemists, too, and veterinary surgeons, como out badly. The figures for drapers much resemblo those for medical men. Those for miners, naturally enough, are not much different from those for iron-workers, though a little worse. Tobacconists, as might be expected, suffer very heavily until middle life. Printers, bookbinders, clerks, commercial travel- lers, glass manufacturers, dock labourers, porters, railway employes, butchers, fishmongers, coach- men, draymen, grooms, all suffer a very high mor- tality. And the very worst positions are occupied by the dealers in alcohol and in lead (tl*e painters), and by the potters. These facts are of considerable practical in- terest in relation to questions of life insurance. Mortality of Diseases. — Some acquaintance with the mortality of diseases, and the extent to which it is influenced by age, sex, climate, I season, &c., is also of great value for prognosis. 1002 MOETALITY. Information on this subject will be found under the heads of the several diseases ; moreover the limits of this article are not sufficient to admit of much discussion cf the subject. A few facts respecting the acute infectious diseases will, however, be of interest — - 1. Typhoid Fever. — The average death-rate of enteric fever was put by Murchison, in accord- ance with British, French, and German hospital statistics, at 17'4 per cent. There is a good deal of ground for putting the average mortality of children and youths at 11 or 12, but it is pro- bable that only the worst cases occurring in children find their way to hospitals. Over fifty years of age somewhere near one-half usually die (Liebermeister). 2. Typhus. — In typhus the mortality varies extremely in different epidemics, sometimes rising above the average of enteric fever, more often, perhaps, falling below it. In Ireland it is usually low, averaging perhaps 9 or 10 per cent., or less. The mortality of children from this disease is much lower than from enteric fever (Murchi- son, Lebert, &e.). The number of deaths as- cribed to typhus (that is continued fever, inclu- ding enteric) in the register, is, however, largest in proportion to the living under five years; is low from 10 to 15, and again from 25 to 35 ; and then increases gradually up to extreme old age. One cannot help suspecting that other febrile affections of children are confounded with typhus and enteric fevers. 3. Measles. — The mortality from epidemics of this disease is often as low as 2 or 3 per cent,, but it has been known to rise to 30 per cent, under unfavourable circumstances, as where chil- dren, or even adults, are crowded together in a hospital. Among ‘ virgin ’ communities (as in well- known epidemics in, Iceland, Farce, Madagascar, Fiji) the mortality is sometimes frightfully large. It is comparatively small in summer; and de- cidedly small among the comfortable classes, owing doubtless to the exercise of greater care. It is beyond comparison greatest in the second year of life, and by the tenth has become quite trifling ; but adults may die of measles. 4. Scarlatina.— There is a prodigious differ- ence in the deadliness of different epidemics of this disease, even in the same locality. In Southern Europe it is comparatively a mild dis- ease; in Britain it is most severe; yet even here eighty successive cases may occur without a death. But a mortality under 10 per cent, may be considered moderate (Thomas, in Ziemssen ); it is often much higher. It is at its maximum from the second to the fourth year, but continues very deadly up to ten or twelve ; by fifteen it has almost reached a minimum, but, unlike measles, continues to be somewhat formidable t hroughout life, especially to parturient women. Season and station in life make little difference in its deadliness. 5. Smallpox. — Smallpox did and does, in un- vaccinated communities, where it has long been at home, destroy somewhere about 10 per cent, of the population ; and of persons unprotected by vaccination, who are attacked, 40 per cent, often perish. Among ‘virgin’ communities it is still more deadly. Age makes comparatively little difference in its fatality. MOTILITY, DISORDERS OF. 6. Whooping cough. — The death-rate of this disease is very Large in the first year of life, de- clining afterwards like that of measles, but rather more rapidly, and becoming quite insignificant before the tenth year. Whooping-cough is more fatal in winter than in summer, in towns than in the country, among the poor than among the rich ; but these differences, except the first, are not very well-marked. John Beddoe. MORTIFICATION (mors, death, and /ado, I make). — A popular name for gangrene. S< Gangrene. MOTILITY, Disorders of. — The power of executing movements of the different parts, or of the body as a whole, may be interfered with in various ways ; and as such disabilities are generally partial, the particular movements that happen to be implicated will also differ amongst themselves in different cases. The disorders of movement to be referred to in this place are principally those in which mus- cles of one of the limbs, or of other external parts of the body are concerned — though disorders of the same kind, and also of different degrees, are likewise frequent, in which we may find per- verted movements of viscera and their ducts, as well as of blood-vessels: in other words, portions ! of the involuntary muscular system are apt to have their functional activity deranged, after some of the same inodes as piortions of the voluntary muscular system. In such cases, almost without exception — and ' to whichever class the defects may belong— the disordered motility is due primarily to some de- fective or abnormal action of the nerve-centres or of the nerves in relation with tho muscles im- plicated, rather than to any primitive disease of the muscles themselves. Classification. — Disorders of motility are divisible into three primary classes, according as they show themselves (A) in response to 1 voluntary incitations ; (B) in response to mere ‘reflex’ impressions; or (C) spontaneously. Thd particular muscles implicated (or the mode oi distribution of the various defects) will neces- sarily differ much according to the extent ant situation of the disease in the nerve-centres o: in the nerve-trunks to which the defects an due. In some cases particular defects of motilit; can be confidently referred to disease of th. brain, and even of particular parts thereof; ii others they may be referred to disease of thi spinal cord in particular regions; or, in othe cases still, they may be as clearly due to som altered condition of nerve-roots or of nerve trunks in their continuity. A. Disorders of voluntary movement: Under this head are to be included different varie ties of disordered movement, thus divisible : — 1. Diminution of motor power. — This vaiie much in degree in difterent cases. There ms be mere weakness (paresis) or actual loss ( power (paralysis) of one or more limbs, or < particular sets of muscles. The type of tl paralysis will vary according to the seat ar extent of the lesion ; thus it may be due to; cerebral lesion, and be of the hemiplegic tyj (see Hemiplegia) ; or it may be due to a spin lesion, and be of the paraplegic type (see Pab MOTILITY, DISORDERS OF. plegia) ; or the loss of power may be owing to disease or injury of some nerve-trunk, and then be of the type of a peripheral paralysis, such as we get in facial palsy. 2. Imperfect coordination of movements. — Here the several muscles concerned with the produc- tion of a given movement act without the rela- tive subordination and gradation of force needful for its proper execution. Some muscles contract too powerfully and others not enough, or some contract too quickly and others too slowly, with the effect of producing a spasmodic or otherwise disordered movement — one by which the end desired is not readily attained. The condition thus produced is known as ‘ataxia.’ of which there are two principal varieties — one caused by disease of the posterior columns of the spinal cord {see Locomotor Ataxy) ; and the other by disoase of the cerebellum (see Cerebellum, Lesions of). Ataxia is, in fact, a condition for the most part caused by the defects described in the previous category, together with that to be mentioned in the next, the two states co-existing (in different proportions in different cases) among muscles called into simultaneous or successive activity for the execution of various complex movements. A kind of ataxy may indeed be induced by mere paresis in some muscles of a physiological group, that is of some muscles whose business it is habitually to act in com- bination with others. 3. Spasmodic action of certain muscles. — On volitional incitations reaching the spinal cord iu certain states of disease, some of the muscles whose contraction is to be brought about are thrown into a condition of over-action or tonic spasm, whereby the performance of the move- ment is greatly interfered with. In such cases there is almost always in addition increased reflex excitability, so that it is in some cases difficult to say how much of the spasm is pri- marily due to the volitional incitation, and how much to reflex spasms — caused by cutaneous im- pressions consequent upon the commencing move- . ment. These conditions are especially met with in cases where portions of the cord are cut oft’ from the so-called ‘inhibiting’ influence of the brain, at the same time that there is hyperaemia, with increased excitability of the then active regions of spinal grey matter. This state of things is par- ticularly frequent in ‘primary sclerosis of the lateral columns.’ On the other hand, the initia- tion of voluntary movements may, in other cases, give rise to clonic spasms in the parts moved, especially in certain cases of disseminated or insular sclerosis. See Spinal Cord, Diseases of. i. Tremors, shapings, or choreic movements. — Tremors (tine or coarse) and shakings are really jftonic spasms of limited range ; and all gradations 'may at times be met with between these several ypes of disordered movement. Such morbid movements of one or other grade, even if they .ixist more or less continuously, are usually in- creased by volitional incitations. This is the ’.ase, for instance, in paralysis agitans; in the rembling from mercurial poisoning or from hronic alcoholism, as well as in that from ■enile changes ; in the shakings met with in SisaemiDated sclerosis ; and also in the more rregular movements, often of wider range, met 1003 with in chorea. See Chorea ; Spinal Cord, Die- eases of ; and Tremor. B. Disorders of reflex motility. — The con- ditions on which disordered movements, due to increase of reflex excitability, depend, have been above referred to. The withdrawal of brain- influence from, and the increased hypercemia of certain tracts of spinal grey matter, seem co be the main causes, and these are met with principally m certain forms of paraplegia, and in spasmodic spinal paralysis, or primary sclerosis of tho lateral columns. The mere weakening of cere- bral influence will, however, lead to an increased manifestation of reflex movements, as may be seen in certain nervous or delicate persons, in infants, or in young children. Two forms of reflex actions have to be dis- criminated, namely, those excited by cutaneous impressions — skin reflexes; and those induced by taps or slight blows upon tendons — tendon reflexes. Both forms are often unduly exalted in the same person, though sometimes the skin reflexes may be normal, whilst the tendon re- flexes are greatly exaggerated. Reflex movements of both kinds may be diminished, either (1) from disease of afferent nerve-roots outside or within the cord, as in locomotor ataxy ; (2) from destructive disease of the grey matter of the cord, as in many cases of severe paraplegia ; or (3) from disease of the motor roots or nerves supplying particular groups of muscles. An increase or a diminution of reflex excita- bility is frequently met with, and is often of much importance, in connection with one or ether of the viscera, such as the heart, the stomach, the bladder, or the intestines. This undue nervous excitability may be depend upon mor- bid conditions, partly of the medulla or spinal cord, and partly of portions of the sympathetic system. As possible conditions of much importance in the aetiology of many’ nervous affections we may here also mention disordered activity of certain vaso-motor centres, which, either immediately or remotely, influence the calibre of the blood- vessels supplying certain portions of the brain or cord. In this manner there may be induced either spasm of their vessels, with greatly lowered blood-supply; or paralysis of vessels, with con- sequenthyperaemia in such nerve-centres. These conditions would correspond with the death-like pallors or the flushings occasionally observable in the face, or other tracts of skin. The doubt exists, however, as to how long such mere reflex pallors or flushings may persist in nerve- centres, that is, when they are simply due to functional defects. Are they al way’s merely tran- sient phenomena, or may they persist for days or even weeks, as some have supposed? C. Spontaneous movements. — The move- ments which are manifested ‘ spontaneously ’ are various in nature or degree, though they are of kinds similar to those that may be excited by voluntary incitations. We need only enumerate these different varieties here, and briefly indicate i either the diseases in which they are encountered, or the conditions on which they depend. («) Tremors, such as present themselves in paralysis agitans, or mercurial poisoning ; ( b ) twitchings, 1004 MOTILITY, DISORDERS OF. or startings, occurring in one or more limbs, either upper or lower, in some cases of cerebral end of spinal disease ; the more irregular but less spasmodic movements, known as (c) choreic, occurring principally in the disease from which they derive their name (being sometimes indefi- nite, and at others distinctly co-ordinated) ; ( d ) spasms, which may be either co-ordinated, as in some eases of chorea ; clonic, as in epilepsy, eclampsia, and other allied affections ; or tonic, as in tetany, tetauus, strychnia-poisoning, and certain spinal affections, as well as in some cere- bral diseases. Conditions of rigidity and contraction, due to a more or less permanent tonic spasm, are scarcely to be described under the head of spon- taneous movements, since in such conditions, although there is powerful muscular contraction, there is no actual movement; and, similarly, the spontaneous jlickerings of muscular fibres, seen in so many cases of progressive muscular atrophy, deserve to be mentioned here, even though no movements are produced, owing to the small number of muscular fibres involved at any one time. The flickerings themselves are really clonic spasms, involving a few fibres simultaneously. Treatment. — The treatment of these different nervous conditions will be considered fully under the various special articles to which re- ference has been made. II. Charlton Bastiax. MOUTH, Diseases of. — The principal dis- eases of the mouth may be thus enumerated in the following order; — 1. Inflammation and itn results ; 2. Epulis ; 3. Gumboil ; 4. Ranula ; 5. Salivary calculus; and 6. Salivary fistula. Diseases of the tongue and of the teeth are treated of in other articles 1. Inflammation. — S ynox. ; Stomatitis ; Fr. Scomatite ; Ger. Mundschleimhautentzundung . — Inflammation of the mouth is fully described under the heading Stomatitis. See also Aphthje ; and Cancrum Oris. 2. Epulis. — Synox. ; Fr. Epulide ; Ger. Epulis. Descriptiox. — E pulis is the name given to a tumour which springs from the alveolar processes and from the periosteum covering them. It is more often seen in connection with the inferior than witli the superior maxilla. It forms a smooth, rounded, or lobulated tumour, covered with the mucous membrane of the gum. It is firm or semi-elastic to the touch. As it grows, it loosens and displaces the teeth. Its intimate structure varies considerably. Sometimes it is a simple fibrous tumour; sometimes a round- celled sarcoma ; sometimes a myeloid. At first it is benign ; but if it be allowed to remain, it is apt to ulcerate, and exhibits something of a malignant aspect and character. Treatment. — T he tumour should be removed, and the portion of the alveolar process from which it springs should be taken away. Unless this be done, the growth is almost certain to return. 3. Gumboil. — Synox. : Parulis ; Fr. Pandie ; G er. Zahnfieischgeschwiir. Description. — A gumboil is a circumscribed inflammation of the mucous membrane, or of MOUTH, DLSEASES OF. the periosteum covering the alveolar processes. It is usually caused by the irritation of a de- cayed tooth. In a severe case the swelling, pain, and discomfort are great ; and the constitutional symptoms often run high. When suppuration takes place the boil generally breaks, and a speedy cure is obtained. If, however, the pus cannot find a ready exit, it may burrow, giving rise to necrosis of the subjacent bone, or it mav form sinuses in various directions — for mstance, on the cheek. Tbeatmext. — The cheek should be poulticed, and the old-fashioned fig poultice is often applied to the gum with advantage. The month is to be frequently rinsed with hot water. The diet should consist entirely of fluids. An aperient should be given at the outset, and sub- sequently a suitable stimulant, such as ammonia and bark. As soon as pus can be detected, the gum should bo lanced. When the acute inflam- mation has subsided, the source of irritation should be removed. 4. Banula. — S ynox. ; Fr. Grcnouillcitc ; Ger. Ranula ; Froschleingeschmilst. Definition. — Cystic formations in the mucous membrane beneath the tongue, which take their origin sometimes in the ducts of the sublingual or sub-maxillary glands, sometimes in the areo- lar spaces, and possibly also in the bursa be- tween the genio-hyo-glossi muscles. A. Internal Ranula. — Descriptiox. — T he ma- jority of cases of ranula are unconnected with the salivary glands ; and, in many instances, a probe may be passed along the ducts, or the saliva may be noticed flowing from them, while the ranula remains unaltered. Other cases belong to that simple variety which depends merely upon an accumulation of the normal secretions in a natural cavitv. such as a duct, which has become temporarily ob- structed. Such obstruction may arise from’ local inflammation, from inspissation of the normal fluid, or from the impaction of a salivary cal- culus, as will be subsequently described. Treatment. — The majority of cysts in this situation lie just beneath the mucous membrane. They are, moreover, always small at their com- mencement, so that if the attention of the sur- geon is called to them early, they can generally be cured by taking up a piece of the cyst-wall, and cutting it off with scissors ; or a seton mav be passed through the tumour and knotted, when the cyst will gradually contract. B. External Ranida. — Description. — These are larger tumours, which lie between the tongue and the jaw. and become prominent at the upper part of the neck. Though the term ranida is applied to them, they are of a different eharacter, and analogous to the sebaceous tu- mours which are so frequently met with in the skin, containing, like them, a thick, gritty sub- stance of a fawn colour, often very offensive. This material is made up chiefly of epithelium, plates of cholesterine, and oil. Sometimes these enlargements advance very slowly; but in other instances their progress is extraordinarily' rapid, and then the disease is called acute ranida. Treatment. — The cure of cases of this class is more difficult and tedious. The cyst should MOUTH, DISEASES OF. be freely opened from the mouth ; the contents Ecooped out ; and the cavity filled with lint. Sometimes it is desirable to make a counter- opening in the neck, and to treat the disease as sn ordinary abscess. Passing a seton may be useful. To dissect the cyst out is an unneces- sary proceeding, and not always free from danger. 5 . Salivary Calculus. — S ynon. : Fr. Calcul salivaire-, Ger. Speichclstein. Description. — Concretions, composed chiefly of phosphate of lime, are not very uncommon in the ducts of the parotid, sub-maxillary, and sublingual glands. These calculi may vaTy in size from a pin’s head to a filbert, or even larger. Not unfrequently they form around some small foreign body, such as a seed or a morsel of woodv fibre, which has made its way into the duct. Occasionally they occupy the substance of the gland, but more often they are found in the duct. Here they may simply obstruct the outlet, and give rise to an accumulation of the secretion, forming a ranula, and inconveniencing the patient by forcing the tongue upward and backward ; or they may cause a local inflamma- tion which terminates in an abscess. Treatment. — If a concretion can be felt, either with a finger or with a probe, an incision should be made and the calculus removed. If there is local inflammation, it should be fomented or poulticed; and, if an abscess forms, it should be opened and then treated in the same way. 6. Salivary fistula. — Synon. : Fr. Fistule salivaire ; Ger. Speichetfistd. Description. — Occasionally the duct of the parotid gland (Steno’s duct) is wounded or in- volved in an ulceration, or an abscess forms in its track and bursts externally. In such cases a salivary fistula is likely to be the result. The secretion from the parotid, instead of making its wav into the mouth, dribbles over the cheek. Treatment. — The treatment of salivary fis- tula consists, first, in establishing an opening into the mouth by means of a few threads of silk, a wire, or a piece of catgut, passed from without inwards, brought out at the mouth, and the ends tied together. The next point is to close the skin of the cheek over the fistulous opening. This may be done by touching tho edges with the actual cautery, so as to make them contract ; by paring the edges, and bringing them accu- rately together ; or by dissecting the skin around the wound, sliding it along so as to cover the opening, and securing it with stitches. But the cure of salivary fistula— a purely surgical pro- ceeding — is always difficult, and a more or less depressed scar is sure to remain. W. Fairlie Clarke. MOVABLE KID MET. See Kidneys, Diseases of. MOVEMENT, Therapeutical Uses of. — Synon. : Movement Cure; Kinesitherapeutics ; ■t'r. (xymnastique Suedoise ; Ger. Kinesitherapie. Description. — The method of treatment of lisease by movement appears to have been first lesigned by Ling, a member of the Koval iwedish Academy, about the beginning of the 'resent century. The movements employed are aid to be of three classes, namely : 1 . Active MUCOUS MEMBRANES. 1005 movements , executed by the patient himself, or by the patient aided by an assistant ; 2. Passive movements, performed by the assistant on the patient; and 3. Acts of resistance to movements, whether executed by the assistant against the patient, or by the patient against the assistant. Uses. — The several classes of movements, for which mechanical arrangements are also con- trived, when scientifically employed, are used in the treatment of paralysis, curvatures of the spine or limbs, and injuries and diseases of the joints. Movements of the nature of friction or shampooing are also employed in the treatment of certain diseases of internal organs, and will be found described elsewhere in this work. See Friction ; and Shampooing. MOX2E (Eastern). — A term for a form of counter-irritation, which consists in producing an eschar by burning certain materials upon the skin of a part. Moxae were originally prepared in Eastern countries from the leaves of the arte- misia ; but when used in this country, cotton- wool and other substances are employed. Sea Counter-Irritation. MUCOID DEGENERATION. — A form of degeneration, which is associated with the production of a mucus-like substance. See Dege- neration. MUCOUS MEMBRANES, Diseases of. This class of membranes, which line organs and passages communicating with the exterior of the body, though presenting modifications as to their minute structure in different parts of the body, exhibit a general resemblance in their construc- tion, and consist essentially of sub-mucous tis- sue; abasement-membrane; epithelium of various kinds covering the free surface; and numerous glands or follicles, differing in their characters in different tracts. They are highly vascular as a rule ; and many of them are richly provided with absorbent vessels. It is only intended in this article to treat briefly, from a general point of view, the morbid conditions to which mucous structures as a class are liable. Those connected with the several mucous tracts are discussed under their appropriate headings. 1. Injury. — Most of the mucous surfaces are exposed to injury from various causes. This may come from without, the cause being either me- chanical, chemical, or excessive heat. As illus- trations may he mentioned injury to the mucous lining of the alimentary canal or air-passages by foreign bodies ; corrosion from swallowing strong acids ; and burning or scalding of the mouth or of parts lower down, in consequence of inhaling a hot blast or swallowing boiling water. In other cases the injury may originate within the body, as by calculi passing along tubes or lodged in cavities ; hardened faeces in the intestines ; para- sites ; or the rupture of enlarged veins, aneurisms, or abscesses opening into mucous cavities. The effects of an injury to a mucous surface differ much in their nature and extent, accord- ing to its cause. Thus there may be a mere contusion; a superficial erosion or abrasion; a more or less extensive wound or rupture, other structures being then also involved; a burn or scald ; or actual destruction by corrosives. More 1006 MUCOUS MEMBRANES, DISEASES OF. or less inflammation follows injury tc a mucous surface. Subsequently ulcers may be produced, which by their cicatrization may give rise to con- striction or actual obliteration of tubes, and other untoward consequences. 2. Hypersemia and Anaemia. — The mucous membranes are very prone to become the seat of congestion, either active, mechanical, or pas- sive. Active congestion may bo a part of a physiological process, as is seen in the gastric mucous membrane during the process of diges- tion. Any slight irritation may also cause it, and it is scarcely practicable to indicate a dis- tinct line of demarcation between this condition and inflammation, of which active congestion constitutes the earliest stage. It is character- ised by bright redness, new vessels frequently coming to view; and at first by a tendency to dryness of the affected membrane, which may be followed by excessive and altered secretion. Mechanical congestion is often an important morbid condition in connection with mucous structures, giving rise to troublesome symptoms. For instance, in cases of cardiac disease ob- structing the pulmonary circulation, the mucous lining of the air-passages becomes more or less congested permanently; and if the general venous circulation becomes overloaded from a similar cause, other mucous tracts suffer, espe- cially that of the alimentary canal. This tract is also directly involved in cases of portal obstruction. Particular portions of a mucous membrane might become the seat of mechanical congestion, if some local vein should become obstructed from any cause. The effects of this condition are in the first instance to make the colour deeper, with a more orless venous hue ; and at last the small veins may be evidently dilated and varicose. The secretion becomes modified in quantity and quality, and in time a permanent discharge is likely to be established, consisting of an unhealthy, thick, and tenacious mucus; while the proper secretion of special glands, such as the gastric juice, is interfered with. In some instances mechanical congestion gives rise to an abundant flow of a watery mucus. The membrane itself is also liable to become altered, being swollen at first ; and ultimately it may become permanently thickened ar.d firmer than normal, owing to increase of connective tissue, while its own special structures degenerate. Passive hyperamia may follow inflammation of a mucous membrane ; or it occurs in persons of relaxed and feeble habit ; or follows undue use of a part covered with a mucous membrane, as in the case of the throat. Aruemia in connection with a mucous mem- brane is important only when this is a part of general anaemia from any cause. Those mucous surfaces which are visible, such as the conjunctive or the lining of the mouth and lips, give the most striking evidence of this condition, as indi- cated by their pallor or even bloodlessness. Ad anemic condition of the alimentary canal inter- feres in an important degree with the functions of its mucous membrane, and with the formation of the secretions which it normally produces. 3. Inflammation. — -Various forms and de- grees of inflammation are of very common occurrence in connection with mucous mem- branes, and a large number of cases in ordinary practice belong to this class. Without entering into any description, it will suffice to state here that the inflammation may be acute, sub-acute or chronic ; and either catarrhal, croupous, or diphtheritic in character (sea Infi^mmation;. Different tracts of membrane present different degrees of liability to these several forms of in- flammation ; and the catarrhal form not only has various grades of intensity, with correspondin'* variety in its products, which may become mue(> purulent or actually purulent, but these products also differ in their nature in connection with dif- ferent membranes of the mucous class. Further inflammation from special causes, such as gonor- rhoea, is characterised by running a definite course, and forming special products. When tho inflammation is of a severe type, it may end in more or less destruction of the mucous tissues, as indicated by erosions, ulcerations, or even gangrene. Where the submucous tissue is loose, oedema is liable to occur. From this cause, as well as from thickening of the mucous membrane itself, or from a croupous or other deposit on its surface, narrowing or oven actual closure of any tube or passage lined by such a membrane is apt to be produced. Inflammation may also give rise to sub-mucous suppuration. When the in- flammation is chronic, permanent changes ;irc set up in mucous tissues, the normal elements being altered or entirely removed, and a fibroid material being formed in course of time, so that the membrane is rendered permanently thickened and tough. The cause of inflammation of a mucous membrane may be local, includin': in- jury. mechanical or chemical irritation, or that resulting from undue heat or cold, morbid pro- ducts or growths ; or general, such as chilling of the body from ‘ a cold,’ blood-poisoning in con- nection with fevers and other conditions; or the inflammation may be a part of some specific disease — for instance, diphtheria or gonorrheea. Some mucous tracts are particularly liable to be affected under certain predisposing conditions, and at certain periods of life. Thus, bronchitis is very common in children and old persons; while the former are exceedingly subject to catarrh of the alimentary mucous lining. 4. Ulceration. —Ulcers are of common occur- rence on mucous surfaces. They usually result from injury or inflammation, or are the termina- tion of certain special morbid processes, as in the case of typhoid fever, syphilis, tubercular disease, cancer, dysentery, or diphtheria. Ulcera- tion may depend upon destruction of the tissues by parasitic growths, as in some cases of thmsh. Some pathologists believe that ulceration of a mucous membrane occasionally arises from plug- ging of arteries, and consequent death of a limited portion of this membrane, which separates, leav- ing an ulcer. In the case of the stomach it has also been supposed that under certain circum- stances the gastric juice may so act upon the mucous lining as to destroy it. A peculiarform of ulcer is sometimes observed in the duodenum after severe burns. Ulceration often begins in connection with the glandular structures; this may he due in the first instance to mere block- ing up of their orifices, leading to accumulation of their products and subsequent inflammation; MUCOUS MEMBEANES, DISEASES OF. but certain special mcrbid processes commence in these structures. Inflammation may cause ulceration, either by directly destroying the membrane rapidly or gradually, or by setting up sub-mucous suppuration. Mucous ulcers differ much in their seat, extent, depth, shape, and other characters, according to their cause. The simple forms are either mere erosions or of the catarrhal or follicular varieties ; and in each of the special diseases already mentioned the ulcers present peculiar characters. Occasionally they assume a gangrenous appearance. If they extend deeply, they involve other tissues besides those of the mucous membrane, and may thus lead to per- foration of cavities or tubes, and other untoward consequences. Cicatrization often takes place, and this may lead to permanent contraction, ' stricture, or even complete closure of channels lined by mucous membranes, with more or less thickening and induration. Ulceration fre- quently destroys the glandular structures, which are not afterwards renewed. 5. Gangrene. — Occasionally the tissues form- ing mucous membrane mortify, as the result either of severe injury, corrosion, inflammation, or vascular obstruction. The gangrene is of the moist kind, and the dead tissues may separate in a mass or in shreds. Consequently an ulcer is left ; or actual perforation of a tube or hollow organ may take place. 6. Nutritive Changes. — Hypertrophy of mucous tissues is sometimes seen, but this may appear to be the case when it is not really so, the membrane being thickened and firm, owing to a chronic inflammation, and the formation of tibrous tissue. Atrophy is not uncommon, espe- cially of certain of the elements of mucous mem- jjbranes, such as the glands or epithelium. De- generation is also often observed, affecting these md other structures. This degeneration may be :f a senile character ; or of a special kind, such (is albuminoid or mucous degeneration. Not un- ■ommonly mucous tissues are relaxed and de- icient in tone, their nutrition being impaired. 7. Deposits and Hew Growths. — The chief lew formations observed in connection with aucous membranes are polypi, villous growths, pithelioma, and tubercle. Syphilitic gummata hay involve these membranes. Cysts also ocea- ionally form, originating from the glands or epithelial structures. It may be mentioned here Jhat certain animal or vegetable parasites are jften associated with mucous membranes. 8. Special Diseases. — It will suffice to re- lark under this head that in certain diseases uucous membranes are particularly affected, Jich as typhoid fever, diphtheria, and dysentery. Symptoms. — The symptoms which may arise connection with one or other of the diseases ifecting mucous membranes just indicated, are the following nature 1. Morbid sensations, usually of a more or jss painful character, are often experienced, aese will vary in degree and kind, not only tk the nature of the disease, but also with the rticular mucous surface which is involved, ne being much more sensitive than others. 1 inful sensations are chiefly met with in con- ation with injury, inflammation, or ulceration, 1 they will be localised in accordance with the : 1007 seat and extent of the mischief. As a general rule it may be stated that the sensation is one of burning, rawness, or soreness ; and it is usually much increased by any irritation of the affected part, to which mucous membranes, from their situation, are specially exposed. Sometimes the morbid sensation consists in a feeling of tickling, itching, or undue irritability and sensi- bility to sensory impressions. It must be borne in mind that serious lesions of mucous surfaces, which, as a rule, cause marked painful sensa- tions, may exist withotit any such effects. 2. Hcemorrhage from mucous surfaces is of common occurrence, the amount of blood lost varying from a mere trace to a quantity sufficient to cause death. The bleeding may apparently take place quite spontaneously, and without any evident cause, as in some cases of epistaxis ; or it may be associated with congestion, injury, inflammation, ulceration, gangrene, new growths, or other conditions. 3. Morbid products are very frequently formed on mucous surfaces, or the normal secretions are modified in quantity or quality. Thus, the mucus may bo deficient or excessive ; and either thin and watery, unduly thick and adhesive, modified in its reaction, or otherwise altered. A free serous flow may take place from a mucous membrane, as the result of congestion or catarrh. Muco-purulent matter, actual pus, and croupous or diphtheritic substance, are among the chief morbid products formed in connection withmucous surfaces. Not only do these materials reveal their presence by being discharged externally in various ways, but they may themselves cause other symptoms, by affecting substances with which they come into contact. For instance, in the alimentary canal unhealthy mucous secretions often lead to fermentation and decomposition of food, with their consequences ; and similar effects are produced on the urine by morbid materials formed in the bladder. Some products are also in themselves irritating, and affect injuriously the surfaces over which they pass, causing pain, or setting up secondary inflammation. Gangrenous tissues may also be discharged. 4. Expulsive actions of different kinds are often excited by morbid conditions connected with mucous surfaces lining passages and organs. These may he illustrated by sneezing, coughing, vomiting, undue action of the bowels, and fre- quent micturition. They may result merely from excessive sensibility of the membrane ; or from the presence of blood, or of the morbid materials already mentioned. 5. The special functions of certain mucous membranes are very liable to be interfered with when they are affected in various ways, espe- cially in consequence of changes in the epithe- lium and glandular structures. This may be best illustrated by the alimentary canal, where dyspeptic symptoms often arise from changes of this character, the secretions necessary for the process of digestion not being properly formed ; and absorption by the intestinal wall is also liable to be interfered with. 6. Obstruction or contraction of tubes or orifices lined by mucous membranes may arise from inflammatory or hypertrophic thickening, submucous cedema or suppuration, thick secre- 1008 MUCOUS MEMBRANES, t.ion, cicatrization of ulcers, or some forms of new growth. The consequent symptoms are similar to those from other forms of obstruction, such as dysphagia when the oesophagus is af- fected, dilatation of the stomach from obstruc- tion of the pylorus, retention of urine when the urethra is involved, or some form of dyspnoea when the air-tubes are obstructed. 7. Physical examination, particularly by in- spection, at once reveals the condition of mucous surfaces which are visible. This may be aided by instruments in the examination of parts which are situated more internally. Special modes of examination give us important information as to the diseases of certain mucous membranes, such as that lining the air-tubes. 8. General symptoms. — Diseases of mucous membranes are often accompanied with symp- toms affecting the general system. The most' obvious of these are fever and wasting, which may arise from various causes. Pyrexia is not as a rule high in inflammation of mucous surfaces. It must be remembered that certain affections of this class of membranes are but manifestations of some general or constitutional disease, which presents its own symptoms. Treatment. — The general principles or indi- cations in the treatment of diseases of mucous membranes may be summed up as follows : — 1. To relieve pain and other sensations by ap- propriate means. 2. To check haemorrhages, if they are in such amount as to need interference. 3. To subdue inflammatory action. 4. To brace up and give tone to relaxed tissues. 5. To influence secretions and morbid products, increas- ing or diminishing the former, checking or modifying discharges, and endeavouring to affect special materials, such as diphtheritic deposits. G. To allay undue excitability, causing violent actions ; or to aid such actions as may be neces- sary to expel excessive secretions or morbid products ; or in other ways to prevent their accumulation. 7. To supply the place of, and prevent the symptoms resulting from the want of secretions necessary for special purposes, which are formed ’ by certain mucous surfaces, such as the gastric juice. 8. To treat particu- lar morbid conditions, such as ulcers, gangrene, new growths, or constriction, with the view of curing them. 9. To treat general symptoms. Local applications ; or such remedies as when administered internally come into contact with the affected surface, are of much value in the treatment of diseased mucous membranes. These may be anodyne, sedative, stimulating, astrin- gent, demulcent, or of other kinds, according to the action required ; and they are often ad- vantageously applied in special ways. Opera- tive procedures are not unfrequently required. General treatment is often of the greatest ser- vice in the management of diseases of mucous membranes, and this may be the only indication needing attention. Moreover, it must be borne in mind that there are certain diseases in which the morbid condition of the mucous membrane is but a part of the general malady, and calls for no special treatment. 1’rtEDF.nicK T. Roberts. MUCOUS BALE. — An adventitious sound MUCOUS TUBERCLES. heard on auscultating the chest in certain forms of disease, and due to the passage of air through viscid fluid in the bronchi. See Physical Exa- mination. MUCOUS SECRETION, Disorders of. See Mucous Membranes, Diseases of; and Secretions, Disorders of. MUCOUS TUBERCLES.— Synon. ; Con- dylomata ; Er. Plaques muqueuses. Definition. — Flattened raised patches upon the soft skin and mucous surfaces of syphilitic persons. See Condyloma. .Etiology. — Mucous tubercles are a certain evidence of syphilitic contamination, and belong to what are commonly known as the secondary manifestations ; they may appear very early in that stage of the disease, or amongst the later symptoms. They are often present in hereditary syphilis. Mucous tubercles are much more fre- quent in women than in men ; in fact they are sometimes the only symptom of the constitu- tional taint in females. Experimental inoculation of the discharge from j these tubercles shows that it is capable of pro- 1 during a hard chancre at the point of insertion, followed by general syphilis ; and from clinical observation it would appear that these lesions are highly contagious, and a fertile source for spreading disease. Description. — Mucous tubercles consist of a circumscribed hypertrophy of the skin and cuticle. They appear as flat, elevated patches, of a round or oval shape, with a broad base, of a reddish colour, and generally covered by a thin grey: pellicle. When in close proximity they coalesce, and form a dense tnberculated mass of irregular shape and size, which is generally fissured, ulce- rated, and encrusted with dried secretion from the neighbouring skin. As a rule they are not 1 painful, but when irritated they become very sensitive. When situated upon a mucous mem- brane they are less raised, patchy in appear- ance, and whitish in colour. This is especially the case in the throat, where they have been termed plaques opalines. At other times they may form superficial ulcerations with inflamed; margins. The favourite locality of mucous tubercles is the genital organs, the anus, and the moist skin adjoining; but they are not frequent on the penis. They may also be found at the umbilicus, axillie, auditory meatus, alae of the nose, on the lips and nipples, and between the toes. The mucous membranes usually affected are those oj the mouth, tongue, and throat ; and occasionally they are seen in the vagina or on the os uteri Want of cleanliness favours their development as does irritation from any cause ; and in stout persons they may be met with in unusual situa tions, where folds of skin meet, and perspiratioi collects. In young children, the subjects of inher.te syphilis, mucous tubercles are generally foun at or about the anus or organs of generation but when the disease has been communicated the mouth and fauces are more usually affected Treatment. — The local treatment of syphiliti condylomata is cleanliness, with some mercuna or astringent application ; and if the patches b MUCOUS TUBERCLES. 'mall and few in number, this will generally be sufficient. If the tubercles be large, indurated, and ulcerated, or if they be very chronic, with little disposition to subsido under the above treatment, an occasional pencilling with nitrate cf silver or tincture of iodine may hasten their removal. General mercurial treatment must be combined with the local remedies. Attention must of course be given to the general health. George G. Gascoyen. MULTILOCULAR, (multi, many, and lo- ■ uli , small spaces).— A term applied to cysts md other forms of growths, and to pulmonary laxities, when they consist of many small spaces ir loculi. See Cysts. MUMPS. — Synon. : Parotitis; Cynanche D arotidea ; Pr. Oreillon ; Ger. Mumps. Definition. — An acute, febrile, infectious isease; attended with swelling of the salivary lands, mostly of the parotids; and ending in ^solution. ./Etiology.— This is an affection more eom- tonly seen in young persons —boys, growing girls, nd young men ; but it may occur in adults of ,ther sex who are much with the sick, and have pt bad the complaint before. Mumps rarely tacks the same person twice. It occurs as an hlemic in large institutions, such as schools id barracks. It is conveyed from person to rson by contagion— that is, by infecting par- ties reproduced in the course of the disease, d given off by the sick, possibly even before 8 glands are affected, certainly for two or Tee weeks afterwards. It has an incubation- riod of from eight days to three weeks. Some hygienic defects may favour the spread mumps. Whether it prevails more at one i.son than another is uncertain. Anatomical Characters. — Not many, pro- My no cases of idiopathic parotitis afford the 1 hologist an opportunity of making a post- 'i Hern examination into the nature of the affec- 1 1 . But arguing from analogy, some maintain tit here, as in the more frequently fatal symp- tiiatic parotitis, the inflammation has its start- i -point in the gland-tissue proper, or in a c irrh of its duct. Others again assert, and ti has long been the prevalent opinion, that the ii rstitial and the connective tissue around the g id are the seat of the mischief. The affection is robably both parenchymatous and intersti- ti But wherever the inflammation has its oiiin, certain it is that the interstitial and ce lar tissue around the gland are the parts w hgive most evidence of the existence of the dbise. They become kypereemic, infiltrated wf serous fluid, and consequently much swollen. A; this (edematous state passes to structures head those pertaining directly to the parotid gl l. Seldom does there appear to be any fibrous exudation poured out; and still less fre.ently do the tissues exhibit any tendency' to eak down and to suppurate. The swelling ctfletely disappears about three days after the ver. On the subsidence of the local lesion a s ailed metastasis to the testicle and other gk. ular and fibrous structures is not rare. Alt itious in the kidney and atrophy of the tea .es have followed; nor have the investments 64 MUMPS. 1009 of the nerves, or the surfaces of the heart, always escaped. Symptoms and Diagnosis. — Some general symptoms always precede the local manifes- tations of mumps ; they may be so slight as almost to escape notice ; or fatigue in the day, restlessness at night, chilliness, or vomiting may mark the ingress. These initial sy’mptoms do not occur until a week after exposure to in- fection, and may not be followed at once by the local signs. Mostly', after a week of malaise, or only a look of illness, the onset of mumps is sudden, with chill, rarely rigor, sometimes vomit- ing, and well-marked fever ; often only a few hours before pain and swelling begin in the parotid or sub-maxillary glands. One restless night follows, either from pain, or from fever, or both. Sometimes the pain is severe, and the temperature only elevated by one degree ; sometimes the fever is more evident. It generally reaches 100° or 101°, and frequently rises to 103° or 10-1° ; at this point ic is not long maintained, but subsides as the local lesion is established, falling to the normal, or even below it, on the third or fourth day of the disease. The temperature may be low while the swelling is still marked and painful ; and in some cases appetite returns before eating is easy. This happens when the patient is kept at rest in bed. Without such precaution sudden and great ele- vations of temperature occur at the end of the first week, either without serious local mischief, or with orchitis, deafness, tinnitus of one ear, and albuminuria, not always transient; rheu- matism, and heart-affections, leaving traces both of pericardial and of endocardial inflammation, may also occur. From face-ache and enlarged lymphatic glands, the sudden sensation of pain or stiffness in the parotid or submaxillary gland, following on the general symptoms, and absence of any such local trouble as usually affects the lymphatics, together with the history of a possible infection, will gene- rally suffice for the diagnosis of mumps. Fur- ther evidence is obtained on examining the spot, where, besides the swelling being at first deeply seated, some degree of swelling of the parts surrounding the gland exists near the lobe of the ear, which very soon thereafter increases to such an extent as to involve more or less the whole of one side of the face, and passes down on to the neck. Coincidently with the appear- ance of this enlargement, the pyrexia declines in some cases ; while in others some days ela'pse before the subsidence of the fever. Pain is now complained of, and the patient can no, longer open his mouth to the usual extent. Yawning excites severe pain ; in fact, it can hardly be effected. The yawn is aborted. So with masti- cation and speaking — they are greatly impaired, and the sufferer prefers to starve and to remain silent rather than endure the pain involved in the effort to perform either act. The saliva is either largely increased, going the length of salivation, or much diminished in quantity. If pressure be made over the swelling, the patient quickly indicates the unpleasantness and the pain of the proceeding ; and the sensation afforded by manipulation is that of an elastic tumour, with a slightly softer feeling in the centre. The skin 1010 MUMPS. MUSCLE VOLITANTES. over the swelling may be slightly reddened; often there is no deviation from the normal colour. In many cases these symptoms are not nearly so severe, and the disproportion between the amount of distortion of the countenance and the actual suffering is sufficiently astonishing, as well to the patient as to the sympathising friends. Most frequently the affection is limited to one side of the face ; but as the swelling of the one side subsides, the other seems to take it up, and it runs through the same series of events, with, possibly, an interval of a few days between them. Rarely are the two sides simultaneously affected; but in such a case the uneasiness, pain, and dis- comfort are of course greatly increased. After the continuance of these symptoms for about six or eight days, they begin to abate, the oedema lessens, the pain is lost, the stiffness and tension disappear, and in a few days later the face acquires its usual appearance. Occasionally there is left., for some time after this, a certain degree of hardness in the neighbourhood of the parotid, which gives no uneasiness, and can rarely be mistaken for tumour. In like manner the history of the case will disclose the nature of other local pains, or of orchitis. Not uncommonly, especially in young subjects, a ‘metastasis’ takes place from theparotid gland to the testicle in boys, and to the mammse or ovary in girls. When this occurs, and it may happen at any period of the disease, an exacer- bation of the fever takes place, and at the same time pain in the inguinal region is complained of. An examination of the parts reveals the fact that there is swelling of the testicle, an orchitis, as well as an accompanying oedema of the scrotum. In the case of the girl the vulva becomes the seat of the oedema, and on pressure over the region of the ovary pain is elicited. The meta- stasis may take place before the inflammation of the parotid has entirely subsided ; and when the orchitis abates, the parotid may again take on the inflammatory condition. Inflammation of the coverings of the brain is to be feared on sudden subsidence of the inflammation of the parotid, if no orchitis follows the disappearance of the original affection. Prognosis. — This is almost invariably favour- able in mumps, unless in the very weakly and in the tuberculous, or in the rare event of meningitis being developed. It may be said to be always a disease of a comparatively trivial nature, pro- ducing considerable pain and much discomfort, but not endangering the life of the sufferer. In very exceptional instances the inflammation of the parotid terminates in abscess. The indica- tions of such an untoward result are increased pain in the centre of the swelling, hardness, and dark red appearance of the skin over the spot. In time the abscess discharges outwardly, or into the external auditory meatus. Atrophy of the testis sometimes follows ‘metastatic’ orchitis. Treatment. — It may not, in every case, and at all seasons, be necessary to confine a patient suffering from mumps to his bed. But little treatment, beyond rest and care for the week or ten days this disease lasts, is required ; still it is more prudent for the first few days to enjoin rest in bed. This is particularly necessary if the pa- tient be young. In every case going out into the open air should be forbidden, and the patient recommended to keep as much as possible to one room. Rise of temperature means increased waste, and this is cancelled by rest. The bowels may require relief, as constipation keeps up distur- bance of the temperature. All active evacuants should be avoided. It may be well to give some simple saline, as potash with lemon juice, and diluents during the first few days; ice is always grateful. A dose of chloral may be required at night (a grain for each year of the patient’s agf in children) if there he any restlessness. As to local treatment, not much is required unless the pain be unusually severe. It wil be sufficient in most cases to protect the par from the air by means of a light handkerchief Should more active interference be called for some anodyne may be used, or soothing embro cation, such as the soap and opium liniment belladonna liniment, or external warmth; dis cretiou in the use of these may safely enoug be left in the hands of the patient himself, if c mature years. If there be the slightest tendene to suppuration, indicated by increase of fever an tenderness over the gland, with redness of tl overlying skin, poultices must be had recourse ;< and so soon as distinct fluctuation is discovert the abscess must be opened, otherwise the glam tissue becomes still further disorganised, tl lobules become softened and break down, and tl gland is permanently destroyed. The applicatie of leeches is useless in reducing the inflammatio: or in staying the formation of the abscess. Tb may be of service in lessening the pain of met static orchitis or ovaritis ; but these are w treated by the same gentle means employed in t case of the parotid itself. It is almost universal recommended in the case of a metastasis to t to induce a return of the inflammation to original source, by the application of irritai to the parotid, such as a mustard poulti This seems unnecessary in the majority of stances, as the inflammation is of such s m type ; besides it implies a belief in the dicti that this is a true metastasis, and not men another manifestation of the same morbid con- tion which originally gave rise to theparoti- Tepid sponging is of use during the course! the disease, and a warm bath, or a pediluvii. may be required when metastasis threats. Sometimes wine or brandy is required. Considerable ansemia and much debility rf persist even when mumps has been mild ins course, especially in the weakly or unhealf. so that tonics, with iron and cod-liver oil, iy have to be continued for some time. C. Mcibheai MURMUR.— This term, as used in ausem- tion. was originally applied to the natural sods heard over the iungs in respiration ; but -s employment has since been extended to inefe a great variety of auscultatory sounds conDe c with the heart, the blood-vessels, the places, &c. See Physical Examination. MU SC-23 VOLITANTES (musca, a volitatis, floating about). — This name is give") the semi-translucent threads, spots, circles . 1 filaments that may be seen, subjectively, to_at and glide about over the field of vision. A' MTJSC^: VOLIT ANTES, form the spectrum of the vitreous humour, and may be seen by every eye. They are stirred up end brought into view whenever the eye is suddenly moved ; and when the eye is fixed •they continue to float about for a time, then gradually subside, and seem to sink down below and away from the axis of vision. True muses volitantes have no pathological significance, and Lrenot visible objectively. They are, however, aot unfrequently associated with some error of refraction, or with disturbed states of cerebral ■irculation. See Vision, Disorders of. MUSCLES, Diseases of. — Synon\ : Fr. naladies des Muscles; Ger. Krankheiten der ifuskil. In describing the diseases of the muscular issue attention will be confined to the voluntary iuscles, excluding diseases of the muscular pbstance of the heart, which are treated of Isewhere. Many of the morbid states of the pluntary muscles come properly under the con- deration of the surgeon, and others of them will e more suitably treated of in special articles on jie various diseases of the nervous system with jhieli they are associated. There still remain, owever. some special diseases of muscles to be escribed. 1. Acute Inflammation. — S tnon. : Myo- :is. — Ordinary inflammation of muscle, lead- ig to exudation and suppuration, arises chiefly a result of injury, rupture of a muscle, or tension of inflammation from neighbouring seased bones. Inflammation sometimes, how- er, arises spontaneously, particularly in the igue, diaphragm, and psoas muscle; in the ter situation forming one variety of psoas ■iscess. The symptoms are pain, tenderness, d swelling, corresponding to the seat of the : 'animation. Exudation of serum and of lymph lies place, and subsequently an abscess may f m ; occasionally the process goes on to gan- line. ■Secondary inflammations and formations of 1 are of more frequent occurrence than simple i animation and abscess. They arise in the c.rse of the various forms of pyaemia. The (■sence of such secondary abscesses in muscles -specially characteristic of glanders and farcy, ^ re inflammatory infiltrations of various sizes a :ar in many of the muscles, especially those °|he arm. Disintegration takes place in their «,re,and a collection of puriform fluid results. Chronic Indurating Inflammation. — i his form of inflammation there is prolife- rs n of cells in the interstitial tissue, causing th muscle to become hard and painfiil. The tv'e muscle may be attacked, or the pro- ce l may be limited to one or more portions. In 1 its are often attacked by chronic inflamma- tiepf the sterno-mastoid muscle. The whole mi|le becomes hard and painful, but rarely sup- plies. The disease usually yields to soothing oal applications ; but if it be of syphilitic on i, the use of internal antisyphilitie remedies mijbe required. In adults chronic indurative mjj tis of a syphilitic character may occur in the :erno-mastoid, the various muscles of the log d arm, the temporal and masseter muscles, MTJSCLES, DISEASES OF. 1011 the tongue, and other parts. The disease may appear either as a diffuse inflammation, with the usual signs of pain on movement, tender- ness, and some swelling, or sometimes a series of beaded swellings ; or as a circumscribed in- flammation, with an abundant infiltration of nucleated cells. If the inflammation does not soon subside, the cellular exudation becomes or- ganised into contracting fibrous tissue, and the compressed muscular fibres atrophy. In diffused myositis permanent contraction of the muscle may result from this cause ; in circumscribed syphib’tic myositis a fibrous tumour in the in- terior of the muscle may result ; sometimes a gummy tumour is formed. Syphilitic tumours thus formed in muscle bear a great resemblance to malignant tumours. Indeed it is often found that the only means of distinguishing the two clinically is by the effect of iodide of potassium in causing the disappearance of the former. 3. Rheumatic Inflammation. — The morbid changes in this form of inflammation rarely pass beyond the stage of congestion and serous exu- dation, though occasionally proliferation of the interstitial tissue may occur, and callosities may be formed. See Rheumatism:, Muscular. 4. Haemorrhage. — Haemorrhage takes place in muscle not only from injury, but frequently in the course of typhus and typhoid fevers and pyaemia. 5. Rupture. — Rupture of muscle is a subject which falls more properly into the domain of the surgeon, but the accident occurs also in circum- stances which may bring it under the notice of the physician. Violent contraction of a muscle, without external injury, may lead to partial rup- ture of its fibres, for example the gastrocnemius. The violent spasms of tetanus occasionally cause complete rupture of a muscle, particularly of the muscles of the back, the' rectus femoris, and the psoas. Rupture of muscles has been known to occur in the delirium of fever ; and may be the cause of abscess forming in muscle, as de- scribed above. Teeatment. — The treatment of ruptured muscle consists mainly in rest ; in the support of the muscle by uniform bandaging; and in suitable applications, should the formation of abscess occur. 6. Lesions of Sensibility. — a. Myalgia . — This term was given by the late Dr. Inman to a painful condition of the muscles arising in those who are in feeble health. The pain is similar to that which is present in a muscle after long-continued and fatiguing exertion— for example, in the limbs after a long walk, or in the diaphragm and intercostals after violent laughing. In persons who are debili- tated, pain may arise in the muscles after very slight exertion, and this constitutes myalgia. It is often accompanied by cramps at intervals. The pain is most commonly felt at the tendinous insertion of the muscle. The abdominal muscles are frequently the seat of myalgia, such as the costal origin of the external oblique — causing, according to some authorities, that pain in the side which is so common in women — and the pubic insertion of the recti. The muscles of the back, and especially the trapezius, also suffer; the muscles of the limbs much less frequently 1012 MUSCLES, DISEASES OF. When situated in the trunk, myalgia is often mistaken for some congestive or inflammatory condition of the liver, spleen, or other viseus lying beneath. The pains of myalgia are dis- tinguished by their hot and burning character. They are increased by exercise of the affected muscle, and disappear -when it is relaxed or artificially supported. However severe the pain may be, the pulse remains unaffected ; but it is usually uniformly weak and fast. The muscles or their fibrous connexions are also the seat of pain in the condition known as muscular rheumatism. Treatment. — The muscles should have rest and support by bandaging. Tonic treatment is required. Dr. Inman especially recommended cod-liver oil and tincture of perchloride of iron. Friction and counter-irritation do little good. Exercise is of no use, unless combined with fresh air and good diet. b. Muscular anesthesia. — This term is given by Dr. Russell Reynolds to a group of symptoms occasionally met with, and believed by him to be caused by loss of the ‘ muscular sense.’ See Muscular Sense, Disorders of. 7. Atrophy and Degenerations. — a. Sim- ple atrophy. — Simple atrophy of the substance of muscular fibres arises either from general de- fective nutrition, during the course of wasting diseases, such as phthisis, in cachectic conditions, or after severe fevers; or as a local condition from disuse of the muscle. The muscles become pale and flabby. The ultimate fibres are re- duced in volume, but preserve their anatomical characters, still showing the longitudinal and transverse striation. The atrophy is sometimes so advanced in parts, that the muscular substance of the fibre entirely disappears, and nothing is left but the sheath of the sarcolemma, which appears in the form of fibrous bands between the remaining muscular fibres. As a local condition, atrophy is most fre- quently seen in muscles in the neighbourhood of a diseased joint, or in a paralysed limb. In these cases the atrophy is usually combined with more or less interstitial deposit of fat between the ultimate fibres, constituting fatty growth on or infiltration of muscle. Occasionally the amount of fat, is so great as to cause an actual increase in bulk of the muscle, so that it appears hypertrophied. The atrophic and other changes arising in paralysed muscles are considered in their appropriate articles. Fatty infiltration of muscles may also arise as a primary condition, when there is an excess of fat in the blood, and atrophy of the muscular substance results from it. b. Fatty degeneration. — Here the fat is depo- sited, not between the ultimate fibres, as in fatty infiltration of muscle, but in their interior. Rows of minute granules appear in the longitudinal striee, and gradually increase until the whole breadth of the fibre is occupied by them, and nothing is left but the sarcolemma. When the degeneration reaches this extent, it is of course irrecoverable. Muscles affected by this change become very soft and friable. This degeneration is met with much oftener in the heart than in voluntary muscles. It is sometimes associated with atrophy of the fibres in the muscles of limbs attacked by certain forms of paralysis. MUSCULAR HYPERTROPHY. It is met with also in fever and phosphorus, poisoning, granular degeneration being the first stage. See Fatty Degeneration. c. Granular degeneration. — Granular degene- ration of muscles occurs in fevers and acute diseases. The ultimate fibres become swollen and opaque, being filled with fine grannies. These clear up on the addition of acetic acid ; this test distinguishing granular from fatty de- j generation. The muscles which are affected bv| it are soft and friable and easily rupture. The' fibres no doubt ultimately recover their natural appearances; but if the disease be severe and long-continued, granular degeneration advances to fatty degeneration, as is seen in cases of; phosphorus-poisoning. d. W axy degeneration ; Vitreous degeneration Myositis typhosa. — This degeneration, which was discovered by Zenker, is believed to be partly a; post-mortem change. The affected fibres swell and lose their striation ; and become of a homogene- ous translucent aspect. After a time transverst fractures appear in each fibre, dividing it ink a series of short cylinders. The nuclei of the sarcolemma also multiply. The change doer] not attack all the muscular fibres of a pari uniformly; for healthy and degenerated fibre- are seen side by side. It is observed chiefly ii typhoid fever, cholera, and other acute febril diseases, being often associated with the granula degeneration. It usually attacks the adducto muscles of the thigh, the abdominal and pectora muscles, and the diaphragm ; appearing i patches of one or more square inches, whic gradually become softened and pulpy, and re semble a muscular abscess (Wilks and Moxon See Degeneration. e. Fibroid degeneration . — Fibroid degeneratia of muscle has already been referred to as a resu of myositis. Chronic or repeated inflammatio: of a rheumatic or syphilitic character, leads the formation of fibrous tissue in muscle, and tl muscle becomes of a tough whitish character. f. Ossification. — Ossification of muscle is rare result of chronic inflammation or irritatic It is observed to occur in muscles which a subject to pressure, as the deltoid in soldie and the adductors in riders. In a few cases os fication of a considerable number of the muse’ has taken place. 8. Tumours. — Besides the syphilitic, fibro’ and gummatous tumours already referred muscle is subject to growths of a sarcomatc and cancerous nature. Fatty, cartilaginous, v cular, and other tumours, are also met with' this tissue, but rarely. 9. Parasitic Affections. — The chief disec of muscles belonging to this group is that <3 to the presence of trichina ( sec Trichinos . The cysticcrcus cellulose is also sometimes fold in muscles. See also Pelodeba. Alexander Datidso: MUSCULAR ATROPHY, PROGBP SIVE. See Progressive Muscular Atrof' MUSCULAR HYPERTROPHY. — n increase in muscular tissue, affecting either.e voluntary muscles, or the muscular tissue)! special organs, such as the heart, the inteste, or the bladder. True muscular hypertrophy b=i MUSCULAR HYPERTROPHY. lot be confounded 'with an increase in the res- ume of muscular structures from hyperplasia of he connective-tissue elements. See Hypertro- phy; and Pseudo-htpertrophic Paralysis. MUSCULAR RHEUMATISM.— A form if rheumatism affecting the muscles. See Rheu- iatism, Muscular. MUSCULAR SENSE, Disorders of. — ly the term ‘ muscular sense ’ is meant the sen- ation by which we are aware of the degree of orce exerted by contracting muscles. By it we .ecome conscious of the resistance to contraction, hat is, the tension of the fibres, rather than of he contraction itself. This sense must be dis- inguished from the 1 common sensibility ’ which luscles possess, and by which we feel — (1) pain n firm pressure ; and (2) pain on tetanic con- '■action, whether spontaneous (‘cramp’), or ex- : ted by faradisation, independently of the ex- itation of cutaneous nerves, as when the skin is isensitive or absent. It must also be distin- nished from (3) the sense of muscular fatigue, (he muscular sense proper has been referred to sensation in the joints, skin, and other parts, f the position of the limb, but it may be un- upaired when this sensation is lost {see Kin.es- ^esis). It has been thought to be merely the msciousness of the degree of the out-going otor-impulse, but it may be lost when motor fewer is normal, as in a case under the obser- ition of the writer, in which the muscular nse was suddenly lost in one arm, although e power was unimpaired. A poker did not em heavier than a feather. The sensibility •obably depends upon afferent fibres, which ive been found by Tschiijew to terminate be- een the fibril]®. They apparently course with e motor fibres in the mixed nerves, but pass the spinal cord in the posterior roots. From Je fact that the common and special sensibility muscles may be lost in different degrees, it s been conjectured that in the cord the paths e not quite the same. Hypermsthesia. — Increase of the common isibility of muscles is not unusual, but very tie is known of that of the muscular sense. The isation of restlessness, impelling movement, s been attributed to it, but without sufficient ison. An increase of the muscular sense has ■o been supposed to exist in writer's cramp 1 chorea (Eulenberg). Anaesthesia. — Diminution of common sensa- n in muscles is frequent, with or without loss voluntary power. Diminution of the special ; isibility, muscular anesthesia , or muscular hlgesia, is occasionally observed, commonly in 1 isequenee of central disease, especially of the : Dal cord, and is usually associated with a ciitution of other forms of sensibility. The \ eases in which muscular an»sthesia is com- i nly observed are locomotor ataxy and hys- ba. In the former it is common, but not in- ‘iable, and bears no necessary relation to the 1 nge in cutaneous sensibility. Iyhptoms.- -In muscular an®sthesia the pa- id is unaware of the degree of force exerted 1 the contracting muscles, and is dependent for 1 knowledge of the position of his limb, and ( its movements mainly upon cutaneous im- MUSHROOMS, POISONING BY. 1013 pressions. Ignorance of the degree of contraction interferes with muscular coordination, by ren- dering this dependent on cutaneous and ocular perceptions. When these are perfect, the amount of incoordination may be slight. The condition of the muscular sense is ascertained by observing the accuracy of movement with and without clo- sure of the eyes, and especially by ascertaining the sensitiveness to movement against resistance so applied as to affect the cutaneous nerves as little as possible. The best method for this pur- pose is to suspend a weight, in a bag or cloth, to the limb, and observe (a) the minimum which can be recognised; and ( b ) the least increase in a greater weight which can be distinctly perceived. The sensibility of the two limbs may be con- veniently compared. In each of these points the muscular sense may present a deviation from the normal, and the change in the two is not always proportioned. The minimum recognisable, and the minimum difference recognisable, vary in different parts. The latter amounts in the case of the arm in health to a difference of ^th in a weight of three or four pounds. Balls of similar size and appearance, but of different weights, have been employed for the same purpose. Treatment. — Muscular anmsthesia usually occurs as part of a wider affection, as in hysteria and ataxy, and rarely requires special treatment. Sudden local loss of muscular sense commonly depends on an acute, localised change in the cord, and requires rest and counter-irritation. In one case under the writer’s care, such a condition in the arm rapidly passed away under this treat- ment. Faradisation of the muscles has been suggested, and may in some cases be useful. W. R. Gowers. MUSCULAR SPASM. See Spasm. MUSCULAR TIC. — A synonym for facial spasm. f a muscle. See Muscles, Diseases of. MYXCEDEMA {pvt,a, mucus, and otSuipa, , swelling). Definition.— A name given by the writer f this article to a progressive disease, in which (he tissues of the body are invaded by a jelly- ike mucus-yielding dropsy, unaccompanied by dbuminuria or other signs of primary affection f the kidneys. ^Etiology. — Beyond the almost invariable ssociation of this disease with the period of dult life in women, no indications of its mode If causation have been recognised. In the fif- teen or sixteen cases so far fully recorded, alco- olism, syphilis, and fevers, are, as causes, e Al- luded by the history. More married than single 'omen are affected. Pregnancy has in one or svo cases been followod by the first appearance f the change. Anatomical Characters. — Hitherto only two odies of persons dying from this disease have sen examined. The results were identical in lese two. A remarkable overgrowth, associated ith a sort of retrograde degeneration, of eon- Bctive tissue was found in all parts of the )dy. The fibrillar element of ordinary connec- ve tissue was everywhere increased, and its ements unnaturally defined ; the corpuscular ements were enlarged and multiplied; the terstitial cement enormously augmented. In irmal tissue this latter element yields some 'ucin. The skin in myxeedema yields many mdreds of times as much mucin as ordinary or asarcous skin. To such amplification and mucous infiltration e skin owes its swelling, its translucency, and ) defect of secretion. The same sort of inter- nal expansion is found in the mucous mem- janes, in glands of all kinds, in muscles, and in e central ganglia of the nervous system, sub- ctingthe proper structural elements of each tis- e to destructive pressure. It is most developed all, perhaps, in the outer coat of arteries. The uinution of the thyroid is associated with an nost complete annihilation of the proper gland- ucture by this stuff ; and the late occurrence albuminuria marks the advanced progress of inroads on the Malpighian bodies and tubules, hether the mental failure of the last stage be 0 to the operation of similar changes in the MYXCEDEMA. 1015 brain, is not a matter upon which a decision is at present possible. There appears to be a general increase of neuroglia, and a very con- siderable development of the connective tissue around all the vessels. On the other hand, the appearances seen in sections of the central gan- glia are not those of disseminated sclerosis. Symptoms. — Tho subjects of myxeedema are, some doubtful cases excepted, always adult fe- males, who present a very characteristic physio- gnomy. The face is swollen in every feature, so as to suggest the existence of renal disease. But while the negative results of a complete exami- nation dispel this idea, the distribution and quality of the swelling are different from what is observed in common dropsy. The swollen skin i« singularly waxy-loolcing and anaemic ; and the swelling affects dependent and non-dependent features equally. Thus the upper and lower eye- lids, and the upper and lower lips are uniformly enlarged ; the aim nasi are thickened and broad- ened ; the ridges of expression are blurred and coarsened, or the lines obliterated. The oedema is resilient; does not pit on pressure ; and shows, as the foregoing statement indicates, no ten- dency to shift by gravitation. Tho cheeks are overspread with a dull pink flush, abruptly limited towards tho orbits, and standing in vivid contrast with the anaemic skin around. The conditions observed in tho face prevail throughout the body. The skin is everywhere thickened, translucent, dry, and rough to the touch ; perspiration being infrequent or absent. The hands, in particular, lose all shapeliness and expression, and have received from tSir William Gull the appropriate epithet, ‘spade-like.’ All visible and tangible mucous membrane is simi- larly amplified. Late in the disease ordinary anasarca is often added to the mucoid oedema. Two other noteworthy phenomena are met with in tho external examination of the body ; first, a diminution, sometimes almost a disappearance, of the thyroid body ; and secondly, a correlated tumefaction, with marked resilience of the skin, in the lower triangle of the neck, above the clavicle. An affection of the nervous system as well marked as that of the skin, belongs to myx- eedema. In the earlier stages an ever-increasing hebetude involves sensation, voluntary move- ment, and intellect; in the later, aberration of mind often supervenes. The face wears a fixed, heavy, and withal most sad expression ; the speech is slow and laboured, though not slurred or slovenly ; the voice monotonous, like that of an automaton, and leathery in tone. Sensation is slow, but finally sure. The movements of the limbs are slow and languid ; the mainte- nance of fixed attitudes requires much effort ; and sudden falls are not infrequent. It ap- pears as if the muscles were toneless and ex- cessively relaxed during rest, so that a con- siderable initial contraction is necessary before they bear on their attachments ; and as if the muscular sense were also torpid. The result is that while there is neither jerking nor tremor of the legs in walking, the balance of the body is painfully maintained, as the weight is thrown on each leg in succession ; and a quiver often runs through the body at the moment of raising one foot from the ground and balancing tho body on 1016 MYXtEDEMA. the other. This tardiness of coordination is altogether different from the vague staggerings and jerks of locomotor ataxy, and from the rhythmical tremors of disseminated sclerosis. And it must be remembered that there is no real loss of muscular power, no ■wasting of mus- cles, and no loss of sensation. Laxity of muscles at rest gives rise to drooping of the head on the chest in some cases ; in others it has led to fracture of the patella, by allowing, first, a yield- ing of the extensors of the leg, and then a sudden arrest of the consequent fall. In the operations of the intellect, thought and volition are again slow. All the patients ob- served have complained of being unable to per- form any of the daily actions of life with their natural expedition. Yet all that they actually do is well done, and they are acutely conscious of their shortcoming in activity. In conversa- tion ideas come deliberately, and are tardily expressed. To write a letter occupies an hour where it would before have taken ten minutes. Yet the language is correct, and the caligrapby unchanged. There is, in fact, an unwieldy state of mind as of body. The difficulty of collecting thoughts gives an early impression of loss of memory. This, in fact, occurs late in the dis- ease, when other aberrations are developed. Two affections of the special senses apparently related with changes of the periphery are often noticed— one a persistent unpleasant taste, some- times of bitterness, sometimes of sweetness, &e. ; the other a persistent unpleasant smell. Other- wise the special senses show no defect save tar- diness. The hair is often scanty, and the teeth decay early — conditions no doubt related with the changes in the skin and mucous membrane. The heat of the body is almost always lower NAILS, DISEASES OF. than normal, ranging between 98’ and 94° Fahr. or even less, ilost patients complain of con- stant chilliness, without appearing to estimate at all readily changes of external temperature The viscera give no signs of organic affection in the beginning of the disease. The urine is usually increased in quantity; lowered in sp e . eific gravity ; and contains no albumin, sugar, oi casts. The uterine functions go on as in health As the affection advances various indications of damage to viscera are declared, and the urine is generally albuminous in the last stage. Then also, together with all the indications of great general debility, the mind often becomes un- hinged. Lethargic good temper is exchanged for moroseness, fretfulness, irritability; delusions or hallucinations often follow; and there is a speedy lapse into coma. Death comes either bv coma, or with the signs of ura-mic poisoning, or by inanition. Prognosis. — The progress of the disease is not readily affected by any remedy. The prognosis is altogether unfavourable ; the duration of ob-i served cases has been from six years upwards Treatment. — Something may be done by keep- ing the patient carefully sheltered from the cold; something by tonics ; something by good food Though these will not cure they will at least help the patient to bear her sufferings better. Of lat the writer has found in two cases benefit from th use of vapour baths. In three others unde! the prolonged use of jaborandi the signs of myx cedema have almost disappeared. Ten to six:- minims of the fluid extract may be given fou times daily. Nitro-glycerinehas benefited one case Dr. Andrew Clark regards the disease as fairi- curable by careful diet, iron, arsenic, baths, and assiduous frictions. 1 Wileiasi M. Onn. N N-ffiVUS. See Tumours. NAILS, Diseases of. — S ynon.: Fr. Maladies des Ongles ; Ger. Krankheiten der Nagel. Onyehopathic or ungual affections admit of a division into — (A.) Diseases of the nail proper ; and (B.) Diseases of the soft parts in immediate relation with the nail. Under the former head may be considered alterations of colour, texture, figure, and develop- ment ; and under the latter, affections of the walls of the nails and inflammation. ./Etiology. — The nails, in consequence of their position, are more than usually liable to injury from undue pressure, from blows, and from foreign bodies forced beneath them, such as splinters of wood, pins, and nails. The great vascularity and sensitiveness of the tip of the fingers and toes, and the close adhesion of the bed of the nail to the deeper structures, are at the same time predisposing causes, and causes of greater intensity of result. Syphilis, struma, eczema, psoriasis, and gout are also causes of onychia and paronychia. A. Diseases of the Nail Proper. — 1. Colour. In colour, the nails, which are naturally clear and translucent, may be brownish or greyish. and dirty in appearance ; or they may be opaqr in round and circumscribed white spots, or i patches of greater extent. The small, whit opaque spots are termed fores unguium or mn dacia, hut when of greater extent and producin a more general whiteness, seiene unguium. Tb transparency of the nails admits of stains in tl derma being visible through them, and these ai not to he confounded with discolouration of ti nail itself. Stains of this kind result from tl development of psoriasis or of syphilis beneat the nail, as also the diffusion of pus and bloo< the latter constituting ccchyrnoma unguium. 1 Since the above was written, many cases of tb disease have been described by observers in England m F rance, but the condition appears to be rare in German These additions to our knowledge make it evident tb more men are affected than the earlier observations i dicated. Several cases of a typical kind in which mal were the subjects have been fully described ; and I Andrew Clark has stated that in his experience mal have been the more frequent sufferers, namely, in abo the proportion of seven to three females. Recent obst rations again bring out more strongly the fact that t central organs of the nervous system are affected, many cases to a large extent, by the destructive incros of the connective tissue element. Marked bulbar paraly has been observed in two cases. Dr. Mahomed has argu strongly in favour of the identity of myxoedema wt Bright’s disease. NAILS, DISEASES OF. 2. Texture. — In texture the nail-substance nay be hard or soft, thick or thin, brittle or flexible, uneven and rough, or fibrous. Thick pail may be the simple consequence of more ictive production of nail-substance, and in this ■espect may be contrasted with the thin nail ; or t may result from interference of growth in ength, which enforces the apposition of lamina ifter lamina to its under surface, until a thick horizontal mass is formed, or, if it be lifted from •ts bed, those elongated, horny, and twisted ylinders which resemble horns rather than . 'ails. A third kind of thickening of the nail re- mits from the formation in excessive quantity fa coarse, lamellated cell-substance on the bed f the nail, which lifts the horny plate into a oblique and almost perpendicular position, nd gives it the appearance of a claw. This tate of the nail is termed gryphosis or onyclio- ryphosis, and is often the first stage of the orn-like nail. Hardness of texture of the nail may retain its uality of toughness, but is more frequently ssociatcd with brittleness to a greater or less stent. In the latter state there may be several mgitudinal cracks or fissures in the nail, sink- ag as deeply as the vascular corium, and the mgitudinal fragments may themselves be trans- ersely fissured and broken. I Softness of the nail is accompanied with flexi- lity ; and the degree of the latter quality will 3 governed by the degree of density of the irny plate. In some instances the covering oi '6 matrix and bed of the nail more nearly sembles epidermis than horn, and may be taken i represent an absence of the nail, or alopecia igualis. Usually smooth and polished on its trface, the nail may be rough , sometimes appa- intly fibrous, sometimes crossed by shallow •ooves or deep fissures, and sometimes fretted ■ eroded as if it were worm-eaten. These irious appearances have suggested the terms sura and tinea unguium, as likewise, scabrities, fadatio, and degeneratio. 3. Growth. — The condition of the nails has re- tion to the state of the system generally, as it well known that they undergo an impairment growth during illnesses which affect the nutri- ye function of the organism. In the case of enail this is exhibited by a deficient formation horny matter, which results in the production a groove across the nail ; and it has been own by Dr. Wilks and Dr. Beau, that if the to of growth of the nails be ascertained, the riod and duration of the illness may be deter- ned by the position and breadth of the groove. 4. Figure. — Aberrations of figure of the nails 5 exemplified in the broad, thin, curved nail dch is met with on the club-shaped fingers of 'uina, and which has received the name of guis aduncus; in the longitudinally contracted I prominent nail termed keel-shaped, arctura ■ guis or gryphosis ; and in the depressed, or h-shaped nail, which looks as if it were tied tvn in the centre and forced upwards at the cumference. 5. Development. — Errors of development of P na 'h giving rise to supernumerary nails, almost entirely restricted to tho bifid or ible nail, which is associated with a broaden- 1017 ing and tendency to bifurcation of the last phalanx. 6. Parasitic Affections. See Tinea. B. Disorders of the Connected Soft Parts. — Disorders of the soft parts connected with the nail, assume the forms of errors of growth, and inflammation. 1. Errors of Growth. — The epidermis which borders the posterior wail of the nail, and is nor- mally adherent to its surface, is apt to be drawn forward with the growth of the nail, and become stretched over its surface as a thin film, which has been likened to a wing, and has received the name of pterygium unguis. At other times this border of cuticle splits up into narrow shreds, some of which separate from the nail and curve backwards. In their abnormal position they are liable to become torn ; and when the tear, as is usually the case, extends to the corium, there is bleeding and pain, and sometimes inflamma- tion. This is the affection which is known by the term agnail, derived from the ancient Saxon word, ange, signifying ‘ angry.’ 2. Onychia. — Inflammation of the end of the finger, involving the soft parts surrounding and beneath the nail, is termed onychia ; but when the inflammation is limited to one or other of the walls of the nails, the case is one of paronychia. Onychia presents the ordinary characters of inflammation, modified by extent and degree ; by the anatomical construction of the p>art ; and especially by the constitution of the patient. Hence we distinguish a common, a strumous, and a syphilitic onychia ; the first probably issuing in suppuration with loss of the nail, the second ir. prolonged ulceration withfungous vegetation, and the third in deep ulceration. Common onychia is intensely painful, and more rapid in its course than the specific kinds. Sometimes the inflam- mation is so severe as to destroy the vitality of the bone. The strumous and syphilitic forms of onychia are sometimes associated with much swelling and congestion of the finger-end ; and have probably been described as onychia maligna. 3. Paronychia. — Paronychia, or inflammation of the walls of the nails, sometimes presents itself in an acute form, as in the painful abscess termed panaris or whitlow ; sometimes as a chronic inflammation of one of the lateral walls of the nail due to pressure against the border of the nail, termed ingrowing nail ; and some- times as a chronic thickening of the posterior wall, which, becoming everted and prominent, is termed ficus ungualis. Tbeatjient.— A prophylactic of the slighter forms of disorder of the nails, is the bestowal of some care and attention on their culture, to pre- vent them from growing too long; to prevent the epidermis growing forward on the back of the nail ; and at the same time to avoid the loosening of this fold and pressing it back too forcibly. Onychia and paronychia must be managed according to the general principles of treatment of inflammation. If tho cause be obvious, such as the presence of a foreign body or an ingrow- ing nail, these irritants must be removed. In acute idiopathic onychia, position, pressure, and cold applications are appropriate to its primary stage ; and water-dressing or poultice if the pain should be severe. Where the issue is by abscess, 1018 NAILS, DISEASES OF. as in ■whitlow, the first appearance of the pale disk which represents pus should be looked for, and a puncture made to give it exit; whilst chronic inflammation and ulceration are to be treated with stimulant applications, the former with linimentum iodi, the latter with the com- pound tincture of benzoin and unguentum resin® ; possibly with lunar caustic. Where an ingrowing nail keeps up a parony- chial inflammation, the body of the nail should be thinned by scraping to diminish the force of pressure ; and by a little manoeuvring, a director may be introduced, beneath tho border of the nail, and the edge cut away with a pair of scissors. A minute compress of cotton-wool should then be passed beneath the adjoining part of the nail, so as to direct the ingrowing point upwards and outwards. As a last resource, avulsion or some other surgical procedure may be found necessary. Its appropriate treatment is removal of the diseasednail,and dressing with powdered nitrate of lead or*a lotion of liquor arsenicalis. Syphilitic, strumous, eczematous, leprous, and gouty onychia and paronychia, besides the or- dinary treatment applicable to inflammation in general, will call for specific constitutional and local treatment, for example, iodide of potas- sium and blackwash for syphilis ; cod-liver oil, iron tonics, and nitrate of silver for struma; arsenic for eczema and psoriasis; and colchicum, inter alia , for gout. Erasmus Wilson. NAPLES, in South Italy. — Changeable climate. Mean temperature, winter, 48° Fahr. Cold winds in spring. Sec Climate, Treatment of Disease by. NARCOSIS 1 , , T1 , ... NARCOTISM / {mpK6 “' 1 become tor P ld )' A condition of profound insensibility, due to the introduction of certain poisons, or excessive doses of certain drugs, into the sj'stem, such as opium or alcohol ; or to the retention there of certain oxeretory elements, as in uraemia. Sec Consciousness, Disorders of ; and Narcotics. NARCOTICS (vapKow, I become torpid). — - Synon. : Fr. Harcotiqucs ; Ger. Narcotische Mit- tcl. — Definition. — Remedies which promote or artificially imitate the natural physiological pro- cesses of sleep ; but which in large quantity produce complete insensibility. Enumeration.- — A convenient division of nar- cotics, in the limited sense of hypnotics, may be made into (1) indirect narcotics, which include many soothing aud hygienic conditions, Ano- dynes, Conium, &c. ; and (2), direct narcotics, of which Opium, Chloral-hydrate, Croton-chloral, Bromide of Potassium, Hyoscyamus, Stramonium, Belladonna. Hop, Indian hemp, Alcohol, Digitalis, and the Anaesthetic vapours are in most general use. Action. — The indirect class of narcotics have no primary influence over tho cerebral circula- tion, but act either by supplying warmth, quiet, and other tranquillising elements, or by removing some disturbing cause which renders sleep im- possible. We know how powerfully sleep is under tho influence of habit and regularity; how an excess of heat or cold, an inconveniently placed NARCOTICS. pillow, or apenetrating beam of morning lightmav often produce more or less restlessness ; and the insomnia of feebleness or exhaustion may readily yield to a little nourishment, or to a well timed dose of alcohol. Rain, again, is in some indi- viduals responsible for many a wakeful hour; and! the evacuation of deep-seated pus, the extraction of an aching tooth, or a dose of quinine mav sometimes prove as effectual an anodyne as the subcutaneous injection of morphia, ora modemtei dose of opium, which stands as the type of lliisl therapeutical group. Conium may prove narcotic, by stilling the dis- orderly movements of chorea or of acute mania. Direct narcotics, on the other hand, either pro- duce some specific effect upon the cerebral grey matter, or have a very decided action on the blood-supply of the brain, and by constricting its vessels, produce that degree of anamia whiel more or less suspends its functions, and cause: sleep. In larger doses, however, an oppositi effect results, and we then see the cerebral con gestion, the livicl face, and the gradually deepen ing coma, which too surely indicate the fata termination of opium-poisoning. Uses. — Enough has been already said regard ing the general principles on which we emplo; indirect narcotics; and the tact and ingenuit- of the physician will often be severely taxed t discover the precise cause on which the want o: sleep depends. When remedies, however, of th more domestic class have been exhausted, v must have recourse to drugs, and a brief resm may now be given of the advantages and disad vantages of those remedial agentswhose soporifi qualities have been firmly established by experl ment and experience. Opium and morphia naturally stand first, an still hold their place as our most potent and r< liable narcotics, all the more valuable becansi almost alone in their class, they are also endowe with powerful anodyne action, in virtue of vliic they may reliere pain without causing sleei Valuable as it is in all forms of insomnia, opiui is especially indicated in typhus fever and oth< acute disorders, when delirium and prolong! wakefulness seem to endanger life. The princip; drawback to opium is the digestive disturbam following its use, and the fact that as toleratic is very rapidly established, gradually increasii doses are needed to cheek the counteracting ii fluence of habit. Chloral is less to be recommended in acu diseases, on account of its tendency to caul cardiac failure, but it is of essential service simple insomnia, in chronic affections where t. prolonged use of narcotics is required, and delirium tremens. In prescribing it we mn not forget its weakening action on the heart, ai on the respiratory centre, or the petechial a I other skin-eruptions which have been describ as following its use. Bromide of potassium is peculiarly well fitt to soothe the brain when rendered irritable over- work, but we must remember that it is re uncertain as a narcotic, and is apt to produce eruption, and an uncomfortable degree of mi cular weakness. See Beomism. Digitalis is of use when flaccid vessels pern a free flow of blood to the brain, thus effectua NARCOTICS. preventing sleep when the patient occupies the •ecumbent posture, the tonic influence of tiie Irug bracing up the arterial tissues, and ena- bling a due amount of cerebral anaemia to be obtained. The other narcotics may be tried when the juore potent remedies of the class fail or lose heir power ; and under certain circumstances a ombination may succeed better than simplicity. Chus chloral and bromide of potassium are more •aluable in acute mania when given together Ilian alone ; and opium and tartar-emetic are well .nown to form one of our most effectual means if dealing with some of those very intractable forms of sleeplessness which occur in the course If typhus. Robert Farquharson. NATAL, in South Africa. — Warm, but healthy climate, with hot, wet summers, and dry, lear winters. High winds from S.E. andN.W. Soil, sandstone and granite. See Climate, treatment of Disease by. NAUHEIM:, in Germany. — Gaseous ther- tal salt waters. See Mineral Waters. NAUSEA (rais, a ship, in relation to sea- sickness). — A feeling of sickness or inclination id vomit, generally accompanied by a sense of isgust or loathing, and sometimes by a feeling |f great depression. See Sea-sickness ; and 'OMITING. NAUSEANTS (rails, a ship). — Definition. gents which produco the condition of nausea. Enumeration. — The principal nauseants are Varm water, Tartar-emetic, Ipecacuanha, To- acco, Squill, and Apomorphia. Action.- — These substances produce irritation f the stomach, loss of appetite, general malaise, afeebled circulation, muscular weakness, and ■equently also salivation and sweating. Uses. — Nauseants have been employed to di- linish appetite, in the hope of causing absorption ■f fatty accumulations, or of pathological depo- ts. They are also used in producing relaxation f involuntary muscular fibre, and thus accele- iting the passage of calculi through the bile- get or the ureters. They were formerly used ■ produce relaxation of voluntary muscles, in tderto facilitate the reduction of dislocations, or > subdue the paroxysms of delirium or mania, .or such purposes, however, they are now re- aced by anaesthetics or other sedative measures, hey are still used to excite sweating. See Dia- ioretics ; and Emetics. T. Lauder Brunton. NEAR-SIGHTEDNESS. See Myopia; and ision, Disorders of. NECRO-BIOSIS (rcKpus, a dead body, and os, life). — Molecular death of a tissue without ,ss of continuity', especially seen in the various nnsof atrophy and degeneration. See Atrophy ; id Degeneration. NECROPSY (FtKp&s, a dead body ; and c oiscw, I inspect). — S ynon. : Fr. Nccropsie ; er. hcichcnschau. Definition. — The inspection of the body after lath. NECROPSY 1019 Method. — After making a complete external inspection of the body, and noticing the general appearance, rigor mortis, change of colour, whether partial or general, oedema, marks of injury, and other points, a post-mortem examina- tion should begin with the head, or, if the spinal cord is to be examined, with the spine. Head . — To open the head, make an incision down to the hone, across the vertex from the base of one mastoid process to the other, and reflect the scalp backwards and forwards ; then divide the bone all round with the saw, beginning in front a little above the level of the super- ciliary ridge. The posterior half of this section should make an angle with the anterior half by being brought over the occipital bone, a little behind the apex of the lambdoidal suture. By this means the skull-cap will, when replaced, rest firmly in its position without slipping back and so causing disfigurement of the forehead. In cases of fracture of the skull the section should be completed with the saw, care being taken not to wound the dura mater. Under other circum- stances the inner table may be conveniently divided with a chisel and mallet. The skull-cap must now he forcibly dragged off; if very ad- herent to the dura mater, a long flexible spatula may be introduced between them, and separation effected. In young subjects, before the sutures and fontanelles are united, it is better to remove the dura mater and skull-cap together, by divid- ing the former with blunt-pointed scissors in a line with the section through the bone, and then cutting through the falx at its anterior and posterior attachments. The longitudinal sinus may now be opened and examined. The dura mater should next be divided on each side with blunt-pointed scissors, or on the level of the section through the bone, and the two lateral flaps turned up ; the falx should next be divided near its anterior attachment, and the whole membrane drawn backwards off the hemispheres. The brain must now be re- moved ; a long narrow scalpel being used to cut through the nerves and vessels, whilst the ten- torium is most safely divided with blunt-pointed scissors. The spinal cord should be cut as low as possible. Any fluid present at the base of the skull should be drawn off with a syringe and measured. Brain . — After examining the pia mater, it should be entirely stripped off, and the surface of the brain examined. It should then he placed on its base, and, if very soft, supported by a towel wrapped round it. A horizontal incision should theu be carried through each cerebral hemisphere, on a level with the upper surface of the corpus callosum, from within outwards, not quite reaching the surface, so as to leave the hemispheres still attached to the rest of the brain. These should be turned back, and nu- merous vertical incisions made in the upturned surface. Each lateral ventricle should then be opened by a vertical incision through its roof, and any fluid contents withdrawn by a syringe. The fornix should now be divided in front, and with the septum and corpus callosum turned backwards. The velum interpositum and cho- roid plexus being reflected in a similar manner, NECROPSY. 1020 numerous longitudinal incisions should then he made in the corpora striata and thalami optici, and in the corpora quadrigemina. An incision should now be made through the superior ver- miform process of the cerebellum, so as to lay open the fourth ventricle. The cerebellum may he examined by making parallel incisions on each side through its lobes, not quite detaching the sections. The brain may now be folded to- gether again, and the under surface turned up and examined. Incisions should be made into the under surface of the cerebral lobes, and into the crura and pons ; and the medulla divided transversely at different levels. Softened por- tions should be tested with a stream of water ; and parts reserved for microscopical examination at once placed in a hardening solution, such as chromic acid 1 per cent. A method of examining the cerebrum prefer- able to the above, when it is desired to deter- mine accurately the exact seat of lesions, is the one recommended by Dr. Pitres. The cerebral hemispheres having been sepa- rated and stripped of their pia mater, are divided into three portions by two transverse vertical incisions, the first passing about two inches in front of the fissure of Rolando, the second a little less than half an inch in front of th-e internal perpendicular fissure, the occipito- parietal fissure of Huxley, which divides the parietal from the occipital lobe of the cerebrum. The cerebrum will thus be divided into three portions, an anterior or prefrontal, a middle or fronto-parietal, and a posterior or occipital. The first and last portions correspond to the non- excitable parts of the cerebrum, lesions of which do not cause either motor or sensory disturbances. The middle region, on the contrary, comprises the corpus striatum and optic thalamus, and the cortical motor zone. This central portion may be best examined by making four vertical sections by incisions parallel to the fissure of Rolando. The first, or pedicnlo- frontal section is made by an incision about three-quarters of an inch in front of the fissure of Rolando, dividing the second and third frontal convolutions close to their insertion into the ascending frontal convolution. This section will especially comprise the third frontal convolu- tion. On its surface are seen sections of the three frontal convolutions, the anterior extremity of the island of Reil, the posterior extremity of the orbitar convolutions, the caudate and len- ticular nuclei of the corpus striatum separated by the internal capsule. The second, or frontal section, is made by an incision at the level of the ascending frontal convolution. Its surface displays a section of the ascending frontal convolution in all its ex- tent, the convolutions of the sphenoidal lobe, the island of Reil, the external capsule and the claustrum, the caudate nucleus, the lenticular nucleus at its thickest part, and the optic tha- lamus. The third, or parietal section, is made by an incision carried through the ascending parietal convolution. It much resembles the former, but the lenticular nucleus and the claustrum are divided where they are smaller. The fourth, or pediculo-par'etal section, is made by an incision about an inch behind the fissure of Rolando at the level of the foot of the parietal lobules, and passes through the pos- terior extremity of the optic thalamus. The lenticular ganglion is no longer visible; the! corona radiata is divided in the region where lesions produce hemianesthesia. By means of these sections the exact relatione of lesions of the cerebrum can be made out! with much greater accuracy than by the ordi- nary methods of examination. Base of Skull, Orbit, and Internal Ear . — The base of the skull and its sinuses may now be ex- amined. In cases of fracture, the dura matei should be carefully stripped off, so as to expose the surface of the bone. The contents of the orbit may be examined by removing its roof The tympanum can be opened by cutting through with a chisel the plate of bone forming its roof This is situated on the anterior surface of the petrous bone, just in front of the eminence o; the superior semicircular canal. To examine the internal ear the petrous bone must be removed This is best done by two converging incision; made with a saw, and then separating its apex from the sphenoid and occipital bones with the chisel. Spinal Cord , — To examine the spinal cord the body must be turned on its face, with the head hanging over the table, and a block placed undei the chest. An incision must be made over the vertebral spines from the top of the sacrum tc the occiput, and the vertebral arches kid bare. These are best divided with the rachitome, a double semi-circular saw, in the absence of whicl a short common savmay be used, ora chisel and mallet. The cord should be removed in its tube of dura mater, the latter being held by the for- ceps, and care taken not to bend the cord abruptly. The dura mater should then be sli; open with blunt-pointed scissors along its an- terior and posterior surfaces, and the core examined, with as little handling as possible, by means of transverse sections made with a sharp scalpel. Eor microscopical examination the cord may be placed in spirit for about twenty- four hours ; and then, after removal of its mem- branes, cut into lengths, and transferred to c one per cent, solution of chromic acid. A method of opening the spinal canal from, the front, preferable in many respects to thi above, is practised at Vienna and many place; on the Continent. The instruments used are < strong knife-shaped chisel, with a cutting beak and a mallet. After the removal of the thoracii and abdominal viscera, the beak of the chisel ): introduced into the lowest intervertebral fora- men, and, by successive blows of the mallet, the pedicles of the vertebrae are cut through on eael side and the canal exposed by removing thi bodies. In this way great disfigurement of thi body and soiling of the table and linen an avoided, and the spinal ganglia are more easil; examined. Thorax and Abdomen . — The thorax and abdo men should now be examined. It is better . lay the abdominal cavity fully open before re moving the sternum, in cutting through th first rib, and disarticulating the clavicle, car I should be taken not to wound the innominate vein NECROPSY. • using cutting pliers, which should be directed as to cut obliquely through the rib into the ticulation, all danger is avoided. If much ascites is present, the belly should tapped before laying open the peritoneal vity. So, if either pleura be full of fluid, rich will be shown by its pouring out when [e cartilages of the ribs are cut through, suffi- »nt should be drawn off with a syringe to ■event any overflow when the sternum is re- ovcd. The lungs should now be drawn out of the :est, adhesions separated, and their posterior irfaces examined. The contents of the medias- imn should next be inspected, and the pericar- um opened. If the case be one of thoracic leurism, mediastinal tumour, or malformation I the heart or great vessels, the heart and lungs tould be removed together. Otherwise, the hart may be first removed and examined. Heart . — The auricles should be laid freely oen with a pair of scissors, by an incision join- ’g the mouths of the great veins and carried to le extremity of the auricular appendage. The impetency of the valves may then be tested. II clots must first be removed, the heart held : an upright position, and water poured into le aorta and pulmonary artery successively, the imiiunar valves being held back with the handle ia scalpel to allow the ventricle to become filled ; t looking into the auricles the competency of te auriculo-ventricular valves may be estimated. 0 test the semilunar valves an opening must be ade into each ventricle; the pulmonary artery id aorta cut sufficiently short to enable the lives to be clearly seen ; and then water poured to these two vessels successively, and the valves oked at from above. The right ventricle may ,yw be opened. The left forefinger should be troduced through the pulmonary artery, and ie anterior wall of the ventricle divided with unt-pointed scissors into the artery, the point : the scissors beiDg guided by the left fore- ager to the junction of the valves. The pulmo- iry artery and aorta should then be separated 1 much as possible, and the left ventricle opened a similar manner along its anterior wall, the ft forefinger as before guiding the scissors to le point of junction of the semilunar valves, he incision must be carried close to the ventri- ilar septum, and the septum between the aorta id pulmonary artery, but without cutting the tter. The most accurate way of measuring the paeity of the orifices is to pass through them ■aduated balls fixed on rods, in default of liich the fingers may be used. Lungs . — To remove the lungs, the trachea ust be cut across at the root of the neck, and ell drawn forwards by inserting the middle iger into the lower end, and the other fingers i each side behind the bifurcation, care being ken not to cut the oesophagus. Larynx and Pharynx . — To remove the larynx id pharynx, the incision in the neck must be rriecl up to the chin ; the floor of the mouth :iened from below; the left forefinger intro- iced, and used to depress the tongue ; a long srrow scalpel introduced above the finger, and rried along each side of the ramus of the jaw ; e tongue then drawn down under the chin ; and 1021 the soft palate and pharynx divided transversely. The pharynx and larynx should then be opened along their posterior walls. Intestines . — In examining the abdomen it is most convenient to begin with the intestines. The largo intestines should be divided between two ligatures below the sigmoid flexure, and drawn out, cutting the mesentery close to the bowel. This process should be continued till the duodenum is reached, when it may be again tied and cut. The intestine should be opeued along the line of attachment of the mesentery. Spleen . — The spleen may next be examined. It should be drawn forwards out of the abdomen, and the gastro-splenic omentum cut through. Stomach .—' The stomach should next be re- moved. A double ligature should be placed round the duodenum about two inches below the pylorus, and another one round the lower end of the oesophagus, and these tubes cut through, so as to remove the stomach without the escape of its contents. If required for chemical analysis, the contents should be emptied into a glass vessel, by removing the oesophageal ligature. The usual practice is to lay open the stomach along its lesser curvature, from the oesophagus to the duodenum ; but in many cases it is better to carry the incision along the greater curvature, for, as ulcers and cancers are more frequently situated near the lesser curvature, this incision is more likely to avoid cutting through them. Unless required for chemical analysis, the mucous membrane may be washed by a gentle stream of water and then examined. Pancreas . — After the removal of the stomach the pancreas may be conveniently examined. Before separating it from the duodenum the con- dition of its duct should be ascertained. Liver . — In all cases of jaundice the liver and duodenum should be removed together, so as to obtain the bile-duct intact. In removing the liver care should be taken not to injure the right suprarenal capsule, which is in close contact and often adherent. In testing the perviousness of the bile-ducts it is better not to squeeze the gall- bladder, as this will often overcome an obstruc- tion, but to open the duct with scissors, aud observe the colour of the lining membrane below an obstruction. This will be found un- stained by bile. Supra-renal Capsules . — In cases of Addison’s disease the supra-renal capsules should be re- moved, united with the semilunar ganglia and solar plexus. Genito-urinary Organs . — In all cases of uri- nary obstruction the kidney, ureters, and bladder should be removed in connexion. The pelvic organs may be removed en masse by carrying a large knife all round the pelvic walls, and draw- ing the viscera upwards and backwards. As much of the urethra as may be required can be pulled back under the pubic arch. The urethra and bladder should be opened with scissors along their upper wall. The uterus may be examined by introducing one blade of a pair of probe-pointed scissors through the os ; making an incision through the anterior or posterior wall to the fundus ; ar.d carrying this on each side to the entrance of the Fallopian tubes. 1022 NECROPSY. The kidney may be bisected by an incision through it from the convex border to the hilus ; the capsules should then be stripped off, their thickness and degree of adhesion being noticed, and the state of the surface of the kidney, both external and on section, carefully observed. W. Cayley. NECROSIS 0 expbs, a dead body).— The ab- solute death of a circumscribed portion of any tissue, but the phrase is usually associated with death of bone. See Bone, Diseases of. NEOPLASMS (veos, new, and irXdo aw, I mould). — A term for new growths. See Tumours. NEPHRALGIA (netppbs, the kidney, and &X-yos, pain). — Definition. — An affection of the nerves of the kidney, unattended by any evident anatomical lesion; characterised by tli6 occur- rence of pain in the region of the kidney, some- times periodic, often accompanying exhaustion, but without any morbid changes in the urine. .ZEtiology. — Exhaustion, exposure to cold, malarious poison, and the nervous, rheumatic, or gouty constitutions, are to be ranked amongst the chief causes of nephralgia. It is probable that the pains in the kidney, due to the presence of calculi in its pelvis, are at times of a purely neuralgic character. Symptoms. — Neuralgic pain in the region of the kidney is sometimes paroxysmal and very intense, at other times more continued and less severe. It is frequently periodic, and is apt to occur when the patient is exhausted, or in a state of nervous depression. It is unattended by any change in the quantity or appearance of the urine, and the pain does not tend to dart down in the direction of the ureter, while tender spots may generally be discovered in the neighbourhood of the spinal column. Diagnosis. — The disease with which nephral- gia is most apt to be confounded is renal cal- culus. The points upon which reliance is to be placed in making the diagnosis are the exact seat of the pain, and the direction in which it spreads ; the presence or absence of tender spots in the lumbar region ; and the condition of the urine. In renal calculus the urine is commonly bloody, and contains crystals or groups of crys- tals, or minute calculi, while in nephralgia it is natural. Prognosis. — The prognosis of nephralgia is favourable. Treatment. — The severity of the pain may be such as to demand subcutaneous injection of morphia. The most valuable remedy for cure is quinine, which may be given in doses of five, ten, or even twenty grains two or three times in the course of the day. Iron, arsenic, chloride of ammonium, acupuncture, or Corrigan’s cautery may be employed in suitable cases, if the quinine faiL T. Grainger Stewart. NEPHRITIC COLIC (vepbs, the kidney). A synonym for renal colic, an affection which is usually due to the presence or passage of a renal calculus. See Renal Calculus. NEPHRITIS (vvppbs, the kidney). —A general term for inflammation of the kidney. See Bright’s Disease ; and Kidney, Diseases of. NERVES, DISEASES OF. | NERVES, Diseases of. — Synon. : Fi Maladies des Nerfs ; Ger. Nervenkranleheiten.- Nerves, in their origin, course, and distributior are connected with the several organs and tissue of the body, and are consequently affected i various ways when such parts are disordered o diseased. But, besides such secondary derange ments, nerves are subject to many morbid cor ditions which affect them ■primarily. In th case of certain classes of nerves, connected wit special functions, the effects produced by diseas are at once so distinct and so important, tba they require separate consideration. Such, fo example, are the glosso-pharyngeal, liypoglossa olfactory, optic, phrenic, pneumogastric, spina! accessory, sixth and third cranial nerves, th morbid conditions of which will be found full discussed under their respective headings. Agair certain forms of congestion or inflammatio:. (whether oceurringin the subjects of gout, rhea matism, malaria, plumbism, syphilis, orinothe] states), when they affect important nerves, cans symptoms of a character so marked, either i. their progress or distribution or by their severity as to deserve a special designation, and t demand separate description (see Intercosta Neuralgia; Neuritis; Sciatica; and Tic Douloureux). In these and in other allied in stances the prominent symptoms are referabl to functional disturbances of the nerves. Ii another class of cases similar phenomen. originate in interference with the genera nutrition, in disease of the nervous centres, o' by reflex action ; and these phenomena will b found discussed in the articles upon Coxvci sions, Neuralgia, &c. In this place there remain for special eon sideration the following subjects : — (1) the effect of injuries of nerves ; (2) the most commo morbid growths involving nerves, which ar generally known as neuromata-, and (3) th effect of cutting or stretching nerves regarded a a means of treatment. 1. Nerves, Injuries of. — Nerves may bl divided accidentally either by tearing or cutting or surgically during an operation, or for th relief of pain or resection of tumours. Th nerves most frequently divided accidentally ar those of the upper extremity, especially th ulnar as it passes behind the inner humeral coe dyle, or as it lies upon the anterior annuls ligament. The median and musculo-spiral nerre are also not unfrequently divided by deep cut; on the fleshy front of the upper fore-arm o wrist. Sometimes, besides being wholly or partiall divided, nerves may be bruised, or have im bedded in their substance particles of friatl foreign bodies, such as glass or slate. Fracture of the humerus at the upper or lower third, ai not uncommonly complicated by laceration of th musculo-spiral nerve, by the sharp edge of one ( the fragments ; for the nerve passes spirally ronn and in close contact with the bone, first on th inner, then on the hinder, and near the elbow i the outer aspect of the bone. Symptoms. — The symptoms of the division i a nerve are loss of power in the muscles, and < sensation in the skin supplied by the offsets ( the injured nerve, as, for example, the radial ar NERVES, DISEASES OF. 1026 usterior inter-osseous branches of the musculo- piral. The complete or the partial division oay be diagnosed by the more or less complete jterruption of their functions. Nerves unite, if the cut ends are placed in pposition, as readily as other structures ; but it i usually some time before the sensory or rotor functions are restored, and then only by low degrees, the former usually taking place ooner. The recovery is sometimes delayed by isplacement or error in the co-aptation of the ut fibrils, and then the brain seems to require ime education and training to correct misplaced jnpressions, which, however, is in most cases ceomplished ultimately more or less perfectly. Vlien an important nerve, such as the great eiatic, is divided, the part of the limb supplied y it suffers in its nutrition, and is apt to bc- iome wasted, and if the patient be growing, to ig behind its fellow in development. Sometimes he muscles may become atrophied ; and if the Jivision is not united in due time, the fibres be- omo subject to fatty degeneration, and may not tterwards regain their power. Other tissues be- ides the muscles may likewise become atrophied. ,’hus wasting or atrophy of the fingers may re- mit from injury of the ulnar or median nerve, ilhis has been thought to be in some degree due i!o the interruption of innervation in certain fibres, rhich are bound up in the spinal as well as in the ympathetic nervous systems, and which preside ver and control the nutrition of the tissues, the o-called trophic nerves. The parts supplied by hem seem to be more liable to the formation of jloughing sores, as is illustrated by the bed- ores which are apt to follow division of or ressure upon the spinal cord, or cauda, equina la fractures of the spine. Severe contusions of erves will sometimes so interrupt their fuuc- ional power as to produce the results of complete ivision. Treatment. — In the treatment of nerves aeci- entally divided all foreign bodies are, in thefirst lace, to be carefully removed by sponge or for- eps, with as little further injury to the nerve- issue as possible; and the wound, if practicable, 1 to be treated antiseptically. Then the limb hould be fixed upon splints in a position which ill bring most easily and closely the cut ends of ie divided nerve into apposition. Carbolised itgut ligature may be applied upon the nerve- leath or closely adjacent textures, so as to hold ie cut ends evenly together ; or a thin wire may 2 applied to the neighbouring tissues, brought it at the surface, and secured over shot or but- ms, and the wound treated in the ordinary ay. If possible, none of the nerve-fibres should e cut away, although a slight trimming off of gged ends may be advisable. Passive motion ' the paralysed muscles should be employed, as >on as the wound is united ; and afterwards weak radization should be applied to the limb, to 'omote nutrition and stimulate nerve-currents. 2. Nerves, Tumours of. — Synon. : Kcuro- ata. The tumours which affect nerve-structure, al- lough no doubt varying in essential character, they do in other parts of the body, have fially been grouped indiscriminately under this ■ad. Surgically they may be classed thus : — (a) constitutional, which affect the whole of a particular group or groups of nerves, and are clearly constitutional in their origin ; and ( h ) traumatic, such as form on the cut ends of nerves after amputation, or result from local injury of some kind. (a) Constitutional. — Numerous cases of mul- tiple neuromata are on record. In one case, recorded by R. W. Smith, upwards of 2,000 tumours were found. In most instances they are confined to one particular set of nerves and their branches. For instance, they have been found in the posterior tibial and plantar nerves, as in a case recorded by Van der Byl ( Patho- logical Society's Transactions, vol. vi.), where the growth may have been round-celled sarcoma or cancer. In another remarkable case of mul- tiple neuromata, recorded by Dr. Wilks {op. cit., vol. x.), perhaps of syphilitic origin, a simplo fibroid deposit was found within the neurilemma, causing in some places hardening and contrac- tion, and in others neuromatous tumours. One of these had formed in the substance of the pneumogastric nerve, and was thought by Dr. Wilks to have caused the disease of the lung which proved fatal. In another case, recorded by Mr. F. Smith, multiple tumours affected the internal cutaneous and interosseous nerves of the arm, and the larger tumours were found to have undergone calcareous degeneration {op. cit. vol. xii.). A single neuromatous tumour has been found on the auditory nerve, causing deafness (Toyn- bee, op. cit. vol. iv.), and on the musculo-spirul nerve in several recorded cases {op. cit. vol. viii. ), by Nunn and Barber. In one of these cases acute sensibility and intense pain in the course of the distribution of the nerve were present. In the other case, no pain was felt unless the tumour was pressed. In a tumour upon the same nerve, recorded by Shillitoe {op. cit., vol. x.), of the size of a billiard ball, a blood-cvst containing clot and serum was found in the in- terior, surrounded by fibro-cellular structure. 1). Traumatic. — Neuromatous tumours which form on the cut ends of nerves after amputation, are rounded or oval masses placed near, but not usually quite at, the extremity of the cut nerve. A small portion of the extreme end frequently forms a sort of tapering tail to the tumour, giving to it a resemblanco to a turnip-radish. On sec- tion the tumour is found to consist of a fibroid substance, hard, resisting, and firm to the touch, with a somewhat glistening surface. Under the microscope there are seen the same general charac- ters which are found in neuromata, namely, fib- roid elongated or spindle cells within and around the neurilemma, pressing upon and displacing the nerve-tubules, which are seen convoluted, dis- torted, varicose, or lost entirely in the tumour- substance. Some few may be traced through the tumour itself into the tail-like termination, but this latter usually consists of fibrous tissue only. These tumours seem to occur more commonly after amputation of the upper than of the lower ex- tremity. These neuromata are not uncommonly associated with pain, more or less acute at in- tervals. They may last a long time — in some cases during the whole of the life of the in- dividual. Sometimes neuromata give riso to 1024 NERVES, DISEASES OF. acute sensibility or tenderness or the stump, and more rarely to spasmodic twitchings of the muscles or even epileptiform convulsions. Tbeatment. — Neuromata on the continuity of a nerve, if painful or situated so as to be easily accessible, and liable to injury, maybe dissected out carefully and with antiseptic precautions. Sometimes it will be found that the tumour can be extirpated without taking away the entire section and continuity of the nerve, which when a large one (as for instance the great sciatic) it is important to preserve. In case this cannot be done, the whole section of the nerve-trunk may be taken away, and the smoothly cut ends brought together with fine catgut sutures put through the outer nerve-sheath only, the limb being placed in a position to relax the nerve and lessen tension to the utmost. This proceeding, as before remarked, has been successful in uniting the ends of nerves accidentally cut through. In cases of neuromata in stumps the same treatment is sometimes available and effective. Opening the cicatrix and dissecting out the tumour or tumours may be all that is required. But in other instances the pain and tenderness are so diffused, and the growths so numerous, that re- amputation a few inches higher up, gives more complete and satisfactory results. Yet in some patients the tendency to the formation of these tumours is so great that they reappear, even after re-amputation, and the prognosis must always be guarded on this point. 3. Nerves, Surgical Division and Stretching of. (a) Nerve-scctilm. Synonv : Neurotomy. — Surgical division of nerves has been employed for the cure of painful affections such as neuralgia, and for tetanus and other obstinate and sustained spasmodic movements. It has been usually performed subcutaneously, and most frequently in the case of the branches of the tri-facial nerve, at their exit from the bony fora- mina, such as the supra-orbital, the infra-orbital, and the mental branches. The division should be thoroughly and completely done. It has been found, however, that in a comparatively short space of time, the operation, though perfectly suc- cessful in removing the pain and sensation at the peripheral distribution of the nerve, is of no avail. The nerve, after simple subcutaneous division, unites in a few weeks or months ; and first sensation and then pain recur in the part. In cases of intracranial disease the operation is of course useless. Efforts have been directed to prevent this union of the cut nerve, by taking away a considerable portion, so as abso- lutely to prevent contact of the ends ; and the operation then must necessarily lose its subcuta- neous character. When the nerve, as in those nerves above-named, spreads out to its distribu- tion in all directions, it is difficult to secure this absolute removal, and a good deal of the adja- cent soft parts must be excised to insure its being done thoroughly. In a case of obstinate neuralgia of the inferior dental nerve, the late Sir William Fergusson gouged away the outer wall of the mental foramen for the space of an inch, and dissected out the nerve from the canal to the same extent, with the effect of curing the disease. In some neuralgic cases the cause of the pa; lies within the cranium or brain itself, as aW mentioned, and is of course not to be reached b surgical operation. In traumatic tetanus division of the nerv going to the wounded part has been practise! by Hilton ( Medical Tones and Gazette , vol. i 1869), and by Sir Joseph Fayrer (Rankin'. Abstract , 1863, vol. ii.), as well as by Nelatoi and others. The results, however, do not seen to be as favourable as in the more recently in troduced treatment of nerve-stretching, -whilst) the injury inflicted on the structures is certainh greater, and the disabling results are more ap" to be permanent. (b)Ncrve-stretching . — This is one of the moden modes of the treatment of disease, which has so far achieved a certain amount of success. It ha; been practised in cases in which section of the! nerve may be considered justifiable, such as con- tinuedand severe pain or spasm, acute or chronic' of the parts supplied by a nerve, which has re- sisted all milder treatment, and in loeomotoi ataxy. Cases of traumatic tetanus also claim ; trial of this method of cure. Method. — Nerve-stretching is effected 1)_\ cutting down upon the nerve-trunk, detaching it from its connections for the space of a fei\ inches, laying hold of it with the fingers, forcibh stretching the whole nerve from its origin t"c such an extent as to affect powerfully its func- tions, and then closing up the wound. In some, instances a certain amount of loss of sensa- tion or muscular power in parts to which the nerve is distributed is the immediate result 1 which, however, passes away after a certain interval, and the nerve-function becomes mort or less completely restored. Application's. — A number of cases have beet recorded within the last few years, in whicl nerve-stretehiDg has been employed with con siderable success. Thus in a case of spastr affecting the whole of the muscles of the lef arm, with considerable ana?sthesia, Nussbanm of Munich, stretched the nerves of the arm it three places — namely, the ulnar nerve at thi elbow; the median, musculo-spiral, and ulnar it the axilla ; and the primary trunks of the thrv lower cervical nerves above the clavicle. Th; patient recovered in eleven weeks, with restore tion of the healthy action of i he muscles of th limb. The late Mr. Callender has described th' case of a man in whom re-amputation of th' stump of the fore-arm for neuralgia had been per formed, and which he operated on by strctchin; the median nerve for three-fourths of an inch There was no return of the pain, and the nu trition of the stump and arm, which had wasted was much improved. The writer lately cut dow: upon and stretched the external popliteal (perc neal) nerve, behind the biceps cruris tendon, in case of painful spasm of the extensor and peronee muscles, with a success which was permanen months afterwards. Still more recently Mi Godlee has treated two cases of facial spasm c many years'' standing, by stretching the porti dura at its exit from the stylo-mastoid forame: one with complete success. In cases of traumatic tetanus, the applicatio NERVES, DISEASES OF. f nerve-stretching seems sufficiently appro- riate, and accordingly it has not failed to be •ied. A striking case of this description is icorded in the Centralblatt fur Chirurgie , Oct. 7, 376, No. 10, by Vogt. In fifteen cases of teta- us collected by Johnstone of Kentucky, seven of hich were operated on in late stages of disease, is stated that there were five cases of re- ivery from this fatal disease — a much greater •oportion than from any other method of treat- ent. The results in cases of nerve-stretching r traumatic tetanus, practised in London during je last few years, do not add to the favourable ipression that the preceding cases were calcu- ;ed to give as to the efficacy of this operation, has been tried in various hospitals, lately in ing's College Hospital, without success. In |e case it seemed rather to hasten the fatal rmination, And it can scarcely be said that e infliction of a further injury on the continuity the nerves of the affected part, with a corre- onding impression upon the nerve-centres, is, priori, likelv to cure the consequences of a mary injury, which has already so powerfully .i fatally influenced the condition of these same live- centres. Still more recently nerve-stretching has been pctised upon the nerves of the limb for the fief of the pains cf locomotor ataxy. The lults, in Some instances, appear to have been icessful even beyond expectation ; for not c y have the pains been removed, but the tturbances of co-ordination have also been minished, though to a limited extent. Principles. — A satisfactory explanation of ft modus operandi of n6rve-stretching is not eily given. Nussbaum suggested that the suc- c 5 may be owing to an alteration in the relations 1 ween the nerve-fibres, having the effect of i iroving their nutrition ; whilst Callender attri- led it to the consequent numbing of the nerve, tit is, the temporary suspension of its func- t is, by interfering with the transit of painful a abnormal impressions, the nerve-centres t ing time to resume their normal control. Vli regard to this explanation it may be p ited out, however, that both motion and station are often uninterruptedly retained after tl successful stretching of a large nerve, ill certain eases of rheumatic neuralgia it might Conjectured that a degree of contraction may fi iw a rheumatic or gouty deposit in the nerve- el tli, and thus affect the nerve-current in the c ral axis of the fibre ; and that this may be d rn out, overcome, or broken by the nerve- st:ching, the normal function of the nerve- tvde being thus restored temporarily or puanently. Whether a similar explanation w suffice for the recorded cases of cure of te-ius may be more than doubtful, and we m t wait for further evidence of fact before wan explain the phenomena with any appear- ai , of probability. Brown-Sequard has recom- nvied exposure' of the nerve, and washing it wr ether, to effect the same end. John Wood. W|! Ti ERVI, in the Eastern Italian Riviera, n, moist, winter climate. Seo Climate, ;ment of Disease by. 65 NERVOUS SYSTEM. 1025 NERVOUS. — A term used variously in re- ference to persons, to temperaments, or to morbid conditions. A person is said to be nervous, or of a nervous temperament, who seems to present a special susceptibility to pain, or who exhibits an undue mobility, as it is termed, of the nervous system — that is to say, when the person starts or shakes on the occasion of abrupt or intense sensorial impressions, or when he exhibits a proneness to convulsions or manifests an exalted emotional susceptibility. An organisation of this kind characterises children rather than adults, and, amongst the latter, females more than males. Nevertheless, in persons of both sexes such a bodily disposition is frequently to be met with, varying not only in degree, but also in kind or type. As one of the most important of these varieties, we must include the as yet very imperfectly understood condition known as hysteria ( see Hysteria). A nervous disposi- tion may be either inherited, or acquired during the life of the individual, and it then ensues as a sequence of some severe illness, of some gvuve anxiety, or of some physical or moral shocK. In reference to disease, the term nervous is used with different significations in dilferent cases. Sometimes it is used in more general terms to signify that the disease is one impli- cating the nervous system rather than any other part of the body. At other times the use of the term is very variable. Thus, by the term ‘nervous aphonia’ we imply that the voiceless- ness is due to some functional nervous inhibition, rather than to any distinct paralytic condition caused by structural disease ; whilst, by the term * nervous deafness,’ we should imply that the deafness is due to disease, functional or organic, of the auditory nerve or its centres, rather than to an inflammatory or other affection of the middle ear. H. Charlton Bastlan. NERVOUSNESS. — A term applied to the state of, or to the conditions manifested by, a person coming within the description of ‘ner- vous ’ as above defined. Sec Nervous. NERVOUS SYSTEM, Diseases of. — The complexity of the nervous system, its manifold functions, and its extensive distribu- tion, render its diseases more varied than thoso of any. other system of the body. From the manner in which the nervous and vascular systems interlock, their diseases or pa- thological conditions are to some extent insepar- ably related to one another. The modes of inter- ference with the functions of the vascular system through altered nervous action are compara- tively few and simple. The heart may, under the influence of modified nervous stimulation depart from its customary order and rate of contraction, or in extreme cases cease to beat ; the smaller arteries over a greater or less extent of the body may diminish in their calibre, or become dilated ; but, save for such events as these and their direct consequences, the work of the vascular system is habitually carried on without variations impressed upon it by abnormal states of the nervous system. On the other hand, the diseases of the nervous system which may be induced by altered quality NERVOUS SYSTEM, DISEASES OF. i026 A blood, or by alteration of function in the heart or some part of the vascular system, are numerous and varied. The functional activity of the system as a whole may be degraded, owing to the fact of its receiving an inadequate amount of blood from a feeble or slowly acting heart. Ortho functions of a part of the system may be interfered with by an undue contraction or dilatation in its small arteries, or by an impediment to the outflow of blood, inducing a mechanical congestion. Again the complete or partial arrest of the blood-flow in the vessels of some important region (owing to thrombosis or embolism therein), or the rupture of one of the branchesof such a vessel, with extravasation of blood into the organ, — either of these events may impair or destroy the functions of that particular part, even if it cause no more general disturbance of nerve-function. In short, both local perversions of function and structural changes in the nervous system, are far more fre- quently initiated by altered quality of blood, or unnatural phenomena in the vessels of the part, than by primary morbid changes in either of the other two components of nerve-tissue, namely, the nerve-elements themselves, or their interstitial connective tissue. But, as already intimated, the number of different nervous diseases is referable princi- pally to the great complexity of this system. It is now a familiar fact that the same kind of morbid change existing in different parts of the nervous system tends to give rise to wholly dis- similar groups of symptoms. Hence the impor- tance, from a clinical point of view, of studying the varied functions and functional relationships of the several parts of the nervous system. The most practical and useful classification of the principal component parts of the nervous system is as follows r — 1. The Cerebro-Spinal Division (or Nervous system of animal life). a. The Encephalon. b. The Spinal Cord. c. The Encephalic and Spinal Nerves. 2. The Organic Division (or Nervous system of vegetative life). a. The Pneumogastric or Vagus Nerves. b. The Great Sympathetic System (with which is included the ‘Vaso-Mo- tor’ System of Nerves). This classification, though in part natural, is also in other respects purely artificial. The cerebro -spinal and the organic nerve-centres are structurally continuous at many points. The vagus nerves, and the vaso-motor system of fibres In part, have an encephalic origin, though the latter are distributed almost throughout with the sympathetic system, of which it is often supposed to constitute the most important part. This sympathetic system is connected at inter- vals with the whole length of the cerebro-spical system, from the lumbar enlargement to the base of the brain, chiefly by connecting filaments passing between it and the anterior spinal nerves. Some of these connecting filaments are afferent, Others are efferent. The brain again is brought into immediate relation with the sympathetic system through the wide-spread filaments of the pneumogastric nerves, which mingle with almost all the visceral plexuses both of the thorax and of the abdomen. The spinal accessories seem to be the motor nerves through which the more j direct impressions brought to the medulla by the pneumogastrics are reflected upon some of the viscera ; and, similarly, the tranference of motor- stimuli direct from the spinal cord to the viscera, in response to afferent impressions conveyed tc it by certain nerves of the sympathetic system, takes place through motor fibrils in the filament! connecting the anterior spinal nerves with thi- system. The sympathetic system also possesse: its own intrinsic motor fibres and vaso-motoi centres. Other intrinsic motor centres probabb exist amongst the sympathetic ganglia, whicli' like those of the heart, may be capable of bring ing about muscular contractions iu the parts wit] which they are severally in relation. The direct consequence of the close relation ship between the viscera and the fibres of th pneumogastric and spinal accessory, as well a between the spinal motor nerves, and thos emanating from the central connections of tb! vaso-motor system, is that we find lesions <| some portions of the cerebro-spinal system fri quently involving altered actions in parts undi the immediate influence of the nervous syste of organic life — as when diseases of the medull and its neighbourhood disturb the action the heart or the respiratory processes, whc vomiting is produced by cerebral or spin disease, when diabetes or polyuria are indue by irritations of the fourth ventricle. Su effects, again, are illustrated by the flow of tea) under the influence of grief, by the arrest of t salivary secretion under the influence of fear,' by the occasional production of an increased fl of the same fluid at the thought of savoury fo Or. the action of the two nervous systems upon another may take place in an opposite directij as when in a neurotic subject an irritant in intestine, or t he passage of a renal calculus dot the ureter, gives rise to convulsions ; when foit- of ‘ reflex ’ paralysis are produced ; when ■ ‘spirits ’are depressed under the influence i visceral disease, sometimes to such an extents to induce melancholia; or when, on the otr hand, irritative states of the ovary lead to tit form of insanity known as nymphomania. Sympathetic disturbances are also apt to sly themselves in the functions of certain parts cl- prised within the sphere of the cerebro-spd system itself, when some other portion of itf- comes the seat of disease, though the extend which this occurs is still involved in much do t- Brown-Sequard believed that hemiplegia i|lf is often induced by an ‘inhibitory’ influeo. emanating from some morbid portion of brain and acting upon certain motor-cell^ the spinal cord. Similarly we find an irrita’n occurring in one portion of the organic neris system entailing morbid manifestations in s:e other and perhaps distant part of thissysu. as when the early stage of pregnancy or wn ovarian or uterine disease leads to vomit: . when certain irritations of the stomach ejte the act of coughing; or when irritatioij 11 the bronchial mucous membrane lead to rd ■- ing. Essentially similar phenomena are e. when suprarenai-capsular disease leads to •» NERVOUS SYSTEM, DISEASES OF. 1027 isss ; or when a blow on the epigastrium, by con- •yin'g a shock to the semilunar ganglia, causes i arrest of respiration or of the heart’s action. '« Sympathetic System, Disorders of. This tendency to the establishment of sym- dhetie or related disturbance of distant parts local diseases of the nervous system, is one the principal sources of the great complexity diagnosis in these affections. Thus, though lesion in the brain may give rise to a certain ; of direct effects, the consequences of the me lesion may also, and mostly do, become dtiplied by a reverberation of impressions i’oughout the nervous system. In this way ■ at are called indirect effects are produced. ;fch indirect effects may show themselves either i the direction of arrest or of exaltation of liction, and in the former case they are often Jd to be brought about by ‘ inhibition.’ The proportion between the direct and the i irect, effects resulting from an injury to ner- t|s tissue varies greatly in different cases, fording to the seat, the extent, and the nature t|he lesions, as well as according to the age, sex, : 1 general health of the patients. Hence it (In happens that the same kind of lesion seems mlifferent times to give rise to a different set odinical accompaniments. ;n regard to diseases of the organic nervous Am our knowledge is at present extremely djietive. The recognition of the diseases of til s\stem— that is, as diseases having such or s ; ia pathological starting-point — is beset with p tliar difficulties. This is in part attributable tlhe free connections existing between the or- gjic and the cerebrospinal nervous system, and t ; consequent difficulty, so frequently arising, well opposes itself to our settlement of the q’ition, as to whether any particular group of sjptoms, possibly due to some primary disease oil portion of the organic nervous system, rely owns such a cause, or whether it is rather d to some disordered condition of the cerebro- s|al centres, which induces indirect effects on traside of the nervous system of organic life. Tin, again, in other cases, disease of some pijion of the organic nervous system may rtfy exist, which, by reason merely of our pi ent defective physiological and pathological kiyledge, remains unsuspected as a disease tang that particular nature and origin. he nature of the functions performed by the otlnic nervous system sufficiently explains this di'.ulty. In part it serves to link the func- ti jil activity of certain viscera with sensory inf essions or motor acts referable to the cerebro- sfil system, as in the processes of ordinary or'isturbed respiration, parturition, &c. ; in pa ; also it brings different • organs into co- nr j.ated activity, as when the presence of food in 9 alimentary canal excites the simultaneous uejity of the pancreas, the liver, and other glilular organs. And how well such functions nslose last-named are performed we are often (affable to estimate vaguely, if at all, since the is of those portions of the nervous sy r stem on' licit they depend do not reveal themselves oit : by sensible impressions, or by movements of Jets of which we are conscious. ter functions of the 1 sympathetic’ nervous system, such as those which have to do with the maintenance and regulation of the functional activity of the blood-making or ductless glands, namely, the liver, the spleen, the supra-renal capsules, or the lymphatic glands, are even still further beyond the pale of recognisable pheno- mena. Yet disturbances of these purely organic functions may give rise to certain general affec- tions, which we are unable to refer to morbid states or actions of this portion of the nervous system. Suprarenal-capsular disease, leucocy- thaemia, diabetes, chlorosis, various forms of anaemia and other conditions of general mal- nutrition, are instances of diseases possibly due to deficient or perverted action of some of these blood-making organs, immediately occasioned by morbid conditions of the sympathetic nerve- centres in relation therewith. And it may be fairly presumed that the functional activity of these, organs is influenced by the nerves and nerve-ceutres with which they are in connection — just as that of ordinary secretory glands (such as the parotid and sub-maxillary) is known to bo under the influence of the nerves with which they are supplied. The true pathology of such general diseases as have been named, we may hope will be ultimately elucidated by the application of the same means as have led to our present knowledge concerning the symptomatology of local diseases in the cerebro-spinal portion of the nervous system. This means, therefore, would consist in a more searching and habitual examination of the several parts of the nervous system of organic life, so as to endeavour to connect morbid appear- 'ances in its several centres with appreciable pathological states of ductless and other organs, and the still further endeavour to colligate these morbid appearances with the respective states of health or symptoms exhibited by the patients during life. Slow and difficult as this method is, it is the only one (apart from the experimental method with lower animals, which is here available only to a very limited extent) that would appear to hold out any probability of ultimate success. The obscurity prevailing in reference to dis- eases of the cercbro-spinal nervous system, is not to be compared in extent with that relating to the nervous system of organic life. The reason of this is obvious. Deviations front its proper functions come much more easily under the ken of the physician and of the patient ; whilst, in addition, morbid changes in this part are a few degrees less difficult to detect, and as they are situated in parts which are also much more frequently scrutinised in the post-mortem room, such changes are in reality far more frequently recognized than when they occur in one or other of the more scattered centres of the nervous system of organic life. For some general remarks on the diseases of the cerebro-spinal nervous system, the reader is referred to the articles, Brain, Diseases of; and Spinal Cord, Diseases of. ./Etiology and Pathology. — The proper and well-balanced working of the nervous system, as a whole, depends upon the maintenance oftho accustomed degree of excitability in its different nerve-centres ; and the proper nutrition of such 1028 NERVOUS SYSTEM. DISEASES OF. centres, upon 'which their normal molecular mobi- lity depends, is certainly largely dependent upon their habitually receiving a supply of blood which is definite in amount, and uniform in quality. But the amount of blood going to any tissue or part is subject to the regulating influence of the local vaso-motor centre, with which the vaso-motor nerves supplying the blood-vessels in question are in relation. By the influence of other parts of the nervous system, or owing to the condition of these vaso-motor nerve-centres, the vessels dependent upon them may be either unduly con- tracted, or unduly dilated. Again, the proper quality of blood is subject to much alteration in different diseases ; for instance, it may be thin and poor in anaemic states, it may contain poison- ous ingredients in workers with lead and mercury, whilst it may contain varied noxious constituents in those suffering from grave renal disease, from septicaemia, and from the acute specific fevers. In this latter group there is, however, reason to believe that some of the abnormal nervous pheno- mena which are apt to manifest themselves may be due t not so much to the direct toxic influence of altered blood, as to the fact that in such states of the system the blood may be, at times, more prone than natural to coagulate in the minute vessels of the nervous system. Such undue proneness to coagulate sometimes depends upon the existence of an increased number of white blood-corpuscles, which, either from the state of the blood-plasma, or from the condition of the tissues outside, show a more than usual amoeboid activity. Or an undue proneness of the blood to coagulate in some of the small vessels of the nervous system, during or after some of the acute specific diseases, may be due to an unnatural tendency of the fibrin to separate from such altered blood. The nutritive changes taking place in different tissues are chemical changes, differing from one another in exact nature, and therefore capable of reacting dif- ferently upon the blood circulating through such parts. These facts suffice to show how difficult it is to draw the line between what are probably mere toxic effects of an altered blood, and those which are due in the main to minute and almost inappreciable changes in the condition of the smaller blood-vessels of a nerve-centre. But whenever variations take place in the nutritive condition of any centre, these varia- tions are apt to involve not only an altered action in that particular part, but a perverted functional activity of other related parts. It often happens,, therefore, that an exaltation or diminution of functional activity in some one part of the nervous system, causes a diminution, exaltation, or other perverted activity in distant parts of the system. Thus, owing to the many possible permutations and combinations, we may get the most varied grouping of abnormal phenomena traceable to altered actions in the nervous system, and having for a starting-point some perverted functioning of one or more nerve-centres. We have here the mode of pro- duction of what are commonly called functional diseases. Diseases of this type are specially apt to manifest themselves after some unusual strain has been thrown upon the nervous, sys- tem, especially if the general health was at the same time lowered. The strain may have ariser from prolonged over-work and deficient sleep or from some sudden mental shock, whethe; of joy or terror, but more especially the latter At other times such functional diseases appea: without any assignable cause, more especial]} in persons of a neurotic habit of body. G-rea differences exist amongst different individuals ii this respect, that is, in their proclivity to disease of the nervous system, though it is a matter o common observation that children and female are, as a rule, much more prone than men to be ! come affected by nervous diseases of this type. It is now a well-established fact that person! who are endowed with a neurotic habit of bodv very frequently transmit a similar tendency t their children. It is not a tendency to any or particular disease, but a vulnerability of th nervous system as a whole which is transmitted so that under the influence of even a compar. tively slight strain, this weakness may manife: itself in one or other of various ways. It ma reveal itself by mere general nervousness n tremors, by attacks of chorea, by epilepsy, orl one or other of the forms of insanity. Vfh>- the neurotic habit of body exists to a wel marked extent — either in one or in both parent different children may be affected in several ' these modes ; yet it is not necessarily so, f the inherent vigour of some of their progei may cause such tendencies to be dwarfed af practically blotted out. Other diseases of the nervous system a induced by definite and easily recognisab structural changes belonging to one or oth' of the following varieties. Rupture of bloc vessels often happens, causing hamorrho j either into or upon the brain or spinal cor; though haemorrhage into the latter organ is extremely rare event. Or changes may occur the vessels of some part of the nervous syste leading to their narrowing or actual occlusi; by the combined influence of degenerations aj thrombosis; or a similar result may be broug. about by the lodgment of an embolus, and each case the consequence, if the patient 1 long enough, is the establishment of a focus; softening in the brain or spinal cord. In addit . to these changes we have others of an irritat or inflammatory nature. These may affect 1> surface of the brain, when they are associail with simple or with tubercular meningitis;: they may implicate some deeper portion of ^ substance, though unfortunately we are at p- sent only very imperfectly able to separate the inflammatory affections from the more sime degenerative softenings, either at the bedsider in the post-mortem room. If, however, the - flammatory focus should subsequently beccte the seat of an abscess, the latter difficulty woi disappear. In the nerve-trunks an inflammatv condition, affecting principally their connecti- tissue envelopes, is not unfrequently met w , and goes by the name of neuritis. Again, tumos may be found, either arising in or pressing uo some portion of the nervous system. Thesery have been produced under the influence of scrc- losis or syphilis, or they may be cancerous, r wholly unrelated to any general diathetic stA Accphalocysts or cysticcrci are also occasion!? NERVOUS SYSTEM. i':t with pressing upon the surface, or within the ibstance cf the brain ; or fluid may accumulate ■thin the ventricles, as in hydrocephalus. But ifar more frequent morbid condition consists i an overgrowth of the interstitial connective ■sue, leading to the formation of patches or ■lets of sclerosis in the brain and spinal cord. ' is change constitutes the basis of several well- lognised morbid conditions of a progressive oe. Lastly we may have certain special forms- • atrophy and degeneration, showing themselves ore especially in the nerve-cells of various parts the brain, spinal cord, or sympathetic ganglia. Treatment. — For the treatment of nervous ieases we have at our disposal a number ■ invaluable remedies, whose action is more less special. Thus, wo have strychnine 1 bromide of potassium, possessing the oppo- le properties of increasing and diminishing fe reflex excitability of the nervous system, addition to other beneficial modes of action, e have chloral and morphia acting either ,-ectly or indirectly as hypnotics, and thus lowing the curative action of rest to como 0 play. We have opium and Indian hemp, bcutaneous injections of morphia, and the con- mt galvanic current as pain-subduers. We ; ve drugs like ergot and nitrite of amyl, capable [influencing the calibre of the smaller arteries, e have in conium and chloroform most power- 1 agents for relaxing the whole muscular system, e have iodide of potassium, which in syphilis d other cachectic states of the system seems ilact as a direct antidote for the dispersion of inective-tissue overgrowths. Whilst in the rious forms of electricity we have special ents of the highest value, not only for mitiga- jg pain, but for allaying spasm, for improving e nutrition of wasted muscles, and for facili- ing the bringing of them again under the luence of the will in cases of paralysis. The above are only some of the chief special nedies which we employ in the treatment of :vous diseases. We have, as more general re- dies— so-called nervine tonics — the prepara- ns of zinc, arsenic, iron, quinine, phosphorus, 1 1-liver oil, &c. ; whilst we have also frequent msion to call to our aid ordinary tonics, ; ! rgatives, emmenagogues, anthelmintics, and 'inter-irritants, together with cold or tepid itches and the shampooing of paralysed limbs. The manifestations of nervous disease are im- i nsely influenced by the general state of health i the patient, and this not only in so-called 1 ctional, but even in the gravest of structural i eases. There is indeed no class of affections i which more good may result from a minute i ard to diet, exercise, amount and kind of 1 our, and that general attention to all hygienic (jails upon which those most skilled in the t itment of these diseases always largely rely. . ire are few chronic diseases of the nervous (jtem, even of the most obstinate and progres- ■'3 type, in which very much may not be done tier to arrest or to stay their progress, by •pful attention to such hygienic details, by t judicious administration of drugs, and by i ntaining the general health of the patient at 1 highest possible standard. H. Charlton Bastian. NEURALGIA. 1029 NERVOUS TEMPERAMENT. See Temperament. NETTLE RASH. — A popular synonym fo* urticaria. See Urticaria. NEUCLEUS. — Ste Cell; and Appendix. NETJENAHR, in Germany. — Thermal al- kaline waters. See Mineral Waters. NEURALGIA [vtvpov, nerve, and i\yew, I suffer pain). — S ynon. : Fr. Nevralgie ; Ger. A’ew- ralgie. — This is a term applied to a disease of the nervous sensory apparatus, marked by paroxys- mal pain, which is for the most part unilate- ral, and in the course of nerves. In many cases no evidence of change in the periphery of the nerve is discoverable, and to these the term neuralgic is perhaps most properly ap- plied ; in others, however, there is reason to think that inflammation of the sheath of the nerve is at least the starting-point of the dis- order. The diagnostic points are as yet not sufficiently certain for these cases of peri-neuritis to he absolutely separated from those of neu- ralgia, and they may so far be considered to- gether. Relative constancy in the pain, with paresis and atrophy of muscles supplied by the affected nerve, and swelling of the nerve-trunk, point to peri-neuritis. See Neuritis. .(Etiology. — Neuralgia is prone to occur in families marked by neurosal tendencies, not necessarily of neuralgic character, but which display themselves in various phases of psy- chical disturbance, as insanity, hysteria, hypo- chondriasis, or in the shape of epilepsy and chorea. Rare before puberty, that crisis has a strong predisposing influence. In the middle period of life, though first attacks are not very common, revivals of old-standing disease are apt to occur, as a result apparently of the depression occasioned by the cares of life. Premature agedness (marked by atheromatous changes in the vessels, arcus senilis, permanent greyness of hair, bagging of the cheeks, pulmonary em- physema) conduces to severe and intractable neuralgias. Malaria is a potent cause. Amemia and mal-nutrition generally, however brought about, play an important part. So also do sexual excesses, and perhaps likewise a state of celibacy. Pregnancy, over-lactation, and menor- rhagia are each predisposing causes. The most frequent exciting causes are cold, especially damp cold ; injury to the nerve by violence, or by the encroachment of morbid growths ; syphilis ; gout ; and the presence of lead or mercury in the system. Irritation of peripheric organs may excite neuralgia in nerves nearly or remotely associated. So dental caries may induce supra- orbital neuralgia ; uterine disease may excite neuralgia of distant nerve-trunks — as, for ex- ample, the occipital ; and the presence of intes- tinal worms may explain the occurrence of neu- ralgia in parts quite unconnected with the bowels. Neuralgia is a common sequel of relapsing fever. Anatomical Characters. — In neuralgia pro- per no definite lesions are discoverable — at least, none that arc constant enough to deserve the place of necessary accompaniments or factors of the disease. As a result of neuritis or peri- NEURALGIA. 1030 neuritis the nerve-trunk is sometimes found swollen and hyperemic; or, in a later stage, it may be atrophied and its fibres degenerated. Symptoms. — After some little preceding numbness, cutaneous anaesthesia, or other ab- normality of sensation, the import of which gets to be well understood by persons liable to neuralgia, the patient is seized with pain, which at first is not severe, and ceases quickly, but returns in a few seconds or minutes, lasting for a short time, and then remitting. These darts revive with shorter and shorter intervals, so that in a little time the pain appears to be almost continuous, or interrupted only by waves of intensity, and it will last for some seconds or more than a minute together. Then comes a respite, to be followed by recurrence, and these alternations may continue for a few minutes or as many hours. In attacks of long duration where no treatment is applied, the pains gradu- ally get less acute, the intermissions longer, and the outbreak slides off into a confused feeling of discomfort and bruising about the seat of pain, coupled with a sense of exhaustion and desire for sleep. The character of the pain varies; it is described as darting like a knife or like lightning, crushing, hammering, boring, and sometimes burning. In neuralgia about the head the patient will often be seen to cringe and recede before the plunges of pain, as though he were receiving blows. When the pain is at its worst there is often a radiation of it to other nerves, and especially to those placed symmetrically with the one affected ; but this secondary pain never attains anything like the severity of the original. Not always, but very commonly, certain definite points where pressure is exceedingly painful may be found by palpa- tion. These, the ‘points douloureux’ of Val- leix, have a certain diagnostic importance. Rare in first attacks, they are much more com- mon in patients who have been subject to recurrences during many years. There is always a nerve-branch under the skin at these points, and more often than not they correspond with the point of emergence of a nerve from a bony groove or opening, or its passage through a muscular aponeurosis. Pallor of the skin, fol- lowed by intense redness, horripilation, and other evidences of vaso-motor disturbance are common. In the case of nerves being attacked which preside over glands there is often in- creased secretion. The tactile sensibility of the skin is almost always diminished after a time in the neighbourhood of the affected nerve, though at first, there is some bypertesthesia. Local Varieties. — The varieties of neuralgia are divided into two primary groups, namely, I. Superficial ; and II. Vieoeral. I. Superficial. — These include the follow- ins: : — (a) Trigeminal neuralgia. See Tic Doulou- reux. (b) Cervico-occipital neuralgia . — The poste- rior branches of the first four pairs of spinal nerves may be affected, but it is that of the second, the great occipital, which is most im- portant, from its size, and the frequency with which it is attacked. Shooting pains start from just below the occiput, and run over the back and top of the head, sometimes into t] external meatus, and often to the front of t head and face. Giddiness, noise in the ea and some confusion of ideas are often associat ! and frequently cause cervico-occipital neural; to be mistaken for commencing organic diset of the brain. It may begin by such act tenderness of the scalp as makes it an agony ! brush the hair. (c) Cervico-brachial neuralgia. — The nerves the brachial plexus and the posterior branch of the four lower cervical nerves are here a cerned. The pains affect the neck and shoulde j or shoot down the arm to the hand, in the com! of one or more of the nerve-trunks. Pain: points may be found in the axilla, over t upper part of the deltoid, at the bend of t elbow, three inches above it externally, the groove between the inner condyle of t humerus and the olecranon, at the ulnar side the annular ligament, and where the rad nerve becomes superficial. The ulnar nerve that most often affected, but the neuralgia us ally spreads to other trunks. This form neuralgia is sometimes associated with the pi; sence of carious teeth. (d) Dorso-intercostal neuralgia. S:e Lvri costal Neuralgia. (e) Lvmbo-aJjdominal neuralgia. — Here t 1 superficial branches of the lumbar plexus to t abdominal walls are affected. It is less comm than intercostal neuralgia, but resembles i generally. Tender points maybe found close I the spine, at the middle of the crest of the ilia iu the hypogastric region, in the groin, and ' the scrotum. The female sex is apt to be m affected. (/) Crural neuralgia. — This variety is aim always met with as a complication of sciati being rare by itself. Pain occurs in the front 1 the thigh and knee, and inner surface of the . and foot. The long saphenous branch of i- anterior crural nerve is most commonly affect. This form of neuralgia is not unfrequent in h- joint disease, where it is secondary to irritatl of the branches of the obturator nerve supp- ing the joint. (g) Obturator neuralgia affects the inner si of the thigh. ( h ) Fcnioro-poplitral neuralgia. See Sciati. (i) Coccydynia . — Pain in the neighbourly! of the coccyx, more properly called coccygodm, especially apt to occur in women, is sometin, but by no means always, due to neuralgia of e coccygeal plexus. The pain is felt particular in sitting, and shocks from rapid movemt or jumping will cause great distress. So cp sometimes the act of delineation may be so pc- ful as to suggest the presence of fissure of e anus. More often than not the affection folks an injury, especially a fall in the sitting p - tion, and happens sometimes aftor difficult p- turition. II. Visceral. — (a) Cardiac. — A certain ] - tion of the class of cases called angina pectj s depends upon cardiac neuralgia (see Atccfi Pectoris). There is sudden severe pain at |0 lower end of the sternum, darting to the b* and down the left arm, or it may be diffi ,j over the chest and affect both arms. The Ini EURALGIA. feals as though it were grasped, the face loses .colour, the pulse becomes altered iu character, there is cold sweating, and generally the aspect and feeling of approaching death, tiueh attacks .may be confined to two or three repetitions, or there may be a constant tendency to their recur- rence under circumstances of fatigue or strong 'emotion. (b) Uterine and ovarian neuralgia. — Pain at- tendant upon menstruation, independent of any nechanical difficulty, is thus named. It may he excited by such sources of peripheral irritation is ascarides, leueorrhcea, renal calculus, pro- apsus uteri, tumours, ulceration of the cervix, ir impaction of feces ; or the sources may he in some distant part of tho body. Ovarian neu- ralgia may be accompanied by congestion of the wary. (c) The urethra , bladder, rectum, lcidney, and 'testis may each ho affected by neuralgia. The latter may result from self-abuse, or be con- sequent upon renal concretion. See Nephralgia. (d) Gastralgia. — Abdominal neuralgia is eha- ■acterised by intensity of colicky pain, occurring n paroxysms in circumstances differing from hose which induce ordinary dyspepsia. There is nearly always a history of neuralgia in some >ther part of the body. Vomiting sometimes, md constipation invariably, accompanies the ittacks. See Gastralgia. Complications and Sequel.®. — Neuralgia vhen it attacks mixed nerves may produce huscular powerlessness, which is not merely a hrinking from making muscular effort because if the pain attending it, but a temporary paraly- is. Or there may be spasm of muscles. Long- ontinued neuralgia is attended by more or less trophy of the muscles supplied by the affected erves, which may be temporary, or, in cases there frequent recurrences of the attack take ■lace, may be permanent. Certain forms of euralgia, especially that of the first division of he fifth, intercostal, and sciatic are liable to be ccompanied by a herpetic eruption {see Herpes). maesthesia of a portion of the skin will often ersist, though the pain itself may be absent. Diagnosis. — It may be said perhaps that for ain to be strictly accounted neuralgic there fould be no obvious cause for it, such as local lfiammation, tumour, or injury: it should be jlitsSnittent, or at least liable to great exacer- itions, and independent of movement or any ex- Tnal agency ; it should take the course of one or lore nerves ; and there should be spots painful 1 pressure in some of the localities already in- 'eated. Neuralgia is distinguished from mval- |a by tho latter involving the attachments of a uscle, not occurring in paroxysms, but depend- it upon movement ; from aneurism by careful ■ lysical examination, which is especially neces- ry when the pain is about the chest and ins. In chronic rheumatism the pain is dif- sed, influenced by movement, and it does not ‘feet the district of a particular nerve. Acute eumatism is accompanied by elevation of mperature, sweating and swelling of joints. ie thermometer, and the known symptoms and !;ns of the several diseases, will also at once elude pleurisy, pneumonia, and peritonitis, philitic periostitis is evidenced by the sight 1031 and touch, as well as (if it occur early iu the disease), by the presence of febrile move- ment. Where pain in the back is supposed to be of neuralgic origin it is important to ex- clude the presence of hernia. Examination should be made per vaginam to exclude flexions or tumours of the uterus, and per anum for the presence of abscess about the rectum or malignant disease. Organic disease of the brain must be excluded by the absence of local palsy, vomit ing, intellectual disturbance, or optic neuritis. The pains of Bright’s disease must be carefully ex- cluded by search for albumen, signs of arterial thickening, and cardiac hypertrophy. Spinal irritation is accompanied by pains which, how- ever, fail to mark the district of particular nerves, and are vague and shifting. There is hyperaesthesia of the skin over some of the verte- bral spines. Locomotor ataxy is characterised by pains of lightning-like rapidity, and neuralgic in character ; but they shift, are often accompanied by a staggering gait, sometimes by diplopia. Absence of the patellar tendon reflex (the quadri- ceps extensor muscle at the same time responding freely to faradization and blows) is a strong indication of locomotor ataxy. The pains of syphilis in its second stage maybe distinguished by the presence of fever, usually also of a rash, and the fact that they affect many parts at once. Prognosis. — Youth, the absence of strongly- marked history of hereditary neurosis, the fact that neuralgia has followed exposures to unusual strain, severe weather, or passing defects of nutrition, and that its attacks are influenced readily by treatment, afford a favourable prog- nosis. The onset of the disease after middle life, and its concurrence with signs of arterial degene- ration, are unfavourable as regards cure. Neu- ralgia of itself can scarcely he said to affect the duration of life. On the whole neuralgia of tho fifth nerve is the most persistent. Treatment. — In patients suffering from mal- nutrition the diet should he ample and nutri- tious, and should include a fair amount of the fatty element, in the form of cod-liver oil, butter, or cream. A little stimulant may sometimes he necessary, enough to promote primary digestion, hut no attempt should he made to relieve pain by its direct agency. Rheumatism should be treated by salicylate of soda in 20-grain doses three or four times a day. Two or three grains of iodide of potassium with fifteen of car- bonate of soda taken every four hours will often remove neuralgic pain connected with rheu- matism. When malaria is suspected it is well to follow up this treatment by quinine in doses of from five to ten grains twice a day. A mercurial purgative may he usefully combined with a dose of quinine. If there be syphilis, iodide of potassium in 10-grain doses three times a day must he had recourse to; if gout, the acetic extract of colchicum may he given in one-grain doses twice daily, coupled with saline purgatives. Even where there is no history of malaria quinine will often he very useful, especially in neuralgia of the first division of the fifth ( see Tic-Doulourf.ux). Phosphorus in its free state, in capsules containing gr. twieo a day, after food, is sometimes of service. Or the hypophosphite of soda or potash may hi 1032 NEURALGIA, given in doses of from five to ten grains. Phos- phoric acid is not of value. The liquor potass® arsenitis, in doses of iniij, increased cautiously to inviij, or n\x, and the tincture of steel, in doses of raxxx, largely diluted with water, may sometimes be used with advantage; and the latter will occasionally succeed even when there are no ordinary signs of chlorosis. As anaemia may exist with a well-coloured face, the state of the gums and inner surface of the lower eyelid should be examined for undue pallor. Strychnia, in iniij to n\.v doses of the liquor three or four times daily, is especially useful in gas- tralgia, and belladonna, in ^ gr. doses of the ex- tract or inx doses of the tincture, in neuralgia of the pelvic viscera. Seclusion from irritation of various kinds — movement, cold, noise, dazzling light, worry — should he carefully maintained in cases of trigeminal neuralgia. All sources of peri- pheral irritation, of which decayed teeth, foreign bodies under the skin, intestinal worms, imper- fectly-fitting boots are examples, should he care- fully searched for, and where practicable re- moved. If lead be suspected the drinking water should be tested, and if the mineral be found iodide of potassium may be administered. Re- moval from imperfectly ventilated rooms, or from exposure to noxious gases, is essential. A warm, dry climate, such as Egypt or Algeria, will often cure when all other remedies have failed. Por immediate relief morphia may be injected hypodermically, either near the seat of pain, or in an indifferent part of the body. It is best used pretty freely diluted, iniij of a solution of acetate of morphia, 1 to 30, being commenced with, and repeated, if necessary, when the pain returns. This dose may be gradually increased to one of in xv, but an effort should be made to do with as little as possible and to avoid nar- cotic effects. The following pill is often useful : Quini® gr. j, Eerri Tartarati gr. ij, Morphi® Acetatis gr. i, repeated every hour or two when the onset is expected. Next in value to morphia is the use of small blisters (size of a florin), applied in the neigh- bourhood of the principal focus of pain, one following another at intervals of two days, not on but near the already blistered surface. The continuous current, derived from so many cells of a battery as cause a characteristic feeling of burn- ing, may be so applied that the affected nerve is as completely as possible included in the voltaic circuit. Sponges moistened with warm salt water should convey the current, and be kept firmly pressed upon the skin for about ten minutes ; or, whilst one is still, the other may be slid along so as to linger in turn upon each focus of pain. To avoid shock the circuit should cot be broken by the lifting of a sponge till the battery is ‘letdown’ to zero. If relief be afforded the application may be repeated many times a day. No notice need be taken of the position of the poles ( + and — ), the object of the proceeding being simply to alter the electric tension of the tissues which are made to form part of the circuit. In rare instances, but especially in ovarian neuralgia, the hypodermic injection of atropine er . to i gr. of the sulphate) may prove serviceable. Where there is great restlessness NEURITIS. and irritability of the nervous system, bromide of potassium in 30-grain doses two or three times a day should be used. Relief, in slight 1 cases of neuralgia, is obtained by applying to the skin such liniments as the following; Chlo- roformi :ss, Tincturae Opii Jss, Linimentum Belladonna ad yiij. ; or Ijc Spiritus Ammonite aromatici, JEtheris", Tinctur® Opii, Spiritus Vini rectificati aa 51 . Aconite and veratria be- numb the sensory nerves, but they are uncertain remedies and very apt to cause irritation. In unusually severe cases, which have lasted over years, a portion of the nerve may he ex- cised ; or, what is better, the nerve, which has been exposed by an incision, may be lifted from its bed and so firmly pulled upon as to be stretched (see Nebves, Diseases of). Veiy satis- factory results have followed this procedure In a case, treated by the writer, of terribb severe neuralgia of the first two divisions ol the fifth nerve, the operation was performed on each division of the nerve in turn, with immediate and, as far as at present observed, permanent relief from pain. Some time after the enre cl a neuralgia there may be threatenings of a revival (dull heaviness, with tenderness, of the part) following great fatigue or worry, but not immediately amounting to anything. Sleep is the best remedy for this condition, and this, i' necessary, may be aided by giving ten grains; of chloral hydrate. Special reference must be made to the treat- ment of coccydynia. This consists in sub- cutaneous division of tho muscles and fibrous structures attached to the coccyx with a teno tomy knife. In very troublesome eases tlx* coccyx has been excised. The application of ; leech or small flying blisters in the neighbour hood, will sometimes relieve. The bowels shoulc be kept rather loose, and rest enjoined. In ob stinate cases, where it seems probable that loi irritation exists, the above-mentioned operation of Sir J. Simpson may be performed with ad vantage. T. Bczzabd. NEURITIS (vevpov, a nerve). — Definition Inflammation of a nerve. ..Etiology. — This process occurs sometime as an idiopathic change, whose origin is alto gether obscure, as where it implicates some c the intercostal or other spinal nerves, and is the often associated with an eruption of herpes coste in corresponding regions of the skin. At othe times, as in some of the cases when it attack the facial especially, or the sciatic nerve, neuriti seems to he set up as a result of local exposur to cold (see Facial Neeve, Paralysis of; an Sciatica). Such forms of neuritis as these a: commonly spoken of as ‘ rheumatic inflammt tions ’ of the respective nerves. Sometimes th appellation may be distinctly justified; ht whether such changes have necessarily to d either with rheumatism or with a rheumst predisposition— or, indeed, with gout — seen in many cases fully open to doubt. A proce essentially similar does, however, unquestionab) occur with especial frequency in connectic with the roots of cranial or spinal nerves, ; persons affected with syphilis. At other times neuritis may ho of tramnat ! NEUKITIS. origin, or it may spread along the nerves leading from some -wound or sloughing sore. This latter cndition of things has been found to exist in :ome cases of traumatic tetanus. See Tetanus. Anatomical Characters.— Strictly speaking, ve have to do, in this pathological state, with inflammation of the sheath of the nerve, rather han with changes in the nerve-fibres them- ;elves. It is possible, of course, that the nerye- ibres in this condition may undergo some dis- inetive pathological changes, but what is at , resent known is, that the neurilemma, or con- ective-tissue sheath of the nerve (including its ainute prolongations between and around sepa- rate bundles of nerve-fibrils) becomes much more kypersemic than natural, and that on microscopi- al examination there is to he found, in addition jo the increased vascularity, a multiplication of ew tissue-elements and the presence of migrated leucocytes. These changes may cause consider- ate swelling of the nerve-sheath and of its pro- bations, and thus may produce either mere :ritation or more or less compression of the erve-tubules, according to the amount of new lements which accumulate in or are produced ithin the nerve-sheath. Symptoms. — The symptoms of neuritis will ecessarily vary much according to the functions ith which the affected nerve is concerned, 'here may be impairment of special or common visibility, or pain may exist (referred to the eripheral distribution of the nerve), with more ■c less distinct tenderness along its course. In rese cases the pain is generally paroxysmal, id possibly a pustular or vesicular skin-eruption ay present itself along the course of the nerve, ter some more than usually severe attack 1 pain. Where a motor nerve is implicated, lere may be twitchings of the muscles to which is distributed, followed, perhaps, by more or ss distinct paralysis. In the case of a mixed are, like the sciatic, being involved, both □ds of symptoms present themselves— that is, ore or less severe pains and tenderness, to- |ther with a distinct paresis of the muscles to lieh the nerve is distributed. Treatment. — The treatment of neuritis is tli general and local. The general treatment of especial importance in cases where the fldition seems attributable to the influence of jphilis, and then the administration of small ses of bichloride of mercury, in combination th large doses of iodide of potassium, will en produce marvellously beneficial results, uller doses of iodide of potassium alone, or :h colchicum, are to he given in other cases, in ' ich rheumatism or gout may seem to be one 'the factors in exciting the nerve-inflammation. • t in these cases, and also in thoso which are i lple results of exposure to cold, the cure may loften expedited, and the patient also tempo- i ily relieved, by local treatment, such as the i plication of a leech or two (especially in the ' ly stages), hot fomentations, or small flying I iters. luring the course of the treatment special i lptoms may become all-important ; thus, pain •If become so agonising as imperatively to de- [ id measures for its relief; and, where paralysis 1 ne of the symptoms, galvanism must he em- NIGHTMARE. 1033 ployed daily, or two or three times a week, in order to prevent as much as possible the muscles from degenerating whilst the pathological condi- tion in the nerve is being cured— that is, in cases in which a cure is possible. H. Charlton Bastian. NEUROMA ( vevpuv , a nerve). — A tumour connected with a nerve. See Nerves, Diseases of. NEUROSES ( vevpoi ' , a nerve). — Synon. : Fr. Neuroses ; Ger. Ncrvenleiden. Definition. — Affections of the nervous system occurring without any material agent producing them, without inflammation or any other con- stant structural change which can he detected in the nervous centres : in other words, functional affections of the nervous system. Many of the disorders which may he included here are characterised by symptoms such as neu- ralgia, convulsions, &c., which also accompany other disorders associated with morbid changes. It is very necessary, therefore, in inquiring into any particular case not to rest satisfied with the presumption that the disorder is functional until the condition of the nervous centres has been investigated; lest, regarding the symptom as the disease, the central mischief to which it is due may be overlooked. It is highly probable, more- over, that many of what we now regard as func- tional diseases will, on further investigation, he found to depend upon some corresponding change in the organ affected. Enumeration. — The neuroses may he classi- fied according to the organs or functions in- volved : — a. Visceral Neuroses, namely, those of the re- spiratory, circulatory, or digestive organs. b. Localised Paralyses-, for instance, palsy of the facial and other peripheral nerves. c. Localised involuntary or reflex movements, such as spasm of the facial nerve, and writer’s cramp. d. Disorders of general sensibility, including the various forms of neuralgia — trigeminal, cervico-occipital, sciatic, crural, &c. e. General Neuroses, namely, chorea, tetanus, epilepsy, catalepsy, hysteria, and allied affec- tions. f. Disorders of the mental faculties — hj-pochon- driasis, melancholia, and other forms of mental derangement. P. W. Latham. NICE, on the Erench. Riviera. — Fairly warm, rather variable and windy, dry, bracing winter climate. Mean temperature, winter, 4S’33° Fahr. See Climate, Treatment of Disease by. NICTITATION J ( mc - tio > I wlnk often). A rapid involuntary winking of the eyelids, usually due to some nervous disturbance. See Chorea ; and Facial Spasm. NIGHT-BLINDNESS. See Nyctalopia. NIGHTMARE. — This is a condition cha- racterised by an abiding sense of discomfort or extreme uneasiness, occurring in the midst of a disturbed sleep, sometimes associated with a feeling of weight at the epigastrium, in conjimc* 1034 NIGHTMARE, lion with more or less definitely oppressive dreams. It is principally associated with the taking of a heavy meal or of indigestible food before going to sleep by some persons, especially those of a nervous temperament, whose diges- tion is weak. A closely allied condition is, however, apt to be met with as a consequence of brain-exhaustion and chronic disturbance of- sleep in those who are overworked, either by application to study, business details, or literary pursuits. Such a condition also has its affinities with certain forms of incipient delirium, occurring either in various febrile diseases or as a result of alcoholic excesses. Sec Sleep, Disorders of. H. Charles Bastian. NIGHT-SIGHT. See Hemeralopia. NIGRITIES ( niger , black).— Synon. : Fr. Koirceur ; Ger. Sckwcirzc. — Nigritics cutis sig- nifies blackness of the skin. It may be of various degrees ; and results from aberration of deposit of pigment, or, more exactly, from an excess of black pigment in the integument. See Melano- PATHIA. NILE, The. — Very dry winter climate. Un- suitable for cases of active pulmonary disease. Mean temperature, winter, 57° Fahr. See Climate, Treatment of Disease by. NIPPLE, Diseases of. — Synon. : Fr. Ma- ladies du Mamelon ; Ger. Krankhciten dcr Brust- warze. — Some of the more ordinary affections of the nipple will be found described under Breast, Diseases of, and Lactation, Disorders of. Here it is proposed to treat of certain graver diseases, which claim a separate consideration. Malignant Disease. — The nipple may be the seat of epithelioma, which commonly commences as a crack or fissure, with an indurated base, often in the areola or at its junction with the nipple. It presents no special features which distinguish it from similar disease of the in- tegument of adjoining parts. Hard carcinoma too may attack the nipple, involving its deeper structures and producing general induration and enlargement, so that the diseased mass projects from the summit of the breast like a knob or large nut. The disease probably originates in the epithelium of the galactophorous ducts, or in that of the sebaceous glands. Of greater interest than either of these is an affection frequently associated with malignant disease of the breast, to which Sir James Paget has lately drawn attention — an eczematous con- dition of the nipple and areola. It may occur in the form of a dry, seal}', or bi'anny eruption, affecting the entire surface of the areola and nipple, which is darker-coloured, a little firmer, and less pliant and elastic than its fellow. Or, with more characteristic signs of inflammation, small vesicles or pustules may form, and, break- ing or being rubbed off, may leave behind them tiny scabs or ulcers, or a surface raw and red. Either condition may exist for many months or even years with little alteration, and with scarcely any tendency to spread beyond the margin of the areola. But the second form, causing more irritation than the first, is often subjected to treatment, and being very difficult to cure, is sometimes so severely treated with caustics that NOLI ME TANGERK. destruction ensues, not of the disease, but of tb nipple, which appears to have been gradual! eaten away by the eczematous affection. Bet forms are uncommon, but they are rare befoi the middle age. A study of their clinical an ! pathological characters leads to the conclusioi that they are due to inflammation. The diseas has been noticed in men as well as women. Treatment. — This disease may be treatc- by protecting the parts with a carefully acj justed, ventilated shield, and by the appl cation of vaseline, or liniment of lead an oil, or similar soothing dressing. But it is vei intractable, in some cases apparently incurahll It might seem as if an affection so trivial w« not worthy of so much attention ; but unfa tunately there appears the strongest reas to believe that these conditions of the nipp and areola are not infrequently the precursors carcinoma of the breast, sometimes by only few months, sometimes and more often, by period of years. It is probable, too, that tl carcinoma is directly due to the eczematous df ease; for it induces changes in the epithelium the ducts which can be traced deeplv into tl substance of the breast, whose acini become length distended with proliferating epithelim. On this account it has been proposed, when a the lesser methods of treatment have been us. in vain, to remove the entire breast. Opinio which are divided on the necessity of this me sure, so severe, are united in its favour whe with the superficial inflammation, there exists .• appreciable induration, however slight, with the breast. Care must he taken not to confoti these eczematous affections of the nipple aj areola with those more widely diffused surfa inflammations of the breast, with which th have little in common, either in the ohstina with which they resist treatment, or in the deep disease to which they may give rise. Henry T. Butlin. NOCTAMBULATION {node, in the nig and ambulo, I walk). — A term for sleep)- walkii See Sleep, Disorders of. NOCTURNAL EMISSIONS.— Invoh- tary emissions of semen occurring during sle. See Sexual Functions in tub Male, 11- orders of. NOCTURNAL INCONTINENCE. — voluntary escape of urine during sleep. ‘ Micturition, Disorders of. NODE {nodus, a swelling). — A circumscrill swelling on the surface of a bone, connected wi the periosteum, and usually due to syphilis. ‘ Bone, Diseases of ; and Syphilis. NODI DIGITORUM (Latin).— Swallip of the distal phalanges of the fingers, usuff associated with gout. See Gout. NOLI ME TANGERE (Hit., Touch-i- not). — A term of dread, which has been appU to a state of severe ulceration of the nose. ■ tended with fungous growth and more or less - formity. The phrase is subjective, and has bn used somewhat indiscriminately in connectu with lupus, cancer, and syphilis. It has & very properly fallen into disuse, or, when • NOLI ME TANGERE. ployed, is restricted to lupus exedensof the nose. See Lupus Vulgabis. Erasmus Wilson. NOMA (ve/xu, I devour;. — Synon. : Fr. Rome; Ger. Wasserkrebs. — A synonym for cancrum oris. See Cancrum Oris. NOSE, Diseases of. — Synon. : Fr. Mala- dies du Nee:; Ger. Krankhciten der Nase. — The diseases that affect the nose may be conveniently divided into — (A.) The diseases of the External Nose ; and (B.) the diseases of the Internal Nose. A. Diseases of the External Nose. — 1. Acne Hosacea. — Synon.: Pop. ‘Gin- drinker's nose.’ — This affection of the nose is generally met with in later adult age. Not un- frequently the cause is to be found in alcoholic indulgence. In other cases it may be associated with some irregularities of menstruation. Description. — The organ is swollen and red; its surfaco is shiny and. greasy-looking ; the skin is highly injected, the venules particularly appearing almost varicose ; the sebaceous fol- licles are enlarged, though not invariably ; and the skin is hypertrophied, the whole condition giving rise to an unnatural protuberance. At a later stage of the disease the nose appears tuber- culated and blotched, often pustular, and covered with crusts and scales ( acne hypertrophica). The • blood disappears under pressure, and increases under mental excitement. Treatment. — Mild cases are "best treated by lead lotion, a weak solution of tho bichloride of mercury, or zinc ointment. In severe cases the subcutaneous division of the larger vessels by a fine tenotomy knife causes a rapid shrink- ing and improvement. In all cases of acne atten- tion must be paid to the manner of living and general health of the patient. 2. Boil, or Furuncular Inflammation. — A very painful form of boil is liable to develop on the tip or aim of the nose, causing great disfigurement and often intense suffering. It commences in the subcutaneous cellular tissue, or beneath the perichondrium ; and by its gradual increase and extension to skin and fibro-carti- lage, causes great swelling, tension, and throbbing pain, owing to the peculiar toughness of the tissues entering into the formation of the inte- gumentary structures. .Etiology. — This affection is generally met within young or middle-aged persons of intem- perate habits, although frequently it is seen in the delicate and ancemic. Elderly persons, high feeders, who do not attend to the proper condi- tion of their intestinal canal, are also liable to it. Treatment. — If detected early, boil of the nose may be treated by painting with strong lead lotion, or just touching the part with the acid nitrate of mercury, and immediately' rub- bing it off. If very severe, and in order to avoid he pit or scar which might be left by allowing ■.he disease to take its course, a very fine teno- tomy knife may be passed through the nostril md into the boil, to relieve tension, and to allow 'f the escape of the pus into the nostril. 3. Deformities. — (o) Congenital absence . — ^ases have been recorded of congenital absence if the nose. It does not appear that this con- NOSE, DISEASES OF. 1035 dition can be satisfactorily assisted by surgical interference. (£) Congenital occlusion. — Congenital occlu- sion of one or both nostrils is a very rare affec- tion, and obviously' must interfere seriously'with sucking and respiration. It is either the result of a continuation of the integument, or is formed of fibrous tissue. The treatment, which should be undertaken at once, consists in making care- ful incisions through the obstruction, and keeping the nostril dilated with a piece of gum or metal catheter or a bougie for some weeks. (y) Deviation of the septum. — This deformity usually consists of a lateral curvature of the septum, and generally of some hypertrophy of its extremity, causing an inclination of the organ to one side or the other. As a result there is often great disproportion in the nasal cavities or nostrils, in some instances amounting to almost complete occlusion of one side ; and the projec- tion of the inferior turbinated bone of one side may be mistaken for a growth, on account of its protrusion. The treatment consists in carefully' paring away the thickened septum, and subse- quent dilatation of the nostril. 4. Expansion of the Nose, Morbid. — The tip occasionally' becomes enormously developed, all the tissues being involved. This condition may require the removal of a wedge-shaped portion of the extremity, including the growth, and the subsequent adaptation of the parts. 5. Fracture. — In fracture of the nasal bones the displaced bone or bones should be raised, by- introducing a pair of stout forceps with flat blades into the nostrils, guiding them up to the nasal bones by means of the septum, and then forcibly elevating them. The bones should be retained in position by plugs, or the small screw-clamp lately introduced, assisted in severe cases by some such mechanical appliance as a screw truss, passing round the head, and exerting pressure laterally upon the displaced bones. In cases of fracture of the septum with displacement, and subsequent deformity, the shape of the nose may be restored by this method, great attention being paid to the management of the plugs and clamp. 6. Hypertrophy of the Integument. — Synon. : Lipoma Nasi. — This consists of a hyper- trophied condition of the integuments and of the subcutaneous adipose tissue, constituting irregular fleshy excrescences, and occurring in cases of severe and old-standing acne rosacea. Description. — The term ‘lipoma’ is an iu- • appropriate one, inasmuch as the mass consists of hypertrophied infiltrated skin and cellular tissue, with enlarged sebaceous follicles, which occasionally become developed into distinct cysts and dilated veins. The growth is chronic anu painless, varying very much in the degree of its development aDd appearance, sometimes scat- tered like small warts, at others pedunculated and lobulated, and often attaining an enormous size. It does not affect the cartilages. Treatment. — The only treatment is removal by the knife, dissecting the mass carefully off the underlying cartilages, and allowing the sur- face to heal by granulation. 7. Lupus. — The forms of lupus attacking the nose are fully' considered elsewhere in this 1036 NOSE. DISEASES OF. work. See Lupus Erythematosus ; and Lupus Vulgaris. 8. Malignant Disease.— Epithelioma is a rare form of malignant disease in the nose. It com- mences with the characteristic wart, which passes on to the ulcerative stage; and its first appearance is either at the junction of the skin and mucous membrane, or in the membrane itself. It may he stationary for years, but ultimately ends in destruction of the organ. It must not be con- founded with syphilis. The history of the case is often enough to establish the diagnosis ; whilst 'the epithelial patch is nearly always single, and the specific multiple. The disease affects the glands sooner or later. Schirrus and Encepkaloid cancer occasionally involve the nose, generally growing from within outwards. These growths may be either excised, or destroyed by escharotics. 9. Nsevus. — Nsevus may exist in all degrees in the external nose, from the merest patch to a large disfiguring tumour. If very small, inocu- lation with vaccine matter may entirely destroy it. Ligatures invariably, if the growth be large, leave a scar; injection with perchloride of iron is very dangerous. The best method of treat- ment is the galvanic cautery; or in some in- stances the entire removal of the growth with the knife. 10. Kodent Ulcer. — Eodent ulcer is occa- sionally met with in the nose. It somewhat re- sembles lupus, but occurs in later life. The ulcer spreads gradually ; and the pain is described as of a severe aching character. It has been classed with the cancers, but it lacks several of the cha- racteristics of that kind of growth. There is no constitutional infection; and it has been abun- dantly proved that, if entirely eradicated with the knife, it need not return. See Rodent Ulcer. 11. Sebaceous Tumours. — Sebaceous tu- mours are occasionally met with on the sides and tip of the nose, and require removal. 12. Syphilitic Disease. — Syphilitic ulcers of the nose are of special interest as being one of the causes of ozsena. The symptoms and treat- ment of this condition are fully described in a separate article. See Ozhsna. 13. Wounds. — -Wounds of the integuments or soft parts of the external nose require the neat- est coaptation, by the use of very fine silver wire sutures, or of isinglass plaster ; and as union is generally very rapid, owing to the great vascu- larity of the tissues, unless this be attended to serious deformity may result. Any tendency to falling in of the nostril must be counteracted, by introducing a roll of lint or piece of bougie. It may be worth mentioning that instances have occurred where the nose has reunited after its complete removal from the face. Plastic Operations. — Plastic operations on the nose, for the restoration of lost parts, or for the improvement of deformities, are described in works on operative surgery. B. Diseases of the Internal Nose. — 1. Anosmia.— Anosmia, or loss of the sense of smell, when of traumatic origin, is either the result of injury, such as blows on the head, or of the inhalation of noxious vapour ; or it de- pends on cerebral disease. In the former case, a very frequent cause is a blow on the head, probably rupturing some filaments of the olfac- tory nerves, as they pass through the cribriform plate of the ethmoid bone, according to Offle (Med. Chir. Trans, vol. liii). The external root only of the olfactory nerve is the one directly concerned ; n olfaction, ‘and it depends upon the degree to which this root or its central ter- mination has been disorganised, whether the loss of smell be complete or partial.’ Anosmia from other causes than injury is described elsewhere. See Olfactory Nerve, Disorders of; and Smell, Disorders of. Treatment. — The treatment of anosmia is somewhat unsatisfactory. In cases where it de- pends on cbvious causes, the removal of these may entirely or partially restore the sense of smell ; and in other cases the excitation of the Schneiderian membrane of the nasal cavitv, by the continuous galvanic current, promises better results than the administration of medicine or local applications. 2. Blood Clots. — As a result of injury, or of very violent blowing of the nose, extrava- sations of blood may take place, and form masses in the nostrils, which often set up in- flammation, terminating in ozaena. In a case lately under the writer's care, a large, hardened blood-clot — which had been originally’ diagnosed as a morbid growth, and given rise to great inconvenience — was detached from the posterior nares, by the repeated use of the nasal douche. 3. Foreign Bodies in the Nasal Pas- sages. — Peas, cherry-stones, and the like are often inserted into the nostrils by children, and: if found out at once can he, generally speaking, readily removed. When a foreign body has remained for any length of time in the nasal fossae, it becomes coated with calcareous matter and forms a calculus, setting up a most offensive discharge, ulceration of the mucous membrane, and necrosis of the cartilages or bones. In all cases of persistent discharge from the nostrils the impaction of a foreign body' should be sus- pected, and examination made by gentle pro- bing or the rhinoscope. Treatment. — In attempting to remove a foreign body from the nasal passages, it is as well to avoid the use of forceps, as the blades it attempting to catch the body, are liable to cause its impaction. A small slender hook may It passed behind the body, or a very fine screu into it, and so it can be withdrawn, as sug- gested by Gross. The removal of masses thai have long been retained in the nasal passages may sometimes he effected by the nasal douche, usint a strong stream directed into the sound nostril or by means of curved bougies passed from be hind. Pushing the impaction backwards inn the pharynx is always rather hazardous, as : may pass into the larynx. Occasionally foreigi bodies have been so long in the nose, and bej come so firmly impacted, that external incisic! has to he made, and the structures tonning th external nose freely divided in order to rea • them; or the method of Pouge, of eperatn., through the month, may be employed. Insects, leeches, or intestinal worms may g’- into the nasal passages, and from them pass int the sinuses. It has been proposed to destro these by vapour of alcohol or turpentine. NOSE, DISEASES OF. 1037 4. inflammation of the Septum Marium.— icute inflammation of the septum narium is Venerally a result of injury, and may terminate a abscess, the diagnosis of 'which from polypus s easy. The abscess should be promptly opened. In chronic inflammation of the nasal septum, which is very frequently the result of syphilis or .icrofula, there is often necrosis of the cartilagi- nous septum, resulting in perforation, which may dve rise to great deformity, on account of the depression of the nose following it. As regards reatment, in some instances, perhaps, the per- sistent dilatation of the nostril may be useful ; md should there be a disposition of the ulcerative process to spread, the edges should be touched nth either a strong solution or the solid stick if nitrate of silver. The constitutional treat- ment must, of course, he dependent on the cause if the ulceration. 5. Khinolith.es, or Nasal Calculi. — These basses are generally the result of the impaction if some foreign body, around which the inspis- ;ated mucous and purulent secretion of the nasal passages has formed, retaining it as a sort of mcleus. Or they may occur spontaneously ; and, .ceording to Demarquay, consist of phosphates If lime and magnesia, and carbonate of lime, aagnesia, and soda. Ehinolifhes cause symptoms of obstruction .nd irritation, and sometimes set up severe in- jammation and discharge. Before attempting heir extraction, the posterior nasal douche mould be employed to wash away the accumu- ited secretion, and to assist in dislodging the lass, which may be subsequently crushed, and emoved piecemeal or entirely. 6. Submucous Infiltration of the Sides f the Vomer. — -This affection has been called 'ttention to by Cohen, and ‘ consists of a puffy audition of the mucous membrane over the vomer, inch, by giving rise to symptoms of obstruction t the posterior part of the nares, has been mis- iken for polypus. On examination with the linoscope, there is observed on each side of ,ie septum, and confined to its posterior portion, tumid mass of whitish colour, markedly dis- act from the red colour of the adjacent mucous jembrane. The affection is usually symme- ical, but often exists to a greater extent upon he side than the other. The masses are round- b, with very convex outlines, and sometimes fiend half-way across the fossae, and oeea- onally very close to the outer margin of the ares, if not in contact with them. The disease ipears to consist in an cedematous protrusion the mucous membrane, from an accumulation meath it of serum or serous mucus/ Treatment. — The treatment consists ‘of tear- g away portions of the protrusions, by for- ps carried up behind the palate or through e nostril, and subsequent cauterisation of the ■its. The affection is an obstinate one, and ly recur again and again.’ In the cedematous .embrace, removed in one such case, there was undant evidence of mycelium (Cohen, Diseases the Throat.) 7. Tumours. — a. Cartilaginous growths have en met with in connection with the septum. b. Polypi of the nasal passages are fully de- abed elsewhere. See Polypi. c. Neuromata have been met with in the nos- tril, and mistaken for polypus. d. Adenoma of the pituitary glands has been recorded ( Archives generates, Oct. 1876), occupy- ing the superior and anterior portion of the nasal fossae. The growth was removed by ex- ternal incision. e. Adenoid vegetatir/ns in the naso-pharyngeal cavity have been described by Meyer, of Copen- hagen (Trans. Med. Chir. Soc., vol. liii). They may spring from any part of the naso-pharyngeal cavity, except the septum ; and the most pro- minent structural character of the growth is adenoid. They vary in shape according to the wall from which they spring, being sometimes cristate, cylindrical, or flat; and they are in general highly vascular. Symptoms. — The symptoms of such vegeta- tions depend, of course, on their number, size, and locality ; but one is led to their detection by observing that the patient is compelled to keep the mouth open, on account of the closure or partial closure of the air-passages through the nose ; by the attenuation of the external nose ; and by the voice losing its resonance in the naso-pharyngeal cavity, which causes a pe- culiar ‘deadness’ of the pronunciation. There may he, moreover, a sensation of the existenco of a foreign body, from the involvement of tho Eustachian orifice. Meyer lays down the general rule that ‘ a deaf patient who breathes througli the mouth, and has a thin compressed nose, is affected with vegetations in the naso-pharyngeal cavity.’ The detection of these growths is often best accomplished by the finger passed up be- hind the velum, when they may be felt as soft masses yielding to the finger, and giving the sensation of a bunch of earth-worms. Ilhino- scopic examination is very difficult and, as a rule, unsatisfactory in these cases. The writer has recently met with a case of this nature, which was readily diagnosed by the finger. Treatment. — The treatment consists in caute- risation, if the growths are soft and small, and the use, by means of the nasal douche, of a watery solution of common suit, or bicarbonate of soda (1 in 500), which washes away the mucus, and also alters the condition of the se- cretory surfaces. When larger vegetations exist, operative methods, such as crushing or scraping off the masses as near their bases as possible, must be resorted to through the nose, or the employment of the galvano- cautery. f. Cancer in all its forms may involve the nasal fossae, originating most often in the an- trum ; epithelioma usually commencing on the outside, or edge of the alas. The only treatment is obviously prompt removal on detection, and even then the prognosis is most unfavourable. g. Osseous tumours occur frequently in the internal nose. Dr. Olivier (Sur les Tumeurs osseuses de Fosses Nasales,et dcs Sinus de la Face : Paris, 1869) calls attention to growths of this nature, which are developed either in the nasal fossae, or in the tissues connected therewith, and states that they are characterised by the follow- ing conditions. 1. That they contain in their anatomical constitution only the elements of os- seous tissue, spongy or compact. 2. That they are primarily developed in the fibro-mucous 1038 NOSE, DISEASES OF. membrane which lines the cavities of the nasal fossae and the sinuses. So far a3 they involve the nasal cavities, the following facts present themselves. The tumour is generally to be seen at the anterior portion of the nostrils. If the bony tissue be still covered by the mucous mem- brane, that membrane retains its usual cha- racters ; but if the growth be carious, it becomes of a greyish hue ; and in the event of ulceration, the growth can be readily distinguished. These osseous tumours of the nose invariably cause some exophthalmos, whilst respiration and pho- nation are interfered with. Treatment. — The treatment of osseous tu- mours of the internal nose consists in their re- moval by methods which must be obviously conducted according to their position, size, or nature. Sometimes they are so enormously hard that no instrument will touch them, and some- times so soft and friable that the greatest care is necessary to remove them in their entirety ; and indeed it has been suggested by Ollivier, in the instance of these friable growths, to attempt to remove them in fragments before making external incisions, which will expose the growth entirely. In a case of the ivory variety lately under the writer’s notice, the tumour sprang from the frontal sinus and extended along the infundibulum, presenting in the nose as a large round nodule about the size of a marble, covered with mucous membrane, and of stony hardness ; there was little if any dis- placement of the external parts. With regard to the operative proceedings for the removal of such growths, or indeed for gaining a thorough view of the nasal passages, the method devised by Kouge, of Lausanne, is by far the most effec- tive. It consists in dividing the mucous mem- brane of the upper lip, at its junction with the jaw, freely, into the base of the anterior nares; in cutting subsequently through the nasal car- tilages; and in turning the lip and external nose upwards, so that a complete view of the nasal cavities is thus obtained over the roof of the palate. Other diseases affecting the internal nose are discussed in separate articles. See Cobyza; Epistaxjs ; Influenza ; and Oz.exa. Edwabd Bellamy. NOSOPHTTA (v6oos, a disease, and tpvrdv, a plant). — A term employed by Gruby to desig- nate a group of cutaneous affections, in which a fungus-formation constitutes an essential part of the disease. Naturalists have identified this fungoid growth with vegetable fungi in general, and have noted several species. Pursuing the same idea, they have regarded this fungoid matter as real fungi, vegetating in the skin, drawing their sustenance from the juices of that tissue, producing sporules, and diffusing those sporules, after the manner of seeds, as the means of propagating the species, and consequently, the disease. In this view of the nature of the fungoid de- velopment, those diseases in which the fungi are found are termed ‘ parasitic,’ and the con- tagious nature of such affections is thence in- ferred. One additional factor becomes necessary, namely, that the skin should be in a condition NURSES, TRAINING OF. favourable for the reception and development of the parasitic plant. The precise pathological state constituting the disease may *be denomi- nated ‘phytosis,’ whilst the seat of its manifes- tation is the epidermis, the rete mucosum, the epithelium of the follicles, the nails, and the hair. One of the most important of the cutaneous nosophyta is tinea, or ringworm ; hence the word tinea is employed synonymously with phytosis; and we are enabled to enumerate as examples of the disease: — Phytosis scu Tinea tonsurans, circinata, favosa, and versicolor ; whilst we also note that phytosis is present in certain forms of folliculitis, for example, in lichen marginatus : and. in sycosis. Phytosis, moreover, is a con- comitant of onychogryphosis. See Phytosis; Ringworm ; and Tinea. Erasmus Wilson. NOSTALGIA ( viScrros , return, and &\y os, sadness). — Synon.: Fr. Nostalgic, Ger. Heimweh. — A form of melancholia, sometimes occurring in persons who have left their homes. The symptom from which it derives its name is aa intense desire to return home ; and this is accom- panied by great mental and physical depression, which may end fatally. See -Melancholia. NUMMULATED SPUTUM ( numma , a coin). — A form of sputum which, when spreading ; 1 out on a surface, resembles a coin in shape. Sec Expectoration. NURSES, Training of. — Training is to teach not only what is to be done, but how to do it. The physician or surgeon orders what is to be done. Training has to teach the nurse how to do it to his order ; and to teach, not only how to do it, but why such and such a thing is done, and not such and such another ; as also to teach symptoms, and what symptoms indicate what of disease or change, and the ‘ reason why’ o> such symptoms. Nearly all physicians’ orders are conditional; Telling the nurse what to do is not enough and cannot be enough to perfect her — whatever heij surroundings. The trained power of attending td one’s own impressions made by one's own senses so that these should tell the nurse how the patient is, is the sine qua non of being a nurse at all. Tin nurse’s eye and ear must be trained — smell and touch are her two right hands — and her taste i; sometimes as necessary to the nurse as her head: Observation may always be improved by trainin' — will indeed seldom be found without training for otherwise the nurse does not know what to lool for. Merely looking at the sick is not observing To look is not always to see. It needs a higi degree of training to look, so that looking shal tell the nurse aright, so that she may tell tli medical officer aright what has happened in hi absence — a higher degree in medical than i| surgical cases, because the wound may tell it own tale in some respects ; but highest of a: of course, in children's cases, because the chill cannot tell its own tale ; it cannot alway answer questions. A conscientious nurse is nc necessarily an observing nurse ; and life or deat may lie with the good observer. Without atraine power of observation, no nurse can be of any us NURSES. TRAINING OF. 1030 >3 reporting to tho medical attendant. The best ne can hope for is that ho ivill ho clever enough jot to mind her, as is so often the case. Without j: trained power of observation, neither can the urse obey intelligently his directions. It is most uportant to observe the symptoms of illness; it L if possible, more important still to observe he symptoms of nursing ; of what is the fault jot of the illness but of the nursing. Observation Ills how the patient is ; reflection tells, what is in be done ; training tells how it is to be done, framing and experience are, of course, necessary [jo teach us, too, how to observe, what to observe, "ow to think, what to think. Observation tells s the fact; reflection the meaning of the. fact, lellection needs training, as much as observation. Itherwise the untrained nurse, like other people (idled quacks, easily falls into the confusion of j on account of,' because ‘ after ’ — the blunder of [he ‘ throe crows.’ The nurse is told by the ledical attendant, ‘ If such or such a change ccur, or if such or such symptoms appear, you re to do so and so, or to vary my treatment in iich or such a manner ' In no case is the hysician or surgeon always there. The woman lust have trained powers of observation and feflection, or she cannot obey. The patient’s fe is lost by her blunder, or ‘ sequelae ’ of in- arable infirmity make after-life a long disease ; lid people say, ‘ The doctor is to blame ; ’ or, orse still, they talk of it as if God were to lame — as if it were God’s will. God’s will is ht that we should leave our nurses, in whose lands we must leave issues of life or death, ithout training to fulfil the responsibilities of ich momentous issues. To obey is to understand orders, and to un- irstand orders really is to obey. A nurse does at know how to do what she is told without ich ‘training’ as enables her to understand hat she is told ; or without such moral and sciplinary ‘ training ’ as enables her to give her hole self to obey. A woman cannot be a good id intelligent nurse without being a good and kelligent woman. Therefore, what ‘training’ gnifies in tho wide sense, what makes a good fining-school, what moral and disciplinary paining’ means, and how it is to be attained, e to be clearly understood. I. What makes a good Training-school for Sums ? (1) A year’s practical and technical training hospital wards, under trained head-nurses D-called ‘sisters’ of London hospitals), who emselves have been trained to train. For a district nurse, an additional three jnths’ training in nursing by the poor bedside, der a trained and training district superin- ldent, is essential. The training of probationers should be as ich a part of the duty of the head nurse jiister, ’) as directing the under-nurses or seeing the patients. To tell the training, you require weekly re- 'ds, under printed heads corresponding wi:|i ! ‘List of Duties,’ kept by the head-nurses of p progress of each probationer (pupii) in her rd-work, and in the moral qualities necessary (her ward-work ; a monthly record by the ma- d cf the results of the weekly records ; and a quarterly statement by her as to how each head- nurse has performed her duty to each proba- tioner. The whole to bo examined periodically by the governing body. (2) Clinical lectures from the hospital pro- fessors ; lectures on subjects connected with nurses’ special duties, such as elementary in- struction in chemistry, with reference to air, water, food, &c. ; physiology, with reference to a knowledge of the leading lunctions of the body ; and general instruction on medical and surgical topics ; examinations, written and oral, at least four of each in the year, all adapted to nurses ; as also lectures and demonstrations with ana- tomical, chemical, and otherillustrations, adapted especially to nurses — all in the presence and under the care of the matron (Lady Superin- tendent) and mistress of probationer’s (Class- mistress and ‘ Home ’-sister) ; together with in- struction from a medical instructor, one of tho hospital professors and hospital medical staff, specially selected to teach the nurses. A good nurses’ library of professional books, not for the probationers to skip and dip in at random, but to be made careful use of, under the medical instructor and class-mistress. (3) Classes for a competent mistress to drill the professorial teaching into the proba- tioners’ minds ; the mistress of probationers to be above alia ‘ home ’-sister, capable of making the ‘home’ a real home, and of training and dis- ciplining the probationers there in all good — in moral qualities, customs and habits, and man- ners, without which no woman can be a nurse, and in their duty and feeling to God as well as to their neighbour. (f) Tho authority and discipline over all the women of a trained lady-superintendent, who is also matron of the hospital, and who is herself the best nurse in the hospital, the example and leader of her nurses in all that she wishes her nurses to be, in all that training is to make her nurses. (5) An organisation not only to give this training systematically, and to test it by current tests and examinations, but also to give the pro- bationers, by proper help in the wards, time to do their work as pupils as well as assistant- nurses, and above all to make it a real moral as well as nui’sing probation— for nursing is a pro- bation as well as a mission. ( 6 ) Accommodation for sleeping, classes, and meals ; arrangements for time and teaching and work ; surroundings of a moral and religious, and hard-working and sober, yet cheerful tone and atmosphere, such as to make the training- school and hospital a ‘ home ’ which no good young woman of any class need fear by entering to lose anything of health of body or mind ; with moral and spiritual helps, and an elevating and motherly influence over all, such as to make the v hole a place which will train really good women, who can withstand temptation and do real work, and ueither be 1 romantic’ nor ‘ menial,’ For, make a hospital as good as you will, hos- pital-nurses require more such helps, and get less, than women either in their own homes or iu domestic service. Every hospital should have and he such a school for training nurses for itself and other 1040 NURSES. TRAINING OF. institutions, including district and private nurses, who must be trained in hospitals, and therefore cannot have a training-school of their own. Professors and medical staff cannot be always, or indeed ever at hospital bedsides, showing nurses what to do. Let each give the pupil-nurses a clinical lecture once a week. Above all, this is necessary for those who are to be head-nurses, matrons, and lady-superinten- dents. The success of any training-school depends mainly upon having trained nurses themselves capable of training others — (a) in ward-nursing; and (b) in cases, so as to be able to understand what physician and surgeon order, and do it. II. Course for all Probationers. (1) To do duty as assistant nurse and pro- bationer successively in one or more wards of each of the hospital divisions, one or two or three months in each, male and female surgical, male and female medical, children's, obstetric, ophthalmic, Magdalen; ending her course, if possible, in the medical-instructor’s wards. The course should, if possible, begin in the female medical wards. No two fresh proba- tioners to be in the same ward. One nurse- probationer and one lady-probationer to be to- gether, where possible. (2) To learn ward-management by being in charge of wards during the head-nurse’s dinner- hour, and during nurses’ recreation hours ; to take, when sufficiently advanced in the year's training, day or night staff duty for staff-nurses on their holidays ; to have at least one month’s night duty — a fortnight at a time — in the year’s training. (3) To take, when sufficiently advanced, special duty, by day or by night, upon special cases, such as ovariotomy, lithotomy, tracheo- tomy, typhoid, &c., in the single-bed wards. (4) To make a set of all the different band- ages required. (5) To learn from the head-nurse to read the * cards,’ or patients’ bed-tickets, especially in the medical wards. (6) To keep a diary of her ward duties. Besides this diary, each probationer at least once a month to draw up a sketch of her day’s work, not merely as a ward assistant or assistant nurse, but as a probationer in training, namely, what she has learnt that day from ward-sister and staff nurse, what she has observed on special cases in the ward, &c. Warning is given outonly after the day’swork, that it is such and such probationer's day to write it out. (7) To take careful notes of cases. A case- paper should be regularly kept by every proba- tioner of cases selected by the medical instructor. The case-paper to have printed headings, such as ‘Temperature,’ ‘Pulse,’ ‘Respiration,’ to be taken morning and evening [in some cases the physician will require the ‘ temperature ’ to be taken as often as every hour, or even every quarter of an hour] ; ‘ Sleep,’ ‘ Nourishment,’ ‘ Urine,’ ‘ Stools,’ to be noted every twenty-four hours — in each case character as well as quantity; ‘ treatment,’ to be noted daily, in English, and not copied off the ‘ cards ; ’ and other such heads ; preceded by a real medical history of the case— of the causation of the disease ; for example, in typhoid fever and other dirt diseases, producer by foul air and foul water. This is followed In remarks on the termination cf the case. Thes’i case-papers should be rigorously overhauled b> ward-sisters and the class-mistress, as well a: by the medical instructor, who should alsoathi: own hospital-beds check the case-taking. (8) To take careful notes of all lectures, als- overlooked by class-mistress and medical in structor. (0) To read and be shown illustrations of th; cases nursed in the wards, [the keen professions, interest felt by a promising probationer in find ing her own cases in a book must be encouraged. (10) To jot down afterwards, but while stU' fresh in the memory, any remarks suitable fo her own instruction made to the students by th hospital physicians and surgeons in going theij rounds, and to write out her jottings in th class-room under the superintendence of th ‘ home ’-sister. (11) To write out under the superintendent of the ‘ home ’-sister what has been learnt bot from ward-sisters and medical instructor as t what is to be done and how to do it in nursing as to why it is done, and why something else i not done ; as to symptoms and the ‘ reason why of such symptoms. Without (a) time for these things, averag nurse-probationers degenerate into conceits ward-drudges. Without ( b ) a system for thes things, they potter and cobble out their yet about the patients, and make not much progrei in real nursing, that is, in obeying the ph’ sicians’ and surgeons’ orders intelligently ar perfectly. III. Training to Train. — To enable nurses t train nurses, a special training is required ; ai for this a longer period than a year in the ho pital is necessary. To train to train needs system : — (1) A systematic course of reading, laid dov by the medical-instructor, who recommends t; books for the training-school library. Hours study, say two afternoons a week ; class-mistre (‘ home ’-sister) to lead one at least of the afternoons. (2) Regular oral examinations by medicr instructor ; each training-nurse must acqui powers of expression to train others. He mu cultivate these in answering him. Some syste of mutual examination. (3) At least four written examinations in t year on written questions, by the medical i structor. Essays to be written on given subjet in nursing. (4) Pre-eminently careful notes of lecturi in order to enable nurses in future to drill oths in understanding the professorial lectures, they have themselves been drilled. (5) Pre-eminently careful notes of cases the touchstone for the future trainer. If £ cannot observe and understand her own cas how can she teach others to observe and undi_ stand them? If she never learn the reason: what is done, how can she train others to let' it ? ‘ Reading up ’ her own cases. (6) A current constant course of cure; learning from head-nurses and medical instruct and physicians or surgeons in wards where i NURSES, TRAINING OF. 1041 s probationer, to know not only what symptoms re there, and. what symptoms are to be expected a such and such an event, but also the meaning jf such symptoms — the ‘ reason why.’ To know ot only when a wound or surgical injury or peration ‘looks well and when it ‘looks ill,’ ;,ut why it looks well or ill ; and to be able to ■11 others why. To know not only what is to [e done, and how i t is to be done, but why that done, and not something else. (7) At least twice in the year’s training, but pt at the beginning, to have a week or more of ping the night-rounds with tho night-superin- ndent of nurses, which is equally good for ght-superintendent and for probationer. (8) To spend at least a week, but not at the ginning of her year, in the linenry. (9) Tho future superintendent, who is to have training school, should have at least a fnrc- ght in the year, about six or nine months on in draining, in the ‘ Home,’ if possible, taking or listing at classes, and doing all but the ‘Home’ iter’s secretarial work. (10) Taking temporary duty of ward-sisters their holidays, and — the best — of ‘ Home ’ ;ter on her holiday. Of course no fresh proba- |mer, however gifted, would be put on such duty. (11) Being relieved of the more menial ward- ■rk, such as cleaning lavatory basins, w.c. pans, i?,., when she can do it so perfectly of herself thout being told, that she can teach others to ( it. This will scarcely be, for all kinds of this ' rd-work, before she is a six months’ old pro- 1 :ioner. 12) A second year's training for the higher Its. A future matron or lady-suporintendent t have had experience as ward-sister, and to l 'e had at least one year as assistant-super- undent and as night superintendent, in some 1 pital under a trained lady-superintendent. 13) The matron must give future matrons or s erintendents insight into her duties. There nst be an examination and questions given on s erintendents’ work. V. Current tests, current records of progress, a examinations. 0 The candidate should fill up a form of & lication, answering printed questions. Regu- hbns of training printed on the back. I 1 ) Should enter on a month’s trial. She re- cces the time-table and the list of duties. ; the candidate is accepted after the month as pliationer — 1) Each ward head-nurse or sister keeps a re ed of each probationer, under printed heads cc isponding with the list of duties. She fills uijre columns with suitable marks once a week. 1 matron, after examining tho ward-sister’s re cts with ward-sister and ‘ home ’-sister pre- 80, and questioning each ward-sister on each pr,ationer, records her own opinion on the sujr's reports. The medical instructor once a m< jh should examine each probationer sepa- nty, upon the duties which the ward head- ! ,u j> (sister) has ‘recorded’ her as defective in, m 3 presence of ward-sister, ‘ home ’-sister, and rospn; and also should examine each ward- 613 j' separately upon her records of each proba- tio'r in the matron’s presence, but not in the pri .tioner’s. The ‘home ’-sister also furnishes a record of each probationer’s conduct at the classes and in the home. (d) A register with two pages for each proba- tioner should be kept monthly by the matron assisted by the ‘ home ’-sister. It corresponds with the ward-sister’s book, and has monthly entries for the whole year of training. The accounts in these books must tally at the end of the year, or somebody has been wanting in moral courage. (e) While the ward-sisters keep a weekly and tho matron a monthly record of the progress of each probationer, she is required to keep a diary of her ward work, to keep ‘ case-papers’ with the daily changes in case and treatment, and to keep notes of lectures ; and the careful examination of these aifor ls important items in the records of results of training, and of the capabilities of each probationer. The medical instructor enters his verdict on professional points in the monthly register. (/) The medical instructor, and each hospital professor who gives lectures to the probationers, examines them orally in tho presence of matron and home-sister. He examines their notes of the lectures and awards marks. It is communicated to each probationer how she stands as to marks. (g) Written questions are given by tho medi- cal instructor at least four times a year, to be answered in writing, at least by t.he proba- tioners who are training to train others. Marks are awarded, and the number of marks received communicated to each probationer. Possibly prizes may be given for proficiency. These are some of the current tests of the results or non-results of training, of progress or no progress. Without some regular system of this kind, there can be no real organization for training. The heads of the trainingsehool must ‘take stock’ and know where each probationer really stands, and what the training is really doing, and must let each probationer know where she stands. The matron must be one whose desiro is that the probationers shall learn : a rarer thing than is usually supposed. But besides this there is a constant, motherly, intan- gible supervision and observation to be exercised, for there are qualities which no written tests can touch and no examinations can reach. The pro- bationers must really be the matron’s children ; the ‘ home ’ sister must really be their elder sister. A training school without a mother is worse than children without parents. And in disci- plinary matters none but a woman can under- stand a woman. V. Staff of Training School : — 1. The superintendent of the training school is the matron of the hospital, and head of all the women in the hospital. She is presentwhen possible at the probationers’ lectures and demon- strations, and oral examinations, with the 1 home’ sister, who is always present. The night-super- intendent of nurses trains the probationers told off to accompany her at night. 2. The trained ‘ home ’-sister (class-mistress ; mistress of probationers) resides in the ‘ home ’ ; is in charge of the * home ’ and its servants and of the probationers. She gives two classes a week at least to the senior nurse-probationers and two 66 NURSES, TRAINING OF. 1042 to the juniors, drilling them in the medical in- structor’s lectures, &e. &c. She superintends two afternoons at least in the week the study hours of the probationers training to train others, that is, all who are to be in future in charge of nurses, whether as ward-sisters, matrons or superintendents, and gives direct instruction on one at least of these afternoons. She gives singing and Bible classes. She must from time to time communicate with the ward-sisters on the defects in the probationers’ work, and con- cerning probationers about whom she may feel uneasy. Cutting off communication between hospital and ‘ home ’-sister is very objectionable ; the hospital-sister must not want moral courage to let the probationers know any unfavourable report she has made of them in the Sisters’ Records. This is unfair to the probationers. The ‘ home ’-sister must attend all clinical and other lectures, demonstrations, and examinations. 3. Ward-Sisters (Head-nurses, Training- nurses). — The ward-sister must train the proba- tioners in all the duties of a nurse. Nee Nursing the Sick; and above, ‘II. Course for Probationers.’ The ward-sister, or — instructed by her — the staff nurse, is to show every new probationer how to do her work ; not only what things are to be done, hut how she is to guard against the way they are not to be done, as well as against what is not to be done. She is to instruct the nurses how to instruct prooationers. As it is impossible for a ‘ sister ’ with a sister's duty in a ‘ heavy’ ward always to have time to show all needfuL things herself to the probationer ; the sister must from time to time question her to see if she has been shown her duties and how she does them, re- membering that it is of use to the probationers to put these things into words ; and for this pur- pose each probationer is to be occasionally taken by the sister on her ward rounds, and examined as to what she has done in each case under her charge, whether she has learnt to do it rightly and knows ‘ the reason why.’ The ward-sister must also train the proba- tioners in alacrity of intelligent obedience to her medical authorities, which must be the proba- tioner’s lesson of what obedience ought to be. She must regard the probationers less as hos- pital servants, than as pupils to he trained for hospital ‘sisters’ and nurses. The training- nurse must he a bridge for the pupil-nurses. ‘ He who will he a chief, let him be a bridge.’ She must not make them too little of pupils, too much of assistant-nurses — or, rather, they can- not be too much of assistant-nurses, hut being too little of pupils makes them too little of real assistants, and (for all their future) of real nurses. The training-nurse must interest the piupil-nurse in her cases. The pupil cannot have a nurse's interest in them without knowing what they are. Cases she is interested in she nurses with twice the efficiency. 4. Medical Instructor. — The medical instruc- tor, one of the hospital staff who will under- take the duties, gives a lecture once a week on medical and surgical topics specially connected with nursing duties ; demonstrations with ana- tomical and other illustrations, specially adapted to nurses ; lessons on the elementary know- ledge of physiology, anatomy, the situation of ; the principal arteries, &c. ; lessons on ban- daging; lessons in hygiene, both of wards and patients ; lessons on the causation of disease ; on what is to be done iD emergencies; on howto make beds for various operations and diseases &c., &e. He is to lay down a systematic coursf of reading for the probationers who are to trair' others; to examine them by written questions all least four times in the year ; to give them sub jects for essays, and to examine these; to awar marks. He is to examine all the probationer orally; to examine their notes of lectures, ti award marks ; to examine their case-paper. 1 He is to give clinical lectures at least once week, at his own ‘ beds ’ (it would be desiratl if each probationer could end her course of ward in the medicalinstructor's wards), and to examiD ‘ case-papers ’ taken of his own cases ; to teac symptoms, and what symptoms indicate, and wh such or such a treatment; and what shows a cai to be ‘ doing well ’ and what ‘ ill ’ ; and to teac the probationers so that they can teach othi probationers in their turn. He will encourage ; every way the professional interest of the nur in the cases she is nursing ; he will point o these cases in medical and surgical hooks. On a month he will examine each probationer sep rately upon the duties she is defective in; ail each ward-sister separately upon her record experience of each probationer. He will fill • the monthly register at the end of each proa tioner's year of training, with his verdict onl, capacities, and on such professional results her training. He will make up the purely p: fessional columns— such as ‘ observation,’ ‘ope: tions’ — every month, seeing the matron andwai sisters for the purpose. The medical instruc should be one of mature age and experien should be really a father to the pupil-nurses, i oue whom the matron can freely consult wi If the hospital have a permanent resident medi officer fit for the purpose, he should be the ■ structor. 5. The medical instructor also gives elem- tary instruction in chemistry, physiology, a - tomy, surgery, medicine, as far as they br upon nurses’ duties. 6. Lady Visitor. — The lady visitor should it be resident in the hospital, but should her f havo been a trained nurse, so as to knowwt training is. She will be an essential assistae to the matron, in infusing spirit from witbt into her training school, and in saving e matron from the appearance even of arbitry power. Training, general consideration of- A year’s training is simply teaching the nue her A B C — teaching her how to go on le3n_g for herself, learning to understand her docl 9 orders and to read her own experience, for if e experience may only teach the ‘ post hoc, W propter hoc.’ A nurse without training is li a man who has never learnt his alphabet, whous learnt experience only from his own blunt's- Blunders in executing physicians or surgu = orders upon the living body are hazardous th'.> and may kill the patient. Training is ton- able the nurse to see what she sees — facts,! 1 to do what she is told ; to obey orders, not v by rule of thumb, but by giving her a ra NURSES, TRAINING OF, i thought or observation. Othenvise she finds out her own mistakes by experience acquired I out of death, rather than life, or does not find .hem out at all. Medicine, surgery, pathology, and, above all, 1 hygiene, have made immense strides, partly in consequence of improved tools, improved instru- ments of observation. Nursing, their agent, has to be trained up to them. A good nurse of twenty years ago had not to do the twentieth part of what she is required by her physician or sur- geon to do now. And every five or ten years a 'nurse really requires a second training now-a- Idays. Nursing needs its instruments nearly as much as surgery, and yet more than medicine. The physician prescribes for supplying the vital force — but the nurse supplies it. Training is to each the nurse how God makes health and how tie makes disease. Training is to teach a nurse to enow her business, that is, to observe exactly, to mderstand, to know exactly, to do, to tell exactly, n such stupendous issues as life and death, lealth and disease. Training is to enable the nirse to act for the best in carrying out her Orders, not as a machine but as a nurse ; not like lornelius Agrippa’s broomstick which went on 'arrying water, but like an intelligent and re- ponsible being. Training has to make her, not errile, but loyal to medical orders and authori- ties. True loyalty to orders cannot be without he independent sense or energy of responsibility, ■hich alone secures real trustworthiness. Train- hg makes the difference in a nurse that is made i a student by making him prepare specimens ;r himself instead of merely looking at prepared becimens. Training is to teach the nurse how i handle the agencies within our control which [store health and life, in strict obedience to the hysician’s or surgeon's power and knowledge — bw to keep the health-mechanism prescribed to ;r in gear. Training must show her how the fects on life of nursing may be calculated with ce precision — such care or carelessness, such a :k-rate, such a duration of case, such a death- |te. Flobence Nightingale. NURSIN' G THE SICK. — Nursing proper, it is, nursing the sick and injured, will be here fated of, and not Preventive or Sanitary Nurs- t, or nursing healthy children. Nursing is performed usually by women, under entitle heads — physicians and surgeons. Nurs- ; is putting us in the best possible conditions Nature to restore or to preserve health — to ' went or to cure disease or injury. The physician ' surgeon prescribes these conditions— the nurse dries them out. Health is not only to be well, ; . to be able to use well every power we have t].ise. Sickness or disease is Nature's way of thing Tid of the effects of conditions which t |- e interfered with health. It is Nature’s at- t ipt to cure — we have to help her. Partly, per- il's mainly, upon nursing must depend whether - ure succeeds or fails in her attempt to cure l sickness. Nursing is therefore to help the pient to live. Training is to teach the nurse taelp the patient to live. Nursing is an art, a ! an art requiring an organized practical and s ntific training. For nursing is the skilled f . ant of medicine, surgery, and hygiene. NURSING THE SICK. 1013 Nursing may be divided under four heads : — (a) Hospital nursing. (A) Private nursing : that is, nursing one sick or injured person at a time, at home ; giving the whole time to that one patient, generally of the richer classes, (c) Dis- trict nursing : that is, nursing the sick or injured poor at home, taking as many cases as can be well attended to by one nurse. District nursing, or nursing the sick poor at home, is a branch of nursing of the highest importance, and requires the highest qualifications, because the district nurse has not, like the hospital nurse, a medical and surgical staff always at her call, and never hospital appliances to her hand, (rf) Midwifery nursing will not be treated of here. It differs from other nursing in this — that the lying-in woman, the patient, is not, or ought not to be, sick, and that the nursing consists in a surgical operation and in hygienic precautions. [Mid- wifery and general cases should never be attended by the same nurse. No ordinary precautions will secure the lying-in case from danger arising out of this practice.] (u) Hospital Nursing. — Nursing proper means, besides giving the medicines, and stimulants prescribed, or applying the surgical dressings and other remedies ordered : — 1. The providing, and the proper use of, fresh air. especially at night, that is ventilation, and of warmth or cool- ness. 2. The securing the health of the sick- room or ward, which includes light, cleanliness of floors and walls, of bed, bedding, and utensils. 3. Personal cleanliness of patient and of nurse, quiet, variety, and cheerfulness. 4. The adminis- tering and sometimes preparation of diet (food and drink). 5. The application of remedies. In other words, all that is wanted to enable Nature to set up her restorative processes, to expel the intruder disturbing her rules of health and life. For it is Nature that cures : Dot the physician or nurse. "We shall now discuss these duties in succession. 1. Ventilation. 'Warmth and Coolness. — a. Ventilation is the removal of the air poisoned by the breath and other human emanations, and supplying its place with/rasA air. The very first canon of nursing is to keep the air inside as fresh as the air outside, by night as well as by day, without chilling the patient. The best rule of ventilation is still: Poke the fire, open the window, but at the top. for fresli air coming in at the ceiling permeates the whole room, without causing draught, and foul air escapes. Air coming in at the floor or at the level of the patient remains there and chills him. and foul air does not escape. Always air from the outside air. Windows are made to open ; doors are made to shut. If the nurse ventilate the patient’s room or ward through the door — that is, making the room draw the foul air from the rest of the house or building — she ventilates him with foul not fresh air. But ventilation is im- possible without sufficient floor and cubic space, and unless the windows open near the ceiling. "Where other patients want air, fever patients, for example, want wind ; where, other sick want a well-aired room, without draughts, pysemic patients, for example, want the freest possible supply of air about their beds. h. Warmth, or coolness. — This the physician 1044 NURSING aas to prescribe the nurse has to see to it. In fever, for instance, the physician -will require her to examine the patient’s feet and legs, at least every hour, to ascertain whether they are chilled, and to keep the extremities warm, even though his temperature he high, whether in summer or winter. In bronchitis, in ovariotomy, &c., an even, high, moist temperature may be necessary, and a steaming kettle may be required on the fire night and day. But ordinarily it is not advisable to keep the sick-room always at the same temperature. A cooler air at night is necessary. But whether cool or warm, the air must be fresh. Sick chil- dren become fretful in foul air at night. And young as well as old night-nurses require train- ing to see that the physician’s orders are obeyed as to keeping the air of the ward fresh by night, and not above or below a certain temperature. The head of the sick should never be higher than the throat of the chimney, which ensures the best air. And the chimney should never be closed with a chimney-board. 2. Health of Sick-Room, or Ward. — This might be called ‘ nursing the room.’ The placing the sick-bed in the best position to secure air without draught, light without glare, quiet and cleanliness — and this often necessitates re- arrangement of the furniture of the whole room — is one of the essential arts of nursing. In district nursing of the poor, it must be one of the nurse’s first duties to put the room in a state so that the patient can recover. So, too, must the hospital and the hospital-ward be built so that the patient shall not ‘ die of hospital.’ To get rid of the conditions which have interfered with health is of course the first nursing step in help- ing Nature to get rid of the effects of those con- ditions. a. Light. — Second only to air is light as an essential for growth, health, and recovery from sickness — not only daylight but sunlight — and indeed fresh air must be sun- warmed, sun-pene- trated air. This should be meant to include colour, pleasant and pretty sights for the patient’s eyes to rest on — variety of objects, flowers, pic- tures/ People say the effect is on the mind. So it is ; but the enlightened physician tells us it is on the body too. The sun is a sculptor as well as a painter. The Greeks were right as to their Apollo. b. Cleanliness. — Cleanliness and fresh air do not so much give life as they are life itself to the patient. Cleanliness — clean air, clean water, clean surroundings, and a fresh atmosphere every- where are the true safeguards against ‘ infection’ — not segregation — or rather segregation by ample floor and cubic space, ample ramparts of fresh atmosphere : not segregation by walls and divisions. You cannot lock-in or lock-out the infectious poison ; you cannot wall-out infection. You can air it out, diffuse it, and clean it away. ‘ Infectious Hospitals ’ and ‘ Wards,’ whether necessary or not, are not a part of hygiene; and the doctrine of ‘ disease germs,’ in the sense in which it may lead to considering ‘infection’ in- evitable, must not be taught as a principle of sanitary nursing. That there is no such thing as THE SICK. ‘inevitable’ infection, is the first axiom of nursing. Cleanliness of floors, ceilings, walls, bed, bed- ding, and utensils, and of sinks ; also of lockers, if any, but there should be none. Floors and walls . — Medical men forbid scrub- bing in the sick-room. No sick-room floor ought ever to be washed, except by the doctor’s orders and at the hour he orders. The only clean floor is a floor planed, satu- rated with ‘ drying’ linseed oil, well rubbed-iu. stained (for appearance sake), not too dark, so as not to hide the dirt, and beeswaxed with tur- pentine and polished. The floor to be wipc-d with a damp cloth and dried with a floor-brush, or cleaned by a brush with a cloth tied over it. Anything offensive spilt to be washed off at once with soap and water. Hospital-ward floors should be scraped and polished every fortnight by a frotteur and dry-rubbed by a man every day. The patients should be provided with slippers. No carpet, of course, in a sick-room, except a piece of washing drugget by the bed- side. A dirty carpet literally infects the room. The only clean wall is one that is oil-painted. From this you can wash the animal matters. These are what make a room musty. The worst wall is the papered wall. The next worst is the plastered wall. But the plaster can be made safe by frequent lime-washing and occasional scraping. The paper requires frequent renewing. A glazed paper gets rid of a good deal of thel danger. But the ordinary bed-room paper is all that it ought not to be. Furniture — as little as possible in the sick room — should all be of polished wood, metal, ot. marble, kept clean by being wiped with a dot! wrung out of hot water. Air can be soiled just like water. Airis always soiled where walls and carpets are saturated witl animal exhalations. Dust consists greatly o organic matter. There should be no ledges ou' of reach capable of holding dust. An Amott’: ventilator in the chimney will keep an ordinar paper longer clean, showing the connection o ventilation and cleanliness. Inattention to thes essential matters all but foils the best nurse best efforts. How to chan . — Dust is the harbourer an harbinger of disease. Dust in hospitals ma contain epithelial scales from the mouth, skit epiderm, pus-cells. As there appears no lim to the reproduction of epiderm or epithelium, s there is no limit but excessive cleanliness to ll deposit in dust in a hospital ward, ‘which,' as great surgeon has said, ‘ never rests from foulir itself.’ The onlv way to remove dust is to wipe ever thing with a damp cloth. And all fumifu ought to be so made that it may be wip( with a damp cloth without injury to itself, at so polished or glazed that it may he damp' without injury to us. Flapping, by way of dus ing, is not cleaning. To ‘ dust.' as now practise merely means to distribute dust more equal over a room. To ‘tidy’ a room, or ‘put t room to rights,’ means to remove a thing fxe one place which it has kept clean for itself on another and a dirtier one. NURSING THE SICK. No one atom of dust ever actually leaves the oomunderthe present system of ‘dusting.’ The treater part of nursing consists in keeping clean, lo ventilation can freshen a sick room where lie most scrupulous cleanliness is not kept. Bed and bedding; linen, $c. — Feverishness : generally supposed to be a symptom of fever ; i nine cases out of ten it is a symptom of bod- ing. The patient has had re-introduced into is system the diseased emanations from himself, d eliminate which from his system Nature had ppointed the disease. These, day after day and eek after week, soak into his unaired bedding :om below as well as from within, if the chamber- tensils are left, as is too often the case, unemp- ed and without a lid under the bed. Erysipelas nd pyaemia are produced by an uncleansed state f bed and bedding. Black flock is sometimes sed for fracture pillows. This gets full of dust, nd may be the cause of erysipelas. The most dangerous effluvia we know are from ! he excreta of the sick; these are placed, at last for a time, where they must throw their ffluvia into the underside of the bed, and the pace under the bed is never aired ; it cannot be •ith our arrangements — a valance or counter- ane down to the floor, or perhaps the quilt Ip carefully pinned over that no air can pass nder the mattress. An adult in health exhales by the lungs and tin in the twenty-four hours three pints at least f moisture, loaded with matter ready to pu- ■efy; in sickness the quantity is often greatly icreased, the quality is always more noxious, his goes chiefly into the bedding because it mnot go anywhere else : and it stays there, icause, except perhaps by a weekly or bi-weekly lange of sheets, scarcely any other airing is tempted. A nurse will be careful to fidget- ness about airing the clean sheets from clean imp, the clean night-gown from clean damp, the ;w mattress from clean damp ; but airing the rty sheet* from dirty damp, the dirty night- wn (which she is goiDg to put on the patient ter washing him) from dirty damp, never so uch as occurs to her. And a mattress is sup- 'sed to be aired by somebody else sleeping on and saturating it with his own damp before e patient comes to exhale into it the patient’s mp. The bed is always saturated with the patient, d the unfortunate patient who lies in it is ways being saturated with the bed. The ordinary sick-bed of a private patient is nerally exactly what it ought to be to bring is poisoning process to perfection : a wooden rr-poster with curtains, two or even three stresses, or even a feather-bed, piled up — • ihaps to a height above the throat of the imney or above the lower chink of the sash- adow, which is all that is ever opened; the adow not opening or opened at the top; a ( ance fastened to the frame. Nothing ever oroughly dries or airs such a bed and bedding. The best bed and bedding are: An iron bed- ad with Rheocline springs, or the woven-wire ttress, no valance and no curtains, of course ; ' thin hair mattress, light Witney blankets, heavy cotton counterpane, which retains per- ration ; no blanket under the patient, which 1045 acts like a poultice and promotes bed-sores — bed-sores which are, all but always, a symptom not of the disease but of the nursing. The patient should, if possible, be able to see out of window from the bed. Two beds, one for the day and one for the night, are necessary for the best nursing of the patient. A true nurse always knows how to make a bed, and always makes it herself. And bed-making has much to do with bed-sores. She hangs up the whole of the bedding to air for a few hours whenever possible. Sho makes the changes of linen and bed-linen — sheets and draw- sheets — as often as is necessary, which is a great deal oftener than is usually done. In hospitals, she sees to no patient using his neighbour's towel; and to different towels being used for different purposes. She sees to all dirty linen, and especially bandages, being instantly removed, and, after a previous careful disinfection by steeping in boiling-water with a proportion of carbolic acid, 1 to 100, being washed at a laundry separate from any other building — if she has such a laundry. No disinfection will enable dirty linen to be kept with safety a single day in the same building with the sick. It is cruel to allow dirty linen from ‘ infectious ’ patients to be taken home by the relatives to be washed in the crowded rooms of the poor. Dirty linen should be removed immediately from the sick-room and sent to the laundry, at least every day. If we are careful to take away and empty bed-pans directly, surely this is still more important with soiled sheets. It must not be supposed that even a good sprinkling of carbolic powder (which besides injures the sheets) over the dirty linen lying in a basket, will at all obviate the neces- sity of instant removal. Foul-linen shoots, with a receptacle at the bottom to receive the linen in preparation for instant removal, are a necessity of every hospital. Bandages with pus on them are always to be burnt at once — to be carried straight to the ward fire, or to a furnace. The best economy is to burn them ; but one must make up the fire so that the burning shall not smell. Bandages used for fractures, &c., are the only bandages that may be washed. Soak these with chlorinated soda, a diluted pint ; then boil them all night with soft-soap, soda, and chlorinated soda — a quart bottle for the two. The bandages are then to be rinsed in a tub. The boiler must, of course, only be -emptied in a closet-sink. But this washing of bandages ought never to be done inside a dwelling-house or hospital. All disinfectants are more or less a 1 mystic rite,’ as a great surgeon said. Absolute cleanli- ness is the true disinfectant ; but chlorinated soda, if disinfectants are to be used, is about the best. Always have chlorinated soda for nurses to wash their hands, especially after dressing or handling a suspicious case. ‘It may destroy germs at the expense of the cuticle ; ’ but, ‘ if it takes off the cuticle, it must be bad for the germs,’ said the same surgeon. Fire is the right way, if a thing is so bad that it wants a disinfectant. Hair (and all hospital beds should be of hair) should be heated -to about 350°, teased, and exposed to air. Boil, wash, scour with much soap and water and, say, chloride of 1046 NURSING Lime , then dry and expose to air all bed-ticks, blankets, coverlids, &c. Utensils . — All chamber-utensils and bed-pans should be of white glazed earthenware, with well-fitting lids. None should ever be left under the bed, but be brought to the room, and, when used, carried immediately to the closet-sink, emptied, and rinsed there. No zinc pail, or pail without a lid, should be carried through a ward or sick-room. The pail should be of glazed earthenware with a lid. But better no pail at all in a sick-room. Without care for these things, the doctor will tell us, ‘ it is impossible to nurse.’ Excreta have often to be put by for medical in- spection ; the nurse must see to this being done properly and inoffensively, in a closed vessel — never in the patient’s room or ward. As for urine, if it has to be measured and tested, there are glass-measures, with covers, fit for the purpose. Bed-pans should have carbolic-powder in them lavishly. All bed-pans should have lids. Glass urinals, with wide necks, -washed with warm water and soda, are the only really clean ones ; ziucand white earthenware, with long necks, are never clean. After being used, they should be put by the bedside, not under, and taken away and emptied at once. Small white chamber-utensils are useful, and district nurses may find old jam- pots the cleanest thing for urinals. Chamber- utensils in a hospital should be ranged on their sides in a sort of hutch open to the outward air through perforated zinc, in the lavatory or other compartment. If in alargehospital-ward cham- ber-utensils must unhappily be allowed under the beds at night, they should all, of course, have lids. Two glazed earthenware (not zinc) pails, with lids, may then be carried round the last thing at night and the first thing in the morning: one pail to empty into, with some carbolic-po-wder in it; one pail to rinse with, with soda or chlori- nated soda in it. The chamber-utensils should be then carried off to the hutch in the lavatory. But this is only a pis allcr ; a slop-pail should really never be brought into a sick-room or ward at all. It should be a rule, invariable — rather more important in the privato house than else- where— that the utensil should be carried directly l o the water-closet, emptied there, rinsed there, and not brought back till it is wanted. There should always be -water and a tap in every water-closet for rinsing. Towels in a hospital should be kept separate for three separate uses, changed for clean ones as often as possible, and marked ‘ Hands,’ ‘ Bed- pans,’ and ‘ Basins.’ A bottle of chlorinated soda and a bottle of glycerine should always be by, to wash the hands. A young nurse, dressing an ulcerated leg, has been known to wipe it with the sheet, and alleged that she had seen it done elsewhere ! There should always be a special towel for such cases. Charcoal may be employed in offensive cases ; it may be placed under the bed in pans, or under the limb (if slung) in the bed. Car- bolic powder may be placed in the chamber- utensil (clean), if under the bed, or little bags of carbolic powder in the bed. Condy's fluid is sometimes placed in saucers, but this is not of much use. Carbolized tow may be used for cancer cases to lie upon, and changed frequently. THE SICK. Wool, with salicylic acid, is sometimes used to cover the dressing of an offensive wound or salicylic lotion for a warm water dressing Slop sinks may be sluiced down with carbolic acid. Water-closet pans should be scrubbed with strong nitric acid, if they have been allowed to get at all offensive. Urinals, if allowed to be- come furred, must be sluiced out with boiling water, and then, if necessary, scraped withaknik all round and inside the grating. Also water- 1 closet slop sinks. These all should be scrubbed! with sand and chlorinated soda at least twice a -week. In hospitals the head-nurse ought to mop" out and rinse-down the urinals every morning herself with a little bed-pan mop. and let boiling' water run through ; the same with the water closet pans. The lavatory basins, when used should he mopped-out every morning, anc scrubbed at least twice a week with sancLTher! should be two mops — one new one for Lavatory basins, appropriated when a little old to the bed-' pans, and the old one replaced with new : thenevj small mop to hang over the lavatory basins, tin old one to hang over the slop-sink for bed-pans an old bottle-brush for the handles of bed-pans a new bottle-brush, kept in the ward-kitchen, fo bottles. Ordinary basins should be washed wit!! tow. 3. Precautions against finger-poisoning &c. — One of the most important points nurse have to be taught on beginning surgical ward! work (and, indeed, surgeons also,) is how not t poison their fingers. No good nurse will poiso her own fingers any more than her patient’s. The following rules should be strictly oil served : — Pare the finger-nails close ; keep them, as we as fingers and hands, scrupulously cleaned; auj thing which has soiled the fingers is a possibl source of contagion to others and to yourself an agnail, or crack, or scratch, or pin-punctur., is as likely to produce a poison-nest to others c to yourself, even more than an open wound i sore. Such poison-nests must be made harmle; by first washing -with pure water, next by appb ing styptic colloid, thirdly by putting on an indi; rubber finger-stall. Immediately before begh ning any dressing, and in every case after toucl ing the patient, whether in dressing wound rubbing in applications, administering enemat, internal syringing, washing out eyes, ears, nos; mouth — dip the hands into watery solution carbolic acid, 1 to 80, and then wash han< and nails carefully with carbolic soap. 1 Dres ing forceps,’ or syringe, or whatever is use to be dipped in solution cf carbolic (1 to S before use as well as after. The teeth and join of the ‘dressing forceps’ to be brushed clea Remove soiled dressings with ‘ dressing foreep and not with the fingers ; on no account serat up adhesive plaster or other adhering dres ing -with the nails. Nurses of the old scha will boast that they are not afraid. The fe of dirt is the beginning of good nursing. W i all internal cases, keep the nails short, fill t same with carbolic soap, and carefully ano: the fingers you are about to use, especially t first and second fingers in attending on vagii cases, with carbolic oil (1 in 20). Oil theta or nozzle, &c., to be used for any internal apt atioa, with carbolic oil (1 in 20). ie appliance used might convey “latter from one patient to another, se two basins in washing wounds, so as not to ip the fingers in dirty water. Catheters must e cleansed and disinfected, first with a stream f warm water, and then with a stream of atery solution of carbolic acid (1 to 40}. atheters of other material than silver should ot be soaked in carbolic acid solutions, as the jid injures varnish and gum Never ‘blow down ’ iwards the eye first instead of last, for so some idgment will always be effected at the bottom. : ever fail to take your own carbolic soap, with hich you will be provided, in your own soap-tin, ito the ward each morning and evening in your octet. But take it out before beginning ‘dress- igs,’as otherwise you put a dirty hand into your octet. Always dry your cleaned fingers and mds on towels not used for any other purpose. ! fter offensive cases, blow the nose and expec- irate, and rinse mouth and throat with Condy id water, or with permanganate of potash, a w grains in water. Cuffs and sleeves and stuff .•esses are possible carriersof contagious matter, lways change the apron and over-sleeves which ou have worn about the sick before eating or •inking. Report immediately any scratch or ;nail or sore you may have to the ward- ster; ask immediate advice after breathing in fensive air. Never go on duty in the morning thout having taken a meal. The nurse must be taught the nature of con- gion and infection, and the distinctions be- feen deodorants, disinfectants, and antiseptics. Mischief done by students and dressers might ve been saved, and valuable lives spared, even tong surgeons, if such precautions had been al- '.ys scrupulously observed by them. 4. Food and Drink (Diet). — The physician ll tell us that, to give food and stimulants in 'e way, at the time, of the kind, with the cook- ; and preparing, that will best enable the poor feebled. digestion to assimilate it, is one of the ; ?at nursing arts. No chemical rules can be (• en for this as absolute. The patient’s stomach i the laboratory, and also the chemist. It is t sole judge of whether the physician's orders i right; and the nurse has to watch and tell 1 1 what the patient's stomach says. She must Iff course trained and cultivated to understand ' it it says. Ihe patient's stomach sometimes craves, and a milates too, what no rules would have pre- s bed for it. The nurse must ask the physician ' :ther she may gratify these cravings. Sick- ckery should do half the digestion's work ; a proper variety is essential. If a patient is s after taking food or drink, or feverish, or 1 1, or torpid, it is often a symptom not of the d ase but of the nursing. Indeed, how mucli o he suffering of illness, as well as cf its dj?er, is the fault not of the illness but of the n :ing, is well known to the skilful physician 6 surgeon. pe nurse, of course, has nothing to do with d prescribing of stimulants any more than ledicines. But life often depends — especially it vers and severe surgical injuries — upon the me knowing howto follow the indications of 104/ tfie changes to be looked for in the patient's state given her by the physician, and to change the times of giving the stimulants accordingly. The nurse must know how to make gruel, arrowroot puddings, egg-flip, drinks, good beef- tea, and other kinds of sick cookery, so as to pleus« the patients’ taste and vary their diet. People say 'fanciful patients’ must be ‘humoured.’ So they must ; but it is in order to excite the proper secretions of saliva and gastric juice necessary for digestion. Nothing should ever be cooked in the ward or in the patient's room. But though 1 sweet JackPalstaff’ says, ‘A nurse is a cook,’ the whole of the cooking must not be thrown on the nurse, if she is to nurse ; and above all, if she is to eat, she must not be expected to cook for herself. But she will always be required not only to see that the patient's food and drink be as prescribed, but that it be well cooked, and punctually and well served. The physician con- siders that upon the nurse's power to give weak patients food in the way they like often depends their taking, or at least assimilating, any food at all. She has also to feed, for example, fever- cases so that they can eat. The mere lifting-up of a patient in bed to give him food may terminate fatally a fever-case. The nourishment or stimulant ordered may have to be put into his mouth per- haps every half-hour — perhaps every five minutes — even during sleep, without rousing the patient — the test of a good nurse. The physician ex- pects the nurse to be able intelligently to make the variations he prescribes in giving these things, especially during the night, according to the state of pulse and other symptoms, which she must know how to observe, in order to follow his conditional directions, upon which hangs the patient’s life from hour to hour, often from minute to minute. In convalescence from typhoid fever, one single false indulgence has often in- duced a relapse and terminated a case fatally. 5. Application of Remedies. — The phy- sician or surgeon requires the nurse — To be able to apply leeches, externally and. internally, in the best way; to dress blisters, burns, sores. To administer stimulants and medicines as ordered, enemas and injections to men and women, and suppositories. To manage trusses, appliances in uterine com- plaints ; to pass the catheter — at least for women. The district nurse is often now required to pass the speculum, also the catheter for men, because there is no one else to to do it. To use the best methods of friction to the body and extremities ; to make and apply fomen- tations, poultices, and minor dressings, wet and dry and greasy ; to syringe wounds ; to syringe the vagina. To manage helpless patients — fever, operation, and surgical cases — that is to move, to change them, to keep them personally clean, warm or cool. The medical attendant will expect the nurse to maintain an exquisite cleanliness of the pa- tient's whole person and skin, and, as in fever — the daughter of dirt — to clean herself the patient's teeth, gums, and tongue, with lemon-juiec or white-of-egg beat to a froth. A nurse is no nurse who cannot wash or sponge a patient's NURSING THE SICK. Otherwise contagious Always 1048 NURSING whole body without exposure or chill to any part. In typhoid and other fevers, this is now an essential part of the treatment. To give food and stimulants to helpless pa- tients — fever, operation, and surgical cases ; to manage the position of such cases ; to prevent or to dress bed-sores. To make the sick-bed, and especially to make the bed with the patient in it ; to change the under-sheet without moving the patient, as in fever and operation cases. The ‘ best way’ in- cludes, in this as in all other things, the doing them at the least expense to the patient’s vital powers. To prepare the bed for fever, for accidents, for ovariotomy, and various kinds of operations ; to undress, handle, and put to bed accident cases. To attend at and prepare for operations — in- cluding ovariotomy, lithotomy, hernia; to pre- pare patients for and manage them after opera- tions and anaesthetics — and all this with the least call upon their small strength. To be able to do the first thing in case of haemorrhage, namely, compression by hand, by extemporary tourniquet and plugging. To bandage all the various parts of the body, arm, leg, and chest (in Paris the infirmiers of military hospitals are made to practise all this, till not only it is done perfectly, but in a given number of minutes). To make bandages of the various kinds used ; T-bandages, double-headed, compound, 4- and 6-tailed, many-tailed, finger, ovariotomy, trian- gular, perineal, starched, and plaster-of-Paris, and other stiff bandages. To make rollers, to line and pad splints, to make gutta-percha splints, fracture and chaff pillows (black flock fracture-pillows harbour dust), and sand-bags. The nur3e is sometimes now required to give abcutaneous injections, to use the galvanic battery, and to dry- and wet-cup. She is required to be able to apply dry and moist heat, to give inhalations and use the spray-disperser ; to apply cold, with the use of siphons and with ice ; and antiseptic treat- ment. Observation of Patients. — The physician and surgeon require every nurse to bo able to observe correctly, and to report correctly, on the state or character of secretions, expectoration, pulse, skin, appetite ; effect of diet, of stimu- lants, and of medicines ; eruptions ; the forma- tion of matter; as to intelligence, with regard to delirium, stupor, &c. ; as to breathing, whether quick or slow, regular or irregular, difficult, &e. ; as to sleep, whether sound, starting, heavy, &c. ; and as to the state of wounds. The physician also requi res the nurse to be able to ‘ take ’ and to record the temperature, sometimes every quarter of an hour in critical cases — the pulse, the respiration ; to measure and sometimes to test the urine for him. She will be required to make these observations — if possible still more accurately— for child-patients, who cannot tell what is the matter with them ; to understand the management of sick children and children's wards, which need a yet more exquisite cleanli- ness. And children show a much more rapid change of symptoms for life or for death gene- I THE SICK. rally than adults. Children are the best air- test, the best test of sanitary conditions. VI. Other Duties. — She must understand the management of convalescents — a whole de- partment of nursing in itself — and the sooner a convalescent, especially a convalescent child, is removed from hospital to a country ‘ home’ the better. She mustba competent for the charge of linen — a mos timportautitemofnursing, when we con- sider that on extreme cleanliness of bed and pa- tient's linen — in other words, on linen and nurse depends the not re-introducing disease intc disease. The physician considers that fever, above al other diseases, tests nursing power, and depends upon this for life or death. ‘ Dr. ’ (of St Thomas's Hospital) ‘ doesn't think much of the nurse who loses a fever patient,’ was said o that wise man. Night-nursing. — The physician or surgeoi roquires the night-nurse to be as good as th' day-nurse, or even better — for the most critica times of fever and severe surgical injury oftei occur at night, or in the very early morning But quite the same kind of business capacity i: not required in the night-nurse as in the nursi in day charge of wards. Night-nurses, to d< their work well, must have at least seven o eight hours in bed where they can sleep undis turbed bj' day ; (even horses in the NewYor ‘ Horse Hotel,’ which work by night, have separate dormitory to sleep undisturbed by day They must have hotmeals prepared for them whe they come off duty in the morning, and befor they go on duty at night ; besides breakfast a 1 or 2 a.m. They must have one and a half ( two hours’ exercise. In a hospital they shorn' be obliged to show their pass. It is rather mo) necessary for a night-nurse to be regular in h habits, if she is to be well and efficient, than a day-nurse. And there appears no reason wl nursing by night, if properly managed, should ! more trying than by day. But regularity habits, of meals, of sleep, of exercise, of pe sonal cleanliness, is the sine qua non. Occasion breaks or transfers to day duty may be nece sary ; or a night or two in bed every month f a night superintendent. Holidays. — All nurses, especially nigh nurses, must have holidays. A month in t. year is not too much. Yet more do matrons a: superintendents and all women filling nursi offices of great responsibility require an annn holiday if they are to maintain vigour of 1» and mind, and not to wear out prematurely, i occasional three months’ holiday besides m;g be great economy. What a Nurse is to be. — A really go nurse must needs be of the highest class character. It need hardly be said that she mi be (1) Chaste, in the sense of the Sermon on t Mount ; a good nurse should be the ‘ Sermon the Mount ’ in herself. It should naturally se< impossible to the most unchaste to utter ev an immodest jest in her presence. Rerneml' this great and dangerous peculiarity of nursi. and especially of hospital-nursing, namely, th it is the only case, queens not excepted, when woman is really in charge of men. (2) Sob NURSING THE SICK. n spirit as well as in drink, and temperate in ill things. (3) Honest, not accepting the most rifling fee or bribe from patients or friends. (4) Truthful — and to be able to tell the truth includes mention and observation, to observe truly— me- nory, to remember truly — power of expression, o tell truly what one has observed truly — as veil as intention to speak the truth, the whole ruth, and nothing but the truth. (51 Trust- rortky, to carry out directions intelligently and perfectly, unseen as well as seen, ‘ to the Lord ’ s well as unto men, — no mere eye-service. (6) ’unctual to a second, and orderly to a hair— laving everything ready and in order before she logins her dressings or her work about the ■atient ; nothing forgotten. (7) Quiet, yet uick ; quick without hurry ; gentle without lowness ; discreet without self-importance, no ossip. (8) Cheerful, hopeful ; not allowing her- lelf to be discouraged bv unfavourable symp- oms ; not given to depress the patient by antL- ipations of an unfavourable result. (9) Cleanly ) the point of exquisiteness, both for the patient’s ike and her own ; neat and ready. (10) Think- ig of her patient and not of herself ; 1 tender ver his occasions ’ or wants, cheerful and kindly, 'atient, ingenious and feat. The best definition jin be found, as always, in Shakespeare, where e says that to be ‘ nurse-like ’ is to be ‘So kind, so duteous, diligent, So tender over his occasions, true, So feat.’ A patient wants according to his wants, and ot according to any nurse’s theory of his wants • 1 occasions.’ ‘ Tender over his occasions ’ she ust be ; but she must have a rule of thought ; id this the physician or surgeon has to give fer in his directions ; which her training must ivo fitted her to obey intelligently, using dis- ction. The nurse must have simplicity and single eye to the patient’s good. She must ake no demand upon the patient for reciproca- pn, for acknowledgment or even perception of ■r services ; since the best service a nurse can !ve is that the patient shall scarcely be aware any— shall perceive her presence only by per- iving that he has no wants. The nurse must Ways be kind, but never emotional. The patient ast find a real, not forced or ‘ put on,’ centre of lmness in his nurse. To call upon a patient • emotion for emotion is the most cruel, be- luse useless, demand upon his strength. It is king him to bear your troubles and your xiety as well as his own. Suppressed emotion as bad — it makes the nurse constrained. It j exposing the patient to both frost and fire, ilf the battle ot' nursing is to relieve your sick tom having to think for themselves at all — least all for their own nursing. Florence Nightingale. MTTTBIEG-LIVEIt. — A form of disease of i liver, the appearance of which on section newhat resembles that of the cut surface of a hneg. See Liver, Nutiieg. NUTRITION, Disorders of. — The nutri- a of the body, by which we understand the ; intenance of its parts in a fit state to perform ir functions, depends on three main factors — NUTRITION, DISORDERS OF. 1049 the supply of suitable food ; the assimilation of food; and the prevention or control of waste. When any of these factors arc disturbed disor- ders of nutrition result. If food be inadequate or unsuitable, other things being normal, gen- eral atrophy will be the consequence ( see Atro- pht, General) ; and the same result will evi- dently follow if the organs of assimilation are at fault, or if waste be excessive, even though food be abundant. Hence cancer of the stomach on the one hand, and diabetes on the other, may be taken as the types of ‘ wasting diseases.’ Increased supply of food, on the other hand, does not im- prove the nutrition or cause hypertrophy with the same certainty as want causes atrophy, caus- ing increase chiefly of a single tissue, as shown in the articles on Hypertrophy and Obesity. Similar principles apply, mutatis mutandis , to local nutrition or the nutrition of parts of the body ; in which the three factors are — the supply of nutritive material by the blood ; the power of assimilation possessed by the tissues, depending on the condition of their minute elements ; and the amount or rapidity of waste. Ilencc, as shown elsewhere, local atrophy results from ob- struction in the blood-supply to a part ; or from the inability of the part to appropriate nourish- ment, either through faulty innervation or the condition of the tissue-elements. In some cases excessive use, leading to waste, is also a cause of local atrophy. Increased blood-supply alone does not, on the other hand, by itself lead to hypertrophy. See Atrophy, Local. When the disturbance of nutrition, however produced, causes a qualitative rather than a quantitative change in the tissue or organ, this change receives the name of Degeneration, of which there are several kinds ( see Degenera- tion). Besides special kinds of degeneration, there is one general change which often results from impaired nutrition, namely, softening , but this is no longer regarded as a distinct process, since it differs, in its minute characters, accord- ing to the tissue which is affected. Induration, also, once regarded as among the general conse- quences of impaired nutrition, can hardly now be regarded as a distinct and substantive pro- cess ; but may be understood in the sense of fibroid degeneration. In this place we can only refer to some instances of disordered nutrition, which are not precisely cases of atrophy or hy- pertrophy, but are yet dependent on disturbances of some of the factors of nutrition spoken of above. In these cases, where the blood-supply is not interfered with, the assimilative power of the tissues must be in fault, and this will depend upon either innervation or the condition of the tissue-elements. In some of these the nutritive disturbance leads to inflammation. There arc many curious instances of local changes of nutrition in which the blood-supply is quite unimpaired, and the cause has to be sought in some other disturbance, more espe- cially one of the nervous system. Reasoning from certain well-marked cases of disorders of nutrition originating in the nerves, it may be plausibly conjectured that many other changes, and particularly many ordinary diseases, which we usually regard as idiopathic, may be simi- larly due to disturbance of nervous influence. NUTRITION, DISORDERS OF. 1050 Again, the nutrition of a part may be affected, not by direct nervous influence, but by reflex innervation, and thus depend upon the condition of some other organ. A very clear instance of a lesion of nutrition depending on the nerves is seen in the disease, herpes zoster, and in some other skin-diseases, the distribution of which is obviously regulated by the distribution of certain nerves. The dependence of nutrition upon the nervous system is also seen in some instances of healing, as in the case of ulcers of the leg, pointed out by Mr. Hilton, where rapid healing follows the section of a nerve-branch leading to the ulcerated patch. On the other hand, the. loss of vitality dependent on nervous disturbance is seen in the rapid formation of bed-sores on the sacrum in cases of paraplegia. The same con- clusion must be drawn from the nutritive dis- turbances, beside the ordinary disturbance of the sensory or motor function of the nerves, which sometimes follow injuries to nerves. Thus injuries of the brachial plexus, not severe enough to cause actual paralysis of motion, may produce a state of swelling and hyperaemia in the fingers — the condition called ‘ glossy fingers ’ by Paget. Similar and more complicated changes have been observed as the consequence of gunshot wounds affecting the nerves. These cases, and such as these, have raised the question whether there are ‘ trophic nerves,’ that is, whether, in addition to the fibres passing to the muscles and to the periphery, which are concerned in motion and sensation respectively, there are others dis- tributed to the tissue-elements themselves, whose function it is to keep theso elements in a proper state of nutrition. It is impossible to discuss this theory here ; but we can only say that some of the phenomena which are thought to make necessary the theory of trophic nerves appear to be explicable by assuming the presence in the mixed nerve-trunks of some fibres de- rived from the sympathetic system. The con- nection of the sympathetic nerve-fibres with nutrition, though chiefly displayed through variations in the circulation, is undoubted. In the rare cases which have been observed in the human subject of lesion of the sympathetic nerve in the neck, a permanent change in the nutrition of the affected part is observed when the well-known vascular changes have passed away or become greatly modified. Lastly, it should be pointed out that in certain diseases of the spinal cord, for example, locomotor ataxia, affections of the joints, resembling chronic rheumatism, have been observed, which may be very plausibly, though not yet with certainty, ascribed to nervous derangements. On the strength of these cases it has, been supposed that in other forms of rheumatic and rheuma- toid disease, the distribution of the morbid changes depends upon the nervous system ; but this must be regarded ns quite theoretical. Still more uncertain are the theories which have been framed to explain the occurrence of in- ternal diseases, such as inflammation of the lungs, &c., us a consequence of nerve-lesions. When we find disorders of nutrition neither caused by changes in the distribution of the blood, nor connected with any nervous derangements, I the fundamental change must be referred to the tissue-elements themselves ; and it is probable that the number of disorders depending upon such changes in the minute tissue-elements is very large ; and the field of ‘ elemental pa- thology’ may be larger even than that of nerve- pathology or blood-pathology. Such an expla- nation is particularly reasonable when the changes are symmetrical on the two sides of the body, and when they are connected with advancing age ; as, for instance, fatty degenera- tion of the cornea, turning grey of the hair, and primary degeneration of the walls of arteries. In these cases it seems unnecessary to suppose any implication of the nervous system, and dis- turbances of the circulation plainly do not account for the facts. It can only be supposed that the tissue-elements, like the organism it-; self, have their natural term 'of life, and that! this term varies in different individuals, in whom, therefore, these failures of nutrition are merely the expression of the, more or less, premature, old age of certain elements. These changes may be, and often are, the expression of the! general condition of the whole body, which is more obvious in some parts than others, simply because the tissue-elements in these parts are older or less vigorous. Treatment. — Having spoken of the chiei causes of disorders of nutrition, it remains tc consider whether there is any general treatmem applicable to such disorders, independent of the special treatment proper to many of them ai special diseases. With regard to the general nutrition of th body, we can only refer to what has been saio under the head of Ateopht, General, sine- hypertrophy is not a condition which practi cally requires treatment, unless exceptionally as hypertrophy of a special tissue. With re gard to local disorders of nutrition, the firs and only generally applicable rule must be tore move, if possible, the local cause. If the cause i obscure, or, when discovered, cannot be obviatec , the treatment must be guided by circumstance: but will usually be more of a general characte: As an example of the removal of the cause ( disordered nutrition, we have instances in whic the phenomena of nerve-lesion above referre to have disappeared entirely on removing fragment of lead or other irritating substanc from the nerve-trunk. A more familiar instant is where the lower part of the leg is in a pe: manent state of malnutrition from stagnatic of blood in varicose veins ; oedema, eczema, sal cutaneous induration, and ulcers may resul If, by suitable pressure or surgical treatment i the diseased veins, the circulation is rendere normal, all these morbid conditions will l healed. On the other hand, certain local di orders of nutrition can only bo treated by in proving the nutrition of the whole body. C chectic children, for instance, may exhibit chron conjunctivitis, bronchial catarrh, eczema of t] flexures, and the peculiar sloughing sores the fingers which have no distinct name, but a weU-known indications of malnutrition. If, place of, or in addition to, local treatment, v use general treatment, directed to improve t) nutrition of the body, all these local disorde may entirely and perhaps simultaneously g NYCTALOPIA. vJ, as they depend only upon the deficient jver of resistance possessed bv the tissues in Aeral. J. F. Payne. NYCTALOPIA. — Like hemeralopia this \ieral state of disordered nutrition of the body, aracterised by an excessive development of the • pose tissue, more especially in those situa- |ns where it is normally most abundant, tnely, the subcutaneous, subserous, and inter- i;scular connective tissue. Etiology, — a. Predisposing causes. — The i uence of heredity in transmitting the liability t obesity is undoubted, and is a matter of com- i n knowledge. Sex and Age. — That excessive dpulence is more common among women than ;]ong men is also well known. Several circum- f.nces have been suggested to account for this, f h as the menstrual functions of women, their 1 5 muscular activity as compared with men, and t ir frequently diminished oxidative power, due t ooverty of red blood-corpuscles. Age appears tjhave considerable influence in determining t> condition. Under a healthy regimen cliil- j c,n get fat from birth, notwithstanding that ■ t the same time the albuminoid ingesta must Largely employed in the construction of the l idly growing tissues; and hence, at this period c life, the fat and amyloid food-stuff’s are the v if source of the adipose deposit. How fre- c ntly are seen children improperly fed on Loss of starchy matter, very fat, whilst their | oral nutrition is much impaired. A fat child ‘ from necessarily being a healthy one. At I puberty there is frequently a diminution in I weight, Loth relatively to the height and abso- lutely' ; but the contrary to this sometimes ! accompanies the establishment of menstruation, especially if the subject be very chlorotic — that is, with au enfeebled oxygen-carrying blood- power. After the age of forty, particularly in women at the chmacteric, the influence of age markedly asserts itself. Even the manifestation of the hereditary tendency may be postponed until that period, and for women to become fat at that time is almost the rule. The perversion of nutrition now under consideration is, in some unknown way, curiously but distinctly associated with the degree of development of the sexual functions, and in an inverse direction. This is very noticeable in eunuchs and animals whoso generative organs have been removed, and tho part played by the cessation of ovulation has been already mentioned. Even during preg- nancy, when ovulation is suspended, it is no un- common occurrence for the subcutaneous fat to be increased in amount. Race.— Among certain races obesity' appears to prevail, as for instance the Hottentots ; and whilst amongst some, such as certain castes of Hindoos, the condition has been highly estimated, amongst others, as the Greeks and Romans, it was regarded as dis- graceful. Climate. — Although very fat people are met with in all climates, there appears to be a special tendency to their predominance in low- lying, damp countries, whilst, with certain ex- ceptions, they are less often seen in very hot and in mountainous districts. Nervous Influence. — Since the nervous system so directly influences tissue-changes, it is not tc be wondered at that certain nervous states favour obesity ; it is common in idiots. 1062 OBESITY. b. Determining causes.— Excess of. food is the first of these to be mentioned. Whilst no doubt a large excess of food may lead to corpulency, it .must be confessed that it very often does not do so, and extremely thin men are often large eaters. And, on the contrary, many women who become excessively obese have poor appetites. Nor does it seem in these different classes of cases, that the kind of food makes much difference. Some get fat, eat what they will ; others do not, whatever the diet. Brink. — It is, however, usually the case that very fat people take a large amount of fluid food. How alcohol acts in the production of fat is not very clear. It is asserted that it does so by diminishing oxidation; but this is not the entire explanation, for the extent of obesity is far from being proportionate to the amount taken, and not unfrequently an exces- sive ingestion is not associated with corpulency. There would seem also to be something due to the form in which the alcohol is taken. Exercise. — Deficient muscular activity, by diminishing the amount of oxidation of tissue, favours obesity ; and since, as a rule, the stouter the person the less capable is he of exercise, these two conditions react one upon the other, to the advantage of fat- production. Disease. — Exceptional cases of cor- pulence have followed recovery from fever, and extensive bleedings, even when there had been no predisposition ; and a similar result has been met with after prolonged administration of mercurials and arsenic, which is perhaps to be explained by the deteriorating influence that these drugs are said to possess on the red-blood corpuscles. Pathology. — Assuming that the current views on lipogenesis or fat-formation are known to the reader, it is sufficient here to state that from whatever source the fat of the body be derived, whether from the fatty, the amyloid, or albu- minoid elements of the food, or from all, as is most probable, the fact of its being stored up as adipose tissue must be regarded chemically as an expression of deficient oxidation ; a process which, if it had been more complete, would have resulted in the conversion of these elements into carbonic acid and water, to which the fat itself is reduced when it is subsequently used up in the economy. It is thus that the corpulence that frequently attends such morbid states as anaemia, chlorosis, haemorrhage, some pulmonary and car- diac diseases, and alcoholism, is to be explained ; since in all these diseases the oxygenising power of the blood is deficient. The fat of the body in an average male adult constitutes about one-twentieth, and in the female rather more, of the total weight. It is not for months after the commencement of develop- ment, that the adipose tissue is sufficiently dif- ferentiated to be distinguishable ; it gradually in- creases in amount , being considerable at birth and up to puberty, when it often diminishes slightly; during maturity it increases, or the reverse, being very variable in amount; and during old age it decreases. During childhood the adipose tissue is more evenly distributed in the subcutaneous tissue than in later life, when fat tends to diminish on the surface in proportion as it be- comes deeper-seated. In the three situations in which the fat is chiefly deposited — namely, tho subcutaneous, subserous, and inter-muscular connective tissue — there a certain areas which are preferred by it, as the are others which escape. Whilst the ’abdonw buttocks, and back of the neck are especially p; minent, the wrists, ankles, eyelids, scrotum Y penis are free from fat Beneath mucous me branes it is very unequally distributed. Fat i never seen beneath tho peritoneal coat of t stomach or intestines, the parietal pericardii or the visceral pleura ; whilst the great omenta i which usually weighs about Mb., may reach 7 lbs. or 8 lbs., or, it is said, even 30 lbs. ; a 1 under the synovial membranes fat may be ( posited to such an extent as to interfere w the movement of the joints. The ordinary state of the organs found in v( corpulent people is, that the lungs are sma the heart and the liver large, and infiltraf with fat; the gall-bladder containing only a lit pale bile or mucus ; the stomach large and mi cular, but well-developed : the kidneys sma'. as also the spleen and lymphatic glands; a the pancreas largely developed. Like many other conditions of disease, it impossible to define the exact line at which morbid obesity may he said to commence. ;| degrees of corpulence, indicated by such terms ‘stout,’ ‘embonpoint,’ &c., occur, to which tl notion of disease is wholly inapplicable. N as will be seen, can the disturbance of funct? be taken in all eases as the measure of a morl state, since the impairment of function is ij always proportionate to the amount of fat. As instances of extreme corpulency the foiloi ing may be quoted: — Daniel Lambert, who at twenty-three ye; old weighed 32 stone, but could walk frd Woolwich to London. His subsequent maximi weight reached to 52 st. 11 lbs. Edward Wright, 44 st. Dr. Wardell records the case of a you married woman, who, at eighteen was thin a', delicate, had no children, and lived well; s> died at the ago of forty-one ; the thickness of t> subcutaneous fat on the sternum was 4 inch, and midway between pelvis and umbilicus; inches. The heart weighed 36 oz., the li" 118 oz.,and there were prolongations of fatfri the omentum 1 to 4 inches long, as thick at candle. As illustrations of precocious obesity, caS are on record of a girl weighing 13 st. at b age of twelve years ; and a boy weighing 8 st. 1 2 1. at three years. This boy had three teeth at bif, and twenty -six at thirteen months old. Thus, in extreme cases, one-half, or foui-fil 5 even, of the body-weight may he fat Symptoms. — The general appearance ofi corpulent person scarcely needs descripti. The condition may he associated either wi a hypersemic or full-blooded, or with an anseic state of body, and it is desirable to recognise ts in view of treatment. Owing to the fatty infilt- tion of the muscular tissues, and the degenerata of the fibres, the muscular energy is diminish, this being especially noticeable in regard to e heart, the action of which is easily disturbed, ii palpitation is a frequent symptom, accompani by dyspncea, induced by slight exertion. s affection of the voluntary muscles manifests - OBESITY. iq£3 s: in an indisposition to active exercise. The destive power is often very well maintained, and t; notwithstanding the frequent excess both in t quantity and in the quality of food indulged i Periodical impairments are, however, fre- est, and flatulence and constipation are often tublesome. The cardiac sounds are usually fble and distant, though the reverse obtains ven there is a hypertrophied ventricle. The j se is fall, or small and weak, according to t plethoric or feeble state of the individual. !e mental activity is variable, and many ex- tnal causes tend to modify it ; but the tempera- rnt is proverbially ‘ easy-going,’ indolent, and liargie, especially after meals, although very fquently interrupted by attacks of peevishness pi irritability, or by unusual somnolence and cet. Examples, however, of considerable in- t.ectual attainments are not unknown among t, corpulent. The excretions are usually copious, hfnse sweating is induced by slight exertion, pi the secretion of the sebaceous glands is abun- nt. The urine generally is acid, and contains ; excess of uric acid. Partly from chafing, and ; fly from the excessive cutaneous secretions, i ertrigo and other eruptions are apt to occur i the folds of the groin, helow the mammse, pi in similar parts. The vessels share in the peral malnutrition of the tissues, and atheroma cthe arteries is often found, whilst the veins home distended and varicose, forming kaemor- i lids and varicocele. Depending upon these vcular changes are the congested and bloated poearance of the face, and the liability to head- ; ies, vertigo, and giddiness. The sexual appetite i rcquently deficient in both sexes, and sterility i common in women. Disturbances of sight i t hearing are frequently noticed in fat people. The condition of obesity, like other general ] 'versions of nutrition, such as tuberculosis and i kets, most distinctly presents other character- i'.cs than the mere signs and symptoms above umerated. There are certain tendencies and i lilities which the state engenders ; and iercnrrent maladies come to possess special i tures. Periodically, the fat man ails without jhaps any obvious cause, and such ailments i st be regarded as the expression of malnutri- 1 1 of the tissues produced by the excess of fat. . long the more prominent of these affections i i proneness to catarrh of the respiratory and pnentary mucous membranes, and periodical ‘ Ids’ and diarrhoeas are frequent. This is in fiat part due to the fact that the power of self- t ulation of temperature, which the body pos- tses, is diminished by the thick layer of sub- c aneous fat, which is a bad conductor of heat, e interferes with compensatory radiation. At t same time the plethoric condition, the hy- fiaemia, and the enfeebled circulation due to t weak heart, all tend to the same end, namely, f ability to congestion of the ill-supported tis- f s, such as the mucous membranes, with the I ilts of such congestion in excessive secretion t other derangements of function. he obese subject is quite as liable to the t te diseases as is the thin man ; and these t adies run in him a singularly unfavourable ( rse. The. diminished power of heat-radia- I I increases the pyrexia ; and the weak heart favours the establishment of the adynamic state. Such means for lowering the temperature as cold applications have but little effect through the thick fat ; and aconite is contra-indicated by the pulse. But since the oxidising process in the corpulent is diminished, the temperature in the febrile state is rarely very high, and at the same time is but ill resisted. The effective agent in lipogenesis, namely, deficient oxidation of the ingesta, especially the albuminoids, also favours the formation of uric acid, and hence the fat are often gouty. Saccharine urine (a condition which, whatever view be taken of its pathology, is manifestly a state of defi- cient oxidation of certain tissue-elements) — es- pecially that form which is met with in those advanced in life — very frequently occurs in stout people. In 32 of 140 cases of diabetes observed by Seegen, obesity preceded the glycosuria. Progress and Prognosis. — The progress of obesity is essentially chronic, and rarely, if ever, tends to other than increase of this state. Ex- treme fatness in the very young, as said, usuallv subsides ; but the obesity of advanced life never does, unless any exhaustive disease should co- exist, such as cancer or diabetes ; and the latter by no means produces then the emaciation that it causes in young people. Obesity should, on the whole, be regarded as a grave matter, since very fat people rarely reach an advanced ase ; whilst a decrease of fat at middle age in a person hitherto stout should be regarded with suspicion. In obesity death by syncope may result from an extremely fatty heart ; from apoplexy, caused hy rupture of an atheromatous vessel in the brain ; or from bronchitis, with general oedema from cardiac dilatation. Treatment. — Limited space prevents even an enumeration of the nostrums that a fanciful empiricism has suggested for the prevention or cure of obesity. Eecognising that accumulation of fat is a per- version of nutrition, which, if once established, and with a strong hereditary predisposition, can- not he cured, it follows that we should endeavour to prevent as far as possible its increase, by avoidance of those factors which pathology tells us are favourable to its development. The cardinal rule in any procedure that maybe adopted is to avoid heroic treatment, for though thereby the fat may be diminished, the result may bo attained by establishing a worse state of the body, if not oneleadingeven to a fatal termination. Theguides as to how far a given plan may be proceeded with are, first of all, the age and general con- dition of the patient, especially as regards the heart's power ; and, secondly, the feelings and capability of the patient as the treatment is pur- sued. Each case must be treated according to cir- cumstances, bearing in mind that the objects to be aimed at are to diminish the sources of the fat, and to increase the oxygen-carrying power of the blood and oxidising power of the tissues. The diet must be regulated in quantity and quality. Since a healthy diet should consist of certain proportions of nitrogenous, amyloid, and fatty principles, and since from all these three substances fat may be formed in the body, the question arises which can be most advantageously diminished. Experience supports our patho- 1054 OBESITY, logical knowledge in advocating a withdrawal as far as possible of fatty and starchy food, whilst at the same time a moderate increase in albu- minoid matter is permitted ; for with a fair quantity of the other food-staffs, proteids increase tissue-change. It is on this principle that systems of dietary for the corpulent are founded, the best known of which bears the name of Banting, who for a year (1863) successfully followed out a plan laid down for him by Dr. Harvey, with the result of losing 44 lbs. in weight, and without the re- currence of corpulence when ordinary diet was resumed. There are many other cases recorded. Dr. Cheyne, who weighed 32 stone, reduced himself a third in weight, and lived afterwards in good health to the age of seventy-two (Dr. Wadd on Corpulence, 1822). Lean meats, sweetbreads, fish, except rich kinds, such as salmon and eels, clear soups, poultry, game, eggs, cheese, green vegetables, toast, gluten bread, fresh fruit, and pickles are allowable articles of diet. An average diet for an adult would be 12 oz. lean meat, 6 oz. rusks or gluten bread, 4 oz. green vegetables, 1 oz. butter, and tea f-pint. Much difference of opinion exists as to how far water should or should not be freely allowed. Alcohol generally should be avoided, but especially spirits and beer, which must be absolutely forbidden, except on emergency; cider or the light dry wines, both white and red, diluted with water, are less objectionable. Tea and coffee are supposed to interfere with tissue-change, and therefore should be taken sparingly ; and milk, from the quan- tity of fat it contains, is to some extent inadmis- sible. Exercise, within the limits of the patient's powers, such as riding, walking, rowing, and gymnastics, is of great benefit, by directly induc- ing an increased oxidation of tissue, and improv- ing the quality of the blood, and therefore its oxygen-carrying power. Cold-bathing, if well borne, is of advantage on similar grounds, but extreme sweating is unadvisablc, and may be dangerous. Breathing compressed air, with the object of increasing the tissue-oxidation, has been recommended. It is in carrying out a system rather than in devising one that the difficulty occurs. The regularity and restraint prove irksome to the patient, and are frequently broken. Hence it is that the regimen and spare diet of the various spas, such as Carlsbad, Marienbad, Kissengen, and Ems have great advantages, since at such places, and in such surroundings, the patient more readily and willingly pursues a given plan. In the treatment of intercurrent diseases it is essential to remember the enfeebled resisting power of the patient, and the necessity for stimu- lants. Among the many drugs that have been used, may be mentioned alkalies, iron, and iodine. Soap was formerly much employed, as much as three ounces being given daily with milk and lime water ; and some of the good effects of the various 1 waters ’ are ascribed to their alkaline properties, especially the alkaline aperients of the above-mentioned spas. Iron is an essential in those forms of corpulence associated with anaemia, and most satisfactory results follow its administration, as the health improves and the I OBSTRUCTION", AND OCCLUSION, fat diminishes. Young chlorotic subjects ben. by this treatment, which may be advantageon carried out at some chalybeate spring, such ‘ Tunbridge W ells, Harrogate, or Spa. The iodic ' such as those of potash and iron, given in k doses, undoubtedly effect a reduction in t amount of fat, but not always with a correspoi ing improvement in health. So long as this dJ not suffer and the patient improves, the drug ji be persevered in, but it is frequently very ba. borne when taken in quantity. The preparatii of fucus vesiculosus, the basis of certain qua remedies, appear to depend for their value : the iodine contained in them. W. H. Aixchix. OBSOLESCENT, ( obsolcsco , I grow out use). — A term applied to miliary tubercle, wt instead of undergoing destructive changes, becomes dried up, shrunken, and hard, and tl remains inert. See Tubercle. OBSTRUCTION, and OCCLUSION Obstruction and occlusion of the different tu! and orifices of the body are mainly effected three different ways: — first, by blocking tube by its contents ; secondly, by alteration its walls ; thirdly, by pressure from without. 1. Blocking. — The first mode of obstruct is met with in most of the tubes of the body, aj may be produced in various ways. The o;c : ding mass may be composed of the normal c tents of the tube ; of these contents variou' altered ; or, lastly, it may be some foreign s- stance introduced from without. Examples f the first of these modes occur in the intestine,, cases of impacted faeces or intestinal concretio: in the biliary and urinary passages from calci: in the ducts of glands from the products! catarrh or inspissated mucus ; and in the bloj- vessels from deposits of fibrin. Obstruction' foreign bodies may of course occur in all tw in direct communication with the external s- face, but even internal tubes are sometimes - structed in this manner. As examples of Is may be cited the occasional obstruction of e bile-ducts by hydatid cysts, or by the asci« lumbricoides ; of the pulmonary artery by hy- tids ; of capillaries by masses of bacteria ; d of the pulmonary capillaries by air sucked iny a wounded vein. 2. Parietal Changes. — Obstruction of tus from alteration in their walls is the most e<- mon cause of the various forms of pennant stricture, and may arise from many different c- ditions. First, in those tubes whose walls e muscular, it may be the result of spasm. Is form of obstruction is usually only of tempoiy duration, and is probably not of very freqrt occurrence. It is supposed to take place in a urethra and the bile-duct, but the most imp tant instances of it are met with in the resp - tory and vascular systems. In the former c have examples in spasmodic closure of theglois, and also in the narrowing of the bronchial tus in spasmodic asthma ; in the latter in the In- struction by spasm of the small arteries of .e base of the brain, to which the initial phenoma of the epileptic seizure are ascribed. ToasimJ spasmodic occlusion of the arterioles of e lungs Dr. George Johnson ascribes many of a OBSTRUCTION' AN'D OCCLUSION', ohenomena of cholera. To a more prolonged 3 pasm of the blood-vessels the gangrene produced oy ergot has been attributed. Obstruction from more permanent alterations ,n the vails of the tubes may be produced, first, oy acute inflammatory swelling and oedema, md by the formation of false membranes ; and secondly, by chronic inflammatory thickeniugs ind cicatricial contractions. These form the aon-malignaut permanent strictures, as of the irethra, ^oesophagus, pylorus, and intestines. Thirdly, the growth of some malignant or other umour in the -walls of tubes may lead to the ’same result. This form of stricture is especially common in the digestive canal, from the pharynx downwards. 3. External Pressure. — Lastly, obstruction ind occlusion are often the result of pressure from vithout. This pressure may be exercised by a umour of some kind, or by enlargement of an >rgan, as, for example, the obstruction of the raehoa produced by an enlarged thyroid body, dr the pressure from without may be produced py the effects of inflammatory processes occur- ■ing in the surrounding parts. We have ex- tmples of this in occlusion of the intestine by jbrous bands, and in obstruction of the tubuli iriniferi of the kidney by the cirrhotic process. )ther examples of pressure from without, causing destruction, occur in displacements of the intes- ine in hernia, with which may be classed the ■arious forms of volvulus. Effects. — The effects of obstruction and oc- lusion differ, of course, according to the tube or rifice affected. They are in part due to the arrest f function of the tube, and in part are purely leehanieal. The most general mechanical effect p dilatation of the tube behind the seat of the bstruction, owing to the accumulation of its patents (see Dilatation), and arrest of func- ;.on beyond it. When these contents are them- ?lves irritating, or when the disturbing cause Iso constricts the blood-vessels, ulceration, or angrene and perforation, are liable to occur. ; he other effects are mainly due to the backward pessure of the accumulation. In cases where ie tube is the duct of a gland, the ultimate effect to arrest the secreting function, and cause -rophy of the gland. This is attended by cessa- on of any further accumulation ; and sometimes pmplete absorption of the previous accumulation kes place, and the dilated duct shrinks and be- i mes completely atrophied. Examples of this ■ ries of changes occur not infrequently in the eter and kidney. W. Cayley. OCCUPATION, etiology of. — See Dis- se, Causes of ; and Public Health. (EDEMA (olSea, I swell). — S ynon. : Fr. I ’dime; G-er. GEdem. — A dropsical effusion in 3 cellular tissue, whether subcutaneous, sub- : icons, snbserons, or in the interstices of organs, s Dropsy. (ESOPHAGUS, Diseases of. — Synon.: Fr. iladies d (Esophage ; Ger. Krankhedten der eiserohre . — The diseases of the oesophagus may considered in the following order : — H. (Esophagitis. — Inflammation of the ceso- igus. Etiology. — Inflammation of the oesophagus, (ESOPHAGUS, DISEASES OF. 10-to arising in its structures and confined to it. is an affection of rare occurrence : or it may bo that it offers so few marked symptoms that but small attention is paid to ir, and it never comes before the physician. But by no means uncommon is the extension of inflammation to the (Esophagus from neighbouring structures. Thus, a catarrhal inflammation of the throat and fauces may pass down the cesophagus. In cliildren thrush has been seen to extend into the gullet, setting up a certain amount of inflammation ; and the same holds good with regard to diphtheria and croup. Where organic disease of this organ exists, a certain amount of inflammation is liable to be set up. But by far the most common causes of acute oesophagitis are the ingestion of irritating or corrosive substances, such as boiling water, alkalies, or acids ; and mechanical injury from the introduction of foreign bodies. Symptoms. — Somewhere in the line of the (Esophagus pain, varying in intensity, of a burn- ing or lancinating character, is complained of, at times so severe as to induce vomiting. This pain is rendered intensely acute by all attempts at swallowing. Even the passage of the saliva is sufficient to set it up, and hence it is that this fluid is seen dribbling from the mouth of the child who is the subject of this disorder. Thirst is a usual accompaniment of cesophagitis ; hut rather than endure the agony of swallowing fluids, the indi- vidual will put from him all fluids, however bland. If the attendant insist upon an effort being made to swallow some sustenance, most usually this is speedily rejected, accompanied with much viscid mucus, flaies of lymph, mem- branous shreds, and sometimes blood or pus. The amount of fever and constitutional disturbance is in proportion to the intensity of the inflammation. Peognosis. — If simple, acute oesophagitis usually terminates in resolution, and somewhat speedily. If it he due to the passage of acrid or hot substances; ulceration of the (Esophagus may result; or simply a permanent thickening of the coats of the tube, whereby its calibre is reduced, and stricture is the result. Treatment. — It is best to abstain from all attempts to give nourishment in the ordinary way, and to rely entirely upon nutritive enemata till the acuteness of the affection has passed. Ice may, however, be given to the patient to suck, if it prove agreeable to him. For the relief of the pain warm poultices may be applied externally, or opiate fomentations. Opium may he adminis- tered either by enema, or subcutaneously. The state of the bowels must be attended to. 2. Ulceration. — TEtiology. — This affection, as we have already seen, may arise as the result of the passage of irritating fluids through the cesophagus. More commonly it is brought about by the swallowing of certain pointed or angular bodies which stick in the gullet, and cannot be dislodged, or before their removal have eroded the mucous membrane and produced ulceration. Simple ulcer and perforating ulcer of the oeso- phagus have also been described; they are similar to those which are observed in the stomach, but are of rare occurrence. Symptoms. — These are similar to the pheno- mena described under oesophagitis, only the pain is more localised, and is more generally referred L066 (ESOPHAGUS, DISEASES OF, to a circumscribed spot between tlie scapulee in the back, at the top of the sternum, or in the prsecordia. The same difficulty in swallowing is experienced, and, on account of the slowness of the ulcerated surface to heal, is much more protracted, so that the patient emaciates rapidly, and death from starvation has even been known to occur. In the perforating variety a commu- nication may be established between the (Eso- phagus and one of the bronchi — more likely the left, the pleura, or the pericardium. Ausculta- tion may reveal a change of tone in the sound of the swallow, it being more dead in quality than in health. The bolus swallowed seems also as if it were di minished in bulk, but much elongated, so that it takes longer to pass the ulcerated spot than it does at any other portion of the tube. Prognosis. — This must be founded on the nature of the ulcer, but it is always serious. Treatment. — Not much reliance is to be placed upon medicinal treatment. The patient’s strength must be sustained by the liberal use of generous diet if he can swallow, or by nutrient enemata. It may be possible to pass into the stomach a small-sized oesophageal tube (catheterNo. 15) and, by attaching it to the stomach-pump, thereby introduce plenty of nourishment. Stimulants will also most likely be called for. Ice may be freely allowed. Local application of nitrate of silver, tannic acid, borax, and other agents, by means of bougies, has been advised. 3. Dilatation. — Dilatation may affect the oesophagus in its entire length, but more com- monly involves merely a portion of the tube, as is frequently observed in cases of stricture of the oesophagus. In addition to this, sacs are met with in the walls of tho canal, which commu- nicate with it. These divertieuli are usually formed by the distension of all the coats of the oesophagus, but sometimes by the mucous membrane alone becoming dilated, and pushod between the other coats. The causes which give rise to this condition, in addition to stricture, are the lodgment of some foreign body in the walls of the oesophagus (this is one of tho most fre- quent origins of the diverticula), and paralysis of the walls induced by chronic catarrh. Symptoms. — These are not marked. If the dila- tation be idiopathic, and involve the whole length of the tube, nothing very abnormal will be present to lead to the discovery of this condition. If it be secondary, dependent upon stricture, then in ad- dition to the symptoms described under that head, it will be observed that the food, after it has been swallowed, is much longer retained than formerly. There is also experienced a sensation of fulness, which may sometimes be perceptible to vision, at the point above the stricture, and this is ac- companied by a desire to relieve the sensation by vomiting, which sooner or later occurs, spon- taneously or induced by the patient himself, and affords great and immediate comfort. In the case of diverticula, when of some size, the symp- toms are very similar to those above described. In addition, it may be noticed that a very had odour is given off from the mouth of the patient, due to the retention and decomposition of the food in these pouches. According to their site, tumours, varying in size as the individual has more or less lately been partaking of food, may be observed. These may sometimes interfere with respiratioi cr circulation. Auscultation in the case of simple dilatation indicates that no obstruction to the passage of the bolus exists, and there is no pro- longation of the time it takes to pass into the stomach. But an alteration in the vigour of the! peristaltic action is observed. There is a defi ciency or entire loss of the contraction of the muscles, and the gradual transmission of thij bolus onwards is no longer heard, but it appear: to run or drop at once into the stomach. It h generally believed that men are more subject til this affection than women ; and it is met with irj the decline of life. Treatment. — Treatment is of no avail fo, dilatation of the oesophagus, except so far a to remove the cause, if possible, and to trea symptoms. 4. Stricture. — This affection may be the re suit of either of the two first-named, disorders or of a changed condition of the walls of the teso phagus, brought about by the existence of som new growth, such as that resulting from cancer o. syphilis. Further, contraction of the cesophagu may be due to the presence of a tumour or othe.i growth pressing upon, and so narrowing it calibre. Or, finally, it may be simply function!) in its nature, giving rise to temporary obstruc tion. known as spasm ( oesophagismus ) and fane tional paralysis of the oesophagus. Symptoms. — Organic stricture of the msopha! gus may have existed for some time before th patient or his medical attendant realises the grn vity of the complaint, because the symptoms dt ! velop themselves only very gradually. Themos noticeable of all is the difficulty in swallowing At first this may be merely occasional, an only perceived when a tolerably large bolus \ attempted to be passed down the gullet ; bn gradually the difficulty increases, and it is no not only confined to the attempt to swallo . solids, however finely masticated, but semi-solic give rise to the same sensation as if the foo never passed a certain point, this point bein usually referred to the manubrium stemi, : the upper or lower portion, wherever the stri ture is situated. If the patient, by dint of gre; resolution and perseverance, overcome the dill culty to such an extent as to swallow son food, the first morsel passed being always tn greatest trial, it may be retained for a time, hi is ultimately rejected. This desire to get r of the food swallowed increases to suchanexter that all aliment is regurgitated, rather thq vomited. The rejected matter consists of tl food, but little altered, largely mixed with m cus, or sometimes with a little blood and pn The reaction is always alkaline. Finally the dy phagia becomes so marked that even theattem to swallow liquids is given up as hopeless. C incident with the advance of this dysphagia do the emaciation progress; the abdomen falls n and the patient dies from starvation. The passa of a bougie will definitely settle any doubt ^ to the existence of an organic stricture, besia affording information as to its site, extent., a: form ; but the operation must not be perform without due cousideration, as it has happen that an unrecognised aneurism has been open by this instrument. Auscultation will also aid (ESOPHAGUS, DISEASES OF. t diagnosis. It ■will reveal the same slowing o', fie passage of the bolus already referred to, a the same elongation of it. In addition, if the fctuve be very narrow, then the food will be h(rd to pass through it with difficulty and with aTeaking sound; while if it be narrower still, p ticiilarly if the food be fluid in its consistence, ■ eddies as it were in a funnel, with a prolonged renant gurgle,’ as described by Allbutt. pasmodic stricture of the oesophagus differs fia the organic form in the suddenness with weh the dysphagia comes on ; its paroxysmal ndre ; its not unfrequently being but one of the nay symptoms of hysteria ; its occurrence in vmg anaemic females, or hypochondriacal men ; a: though dyspepsia may bo complained of, and era prove an exciting cause, still emaciation del not exist. The point where the impediment tc he passage of the food is experienced is ufilly at the upper part of the oesophagus or plrynx. Occasionally pain is complained of oi attempting to swallow, and food taken is scetimes ejected. But the spasm soon yields, a: food finds its way into the stomach. The di.culty in swallowing is much increased by tfc attempt being witnessed by sympathising fr ids, and a stern command to cease from such fr olous efforts often succeeds, to a surprising de'ee, in overcoming the dysphagia. On in- trucing a bougie, it will of course be stopped if e spasm exists at the moment; but gentle, carful, continuous pressure will ultimately cafe the spasm to give way, and thus its true nage will be reveaied. iognosis. — The prognosis in cases of real or nic stricture cannot be otherwise than always gre. If it be due to cancerous growth, then it 11 st necessarily be most unfavourable. Spas- mfc stricture is very hopeful. ieatment. — The treatment appertains more to ie domain of surgery than of medicine. In tli.ase of organic stricture, the frequent passage of mgies of varying size often proves valuable, oxot in the case of cancer, when it should neir he attempted. Diet must be attended to, tli state of the stomach looked to, and dys- pe c indications combated. If food cannot be sw owed a small catheter may be introduced thigh this stricture, and the patient fed by tin stomach-pump ; or nutrient enemata may be ministered. Forthe spasmodic variety, the gefl-al system must be braced, tonics prescribed, ani.he usual anti-liysterical remedies ordered. Morbid Growths. — By far tile most com- mciorm of growth in the oesophagus is cancer. Ociiionally fibroid tumours are seen, either as ch, or as polypi, situated about the level of tluricoid cartilage. When carcinomatous, the grcj.h may be any of the usual varieties of ou r; and it will frequently he found to affect thepper third, more commonly the lower third, 'ok ery rarely the middle of the gullet. It com- mel;s in the submucous tissue, speedily involv- 'ngiie other coats of the tube. From this it nia.xtend to otherorgaus, and perforation of the ,r a ; :a, bronchi, aorta, or pericardium may tako pin v iptoms. — Confining the attention to cancer of I oesophagus, this disease may well be sus- P ec l if, in an individual above middle age, 67 CESTEUS. 1057 gradually increasing dysphagia be complained of ; if symptoms of stricture be pronounced ; if pain be experienced, especially of a lancinating character, about the spine and shoulder-blades ; if nausea and retelling he observed, together with irritating cough, and occasional hiccough ; if the patient continue to emaciate, and present the dirty greenish-yellow complexion common in cancerous cachexia, together with enlargement of lymphatic glands : and most certainly shall wo be confirmed in our diagnosis if, on examina- tion of the vomited matters, cancer-cells be seen. Prognosis. — The prognosis is of the worst description. The patient gradually becomes ex- hausted, and dies of inanition. Treatment. — Treatment can bo merely pal- liative. It consists in relieving the pain by nar- cotics; and endeavouring to sustain the patient’s strength as long as possible. Claud Mcirhead. CESTEUS ( olarpos , a gadfly). — Synon. : Fr. Ocstrc ; Ger. Bremse. — A genus of dipterous in- sects, called gadflies, the larvae of which, vulgarly known as maggots or hots, live parasitically in man and animals. The ordinary human bot, GEstrus hominis, is of rare occurrence in England, but is not unfrequently met with in warm coun- tries, especially in South America. The larva of the gadfly of the ox, (Estrtis bovis, also occasionally attacks man. Dr. J. M. Duncan has recorded an interesting case of the latter kind [Edinburgh Monthly Journal, 1854), and Bracey Clark long previously noticed a similar instance. Cases of GEstrus hominis were either described of noticed by many earlier observers, amongst whom were Linnaeus, Gmelin, Endolpbi, Olivier, Gill, How- ship, and Treherne. The writer is in possession of full particulars of a case forwarded to him. with the parasite, by Mr. Higginson of Liver- pool. It occurred in a boil at the back of the thigh. A third species of human bot, (Estrus guildingii, from Trinidad, is described by Guild- ing ; besides which, nearly a score of other similar cases have been placed on record by various authors who were not able to identify the species. True maggots and other bot-like larvae are continually encountered in medical practice. As a rule, their identification as species can only be determined by skilled entomologists. Some forty years ago Mr. Hope referred the forms then known to upwards of twenty separate genera of insects ( London Medical Gazette , 1837-38). Amongst cases of insect larvae possessing more than ordinary interest we may particularise the following: — 1. Several cases in which the larvae of the coleopterous insect Blaps (B. mortisaga) passed from the stomach and intestines. In Pickell’s celebrated case 1.206 larvae were found, besides several of the full-grown insects, which are popularly known as the churchyard beetle. The writer recorded a case ( British Med. Jour., 1877), from the practice of Dr. Horne, of Barn- sley, where a living larva was passed by an infant. 2. Numerous cases of the larvae of An- ihomyia canalicularis. Several of these have occurred in the writer’s practice. 3. In Hope’s list ( loc . cit.) nine case? of mealworm are given ( Tencbrio molitorX 4. Hie occurrence in the 1058 OESTRUS, human body of the maggots of various species of fly has frequently been noticed ( Musca dornes- tica, M. carnaria, M. sareopkaga, M. vomitoria, &c.). 5. In several instances, the so-called rat- tailed larvae ( Helophilus ) have been passed per axum. One such case was brought under the notice of the writer by Mr. Hoot ; and a more recent instance has occurred in tbo practice of Dr. W. H. S. Westropp, at Lisdoonvarna, Ire- land. The writer identified the parasite in both cases. 6. The late Dr. Livingstone, when in Africa, was attacked in the leg by a small bot- like larva, which Dr. Kirk removed by incision. The specimen was presented to the writer, and is now preserved in the museum of the Royal College of Surgeons ( Catalogue of Entozoa, No. 196). In actual practice it is not uncommon to find the larvae of various species of moths (. Noctuce ), either in the night-stool or chamber- utensil ; these, for the most part, being acciden- tally introduced. In like manner the maggots of various butterflies and other insects, are often passed, having been previously swallowed along with food. Lastly (7), we may refer to the horrible habits of the larvte of the golden fly {Lucilia hominivorax). This insect, according to M. Coquerel, is particularly destructive to the convicts of Cayenne. The larvae, hatched from eggs previously deposited in the mouth and nos- trils of the victim, penetrate and devour the living tissues, after the manner of ordinary maggots in putrid flesh. According to M. Bouyer {Tour du Monde , 1866), the majority of the cases prove incurable. Other species of Lucilia have the habit of attacking the eyes, mouth, and nostrils of toads and frogs, the maggots eating into the tissues of the living batrachians. Dr. McMunn (of Wolverhampton) and the writer have seen instances of this, and have confirmed the observations of Herr Boie, and of M. Girard, M. Moniez, and others. Treatment. — As regards the treatment of intestinal insect-parasites, ordinary purgatives, salines, and vermifuges, especially turpentine, will usually dislodge them ; whilst for those that occur in wounds or ulcers at or near the surface, nothing is better than the application of carbolic acid solution. See Extozoa. T. S. Cobbold. OEYNHATJSEN, or EEHME, in Ger- many. — Gaseous thermal salt waters. See Mineral Waters. OPEN, in Hungary. — Sulphated waters. ' See Mineral Waters. OIDITTM ALBICANS. — A vegetable para- site, associated with aphthae or thrush. See A.PHTH.E. OINOMANIA (oTvos, wine, and pavla., mad- ness). — A synonym for dipsomania.’ See Dipso- mania. OLD AGE, Signs of. See Senility. OLFACTORY NERVE, Morbid Con- ditions of. — Tho principal morbid conditions that occur in connexion with the nerve of smell are the following : — • 1. Olfactory HypersBSthesia. Synon. : Hyperosmia. OLFACTORY NERVE. Definition. — -Increased sensitiveness of thi olfactory nerve. HJtiolooy and Symptoms. — This condition i seen in the increased nervous sensibility whiei results Irom chronic debilitating illnc-ss. I occurs also in hysteria, in which remarkable^ almost animal, acuteness of the sense is some times present, so that not only objects but per sons have been discriminated by this means. I insanity the same condition is sometimes seer It is usually associated with, and lias to ll distinguished from, an altered appreciation c odours, shown in the abnormal enjoyment of y disgust at the odours which are recognised wit natural or preternatural acuteness. Treatment.— The condition rarely calls ft; special treatment. 2. Subjective Sensations of Smell. — Sul jective sensations of smell occur from centr disease, or from irritation of the nerve of sine In the insane olfactory hallucinations occr though less commonly than those of the opt or auditory nerve. Sehlager met with them five cases out of six hundred. In epilepsv sul jective sensations of smell occur as occasior prodromata of fits, and the disease in these cas probably involves the olfactory centre in t] anterior part of the temporo-sphenoidal loli It was so in a case of tumour recorded by Sand Irritation of the nerve, from meningeal dise; or injury, also, in rare cases, causes olfacM hyperaestliesia. Dr. Quain lias recordod an tercsting case of perityphlitis, in which an apv rently subjective sensation of a foul odour v persistently complained of by the patient, ui evacuation of the contents of the abscess, wh the supposed smell completely disappeared. 3. Perversion of tho Sense of Smell- Synon. : Parosmia. — This is a rare condith which occasionally results from irritation of e nerve or central organ. In a case recorded y Legg, some time after an injury to the hi all substances ‘ tasted ’ of gas or paraffine, 1 thero was marked diminution in the acutenes.f the sense of smell. 4. Olfactory Anaesthesia.— Synon. : Ai- mia. Definition. — Loss or diminution of the soe of smell. ■/Etiology. — The causes may be local chans in the organ of smell ; disease of the nerve ir disease of the centre. a. Among local causes may be mentioned ie following: — (1) acute and chronic catarrh ofie olfactory mucous membrane, the latter cauig thickening ; a condition sometimes produced? excessive snuff-taking. (2) Dryness of pe mucous membrane, as in cases of destruction! the external nose (Xotta), or in paralysis olie fifth nerve. (3) Occlusion of the passagin' polypus, preventing the access of air tohe olfactory region. (4) Impaired access of-ir consequent on facial paralysis. The loss oihe power of dilating and keeping expanded he nostril prevents a due quantity of air log drawn through the nasal passage ; and, n'e- over, the loss of power of compressing the i»- tril in ‘sniffing,’ prevents the air being dirted into the olfactory region. (5) Iniare casepss of pigment in the nose, consequent on geM OLFACTORY NERVE, oss of pigment, has appeared the cause of loss f smell. b. Damage to the olfactory nerve may result rom injury or disease. It is not an uncommon fesult of blows or falls upon the head, and it is irobable that in these eases the delicate olfac- ory nerves are torn from the bulb (see Nose, diseases of). The bulb, or tract, may also suffer h adjacent disease, as tumour, abscess, caries f the bone, and meniDgeal changes, especially yphilitic. Spontaneous atrophy of the olfactory nibs occasionally occurs in old age (Prevost), ud has been met with in younger persons in the essential anosmia ’ of Notta. e. In cerebral disease the sense of smell is ometimes lost. It may be impaired in so- tiled functional disease, as in hysteria, and in “generative disease, as paralytic dementia. It 1 occasionally lost in organic disease involving lie roots of the olfactory nerve. Unilateral nosmia has been met with in cases of aphasia dughlings Jackson), an association which is tpkined by the passage of the external root the olfactory nerve past the island of Reil • the anterior part of the temporo-sphenoidal ibe. It is to be remembered that the olfactory rves are sometimes congenitally absent. Symptoms. — The evidence of anosmia is the ss of the perception of odours. This may be Irtial or complete, according to the extent of yolvement of the nerves. It may be lost on .tit sides ; or when due to degenerative changes, . one side only. When clue to organic brain- sease it is lost on the side on which the cerebral ion is situated. Diagnosis. — The diagnosis presents little jhculty. The affection is commonly com- lined of, but often as ‘ loss of taste,’ the uinished perception of jlavotirs being more nous to the patient than the loss of smell, e sensations included under the term ‘ flavour ’ it need hardly bo said, really olfactory and ; gustatory. In examination, care must be 'ten to employ only substances— as aromatic ■i, &c. — which affect the olfactory nerve, and : : acrid substances, as ammonia and acetic acid, ' ich stimulate also the fifth nerve. Prognosis. — The prognosis in anosmia is fourable when due to a local cause, but when '• re is reason to suspect injury or disease of i olfactory nerve or centre, recovery is im- 1 , bable. 'reatment. — -Anosmia, as a symptom, rarely c s for treatment, which should be directed to r cause. Sometimes local stimulation is of t 'ice; and occasionally counter-irritation, by bters to the neck, has appeared to assist re- c tv. In hysterical cases faradisation of the niil mucous membrane has been recommended; the olfactory nerve itself is not accessible toiectrical stimulation. W. R. Gowers. LIG-iEMIA (o\iyos, small, and al pa, blood). I.cieney of the total amount of blood in the See Blood, Morbid Conditions of. MAGHA (&yos, the shoulder, and &ypa, a stiU'e). — Synon.: Fr. Omagre ; Ger. Schulter- 5' ‘ — A name for gout in the shoulder. See ufr. OPHTHALMOSCOPE. 1050 OMENTUM, Diseases of. See Perito- neum, Diseasos cf. ONANISM (Onan). — A synonym for mas- turbation. See Masturbation. ONYCHIA (ijw£, the nail). — An inflamma"- torv affection of the matrix of the nail. See Nails, Diseases of. ONYCHOGK YPHOSIS (orv', the nail, and ■ypuirds, curved). — This term is applied to curva- ture of the nails ; and, more particularly, to the oblique elevation of the nails from their matrix by the accumulation beneath them of crude cell- substance, which forms a kind of wedge, and crumbles away upon desiccation. See Nails, Diseases of. ONYCHOMYCOSIS (Sm(, the nail, and /mvktis, a fungus). — Parasitic disease of the nails. See Epiphytic Skin-diseases ; and Nails, Diseases of. OPHIASIS (oen through the semi-transparent nerve-tissue, he vessels pass over its margin without devia- pn or change of plane. The apparent size and iape of the disc depend much upon the refrac- on of tho eye. As seen in the inverted image, ■ appears comparatively small in a myopic eye, id largo in a hypermetropic; while, in cases of tigmatism, it is distorted into the appearance an oval. In the same way, the refraction pdifies the apparent actual, but not the rela- te calibre of the vessels. In the myopic eye 0 vessels appear of small diameter, and in tho ■ permotropic they appear of large diameter ; that no conclusions about their actual size can drawn until the state of refraction has been ten into account. The fact that the veins are atively larger or smaller than usual, when npared with the arteries, is, of course, not in- duced by refraction, except that, in a hyper- ■tropic eye, such a difference would be more ■ ispicuous than in a myopic, by reason of the re magnified image produced by the optical ■ iditions of the media. i. Circulation. — In a general way, the blood- 1 'rents in the vessels of the retina are continuous tl uninterrupted; but any hindrance to tho < ranee of blood may be attended by pulsa- 1 1 , first in the voins and subsequently in the fbries. Such hindrance may arise- from dis- tered action of the heart, as in cases of insuf- f|;ncy of the aortic valves ; from disease of the Its of the arteries; or from increased resist- ive on the part of the fluids already occupying tj cavity of the eyeball. The venous pulse de- I ds upon an arrest of the outflow through the ys by the pressure of the entering arterial Tent; which, at the acme of the pulse- wave, has force enough to push back the venous current when there is not room enough for both. Hence, in the venous pulse, the vessels empty them- selves in a direction from the centre of the disc towards its periphery, and refill in the opposite direction. The ordinary cause of venous pulse is increased tension or fulness within the eyeball, so that it is among the early symptoms of glau- coma ; but it is also to be seen in a small propor- tion of cases in which no excess of tension is to be discovered either by touch or by symptoms, and in which the eyes appear to be healthy. In the arterial pulse, the resistance to the entrance of blood, or rather the disturbance of the balance between the propulsive and the resisting forces, must be considerable ; and the course of events is that the arterial current can only make its way into the eye at the acme of the pulse-wave, during which the arteries fill from the periphery of the disc to the centre, to collapse again as soon as the impulse of the Systole diminishes. In such a condition, the impediment to the en- trance of arterial blood is sufficient to imperil the nutrition of the nerve-tissue ; and the writer has seenat least one case of partial nerve-atrophy, attended with arterial pulsation, for which no other cause than excessive arterial tension could be assigned. Arterial pulse is probably always present in advanced stages of glaucoma, but by the time it is produced the fuudus is usually ob- scured or rendered invisible by other changes. Apart from glaucoma, its most frequent cause is aortic regurgitation ; and in this form the eye does not suffer, except together with other parts of the organism. 7. Optic Neuritis and Atrophy . — The morbid appearances seen with the ophthalmoscope, and interesting to the physician, are chiefly those which point to the existence of some diathesis, or to the presence-of disease in other organs. Swell- ing of the infra-ocular extremity of the optic nerve, with obliteration of its margins and ob- struction to its vessels, occurs in many forms of intracranial disease, especially in connection with intracranial tumour, and is often followed by atro- phy and blindness when life is sufficiently pro- longed. The most interesting characteristic of these cases is that, since the swelling affects only the connective-tissue layer, which is absent over the region of the yellow spot, there is commonly no diminution of the acuteness of central vision until the atrophic changes have commenced ; by which time, in many instances, the primary swelling has passed away. Hence, for many years, there existed great uncertainty about the cause of the atrophy, and this uncertainty was only removed when physicians began to examine the fundus oeuli in all cerebral cases, without regard to the state of sight. Prior to that time, the intra-ocular changes were apt to remain undiscovered in their primary stage, and until commencing impair- ment of vision produced resort to an ophthal- mologist, followed by an ophthalmoscopic exa- mination in due course ; and then the atrophy was often attributed to many fanciful causes, among which the smoking of tobacco held a pro- minent place. It is not necessary to assume that tobacco is never injurious to the optic nerves, in order to be quite sure that the ma- jority of the instances of atrophy once attributed 10C4 OPHTHALMOSCOPE, to its influence were, in reality, due to a totally different cause. The changes associated with intracranial diseases will be found described in a special article. See Ophthalmoscope in Medicine. 8. ‘Albuminuric Retinitis .’ — Very frequently i n albuminuria, and occasionally in diabetes mel- litus, the fundus of the eye becomes studded over with spots or patches of a glistening white colour, which are probably due to fatty degeneration of the connective tissue of the retina, and which are often associated with scattered haemorrhages. The blood, in these instances, is usually effused into the fibre-layer, and, following the course of the fibres, becomes spread out into somewhat striated spots, with brush-like terminations. Every case in which either the white patches or the haemorrhages, or both, are detected by the ophthalmoscope, whether with or without im- pairment of sight, calls for a careful examination of the urine, and renders it proper to follow mainly the indications of treatment which such an examination may afford. 9. Haemorrhages . — Without the white patches, haemorrhages may occur in the retina under various conditions. Sometimes they are distinctly arterial, in which case they are generally small in absolute amount, and may often be traced to some manifest point of rupture in the vessel from which they have occurred. These haemorrhages seldom produce extreme impairment of vision, although they are usually discovered on account of some degree of impairment ; and their chief i niportance is derived from the warning they may give of a state of brittleness of the arteries, and of a con- sequent liability to similar bleedings elsewhere, as in the- brain. They call for all the precautions which such a state would suggest, as for the con- sumption of a diminished quantity of fluid, and for the avoidance of constipation and of all violent bodily efforts. Haemorrhages which are distinctly venous occur not unfrequently in connection with the dis- turbances of circulation which are incidental to the cessation of the menstrual function, or to the irregularities by which cessation is preceded. The blood may proceed from comparatively large veins, in which case it often forms a layer im- mediately beneath the membrana limitans of the retina, causing great temporary impairment of sight, or even total blindness ; and yet, in many cases, being quickly absorbed without permanent injury. In other instances it may proceed from smaller and deeper-lying veinlets, in which case che effusion will usually be situated in the fibre- layer, and will be moulded, so to speak, by the fibres, into what have been described as 1 flame- shaped’ haemorrhages. These are generally multiple, and usually cause an impairment of function, which is decided although not total, and is often permanent. The flame-shaped haemorrhages are said by Mr. Hutchinson to occur preferably in persons of gouty diathesis, and he holds the same doctrine with regard to a less common form, of which some remarkable examples have been observed by himself, and by Mr. Bales of Birmingham. In these cases, tho subjects were young males, of constipated habit, and in many instances of gouty family history, rfco bleedings were large in amount, so as to OPHTHALMOSCOPE IX MEDICINE. penetrate into the vitreous body and to cause fc a time total loss of sight, and were frequent! recurrent. To what extent they were due t deficient plasticity of the blood, to abnorm; friability of the vessels, to variations in vast motor tension, or to the withdrawal of extern: support from the vessels by diminished tensio 1 within the eyeball itself, is at present a matti of conjecture. It is obvious that the treatment, such cases, and.of retinal haemorrhages general! must resolve itself into that of the consfin tional conditions with which they are associate! The only special indications, as regards the eyl will be the enforcement of functional rest, ar'- the maintenance cf an elevated position of tl head during sleep. In cases connected with til cessation of the menstrual function, the absor tion of the effused blood often appears to be pr moted by the careful administration of iodic of potassium, which should usually be combine with ammouio-citrate of iron, or with some oth 1 suitable, tonic, and care should always be tab to maintain a moderately relaxed condition of tl bowels. Even apart from the injurious effec likely to be produced by straining, constipa:;. appears to predispose to haemorrhage. 10. Embolism of the Central Artery. — Sudd, loss of vision is sometimes occasioned by fi plugging of the central retinal artery by : embolus. This is especially to be suspected • cases of known valvular disease of the hea: and the condition is readily recognisable with i ophthalmoscope. The retinal veins are usna somewhat dilated, but their contained blood broken up into irregular portions, in which . uncertain or wavering movement may sometin! be detected. The arteries are either obliterat or so dwindled as to be scarcely visible. I connective tissue of the retina rapidly becon cloudy and opaque, so that the general surf of the fundus is milk} - or opalescent; but in fi region of the yellow spot, where there is lit) or no connective tissue, this opacity cannot? produced, and the red colour of the chor. shines through, producing the effect of a cher- red spot on a white ground. After a few wen the retina regains its transparency, but the op- nerve Dasses into a state of absolute atrophy. E. Bbcdenell Caeteb OPHTHALMOSCOPE IN MEDICIK. In a large number of diseases which come un: the care of the physician — diseases of the nervs system, kidneys, blood, and other structure - intra-ocular changes occur, and may be obser* with the ophthalmoscope. Hence this inst- ment is highly useful to the physician. By s aid we can observe, magnified about twev diameters, the termination of an artery, ofa v(. and of a nerve ; a peculiar vascular struets (the choroid) ; and a peculiar nervous structe (the retina). Nowhere else are nerve and V sels exposed to direct observation. Many chans affecting these, tissues throughout the body r. v be first and best detected here, and in snin renal disease associated with albuminuric :initis. In the latter they indicate vascular >ease, but not necessarily that a cerebral lesion haemorrhagic, since they are often associated th softening of the brain. In softening from embolism, retinal embolism ji'.y be, in rare cases, associated. In ulcerative pocarditis septic haemorrhages may be seen in P retina. Consecutive changes are, as a rule, sent; occasionally slight optic neuritis is de- :oped. In softening from arterial thrombosis, when is is due to atheroma of the vessels, associated tinges (haemorrhages, or renal retinitis) may found in the retina, but there are usually no > isecutive changes. The latter are also absent thrombosis from syphilitic disease of arteries ; associated changes — the various ophthalmo- pic manifestations of syphilis — are common, : 1 are often of the highest diagnostic impor- l ce. n abscess of the brain, optic neuritis occurs ; a considerable number of cases, although not ill. It has no known relation to the position ! the abscess, but is perhaps most frequent in 1065 the cases in which the abscess results from an injury. Tumours of ihe brain .— Associated changes are very rare, and are confined to the cases in which a similar growth (glioma or tubercle) exists within the eye. Consecutive changes are more common than in any other cerebral affection. Optic neuritis occurs in about four-fifths of the cases. On what its occurrence or absence de- pends we do not know. Neither position, size, nor nature of growth seems to influence it in any considerable degree. It does not depend on in- crease of intracranial pressure. In some cases it is at least aided by the occurrence of menin- gitis. In many eases a slight descending inflam- mation maybe traced from the optic tracts down the nerves to the eyes, and this, at the papilla, seems to excite a more intense degree, perhaps aided by mechanical congestion or oedema of the sheath. The latter is commonly found after death, but probably does not constitute the chief mechanism by which neuritis is produced. A tumour may exist for a long time without neuritis, or the neuritis may be present as soon as the symptoms of tumour manifest themselves. Often the neuritis and the tumour correspond in their course, each being acute or chronic. Both may even be almost stationary for years. An acute neuritis, occurring during the. course of a tumour which appeared chronic, usually indi- cates an increase in the growth, aud is of bad prognostic significance. The degree of neuritis varies ; it is least in the tumours of most chronic course, and greatest in the rapid growths. It is often accompanied by hsemorrhages. Com- monly bilateral, it is in rare cases unilateral, and is then usually in the eye opposite to the seat of the tumour. It may exist in consider- able degree without impairing sight. Perception of colour may be affected before acuity of vision. If the tumour be arrested by treatment, as in syphilitic and tubercular growths, the neuritis will subside, but too often, before this result is obtained, sight has been damaged beyond re- covery. Simple atrophy of the optic nerves sometimes results from tumours, although far less commonly than ‘ consecutive atrophy.’ Intra-cranial aneurisms are rarely accompanied by intra-ocular changes. Now aud then, an aneu- rism of the internal carotid has caused atrophy by pressure, and even optic neuritis, single or double. Internal hydrocephalus is usually accompanied by no other ophthalmoscopic changes than slight fulness of the veins. Occasionally simple atrophy occurs, commonly from the pressure of the distended third ventricle on the optic chiasma. Meninges .— Growths in the meninges lead to optic neuritis, just as do tumours in the cerebral substance. The effect of meningitis varies according to its form and seat. Simple meningitis of the convexity is rarely attended by ocular changes. It is very different with basilar tuber- cular meningitis. Occasionally, though rarely, tubercles of the choroid may be seen. In a con- siderable number of cases there is distinct neuri- tis ; it is well-marked in at least half. Usually too late to be of diagnostic importance, it is now and then sufficiently early to decide th« OPHTHALMOSCOPE IN MEDICINE. 1066 nature of the case. A similar change is common in both syphilitic and traumatic meningitis, hut is very rare in the epidemic cerehro-spinal form. Diseases of the cranial bones. — Caries of the sphenoid hone may cause descending neuritis ; caries elsewhere usttally only affects the eye by causing meningitis or abscess. Thickening of the cranial hones may he attended by well- marked, sometimes intense, neuritis, with haemor- rhages. This is apparently produced by the resulting constriction of the nerve and sheath at the optic foramen. Inflammatory mischief, or growths in the orbit, frequently cause neuritis or atrophy, the optic nerve-trunk being damaged directly. In these cases the affection is unilate- ral, at least for a long time, and is often accom- panied by prominence of the eyeball, and tender- ness when it is pushed back. Injuries to the head may affect the eye in various ways. (1) The retina may suffer in consequence of the immediate concussion. (2) Optic neuritis may come on after a few days, commonly as the result of a traumatic meningitis. (3) Direct injury to the optic nerves may cause loss of sight and simple atrophy. (4) Optic neuritis may come on some weeks after the in- jury, and is usually due to inflammatory pro- cesses in the damaged brain. 2. Spinal cord -Acute myelitis and spinal me- ningitis are very rarely attended by eye-changes. In one or two cases coincident optic neuritis has been observed. The connection between the two is obscure. Sclerosis of the posterior columns (loco- motor ataxy) is accompanied by atrophy of the optic nerves in a considerable number of cases, al- though not perhaps in more than fifteen per cent. When it does occur it is frequently an early rather than a late symptom. It is always the simple form of atrophy, often grey with unnarrowed vessels. Sight usually suffers gravely ; the field of vision is much restricted; and perception of colours may be lost. The atrophy is not the re- sult of any extension upwards of the disease in the ' posterior columns. It may occur when this has scarcely commenced, and even years before the earliest symptoms. It is apparently an associated degeneration. In lateral sclerosis ocular changes are doubtful. In disseminated, sclerosis, optic nerve-atrophy may occur, just as in posterior sclerosis, hut less frequently. Damage to sight, without opthalnroscopic changes, occasionally re- sults from the sclerosis invading the optic com- missure or nerves. In caries of the spine changes in the optic disc are practically unknown. In very rare cases of injury to the spine, neuritis and subsequent atrophy have been observed, but these results are so rare that their precise significance is doubtful. 3. Functional Diseases. — In exophthalmic goitre the only ophthalmoscopic change is in- creased size of the retinal arteries, which may pulsate visibly. In chorea, embolism of the central artery of the retina has been once or twice observed ; and so also has optic neuritis, slight in degree. As a rule, however, the fundus is normal. With neuralgia of the fifth, optic nerve atrophy has been observed ; the nature of the association is doubtful. In idiopathic epilepsy the appearance of the fundus is, as a rule, perfectly normal. Even during an attack it is probable that the only change is venom distension during the stage of cyanosis. Bnl during the status epilepticus, when attack: recur with great severity for several days, a con dition of slight neuritis may be produced, sub ' siding after the attacks are over. In cases c I convulsions from organic brain-disease, it mus he remembered, optic neuritis or its effects ar often met with. The frequency with whid| morbid appearances are to he seen in the eye if insanity has been variously stated, and by som writers unquestionably exaggerated. They ar most frequent in general paralysis of the insane Optic-nerve atrophy is the usual change, and i sometimes an early event, just as in locomotc! ataxy. In very rare cases slight neuritis ha been seen. In mania, melancholia, and dementi it is probable that there are no related morbi appearances in the eye. II. Diseases affectin'} the Umnae System 1. Bright’s Disease. — Sight may he impaire in this complaint by uraemic poisoning, or b retinal changes. The latter may occur, even i considerable degree, without any affection cj vision. The arteries may occasionally be eoi spicuously narrow (contracted), and in rail cases may present sclerosis of the outer coat, c minute aneurisms. Aneurismal dilatations c the capillaries may often he found post morten in association with other degenerations, and pre bablv lead to the occurrence of a very commc change in the retina — haemorrhages. These a>, usually striated, situated in the nerve-fibre lave sometimes they are irregular in shape, ar situated in the deeper layers. They may detac the retina from the choroid, or hurst through in the vitreous. Sometimes they exist alone ; mo commonly they are conjoined with other change to which the term ‘albuminuric retinitis ’ is give This latter change may occur in all forms renal disease, hut is by far the most common the granular kidney. It is alato symptom, nev appearing until the general system is sufferiD The disease of the retina presents certain elemen which are variously combined ia different cast 1. Diffuse slight opacity and swelling of t retina, due to the infiltration of its substance an albuminous coagulable liquid (oedema). White spots and patches of various size a distribution ; some large and soft-edged ; othc minute, and of pearly whiteness. They are d to fatty degeneration of the retinal elemenj or to granular degeneration of albumino exudations. The small white spots often radia around the macula lutea. 3. Hoemorrhag; 4. Inflammation of the optic papilla — ‘ nenrit. 5. The subsidence of the inflammatory chans may be attended with the signs of atrophy the optic nerve and retina. According to t predominant character, four types of retii affection may be distinguished : a degenerati , haemorrhagic, inflammatory, and neuritic for In the first the white spots predominate, a there are usually extravasations, hut there* little diffuse opacity. In the second t haemorrhages are so abundant as to be 1* chief feature. In the third there is much c- fuse opacity and swelling of the retina. In a fourth the optic neuritis is in excess of the otr I OPHTHALMOSCOPE IN MEDICINE. dianges, and the appearance may easily he as- cribed to cerebral disease — the more so that it s often conjoined with headache, and other vidence of cerebral disorder. The conspicuous 'ombination of white spots and hcemorrhages Isually enables the retinal affection of all'u- ninuria to be recognised without difficulty. It nay be confounded with the degeneration left |y a previous wide neuro-retinitis, but in such ases the signs of atrophy will be conspicuous. The course of the affection in Bright’s disease is iften progressive, but arrest and even recovery hay be obtained by the treatment of the renal dsease. When extensive, sight is usually im- paired, but is rarely completely lost. 2. Diabetes.— In diabetes, in rare cases, re- inal changes have been observed exactly similar 0 those of the degenerative form of the albumi- .uric affection, and this when there was no albu- nen in the urine. Miliary aneurisms have been ound post mortem,. A distinction from the renal orm is the frequency with which there are opa- ities in the vitreous, due probably to slight ex- ravasations of blood. HI. Diseases of the Heart. — The peculiar ;onditions of the intra-ocular circulation prevent oy dynamical changes in the circulation, fenous distension, if considerable, may be isible in the eye, especially in cyanosis. When rterial pulsation is strong it may be visible in he retinal arteries, as in exophthalmic goitre nd in aortic regurgitation. In these cases also he arterial pulsation may (probably in the Heretic ring) be communicated to the vein, and iiis also may pulsate. Embolism of the central rtery of the retina may occur, and, like embo- sm elsewhere, is most common in mitral con- triction. In ulcerative endocarditis, aceom- anied with multiple embolism, retinal hsemor- hages occur, for the most part round, with a ale or white centre. They are almost pathog- ;omonic. IV. Diseases of the Blood. — Acute ancsmia i’om haemorrhage may bo followed by loss jf sight, slight or considerable, transient or ennanent. The accident most commonly' follows aematemesis, uterine haemorrhage, or venesec- on. In some cases no ophthalmoscopic changes Jive been fouud ; in others there has been neuro- litinitis. The mechanism of the affection is ob- jure. Simple chronic anaemia is accompanied f marked pallor of the veins, sometimes of the uoroid and disc, but the latter is always within ae physiological variations in tint. Occasionally chlorosis optic neuritis is met with, disappear- 1 g rapidly under iron. In pernicious ancemia the jioroid is notably pale, the arteries small, the jiins very broad (atonic) and pale. Hsemor- puges are frequent, especially around the optic |sc, and they are often associated with white Ltches. Some extravasations are rounded, with white or pale centre. Occasionally there is ,arked neuritis. In leucocythcemia. the pallor >d width of the veins are very striking. Extra- ctions are almost invariable at some period : bite spots are frequent, some degenerative, hers due to aggregations of leucocytes. Some e surrounded by a halo of extravasation. There ay also be considerable general swelling of the tina, throwing the distended veins into con- 1067 spicnous antero-posterior curves. In purpura and scurvy retinal haemorrhages also occur. In the intense forms of purpura, indeed, they are probably constant. In rare cases of menstrual disorders, and still rarer instances of intestinal disturbance (chronic diarrhoea) optic neuritis has been observed. Suppression of the menses has been followed by retinal haemorrhages. The connection between the several events is obscure. V. Chronic General Diseases. — In chronic general diseases ophthalmoscopic changes are met with occasionally. In tuberculosis, tubercles may form in the choroid, and bo recognisable as small, round, yellowish-white spots, free from pigment. They have more frequently been found in this situation after death than during life, perhaps be- cause not looked for with sufficient perseverance, since they may form rapidly. In syphilis ocular changes are, as is well known, common, but they come chiefly underthe care of the surgeon. Traces of past iritis, or of choroiditis — areas of choroi- dal atrophy with irregular accumulation of pig- ment, frequently afford the physician important evidence of the previous existence of syphilis, acquired or inherited. In the latter the cho- roidal changes are of especial importance, and may be confined to small round white spots with pigment in the centre, or there may be evidence of more extensive choroiditis or merely of eho- roiditic atrophy, a yellowish disc, with the edge a little blurred, and very small retinal vessels. Gout has been supposed to cause retinal haemor- rhage (Hutchinson), but its connection with oph- thalmoscopic change (except through the me- dium of kidney-disease) is not well-established. In lead-poisoning, besides the amblyopia which may come on without ophthalmoscopic changes, atrophy of the disc is occasionally met with, pre- ceded, in some cases, by a stage of congestion, a red disc, with softened edges, without swelling. A considerable degree of neuritis, double, with swelling and haemorrhages, occurs occasionally, especially in connection with cerebral symptoms,, but without any coarse lesion of the brain. In chronic alcoholism, optic-nerve atrophy has been described, and also a condition of congestion. The amblyopia w'hich accompanies the atrophy is said by Eorster to be characterised by loss of central vision for colour. The same fact is well established with regard to tobacco amaurosis, in which similar congestion and atrophy may occur. YI. Acute General Diseases. — In acute general diseases, changes in the fundus arc for the most part rare. After typhus, typhoid, and scarlet fevers, optic neuritis has been occasionally observed, apart from any renal or cerebral com- plication. The kidney sequelae of scarlet fever may of course lead to the special retinal changes. Malarial fevers, ague, &c., are frequently attended with retinal haemorrhages (Poncet, S. Mackenzie). Sometimes the extravasations have paler centres. Optic neuritis and atrophy have also been ob- served. Erysipelas of the face has been accom- panied by loss of sight, and foEowed by atrophy, probably by the extension of the inflammation to the orbit, and to the trunk of the optic nerve. Pycemia anisepticamia have long been known t-c be occasionally accompanied by metastatic pan- ophthalmitis, and recent observation has shown 1068 OPHTHALMOSCOPE IN MEDICINE, that slighter alterations in the fundus oculi fre- quently accompany the severer forms of these affections. Of these the most important are retinal haemorrhages, round or irregular, some- times large, and often with pale centres. It is probable that they are in some cases due to septic embolism, but they may occur without en- docarditis, and are probably due, in some cases, to chemical changes in the blood. They are al- most invariable in puerperal septictemlo, (Litton), and are also found in other forms of ulcerative endocarditis. Usually, they occur only a few days before death. In other cases a peculiar form of retinitis has been observed, with white spots about the papilla and macula lutea (Roth). Most of the appearances mentioned above will be found figured in the writer’s Manual and Atlas of Medical Ophthalmoscopy. W. R. Gowers. OPISTHOTONOS (u7r«r0ej/, backwards, and tovos, a stretching). — A tetanic spasm, in which tho body is arched backwards, so that it rests on the head and heels. See Tetantjs. OPIUM, Poisoning by. — In consequence of the extent to which opium and its preparations, including morphia, are used for the relief of pain, and the readiness with which the drug is procurable, poisoning by opium is of frequent occurrence ; and there is no doubt that great numbers of infants perish every year in this country through the improper use of quack remedies containing opium. So far as toxicology is concerned, the effects of opium may be referred exclusively to morphia; since the effects of the other active constituents of the drug are overshadowed by those of the chief alkaloid. Anatomical Characters. — The post-mortem appearances after opium-poisoning may be al- most nil. As a rule the brain is congested, the puncta omenta being especially marked; and the lungs and right side of the heart may exhibit an engorgement, as if from a modified asphyxia ; but, this condition is by no means invariable. Symptoms. — The first effect of the administra- tion of a toxic dose of opium — a stato of bien- faisance or exaltation— commonly observed also after the administration of a medicinal dose, may be either very short or entirely wanting ; and this is commonly the case when morphia is injected hypodermically. A second stage, in which the symptoms closely resemble those of congestion of the brain, soon sets in. The face is either suffused or cyanosed; the pupils strongly contracted; the skin dry and warm; the breath- ing slow, deep, and becoming stertorous. The patient is apparently unconscious, but may be aroused by shaking, or shouting in the ear ; and when he is aroused, the respirations become more rapid, and the skin may regain its normal colour. The symptoms of this secondstage may gradually ameliorate under appropriate treat- ment ; or a third stage— that of prostration— supervenes. The coma is now profound, and it may bo impossible to arouse the patient. . The pupils are contracted to tho size of pin-points ; or towards the termination of life may be widely dilated. Respiration is now' very slow, shal- low, with gradually increasing intervals, during OPIUM, POISONING BY. which there are no signs of breathing, and ti patient lies in a death-like calm. The face ij at once pallid and cyanosed; the skin is hatha in perspiration, at first warm, and then cold an' clammy. The pulse increases in rapidity, wit) progressively increasing feebleness. The patien may even now recover, signs of life returnini very gradually ; or death may occur from failur of respiration, the other functions of life bccoin ing also gradually extinguished. Unusual symptoms in opium-poisoning are trie mus and convulsions. In children toxic dose may produce very rapid effects, the second stag of the intoxication being wanting, and sever 1 collapse and complete unconsciousness rapid!; supervening. Diagnosis. — The certain diagnosis of opium poisoning is often a matter of great difficulty, a: the symptoms may differ in no material respec from those exhibited in congestion of the brain however produced, apoplexy, and ursemia. Th' case may also be confounded with profound alcd holic intoxication. It may also be difficult c impossible to diagnose from poisoning by ehlcrr hydrate — a matter of less importance, since th treatment of the two cases would be simila: The differential diagnosis of opium-poisonin rests upon the equally and minutely contracte’ state of the pupils, a condition which is all by universal in the second stage of opium- poisoning our ability to arouse the patient temporarih 1 the rousing being followed by more or lesj complete disappearance of the cyanosis of th countenance, and by increased rapidity of re spiration ; and the profuse warm or clamra perspiration. An examination of the urine ft; albumin, which may have to be drawn off bytl catheter, should always be made ; but it must! borne in mind that urtemia and opium-poisonin may bo co-existent. Prognosis. — This is at all times doubtfn There is great liability to relapse, even whentn patient appears to be doing well. Treatment. — First, evacuate the stomach n means of the stomach-pump, or failing this, b the use of emetics. These, however, act wit difficulty in cases of opium-poisoning; andthei is a special danger in the use of depressin emetics, as, for example, tartar emetic, on a- count of the possible retention by the stomac of a fatal dose of the emetic. AVarm mustai and water, and carbonate of ammonia are tl best emetics to administer. Secondly, the p; tient must be prevented lapsing into a state • somnolence by walking him about ; alterna warm and cold applications to the chest ; flicJdi the feet with a damp towel ; shouting into tl ear ; and the application of the faradic curret These means will have the additional advanta^ of maintaining the flagging respiration, and r storing normal breathing. In the last resoi artificial respiration must be freely employe The absorption of the alkaloids of opium m; be delayed by the freeadministrationot soluiioi containing tannin, so as to render the alkalot insoluble ; and among the best media contains tannin are strong infusions of tea and cofit The caffein which these infusions contain, its< also exerts a powerful remedial influence in tl form of intoxication. Atropin, as a respirsto OPPRESSION. imulant, appears also to be serviceable as a jrect antidote to morphia. It is best given by bcutaneous injection, in doses of Ath grain, lcoholic stimulants should be freely given. Thomas Stevenson. OPPRESSION. — A term applied to a sense weight in any part of the body, but more equently used in connection with the chest, he expression is sometimes also employed in ferenee to a general feeling of the system being rer-loadcd or over-weighted, which is felt at e commencement of certain acute diseases. OPTIC NERVE and TRACT, Diseases , — The optic nerve may be damaged by various tra-ocular processes ; but these, and also its irnary atrophy, have been already described is Eve and its Appendages, Diseases of ; ■hthalmoscope ; and Ophthalmoscope in edicine). In this article only those affections iiich are situated behind and independent of e eye will be described. Passing from the orbit into the intracranial jrity by the optic foramina, into which they jsely fit, the optic nerves are connected at the iasma, where an approximate semi-decussation tos place. In spite of recent assertions of isiadecki and others, the existence of the mi-decussation is quite beyond doubt. From p ehiasma each optic tract, containing fibres >m the corresponding halves of both retinae, sses backwards, between the crus cerebri and e inner edge of the temporo-sphcnoidal lobe, the posterior portion of the optic thalamus, here it becomes connected with the corpora niculata. Fibres pass thence in three direc- fns, namely: — (a) to the posterior extremity ilvinar) of the optic thalamus ; ( b ) to the cor- ra quadrigemina, especially the anterior ; and ( to the convolutions (occipital lobe and angu- i gyrus). Experiments on monkeys (Ferrier) ■ nonstrate that these convolutions are con- ned in vision. Ktiology. — In the orbit the nerve may he ■jnaged by inflammation ; such as orbital cellu- . 3, arising by the extension of facial erysipelas, 1 produced by exposure to cold. The inflam- ition rarely invades the nerve, on account of the ickness of the sheath which invests it, but 1 : nerve is damaged by the pressure of the in- nmatory products. It may also be compressed an aneurism of the ophthalmic artery or by d'ital tumours; or may be itself the seat of t riad growths or of hemorrhage. At the optic 1 amen the nerve may be compressed by a nar- rting of the foramen, such as occurs in thicken- ii of the cranial bones, an occasional consequence (jiyphilis, acquired and congenital. Within the t’dl, the nerve in front of the ehiasma may be imaged by the extension of inflammation from l meninges. The optic commissure is oeca- sially involved in growths, and may he com- Jssed by growths in, or great distension of, • third ventricle. The nerves in front of the ijasma, and the ehiasma itself, are liable to be 1 aaged by the pressure of aneurisms of adja- * t arteries. The optic tracts may be involved ’ hemorrhage into, or softening of, the crura < ibri ; but the most frequent cause of their 1 aage is a tumour arising at the base of the ° 1 OPTIC NERVE AND TRACT. 1069 brain, or in the adjacent part of the temporo- sphenoidal lobe. The central connections of the optic nerves, the corpora geniculata, optic thala- mus, white substance outside it, and convolu- tions, may be damaged by tumour, softening, or haemorrhage. The corpora quadrigemina are rarely affected, so as to cause ocular symptoms, except by growths. Symptoms. — Damage to the optic nerve, be- tween the optic commissure and the eye, is evi- denced by affection of sight in that eye only. There may be either a concentric or sector defect in the field, or complete blindness ; the reflex action of the pupil is impaired. When the nerve is slowly compressed, the loss of sight is fol- lowed by slow atrophy of the intra-ocular ex- tremity. When it is invaded by inflammation, this usually descends to the eye, and is visible as intra-ocular neuritis, and may ascend to the com- missure, so that the sight of the other eye may subsequently suffer. Inflammation at the back of the orbit usually also involves the motor nerves, and so may cause paralysis of all the ocular muscles. These recover, however, much more readily than does the optic nerve. When the nerve is compressed by narrowing of the optic foramen, the loss of sight is usually accom- panied, sometimes preceded, by intra-ocular neuritis. This is also present in most cases in which inflammation extends from the meninges to the intra-ocular part of the optic nerves, the optic ehiasma, and even in extension to the optic tract. Damage to the ehiasma usually affects the sight of both eyes. In most cases the decussating fibres suffer chiefly or alone, and consequently there is loss of function of the inner half of each retina, and loss of the outer half of each field of vision — temporal hemiopia or hemianopsia. Damage to the outer part of the commissure on each side affects the fibres which do not decus- sate, and so causes loss of function of tlic outer half of each retina, and so loss of the inner half of each field — nasal liemiopia. This is very rare, but has been seen from disease of arterial trunks on each side (Knapp). In irregular damage to the ehiasma the loss of vision may be irregularly distributed in the two eyes. The optic tract receives fibres from the half of each retina on the same side, and its damage thus causes loss of sight in the opposite half of each field of vision — lateral hemiopia or hemian- opsia. The area affected is often rather more extensive in the eye on the side opposite to the lesion than in the eye on the same side. Since the motor tract, in the adjacent crus cerebri and hemisphere, has decussated at the medulla, if it is also involved in the lesion, there is hemi- plegia on the same side as the loss in the field of vision. The patient is unable to see to the side on which he cannot move the limbs. Thus the writer has recorded a case in which a patient had, first, right hemiopia, and afterwards right hemiplegia. Both were due to a small tumour of the inner part of the temporo-sphenoidal lobe, which had first invaded the optic tract and then the crus. Disease of the corpora geniculata also causes hemiopia. Regarding the effect of lesions of the fibres which extend from the corpora geniculata to 1070 OPTIC NERVE AND TRACT, the posterior part of the optie thalamus and to the convolutions, there is some difference of opinion. It has, until lately, been held, -with Von Graefe, that lesions of the convolutions to which these fibres proceed, or of the fibres them- selves, cause hemiopia, just as does a lesion of the optic tract. But Charcot has called atten- tion to the fact that hysterical hemianaesthesia, believed to be due to a disturbance of the sen- sory function of one hemisphere, is commonly associated, not with hemiopia, but with ‘crossed amblyopia,’ that is, with partial loss of sight of the eye on the anaesthetic side, diminished acuity of vision, restricted field, and the fields for colour- vision are also lessened. These fields vary normally, in extent, for the several colours, and some or all may be so lessened as to cause partial or complete colour-blindness. Similar crossed amblyopia has also been observed as a consequence of organic lesions causing hemian- aesthesia, and therefore probably involving the fibres of the posterior part of the internal cap- sule, outside the optic thalamus. Hence Charcot has put forward the hypothesis that the fibres which pass from the optic tract to the corpora quadrigemina are those which ha ve not decussated at the chiasma, and that in the corpora quad- rigemina a complementary decussation takes place, the fibres passing to the other side and there joining the fibres which decussated at the chiasma, so that the convolutions of each hemi- sphere receive the fibres, not from one half of each retina, but from the whole of the retina on the opposite side, and so the association of crossed amblyopia with hemianaesthesia is in- telligible. Hemiopia, Charcot believes, is always due to damage to the optic tract, and diseases of the hemisphere which cause hemiopia only do so by pressure on the optic tract. The facts avail- able as evidence on this question are not very numerous, but they are decidedly opposed to Charcot’s theory. Clinically, hemiopia is not unfrequently met with in association with hemi- plegia, hemianaesthesia, and occasionally with aphasia, in cases in which there is no reason to believe that there is more than one lesion, or that it is situated elseu'here than in the hemi- sphere. Such clinical evidence alone is of little weight, but it derives significance from a few reliable pathological facts, in which a lesion near the surface of the brain, such as a haemorrhage, the size of a walnut, beneath the occipital convo- lutions (Baumgarten) has caused hemiopia. The symptom has been due to tumours in this situa- tion in many recorded cases, and in one which has come under the writer’s notice. These facts make it probable that when crossed amblyopia results from a unilateral cerebral lesion, the effect is due to a reflex rather than to a direct influence. The direct effect cf a unilateral cere- bral lesion is to cause hemiopia. The same symp- tom may also result from a lesion of the posterior part of the optic thalamus. Charcot suggests that this always results from tumour or haemor- rhage in this situation, which has compressed thelract. But no case exists which affords sup- port to the opinion that the pressure of an adja- cent haemorrhage on the ‘ optic tract could cause hemiopia, and two cases have come under the writer's notice — one in a patientof Dr. Hughlings ORBIT, DISEASES OF. Jackson, who has published the case— in whici hemiopia resulted from a simple softening o the pulvinar. Disease of the corpora quadrigemina hag use ally caused complete loss of sight in both eyes hut in almost all cases the lesion has been tumour, which may have compressed the adja | cent corpora genieulata, or caused optic neal ritis. If Charcot’s theory were correct, a lesioJ here should cause nasal hemiopia, hut such a: effect has never been observed. Diagnosis. — The chief points which are ou; guides in determining the position of post-oculal disease, causing loss of sight, have been ahead stated. If the affection of sight is confined t one eye, it is probably — and, if associated wit unilateral optic neuritis, it is almost certainly-' due to disease of the nerve in front of the chias ma. In this case the reaction of the pupil t light is impaired. On the other hand, if th unilateral affection of sight is associated wit hemiplegia, and especially with hemianaesthesia on the same side, it is probable that the diseas is in the hemisphere, and the failure of sigh: i produced in some manner at present unknown In this case the pupil often acts well to light Lateral, homologous, hemiopia indicates diseas ; of the tract, posterior part of the thalamus, c! white substance between the thalamus and th] occipital and angular convolutions, or of thesj convolutions themselves. In which of thes! positions it is must he determined by the ind. cations of the localisation of disease of the brail ( see Convolutions of the Brain and Cobte Cerebri, Lesions of). Nasal or temporal hem] opia indicates disease of the optic chiasma. Prognosis. — This must be influenced byt! position of the disease, and by its nature. IVhtj there is simple pressure on the optic nerve, suft cient to abolish sight, the prognosis is very ui favourable. Damage by the extension of i: flammation often lessens considerably. In diseas of the optic commissure or optic tracts theproe nosis is also grave, because the morbid processc from which these parts suffer, rarely recede. G the other hand, in disease of the hemispher! considerable improvement often takes place, juj as it does in other symptoms. Often, howevel the symptom is thought to have disappears when it still persists in a diminished degree. Treatment. — The treatment is essential that of the disease to which the symptom due, and need not be further discussed in th place. W. R. Gowebs. OPTIC THALA.MUS, Lesions of. $ Thalamus Opticus, Lesions of. OHBIT, Diseases of. — Synon. : Fr. Mat dies de TOrbite-, Ger. Krankheiten dcr Augc\ hohlc . — The diseases of the orbit are notnumerot and are almost exclusively surgical in their ch racter. The bony walls of the cavity are liab to be fractured by direct injury, which genera: implicates other portions of the skull ; the co tained tissues are liable to phlegmonous or suj purative inflammation ; and the cavity may he t seat of tumours of various kinds, arising eith from the walls or from some portion of the co tents. 1. Haemorrhage. — Haemorrhages into t ORBIT, DISEASES OF. orbit, excepting as results of injury or from the rupture of aneurismal tumours, are extremely rare ; and the few cases which have been recorded have nearly all occurred in persons of generally htemorrhagie tendency, as one local manifestation among others of a constitutional malady. 2. Emphysema. — Emphysema of the orbit [is not unknown, and the writer has seen a young man who, in blowing his nose violently, must have ruptured, some of the ethmoidal cells, for he distended his left orbit with air, and, in his dwq words, blew his eye nearly out of his head. The distension soon subsided, and no permanent injury was done. 3. Inflammation. — Inflammation of the tis- sues within the orbit is not a common affection, but t is liable to occur as a complication of fevers md other debilitating diseases, and especially as i ccmnlication of erysipelas of the head and •ace. It is marked by brawn y swelling of the syolids, with some protrusion of the eyeball and i ome limitation of its movements, the symptoms .ppearing too suddenly and increasing too quickly o be attributable to the growth of a tumour, the injection of the conjunctiva is generally less narked than that of the lids, and sight is scarcely r not at all impaired as long as the swelling is Jnly moderate in amount. When the injected onjunctiva of the eyeball becomes cedematous, ndmore especially when the oedema is limited o one sector of the globe, or is much more pro- ounced over one sector than elsewhere, it is, a the opinion of the writer, an almost patho- inomonic sign of suppuration ; and the localisa- ion of the oedema will serve as a guide to the osition in which pus may be looked for. Other ymptoms of suppuration, such as rigors, must f course be taken into account. Treatment.— As soon as pus is believed to xist, it should be evacuated, since its retention mong the orbital tissues may be productive of prions injury, not only to the eye, but also to he ocular muscles and to the nerves which ■averse the orbital cavity. The evacuation is sually best effected by introducing a narrow Iraight knife through the skin, near the margin : the orbit in the selected position, and by irusting it carefully onward as far as may be hudent, giving the blade an occasional turn ion its axis, to allow of the escape of pus as on as it is reached. The direction of the point ould be governed by complete knowledge of e anatomy cf the parts; and it is better to thdraw the blade too soon than to incur any hk of wounding important structures. When is withdrawn, if no pus follow, the puncture hy be carefully deepened or extended laterally a probe ; but it is not necessary to be very ■enuous in such endeavours, because if the i>und through the skin and fascia be kept from ‘aling by the introduction of a' strip of lint, or a bit of drainage-tube, the pus will soon find way into the channel of escape thus provided ■' it. The cavity of the abscess should be ringed out from time to time, according to the ount of discharge, with some suitable astrin- it or antiseptic lotion ; and care must be :en that a free opening is maintained as long pus continues to be secreted, f Caries.— In strumous children, caries of ORGANS, DISPLACEMENT OF. 1071 some part of the margin of the orbit is not un- common ; and, after the diseased bone has come away, we frequently see much deformity of the lids produced by adhesions between the skin and the deeper tissues, or by the contraction of cicatrices. Many of such cases l-equire plastic operations ; but each one, before any operation is undertaken, must be carefully studied in order to discover the most promising method of pro- cedure. In a lad with inherited syphilis, the writer has seen very extensive necrosis of the orbital margin, subsequent to the partial re- moval, and partial absorption, of a large gum- matous tumour in the cavity. 5. Tumours. — Tumours of the orbit may be cysts (hydatid, dermoid, or sebaceous) ; lipo- mata ; gummata ; sarcomata, originating in con- nective tissue, and presenting the characters of myxoma, or of the sarcomatous growths distin- guished respectively by round and by spindle- shaped cells ; or they may be gliomata, springing from the connective tissue of the optic nerve. In other instances they may commence as an appa- rent hypertrophy of the lachrymal gland; or they may be cartilaginous, or osseous. All alike produce protrusion of the eyeball, and limitation of its movements, together with an amount of disturbance of vision, which depends upon the degree of pressure or of stretching to which the optic nerve is subjected, or upon the degree in which the intra-ocular circulation is im- peded. Many of the forms are liable to recur- rence, and may thus ultimately destroy life. Treatment. — All tumours of the orbit alike require removal, if possible, without sacrifice of the eyeball. R. Brudenell Carter. ORCHITIS (opx is > a testicle). — Inflamma- tion of the testis. See Testes, Diseases of. OREZZA, in. Corsica. — Iron waters. See Mineral Waters. ORGANIC DISEASE.— This expression indicates the nature of a disease in which there is a structural change in the part affected, as distinguished from a merely functional disorder, in which there is no evidence of such change See Disease. ORGANS, Displacement of.— The special malpositions of the chief individual organs are considered in the articles which are respec- tively devoted to these organs, and it is only intended here to discuss the subject from a general point of view. A distinction is some- times made between malposition and displacement, the former including all changes of position, from whatever cause ; the latter implying that the organ has by some force been removed from its normal situation after it has occupied it; and the term dislocation has also been used in the same sense. For all practical purposes they may be considered together, ./Etiology and Pathology. — The circum- stances under which an organ comes to oc- cupy an abnormal position may be thus sum- marised : — 1. The condition may be congenital, the organ never having been in its proper place. In this way all or part of the organs occupying the chest and abdomen may be transposed to the 1072 OKGANS. DISPLACEMENT OF. wrong side of the body (see Malformations). In this connection may also be mentioned the fact that an organ, which some time or other after birth changes its place in the ordinary course of development, may fail to do so, and thus remain in a wrong situation. This may be illustrated by the testis, which occasionally is retained in the cavity of the abdomen or the inguinal canal, instead of descending into the scrotum. 2. A violent strain or effort is liable to cause displacement of an organ, especially if repeated several times. This has been made to account for some cases of movable kidney ; and hernia may certainly arise in this way. 3. Mal- position may depend upon imperfection in the attachments of an organ. This may be conge- nital, the attachments being unusually long or loose ; or they may become repeatedly stretched from different causes, and thus rendered in- efficient. The kidney will again afford an illustration of this cause of displacement, and also the intestines, certain portions of which may come to occupy an abnormal position owing to the unusual length of their peritoneal attach- ment. 4. Another cause of displacement of organs is to be referred to abnormal condi- tions connected with orifices or canals, which either remain patent or too large, when the}’ ought to have closed or contracted; or which have been artificially formed, as the result of injury or other causes. Thus, a large inguinal canal and orifice, or non-closure of the peritoneal prolongation, may account for inguinal hernia ; or a new opening may be produced in some part of the muscular or tendinous structures of the abdominal wall, leading to some form of ventral hernia ; or an opening may remain, or be formed after birth, in the diaphragm, and hence an organ be displaced from the abdomen into the thorax, or vice versa. 5. Pressure is an impor- tant cause of displacement of organs. This may come from without, as from wearing tight stays or a belt ; but is of most importance in connec- tion with morbid conditions within the body. Accumulations of liquid, gas, or solid, whether the last-mentioned be due to enlarged organs or separate tumours, are frequent causes of malposition of organs, either temporary or permanent. This is well illustrated by the effects of pneumothorax, pleuritic effusion, or an intra-thoracic growth upon the lungs and heart, or even upon certain abdominal organs ; and the same thing occurs from similar conditions within the abdominal cavity. 6. Traction is another force which causes displacement of organs. The action of the lung free to ex- pand in cases of unilateral pleuritic effusion has been supposed to aid in the lateral displacement of the heart, by exercising a kind of elastic traction upon it ; but this cause is best ex- emplified by the effects of the contraction of diseased organs upon neighbouring organs, to which they have become adherent. For instance, the heart is frequently altered in its position as the result of a contracted cavity at the apex of the lung, in cases of phthisis. The contraction of adhesions themselves may assist inforiginating more or less malposition, and they frequently cause the altered situation of an organ to be permanent, by fixing it in its new position. 7. Disease in an organ itself may originate its own displacement. It com- monly happens that such disease enlarges or contracts an organ, and thus causes it to pass beyond or to bo drawn within its normal limits ; but further, an organ may become so heavy as the result of disease, that by its own weight it displaces itself. 8. In the case of certain mus- cular hollow organs, such as the intestines, ex- cessive or irregular action of the muscular coat may lead to malposition. In this way hernia may be originated, or internal strangulation of the intestine, or intussusception of one part of the bowel into another. In this connection the in- fluence of straining at stool in causing protrusion of the lower part of the rectum may be alluded to. 9. The displacements of the uterus con- stitute a special group, the causes of which are much discussed. Probably prolonged standing is one element in the causation of some of these displacements in certain cases varieties. — The principal varieties of mal- position of organs have been casually indicated in the preceding remarks, but it may be useful to arrange them more systematically. 1. An organ may lie in a wrong cavity altogether; for example, the stomach or liver may lie in the j chest, or partly in both chest and abdomen. 2. There may be a transposition of one or morel of the viscera to the wrong side of the body. 3. An organ remains in its proper cavity, but is more or less removed from its normal position. This may merely be a temporary change, the organ returning to its place whem the cause of the displacement is got rid of or it is a permanent condition, ’ the orgar being fixed in its new site. 4. Instead of beinc fixed, an organ may be more or less freely mov able, so that its situation alters with change o posture, manipulation, or other causes of move- ment. 5. A portion of an organ may pass out o.j its cavity, so as to lie under the skin or amongst the muscles, as in external hernia ; or it ma; even come altogether out of the body, as hap pens when organs are protruded in consequenci of injury, with an external wound. The dis- placements named procidentia and prolapse may also be mentioned here. 6. In the cas- of the intestine, one part may alter in its rela tions to other parts, as happens in the case o invagination. Coils of the bowel also occasion ally find their way into curious positions, owin' to the presence of bands of adhesion, opening in the mesentery, and other abnormal condition which predispose to their displacement. 7. Tk uterus presents special malpositions, both a a whole, and in relation to its different parti which need not be discussed here. See Mom Diseases of. Effects and Stmptoms. — There may be n manifest results whatever of the displacemei of an organ, or at least such as can be regarde of much or any consequence. On the othe hand, this condition may, if brought abot suddenly or acutely, be attended with immediat symptoms of a grave nature. For instance, in tb case of the intestine, the passage of its content is often prevented, and other serious results ensu familiar enough in cases of hernia ; while rapi displacement of the heart may lead to grat ORGANS, DISPLACEMENT OF. embarrassment of its action, and prevent the passage of blood into the arteries, by altering ;he relation of their orifices to the cardiac :avities. In chronic cases also displacement of an organ frequently gives rise to phenomena If greater or less importance. Thus, its own .'unctions are not uncommonly disturbed, and nay be seriously interfered with, as happened n a case observed by the writer, where the tomach passed through the diaphragm into lie thorax. The displaced organ may also reduce physical effects, such as irritation or ■ressure, and thus give rise to pain or other objective sensations, or to symptoms obviously jnnected with other structures and organs, jhysical examination often reveals malposition : an orgaD, and this is one of the conditions Inch should always be borne in mind when ;amining either of the more important viscera. I some instances it assumes the characters of tumour, as in the case of movable kidney; id this may prey so much upon the mind of ,e patient as to lead to considerable general sorder, although the condition may really not of much moment. It must be remembered it an organ may be diseased at the same time iff it is displaced, and then the symptoms are 1 ely to be more marked. Treatment. — When an organ is suddenly or ntely displaced, and the displacement is at- tided with serious symptoms, the first aim in t’atment should be to get it restored to its vimal position as soon as possible. This maybe i stralod by the treatment of hernia and other fins of intestinal displacement, or of protruded o ans, as the result of injury ; and by the re- ntal of pleuritic effusion, by means of aspiration, wn it gravely impedes the cardiac action in ^sequence of displacing the heart. In chronic Ciis the same principle should be kept in view lithe first instance. For this purpose any c;,es of displacement should be removed, and it ay be necessary to employ mechanical means, oiven to adopt operative procedures, to pre- v< a recurrence of the malposition. This may a! be exemplified by the treatment of hernia, at of displacement of tho uterus. In many eas, however, the restoration of an organ to its Doiial position is impracticable. Under these cii.mstances no particular treatment may be reiired; or perhaps any ill- effects resulting frc. the malposition may be obviated by the ap- tlition of a bandage or other means of support, as the ease of movable kidney. Medicinal agvs maybe of service in combating symptoms, ant n improving the general condition, if re- qu;a. When a malposition is of no conse- quiie, the patient's mind should bo made quite eas on the point, especially if any notion is entrained of the existence of a tumour. Frederick. T. .Roberts. GTHOPNG3A (op0bs, erect, and ttveu, I brehe).. — A form of difficult breathing, in which thehtient is unable to lie down, and is com- Pjd to assume tho sitting or erect posture. ^ .inspiration, Disorders of. C THOTONOS (opQbs, straight, and tuvos, 1 st ching). — A form of tetanic spasm, in which the dy i s rigidly extended. See Tetanus. 68 OVARIES, DISEASES OF. 1075 OSMIDROSIS odour, and iSpSs, 'sweat). — A condition of the perspiration in which it yields an unusually strong or fetid smell. See Perspiration, Disorders of. OSSEOUS DEGENERATION.— A kind of degeneration, in which the affected textures as- sume the characters of bone. See Degeneration. OSSEOUS SYSTEM, Diseases of. See Bone, Diseases of. OSTEITIS (bareoy, a bone). — A synonym for inflammation of bone, which may be of various kinds. See Bone, Diseases of. OSTEOCOPIC PAINS (oareov, a bone, and k<5ttos, fatigue). — Aching pains in bones. See Syphilis. OSTEOID CANCER. — This term has been vaguely employed, as implying a cancer includ- ing bony structure, or with reference to malig- nant disease involving a bone. See Bone, Dis- eases of; Cancer; and Tumours. OSTEO-MALACIA (oareoy, a bone, and fia.Aa.Kbs, soft). — A synonym for mollifies ossium. See Mollities Ossium. OSTEO-MYELITIS (bcrriov, a bone, and peveAbs, the marrow). — A name for inflamma- tion of the medulla of bone. See Bone, Dis- eases of. OSTEO- SARCOMA ( bariov , a bone, and cropf, flesh). — A sarcomatous growth in connec- tion with bone. See Bone, Diseases of ; and Tumours. OTALGIA (o3 s, Sires, the ear, and &Ay os, pain). — Pain in the ear ; ear-ache. See Eab, Diseases of. OTITIS (oSs, the ear). — Inflammation of the ear. See Ear, Diseases of. OTORRHCEA (oOs, the ear, and f>eu, I flow). Discharge from the ear, usually purulent. See Ear, Diseases of. OVARIES, Diseases of. — Synon. : Fr. Maladies des Ovaircs; Ger. Krankheiten der Eicrstocke : Krankheiten der Ovarian. In the article Abdomen, Diseases of, a section is arranged in one of the groups for diseases of the female generative organs, including the uterus and its broad ligament, the Fallopian tubes, and the ovaries. Under the heads Menstruation, Disorders of, and Hysteria, much information may be found upon subjects which might be included among the diseases of the ovaries. But there remains something regarding the patho- logy, diagnosis, and treatment of ovarian diseases interesting to the physician, without entering upon the more surgical question of such cysts and tumours of the ovaries as call for tapping or ovariotomy. In proceeding to estimate the frequency and importance of the diseases of the ovaries, we have to consider the wonderful series of periodical processes which go on in women every month for some thirty-five years; sometimes without any interruption by pregnancy, sometimes inter- rupted by many pregnancies; some carried on to the full period, some interrupted at different stages, followed by lactation for periods variously OVARIES, DISEASES OF. 1074 prolonged, and perhaps suddenly stopped by the death of the child or by another pregnancy, attended by losses of blood of less or greater quantity, and ceasing usually from forty-five to fifty-five years of age, after more or less ir- regularity. We have to remember that at each menstrual period one or other ovary becomes swollen ; that one or more of its ovisacs en- larges, opens, and admits of the escape of the ovum it contained ; that the fimbrial end of the Fallopian tube grasps the ovary, receives the ovum, and allows of its passage into the uterine cavity; that the uterus itself receives an in- creased supply of blood ; and that its mucous membrane undergoes a series of exfoliative changes. We must consider, farther, how these periodical processes are associated with much that is of supreme importance in the state of the nervous centres, and in the mental con- dition of woman ; that the normal process, in- stead of recurring at regular intervals, and ceasing in a few days, may be abnormally pro- longed, and may recur at most uncertain pe- riods; and that evolution and involution may be both affected by pregnancy and lactation. When we bear in mind all these highly complex conditions, processes, and relations, the wonder is, not that ovarian diseases should be frequent, but that so many women pass through life with- out suffering from them. If an ovary become swollen and tender, its blood-vessels overdis- tended, and extravasation (or apoplexy of the proper ovarian tissue) take place ; or if blood escaping into the peritoneal cavity, becomes en- capsuled, or forms a hasmatocele of the loose cellular tissue between the layers of one or both of the broad ligaments, we can only wonder that such an accident does not happen more frequently, and be prepared to recognise the effects of repeated slight extravasations. These are uneasiness in the abdomen, increasing to pain, more or less severe, want of sleejo, and raised temperature, preceding discharge of blood from the uterus ; then swelling and tenderness in one or both groins, bearing down, like la- bour-pains, recurring at intervals, with dis- charge of fluid or clotted blood or of mem- branous shreds ; extension of pain to the loins, and irregular flow of urine — all symptoms so often observed as to be almost neglected. And if a vaginal examination is made, especially when combined with examination by the rec- tum, not only may one or Loth ovaries be felt larger and lower down than they ought to be, behind and on either side of the uterus ; but they may be extremely tender on pressure, and there may be more or less evidence of peri-uterine ex- travasation. After repeated attacks of this na- ture, permanent hardening and enlargement of ovaries and uterus, and their impaired mobility, due to organisation of blood-clot or ot plastic lymph, are among the most frequent pathologi- cal changes which the practitioner is called upon to treat. The diseases of the ovaries, which will he spe- cially described in this article, are as follows : — • 1. Abormalities; 2. Displacements; 3. Disturb- ances of Circulation ; 4. Acute Inflammation ; 5. Chronic Inflammation ; and 6. Tumours, in- cluding Cysts. 1. Abormalities. — Absence of the ovanw or their imperfect development, may occasional! be inferred; and the presence of a third c accessory ovary, now and then observed in th dissecting-room and on the operating table, ma probably account for the recurrence of regnla menstruation in spite of serious disease c both ovaries, or after the removal of both b ovariotomy. 2. Displacements. — Congenital or acquire displacements are also observed, as hernia int the inguinal canal, or prolapse to the bottom < Douglas's pouch. 3. Disturbances of Circulation. — Hype: semia, when not excessive, may be considered ; an essential part of normal menstruation, very little excess may lead to the formation < a large clot in an unbroken ovisac, or extr vasation into the stroma of the ovary, constit ting apoplexy ; or between the layers of tl broad ligament, or into the peritoneal cavit thus forming peri-uterine or pelvic hsematoce) In some cases, apoplexy of the ovisacs is clear traceable to torsion of the ovary upon its n trient blood-vessels. 4. Acute Inflammation. — Acute oophori! and peri-oophoritis are probably of much mo frequent occurrence than acute orchitis in t male. The testicles are far more liable to m chanieal injuries, but are probably not me liable to extension of the poison of gonorrha or its sympathetic effects, and they are free fit theperiodical hyperaemia which may be regard as the first step in the process of ovarian infla mation. This periodical hyperaemia, influend by accidental sudden suppression of discharge blood from the uterus, is the usual history of acute attack of oophoritis. Symptoms. — The symptoms of acute infia mation of an ovary are pain over the pul tenderness on pressure in one iliac region, irri tion of the bladder, tenderness of the vagi and pain on moving the cervix uteri, and on pa ing the finger behind and on one side of » cervix towards the sacro-iliac synchondrosis. - patients with lax tissues, by combined red and vaginal examination, the swollen ovary n' very often be felt. If one ovary can be s and moved, the patient at once complains! greatly aggravated pai n . Treatment. — The treatment should consis t absolute rest on the back, with the hips rail and thighs flexed ; or on the side not affect, if dry-cupping glasses can be applied over e sacrum. Mustard poultices, or turpentine .1 chloroform liniment, may also be applied cr the sacrum and on the iliac region. Thebovs should be well cleared out, and small doses! blue pill and Dover's powder given frequetf, with a sufficient quantity of bromide of potassii- Leeching the cervix uteri has been reeommeaa ; but the local disturbance caused by it usuj does more harm than the loss of blood can nt e up for. Sometimes the pain is so very set® that it may be necessary to give chloroform same other anaesthetic, and repeat it more t" once before the pain subsides. 5. Chronic Inflammation. — Chronic oo a* ritis, distinguished by those paroxysmal attfes of paiu recurring at the menstrual periods. (“* OVARIES, DISEASES OF. 1075 iionly known as ovarian dysmenorrhoea, is a ouch more common condition than the acute enn of the disease. And there can be little loubt that both amenorrhaea and menorrhagia pay be often due to changes in the ovaries, vhich are the result of repeated attacks of sub- cute inflammation. Some turgescence of the mtcous membrane of the uterus and Fallopian Lbes is a condition attendant upon ovulation ; ml is physiological or pathological in close re- ttion with the normal or abnormal process in [lie ovary. So far as anatomical examination Baches us, it is rare to find much change in the varies alone, without proof of what is called eri-oophoritis ; adhesions between the surface '( the ovary and the fimbriae of the Fallopian ibe or the tube itself ; adhesions due to pelvic britonitis ; hardening and enlargement of the ,-ary itself ; hard clots in some of the ovisacs ; \ on the other hand, a shrivelling, or contrac- pn, or atrophy of the gland. Trkatmext. — W hether the chronic form of [e disease has succeeded an acute attack — non- lerperal or puerperal — or one or more attacks gonorrhoea, or repeated abortions, or has erely increased in intensity or duration after peated recurrence, the treatment must still the same : namely, avoidance of known causes, iit, attention to the general health, counter- itation, and the use of sedatives, especially ilium and the bromides. In cases of distinct {ling downwards of one or both ovaries, an • Stic ring pessary, worn in the vagina for a ly weeks, is sometimes of signal service. Hard psaries are not well borne. When all other ikns fail, the operation of extirpating both tries — Battey’s operation — must be seriously tsidered in consultation. We require more fits, accurately observed and faithfully re- eded, especially as to the mortality, and to t results obtained by the operation when it (2s not prove fatal, and the state of the pent’s health of body and mind for some yjirs afterwards, before the true value of the o ration can be estimated. But enough evi- dfce has been already collected to prove that, ajr ordinary measures have failed, and morbid pjsieal and mental conditions are clearly de- pflent on abnormal menstruation, and possibly u; 1 morbid conditions of the ovaries, the physi- ci wouldbefullyjustified inadvisingthe patient oiler friends to call for the aid of surgery. Tumours. — Of all the diseases of the ov ies, far more common than any malforma- tio or displacement, even more commonly the cap of such suffering as to lead a patient to sei. for medical advice than either the acute or ironic forms of ovarian inflammation, or th; ; the ovaralgia or nervous hysterical form oh-arian irritation associated with dysmenor- rhr, and with various forms of eccentricity, and popbly of hypochondriasis, melancholia, or ma- nia! excitement — common though these con- <>it is may be — cysts of one or both ovaries are tkeaost frequent of all the diseases of these orgis. So far as regards their pathological ana my, for all practical purposes of diagnosis *sc reatment, they may he divided into simple nr ; ilecidar, and compound or multilocular — the rmer a dilated dropsical ovisac, the latter a proliferating cystoma or a dermoid cyst. A still more practical, if less scientific, division might he made into (1) Cysts , and (2) Tumours of the ovaries, including in the former division such sim- ple or multiple cysts as from the preponderance of fluid and small amount of cyst-wall, may pro- perly be considered as ovarian dropsy — hydrops ovarii, or hydrops folliculorvm. Graafii ; and in the latter such solid or semi-solid tumours as, under a general class of proliferating cystomata, include pseudo-colloid tumours, myxo-cystoma, cystoid adenoma, sarcoma, fibroma, papilloma, carcinoma, and (as a separate class) dermoid cysts. The histogenesis and the microscopic character of these varied forms of disease must be studied by the aid of special treatises or mono- graphs. Here their clinical history is of chief importance. Symptoms and Diagnosis. — Clinically the main points for consideration in eases of fluctu- ating abdominal tumours are whether the fluid is contained within a cyst, or whether it is in the peritoneal cavity, either free or limited by visceral adhesions. In solid tumours the seat and nature of the tumour must be investigated. The diagnosis between fluid in an abdominal cyst and in the peritoneal cavity has been laid down in the article Ascites. Ilere it is only necessary to add that the limit of fluctuation as recognised by palpation, and the limit of d ill- ness as ascertained on percussion, exactly cor- respond when the fluid is encysted. The wave of fluid cannot be made to pass beyond the line of dulness on percussion. But, when the fluid is free, the resonant intestines are float ingin it, and fluctuation may bo detected where percussion gives a resonant or tympanitic note. The wave of fluid is not stopped by any cyst-wall. Chemical and Microscopical Examination. — If tapping have been resorted to, in order to givo temporary relief to urgent symptoms, or to com- plete a doubtful diagnosis, chemical and micro- scopical examination of the fluid affords valu- able information. The albumen in the serum secreted by the peritoneum is ordinary albumin, which is coagulated by heat, and will not redis- solve in double its volume of strong boiling acetic acid. The albumen secreted by the epithelial layer of an ovarian cyst is that secreted rather by mucous than by serous membranes, known as metalbumin and paralbumin, which (like true albumin) is coagulated by heat, but (unlike true albumin) is re-dissolved, or converted into a translucent gelatiuiform liquid, after having been boiled in double its volume of strong acetic acid. Then on examining the deposit which subsides after ovarian fluid has been at rest for some hours, there may be found in the field of the micro- scope the nuclei of the epithelial cells which line the interior of the cyst. The scales are thrown off, the eell-walls break down, and the nuclei remain. These are the so-called ‘ovarian granule-cells ’ of Nunn, Bennett, and Drysdale, and are characteristic of innocent growth. In addition to these there are found in malignant growths characteristic groups of cells of different sizes, described about the same time by Foulis and Thornton as large pear-shaped round or oval cells, containing a granular material, with one oi several large clear nuclei, with nucleoli and a OVARIES, DISEASES OF. 1076 number of transparent globules or vacuoles. The great variety in size and shape of the cells com- posing the groups is the characteristic feature. When these large groups are found in fluid re- moved from a cyst, it is extremely probable that a malignant growth projects into the cavity of the cyst. When the groups are found in peritoneal fluid, there is either some malignant growth, or an ovarian cyst of a malignant character has burst into the peritoneal cavity. Some of the cells have planted themselves upon the surface of the peritoneum, where they have grown and multiplied. Some observers believe that when such groups of cells are found in fluid removed from a cyst or from the peritoneal cavity, the evidence of the malignant nature of the disease is so strong that no other than palliative treat- ment is justifiable. But microscopic knowledge lias certainly not yet reached such perfection as to justify a surgeon in refusing to attempt to save life by removing a tumour, if it can be re- moved, even if it be characterised by the forma- tion of such groups of cells as have been described. Several such ovarian tumours have been removed after they had burst, and after several tappings of the peritoneal cavity, with the happy result of recovery from the operation and subsequent good health. After the removal of a proliferating cystoma recurrence of the disease has been ob- served, but there is good ground for believing that recurrence is exceptional. Semi-solid tumotirs. — Semi-solid ovarian tu- mours are more common than simple cysts. In- stead of a smooth uniform surface, irregularities may he felt, due to cysts, or groups of cysts, of different shapes and sizes, or to thickening of por- tions of the wall of the main cyst. The wave of fluctuation is interrupted by septa in different directions ; and hard nodules, or bone-like pro- jections, may perhaps he detected. Occasionally a deep sulcus between two portions of a semi-solid tumour, with resonant intestine in the sulcus, may lead to doubt whether both ovaries are not affected. Solid tumours. — Ovarian tumours which are entirely solid, not fluctuating in any portion of them, are very rare, but still are occasionally met with, both as innocent fibroma and as true cancer. Adhesions. — Any ovarian tumour — cystic, solid, or semi-solid — may be free from adhesion to the abdominal w r all or to the omentum or viacera, or may be adherent anywhere within the abdominal or pelvic cavities. But as the result of ovariotomy is very little affected by the presence or absence of adhesions, a very minute diagnosis of the nature and extent of adhesions is not of much practical importance. Still if there are firm adhesions low down in the pelvis, fixing the uterus, rectum, and bladder together, or fusing them, as it were, into one mass with tbo ovarian growths, ovariotomy should not he performed, or only after a very guarded prognosis. Inflammation, haemorrhage, and gangrene . — Any ovarian cyst, simple or compound, may he the seat of inflammation either on its surface, when the symptoms do not differ from those of peritonitis, or in the cyst-wall or lining mem- brane, when (without any peritonitis) there may be pain and considerable fever, sometimes followed by rigors and suppuration. Haemor- rhage into one or more of the evst-eavities mat lead to all the symptoms and effects of internal haemorrhage. Ur the whole or portions of the tumour may become gangrenous, from a twisting of the pedicle obstructing the circulation of blood in the vessels of the tumour. In some cases twisting of the pedicle may be followed by a com- plete separation of the tumour from its ordinary supply of blood. In this condition the tumour is nourished by vessels in the omentum, abdo- minal wall, or some other structure adherent to the peritoneal coat of the tumour, if the woman's death is not speedily caused by gangrene of the growth. Other abdominal tumours. — The abdominal tumours most frequently mistaken for ovarian tumours are fibroid or fibrocystic tumours of the uterus, and tumours or cysts of the spleen, brer, or kidney. Pregnancy, either normal or extra- uterine, m.-\y also be mistaken for an ovarian tumour, or may be present at the same time. It is not rare to find a woman with an ovarian or a uterine tumour to he also pregnant ; so that the ordinary signs of pregnancy must be borne in mind in examining any woman who has an ab- dominal tumour. And the frequency of fee?, accumulations, or of tympanitic distension o: the intestines, with thick or rigid abdomina walls and a fat omentum, must also be re membered and excluded, as well as fatty o fibro-fatty tumours which may form in th dyspepsia, and hypochondriasis, which aresaii characterise this so-called diathesis, and so foi impressed the professional mind with the clinic association of these symptoms with— if not the] actual dependence on — oxaluria, that the mo accurate and recent observations of Beale, Bene! and W. Roberts, have scarcely yet succeeded * dissipating the error. These observers ha proved that, in the large majority of casos which the characteristic symptoms are preset no oxalates are found in the urine; and col versely, where oxaluria is most pronounced, t| symptoms are absent. Oxalate of lime in t urine is often found in persons enjoying go; health. From what ha3 been said of its aetiolog its presence in various chronic diseases, such phthisis, chronic bronchitis, cardiac lesions, & in which oxidation is retarded, is explain So, too, oxaluria is present in many conditio of deranged digestion and mal-assimilation, a in diseases which lower nervous tone and pow Treatment. — It will be gathered from t! foregoing remarks, that oxaluria demands direct or uniform therapeutical treatment. T indications are, to obtain perfect digestion selecting a diet not too rich in nitrogenous auimal food, and by prudence as regards qua tity, so that crude or imperfectly assimilal matters are not absorbed ; to promote the heala action of the skin and lungs by sponge shower-baths, and free exercise in a hraci country or at the seaside ; and by tonic remed' to improve digestion, and strengthen the nerve, system. 2. Oxalate of lime calculus. — D esckipth M ulberry or oxalate of lime calculus is usua' of a dark brown, sometimes almost black colon generally ovoid or spheroidal in shape ; wit., rough and tuberculated exterior ; and of a h;l compact interior. The absolute nucleus is cc posed of dumb-bell crystals, united by molecu.' coalescence in, and through the medium of, so-' viscid organic matter. The influences which c - trol this deposition and growth of calculi hi; been much elucidated through the researched Dr. Carter aud Dr. Ord, but need not he special described here. See Calculus. The great insolubility of oxalate of In OXALIC ACID DIATHESIS. lavours the chances of its deposition in the renal ubules. It has been detected in the kidneys of ho fcetus ; it is especially liable to occur during hildhood; and this liability decreases asage ■dvances. In England calculi composed entirely If oxalate of lime are rare in the adult, but in ndia they are comparatively frequent. Mul- erry calculus in the young causes intense Buf- ferin«’ ; but in the adult, notwithstanding the unnidable tubercles and rough exterior, the ymptoms of stone are often mild ; not impro- bably because these projections become entangled a the muscular columns of the bladder, and the alculus is thereby fixed in position. The symp- pms of renal calculus are fully described in bother article. See Kenal Calculus. Treatment. — Microscopic mulberry calculi, ere it possible to detect their existence, could robably be washed away and carried off by iluents and diuretics ; but a palpable stone is subject for surgical treatment only. W. Cadge. OXALIC ACID, Poisoning by. — See OIsOXS. OXYUHIS (o| us, sharp, and ovpa, a tail). — ynon. : Er. Oxyure ; Ger. Spitzschwanzwurm ; \adcnwurm. — A genus of nematoid parasites of hich the little threadworm or seatworm forms le best known type. Most English practitioners ill 6peak of the common threadworm, Oxyiiris trmicularis, as belonging to the genus Ascaris. 1 nine cases out of ten, when children are said ■be suffering from ascarides, it is meant that ley are infested with oxyurides or thread- arms. These parasites not only differ from the carides proper in respect of size, but also as gards the form of the body, which is more less spindle-shaped, the tail being sharply ■intod. Hence the generic title. Oxyurides fest animals as well as man, the large species the horse, Oxyuris curvula, being almost as jurious to that animal as the little threadworm to ourselves. See Ascarides; Seatworm; and jlREADWOBM. T. S. CoBBOLD. OZJENA (2£b, a foul odour). — S ynon. : Er. '.naise ; Ozene ; Ger. Stinknase. Definition. — Ozaena is generally understood mean a chronic, highly foetid discharge from a nose, or its accessory cavities. This dis- irge, however, and its characteristics, are . Iter to be regarded as symptomatic of disease, in as disease itself, and is a result of some healthy ulceration of the mucous membrane. Etiology. — The causes of ozaena are various, ■ : most common being syphilis, struma, lupous i.eration, canes, or necrosis of the bones or c tilages, although these may themselves be i lendent upon the presence of some foreign lly, or other cause of occlusion of the meatus. < ena may exist in an idiopathic form, which is i arded by some authorities as depending upon nbnormal condition of the nasal secretion, or i. analogous to the offensive odour sometimes i j with in the feet or axillae. Ozaena has been l some attributed to the abuse of mercurials, but t 'e conclusive evidence on this point is wanting. ymptoms. — The ulceration, on which ozsena lends, generally commences high up in the t ), though it may be first noticeable as lew OZiENA. 1079 down as the inferior turbinated bono or septum. In the strumous form only one side may be affected, whereas in the syphilitic variety both are generally involved, and there is a greater derangement of health. The diagnosis, however, is rendered the more difficult in children, since it frequently occurs that the two conditions coexist. The nature of the discharge varies with the case and with its progress, whatever may have been its origin, and it may be influenced by p. cold, overwork, or the approach of the menstrual period. It may be either profuse or scanty, thick or thin, purulent or sanious, almost colourless or greenish yellow, and streaked with blood. It often forms crusts, or masses of inspissated mucus, which may accumulate at the posterior nares, being discharged from the nostril as horribly offensive concretions, every few days, and quickly reforming: The complications consist in the implication of the bones and destruction of the septum, most frequently occurring in the strumous or syphilitic form, so that the nose falls in, pro- ducing great deformity. Diagnosis, — It is of the greatest importance to distinguish between ozsena and the various forms of foetid breath consequent on bad teeth, ulceration of the mouth and fauces, the presence of foreign bodies or of retarded secretion, or disturbance of the general health — a point which may be readily made out by causing the patient to close the mouth and nostrils alternately, or by rhinoscopic examination. Treatment. — The treatment of ozsena must be both local and constitutional, and obviously di- rected to the exciting cause. Local treatment consists in the removal of all sources of irrita- tion, by washing out the choanse, and by the in- sufflation of powders, although this latter is net so frequently resorted to. The most valuable, undoubtedly, is the nasal douche of Thudichum, the action of which is dependent upon the fact that, while the mouth is kept open, the nares can be thoroughly washed out, and no fluid pass into the mouth, since the velum pendulum palati is closely forced against the upper portion of the pharynx. The instrument itself consists of a tube of varying length, with a perforated nozzle, which is to fit accurately to the nostril. This tube descends from a small cistern, placed at such an elevation that, by turning a stopcock, a current offluidis injected into the cavity. The fluid used depends on the nature of the case, but is generally some saline solution, such as a w-eak one of common salt, or salt and carbonate or phosphate of soda; a weak solution of carbolic acid, of Condy’s fluid, or of chlorinated soda; or a mercurial *n some cases. An ordinary well made syringe, capable of supplying a tolerably continuous stream, will answer very well in many instances. Where ulcerating surfaces can be seen or reached, they should be touched by a sponge or camel' s-hair brush steeped in a solution of ni trate of silver, nitric acid, or carbolic acid, and the apposed surfaces kept from contact by sponge tents or laminaria. The great pain at- tendant on idiopathic ozaena may be relieved, by applying to the frontal region an ointment con- 1080 OZiENA. taining about 2 or 3 grains of morphia to the ounce. The injection of glycerine is often of great use, especially in strumous ozsena, and it may be combined with a grain of iodine to every ounce with advantage. With regard to insufflation, or the snuffing up or administration of medicated powders by an instrument, benefit is obtained in some instances from the use of sub-nitrate of bismuth rubbed up with Venetian chalk, or calomel rubbed up with sugar, in the proportion of a grain to an ounce. Tannin, camphor, and cubebs have all been recommended. The principal remedies used in the form of vapour, have been mer- curials, such as calomel or bisulphide of mer- PAIN. cury, sublimated by a lamp and inhaled. Th vapour of hvdrochlorate of ammonia is als useful in all forms of ozaena. With regard to the constitutional treatmeni in the strumous variety, cod-liver oil, quinim iodide of iron, and arsenic seem to be of mos service. Those cases which are obviously syphilitic ar usually more tractable than either the stramou or idiopathic varieties, under the influence c bichloride of mercury or iodide of potassium. ; the patient be robust. In cases where the healt is impaired, generous living, with quinine an iron, would be indicated before entering upo specific treatment. Edwaed Fellahy. P PACHYDERMIA (-rraxv, thick, and oipua, the skin). — A state of thickening and conden- sation of the integument, which is sometimes observed in the lower limbs, associated with in- filtration and induration. In chronic cellulitis a state of pachydermia is also met with ; and thickening of the epidermis, as in the instance of callosity, has received a similar name. But the term is wanting in the scientific precision necessary for its adoption in pathology. Erasmus Wilson. PACHYMENINGITIS (iraxus, thick, and P-hviy^, a membrane). — A synonym for inflamma- tion of the dura mater. See Meninges, Cere- bbal, Diseases of. PAIN. — Synon. : Fr. Doulcur ; Ger. Schmcrz. Definition. — Pain is the representation in consciousness of a change produced in a nerve- eentre by a certain mode of excitation. It would seem that some special perturbation of nervous impulses, and not a mere exaltation of the normal functioning of the sensory apparatus, is necessary to the production of pain. For it will sometimes happen, in disease, that whilst the faculty of perceiving painful impressions made upon the skin is wholly, or in great part, lost, touch is felt nearly as well as in health. On the other hand, in hypersesthesia of the surface, where the slightest impression produces exqui- site pain, the power of tactile discrimination is actually diminished. .ZEtiology and Pathology. — Pain is excited by many agencies applied to the skin — mecha- nical, thermic, chemical, electric, pathological. Of these it is probably only the last which are able to produce pain when applied to the viscera, bones, and blood-vessels. The situation of the stimulus exciting pain may he at any part of the sensory apparatus, from the end-organ in the skin to the central ganglion ; but the feeling of pain is always referred to the periphery of the sensory fibre, no matter what portion of the sensory tract has received the irritation. As regards pain, therefore, which is referred to some part of the interior of the body, it must be icmembered that thecause (always some pathological agency) may be operating either upon the termination of nerve, its trunk, or upon the nervous centre i the spinal cord, or superior ganglia. There ma be encroachments upon the structure of th nerve-fibre or ganglionic centre, arising froil hyperaemia, effusion, or growth in neighbourin tissues. Pathologically, pain is of at least twofold in portance. 1. It causes distress and exkaustio of nervous energy, interferes with sleep, inten rupts the appetite and digestion, so that the ni trition of the body is damaged, and thus, if long! continued, it can lead to changes shortening es istence ; or it may be so severe as of itself t occasion death. 2. Its aid in diagnosis is frt quently of higher value than that of any othi single symptom. Varieties and Diagnosis. — It may he usefi to refer briefly to a few examples of the diat nostic importance of pain. Pain in the head . — When of a continuous, dul aching character, pain in the head may he da to rheumatism of the scalp, and this is especiall likely if it he increased by bending the hea down. A headache of similar character, an affecting the forehead, may be dependent upo gastric derangement. Fixed in one spot, eithe on the head or face, and darting from that spo if sharp and paroxysmal, it is likely to be net ralgic. If, in addition, it bo accompanied b vomiting and giddiness, it may indicate migraim Now, migraine much more often than not, ei dures for a day only at a time, or a little mor If, therefore, these symptoms be continued b( yond this period, they should always be regarde with anxiety, as probably connected with brai; mischief. The use of the ophthalmoscope : most important here. Should pain in the hea be accompanied not only by vomiting and gidd ness, but by squint, or some other evidence of localised paralysis of a cranial nerve, it is almo: certainly due to intracranial disease of a coan kind — tumour, aneurism, abscess, hsemorrhag or meningitis. In cases of more or less comple hemiplegia from vascular changes and thrombi sis, after the apparent recovery of the patien more or less fixed pain in the head will oftc PAIN. emain. Whilst this persists, a guarded prog- iosis is essential, for much more often than not urther mischief -vs-ill follow before long. In all ■ases of persistent pain in the head, the urine hould be carefully examined, not only for albu- men, but also for sugar. Pain of a severe kind, specially apt to attack the back of the head, is ften found in the course of Bright’s disease. It -ill then be accompanied by albuminous urine ; nd the ophthalmoscope will very likely show lbuminurie retinitis. There is also a form of lore or less continuous headache, with occa- onal violent exacerbations, which accompanies lycosuria. A recurrent pain in the head, of excessive iolence, and described as a feeliDg as though le bones were being crushed, whilst it may icasionally be due to rheumatism, is far more ’ten dependent upon syphilis. Generally speak - iig, persistent pain in the head, in a person un- customed to it, is a symptom which should ways be regarded with anxiety, and the use of 16 test-tube and ophthalmoscope should never such circumstances be omitted. This should pecially be insisted upon if the patient be a male, and certain concomitant symptoms in- ine the observer to believe the affection to be ■sterical. In obscure cases the possibility of the toxic fluence of lead in causing pain in tho head ■ould not be forgotten. The pain in the head which accompanies chlo- sis is often fixed in one spot, and described by e patient as a feeling of a nail being driven ■a the head. This symptom not unfrequently companies hysterical conditions. The pain in ie head complained of by school children, as tacking them in their studies, is very often due some abnormality of refraction or weakness of ■tain muscles of the eye, which needs the help i an ophthalmologist to investigate. Pains in v; head of a darting, shooting character, are ••netimes due to locomotor ataxia. Vain in ilie neck . — This is not at all uncommon, 1 1 is usually due to rheumatism affecting the 1 'ous covering of the large muscles. It is pro- 1 ole, too, that in many cases it depends upon i tation of the loose connective tissue which t;.bles one muscle to glide over another, and ' :ch is really an expansion of the lymphatic E.tem. Uric acid, or some equivalent, becoming dosited in this lymphatic space, will excite :> : ttle subacute inflammation, and produce a v,y acute pain. The diathesis of the patient s uldbe inquired into, his urine and evacuations curved, and his mode of living investigated. 1 re may be, too, sometimes pain in the neck f; a neuralgia. This will be distinguished by it paroxysmal character, and its being indepen- d i of muscular movement. Neuralgic pain in tl neck is usually accompanied by pain in the djrict of one or other of the divisions of the bj'hial plexus in the arm. ■ ain in the chest . — This may be referred to ti chest-wall, or to the interior of the cavity. Ii'he former case it is Decessary to determine w dier the pain be due to muscular rheumatism, Politic periostitis, intercostal neuralgia, or the -i oachment of an aneurism or' a tumour. Ab- 5 of febrile movement, as shown by the ther- 1081 mometer, and the entire dependence of the pain upon movement, point to the first of theso causes. A node perceived by the finger upon the sternum, clavicle, or ribs, would indicate syphilitic perios- titis. The character of the pain, and the pre- sence of tender points, coupled very probably with a history of previous neuralgic attacks in some other part of the body, suggest intercostal neuralgia. Physical examination will detect or exclude aneurismal tumour. Pleurisy causes a pain referred to the chest-wall, which, as it is particularly marked when the patient coughs, may be confounded with muscular rheumatism or intercostal neuralgia. The elevation of tempe- rature by which pleurisy is accompanied, will ordinarily distinguish it without difficulty, even before there are any auscultatory signs. Con- tinued dull pain deep in the chest may indicate an intrathoracic growth, abscess, or aneurism. Careful physical examination and observation are the means by which the diagnosis of this condition can be made. Pain is often experienced about the heart more or less early in the course of acute rheumatism. It may be dependent upon commencing peri- or endocarditis, which will be disclosed by tho stethoscope. There is a dull, more or less con- stant pain about the heart, which occurs in con- ditions of nervous debility, and is not connected with organic disease of the organ. There is also a rather sharp pain just under the mamma, ac- companied by cardiac palpitation, which is often complained of by epileptics, and by persons af- fected with hysteria. It is not accompanied by any evidence of organic change in the heart, and its origin is probably in the central nervous system. Pain in the heart, of an extremely sud- den character, as though the muscle were being grasped, and accompanied by intense apprehen- sion of death, with facial pallor and some dyspncea, points to angina pectoris. The pain is not con- fined to the heart, but extends to the left arm, and to various parts of the chest. The pains in the chest which accompany various diseases of the lungs and pulmonary tubes will require to be investigated with reference to these conditions. Pain, in the spinal column . — Acute pain and tenderness of any of the vertebral spines is a symptom, not of disease of the spinal cord, but of a peculiar state of nervous exhaustion. It is common in hysterical persons, and in others who have from any cause become greatly debilitated. As a rule there is very little pain in the spine in diseases of the cord. In spinal meningitis the patient only complains of pain on movement, and especially if he endeavour to turn over in bed. Pressure upon any part of the vertebral spines usually causes no complaint. There may be a little uneasiness complained of when they are strongly percussed. Pain of an encircling kind, in a sort of band in the wall of the chest or abdomen, accompanied by what is often de- scribed as a ‘ bloated feeling,’ is a serious symp- tom, and points to myelitis. There should be, however, some other confirmatory symptoms, ere this view is decisively fixed upon. In such a condition there would probably be found more or less weakness of the lower extremities, with some cutaneous anaesthesia, below the band of pain. It may happen that an aneurism encroachos PAIN. 1082 upon the spinal vertebrae, or a malignant growth invades some of them. In such conditions there is often constant and excessive pain, with, not uncommonly, a good deal of tenderness of the surface. The possibility of these conditions should always be borne in mind. In commencing caries of the vertebrae a 1 stinging ’ pain is often complained of in the chest-wall, and pain may also be complained of on pressing somewhat heavily upon a vertebral spine. In such a case, too, the act of stooping and lifting weights is apt to cause complaint of pain in the spinal column. Pain in the abdomen . — This may, like pain in the chest, be referred either to the abdominal wall or cavity. There may be inflammation and abscess of the abdominal wall. There may be neuralgia of tho superficial branches of the lum- bar plexus, in which case the pain is paroxysmal, sharp, and may be accompanied by herpes. But pain in this situation is more often myalgic, and will be found to correspond to tho insertion of some abdominal muscle, which is subject to over- strain or fatigue. Acute abdominal pain referred to the contents of the belly, may be dependent upon internal strangulation of the bowel, in which case it will be accompanied by vomiting, constipation, and probably by abdominal distension, with marked peristaltic writhings of the intestines. Or the cause may exist in a hernia which is strangu- lated. The symptoms in this case will be much like those above described, and therefore it is in all cases of acute abdominal pain with constipa- tion absolutely necessary to make, first of all, a thorough examination, to ascertain that no her- nial tumour is to be found. If pain in the abdo- men be accompanied by tenderness on pressure, and be increased by coughing, there is probably peritonitis. In such a case the pulse will be found quick and small, and the temperature somewhat, but not necessarily, much raised. The patient will prefer to lie on the back with the knees bent, and the face will betray anxiety. In hysterical women great abdominal pain and tenderness is often complained of, and it is some- times not very easy to distinguish this from peri- tonitis. It is best done by engaging the patient’s attention, and noting that there is then no evi- dence of tenderness at a point which had been previously exceedingly painful. The pain and tenderness may be due to enteritis or perity- phlitis, in which case there will be obstinate con- stipation, a tympanitic state of the whole intes- tine or the csecum, and most probably vomiting. Cancerous tumours of various abdominal organs will have to be diagnosed by careful palpation, and discriminated from faecal accumulation. Colic due to the poison of lead, causing violent abdominal pain without rise of temperature, re- quires to be distinguished from the symptoms which mark the passage of a biliary calculus. Extreme suddenness and severity characterise the latter, and there is usually more vomiting in the passing of a gall-stone than in colic. But the history will have to bo investigated, and the evacuations, if any take place, should be examined. The absence of a blue line on the gums should be ascertained ere the possibility of the existence of lead colic is abandoned. Pain in the bins and back . — There are mat conditions which give rise to pain in these sittr tions, and which require to be borne in mind i examining a patient. Congestion of the kidney or nephritis, will be shown by the scanty, higl coloured urine, containing albumen and probab blood. Kenal calculus will be attended t unilateral pain in the loin, following the dire tion of the ureter, and affecting the correspom ing testicle. It is paroxysmal in character, at often horribly severe. The urine will conta blood, and possibly pus, and will be passed ve: frequently. As between such a condition ai the presence of an abscess or morbid grow! in the kidney, the points of diagnosis are a strongly marked, and careful observation will 1 requisite, in order to form an opinion. The pr sence of a bad stricture in the urethra, by causii retention and over-distension of the bladder wi urine, will cause pain referred not only to t! hypogastric region, but also to the back. Lumbago is characterised especially by i ability of the patient to rise from his chair wit out the greatest distress, and only slowly ai with difficulty. It may depend upon rheumatis of the muscles, or, still more probably, of su acute inflammation of the connective tiss between the muscles. Or it may be neurak in character, in which case it will be acute stabbing, paroxysmal, and independent of mi cular movement. Pain in the back is frequently caused flatulent distension of the bowels, and by acc mulation of retained faeces. It may be depends upon a tumour connected with the bowel (esp daily likely in the sigmoid flexure and rectur which may or may r not be felt by external p; pation, or reached by the observer's finger, inn ducedprr anum. Nor must it be forgotten tb an abscess in the wall of the rectum will cat long-continued and severe pain in the back, is well to remember that an undiscovered hen may give rise to little or no inconvenience e cept pain in the back. So likewise flexions a morbid growths of the uterus, and uleeratio about the cervix, may be the cause of pain, well as the approach of the catamenial peric which in some women is the cause of great ps in the back. Pains in the extremities . — These may be d to neuralgia, in which case they will be found occupy the district of one or more branches nerves, and to be paroxysmal in character. T pains which affect the extremities and the trui but especially the legs, in the early stage of comotor ataxy, are peculiar in this. A patie who has little complaint to make of his heal will every now and then be kept awake all nig and incapacitated in the day, by sudden, sha lightning-like pains darting through one or nr limbs, and often severe enough to make him e. out. They will occur in paroxysms, lasting hoc. days, or, less often, weeks ; and will subside' suddenly as they began. With such symptoms i patellar tendon reflex should always be test- Other pains affecting the extremities are rh; matic ; or of tho nature of the gnawing f ; aching pains which occupy the jo.nts in act inflammation front any cause, including rheur tisni, and in arthritis deformans. The joints n> PAIN. Iso be the seat of pains of a neuralgic cha- aeter. Treatment. — The treatment of pain is so in- olved in the causation, that but little can here ,e said with advantage on this point. It may be aid generally, that pain ought, if possible, to be elieved, for its continuance is exhausting and lischievous to the nervous system. Rest is, as rule, the first essential. Local applications, in he form of simple poultices, sinapisms, and ounter-irritant or anodyne liniments, constitute iae most ready means of relieving pain in many uses. Food of a suitable kind will often bo iae best means of relieving pain, and where the audition of the stomach prevents its being swal- Vwed, it is frequently desirable to inject susten- ance by enemata into the bowel. Constipation f the bowels, when accompanied by pain, should ever (except perhaps in the case of lead colic) e treated by purgatives. Belladonna, aceom- anied by minute doses of opium, is the best ceatment. The drugs which have the greatest ifluence as anodynes are, doubtless, opium and oloroform, but belladonna and Indian hemp re often used with advantage. They both equire to be used with caution. A habit of rcreasing the dose of opium (even when it is rnployed in the form of morphia with the hy- odermic syringe) is soon acquired. It is un- desirable to allow patients to inject themselves. [> is well, in all cases, to begin with a small ose, say gr. i morph ise — a dose which is sti- ulant and not narcotic. It is the narcotic dose hich apparently is followed by a sort of recoil, jhich suggests the need for a repetition and in rger quantity. « T. Buzzard. PAINTER’S COLIC. — Stnon. : Coliea Uclonum ; Lead colic ; Fr. Colique des pcintres; or. Malerkolik. — A form of intestinal colic, due ■ the presence of lead in the system ; so called a account of the frequency of its occurrence nongst house-painters. See Colic, Intes- xal ; and Lead, Poisoning by. PALATE, Diseases of. — 1. Paralysis. — - ae chief causes of paralysis of the palate are phtheria {see Paralysis, Diphtheritic) ; degene- tion of the nuclei of the medulla oblongata (see ujio-glosso- laryngeal Paralysis) ; growths the basis cranii ; and pressure on the nerves of e medulla. The two first usually cause bi- ;eral paralysis. Unilateral paralysis is com- ply due to cue of the two last causes. Disease the trunk of the facial nerve is commonly re- rded as an occasional cause of paralysis of the late. But this is certainly extremely rare in dal paralysis, and, in the writer’s opinion, its lurrence even is open to question. Symptoms. — In bilateral paralysis the palate ings flaccid, and irritation of the mucous mem- me excites no reflex movements. It is not sed in breathing or phonation ; a convenient t is to make the patient utter the sound ‘ ah ’ ‘a high tone; the central palate should be sed by the levator. Deglutition is interfered li, the soft palate being do longer raised so as 'jshut off the posterior nares ; and liquids are ced up into the nose by the contraction of ■ pharyngeal muscles. Speech is also affected ; 1 resonance of the nasal chambers gives to it PALATE, PARALYSIS OF. 1083 the 1 twang ’ which only the n and ng sounds should possess. The explosive consonants can- not be well pronounced, because the open passage through the nose prevents the air being suf- ficiently compressed to give the sudden sound when the passage between the lips is open. Hence p and b become f and v. Unilateral paralysis of the palate causes little interference with deglutition. The chief muscles which raise the palate meet, it will be remem- bered, in the middle line of the soft palate, and for this reason one muscle is able to effect suffi- cient elevation of the whole palate to prevent the regurgitation of liquids. The voice may have a slight nasal twang, but the articulation of the labial explosives is not interfered with. When at rest, the paralysed half is usually a little lower than the other. The uvula is said to be oblique, inclined towards the opposite side. It is, how ever, sometimes straight in the middle line. A change in form when the azygos contracts may be expected, but is not always to be observed. The chief indication of the paralysis is the un- equal movement, which is best recognised during the utterance of the sound ‘ ah.’ The elevation of the middle part being confined to one side, the base of the uvula is drawn a little towards the non-paralysed side, and a dimple forms above the bas9 of the uvula on that side only. By fara- disation a difference in the contractility of the muscles may be recognised, but the special ap- paratus and difficulties of application render this test not one of general application. Unilateral paralysis of the palate is often associated with paralysis of the vocal cord on the same side, and often with paralysis and wasting of the same side of the tongue. This combination is met with es- pecially when there is pressure on the nerves at the anterior part of the medulla. The paralysis of the tongue is, of course, due to disease of the roots of the hypoglossal ; that of the vocal cord to damage to the highest roots of the spinal ac- cessory nerve. These nerves-fibres arise in prox- imity, and the association of these three paralyses (first pointed out by Dr. Hughlings Jackson) con- stitutes strong evidence that the nerve-supply to the levator palati is derived from one of these nerves. Diagnosis. — The recognition of bilateral para- lysis of the palate depends on its immobility on voluntary and reflex stimulation ; that of unilate- ral paralysis essentially on the inequality of move- ment in the utterance of certain sounds. Difficulty in diagnosis is due to the frequent inequality of the arches, and obliquity of the uvula. The latter is so common undernormal conditions thatno weight can be attached to it as an indication of paralysis. The opinion that the palate is sometimes para- lysed in facial paralysis rests apparently upon the uvula being found to be oblique, and observ- ers have been strangely puzzled by the frequency with which the uvula deviates to, as well as from, the paralysed side, and have formed various ingenious theories to account for the phenomenon. The writer has never observed any defective movement of the palate or uvula in facial para- lysis, although he has looked carefully for it in scores of cases of various kinds. In the face of the strong assertions which have been made, hu does not venture to deny its occurrence, but ha 1084 PALATE, PARALYSIS OF. is convinced that most of tho supposed instances have been examples of natural obliquity. Prognosis and Treatment. — The prognosis and treatment of paralysis of the palate are those of its causes. Locally the muscles may be galvanised by a long electrode, insulated ex- cept at its extremity, and furnished with a con- tact key, so that the circuit is not completed until the instrument is in position. The difficulty of applying electricity for any length of time lessens, however, its practical value as a means of treatment. Food which is semi -solid is usually swallowed better than liquids. 2. For other diseases of the palate see Throat, Diseases of. W. R. Gowers. PALERMO, in Sicily. — Moist, warm, equable, winter climate. Mean temperature winter, 52'7° Fahr. Eighty days’ rain. Season, October to April. See Climate, Treatment of Disease by. PALLIATIVE {pallium , a cover). — A term u-ed in connection with the treatment of dis- ease. when it is directed merely to the relief or mitigation of symptoms. See Disease, Treat- ment of. PALLOR (Lat.). — Stnon. : Fr. Palcur; Ger. Bldsse. This term, which signifies whiteness or ab- sence of colour, is generally applied in descrip- tive medicine and pathology in connection with the state of the blood-supply of any part or organ. Pallor then denotes extreme de- ficiency of that healthy colour of the tissues which is referable to the presence of the red- corpuscles in the capillaries ; and indicates anaemia, whether due to contraction of the blood-vessels, diminution in the quantity of blood generally, reduction in the number of red- corpuscles, or relative deficiency of hsemaglobin in the individual corpuscles. In clinical medi- cine, pallor is most frequently associated with the visible portions of the surface, especially the face, tho lips, and the conjunctivae ; or with parts which may be readily seen by special methods of examination, such as the tongue, fauces, larynx, mucous membrane of the nose, and fundus of the eye. Sec Anaemia. J. Mitchell Bruce. PALPATION (palpo , I handle gently). — A method of physical examination, in which the hands are employed to appreciate certain condi- tions perceptible by the sense of touch. See Physical Examination. PALPITATION ( palpito , I beat or throb). See Heart, Palpitation of. PALSY. — A popular synonym for motor paralysis. See Paralysis. PALSY, Shaking. — A synonym for paralysis agitans. See Paralysis Agitans. PALUDAL I , , , , n , PALUSTRAL J (P alus > a marsh).-Of or belonging to a marsh. A term generally used in connection with malarial, or marsh fevers, on account of their frequent aetiologieal association with marshes. See Malaria. PANCREAS, Diseases of. — Synon. : Er. Maladies du Pancreas ; Ger. KrasiTcheitcn der Panekspeicheldriise. I PANCREAS, DISEASES OF. The pancreas is an organ of great important in the animal economy, as it produces a secre- tion of essential value in the process of diges- 1 tion. Nevertheless, owing to the eomparativt rarity of its diseases, their frequent associatio: with other lesions when they do exist, the posi- tion and relations of the organ in the abdomen and other causes, it must be acknowledged that perhaps there is no organ in the body diseasi of which it is more difficult to recognise during life, at least with anything like certainty. Ai the same time, it may be remarked that if" more attention were paid to the pancreas by the gene- ral body of medical practitioners, our knowledge' concerning its morbid states would probably! be greatly increased, and we should have more definite and precise data upon which to form r diagnosis. Many seem to forget entirely thai there is such an organ, and even when symptoms or signs point to it with sufficient clearness at any rate as being the possiblo seat of mis- chief, they ignore it altogether, and it neve; seems to enter into their calculatioa The writer'; experience has constrained him at the commenir- ment of this article to offer these remarks; but on the other hand, he feels it his duty to wan against attaching too much importance to the pancreas, and emphatically to express his dis- sension from all views which attribute the origin of certain special diseases to functional disorder; of this organ. Symptomatology. — Before considering the diseases of the pancreas individually, it will be expedient to discuss generally the clinical phe- nomena which may arise when this organ is in- volved. The most striking of these are due, not so much to the implication of the pancreas it-! self, as to its effects upon other structures with which it is anatomically so closely related ; tc their being involved in the morbid condition or to the intimate relation existing between its vessels and nerves, and those of other organs. 1. Subjective sensations. — Subjective sen- sations cannot be said, as a rule, to be of much value in the diagnosis of pancreatic affections, They are often absent, even when there is grave disease ; and when present are in many cases o. a very indefinite character. As regards their site the localisation of morbid sensations deep in the abdomen, in the region of the pancreas, a little abovo the umbilicus, might point to this organ There is no reliance whatever to be placed upon the influence of changes of posture in modifying them, as has been affirmed. 'With respect to theii nature and causation, it may, in rare instances happen that pain is felt in the pancreas itself or there may be merely an ill-defined sense cl uneasiness and discomfort, or of weight and op- pression. Deep pressure may then bring out more pain or oppression, or these feelings may only be experienced when such pressure is made More commonly, however, pancreatic disease gives rise to subjective sensations by its effect; on surrounding structures. It may cause pan and a more superficial tenderness than usual, by irritating the overlying peritoneum. IN hen the organ is enlarged and heavy, it may produce sensation of stretching and dragging, amounting occasionally to actual pain, and it is probable that under these circumstances different postures PANCREAS, DISEASES OF. Kght influence the sensation, it being most felt , the erect posture. The most important pain, iwever, connected frith pancreatic disease is at due to implication of the solar plexus and s ganglia, of -which the writer has met with L striking examples. Sometimes acute inflam- ation occurs, when the pain is of an acute cha- rter; or more commonly the nerves are merely [citated,and this is attended with paroxysms of vere neuralgia pain shooting in various direc- ts, which may amount to extreme agony. In jtlier case there is a feeling of great oppression, stlessness and anxiety, with a tendency to intness, or actual syncope or collapse. The ifering maybe very obvious in the appearance the patient. In one case the pain was greatly lieved by pressure. It might be supposed that paroxysmal pain would be associated with the ssage of pancreatic calculi, but of its occur- ,nce there is no adequate proof. It might happen at a continuous dull pain arises from erosion the spine, as the result of pancreatic disease. ,2. Disorders of Secretion. — It may be re- tried as a settled point in physiology that the ncreatic secretion is concerned in the digestion the starchy, albuminous, and fatty elements of pd; and that it not only forms an emulsion |th the fat, but breaks it up into fatty acids and ycerine. Hence it might be anticipated that ry obvious and definite consequences would iso from any disorder of this secretion, whether acting the quantity which is formed or which aches the intestine, or the quality and com- isition of the fluid. Such consequences have en attributed to pancreatic diseases, though air connection has been by no means clearly oved. Hyper-secrction has been supposed to give rise a form of pyrosis, the pancreatic juice entering i stomach, and being discharged through the utth by the act of eructation, as a more or s slimy and viscid fluid ; or there being a istant spitting of a fluid like saliva. This 5 likewise been attributed to salivation, the i.ivary glands secreting unduly, either from mpathy or vicariously — but this is a mere Viory. A form of chronic diarrhoea has also :n attributed to excess of pancreatic secretion, ' ich might at the same time be of irritating ulity, and this formerly received the name of 'i rrhoea or Jlitxus pancrcaticus, and was supposed lj)e characterised by the discharge in the stools i i quantity of viscid or tenacious liquid. That trie is any such special form of diarrhoea is, i:vever, extremely doubtful. \ deficiency or absence of pancreatic juice from I intestinal canal, or an abnormal quality of 1 3 secretion, may be attended with phenomena, II bably of a more reliable character, although He again caution is needed ; among other i sons because it must be remembered that the o irent secretions employed in digestion tend to t ce up for each other’s deficiencies. It is not tikely that these disorders may assist in origi- r m g symptoms indicating deranged intestinal dpstion as well as constipation. More rmpor- t : and definite phenomena, however, have been t rred to this cause. The chief of these is the f sence of a quantity of free fat or oily matter » he stools, which has not been digested and 108.5 absorbed, owing to the want of pancreatic juice. By some writers this symptom has been regarded under certain circumstances as pathognomonic of pancreatic disease. It has been found in a considerable number of cases, and experimental investigations lend support to the importance of the phenomenon. On the other hand, it has been chiefly noticed where the entrance of bile into the intestine was at the same time inter- fered with, and sometimes when this condition alone was present, the pancreas being healthy ; while it certainly is not always observed even : n grave organic disease of the pancreas, as the writer can testify. The amount of the fat has varied much in different cases, and also its cha- racter. It has come away like oil, with scarcely any fecal matter ; or, after standing, oil has floated on the surface of liquid feces. In other instances lumps of fat have been discharged, white or pale yellow and tallow-like, and the stools have even consisted almost entirely of these lumps. In other cases, again, it has been more or less crystalline ; or an oily fluid was discharged, which condensed on cooling, either around the containing vessel, or on the surface of the feces. It has been observed occasionally that the fat was far greater in quantity than had been taken as food ; this has been accounted for by the absorption of fat from the general system, in connection with wasting, to which re- ference will again be made, and its escape from the vessels into the intestinal canal. Another condition of the stools attributed to want of pan creatic secretion is the presence of an abundance of undigested muscular tissue in them ; but it is obvious that this can in no respect be regarded as a reliable sign. It will not be out of place to refer here to the proved value of the pancreas itself, or of preparations made from it and containing the active principles of its secretion, in aiding digestion in many cases, or in digesting certain foods before administering them, especially according to the plan so admirably worked out by Dr. William Roberts ( see Peptonized Food). This may prove of some consequence in relation to the diagnosis of pancreatic diseases, for it has been suggested that if, with the doily ad- ministration of calf's pancreas, the conditions of the stools above described disappear, this is an additional sign of the existence of pancreatic disease. 3. Symptoms from physical effects. — The intimate relations of the pancreas to important structures in its vicinity give rise to some of the most striking symptoms associated with its diseases, apart from the mere subjective sensa- tions already referred to. Of these, one of the chief is permanent jaundice, which often be- comes extreme, due to closure of the bile-duct. In the writer’s opinion this symptom becomes under certain circumstances a most important evidence of pancreatic disease. The pylorus or duodenum are also very liable to be obstructed, thus leading to chronic vomiting, often obstinate, with signs of dilatation of the stomach ; by pres- sure on the body of this organ pancreatic disease has been known gravely to disturb its functions, and even to obstruct its cavity ; or it has ulcer- ated through its walls, and given rise to gastric 1080 PANCREAS, perforation and haematemesis. The vessels in relation to the pancreas are also important, as being liable to be obstructed, and thus to give rise to symptoms. The veins are especially to be remembered, namely, the portal, superior and inferior mesenteric, and splenic, which may be pressed upon or closed by thrombosis. Henc6 may arise ascites, intestinal haemorrhage, en- larged spleen, and other phenomena, although in the writer’s experience they have been absent. The vena cava inferior or the aorta may also he more or less compressed, and in the latter case a pulsation or even a murmur may be .ransmitted through the pancreas, simulating an aneurism ; indeed this lesion has been actually caused by tile compression of the aorta by an enlarged pancreas. By the extension of pan- creatic disease other structures at a more or less remote distance may be interfered with; thus the ascending colon has been obstructed, and also the ureter, leading to hydronephrosis. 4. General symptoms. — It certainly hap- pens that pancreatic disease is not uncommonly attended with marked general symptoms, in the direction of wasting, which may reach extreme emaciation, with proportionate debility and anaemia. There are strong reasons for conclud- ing, however, that these do not depend merely on the want of pancreatic secretion, provided the other secretions are in sufficient quantity to make up for it. In those cases in which the general symptoms are observed, there are other causes to account for them, such as absence of bile from the intostine as well as of pancreatic juice, the nature of the disease itself, interference with the passage of food through the pylorus or along the duodenum, the implication of other structures besides the pancreas, or the presence of severe pain, causing much constitutional dis- turbance. It has been suggested that some cases of so-called Addison’s disease, with bronzed skin, are due to pancreatic disease, but this only occurs when the solar plexus becomes involved in a certain morbid process. Patients suffering from grave pancreatic disease are often very low- spirited and despondent. This may be easily accounted for, without attributing any peculiar influence to the pancreas in relation to melan- cholia and hypochondriasis, a notion which was at one time advanced and entertained. 5. Changes in the Urine. — In exceptional cases of pancreatic disease it has been affirmed that fat appeared in the urine as well as in the stools, either in the form of oil-globules, or of a greasy substance, becoming like butter on cooling. This was supposed to be due to the absorption of fat in the process of wasting, but further observations are needed on the subject. More important is the fact that various morbid conditions of the pancreas have been found asso- ciated with diabetes. These conditions include chronic inflammatory enlargements, atrophy, fatty degeneration, pancreatic calculi, and cys- tic dilatation of the ducts. In some instances diabetes follows the pancreatic disease ; in others it precedes it. In either case the diabetic condition probably depends, not on the pancreas, but on the implication of the solar and cceliae plexuses and semi-lunar ganglia, which un- doubtedly are sometimes concerned in the de- DISEASES OF. velopment of glycosuria. A theory has beer advanced to account for the presence of sugai in the urine, founded on the power of the pan- creatic secretion in decomposing fats and set ting glycogen free, but for this hypothesis there is no foundation. 6. Physical signs. — It is only in very ran instances that physical examination can de- tect the pancreas in health, and most of its; diseases do not alter the organ in such a manner as to render such examination of any value in! diagnosis. Moreover, even more or less marked physical changes are often difficult to be detected,; owing to the situation of the pancreas, and tc distension of the stomach, or pushing forward of the liver. It may be affirmed that palpation or manipulation is really the only practicable! mode of examination in the investigation oi pancreatic diseases, and it must be made when the stomach and transverse colon are empty, and the abdominal muscles thoroughly relaxed. The patient should not only lie on his back, but in some cases help may he derived from placing him on his elbows and knees; and pressure should not merely be made deeply from before backwards, but with both hands laterally from the hypochondriac regions. It may be possible to detect a general enlargement of the pancreas, as a slightly movable swelling, lying across the abdomen in its usual position ; but the im- portant condition to be looked for is a tumour of the head of the organ, which is deeply situated, always of small dimensions, rounded, smooth or nodular, usually very firm or hard, and firmly fixed, as if it were rooted in the depths of the abdominal cavity. Even if such a condition were found, however, it would be difficult to associate it distinctly -with the pancreas alone, but for all practical purposes it would be suffi- cient for diagnosis. The possibility of an en- larged pancreas being the means of communicat- ing a pulsation or murmur from the abdominal aorta has been previously alluded to. Special Diseases. — Excluding certain condi- tions of the pancreas, which are of little or no practical importance, such as malformations, displacements, and certain exceptional cases oi sudden haemorrhage into its substance, the in- dividual diseases of the pancreas may be con- veniently considered under two main groups, namely : — 1. Acute Inflammation. 2. Chronic Diseases. 1. Acute Inflammation. — Svxox. : -Acute Pancreatitis. — This is an extremely rare disease and it is one which, even when it does occur, is with great difficulty recognised during life. The results of the inflammatory process vary under different circumstances. ^Etiology. — Acute pancreatitis, as a primary affection, might possibly arise from some injury over the epigastrium, and it has occurred under other circumstances ; but the causes to which it has been referred are extremely doubtful, and it is better to acknowledge that we are ignorant as to their nature. As a secondary affection, it has been met with in severe cases of acute i'ebj rile diseases, such as typhoid fever and. acute tuberculosis ; and also inpytemie and septicamnc conditions of various kinds. It has been atnrmec PANCREAS. DISEASES OF. 1087 iat pancreatitis has occurred as a metastatic iflammation, in connection with a like eondi- on affecting the salivary glands or testicle ; but his is also a very questionable statement. Anatomical Characters. — These differ under ifferent circumstances. At first usually the ancreas becomes injected and hypersemic, en- ,rged, and firmer in consistence ; and probably, : some instances, the changes may not go irther, the gland returning to its normal con- tion. Small haemorrhages may take place .ito its cellular tissue, or around it, or these arts may become the seat of exudation. Sub- iquently, in certain forms of inflammation, sup- ..lration is liable to ensue, either in the form of a undent infiltration, or of one or more abscesses, ginning in the latter case as separate points 1 suppuration, which afterwards enlarge and balesce. It is a matter of dispute whether the fas is formed within the ducts and acini, or in the llular tissue. In rare instances gangrene has icurred, and, it would seem, especially where acre have been haemorrhages. From mere irri- tion, or the bursting of an abscess, peritonitis ay be set up. In the form of pancreatitis oc- irring in febrile diseases, the inflammation .sumes a parenchymatous form, other organs :ing similarly affected, a so-called acute paren- ymatous degeneration taking place, and the and becoming filled with granular and turbid iterial, of an albuminoid nature. Symptoms and Diagnosis. — In certain cases Lite pancreatitis occurs under circumstances : which no clinical indications whatever of eh a disease c in be expected, or at least any a definite nature. The earlier symptoms, lieh might lead to the suspicion of pancreatitis, 3 deep-seated pain in the epigastrium, with stric disturbance, and some degree of pyrexia, ssibly the slighter cases may subside after s, and recovery take place. In those cases, wev£r, in which the presence of the disease . 5 been verified, tho pain has speedily become : ense and continuous, and either of a dull Mracter, or shooting towards the back or shoul- 0. This was accompanied with deep tender- hs, and tension of the epigastrium, preventing i imination being made. The gastric symptoms 1 ame more marked, including eructations, nau- 1 , and vomiting of a thin or viscid liquid, ofren ( taining bile. There was thirst, and the ! vels were constipated. Other symptoms in- < led great restlessness, praecordial anxiety, 1 ried breathing, and a tendency to syncope, i h weak pulse. In fatal cases the symptoms i idly became worse, and death was preceded l the usual signs of collapse. Most of these I nomena havo been attributed to implication c he solar plexus. Signs of peritonitis might a! e. The diagnosis of acute pancreatitis must a ays be extremely uncertain, but in endeavour- i to make it, it is important to try to exclude a p gastritis or duodenitis, and conditions con- ned with the liver or bile-ducts. This affee- t does not seem ever to cause-jaundice. reatmext. — B ut little can be definitely said o his matter. The most obvious indications Q to keep the patient at rest ; to give only 6 11 quantities of liquid food ; to relieve the P i and gastric symptoms by means of ice, effervescents, with hydrocyanic aciu, opium, or morphia, and other suitable remedies ; to open the bowels ; and to give stimulants for the support of the patient, when these seem to be called for. Ice, or, on the other hand, fomenta- tions or poultices, might be applied with ad- vantage over the epigastrium in different cases ; and it has been recommended to apply a few leeches. Peritonitis must be treated if it should be set up. 2. Chronic Diseases. — It will be most con- venient to indicate, in the first place, the nature and origin of the several chronic diseases of the pancreas ; and then to discuss as a whole their clinical relations and treatment. (a) Changes affecting circulation . — Under this head it will only be necessary to mention that, in cases of general anaemia, the pancreas suffers along with other organs ; that in ail conditions which impede the portal circulation, w’hether in connection with the liver, or with the heart or lungs, this organ becomes the seat of mechanical venous congestion and its consequences; and amongst the latter haemorrhage is to be noted, which occurs in separate points, the blood sub- sequently undergoing changes, and its sites being indicated by altered pigment, or by spaces containing coloured serum, and having pigmented walls. Considerable haemorrhages, leading to the formation of apoplectic cysts, may take place into the pancreas, as the result of rupture of a diseased artery. A peculiar form of haemorrhage has been observed in connection with this organ, in which it becomes haemorrhagic throughout, and no marked change can be found in its sub- stance or in its vessels. Cases of this kind seem to be sudden in their onset, and rapidly prove fatal, but their nature and the real cause of death are undetermined. ( h ) Changes in growth . — -Many cases of either general or partial hypertrophy of the pancreas have been described; but some writers doubt the reality of a true hypertrophy or hyperplasia of the glandular elements, and maintain that the increase in size and weight of the organ in these cases was due to an increase in the interstitial tissue, or to other causes. This is one of the con- ditions said to have been observed in connection with diabetes. Atrophy is an undoubted morbid condition to which tho pancreas is liable. It has been observed as the result of old age ; in cases of general wasting from various causes ; in con- nection with diabetes, where it may become ex- treme ; or from certain local causes, namely, pres- sure upon the gland by morbid conditions in its vicinity, or by diseases within the organ itself. The degree of wasting varies ; but it may be so considerable that nothing is left except a fibrous cord indicating the former site of the pancreas. In lesser degrees the change is often associated with more or less fatty degeneration. (c) Chronic Inflammation . — That the pancreas is subject to a chronic inflammatory process can- not be doubted, but it is by no means clear what should be included under this term. The condi- tion usually recognised, and which is most com- mon, is that in which the organ becomes more or less cirrhotic or fibroid, either throughout its whole extent or in some portions of it ; the head is very liable to be thus affected. The changoa PANCREAS, DISEASES OF. 1088 essentially consist in an increase of the interstitial connective tissue, with wasting of the glandular structures, and the organ becomes proportionately indurated, dense, firm, and tough, and may be granular or irregular. Distinct tracts of con- nective tissue may be visible. This form of chronic pancreatitis may in various degrees result from prolonged venous congestion ; chronic al- coholism, especially indulgence in strong spirits ; retention of the pancreatic secretion, with dila- tation of the ducts; the irritation of morbid growths, such as cancerous or syphilitic growths ; or neighbouring disease, which affects the pan- creas either by directly spreading to it, or by causing pressure or irritation. In some of these cases a chronic parenchymatous inflammation seems also to be going on. Very rarely the pancreas becomes the seat of chronic suppurative inflammation, either by ex- tension from parts around, or from conditions in the organ itself, such as the presence of calculi or the formation of cysts. The pus either infiltrates or collects in one or more abscesses, and the latter may burst into the abdominal cavity or other parts, or dry up and become calcareous. Caseous masses, following chronic inflammation, may form in the pancreas, associated with similar products elsewhere, in cases of scrofulous or tubercular disease. (cf) Degenerations. — The pancreas is liable to the usual two forms of fatty change, namely, a fatty hypertrophy or infiltration, associated with obesity, which, though affecting the interstitial tissue, may eventually cause complete wasting of the glandular structure by pressure ; and fatty degeneration, which affects the gland-cells them- selves ; or the two conditions may be associated. In simple fatty degeneration the organ becomes gradually smaller, softened, and flaccid ; pale or whitish-yellow or brownish ; but its acini are distinct. A fatty emulsion may form in the ducts. The products of degeneration are absorbed or discharged, and coincident atrophy takes place, so that at last the organ may entirely disappear. This degeneration has been noticed as the result of alcoholism, in wasting diseases, and in cases of diabetes. Amyloid disease may affect the pancreas, but it cannot be said to be of any practical conse- quence. (e) Morbid Growths- Cancer is the most impor- tant disease affecting the pancreas. The growth is usually of the scirrhous variety, rarely of an encephaloid, a melanotic, or a colloid nature. In most cases it is secondary, the organ being usually involved by extension from neighbouring struc- tures, or now and then a distinct growth being formed ; but it also occurs as a primary affection. Pancreatic cancer is decidedly more frequent in males than females, and it is rare under forty years of age. The writer has, however, known it to occur in a young man twenty-three years old. Primary cancer has been attributed to injury over the epigastrium. As a rule the head is first implicated, rarely the body or tail ; often the disease remains confined to the head, but in other instances it spreads, so as finally to involve the en- tire organ, or separate deposits form. V hen the morbid condition is confined to the head, it pre- sents a more or less rounded tumour, varying in size, but never attaining large dimensions ; somf what irregular or nodular; very dense and hard i consistence ; and whitish on section. If the entir gland be affected, similar appearances are evider throughout its whole extent; but, if not, th unaffected portion may be the seat of atrophj chronic inflammation, or dilatation of the duct! with the formation of calculi. Distinct sma tumours are found in some instances. If th cancer be of other kinds than seirrhus, it will pr; sent the characters peculiar to each. Usually i exhibits under the microscope the structure ( scirrhous cancer, there being a large amount ( fibrous stroma. Pancreatic cancer always affects, in some way c other, neighbouring structures. It may simpl press upon them ; or it causes irritation, and tht sets up chronic inflammation, becoming adherer to various parts ; or the cancer may spread ; c, destruction and ulceration take place, invoh! ing the duodenum, stomach, vessels, peritonenn diaphragm, vertebra, or other structures; bd not uncommonly the parts are found so matte together at the post-mortem examination, that is impossible to separate them, or to say whet the disease began. The consequences of the s< condary effects of pancreatic disease have alread been pointed out, and need not be further di| cussed here, except to remark that the obstrnctici of the bile-duct., which is a frequent event, seen to be due, not so much to pressure as to contra, tion at the orifice or aloDg the course of the due, the result of chronic inflammation. As rare morbid growths found in the pancre.: it will suffice to mention sarcoma ; tuberel! either as a caseous nodule, or in the form granulations ; and syphilitic formations, whk may be of the nature of gummata, or of a cic- tricial tissue, involving the gland generally • locally. (J) Obstruction and Dilatation of the Ducts- Cystic formations. — The main duct of the pi creas — canal of Wirsung — may be obstructed or near its orifice ; or some of its divisions m. be thus affected. The former depends either upi conditions outside the gland, causing pressur such as tumours in the vicinity, enlarged gland a large gall-stone in the bile-duct, or thickenir and adhesions due to inflammation ; or upon ecr ditions in the gland or duct itself, namely, ma formations causing a bending of the duct, calcul new growths, chronic interstitial inflammation, > catarrh of the duct. One or other of these co ditions also accounts for any localised obstructio The effects of the obstruction will be to produi retention of the secretion, with dilatation of tl main duct and all its branches, either uniform unequal, or of limited portions of these, accor ing to the seat of the impediment ; and ultimate one or several cysts usually become develope which may attain a considerable size. In tl early stage the contents resemble more or less tl ordinary pancreatic secretion, but subsequent they become either serous, purulent, hsme rhagic, caseous, or cretaceous. The walls of t cysts become thickened and indurated, and, 1 encroaching upon the substance of the pancre.' at the same time setting up chronic interstitial i flammation, they may ultimately cause comple destruction of the organ. These conditions ha PANCREAS ieen occasionally found in connection with dia- 'stes. In rare instances pancreatic cysts have feen known to rupture into the stomach or duo- enuin. They have originated, in exceptional isea. from haemorrhage into the pancreas. ‘(a) Calculi and Parasites .- — Calculi occasion- ally form in connection with the pancreas, either its main duet, or, less frequently, in the di- 'sions, or in both places. There may be but one, a large number. They may bo very minute, or tain the size of a nut or walnut, or even larger Intensions. The concretions are usually white, greyish- white, occasionally dark or blackish, and or oval in shape, rarely branched, and ■\ooth or rough on the surface. As a rule they Isist mainly of calcic carbonate or phosphate, d not be at hand, the followi ng simple plan, suftsted by Reybard, will be found very effi- cie The cannula immediately below its ex- ter 1 extremity is surrounded by a linen petti- coa from two to three inches in length, which ■ s 'jl soaked in carbolic oil (1 to 10) before thejistrument is used. On withdrawing the trolir the petticoat hangs down, forming a cha el through which fluids readily pass out- wai. but which collapses instantaneously if lae is any tendency to the entrance of air. Thi!is especially useful in tapping the pleura. The ime result can be obtained by applying a PARACENTESIS. 1091 large veil of lint or rag, soaked in carbolic oil, over the cannula the moment the trochar is with- drawn. In tapping the cranial cavity or the peri- cardium very fine instruments, usually known as exploring trockars, must be used. In some cases, when the ribs are very close together, a flat cannula with a lancet-shaped trochar, may be useful. Before using a trochar it should be passed between the finger and thumb to feel if the free edge of the cannula is perfectly con- cealed by the wider head of the trochar. This is frequently not the case with old instruments, in which the cannula has lost the spring given to it by the two slits at the end. If the can- nula project it may push the pleura before it, the head of the trochar only entering the cavity. A cannula and trochar should be always kept separate when not in use, to prevent rusting, and the head of the trochar should be well pushed in- to a soft cork. A blunt or rusty trochar doubles the suffering of the patient. Immediately be- fore use the two parts of the instrument should be separately well washed with carbolic acid solution (1 to 20), or with some other power- ful antiseptic, and the trochar will enter more easily if it is greased with carbolic oil (1 to 10). These precautions are of the utmost im- portance. A dirty instrument has often caused the death of the patient, by exciting decomposi- tion in the cavity operated on ; and real cleanli- ness can only be ensured by dipping the instru- ment immediately before use in some powerful antiseptic. A perfectly bright and apparently clean instrument may be in reality coated within and without with microscopic dirt, which anti- septics alone can render innocuous. In using a trochar the instrument is held under the hand with the end of the handle in the hollow of the palm ; the thumb is placed upon the rim of the shield of the cannula, ready to push it off without necessitating the employ- ment of the other hand, and the forefinger is firmly pressed against the side of the cannula, at the point to which it is intended to limit the advance of the instrument. No preliminary in- cision is required if the instrument is in good order. It will only double the patient's pain and increase the risk of non-union of the wound. It is advisable to draw the skin aside from its normal position before introducing the trochar, so that the superficial and deep parts of the punc- ture may not correspond when it is withdrawn. A valved opening is thus made, which can hardly fail to close readily. Precautions. — When either of the large cavi- ties is tapped, if a large quantity of fluid is rapidly removed, the patient is apt to become faint. These operations should, therefore, bo always performed in the recumbent or semi- recumbent position, and stimulants should be at hand, the patient beiDg carefully watched. Should faintness occur the operation must be immediately suspended. If the patient fears the pain of the puncture, the skin may be frozen, either by the ether-spray apparatus, or by the application of a piece of ice dipped in salt. 1. Paracentesis Abdominis.— This term is usually applied exclusively to the operation of tapping the peritoneal cavity for ascites, or, in very rare cases, for free gas. When the trochar PARACENTESIS. 1092 ’.s used for tho relief of a distended bladder, or to empty an ovarian cyst or a hydatid of the liver, the simpler term ‘ tapping’ is invariably used. The operation for ascites is performed in the follow- ing way: — the patient must be made to empty the bladder immediately before the operation ; if there is the remotest possibility that this cannot be done perfectly by natural means, a catheter must be passed. A strip of flannel wide enough to reach from the nipples to the pubes, and long enough to go two and. a half times round the ab- domen, must be in readiness. Each end is to be torn into four or five tails. The middle of the flannel is then to be applied to the front of the abdomen, and the tails so arranged as to inter- digitate with each other opposite the spine. By pulling on the tails on each side a uniform elas- tic pressure is maintained over the abdomen during the operation, which facilitates the flow of the fluid, and diminishes the tendency to faint- ing. A circular hole is cut in the flannel at the point at which the puncture is to be made. The patient must be brought to the edge of the bed, and placed in the recumbent position, with the head low. If the quantity of fluid is not great, and the small intestines float up so as to come in contact with the lower part of the abdominal wall, it may bo necessary to raise the patient into a semi-recumbent position, in which the in- testines will float to the epigastric region. Hav- ing put the patient in position, the operator must himself percuss the abdomen between the pubes and the umbilicus immediately before inserting the trochar, and. he will, of course, not proceed with the operation unless there is absolute dul- ness. Having ascertained that everything h in proper order, the skin is drawn a little to one side, and the trochar is plunged sharply through the abdominal walls in the linea alba, at a point midway between the umbilicus and pubes. Other points have been recommended, as the linea semilunaris, but the middle line is now universally preferred. As soon as the trochar is withdrawn, the assistants pull firmly on the tails of the bandage, and continue to do so as long as any fluid flows. As soon as the fluid ceases to flow, the cannula is withdrawn, and a piece of lint, soaked in collodion, is applied over the puncture. The corresponding tails of the flannel bandage are then firmly tied together over the middle line of the abdomen. For ordi- nary cases the aspirator is in everyway inferior to the syphon trochar, and should never be used. If the patient should become faint during the operation the instrument must be withdrawn, the head put as low as possible, and some stimu- lant administered. Dr. Reginald Southey has recommended a more gradual evacuation, in preference to the rapid method above described. He employ's a very fine cannula, perforated laterally by nume- rous openings, and provided with a bulb-head and a shield. To the bulb-head is attached a long india-rubber tube. The cannula is inserted in the middle line, and fixed in position by strap- ping ; and the fluid drains slowly away T at the rate of about one pint per hour. The cannula may be allowed to remain in position, if neces- sary, for about twelve to twenty-four hours. Dr. Southey claims for his method the following advantages— simplicity; freedom from pain ; al sence of any tendency to syncope ; and the avoi: ance of the necessity for bandaging afterward Experience has shown that there is no risk > peritonitis. 2. Paracentesis Thoracis. — Sykon. : Thor centesis. — This is required for serous fluid d pus in the pleura, and more rarely for blood < air. Aspiration should always be preferred • the operation by the cannula and trochar (s Aspirator). Should the aspirator not be .■ hand, the syphon-trochar should be used; o failing that, one of the plans before mention! must be adopted' to prevent the entrance of a| during inspiration. The patient must be brong' to the edge of the bed, and placed in a sen recumbent position, well supported by pillow The spot selected for puncture varies great! It is generally agreed that the trochar shon never be introduced below the tenth rib on t left side and the ninth on the right, for fear wounding the diaphragm. The point mostcoi monly chosen is above the sixth or seventh r between the digitalions of the serratus magm which can usually be clearly seen. Should'D not be visible, any point may be taken in t proper intercostal space between the mid-axilki line and the junction of the posterior and midi thirds of the lateral aspect of the chest. T trochar must alway's be kept close to the upfl border of the rib, in orcftr to avoid the inti costal nerve and artery. In whatever space t operation may be performed the lower border the rib below the space should first be clea ' felt; the skin is then to lie drawn upwards the width of the rib, and the trochar thr sharply in immediately above its upper bord 1 H the instruments are in good order, and the i can be clearly' defined, no preliminary incis. is necessary. If, from partial absorption of ) fluid, without corresponding expansion of lung, the ribs have fallen very closely togeth it may be necessary to use a flat trochar, wit. lancet-shaped head. The precautions as to fai - ness and the closure of the wound are the sa- as in paracentesis abdominis. 3. Paracentesis Pericardii.— This ope- tion is now invariably performed with the ae- rator, as the results of the use of the orcLim trochar have been extremely' unsatisfacttf. See Aspirator. 4. Paracentesis Capitis.— This operation J been occasionally performed in cases of chro: hydrocephalus, but without any very marl benefit. It is not safe to use the aspirator.-' the vacuum might do unexpected damage tco soft a structure as the brain, while a srl trochar may be passed through tho expanl hemisphere into the ventricle without risk, ‘.e instrument used should be the smallest exp'- ing trochar. An elastic bandage must be it applied, so as to exert a very gentle pressure r the head. The trochar is then introduce:'! any point where bone is wanting, except in e situations of the sinuses. The best placo i one side of the anterior fontanelle. The mi t= line must be avoided, not only because ofw longitudinal sinus, hut because in the vast i- jority of cases the fluid is contained in the > tricles. The quantity of fluid removed sh « PARACENTESIS. PARALYSIS. 1093 It exceed two ounces. The elastic pressure 1st be maintained after the operation, which ijy be repeated at intervals of four or five days. Marcus Beck. PARESTHESIA (tt apa, a prefix indicating iegularity, and cuad^ais, sensation). — A term iplied to abnormal sensations experienced by patient, distinct from mere excess or diminu- tb of feeling ; for example, tingling, itching, jl formication. See Sensation, Disorders of. PARALYSIS (irapci, beside, and A I . sen or relax). — Synon. : Palsy ; Paresis (incom- t te paralysis); Fr. Paralysie ; Ger. Lcihmung. Definition. — Loss of the power of voluntarily editing the contraction of one or more muscles, i ho essential condition met with in all forms caiotor paralysis. And similarly, a loss of the psibility of transmitting impressions, either of t special senses or of common sensibility from lious parts of the body, from their seats of : ipheric commencement inwards to those por- v os of the brain which are concerned with t ir realisation in consciousness, is what is cjmonly known as ‘ sensory paralysis.’ These h er defects are, however, considered under the hd of Sensation, Disorders of. Here attention \d be confined to the subject of motor paralysis, t'vhicli, indeed, the term paralysis ought to be lilted. It is more fitting to speak of loss of station than of paralysis of sensation. ’aralysis Motor. — Motor paralysis may, in derent cases, be occasioned by defects in va- rus parts of the neuro-muscular apparatus. C tain primary differences of kind have first to liionsidered. A.) Certain muscles may not contract because Ir customary neural incitations are impeded olbortive at their source in the cerebral cortex -4> in certain forms of hysterical paralysis, or s; , result of definite lesions in some portions of tlbrain-region above mentioned. 3) Other forms of paralysis result because v rntary motor incitations are impeded in Dismission during some part of their course tl'iugh the nerve-centres, but below the corti- cijstratum of grey matter in which they take o in, Under this head are to bo included by f.'fthe larger number of cases of paralysis actu- al! met with; and according as the situation Wes in which the impediment to thetransmis- sij of motor stimuli exists, so do we get the pd.lysis occurring in different forms, that is, •ifking different distinctive groups of muscles, w ior without certain characteristic associations, m le shape of sensory paralysis or disturbance, ideations in the temperature of the skin over (hearts affected, and, after a time, alterations injie nutrition of the muscles whose functions at; n abeyance. These very numerous forms of psjysis fall into different classes, according asje disease or injury preventing the proper tr, mission of motor stimuli occurs (1) in some P'4 ons of their cerebral path ; (2) in some por- ti means so obvious in the muscles of the CO. The above constitute the characters which are the main to be relied on for the diagnosis of iralyses of peripheric origin. Still it must not i forgotten that when the ganglion-cells in the edulla or spinal cord, which constitute the rve-nnelei of the several motor nerves, are .sensed, we may have almost precisely the same fects produced as if the nerve-trunks had been maged in some part of their course — that is, (a may have in each ease the electrical ‘ reae- pn of degeneration’ followed by speedy atrophy the affected muscles. In this case, indeed [here we hare disease of an atrophic character nited to the nerve-cells composing the nucleus a motor nerve or nerves, we should have a rm of paralysis, tolerably well typified by ‘ labio- iosso-laryngeal paralysis,’ which might almost ith indifference be placed either in the eate- ry of spinal or of peripheric nervous diseases, 'ley wouldbe.it is true, spinal in seat; and t they would be attended by all the clinical aracters pertaining to disease of the nerve- unks — and this naturally enough, seeing that e disease would in fact simply affect the proxi- ial extremities of nerve-trunks. What has just been said will serve to explain w it is that in many cases of paralysis of spinal igin, that is, due to large * transverse’ lesions, riously damaging the grey matter of the cord, i may get, together with the wide or general stribution of such a paralysis, evidence that some of the muscles the electrical ‘reaction of generation ’ may be detected as well as early isting. These characteristics of peripheral ralysis will, in fact, occur in muscles where the ey matter at the roots of their nerves has been stroyed. In cases of paraplegia due to large insverse lesions limited to the cervical or to ie upper dorsal region, we might, therefore, l)k for and find the ‘ reaction of degeneration,’ th early wasting in some of the muscles of the per extremities or of the trunk, whilst we .mid not find these characters, nor be war- rted in looking for them, in the muscles of the ually paralysed lower extremities. Of course, in most cases of paralysis, the pa- int’s personal and family history, as well as the : de of onset of the disease, will help to throw Iht upon the question whether, in the case be- 1 e us, we have to do with a paralysis of ence- ) ilic, of spinal, or of peripheric origin. The further characters of paralyses of spinal I strike).— Paralysis of the lower ex» tremities, usually associated with paralysis of the lower part of the trunk, bladder, and rectum. See Paralysis ; and Spinal Cord, Diseases of. 1100 PARASITES. PARASITES (ir apa, upon, and onlw, I feed). Synon. : Fr. Parasite ; Ger. Parasit. Definition. — This term, in its most extended sense, is applied, in general pathology, to those living organisms which derive their nourishment wholly or in part from other living organisms. Parasites may be vegetable or animal— phyto- parasites or zoo-parasites ; may live upon the surface of, or in the textures or cavities of, the organisms they infest — ccto-parasites or ento- parasites ; and may pass through the whole cycle of their existence in the parasitic state, or only during certain stages of their life. This definition will include those organisms, such as tinea and trichina, which feed upon the living tissues of the hosts they infest ; those which subsist on the material prepared by the host for its own nourishment — for instance, torula and taenia; and, lastly, those which only tem- porarily sojourn on the surface of the body, for the purpose of obtaining food, and do not live, for any period of their existence, upon or within their entertainer — for example, fleas and gnats. The majority of these parasites may be re- garded as direct causes of disease, the pathology of which is now being made the subject of accu- rate investigation, and will be found described, so far as is known, in other parts of this work. A few only of the fungi, such as the blue moulds (penicillium glaucum), may be looked upon as a result of a morbid condition, being occa- sionally met with on the surface of old ulcers, in old cavities of the lungs, and on the nails. Vegetable parasites and animal parasites will be separately noticed in the following articles. PARASITES, Vegetable. — Vegetable pa- rasites are included under the general term of fungi. More accurately they are to be referred to the classes Sehizophyta or Protophyta, and Zygo- spore*, which are provisionally the lowest divi- sions of the sub-kingdom Thallophyta. To the order Sehizomycetes of the former class belong Micrococcus, Bacterium, Bacillus, Vibrio, Spirillum, &e. ; and to the order Saccha- romycetes of the same class, the various Torulte or Mycodermata, and Sarcina ventrieuli. These organisms are extremely simple, con- sisting of minute particles of living matter — spherical, cylindrical, filiform, curved, straight, or spiral. They occur in swarms, which are either lree, or imbedded in a gelatinous matrix — the zooglcea-stage. They contain no chlorophyl, and a nucleus is often wanting. They multiply' by fission. The cells of theTorulse, or yeast-plants, are frequently aggregated into simple or branch- ing rows; and in Sarcina ventrieuli the cells are arranged ingroups of four, sixteen, or thirty-two, presenting a very characteristic appearance. The numerous forms included under the term Bacteria are met with normally in many' situa- tions in the body; for example, they are an in- variable accompaniment of pancreatic digestion. Pathologically, they are of frequent occurrence in the blood, urine, and other fluids, and are re- garded as playing an important share in many contagious and other diseases (see Bacteria; Contagion; Micrococcus; and Zyme). The ferment-bodies — Torulse and Sareinae — are also PAROXYSM. found in the stomach during digestion, and the former are abundant in diabetic urine. In the class Zygospore* are comprised the filamentous varieties, such as O'idium albicans, and the various parasites to which the term Tinea is applied (Trychophyton tonsurans, AchorioD Schcenleinii, Microsporon furfur, &c.). W. H. Aixchin. PARASITES, Animal. — A strict defini- tion of the term animal parasites, in the writer’s view, should he understood to include ‘ all those forms of creatures which in a direct manner, by dwelling in or upon other living animals, or by merely visiting or momentarily aiignting on the surface of the body, are thus enabled to acquire means of subsistence.’ A definition of this comprehensive character not only em- braces a variety of creatures rarely spoker of as parasites, such as bugs, fleas, flies, mos- quitoes, and so forth, but it appropriately ex- cludes all those forms of animal life that merely play the rule of fellow-boarders ( commensals ci messmates of Van Beneden), and which, never- theless, are commonly looked upon as parasites Regarded from a purely zoological point of view the classification of the animal parasites is a matter of great difficulty ; but, for all practical purposes connected with medicine and hygiene it is sufficient to speak of the intestinal worms as forming three well-marked groups, namely : — (1) fluke-worms ; (2) tape-worms, including bladder-worms ; and (3) round-worms, including thread-worms. Under the heading Entozoa will be found a full list of the human animal parasites. For an explanation of various terms employed in connection with the study of animal parasites, the reader should consult the articles on Intestinal Worms; Helminths; A'eemes and Worms. The insect parasites (bots, maggots Sec.) are noticed under CEstrus. T. S. Cobbold. PARENCHYMATOUS (vapa, beside, and (yxns from it might be called diseases; but a lief characteristic of living bodies is, not fixity, t variation by self-adjustment to a wide range varying circumstances, and among such self- justments it is not practicable to mark a line Derating those which may reasonably be called althy from those which may as reasonably be ,led disease. The impossibility of marking such a line may tested during changes in any external condi- ns of life, for instance, in the adjustments of Ja skin to a widely varying range of external hperatures. Where and when in the changes skin produced hy long contact with water ing from 20° Fh. to 200° Fh. would health ise and disease begin ? Similarly, in the con- i ;uences of mechanical injuries. The complete iair and reproduction of injured and lost parts in excellent instance of health ; and in many ' nts injuries elicit a greater production of dthy structures than would occur in their i egrity— as in the leaf of a Begonia or a Car- >' nine, in which a fresh shoot may grow from 1 h of many wounds. But while these, and t'lilar adjustments to conditions produced by i lry, may be deemed results and signs of health, PATHOLOGT. 1101 many others, such as those which may follow severe crushings and open wounds of limbs, must rather be called processes of disease, even though they may end in some repair of injury. Among all the cases intermediate between these extreme groups of adjustment to consequences of injuries, it is not possible to separate the healthy and the diseased. In this impossibility of scientific definition the range of pathology is vaguely settled by a general understanding as to what may be called disease, and in this settlement are included all the states which are distant from health, whether they be in the way of diverging from it or in that of returning to it, as in convalescence. And some states are included for which it is hard to assign a better or other reason than that they are not useful to us. When fruits or other parts of plants or animals, which have been made use- ful by cultivation, revert to their more natural state and become useless, they are generally regarded as diseased. Moreover, in the study of any disease its pro- cesses are found, though different, yet not essen- tially distinct or separable from those of health. Even in the instances of the widest deviations from health, as in the diseases called specific or malignant, a considerable part of the phenomena are due to processes tending towards a reversion to health, and even the changes most averse from health are limited within certain methods not wholly unlike the healthy ones. In this view pathology may be regarded as an extension of physiology into the study of living bodies in conditions widely unlike those of their ordinary life. Pathology, herein, accepts the conventional limitation of physiology to the study of the nature of living things ; but the limitation is convenient more than just. It is not possible to give a verbal definition of the difference between the study of crystals de- formed or repairing after injury, and that of monstrosities and the processes of repair in plants and animals. As physiology is not truly limitable from chemistry and physics, so in patho- logy many processes are illustrated by things abnormal or contrary to general rule in dead matter. Pathology finds in physiology its basis, the varying standards of healthy structure and function with which its subject-matters are in contrast, and the models and methods of its study ; but its range is wider than that of physiology, inasmuch as the conditions giving rise to disease are much more numerous and more various than those of health. Moreover, the deviations from health may reach so far and wide, that the facts and general principles of physiology can only with extreme caution be applied to them. For instance, the greater part of what may he called personal characteristics in respect of health can only he observed in phenomena of disease. It is from observation of these that our knowledge is derived of dia- theses or constitutional peculiarities, and of con- ditions predisposing to overt disease. Of them and their various minglings and alterations hy inheritance, and by tendencies to reversion to- wards health, physiology can give no account ; its suggestions cannot be safely used unless 1102 PATHOLOGY. completely subject to the test of pathological inquiry. It seems certain that many erroneous and too narrow systems of pathology have been dervied from the beliefs of pathologists that they could safely, from the general truths of physiology or even from some section of them, infer what must be true in respect of disease. Hence, by means of inferences from the parts of physiology for the time-being most studied, ther6 have arisen the systems of vital and chemical, of humoral and neural, pathology, all containing many truths, but none of them able to stand the test, without which nothing in pathology should be deemed true — the test of a wide and direct study of diseases. It would be well if all sys- tems of pathology which can be thus specially named should be suspected of great error. The science of disease should not be divided or specialised on any other groimd than physiology may be, as by the names of general, comparative, animal , vegetable, and the like. The study of any one of these divisions, wide as it may be, is not safe unless with frequent reference to the others for their aid ; and every study of diseases of one part or of one kind is very unsafe, unless with a constant consciousness cf its narrowness and partiality. Even if it could be made sure that many diseases begin in morbid states of the blood or nervous system, or any other chief con- stituent of the body, it would be nearly as sure that within a few hours, or even minutes, of their beginning the other chief constituents would be involved. For the relations of the several parts are so intimate and, through the nervous system and the circulating blood, their means of communication are so swift, that if one be diseased none can long remain healthy. There is no truth more necessary to be held in pathology, and in its practical applications, than that the health of each part is a necessary condition of the health of all the rest. James Paget. PATJ, in western district of South of Prance. — Cool, variable, damp, calm, sedative, winter climate. Mean temperature, winter, 42° Fahr. Much rain and many cloudy days in winter. Soil, gravel. See Climate, Treatment of Disease by. PECTORILOQUY' ( pectorc . fwm the chest, and loquor, I speak). — A physical sign, connected with vocal resonance, heard on auscultation in some limited parts of the chest. The sounds of the voice in pectoriloquy are directly conducted to the ear, so that the words spoken by the patient may be distinctly recognised by the ob- server, as if proceeding from within the chest. See Physical Examination. PECTORILOQUY, WHISPERING. See Whispering Pectoriloquy ; and Physical Examination. PEDICULUS. — Three species of lice are parasitic on man: — (1) Pediculus capitis ; (2) Pediculus veslimenti vel corporis ; and (3) Pedi- culus pubis. 1. Pediculus capitis. — This species of pedicu- lus infests the head, especially the occiput, and deposits its eggs on the shaft of the hair, usually not far from the root. The ovum is a small, PELLAGRA. oval, semi-transparent body, somewhat cuppee at its free extremity, and very firmly attache; by a short peduncle to the hair. The youn|' are hatched in about five days. The louse whe; full-grown is about a line in length, the femal being larger than the male. The head, thorax and abdomen, which is oval, are distinct. Th. head is furnished with two short antenme, am large, black, prominent eyes. Springing froD the thorax are six well- developed legs, arms with strong claws, with which the animal grasa the liair. On the back of the male is seen .- conspicuous, elongated, conical organ, the penis] The animal is of a semi-transparent, dirty-whitj colour, and is covered with short scattered hairs. 2. Pediculus vestimenti . — This species close! resembles in shape and general appearance th’! pediculus capitis, but is of larger size. It in fests the under-clothing, with a preference fo: that of a woolly kind, and it attacks and irri rates the parts of the skin that are covered tr clothes. The ova are deposited, not on the hai of the skin, but on tho wool or fibre of th clothing, and the young are hatched in ahem five or six days. 3. Pediculus pubis . — This is much smaller aw, relatively shorter than ei th er of the other species and the line of separation between abdomen am thorax is less marked. The abdomen is shor and rounded, which gives the animal a crab-lik shape. Like the other species, it has six legs, armed with strong claws for grasping the hair! This louse infests the pubic region, and occa! sionally the axilla and hairy parts of the facei The ova are found firmly attached to the hair near the roots. The different speciesof pediculi do not bite, a they have no jaws ; but they pierce the skin an; draw blood by means of a sucking apparatus o kaustellum, and in this way they derive thei sustenance from the human body. Regarded b a pathological aspect, the presence of pediculi i described as a disease under the name of morbu: pedietdaris, or phthiriasis. See Phthiriasis. Robert LrrEKe. PELLAGRA ( pellis , the skin, and Hype a seizure). — Synon. : Fr. Pellagrc ; Ger . Pd lagra. Definition. — An erythema of the skin, Erg thema pcllagrosum. which makes its appearanc on the parts of the body most exposed to the light especially the back of the hands and neck am the breast. Pellagra has been regarded as a local coup d soleil, whence it is likewise called mal del sole The disease being indigenous to hot countrie; and common among the picasants in Italy, Spain and the South of France, it has there received th names of mal dc padrone, mal de misere, caitio 'male, and scorbuto Alpino. It has also been desig nated by authors risipola Lombards, rasa ■ Asia riensis, lepra Asturicnsis, elephantiasis Italics and elephantiasis Asturicnsis. These several name point to different features of its history, some times alluding to its appearance ; for example the ‘ red disease,’ mal dc la rosa ; sometimes t the class of people liable to its attack, namelj agricultural labourers ; sometimes to its ore PELLAGRA. roed cause — the sun, misery, and unwholesome lize ( raphania maistica) ; and sometimes to 'eoretical analogies, as in the instance of scor- ;tus, lepra, and elephantiasis. AStroLOGY. — The local symptoms of pellagra epare us for the consideration of a neurosis, which there exists undoubtedly a predisposing use, as well as an exciting cause and subse- |ent constitutional disorder. The predisposing iusos are heredity, which is unquestionable ; iverty ; insufficient and improper food and lathing ; malaria : and especially unwholesome jiizc, which constitutes the staple article of let in some of the countries wherein the disease endemic. A certain fungus, spnrisorium may- L-, has been accredited with being a special juse of the disease. The sun’s rays are regarded \\ the immediate exciting cause, and its pow r er I more particularly evinced in the spring of the ar, and has been expressed by the term ‘ ver- 1 insolation.’ Symptoms. — The local affection, to the outward |e, is at first an ordinary erythema, with a ten- ncy to centrifugal growth. ■ In the beginning jis of a dark-red colour, without swelling ; then becomes more or less deeply pigmented in the ;ntre; and later on, the area becomes bleached id atrophic, while the margin still remains tire. In its early stage the congestion of the jin is attended with tingling and prickling in; subsequently it loses its sensibility, and is bre or less completely benumbed. At a later riod of the local disease there occur desqua- ition, chapping, with exudation and incrus- don, and sometimes vesicles and pustules. The constitutional symptoms of pellagra are jjh as point to a serious injury of tho nervous btem. They are : — nausea, vertigo, heat of epi- strium, diarrhoea, lassitude, disturbed vision, imp and neuralgic pains; the pulse being ble, the tongue red, and the appetite vora- us. These symptoms are attended with pros- ition of strength and emaciation. They con- ue for a period of three months, and aro ble to be re-excited by every exposure to the 1 . The following spring the symptoms re- ■n with greater intensity, affecting more and ire deeply the nervous system and brain ; and ally the patient drifts into dementia, melan- plia, or mania. In the later periods of the dis- ,ie the patient is extremely emaciated ; the skin Uow and shrunken; the lips pale; the pulse ak, sixty to seventy in the minute ; and the iremities cold and tremulous. Serous effusion ' mrs in the cavities of the body, cerebro-spinal |1 visceral ; and the sufferers die from exhaus- ' n, sometimes from softening of the brain and Inal cord, sometimes from colliquative diar- jea, and sometimes from typhoid fever. Prognosis. — Pellagra is generally fatal after (jaw years when left to take its course; but ';My last for a period ranging between one and ' ty years. It is curable, when properly treated, die proportion of 78 per cent. fjtEATMENT. — The most successful treatment 1 pellagra is that which may be reasonably de- 1 :ed from an examination of tho causes of the tease, namely, improved hygienic conditions; nound diet of mixed animal and vegetable ■ d ; beer or wino ; and tonic medicines, espe- PELODERA. 1103 cially quinine, phosphates, and chalybeafes. To this general plan may be added, a careful avoid- ance of exposure to the sun, and the particular treatment needed for complications, for example the nerve-symptoms and diarrhoea. The local treatment should consist in the use of soothing and protective lotions and ointments, such as oxide of zinc and lime-water, or oxide of ziDC oint- ment; and pencilling the margin, when the disease is obstinate, with iodine liniment. In cases of the disease of small extent, such as are occasionally brought to this country from tropical climates, arsenic likewise will be found to be a useful remedy. Erasmus "Wilson. PELODEEA. — The Dame of a genus of ‘ free nematoids,’ one species of which (P. setigera, Bast.), according to the determination of the present writer, has been found as a parasite within the human body, under the following circumstances ; — In the autumn of 1879 a febrile epidemic prevailed amongst the boys on board the reformatory-school ship ‘ Cornwall,’ which was investigated, and reported upon by Mr. AV. II. Power, for the Local Government Board. The symptoms of the disease were in several respects related to those of typhoid fever ; in others to those of trichiniasis. Two months after burial, the body of the only boy who had died was ex- amined by Mr. Power and Dr. Cory. Erom the absence of all characteristic lesions, they decided that this boy had certainly not died from enteric fever. Mr. Power adds; — ‘ This conclusion was more than confirmed by the results of micro- scopic investigation conducted with reference to trichiniasis. In the very first specimen exa- mined — a few fibres from one of the abdominal muscles — was found a wandering and living tri- china ; and further search revealed the presence of these parasites in most of the muscles ex- amined. Although tolerably abundant, in none of the muscles had the parasite reached the stage of encapsulation.’ Doubts were subsequently expressed in some quarters, as to whether the parasites were trichinae ; and it was suggested that they were free nematoids belonging to the genus Rhahditis. All the existing microscopical specimens were therefore handed over to the present writer. The result wept to show that the creatures found were distinctly different from trichinae. They were in their mature state, of about the same size as embryo or muscle trichinae, and, as the drawings furnished by the writer show, they ex- hibited altogether different anatomical characters (see Ninth Report Local Government Board, for 1879; Appendix). He determined that the organ- ism was a previously unknown species of the genus Pelodera, to which he gave the name P. setigera. In relation to the fact that the members of this genus of free nematoids have hitherto been found ‘ in damp earth and decaying substances,’ and especially in fragments of muscle buried in damp earth, it is of importance to bear in mind that these particular nematoids were found alive in a corpse which had been buried for a period of two months. The facts go no further than this, with the addition that the boy died from the effects of an obscure febrile disease. All intermediate links as to source of infection, and as 1101 PELODERA. to the existence of the parasites in the body dur- ing life, or even shortly after death, are wanting. Should subsequent investigation confirm the view that the ‘ Cornwall ’ epidemic was occasioned by tho presence of the nematoids above referred to, then we should have to admit the existence of two distinct fleshworm diseases in the human subject, the one caused by the trichina flesh- worm, and the other by the pelodera flesh-worm. And, just as the one affection is now commonly known as ‘ triehiniasis,’ so might the other be designated ‘ peloderiasis.’ H. Charlton Bastian. PELVIC ABSCESS. — Definition. — An abscess situated in the pelvis, and generally con- nected with some uterine affection. .ZEtioloqy. — T he causes of pelvic abscess are : 1. Breaking down of tubercles; 2. Suppu- rative action, the result of broken-down haema- tocele or suppurating ovarian cyst ; 3. Inflam- mation of tho pelvic peritoneum ; and 4. Inflam- mation of the cellular tissue in connection with the uterine ovaries, broad ligaments, or the general cellular tissue of the pelvis. Pelvic peritonitis and cellulitis being often combined, pelvic abscess may arise from the joint action of these causes ; and, indeed, after an ab- scess has arisen, it is very difficult, if not impos- sible, to differentiate as to its primary origin. Symptoms. — Pain of a shooting character, with increased local tenderness, accompanied by rigors, sweating, and pyrexia, supervening upon the symptoms of pelvic cellulitis or of pelvic peri- tonitis, will generally indicate the onset of the affection. See Pelvic Cellulitis; and Pelvic Peritonitis. An abscess having arisen in the pelvis, it conforms to the same general laws as abscesses in other parts, its direction depending upon the tension of the surrounding tissues, an abscess generally burrowing in the direction of least resistance. Thus pelvic abscess may open in the following directions, singly or combined : — 1. Through the abdominal walls and saphenous openings. 2. Into the pelvic viscera, as the bladder, rectum, vagina, or urethra. 3. Through the floor of the pelvis, near the anus. 4. Through the pelvic foramina, either obturator or sacro- ischiatic. 5. Through the pelvic roof into the peritoneal cavity. 6. Into the lumbar region, in the position of tho kidney. Such are the many and various courses which an abscess originating in the pelvis may take. Eortunately some of those enumerated are rare, such as opening into the peritoneum. No doubt its starting-point has much to do with its subsequent course, which admits of explanation chiefly on anatomical grounds. Should an abscess open into the peritoneum, then our trouble will no longer be with the abscess, hut with the peri- tonitis that ensues, so that we may lose sight of the primary disease in the gravity of the secon- dary. Should the abscess open into the rectum, we shall have a discharge of pus and fecal matter, of a most fcetid character, by the bowel. On its opening into the bladder long-continued cystitis may supervene. Should a communication become established between these two organs, we shall PELVIC CELLULITIS. have the indication of fecal matter present i: the urine. Treatment. — Pelvic abscess must he treatec as deep-seated abscesses in other parts of thi body in the early stages, namely, by inducing pointing by hot fomentations or poultices; but when matter has formed the treatment will van somewhat, according to the position the absces" takes: — 1. When the abscess is threatening t< point above Poupart’s ligament, it is general]; wisest not to use the lancet until the skin is seer to be definitely implicated. 2. When the matte: is burrowing down the leg, or away from th* pelvis, beneath the fascise, it must be treated according to the usual rules laid down in surgen for deep-seated abscesses. 3. Should the matter be in the floor of the pelvis, bulging into the! vagina and rectum, and highly irritative symp- toms exist, then it will he advisable to empty L aspiration, or if pus be clearly observed, to opei with full-sized trochar and cannula. When th« fluid is evacuated, it is well to pass up a drainagi tube, carefully withdrawing the cannula, arc leaving the tube in position, through which hi! cyst should be washed out twice daily with : disinfecting fluid, such as some preparation o! iodine; the tube can be removed when thi discharge ceases to flow. Should haemorrhage have occurred in the cyst, the difficulty of evacua tion of its contents will be great; in this casei; has been recommended to lay open the cyst wi’J a bistoury. The posture the patient assumes is also o: importance, the pus should gravitate to th. opening; thus, supposing the opening in thi rectum or bladder, then the vertical posture nil expedite the cure. In the same way any othe: position may be assumed which fulfils this end. The general health must always he kept u] by the administration of tonics, good food, am stimulants, so as to counteract the exliaustiw due to the prolonged suppuration. J. Braxton Hicks. PELVIC CELLULITIS— Synon. : Para metritis (Schroeder. Virchow, and Matthew Duncan) ; Perimetritis. Definition. — An inflammation of the cellula tissue surrounding the pelvic organs, both inti) male and female, but much more frequently ii the latter, and therefore more especially of th. areolar tissue in connection with the uterus am its appendages. Various views have been heh with respect to the pathology of pelvic cellulitis each author giving a name according to his ide] of its origin ; though, indeed, two distinct affee tions, pelvic cellulitis and pelvic peritonitis, ar. described under the general name of pelvic cel lulitis. xEtiology. — The causes of pelvic cellulitis ar many and various, but it may be broadly statec that it may arise from any irritation to th mucous membrane, either of the uterus, vagina or rectum, whether septic or benign. Of thes the principal are traumatic, and consequent!; most cases are seen in connection with the puer peral state, and after operations connected will the female genital organs ; but in some persons due no doubt to some remarkable idiosyncras; of the patient, the passage even of a sound, or tin PELVIC CELLULITIS. itention of a pessary, slight cause as it may letn, is in itself sufficient to excite all the phe- Dme'na of pelvic cellulitis. Of the other than Lunatic causes may be mentioned dysmenor- icea, suppression of the menses, and gonorrhoea. Anatomical Characters. — It was not until (onat and Bernutz began to study the subject of ■Iric cellulitis that any progress can be said have been made in regard to its pathology, onat seems to have considered that the pelvic llular tissue was chiefly the seat of this affec- L n ; whilst Bernutz, writing shortly after- Lrds, denied that the cellular tissue was in any [y affected, and described it as an affection of je pelvic peritoneum ; lienee we have the term ■cri-uteri ne phlegmon’ of Nonat, and ‘ pelvi- ritonitis’ of Bernutz. Virchow, and Matthews mean, following his suggestion, have used the Has ‘ para-metritis' and 4 peri-metritis , ’ ‘ para-’ rmfying an inflammation of the cellular tissue, eri-’ an inflammation of the serous membrane grounding ihe uterus. Schroeder uses the ■m pelveo-peritonitis in much the same way as rnutz, and adopts the ‘ para-metritis ’ of Vir- tow. Cruveilhier, Champonierre, and Tilt have Anted out the share which they believe the ihphatics play in this disease, and to this they Jfe the name of lymphangitis. The terms pelvic (jlulitis and pelvic peritonitis appear in the no- l.nclature of the College of Physicians, and we h no good reason to alter the names. Patho- iically, no doubt, the distinction can be made ijnost cases, but clinically some difficulty arises, b! many and various have been the computa- tis as to their relative frequency. Schroeder [ uts out that, even pathologically, the false cyst i oelvic peritonitis may become so thickened as t/esemble that of pelvic cellulitis, and as the nSority of cases tend towards resolution, and a .here is a clinical difficulty as to diagnosis, e pled with their frequent coexistence, there mt always be some diversity of opinion as to tl r relative frequency. jelvic cellulitis being caused, as we have said, bisome irritation of the genital organs, the q ition as to the mode of its production, and tl part which the different tissues take in its ti salutation, has been frequently discussed. Si e, after the suggestion of Dance, supposed tb the venous system acted the part of the cajer in conveying the materies morbi. For a lo^ time the profession were content to receive thus an explanation of the phenomena, until Civeilhier and Champonierre showed the part 'vl|h the lymphatics played in this disease. Btjles this, there is reason to believe that, in th ; cases where the passage of a sound and bu; - like simple irritants are the cause of pelvic cel litis, the nerves must play an important pa ! to account for such a rapid effusion of so nr plastic material. Ivic cellulitis begins by an exudation of anibuminous nature into the cellular tissue. Thj as in other cellular inflammations, may bepie absorbed, the fluid portion first, and the lore solid portion at a later period ; or, tns .d of ending in resolution, it may take on a ret ;rnde metamorphosis, and end in abscess. '• » exuded material thrown out in pelvic «eh,itis, follows the same steps wherever it may TO 11G5 be situated in the pelvis, although its name and clinical symptoms vary according to its topographical distribution. But inasmuch as the effused material is thrown out into the cellular tissue near such a sensitive organ as the peri- toneum, the inflammation is liable at any time to spread to and involve this membrane, by reason of its continuity. The peritonitis may either become localised, or may spread and in- volve the whole membrane, giving rise to general peritonitis ; when the latter result occurs it is generally due to a septic cause, frequently spread- ing with extreme rapidity. It is highly probable that lymphangeitis plays an important part in cases of this kind. Symptoms. — A small amount of pelvic cellu- litis may in itself give rise to very slight symp- toms, perhaps merely a sense of uneasiness in the lower por ion of the abdomen. This is often the case in slow recovery from the lying-in state, and may be overlooked, a vaginal examination not being deemed necessary, the symptoms vary- ing much according to the rapidity and the quantity of the exudation. Should a large quan- tity be exuded, the most prominent symptoms will be more severe, namely, more or less tenderness on deep pressure, with dull aching pain in the pelvis, languor, and pyrexia ; along with these there may be obstinate constipation and pain in defaecation. Dysuria also may be a pro- minent symptom. The presence of the last two symptoms will depend upon the situation of the effusion, and its pressure on the rectum and bladder. Physical signs per vaginam . — -In the early stage, there being only an effusion of fluid, its detection will be difficult ; but as the matter becomes more solid, we shall be aware of a dense mass, usually limited to one or other side of the uterus, but if the amount be large, entirely sur- rounding the organ. This effusion is generally in the layers of the broad ligaments, either at- tached to or separate from the uterus, but usually fixed to it ; and when the effused matter has had time to consolidate, it is of considerable hard- ness, similar to that of a uterine fibroid, but generally irregular in outline, often following the form of the roof of the vagina. A uterus fixed by hard, irregular, and immovable swelling is considered by some as pathognomonic of pelvic cellulitis. Pain running down the legs, on flexion and abduction of the thigh, owing to implication of the lumbar nerves, simulating hip-joint disease, is also a valuable diagnostic sign in some cases. At the onset the temperature generally rises in the evening to 101° or 102°, rarely higher, and is lower in the morning. The pulse, according to Dr. Galabin, is full in the benign cases ; but in the septic form it is dicrotic, and towards the end in fatal cases be- comes extremely so. The pulse and temperature form a valuable guide as to the state of the case. Favourable cases may recover in a few days, but generally go on for weeks or months, the absorption gradually taking place, its dura- tion depending much on the general state of the patient and the amount effused. But should the case break down and end in abscess, the pre- sence of this will be shown by increased pyrexia, probably rigors, and localised pain of a shooting 1106 PELVIC CELLULITIS, character. For the signs of inflammation ex- tending to the peritoneum, see Pelvic Peri- tonitis. Diagnosis. — The diagnosis of pelvic cellulitis from the diseases with which it may be most readily confounded, will be found in the articles on Pelvic Hematocele, and Pelvic Peritonitis. Treatment. — When the pathology of pelvic cellulitis is fully considered, it will be seen that the treatment must depend upon the stage to which it lias advanced. In the acute stage we should limit ourselves to the administration of salines, and of sedatives for the relief of pain, opium being given internally ; and locally, hot fomentations applied to the lower part of the abdomen, and hot injections given per vaginam. Leeches are often applied with much benefit to the groin, perineum, or, still better, to the os uteri — three or four at a time, thereby removing any temporary congestion of those parts. The bowels are better moved by an enema, than by purgatives given by the mouth, which if active may cause extension of the inflammation to the peritoneum. When the inflammatory action has subsided, the re-absorption of the plastic material which has been thrown out is assisted by the administration of tonics, as iron and quinine. Iodide of potassium is much relied on by some practitioners, and may be given with advantage combined with tonics ; but probably the best means of promoting absorption is by restoring the general health by every method possible. The Americans and Germans recom- mend the vaginal douche night and morning for about twenty minutes ; they believe that it acts as an absorbent as well as a sedative. In the septic variety much success has attended the exhibition of large doses of quinine, five grains every four hours having been given with advan- taue. In all cases rest is imperatively called for, even after the inflammatory stage is past. J. Braxton Hicks. PELVIC HEMATOCELE. — Synon. : Peri-uterine Hsematocele; Retro-uterine Haema- tocele ; Pelvic Thrombus. Nature. — Nelaton described this affection as a tense bloody tumour situated in Douglas’s cul-de-sac, which pushed the uterus forward towards the symphysis pubis. Afterwards every bloody tumour in connection with the pelvic organs came to be so described by some authors. Thus Dr. Barnes classes ruptured uterus with an effusion of blood into the peritoneal cavity as an example of pelvic luematocele. Any effusion of blood which takes place either from ruptured uterus or from other organs is not by most authorities now considered as true pelvic haematocele ; indeed, blood effused from the liver, kidney, or other organ which has found its way into Douglas's pouch, might thus be included under this name. Pelvic hsematocele consists of two varieties, to which the names of retro- uterine heematoede, or better, intra-peritoneal heemaiocelc ; and pelvic thrombus, have been given. The first of these affections may be described as an effusion of blood into the retro-uterine sac, subsequently shut off from the rest of the peri- toneum by an effusion of plastic material. The second variety, pelvic thrombus , is an effusion PELVIC HiEHATOCELE. of blood into the cellular tissue of the pelv organs, and more especially of that in connectic with the uterus. Even with this limitation < applications, the frequency of pelvic liaematoce has been variously stated by different author- thus Scanzoni and Schroeder reckon it a ra; disease, whilst Zeyfurt reckons it as oceurrii in 5 per cent, of all uterine cases. Inasmui as most cases recover, the diagnosis must depei solely on a careful analysis of the clinic i history. It is well, however, that we should distmgui: between the two affections, and we shall employ f term t hrorabus as applying to an effusion of bloi| into the cellular tissue around the uterus, ai the term retro-uterine hamatoeele to blood whi ! has gravitated into the peritoneal pouch betwei the uterus and rectum. These distinctions a important, inasmuch as they can in most cas be discovered both clinically and patholo; cally. A. Retro-uterine Heematocele. — .Etiolo — The causes of retro-uterine haematocele are follows : — 1. rupture of the uterine wall from a cause, including aneurisms and varices ; 2. rapid of the Eallopian tubes (hsematometra) from exti uterine feetation; 3. ovulation and ovarian tumoi and 4. rupture of other viscera in the abdomii cavity. Symptoms. — -These will be the same as in f rupture of any viscus, and the escape of blq into the peritoneal cavity. Thus, there will sudden onset of pain ; prostration and collap. greater than can be accounted for by l ansemia ; often vomiting, which is at times cessively severe. Nothing can be felt at fi on physical examination, owing to the liq state of the blood ; but as the blood coagula: hardness will supervene, displacing the uteru- the amount and direction of the displace®: depending on the position which the blood ■ sumes. This, as has been pointed out, is ge- rally to be found posteriorly, thus pushing 1 uterus forward towards the pubes. In a sbf time inflammatory action may be set up, so a:i limit the effusion, and in this case will not bef a severe peritonitic type; but, on the otr hand, general peritonitis may be establish, which generally ends fatally ; or, again, e inflammatory process having become limfl by plastic material, it may follow the ud course of pelvic abscess. B. Pelvic Thrombus. — .Etiology. — a chief causes of pelvic thrombus are hsen^ rhage arising from interruption or suppress of the menses, or from sexual excitement ; d haemorrhage from diminished resisting powert the vessels, in the haemorrhagic diathesis, sr- butus, or purpura. Haemorrhage which has thus arisen mayfow the usual course of extravasated blood, nany. coagulation and absorption, or proceed tom formation of an abscess. Symptoms. — These will depend on the amnt of the effusion and its position. In general* quantity will be less than in retro-uterine hai- tocele. It is generally greater when it oers in the layers of the broad ligament, which it 0 separate to a very considerable extent, rea: l s sometimes to the level of the umbilicus. l r PELVIC HEMATOCELE, ver, blood effused into the cellular tissue is ecessarily under restraint, though the pain would |e thereby increased. In this, as in the affection just described, we aye a sudden onset of symptoms, but we do not lave such marked anaemia, for the amount of he effusion is hardly .so large. And we miss Lose symptoms of severe collapse which depend ;pon an effusion of blood into the peritoneal ivity. In fact, here we have more the symptoms . f haemorrhage per so, as in any other case of rtmorrhage, the effusion being situated outside le peritoneum. We seldom have symptoms of Britonitis supervening, but rather those due to ie displacement which the mass occasions. The [fusion may either be absorbed, or it may end . abscess, which pursues the usual course of slvic abscess. Sec Pelvic Abscess. Diagnosis. — These swellings, produced by blood- fusion, are liable to be confounded with many her troubles about the uterus. The most fre- quent position is in either broad ligament, where iey may simulate fibroma, ovarian tumour, and Specially cellulitis of the same part. The next psition in frequency is behind, in the cellular ssue between the uterus and rectum, where the iematocele may imitate retroflected uterus or ,mour in Douglas’s pouch. When the hoamor- iage is found at the roof of the vagina, or I 'tween the bladder and uterus, it gives the lysical characters of a fibroma in the anterior ill, of pregnancy, or of cellulitis. It will thus : seen that the diagnosis depends much on a par clinical history, either from the patient or t friends, which in some cases is difficult to tain. ; Treatment. — This divides itself into two ,rts, the first of which will be the arrest of the Ismorrhage (should it still be going on) ; and e second, the application of such means as tend resolution and absorption of the coagulum. lie first indication will be fulfilled by absolute Jit, and the administration of haemostatics, such gallic acid, lead, turpentine, and other like nedies on which we are wont to place reliance i 1 internal haemorrhage, combined with opiates, it inasmuch as vomiting is often a severe and [eminent symptom, and medicines are with acuity kept down a sufficient time to he of (vice, the opiates may have to be given by the ! tum or hypodermically'. Ice-bags or, if these not at hand, cold lotions, should also be ap- id to the lower part of the abdomen, or even coduced per vaginam. At the same time a -nle ice may bo given to suck. Small doses ojopium, or any of its preparations, repeated alintervals if they can be retained, tend both tpiet the circulation and support the system ujinst loss. Stimulants, however, and hot djiks must be avoided. If rupture of an extra- urine cyst be supposed the cause, or rupture °i]-n ovarian varix, it may be advisable to per- fi;a abdominal section. Jhe haemorrhage having ceased, we must still e j'iu rest for some time, to prevent its recurrence, » to admit of the blood being absorbed. 1 fulfilling the second indication, namely, tl resolution of the extravasation, little will be rt lired beyond keeping the system in good gt ral health by the administration of tonics. PELVIC PERITONITIS. 1107 Iron and quinine are of much service. Som« practitioners rely on iodide of potassium as an absorbent ; it may be given combined with quinine. Should a recurrence of the haemorrhage take place at different periods, the bromides and iodides have been considered of some value in quieting the action of the ovaries. If the case unfortunately end in abscess, the proper treatment will be that of pelvic abscess. Sea Pelvic Abscess. J. Braxton Hicks. PELVIC PERITONITIS. — Synon. : Peri- metritis (Bernutz, Virchow, and Matthews Duncan). Definition. — A local inflammation of that portion of the peritoneum surrounding the pelvic organs, and especially the uterus and broad liga- ments. See Pelvic Cellulitis. Etiology. — P elvic peritonitis is often found as an extension from pelvic cellulitis, both in the puerperal and non-puerperal state. In the non-puerperal state it is associated with uterine flexions and versions; various operations on the genital organs ; rupture of ovarian cysts ; absceso of tho ovary ; escape of blood from the Fallopian tube; gonorrhoea; malignant disease; carcinoma; and tubercle. Anatomical Characters. — Here, as in cellu- litis, the part which the veins, lymphatics, and nerves take is still open to controversy; but the lymphatics, no doubt, take the most important part. Whatever the origin of the peritonitis we have, in the first place, an effusion varying in character — either serous, plastic, or purulent. The serum may either be absorbed, or become encysted by plastic material, and form a false cyst, -which, in an unhealthy condition, may be of a pyoid nature, forming an abscess having the usual characters of pelvic abscess. But there is this difference from the exudation of pelvic cellulitis and that of pelvic peritonitis, namely, that in cellulitis the exuded material may be absorbed, leaving but few, if any, relics of the bygone inflammation, whilst in peritonitis the fluid portion is chiefly absorbed, leaving very often strings or bands of adhesions matting together the various organs. A not uncommon occurrence is for the uterus, if previously retro- flected, to be bound down posteriorly to the sacrum, but it may be equally fixed in any other direction in which effusion has been poured out. The effect of these adhesions is curious, for the ovary has been rent from its attachment, and fixed to the pelvic brim posteriorly. These adhe- sions may stretch and give rise to no permanent displacements, but at other times they are irre- mediable. Pregnancy seems to have most influ- ence in their removal; and, indeed, this has been suggested as a method of cure. In the same way they may hinder the action of the uterus in labour, and cause pain by their rigidity, though they often hinder conception or give rise to abor- tion, and sometimes to severe and even fatal obstruction of the bowels. The influence of adhesions should always be borne in mind after any case of pelvic peritonitis. Should the case end in abscess it may open in any of the ways given under the head of [ Pelvic Abscess. PELVIC PERITONITIS. U08 Symptoms. — In chronic and subacute cases of pelvic peritonitis, the symptoms are usually ob- scure, the patient (often after childbirth) com- plaining only of a dragging sensation at the lower portion of the abdomen. These cases fre- quently pass unnoticed, rest in bed and other remedies sufficing to effect a cure. In acute cases, the symptoms begin with com- plaint of a severe pain, increased by pressure, with fixedness of the abdominal muscles in the lower portion of the abdomen, or the coils of the intestine may be seen mapped out. Along with this there is usually a wiry pulse; but if the disease be of septic origin, it may be dicrotic. The temperature is usually above 102°, but varying night and morning. We may also notice a Hippocratic expression of the countenance. Should this become marked we should have reason to fear an extension to the general peri- toneum. At the same time we may have consti- pation, and generally severe vomiting ; and by pressure of effused material on the bladder and rectum, there may also arise constipation and dysuria. Pervaginam , we may discover a tumour laterally high up in the pelvis, and not easily felt, both on account of the distance from the examin- ing hand, and from the severe pain to which examination gives rise. But again, it must be pointed out that cases do occur in which nearly all the symptoms are wanting, although the attack may be of a most malignant type, the rapid pulse and pyrexia, coupled with a peculiar expression of the coun- tenance, being almost our only guide. A vaginal examination fails to give us any indication as to its nature, owing to the matter being purulent and fluid. These cases are almost always of septic origin. Diagnosis.— Pelvic peritonitis may be dia- gnosed from pelvic cellulitis by the following considerations : — Pelvic Cellulitis. 1. Tumour easily reached; generally easily and early felt in neighbourhood of broad liga- ment, and above pelvic brim. 2. Abdominal pain, increased by deep pres- sure. 3. Temperature usuallynot above 102°; pulse full, soft, dicrotic in septic form. 4. Retraction of thigh with abduction. Pain down leg. 5. Nausea ; vomiting, not excessive. 6. Not accompanied by tympanites. 7. Marked tendency to suppuration. Pelvic Peritonitis. 1. Tumour not noticeable for some days. 2. Abdominal tenderness of an acute kind, quickly increased on pressure. Form of coils of intestines mapped out on abdomen. Fixation of abdominal muscles. 3. Temperature above 102° usually; pulse wiry in benign, dicrotic in septic form. 4. Pain down leg and retraction of thigh never present. 5. Nausea; vomiting excessive. 6. Tympanites present in severe cases. 7. Constipation, often marked. 8. Suppuration not often present. Treatment. — In all cases of pelvic peritonitis whether acute or chronic, our chief point isresi and this cannot be too rigidly insisted upon. Th* stage of the disease, whether chronic or acute will indicate the amount. Should the case be o a subacute nature, then reclining on a couch wil be all that is necessary; but should, on theothe hand, the case be acute, however limited in area then it is essential that we should order absolut rest in bed, as little movement as possible bein;. allowed. In chronic cases this point must l left to the discretion of the physician ; it will b 1 for his consideration what part the local eon dition bears in relation to the general health and whether continuance of the local troubl’ will not cease on restoration of the genera health. The next point to be considered — and wekhot of none in which so much mischief is done b want of appreciation of the true condition — i the administration of purgatives in the acut forms. The same rule holds good here as in th treatment after an operation for hernia, name!} that any increased peristaltic movement of th intestines is liable to cause an extension of th peritoneal complication. We must bear in min that what the inflamed peritoneum wants is rest to lessen the friction of the surfaces; and shod any unhealthy matter be present, time is to gently required for the effhsion of a limitin, plastic material, to shut it off from the rest c the abdominal cavity; and after its formatioii still further repose is necessary to prevent it being broken down. Thus it is that we find on sheet-anchor lies in the administration of fu doses of opium, which not onlij allays the sens tiveness of the peritoneum, but limits the per staltic movement of the intestines. If thebowe are unrelieved for fourteen to eighteen days, n harm will accrue. A mild enema of olive-oil an gruel will be the best measure to adopt wher necessity requires relief. In the more chronic cases, for the same reasoi we should never purge our patient, for there always a risk of extending the inflammatory ai tion to the general peritoneum ; a mild lasativ daily, or, better, an enema, will answer ever purpose. If, from the severity of the constitution; symptoms and the absence of the local, we hat reason to believe that we have a case of sept, origin to deal with, quinine must be given j large doses, say five grains every four hoars, i mouth, by the bowel, or hypodermically. Vei marked results have attended the exhibition < this drug in cases otherwise almost hopeles Sixty grains a day have been given without i result — indeed with the cure of the patien Should the peritonitis appear to be of a pure, sthenic form, the employment of the old remed mercury, will generally he found to be a val' able addition to that of the opiates, at any ra for a short time ; but in any case great caution required lest diarrhoea be induced. In thisfor the employment of leeches to the abdomen w also assist in the reduction of the inflammatio Care, however, must be observed not to debilita the patient. Hot opiated fomentations to tl lower part of the abdomen in all cases aft'o: great relief. Should the case lapse into a chron PELVIC PERITONITIS. ste, iodide of potassium may be of some service aiding tlie absorption of the inflammatory pro- mts. The bromide has also been given with ,e idea of lessening congestion and quieting the (tion of the ovaries. At a later date much good will result from the (ministration of tonics, and from change of air, ,e local trouble being often kept up by the neral condition. Such are the chief indications of treatment, uniting, dysuria, and other complications must treated on general principles. J. Braxton Hicks. PEMPHIGUS (ireVifuf, a bladder). — Saxon. : impholyx ; Fr. Pemphigus ; Ger. Blasenkrank- \t. Definition. — A somewhat rare skin-disease, ( indefinite duration ; in which blebs or bullae, Staining serous or sero-purulent fluid, form in ^sater or less numbers on various parts of the jfly and limbs; burst; dry up, and produce ists; and finally disappear, leaving temporary .ins, but no permanent scars. .Etiology. — At Vienna Hebra found one case .- chronic pemphigus in 10,000 adult persons. i 29,535 patients with skin-diseases of all kinds, eluding the acute exanthemata, there were in trteen years 66 cases — 16 in men, and 20 in imen. At Prague, in five years, out of 38,546 sc children, 54 had pemphigus, 24 being boys ill 30 girls. Pemphigus is much more frequent .children than in adults, and most frequent in t, first eighteen months of life. At Prague 2of 54 cases were under one month old. In silts all ages are nearly equally disposed to it. in childhood females seem slightly more eposed than males ; in adult life pemphigus tgaris attacks three times as many men as men. Pemphigus foliaceus is more frequent i women. Neither geographical distribution, s.son of the year, nor any special diet or habits c. life seem to affect the development of the (ipase. It occurs in persons of all tempera- rats, and in the healthy as well as in the deli- c ;. No definite relation can be traced between (langements of the kidneys and pemphigus, or t ween the latter and the gouty or rheumatic d, dieses. In a few instances there has been aiistinct relation between pregnancy and the ojireak of bull®. Pemphigus is never en- due. Various epidemics, chiefly among chil- d';i, have been described by trustworthy writers, o which the latest occurred in 1869 at Halle, a in 1874 in Paris, both in new-born infants, t> it seems doubtful whether these were cases oi- , rue pemphigus, and not rather allied to vi cella. Outbreaks of pemphigus have ap- pj’edin more than one case to be determined H local injury, such as a puncture of the fin- gt There are one or two instances known in W 'h the disease has been transmitted heredi- ty. J few cases of localised outbreak of bullae — fojixample, on one hand and arm — have been re rted in connection with injuries of peri- P 1 si spinal nerves, and chronic meningitis and ®1 itis of the spinal cord. -mphigus is a non-contagious disease, and dsttempts to transfer it from one person to PEMPHIGUS. 1109 another, by inoculating the contents of the bullse, havd failed. Anatomical Characters. — In pemphigus the capillaries of a circumscribed portion of skin are dilated with blood, and this hyperaemia is fol- lowed by exudation from them of serous fluid, which infiltrates the papillae and the cells of the rete mucosum, and finally makes its way beneath, the epidermis, so as to raise and separate its uppermost layers from the parts below, thus forming a bulla or bleb. The parts of the epi- dermis which are connected with the hair-folli- cles resist the pressure longest, but at length give way, and their remains then hang from the under surface of the covering of the bullae as small threads or processes. The contents of the bullae consist at first of nearly pure serum, which gives on heating a floceulent deposit of albumen ; later on the fluid contains numerous pus-cells, probably due partly to migration of white blood-corpuscles, and partly to proliferation of the rete cells. Occa- sionally it contains small quantities of blood exuded from the surface of the cutis. Bacteria were found in one case during life (Sangster). The reaction is at first neutral, but is faintly alkaline in the older bullae. Soda salts predo- minate over potash salts. In two cases Jarisch has detected urea. No light has been thrown on the nature of the disease by a chemical exami- nation of the urine, or of the blood, although Bamberger believes that there is an excess of ammonia in the latter. No post-mortem examination has as yet re- vealed any constant alteration in the organs or tissues which would account for pemphigus. General anaemia, and wasting of the muscles and other parts, have been found in uncomplicated cases, while some patients have died of intercur- rent pneumonia and of phthisis. In more than one instance amyloid degeneration of the liver and spleen has been found, just as in other chronic wasting diseases. Description. — Pemphigus may occur with- out apparent assignable cause in a previously healthy child or adult. The bullse may form on a perfectly normal skin, or else a circumscribed portion of skin becomes hyperaemic, and the epidermis over it is raised by a rapid effusion of serum into a bulla, which enlarges quickly, so as to outstrip and cover its base. The bullae are mostly hemispherical in shape, and may reach the size of an orange, or larger ; but, as a rule, they vary from that of a pea to that of a hazel-nut or w T alnut. Their contents are at first clear and transparent, but in a day or two they become milky and opaque, and finally purulent. The coverings, previously tensely filled, burst ; and the discharge dries into flat yellow-brown or blackish crusts. The bullie tend to a sym- metrical distribution on the two sides of the body, and also in some cases to an arrangement in circles or semicircles. They may also spread peripherically, fresh bullae forming at the edge of the crusts, or stains of old ones. There is no areola or swelling around the bullse, but red lines are sometimes noticed running outwards from them, probably duo to inflamed lymphatic vessels. At the same time as the skin is affected, small bullae generally form on the PEMPHIGUS. 1110 mucous membrane of the mouth, nose, and pha- rynx ; and they have been seen with the laryngo- scope cn the posterior surface of the epiglottis. They have also been found post mortem on the mucous membrane of the bronchi and of the intestines, and are probably the cause of the diarrhoea and bronchitis from which pemphigus patients sometimes suffer. Pemphigus has a marked tendency to recur at longer or shorter i nter vals, each outbreak being made up of a num- ber of successive crops of bullae. A few bull* may in no way affect the general health, but if they are numerous they may be preceded by rigors and fever — 102° to 103° Fahr. — and even by deli- rium and other cerebral symptoms in children. The disease may terminate after one or two attacks, or may recur at intervals and with in- creasing severity for years, until the patient is reduced in health and strength, and finally dies in a marasmic state, or of some intercurrent disorder. Classification. — We may divide pemphigus into three main varieties:—!. P. acutus ; 2. P. chronieus ; and 3. P. foliaceus. Other varieties, such as P. solitarius, when only one bulla exists at once ; P. gangrenosus, where ulcers succeed the bull* ; and P. pruriginosus, where itching is a conspicuous symptom, have been described, but they scarcely merit detailed notice. 1 . Pemphigus acutus. — By this we understand a bullous eruption which occurs only once in the same individual, has a short duration of from three to six weeks, and generally terminates in complete recover}'. The existence of such cases, which was at one time doubted, is now certain. In its general symptoms P. acutus resembles the acute specific diseases. There is a prodromal stage, a rigor, great prostration, and albumin may appear in the urine (Senftlebon). Fatal cases have occurred. 2. Pemphigus chronieus scu vulgaris. — This, the P. diutinus of Willan.is the most usual form, and the one to which the above description cor- responds. This form may assume a malignant character by the number of bull* present at one time, and by their prolonged duration and rapid recurrence, so that tho patient’s health is under- mined. 3. P. foliaceus (Cazenave). — Under this name has been described a form of pemphigus of a peculiarly malignant character. The bull® are few and small at first, and they are never tensely filled with fluid. Other bull* form round each central bulla, or else the latter spreads peripherically pci' continuum , until at last nearly the whole surface of the body is involved. At the same time the skin does not heal over the situation of the older bull*, but remains moist and raw, and covered either with crusts like those of impetigo, or else with the loosened coverings of the bull*, which form large lamell® or scales, from which the disease derives its name. The scales have- been likened to flaky pastry. This form is happily ex- tremely rare, for it is always fatal. Complications. — Pemphigus has been seen occurring simultaneously with small-pox, and with purpura. Several cases have been reported in which a form of pemphigus occurred in the serly weeks of pregnancy, and continued until delivery. In one ease the disease recarrec during several successive pregnancies. Pem- phigus pruriginosus is a name which has ben given in cases where the disease has been accom panied by severe pruritus. Diagnosis. — The fully-developed eruption o pemphigus is too characteristic for it to be mb taken for any other disease. The diagnosis mu' be difficult at the onset, when only a few bulla have appeared, or else towards the terminatiji of an attack, when only scabs or stains are left ' in the first case the absence of cuniculi willdisi tinguish it from some rare cases of scabies of purely bullous form. At the outset it may bi also necessary to distinguish its bulla fron those occurring in erysipelas; from the use o artificial vesicants ; from burns ; and from th< friction of shoes, clothes, or contiguous portion: of skin. The bull® of herpes iris invariabh commence on the backs of the hands and feet run a rapid course ; and assume a concentrl circular character. The bull* which not unhe quently occur in anssthetic leprosy can scarce! give rise to difficulty, when taken in connection with the macul* and other phenomena attendin: it. In long-standing cases of pemphigus, por tions of skin which are extensively denuded oi their epidermis, may take on a considerable re; semblance to eczema rubrum ; but the history the emaciation and weakness of the patient, th! dark staining of the skin, with absolute absene| of infiltration and only slight irritation, wil, render it easy to form a decided opinion. Sypbi li tic pemphigus is distinguished from true pem: phigus by occurring only in new-born children by involving principally', though not exclusively the palms and soles ; by leaving the mucon membranes unaffected; and lastly, by formin thick crusts when the bull® burst, under wliici deep ulcers form. Prognosis.— This is favourable in the earl attacks, but doubtful as to the ultimate resuii since it is impossible to say whether the diseas may end with a single attack, or go on t gradual exhaustion of the patient’s strength i the later ones. Treatment. — No specific remedy for pempli! gus has as yet been discovered; the neare; approach to one is arsenic, which in some case of relapsing pemphigus, especially in early lit exerts a marvellous action on the disease, no only' removing all traces of it for the time, but ra straining its further invasion during longperioq (Hutchinson). In other cases all drugs ai equally powerless. The treatment which find most general approval consists in the admini^ tration of tonics, especially quinine or bark an iron, and in supporting the strength of th patient by nourishing food and wine. Extern! treatment consists in puncturing the fully-fonne bull®, and then in coating the parts with zin lead, or boracic acid ointment, or else in dus ing them with starch cr oxide of zinc. In t. pruriginous form, preparations of tar and war baths may be tried. In some cases bran bath and in others alkaline baths, have been four beneficial, but it is impossible to lay down ai line of treatment suitable to all cases. Edward I. Spares. 1 Revised by Dr. Alfred Sangster. I’ENIS, DISEASES OF. PENIS, Diseases of. — Synon. : Fr. Maladies •la Verge; Krankheiten der Rathe. — Taken in jeir widest sense, the diseases of the penis in- ude a number of conditions -which are separ- • ely described in this work, such as diseases of ae urethra, gonorrhoea, balanitis, gleet, syphilis, id priapism. For a discussion of these subjects jie reader is referred to the articles under their iveral names. In this place there remain for imsideration the following morbid states: — 1, ingenital abnormalities ; 2, Phimosis, acquired ; Preputial calculi ; 4, Paraphimosis ; 5, Inflam- ation ; 6, Gangrene; 7, Herpes preputialis ; 8, ,ew growths; 9, Cancer; and, 10, Elephantiasis. 1. Penis, Congenital Abnormalities of. — Irious abnormalities are from time to time met th in the penis, which are more or less impor- |nt according to the difficulties in micturition sexual intercourse to which they may gire se, and the consequent ill effects upon the per- nal comfort and general health. Among such ay be mentioned certain rudimentary conditions the whole organ, associated or not with defec- ts development of other parts of the genito- iinary apparatus — undue smallness or even de- iency; disproportionate largeness; torsion or feral deviation ; in extremely rare cases, mul- ilication (double or triple penis) ; abnor- ilities in excess or deficiency of particular parts the organ — epispadias ; hypospadias ; and imosis. The three last named require special lice. la) Epispadias. — Definition. — A condition which, from arrest or defect indevelopment, the Iper parts of the urethra and corpus spongio- m are wanting, and the corpora cavernosa are ■t properly closed together ; and in which, con- luently, the penis appears more or less com- itely fissured or opened along its dorsal aspect, d the fioor of the urethra is exposed. .Symptoms and Effects. — This condition is ust frequently associated with ectopia vesicas e Bladder, Diseases of) ; but the defect may limited to the penis. In most instances the hpuce is long and pendulous below the glans ; :1 this is important, inasmuch as it may often advantageously used in remedial plastic 'orations. The attendant inconveniences and discomforts, i h as incontinence of urine and unfitness for fjual congress, though varying somewhat in u;ree with the extent of the defect, are so great :jl so constant, that any reasonable attempt at lhedy by plastic operation may be considered jjtifiable. It must be confessed that such at- tjipts have hitherto resulted much more fre- rjmtly in failure than in success. In some cjss, however, much good has been effected ; and 'Others the patients have been enabled to wear "’■aratus by which their discomfort has been i Serially diminished. F’or a description of the vjious methods adopted, reference must be made tyorks on operative surgery and special trea- tk I 1 ) Hypospadias. — Definition. — A condition 4 - hich, from defective development of the ure- t i and of the corpus spongiosum, the urethra ojns on the under surface of the penis, at a vari- 1 distance behind the glans; and in which, 111 1 during erection, the penis arches more or less downwards and backwards. The prepuce usually forms a kind of flap, which overhangs, but does not surround the glans. Symptoms and Effects. — The opening of the urethra, which is often very small and slit- like, may be situated either immediately behind the glans, at any point in the under surface of the body of the penis, or just in front of the scrotum. In the first case— by no means an uncommon condition — no material inconvenience results; micturition and sexual intercourse can, as a rule, be fairly well accomplished ; and there is no need for surgical interference be- yond the enlargement, if needful, of the ure- thral orifice. But in cases in which the urethral orifice is far back, the urine passes down the thighs, or backwards ; complete sexual intercourse is rendered difficult, painful, or altogether im- possible; and the semen cannot be properly intro- mitted. Such a state of things often occasions great mental distress, and, thereby, impairment of health; and it may become justifiable and de- sirable to attempt to remedy to some extent the defect by surgical operation. A great variety of methods have been devised and practised, the de- tails of which will be found in surgical treatises. Most of them have resulted in complete failure. But in some few instances very considerable im- provement has been effected. As a rule, opera- tive measures should be delayed until adult life is reached. (c) Phimosis. — Definition. — -A condition, often hereditary, in which the orifice of the pre- puce is so small as to render it difficult or impossi- ble to uncover the glans properly and to the full extent. In some cases the orifice is a mere pinhole, or even scarcely discoverable ; in others more or less of the glans may bo exposed to view. Asso- ciated with this condition there is often elonga- tion of the prepuce, usually shortness and tight- ness of the frienum, and not infrequently undue smallness of the urethral orifice. It is highly important that the existence of congenital phimosis should not be overlooked or ignored, for at all periods of life more or less serious troubles may arise from it ; and acci- dental circumstances — injury, inflammation, ul- ceration, &c.— .may easily convert a comparatively slight congenital phimosis into a severe so-called acquired phimosis. At all ages phimosis is lia- ble to interfere with free micturition — in severe cases from mechanical obstruction, in less severe, or even comparatively slight cases, from reflex irritation and spasm. The bladder consequently may not be properly evacuated, and gradually cumulative mischief may result. Symptoms and Effects. — In infancy and childhood frequent attempts to pass water, ac- companied by straining and sometimes scream- ing, the passage of a small stream, or of a small quantity at a time followed by sudden stoppage; dribbling of the water; irritation and inflamma- tion about the prepuce; and pulling at the penis, are signs and symptoms accompanying, and sug- gestive of phimosis in the first place, however closely they may simulate the indications of stone in the bladder. General irritability and deterio- ration of health, the production of hernia by frequent straining, balanitis, the acquirement oi PENIS, DISEASES OF. 1112 the habit of masturbation, and reflex paralyses, are among the evil results that may arise. In adult life local discomfort, slowness of micturition, imperfect evacuation of the bladder, with all its probable consequences; smallness (from compression) of theglans; difficulty, want of pleasure, or even pain in sexual intercourse ; and liability to infection during impure inter- course, are troubles more or less constantly affect- ing the subject of phimosis ; and to these may be added, in more advanced life, increased lia- bility to cancer of the penis. Treatment. — In comparatively slight cases of phimosis the prepuce may be gradually stretched, and i ts orifice dilated to the needful extent, by fre- quently repeated gentle efforts at withdrawing it, and by inserting, between times, strips of dry or oiled lint between it and the glans. In the more severe cases resort to operation is needful. The methods variously adopted are: — (1) Forcible tearing ; (2) linear incision to greater or less ex- tent; (3) excision of a portion of the prepuce; and (4) circumcision. The first method is clumsy and altogether to be condemned ; the second is easy to perform, hut often leaves the part in an awkward condition ; the third is incomplete, and rarely satisfactory in effect ; the fourth, if care- fully and skilfully carried out is uniformly suc- cessful, yields excellent results, and, as a rule, is to be recommended. The best method of performing circumcision consists in first slitting up the prepuce along the median line on the dorsal aspect, by means of a bistoury or scissors, guided by a director, to a point on a level with or rather behind the corona, and in then starting from this point, and with scissors cutting all round, dividing skin and mucous membrane evenly together. As a rule the frsenum should be cut; indeed, in most cases it is better to excise a portion. In the infant, sutures are not necessary; but in the adult it is better to stitch the skin and mucous mem- brane together by very fine sutures inserted as close to the edges as possible. Inrolling is thus prevented, and if the sutures are tied very tightly they will ulcerate out, and the pain and trouble of removing them will be avoided. The simplest dressing only is requisite; but the parts must be kept scrupulously clean, and free . from all irri- tation. ( d ) Adherent Prepuce. — In some cases of phimosis, and occasionally iu cases in which the preputial orifice is not unduly small, the mucous membrane of the prepuce adheres, to a greater or less extent, to that of the glans. The smegma and other secretions are thus confined; and con- siderable local irritation, accompanied by more or less severe symptoms, often closely simulating those of stone in the bladder, may be set up. Treatment. — The foreskin must he drawn gradually back, the adherent surfaces being se- parated during the process by the fiat end of a probe or other thin 'blunt instrument; the con- fined secretions must be removed ; the parts washed ; the prepuce replaced, unless circumci- sion has been needful ; and strict cleanliness en- joined. If this condition be overlooked during infancy, the adhesions become firm and dense, and se- riously impede the growth of the glans. Their | division in the adult may require the use of ths knife during circumcision. 2. Phimosis, Acquired. — This condition may arise as a result of repeated attacks of in- flammation, with or without chancrous ulcera- tion, followed by induration, thickening of the prepuce, and contraction of its orifice. It is most frequent in those who have had slight con- genital phimosis. See Venereal Sock. Circumcision is the proper treatment. 3. Preputial Calculi. — The subpreputial secretions, if allowed to remain and accumulate, occasionally undergo changes, and become formed into hard concretions, which give rise to more or less serious discomfort and inconvenience. Such concretions are found to consist mainly of phos- phate of lime and ammonio-magnesian phosphate, with a variable amount of organic matter. 4. Paraphimosis. — Paraphimosis is a con- dition in which a tight foreskin, having been forced back, during coitus or otherwise, has led to strangulation, oedema, and inflammatory swell- ing of the glans and a portion of its own mucous membrane. The appearance presented is most characteristic. Treatment. — Reduction must be effected at; the earliest possible moment. If the case be neglected severe inflammation, ulceration, and sloughing to greater or less extent, followed by more or less permanent deformity, are liable to ensue. The method ordinarily adopted consists in grasping the body of the penis between the middle and forefingers of both hands, drawing the foreskin forwards, and at the same time com- pressing and pushing back the glans by both thumbs. This method is very painful and not: always readily successful. A better method, which very rarely fails, consists in slowly ban- daging the glans (beginning at the extremity), and all the swollen parts, with a piece of narrow elastic webbing, the effect of which is gradually to empty the engorged vessels and squeeze out the serum from the swollen parts. On the re- moval of the bandage after a few minutes, reduc- tion is, as a rule, very easily effected. The pro- cess may be facilitated by a few needle or lancet- point punctures, made before the application oi the bandage. In some neglected cases it may be needful toj divide the constricting band by means of a bis- toury. In attempting this it must be borne in mind that the constriction is not immediately behind the glans, but behind the swollen portion of the preputial mucous membrane. After reduction cooling and soothing applica- tions are useful. 5. Penis, Inflammation of. — S inon. : Pe- nitis. — Inflammation of the penis in its totality is very rarely met with except as the result oi injury, or in association with severe venerea, diseases. In some rare instances it is said tc have been induced by excessive sexual inter- course, and in other instances by persisted masturbation. Cases, however, are on record ir which it has occurred during, or among th< sequel* of exanthematous fevers. The treatment must be conducted on genera principles, due regard being paid to the cause ui PENIS, DISEASES OF. pndition in connection with which the Mamma- on has arisen. If the patient survive, the art may recover. 6. Penis, Gangrene of. — Gangrene of the icnis, except as the result of injury, or constric- |on by ligature, rings. &c., in the majority of ises has followed impure sexual congress during depressed general condition. In some cases has occurred in association with small-pox, phus, and typhoid fevers. Death has been the immou result. In some few cases life has been -eserved, though the part has been lost. 7. Herpes Preputialis. — This is a vesicular uption, occurring on the cutaneous or mucous rface of the prepuce, running its course in wut a week, but liable to recur at irregular (tervals. A similar eruption sometimes occurs the glans. The due recognition of this affection is im- irtant, becauso its appearance after doubtful tercourse often excites alarm, and may lead to isehievous treatment. Treatment. — The simplest treatment only is quisite. The avoidance or prevention of all •itation by the clothes or otherwise, and some- nes a little sedative lotion, are, as a rule, all at is needful. 8. Penis, New Growths of. — Cystic, vas- lar, fibrous, and other new growths of benign aracter are occasionally situated on the penis, ley may be left uuinterfered with, or may be t rid of by operation, according to the incon- nience they cause, and the indications afforded. my formations or calcareous deposits in the rous sheaths of the corpora cavernosa are of re occurrence. The discomfort they have in ne instances caused has necessitated their re- oval by operation, which has been successfully lomplished. Papillomata, or warty growths, ; not infrequently met with in persons of cleanly habits. In the majority of cases they ■ ) associated with venereal disease; but they .y arise independently of such association, ijiecially if the prepuce be long, and due regard not paid to cleanliness. They may be few and i.ttered, or many and massed ‘cauliflowerlike’ ('ether. Sometimes they entirely surround the < ona, and sometimes in patches or continuously ( r er more or less completely the mucous sur- ges of the prepuce and glans. In some in- s nces the diagnosis between such growths and I lillary epithelioma is not obvious ; ulceration ( surface indicates the latter. Treatment. — Removal by curved scissors, or t sting off by forceps, is the most speedily effec- I I treatment of papillomata of the penis. But i he warts are few and small, they may be made t shrivel and dry up and disappear, by repeated sdications of oxide of zinc, calomel, tannic a 1, or burnt alum, and the pressure of dry lint l ween the foreskin and glans. Cleanliness is thntial. s I c t! t! ■ Penis, Cancer of. — Cancer in the male ijeet in a considerable proportion of cases narily affects the penis. By far the most mon form is epithelioma, and the most com- l seat of first appearance is the glans, or part of tho preputial mucous membrane PENTAST01TA. 1113 nearly or immediately adjoining. In compara- tively rare cases scirrhus is described as having commenced ‘lumplike’ in some part or other of the body of the organ. In still more rare cases, soft cancer has been met with in young subjects after injury, and the diagnosis from suppuration in the corpus cavernosum has at first been doubtful. Epithelioma seldom appears in the penis be- fore the age of forty, most frequently between the fiftieth and sixtieth years. In 161 cases out of 2i3 the sufferers had been the subjects of phimosis. In some few instances the ori- gin of the malady has been attributed, rightly or wrongly, to marital connection with wives suffering from cancer of the uterus. Epithelioma is first noticed as a small, warty outgrowth, early ulcerated ; or as a flat, excoriated surface, with slightly indurated base, occasionally dis- posed to bleed, and sometimes painful. Scabs form from time to time, which, when removed, leave exposed a gradually extending ulcerated surface. The malady persists and progresses in spite of treatment, infiltrating and destroying. The discharge is thin and sanious, bloodstained and offensive. The ulcer is irregular in outline, with more or less everted hard edges ; and the induration extends into the surrounding parts. Sooner or later the inguinal glands become in- fected, and the general health seriously deterio- rates. Diagnosis. — The diagnosis of cancer of the penis from any form of venereal ulceration is, as a rule, sufficiently easy. Difficulty can scarcely arise, except in tho comparatively rare cases in which there is exuberant warty growth before obvious ulceration. Treatment. — The only treatment worthy of consideration consists in amputation of the penis, well behind the point to which the disease has extended. If the inguinal glands have become in- fected, they should be removed at the same time, if practicable. If they are affected to such an extent as to render their removal impracticable, amputation of the penis can do little, if any, lasting good. 10. Penis, Elephantiasis of. — Elephantiasis of the penis is almost .always associated with elephantiasis of the scrotum, and may demand simultaneous treatment by operation. Arthur E. Durham. PENTASTOMA (ireVre, five, and err ipa, a mouth). — A genus of entozoa belonging to tho family Acaridce. They are sometimes placed in a separate order termed Acanthotheca. The species, two of which are liable to infest man, are characterised by the presence of a ringed or segmented body, the head being armed with four large hooks or claws, arranged in pairs on either side of the mouth. The older writers misunderstood the nature of these cephalo- thoracic feet; hence the generic misnomer which the term pentastome implies. The so-called Peiir- tastoma denticulatum infesting the liver, although tolerably frequent in various parts of Europe, gives rise to no functional disturbance, and is consequently destitute of clinical importance. It is the larval condition of a worm that infests the nasal cavities of the dog, Pentastoma tcenioides. 1114 PENTASTOMA. The other human pentastome, Pentastoma con- tirictum, infests the liver and luDgs, and, on account of its comparatively large size, is capable of giving rise to serious and even fatal symp- toms. It measures from half an inch to an inch in length; being also easily recognised by the presence of twenty-three rings. This entozoon not only occurs in Africa, but also in the West Indies, where European residents are liable to be attacked by it. The museum of the Army Medical Department at Netley contains examples of this parasite, from a case in which the entozoon appears to have proved fatal. The history of the case, originally sent by Dr. Kearney, is given by Dr. Aitken in the later editions of his treatise On the Science and Practice of Medicine. To this work the reader is referred for other par- ticulars of clinical interest. T, S. COBBOLI). PEPTIC GLANDS, Diseases of. See Stomach, Diseases of. PEPTONISED POOD.—' This term may be used as the equivalent of the phrase ‘ artifi- cially digested food.’ In natural digestion albu- minoid substances are changed into peptones, and starchy matters are changed into dextrine and sugar. These processes are of a purely chemical nature, and they can be imitated outside the body very closely by means of artificially pre- pared digestive juices. An extract of the stomach, or of the pancreas, in water, has approxima- tive^ the same powers as the natural secre- tions of those organs. Hence it is possible for us to subject articles of food beforehand to complete or partial digestion; and to administer such artificially digested food to our patients. In cases where the natural digestive powers are more or less in abeyance, it would be an obvious advantage if we had. at command a supply of food thus modified, and yet not so changed as to have lost its agreeable appearance and flavour. Nor is there anything repugnant to physiological science or to the custom of mankind in such a proposal. The essential acts of digestion are not vital operations, but chemical transmutations ; and the theatre of these operations is on the surface of the gastric and intestinal membrane, and not in the true interior of the body. In the practice of itboking wo have, as it were, a foreshadowing of the art of artificial digestion ; and although the latter art may never pass beyond the needs of the sick and debilitated — may never serve the healthy and robust — it is not more absolutely alien from the life of animals in a state of nature than is the art of cooking. The practice of cooking is an exclusively human practice, and it is now spread among all the races of mankind, whether civilised or uncivilised ; and among the higher races the two most important groups of alimentary substances — albuminoid and starchy matters — are eaten almost exclusively in the cooked condition. Now the changes impressed on articles of food by cooking are not merely mechanical ; nor are they confined to alterations in the appearance and savour of the food. By far the most important changes produced by cooking consist of certain chemical transformations, whereby several of the chief alimentary principles are rendered incom- PEPTONISED FOOD. parably more amenable to the action of tl digestive juices than in the uncooked state. ] a sense we may speak of cooked food as foe! which has undergone the preliminary stage of d| gestion. This preliminary stage is accomplish! for us of the human race by the artificial aid . heat ; but in the case of all the lower animals has to be accomplished by the labour of their on digestive organs. The affinity of digestion t the process of cooking goes even much beyon this. It has been shown experimentally th: albumen, when subjected to the prolonged actio| of superheated steam, yields a substance resenj bling peptone, and that starch when similar: treated yields dextrine and sugar. So that would not be inappropriate to describe digestio! as the process of cooking carried a step further Methods of preparation. — Peptonised < artificially digested food may be prepared, eith. 1 by following the gastric method with pepsin arj hydrochloric acid, or by following the intestin | method, and using extract of pancreas. Tl latter method yields by far the better result The pancreas not only acts upon albumins substances, but also upon starch. Pepsin, on tl other hand, is quite inert in regard to starcl Moreover, the products of artificial digestion wi pepsin and acid are much less agreeable to tl taste and smell than those produced by pancreat; extract. By the latter method articles of foa can be profoundly peptonised with little detj ri oration of that agreeable savour which mat them inviting to the palate. The writer vri therefore, in what follows, confine himself to ti pancreatic method, and describe the modes which food may be partially digested beforehan and yet constitute an acceptable nourishme: for invalids. The first necessity is to procure an activ extract of the pancreas. Water is the propj solvent of the digestive ferments ; but, iu order obtain a stable preparation, some preservati agent must be added to prevent decomposition After a trial of various media the writer has con to the conclusion that, on the whole, the be solvent is dilute spirit. A mixture of one pa of rectified spirit with three parts of W3t answers every purpose. The pancreas of the p yields the most active preparation; but the pa creas of the ox or the sheep may be employed,, that of the pig is not obtainable. The pancre of the calf also yields an extract which is acti on albuminous substances, but it is not a cti on starchy materials. In procuring a supply pancreas from the butcher, it is well torememl that the word ‘ sweet-bread,’ which is the Engh vernacular for piancreas, is likewise applied the thymus gland ; and that the genuine swe< bread of the kitchen is the thymus of the ca Butchers distinguish the true pancreas as h ‘liver sweetbread,’ and it is by this name, alo that the pancreas must be asked for in t shambles. Mode of preparation of Extract of Pa creas or Liquor Pancreaticus. — The panerc is first well freed from fat, and cut up into sm pieces with a knife or a pair of scissors. It then mixed with four times its weight ot t dilute spirit, put into a well-corked wide-mouth bottle, and sot aside for a week. The mixtt ' PEPTONISED FOOD. lould be well agitated at least once daily. At ■e end of a week the mixture is strained through tislin, and then filtered through paper until it clear. A very active extract of pancreas is now pre- fred on the large scale by Mr. Benger, under t name of Liquor Pancreaticus, and sent out ! Mottershead & Co., chemists, Manchester. As is a troublesome matter to get a supply of increas from the butcher, and as the filtration the product is a tedious process, it will be and much more convenient to employ Mr. Snger’s preparation, if it can be procured, than rely on home manufacture. In the succeeding struetions for the preparation of peptonised f>d it will, therefore, be supposed that a supply Danger's liquor pancreaticus is available. Directions for the preparation of various nds of peptonised food. — The articles which 'a most easily prepared, and are most likely to serviceable to invalids are the following: — Peptonised milk . — A pint of milk is diluted th a quarter of a pint of water, and heated to {temperature of about 140° Fh. Should no srmometer be at hand, the diluted milk may divided into two equal portions, one of which .heated to the boiling point and added to the c.d portion, when the mixture will be of the quired temperature. Two teaspoonfuls of the {nor pancreaticus and ten grains of bicarbonate ■ soda are then added to the warm milk. The ixture is poured into a covered jug, and fejug is placed in a warm situation under a ‘osey,’ in order to keep up the heat. At the (H (if an hour, or an hour and a half, the pro- mt is boiled for two or three minutes. It can ten be used like ordinary milk. The object of diluting the milk is to prevent t|i curdling which would otherwise occur, and flatly delay the peptonising process. The ad- cion of bicarbonate of soda prevents coagulation c;:ing the final boiling, and also hastens the pcess. The purpose of the final boiling is to If, a stop to the ferment-action when this has i dled the desired degree, and thereby to pre- yt certain ulterior changes which would render t product less palatable. The degree to which t peptonising change has advanced is best j ged of by the development of a peculiar bitter f our, which is always associated with the a ficial digestion of milk. The point aimed at i: i carry the change so far that the bitter flavour fust perceived, but is not unpleasantly pro- r need. As it is impossible to obtain pancre- a extract of absolutely constant strength, the djictions as to the quantity to be added must Fmderstood with a certain latitude. The ex- ti of the peptonising action can be regulated, e'er by increasing or diminishing the dose of the lilor pancreaticus, or by increasing or diminish- ii the time during which it is allowed to operate. Fikimming the milk beforehand, and restoring ti cream after the final boiling, the product is ralered more palatable. eptonised gruel . — Gruel may be prepared t’i l any of the numerous farinaceous articles in c mon use — wheaten flour, oatmeal, arrowroot, *4 i, pearl-barley, pea or lentil flour. The gruel sljild bn well boiled, and made thick and strong. I then poured into a covered jug, and allowed 1115 to cool until it becomes lukewarm. Liquor pancreaticus is then added, in the proportion of a dessert-spoonful to the pint of gruel, and the jug is kept warm under a ‘cosey’ as before. At the end of a couple of hours the product is boiled, and strained. Tho action of pancreatic extract on gruel is twofold — the starch of the meal is converted into dextrine and sugar, and the albu- minoid matters are peptonised. The conversion of the starch causes the gruel, however thick it may have been at starting, to become quite thin and watery. The bitter flavour does not appear to be developed in the pancreatic digestion of vegetable proteids, and peptonised gruels are quite devoid of any unpleasant taste. It is diffi- cult to say to what extent the proteids of the meal are peptonised in this process. The pro- duct gives an abundant reaction of peptone ; but there is a considerable residuum of undis- solved material. Most of this, no doubt, consists of insoluble ligneous tissue, but it also contains some unliberated starchy and albuminous matter. Peptonised gruel is not generally, by itself, an acceptable food for invalids, but in conjunction with peptonised milk (peptonised milk-gruel) or as a basis for peptonised soups, jellies, and blanc- manges, it is likely to prove valuable. Peptonised millc-gniel . — This is the preparation of which the writer has had the most experience in the treatment of the sick, and with which he has obtained the most satisfactory results. It may be regarded as an artificially digested bread- and-milk, and as forming by itself a complete and highly nutritious food for weak digestions. It is very readily made, and does not require the use of the thermometer. First, a thick gruel is made from any of the farinaceous articles above mentioned. The gruel, while still boiling hot, is added to an equal quantity of cold milk. The mixture will havo a temperature of about 125° Fh. To each pint of this mixture two or three tea- spoonfuls of liquor pancreaticus, and ten grains of bicarbonate of soda, are added. It is kept warm in a covered jug under a ‘cosey’ for an hour or hour-and-balf, and then boiled for two or three minutes, and strained, If the product has too much bitter flavour, a smaller quantity of the liquor pancreaticus must be used in the next operation. Invalids take this compound, as a rul,e, if not with relish, at least without any objec- tion. Peptonised soups, jellies, and blanc-mangcs . — The writer has sought to give variety to pepto- nised dishes by preparing soups, jellies, and blanc- manges containing peptonised aliment. Soups maybe prepared in two ways. The first way is to add what cooks call ‘stock’ to an equal quantity of peptonised gruel or peptonised milk-gruel. A second and better way is to use peptonised gruel, which is quite thin and watery, instead of simple water, for the purpose of extracting the soluble matters of shins of beef and other materials em ployed in the preparation of soups. Jellies may be prepared by simply adding the due quantity of gelatine or isinglass to hot peptonised gruel, and flavouring the mixture according to taste. Blanc-manges may be made by treating pepto- nised milk in a similar way, and then adding cream. In preparing all these dishes it is abso- lutely necessary to complete the operation of pep- 1116 PEPTONISED FOOD. Ionising the gruel or the milk, even to the final boiling, before adding the stiffening ingredient. For if pancreatic extract be allowed to act on the gelatine, the gelatine itself undergoes a process of digestion, and its power of setting on cooling is therefore utterly abolished. Peptonised bef-tea . — A pound cf finely minced lean beef is mixed with a pint of water, and ten grains of bicarbonate of soda are added thereto. The mixture is then simmered for an hour and a half in a covered saucepan. The resulting beef- tea is decanted off into a covered jug. The un- dissolved beef-residue is then beaten up with a spoon into a pulp, and added to the beef-tea in tho covered jug. When the mixture has cooled down to about 140° F. (or when it is cool enough to be tolerated in the mouth) a table-spoonful of the liquor pancreaticus is added, and the whol3 well stirred together. The covered j ug is then kept warm under a ‘ cosey’ for two hours, and agitated occasionally. At the end of this time, the contents of the jug are boiled briskly for two or three minutes, and finally strained. The pro- duct is then ready for use. Beef-tea prepared in this way is rich in peptone. It contains about 4 per cent, of organic residue, of which more than three-fourths consists of peptone ; so that its nutritive value in regard to nitrogenised ma- terials is nearly equivalent to that of milk. When seasoned with salt it is scarcely, if at all, dis- tinguishable in taste from ordinary beef-tea. Peptonised enemata . — Pancreatic extract is peculiarly adapted for administration with nutri- tive enemata. The enema may be prepared in the usual way with a mixture of milk and gruel, or milk, gruel, and beef-tea. A dessert-spoonful of liquor pancreaticus is added to it just before administration. In the warm temperature of the bowel the pancreatic ferments find a favourable medium for their action on the nutritive ingre- dients with which they are mixed ; and there is no acid secretion (as in the stomach) to interfere with the progress and completion of the digestive transformation. Experience has satisfied the writer that this method of administering nutri- ment is a valuable resource when the stomach is obstinately intolerant of food, or when there is obstruction in the higher portions of the digestive tract. Uses of peptonised food. — The employment of food which has been wholly or partially pep- tonised is indicated when the natural digestive powers are from any cause enfeebled or suspended. The most striking benefits have been observed in cases of gastric catarrh with pain and intoler- ance of food ; in gastric ulcer ; in the anorexia and dyspepsia associated with valvular heart- disease ; and in the various forms of pyloric and intestinal obstruction. Good results have also been obtained in cases of defective nutrition and intestinal irritation in infants. In using pepto- nised food it is well to remember that it does not keep well, especially in warm weather. Accord- ingly it should either he prepared twice a day, so that it may he never more than twelve hours old ; or, if a quantity sufficient for the twenty-four be prepared at once, the portion which remains over at the end of twelve hours should be re- boiled. Williaii Kobests. PERFORATIONS AND RUPTURES. PERCUSSION (percusso, I strike). method of physical examination, performed striking gently some part of the body, especial the chest or abdomen, for the purpose of pr ducing certain sounds or tactile sensations, may be performed either by the finger or fingc of one hand striking the surface directly, or i directly— the fingers of the other hand being i terposed; or by means of a special instrument instruments. Percussion has been recommend- by Dr. Mortimer Granville as an agent in the tret ment of certain nervous diseases (Brit. Med. Jci Pol. I. 1882). See Physical Examination. PERFORATIONS AND RUPTURE, It will be convenient to discuss these lesioi together, and from a general point of view only, ti more important perforations and ruptures eoi neeted with particular organs being treated of : their appropriate articles. The word rupture used here in its true significance, and not in tl popular sense as applied to hernia. See IUttup. Definition. — Though there is no absolute c!l tinction between perforations and ruptures, the are certain differences by which they are usual broadly recognised. The term perforation is generally only applid to an artificial opening produced in a hollo! organ or tube ; seldom, and only under spec; circumstances, to a lesion affecting a solid tissu Moreover, it implies that the opening is a sma ono, or, at any rate, does not reach large dunci sions. Again, the mode in which the lesion I produced has, in some instances, to do with tl; definition of a perforation. Thus, if the ope:; ing results from injury by a pointed iustrumeu or by any other agent which would cause more ci less of a puncture, such as a fractured rib pent trating the lung, it would be called a perforatior and in this case the term would apply also ; a solid organ or tissue. Finally, the slow di straction of certain structures by aneurisms as other tumours often terminates in an apertur being formed, which is then called a perforation This is well exemplified by the opening formed i the sternum in some cases of aortic aneurism. A rupture may be associated with any stmc ture, and often involves solid organs and tissue; such as muscles. It implies a lesion of sons size, and may reach any dimensions, being mon of a tear or rent than a puncture. There is alsj associated with the term the idea of spontnneon production, or of the lesion originating iron within, or from the effects of some compressin or lacerating injury, instead of a penetrating one ^Etiology and Pathology. — The causes c perforations and ruptures, and the pathologic;! conditions under which these lesions occur, ma be thus summarised : — 1. Injury. — This often comes from withou: and may be of different kinds. The forms d injury most requisite to notice are perforate wounds ; severe compression of the body, as be tween railway-buffers, which may cause extensiv rupture, even of solid organs, without any ex ternal mark of violence ; violent concussion, as ; the case of the brain ; and straining, which is es pecially liable to cause rupture of muscles or at teries. To the category of injuries also beloa; various causes of perforation or rupture comm. PERFORATIONS j'm within, such as corrosives which have been Eillowed, bones and other foreign bodies simi- l'ly introduced, calculi, hardened fasces in the ijestines, and worms. Cases have now and then c urred in which important internal organs have fen penetrated in the attempt made by show- m to swallow swords and similar instruments. ^Violent actions. — Voluntary muscles have by t in own excessive action led to their rupture, a'in cases of tetanus. The uterus has been known trupture itself. In rare instances the healthy l g has given way from violent cough. 3. Morbid Otr notice atuz degenerative processes. — These are ioortant causes of perforations and ruptures of vious kinds, and they include ulceration or gigrene, as of the stomach or intestine ; sup- jjation, leading to the formation of an abscess, eier associated or not with an organ, and which iiy hurst into various internal parts, or exter- rily; cancer; acute fatty degeneration and soften- i. of organs ; and chronic fatty, atheromatous, o'jalcareous degeneration. Some of the condi- t is mentioned are in themselves essentially de- 6 fetive ; others produce such changes that they r Ter a rupture liable to occur from very little e ra force or pressure, such as that which arises fun. a slight strain, a cough, or the act of vomit- i: or defaecation, as is well exemplified by the Wirt and arteries. Even in the ease of the de- s ictive processes, some exciting cause may lead tilhe actual perforation or rupture, such as one o the acts mentioned above, or, in the case of ti alimentary canal, the injudicious administra- th of solid food, or of articles which give rise to tl rlent distension. Moreover, after ulceration a Beatrix may be left, which for a time is very lijle to give way from slight causes, as some- lips happens in connection with typhoid fever. T, perforation of the lung in cases of phthisis is good illustration of the effects of destructive clliges. 4. Gaseous and liquid accumulations. T;se may alone lead to rupture of hollow organs oiiibes, of the walls of cavities, or of cysts, by c; ing extreme distension, as may be exemplified b She occasional rupture of the intestines from o\ -distension, of an emphysematous luDg, of the hl der from an accumulation of urine, of the real pelvis in cases of hydronephrosis, of a dis- tel ed gall-bladder, of a pleuritic effusion through (■..diaphragm, of a hydatid or ovarian cyst, or otSn aneurism. Some slight strain or injury m be the immediate cause of the lesiou in sejral of these conditions. 5. Pressure. — A tu.jur of any kind may cause perforation of va-ms structures, as the result of its mechanical pijiure. In the case of an aneurism the pulsa- ti< assists in producing the lesion. In this w; the most resisting tissues may be destroyed, ac; serious consequences are liable to ensue. 6 ■ spontaneous. — In the case of muscular tissues an arterial structures spontaneous ruptures are sujosed to happen occasionally, but probably in 11 such cases there has been previous de- gejration, which has been tho real cause of the rujire. iatomical Characters. — It must suffice to nit ion here that the morbid appearances con- siSi 'f those presented by the perforation or rup- tu itself; and of tho effects resulting therefrom. Tt ;ormer vary much in extent and character in AND RUPTURES. 1117 different cases, and no general description can be given of them. As regards the effects produced, there may be none, but very commonly haemor- rhage takes place; or the contents of a hollow viscus, or of a fluid collection, may be found poured out in some abnormal situation, and these usually set up inflammation if the patient live long enough, the results of which will be evident on 'post-mortem examination. In the case of slow perforation of structures by tumours, various effects may be produced, of an irritative or de- structive character. Particulars on these points are given in other appropriate articles. In the case of the lung, perforation is likely to lead to the escape of air into the pleura or cellular tis- sue, thus giving rise to pneumothorax or subcu- taneous emphysema. On the other hand, liquid accumulations may open into the lung, and thus be found in the air-passages, or they may pro- duce more or less serious effects upon the pul- monary tissues. Symptoms. — It is not intended hero to describe the symptoms which occur in connection with traumatic injuries, but merely to point out those likely to be noticed in different cases which come under observation in medical practice, Under certain circumstances a perforation or rupture may take place without any obvious symptoms, even when it affects an important structure. This may happen, for instance, even when an opening forms in a hollow viscus, such as the stomach or intestine, provided it has become previously adherent to some solid organ, or to another part of the bowel, with which it then forms a communication. On the other hand, very speedy or even sudden death may ensue, as when a large aneurism or the heart ruptures. The symptoms to be anticipated are those due to the actual lesion itself ; and those resulting from the consequences mentioned under the anatomical characters. As regards the lesion itself, if it is suddenly produced, the event is usually attended with immediate marked symptoms. Of these, one of the most common is a sudden pain at the seat of mischief, often very intense, but vary- ing in its characters. When a muscle ruptures, a feeling is frequently experienced as if a severe blow had been struck, and power is lost at once in the affected part. This is well exemplified in eases of rupture of the gastrocnemius, an acci- dent not uncommon at the present day in connec- tion with the game of lawn tennis. When a hol- low viscus or any fluid collection bursts, or when gas escapes, a sensation as if something were being poured out is often noticed by the patient. At the same time the general system usually suffers more or less gravely, as evidenced by faintness or actual fainting, or by signs of shock or collapse, from which the patient may never rally, if the structure involved is of great im- portance in the vital economy, or if continuous haemorrhage should be going on. The symptoms above indicated may be repeated if the lesion should extend after an interval. It may be men- tioned that when rupture of an abdominal organ takes place from severe compression of the body, there may be no symptoms of the event at the outset, and only the development of grave general symptoms indicates what has happened. The occurrence of hemorrhage into internal parts. 1118 PERFORATIONS AND RUPTURES, or the escape of the contents of the viscera or of a fluid accumulation, may be obvious on phy- sical examination. Should the patient survive in cases of rupture into internal parts, local and general symptoms pointing to the occurrence of inflammation may be expected to supervene. For instance, in the ease of the abdomen there would be signs of peritonitis, or of localised inflamma- tion in some part of the cellular tissue, probably ending in suppuration. In perforation of the lung, symptoms and physical signs of pneumo- thorax appear, or the presence of air in the sub- cutaneous cellular tissue may become evident. When an opening is formed between some col- lection of fluid and any organ or passage which communicates externally, such as the air-tubes or the alimentary canal, such fluid is likely to be discharged in different ways, and this may be a favourable mode of termination, leading to a cure. In the case of slow perforation by a tumour, should it take place in an outward direc- tion, the lesion will probably become evident on clinical examination; if internal structures be affected, the process of destruction may be ac- companied with continuous pain, or other symp- toms ; and subsequently clinical phenomena in- dicative of implication of various structures arise, either suddenly or gradually. For example, when an aneurism or solid growth destroys any part of the spinal column, this is attended with a con- tinuous aching or grinding pain ; and when the canal is perforated, symptoms arise indicating that the spinal cord is involved. Diagnosis. — It is scarcely practicable to offer any useful general remarks under this heading, and it must suffice to notice the following points. The difficulty of diagnosis varies much in different cases, being sometimes very easy, in other in- stances more or less obscure or impossible. The practitioner should always be prepared for the possibility of cases of sudden perforation or rup- ture of internal structures coming under his notice, of which he may have known nothing pre- viously. Under such circumstances a careful inquiry into the previous history may reveal the presence of symptoms of known conditions, which would clear up any obscurity; but, on the other hand, there may be no such histor}'. There ought to be no difficulty, as a rule, if the lesion occurs from some recognised cause, such as certain kinds of injury; or if it supervene in some case under the care of the practitioner for a disease liable to be attended with perforation or rupture of some part, such as typhoid fever, gastric ulcer, an internal abscess, or an aneurism. In the case of slow perforation, it is very important to be able to recognise the meaning of symptoms which may arise from this cause. Prognosis. — Any rupture or perforation taking place internally must altvays be regarded as im- mediately more or less dangerous to life, and not uncommonly the termination is necessarily fatal. Much will depend on the structure involved, the extent of the lesion, and its direct and remote con- sequences. Caution must be exercised in giving a prognosis in all cases, for some patients recover when such a result might not bo anticipated, and especial care must be taken in offering an opinion if the diagnosis should not be quite clear. In the case of ruptures or perforation taking place PERICARDIUM, DISEASES OF. externally, or affecting structures not essentia! life, such as the muscles of a limb, the proemo of each case must be determined on its merits. T reatment. — In the case of sudden internal pi foratioDS or ruptures, the first principle in tre ment should be to counteract the immediate eftb of the lesion, alleviating pain, and rousim; a stimulating the patient by appropriate remedi Opium or morphia and alcoholic stimulants a> of great service, and they may often be advyj tageously introduced into the system by mea of enemata, or, in the case of morphia,” by sn cutaneous injection. Heat to the extremiti sinapisms, and similar applications, are also f: quently of much value. The patient should kept at rest, and it may be of essential impc tance to endeavour to keep an organ which h been [perforated in an absolute state of rest, su as the stomach or intestines, by withdrawing: food, and cheeking peristaltic movements opium or other agents. The same applies some parts of the body, such as a limb, if muscle or a vessel should be ruptured, and he often the position of the limb is of much cons quence. Other appropriate measures will sngge themselves in other instances. Some special inte ference may be indicated. For instance, itmigl be clearly allowable to open the abdomen certain cases ; to strap or puncture the chest relieve pneumothorax ; or to cut down and tie ruptured artery. Haemorrhage resulting from lesion of this kind in internal parts, may som times be checked by the constant application ice externally over the corresponding part of ti body. The subsequent treatment of cases ofrn ture or perforation must be determined by t effects which they produce, which must be dea with according to their nature, each case bein considered on its own merits. The same remai applies to cases of gradual perforation by tumon and other morbid conditions. Frederick T. Kobebts. PERICAEC AT, ABSCESS. — An abscess the cellular tissue around the caecum, if Perittpheitis. PERICARDIUM, Diseases of. — Stxos Fr. Maladies dw Pericarde ; Ger. Krankhdtm i Herzbcutels. The pericardium proper is a membranous ha; one part of which — the visceral layer — close! envelopes the heart and the roots of the gre; vessels connected with it ; while the other— tt parietal layer— is loosely reflected round t!i; organ, and has its external surface intimate! united with a dense fibrous sheath which pas$< upwards, and is gradually lost upon the extern: coats of the vessels, whilst it is continuous belol with the central aponeurosis of the diaphragu A serous fluid bedews the interior of this sa and facilitates the movements of the heart. : that both in structure and function the pe: cardium may be regarded as a joint— somewhs modified, no doubt, to suit its internal, positio as well as the nature of the parts with whic it is connected. The morbid conditions of the pericardium wi be discussed in the following order : — 1. Drop, 2. Inflammation ; 3. Gas in the Pericardiuu PERICARDIUM, Malformations ; 5. New growths ; and 6. Peri- jrdial adhesions. •We may first, however, refer to a condition cf e pericardium which can hardly be described : pathological, consisting of slight opacities, lich are termed mil/c-spots. Tnese are fre- Jently observed upon the pericardium after lath, but they give rise to no clinical symp- 1ns, and are merely to be regarded as callosities ie to attrition. The most common situation at the base of the right ventricle in front, but !sy are also found on the apex, and are occasion- ||y seen as white stripes upon the auricles, jd along the course of the coronary arteries. Jch macule albide are most common on large, f-ong, and hypertrophied hearts, but they are t altogether confined to these. When due solely (attrition, these spots are formed by a mere tokening or condensation of the normal tissue ; jt now and then they are fcund to consist of a inlayerof fibrinous matter which maybe peeled ; leaving the pericardium beneath opaque, but ■Serwise natural. In the latter case, of course, »se spots cannot be regarded as simple callo- Jies, but as the results of some trifling local ri carditis, running its course without symptoms ;d of no clinical importance, except as afford- jr a probable explanation of those temporary 'sic frictions which are occasionally to be heard i those otherwise in apparently good health, as l at least as the heart is concerned. 1. Pericardium. Dropsy of. — S ynon. : Hy- - mpericardium ; IT. Hydropericarde ; Ger. Herz - 'Uelmssersncht. During life and in health the serosity bedew- 5; the internal surface of the pericardial sac •Ists in an appreciable quantity, so that an dice or two of fluid found in it after death is i, to be regarded as anything abnormal. When, llvever, the fluid present amounts to as much : six or seven ounces, or more, the condition i morbid, and is termed hydropcricardium, or cpsy of the pericardium. The contained fluid ija yellowish, greenish, reddish, or reddish- Iwn serosity, containing from one to three I' cent, of albumen, and occasionally a trifling liount of fibrinous matter, which coagulates t' simple exposure to the air — hydrops lyra- mticum (Virchow, Gcsammclte Abhandlungcn, 1,108). The colour of the fluid is of course cl to the amount of blood-colouring matter ijised through it ; and the reddish, or reddish- Iwn colouration is specially present when f n any cause, such as the co-existence of S'rvy, the colouring matter is more readily erased than usual, or in those exceptional cases wire the walls of the capillaries are so altered l nutritive changes as to rupture, all the phenomena present in dropsy of the picardium are precisely similar to those asso- ced with a similar amount of inflammatory e sion, and will be referred to under that head, hlropericardium is a possible occurrence in all •Bases, whenever there is, from physical causes, a mdency to transudation of serum into the c ties of the body. According to the nature oihat cause it may be either an early or a late p nomenon, and it frequently only attains any e iiderable proportion during the act of dying. DISEASES OF. 1119 When dropsy occurs from venous congestion due to disease of the heart, or to disease of the lungs, such as emphysema or cirrhosis, some degree of hydropericardium is not uncommon as an early symptom ; but when the dropsy results from hydrsemia produced by chronic organic diseases of the spleen, liver, or kidneys, or by the ex- haustion due to cancerous or tubercular diseases, the pericardial effusion is usually a late symp- tom. Treatment. — The treatment of hydroperi- cardium resolves itself into the treatment of the diseases upon which it depends; and it is only when the fluid becomes suddenly effused, in a quantity so large as to threaten death by sup- pression of the heart's action, that an indepen- dent treatment by paracentesis may be found necessary. Such sudden effusion occasionally, but only very rarely, takes place in the course of the acute albuminuria following scarlatina, or even in the more chronic albuminuria, the result of intratubular nephritis. 2. Pericardium, Inflammation of. — Sr- non. : Pericarditis ; Fr. Pericardite ; Ger. Herz- beutelentziindung. Acute inflammation is the most serious, if not the most frequent, affection of the pericardium. jEtiology. — This disease, though occasionally idiopathic, is much more frequently secondary in its character. So-called idiopathic pericar- ditis is usually associated with pleurisy, fre- quently with bilateral pleurisy, and is not uncommonly latent so far as any direct symp- toms of pericardial implication are concerned. Secondary pericarditis may be. the result of wounds from without or from within — through the ecsophagus ; of blow r s and contusions on the praecordial region ; of abscesses perforating from the lung, or from the liver — through the dia- phragm; of enteric fever, variola, scarlatina, and pyaemia in all its forms ; of the spreading by con- tiguity of the inflammatory process from neigh- bouring organs, such as the lungs, pleura, or costal periosteum. It may accompany the local development of cancer or tubercle ; or may be due to rheumatism, or to one or other of the chronic forms of Bright’s disease. By far the larger proportion of cases of pericarditis occur in connection with the two last-named diseases, in about the ratio of two of rheumatic pericar- ditis to one of renal pericarditis ; all other forms lumped together forming an infinitesimal and incalculable fraction. In rheumatism, pericar- ditis occurs early ; occasionally precedes the joint-affection ; and though no period of the disease can be regarded as free from the ten- dency to this so-called complication, just as any joint may be implicated at any period, yet ex- perience teaches us that the heart-joint is most usually affected within the first week of the rheumatic onset. In renal disease, on the other hand, it is most usually a late phenomenon, being only too frequently the immediate precursor of that fatal uraemia which its occurrence serves to precipitate. The pathology, symptoms, signs, and treat- ment of pericarditis, however it may arise, are all very much alike, and may be conveniently treated of together. 1120 PERICARDIUM, DISEASES OF. Anatomical Characters. — The morbid ana- tomy of pericarditis is simple enough. Very early pericarditis is rarely seen except as asso- ciated with Bright's disease, and then at first we have merely vascular injection with a few shreds of lymph visible about the roots of the great vessels. In a few days, in those dry forms of the disease where but little fluid is effused, the whole surface of the heart may be covered with a thin fibrinous layer, which may, even at this early stage, have connected together the visceral and parietal layers of the pericardium somewhat firmly (Wilks). More usually there is some serous exudation mingled with the fibrinous matter, which then is found covering the pericardium in a reticular or honeycomb pattern, which Laennec has likened to the appear- ance presented on suddenly separating two smooth pieces of wood between which a small pat of butter has been forcibly compressed. The serous effusion not infrequently amounts to several pints ; it is always turbid from the mole- cular fibrin suspended in it; and is of a yellow- ish, greenish, brownish, or reddish colour. When along with any considerable layer of lymph upon the pericardiac surfaces, there is much fluid effused, the surface of the lymph is covered with shaggy processes floating in the fluid, those processes sometimes presenting a mammillated appearance. In a very short time a fine net- work of capillaries is developed in the fibrinous exudation; and the rupture of these newly deve- loped capillaries now and then gives rise to what is termed ‘ haemorrhagic pericarditis,’ in which the fluid, and even the solid lymph, is deeply stained with the blood-colouring matter. This also happens when pericarditis is associated with purpura or scurvy; and nowand then, from simi- lar causes, layers of coagulated blood are found alternating with layers of unstained lymph. When the disease does not prove fatal, the exudation may be entirely re-absorbed, or it may become organised, or other changes may occur. First of all, the excess of fluid and the molecular fibrin become absorbed ; then the coagulated fibrin may become worn away by the continual play of the heart, and gradually entirely absorbed : and a complete cure may be thus effected, leaving at the most only a slight thickening or opacity of the pericardium. But such a cure is only possible when the amount of exudation has been incon- siderable. More usually, connective tissue is gradually developed in the fibrinous layers; either locally, giving rise to partial adhesions, which about the base of the heart are more dense, but at the apex are often drawn out to fibrous strings ; or the two layers of the peri- cardium may be so closely united that they can only be separated with considerable force, and now and then, after the lapse of some time, they cannot be separated at all, the cardiac muscle being torn in the endeavour. Occasionally pus, or the cheesy or calcareous remains of such a deposit is found, encysted, as it were, between the adhering layers of the pericardium ; and it sometimes happens that this calcareous layer envelops the whole heart, which then seems to be converted into bone. Laennec, Louis, Allan Burns, and others relate cases of this kind, and the heart described by Burns is still preserved in the anatomical museum of the Eiinbnroi University. In every fibrinous exudation witliii the pericardium there is at a particular stag a certain amount of all those elements presea which may become pus, and these give rise t< a milky opacity of the fluid, or if present ii sufficient number, may metamorphose the who! exudation into pure pus. This may be oalj ; transition stage ; the pus-cells may break (Iowa a pathological cream may be formed, and thi whole may be ultimately entirely absorbed But true purulent pericarditis, though a ran occurrence under any circumstances, is mos frequently fatal, and seems to occur chiefly iri connection with serious general disease, or accompany the rupture of local abscesses' pulmonary or hepatic, into the pericardium What has been termed an ‘ ichorous exudation in the pericardium, is simply a putrefaction o, that already existing, which becomes brownis! in colour and stinking. It may arise iron entrance of the air into the pericardium afte paracentesis conducted without antiseptic pre cautions ; but it is also believed that such putre- faction may arise in patients greatly enfeebia by exhausting diseases, such as cancer, withoir any entrance of air into the pericardium. An exudation that has become ichorous may cor' rode the pericardium ; is incapable of furthe metamorphosis ; and is usually speedily fatal by the development of pneumo-pericardium. Se Pericardium, Gas in. Symptoms. — The symptoms of pericarditis an of comparatively little .mportance, because the; are frequently entirely absent in those so-calle; idiopathic forms of the disease which are pro bably always fatal, as well as in renal periear ditis, which is fatal in the majority of cases whilst even in rheumatic pericarditis, in which the mortality is at the most only about 16 pe cent., and is nil according to other author (Bamberger, &c.), the symptoms, though rarel. absent, are generally not very well marked ol distinctive. As a rule, if pericarditis be assoj ciated with any other serious disease, such a| pneumonia, pleurisy, or rheumatism, the svrop toms are apt to be swamped by those of th primary disease. In other instances the ad vent of the pericarditis is indicated by a rigor a rise of temperature, a feeling of anxiety an; oppression at the chest, and the occurrence o increase of dyspnoea. The decubitus is usual!; dorsal, and syncope is liable to be induced 01 raising the patient. There is pain in the car diac region, with palpitation of the heart The pulse is at first full and frequent, alway compressible, frequently irregular, usually
  • n the first few days of the onset of the disve, we perceive by palpation an unusually for ile and turbulent action of the heart, which '» 1 1 occasionally irregular, and is due to in- 71 DISEASES OF. 1121 flammatory irritation of the cardiac muscle. By- and-by, as the inflammation progresses, cardiac debility sets in, and the pulsation becomes less forcible, while in most cases it is still further obscured by the occurrence of fluid effusion, which separates the apex from the anterior wall, with which the baso of the heart always remains in contact. In this way we have produced that phenomenon which is termed ‘displacement up- wards of the apex-beat,’ because the more the true apex is pushed inwards by the effusion, the part of the heart actually in contact with the chest- wall approaches more closely the base of the ventricles. Should the heart be greatly hypertrophied, its impulse may remain distinct throughout the whole course of the disease, the fluid accumulating behind it and not in front. So long as the serous accumulation is incon- siderable, there is no alteration of the percussion- sound ; but whenever this attains an abnormal amount, it is revealed by an increase of the cardiac dulness ; and in the ordinary dorsal decubitus of the patient this is first observed at the base, in the line of transverse dulness along the level of the fourth rib. By-and-by, however, the ordinary pyramidal dulness of the heart, base upwards, becomes reversed, and we have a pyramidal dulness with the base below- and the apex upwards ; and this apex may rise as high as the clavicle, or even above it. The base, on the other hand, may in these cases extend beyond the ordinary position of the apex- beat to the left, especially if the patient be made to lie upon his left side; but it is mobile, and on turning the patient on his right side the dulness leaves the left and passes towards the right. Very groat emphysema of the lungs may obscure this dulness, but cannot altogether annihilate it; but of course this method of diagnosing peri- cardiac effusion can only be put in force when both pleurae are free from fluid. The fluid effu- sion, even when confined to the pericardium, may amount to several pints, and its pressure may not only embarrass the heart’s action, but may also so compress the lungs, particularly the left one, as to give rise to considerable dyspnoea; and the hindrance thus presented to the free passage of the blood through the lungs may give rise to considerable systemic venous congestion, which is readily observed in the turgid condi- tion of the jugular veins. As a rule inspection gives us little, if any, information in regard to the existence of peri- carditis. Should the quantity of fluid effused be very considerable, and the chest-walls flexible, some vaulting of the pericardial region may be observed, due to the effacement of the inter- costal spaces, the ribs beiDg occasionally also more widely separated than usual, at least apparently so ; and the whole prsecordial space under these circumstances takes a less share than ordinary in the respiratory motions. Undula- tory movements due to waves of fluid, as de- scribed by some, are never seen ; such move- ments, if visible, depend upon the wobbling of an enlarged and feeble heart, and not on any fluid waves. Diagnosis. — A friction-sound has been hypo- thetically supposed to be occasionally due to mere dryness of the pericardiac membrane. Possibly 1122 PERICARDIUM, DISEASES OF. this may be the case, but it has never been proved. Even if it be the case, then such dryness, asso- ciated with the symptoms described, can only be an early stage of inflammation. Apart from these it mayor may not be an indication of com- mencing inflammation, and must be watched and treated accordingly. It has also been alleged that calcareous concretions, and tubercular and carcinomatous roughnesses may give rise to a friction-sound. Associated with the symptoms described, any friction-sound, even presuming such a possible origin, must be regarded as a form of pericarditis, whilst apart from these symptoms it must still be watched with sus- picion. The most difficult cases to diagnosticate are those in which the friction-sound is due to pleurisy alone, and is yet audible during cardiac action, when the respiration is temporarily sus- pended. This is a rare occurrence, but it does happen, and the diagnosis is almost impossible. The subsequent progress of the case may show that the pleura is certainly affected, but that is no proof that the pericardium is not also impli- cated; or the pericardium may be assuredly diseased, and yet the friction-sound may be solely due to pleurisy. The general symptoms and the condition of the pulse count for some- thing, but the diagnosis between pleurisy and pericarditis is, in such cases, manifestly a difficult one, only to be solved by the further progress of the case. Now and then we have a friction sound audible towards one or other side — usu- ally the left — of the pericardium, during suspen- sion of the respiratory movements ; the base of the heart being entirely free from friction, and in these circumstances the probability seems greatly in favour of the strictly pleural nature of the disease. But even in such cases a perfectly accurate diagnosis is impossible. There is never any real difficulty in determining between a val- vular murmur and a frictional pseudo-murmur, because in the -case of the latter the sound is restricted to the cardiac area, and usually only to a small portion of that, and not being propa- gated to any extent out of its position of maxi- mum intensity, and then only equally all round, and not in any of the definite lines in which valvular murmurs are propagated. Moreover, the position of maximum intensity of a frictional pseudo-murmur never coincides with that of any valvular murmur, except occasionally with a diastolic aortic one ; while, of course, the natural sounds of the heart are never replaced by the pseudo-murmur, though they may be partially obscured by it, and all the secondary results of the valvular lesion simulated are en- tirely wanting. Prognosis. — The prognosis in pericarditis is not unfavourable ; one in six, or about 16 per eent., is mentioned by some as the ordinary mortality ; but according to Bamberger, peri- carditis associated with rheumatism or any other curable disease invariably terminates favourably, though the mortality is always large when it is associated with Bright’s disease and other incurablo affections, the fatal termination of which is hastened by the pericardiac affection. Pericarditis, like any other acute inflammation occurring in an otherwise healthy iudividual, may be expected to run a favourable course if not unduly treated ; and the danger to life h to be calculated by the seriousness of the so existing complications, and the age and state a the vital powers of the patient. The unfavour able phenomena are, a large quantity of effusion great dyspnoea, feeble heart’s action, small anc irregular pulse, lividity, delirium and other ner vous symptoms. Tbeatmext. — The treatment of pericarditi' must be regulated to some extent by the natur of the disease with whieh it is concomitant I it concur with pneumonia or pleurisy, it un- safely enough he entrusted to the remedies eui ployed for these diseases ; or should it accom pany rheumatism, then we must treat it as par of the rheumatic affection. If we can hopefull employ blood-letting or mercury in the case c rheumatism, then we may employ the same rente dies in pericarditis; otherwise there is no reaso why we should make use of doubtful and dan gerous remedies, simply because the disease ha attacked a more dangerous part, hut rather th reverse. Those who have shown the smalles percentages of deaths have been the least per turbative in their treatment, as we might reason ably expect. A rheumatic pericarditis ought therefore, to be treated simply as a rheumati affection ; but inasmuch as pain implicating th heart has a decided tendency to depress its ac tion, it is of the utmost importance to relieve 1 at once. With this view a large, warm poultic should be applied over the heart ; and morphi injected subcutaneously at once, and repeate! by the mouth, or subcutaneously, at reguh intervals, so as to keep the patient free fro: pain. Perfect rest must be enjoined. Shonl there be much dicrotism of the pulse, or an tendency of the heart to fail, then digital! should be administered at regular intervals, i doses sufficient to keep up the cardiac actioi such as ten minims of the tincture every for hours: and with this may be conjoined the u: of chloral in five or ten-grain doses, which is n- more useful as a sedative than as an antiphl gistic, and which may very well replace tl morphia, having the additional recommendatiq that it does not interfere with the secretion which demand attention, nor promote the swea, ing, so troublesome in rheumatism. Where may be considered advisable to give an alkal such as potash or ammonia, with the digital: it cannot be combined with the chloral, but mn be given separately. In recent times, saliein ai the salicylates have been employed with succe in the treatment of rheumatism. They are n true specifics for this disease, but they tend keep down the fever, and apparently shorten l course. They do not prevent the occurrence pericarditis, but their use is not contra-indicat. by its presence. Blisters are frequentlyrecor mended in pericarditis, but they may tend to in tate the patient and to excite his heart's actio A few leeches often give relief in suitable cast We must, in fact, treat the pericarditis as pa of the general rheumatic attack, only requiri a little more attention than usual in the war warmth, and relieving pain ; and all the pa history of this disease proves that we shail this way be more likely to promote afavounl termination of the disease, than by jeopardisi PERICARDIUM, DISEASES OF. nr patient by dangerous and uncertain medi- ations. Where the amount of fluid effused is very .reat, or -when the symptoms seem to point to he presence of pus, it may become a question 'hether paracentesis should be performed or not. 'ho results of this operation hitherto have not een very satisfactory, but that is no reason thy it should not be resorted to if it seem ne- .issary, especially as it can now-a-days be so ksily done by means of one or other of the ispirateurs. The patient should be placed in ie recumbent position, and the needle entered fetween the fourth and fifth ribs, about half an ch to the left of the sternum, the operation ing, of course, performed antiseptically, and e fluid drawn off somewhat slowly. For this ;ason, therefore, we should be careful in our oice of an aspirateur, as one acting by a iwerful vacuum might induce syncope, by ithdrawing too rapidly from the heart a pres- re to which it has become accustomed. A iated heart has been said to have been punc- red, instead of a distended pericardium, but in ,e present day such a mistake is scarcely pos- jdo, though, of course, it must be carefully arded against. It now and then happens that er the acute symptoms pass away, the peri- ■dium remains obstinately distended with id, and it is, perhaps, chiefly in these cases that l;racentesis pericardii presents the most hope- ii prospects. See Paracentesis. 3. Pericardium, Gas in. — The putrefaction 0 an exudation causes the development of vious gases within the pericardium, and the jjduction of so-called pneuino-hydro-pericar- I' m. This condition is readily recognised by ti clear tympanitic percussion-note over the ijally dull cardiac area, with a metallic gurg- 1 ; accompanying the cardiac movement. Be- tas the circumstance already^ mentioned, pneu- r, hydro-pericardium may also be caused by the t rance into the pericardium of gases from the s nach and intestines, or of air from the ceso- Pjgus or lung, or ab extcrno. . Pericardium, Malformations of. — The informations which may be found in connection Wi the pericardium are described in the article h rt, Congenital Misplacements of. Pericardium, New Growths in.— Both ttyrcle and cancer may become developed irshe fibrinous layers of a pericarditic exu- d9 IP- 2P’ 3P* 4V- 5 P- C P- 7 P* 8 P- # 9 P- 10P- IIP- roxysms of a quartan will take place on the T? |p. Ip. 3 ° P . gV 5 %. V 9 P . And a continued fever existed with tertian or quartan exacerba- tions, the more violent symptoms might be ex- pected to appear on the days indicated. On com- paring the order of days, discrepancies between the three are sufficiently obvious on a superficial consideration, but many of them disappear on more particular inquiry. . . . With regard to the exanthematous fevers, it will be seen at once that the “ critical days ” they exhibit occur in quartan order. . . . Exanthematous typhus ex- hibits the tertian type, and, as might be inferred, the critical days in this fever are the fifth, seventh, ninth, eleventh, and twenty- first. Scar- latina is sometimes tertian, sometimes quartan.’ Since the discrimination of the several varieties of continued fevers, and after the date when Laycock wrote, medical observation lias not tended generally to support the doctrine of PERIODICITY IN DISEASE. 1126 critical days, as it relates to this group of febrile disorders, or to confirm the evidence upon which that doctrine appeared to be founded. Murchi- son’s observations {Treatise on the Continued Fevers of Gr eat Britain, 2nd edit. p. 187) did not support the applicability to typhus ; but in this respect, as he notes, they were not in accord with the observations of Gairdner, Russell, and Traube of Berlin. The last-named, indeed, as also Wunderlich, revived the doctrine. Relapsing fever may, perhaps, be said to illustrate the doctrine, the paroxysm intermitting on the the third, fifth, or seventh day. According to Murchison ( Treatise , p. 547) the doctrine fails with respect to enteric fever, but he adds that he had ‘ often noticed ’ that the disease terminated about the 21st or 28th day. E. S>egn.m{Medical Thermometry, 1876) reproduces the views of Hippocrates on critical days, and Wunderlich’s seeming confirmation of them derived from thermometry, himself accepting the ‘ similitude,’ indeed the ‘ quasi-identity of the results ’ ob- tained, in this regard, by the father of Physic and the modern professor. According to Wunder- lich’s observations the majority of cases of typhoid fever run a regular course, divided into periods corresponding in time with the division into weeks and half-weeks. The ordinary course is about twenty-one day's, and Seguin describes an ‘ effervescence of seven days, a fastigium of seven days, and a defervescence of seven days ; ’ but lie adds, with reference to the irregularities which so often mark the disease, ‘ simple as it looks, how difficult it is to make it out.’ In typhus — simple uncomplicated cases — the ther- mometer marks the fourth day as the height, the sixth to the seventh as the turning point, and a perturbatio critica at the end of the second week. ‘The doctrine of crises,’ says Wunderlich, ‘was for the ancients a dogma .... for us it must become a law.’ Robert Lyons remarks ( Treatise on Fever, p. 74, 1861) : ‘ We are far from deny- ing that at certain periods febrile disease pre- sents an unmistakable tendency to terminate on critical days ; but we think that it is consistent with observation to state that a critical issue of fever is far less common in our day than it once was.’ And this, indeed, would ap- pear to be a legitimate conclusion from the ob- servations made in this country bearing on the subject. It would almost seem, in fact, on com- paring the critical days set forth by the older writers with the order of sequence followed by the paroxysms of intermittent fever, as if tho indications of the former, in the progress of the continued fevers of Great Britain at least, had doclined with the diminution of sources of palu- dal malaria. Laycock, as the general result of his investi- gation of the minor periods — that is, the daily, weekly', monthly, and seasonal recurrences of vital movements — as contra-distinguished from the major periods, that is periods measured by a year, or by a series of years, (which he also discussed, but which will be referred to in this article in another connection), laid down the fol- lowing propositions: — (1) There is a general law of periodicity' which regulates all the vital movements of all animals. (2) The periods within which these movements take place admit of calculations approximatively exact. (3) 'X fundamental unit, — the unit upon which th calculations should be based, — must for t present be considered as one day of twelve hou (4) The lesser periods are simple and compos multiples of this unit, in a numerical ratio 3 r logous to that observed in chemical compound (5) The fundamental unit of the greater perio' is one week of seven days, each day being twill hours ; and simple and compound multiple*, this unit determine the length of these perio by the same ratio as multiples of the unit tw'elve hours determine the lesser periods. Inquiring into the causes of the periodic changes in the vital movements of animals, La cock saw reason to believe that they were ! part dependent upon cyclical processes inhere in the system {esoteric), partly upon period, agencies acting from without {exoteric), or th ; they resulted from a combination of the tv {endexotcric). Prosecuting the inquiry furtherw:; special reference to the exoteric agencies, Ls cock showed how closely the periodical chang observed in vital movements were linked to tl periodical phenomena observed in nature atlarg and this not merely with reference to such obvioij phenomena as the alternation of sleeping an waking in connection with the diurnal rotaticj of the earth, and the succession of day and nigh! but also in respect to the more recondite peri*, dical changes in the vital processes. He set fort 1 data which suggested that those changes, as we as the periodical changes observed in disease, ha! definite relations to the position of the earth wit reference to the sun, and to the position of tlj sun among the spheres ; also to the periodic;' fluctuations occurring in atmospherical temper ture, pressure, and magnetism ; and ia the mas netism of the earth, whether diurnal, season;: or secular. And of the periodicity observed i pathological processes, he endeavoured to shot that (whatever the intimate nature of the path logical process might be) neither the beginnin. the continuance, the fluctuations, the ending, n the recurrence could be rightly' understood apai from its relations to the phenomena of physl logical periodicity on the one hand, and tit periodicity of physical phenomena on the otke hand. He held that there were not wanting it dications in pathological phenomena of a luna period, and particularly of a lunar cycle (eighteej years, Howard's seasonal cycle) ; the indication of solar periods were more obvious : and it wa to bo inferred that in time we should have ev: dence of greater pathological cycles correspond ing with the greater astronomical cycles. Lay cock, indeed, saw clearly that so far as exoteri agencies were active in bringing about the peric dical phenomena observed, in physiological an pathological processes in man, the changes of leas period were linked inextricably to the change of greatest period, and that the study of tb greater periods must be approached, if suece; were to be hoped for, through the study of tl lesser. I Laycock was of opinion that as our knowleog of the periodical phenomena observed in vit; changes becomes more exact and extensive, will be possible to establish a science of rid prolepiics, having for its object ‘to foretell so c: PERIODICITY nd individual suffering —in other words, a cienee of pathological forecasting. Edward Smith examined the question of peri- dical changes in living beings, in health and lisease, from a stand-point different from that taken by Laycock. He limited his observations [o the human system, and prosecuted a series of eseacches on the daily, weekly, and seasonal hanges it underwent, probably unique in their uration and extent. He adopted as criteria of kese changes the rates of pulsation and inspi- ation, the quantities of carbonic acid expired, if air inspired, and of urea and urinary water volved. The data as to these several changes •ere determined by a series of observations hade upon himself and others, some phthisi- a.1, at hourly intervals, without intermission, liroughout the twenty-four hours, during several jays in succession, for the daily period, and at taily intervals for the longer periods of time, ho fluctuations observed in the different pheno- tena of health, being taken as indications of hanges in the activity of the vital processes, it tacame possible to determine the progression nd retrogression of that activity within the |veral periods to which the inquiry was directed, hesc may be briefly stated as follows : — Daily period {cycle). — Vital activity is at the West between the hours of 1 and 3 o’clock a.m. ftcr 3 o'clock a.m. the activity increases, at irst slowly, then more quickly, until a maximum reached between the hours of noon and 2 m. A progressive decline follows, rapid at Irst, slower as the evening draws on and falls to night, until the minimum is reached be- yeen 1 an 1 3 a.m. The day, in fact, as con- rns the changes undergone in the human i'stemmay be divided into two periods, one of iinimum change (approximatively from 8 p.m. to a.m.) ; and one of maximum change (approxi- atively from 8 a.m. to 8 p.m.) Within this ,ily cycle, smaller cycles are observable, ac- rding to the time and quality of the meals. Weekly period {cycle). — A weekly period is not own by a clear line of progression of vital ange throughout the week, but by the indica- ms of a higher drgree of change which follow Ion the first-day rest than are manifested at fi close of the sixth day of labour. The idence of a seven-days’ period of change in 3 healthy system, on the line of investigation rsued by Smith, and apart from the social habit periodical rest, is obscure ; but the social habit rrobably the expression of a physiological want tithe system. Seasoned {annual) period {cycle). — A seasonal • do is very definitely marked by the intimate 'al changes observed in the human system, wards the close of summer vital change has :j.ched its lowest point. With the eommenee- mt of autumn a progressive increase com- i nces, which continues through the autumn al the winter, and reaches its highest degree in sing. Towards the close of spring vital change 1 ins to decline progressively. This decline Ijceeds throughout June and July, at an in- cising rate in the latter month, and attains its ljest degree early in September. The summer tnges in the system exhibit the following t mum and maximum conditions : a minimum IN DISEASE. 1127 of carbonic acid and vapour exhaled, of air in- spired, of the rate and force of inspiration, o? alimentation and assimilation, of animal heat generated, of muscular tone and endurance of fatigue, and, in general, of resistance to adverse influence. A maximum of the rate of pulsation, of the action of the skin, and the elimination of vapour, of the dispersion of heat, of the supply of heat from without, and of excess of heat, of the elimination of urea and urinary water, of the distribution of blood to the surface, of the imbibition of fluids, of relaxation of the tissues, and of poverty and carbonisation of blood. In the winter season the above conditions are, for the most part, reversed. The autumn season is marked by the conditions peculiar to the summer or the winter, as the character of the season resembles the one or the other ; it is essentially a period of change from the minimum to the maximum. The spring season is character- ised in its early and middle parts by the highest degree of efficiency of every function of the human system, but as the season advances to the close, these conditions merge into those peculiar to summer. The effect of season, Ed. Smith observes, is more than the physical phenomena of tempera- ture and atmospheric pressure explain, and is so universal that even the same amount of exertion, made at two different seasons, produced different degrees of effect upon the vital changes — less carbonic acid being evolved from it in summer than in winter, iu proportion to the relativo amounts when at rest at these two periods. The periodical changes here set forth have important bearings both upxm the liability to and the treatment of disease. Smith endeavoured to formulate these bearings and thus to furnish a rational statement of many facts which the ex- perienced practitioner learns at the bedside, and which he applies empirically. Hut the interest of the seasonal period is more conspicuously marked as it influences the liability to and recurrence of disease and parti- cular kinds of disease. And here it should be noted that Ed. Smith discusses a question which, perhaps, has been too little considered, namely, the viability of children born in the different seasons of the year. This question he believed to have an important bearing upon the great loss of infant life which occurs in the summer season. Smith concludes that the viability of those children is greatest who are born in the winter and spring months. The periodical fluctuations observed in the progress of current diseases in the course of the 'year appear to be mainly determined by the in- fluence of seasonal changes on the individual. This subject has recently been examined by Alexander Buchan and Arthur Mitchell, M.D. {Journal of the Scottish Meteorological Society , Nos. xliii.-xlvi.), with reference to the variations of mortality in relation to the weather for dif- ferent diseases, at different ages, in London, for a period of thirty years. The results obtained by these gentlemen are of exceptional value for the length of period over which it has been practi- cable to extend their examination — a period un- attainable, for a like number of diseases and approximate correctness of data, in other mtio- 1128 PERIODICITY IK DISEASE. logical records. A series of researches made by Edward Ballard, M.D., on the prevalence of cer- tain sorts of sickness, in a particular district of London, with reference to meteorological condi- tions, corresponds closely with the results shown for the mortality in similar kinds of sickness by Buchan and Mitchell, the minima and maxima of the sicknesses necessarily preceding by a longer or shorter period the minima and maxima of the mortality arising from them. The general results obtained from the London mortality may be taken as representing the influence of seasonal changes on disease ; but the progress of the diseases will be found to follow the progress of the seasonal changes, as these may be found to differ in, and may be modified by, different local- ities. The following is a brief tabular statement of the seasonal mortality of the more important diseases current, or occasionally present, in London : — L O bij t-.’ o s a s G s is m m < c3 .d % u >. c o d 3 < < rjj (J r "‘ Small-pox .... + + 4- ] + t 4- - - = - - _ Measles + — — + t 4- — — — 4- l Scarlatina .... + + X 4- 4- Diphtheria .... + 4- + 4- i x Quinsy (1G years) Croup + + 4- — ~~ — — 4- 4- t + 4- 4- 4- 4- 4- Whooping Cough j + 4- 4- 4- 4- — \ — = = | = — 4- Fevers + 4- 4- — Typhus . G years) . . + + 4- 4- — — + — 4- — + Typhoid (G years) . + 4- 4- H- 4- t 4- Simple contind. fever + 4* + 4- Erysipelas .... + 4- + t X Puerperal fever . . + 4- 4- + + + Dysentery .... — — — — — — 4- 4- i + — — Diarrhoea .... t t 4- — — — Cholera + t t + — — — Rheumatism . . . + 4- 4- | + + 4- Privation .... — — — — — — + + 4- — — — Purpura and Scurvy — — 4- 4- + 4- Alcoholism .... — — — — 4- 4- 4- 4- 4- — — — Thrush — — — — — — 4- 4- 4- 4- — — Gout + 4- 4- 4- 4- Phthisis 4 4- 4- 4- + 4- Tabes Meaenterica . 4- 4- 4- — — — Hydrocephalus . . — 4- 4- 4- 4 - 4- 4- Heart-disease . . . + 4- 4- 4- — — — — — — 4- 4- Laryngitis .... 4- 4- t 4- 4- 4- Bronchitis .... t 4- 4- 4- ~ — — = — | — 4- 4- Pneumonia .... ; + 4- 4- 4- — — — = — — 4- 4- Asthma j + 4- 4- 4- 4- t Pleurisy 4- 4- 4- 4- — — = — — 4- 4- Lung-disease . . . ! + 4- + 4- — — — = — — 4- i Enteritis ' Teething .... ! + 4- 4- 4- 4- 4- 4- 4- 4- Old age 1 1 4- 4- 4- V Above the average. J Maxima. — Below the average. — Minima. This table indicates the seasons of prevalence of the several maladies above and below the average, as shown by their mortality, also the seasons of maximum and minimum prevalence, but it does not exhibit the order of progression and magnitude of movement of the diseases in the different seasons. In this place, however, we are concerned solely with the fact of periodi- cal changes in the prevalence of disease corre- sponding with and, it is inferred, depending upon the seasonal changes. These changes, while occurring more or less in each of the partienla affections, and notably in certain groups of affec tions, such as the diarrhceal and pulmonan manifest widely varying relations between til several kinds of maladies, except in the group referred to and the different seasons. Periods of Seasons or of Years . — Epidemics.- A series of periodical phenomena have now t be considered which have been a source of th most eager speculation from the earliest times o medicine to the present day. So far as mediem is concerned these periods have been marked b epidemic morbid phenomena — epidemics in mar epizootics in animals, epiphytics in plants. Th recurrence of these phenomena at intervals show that over and above the periodical mor’oi' changes which have hitherto been noted, an' which are completed within the day, the weel or a series of weeks, and the seasons within year, there are periods of change which requir for their completion a series of years of longer o shorter duration, and which for their elucidatio (as Laycock showed) require to be considered i connection with the previously-mentioned period. 1 These periodical morbid phenomena are of tw sorts, the one relating to particular localities districts, or countries ( epidemics ) ; the other t groups of several countries or to the world gent rally {pandemics). There are, in fact, circuit scribed (local) and general epidemics, the sma and the great epidemics of some writers; th former, local evolutions of disease having rein tion chiefly to the physical and moral states c communities, the latter, secular evolutions (t| use Charles Anglada’s phrase : Maladies Eteinit et les Maladies NouvelUs, 1869), which appeart have relation to, as yet, undetermined cosmic phenomena. To these secular evolutions of di: ease (‘facts of cosmo-ehemical disturbance John Simon) some epidemiologists would rr strict the term epidemic. The law of periodicity of the several disease current in a country, and which are apt to be come epidemic, has not been determined. Eac disease will need to be considered apart ; and i those which are communicable from the sick t the healthy, the influence of an aecumulatio of susceptible persons in the intervals betwee epidemic prevalence 1 will have to be distil 1 The writer has the following from a mathematic, friend:— As a first case, let all epidemics be or eqm intensity ; and let there be no condition operative i determining an epidemic beyond the accumulation < susceptible people. Let p be the number of susceptible people remainm in a population after an epidemic. Let r be the annual excess of births over deaths (a causes), with other increments of susceptible popi lation. Let x he the number of people attacked, or otherwu rendered insusceptible during an epidemic. And let n be the cycle of an epidemic. To find n. After an epidemic, the susceptible = p. Next year „ „ = p+r. „ .» = p+2r. When epidemic comes „ = p+nr. After epidemic gone ,, = p+nr—x But this = p. .■. nr = x; and n=A. r On this rule, take the case of scarlatina (always presei and waiting to be epidemic until accumulation of R over and above p has taken place, and let us suppose oc: selves concerned with a community of 1,000, of when PERIODICITY ( ished from extraneous conditions presumably lerative in determining the periodicity. Thus, j er the year 1840, the fluctuations of small- ]x in the metropolis were obserred to have a < se relationship with the fluctuations in quan- ty of unvaccinated children — so close, indeed, lit the periods of recurrence of epidemic small- ]s could be pretty certainly forecasted ; but i 1871, when one of the periods of epidemic i rease arising from an accumulation of un- ptected individuals was due, some other determined condition concurred and gave to tp epidemic of that and the following year a qiracter which had not been observed in small- jc since the general introduction of vacci- r ion. The usual histories of epidemics are dost valueless for scientific purposes : they do i ; discriminate those outbreaks which are essen- t ly of a local nature, and dependent chiefly uin the state of a particular place and popula- te, from those which are governed by more v ely operative influences. In England the data a liable for such determination do not exist for n?e than forty years. Previous to the eom- psory registration of deaths, and for a short t e afterwards, the records of the causes of dth (which can alone at present be applied to ti purpose) were too imperfect to be made use Kind the popular accounts of the recurrence o maladies were untrustworthy. From the Iitistrar-General's Reports, for the 28 years 1 .0—77, it may be inferred that small-pox was e)lemic in 1850-52; 1858; 1863-65; and in la-72. Measles in 1851 ; 1854; from 1858 tc 863 ; in 1866 ; 1868 ; and 1874. Scarlet Fever ip 857— 58 ; 1863-64; 1868-70; and in 1874. Lhtheria from 1859 to 1866. Whooping Cough ir 850 ; 1854-55; 1857-58; 1861-63; 1866- and 1872. ‘Fever,’ from 1851 to 1855; in 181-58; from 1862 to 1866; and in 1868. Esipelas from 1850 to 1856 ; 1858-59 ; 1864 ; at 1874-75. Puerperal Fever in 1864-65 ; and fr 1 1870 to 1876. Dysentery from 1850 to 1859. ce in number are insusceptible, and another number [p does not at present matter what number) are sus- ce ble then let >-=2 (births -deaths yearly, &c.) ; 1 L let x= 10 (attacks in an epidemic, probably about x one death) ; '■ n n = _ = 5 years as the cycle of epidemic recurrence. r - v, in the same community, with the same r, let x be, later than in another otherwise similar community (M ‘Vhen the epidemic comes it attacks more people, mr ig them insusceptible) ; the interval between suc- cet , e epidemics wall also be greater ; thus if x = 20, n dp years, and so on. On the other hand, it r be larger (ei r through large birth-rate or other immigration of sus itible persons) while x is constant : the interval betjcn successive epidemics will be less; thus, if x= and r= 3, n= years, and so on. Siagain, fluctuations in the amount of p (from what- cvc ause arising) will make a difference in the quantity P -Jr, the number requisite for the appearance of an epi oic ; and the interval between successive epidemics caxi altered in this way as well as by change in n or r. i e now the case of an epidemic influence needing to he roduced from without, and supposing the degree of J; s , ensity not to vary ; with this alteration of hypo- tnc, the cycle of an epidemic will not be less than the nm. t, bat may be indefinitely greater, owing to the leqjte introduction not taking place. 1, easy, in these considerations, to .find reasons for iiD nces in epidemic cycles among different com- bm.es, for differences in the intensity of successive epp uc8,ana for apparent alterations of susceptibility pn-.' communities. And these reasons will deserve to oe ( ndered before going in search of other reasons. IN DISEASE. 3129 Diarrhoea m 1852; 1854; 1857; 1859; 1865; 1868; and 1870-71; the mortality from this cause being moreover in excess throughout the whole period 1867-74. With regard to cholera and ‘ fevers ’ it must here be noted that Robert Lawson bolds, from a widely-extended range of observation, that a series of fluctuations may be distinguished in the prevalence of cholera and ‘ fevers ’ fol- lowing in regular sequence at intervals of two years. Theso fluctuations are common to both hemispheres, and as they appear to move from east to west, he has designated them ‘ pandemic waves.’ These waves have a definite relation, ho believes, to the magnetic isoclinal lines, and he has laid down rules for determining their position at anytime. (Trans. Epidemiological Society of London, vol. iii. p. 216.) The facts relating to the secular evolutions of diseases are amongst the most interesting, if the most lugubrious, in the history of the human race. Although their too-frequent obscurity and their extreme complexity have hitherto inter- posed an insuperable barrier to the construction of a general doctrine regarding their occurrence, it is not the less necessary that they should re- ceive attention. Here it is possible only to note some of the more salient indications of secular periods of morbid evolution. The following illustrations (chiefly according to Anglada) may be mentioned : — - (a) The great pestilence of the 5th century- before Christ, of which the so-called ‘ plague of Athens,’ as described by Thucydides, was an in- cident. (b) The pestilences of the 2nd and 3rd cen- turies of the Christian era, which are believed to have been of the same nature as the pesti- lence of the 5th century n.c. After the 3rd cen- tury this form of pestilence disappeared from history. (c) The explosion of bubonic (inguinal) plague in the 6th century after Christ, when, for the first time in history, this formidable disease assumed the epidemic character which it maintained to the early part of the present century'. Breaking out in the reign of Justinian (a.d. 542), the disease quickly occupied the whole of the then known earth, and began a tragic course which has con- tinued even to our own time. For twelve hun- dred years it had held a pre-eminence among pestilential maladies, sometimes more, some times less prevalent, but at all times deadly. In the 16th century, when quarantine was estab lished (see Quarantine), 69 outbreaks of tho disease were recorded in Europe, of which five happened in England; in the 17th century, 56, six in England; in the 18th century, 28, none in England; and in the first half of the 19th century, 15. In the 17th century, the area of prevalence of the disease began to decrease. This decrease went on progressively throughout the 18th and the commencement of the 19th centuries, the latest outbreaks of the malady', however, being not less fatal than the earliest; and in 1844 it apparently became extinct. But about ten years afterwards the disease again showed itself in tho Levant, and from that time to the present scat- tered circumscribed outbreaks have occurred id W estern Arabia, (1853, 1874, and 1879), North i 1 30 PERIODICITY IN DISEASE. Africa (1855-59 and 1874), Mesopotamia (1867 and 1873-77), Persia (1863, 1870-71, and 1876- 77), and after an absence of thirty-six years from Europe in the province of Astrakhan, Russia (1878-79). Here, then, we appear to have re- cords of one complete secular evolution of plague, and to be witnessing the beginning of another. The 6th century most probably also gave birth to or determined a new phase of activity in small-pox, measles, and even scarlatina, as great epidemics. ( d ) The gangrenous pestilence of the middle- age (10th, 11th and 12th centuries), a disease long extinct. (c) The black-death of the 14th century, a disease held by the most competent writers to differ essentially in nature from bubonic plague, and long extinct — unless, indeed, according to some writers, the Pali plague of India is to be regarded as the dregs of the blade-death of the 1 4th century. See Plague. (/') The sweating sickness of the 15th and 16th centuries, which, born towards the close of the former century, after five visitations (1485- 86, 1507, 1518, 1529, and 1551) disappeared, about the middle of the latter century. Also, the great epidemic of syphilis of the 15th century. ( g ) The choleraic pestilence of the present (19th) century. (h) The exceptional development of fatal diarrhoea, especially of infantile diarrhoea, in this century. (A The occasional extension of the yellow fever of the tropics into Europe, notably at the beginning of the present century. (j) The great development of diphtheria, a disease that had been well-nigh forgotten, within the past thirty years. (I-) The appearance within recent years of cercbro-spinal fever. In these phenomena we have evidence of secular pathological changes, to which a clue is sought in studying their relation with secular meteorological and telluric changes. In the epi- demics of short recurring periods— the lesser epidemics, so to speak— it is becoming possible to construct a theory of recurrence, founded on the relationship of man to his physical and social surroundings, and the periodical changes which he and they undergo in common and in subordination to the periodical changes observed in Nature at large, and when the disease is communicable in relation to the number of sus- ceptible people among a community. In the epidemics of long-recurring periods — the greater epidemics — the same conditions obtain ; but it would appear as if there were in addition some slowly-developed cumulative influences at work, which manifest themselves only after long in- tervals of time. So far as these influences may consist in meteorological changes we look princi- pally to India, where these changes are more uniform in their occurrence, for the earliest clear light on the subj ect. There, for example, cholera is constantly present— now as a disease endemic to a particular region, now as a wide-spread epidemic within the limits of the peninsula, but ever and anon breaking its bounds and spread- ing pandemieally throughout the world. James PERIPROCTITIS. L. Bryden, M.D., has shown that the differ.;] developments of cholera within the boundaries i India have very definite relations to particnlr meteorological phenomena; and it seems not U! reasonable to suppose that, following the line , research inaugurated by him, in progress of tin it will become possible to discriminate betvee; the meteorological changes which determine < concur with epidemic prevalence of the disea within India, and those which determine ( concur with wider extensions of the malady- such as affected Europe in 1829-37. 1847-5 1852-56, 1865-67, and 1869-73. Blandford: meteorological researches promise much help ' this direction, inasmuch as they are tending i show a close relation between the greater cvd< of meteorological change in India and cycles meteorological change in the sun s atmospher particularly as observed in the sun-spot period 1 It mightherebe added thatthe late research of Crudeli and Klebs on the development of tl bacillus malaria in. the blood in intennitte fever, and the well-known observations on tl appearance and disappearance of the spirillum relapsing fever, seem to suggest a connection h! tween the periodical character of these diseas and the life-cycle of these organisms. J. Nf.ttf.n~ Rtdcliffe. PERIOSTEUM, Diseases of. Sec Box Diseases of. PERIPHERAL (wepl, around, and yep*. carry). — Of or belonging to the periphery or ci cumference, as opposed to the centre. Thetei; is now applied chiefly to morbid conditions nccted with nerves or their terminations, as dl tinguished from those situated in the nerr centres, for example, peripheral paralysis, pc. pheral pains. Peripheral may also be associat with the vessels, as distinguished from the hea for example, peripheral resistance ; and with t outer zone of the lobules of glandular organs, i for instance, of the liver. PERIPNEUMONIA NOTHA (« around, Trretjpwi', the lungs, and v6Qos, false). - obsolete term, which was formerly vaguely a plied to a variety of forms of acute inflame: tion of the bronchi and lungs. PERIPROCTITIS (wep! , around, and T ds, the anus). — Definition-. — Inflammation the tissues surrounding the rectum. The lumen of the rectum is normally, exce in the act of defecation, obliterated by the mucq membrane being thrown into folds from eontr tion of the muscular coats of the bowel ; so th a transverse section cf it in this state would p sent the appearance of a solid oval, with the lo diameter transverse. During defsecation the boy is distended by the passage of faeces, and m p sons subject to constipation or flatulence this a tension is often found considerably increased accumulations of faeces or of flatus. The re, ] is, in order to admit of this mobility, surronno bv a considerable quantity of loose cellular! sue, which below passes by direct contmuityir the masses of adipose tissue which fill the is, rectal spaces. ... In consequence of tlie dependent position, comparatively great exposure to injury, uie PERIPROCTITIS. lularity and the liability to congestion from the unction of the portal and systemic venous sys- sms, this cellular tissue is very liable to inflam- mation, which usually goes on to suppuration. Periproctitis may be either acute or chronic. Etiology. — Acute inflammation around the ‘ectum may be of traumatic origin. Unskilful atheterisation in the male subject, by -which the oint of the catheter is forced through the rethra into the space between the bladder and >ctum ; penetrating wounds of the bowel, caused y instruments, such as injection-tubes, stric- ire-dilators, &c., or by foreign bodies intro- duced by patients themselves, or by sharp sub- iances. such as fish-bones, which have been taidentally swallowed ; gunshot wounds of the art; penetrating wounds, caused by falls on jarp substances ; or even contusions, the result 'falls or kicks, may set up such inflammation. Or maybe the result of extension of inflammation |om surrounding parts. Thus prostatitis, cys- tis, pericystitis, ulceration in the membranous irtion of the urethra, sloughing ulceration of ,e vagina, and the various kinds of ulcers in the ctum, may be the exciting cause. If perforating cers be the cause, so as to lead to extravasa- >n of urine or faces, the inflammatory process very severe. In some rare cases no exciting use can be traced, and such cases are known ■ the misleading name of ‘ spontaneous peri- octitis.' Chronic periproctitis always results from the tension of inflammatory processes from neigh- uring parts. Disease of the sacrum, coccyx, lower lumbar vertebrae, or chronic disease of e pelvic viscera, often leads to it. It is charac- rised by considerable infiltration and thiek- •mg of the cellular tissue, as well as by sup- ration. Pyaemia resulting from ligature of imorrhoids may be attended by abscesses in is tissue ; which also, though very rarely, have en found in pyaemia from other causes. Symptoms. — In acute cases the patient com- fins of a feeling of weight in the part, and of ,in, which is much greater during defecation, the thickness of the integument in this region, d the fasciee of the part retard the pointing wards the surface, extensive mischief may (st with little external sign. Hence the im- I'tance iu all suspected cases of careful digital (j)loration of the rectum, by which local ten- cness, increased temperature, and either hard- t s or fluctuation, according to the stage of ■lamination, may bo detected. In chronic c es the symptoms are usually masked by those cthe exciting cause. Treatment. — In all cases accumulation of f es in the rectum must be prevented by the i of simple enemata ; whilst in acute cases dly surgical interference is imperatively re- c red. In other cases, the exciting cause must 1 discovered and treated according to circum- s.ices. Jeremiah McCarthy. ’ERITOHEUM, Diseases of. — The peri- t', 2 um is by far the most extensive serous r ubrane in the body, while it has numerous f s and attachments, and is in relation with • iral organs and structures, so that the con- • ^ration of its diseases, though similar in their PERITONEUM, DISEASES OF. 1131 nature, is a much less simple matter than in the case of the other membranes of this class. It must also be remembered that in the female the peritoneal cavity is in direct communication with the uterus, through the Fallopian tubes. The morbid conditions of the peritoneum may be dis- cussed according to the following arrangement : — 1. Peritoneum, Acute Inflammation of. - Synon. : Acute Peritonitis ; Fr .Peritonite aigue ; Ger. Acute Bauch/eilentsundung. ^Etiology and Pathology. — Acute perito- nitis may arise under several conditions, which can be conveniently included under certain heads. a. Traumatic. — It was formerly believed that any kind of injury to the peritoneum was highly dangerous, and would lead almost inevitably to inflammation. Not only, however, may it be punctured with an aspirator or trochar without any harm resulting, but it may even be freely opened and manipulated, under proper conditions, without any injurious effects, as is constantly exemplified in the operation of ovariotomy, and in performing abdominal section for various other purposes. At the same time a very slight ope- ration affecting the peritoneum may lead to serious or even fatal peritonitis, especially in certain states of the system, or if septic mat- ters are introduced into its cavity. Penetrating wounds of the abdomen are very likely to be followed by peritonitis, but not necessarily. The rupture by violence of an abdominal organ will also lead to this result, should the patient survive long enough, from the escape either of blood, or of the contents of a hollow viscus. Peri- tonitis has been attributed to a mere contusion over the abdomen. When it arises from a wound, it is probably not the simple injury to the peri- toneum that causes the lesion, but its exposure to the air, the introduction of septic matters, or haemorrhage into the peritoneal sac. b. Perforations and Euptures. — In addition to lesions due to injury, there are several other kinds of perforation and rupture which are liable to give rise to peritonitis. These have been dis- cussed at length in a special article {see Per- forations and Ruptures), and it will suffice to mention here, that acute peritonitis may follow eitherofthe followingforms of perforation or rup- ture, if they do not prove fatal too speedily (i.) of hollow viscera, with escape of their con- tents ; (ii.) of solid organs which have become so softened as to give way; (iii.) of cystic or other localised accumulations of fluid ; (iv.) of collections of pus in connection with any struc- ture within the abdomen, even the peritoneum itself, or in the abdominal wall ; (v.) of an aneu- rism ; (vi.) of a dilated receptaculum chyli ; (vii.) of fluid accumulations within the chest, which have burst through the diaphragm into the ab- domen, such as empyema, pulmonary abscess, or a hydatid cyst. The peritonitis depends mainly on the materials which thus gain access into the peritoneal sac, whether gaseous, liquid, or solid, and which irritate it more or less according to their nature. Urine is one of the most viru- lent of such materials ; and unhealthy pus or gangrenous particles are also highly injurious. The nature of the irritant will also materially influence the kind of peritonitis which is set up 1132 PERITONEUM, DISEASES OR c. Direct irritation of the peritoneum. — This is a common source of peritonitis, and the irri- tation may be general , affecting more or less the whole peritoneum ; or local. Thus it is supposed that general irritation may result from distension of the peritoneal sac in cases of ascites ; and certainly from extensive morbid deposits, such as cancer or tubercle. Local irritation may be excited by many different conditions, including mere mechanical pressure or friction, as from a tumour, an enlarged cancerous organ, or an accumulation in the bowels ; as well as localised inflammation, suppuration, ulceration, or gan- grene. A very severe form of peritonitis is liable to be set up by a strangulated hernia or certain forms of acute intestinal obstruction; and this complication has also to bo borne in mind as a result of mere local irritation in typhoid fever, and in dysentery. In some in- stances a minute and careful search has to be made for the source of irritation before it can bo discovered; for instance, it may be merely a suppurating absorbent gland, deeply situated. Peritonitis thus originating may be limited, or may spread universally, this depending very much on the nature of the irritant. Extension is due either to the products of inflammation passing along the sub-serous cellular tissue, or being conveyed by the absorbent vessels. d. Extension. — Besides the extension of peri- toneal inflammation from a local irritation, it now and then happens that pleurisy or peri- carditis, especially if of a septic nature, spreads through the diaphragm to the peritoneum, pro- bably by means of the system of lymph-canals existing between the serous membranes and the diaphragm. Inflammation may also pass along the Fallopian tubes directly from the uterus to the peritoneum. In this connection it may further be mentioned that infectious emboli in branches of the abdominal aorta have given rise to peritonitis ; which has also been attributed to phlebitis and peri-phlebitis, extending from the umbilical and spermatic veins. e. Secondary.-— This term refers to cases of peritonitis originating as a complication or local manifestation of some general condition. Under such circumstances the disease usually results from a morbid or poisoned state of the blood — especially when it contains products of excessive tissue-change as in low fevers, abnormal ma- terials, or infective agents. Other causes may, however, assist in its development. The most im- portant diseases in which secondary peritonitis oc- curs are Bright’s disease ; septicaemia and pyaemia, to which puerperal peritonitis probably belongs ; erysipelas, small-pox, glanders, and other dis- eases of this class; and perhaps acute rheu- matism and gout. It has also been said to follow scurvy’ ; but in a large number of cases of scurvy, which have come under the observation of the writer, peritonitis never occurred. f. Idiopathic. — Occasionally cases of perito- nitis occur, which cannot be referred to any of the recognised causes. These have been called idiopathic, and have been attributed to exposure to cold, excessive eating or drinking, and va- rious other causes in individual instances. Many authorities, however, doubt their reality. g. Contagion. — Peritonitis may be originated by contagion, when of the puerperal variety, and may thus become epidemic. Peritonitis in Pemales. —A few special re- marks are called for on this point. Peritonitis is much more common in females than males, or account of the relation of the peritoneum to the- uterus, and the various conditions connected with the genital organs and functions which art liable to atfect it. The following are the principal of these conditions to which peritonitis has beer referred: — (1) the uterine congestion attending menstruation, aided by the effects of cold, es- pecially if this should give rise to inflammation of the womb; (2) the puerperal state and its! accidents, puerperal peritonitis being a most im- portant form of the disease, which is discussed! separately ; (3) premature delivery, and es- pecially the use of instruments in proenrin^ abortion ; (4) extra-uterine pregnancy ; (5 local diseases, such as inflammation of the sub stance of the womb or its lining membrane, oi in the vicinity of the organ ; ovaritis ; uterine or ovarian tumours; peri-uterine haematocele: and inflammation or ulceration of the Fallopiar tubes ; (6) gonorrhoeal inflammation spreading upwards; and (7) injections into the cavity oil the uterus. Predisposing Causes. — In addition to sex, age has to be regarded as a predisposing cause 0: peritonitis. It is very rare in children, except in new-born infants, in whom it occurs com- paratively frequently, either from inflammation or mortification of the umbilicus, or umbilical hernia ; or as the result of infection from thej mother. The affection is said to be not uncom- mon in the foetus, causing its death. Inehildrer peritonitis is usually associated with the acut: exanthemata or pyiemia, even sometimes follow ing vaccination ; but it may also be due to tu- bercular disease or intus-susception, and in very rare instances has been traced to an undescendec testis, or to injury in administering an enema Peritonitis is predisposed to by previous at- tacks ; and, it is said, by accumulation of faces and excessive use of strong purgatives habitually Chronic renal disease may be regarded as 1 powerful predisposing, as well as an exciting cause of the complaint, a very slight irritatioi readily setting it up when this affection is present Anatomical Characters. — The pathologies changes in peritonitis present much variety undei different circumstances, as regards their nature progress, and extent; and although they re semble in a general way those observed in othe: serous inflammations, tliev exhibit in most case: distinguishing peculiarities of a striking kind. In the early stage increased vaseularisatici is always noticed, but it may subside at 3 late period, or be obscured by the inflammatory pro ducts. There is capillary injection more or les diffused, the vessels being enlarged and elongated This is often very marked, giving rise. to intens redness, frequently not uniformly distributed, bu being especially observed where coils of intestm touch each other, and at the starting-point oftk inflammation in certain cases. Small extravasa tions of blood are not uncommon, and may b numerous. The products of the inflammatory process ar very variable, as regards both their nature an PERITONEUM, aount. In certain cases they consist almost tirely of a fibrinous exudation or organi sable mph, with a very little serum, often more or ! is tiDSed with the colouring matter of the blood, d containing flakes of lymph— adhesive peri- intis. The lymph is of a jellowish-grey colour, d at first very soft and easily separable, but ierwards it tends to become firmer and more jherent. It is deposited as a film, which be- nies thicker by degrees, and may attain con- lerable thickness. Usually the exudation forms continuous layer, though of unequal thickness, it occasionally it occurs in separate patches, mats together loosely, or more or less firmly, ,3 coils of intestines ; and covers the solid vis- la, where it tends to attain a greater thickness, te subsequent progress of this form of peri- hitis in cases of recovery is towards organisa- n of the lymph, and the formation of thicken- ■is, bands of adhesion, and agglutinations, :ich may lead to grave consequences. In a small proportion of cases of acute peri- • litis a fluid effusion constitutes the principal irbid product, varying in quantity, but it may come so abundant as to distend the peri- tieum to an extreme degree. There is a little (posit of fibrinous exudation. The eflfusion may I mere serum, resembling dropsical fluid, and, deed, some writers have regarded certain eases Mally looked upon as those of ascites, as being i lly of inflammatory origin ; while ascites may site peritonitis, and thus lead to an admixture ({inflammatory effusion. In other cases the f d is sero-fibrinous, being spontaneously coa- t able, and greenish-yellow, or turbid or milky ; vile flakes or larger fragments of lymph float i, it. In this condition there is often much f'inous deposit. If the fluid is absorbed, ad- bions will subsequently form. n the majority of cases the products tend to 1 of a lower type than those thus far described. 1) exudation is frequently soft and non-organis- ae, or sometimes greasy in appearance ; not un- cimonly it is greenish-yellow, and infiltrated Vh pus-cells. The fluid is also sero-purulent e'ictually purulent. It may be thick, laudable p ; or more liquid and unhealthy-looking; or d’oloured, and more or less offensive and foul- s' liing ; or mixed with blood in various propor- t|s, especially in scurvy and low fevers. The pj collects mainly in the pelvis as a rule ; but evictions of it are also'found between the coils oi.ntestine, and in other parts, pent up by b ph or adhesions, which look like abscesses, a may be of some size. These collections si etimes give way, and thus set up secondary p tonitis. In exceptional cases purulent peri- tc tis becomes chronic, and accumulations of P burst externally or into the intestines. In r. instances a gelatinous or colloid material cc; titutes the effusion in peritonitis. r ith regard to obvious changes presented by tl peritoneum and sub-peritoneal tissue, there u*; be none, when the lymph is separated, the p .oneal surface being normal. In other case* it .dull, lustreless, swollen, softened, and oedema- tc . as well as the subserous tissue, so that the Be as covering can be easily torn off from the 01 ns. Occasionally the structures are infil- tr j '-d with actual pus ; and under certain cir- DISEASES OF. 1133 cumstances localised gangrene occurs at one or more spots. The microscopic changes and appearances differ in the several conditions indicated, but it must suffice to state that they are similar to those observed in other forms of serous inflammation, such as transudation from the vessels ; migration of corpuscles ; separation of, changes in, and proliferation of the endo thelial cells ; proliferation of the connective- tissue corpuscles ; and the formation of vascular granulations. The proportion of cells, and their vitality, differ very much in the several kinds of exudation. The changes which take place in the formation of adhesions and allied conditions are also like those noticed in other serous mem- branes. See Serous Membranes, Diseases of. In certain forms of acute peritonitis foreign materials of different kinds are found in the peri- toneal sac. Foetid gas may be present, either from decomposition of inflammatory products, from transudation through the intestinal walls, or from perforation. The last-mentioned cause also accounts for the presence of foreign bodies, the contents of the stomach or intestine, worms, bile, gall-stones, urine, and other materials which have set up the peritonitis. The muscles of the abdominal wall are often found more or less softened, pale, and degene- rated in severe cases of peritonitis. The in- testines are almost always distended with gas, in some cases to an extreme degree, so that they protrude when the abdomen is opened. Their walls are infiltrated, cedematous, and soft- ened ; and the mucous layer can be readily sepa- rated. The stomach is usually small and more or less contracted, being covered by the intes- tines. The liver and spleen are often pale, or discoloured to a slight depth. The morbid appearances in acuto peritonitis may be more or less general or diffuse, the whole extent of the membrane, however, being rarely involved; or local or circumscribed, the latter being due to some local irritation, and not spreading, either owing to the nature of the inflammation, or because it is prevented by ad- hesions. It may lead either to a local forma- tion of lymph, as over the liver or some other organ ; or to a circumscribed collection of pus, which becomes practically an abscess, and may burst in various dii-ections according to its seat. Some local varieties of peritonitis have received special names, such as pelvic, parietal, omental, hepatic, nephritic, and vesical. It must be remarked that special care is re- quired in making a post-mortem examination in cases of acute peritonitis, as in many forms of the disease the products are extremely virulent, and cause dangerous or fatal septicaemia if intro- duced into the system in the smallest quantity. Moreover, in some forms infection is very liable to be conveyed to other persons, and extreme pre- cautions are demanded in this matter in dealing with women in the puerperal state. Symptoms. — The fact must be clearly recog- nised at the outset that the clinical history of acute peritonitis varies considerably in different cases, according to ils immediate cause, the con- dition with which it is associated, its seat and extent, the course which the inflammation takes. U34, PERITONEUM, the products which it originates, and other circumstances. So far as the peritonitis is concerned, the phenomena to he anticipated are heal and general. The local phenomena are due to the inflammation itself; to its products ; and to its direct effects upon abdominal organs and structures, especially upon muscular tissues, which it first irritates and then paralyses. They may be further subdivided into abdominal and thoracic. The general symptoms are either of a febrile character ; or depend upon the absorption of purulent or septic matters formed in the peri- toneum ; or are indicative of collapse. It will be expedient, in further discussing this subject, to indicate first the usual clinical course and phe- nomena of acute peritonitis ; and then tc point out the more important clinical varieties of the disease. The invasion is usually distinct, being indi- cated by shivering or actual rigors, which may be repeated several times. If the peritonitis is due to perforation, however, the phenomena attend- ing this lesion constitute the initial symptoms, but even here rigors not uncommonly occur sub- sequently. The local and general symptoms characteristic of peritonitis speedily supervene. Local symptoms . — Pain is one of the most constant and striking symptoms of acute peri- tonitis, and it comes on very speedily, or in cer- tain cases may even precede rigor. It depends directly on the inflamed condition of the perito- neum. As a rule it commences locally, and especially in the lower part of the abdomen, but it rapidly spreads more or less extensively, being often felt over the whole abdomen, though not uncommonly more marked in one or more spots, such as where the inflammation started from, and also in the umbilical region. This may depend upon greater intensity of the inflammation at these points. The pain is usually exceedingly severe and intense, and it maybe excruciating or agonising, as evidenced in the expression of the patient’s face. In character it is variously de- scribed as hot, burning, cutting, boring, shoot- ing, darting, and so on. Prom time to time exacerbations are liable to occur, owing to spas- modic movements of the intestines disturbing the inflamed structures. Any movement of the body increases the suffering, so that the patient in- stinctively keeps the trunk at rest, and assumes a characteristic posture, so as to relieve all ab- dominal tension, namely, lying on the back, with the thighs and knees flexed, and the legs drawn well up. Moreover, abdominal respiration is restrained or entirely checked, as the necessary movements increase the pain ; which is also ag- gravated by any such disturbance as the act of coughing, vomiting, or deftecation causes. At the same time there is the most exquisite tenderness, so that the patient dreads any objective exami- nation, and cannot bear the least touch, though deeper pressure is still more unendurable. In some cases even the weight of the bed-clothes cannot be tolerated. Prominent symptoms occur in connection with the alimentary canal. The appetite is com- pletely lost, but there is intense thirst. The tongue is furred, and often presents a peculiar appearance, being very small, red, and irritable- louki ng, and soon tending to dryness. The taste DISEASES OF. is affected, and becomes bitter or otherwis- disagreeable, or even disgusting. Nausea am vomiting are usually urgent symptoms, and, a a rule, set in very early. Vomiting occurs whei anything whatever is taken, and even spot taneously, while there is a constant feeling o sickness. At first the vomited matters consis of mucus and altered food ; subsequently the' present a grass-green appearance ; or under cer tain circumstances they may become faeculent even quite apart from intestinal obstruction Gaseous eructations are also common. Obsti nate constipation is the rule in acute peritonitis! but exceptionally diarrhoea occurs. At first tin intestinal walls are more or less spasmodical! contracted, but they soon become paralysed, si that they are distended to a variable degre with gas, and this frequently culminates ii extreme tympanites or meteorism. During th< development of this symptom, irregular am inefficient peristaltic movements of the hove often occur, or certain parts are more distendet than others, and these conditions may be seei or felt, while they give rise to audible rumblinj or gurling sounds or borborygmi. The rapidity of the distension of the abdomen will depenc much upon the previous condition of the abdo-; minal walls, as to whether they are firm or las and yielding ; and upon the rapidity with which their muscles become paralysed. The only other notable local symptoms in the abdomen are referable to the urinary organs The urine not only presents febrile characters but is usually markedly diminished in quantity and may even be suppressed. What is passed i often hot and scalding. Micturition may at firs be very frequent, owing to irritation of tb bladder ; subsequently retention is liable t( occur, owing to paralysis of this organ. Tb urine is not uncommonly albuminous. Jaundice is now and then observed in cases o acute peritonitis. The thoracic symptoms which may resul; from the local effects of acute peritonitis ar< hiccough, which is in many instances very dis tressing ; the form of dyspnoea in which tin respirations are very hurried — reaching 40, -50 60, or more — shallow, superficial, and costal sometimes cough, although the patient make: every effort to suppress it; and cardiac dis turbance, the action of the heart becoming very rapid. The disorder of the respiratory and cir- culating functions is partly due to the genera condition, but they are also locally influenced b} the pain accompanying peritonitis; by its direc effects upon the diaphragm ; and by the me chanical effects of gaseous or fluid accumulation upon the diaphragm and thoracic contents. More over, morbid conditions within the chest may b associated with peritonitis, such as pleurisy pneumonia, or pericarditis. Physical signs . — The conditions resulting frou peritonitis give rise to certain physical signs which need to be briefly indicated. It must b remembered that in this disease physical exami nation ought to be practised most gently an< cautiously. The causes of the abnormal physica signs are the pain ; the distension and other dis orders of the intestines ; and the presence of in flammatory products or of other materials in t. PERITONEUM. DISEASES OE. 1136 ■ritoneal cavity. 1. The abdomen at an early ■jriod of the case may be slightly depressed, anir to tension of the muscles, but soon be- cues more or less enlarged, and often attains a (feat size, the skin being stretched, and the lower ]rt of the chest also distended. Generally fe enlargement is quite symmetrical, but no t al- i yg. A transverse groove is sometimes visible, losing across the epigastrium. In very mus- i ar individuals the abdomen may be but little barged in peritonitis. 2. There is marked Hence of diaphragmatic respiratory movements, ifl these movements as a whole are restricted. 1e lower intercostal spaces do not fall in during rpiration. Very rarely a friction-fremitus i y be felt in some part of the abdomen when a f;l breath is taken. 3. Intestinal movements s often seen or felt. 4. Palpation reveals that 4 abdomen is smooth and regular; at first the riscles are felt to become as it were instinc- tJbly contracted when palpation is practised ; s>sequently the sensation is usually that of rre or less tympanitic or drum-like tension, 'lere are exceptional cases in which it is that t fluid. 5. Percussion usually yields chiefly ffnsre or less tympanitic sound, though not nessarily uniform in tone and pitch over the e.ire abdomen. The hepatic and splenic dulness a diminished or completely annulled, even t'ugh there be no gas in the peritoneum itself, /[mall quantity of fluid cannot be detected, or oy by careful examination in certain postures (; Ascites), and it is usually hardly worth v ie in cases of peritonitis to disturb tho patient fij this purpose. Generally the dulness due tcfluid can be elicited in dependent parts of tl abdominal cavity, being as a rule distinctly ni able with change of posture. It is said that titline of demarcation between the dulness and tjpanitic sound is found to be zigzag when Cilfully percussed out, owing to the fluid getting imetweon the loops of intestine. In exeep- tinl cases of acute peritonitis the dulness of flu is the main percussion-sound noticed. Futuation will be present where there is fhj, but it is not a very reliable sign in adie peritonitis. 6. Auscultation, as a rule, mely reveals, if anything, sounds of the moments of flatus in the stomach and intes- tiij; or succussion-sounds, due to the shaking up,of fluid and gas in these organs. Fric- tioisound is for several reasons a rare phe- ncjmon, but may occasionally be heard over sol spot if the patient can be made to breathe sudently deeply, mainly over a solid organ, an especially the liver. 7. Examination of th chest often reveals more or less compression of'ie lower parts of the lungs ; and displace- mt, of the heart upwards and towards the left. \ncral symptoms .- — Pyrexia usually speedily set n in acute peritonitis, but in certain cases tin is no rise of temperature throughout. IVljs presenting considerable differences, as a ru!;he temperature rises markedly at an early per l, and continues high for a time, though genilly with remissions, having, however, no regiir course. There are the usual accom- paihents of fever ; and the urine is markedly teb'a, being concentrated, high-coloured, and dep iting urates abundantly. The pulse be- comes very frequent, reaching 120, 140, or even 160 ; it is also small, sharp, and often peculiarly hard, wiry, or thready. The increased rapidity of breathing is partly due to pyrexia. The pa- tient soon presents an aspect of serious constitu- tional disturbance ; the expression of the face is one of pain and grave anxiety, and the features are sunken, pinched, and withered. There is much debility or actual prostration, while at the same time the patient is generally uneasy and restless, tossing the arms about, but keeping the trunk motionless. A more or less cyanotic ap- pearance may be evident. There are usually no prominent nervous symptoms at first, except, per- haps, headache and sleeplessness. The intellect generally remains clear to the last, and it oc- casionally happens that the supervention of peri- tonitis rouses a patient whose consciousness has been previously more or less blunted. In ex- ceptional cases delirium or impaired conscious- ness are early symptoms. The further progress of the general symptoms will be indicated under the following heading. Course and Terminations. — The large ma- jority of cases of acute peritonitis terminate fatally, and usually within a few days, the pro- gress being rapid. It is important to notice that the patient may feel better, and that the pain often diminishes or even subsides, sometimes suddenly, while the general condition is becoming worse and worse. The tympanites may also become less, or disappear. Sometimes before the close an abundance of dark, blood-stained fluid is discharged from the stomach and bowels, without any effort. Death may occur while the pyrexia is still high ; but usually the phenomena observed become those of collapse, combined with signs of impaired respiration and stagnant circu- lation. The patient is greatly prostrated. The countenance assumes more and more the as- pect of collapse, the eyeballs appearing sunken and surrounded with dark areolae, the cheeks hollow, and the features markedly pinched, with blueness of the lips; the expression is that of extreme anxiety. The temperature falls, and often becomes sub-normal ; the extremities are cold ; and the skin is covered with clammy sweats, while the prominent parts are peculiarly cold and blue. The pulse becomes extremely rapid ; feeble, sometimes to complete extinction ; and irregular. The respirations are very hurried and shallow ; and the voice is weak or lost. As already stated, the mind generally remains clear to the last ; but in some cases the mental faculties are somewhat obscured towards the close, and delirium of a low type occurs ; occasionally a co- matose condition supervenes. In some instances the symptoms become those of the typhoid state. Acute peritonitis occasionally subsides into a chronic condition, in which localised accumula- tions of fluid remain, and the patient lingers on, the temperature continuing elevated, but presenting irregularities. Different events may then occur, such as bursting of fluid-collections in various directions, the supervention of septicaemia or pyaemia, or general wasting and anaemia, death ultimately taking place after a variable interval. Recovery ensues in a certain proportion ol cases, where the inflammation has not been ex- tensive, and where its products are either fibri -1136 PERITONEUM, DISEASES OF. nous or sero-fibrinous. Improvement is indicated by a concomitant diminution of the abdominal symptoms ; restoration of the action of the bowels ; sometimes an increase in the quantity of urine; a change in the aspect and expression of the patient ; increased fulness and force of the pulse, and diminution of its frequency ; a gradual fall of temperature; restoration of sleep; and sometimes the occurrence of perspiration. It is said that occasionally a crisis, with critical discharges, occurs, but this is quite exceptional, the decline of temperature being usually by lysis. After ap- parent recovery from acute peritonitis the effects of adhesions may prove serious. Clinical Varieties. — It will only be practi- cable to indicate here the most striking of the clinical variations presented by cases of acute peritonitis. Two special forms are described in separate articles. See Puerperal Diseases; and Pelvic Peritonitis. (a) Peritonitis from Intestinal Obstruc- tion. — Here the symptoms of the obstruction are the most prominent, and the peritoni tis only modi- fies them, and helps to hasten the fatal issue, which is mainly due to the intestinal condition. It is in these cases that the movements of the bowels are most evident, and the meteorism is extreme. The temperature may continue normal or even sub-normal throughout. The course is usually very rapid. ( b ) Perforative. — When general, this is an intense and very fatal form of peritonitis, and usually runs its course very speedily, especially if highly irritating materials gain access into the peritoneum. Usually it is distinctly pre- ceded by the characteristic symptoms of the perforation ; or some condition is present in which a perforation may be anticipated. Therefore, if rigors occur, they follow a sudden local pain, which spreads rapidly over the abdomen. The local symptoms are extremely marked, and the vomiting is likely to be most violent, except, it is said, in those cases where the stomach itself is the seat of a large perforation. Moreover, there may be signs of gas in the peritoneal cavity ( see Peritoneum, Gas in). The symp- toms of collapse are evident from the first, and quickly become aggravated. The temperature is often below the normal. Should the perforation take place into a limited portion of the perito- neum, the symptoms are correspondingly limited, and less severe. (c) Adynamic or Typhoid. — Cases of peri- tonitis maybe thus grouped which exhibit a dis- position to the rapid development of adynamic or typhoid symptoms. These may depend upon the condition with which the peritonitis is asso- ciated ; or upon septicaemia or pyaemia, arising from the absorption of inflammatory products from the peritoneum. In some of these cases the local symptoms are not so evident, and may be quite latent. (d) Latent.— This term implies that the cha- racteristic symptoms ofperitonitis are either alto- gether absent, or so indefinite as to be practically valueless for diagnostic purposes. Such may happen in cases belonging to the adynamic group, where the patient’s consciousness is so impaired that he cannot feel pain ; but even then pressure over the abdomen may bring out indications of pain, if carefully watched for. For some latent cases of acute peritonitis, of which the write has seen a striking instance, no explanation can be given. To this class may also be referred those cases where it is really difficult to draw the line between mere ascites and peritonitis with abundant fluid effusion. (e) Infantile. — This has been described as a variety of peritonitis. In young infants pain and tenderness in this disease are indicated by the expression, and by a short cry or whitie They do not cry loudly, on account of the pain thus caused. The abdomen is greatly distended with flatus. Vomiting is less common in children than in adults. Pyrexia is usually considerable at an early period ; and the pulse becomes ex- tremely frequent, even uncountable. Occasion- ally convulsions occur. The course is very rapid in young children as a rule. (f) Local or Circumscribed. — Casesoflocal- ised peritonitis belong practically to two groups The first includes those in which there is a limited fibrinous exudation, set up by some local irrita- tion, especially in connection with some solid organ, such as a cancerous liver, or with a ru- mour. Such a condition is only indicated by s correspondingly localised pain and tenderness with perhaps friction-fremitus and sound, elicits during the respiratory movements. The othe; local, as well as the general symptoms of peri tonitis, are absent, and the constitution frequent! does not appear to suffer in the least. In th- second group a limited effusion occurs, whicl becomes purulent ; or there may be several suel efiusions. Here the symptoms are more severe but the pain and tenderness are still circum scribed, and in time external objective sign often appear in tlje corresponding region of th abdomen, such as limited fulness, a feeling c firmness followed by fluctuation, redness of th skin, and dulness on percussion. The mor characteristic local symptoms of acute peritoniti are either absent, or much less prominent tha usual. The general symptoms, however, nr frequently very marked, but they are merely c a febrile character, preceded in many cases 1' rigors. The subsequent progress of the symp toms will depend upon the course of event! Thus, general peritonitis may be set up; th accumulation may burst externally ; a commun: cation may be formed with some internal hollo organ, especially the intestine, when gas finds it way into the space, giving rise to a limited tyn panitic sound on percussion, and the fluid is evf cuated by the bowel ; pytemia may occur ; or tit- condition may become more or less chronic, an the fluid is ultimately evacuated in some dire- tion or other, or undergoes a caseous change. < is absorbed, a cure resulting, with the formate of thickening and adhesions. Any’ organ in tf vicinity of localised peritonitis is likely to 1 disturbed in its functions ; and the accumulate of inflammatory products may physically inte fere with neighbouring structures. Inflammatic of the great omentum is attended with ve marked superficial pain and tenderness. (o') Complicated. — Clinical varieties of pei tonitis not uncommonly result from itsassociatl conditions. Thus it may be modified by soi disease to which it is secondary, such as typho PERITONEUM, DISEASES OF. ■ver or pyasmia; or it is accompanied by some her affection, such as muco-enteritis, pleurisy, • pericarditis ; or the peritonitis gives rise to eondary lesions, which modify the clinical his- jry of particular cases. Diagnosis. — In well-marked cases the dia- osis of acute peritonitis is sufficiently obvious, evidenced by the cause of the disease; its ode of onset ; the severity and character of the ■,al symptoms; the physical signs; the nature jji gravity of the general symptoms ; and the lpid progress of the case. More or less diffi- aty may be experienced when the peritonitis iissociated with certain other conditions in the tiomen, modifying its symptoms ; when it is ob- t red by the general stato of the patient; when i symptoms are quite latent ; or when the dis- 66 is local. In some instances it is impossible caistinguish between mere ascites and inflam- n:ory effusion. It is very important to bear in nld the conditions in which latent peritonitis is liile to occur. It may happen that the dia- g ; sis of peritonitis is clear enough, but that its c:se cannot be discovered, or only after very ti tough investigation. here are certain affections which must be rtembered, as being liable to simulate, and to btnistaken for, acute peritonitis. 1. The writer hi seen cases of extreme tympanites, accom- pffled with pain, in typhoid fever, and in low fe|le diseases, such as erysipelas, very much re/mbling some forms of peritonitis. 2. Pain- fuconditions of the abdominal wall may prove tnblesome, namely, muscular rheumatism, lotised inflammation, and cutaneous hyper- asesia. Here, however, although there is su rficial and usually diffused pain, with marked tewrness, which may be extreme, there are no of the grave abdominal and general symp- toi observed in peritonitis, with the peculiar pa and other characteristic phenomena. In coi iction with hysteria i ntense hyperassthesia of the bdomen is occasionally met with, with more or ;s distension, sickness, and constipation, and evqapparently severe constitutional disturbance a ubination of symptoms which may closely sm ate peritonitis. Due care should, however, prent any mistake in diagnosis, for the patient is nerally obviously hysterical ; no cause of per .nitis can be discovered; the hypersesthesia is Vy superficial, and pressure can be borne if the'atient’s attention is taken off; while the gen ii symptoms are not really those of peri- ton, s, and there is little or no pyrexia. 3. Pai d affections within the abdomen have to be (jtinguished from peritonitis. These include erat in the stomach ; intestinal colic ; the pas- sage hepatic or renal calculi ; painful affections com ted with the female generative organs ; and perils neuralgia implicating certain abdominal vise li. In many cases the pain is accompanied with omi ting, frequent pulse, and considerable genc-jl. disturbance, tending more or less to- vrarit collapse. The previous history of the case ;he mode of onset of the symptoms ; as well their precise character, ought as a rule to rend the diagnosis at once evident. Moreover, the ijicky and neuralgic pains are usually re- lieve by pressure. Doubtful cases must he watc 1, when any difficulty will probably soon 72 1137 be cleared up. It must he romembered, how- ever, that some of the conditions mentioned may set up local inflammation, and even peritonitis, and thus the diagnosis will be rendered more obscure. 4. Certain objective morbid conditions within the abdomen must also be alluded to in relation to the diagnosis of peritonitis. It may- be impossible to distinguish between this com- plaint and tho graver form of enteritis, espe- cially that resulting from intestinal obstruction, but the diagnosis is not of practical moment, and the two diseases are usually combined sooner or later. The positive diagnosis of peritonitis in some cases of perforation may also be impractic- able. In the local forms of inflammation com- mencing in cellular tissue, such as perinephritis and perityphlitis, it cannot be certainly known whether the peritoneum is involved or not; but it may be assumed that the neighbouring por- tion of the membrane is very soon implicated, and the peritonitis may become general. Pos- sibly, circumstances might arise under which ac- cumulations of fluid, such as an ovarian cyst, a hydatid cyst, or a distended bladder, might simu- late peritonitis with effusion, but there rarely ought, to be any real difficulty in these cases. ; These conditions, as well as other tumours, may, however, set up peritonitis. 5. It must bo men- tioned that at first acute pleurisy or pneumonia may simulate peritonitis, the pain present in these diseases being referred to the upper part of the abdomen, or even to a more extensive area, and being accompanied with tenderness. It may be that in somo of these cases the peri- toneum is locally inflamed. Pbognosis. — Acute peritonitis must alway-s be regarded as a serious disease, and in many cases the prognosis is extremely grave, or even hope- less. Moreover, its progress, when general, is usually very rapid, so that the patient may die within thirty-six or forty-eight hours, and gene- rally succumbs within a week. Death may occur, however, in three or four weeks, or even at a ! later period. In some of the cases of very short duration, death is due rather to the cause of the peritonitis, such as intestinal obstruction or perforation, than to the disease itself. The indications giving hope of recovery have already been pointed out, but the practitioner must guard against being misled into giving a hopeful pro- gnosis from mere improvement in the subjective feelings of the patient, without any correspond- ing amelioration in the objective local symptoms, and in the general condition. Even in cases where recovery takes place, the effects of adhesions and other remaining morbid conditions must be borne in mind, as these may subsequently become troublesome or even dangerous. The prognosis of acute peritonitis will be ma- terially influenced by the following considera- tions; — 1. Its (Etiology . — The most grave forms are those due to perforation ; and those of septic origin, especially puerperal peritonitis. That as- sociated with Bright’s disease and other forms of blood-poisoning, is also very serious. When the disease arises from direct injury, or from some local irritation, the prognosis is much more hope- ful. 2. The patient . — In young infants peritoni- tis is absolutely fatal, and it is extremely grave in children generally. A weak or low condition 1138 PERITONEUM, of the patient, from bad living, intemperance, previous illness, or other causes, renders the prognosis more serious. 3. The extent , rapidity, and precise nature of the disease. — Peritonitis is more serious in proportion to its extent, and when it is local the result is much more hopeful, especially if the products of the inflammation seem to be merely lymph or sero-fibrinous fluid, when no particular danger need be anticipated. If the course of the disease is very rapid, the prognosis is exceedingly grave, partly because the inflammatory products are then probably of a low type. When peritonitis shows any ten- dency to become chronic, there is more hope ; but even then a fatal issue may ultimately occur from various causes. 4. The symptoms. — It may be stated generally that the more severe the symp- toms of peritonitis are as a whole, the more dangerous is the case. Among the chief indica- tions of special danger may be mentioned extreme tympanites; urgent vomiting; the passage of bloody fluid from the stomach or bowels ; great dyspnoea; incessant hiccup; very high fever; rapid development of signs of collapse ; typhoid symptoms, with low nervous phenomena; and an extremely rapid, feeble, and irregular pulse. 5. Complications. — These may increase the gravity of a case of peritonitis, such as pleurisy, pneu- monia, or pericarditis. Theatmext. — It will be evident that no uni- form plan of treatment can be applicable to all cases of peritonitis, and much judgment and con- sideration on the part of the practitioner are often needed in the management of this serious dis- ease. There are, however, certain definite in- dications to be recognised, which will now be pointed out, as well as the principal means by which they should be carried out. a. Attention must, in the first place, be di- rected to the cause of the peritonitis, which in obscure cases should be carefully sought for, and, if possible, got rid of, or mitigated. This may be illustrated by an accumulation of faeces, hernia, and other forms of intestinal obstruc- tion. In most cases, however, this indication cannot be fulfilled ; but even then attention must be directed to the cause. h. The next indication is to endeavour to com- bat the inflammation itself, so as to arrest or subdue it, to influence its products, and to obviate its injurious effects upon the abdominal organs. Rest for the affected structures is most important, so far as it can be obtained. It will rarely bo necessary to enjoin rest for the abdomen gener- ally, and relaxation of its muscles, as the patient will instinctively attend to this. It may be de- sirable to raise the bed-clothes from the body, by means of a cradle or other suitable apparatus, so as to prevent all irritation from this source. If not otherwise indicated, it is extremely im- portant in early cases of peritonitis to give as little as possible in the way of food. Only frag- ments of ice, or small quantities of iced drinks should be allowed, or iced milk or beef-tea, if they can be retained. Not uncommonly the stom- ach rejects everything, and then recourse may be had to small enemata, and it might be useful to employ artificially-digested aliments in this way, according to the plan of Dr. 'William Roberts. Abstraction of blood, either by venesection or DISEASES OF. by the application of leeches to the abdomen, is a common practice in acute peritonitis. If this measure is thought desirable, it is certainly pre- ferable to remove the blood locally: from ten to thirty leeches may be applied in different cases, but it certainly can never serve any useful pur- pose to put on a larger number than this, and would probably be followed bv untoward results. Removal of blood can only be of service in the early stage of the disease, and is decidedly in jurious when the inflammatory process has pro- gressed considerably, and especially if it has advanced rapidly. Moreover, it must not 1* practised in low forms of peritonitis, or if the patient is badly nourished and weak from any cause. Healthy, strong, and plethoric subjects are most likely to be benefited by removal of blood. This measure is also likely to bo useful in some forms of local peritonitis. The chief medicines which are employed for their immediate effects upon peritonitis are calomel and opium, and they are usually given in combination, in the form of pill, every two to four hours. The calomel is administered until the system is brought under the influ- ence of mercury ; or, in the case of infants, this is sometimes effected by inunction with the mercurial ointment. In the writer’s opinion, mercurialisation as a routine plan of treatment in peritonitis is to be strongly deprecated, and he has never seen any good result from its em- ployment. Opium, however, is a remedy oi extreme value, and is often our sheet-anchor Amongst other beneficial effects, it acts upon the stomach and bowels, being generally supposet to arrest peristaltic action in the latter, thong) some are of opinion that it excites peristalti action, hut diminishes reflex irritation. In what ever way this drug acts, its beneficial effects upo these organs are very manifest. Opium is usuall given in the form of pill, containing from gr. togr. ij of the powder, and repeated every two t four hours. It is remarkably tolerated in acut peritonitis, unless there be renal disease, whe it must bo given very' cautiously, nr not at al In children it must also be administered wit, due care. If the stomach is extremely irritabl tincture of opium may be administered in tb form of enema ; or, which is preferable, morph may he substituted, especially by subcutaneoi injection ; and this may be also employed as a adjunct to the internal exhibition of opium, the pain should be very intense. Tincture c aconite, veratrum viride, and digitalis have bee employed for their effects on inflammation in tl early stages of acute peritonitis, but they canm be recommended. The question of local applications to the a domen, as regards their immediate effects up< peritonitis, is important, and byno means decide The common practice is in favour of employn hot applications, in the form of light poultices fomentations, to which anodynes may be adde> or turpentine stupes or sinapisms. The use cold has, however, been strongly advocated many authorities in the early stage of peritonit and deserves a more extended and thorough tr than it has hitherto received. It may be c; ployed either by means of cold compresses, £ quently changed; a bladder containing pound 1139 PERITONEUM, 'ice, not too heavy ; or flannel dipped in iced- lvater. The effects claimed for this treatment are that it contracts the vessels ; allays nervous irritability, and consequently intestinal distur- bance ; and alleviates pain. The sensations of , the patient must be some guide as to its con- tinuance. At a later period hot applications are decidedly to be preferred, as the cold applica- tions can be of no service, and -will probably prove injurious. As certain cases advance, it may be advisable to apply blisters to different parts of the ab- domen, vrith the view of promoting the iibsorp- jtion of inflammatory products. Operative in- terference is decidedly indicated in some cases hf considerable effusion, the fluid being removed by a trochar. It may also become a question whether purulent collections should not be let nit, after acute symptoms have subsided. Cer- ainly this measure is indicated if there is any oeal accumulation of pus. c. The general condition of the patient in ■ases of acute peritonitis always demands con- rant attention, and in many instances it is the hief matter for consideration. Whenever any endency to collapse or adynamia sets in, alco- lolic stimulants are called for, in variable quan- tity according to circumstances, brandy and ihampagne being the most suitable. Their ad- ministration must not be left until too late a eriod. They are best given at frequent inter- als in small quantities. If stimulants cannot e borne by the stomach, brandy should be given 1 enemata. Liquid nourishing food is also often quired in large quantities, and may he admin- tered in the same way. Quinine in full doses, .her, musk, camphor, ammonia, hark, and tur- lintine, are the chief medicines which may be lied for in bad cases, to combat the general mptoms. Subcutaneous injection of ether or mphor may be of service in extreme conditions. d. Symptoms often call for special treatment acute peritonitis, although most of them tend be alleviated by the measures already con- dered. It will only he necessary to allude ether to the following. Nausea and vomiting ly call for small doses of iced efferveseents, th hydrocyanic acid and morphia ; soda-water 1 milk ; or drop-doses of creasote. Constipa- n in many cases ought on no account to be dis- ■bed; if any treatment is indicated, calomel at c,t, followed by enemata, will answer the purpose. ,cessive diarrhoea in certain cases may require i‘be checked by enemata containing laudanum, teorism is sometimes relieved by calomel ; if ry troublesome, the use of enemata containing t pentine, the passage of a long tube per rec- 0, or, in extreme cases, the puncture of the o. ended intestines in several places with a fine t char, are the measures indicated. The relief c -Lis symptom is the only direct way of in- ducing dyspnoea. Hiccup calls for narcotics, ^sr, the local application of sinapisms or blis- t ', and, if dangerous, inhalation of chloroform. In cases where recovery ensues, much care acquired during convalescence, as regards diet a general management ; and the absorption of s bid products may be aided by applying blis- -* or iodine to the abdomen, and by baths and oi r measures. DISEASES OF. 2. Peritoneum, Chronic Inflammation of. Stn'on. : Chronic Peritonitis. — This affection, like the acute form, may involve the peritoneum more or less generally ; or only over a localised and limited area. The conditions included under the term are somewhat indefinite, but not un- commonly they are well-marked pathologically, as well as of considerable clinical importance. H5tiology axd Pathology. — Without enter- ing into detail*;, it must suffice to point out the circumstances under which chronic peritonitis may occur: — 1. There is no doubt as to its being a sequel of one or more attacks of acute peritonitis in some instances, either general or local, but especially the latter ; and after a circumscribed acute peritonitis the chronic affection may spread more or less generally. Moreover, the conditions remaining after acute peritonitis are liable to set up further mischief in a chronic manner. 2. Chronic peritonitis may become associated with ascites, but more particularly when re- peated paracentesis has been performed for the relief or cure of this condition. 3. Localised chronic peritonitis is very common as the result of continued irritation, set up by some diseased organ, such as a cirrhotic or cancerous liver, cancer or chronic ulcer of the stomach, old her- nias, tumours, and various other obvious con- ditions. There are, however, cases occasionally observed in which the cause is not so evident, and these have been referred to irritation by accumulations of feces, or to repeated pressure or other mechanical causes acting from without. 4. Morbid formations in the peritoneum itself are very liable to set up chronic inflammation. Of these the principal are tubercle and cancer, and tubercular and cancerous peritonitis consti- tute important forms of this disease. 5. In rare instances a chronic inflammatory effusion col- lects in the peritoneal cavity, without any ob- vious cause. This cannot he separated by any- marked line of demarcation from some latent cases of acute effusion. The fluid may be actu- ally purulent under these circumstances, hut is generally serous, and cannot he distinguished from that of mere ascites. This chronic effusion has been noticed during convalescence from fevers ; and has also been attributed to cold and wet. It may he mentioned here that some cases of chronic peritonitis have also been referred to chronic renal disease, and to rheumatism. .Anatomical Chauacters. — The precise con- ditions present in an individual case of chronic peritonitis are subject to great variety, as regards their nature, extent, and site ; hut their general characters can be readily indicated. Adhesions or thickenings connected with the serous membrane are almost constantly- present in different degrees, and not unfrequently they constitute the sole anatomical evidences of chronic peritonitis. They result from the development of the inflammatory products, and the formation of connective or fibrous tissue, with new vessels. The thickening varies much in degree, ranging from what is scarcely perceptible, to the produc- tion of a dense fibrous mass, an inch or more in thickness, as the writer has seen. It may he evi- dent. in the parietal peritoneum; around organs, forming more or less thick and firm capsules ; or in the peritoneal folds, especially the omentum 1140 PERITONEUM, and mesentery. Adhesions or agglutinations also form between different parts, thus uniting organs to each other, to the abdominal walls, or to the mesentery or omentum ; or sometimes matting the whole together into an inseparable or indistinguishable mass. They present great variety, and by the movements which take place within the abdomen, they may be stretched or made more loose, or even be got rid of altogether in some instances, when they have formed after an acute attack. On the other hand, in many cases the adhesions and thickenings tend to be- come gradually stronger and denser, and at the same time to undergo contraction, so that they produce serious effects. In many cases of chronic peritonitis effusion of somekindis observed. It may be merely serous, or containing fibrinous flakes, sero- purulent, or actually purulent. Blood may also be present in it. Occasionally this is the prominent or only anatomical change ; and the fluid may range in quantity from a small to an enormous amount. Usually it is associated with the other condi- tions already described, so that the fluid is not free to move about, and may be actually circum- scribed, or even lie in the substance of great thickenings. Purulent accumulations are likely to make their way in various directions, either outwards or into internal parts. When chronic peritonitis depends upon the presence of tubercle, cancer, or other morbid formations, these will be evident on 'post-mortem examination. Moreover, the inflammatory pro- ducts may undergo degenerative processes, and hence caseous or cretaceous particles or masses be found. It is highly probable that tubercle may be formed secondarily, as the result of infection from caseous or purulent collections. Pigment is also often present in abundance. It is important to notice the obvious effects liable to be produced upon the abdominal or- gans and other structures by chronic peritoni- tis. They are fixed by the adhesions and thicken- ings, and may be displaced at the same time. Compression or constriction is often produced, especially important in the case of hollow viscera, as well as distortion, twisting or torsion, and in- carceration. Some of these effects may occur acutely in connection with bands of adhesion, thus giving rise to grave consequences ; and fixation of the bowel may also lead to intussuception. The omentum may be greatly distorted, or fixed in some abnormal situation ; while the mesentery has been found extremely shortened, so as to contract the small intestine to half its length, its serous covering and longitudinal muscular layer being shrivelled, and its mucous lining thrown into transverse folds. The deeper tissues of some of the abdominal viscera are likely to be affected by long-continued chronic peritonitis; and atrophy from compression may ensue. As one good result of this condition, mention must be made of the fact that it is not uncommonly the means of preventing or modifying the injurious consequences resulting from some forms of per- foration of abdominal viscera, by giving rise to previous adhesions and thickenings, and thus ob- viating the escape of their contents, or limiting their dissemination. Symptoms. — The clinical history of chronic DISEASES OF. peritonitis necessarily presents much diversity. The phenomena observed result from the mere presence of the inflammatory products ; the effects produced upon the organs within the abdomen by these products, whether in the way of mere func- tional disorder, or other more obvious derange- ments ; the consequences of direct pressure upon tubes, vessels, or other structures; and the gene- ral or constitutional disturbance often present. According to its mode of origin, chronic peri- tonitis either remains after an acute illness, or after a succession of more or less acute attacks or exacerbations; or its onset is gradual and chronic from the first, and may be very insidious. Of slight adhesions left after acute peritonitis, or originating from chronic causes, there are often no clinical signs ; or there may be uneasi- ness and discomfort, or even painful sensations at times in some part of the abdomen, especially the iliac region, with a tendency to intestinal disorder, in the way of spasmodic movements and constipation. Even when there are no symptoms whatever, adhesions may at any time cause serious consequences. In well-marked cases of ehroni- peritonitis the symptoms to be expected are of the following nature : — Abnormal subjective sen- sations are usually experienced in the abdomen, such as tightness, fulness, dragging, or actual pain. The pain, when present, is of a dull cha- racter, not severe, and liable to come and go, or to present exacerbations from time to time ; it is often localised, and especially if the peritonitis be circumscribed ; sometimes there is a feeling of local soreness or heat. The painful sensations tend to be increased by movement, and by shak- ing the body. They are sometimes aggravated by posture, in some eases by bending forwards in others by the erect posture ; and they may be; increased by going up stairs, especially if the ab- domen is distended. More or less tenderness on pressure is very common, even when there is net spontaneous pain, but not invariable ; it is fre- quently more evident at certain spots, where it may be considerable. Colicky pains are not un- common in chronic peritonitis, and may occur in severe paroxysms, especially after food, being due to the disturbed action of the bowels, as- sociated with the formation and movements oj flatus, which may be abundant, even amounting to tympanites. Appetite is often impaired or variable ;- and dyspeptic symptoms are frequent' Constipation is the rule, and may be very ob- stinate, even amounting to obstruction under cer- tain conditions. Sometimes diarrhoea is present or it may supervene at times, and occasionally assumes a dysenteric character. This sympton is very common in tubercular peritonitis, in con sequence of the bowel being the seat of ulcera tion. In some cases vomiting occurs from tim to time. When there is considerable effusion i: the peritoneum, the secretion of urine is dimm ished. Respiration may be mechanically inter fered with from the same cause. As the resul of pressure by thickenings and other conditior upon different structures, jaundice, ascites, oedem of the legs, thrombosis, albuminuria, or neuraig pains may supervene. When the organs are a matted together, their entire functions must 1 more or less interfered with. General symptoms are usually present in v; PERITONEUM, ous degrees in eases of chronic peritonitis, but . many instances they depend mainly upon the mdition with which this disease is associated, ;pecially tuberculosis, though they may also be •odoced by the peritonitis. These symptoms 'elude pyrexia, not high, and having no regular ■urse, but presenting exacerbations, either per- stent or occurring at intervals, and in some ,ses assuming a hectic character; increased fre- tency of the pulse ; a sense of languor or weak- ,ss ; and more or less general wasting and anae- Ba, with dryness and harshness of the skin. It must be noted that in some cases of chronic ritonitis, even where there is considerable ef- ision, the local and general symptoms are very ght and indefinite, and the patient only suffers mi the discomfort due to the accumulation of jd. On the other hand the progress is not commonly from bad to worse, ending in extreme laciation and exhaustion, with the formation bed-sores ; or there may be a succession of provements and relapses; while various phe- mena result from the opening of collections pus in different directions. Thus death may adually or rapidly' terminate a case ; or pyaemia y supervene. Even in bad cases, however, imperative recovery may ensue, only the effects i the inflammation remaining, and being more i less troublesome. Physical Signs. — These require separate tice, and they may be the only clinical indica- ms of chronic peritonitis. They necessarily ifer in detail according to the nature of the normal physical conditions present in the ab- onen, and they are also liable to alter during the pgress of a case ; but their general characters sufficiently clear. 1. In general chronic peri- t/.itis enlargement of the abdomen is observed, : inly in proportion to the amount of fluid pre- s t ; but it depends partly on gas in the intes- tes, or sometimes on solid exudation. As a rule i s not very considerable, but the abdomen may t un an enormous size, with stretching of the e l and other accompanying phenomena. While i.ular in shape on the whole, it may present more o ess want of symmetry, especially after a time. C the other hand, in some cases the abdomen comes locally or generally retracted, and may t,i exhibit marked irregularities. 2. The sen- s ons on palpation are very variable, but often Ally characteristic. It may happen that thereis a iiform feeling of fluid. More commonly the S' ations are not uniform, but differ in differ- e parts of the abdomen, including indistinct fl mation in localised areas, sometimes very li. ted and in unusual situations ; with firmness o: isistance around or in other parts, ill-defined, oijsionally nodulated ; and even distinct tu- u|rs may be felt, more or less irregular. These itiome instances are due to morbid growths, sr. as cancer, but they also originate in or- g: sed inflammatory products. Under certain cej itions the abdomen yields a peculiar feeling 0 ‘i-ing movable as a whole. Movements of the b< sis are sometimes recognised. When there 11 ocalised adhesions between the visceral and pcistal peritoneum, if pressure is made at a h 1 ) distance from the seat of adhesion, a fold tf; e skin will appear where this adhesion exists. Ptibly general adhesions might be made out DISEASES OF. nil by palpation. 3. Percussion occasionally reveals freely movable fluid. Asa rule, however, it shows that the fluid is not freely movable, or that it is actually loculated irregularly, this condition being associated with more or less solid ma- terial. Hence there is extensive and diffused dulncss, which may be noticed mainly in front, and not in dependent parts. Not uncommonlv patches of dulness and tympanitic resonance arc found contiguous to each other, and irregularly distributed, unaffected by posture. Over the fluid fluctuation ma} r , perhaps, be elicited, but indistinctly ; and where there is much solid the sensation on percussion is that of resistance. 4. Friction-fremitus and -sound are sometimes present. 5. Changes of posture, as a rule, pro- duce comparatively little or no effect upon the shape of the abdomen, the sensations, or the per- cussion-sounds. When chronic peritonitis is localised, it may be practicable to detect the condition by palpa- tion and percussion. Moreover, when organs become fixed by peritoneal adhesions, especially if they are diseased at the same time, this state of things may often be recognised by noticing that the affected organ does not present its normal mobility in relation to manipulation and respira- tory movements. Diagnosis. — In most instances chronic peri- tonitis, if of any extent, can be recognised with- out much difficulty, by attending to the history of the case, the symptoms, and the physical signs. It may be very difficult, or even impos- sible, to distinguish positively between mere ascites and chronic inflammatory effusion. All the circumstances of the case must be taken into consideration ; and in doubtful cases the re- moval of some of the fluid, by means of a small trochar, will aid the diagnosis materially. It is important to determine the cause of chronic peritonitis, when present, and especially whether it is simple or tubercular. Here, again, the whole case must be considered, not forgetting the age of the patient, the family history, the condition of the main organs, and other points. Tubercular disease in other parts may, however, be accompanied with simple peritonitis. It has been said that a haemorrhagic character of any fluid removed is significant of tubercular peri- tonitis, but this certainly cannot be relied upon; and the same remark applies to the occurrence of redness and oedema about the umbilicus, which has been supposed to be diagnostic of the tuber- cular disease. It is quite impossible to diagnose with cer- tainty obscure cases of localised chronic peri- tonitis; and it may become very difficult, even in evident cases, to determine the precise con- ditions within the abdomen. Prognosis. — The prognosis of each case of chronic peritonitis must be considered on its own merits, as regards the cause of the disease ; its extent and products ; the progress of the morbid changes ; the effects produced on the abdominal organs ; and the general symptoms. Some cases are of little or no conseqnence ; others are very serious; but even in apparently serious cases groat improvement, or even practical recovery, may take place. The dangers to be feared from the opening of purulent collections in various 1142 directions must be borne in mind ; and also those liable to arise from the presence of bands of ad- hesion within the abdominal cavity. Tubercular and carcinomatous peritonitis are necessarily very grave forms of the disease, but the former may certainly be recovered from. Treatment.— With regard to the local condi- tions in chronic peritonitis, it is often desirable to endeavour to promote the removal of morbid products within the abdomen. For this purpose it may be important to keep the patient entirely at rest in bed fora time. The internal adminis- tration of iodide of potassium or syrup of iodide of iron may be tried; and in some instances diu- retics might be of use. Possibly the careful employment of some mercurial preparation would be serviceable in appropriate cases. Violent purgation is to be deprecated ; but where there is much fluid, advantage might be derived from repeated diaphoresis, induced by means of the hot-air, vapour, or Turkish bath, or by the use of jaborandi. Local measures are in some in- stances of essential service, namely, counter-irri- tation, especially by the application of iodine ; friction with some oil or ointment ; and pres- sure. The writer has found pressure decidedly valuable in aiding absorption in certain cases, as well as in giving support, the abdomen being covered with cotton-wool, and a suitable band- age applied more or less firmly. A flannel bandage answers best. In cases of large effu- sion, where absorption cannot be effected, the writer has no hesitation in recommending para- centesis, even repeated when required, having seen signal benefit follow this treatment. A localised purulent accumulation must be treated on general principles. General treatment is often of essential value in cases of chronic peritonitis. It is directed the condition upon which the disease depends, such as tuberculosis, or to its effects, but the measures are similar in the main, consisting of good nutritious diet, suitable sanitary conditions, change of air, and the administration of cod-liver oil, quinine, preparations of iron, and other tonics and nutrients. AVine may often be given with advantage. Symptoms will probably need attention from time to time, such as pain, flatulence, dyspeptic symptoms, constipation, diarrhoea, and various others. The organs generally must be looked to, and their functions promoted. A free flow of urine often follows absorption of fluid, or its removal by operation. There are many cases of chronic peritonitis which need no special treatment, especially when it has merely caused local changes. 3. Peritoneum, Gas in. — S ynon. : Pneumo- peritoneum ; Ty mpanites peritonei. Gas may be present in the peritoneal cavity from three causes, namely: — 1. Its escape from the alimentary canal through some abdominal communication ; 2. Transudation of gas through the intestinal wall ; 3. Decomposition of mate- rials in the peritoneal sac. The gas may be generally diffused ; or limited by adhesions. The condition cannot bo said to give rise to any de- finite symptoms, but it may increase abdominal distension and discomfort. When general it might DISEASES OF. be recognised by the following physical signs 1. There is extreme and uniform distension of th< abdomen, with a specially prominent epigastriun as the patient lies on his back. Sometime, donghy fluctuation is felt in the epigastric region with a peculiar pitting on pressure. 2.'lh percussion-sound is markedly tympanitic or evet metallic, full and deep in tone ; and this sound!; very extensive, completely annulling the anterio hepatic and splenic dulness. 3. Succession i sensations and sounds may be produced, owin: to the presence of gas and fluid in the peritonea sac. These are more uniformly and extensive! diffused than when such phenomena arise fron ; similar conditions in the stomach or intestines The aortic sound may also have a diffused me; tallic quality over the abdomen. A local collet tion of gas might cause a corresponding fulnes of the abdomen, and yield a localised tympaniti or metallic percussion-sound, as well as suceus sion phenomena. 4. Peritoneum, Dropsy of. — See Ascitks. 5. Peritoneum, Haemorrhage into. — Ekol may escape in quantity into the peritonet cavity as the result of injury; or from the rup ture or perforation of different structures withi the abdomen. An important form of hsemorrhng! is that which results from the rupture of a aneurism. More or less blood may be presen in inflammatory or dropsical effusion; or itma originate in the opening of vessels by morbi growths, or the spontaneous rupture of nej vessels. Haemorrhage is not uncommon in cor nection with tubercle. It may also occur fro: scurvy or purpura. Symptoms. — It might possibly happen th; peritoneal hsmorrhage could be recognised, there were some evident cause for this conditio! followed by the physical signs of the presence' blood in the peritoneal cavity ; and general indi cations of loss of blood. As. a rule, however, t! condition cannot he detected. The hamorrhag nature of an effusion can only he recognised l withdrawing it. Treatment. — This merely consists in the lot* and general treatment for loss of blood, if an; thing can be done or is required. 6. Peritoneum, Injuries to. — The pel toneum is liable to be injured from without 1 contusions and wounds of various kinds; at from within by perforations and ruptures, t! injury being aggravated in many cases of th kind by the introduction of matters into t: peritoneal cavity, causing mechanical or chemic mischief, such as gases, food, faeces, calculi, bil urine, pus, or worms. The mere injury to t. serous membrane itself cannot be said to pi duce any evident phenomena, unless it he exte sive ; but it leads usually to serious effeq which have already been considered — name! haemorrhage, which may be on a large or fat scale ; and acute inflammation of an aggravat type. Of course it must be remembered th along with the injury to the peritoneum, there usually associated some more or less severe i jury to an abdominal organ or other structw and the phenomena resulting therefrom will present. PERITONEUM, 1143 PERITONEUM, 7. Peritoneum, Morbid Formations and New Growths in. — These require brief notice, ind may be considered in the following order: — P a. It is necessary to call attention to the fact .hat the sub-peritoneal tissue, especially that of ;he peritoneal folds, becomes in obeso persons the seat of a large deposit of fat, an overgrowth of that normally present, and this is particularly noticed in the omentum. As a consequence the 'unctions of the alimentary canal are unquestion- ably liable to bo interfered with, and various lyspeptic symptoms, flatulence, and constipation [nay arise. Moreover, this condition assists in broducing enlargement of the abdomen ; and in uuffling the natural tympanitic sound. It can oo recognised at once by the appearance of the oatient ; but it is important to remember that it may conceal some other morbid condition within .he abdomen. The treatment is that for obesity jeuerally (see. Obesity). In very exceptional instances distinct fatty tumours have occurred n connection with the peritoneum ; and these nay become separated by constriction of their vttachments. b. Tubercle is the most common and important lew growth in connection with the peritoneum, t occurs in three classes of cases, namely — (1) is a part of general acute tuberculosis, the tu- bercle appearing in the peritoneum as a diffuse [biliary deposit, presenting the usual characters ; '!) in connection with tubercular ulcers in the ntestines, localised granulations forming on the ||orresponding surface of the peritoneum ; (3) as ,n independent disease, usually assuming a more :r less chronic course, and accompanied with aflammatory changes. This form is usually econdary to, and associated with, similar changes Jsewhere, especially pulmonary phthisis ; but it B occasionally primary, and may oxist for a time r throughout alone, as the result of infection tom caseous glands, from products remaining Jfter peritonitis, from caseous deposits in the pididymis, or from othersources, or exceptionally ithout any obvious cause. This diseaso occurs lainly in young persons, but is rare undor four iars of age. Anatomical Chabactebs. — The morbid condi- ons found on ■post-mortem examination in cases [-longing to the third group, consist of a corn- nation of disseminated tubercles in different pages, with signs of chronic peritonitis. Some- jnesthe tubercle has entirely undergone caseous Ganges. As the result of the peritonitis, great ickeuing and extensive adhesions are usually esent, with much contraction. Hence the omen- imis often drawn up into a firm mass across the iper part of the abdomen; and the mesentery is ho contracted, drawing the intestines together, d distorting thsm. More or less etfusion is nost always present, which generally contains -ered blood in variable quantity. Sometimes undant haemorrhage takes place into the peri- neum. Morbid changes, either of a tubercular iracter, or resulting from this disease, are tally found in other parts of the body. [Symptoms. — The clinical phenomena present isiderable variety in different cases, as regards ir nature and progress. In some instances lercular disease of the peritoneum begins itely,or in a succession of acute attacks, usually DISEASES OF. circumscribed, with symptoms like those of peri- tonitis, then subsiding into a chronic condition. Ear more commonly the progress is very chronic and insidious, or latent, ending in signs of effu- sion. In other eases there are marked remis- sions of the symptoms during their progress, both local and general. The phenomena may be sum- marised as those of the peritoneal inflammation ; with general symptoms of tuberculosis ; and often signs of implication of important organs in the morbid condition. When the peritoneal disease is secondary, it can be readily recognised. The course of the diseaso is usually chronic ; and as a rule it terminates in death, but not invariably. Treatment. — The treatment for tubercula? disease of the peritoneum is that of the general disease ; with that suitable for chronic peritonit is. c. Cancer is comparatively rare in the perito- neum. It is by far most commonly secondary, originating from extension, or as a distinct se- condary formation ; and especially following malignant disease of the alimentary canal, liver, retro-peritoneal glands, and sexual organs. Rarely this disease is primary, and has then been referred to injury in some instances. It occurs almost always after middle life, but ha« been met with in children. Peritoneal cancer generally occurs in the scirrhous form, but is occasionally encephaloid, melanotic, or colloid, the last being compara- tively frequently found in the omentum, and it may form an enormous growth. Rarely the dis- ease assumes an acute character, the cancer being in diffused nodules. Usually chronic, it either takes the form of separate nodular masses, which may become depressed ; or of an infiltration, sometimes of great thickness. Generally there are associated signs of chronic peritonitis, with more or less effusion, which may be haemor- rhagic ; extensive haemorrhages sometimes take place. Abdominal organs are often found im- plicated ; or the cancerous process may lead to their destruction or perforation. In some in- stances there is large dropsical effusion in the peritoneal cavity. Cancer of the peritoneum may be usually re- cognised clinically when it occurs as a secondary event, but oven then its diagnosis is not always clear. As a primary disease it is generally difficult to detect. The phenomena include the physical signs of the morbid grow-th, especially as revealed by palpation and percussion ; the signs of ascites or chronic peritonitis ; disturb- ance of the abdominal organs; the general symptoms and cachexia of cancer ; and the evi- dence of the existence of the disease in other parts. Pain is a common symptom, and is usu- ally paroxysmal, being due to the cancer itself, as woll as to other causes ; tenderness is also marked. The cancerous nodules may originate friction-sound. The course of the disease is occasionally acute, with pyrexia ; as a rule it is chronic, with little or no fever, or this only occurs at intervals. Hsemorrhage may cause marked anaemia or fainting. The cancerous masses may also originate pressure-symptoms. This disease is necessarily fatal; and treatment can only be symptomatic. With regard to colloid of the omentum, it is desirable to notice specially its physical signs 1144 PERITONEUM, DLS EASES OP. 1. The abdomen may be greatly enlarged, but is not uniform or quite symmetrical ; the umbili- cus is only stretched, not everted. 2. Palpation generally reveals firm, irregular masses. If present, fluctuation is very indistinct, 3. The anterior regions of the abdomen are dull ex- tensively. 4. Usually a change of posture pro- duces little or no effect upon the physical signs. 5. A slimy, gelatinous fluid may be removed by the exploratory needle or aspirator ; and occa- sionally a similar fluid is said to be discharged per rectum, or from the stomach. d. Among rare formations found in the peri- toneum may be mentioned hydatids, associated or not with a similar disease in one or more organs ; serous, dermoid, and colloid cysts ; fibro- mata ; myxomata ; and remains of blood-clots. 8. Peritoneum, Malformations of. —It will suffice to mention under this head that the folds of the peritoneum, such as the mesen- tery, may be abnormal in length or formation ; that unusual bands or openings may be present ; and that prolongations of the peritoneum, which naturally become obliterated or shut out from the general cavity, sometimes do not undergo these changes, as may be illustrated by the occasional patency of the process which descends with the testis into the scrotum. As the re- sult of these abnormalities displacements of organs may occur ; or their movements are restricted or too free ; or constriction of the intestine may take place. These conditions can only be recognised clinically by their effects; and not uncommonly they cannot be made out. Treatment may sometimes be directed to their cure, as is exemplified in the radical cure of a congenital hernia. Frederick T. Eobebts. PERITYPHLITIS (wepl, around, and ?ust regarded as a monomania. This smell gave Vi patient no further annoyance after the abscess !I discharged and subsequently healed. Ioukse and Terminations.' — 'When an ab- i ss has formed, the result will much depend i where it opens, and to what extent it com- vnicates with the caecum. Rupture into the ] itoneal cavity will almost surely be fatal, and < n those abscesses which burst on the surface i ! y lead to death, by the exhaustion caused by a c onic cavity prevented from healing by its dis- (jrging faecal matter. In the most acute cases, v.Jre no perforation into the bowel has taken pe, the resulting abscess may burst on thesur- fji ; and the same may be said for many of the r , :e chronic cases, when the progress of the in- 1 imation has become arrested before it has im- [■ ated the bowel to any great extent, and when B'.rtial absorption of the inflammatory tissue has 11-15 taken place. But in other cases, and especially where there are burrowing sinuous channels in the iliac fossa, with more or less communication with the caecum, recovery is of rare occurrence, and the patient dies from exhaustion, with per- haps-caries of the bone, a faecal abscess, and a chronic diarrhoea. Diagnosis. — The diagnosis of these cases, pre- vious to the recognition of a swelling in the iliac fossa, is only provisional. The history of typhlitis, with subsequent tenderness and, per- haps, high temperature, and especially an ill- defined feeling of illness, the patient steadily deteriorating in health, should lead to a sus- picion of the extension of the inflammation be- yond the caecum. Should an abscess form and point, it will not be difficult to recognise, and when a swelling is to be felt, its nature will be ascertained by attention to the history of the case, the pressure-symptoms in the right leg, and the fixity of the tumour. The variable state of the bowels renders them of little account in forming a diagnosis. There is reason to believe that this malady is often passed over unrecog- nised, and is of more frequent occurrence than is supposed. This is said to be the case in children, in whom cases of iliac abscess around the csecum are liable to be mistaken for hip-joint disease, though with perhaps scarcely sufficient reason. Prognosis. — In the acute cases where a fecal abscess forms and bursts, a fatal result, sooner or later, is to be feared. If rupture takes place into the peritoneal cavity, death will follow, and even where perforation of the abdominal wall occurs, the ensuing exhaustion is often fatal. Those cases of abscess in which the communica- tion with the bowel has not existed, or has been cut off, are the most favourable. Among the chronic cases where the suppuration is but slight, the prognosis seems very much to depend upon tho extent to which the intestine is implicated ; if this be tolerably free a favourable result may be expected. Treatment. — A large proportion of the cases of perityphlitis are amenable to treatment. Perfect rest in bed is of primary importance ; and, since the symptoms are directly relieved by the reclining position, the imprisonment is readily submitted to. Hot poultices of linseed meal, or fomentations over the ciecum, and changed as often as necessary, almost invariably give marked relief ; when an abscess is in pro- cess of formation, the hot applications favour its development, and so promote the cure, by afford- ing an opportunity for its being opened. This plan, pursued for a week or ten days, may be sufficient. In the more chronic cases it may be necessary to continue them for a longer period, even when the tension appears to be lessened, and the pain in the limb decreased. When the more acute inflammatory symptoms have subsided, counter-irritation, by blisters or by a solution of iodine applied over the affected part, tends to promote absorption, and thus to remove thick- ened or condensed tissues. Attention should be especially directed to- wards maintaining the general health. The diet should be small in amount, frequently adminis- tered, and of the most nutritive quality. Ad- vantage is to be derived from the simultaneous il 46 PERITYPHLITIS. administration of the prepared digestivo juices of the stomach and pancreas, so that a minimum of indigestible food may reach the lower bowel. Stimulants, carefully administered, are often necessary. Care is required in giving aperients when the bowels are confined. As a rule this condition is best relieved by enemata and gentle laxatives, such as confection of senna or castor oil. Constipation is more favourable to the patient than diarrhoea, which is often uncontrollable, or obstinately resists the usual treatment of acids and opium, tannin and other astringents, whether given by the mouth or as enemata. It is much easier to relieve the bowels than to arrest their excessive action. Tonics, such as iron, ammonia, and bark, are of value, and should be given from the outset, since the disease is one that tends to wasting, and it is usually in a somewhat enfeebled con- dition that the patient first presents himself. When the acute phase has passed, change of air, a sea-voyage, and other aids to convalescence are required. W. H. Alt.chist. PERI-UTERINE HEMATOCELE. See Pelvic PLejiatocele PERSONAL HEALTH. — Personal hy- giene is the science of individual health. As there are public acts and laws which, observed, promoto the health of communities, so there are rules of living and habits of life, inculcated by competent observers, by attention to which the health of the individual may be preserved or increased. Health is a quality of body easily comprehensible, but difficult to define. It is dealt out in different measures at different periods of life, and is perhaps best described as exemption from disease. It admits, however, of being estimated, and we shall first show how this may he done. First, the form of the individual must be ex- amined, to ascertain how far it agrees with or departs from certain mean standards, such as are laid down by anatomists and practical hygienists, and which give, in tables for each age, what the height, weight, girth of chest, and mobility of thorax ought to be every year of life. Thus above the weight of 161 lbs. avoirdupois, the cir- cumference of the chest ought to increase 1 inch for every 10 lbs. of additional weight ; and for every inch in height over 5 feet 8 inches the mobility of the thorax ought to increase in a definite ratio ( see Parkes’s Hygiene , p. 480). Then the girth-measurement, taken round the mamma, should be in excess of that taken lower down, at the level of the xiphoid cartilage, in every man, although not disproportionately so, as it is in women who lace tightly. Secondly, the manner in which the various functions of the body are performed must be ascertained. The situation of the heart’s apex- beat is to be determined ; its impulse ; its mode of action ; the rhythm of its sounds ; the way in which the circulation is being carried out ; how temperature is maintained .at the extremities; and what individual capacity exists to resist conditions calculated to lower the body tempera- ture. The respiratory, cerebral, and spinal func- tions must all be determined; the organs of digestion, sanguification, and excretion, as well PERSONAL HEALTH, as their performances, will have to be examined in due order ; and the state of general nutrition and the condition of the skin appraised. That state of body which enables it to per- form every function which can be reasonably required of it, to accomplish each ordinary task, and be equal to some exertion of brain and' muscle without painful sense of fatigue, is what we ordinarily understand as healthj It would be difficult, however, if not impossible, to lay down the amount of work or exertion, short o’: positive fatigue, which a child, lad, woman, oi man ought to be equal to without preparatior or training of any kind. Erectness, firmness good balance of body and mind, testify to : man, as they do to a racehorse or a gamecock An experienced eye recognises at a glance tb particular build of man suitable to particula taskwork ; likely to excel in particular exercises sports, or games ; fitted to labour with his head or with his hands ; to run, swim, or fight well' There is, perhaps, a little less difference be tween man and man than between carthorse and racehorses, but it is one of degree only Fortes crcantur fortibus, and for perfect bod’! aptitude for any trade, profession, or particula craft, the individual must be bom, bred, an' trained accordingly. We arrive at the folio win signs or evidences of health : — a. Good construction ; b. Accommodativenes to change, individual adaptability to widely di verse conditions of life, or of climate, withou deterioration of energy ; c. Endurance ; d. Seb control — mental, emotional, sexual ; and e. K( sistance to morbific influences. Prom birth onwards to old age health is nc uniform; it varies as the body varies, accordic to wear and tear, and treatment — a sufficient! obvious proposition. At different epochs of lit the strain, or stress, is felt in different part falls upon different organs, and issues in pn clivity to disorder of their several functions, (j in wear or degeneration of the tissues of whic- they are built." Our object here is to dernoi strate how individual health may be secured how disease-tendencies may be avoided or dim nished; and how a reasonable measure of healt may be attained throughout life, and at evei period of it. To fulfil this endeavour we divic the life of a human being into the followir periods, and consider them separately in relatic to their special physiology, to morbid imm nencies, and to probable accidents, laying dow the best rules of guidance in diet, clothin habits, exercise of body and mind ; indicator whatever appears most conducive to the heal! of the individual at the age mentioned. It of course of first importance to be born of healthy, long-lived stock; but for heredity ar its effects the reader is referred to the articj Disease, Causes of. Life periods. — The following are theperio. of life, as they will bo successively co sidered : — 1 . Intra-uterine life and Gestation. 2. Birth. , 3. Infancy, the period between birth and tl completion of the first dentition. 4. Childhood, the period boiwocn 2 and years. PERSONAL HEALTH. 5. Adolescence, the period between 7 and 14 years. 6. Puberty, the period between Hand 20 years. 7. Adult age, the period between 20 and 30 years. 8. Maturity, the period between 30 and 45 years. ' 9. Turning-time, the period between 45 and 30 years. 10. Advanced life, the period between 00 and 82 years. 11. Old age, the period between 82 and 100 years. 1. The Intra-uterine and Gestation Period. The health, habits, and conduct of the mother during pregnancy modify the future individual considerably. Whatever affects the blood of the nother affects that of her fcetus, and vice versa. There are grounds for thinking that the mother Dossesses and exercises purifying and excretory oowers over the blood of her foetus, appropriating ato her own eliminating organs, and in some legree removing from her offspring, taints or lisease-germs derived from the father of the child, perhaps suffering from these herself incuriously. This surmise has been offered to ■xplain a fact not infrequently observed, that ireviously healthy wives, born too of healthy tocks, married to consumptive husbands, after breeding one or more children, tend to die hemselves of a rapid form of phthisis, al- though bearing children not necessarily con- umptive. On the other hand, delicate women rho have been impregnated by exceptionally ound sires are observed to improve in vigour nd robustness with each succeeding pregnancy, t is certain that smallpox, scarlatina, and measles lay be conveyed by the mother to the child in tero ; that typhoid fever occurring to the mother ; usually fatal to her fcetus ; and that the poison f syphilis derived from either parent is ex- remely pernicious to the growth and develop- lent of the fruit. Alcoholic abuses committed by the mother uring pregnancy favour premature delivery', and ppear beyond this distinctly prejudicial to the ealth of the children when these are born alive, .16 constitutional flaw not showing itself by ipparent malnutrition so much as by undue Proclivity in them to manifest disorders of the iervous system — chorea and epilepsy in child- !ood, hysteria and insanity in adult years, xperience shows the hygiene of this period to insist in temperate living. The pregnant oman should avoid excitements of all kinds, ike moderate exercise, rise and go to bed irly, not alter her habits of life abruptly. In he later months she must dress herself appro- riately to her state, not so as to interfere with le emerging of the uterus from the pelvis, or 1 as to limit tho movements of the babe in 'era. \ 2. Birth. — Beclard in his work {Hygiene de Premiere Enfancc, Paris, 1852) pointed out a ct of some importance in the hygiene of birth, lien the foetus with its membranes and acenta are separated from the mother, and dependent existence is commenced, a good ial of blood, properly the newborn child’s, re- 1147 mains and is for a short time after actual birth lodged in the cord and placenta. If time enough be allowed, and the newborn be kept properly warm the while, all this blood — somo two ounces or thereabouts, and therefore no unimportant quantity when the weight of the child is considered — will find its way into the infant’s body ; whereas, if the cord be tied and divided too quickly, and before tho umbilical vein becomes collapsed and empties itself, the child is mulcted of its natural blood-endowment. According to Pinard’s observations, it is easy to distinguish the babies who thus receive their full complement of blood at birth from those who do not. The skin of the former is rose- coloured and well plumped out, whereas the skin of the latter has an anaemic or icteric tint, and is poor ; the former infants grow and develop more rapidly, and are altogether more vigorous than the latter. As a guide to the accoucheur’s practice, he inculcates careful observation of the cord at birth. All pulsation ceases in the um- bilical arteries directly the newborn breathes and cries ; but for some while, different in dif- ferent cases, the umbilical vein remains full ; and the blood in it continues liquid up to the moment when its last drop is absorbed into the child's body. But the cord must not be liga- tured until the umbilical vein is flat and empty. The accidents incidental to birth are multifarious, and belong to the subject of parturition. "We may notice specially' asphyxia from prolapse and compression of the cord ; and prolonged pressure upon the infant’s skull inducing epicranial cephal- hematoma, and, rarely, apoplexy and paralysis. If the temperature of the external air is about 60°, children may be allowed to go out when they are eight or fifteen days old, after cicatrisation of the umbilicus. Children born in February and September appear to possess the greatest vitality, those born in June the smallest. According to statistics carefully col- lected by Hr. E. Smith in his work on Health and Disease, p. 267, ‘ the viability of the infants born in the winter and spring months is greater than that of those who come into the world in summer or autumn.’ No artificial purgative oil, gruel, or sugar- water, should be allowed in lieu of the mother’s first colostrum milk. 3. Infancy. — The period of infancy might be subdivided into early and late ; early compre- hending the time from birth to eruption of the first teeth ; late, that from the commencement to the completion of the first dentition. The lead- ing anatomical feature of this age is the large amount of blood relatively to the solids of the body, the laxity of all the tissues, the dispro- portionate quantity of component water, and the large relative amount of red blood-corpuscles and of irou, which appears far in excess of that existing in adults. See E. Smith’s Cycle of Ages, p. 247. The circumstance of chief physiological im- portance is that the greatest growth occurs in the first years of life. Quetelet in his essay, Sur V Homme, shows that the near average weight of male infants exceeds that of fe- males ; boy's at birth weighing 3 kilogrammes 20 grammes, and girls 2 kilogrammes 9 grammes. 1 143 PERSONAL HEALTH. There is no indicator so infallible as the balance to prove whether an infant is or is not being properly nourished. It appears that from birth up to the end of the second day all new- borns lose weight a little ; they do not increase perceptibly till after the end of the first week. 1 M. Odier states that it is usual to find an infant increase 30 or 40 grammes (461 to 606 grains) per diem during the first five months of life, 20 grammes (308 grains) a day from the fifth to the eighth month, and 10 grammes (or 155 grains) daily between the eighth and the twelfth month. Dentition is the change most characteristic of the infant’s growth and development. In infantile life all the vital functions go on rapidly. The pulse at birth ranges from 130 to 140 per minute ; and to the end of the first year is from 115 to 120. The rate of respiration is from 25 to 30. While the circulation is rapid, the skin, from its softness and vascularity, dis- perses heat rapidly ; the cooling agencies are at a maximum ; and the heat-maintaining powers, (that is, resistance to depressing influences) are at a minimum. ‘ The food taken by infants is, in proportion to the weight of the body, from three to six times greater than that taken by adults.’ (Dr. Smith, op. cit., p. 247.) The perils from without to infant life are mainly derived from cold, those from within result chiefly from improper or defective feeding and hyper-nervous impressionability. It is not easy to over-feed young infants. If proper food, that is, their own mother’s milk, be given them, they get rid of excess quickly enough by vomit- ing it, and the part not appropriated in growth or maintenance is stored up for future use as fat. The morbid tendencies of this age are towards tho intestinal and mucous tracts. Catarrhal diarrhoea and bronchitis, thrush and stomatitis, are epiphenomena of all febriculas and states of malnutrition. Delirium and convulsions attend all general disorders. Over-rapid dentition is associated often with tuberculansation, retarded dentition with rickets. The more rapid the eruption of the teeth, the greater the attendant disturbance ; the more closely the evolution of the teeth follows its normal periods ( see Teeth- ing'), the less conscious are infant and mother of their appearance. The hygienic rules for this period have reference principally to feeding, cleanliness, clothing, and open-air exercise. Diet. — For diet the reader is referred to p. 362, where the proper aliment for infants is fully discussed. Experience proves that nature will not be contradicted — that no aliment is so appropriate as the milk of a mother, or of a wet nurse aged between twenty-two and thirty-five. Next best to this comes suckling by a goat, ; and next, again, a mixture of equal parts cow's and ass’s milk given by a feeding-bottle. The suck- ling of her own infant by the mother for nine months is good not only for the child but for its mother. The uterus passes through its retro- grade involution more properly, no periodic ute- rine congestions delay it, and ovulation is de- creed. \V ith respect to the frequency of feeding, • The infant should be weighed naked in a warm room lying on a piece of flannel of ascertained weight, in th( Beale of a balance sensitive to a drachm. and the quantity taken, tho reader may be to- ferred to the statements of Proust. 1 During the first day of life, what with scantiness of the colostrum, mechanical obstacles to suction, and, the weakness of the infant’s efforts, the child' does not extract more than a drachm each time it is placed to the breast. It needs no more, however. During the first week of life it should be nursed ten times in the twenty-four hours arranging times so that the mother gets six hours consecutive rest at night. On the second dav each suckling should furnish about 5 drachms of milk. On the third day each suckling should furnish about 1 J ounces of milk. On the fourth day each suckling should furnish about 2 ounce; of milk. During the first month average-sized infants require and obtain nearly 3 ounces o: breast-milk at each nursing, and should lit nursed nine times in the twenty-four hours, oil receive about 27 ounces of milk a day. During the second month each suckling should furnish 4| ounces of milk, and the number of feeding; may be reduced to seven per diem, which allow; 3 It) ounces each twenty-four hours. At three months old the infant sucks about 5 ounces at ? meal, an equivalent of 35 ounces each twenty- four hours ; and at four months it extracts a; much as 6^ ounces of milk at each meal, which may be again curtailed to six each day, giving 37) ounces of aliment. This continues to ba the quantity of milk and frequency of feeding 1 required of a good nurse up to the end of the ninth month, but the quality of the milk daring this period steadily improves, becoming enrichei according as the child sucks more vigoronsl}; and at longer intervals, a provision fraught with mutual advantage to child and mother. At the ninth month the child may be gra dually weaned, although the age for weaning should be governed by the health of the mothei or nurse, the forwardness of dentition, and the infant’s own craving for other food. The lies' time to seize for the purpose is the interval o: pause after the four lateral incisors are ent, and before the first molars appear. Dentition, normal order of . — The two inferior incisors should pierce the gums between the fourth and seventh months ; their eruption is attended by a slight six days’ disturbance ot health. Between the eighth and tenth months the two superior incisors and two superior latere, incisors appear within three or four weeks c:i each other, their eruption also being attendee by slight fever and restlessness. A pause non ensues of from six to twelve weeks’ duration after which, and at some period between the twelfth and fifteenth months, six more teeth burst through within a few weeks. First, as a rule, come the two first molars of the nppei jaw, then the two lower lateral incisors, anc lastly the two lower first molars. Again c pause follows, lasting from eight to twelvt weeks ; and now, between the eighteenth an. twenty-fourth months, the two lower canines appear, the upper ones succeeding them. I eri little disturbance marks their eruption. At interval of six months now intervenes, and between the thirtieth and thirty-sixth months or nearly on the completion of its third year * Traiti d' Uygiine : Paris, 1S7", p. 1 15. PERSONAL ie child acquires its four last or permanent idars, the lower preceding the upper, and their itting being attended often by general disorder, roupy symptoms, diarrhoea, and convulsions. Cleanliness and Care. — The infant requires ashing all over from top of head to solo of Lt night and morning every day, and is best, ecause most quickly, immersed in a tub once aily. Infants who have had convulsions at any eriod of their lives are, as a rule, better washed 11 over with a sponge in the lap of their nurse lan immersed in a bath, as immersion is apt to ighten them. The water should be the softest rocurable. Rain water is best. The tempera- ire of the room during the bath should be be- veen 65° and 70° Fahr. ; that of the bath itself, red by the thermometer, between 70° and 90°. ixing the temperature of the bath should not e left to the possible indiscretion of a nurse ; iany a woman’s hand will support water at a feat enough to parboil a baby. The nurse should be required not to dawdle rer bath or dressing ; the former should occupy re minutes, the latter not more than twenty, little or no soap, or only soft soap, should be nployed. The drying should be accomplished iith soft dry cloths, and for baby powder, tc :event excoriations, fuller’s earth cannot be upassed. Eczema and intertrigo are obviated V due attention to the frequent change of apers and sufficient cleanliness. Clothing. — No infant ought to be swathed ke a mummy; it requires keeping warm, but lould not be overweighted with clothes. Its lest must be free to expand, its limbs at oerty to move. The more lightly its head is vered, and the more quickly all caps are dis- eased with, the stronger will be its hair and e less its susceptibility to catarrh. Night- ps are dirt-traps, and in all classes alike omote scalp eruptions by provoking perspira- m, with which the skin is softened, and by lose decomposition the sebaceous follicles are Rated and clogged. General Rules and Hygienic Advice. — Even e youngest infants require sunlight and open Due discretion must be employed, how- ler, in sending them out. They are better tried in their nurse’s arms, and thus assisted maintain their own heat by that derived from jsir nurse’s body, than placed in perambula- ■s. So soon as they can crawl they should be louraged to do so, either on a carpet, in a tden, or on a dry, sandy pathway protected m wind and open to sunlight. Cold and ' rk places are specially inimical to them; and en the weather is cold they should be en- < iraged to amuse themselves on a blanket or 1 1 hearth-rug, so as to learn to stretch their i ibs and co-ordinate all their muscular move- nts. They learn first to sit up, then to stand, 1 ped by their arms, against a chair, next to i nd without support, and at some period ween one year and two years of age should 1 able to walk about by themselves. ileep. — Infants require day as well as night f 'P- Very young babies do little elso but suck ‘ ; sleep. As they grow they need and take less i less sleep, and by the time first dentition is i implished— three years of age— a child may HEALTH. ‘ 1149 usually dispense with day sleep altogether, ex- cept a short hour’s nap early in the afternoon or between eleven and twelve. Sound sleep co- incides in the infant, as in the adult, with short sleep hours, and the strongest children require least sleep. The infant should have its own cradle, and the child its own cot, placed close beside the bed with its mother or nurse. In extra cold weather, hard frosts, the cot should be artificially warmed by a hot water-bottle. The sleeping nursery ought not to be kept warmer than 65°, or colder than 50°, whilst the nearer it is maintained to 55° during the winter months, and 65° during summer, the sounder the child will sleep. The more freely the whole house and nurseries are ventilated, the less prone the in- fant will bo to all infantile disorders. 4. Cblldhood. — In this period, between the second or third and seventh years of life, the first dentition is accomplished, the second uncom- menced. The rate of pulse falls from 115 to 90 per minute, and respiration commensurattly. The excretions are all absolutely increased. In the co-ordination of muscular movements and in mental operations great progress is being made. The cerebro-spinal structures, which nearly double in volume between birth and the second year, continue to develop disproportionately to the growth of the trunk and limbs between two and seven. The cellular tissues are loose and vascular still, and the cutaneous and mucous surfaces therefore extra vulnerable. A notable physiological feature of this age is the readiness to swell observable in the lymphatic glands upon the slightest irritation, and the general functional activity of all the lymphatic struc- tures. It might be distinguished as the life period of greatest lymphatic activity. From these facts the morbid imminences may be in- ferred, namely, a tendency to eczema and to catarrh of mucous surfaces, diarrhoea, laryngeal and bronchial catarrh, general anasarca, hydro- cephalus, susceptibility to contagious impres- sions, proclivity to tubercular meningitis, and to functional cerebral disorders like delirium and convulsions. The incontinence of urine, so frequent in early childhood, may be likewise referred to the reflex irritability of the spinal centres characteristic of this age. According to Lebert the cerebellum attains its largest size, relatively to the cerebrum, between four and five, to which circumstance has been referred tho occasional sexual excitability and vicious prac- tices discovered in some children at this early age. However this may be, the importance of good nurses and wise supervision cannot be too much insisted on, as also the inculcation of healthy habits and provision of proper amuse- ments and employments. Diet. — While bread, starch, and flesh foods are taking the place of cows’ milk very greatly, they must not be allowed to wholly supplant it. Eight ounces of bread may be reckoned about equivalent in nitrogen content to one pint of milk, but the former exceeds the latter in car- bon. The food must be nutritious and abun- dant. The error committed is far too often that of under than of over-feeding. Young children do not require so much variety in their food us adults do, but are greatly benefited by a change PERSONAL HEALTH. 1150 in their bread and meal stuffs, and a dietary not too monotonous. They do not need meat more than once a day, and fish may bo substituted for meat, if cream or butter sauce be provided with it, once or twice a week. Milk, bread, porridge, suet puddings and milky puddings should form the staple of their dietaries ; fresh vegetables well cooked, watercress, cooked fruit, and oranges are most useful adjuncts; while the addition of fried bacon, clotted cream, and oil, or butter, when the drinking water is hard, and the ten- dency of the child is rather towards constipation than otherwise, is now fairly generally under- stood. It is usually easy and always beneficial to instruct young children to secure an alvine evacuation directly they rise of a morning and before their bath. Four meals a day are most appropriate — a breakfast at eight, a dinner at twelve, a tea at four, and a supper at eight. Cleanliness. — Washing all over once a clay, and in the morning, is as necessary as ever ; but after first tubbingin warm water between 98° and 100°, the child should stand up and be sponged all over from a basin of cold water, and be briskly dried with a largo towel. Sleep. — A child should sleep in a cot or bed by itself, but in the same room with its parent or nurse, since they are apt to show any dis- order by night vagaries, delirious talking, rest- lessness, or sleep-walking. Between two and five most children are the better for twelve hours of sleep out of the twenty-four. At seven years of age they do not require day sleep, but should be in bed at eight, and up at six in summer and between six and seven in winter. The best bed for this age is an ordinary iron bedstead, with firm and level wool and hair mattresses ; not spring beds, which do not adapt themselves so well to light bodies, or keep them uniformly warm. Cotton sheets, blankets, and counterpane must be used according to season. Beyond saying that the day clothing should be warm, and merino or wool put next tne skin, we can add nothing further about clothing. Exercise. — Two things are requisite for healthy growth and development and a happy childhood — a play-room and a garden. Children need a place like an empty barn, in which they can swing and amuse themselves in wet and wintry, as well as in hot sultry weather, prac- tising those games which are requisite alike for the schooling of their muscles and nerves. Teaching. — Teaching such as they need should be conducted on the Kindergarten system ; but the main rule for their lives is open air and ex- ercise, the chief objects being to harden their skins, develop their muscles, and teach them self-control, love and respect for those to whom they render implicit, because well-nigh uncon- scious, obedience. 5. Adolescence. — The consideration of this, the period of second dentition, between the ages of 7 and 14, is best prefaced by the order of aruption of the second teeth. About 7 years the 4 anterior molars (perma- nent teeth) are cut. About 8 years the 4 central incisors. ,, 9 „ 4 lateral incisors. „ 1 9 ,. 4 anterior bicuspids. About 11 years the 4 posterior bicuspid*. „ 12 to 12j 4 canines. „ 12^ to 14 4 posterior molars. The teeth of the lower jaw usually precede those of the upper. Second dentition is accom- plished leisurely, and accompanied therefore usually by no such grave disorders as mark first dentition ; but in nervous children nervous tricks may manifest themselves, as well as marked lack of emotional control. Some are hypersensitive, others contradictory and difficult; and most parents admit that between 7 and 8, if not be- tween 7 and 14, they learn what the charac- ters of their children really are. Physiologi- cally, absorption of the subcutaneous fat goes on rapidly, while the muscles become more pro- nounced, the skin gets tougher, its epidermis harder, and it perspires less readily. In our climate the morbid tendencies of this age are to rheumatism, chorea, epilepsy, the exanthemata, and typhoid fever. Between 7 and 8 the appetite is apt to become capricious ; the child physiologically does not require 60 much hydrocarbonaceous food ; and, while growing fast and becoming leaner, protests against fat, often while showing marked longing for fresh fruits, in which nature should be in- dulged. After 8, however, any marked defect of appetite or loss of weight is suggestive of undue cerebral excitement, attributable to OTer- study or some infraction of the laws of health. Diet. — Three good meals a day are sufficient, but four are more advisable. Constipation at this age signifies usually irregular feeding and: overloading with pastrycook supplies, or im- proper food. Breakfast at eight, dinner at one, tea at. five, and supper at eight appears the best distribution. By supper is meant such a meal as growing lads and girls positively need. They require either soup and potatoes, and bread and butter, or some one hot dish of meat or fish, and the drink should be either warm milk or cocoa to about half-a-pint of fluid ; aliment enough is needed to improve the circulation at the extremities and obviate chilblains. Boys and girls may retire to bed within an hour on their supper, which, instead of making them dream, will secure good and refreshing sleep. The greatest dangers at this age arise certainly from defective nutrition and an over sensitive- ness of the skin. Neither wine nor beer is necessary, nor should it be allowed without medical authorisation. Clothing. — The objects of clothing are warmth, cleanliness, and convenience. Cotton or silk shirtings should lie next the skin of the chest and trunk. Merino, flannel, or woollen materials should protect the legs and feet ; cloth, woollen jerseys, furs, and skins are better adapted for ex- ternal coverings. But a whole chapter could be devoted to the foot alone, and its clothing during its growth and development. The desiderata appear to be length and breadth enough, low heels, impervious soles, old and flexible skin; for uppers. Boots for out-door exercise are advised for children, because their ankles nee* support ; shoes a little later on, because theyart cheaper and do not repay re-soling, and may lit discarded at once when worn out. The sam( boots should not be worn day after day. thci PERSONAL HEALTH. squire time to dry properly in damp weather, ,nd the foot at that age profits by change of pressure. During youth the adaptation of clothes |o special sports and exercises is far from unim- portant to healrh. For violent muscular exer- ise flannel or merino next the skin, and an easy flannel jacket or over-jersey should be worn ; Joth after being used should be hung up to dry nd air before being worn again. It is well that outh should be reminded that rheumatism is irobably too often inflicted upon those who are areless about their dress, and negligent enough o wear the same clothes which have been satu- ated over and over again with the secretions rom the skin. Rest and Exercise. — These- are requisite for jloth body and mind at this age ; the duty be- longs to parents and schoolmasters to study what Is appropriate. We annex, therefore a table from f’riedlander, which shows how the twenty-four ours may be wisely apportioned Hours for Age. Exercise. "Work. Leisure. Sleep. 7 8 2 4 9 or 10 8 8 2 4 9 or 1 0 9 8 3 4 9 10 8 4 4 8 11 7 5 4 8 12 fi 6 4 8 13 5 7 4 8 14 5 8 4 7 15 4 9 4 7 6. Puberty. — The physiological feature of his age is the more rapid growth of the whole ody, and tho gradual perfectioning in their inctions of its several organs. The human lant attains the fulness of its organic life, and le energies are rather expended on corporeal irmation than on intellection (if we may coin rch an expression). Growth in man, as in Sants, proceeds by fits and starts, succeeded by piods of quiescence ; seasons affect it, so do applies of food ; boys do not develop so rapidly autumn and winter as in spring and summer, iris at this age often fall back, as it were, a tie in winter, when they are much more con- led indoors, to make a greater push forwards spring. It is even difficult for the digestive and assi- jilative powers to keep pace with tho bodily quirements, so that the tendency is for the mperature of the body to fall somewhat, to be maintained at the extremities, and for the id bath to be shunned for lack of adequate action in those who are manifestly growing J rapidly. The heart in some is hardly equal to the task 1 ttj and when diseased we perceive both pwthand the attainment of puberty retarded, e lungs, again, as Dr. E. Smith pointed out 288, op. cit.), more often in girls than in boys, not expand in proportionate ratio with the t of the body. The body runs up tall, but 1 thorax remains narrow and flat, and the ‘ ces of the lungs approach too closely to each 1 er. The definition of a line — length without 115) breadth— is too closely imitated. The morbid imminences of this age are few: disorders of the nervous system, chorea, and epilepsy may arise ; anaemia and rheumatism are common enough. Girls suffer more than boys, probably in conse- quence of insufficient gymnastic exercises, over- study in cramped postures, and from that folly of follies, a forcing-pit education, ‘all articles warranted to bo turned out highly finished by eighteen years.’ It is the age of all others when good or bad habits of life are formed ; the time, too, when the seeds of disease are sown broad- cast, to spring up in tho after age of maD- and womanhood. Diet. — -Food should be abundant, varied, but uustimulating. Three or four moderate meals a day are requisite ; if at any period of life fer- mented liquors are beneficial, now is that time. Light bitter unadulterated table beer or claret and water should be provided at dinner, but not more than half or three-quarters of a pint of it allowed. If violent exercise has provoked thirst, this may be satisfied with plain water or toast- and- water ad libitum. Girls should take cocoa- nibs for breakfast, with bread and butter, meat, eggs, bacon, or fish, as much as they like. School dietaries err usually on the side of deficiency. At dinner, as well as substantial meats, fruits, vegetables, suet and milky puddings are re- quired. Tea should be allowed only once in the twenty-four hours, at six o’clock, and a warm supper be provided at nine o’clock. Clothing. — Nothing need be added to what has been already advised. Without entering into minute particulars, it should be season- able, rather extra warm, and offer no uncomfort- able restraints. AVhen mothers complain of their daughters’ neglected figures, the hygienist retorts, What gymnastic exercises did you require of them? It is the age for exercise of the body as w T ell as of the mind ; boys’ spines are straight and girls’ backs crooked because the former use all their muscles and the latter do not ; as the body is making its most rapid growth, so the evil of unilateral use of muscles is particularly baneful. Sitting over-long in a slouching atti- tude will tend to contract the chest, as carrying too heavy weights over the back will spoil the normal spinal curves ; so leaning too much on one side, standing too long on one foot, even carrying constantly a pocketful of articles on one side of the dress, will suffice at this age to induce spinal curvature. Tho daily use of the trapeze, swing- ing, playing games like la gr&ce, in which both arms are used, badminton, and lawn-tennis, in which arms and legs are employed, and every muscle brought into due action, are quite essen- tial to the proper development of the thorax and the muscles of the trunk. Girls should row and run and ride and swum and skate no less than lads do, in order to become fit mothers for a nation like ours. The best temperature for a sitting-room is 60° ; that for a sleeping-room between 50° and 55°. The hygiene of the bedroom and the bed needs a few words. The temperature of the room should not rise above 65° in summer, or fall below 45° in winter ; it must be thoroughly ventilated with a constant amount of fresh air passing through it during the day. The deside- 1152 rata for a bed are coolness for the spine, restful- ness for the trunk muscles, and warmth without too great heat or too burdensome a weight of bed- clothes : all objects are well attained by a French somnier elastique. A horse-hair bolster is prefer- able to a pillow, and a paper pillow to a feather pillow ; a feather pillow enwrapping the neck and head heats the upper part of the spinal cord undesirably. Posture in bed is not unimportant. The head should be low, the feet perhaps a trifle raised, certainly not dependent. ‘ Sleep not on your back, as a dead man,’ is a maxim attri- buted to Confucius ; the opposite attitude, on the stomach, is restrictive of the intestinal move- ments, and uncomfortable. It is as well to begin the night lying upon the right side so long as food remains in the s-tomach, and to turn on first waking upon the left side. The best atti- tude is probably that crouched one habitually selected. Good advice is to stretch yourself straight whenever you wake, in order to render the circulation of the blood freer. In winter the arms should lie under the clothes, in sum- mer above them. The cold bath, or cold sponge, or shower-bath should be taken by the robust every morning ; with an occasional warm or tepid bath once a week, for cleansing purposes, throughout sum- mer and winter. Whilst the young of both sexes should be encouraged to swim, in seasonable weather, the length of time they stay in the water must be strictly limited according to the temperature. We abstain purposely from any discussion of the hygiene of mental education. 7. Adult Age. — This is the prime of life, between 20 and 30. Anatomically, the body broadens, the chest deepens ; for feats of mus- cular prowess — short, severe labours— it is at its best. The intellectual and cerebro-spinal sexual energies are at their maximum. What the French call the greatest latitude of health, that is, strength, exists at this period ; severe strains are supported with apparent ease. In male adults the body gains weight by small amounts for about twenty-eight days, then re- lapses to its normal average by a sudden crisis, attended by head-heaviness, loss of appetite, and copious discharge of urine, or seminal evacuation. It is not a time about which the hygienist has much to say. If the preceding periods of life have been wisely ruled, the indi- vidual is at his or her best. The morbid im- minencies directly belonging to this age should be few, and certainly are usually due to direct contravention of the laws of health : to exposure to contagious influences, to irregular living, espe- cially drinking, to excessive strains upon the heart or its blood-vessels, to pulmonary inflam- mations, to contravention of proper sexual rela- tions, to over-emotional excitement, or to mental worry and loss of sleep. The guiding rule for this period is succinct enough : 1 Sustine et abstme' Qui studet optatam cursu contingere metam Multa tulit fecit qite puer sudavit et alsit, Abstinuit Venera et Baccho. Hitherto excess in feeding was difficult to effect, quickly punished, and admitted of rapid and spontaneous repair ; but now he who would rise HEALTH. above the ruck must rule with a tight reia all his appetites. The penalties are not exacted directly after the offence is committed; they are kept in store, but nature inflicts them with piti- less justice. Total abstinence from alcoholic drinks may be recommended. Not only does it favour health, but lessens all the temptations incident to these important years, in which a man carves out his own career. A question not infrequently pro- pounded is, How shall I know when I have eaten more than is good for me ? If individuals are dull or drowsy after a meal they have usually eaten too much ; if they can converse, write, or transact business with ease after a meal, they have fed temperately. Women may be advised to marry not earlier than 21 — between 21 and 28 — when in our eli- mate they are best fitted to become wives and mothers. Men had better wait till between 28 and 35 to undertake the responsibilities of being parents. For the generality of men and women we must insist once more on their not giving up out-of-door muscular exercises. An entirely sedentary trade or office-life cannot be a healthy one for either body or mind ; the latter appears to suffer most from it — the sense of morality becoming blunted. When the struggle for ex- istence is so severe that, with early rising and very limited hours of sleep, no leisure hour remains for sports or amusement, the time has arrived for emigration, war, enforced military service, or revolution. Sleep. — Doubtless different constitutions and individuals differently employed require different amounts of sleep. While nothing dulls the in- tellect and weakens the recuperative faculties more than too much sleep, except over-feeding and drinking at this age, so few things are more certain than that a man may rise too early for making the best use of his twenty-four houTS. He must live in the world and keep the world’s pace still. John Wesley’s advice in this matter is worth recording. He writes that any man can find out how much sleep he really requires to repair his nervous system by rising half an hour earlier every morning until he finds that he no j longer lies awake at all on going to rest in bed, or wakes up until it is time for him to get up. Six to eight hours is usually ample for healthy adults, with nine hours every seventh day. The i mistake too often made is that of endeavouring to make up for overhard mental efforts by over long sleep hours. Mental over-fatigue is to be repaired not by sleep but by bodily exercise in tho open air. Exercise directs the blood-flow from the head towards the muscles, and renews the appetite. As we have pointed this out. as the suitable age for marriage, we may mention some things which conduce not slightly to health- ful and happy marriages : parity of station, similarity of temper and tastes, and no dispro- portion either in age or size. 8. Maturity -The body has now reached its maximum weight and solidarity, and the period is that of maximum endurance. Men reach then full weight at 40 ; women later, sometimes not till 50. At this age the soldier is fittest fot service, the labourer for work, the artisan and professional man for their respective duties PERSONAL PERSONAL Hijih to soar and deep to dive is given to man it thirty-live.’ The morbid tendency is towards knaemia and obesity, the former promoting the atter, and both alike being determined by a too Sedentary town-life and by daily occupation in •lose, ill-ventilated, and badly-lighted chambers. Tow are perceived the first attacks of gout ; vhilst visceral degenerations and atheroma of rteries may manifest themselves — events all f which may be delayed, if not wholly pre- lented, by attention to the laws of health. It desirable that each individual should pay eed to his weight at this age, since this indi- cates whether or no he is living wisely. Celsus 74. 2, cap. 1) writes: — ‘Corpus autem habilis- mum quadratum est nequo gracile neque besum. Nam longa statura ut in juventa de- ira est sic matura senectute confieitur. Gracile )rpus infirmum, obesum hebes est.’ When, jwever, men are engaged in trades or profes- tms there is no more difficult task than to aintain their weight at this age, the juste k lieu referred to being a hard matter to secure, he advice given by Celsus (lib. 1, cap. 1) can- )t be surpassed in force or brevity: ‘Sanus >mo qui et bene valet et suse spontis est nullis ■ligare se legibus debet ; hunc oportet varium ■here vitae genus, modo rnri esse, modo in be, saepiusque in agro, navigare, venari quies- re interdum ; siquidem ignavia corpus hebetat oorfirmat.’ As to diet, clothing, and habits, ■ need add nothing to what has been already vised for a previous age ; but on exercise of jy and mind there is much to be written. A. good rule is laid down by Lynch, too, in i Guide to Health (p. 290), that the lean smld exercise ad ruborem , i.e. to glow-point, t until their bodies and spirits are heated, 1 that will fatten them ; and the fat ad sudo- The more luxuriously a man lives, the ifre exercise, and the more active exercise, he lids. Want of it, and the costive habit thus S'Orinduced, may, as Kotzobec observes, extin- £.ih the divine flame of genius and seriously i >air the intellectual powers. Hypochon- ihsis and hysteria are the special punish- nits of ease and affluence and indolence. Ob- v isly a portion of each day should be set apart f exercise. In the households of the wealthy a ’mnasium is at least as important as a bath- rln; and twenty minutes every morning before bij.kfast might well be devoted to breathing the n: cles — that is, calling into play every muscle ol le trunk and limbs. The chest should be ex- P= led by clubs and dumb-bells ; swinging on tl trapeze, and hanging by the arms and legs, in be recommended. Again, before forenoon or id-day meal, an hour's ride or walk must be ob.ined, and a third time in the day an hour ai i a half’s exercise — funcing, or walking, or ro eg — should be arranged before bed-time, in di pring and summer seasons. A great point is : vary the exercise by every means at hand ; t'lange the set of muscles called chiefly into pkupon different days, as Celsus advised; to 8"', ride, fence, sail, row, shoot, fish. Lastly, n recommend only those who are very robust to ke a long walk before breakfast. Bodily ise should not be undertaken immediately ill a heavy meal ; nor should those who have 73 HEALTH. 1153 sweated themselves violently sit down at once to a full meal — at least an hour's rest should intervene. Mental exertion is advantageous to health; even carried to excess, it lessens, rather than increases, waste of tissue. Over- work of a mental kind, with anxiety, appears attended by lessened appetite, lessened nutrition, and loss of body- weight — proof positive of detriment received. 9. The Turning Period. — This period of life, which lies between 45 and 60, is also known as the grand climacteric, or middle age. The skin wrinkles. Up to 60 years of age the skull may continue to increase in size, principally at its anterior part, by enlargement at the frontal sinus ; after 60 the skull-cap loses weight, and the brain may waste but gets tougher and firmer. The heart grows a little larger, and its walls are thicker. The lungs grow denser, a change com- mon to every tissue of the body. The hair grows gray ; the features sharpen ; the sight alters ; and the hearing grows dull. Pressure and wear and tear begin to tell at every part. Upon the blood-vessels their effects are more marked in males than females, because ordi- narily the former labour harder than the latter; further, the death-rate of men is greater than that of women at this age. As the sexual powers decline, which they do by a quick descent between 46 and 63, the intellectual powers in- crease, so that mentally there is often exhibited a marked increase of vivacity and agreeableness, more noticeable in men than in women. In the latter the cessation of the catamenia is attended usually by some rejuvenescence, attributable to their recovering a little embonpoint. It is an age, however, at which women kick rather, and become restless and uneasy, the change of life being attended in many by a renewal of their juvenile tempers, as between 7 and 14, and occa- sionally by a revival of their youthful ailments as eczema, skin eruptions, and various neuroses, insomnia, hysteria, and sometimes epilepsy. In character, whatever obstinanev exists reaches its climax. Morbid Imminences. — The inflammatory dis- position is lessened, but there is a tendency to venous plethora of the abdominal viscera and towards vicarious hsemorrhages. Gout assails its victims with well-characterised attacks. New growths, simple and malignant, tend to demon- strate themselves, and rheumatoid arthritis to appear. Dr. "Waterhouse, in a letter to Sir T, Sinclair, published in his Cede of Health and Longevity (vol. i. p. 33, Edinburgh, 1807), no- tices the three following periods as very im- portant in every human life, as sickly or moulting times. The first he had noticed to befall males chiefly at thirty-six years of age, when the lean person becomes fatter and the fat kine leaner. • The second sickly period hap- pens at some time between forty-three and fifty, and lasts a year, or perhaps two. During it the complexion fades, the appetite fails, the tongue becomes furred at the smallest over-exertion of body or mind, the muscles are flabby, the joints are weak, sleep is unrefreshing, and the spirits droop. It is no particular organ that suffers, but a uniform deterioration that is manifested At this time a man first experiences a reluctance PERSONAL HEALTH. 1154 io stoop, prefers a carriage to riding on horse- back, and perceives each change of the weather affect him. This observation of Hr. Water- house has, according to the experience of many, much justice in it; as also that between sixty- one and sixty-cwo a similar deterioration of health takes place, hut with aggravated symp- toms. Hygienic Rules. — At the menopause women should be advised to abstain, as a rule, from alcoholic drinks, and avoid highly spiced and seasoned dishes. They may bo recommended to take meat not more than once daily, and to live chiefly on farinaceous food, milk, eggs, vege- tables, and fresh fruits. A tablespoonful of lime-juice taken twice daily occasionally for a week or ten days at a time has a salutary, depu- rating effect upon both stomach and kidneys, and clears the tongue when this is foul in the morning. Riding and walking exercise are highly appropriate, but very violent muscular efforts should be avoided. If the individual be thin and growing thinner, the clothing should be extra warm. Flannel abdominal belts may he worn advantageously in all seasons, but espe- cially in autumn and winter. Both sexes should avoid emotional excitement and the stimulation of waning sexual abilities. Prolonged exposure to wet and cold is sure to be seriously resented. Hot or Turkish baths, succeeded as they should be by cold plunge or douches to remove the lassitude otherwise provoked, are very beneficial, and taken once a week may be safely indulged in throughout the year. It becomes extra important as the subcu- taneous fat gets absorbed, and the skin wrinkles, to keep its pares clean and open and capable of perspiring. 10 and 11. Advanced Life, and Old Age. The period of advanced life — sixty to eighty- two, and old ago, -from eighty-two upwards, may be advantageously considered together. When a man turns his toes out much in walking and treads upon the whole base of his foot, and is always stopping to look hack, he is already old. The sagacious ‘boots’ at an inn can tell a man’s age by the state of his shoe-leather. ‘ Seneetus ipsa morbus insanabilis.' Some de- generate earlier than others, hut the decline of life is characterised in all human kind alike by an indurating condition of every tissue diametri- cally opposed to the cellular softness and laxity of infancy. The capillaries thicken, the arteries harden, the nutritive metamorphoses proceed more slowly. The muscles waste ; the subcu- taneous fat lessens; the blood becomes poorer and paler.; the skin dry, sallow, and wrinkled; further, it gets less vascular, and the mucous surfaces become relatively more so. The teeth loosen and fall out ; the gums recede from them ; and the digestive juices fail. The arteries be- come atheromatous and calcareous, lose their elasticity, and. are liable to fibrinous throm- boses, or to embolic pluggings ; and while they fend to block up at one part, their coats may split and yield to pressure, bulge out, and form aneurisms or dilatations in other directions. Hence happen apoplexies, brain-softenings, and senile gangrenes. The heart up to an uncertain period grows progressively larger and mor« mus- cular, to meet the obstacles offered to the cir- culation ; hut finally it, too, degenerates, and its walls grow thinner and dilate. The air-cells of the lungs lose their elasticity, and progressively enlarge ; then merge into each other ; and become emphysematous at the edges of the lobes where least supported. Emphysema implies degene- ration of capillaries and diminution of aerating surfaces ; and as the pulmonary area becomes thus lessened, the right heart becomes hypertro- phied and dilated. The dryness and lessened secretion of the skin cast harder work upon the kidneys in eliminating water, and increase the disposition to catarrhal fluxes from the nasal passages, the bronchi, and the intestines. Thus, while there is a constant predisposition to skin-irritation from its dry- ness, and to eczema from scratching and rubbing it, the other morbid imminencies towards bron- chial catarrh and diarrhoea very closely follow the direction given them by the season of the year and greater or less degree of external cold. The bladder grows thicker with age, and its ca- pacity is less ; the prostate gland enlarges. Feu persons after 60 pass seven hours in bed without; requiring to micturate. Dr. Rush regarded the necessity for more frequent micturition the firs: symptom indicative of a man's years impairing: his bodily functions. The pulse feels firmer ant fuller ; fills quickly after food is taken ; but falls in frequency and flags in power in a marked de gTee after fasting. It is a far less trastwortin indicator of the gravity of any febrile disorder or of degrees of asthenia, than it was in youti or middle age ; and it fails to poiut to the prac titioner the nearness of death, unless he hav large experience of it. There is a default of reaction manifest in ad vanced life, so that all acute disease is clinicall less easy of recognition, and the beginning of tb end is therefore apt to pass unobserved. Th thermometer warns the doctor of changes whic old people do not notico themselves, but whic it may be of considerable importance to notice A slight elevation of temperature means ranch i old age, and should be heeded accordingly. Tl: slightest change excites a young child ; nothin seems to move the old man. In extreme old at life is little more than vegetative existence; tl individual eats and sleeps and dreams. Tl sleep the aged get by night does not satisl them. Memory is one of the first mental facu ties to become impaired, but finally every seni and faculty fail. Up to 75 the strong of bo sexes retain their digestive powers, and a fa amount of mental and muscular vigour. Hygienic Rules. — A prime necessity for o age is warmth ; nothing kills the aged so ce tainly as cold. It is of first hygienic importan after 75 that tho individual should he lor and cared for ; old people do not, perhaps cann take care of themselves. Those who live longest and enjoy the full' measure of activity are those who do not on tax their stomachs when their teeth begin to f them, and who adapt their aliment to their < feebled powers of mastication by having th food properly cooked for them. Stews, miuc meats boiled and afterwards baked — cooked, t> is, twice — are more easily digested than itv PERSONAL HEALTH, roasts or close-fibred meats. A moderate amount Df wine both cheers and comforts old people ; a ? [ass or two of good Burgundy or of champagne, md an occasional glass of old port wine, is most •beneficial to aged persons, and is better for them than overloading their stomachs with milk and farinaceous foods. Great attention should be paid to the func- ions of the bowels and of the skin. Galen jointed out that old people should not suffer heir bowels to remain costive beyond two days; in the third they should take some gentle purge, mch as by experience they have found adequate o open their bodies. A hot bath once a week, md a hot foot-bath every night, may be advised. A short nap after breakfast and before dinner is he natural habit of the aged. Further, their lothing should be extra warm, and their cham- >ers night and day be heated. They should >e encouraged to go out in the open air only in easonable weather, and when they are equal to t should take a little walk on a dry gravel path n some warm locality, sheltered from north- asterly winds. All change and cheerful society ts good for them. If their purses admit of it, hey should follow the swallows to warm winter juarters. If they must winter in England, let jiem shut themselves up throughout it in a well- irmed house. Summary. — Ad vice for every ago may be thus iriefly given : for infancy and childhood — sus- ne ; for adult years — sustine et abstine ; for old r 6— sustine again. There is less need now to join abstine. The hygienist, however, seeks not to lengthen t the days of age and decrepitude; his art is •t to prolong life beyond its natural term, oughthis may come subordinately, but to ren- r its period of activity and utility longer — ‘ Hie ‘tor hoc opus cst.’ Some cynic observes that we ve pointed out very few habits as worth culti- ting, the truth being we believe what we have dsted on— that most bodily habits need resist- ;. Individual health is attained by self-denial ; oits imply self-indulgence. Reginald Southey. PERSPIRATION, Disorders of. — Synon. : 1 Trotdtles de la Sueur ; Ger. Storungen des l. misses. 'his subject will be discussed in the following oer: — 1. Hyperidrosis ; 2, Anidrosis ; 3, Os- njrosis ; 4, Chromidrosis ; and 5, Haematidro- si • Hyperidrosis. — D efinition. — Excess of P duration. ‘.Stiology. — T he cause of hyperidrosis, though ci iinly connected with the vaso-motor nerves, Mill obscure. Often hyperidrosis seems to be k x, and excited by irritation of a more or less ( u int part, such as food in the mouth, by which d. nuscles of the blood-vessels relax, and admit m ) blood to the sweat-glands ; there being, as fa. sis known, no direct connectionof the sweat- gl is with the nerves. •ascription. — Hyperidrosis may be either 9 e 'al or local. neral hyperidrosis occurs in acute rheuma- gout, intermittent fever, pyaemia, phthisis, S e -al debility, alcoholism, and the defervescence PERSPIRATION, DISORDERS OF. 1155 of febricula ; in hot weather ; in emotional ex- citement ; or after severe exercise. It also fol- lows the use of the vapour or Turkish bath ; and is produced by diaphoretics, such as spirit of nitrous aether, opium, antimonials, and espe- cially jaborandi. Paroxysmal sweating* of rapid onset lias. been seen in one or two cases where the patients still had, or had had, epileptic fits. Partial hyperidrosis usually occurs on one side of the body, or of the face and head. Nu- merous cases are recorded where unilateral facial sweating followed cerebral haemorrhage, and accompanied hemiplegia ; or occurred with sup- purative parotitis and salivary fistula of the same side. In these the sweating occurs chiefly during mastication, the cheek being also red- dened. Hyperidrosis lateralis sometimes occurs on the right or left side when the tongue is touched with salt on the corresponding side. Some cases of lateral hyperidrosis faciei occur ■without previous assignable cause, and in one the affection was transmitted for three generations. Partial sweating may be limited to the palms or soles, and is sometimes hereditary. Tne sweat is constant and profuse, and the parts are red. tender, and sodden. Excessive sweating may cause sudamina and miliaria, and lead to an eczema of considerable severity. Treatment. — In the treatment of excessive sweating general tonics, sulphuric acid, quinine, iron, or strychnia, may be employed. Flannel should bo worn, instead of cotton, on the skin, and woollen socks instead of cotton. The skin may be sponged with very hot water ; with vinegar and water (1 to 3) ; or with lotions, such as one thus prepared — Ijb acidi sulphurici di- luti 3ij, aquseOj.; or Ijb acidi tannici 5j, spi- ritus vini rectificati Jvj. Powdering with talc or violet powder will relieve temporarily some cases of profuse sweating in acute rheumatism. Hyperidrosis in phthisis has been temporarily benefited by zinc, hyoscyamus, or sulphate of atropia (j 0 to A. of a grain pro die ) administered with care. Belladonna liniment is one of the best remedies in local hyperidrosis of hands and feet. 2 . Ani drosis. — Anidrosis, or deficiency of sweat, is merely a symptom in general diseases with a large flow of urine or renal disorder— for example, diabetes insipidus and mellitus, and Bright’s disease. It accompanies the earlier stages of fever; and is a constant symptom in skin which is the seat of ichthyosis, psoriasis, or prurigo vera. Some persons habitually sweat little, especially in winter, and the skin is dry and rough, partly from deficient sebaceous secretion (xeroderma)." 3. Osmidrosis. — In some persons the sweat, if retained on the skin, has a bad smell, especi- ally that secreted by the armpits, perinaeum, genitals, and the feet and toes ; and to this dis- order the name osmidrosis is given. The smell appears to be due to chemical conversion of the mixed secretion of the sweat and sebaceous glands, under the influence of moisture, and in the presence of macerated epithelium, into the higher fatty acids (caproic, &c.). Removal of the accumulated secretions by thorough washing removes the smell for a time. The underclothes 1156 PERSPIRATION', DISORDERS OF. also become saturated with the sweat, and smeE badly. This affection is not uncommon in fe- males in the armpits, and it may be a serious affliction from the annoyance it causes to others. Treatment. — This consists in extreme clean- liness, repeated washing with tar-soap, thorough drying, and frequent change of linen. The parts should be powdered with oxide of zinc and rice- starch (1 to 4), and tincture of belladonna inter- nally should always be tried. Hebra strongly recommends the foEowing ointment ( Unguentum diachyli) for foetid sweating of the feet, 1)1 Olei oliv® optima Lithargyri, jiij, 3vj ; Coque ; ft. unguentum. The ointment to be applied on strips of linen every twelve hours. Thin and others have had good results from disinfecting the stocking soles with a saturated solution of boracic acid. Cork soles must be worn, and disinfected in like manner. Careful inquiry should be made into the state of the general health. 4. Chromidrosis. — This condition, in which there occurs a secretion of coloured matter (indigo) by the skin, is so rare as to be of no clinical importance, though of much physiologi- cal interest. 5. Heematidrosis. — This, the so-caEed ‘bloody sweat,’ is also a variety, if it ever really occur. The reported cases are probably due either to rupture of superficial capillaries in the cutis, or to a similar rupture into the duct of a sweat- gland, out of which the blood finally escapes. The mechanism of this rupture, which seems quite unconnected with the secretion of sweat, is very obscure, though the highest authorities are sure that such ‘ spontaneous ’ bleedings do occur. A number of cases which have been reported in hysterico-neurotic persons were un- doubtedly due to self-inflicted punctures. Edwaed J. Sparks.’ PERTUSSIS {per, signifying excess, and tussis, cough). — A synonym for whooping cough. See Whooping Cough. PESTIS (Lat.). — A synonym for plague. Sec Plaque. PETECHIAE (Ital. Petecchics, flea-bites). — Synon. :.Petieul(B ; Fr. Petechias ; Ger. Petechien. Description. — Petechi® are small crimson and purple spots of the skin, resembling those that re- sult from the bite of a flea. They are circular in figure ; are developed around the apertures of the follicles ; have an average size of one or two lines in diameter ; and are consequent on the transudation of t he colouring matters of the blood, through the capillary vessels of the follicles, into the imme- diately adjacent tissues. They are distinguished from spots resulting from simple hypersmia by pressure with the finger. Under pressure the hypermmic spots disappear, but the petechi® re- main permanent. They are differentiated from flea-bites by the presence in these of the punc- ture, which is always perceptible, and contrasts strongly with the lighter colour of the rest of the disk ; although it is to be remembered that the centre of the petechial spot is always deepest in colour, and becomes lighter towards the cir- cumference. Petechi® vary in tint of colour 1 Revised by Dr. Alfred Sangstei. PH ANT Oil TUMOUR, according to age and the amount of effused blood being at first brightly crimson, then purple, next almost black, and subsequently fading away through the ordinary colours of a bruise. Hence it is usual to find them scattered over the skin of various shades of colour, ranging through all the tints already mentioned. Petechi® are met with on the mucous mem- branes, as well as on the skin, in purpura, scor- butus, malignant fevers, and in several forms o! congestion of the foEicles of the skin, associate-1 with constitutional diseases. Petechia do not call for special treatment. See Purpura _ The term ‘petechial is applied to certain varie- ties of diseases, such as typhus, when petechia occur in their course, or the eruption becomes hmmorrhagic. See Extravasation ; and Typhus. Erasmus Wilson. PETIT MAL (Fr.). — A term applied to attacks of epEepsy which are of short duration and slight intensity. See Epilepsy. PPAEITERS, in Switzerland. — Simple thermal waters. See Mineral Waters. PHAGEDAllfA (e serviceable in some cases. The bowels should ie kept freely opened. Feed EiucK T. Egberts. PHABYNX, Diseases of. — The pharynx 3 often involved in acute general diseases which fleet the throat, such as scarlatina and diph- lieria ; or it may be implicated along with other Structures in diffused inflammation of the throat, deeration, gangrene, or morbid growths ; but he diseases of practical importance connected ,-ith the pharynx itself which need to be discussed ere are three, namely, 1. Acute inflamma- ion ; 2. Chronic infla mm ation ; and 3. Fol- icular inflammation. 1. Acute Inflammation of the Pharynx. — ynon. : Fr. Pharyngite aigue ; Ger. Acute 'chlundkopfeiitziindung. Definition. — An affection of the pharyngeal •ucous membrane, characterised by a non-exuda- ve catarrhal inflammation. /Etiology. — Some persons, though otherwise \bust enough, show a particular predisposition i pharyngeal catarrh ; and previous attacks ' em to increase the predisposition. The young "e, on the whole, more liable to the complaint an those more advanced in nge ; while all that •ings the strength of the individual below par, Aether over-work, exposure, or disease, more .rticuiarly of a specific nature, acts as a pre- sposing cause. Two of the most common ex- ,ing causes are cold and damp. At other times maytake origin in an extension of the catarrh im other organs, in a blood-poison, or in a direct ■itant. Symptoms. — Most frequently, though not uni- Irsally, the attack is ushered in by a certain hount of fever. The patient experiences some gree of chilliness, if not actual rigor ; is rest- |»s ; his temperature is exalted ; the skin is dry ; I languor and stiffness of the body are com- tined of. This may precede the pharyngeal nptoms by some hours, but soon these begin arrest attention. The patient discovers in his ■ ■oat a feeling of soreness or fulness, speedily ounting to pain. This is particularly noticed ■ en an attempt is made to swallow. And yet s very condition of dryness of the throat pro- ves him to renew the effort to swallow, the ' pleasantness of which he manifests to the by- 1 nders by the wry faces thereby induced. This 1 ire to swallow is greatly aggravated if the fla. happens to be involved in the catarrh, as I n its swollen condition it suggests the pre- PHABYNX, DISEASES OF. 1167 sence of a foreign body, which the patient endea- vours to rid himself of by repeated swallowing. Cough is a frequent accompaniment, especially if the inflammation have extended downwards. The inflammation may not extend into the larynx, but more usually this part is involved, and then the voice is altered in tone, becoming husky or hoarse, and it acquires the well-known ‘nasal twang.’ On inspecting the throat, it will be ob- served that the mucous membrane is consider- ably altered in appearance and colour, being tumefied and redder than in health. At first it is dry, often glistening, and tense. But as the case progresses this condition is altered, a secre- tion of mucus, more or less abundant , being poured out, bathing the tonsils and posterior parts of the pharynx. This gives rise to repeated hawk- ing and attempts to expectorate. Occasionally this catarrhal inflammation extends into the Eustachian tubes, exciting considerable deafness and pain in the ears. At the same time the oral mucous membrane is affected, as evidenced by the usual symptoms of foul tongue, had taste in the mouth, accumulation of saliva, and offensive breath. This acute variety, under effective treat- ment, usually subsides within a week. Treatment. — Dr. Binger urges the use of tincture of aconite, in drop doses every quarter of an hour for the first two hours, and afterwards hourly, if the angina has been seen at the very commencement. He states that the inflammation rarely fails to succumb to this treatment in twenty-four to forty-eight hours. The patient should he confined to bed ; a brisk purgative ad- ministered ; and bland nourishment allowed, in- cluding abundance of milk, ice ad libitum, and stimulants if called for. Warm fomentations or poultices may be applied externally, or a wet com- press. Steam may be inhaled, and a warm spray, medicated with morphia, thrown into the throat every two hours. "When the swelling and redness subside, and the parts no longer present the dry, tense appearance, hut are covered with mucus or pus, then is the time to bring in the astringent gargles, or to paint the throat with glycerine of tannin or nitrate of silver. And now, also, tonics will prove useful. 2. Chronic Inflammation of the Pharynx. Synon. : ‘ Eelaxed throat.’ — This is by no means an uncommon affection, and may exist without having passed through the acute form. Symptoms. — As in the acute variety, so here there is the same difficulty in swallowing, amounting even to pain when irritating sub- stances are attempted to be passed into the gul- let, but of course in an infinitely less’ degree. Persons suffering from this form of sore-throat are specially liable to exacerbations of the ca- tarrh, giving to the affection more of a sub- acute character, and then their usual symptoms are all aggravated. The hawking and expectoration, which habitually go on, more or less, during the whole time of t.heir toilet-making, is increased ; and finding some difficulty in removing this tough mucus from the hack of the throat, this hawking is continued till the mucous membrane itself is strained, and some of the ramifying ves- sels give way, and the patient is alarmed to see blood mixed with the expectoration. In some instances, especially in the case of those who arc PHARYNX, DISEASES OF. 1158 habitual topers, this hawking in the morning is the prelude to the morning vomiting. The voice is apt to be husky, more particularly if the ca- tarrh have at all invaded the larynx. On inspec- tion of the throat, it will be observed that the mucous membrane is more or less reddened ; it presents a roughened appearance ; and is some- times puffy-looking, with numerous veinlets running across it, and a quantity of mucus ad- hering to the posterior part of the throat : this last appearance is more common in the relaxed condition of the throat. This variety is not ■•.infrequently found as an accompaniment of other diseases, as of phthisis, syphilis, disorders of the stomach, gout, and the effects of intemperance. The affection is usually very obstinate. Treatment. — If the disorder be dependent upon any other affection, then of course the pri- mary disease must be attacked. But in the case of simple chronic pharyngitis it will usually be found that the sufferer is considerably below par in his general health. This indication must be met, and the patient supplied with tonics; his habits of life altered, his business suspended, and much out-of-door exercise enjoined. Good nourishing diet should be ordered. Smoking must either be entirely prohibited, or if this be impossible, it must be much reduced. Locally, the affection is best treated by sprays or swab- bing. Gargles seldom reach the parts ; but if these are to be used, the best are those of alum, tannin, chlorate of potash, or bromide of ammo- nium. This latter is especially valuable in re- laxed throats, with elongated uvula, and irritable cough. As sprays, many different remedies are employed, the most valuable being solutions of the following in distilled water, in the pro- portions indicated to the ounce: — Nitrate of silver, 5 to 10 grains ; tannin, 5 to 15 grains ; alum, 10 to 30 grains; sulphate of zinc, 5 to 10 grains ; common salt, 10 to 30 grains ; or glycerine diluted with water. In swabbing the throat, glycerine of tannin may be used, Lugol's solution, or the simple tincture of iodine. In some eases mineral waters are prescribed with success. 3. Follicular Inflammation of the Pharynx. — Synon. : Granular pharyngitis ; 1 clergyman’s sore-throat ; ’ Fr. Angine glandu - ','Mse ; Ger. Chronischer Pharyngitis. This is another, by no means rare, form of chronic pharyngitis. On inspecting the throat •cf a sufferer from this affection, the posterior wall of the pharynx will be seen to present a mammi Hated appearance. The mucous follicles are much more prominent than is usual in health, and seem as if distended with their proper secre- tion. The submucous tissue, in which they' are imbedded, is also thickened and hypertrophied. Occasionally these tubercles coalesce, and then a large confluent prominence is observed, stud- ding, here and there, the posterior wall of the pharynx. In addition to the distension of these follicles, in some cases a large secretion of mucus is poured out, which, especially at night, hardens and concretes, and presents a dry, ugly, greenish- coloured crust on the back of the pharynx. At ether times there is, on the contrary, a deficiency of mucus, and then there is observed a dry var- nished-like appearance on the back of the throat. Symptoms. — Each of these conditions gives rise to a considerable amount of coughing and hawk- ing ; more particularly is this the case when the adherent mucus is tough, tenacious, and difficult of expectoration. The voice becomes hoarse and husky, this being very observable after any con- tinuous effort at speaking or reading. Swallow- ing is not attended with difficulty or pain. But the presence of these enlarged follicles in the throat suggests to the mind of the patient the* necessity of swallowing, and consequently he makes frequent uncalled-for attempts to swallow At the same time he perceives a sensation o' dryness or pricking in the thro'at. Those wh- are the subjects of this disorder will general!, be found to be over-worked men — often clergy men ; and hence the erroneous name for the affection of ‘clergy-man’s sore-throat ’—or thosi whose bodily and nervous energy have beer in any way reduced. It is a tedious disorder often lasting for years. There seems to be small disposition for the disease to extend t the larynx or lungs ; but on examination M means of the rhinoscope, the same enlarged ap pearanee of mucous follicles may, in some cases be seen to extend to the utmost limits of th. pharynx, and the mucous membrane is itsel tumefied and thickened. If this condition b? neglected, it may ultimately proceed a stag, further, and the character of the secretion be! comes altered, presenting a muco-purulent ap pearanee, while the glands themselves becom indurated and, in some cases, ulcerated. Oeca sionally it will be found that the mucous mem brane and the follicles of the larynx take on thi same form of chronic inflammation, specially when the disorder is persistently ignored fo years. Arrived at this stage, the general symp toms become so aggravated as to forbid th patient, or his friends, any longer to neglec the disease. The hoarseness, always presea in a certain degree when speaking or siDging becomes constant and intensified ; and if th] larynx be considerably affected there may b complete aphonia. And now more decided pah is complained of, and the individual no longe, exhibits the same alacrity and interest in th pursuit of his avocations, but becomes indit ferent to them, in consequence of the increase* debility and general languor which pervades hi whole system. Cough, however, is not a strik ing symptom ; for if tile disease do not inrad the larynx to any- great extent (and its tendency is rather to progress upwards than downward?' then the patient maybe comparatively freefron cough. The other structures in the neighbour hood of the pharynx become implicated, whe the disease assumes the ulcerated form ; and th uvula, tonsils, and soft palate become tnmefieij swollen, elongatod, and generally so enlarged a greatly to interfere with the inspection of th parts. The epiglottis also exhibits, in sever cases, a tendency to become crooked and ul« rated. j Treatment. — The general rules already lai down wi th regard to the treatment of chronic ph: ; ryngitis apply equally in this disorder, only, per haps, with greatcrforce. The constitutional treai ment must be more decided. The patient must 1 absolutely- forbidden to prosecute his employmer or profession any longer, if he has any respect '< PHARYNX, DISEASES OF. lis health, be he clergyman, physician, barrister, linger, photographer, or inveterate smoker, forthe Lbits and pursuits of these individuals are the -ery provocatives of the disease. The constitution iiust be braced in every possible way, by the Ise of generous diet, tonics, bathing, travelling, bnd to further the cure of the affection, atten- ion must be paid to the secretions generally, ihese being stimulated or altered by the exhibition f small doses of blue pill, podophyllin, and does. Iodine in some form should be giveD. 'lut the local treatment is equally, if not more, 'mportant, and to be effective must be regularly nd conscientiously persevered in for months, "hero are various methods of effecting this, as inhalations of medicated fluids, insufflation of arious powders, as alum or tannin ; but the lost certain and efficacious, because at once sacking the affected parts, and producing de- ided and visible effects, is the direct application f the selected remedy to the diseased parts by [leans of a large camel's-hair brush. And one i the best of these applications is a strong elution of nitrate of silver, varying in strength •om twenty to eighty grains to the ounce of dis- hed water. If the pans be much ulcerated, a ill stronger solution may be employed. Other edicaments which may at a later stage be used ■e the glycerine of tannin, or a solution of tan- n in water (equal quantities of tannin and ater), bromide of ammonium, tincture of iodine, • nitrate of uranium. Of course it must be ft to the discretion of the practitioner to decide >w often he should repeat these strong applica- nt, as it all depends upon the nature of the so ; but as a general rule it may be laid down at cnce every second day will be quite suffi- pnt for the first fortnight, and after that two three times a week will be often enough, lis is to be kept up till the nodulated appear- ce is got rid of. As soothing applications the ycerine of borax will be found valuable, or yrerine alone, or olive or almond oil. Gargles e useless, as they never reach the affected parts, course of mineral waters is sometimes of tho eatest value. Sec Mineral Waters. Claud Muirhead. PHIMOSIS ( penis, in which the glans cannot be suffi- ntly uncovered, on account either of congenital > allness of the orifice of the prepuce, or of 1 turbance of the natural relations between i latter and the glans by disease. See Penis, . leases of. ?HLEBECTASIA(^>\6i|/, a vein, and e/mzcns, i 1 ension). — Synon. : Hypertrophia vcnarum. Definition. — An increase or spreading of ’ ns, especially applicable to the minute ve- l es of the cutaneous or mucous surfaces. Description. — Phlebeetasia is sometimes con- f ital,aswhen it gives rise to venous nsevus ; and either times accidental, proceeding from relax- f in of the tissues, or obstruction of the venous i illation. Phlebeetasia, from want of tone of f tissues of the skin and weak contractile energy c the vessels, is most frequently met with on t cheeks and nose ; whilst that which results I n venous obstruction occurs generally upon the PHLEGMASIA ID GLENS. 1159 lower limbs. On the nose it is associated with small venous trunks which carry, the returning blood into the deeper venous plexuses, and are very conspicuous. Treatment. — The treatment of phlebeetasia consists in improving the tone and vigour of the skin, removing palpable causes of obstruction, and applying local astringents. When torpid action is the chief cause, as happens in acci- dental phlebeetasia of the face, daily friction with sulphur ointment is useful in exciting an improved nutritive vigour. Where large venules are present, as on the nose, they may be oblite- rated by a careful touch with potassa fusa, which forces the blood to seek a deeper channel. In phlebeetasia of a naevous character a good treat- ment consists in painting the surface night and morning with liquor plumbi. But the capillary venous hypertrophy of varicose or obstructed veins is only to be benefited by the removal cf the cause. Erasmus Wilson. PHLEBITIS a vein). — Inflammation of a vein. See Phlegmasia Dolens ; and Veins, Diseases of PHLEBOLITH a vein, and Af 60s, a stone). — A concretion formed in a vein. See Veins, Diseases of. PHLEBOTOMY ( a vein, and reyva, I cut). — A synonym for venesection. See Blood, Abstraction of. PHLEGM (cpAeyw, I burn; I distil). — A popular name for matter expectorated. See Ex- FKCTOKATION. PHLEGMASIA DOLENS (phlegmasia, inflammation ; and dolens , painful). — Synon. : Phlegmasia alba dolens; Pop. White Leg. ; Fr. Phlegmasia alba dolens ; Ger. Phlegmasia dolens. This is a disease having very distinct charac- ters and easily identified. It has, therefore, been long familiarly known both to the profession and the public. Except in lying-in women, it is un- common, few medical men seeing well-marked or characteristic cases of it under any other circum- stances ; and it is for the most part ns a disease of the puerperal state that it has been the subject of study and investigation. FEtiology. — Phlegmasia dolens affects both sexes, and no age is exempt from it. It may attack any part of the body, but one or other of the lower limbs is the ordinary seat of it. Occasionally it seizes one lower limb first and then the other, or the disease may extend from the one to the other. The well-character- ised disease, as it affects lying-in women, is an affection of the lower limbs. The left leg is far moro frequently affected in the puerperal state than the right ; and the left leg is supposed to be more frequently affected than the other under whatever circumstances the disease occurs. In lying-in women the comparative frequency of this affection, and of several other morbid con- ditions on the left side, is believed to depend on the circumstance that the parts on that side of the pelvis are more frequently subjected to pres- sure and bruising than the parts on the other side. This probably arises from the compara- tive frequency of the right lateral obliquity of PHLEGMASIA DOLENS. 1160 the uterus throwing the direction of the uterine power of labour across the mesial line to the left side of the pelvis. The disease affects mul- tipart more than primiparoe. It is prone to occur in successive confinements. From the variety of circumstances under which the disease may occur,.-it will be easily appre- hended that it may arise in any period of preg- nancy or of the puerperal state, but the time of appearance of the ordinary disease in lying-in women is the second week after delivery. It rarely commences in the first days ; generally in the second or third week ; seldom subsequently, in the puerperal state. The special proneness of lying-in women to this disease probably depends on their liydraemic condition. Besides the puerperal state, other conditions render the body liable to it. Among these are convalescence from fever — especially typhoid, dysentery, disease of the rectum, malignant disease of the uterus, interference with uterine fibroids, arrestment of menses, and malignant and tubercular disease generally. The disease has been frequently observed to affect the leg of the side corresponding with a previously commenced pleurisy. Occurring in connection with any of these conditions, the disease may vary greatly in severity, from being scarcely recognisable to its utmost degree of intensity. But its liability to severity is not the same in all circumstances. For example, in connection with malignant diseases of the womb it is often very slight and chronic. Anatomical Characters. — The 'post-mortem appearances referable to phlegmasia dolens vary, especially in the presence or absence of throm- bosis of the veins. Phlebitis, periphlebitis, and thrombosis are generally found ; but besides these nothing special has been made out. The blood-clots vary in extent, sometimes occurring as high as the vena cava inferior. They vary in appearance, being more or less decolourised, more or less softened, or even diffluent. They may be adherent to the veins, even organised, or separable from them. They may block the veins, or may allow passage of blood through their substance. In recent cases the clot adheres to the internal coat of the vein, which is blood-stained. These coats are thickened and inflamed, and the surrounding cellular tissue is also sometimes specially hardened. In cases complicated with pyaemia there may be found suppuration in the clots, and other appearances observed in that condition. Pathology. — Various theories, which reflect the pathology of the times at which they ap- peared, have been held concerning the nature of phlegmasia dolens. The disease was ascribed to a metastasis of lochia by many pathologists, and by others to a metastasis of milk. These views had no basis of facts, or very little ; they rested almost entirely on authority, and disappeared as pathology improved. The discovery of the lym- phatics in the last century led to the first attempts of a truly scientific kind to solve the mystery of the nature of this affection, the suggestion being that it arose from thoir injury and obstructi'Vi. Bat considering how imperfect is our acquaint- ance even now with the ongin and distribution of these vessels, with the circulation through them, and with the effects of their injury or obstruction, we must still seek for information. The next attempt to account for this disease was based on the important discovery of the throm- bosis of the veins of the affected limb. This was erroneously assumed to be an invariable or essen- tial condition of the disease, which was accord ingly now regarded as phlebitic. But the recur- rence of the lesions regarded as essential, the phlebitis and thrombosis, without the develop- ment of the characteristic appearances of the affected limb ; and, on the other hand, the occur- rence of the characteristic appearances without the simultaneous presence of the phlebitis and thrombosis, demonstrated the insufficiency of the phlebitic theory. The next theory to be mentioned is a sort of retrogression to humoral pathology. It alleged, but merely alleged, that a morbid con- dition of the blood, of undefined nature, is, along with phlebitis and thrombosis, necessary for the production of the disease. This theory is nearly as deficient in basis as the lochia or milk theory. The confirmatory experiments on the lower ani- mals, by injecting lactic acid into the circulation,' are in the highestdegree insufficient; anditleares unexplained important points, such as the seat of the affection. The last theory to be mentioned is, perhaps, from its very novelty, likely to get more favour than it as yet deserves. It is that the disease, as it is seen in lying-in women, is essentially a parametritis— that is, an affection of the cellular tissue, commencing, indeed, in the ; close neighbourhood of the womb, but extending to remote parts ; and, it may be, prevailing in them, while the original inflammatory affection of the womb and its immediate neighbourhood has diminished, or even disappeared. Parame- tric inflammation extends in a similar manner occasionally as far as the cellular tissue around the kidney. When it extends to a limb it is supposed to be the eauso of phlegmasia dolens, and to have the phlebitis and thrombosis as con- comitants or consequences of it. This theory is to a certain extent an old one in modern habili- ments. It is easily applied to all forms of the disease. The most recent observations with a view to the elucidation of the pathology of this disease, are concerned with the thrombosis of uterine sinuses, which goes on in the latter part of natural pregnancy, as well as more extensively, after delivery. The great barrier to progress in our knowledge of the nature of phlegmasia dolens is the rarity of necropsie investigations, and the sometimes doubtful character of the evidence they afford. Very few unexceptionable post-mortem investiga- tions have ever been made in this disease. Sueha post-mortem inspection must be made in an early stage, and in a patient dying accidentally from some cause unconnected with the disease of the limb. Now, the disease is not only not fatal in an early stage, but it might be asserted that it is not fatal at all — that death, apparently from it, only occurs in complicated cases — in such as run an extraordinary and rare course. In the mean- time, then, no theory of the disease can be re- garded as established, or as having been shown to be sufficient. Some modern pathologists believe that theN PHLEGMASIA DOLENS. 1161 .ro varieties of phlegmasia dolens dependent on ts origin in disease of the lymphatics, in disease f the veins, or in areolar inflammation. This ubdivision has strong arguments in its sup- ort, but they are far from being conclusive ; i.nd it cannot be used in practice, nor made he basis of any separate description of tho arieties, which should be held by the advocates |t this viow to be distinct diseases. Whilst cases [f obstruction of the veins with cedema are com- lon, cases of obstruction of the lymphatics with ifdema are probably rare ; and neither of these bstmctions, nor both of them, can as yet be lade to account for all the phenomena of phleg- iasia dolens. The distinctive characters claimed hr the cases cf lymphatic obstruction are the bsence of pain, absence of lividity or blueness, hd the presence of hyaline lines, indicating the burse of distended superficial lymphatics. But : requires only a very limited experience in the isease to be convinced of the insufficiency or ■equent inapplicability of this distinction during ife. Symptoms. — As a rule phlegmasia dolens is receded by a slight access of feverish pheno- ena, seldom by a distinct rigor. The pyrexia ion becomes slight or disappears. It is only severe cases, while rapidly progressing to a imax, that the temperature of tho affected part is been observed to be raised. Premonitory symptoms . — Premonitory symp- ;ms are frequently absent, indeed generally so ; Sit there is sometimes an indefinite malaise, even feverishness, for a day or two, before e pain in the limb is complained of. Another emonitory symptom is described, but it also certainly not always present — namely, pain d tenderness in the region of the womb, espe- illy affecting that side of it corresponding to e limb about to be affected. Invasion . — The first announcement of the dis- ■se is generally pain and tenderness in the groin, mg tlie course of the femoral vein, or in the m along the course of the external saphena, these situations the thrombosed vein can fre- ' ently be felt, but not invariably, for sometimes ) tenderness, sometimes the swelling, prevents being made out ; and sometimes this throni- ng is absent, at least in parts where it can be ; ; through the skin. Soon the pain and tonder- : ;s extend over the whole affected parts, which i y be the whole limb, and often a feeling as of iliing in the bones is complained of. The pain (sometimes along tho internal saphena vein, vich may be traced by the finger till it dips t oin the femoral. iimultaneously with the complaint of pain, or t hin a day or two after it, swelling appears, inch gradually spreads and increases in hard- i|s. This swelling is not like ordinary oedema- t s or anasarcous swelling in the sensation it ehmunicates to the hand of the physician, or in tj history of its commencement and progress, b en it commences, and again as it disappears, i nay be, comparatively to its perfect state, s , and it may pit on pressure ; but when, a f days after its appearance, it is fully de- q 'ped, it is elastic, and nearly as hard as a solid ili'.a-rubber ball, and does not pit on pressure. 1 swelling may appear at once all over the limb, but frequently it commences above and spreads downwards. Sometimes the inverse course is followed. It not rarely affects only the lower parts of a limb, very rarely the upper parts only. It does not affect the lower more than the upper surface of the limb. It rounds off the figure of the limb, but does not distend the skin or de- stroy the form so entirely as a huge anasarca. Occasionally there is an erythematous blush over parts of the limb, but this is not common, and it may be confined to a narrow surface along the course of a subcutaneous vein or lymphatic. In a characteristic and fully developed case, such as is frequently observed in the puerperal state, the limb presents a remarkable appearance. The swelling affects the labium and hip and the whole limb. The form of the limb is partly re- tained, but its features are all rounded and nearly lost in the swelling. Its colour is pale or sallow, like that of a dead limb, and hence tho disease is called ‘ white leg.’ But besides being pale, it is glossy, as if greased over; or, more clearly, its surface resembles that of polished marble, and the disease is sometimes called ‘ marble leg.’ In the milder cases the swelling is less, is softer, and may be confined to a part of the limb. The limb may be kept in an extended attitude, or it may be slightly' flexed at the joints. Move- ment of it causes much suffering, and the power of voluntary motion is almost completely lost while the disease continues. After the disease has lasted nine days or there- abouts, it generally makes no further progress, but recedes, the pain and swelling diminishing, The rate of this recession varies very much, being probably more or less directly in propor- tion to the restored permeability of the vessels. In a favourable case several weeks may elapse before the disease disappears, whilst in others the cure may be further or even indefinitely delayed. Sequelje, Complications, and Prognosis. — The most frequent sequela of phlegmasia dolens is persistent aching of the limb, increased by cold and damp weather, and by derangement of the general health, as well as by exercise. Another is a tendency to cedema of the ankles, or a persistent cedema in that situation. Sometimes the limb remains deficient in muscular power. Rarely, the limb is not only powerless but wasted. And in some very uncommon cases it is the subject of a great hypertrophy of the cellular tissue, or elephantiasis, simultaneous with muscular wast- ing; and the elephantiasis may be complicated with more or less extensive and intractable ulceration. Such cases probably' result from per- manent destruction of large vascular passages ; and, falling into surgical hands, demand occa- sionally treatment by amputation. The disease is sometimes, not frequently, complicated by other affections, or by aggra- vations of some of its conditions. Among such occurrences are inflammation and suppuration of the intrinsic joints of the pelvis, erysipelas, limited abscesses (periphlebitis), diffuse suppu- ration of cellular tissue, gangrene of any part or of a varying amount of the entire lower portions of the affected limb. These complications or aggravations cause much danger to life, and in this respect their influence varies according to circumstances. But there are other complies 1162 PHLEGMASIA DOLENS. tions or aggravations which are more often fatal. They may be summed up in the terms embolism and pyaemia, and are the consequences of detach- ment of a thrombus in the femoral, or in still larger veins, or of a more slow breaking up of blood-clots into debris, more or less puriform, which enters the circulatory current. Diagnosis. — The diagnosis of phlegmasia dolens requires no discussion. The disease can scarcely be confounded with any other if its history is taken into consideration: only, it is necessary to remember that cedema with phlebitis or accompanying varicose veins may somewhat resemble it. Treatment. — The treatment of phlegmasia dolens should be both constitutional and local. The former has no special points, being varied according to the circumstances of the case, and the views of the practitioner. Generally some opiate is required to procure sleep, and Dover’s powder is a favourite form for its administra- tion. Local treatment is very important. The limb is to be kept at rest, either in an extended or flexed position, as may prove most comfort- able. It should be fomented several times daily, if not constantly. This may be effected by the flannel bandage wrung out of hot water, pre- cautions being taken for the protection of the patient and bed from damp. The fomentations are sometimes made anodyne by using decoctions of poppy-heads or otherwise. Sometimes infu- sion of chamomile flowers is valued as a foment- ing medium. Leechos are sometimes applied along the course of an inflamed vein, but their utility is, to say the least, often doubtful. After the acute stage of the disease is past the sequel® have to be dealt with. Of these the most frequent are aches, swelling, cedema, and muscular weakness; and for these the most efficient, but by no means invariably successful, remedies are frictions, bandaging, and faradisa- tion. After all active disease has disappeared, and after danger of the moving of thrombi has passed, the patient should diligently resume the use of the leg. No exact statement can be made of the time at which the danger of embolism is passed. It may prove suddenly fatal thirty- seven days after delivery. Persistent local hardness and tenderness, pro- bably periphlebitic, may be treated by gentle frictions with a mixture of mercurial and bella- donna ointments. In using frictions of all kinds the danger of dislodging a thrombus is not to be overlooked. J. Matthews Duncan. PHLEGMATIC TEMPERAMENT. See Temperament. PHLEGMON ( the individual the legacy of caseous matter ther in the lungs or glands, which prove the ■ntres of subsequent tuberculisation. 4. Syphilis. — Syphilis, by its debilitating in- uence, predisposes to phthisis ; but it also ap- ears to act as a cause capable of developing two ■rms of the disease, namely (1) limited con- ilidation with no great tendency to excavation ; lid (2) a form of laryngeal phthisis, characterised |r ulcers in the larynx and in the pharynx, fficult to heal except by specific treatment, jiis last has been called syphilitic disease of e larynx; but as in the writer’s experience is always associated with tubercle in the lungs, i thinks that the phthisis is caused by the philis, and should be classed accordingly. 5. Debilitating conditions. — Miscarriages, .favourable confinements, over-lactation, insuf- jent food, and alcoholism are recognised causes ; t the cessation of habitual discharges is not clearly admitted. The stoppage of the dis- urge of a fistula in ano, and the drying up of old ulcer, are frequently' followed by an out- eak of tuberculosis in the lungs. C. Mental depression. — This is often mixed with other causes, hut occasionally acts alone. 7. Bad ventilation. — Dr. Guy has shown it consumption is more rife among persons of door occupations than among those employed ' : of doors ; this being true not only of the ljier classes, as printers, compositors, and tailors, i. also of the tradesmen who live in hot gaslit tops, and often sleep in miserably ventilated llrooms. These are not ill- fed, but are never- tless twice as liable to consumption as the i|)er classes. Hawkers and other outdoor tdes, though much exposed to catarrh, are flwn to be less liable to consumption than i oor workers. Of nearly 6,000 cases of phthisis ajaitted into the Brompton Hospital during t years, two-thirds had indoor occupations. i' ongst them milliners, sempstresses, and tailors Ijiish the largest quota, who all live in close r,ns, to which they are almost entirely con- fid. . Climatic influences. — A moist atmo- S'ereismore favourable to the development of c| sumption than a dry one ; and, while we recog- that the combination of cold and moisture i-Ae of the principal causes of the inflammatory h is of the disease in Great Britain, the testi- mony of Dr. Guilbert indicates that a combi- nation of heat and moisture, as exemplified in the littoral of Peru, in the West Indies, &rc., produces an acute form of consumption, largely prevalent in those districts, attacking the abdo- minal organs in addition to the lungs. 9. Dampness of soil. — The researches of Dr. Buchanan have demonstrated that the death- rates from phthisis in the districts of Surrey, Kent, and Sussex, depend to a great extent on the geological formation of the soil ; for while in the light and sandy strata, deaths from phthisis are rare, in the heavy impermeable ones, in which clay predominates, the mortality from this cause is high. The conclusion that wetness of soil is a cause of phthisis to those living on it, has been confirmed by the Eegistrar-Gcneral of Scotland, and by Dr. Bowditch of the United States ; the latter testifying that this law holds good, not only as regards villages and towns, but eveu as regards individual houses — the houses on clay becoming the foci of consumption, while others but slightly removed from them, but on a dry soil, wholly escape. 10. Inoculation. — From the time of Laennec until the present, experiments have been carried on by numerous observers to ascertain whether tubercle is, or is not, inoculable ; and the results of these experiments prove that in guinea-pigs and rabbits tubercle can he produced artificially by the insertion underneath the skin, not only of tubercle, hut of various other materials, such as pus, putrid muscle, and diseased liver, taken from non-tubercular subjects. There was nothing specific in the results of the inoculations, for the materials most efficient in producing artificial tubercle were those taken from low pneumonia, pyaemic abscess, &c. ; while human tubercle, phthisical sputa, foul pus, and putrid muscle were less successful, bio results were obtained from the material of acute sthenic pneumonia, from pneumonic and bronchitic sputa, healthy abscess, diphtheritic membrane, syphilis, typhoid intestine, and cancer. It was found by Dr. Burdon Sanderson that tuberculosis might he induced in the guinea-pig by the insertion of a cotton thread under the skin, hut if the seton was steeped in carbolic acid, no tubercle was produced. To ascertain the results of mechanical injury with- out exposure to air, the scapulae of guinea- pigs were fractured subcutaneously. No tuber- culosis resulted. It is evident, from these experiments, that tubercle is not so potent for infective purposes as many other materials, and especially those of a septic nature, such as pyaemic pus and putrid muscle ; and this is still further borne out by the seton experiments, where the purification of the wound by carbolic acid appears to have prevented the infective process, as also by the cases in which the scapulae were fractured. These facts warrant the conclusion that tuber- culosis is closely associated with pyaemia, and among animals the difference between these two diseases would appear to be one merely of de- gree ; for Dr. Sanderson found that while the injection of pus into rabbits produced death from pyaemic abscesses in forty-eight hours in some, in others the slower results of tubercu- losis followed. This process generally consistod in the development of granulations at the seat PHTHISIS. 1163 of inoculation, from which tho neighbouring lymphatics became infected, and this led to a dissemination of the products through both the lymphatic and circulatory systems. Chauveau found that heifers might be infected by mixing tuberculous matter from their own species with their food. Bollinger confirmed this experiment, but found that carnivora could be fed with impunity on fresh tuberculous mat- ter taken from animals of the bovi.ne species. 11. Infection. — The idea of infoetion being a cause of phthisis still prevails in the South of Europe, and has lately been revived by Dr. Budd in England. The evidence of the Brompton Hos- pital negatives the idea of a contagion such as is present in small-pox or scarlet fever ; for it has been demonstrated that the percentage of ac- quired phthisis occurring among the resident staff of the institution is less than that of most general hospitals. An infective influence may arise from the expectoration of advanced cases of phthisis or of bronchitis, whicli should bo counteracted by antiseptics and good ventilation. That phthisis may be communicated from husband to wife is strongly maintained by Virchow and many Eng- lish physicians, and Dr. Hermann Weber has lately indicated by some striking cases the danger of pregnancy to the wife of a consumptive. Cohnheim, who appears to liavo confirmed by his own experiments the doctrine of specific in- fection, holds, in opposition to the above views, that the test of tubercle is its inoculability, and prefers this to any structural test. He con- siders that tubercular particles are conveyed by means of organisms to the lungs, thus affecting the pleura and bronchial glands, and later the larger bronchi. The infection of the intestinal canal arises from swallowing the sputum. Cohnheim believes strongly in infection through suckling, and states that he has noticed scrofulous inflammation of the mouth and pharynx arise in that way. Weigert maintains that meningitis has been caused by infection through the upper nasal passages. 12. Local causes. — The local causes of phthisis are those which injuriously affect the bronchi and air- passages, causing large epithelial proliferation and various inflammatory lesions, followed by thickening and induration of the alveolar walls, and in time caseation or fibrosis. Bronchitis , or bronchial catarrh, after existing for many years in a person, may extend more deeply into the alveoli and pass into a so-called catarrhal pneumonia, producing consolidation and eventually excavation of the lung. Bron- chitis was the origin in nearly 12 per cent, of the writer’s 1 ,000 cases ; and a very large num- ber of the poorer classes trace their disease to neglected catarrh. Pneumonia is a fruitful source of phthisis, though some forms are more capable of giving rise to it than others. In croupous pneumonia, where the exudation is fibrinous, and has but little epithelium or leucocytes intermingled with it, absorption generally follows, if the patient’s constitution be in a fair state, and few of these cases go into phthisis ; but where leucocytes and. epithelial products largely predominate, absorp- tion is slow, the pneumonia becomes chronic, and thickening of the alveolar wall and caseation of the epithelium take place, accompanied sooner or later by the signs and symptoms of consump- tion. A third form of pneumonia which may ori- ginate consumption is pleuropneumonia, or inter- stitial pneumonia, where the inflammation extends to the pleura, and the interlobular connective tissue is largely increased. Many instances, too. of phthisis have arisen in empyema, through ab- sorption of the purulent fluid, the channels being the elaborate network of lymphatics which the pulmonary pleura has been shown by Dr. Klein and others to contain. 13. Trades and occupations giving rise tc a dusty or gritty atmosphere. — The constant inhalation of particles of flint, iron, coal, haru clay, and even of cotton, flax, and straw, as is the case in certain trades, such as stonemasons, fork- and needle-grinders, colliers, potters, cotton- carders, chaff-cutters, and others, has beer shown by Dr. Greenhow to induce the disease The various irritating particles have been de- tected microscopically and chemically in the} lungs, where they appear to cause great irriti- tion, followed by thickening of the bronchi andi subsequent induration of the lung-tissue, wiriij increase of pigment. Intermingled in the con- solidations are found grey and yellow tubercle, and also extensive cavities, proving the identity of the disease with phthisis. 14. Injuries to the lungs. — Injuries to the! lungsthrough wounds are somewhat rare causes oi phthisis; and their action is chiefly by inducing the inflammatory processes, chronic suppuration and abscess, or induration with shrinking of the lung-tissue. Anatomical Charactehs.— The morbid ana- tomy of phthisis, acute and chronic, presents considerable difficulties, partly from the variety of pathological products, and partly from the complete disorganisation of the normal structure and even of the invading growths. It often hap- pens that several processes have been going on it; the lungs simultaneously, each of which brings about the work of destruction by a different method and at a different rate, some by obstruc- tion through consolidation, others by caseation and excavation. On the predominance of oneoi the other depends the future of the lungs, for we sometimes see one pathological element which has invaded a large portion of these organs superseded and gradually destroyed by another o; more recent date, but endowed with a higher de- gree of vitality. In advanced cases the lungs are for the mosf part devoid of vesicular tissue, and consolidatec by various kinds of growths and exudations They are also occupied by cavities, varying ir size from a microscopic point to ODe of so large a capacity that the lung is converted into r mere hag of thickened pleura. The cavities art of every conceivable form and shape, sometime; oval and well-defined, lined with a secreting membrane, at other times irregular, sinuous, an fractuous, and presenting on section either ai uneven surface, from which portions of the wal stand out like the column® carne® of the heart or a very rugged surface, on which ulceratioi and suppuration appear to have done thei worst ; but, whatever be their shape or thei size, they indicate the destructive character o PHTHISIS. :he retrograde processes by which the disease •ailed pulmonary consumption is characterised. The consolidations vary, but all partake more , r less of a tubercular character. In some cases {he lungs are disseminated with miliary tuber- les from apex to base, the intervening tissue ieing free from excavation, and either engorged r consolidated with red hepatization, or some- imes apparently healthy; in others no trace of piliary tubercle can be found, but the lungs are ansolidated throughout by caseous pneumonia, ijntaining cavities of various sizes. Sometimes nere are aggregations of the different forms of lbercles — white, grey, and yellow in the same ing— while the opposite lung may bo entirely ear ; sometimes a lung may be shrunk to the Jze of a fist, its pleura thickened, its lobules ivaded with white fibrous bands, its tissue inverted into an iron-grey structure by fibroid iowth. All these, and many other diverse mor- |d appearances, are found in the lungs of per- ;ins dying of phthisis, and we must classify and stinguish them, first describing their naked-eye ipearances; secondly, their histological phe- )mena; thirdly, we must consider the changes hich take place in other organs of the body ; id fourthly, wo must indicate the pathological lation these all bear to one another and to the sease generally. The pri nci pal pathological element s and changes a; — 1, grey and dark granulations, or miliary bercles ; 2, white granulations ; 3, yellow anulations, or yellow tubercle ; 4, caseous isses, or yellow infiltration ; 5, grey infiltra- ' n, or catarrhal pneumonia ; 6, red hepatisa- |n ; 7, fibrosis ; 8, cretaceous masses ; 9, fibri- ns nodules (blood-residues) ; and 10, vesicular f physema. 1. Grey granulations, or miliary tuber- c s. — These vary in size from a millet-seed ( nee the name miliary) to a hemp-seed, scat- tad throughout the lung-tissuo. When first f med they are greyish-white, more or less trans- p ent, and will yield to firm pressure ; but after a hilethey either undergo caseation, being con- vied into the yellow variety, or losing moisture, borne drierand harder, attaining the consistency oaartilage. At the same time pigment is ab- smed by them ; the colour passes from a light to a rk grey, and to black; the granulations simul- tf : ously drying up and becoming obsolescent. Tjse hard grey granulations are not uncom- mlly found after death in old persons, and are ai valence of tubercle having appeared at some ptpd of their lives, and of its having after- w ls become obsolescent. 'ore commonly these grey granulations in- erse in number, and form aggregations or clus- te much resembling bunches of berries, stand- in, ,iut in bold relief against the healthy or con- ge d lung-tissue ; their principal locality being th pper lobes of the lungs, and especially the poirior portions. In some instances this ag- p . tion spreads quickly and extensively, and lln rhole lungs become so densely packed with mi ry tubercle that it is difficult to find any foi m of the respiratory surface free. This r )h formation of tubercle is sometimes suffi- tle ; to cause death by asphyxia, but more com- 910 ' the intense crow'ding of the pathological 74 1169 products gives rise to their destruction. Casea- tion commences in the centre of the groups, und cavities subsequently form. The discrete form of grey tubercle is generally found in acute miliary- tuberculosis, and does not vary much in size with the different organs attacked by tubercle, ns the peritoneum, pleura, &c. This identity of form suggests very forcibly the hyperplasia of some normal structure present in all the several organs, rather than an adventitious growth. 2. White granulations. — These formations are more opaque, and softer than the grey', and differ from the latter, as we shall hereafter see, in the arrangement of the histological elements, there being more epithelium and less reticular growth in them than in the grey variety. 3. Yellow granulations. — Yellow granula- tions or yellow tubercles exist in greatly varying sizes, from a pin’s head to a pea. They are opaque, soft, granular, amorphous, easily sepa- rated from the adjoining tissue, and sometimes surrounded by a circle of pearly, transparent material. Dr. Wilson Fox describes a form of yellow tubercle among children dying of acute tuberculosis, which is with difficulty separated from the parenchyma of the lungs ; but in adults it is generally easily removed, the grey granula- tions with which it is so often associated remain- ing behind. Yellow granulation is by far the commonest form of tubercle, and its frequent occurrence in phthisis led Laennec not unnaturally to the con- clusion that it was a sui generis production, es- sential to the disease. It seldom occurs alone, but is ordinarily associated with the grey and white granulations, sometimes forming with them racemose groups in various parts of the lung, chiefly in the upper lobes. At other times it is the centre of an affected portion, groups of grey- granulations apparently radiating from it, thus naturally leading to the supposition that a species of local infection has been set up by the yellow or caseous mass. These groups, as theyinerease, exercise great pressure on the various granula- tions composing them and on the intervening lung-tissue, depriving them of nutrition, and ihus causing death of the part by caseation. The decayed portion is gradually removed either by absorption by the lymphatics, or by expectoration ; in the latter case cavities result. Careful study of one of these tubercular groups will demonstrate that the yellow tubercle is but a later condition of the grey, in which caseation has commenced; and that the cavities, large or small, in its neigh- bourhood are the result of the softening and re- moval of the yellow tubercle, and whatever lung- tissue happens to be intermingled with it. 4. Caseous masses. — Caseous masses and yellow infiltration are identical in constitution with the yellow tubercle, but differ in size and form, arising sometimes from the aggregation of a number of yellow granulations, but oftener from the rapid caseation of inflammatory exudations ; and in this case whole lobes become affected with what is then called yellow infiltration. 5. Grey infiltration : catarrhal pneumo- nia. — This change is identical with the ‘gela- tinous infiltration’ of Laennec. The pressure on the walls of the alveoli caused by the epi- thelial aggregations, as well as the inflammatory PHTHISIS. 1170 exudation, gives rise to obliteration of the vessels and consequent caseation, and in this way large tracts of grey pneumonia are converted into yellow masses and subsequently become exca- vations. 6. Red hepatization. — The result of ordinary croupous pneumonia is often found associated with one of tho above forms of tubercle, but more commonly occurring in the lower lobes, than in the upper. See Lungs, Inflammation of. 7. Fibrosis. — Fibrosis is largely present in phthisis, but preponderates in (1) cases originat- ing in pleuro-pneumonia, pleurisy or pneumonia ; and (2) in cases of long duration. Fibrosis is the great element of the contractile process, whereby the lungs are reduced considerably in size, cavi- ties of large capacity are cicatrized, and caseous masses encapsulated; and sometimes grey tuber- cle is converted into this tissue. A lung invaded by fibrosis is reduced in size, and presents on section a dense, tough, and very hard structure, resembling cartilage in its resist- ance to the knife. All traces of the alveoli have disappeared, and nothing remains but a dark grey or black fibrous material, into which run long bands of whitish fibrous tissue, harder than the darker portions. The pleura is generally thickened, and the septa apparently arise from it and from the connective tissue at the root of the lung, which is also largely increased. Fibro- sis is found in limited portions of the lung, in nearly all kinds of phthisis, forming the scars of contracted cavities, or tendingto isolate caseous masses and tubercular aggregations. When mi- liary tubercle becomes converted into fibroid growth, the resulting tissue is of short duration, owing to its deficiency of blood and lymph- vessels ; caseation consequently takes plaoe at various points, and it thus perishes. 8. Chalky masses. — Cretaceous or chalky material is found in chronic cases, lying iu small masses in various parts of the lungs, chiefly at the apices, in the neighbourhood of old cavities or caseous tracts, and generally encapsulated by fibroid tissue. 9. Fibrinous nodules. — These bodies have been neticed by Dr. Reginald Thompson in cases where large haemoptysis has occurred. These vary greatly in size, and consist of inhaled blood : they -are situated at portions of the lung where inspiratory action is strongest. When first found, they appear as white nodules with a zone of red colouring matter; and even in the old specimens some traces of blood in the form of crystals of hae- matine are to he found. Microscopically they are shown to consist of fibrin and red corpuscles, fill- ing the alveoli and even penetrating the alveolar wall. The masses eventually either (1) separate from the surrounding tissue through contraction of the fibrin, leaving a capsule adherent; or (2). owing to admixture with bronchial secretion or some such septic matter, they soften into a mortar-like material, and are got rid of by ex- pectoration ; or (3) if the nodule be sufficiently large, and there he no exit for its contents, the re- sult is the formation in time of a species of cavity filled with glairy yellow fluid, resembling honey. 10. Vesicular emphysema. — Two kinds are noted in the lungs of phthisical patients. Acute vesicula r emphysema is found distributed through- out the lungs of those dying of acute tuber- culosis ; and chronic local emphysema oecure in connection with chronic tubercular masses, and specially in the neighbourhood of cicatrized cavities. The vesicles are few in number, and often as large as a hazel nut, and are generallj to be found at the apex, or along the anterioi border of the lung. Microscopical Characters. — In cases cl tuberculosis and phthisis, the following histo- logical features (as classified by Dr. Green) arc present in the lungs. The amount of important to be attached to each element has not yet beer determined. 1. Exudation. — Exudation of fibrin and leu oocytes into the alveoli, resembling that of crou pous pneumonia, the fibrillation not bein'gquit so distinct, nor the coagulum so abundant. L a large number of cases of phthisis, the lung consolidation consists of exudatory product mingled with epithelial proliferation ; and h some of the most acute instances, these two pro cesses have constituted the only lesion. 2. Epithelial accumulations. — An accumulate of large epithelial cells may be found within th alveoli. These are generally large, spheroids cells, about four or fire times the size of leucocyte, containing granular matter, and nucleus and nucleolus. Some smaller ones at also observed, indistinguishable from leucc cytes. Within the alveoli also are found th so-called ‘giant cells,’ which are held by Hetic to be lymphatics cut across ; by Friedlander t be the basis of tubercle; by Klein and Gree to be derived from the alveolar epithelium, b| fission or excessive development. These appec at first as spheroidal masses of faintly granule protoplasm, reaching jjgth inch in diameter, wit numerous nuclei — sometimes as many as thirt; and bright nucleoli. After a while they inerea: in size, and send out branched processes, fro which are developed other smaller protoplasm masses, so that a branched reticulum is forme round the original giant-cell, connecting it wit other giant-cells. These branches are often d rectly continuous with the lymphoid or adeno network of the alveolar wall, to he present alluded to, which forms a circle round the giaD cell system. Giant-cells are not found in tl earlier stage of tubercle-development, and a pear after some of the products of exudatis have been absorbed. They are devoid of at vascular supply, and are consequently subje to caseation, having in such cases previous undergone a peculiar transformation into fibrillar material. Giant-cells are regarded Green as a product of low vitality, incapable forming organised tissue; where the protoplas grows, the nuclei multiply, but the highs manifestation of cell-life— division of the cell does not take place. 3. Interalveolar growth. — This is a thickeni of the alveolar wall by a small-celled lymphs tissue, consisting of minute cells not larger th a leucocyte, separated from each other by a vs delicate reticulum. This growth appears to eo mence in the walls of the alveoli and termh bronchi, first in the form of a few lvmphc cells, the network appearing later, and has U demonstrated by Sanderson to be a hyperplasia PHTHISIS. 117) the adenoid tissue already existing in the lungs; for it must be borne in mind that lymphatics and lymphoid tissue are largely present in these organs, and that the alveolar wall is considered ODe of the densest lymphatic plexuses of the whole body. The small-celled tissue spreads rapidly through the alveoli, invading the walls of the capillaries, the peribronchial and perivascular sheaths, di- minishing by pressure the calibre of the vessels, ind in time obliterating them, and thus giving rise to necrobiosis by caseation and ulceration of he surrounding tissues. The growth fills up he alveoli, and thus infiltrates whole tracts of lie lung, which in time become cut off from joth air and blood supply. This either degene- rates by caseation, giving rise to the formation f cavities ; or the cells become more spindle- 'uaped and branched ; the reticulum more fibri- ated ; and then gradual fibrosis of the nuclear issue takes place. Owing, however, to the dis- ppearance and obliteration of the vessels, this ssue is not properly supplied with nourish- ient, and soon undergoes caseation. 4. Interlobular growth . — Increase in the in- irlobular connective tissue resembles the pro- ;ss prevailing in the liver, kidneys, and other -gans during chronic disease, and is not necessa- ly associated with consumption. This feature is ost marked in cases of inflammatory origin, or ■here the disease is of very long standing ; and the suit is best seen in the large fibrous septa often "companying the bronchi and great blood-ves- 1s, as is specially exemplified in fibroid phthisis, ieroscopically it is difficult to distinguish be- een the interlobular tissue and the alveolar enoid growth in their early stages, both being ■hly cellular ; the main differences being the nation of the former around the lobules, I in the neighbourhood of the great air and )od-vessels, whereas the latter is found in the r-eolar wall and smaller bronchioles. The '.erlobular tissue is not so liable to retro- |.de changes, owing to the vascular supply t ng less liable to obstruction and obliteration; |i, again, the alveolar growth has a more deli- ( e reticulum of fibres. Changes in the bronchi, pleuree, and bnehial glands. — Th ^bronchi show, in many (lies, catarrh of the mucous membrane, giving );! to a richly cellular secretion, which forms t; greater proportion of the expectoration of ifhisis, as tiie principal lesion, and extending ) acute cases throughout the whole bronchial tj; ; but in more chronic forms being limited ti he bronchi leading to the affected lobules. A Bind and more important change is the infil- t. ion, noted by Kindfleisch, of the sub-epithelial claective tissue by large cells characteristic o crofulous inflammation, and very difficult of a 1 irption. The mucous membrane appears s'jlen and opaque ; the epithelium may be sll; and if the sub-epithelial infiltration dis- itjrate, small ulcers are formed. A third cl ige is the infiltration of the peribronchial ti le, and the proliferation of lymph-follicles in tl walls of the smaller bronchi, owing to trans- u. j ion of infective substances from the bronchi ti ugh the lymphatics. The bronchi from these c! iges become reduced in calibre, and conse- quently the adjoining ones, as noticed by Gran- cher, are often dilated through the action of increased air-pressure on their walls. In laryngeal phthisis ulceration is to be found in the bronchi, as in the larynx, the changes in which will be presently stated under the head of Laryngeal phthisis. The pleura is often adherent over the region of tuberculisation, when the formation has taken place slowly, and is comparatively superficial. It is often considerably thickened, as in fibroid phthisis, to the extent of three quarters or one inch diameter, the layers being sometimes sepa- rated, as Dr. Douglas Powell has shown, by a gelatinous material, consisting chiefly of con- nective tissue. The pleura, peritoneum, arachnoid, and even the pericardium, may be the seats of miliary tubercle in the most acute form of phthisis, namely, miliary tuberculosis ; but it is generally noted that the lungs are the first organs at- tacked, and it is extremely rare for tubercle to exist in any organ without being also present in the lungs. The bronchial, cervical, mesenteric, and other glands undergo various changes. In many, and especially in advanced cases,* the bronchial glands enlarge and become deeply pigmented ; in others they seem to partake of the changes proceeding in the lungs ; they become affected with grey tubercle, and caseate, and occasionally cretify, the cretaceous material being, as a rule, in the centre of the gland, though the reverse is occasionally the case, and the calcareous mat- ter forms a shell over the whole gland (see Bronchial Glands, Diseases of). The other lymphatic glands, especially the mesenteric, are liable to similar changes. Other organs.— The stomach and intestines in protracted cases become greatly attenuated, all the coats being thinned and wasted, and in many cases are found to have undergone lardaceous de- generation, which is a common cause of diarrhoea in phthisis. Where the diarrhoea has been very persistent, it is common to find extensive ulce- ration of the jejunum, ileum, csecum, and large intestine, extending even to the sigmoid flexure and rectum, the caecum being earliest attacked, and generally in a more advanced stage than the small intestine. The ulcers vary much in form and extent; in some instances they are circular, clearly cut depressions ; in others, and this is the commoner form, they present large, raised, irregular edges, with faeces adherent to their ragged surfaces, and can be often seen through the attenuated external wall of the intestine. The peritoneal coat, as a rule, is thickened in their neighbourhood, and thus perforation of the intestine prevented. The earlier stages of this process appear to be : — miliary tubercles form in the submucous coat, not only in the solitary glands and Peyer’s patches, but scat- tered throughout the submucous layer, appear- ing as shining granules through the epithelium ; yellow points of caseation become visible in some parts, and small abscesses form in others, the latter appearing to have their seat in the solitary and agminate glands ; and, later on, these discharge, leaving ulcers of different forms. Ulceration of the large intestine pene PHTHISIS. 1 172 trates very deeply, and often resembles that of old dysentery. Perforation rarely occurs, on account of the thickening of the peritoneal coat taking place outside the ulcers, but occasionally it does occur, causing fatal peritonitis. The liver is rarely normal, but generally un- dergoes either fatty or lardaceous degeneration. The spleen is softened, and very commonly larda- ceous. The kidneys are not generally affected, but where albuminuria has prevailed towards the close of the disease, fatty or lardaceous changes occur. The heart is usually small, and the mus- cular tissue pale, and very often in a state of fatty degeneration (Quain). Fatty growths may be found on the surface. Pathology. — The nature of tubercle has long been a subject of discussion. In the sixteenth century two forms of tubercle (scirrhous and caseose) were recognised, showing that even at this period a distinction had been drawn be- tween grey and yellow tubercle. Later on, the similarity of the changes occurring in the tuber- cular masses to the softening of scrofulous glands, led Portal to conclude that tubercles were en- gorged lymphatic glands situated at various parts of the lungs, the engorgement terminating in suppuration. Laennec applied the term tu- bercle to miliary and yellow granulations, as well as to grey and yellow infiltration, hut con- sidered that it was a sui generis production, unconnected with inflammation. Brottssais, An- dra.1, and Cruveilhier assigned an inflammatory origin to tubercle, the latter considering that tubercle is the result of chronic inflammation of the lymphatics of the lungs. At length Virchow restricted the term 1 tubercle ’ to the grey granu- lation, which, according to him, originates in the connective tissue, and is of a cellular nature. Kokitansky, Dr. C. J. B. Williams, and others considered that tubercle is principally an exuda- tion from the blood-vessels, the different varieties depending on the kind of exudation, and on the part played by the leucocytes. Dr. Williams does not exclude the additional action of the local tissues, the connective tissue, the epithe- lium, and the adenoid tissue of the lung ; but he assigns the principal part to the exuded materials from the blood-vessels, especially to the leuco- cytes, regarding the lymphatic cells in the small-celled tissue ns identical with leucocytes in their nature and action, and that 'when in- creased in their number in denser masses, they constitute grey tubercle. This may pass into the state of yellow tubercle by the process of caseation, whicli consists of fatty degeneration and disintegration of these masses, entirely de- stroying their remaining vitality. Drs. Sander- son and Wilson Fox have demonstrated the grey tubercle to consist of the small-celled adenoid tissue with such epithelial accumulations as may be imprisoned in the course of its growth ; and the latter holds that this small-celled tissue is to be found in all forms of tubercle and in con- sumptive infiltrations. Dr. T. H. Green main- tains the existence of all four classes of histo- logical elements as enumerated above, in the lesions of phthisis, and that the small-celled tissue is not typical of phthisis, as it may ap- pear in chronic inflammations of various organs, as of the kidney and liver. In some of the most rapid instances of acute phthisis (not acute tuberculosis) he can detect nothing but the products of exudation so closely packed as to cause their own breaking down. At the same time he admits the large part played by the adenoid growth in grey granulations. Charcot, after careful histological study, strongly advo- cates the unity of phthisis, and affirms that in caseous pneumonia he finds, as in grey granula- tion, two zones — first, a central region, consisting of little else than exudation-products and caseous debris, in which reagents can bring to view fibres of lung-tissue ; and, secondly, a peripheral re- gion (‘ zone embryonnaire’) made up of adenoid growths and giant-cells. He considers that the last two elements are the basis of tubercle, which is always a peribronchial product, and that caseation does not take place without their being present. Charcot points out that croupous pneu- monia occurs in tubercular lungs, and clears up, leaving no residue behind ; and argues that pneu- monia alone cannot produce the caseous masses. Though great difference of opinion thus ap- pears to exist as to the relative parts played bv exudation and adenoid growth in the pathology of phthisis, it will not be difficult to deduce some general conclusions which may elucidate manv of the difficulties. The part played by inflammation in phthisical lungs, in spite of Charcot’s doctrine, is very large, and we may conclude that grey and yellow infiltration are varieties of the pneumonic pro- cess, probably of a low type, with, as Dr. Fox remarks, ‘that invasion of the alveoli by the small-celled tissue which leads to the obliteration of the capillaries and slow necrobiosis of tho part involved.’ Of the inflammatory products found in phthisis, the fibrinous or easily absorbed element is scarce, and the corpuscular, or cellular, which is not easily absorbed, is common ; and this last ele- ment, in order to be absorbed, has generally to pass through the process of caseation. The absorption of caseous matter by the lymphatics is attended by a considerable amonit of irritation, and thus we get adenoid hyper- plasia or tuberculosis. This may be local, as when we see a group of miliary nodules sur- rounding a caseous centre, the rest of the lung being apparently free ; or general, infecting the lymphatics of the lungs, and it may be of other organs, as is seen in acute tuberculosis. The future of grey tubercle depends to a great extent on its rate of production, and its relation to blood-vessels. When not clustered closely to- gether, and when unaccompanied by inflam- mation, it may gradually dry up, aud even ir time be converted into fibrous tissue; but it, as is usually the case, increaso of the adenoid growth leads to obliteration of the capillaries we have caseation and excavation, with fresl local infections. The two principal factors in the pathology o phthisis then are irritation and infection : — Irritation . — Under this term may be include* the various inflammatory processes and othe local agents, which affect the alveolar wall is proportion to the intensity of their action. Infection . — Infection is either local, throng inflammatory processes, as the result of lmtatior PHTHISIS. >r from general state of system, as in eases from family predisposition, where the lymphatics are oriraarily affected. It, therefore, appears most probable thr.t the various pulmonary processes — the exudation of cucocytes, the formation of giant cells, the ade- tboid hyperplasia, are alL indications of some General blood-erasis, manifesting itself chiefly in :he lungs, on account of the large circulatory irea involved, but not necessarily confined to heir limits. We may suppose that under these feireumstances the blood has a tendency to form md exude cells, which grow and do not develop ,-nto tissue, but die and caseate, and in this state irritate the lymphatic system, and the pulmo- nary lymphatics in particular, We must hear n mind that the increase of the adenoid tissue akes place after the exudation, the epithelial iiroliferation, and formation of giant-cells. What he irritating quality of the blood is, whether hemical or histological, and why cellular exu- ltations should be less easily absorbed than fibri- loue, are problems still to be solved. Symptoms. — (a) First stage. — The symptoms if pulmonary phthisis in the first stage may be hus summarised : — Cough, becoming more per- sistent ; mucous expectoration ; loss of colour and trength ; emaciation; night-sweats ; sometimes nss of hair ; pulse somewhat quickened, though iis is not invariable ; and a temperature rising jbove the normal in the afternoon, and sinking elow it in the morning. M. Peter has noted in lany cases a rise in temperature on the affected de during this stage ; and with regard to the eneral temperature of the body, though slight yrexia is often present, tubercle-formation is uite possible without any rise of temperature, or iay even be marked by a depression, as Surgeon- lajorAlcock and others have shown. Pain in the pper parts of the chest is occasionally present ; id the number of respirations are generally in- ■eased, though this depends on the amount of ilierculisation proceeding. Some hold that dys- jcea is an early symptom and precedes all others, itthe writer has found quite the opposite — that itients do not notice their breath to be short itil their lungs are seriously involved. Disturb- ce of the digestive powers, and considerable stability of the intestinal mucous membrane, th a red streak on the gums, is noticeable in me, though chiefly in the acute forms. The fgue becomes white, the bowels torpid, and the ine scanty. The most constant of the above ‘mptoms are the persistent cough, with mucous pectoration, and the progressive emaciation ; d in many eases so obscure are the beginnings the disease, that these are the only symptoms icoverable. Physical signs. — The physical signs, after the 1st stage, depend to a great extent (1) on the mber and aggregation of the miliary tubercles ; I on the amount of consolidation they give rise > and (3) on the irritation which their forma- n causes in the lung. As a rule tubercle-formation commences at I 3 apex of one lung, and is detected by the i mice of certain physical signs in the supra- pular, supra-clavicular, or sub-clavicular re- us, the signs extending downwards at a later :e. The signs vary much in particular cases, 1173 but consist at the first in an impairment of the ordinary respiratory murmur by a species of crepitation, differing from the pneumonic crepi- tation chiefly in its more scattered character, in its being audible with both inspiration and ex- piration, and in its crumpling nature. Many authors, however, maintain that an earlier sign is the ‘ wavy ’ breathing (T. Thompson), or ‘ respi- ration saccade ’ of the French. Accompanying this is increased vocal resonance and broncho- phony, with more distinct conduction of the cardiac sounds ; and percussion discovers dul- ness of varying shades in one of the above- mentioned regions. When a certain definite amount of consolidation has taken place some impairment of the mobility of one side of the chest may be noticed: this is to be detected under the clavicle, where, if any adhesion of the pleura exists, there may be some flattening. Another significant sign is the dry friction- sound, audible generally in the supra-scapular and scapular regions, and indicating limited pleuritis from a nodule of tubercle formed im- mediately below the membrane. The sub-clavian murmur, much dwelt on by old authors, is too uncertain to be depended on. The dulncss usually appears first above the scapula, next over the sternal end of the clavicle, and gradually extends downwards, being limited generally for a considerable period by the third rib. A careful comparison must he made between the two sides of the chest, and often between different portions of tho same side, as otherwise the slighter shades of dulness, and the minor dif- ferences in the respiration-sounds, which charac- terise the presence of tubercle in the lung, will escape notice. When the crepitation and the wheezing — which may be considered as indicative of irritation in the pulmonary tissue, caused by tuberculosis — have subsided, prolonged expiration, and certain varieties of tubular sound, show condensation of the lung-tissue around the neighbouring bronchi; and a certain amount of dulness is to be de- tected. (b) Second and Third stages . — The symptoms which accompany the second stage, or that of soft- ening of tubercular masses and their subsequent excavation, are by no means uniform. Many authors associate this stage with marked signs of pyrexia, with copious night-sweats, and in- crease of cough and emaciation ; but this is not always tho case, for, according to the writer's experience, the process may go on with even sub- normal temperatures, and with gain of weight ; but as fresh formation of tubercle often accom- panies the softening process, some of the above symptoms, which have been assigned to soften- ing, may be due to the tuberculisation and pneumonia accompanying it. The symptoms which should be most depended upon for the de- tection of softening are — increase of cough, an 1 expectoration of a yellow colour, occasionally streaked with blood. If the expectoration be care- fully collected and boiled -with an equal volume of caustie soda, of the strength of 20 grains to the ounce, and the sediment then placed under a moderate magnifying power of the microscope, delicate filaments of yellow elastic tissue, of hook-like shape, or else exhibiting the cha^a© PHTHISIS. 1174 ters of the alveoli, may be detected. The sputum chiefly consists of pus, with 2 to 4 per cent, of albumen, and a large proportion of phosphates. Pouehet found monads and bacteria ; and Koch has recently described the peculiar bacilli, be- lieved by him to constitute the virus of tubercle. Dr. Ehrlich has given an elaborate process for showing these bacilli in the sputum. ( Deut . Med. Wochensch. May 6 ; and Med. Times and Gosz,, May 27, 1882.) See Bacilli, in Appendix. Physical signs. — The signs which these changes give rise to are often obscure. The percussion- sounds vary ; sometimes there is an increase of dulness, possibly due to pneumonia of adjacent lobules ; at other times, hyper-resonance, as if air had taken the place of the expectorated masses. In all these cases much depends upon the situation of the lesion. The formation of a cavity deep in the lung, and far from the chest-walls, may take place without being detected, except by the expectoration ; wdiereas the formation of a similar one on the surface gives rise to unequivocal signs. Auscultation reveals — where formerly bronchophony and fine crepitus existed — crepitation of a very coarse character, commencing with a click sound, and after a w’hile developing into a croak. When this last note has been reached, loud tubular sounds become audible on coughing, and we soon get the sounds characteristic of a cavity. The great distinguishing features of these moist sounds of softening are their variety, their short duration, and their concentration over one small portion of the lung. In phthisis, crepitation much more commonly signifies tubercle-formation or pneumonia than it does softening of already formed tubercular masses. The formation of a cavity is generally followed by regular morning expectoration, usually opaque, and nummular in form, and in the majority of cases, unless interfered with by treatment, by the usual con- sumptive train of symptoms, if these have not already appeared. These are — night-sweats, slightly elevated temperature at night, and rapid loss of flesh, strength, and colour. The drawn look of the face, the hectic spot on the cheek, the pearly white colour of the sclerotic, the club- bing of the fingers, and other signs which mark the confirmed consumptive, generally belong to this stage, and all more or less denote blood- infection from the lung-products, sometimes even simulating pyaemia. The weakness of voice, so common in chronic phthisis, is distinct from the total aphonia of laryngeal phthisis, and has been shown to be due to granular degeneration of the muscles of the larynx. Marcet has shown that in phthisis the muscles generally undergo degene- ration. The history of a cavity follows one of four courses. See also Cavity ; and Vomica. 1. It may remain patent, secreting pus, like a chronic abscess, but not increasing in size. 2. It may enlarge by caseation and ulceration going on in its walls, by which process blood- vessels may become exposed. In this case the expectoration becomes more nummular and Abundant, containing quantities of lung-tissue and remains of bronchi ; and excavation may in time convert the lung into a mere pleural bag, devoid of lung-tissue, with what remains of the bronchi opening into it. The physical signs attending this increase in size are amphoric breathing, and often hvper-resonance on percus- sion, or cracked-pot sound ; and the voice and, cough may be accompanied by metallic tinkling, especially if the communication with the bronchi is narrow. 3. It may open into the pleura, and cause pneumothorax or pyopneumothorax. That this does not occur oftener is owing to the adhesive pleurisy which so often accompanies the early consolidations of phthisis, especially if the tu- bercle be superficial. See Pleura, Diseases of. 4. It may contract, and the sides approach- ing each other form at length a firm, tough cicatrix, causing a stretching of the surround- ing tissue, and often considerable displacement of the neighbouring organs. This is the natu- ral cure of the third stage of phthisis, and is, evidenced in most cases by a flattening of the chest-wall, chiefly in the infra-clavicular space, a disappearance of the cavernous sounds, and a substitution of deficient or harsh breathing, and! sometimes of healthy sounds over the seat on the cavity. Percussion often discovers that that sound lung is drawn across the median line to the affected side ; and if the cavity be in the leit lung, the heart and stomach may be displaced, upwards, the former organ being generally tilted, towards the axilla, the apex describing the arc of a circle, of which the centre is the commence- ment of the aorta. If the cavity be in the' right lung, we may expect the liver to be drawn up, and the heart displaced to the right of the median lino, reaching occasionally beyond the right nipple. Contraction of a cavity always takes place towards a fixed point, which is sometimes an adhesion of the pleura, but more generally the root of the affected lung ; and in this way the remarkable vagrancy of the physical signs is explained ; for it is not unusual to find the cavernous sounds audible above the scapula, long after they have ceased to be heard in the sub-clavicular region, and again in the inter- scapular regions after they have ceased to he: audible in the supra-scapular fossa. Of these destinies of a lung-excavation, the two first are undoubtedly the commonest IV here the cavity remains quiescent, and no fresh tubercle-formation takes place, the patienpmav live on for years, with only the inconvenience of regular expectoration and occasional dyspnoea, and preserve the appearance of actual health. Where a cavity continues to increase by further ulcerative processes, tuberculosis soon attacks the opposite lung ; and this organ passing rapidly from consolidation into excavation, the cough and expectoration increase, hectic fever becomes more frequent, the patient reaches an extreme state of emaciation, the adipose tissue disappear.- from all parts of the body, the temporal and malar bones become prominent, the jaws art sharply defined, the scapulae, ribs, and sacra al stand out, as if, as is really the case, they were only covered by skin, and the patient becomes to all appearances a mere skeleton. By an all wise arrangement a kind of balance seems to be maintained between the diminished requirement! of the body and the mass of the blood, for this itter is reduced in bulk in proportion to the tssened respiratory surface, and the individual bus gradually dwindles and. sinks. In the last stage of phthisis various symptoms ppear indicative of the disorganisation the blood as undergone, and the manifest lowering of the ;andard of lifo. Thromboses may arise in the eins of the extremities; cedema of the ankles ■nd feet ensues ; bed-sores form on those parts ■here the pressure is greatest, as, for instance, n the hips, buttocks, and sacrum ; and aphthae ppear on the tongue and fauces, and when ■amoved are succeeded by a fresh crop, rapidly ipreading round the hard palate, buccal surface, nd gums. Ulceration of some part of the lucous membrane of the mouth and pharynx is jot uncommon, the part affected being gene- ally the edge of the tongue, or the buccal sur- ice in the region of the back molars. Ulcera- on of the soft palate rarely occurs except in onnection with syphilis. Near the end profuse weats follow the swallowing of all fluids. The jreathing becomes quicker, and expectoration lore and more difficult. Diarrhoea prevails at Jiis stage, and often proves fatal before the ulmonary lesions have reached their furthest levelopment. Death may occur in several ways, either — 1) by apncea, from inability to expectorate; 2) by thrombosis of the pulmonary artery, in- uring lividity and dyspnoea ; (3) by pneumo- iorax; or, (4) by exhaustion, the heart’s action radually failing, the patient being utterly pro- rated, either by the wasting course of the iisease, or by the attendant diarrhoea. Hsemo- tysis may cause death, either by collapse from >ss of blood, or by suffocation through the blood ipidly filling the air-cells. Some of the principal symptoms of phthisis jqutre a fuller description. Temperature, pulse, and respiration. — - ho teuiperature of phthisis is both pyrexial nd subnormal, its varieties depending partly a the amount of tuberculisation and inflam- matory process going on. and partly on the ex- :nt to which the constitutional powers are de- ressed. The high temperatures are duo to the inner, the low ones to the latter cause. The singe extends from 106° F. or 107° F., noted in cute phthisis, down to 90-5° F., observed by Le- Jsrt. The writer has seen morning records as low ji 91'6°F. In many cases of quiescent phthisis i the first and third, stage, the observations are pr the greater part of the day subnormal, and lly reach the healthy standard in the after- bon. It is even possible for tubercle to form, id for softening and excavation to take place, ithout any rise of temperature. Where, however, tubercle-formation is accom- mied by elevation of temperature it is post- eridian, and by no means continuous in cha- rter, the phenomena being as follows : — The ,se commences after 2 p.m. and continues till p.m., when the maximum, which may attain •3° or 104° F., is reached. A fall then begins, d continues till 4 or 5 a.m., when the minimum, rich may be as low as 94° F., but is generally out 95° F. or 96° F., is attained. After this gradual recovery takes place, and by 10 11 a.m. normal temperatures are reached. ISIS. 117b During the process of softening the post- meridian rise appears to he maintained later in the day, the maximum being reached at 10 or 11 p.m. In active cases in the third stage, where excavation is proceeding or extending, and where also fresh tuberculosis may be taking place, the thermic chart approaches more closely to that of suppuration and pyaemia, and shows great extremes, the highest and lowest tempera- tures of phthisis being noted at this stage. The rise commences soon after noon, and con- tinues till 5 p.m., or even till 10 p.m., when the maximum of 103° to 104° F. is reached, and a fall rapidly follows, 95° F. and 94° F. being very commonly reached before 6 a.m. Then re- covery sets in, and normal records are observed about 10 a.m. The chief characteristics of the temperature in phthisis are — (1) the post-meri- dian form of its pyrexia ; and (2) the remarkable fall at night to subnormal figures, showing cci- lapse of the vital powers. Tho occurrence of liaunoptysis does not gene- rally affect the temperature, unless a large amount of blood has been inhaled into the air- cells. Under these circumstances catarrhal pneu- monia is set up, and the temperature remains elevated until its subsidence ; or, if it does not subside, but gives rise to secondary tubercle, the chart will assume the pyrexial character of acute tuberculosis. Night-sweats, as a rule, lower the temperature for the time, but they are not to bo regarded as a consequence of the pyrexia, as they are -noted sometimes in nou- pyrexial cases, but rather as a flux from the skin, due to loss of power in its vaso-motor sys- tem. The influence of diarrhoea on the tempera- ture depends entirely on its form and causation. Where it depends on acidity of the prim* vi* and dyspepsia, it exercises no influence ; where it arises from lardaceous degeneration of the intestines, and is accompanied by dropsy, a lowering of the standard may he looked for. AVhere, as is generally the ease, it is due to in- testinal ulceration, a decided rise of temperature takes place, generally in the evening, succeeded by equally well-marked morning remissions, if the ulceration is extensive. Albuminuria, from whatever cause arising, tends, to lower the tem- perature, and the more so as the kidneys become more deeply involved, the blood is more dis organised, and dropsy supervenes. The pulse varies greatly, according to the form of the disease, and tho amount of lung- surface involved. In the greater number of cases of chronic phthisis its character is weak, regu- lar, and little above the normal standard. In cases of acute disease, it has a frequency of 100 to 140, but its rise, as a rule, follows, sometimes after a long interval, that of the temperature. Considerable changes may take place in the lungs without any rise of pulse. j Respiration varies according to the amount of lung-surface involved, being normal in early quiescent stages, and rapid in cases of extensive advanced disease. Nevertheless in acute phthisis and acute tuberculosis, the respirations are gene- rally rapid, even before the lungs are largely obstructed, and in these cases there is a definite pulse-respiration ratio. In phthisis generally this cannot be said to exist but the observation PHTHISIS. 1176 of the number of respirations i3 of far more importance than that of the pulse. Diarrhoea. — Diarrhoea has a great influence on the course of the disease, and tends more to weaken and emaciate the patient than the harass- ing cough, the persistent pyrexia, or the drenching night-sweats. In the first stage an opposite condition, namely, constipation, prevails, but in the third stage it is tolerably common and very obstinate in character. The diarrhoea varies in intensity, according to its cause. Sometimes it proceeds from (1) acidity of the primae viae and consequent indigestion, and is trivial in character. Sometimes it is due to (2) atony of the intestines, and partakes of the character of a flux, like night- sweats; (3) in other cases it is due to lardaceous degeneration of the intestines, especially of the small intestine. The diarrhoea is not always very profuse in these last cases, but it is very persistent, and not uncommonly accompanied by vomiting of a very obstinate kind. Lastly (I) it may originate in ulceration of the intestines, as has been described. Here the diarrhoea is very persistent, the stools ochrey and soft, and some- times streaked with blood; the patient often com- plains of pain in the abdomen, referred to the seat of ulceration, and experiences tenderness on pres- sure. This is usually found over the ileo-caecal valve, but in cases of extensive ulceration the writer has traced it throughout the whole of the ileum, into file colon (ascending, transverse, and descending), and the sigmoid flexure. Flatus and a tympanitic condition of the abdomen is often present in extreme cases, but generally after in- testinal perforation. The diarrhoea prevails most at night, but in advanced instances continues day and night, and exhausts the patient greatly. State of the Blood. — The principal changes in phthisis are a diminution of the red cor- puscles (Malassez), and of the haemoglobulin (Quinquand) ; and an increase in the number of leucocytes, and in the proportion of fibrin and phosphate of lime. In advanced cases aggrega- tions of granules, varying in size from -^th to £ a red corpuscle, have been observed. The masses are often large enough in size to occupy a third of the field of the microscope ; and when ob- served for one or two hours at a temperature of 98° or 100° F. these granules appear to develop into organisms, and to move about in the blood. Their nature and function are quite unknown. Varieties. — We have hitherto traced the course of a typical case of consumption in its various stages, and we must now draw attention to the different forms the disease includes, always pre- mising that while they differ in symptoms, in prognosis, and iu duration, they cannot be erected into distinct pathological varieties, as they are merely forms of the same disease, and between each is to be found every kind of anatomical and clinical connection. The following table gives the principal forms : — I. Acute. — 1. Acute tuberculosis. 2. Scrofu- lous pneumonia, or acute phthisis. 3. Acute tuberculo-pneumonic phthisis. II. Chronic. — 4. Catarrhal phthisis. 5. Fibroid phthisis. 6. Scrofulous phthisis. 7. Haemorrhagic phthisis. 8. Laryngeal phthisis. 9. Chronic tubercular phthisis. 1. Acute Tuberculosis. — This term is re- stricted by the Germans to cases of general tuber- culosis where more than one serous membrane is affected with tubercle, in addition to the lung, but it is here used to denote all acute pulmonary cases where miliary tubercle, which has Dot begun to easeate, is the principal lesion. The history is as follows ; a young person of either sex is suddenly attacked with feverish symptoms, pungent heat of body, rapid pulse, extreme oppression, and over- whelming weakness, dry-coated tongue, red at' edges, soon becoming brown in the centre, 6orde« on the teeth and lips, gastric disturbance end diarrhoea, and occasional delirium, the symptoms closely resembling those of enteric fever, foi which the disease is often at first mistaken. Cough and slight expectoration come on; fine crepitation and bronchial rhonchus take the plaw of the ordinary vesicular sounds ; and occasionally some dulness is detected over the posterior re- gions of the chest. The patient wastes rapidly ; the breathing becomes more and more embar- rassed ; the sputum rusty ; the crepitation mort general and louder. Later on, the symptoms ol collapse appear — the pulse becomes more rapid and feeble, the aspect ghastly or livid, cold per- spirations appear, and death occurs within a feu weeks from the date of the first onset. Or the symptoms may be more cerebral in character denoting that the meninges are the seat of miliary, tubercle. The patient complains of pain in the head, vomiting, and intolerance of light ; begins tc mutter and to give wrong answers ; and then has marked delirium. The aspect is heavy aDd coni fused; hyperesthesia of skin (Empis) appears . and double vision, though squinting is not always noticeable. Granulations can often be detected by the ophthalmoscope in the fundus oculi Twitchings of the muscles of the extremities and sometimes of the face occur, followed by convul sions, and by paralysis of the sphincters. Dila- tation of the pupils and other signs of effusion supervene, and the patient dies comatose. In this variety, as a rule, the temperature remain: continuously high (between 100° and 102° F. 1 but in some instances under the writer's notice it has not risen above 100° F. for the last ten days of the patient's life. After death the lungs are found highly congested and pervaded with miliary tubercle, soft in character, but devoid of caseation ; the bronchi full of frothy mucus ; and tubercle may also be found in the peritoneum, brain-membranes, or pleura, with effusion into the ventricles. This form is distinguished from capillary bronchitis by the presence ot tever; from enteric fever by the different physical signs; from scrofulous pneumonia by the great dyspnea and scanty expectoration; and by the head symptoms (when present) from all the above. Acute tuberculosis is the most fatal form of consumption, terminating in a few weeks or even days, and is characterised by gastric distur bance, the presence of family predisposition (Pollock), and the absence of haemoptysis. 2. Acute phthisis. — Acute phthisis or scro- fulous pneumonia, is another very acute variety. The patient, generally young, who may have ha- cough previously, is attached with sharp pam in one side of the chest, quick pulse, high tem perature, the skin being quite burning to the ear of the auseultator, alternating with night chub PHTHISIS. im ad sweats. The general appearance betokens .neumonia, but the crepitation commences at the •pices, extending to the whole lungs, and is not 0 fine and even as in pneumonia. The cough in- reases ; the expectoration becomes opaque and urulent, containing quantities of lung-tissue ; nd the temperature assumes the intermittent pe. The physical signs show at first gradual nsolidation of both lungs, but later on declare scavation to have taken place ; and this contin- es, the patient rapidly wasting and dying in a w weeks. Sometimes the cavity opens into the leura, which in these cases is rarely adherent, hd death ensues by pneumothorax. This form not quite so hopeless as acute tuberculosis, and lie disease may stop short of utter lung-destruc- |on, the patient remaining in a state of crippled 1 spiration and of health for months and even jars. The writer has notes of one case lasting iree and a half years ; another sixteen years and jill living. After death the lungs are found 'ore or less consolidated, with adherent pleurae, |c indurations consisting of red hepatisation id caseous infiltration, the latter largely pre- iminating. Excavations abound in all direc- ts, and but little or no miliary tubercle is pres- t. The characteristics of this form, are (1) the luteness of the disorganising processes, exca va- in quickly succeeding consolidation ; (2) the flammatory nature of the lesions, and the rarity miliary tubercle ; (3) the occurrence of pneu- pthorax ; and (4) the freedom of other organs im tuberculosis. 3. Acute tuberculo-pneumonic phthisis. uiis is a third variety, which constitutes a con- eting link between the above forms, scrofulous eumonia and acute tuberculosis, as it presents neofthe clinical and pathological features of ■ ;li, resembling the latter in so far that the tu- •culisation takes place rapidly in the lungs, d often involves other organs, as, for instance, i ; intestines ; and being more akin to the former i thc presence of consolidations of a pneumonic fen, yet differing from them both in that the lliercle aggregates, tends to cascate, and thus to im cavities, through the breaking down of tjiercular masses, and not of catarrhal pneu- i nic products, this occurring while rapid tu- bculisation is taking place in another part of t lungs. . Catarrhal phthisis. — Catarrhal phthisis sjicwhat resembles the last-named variety, and I its origin in bronchitis which has gradually psed into catarrhal pneumonia. The patient l'i been subject for years, perhaps, to attacks of ''iter catarrh, which disappear in summer ; and fuist, owing to a severe season, or from his being ii less favorable circumstances than usual, his cgh docs not cease, as formerly, but remains p sistent, and is accompanied by some purulent egetoration, loss of flesh, and night-sweats. I I bronchial rales , sonorous and liquid, as they d, ppear from certain parts of the lung, become n' e prominent and localised in others, espe- e y under the clavicles, and above and between t!J scapulas. The rales become coarser, and the s' irous rhonchus assumes a croaking character. S : is of consolidation soon appear, but are never S', imminent as in other forms, owing to the teporary emphysema accompanying the bron- chitis ; the dulness appears in patches over the centres of increased rhonchus ; the liquid rales diminish, owing to increasing obstruction, and give place to a tubular sound conveyed by the extending consolidation from the larger bronchi, and heard best in situations overlying them, as below the clavicle, and above and within the sca- pula, in the axillary and middle dorsal regions. The tubular sound has a sharp, whiffing charac- ter, and is often unaccompanied by bronchopho- ny, from the consolidation being insufficient, and the bronchial tubes too choked to produce it. If the case goes on unfavourably, the expectoration becomes more abundant, and excavation soon takes place, with the usual symptoms ; the pa- tient assumes all the appearances of advanced cavity-phthisis, and the case from this date can hardly be distinguished clinically from those of a strictly tubercular origin. After death the lungs are found to be more or less consolidated, the indurations taking the direction of certain lobules and generally not affecting entire lobes. The indurations are of a grey or yellowish tint, with numerous yellow masses of caseation inter- vening. Portions of the lung may be found in the first stage of catarrhal consolidation, so well described by Dr. Hamilton, with isolated lobules or groups of lobules of a leaden or purple colour, and the adjoining ones may be emphysematous. Wedge-shaped patches of consolidation can be traced on the pleural surface, exuding on section yellow catarrhal fluid similar to that contained in the bronchi. Numerous excavations of irregular form are seen, but in most instances no trace of tubercle is to be found, though it is occasionally present. The bronchi are generally dilated, and full of purulent matter. This form is more com- mon among the young than the old, and arises from wdiooping-cough, measles, and bronchitis, the pathology being extension of catarrh from the bronchi to the alveoli, implication of tho interstitial tissue, large epithelial proliferation, causing pressure and emptying of capillaries, degeneration and caseation of the alveoli and their contents, and consequent excavation, with occasionally lymphatic infection. 5. Fibroid phthisis. — This term, introduced by Dr. Andrew Clark, is applied to cases of which fibrosis is the principal feature. While this process accompanies most instances of chronic phthisis, it specially characterises those in which interstitial pneumonia is present, and entirely modifies their history and symptoms. It is gener- ally secondary to attacks of pleurisy and pleuro- pneumonia, or to chronic pneumonia, resulting from long-continued irritation of the lungs, through the inhalation of dust or grit, as prevails among fork and knife grinders, colliers, and button-makers. Taking the pleuritic origin as an example, the following are the symptoms. A patient has an attack of pleurisy with ef- fusion, from which he recovers with absorption of fluid ; but percussion shows dulness over the whole side and somewhat feeble respiration. The patient experiences dragging pains in the side ; a dry, hacking cough, somewhat paroxysmal in character, with little expectoration, continues ; and the breathing, always short, becomes still more so on exertion. These symptoms increase, and a few months later we find marked imrno- PHTHISIS. 1173 bility of the affected side,dulness throughout, and now considerable shrinking ; the circumference of this side, measuring one or two inches less than the healthy side. On auscultation we notice the breathing to be very deficient in some parts, ar.d in others bronchial, and sometimes cavern- ous in character ; but generally there is every- where absence of true vesicular breathing. Careful percussion of the opposite side of the chest shows the line of resonance to extend beyond the usual limit, passing to the edge of the sternum, and often an inch or two further ; demonstrating that the contraction of the af- fected lung has caused the healthy one to be drawn across, in order to fill up the void. Other organs are likewise displaced. If the left lung be affected, the heart is tilted, not necessarily upwards, as when a cavity is contracting, but outwards. The stomach rises, its note being audible as high as the fourth rib. The heart is not only displaced, but is uncovered by the retreating lung; and the right auricle and ventricle are clearly distinguished by their pulsations, while the right lung is drawn across to the left side to the extent of one or two inches. If the right lung is affected, the left may be drawn over, and the area of resonance may extend as far as the inner half of the right clavicle, and a line drawn thence sloping to- wards the middle of the sternum. The heart is transposed, and its impulse may be traced in the fourth interspace on the right side. The liver rises up to the fifth rib, and shrinking of the chest-walls takes place, as on the other side. The pulse may be slow ; the respiration often rapid, rising to 50 and 60 per minute. The temperature seldom rises above the normal, and is sometimes subnormal. When the temperature rises over 100° F. it signifies that something beyond fibrosis is going on. The cough is troublesome, and often induces vomit- ing ; and the expectoration becomes more and more difficult, and in time, on account of re- tention, foetid. Meanwhile the dyspnoea in- creases, the other lung becoming involved ; signs of obstructed circulation appear ; dropsy of the extremities takes place and rapidly increases ; the urine becomes albuminous ; and the patient dies, either of dyspnoea or of blood-poisoning, his death contrasting strongly with the ordi- nary termination of consumptive disease. The patient may, however, die of apnoea, without albuminuria or dropsy. After death we find a lung contracted to the size of a man’s fist, with enormously thickened and adherent pleura and widely dilated bronchi, with interlobular septa much increased in size and encroaching on the lung-structure, which seems to be replaced by a fibrous hard tissue, in parts mottled with grey, deeply pigmented, and resembling cartilage in its resistance to the knife. Imbedded in this structure are found caseous and cretaceous masses, or again, excavations of various sizes ; the walls of these and of the dilated bronchi being rigid and inelastic, from the presence of the fibroid material, and thus affording some explanation of the difficult expectoration and consequently troublesome cough. Besides these changes, we may find the other lung the seat of tuberculosis, though this is not constant; but commonly the bronchial glands are hardened and deeply pigmented. There is often amyloid disease of the liver, spleen, and kidneys. 6. Scrofulous phthisis. — This is a variety where consumptive disease of the lung is precedec by, or accompanies, scrofulous affectionsof various joints, caries of the sternum, ribs, and vertebra* lumbar and psoas abscesses, otorrhoea, fistubi in ano, or, as is most common, enlarged an caseating glands, cervical, bronchial, axillary or mesenteric. Kindfleisch explains the non-ai> sorption of scrofulous matters by the presence it exudations of this character of relatively larg* cells with glistening protoplasm, and by the fac that the emigrated leucocytes, which pass fron the blood-vessels of the inflamed part into tb adjoining structures or into the lymphatics, L scrofulous persons tend to grow larger on thei way through the connective tissue, by absorptio: of albuminous substances. The large size of th cells has been verified by Godlee, Schuppel, Greet and others. Cases of scrofulous phthisis shot an early infection of the lymphatic system, and* remarkable correlation appears to he* establishe* between the external gland or discharging snrfac and the condition of the lungs. If the gland are suppurating, or if the fistula is open, or i the carious bone freely discharges, the lung disease will remain quiescent, and progress ma be made towards arrest ; hut if, on the othe hand, any of the above discharges should b checked or cease, the lung-disease passes int fresh activity, making considerable advanc and extension. The temperature-course in thes cases, if active lung-changes are taking place, i remarkably fitful, showing evening exacerbation of 102° F. to 101° F. and morning depression of 96° F. to 97° F. ; and night-sweats are usuall very profuse. Patients of this type lose an gain flesh with great rapidity, owing prohahl to the pyrexia and fitfulness of the appetite. Scrofulous phthisis is strongly hereditary : i prevails chiefly among children not exceedia fifteen years, as shown by Pollock, many c these presenting the well-known strumous aspec' the clear complexion, enlarged glands, ckroni inflammation of the eyelids, or discharging ear: They are attacked early with haemoptysis, accon: panied by cough and wasting. The course of th disease, probably on account of the relief affords by the various discharges, is slow, and the patier lives on for a considerable period ; but, as migb be expected, the development of the individur is slow and often stunted. Post-mortem exam nation generally shows the ordinary destructiv lung-changes of advanced tubercular phthisi with considerable enlargement of the vanoi glands — bronchial, mesenteric, cervical, &c. 7. Haemorrhagic phthisis. — This name : intended to designate, not phthisis arising froi the results of haemoptysis (phthisis ab hemojit — Niemeyer), but a form recognised by C. J. 1 Williams, Peacock, Hughes Bennett, and th writer, in which large and repeated hmmorrhai is the principal feature, associated with a sma amount of detectable disease. It is more con mon among men than women, in the propordo of five to one : and the period of attack is lats than in the ordinary forms, possibly owing t the element o: heredity being generally abseu PHTHISIS. 10 patient may have had signs of failing health fore the haemoptysis, but often he is appa- ,ntly in good health when he is suddenly tacked with profuse haemoptysis, the blood Ing florid, the haemorrhage sometimes lasting any days, and always causing a reduction in ish and strength. Cough and expectoration How, yet examination of the chest only indicates ight signs, and sometimes none at all. When ■esent they are to be found in the supra- or ter-scapular regions, or below the clavicle. Tho itient improves, and often entirely loses his iugh before the recurrence of the haemorrhage, Inch may not take place, for days, weeks, onths, or even years. If the attacks recur j'ten, the cough becomes persistent; the expecto- ition, when not sanguinolent, is muco-purulent ; astingand night-sweats appear; and the physi- .1 signs now show unmistakable consolidation, hich goes on to softening and excavation. In ost cases the disease does not extend beyond ■nsolidation, and large quantities of blood are ipectorated without fatal results, the patients (covering in the intervals, and sometimes living a considerable age. Peacock says that in ost instances some more or less exciting cause to be detected, in the form of syphilis, cold, 'sentery, bodily strain, exertion of voice ; but e writer has often failed to find one. The ithology of this form of phthisis is uncertain, ■cause few of the patients die in the early age; but it is probable that the haemorrhage j produced by tubercular formations in the ■ighbourhood of, and implicating the wails of, me of the larger vessels at the root of the ngs. Though this can be considered only a inical variety of pulmonary phthisis, the cases e genuine instances of consumption, as is proved • the fact that, if they live long enough, they n the same course of increasing consolidation d excavation as ordinary phthisis. 8. Laryngeal Phthisis. See Larynx, Dis- ses of. 9. Chronic Tubercular Phthisis. — This con- tutes the ordinary type as sketched under the ad of symptoms. In the autopsies of this ?m are to be found all the pathological elements phthisis, namely, tubercle — miliary, grey, and lite— caseous masses, and infiltration — grey and sarrhal — croupous pneumonia, fibroid tissue, d calcareous deposits, — showing that no abrupt thological line of demarcation can be drawn (tween the different varieties of phthisis, vvhat- |er clinical peculiarities they may present ; and it the appearance of miliary tubercle is a jitter of infection of the lymphatics, in which ie plays an important part. Diagnosis. — Phthisis is distinguished from ler chest-affections principally on the evidence physical signs. The evidences of consolidation larate it at once from bronchitis ; while the jidency of the signs to become localised in the , ces of the lungs, their special characters, and {> combination of consumptive symptoms, dis- ' guish it generally from pneumonia. If the various forms of phthisis, the most dif- ) lit to diagnose from other diseases is acute : Hry tuberculosis, which at its onset is some- ■jies mistaken for acute bronchitis, from tho riles and rhonchi accompanying the miliary 1179 formation. It has also been confounded with enteric fever, from the high pyrexia, the depres- sion of the patient, and tho occasional diarrhoea accompanying it ; but in both cases the rapid iy advancing symptoms, and the steadily progressing physical signs, such as increased and scattered crepitation, if proper and frequent examinations be made, ought to leave us iu no doubt as to the nature of the case. The diagnosis between scrofulous pneumonia (acute phthisis) and croupous pneumonia is not easy at the ushering in of these complaints, the physical signs not always sufficing for this pur- pose. In a short time, however, the detection of lung-tissue in the sputum, and the rapid wasting, make matters quite certain. The diagnosis of chronic tubercular phthisis from anaemia and chlorosis, sometimes confused with it on account of the amenorrhoea often common to both, is made by the physical signs ; by the different kinds of pallor in the two dis- eases ; and lastly, in chlorosis, by the absence of wasting. The diagnosis of excavation in phthisis from bronchiectasis is by no means easy, as the position of the cavernous sounds is not always sufficient to determine the nature of the lesion. Dilated bronchi are found in the subclavicular and interscapular regions, and where ulceration is proceeding in bronchiectasis lung-tissue may be detected in the sputum. The convulsive character of the cough, and the feetid expectoration, abundant, but mixed largely with air, generally enable us to decide in favour of dilated bronchi. Duration and Prognosis. — Early detection of the disease, and improved treatment have worked a great revolution in our ideas as to the duration of phthisis. The estimates of Laennec, Louis, Bayle, and others assigned two years as the mean duration of life in phthisis generally. Pollock's statistics, founded on between 3,000 and 4,000 hospital cases, give a considerable extension of this, in- asmuch as at the end of two years and a half the majority were sufficiently recovered to have a fair expectation of life. The statistics of C. J. B. AVilliams and tho writer, founded on 1,000 cases among the upper classes, give an average duration in 198 deaths of 7 years S‘7'2 months ; and in 802 living of 8 years 2 months. The fact of these patieuts having all been one year and upwards under ob serration necessarily excludes some of the acute cases ; but with this limitation these figures, striking though they be, may be taken as a cor- rect averageforthe durationof the disease among the upper classes under modern treatment, es- pecially as 72 percent, of the living had recovered sufficiently to pursue their usual avocations, and many among them had already lived upwards of twenty years since their first attack. The duration of the disease is found to be considerably' influenced by age ; for it is longer in proportion as the age of attack is later, this retarding influence being more conspicuous among males than females. Females are attacked earlier, and the disease in them runs a shorter course by nearly two years than among males. Of the varieties of phthisis acute tuberculosis is the most rapid iu its course, generally term! PHTHISIS. 1180 Bating in a few weeks, or occasionally in a few days. Scrofulous pneumonia has hardly a less rapid course, though it may occasionally be re- tarded, the disease becoming chronic, and the patient surviving for many years. Laryngeal phthisis has a short duration, and most un- favourable prognosis. Catarrhal phthisis has an average duration somewhat below the ave- rage of eight years of ordinary phthisis. Fi- broid phthisis, on the other hand, exceeds the ordinary duration by nearly two years. Htemor- rhagic and scrofulous phthisis are both of long duration. These calculations are based on sta- tistics of patients of the upper classes treated according to the best medical and hygienic treat- ment known ; but if hospital cases are reckoned, the average of duration of phthisis generally, and of its various forms, must be held to be much lower than the above estimate. The prognosis in phthisis depends chiefly on the extent to which the system is infected, and especially whether or not other organs are the seats of tubercle. Cases of acute tuberculosis resemble closely those of pyaemia in their symp- toms and fatal course, and only differ in the nature of the pathological products. Similarly single-cavity cases, where the disease is strictly limited, bear a strong resemblance to chronic abscesses, which go on discharging for long periods, without materially curtailing the life of the patient. The future, therefore, of the patient depends to a great extent on whether the dis- ease may be considered local or general, though of course we admit in both instances a consti- tutional predisposition, possibly of different degrees of intensity. Where the infection is rapid and complete, as in acute tuberculosis and most instances of scrofulous pneumonia, the pro- gnosis is most unfavourable. Where, again, the disease is limited to one lung, and associated with similar processes in the joints, as in scrofu- lous phthisis, which act as diverticula to the central disease, the prognosis becomes far more hopeful, and the individual may last on for many years. The prognosis in laryngeal phthisis is most unfavourable, on account of these cases being always associated with extensive lung-tuber- culosis ; while in haemorrhagic phthisis, where the pulmonary mischief is small and limited to the root of the lungs, it is favourable, excepting of course the accident of death during an attack of haemorrhage. The most favourable prognosis, of phthisis must be retained for cases of inflam- matory origin, for here the disease often remains limited for considerable periods of time, and the patient may live on, almost unconscious of it, to the natural term of life. If, however, the fibroid element be largely produced, a new danger arises from the obstruction to the circulation, caused by the contraction of the lungs, dropsy, dilatation of the heart, affection of the kidneys, and death. The influence of heredity on prognosis lies in its precipitating the onset of the disease, and not in its curtailing its duration, though, of course, an individual attacked earlier will die at an earlier age, the duration of the disease being the same. The influence of stage must be duly taken into account, for statistics show a far more favour- able prospect for mere consolidation than when a cavity is formed, and this is obv.ous from tl increase of danger arising from two source namely from purulent infection and pulmonai aneurisms. The grounds for an unfavourable proouos are: — 1, rapid extension of disease or of luu| excavation ; 2, persistent afternoon pyTexi; 3, symptoms of great irritability of the eastr intestinal tract, red tongue, diarrhcea, twin ■ the abdomen ; 4, great wasting with, or witi out, pyrexia, combined with a good appetite : an 5, strong hereditary predisposition, showins i 6elf in several brothers and sisters being attache at an early age. Treatment. — The treatment of phthisis roa be considered under three heads— 1. medicimi 2. dietetic and hygienic ; and 3. climatic. 1. Medicine. — The medicinal treatment mu: be directed to three objects : firstly, to pais the standard of nutrition and to counteract tl phthisical cachexia ; secondly, to reduce and alia the local inflammations and congestions whic accompany, and considerably complicate, th tubercular changes ; and thirdly, to relieve ;h| various urgent symptoms. The first object i carried out by tonics, such as iron, quinim arsenic, the mineral acids, and, above all, ccd liver oil, which has been shown to be the mo; effective agent of all in counteracting phthisicc disease. Some precautions are, however, nece; sary to ensure its being tolerated for Ion periods. The pale oil should be preferred, an; ordered in doses of from 5j to yss shortly be 1 fore or after meals. The best vehicles for it ar the vegetable bitters — such as gentian, calumba quassia, nux vomica and strychnia, hop, came mile, and cascarilla — combined with an acid o alkali, according to the state of thegastricmuccn membrane, and rendered more palatable by th: addition of tincture or infusion of orange pcc or syrup of ginger. Various other vehicles ar used, such as milk, salt and water, lemon-juice orange wine, and sherry; while many patients especially children, take it best in an emulsion composed of cod-liver oil, a few drops of strop liquor potass* or liquor ammonia, with a: essential oil, like that of cloves or cinnamon, t< cover the taste. In the great majority of case cod-liver oil is well borne, if exhibited wit discretion. Other oils are of use, but few equa the cod-liver oil in efficacy, on account of it great penetrative power, and of its forming wit. the biliary and pancreatic juices a componn 1 easily absorbed by the laefeals. JIalt extrac aud similar preparations, though of greatly m ferior nutritive power to cod-liver oil, ofte cause increase of weight, chiefly by assisting th patient to digest more starch. Of greatly m ferior utility to the oil are the preparations c phosphorus and sulphur, such as the hype phosphites of lime, soda, and iron, snlphnron acid, and the sulphites, all of which have a con siderable amount of testimony cited in thci favour as tonics and blood-purifiers. In France the sulphur springs of EauxBonn, - Cauterets, Bagneres de Luchon, and Bagneres >. Bigorre are largely frequented by consumptive: the ground of this treatment being that the ft suits of Claude Bernard's experiments show tba sulphur when absorbed is excreted through th PHTHISIS. jpiratory mucous membraue. Peter considers it any benefit that may accrue is owing to the iuence of sulphurous acid on the catarrhal editions. The arsenical waters of La Bour- se and Koyat are strongly recommended by [. Noel Gueneau de Mussy. We may here consider the treatment of the rexia of phthisis. In addition to rest in bed, {ti-periodics, as quinine in large doses in an t’ervescing saline, salicine (gr.x), and salicylate ■ soda (gr. x to xx), may be given every four i. six hours, if the pyrexia be considerable. If p temperature only slightly exceed 100° F., .d if it be followed by much sweating, then seuic, in the form of liquor arsenicalis or liquor .jenici hydrochloricus (n\ii to v), three times a , y, is indicated. Where these medicines fail, course may be had to cold compresses over je chest, to sponging with vinegar and water, .d if the patient’s strength permit, to the ‘ wet ck,’ swathing the patient in wet sheets; and j the pyrexia be very persistent and tormenting the sufferer, immersion in a bath of 90° F., vered gradually to GO 0 F., may be tried. The luction of temperature and consequent relief : great, but not always permanent in character, $ pyrexia in phthisis may be considered one (its obstinate symptoms. The second object of treatment, the reduction ( local inflammation, is best accomplished by lid antiphlogistic means, such as salines, with J without antimony ; and counter-irritation to t) chest-wall by blisters, iodine, or vesicating liments, mustard, or the milder but still effec- 1 .1 application of linseed-meal poultices. Steady mtinuance with these will often render seda- tes for the cough unnecessary. The third object, namely, the palliative treat- i nt, includes that of the various urgent symp- t is. The cough, when not reduced by the counter- i tation, may be to a certain extent allayed by combination of sedatives, such as opium and i salts, conium, henbane, hydrocyanic acid, iierican cherry, with mild expectorants, of tick chloric ether, lemon juice, and squills are e.mples. Where the cough is frequent and the e.'ectoration difficult, and there is proof of ac- ts disease, tubercular or pneumonic, proceeding i the lungs, an effervescing saline, containing cibonate of ammonia, with small doses of opium 8 . antimonial wine, taken two or three times at ijht, will greatly relieve the symptoms, the rule i he treatment of consumption being to restrict t sedatives, as far as possible, to the night, so as t to interfere with the appetite and digestion. I s preparations of tar, in the form of capsule, 1 , or solution, are useful in reducing profuse e ectoration. The inhalations of iodine, com- pnd tincture of benzoin, carbolic acid, crea- so, larch and turpentine, are useful if expecto- r on is offensive or requires stimulating ; or a,m, those of chloroform, conium, hop, when t 1 cough is convulsive and dry. ho pains in the chest may be alleviated by Fating with tincture of iodine or stimulating 1 nents, such as turpentine and ammonia ; or on Dr. Koberts’s plan, by securing the ina- bility of the side by strapping. : ight-sweats, when profuse, may be reduced 1181 by oxide of zinc (gr. ij to iv), by gallic or sulphuric acids, by sulphate of iron, by r arse- niate of iron (gr. £ to •!■), but most effectually of all by tho preparations of belladonna, in the form of the extract (gr. J to gr. 1), or as solu- tion of sulphate of atropia (iuj to ij), or used hypodermically. Dover’s powder in 10-gr. doses is useful, but Dr. Murrell has lately strongly re- commended picrotoxine (gr.jjo, inform of a pill), or muscarine (ii\v of one per cent, solution), to be taken at bed-time, as more effectual. Diarrhoea, where due to bilious derangement and an acid state of the prim® vise, is best treated by mercurial purgatives, combined with carbonate of soda or lime-water. Where it partakes of the nature of a flux, accompanied by a pale tongue and great debility, it may be checked by astringents, such as hsematoxylon, catechu, krameria, bael, and carbonate or citrate of bismuth. When ulceration of the intestine is proceeding, it is characterised by a red, irri- table tongue, pain and tenderness of the abdo- men, and persistency of the diarrhoea. Here, as in other forms of ulceration, opium and its salts answer best, and may be given internally with sulphate of copper (grain | to £) every three or four hours. When the stomach is too irritable to tolerate medicine by the mouth, opium and morphia suppositories are useful, but still better are opiate enemata, which, acting directly on the irritable ulcers, check the pain and diarrhoea, and often afford considerable re- lief. In very obstinate cases tannic acid (four to five grains), acetate of lead (three to four grains), may be added to the injection. The opposite state of bowels, namely, constipation, is very common in the early stages of phthisis, and is best corrected by changes in diet, such as the use of brown bread and oatmeal, cooked and fresh fruit, regular exercise, and if these prove insufficient, a mild aloetic or rhubarb pill, or the use of some mineral water, as Friedrichshall, Pullna, Carlsbad, Hunvadi Janos, and others. Tho dyspnoea of advanced cases generally arises from difficulty of expectoration, and the greatly curtailed respiratory power, and may be relieved by spiritus setheris, carbonate of am- monia, and other diffusible stimulants. The pain arising from perforation in pneumothorax is best treated by opium, and strapping the side to limit tho movements of respiration, and if much liquid effusion or accumulation of air takes place, it is sometimes advisable to tap the chest; but, as a rule, the state of the patient does not allow of very active measures. Bed-sores should be prevented by the use of a water-bed, and the skin of the dependent parts can be fortified by lotions of spirit and water (one part in four). If a bed-sore has formed, it is best to protect it from friction by the use of circular air or down cushions, or thick felt- plaister, and the raw surface can bo painted with collodion, or be regularly dressed. 2. Diet . — The great object being to introduce as large a quantity of nutritious food as can be digested, abundance of meat, plainly cooked, with fresh vegetables, and a fair amount of bread and starchy food should be given. Fatty mate- rial, if it can be digested, should be largely- represented in the dietary, and many physicians PHTHISIS. 1182 advise large quantities of cream, butter, and suet ; but, considering the large amount of fatty matter included in cod-liver oil, which is r. severe test at first to the digestive powers, it is not advisable to increase the amount of fat until the oil is well tolerated. Milk (1 to li pints a day), alone or with lime-water, is a staple food for the consumptive; and when cow’s milk disagrees, ass’s or goat’s may often be substituted with advantage. Koumiss and whey are frequently used in (lermany and Kus- sia, but they have not become popular in this country. The digestive powers being, as a rule, weakened, much good may be done by the addi- tion of animal ferments, such as liquor pepticus and liquor pancreaticus (Benger) to the food, which, becoming peptonised, is much more easily assimilated {see Peptonised Food). In the early stages stimulants are not largely required, as they increase the cough and lung-irritation ; but when the strength fails, and the powers of diges- tion are weak, they may be given frequently, and advantageously combined with liquid nourish- ment, such as eggs, soups, various meat-essences and panadas, arrowroot, and jelly. When wine is required, in chronic cases, it will be found that claret, hock, sauterne, and cliablis tend to irri- tate the cough less than the stronger vines. Hygiene . — The consumptive patient should inhabit a well-ventilated, well-drained house, built on a dry soil, sand or gravel, sheltered from cold winds and well exposed to the south, not hemmed in by trees, the most suitable for the neighbourhood of the house being of the coni- forae order. The bed-room should be lofty, provided with a fireplace for warmth and outlet ventilation ; and unless the cubic space be abun- dant, inlets for the supply of fresh air, in the form of vertical tubes, should supplement the ordinary indraught of the door and window. Clothing and Exercise. — The underclothing should be woollen, either flannel or lambswool, or perhaps in summer merino may be allowed, the object being to secure a good non-conductor of changes of the temperature which will, at tho same time, absorb cutaneous moisture. The rest of the clothes must be adapted to the season, the invalids, male or female, always bearing in mind their greater liability to catarrh than ordinary persons, and using wraps freely, more especially when driving. Exercise must depend on the stage of the dis- ease, and the strength of the patient. In the first stage, especially when the disease is limited to one lung, and no fever or haemorrhage is present, active exercise in the form of walking is ad- visable. Under careful superintendence cer- tain gymnastic exercises may be of benefit, which, by raising the arms, lift the upper ribs, and increase the size of the thoracic cavity, especially in the upper regions, and thus necessi- tate a larger inspiration of air, and in time this leads to further development, and even to hy- pertrophy of the healthy lung. Emphysema may be produced in the diseased lung by this means, which is useful in limiting any further advance of infective tubercular disease. Hiding is excellent for a large number of patients, being intermediate between the active and passive varieties of exercise. Where tho disease is more extensive and advanced, only tl passive forms of driving and sailing are po sible. 3. Climate . — The main point to be held in vie is to give the consumptive a climate in which i can breathe freely, take abundant outdoor exe cise, and experience that amount of stimulati: influence which, while it improves his appeti and powers of digestion, does not irritate tl mucous membrane of the lungs or increase tl cough. The selection is generally difficult, ai depends not only on the class of cases, but mu be sometimes modified by individual peculiarity See Climate, Treatment of Disease by. The writer’s statistics, founded on 251 consum' tives, who passed one or more winters out . England, assign the most favourable results sea-voyages, and the next to Egypt and other dj climates. The Mediterranean basin followsne. in point of success; while the moist tempera climates of Pau and Home give far less got results, and Madeira only slightly surpass! these. The same statistics show the foreig health-stations to be on the whole more sncces ful in prolonging life than the English one.- but we must not forget that the most advance cases fall to the lot of the latter, on account of tl difficulty of travelling ; and, on the other ham a great advantage enjoyed by the home statiorl is the superiority of the food and appliances fc invalids, which may in some degree eompensa: for the smaller number of days in which exercb can be taken, and the greater vicissitudes < weather. Of the British health-resorts the drye ones, such as Hastings, Ventnor, and Bournt mouth, have afforded more favourable resultstha T orquay and Penzance. It is impossible in a fe sentences to lay down rules for climate-selectio; but a few general outlines may be given of tl suitability of different groups of agencies. The British south-coast stations are benefid in scrofulous phthisis, and in many cases whei the appetite is poor, and tendency to catarrh nt the prevailing feature. In the catarrhal form c phthisis Madeira, and the West India Island, especially the Blue Hills of Jamaica, are ac visable; the combination of warmth with salir influence, and the absence of stimulating qual ties, seeming to answer best. Dry stimulating marine climates, such as th Riviera, Malaga, and Algiers, are recommends in phthisis of inflammatory origin, and in a. cases where it is desirable to combine stimulatin influence with a moderate degree of warmth, an decided dryness of atmosphere. Where the stimulating influence is undesirable as in patients of excitable temperament, or irr: table gastric mucous membrane, the very dr inland climates, like those of Egypt or Sout Africa, are preferred. Sea- voyages to Australia and New Zealand, o the shorter one to the Cape, are indicated i cases of haemorrhagic phthisis, in cases of lim: ted first or third stage, where the patient strength is unequal to much exercise, and wher he or she have suffered from close confinemen in crowded cities. High altitudes . — The increasing mass of testi mony in favour of this form of climate-treatmen for consumption, in both Europe and America PHTHISIS. Lugurs that in a few years it will he used more largely. At present the Andes, the Eocky Mountains, ind the Alps, and even the South African high- lands, are frequented by consumptives ; but the Renditions of temperature and altitude manifestly vary greatly ; and while the climates of Quito and Santa Fe di Bogota resemble in temperature hat of Malaga, the winter extremes of Davos in the Alps are more nearly akin to those of panada. In all these places, however, there Exists a distinctly specific influence apart from hat of heat and moisture, in the form of di- ninisked barometric pressure, which is shown to the patients residing at high altitudes. The Shest becomes expanded, and hypertrophy of She healthy lung-tissue takes place, accompanied py vesicular emphysema around the lesions. Patients in the first or third stage of phthisis Syith only limited lesions, endowed with fair nwors of circulation and able to take exercise, .re the proper cases for this form of climate, nd in many of such complete arrest of the dis- ease may be confidently predicted. C. Theodore Williams. PHYSICAL EXAMINATION-.— 1 The ob- ject of a physical examination is to ascertain [he precise seat, limits, and characters of those evidences of disease which are recognisable by lur senses, and which are called physical signs, n making such an examination we bring to hear i’ll our senses, with whatever instrumental aids |iiay he available to detect the signs of disease. !n the present article a description will be given if the physical examination of — (1) the patient isnerally ; (2) the cerebro-spinal system ; (3) the ispiratory system ; (4) the organs of circulation ; p) the mediastinum ; and (6) the abdomen. 1. General Survey. — Our attentiou will first f all be naturally attracted to the physiognomy f the patient, that is to his general appearance ad build. We note his apparent height and eight, and, if possible, correct our observation y scale and measure. We observe the state \f nutrition, firmness or laxness of muscle, cor- ulence, thinness, emaciation — atrophy of any articular muscle or group of muscles. The implexion of the patient is to be remarked, hether clear, sallow, dark, fair, jaundiced, or gmented ; also lividity or pallor of surface and ucous membranes. The apparent age as con- asted with actual years of the patient; elas- pity of features, condition of hair, presence of reus, &c. The symmetry and play of features, lie expression whether of vivacity, despondency, iffering, anxiety, paralysis, or hysteria. See HYSIOGNOMY. Whilst making these preliminary observations, 'general outline of the history of the patient and his present illness will have been elicited. The pulse should next he noted (see Pulse). e may, in important cases, extend our in- juries or record our observations by means of e sphygmograph. See Sphygmograph. The respiration of the patient requires atten- m as regards rapidity ; mechanism, that is, hether abdominal or thoracic in normal pro- ntion ; rhythm, regular or irregular, easy or boured; and freedom or otherwise from pain. PHYSICAL EXAMINATION. 11 S3 The action of the nares, and any recession or otherwise of soft parts during respiration, should be especially observed. See Spirometer. In health and under physiological conditions of age, exercise, emotion, &c., there is a tolerably constant ratio between the respiration and pulse- rate, namely, one respiration to from three to four pulse-beats. In disease this ratio is often much altered. The average respiration-rate in a healthy adult is from 17 to 20 per minute, in the infant about 40 per minute, between one and five years about 26 per minute. In old age the prepirations are very slightly accelerated: in children they arc quick and otten irregular, being momentarily suspended by anything that excites their wonder or close attention. The odour of the hreath may attract attention. It may under morbid conditions be fetid, uri- nous, ‘ mercurial,’ alcoholic, or gangrenous. See Breatii, The. The condition of the shin, whether dry or hot, moist or sweating, and the presence or ab- sence of any eruption, scars, ulcers, or pigmen- tation, will be duly noted. The presence of pyrexia will be exactly ascertained by the use of the clinical thermometer, an instrument which ranks with the stethoscope in value ; hut the employment of the thermometer does not exclude the necessity of testing the condition of the surface by the hand, whereby we observe the resultant, so to speak, of the bodily heat, tem- pered it may bo by evaporation, or exaggerated by undue dryness in exposed parts. Probably the use of the surface thermometer, in combi- nation with the ordinary clinical instrument, would more exactly give us this information, upon which important therapeutical indications rest ; but the hand of the skilled observer fully suffices for the purpose. The surface thermo- meter is of value in estimating localised eleva- tions of temperature ; for example, over the site of an empyema, in peritonitis, and in connection with certain nerve-lesions. See Thermometer. The condition of the finger-ends— clubbiug, lividity — must be observed. Important infor- mation as to previous acute illnesses within the past six months can be obtained by inspecting the nails, a transverse furrow marking the period of defective or arrested nutrition during such illness. The condition of the teeth may indicate pre- vious illness or syphilitic inheritance. The state of the eyes, and especially any ir- regularity of the pupils, requires attention. The condition of the tongue and gums furnishes us with valuable information. The careful superficial inspection of the patient in the manner above sketched w’ill perhaps at once lead to a more minute examination of some one organ or system of organs as the probable seat of disease ; and having thus far succeeded in locating the disease, the other organs and functions of the body will of course come under review, but the physician will be more especially inquisitive with regard to such organs or func- tions as may he in sympathy with those in which disease has been detected. It may he, however, that on careful examination we fail to find any organic lesion to account for the symptoms present, and for signs of wasting, PHYSICAL EXAMINATION. 1184 pyrexia, &e., which notify the illness of the pa- tient. We may then — but not till then — refer the case to one of those blood-conditions which for a time run their course without manifesting any definite lesion. Again, it may be that certain signs of general illness, and especially pyrexia and wasting, can- not be accounted for sufficiently by the amount of disease discovered. Here we must suspect that the lesion we have ascertained is but an ex- pression of a more general state. Having made these remarks — relating to orderly measures of inquiry, without a due re- gard to which no physician or surgeon, however skilful in any one department, can fail to com- mit the errors of the narrowest specialist — we will proceed to consider the physical examination of those regions of the body, especially the chest and abdomen, in which objective signs can be accurately observed. 2. Cerebro-spinal System, Physical Ex- amination. of. — The objective phenomena of disease affecting thenervous system are often very obscure, and it is the more important that they should be sought for in a methodical manner. (a) The Head, — The head should be examined ks to size, shape, condition of fontanelles, the presence of wounds, tumours, or depressions. The size of the head varies greatly in different people, without any seemingly corresponding variation in the condition of the brain. It is very difficult to say whether enlargement of head is due to thickening of the skull or en- largement of its contents. In rickets and in hydrocephalus the head is relatively large ; in idiocy relatively small. The shape of the head is of more importance than the size. We may recall the long head, with square, high forehead, of rickets ; the broad, vaulted skull, with shallow orbits and prominent eyes, of hydrocephalus. The condition of the anterior fontanelle must be carefully observed in all cases of children with cerebral symptoms— it should be neither tense nor depressed. The detection of local changes, such as thicken- ings, tumours, scars, or depressions over the skull, will throw much light upon a case presenting cerebral symptoms. (b) The Spinal Column. — -The spinal column must be carefully examined for undue promi- nence or depression of spinous processes, or other tumours, and for lateral or antero-posterior curvature. Kneading and percussion should be employed over each spinous process to elicit any tenderness. The fingers should be passed firmly along the spinal groove on either side to ascertain if there be any painful point, and much care must bo taken not to confound such pain (com- monly neuralgic) with true spinal tenderness. The application of the hot sponge, or ice-bag, successively to different parts of the spine is a means of eliciting valuable signs of disease. In all cases of suspected spinal or cerebral disease the superficial and deep reflex actions should be tested, as affording important indi- cations respecting the integrity of successive portions of the cord, and the condition of the parts above. See Spinal Cord, Diseases of. By the ophthalmoscope an example of the cere- bral circulation may be observed in the retina, and the condition of vessels noted. Certain lesions of the optic disc correspond also with deeper and more widespread nervous disease (see Ophthalmoscope in Medicine). By the use of graduated compasses the sensibility of the peri- pheral nerves may be estimated. Electricity enables us to ascertain the irritability of volun- tary muscles; and by the dynamometer we may compare muscular power on the two sides, ike Electricity ; and Dynamometer. Further details respecting the diseases of the nervous system, and the methods for their diagnosis, will be found under appropriate headings. 3. Respiratory System, Physical Exami. nation of. — The respiratory system includes the respiratory tract and lungs. (a) Larynx. — The condition of the larynx and trachea vs examined into by listening to the voice, whether husky, altered in tone, or sup- pressed Any tenderness or external deformity is ascertained by careful palpation. By means of the laryngoscope the condition of the epiglottis, larynx, and trachea can be thoroughly explored. See Laryngoscope; and Larynx, Diseases of. (b) Chest. — In making an examination of the chest, the physician should follow a methodical routine of inspection, palpation, percussion, and auscultation. 1. Inspection. — The general shape and build of the chest is observed — whether it be the broad, well-formed chest of robust health; or the small, narrow, long chest, with antero-posterior and lateral diameters diminished, costal angle narrow, and ribs oblique and approximated — adapted to small lungs. Or the thorax may be unduly expanded, with wide intercostal spaces, straightened ribs, widened costal angle, and deep antero-posterior diameter, to accommodate large lungs. Again, the thorax may be distorted by various kinds of spinal curvature, or as the re- sult of rickets, or from external pressure, as in the depressed lower sternum of shoemakers (see Deformities of the Chest). Lastly, there may be local flattenings or bulgings. The movements of the chest are of great impor- tance in diagnosis. We estimate the freedom or otherwise with which air enters the chest during inspiration by the equable expansion of itsseveral parts, or by the immobility or recession of any portion the entry of air into which is retarded or impeded; and thiscan be accurately done bymeans of the pneumograph. In cases of general ob- struction to entry 7 of air, whether by impediment at the main air-passage or in itsentire distribution, there is universal recession of all the soft parts — the supra-clavicular region sinks downwards, the hypochondria recede, and the intercostal spaces deepen during the effort to expand the chest against atmospheric pressure. On the other hand, when the difficulty of expansion, whether from intrinsic disease or obstruction of passages, is re- stricted to one side of the chest or to a portion of one lung, the restrained expansion during inspira- tion is limited to that portion. Thus from in- spection alone we may often forma shrewd gnosf PHYSICAL EXAMINATION. HS5 as to the seat and even the nature of the disease present. In estimating local alteration of shape the eye is perhaps more useful than any instrument of measure. Calipers of various patterns may he used for taking diameters in different direc- tions. Eut for recording differences of shape on the two sides the cyrtometer is very useful. This instrument was originally introduced by M. TVoillez, and consisted of two halves of a jointed whalebone measure, connected by a hinge, which could be adapted accurately to the shape of the chest, and after removal the various curves on the two sides could be traced on paper. The cyrtometers now most in use are made of soft metal, two sufficiently long pieces of which are connected by an indiarubber joint or hinge. Double tape-measures are also used for ascer- taining the circumference on the two sides, and by their means the relative expansion during respiration on the two sides can be compared. Various forms of stethometer have been designed for the same purpose. See Stethometer. The vital capacity of the lungs may be very accurately estimated by means of the spirometer. See Spirometer. 2. Palpation. — Palpation is employed in aid of both inspection and percussion. # a. During preliminary inspection of the chest the position of the heart's apex-beat should be invariably, and as a matter of habit, ascertained, and any deviation front its normal seat, namely, the fifth intercostal space one inch to the sternal side of the left nipple line, should be noted. b. Any local bulging or tumour will naturally bo manipulated to ascertain its relation with bone, or soft structure, whether it be solid or soft, fluctuating or pulsatile. c. In connection with percussion, the trained observer will note differences of resistance, as well as of sound, over diseased areas. d. Increase or diminution of vocal vibration or fremitus will be noted over any spot of altered resonance, by applying the hand and making the patient utter some resonant words, such as ‘ninety-nine.’ Vocal fremitus is increased by consolidation of lung; diminished by much thickening of the pleura, by obstruction to the main bronchus, or bv air in the pleura; annulled by fluid in the pleura. N.B. — In many cases of fluid in the pleura some vibrations are felt, probably communicated from above. The loudness or feebleness of the . voice must of course be taken into account in estimating fremitus, and corresponding parts on the two sides should always be compared. Loud, coarse, bronchial rales may cause the riiest-walls perceptibly to vibrate, producing rhonchal fremitus. Pleuritic friction may like- wise be perceptible to the hand applied — friction fremitus. In cases of effusion into the pleural cavity, or in hydatid cysts near the surface, fluctuation may be elicited on palpation. 3. Percussion. — Percussion is the method of examination by which we detect the various de- grees of resonance of different parts of the chest, depending upon the relative amount of air and •olid structure. It is best to use the fingers for percussing, one finger of the left hand being placed firmly over the point to be percussed, and struck with one or two of the fingers of the right hand, semi-flexed, so that the tips of ths fingers fall vertically upon the pleximeter finger. Percus- sion should be made from the wrist, not from the elbow ; the stroke should, as a rule, be light, and always perfectly even on the two sides ; sometimes a heavier stroke may be needed, but, as a rule, far more information is obtained from light than from heavy percussion. In comparing the percussion note over the two sidos of the chest, points exactly corresponding must be taken, and the pleximeter finger must be placed in a corresponding position ; for example, it must not he placed parallel with the ribs on one side and across them on the other. The sense of touch is very valuable in per- cussion in estimating resistance of the part struck. Dulness, and particularly the hardness and want of resilience over thickened adherent pleura, may thus be readily felt by the pleximeter finger during percussion. This sense of touch should be carefully cultivated, and its depriva- tion is a great disadvantage in the use of the artificial pleximeters and percussors first intro- duced by Piorry, although possibly these may be useful for demonstration to a class. The ob- server should not be content with comparing corresponding points on the two sides of the chest front above downwards, but he should in- variably trace any dulness or resonance from either side across the sternum to ascertain the limits of resonance or dulness in this direction. From neglect of this, important information is often missed. The height to which the pulmo- nary note extends above the clavicle on the two sides should be compared. Regions of the Chest . — For convenience in describing the distribution of signs, both of per- cussion and auscultation, it is customary to divide the chest into regions. The names employed to distinguish these regions sufficiently define their limits, namely, the supra-clavicular, clavicular, infra- or sub-clavicular, mammary, infra-mam- mary regions on each side in front; the superior and inferior axillary regions ; the supra-spiuatus, infra-spinatus, interscapular, and infra-scapular regions on each side posteriorly. (a) Normat. Percussion Signs. — There is a certain standard degree of resonance over the lungs, only to be duly estimated by experience, which is known as normal pulmonary resonance. In certain regions of the chest the pulmonary resonance is naturally lessened or replaced by dulness. Pulmonary resonance should commence 1^ inch above the level of the clavicle. In the clavicular and sub-clavicular regions, on firm percussion, the note should be even on the two sides, as low as the third rib. Below this level on the right side, we still obtain full resonance until we arrive at the fourth space, where in the mammary line the note becomes slightly raised and shortened, becoming dull in the fifth space and downwards to the margin of the cartilages. On very light percussion the pulmonary re- sonance may be obtained half a space lower, and at least an inch to two inches’ difference in level may be obtained between the extreme limits of deep expiration and inspiration. In the lateral (axillary) region the limit of percussion-resonance 1186 PHYSICAL EXAMINATION. reaches about an interspace lower. At the sternal margin it is a little higher, from the encroachment of the right side of the heart upon the inferior angle of the lung. Roughly, and for clinical purposes, a line drawn outwards from the base of the xiphoid cartilage may be said to define the upper border of the liver-duhiess. On the left side, in the line midway be- tween the sternum and nipple, we already, at the third cartilage, obtain elevation of pitch and shortening of the percussion note; and at the fourth space dulness.from the underlying heart. Between this (mid-sterno-nipple) line and the sternum, and bounded above by the fourth carti- lage and below by the level of the apex-beat, is the normal area of superficial cardiac dulness. In the nipple line at the corresponding levels 1 some deadening of percussion note may be obtained, but pulmonary resonance is otherwise clear to the sixth rib ; in the lateral axillary region to the seventh. Below the sixth rib in front, and the seventh laterally, stomach resonance is obtained. Over the sternum , percussion is naturally somewhat wooden and resisting, within degrees varying with the condition of the bones. The first piece of the sternum is normally some- what less resonant than the next two pieces, but it should be, on firm percussion, by no means dull. Below the level of the fourth cartilages the heart and liver cause the note to be dull, although even hero a certain degree of reson- ance is in health communicated from the adjacent right lung. In the posterior regions of the chest the degrees of resonance are almost entirely in ac- cordance with the thickness and character of superjacent tissues. Thus in the scapular and inter-scapular regions increased force of percus- sion is necessary to elicit pulmonary resonance, whilst in the lateral and infra-scapular region the percussion note is full and low-pitched. On the right side this resonance is replaced by dul- ness below the tenth rib, and deep percussion will elicit a certain impairment of resonance as high as the ninth rib, in the mid-scapular line. On the left side resonance should be good to the extreme base, except that in the posterior axillary line a small and restricted area of dulness may be sometimes made out, corresponding with the position of the spleen. (b) Mobbid Percussion Signs. — Modifications in the distribution of percussion-resonance over the chest may be produced either by general or by local causes. General causes.— Pulmonary vesicular emphy- sema, by enlarging the lungs and extending their boundaries, causes encroachment of pulmonary resonance over those regions — the prsecordial, . right infra-mammary, sternal, and right inferior basic, which are normally dull. In congenital smallness of lungs the boundaries of pulmonary resonance are somewhat retracted, so that liver- dulness in front and behind is slightly higher, and heart-dulness more extensive. Local causes. — One class of these are encroach- ments of other organs. Enlargement of the heart 1 By employing the terms ‘ lines ’ and ‘ levels ’ to mean the vertical lines and horizontal levels, in connection with definite anatomical points, e.g. mid-scapnlar-, nipple- lines, nipple-, second-, third , fourth-, &c., rib levels, any portion of the chcst-eurface may be accurately defined. will cause increased area of praecordial dulness upwards and to the left, or upwards and to the right, according as the left or right side of the heart is most affected. Effusion into the peri- cardium will cause similar dulness, extending up- wards towards the manubrium stemi, and to the right beyond the sternum. Aneurismal tumours in connection with the heart or great vessels, give rise to dulness, chiefly in the neighbour- hood of the sternum above the fourth carti- lage, or in one or other inter-scapular region. Enlargement of the liver and spleen will cause them to encroach upon the pulmonary resonance. Effusion into the peritoneum, if extensive, will cause displacement upwards of the abdominal organs and diaphragm, encroaching upon the lower area of pulmonary resonance, and even causing collapse of the lower portion of the lungs, thus giving rise to dulness. Effusion of fluid into the pleura will give rise to absolute dulness to the level to which the effusion extends upwards. The upper boundary of this dulness, if the lungs be sound, varies slightly with the position of the patient. In order, however, accurately to define the upper margin of dulness from fluid effusion the lightest possible percussion must be employed. In any case of considerable effusion into the pleura the dulness encroaches upon the median line, and to- wards the opposite side. See Pleura, Diseases of. The chief kinds of morbid percussion signs will now be discussed. Dulness, hardness, flatness . — These terms are by no means synonymous with regard to per- cussion sounds. Dulness varies infinitely in degree. Thus over a pleuritic effusion the tone- lessness is absolute : and to this degree of com- pleteness of dulness the term flatness of percus- sion-note is sometimes applied. There are but a few other chest-conditions in which such abso- lute dulness is obtained ; for example, extensive pericardial effusions, hydatid tumours, extensive malignant growths invading the lungs and in- filtrating the bronchi. In inflammatory conso- lidation of the lung there is always a certain degree of wooden tone in the percussion note. In cases of scattered patches, or nodules, of consolidation in the lungs, with air-containing tissue around, the dulness may be only very slight, amounting to a mere shortening of the note with elevation of pitch. In estimating the slight shades of dulness elevation of pitch is the first point to arrest the attention. Hardness oi percussion, always more or less appreciable with dulness, is associated especially with consolida- tions of lung overlaid by thickened adherent pleura. Skodaic resonance. - — In all eases of con- siderable effusion of fluid into the pleura, in whiclt the lung is not completely collapsed, a peculiar high-pitched tympanitic resonance is found at the sterno-clavicular region on the same side. This resonance, called Skodaic resonance, is a very characteristic sign, and has been attri- buted to relaxation of luDg still in contact with the chest-wall. As the effusion advances tc completely fill the chest, this resonance becomes replaced by dulness. When effusion of fluid follows upon pneumo- thorax, the lung, unless held above by stn nj PHYSICAL EXAMINATION. 118? adhesions, is already completely collapsed ; and above the level of the dulness caused by fluid there is a tympanitic note, caused by free air in the pleura. In this case the level of the fluid in the pleura shifts with every change in the position of the patient. Whether the effusion be of serum, pus, or blood, the percussion signs are the same. Wooden percussion-note is obtained by per- cussing over thickened pleura with some air- containing tissue beneath. The sense of re- sistance is marked, the pitch high, and the dura- tion of sound short. This degree of dulness, with increased resistance, is commonly present below the clavicle in cases of phthisis, with thickened pleura, and perhaps small, empty cavities, bounded by hardened lung-tissue. Amphoric or tubular percussion is the sound elicited by percussing over a superficial empty cavity, connected by adhesions to the chest- wall. The pitch varies with the size of the cavity, but is always somewhat high. The Eound can be exactly imitated by percussing the cheek drawn tensely over the teeth, with the mouth slightly open. Cracked 'metal sound , or bruit de pot file, is obtained by sharp percussion over a cavity such ns the above. Sudden displacement of air in the cavity will cause the sound, which somewhat resembles that produced by placing the two aands hollowed in apposition, and striking upon \lie kn.ee. A little secretion in the cavity will fa- cilitate the production of the sound. This sound may often be appreciated by the touch before it can be heard. It is of little clinical value. Bell-sound is elicited by combined percussion and auscultation, and when present is charac- , teristic of pneumothorax. The stethoscope must oe applied over the resonant part of the chest, md at another point within the same area a piece of metal, such as a coin, laid upon the chest, must be smartly struck with a second piece of metal. The auscultator hears a sound of a clear bell-like character within the chest, which is of .quite a different quality from that produced by the mere contact of metals. It is essential for the production of this sign that the stethoscope and the struck metal be both within the area of'ehest- surface corresponding with the air-containing sac of the pleura. If, for instance, either be placed over a point below the level of any fluid effusion present the sound will be lost, to be recovered .n altering the position of the patient so as to displace the fluid. By means of this sign, the imits of a pneumothorax may be accurately lefined. Hydatid fremitus is a vibratile sensation, (ometimes to be felt on smart percussion over an lydatid effusion. In cases of pyo-pneumothorax . similar sensation may sometimes be felt, on iercussing at the exact level of the surface of he effused fluid. 4. Auscultation. — Auscultation simply means he act of listening ; but the art of auscultation mplies a great deal more than this, namely, the ppreciation of the healthy or morbid conditions 'hich produce the sounds heard on applying the it to the chest or to other parts. If the ear f the observer be directly applied to the chest ’ part under observation, auscultation is said to be immediate. If some substance or instru- ment be used as a medium between the ear and the part under observation, mediate auscultation is said to be practised. Such an instrument is named a stethoscope. See Stethoscope. (а) Normal Respiratory Sounds. — If the ste- thoscope be applied over the trachea of a healthy person, tubular blowing, or bronchial respiration, is heard — that is, a sound as of air blown to and fro through a tube, and with moderate velocity ; the mechanism of the sound being the entrance and outflow of air-currents through the narrowed glottic aperture of the trachea, producing sono- rous vibrations within the tube below. As the stethoscope is passed downwards to the first piece of the sternum, the same sound is still heard, but more distant and muffled. In the upper inter- scapular region, where the great divisions of the bronchi arc comparatively superficial, the tracheal sounds may still be indistinctly recog- nised; but below and. aside from these points these sounds are normally obscured by the vesi- cular pulmonary sounds, into the production of which they, however, necessarily enter. • The pulmonary vesicular breath-sound is pro- duced by the friction of air entering the air-sacs from the minute bronchioles, and it is supple- mented by the conduction of what remains of the glottic breath-sound, now infinitely subdivided. During calm breathing the sound, accompany- ing inspiration should be soft and breezy, giving the idea of innumerable similar and associated sounds. In intensity the sound is even from commencement to near the end, when it fades without perceptible interval into the expiratory sound. The expiratory sound commences at the moment inspiration ceases, being continuous with the inspiratory sound, but it rapidly fades in intensity', ceasing to be audible after the first one-fifth or one-third of the expiratory act. Of the time occupied between the commencement of one inspiration and that of the next, the in- spiratory act occupies nearly one-half (A-ths), the expiratory act the remainder, with the ex- ception of a very brief interval of pause, between the end of expiration and the commencement of the next inspiration. It may here be observed that when the expiration is said to be prolonged, it is meant that the expiratory sound is audible through a longer period of the act than natural. If the respiration be hurried- and forced, the inspiratory sound is coarser and louder, and the expiration more audible, these sounds ap- proximating to the puerile breathing which is normal to young children. In health the vesicular breath-sound should be about equally well heard over the front and back of the chest, allowance being made for additional thickness of covering over certain regions. (б) Morbid Respiratory Sounds. — Puerile, compensatory, or supplementary breathing is characterised by increased loudness of vesicular breath-sound, with some prolongation of expi- ration. Besides being audible over the chest generally in healthy young children, this exag- gerated breath-sound may be heard over certain parts of the chest in persons who have some other part disabled or diseased. Thus, with effusion of fluid into one pleura, the respiraton PHYSICAL EXAMINATION. 1188 sounds over the opposite lung are exaggerated cr puerile. If one apex be diseased, the breath- sound at the other apex is exaggerated. This increased breath-sound to make up for deficient function elsewhere is called compensatory or sup- plementary breathing. The breath-sound may be enfeebled over the whole chest, as in cases of emphysema or thoracic muscular debility. Localised enfeeble ment of breath-sound may be due to several causes— (I) local emphysema ; (2) adherent and thickened pleura, as after old pleurisy at the base ; (3) blocking of the alveoli by catarrhal products — common in commencing phthisis at one apex; (4) closure of bronchial tubes by plugs of mucus, or from spasm. If the rest of the lungs be free, this local enfeeblement is made up for by com- pensatory breathing on the opposite side, or in other parts of the same lung. Suppressed breath-sound signifies removal of lung from the surface by effusion of air or of fluid into the pleura, or occlusion of a main bronchus by compression or morbid growth. Wavy and jerking respiration are terms cha- racterising a kind of respiration, in which the inspiration is either partially or completely in- terrupted several times. The expiration is rarely thus affected. Waviness of respiration may be due— (1) to an irregular action of the inspiratory muscles, common in nervous people; (2) to car- diac impulse, in which case these interruptions are rhythmic with the heart’s pulsation ; (3) unequally distributed impairment of the lung- elasticity, for example in early tubercle-deposits. Dr. Walshe considers that pleuritic adhesions may have the same effect. It will be seen then that waviness of breath-sound is very com- monly independent of any organic change, and requires other signs to render it of any value in diagnosis. Jerking respiration or interrupted breath-sound is more commonly due to organic lesions of the third kind mentioned. Cogged breath-sound is a somewhat clumsy term applied to a form of interrupted respiration in which the interruptions are very even, three or four to each inspiration. Much importance is attached to the sign by some authors. It ap- pears. to be due to obstruction in the smallest bronchioles, either by dryish secretion or small nodules of tubercle, requiring some accumula- tion of inspiratory force to overcome it. The sounds commonly give place to a bubbling rale. Harsh respiration with prolongation of expi- ration implies a want of vesicularity in the sound. Whilst vesicular breath-sound has been compared to the sound produced by the breeze passing through leaf-laden trees, harsh breath- ing, on the other hand, resembles a similar breeze traversing their naked branch-tops. Some prolongation of the expiratory sound is insepa- rable from harshness of breath-sound. Harsh- ness of breath-sound by no means implies in- creased loudness — rather the contrary. En- feebled respiratory murmur is commonly harsh — always so when due to alveolar obstruction. The meaning of harshness of breath-sound is simply commencing consolidation; it goes with incipient dulness, and is one of the earliest signs of apex-disease in consumption. There can be little doubt that its real mechanism depends upon the extinction of the vesicular part of thi normal breath-sound, and the better conductios of the glottic sounds, which at peripheral parts of the lung are usually muffled and obscured by the vesicular sounds. The prolongation of the expiration is very characteristic of this early alteration of the respiratory sounds; and it may here be observed, in passing, with regard tj morbid breath-sounds, that the expiration is the most important part of the respiratory act to attend to in auscultation. Divided respiration, usually described as a se- parate evidence of disease, is really an inseparable factor of harshness of respiration. Instead of the two component sounds, inspiration and ex- piration, fading imperceptibly into one another, they are more or less distinctly separate, the more so as the more typical bronchial type of breathing is acquired. Deficiency of elasticity is the cause to which the division is usually ascribed ; it is, however, a significant feature of glottic breathing. Bronchial respiration is most typically heard over simple lung-consolidation, as pneumonia at the base orapex. Skoda well describes the sound as acoustically identical with that produced bv placing the mouth in the position to pronounce the guttural ch (as in cAoir or Christian), and drawing the breath to and fro. The inspiratory and expiratory sounds are about equal in length, nearly r identical in pitch, and distinctly divided from one another. The sound varies in intensity and definition from the most intense tubular or tracheal breath-sound, to the lower-pitched and more diffuse blowing respiration {diffused bronchial breathing'). Besides hepatisation of lung, this form of respiratory sound may be produced by other condensations of lung, for ex- ample, Horn pressure, or by tumours extending from the neighbourhood of a large bronchus to the surface, such as enlarged bronchial glands, me- diastinal growths, and aneurismal tumours. The more diffused blowing sounds are due to less com- plete consolidation. Itis essential that the bronchi be patent, in order that bronchial respiration maybe heard; thus, in cases of cancerous growth invading a lung from its root and occluding the bronchi, no respiration is audible. As regards mechanism, however, it can scarcely be main- tained that the sound is produced by the passage to and fro of the air in the bronchi of the conso- lidated lung ; for (1) at the period when bronchial breathing is most distinct, the lung is immovably fixed by exudation ; (2) the play of the chest-wall on the affected side is almost or quite restrained: (3) the air-cells being occupied, there is no reason why air-currents should penetrate the bronchi. Hence it would seem that bronchial respiration is but the glottic breath-sonnd re- verberating through the bronchial tubes, and well conducted to the surface. A remarkable experiment of MM. Bondet and Chauveau (Revue Mensuclle, 1877) strikingly confirms this view. In a horse with hepatisation of the base of one lung and bronchial breath-sound over the part affected, the trachea was incised below the glottis, and the wound held widely open' the bronchial breathing immediately disap- peared, all respiratory sounds ceasing over this portion of lung, whilst elsewhere the vest PHYSICAL EXAMINATION. tolar breath-sound -was unimpaired. A musical reed was now inserted into the wound, and the musical sounds were well-conducted over the consolidation, but little audible over the healthy portion of lung. Cavernous respiration is a breatli-sound in which the inspiration and expiration have both a hollow blowing quality. It is to the expiration that the hollow wavering' quality characteristic of this breath-sound is especially attached, and, as pointed out by Dr. E. Thompson, the expi- ratory sound is lower in pitch than the inspi- ratory. Cavernous breathing signifies pulmonary cavity usually phthisical, — (1); exceeding in size an unshelled walnut; (2) either empty or at least partially so ; and (3) communicating with one or more patent bronchial tubes. Softening of tubercle or caseous pneumonia, pulmonary abscess, or bronchial dilatation of sufficient size, are the most common causes of cavity in the lung. This abnormal sound is formed by — (a) the passage to and fro of air into a cavity with the respiratory movements; (b) the con- duction and modified reinforcement of the glot- tic respiratory sound within a cavity. Amphoric breath-sound is a variety of caver- nous respiration having the same characters, but on an exaggerated scale ; that is, not necessarily exaggerated as regards loudness, but having all the qualities— blowing character and hollow- ness — intensified. This sound is heard over a large superficial cavity, either in the lung, or in the pleura freely communicating with the lung. Its mechanism is identical with that of caver- nous respiration, only that the size of the cavity ie large. (c) Adventitio ns Avscui/tatoby Signs. — A rale or rhonchus is a sound produced by impediment to the entry or escape of air within the lungs or bronchial tubes. The impediment may be from narrowing, or secretion within the tubes ; from secretion within the alveoli ; or from destructive softening or oedema of the lung-tissue. The rales that may be audible over the chest, are — sonorous , sibilant, crepitant, sub-crepitant, mu- cous, dry crackling, moist crackling, and caver- nous. Sonorous and sibilant rales are noises of a snoring or whistling kind, which are produced in the air-passages. They are audible with both inspiration and expiration (or with either), and are for the most part transitory sonnds, being temporarily or permanently removed by cough, or in other cases by the relief of the spasm which has occasioned them. They obscure or alto- gether mask the normal respiratory sounds. Any narrowing of an air-tube will give rise to a sonorous or sibilant rale according to the degree of narrowing and the size of the tube. Thus, if the larger tubes be affected, and the narrowing not great, the coarser sound is produced. If, on the other hand, the finer tubes be partially occluded, or a larger tube be greatly narrowed, the finer sibilus is caused. The rales are audiblo throughout the territory of the tubes affected. Thus if a main bronchus be compressed or nar- rowed, the sonorous rd/e so occasioned will bo heard throughout the lung on that side. Throat- sibilus in croup is conducted all over the chest. lias The precise causes of these rales are — (1) narrowing of a bronchus from external pressure (uncommon) ; (2) narrowing from local, cica- tricial, thickening and contraction of the fibrous coat of the tube (uncommon) ; (3) mucous col- lections in the tubes giving rise to imperfect plugs which vibrate, causing the musical sounds (very common) ; and (4) spasmodic contraction of the medium-sized tubes (sibilus in asthma). Dry rales signify — (1) Bronchial catarrh, or bronchitis, local or general, as the case may he, affecting the larger and medium-sized tubes ; (2) tumours pressing upon the trachea or one of the main bronchi ; (3) numerous minute bronchial obstructions occasioned by pulmonary miliary tuberculosis ; or (4) asthma. Stridor is a variety of sonorous rhonchus, due most generally to pressure of a malignant or aneurismal tumour upon a main bronchus, and heard chiefly over the corresponding side. It is a coarse, vibrating sound, which, however, the trained ear can readily detect to he of distant origin. Paralysis of the vocal cords will, in some cases, lead to stridor. Crepitant rale, or fine, dry crepitation, is a minute dry crackling sound, in which the crackles are infinitely small and even, and occupy chiefly the latter part of inspiration. The. sound has been compared to the crackling of salt upon the fire, or that produced by rubbing a pinch of hair between the fingers close to the ear. Probably the exact mechanism of the sound is the abrupt sepa- ration of alveolar surfaces, collapsed by inflam- matory or other oedema. But there are difficulties in the way of any present explanation of the sound. There are at least four conditions which will give rise to identically the same sound, as far as the ear can appreciate it, namely (1) incipient pneumonic consolidation (inflamed cedema stage) ; (2) ffidema of the lungs when not excessive, as in certain stages of kidney-disease, in obstructive heart-disease, &c. ; (3) mere collapse of lung from disease, crepitant rale being often tem- porarily heard from this cause at the extreme posterior bases, to disappear after a few deep inspirations ; and (4) certain cases of (edema of the pleura dependent upon old lung-disease. The fine crepitation of pneumonia is peculiar only in being associated with commencing tubu- lar breath-sound, the consolidation associated with which gives an increased intensity and de- finition to the crepitant rale. When associated with acute febrile symptoms, fine crepitation indicates the congestive stage of acute pneu- monia. If seated about the base, the pneumonia is most commonly of the typical croupous er exudative variety. If at the apex, or in patches, the disease may be incipient catarrhal or embolic (pyaemic) pneumonia. Sub-crepitant or muco-crepitant rale is a fine bubbling rale, of sharp definition, and well- conducted to the ear, audible principally dur- ing inspiration, but in less degree also with expiration. This rale is produced in the minute bronchioles and alveoli, by the penetration of air through a thin liquid. A certain amount of lung-condensation is necessary to give sharpness of definition to the sound. Sub-crepitant rale is most typically heard in the resolution stage of pneumonia. In the second (secretion) stage PHYSICAL EXAMINATION. 1190 of broncho-pneumoma it is also heard. There are many rale sounds intermediate between true dry crepitation and the sub-crepitant rale, which are fairly described by the general term crepi- tant rede, fine or coarse, according to their size. Many degrees of fineness or coarseness may be distinguished in different parts of the same lung in some pneumonic forms of phthisis, and it will be generally found in any such cases that the rales increase in coarseness as we ascend from below upwards. Dry crackle is the term used to describe a rale consisting of three or four distinct small crackles heard during inspiration. The crackles are dry in character, and sharpl-y defined. The inspiratory breath-sound attending this rhon- chus is usually feeble and harsh, the expiration harsh and prolonged, but unattended with any rale, unless it be some sibilus. Dry crackling most commonly signifies commencing softening of ‘ tubercular’ deposits, and the sound may be most frequently recognised in the sub-clavicular region, where this condition is most often found uncomplicated by conditions depending upon other stages of the disease. Moist crackle, or humid, clicking rale, con- sists of a few crackles, heard during the latter part of inspiration and the commencement of expiration, sharply defined, sometimes metallic in quality. The crackles vary in size and in the degree of liquidness, as must be the case from the mechanism by which they are produced. For this rale is significant of liquefaction of tubercular or caseous pneumonic nodules in com- munication with bronchial tubes ; and as such adjacent softenings coalesce and increase in size, the crackles become larger, until they develop into the gurgling or cavernous rale. The moist, crackle may be associated with other rales, since a softening caseous nodule is often sur- rounded by congested pulmonary tissue or pneu- monia, giving rise to fine crepitant or sub-crepitant sounds. As a rule the breath-sound is more or less masked by the crackling rale. Cavernous and gurgling rales are but larger and more liquid rales, produced in a cavity or cavities of moderate dimensions. Metallic tinkling rale requires for its develop- ment a large empty cavity in which it may be produced — (1) by the bursting of one or more air-bubbles through viscid contents ; (2) by the impingement of a drop of secretion against the cavern-wall ; or (3) by a bubbling rale pro- duced in a bronchus near the cavity, and freely communicating with it. In either case the large empty cavity, necessarily near the surface, re- sonates and re-echoes the sounds, and gives them their peculiar metallic quality, which has been likened to that produced by a pin dropping into a large empty bottle. Metallic tinkling is by no means solely significant of pleuritic cavity, as was supposed by Laennec ; it may be most typically heard over a large dense-walled empty pulmonary cavern. Metallic echo is sometimes confounded with metallic tinkle, with which it is often associated, and, indeed, of which it may be said to form a part. It is really not a rale at all, however, but an echo in a large cavity, produced — (1) by air- vibraninj caused by cough ; (2) by vibrations on i the surface of fluid with a large air-space above or (3) by vocal vibrations reaching through the cavity after true Toice-sound has died away. Hippocratic succussion-soimd is the splaahin" sound heard in a pleura containing both air and fluid, on shaking the patient somewhat vigo- rously, while the ear is applied to the chest- surface. Cough-sounds. — A cavernous splash sound may frequently be heard on listening over a cavity, and causing tho patient to cough, the forcibie entry of air into the cavity in itself largely con- tributing to the sound, and setting up gurgling and splashing rales by the disturbance of con- tained fluids. Cough-sounds require no explanation, but they should be invariably tested in chest^examination". Crepitant sounds are often developed after a cough, which are not to he heard either on ordi- nary or deep inspiration without it. Cavities which are not in free communication with bron- chial tubes may yield no characteristic breath sounds ; but the forcible propulsion of air into them at the moment of chest-compression with closed glottis elicits at once a characteristic localised snccussion-sound, attended with more or less coarse gurgling rale. Voice-sounds. — In the ordinary healthy spongv condition of lung, the voice-sounds are heard but distantly and imperfectly, save in certain parts of the chest in the neighbourhood of the trachea and its bifurcation, that is, in the upper sternal and the upper interscapular regions, where the sounds are better conducted. Bronchophony. — At any portion of the chest where there is consolidation of lung, in associa- tion with patent air-tubes, the voice-sound is heard loudly, as though produced near or close, under the stethoscope. Although loudly heard, the sound appears to pass away from under tho stethoscope. Any solid medium of conduction between a large bronchus and the stethoscope will give rise to bronchophony, whether by super-position, or by the portion of bronchial tree concerned being imbedded in solid lung, as in lobar pneumonia, of which the sound is most typical. If, however, between the conducting medium and the larynx the bronchial channel he occluded, bronchophony is no longer heard, the voice-sounds being enfeebled or annulled. Pectoriloquy. — If, on the other hand, a cavity be present beneath the spot auscultated, and in free communication with a bronchus, the voice- sound appears to be concentrated at the end cl the stethoscope, and to pass through the instru- ment direct to the ear, with exaggerated and even painful distinctness. It is rather the noisi of the voice that we hear in bronchophony, but in pectoriloquy the sounds are most distinctly arti- culated. This distinction is even better appre- ciated by listening to a whisper, which under bronebophouie conditions is merely a conducted hissing sound, whilst in pectoriloquy each syllable penetrates distinctly to the ear. Pectoriloquy may, however, he clearly, although not exactly, imitated by consolidated lung in the neighbour- hood of a large bronchus. Hence the diagnosis of a cavity near the root of the lung requires much caution. JEgophony. — JEgophony is a form of modified PHYSICAL EXAMINATION. bronchophony in which the voice-sound, conducted through condensed lung, has further to penetrate a thin layer of fluid in which the coarser vibra- tions are lost, a certain quavering nasal quality being given to the sound that reaches the ear. It is significant of effusion into the pleura. The Bound is only to be heard near the upper limits of the effusion, where the layer of fluid is thin. With regard to the mechanism of these three sounds — bronchophony, pectoriloquy, and aego- phony — there can be no dispute about their being glottic sounds. In bronchophony they are conducted through subdividing tubes of increas- ing fineness enveloped in solid tissue ; hence the sounds, although loudly heard, are not well- defined, being largely converted into the coarser vibrations perceptible to palpation as fremitus. In pectoriloquy , on the other hand, the glottic sounds are conducted through tubes which, after one or two divisions, terminate in a resonating cavity ; hence the vocal vibrations are concen- trated and conducted with intensity to the ear as through a speaking-tube. Finally, in agophony one may suppose the bleating character of the sound to be due to secondary, and to a certain extent disturbing vibrations in the fluid medium through which the sounds are conveyed. In sego- phony one may commonly note a lisp or whisper- sound in addition to the voice-sound, and better conducted than the voice-sound. And it has been affirmed by Bacelli that in cases of serous effusion into the pleura the whisper is heard well-conducted with distinct articulation — pcc- toriloquie aphonique — through the thicknessof the fluid, whereas in purulent effusion such whisper is not conducted. This statement will be found to apply, however, only in certain cases. The whisper may sometimes be heard well-conducted through purulent fluid. The voice-sounds are weakened or wholly ex- tinguished by conditions which — (a) shut off the main bronchi from the part auscultated, as in malignant growths invading the bronchus at the root of the lung ; (4) separate the lung-surface from the thoracic wall, as in pleuritic effusions, (edematous thickening of pleura, &e. (Here, however, we must make exception in certain eases, in which pectoriloquie aphonique is heard); (c) in rarefaction of the lung by emphysema the voice-sound is enfeebled ; and (cf)inpneumothorax it is either much enfeebled or annulled. In cases of pneumothorax, however, a faint metallic echo may often be heard with, or rather after, the voice-sound. This echo has probably a precisely analogous mechanism to segophony, save that the medium of secondary conduction is air in- stead of fluid, and hence the conduction is less distinct. Autophony. — On listening over a superficial cavity with condensed lung-tissue around, the voice of the auscultator — for example, when re- questing the patient to cough or to speak — will be noticed by himself to he intensified. The term autophony is applied to this increased re- sonance, which is a sign of little clinical value. Pleural sounds.— The sounds originating in diseased conditions of pleura are commonly in- cluded under the general term 1 friction sounds ’ — a term, however, very inadequate to describe the varieties. 1x91 Th & pleuritic nib or dry friction is a wavy or uneven rubbing sound heard close under the ea" with both inspiration and expiration, but chiefly with the former, unmoved by cough, and usually attended with pleuritic pain. We may often fail to obtain this sound, through the patient involuntarily restraining the movement of the affected side on account of the pain. A deep in- spiration must, therefore, be always called for. In well-marked cases the friction is very loud and leathery, and may be perceptible to the hand applied — -friction fremitus. Pleural creaking is a sound that may he some- times distinguished over a portion of the chest, when the pleurae are densely thickened and adherent. Moist or spongy friction is most difficult to distinguish from fine moist crepitation. It is heard almost entirely at the end of deep inspira- tion, and closely resembles the crepitation of a moist sponge. The sound is due to the pleura being adherent by moist, recent lymph, as in the early stage of adhesive pleurisy in pleuro- pneumonia. In cases of cedema of the pleura a fine crepi- tating inspiratory sound or pleural crepitus may be heard, which it is impossible to distinguish from a pulmonary sound. The diagnosis must rest upon the very superficial character of the sound, and its being unchanged by cough ; also upon its being associated with deficient breath- ing without tubular quality, and with lessened vocal fremitus. It is an inspiratory not an ex- piratory sound, being engendered by the pulling out of the spongy oedema-tissue during inspira- tion. 4. Circulatory System, Physical Exami- nation of. — The condition of the heart and circulation may he investigated with great ex- actness, chiefly by palpation, percussion, and auscultation. Polsb. — The p'ulso gives ns very important information respecting the state of the circula- tion. Por a full description of the pulse and its different characters in disease, sec Pulse ; and Sphygmograph. Heart. — (a) Inspection. — In health and during quietude the cardiac impulse is barely perceptible. Under excitement, however, throb bing impulse may be noticed over the prsecordia and left epigastrium. In cases of great hyper trophy and dilatation of the heart, especially in children, the praecordial region may he obviously bulged. The impulse of the heart may be ob- served to be diffused over an increased area, between the nipple-line and sternum, in cases of hypertrophy and dilatation. In cases of dilated hypertrophy of the right ventricle, or in displace- ment downwards of the heart in emphysema, the impulse is very perceptible at the epigastrium to the left of the eusiform cartilage. A diffused un- dulating impulse may he observed in some cases of pericardial effusion and in adherent peri- cardium. The heart is often uncovered, and its impulse revealed on one side or the other by re- traction of the lung in contractile or wasting pulmonary diseases. (4) Palpation. — The position of the heart’s apex should first he ascertained; and the area. 1132 PHYSICAL EXAMINATION. force, and rhythm of the cardiac pulsations, and the presence or absence of thrill or other adven- titious palpation-signs, should next be noted. Normally the heart, enclosed in its own peri- eardial sac, is situated in the anterior and central part of the thoracic cavity, immediately above the diaphragm. Its position may be roughly defined as within the area bounded above by a line drawn across the sternum at the level of the lower border of the second cartilages; on the left by a vertical line passing just within the left nipple ; and on the right by a similar line drawn at one-third of the distance between the border of the sternum and the right nipple line. A slanting line from the base of the ensiform cartilage to the upper border of the sixth rib in the left nipple line defines the lower border of the heart. Behind this area the heart lies ob- liquely, its base directed upwards to the right and backwards, its apex to the left downwards and forwards. The organ, moreover, is so placed that the right auricle and ventricle occupy nearly the whole anterior surface ; the left auricle and ventricle the posterior and left surface. The apex of the heart in the adult impinges in the fifth interspace, one inch within the left nipple line. The aortic and pulmonary valves correspond with the upper border of the third left cartilage at its junction with the sternum, the aortic being on the right of and a little lower than the pulmonary. A lino drawm from the middle of the third left cartilage as it joins the sternum, to the upper border of the fifth right cartilage at the sternal margin, would correspond with the mitral valve superficially and above, the tricuspid more deeply and below. An altered position of the apex-beat may arise from congenital displacement of the organ, for example, from transposition of viscera. It may arise from enlargement of the organ by hyper- trophy or dilatation, affecting its right or left cavities ; or from displacement of the organ, for instance, downwards, by emphysema, aneurism, or tumour; aside, by pleuritic effusion, malignant disease, or contraction of lung ; upwards, by abdominal distension, disease in the abdomen, or sontraction of lung. In continuance of palpation, the condition of the arteries and veins at the root of the neck must be observed, whether the arteries unduly pulsate, or the veins on one side or both remain full, or pulsate. (c) Percussion. — The praecordial dulness may be enlarged by retraction of the margin of one or both lungs ; by effusion of fluid into the peri- cardium ; or by enlargement of the heart itself, either general or restricted to one or more of its divisions. The cardiac dulness may be diminished or obscured by enlargement of the lungs enveloping it, or by air effused into the pericardial sac. (d) Auscultation. — By the simultaneous con- traction of the ventricles, the closure of the mitral and tricuspid valves, and the impinge- ment of the apex of the left ventricle against the ribs, a single sound is produced, the first sound of the heart. The sudden tense closure of the mitral valve is the principal cause of this s ide, sometimes on both. If there be pressure on he trachea or large bronchi, or if there be para- ysis of therecurrent laryngeal nerve, many of the nuscular strains already noticed may be present ; f there be paralysing pressure on the sympa- hetic, the pupil on the same side will be com- PHYTOSIS VERSICOLOK. 1197 paratively contracted, all the tissues on the side more swollen, and the secretions increased. If with aneurism there be aortic regurgitation, violent pulsation of all the arteries will usually be noticed, bringing into strong relief arteries generally quite unseen. In these illustrations the appearances seen in the head and neck only are considered. If the modification of bodily conformation, movements, and attitudes which go to make up the full physiognomical picture were also detailed, a large addition, exceeding the limits of this ar- ticle, would be involved. But even so much as is here portrayed will serve to remind us of the large amount of suggestive information which may be gleaned by the observer before proceeding to actual physical examination of the patient, and may stand for an example of the process which, under careful training and prac- tice, is at last performed almost unconsciously by the experienced physician. William M. Oed. X PHTSOMETEA (cpvaa, air, and firirpa, the womb). — A condition in which a collection of gas or air is formed in the uterus. See Womb, Diseases of. PHYTOSIS (, I congeal). — A term associated with phlegm or expectoration, wheD this is of the nature of thick and adhesive mucus. See Expectoration. PITYRIASIS (irlrupov, bran). — Stnon. : Furfur; Porrigo ; Fr. Pityriasis-, Ger. Kleien- grind. Definition. — A branny exfoliation of the skin ; giving rise to scurfiness or scaliness of the epi- dermis ; and accompanied with heat, dryness, redness, and pruritus. JEtiologt. — The cause of pityriasis must be regarded as a feeble state of the skin, probably dependent on a low condition of the general system. In a symptomatic form, however, it may be due to the causes which control the parent disease, as in the case of eczema. Anatomical Characters. — Pityriasis is a su- perficial chronic inflammation of the skin, with- out exudation or swelling, but especially charac- terised by disturbed nutrition of the epidermis and its desquamation in minute scales. Essen- tially it is a mild manifestation of eczema, and must bo regarded as one of the forms of dry eczema. Description. — The most common seat of pityriasis is the scalp — for example, P. capitis-, and in that situation it may present several de grees of severity, ranging between the pityriasis with silvery scales of elderly persons ( rerasia ). or the mere accumulation of epidermic exuria? in children and young persons, called ‘dandruff,’ and the more extensive desquamation, attended with chronic inflammation, of a declining ec- zema or even of psoriasis. On the sensitive skin of children, particularly those of light complexion, it is apt to appear on the face in the form of small, circular, reddish discs, coated over with a fine furfur ; and occa- sionally it is met with in patches on the body and limbs, and always maintaining the same characters, namely, heat, redness, and pruritus, but a total absence of serous exudation. The term pityriasis, whilst strictly signifying an exfoliation of fine scales upon a skin which ir more or less congested, yet falls short of the acti- vity of eczema, has also been applied to a fur- furaceous state of the skin accompanying other morbid affections of the texture ; for example, elephantiasis Grtz-corum, and especially xero- derma in its transition to ichthyosis. Another form of exfoliation of the epidermis associated with a yellowish pigmentation of the skin, re- ceived from Willan the name of pityriasis ver- sicolor ; but as the pathological conditions of the latter are totally different from ordinary pity- riasis. and are identical with the phytiform or so-called parasitic diseases, this affection will be found treated of under the head of Phttosu versicolor. PITYRIASIS. Diagnosis. — The description of the physical gigns and the pathological condition of this af- fection will sufficiently distinguish it from other diseases ; although, as will be perceived, it may be an accidental accompaniment of a variety of cutaneous affections, such as dry, chronic eczema. Indeed, its idiopathic form is its rarest manifes- tation. Prognosis. — Taken by itself, pityriasis must be regarded as a trivial affection, and one which will speedily yield to appropriate treatment. Treatment. — Our efforts in this direction ' should be aimed at the improvement of the nu- tritive function of the skin, aud the relief of local inconvenience or suffering. The first indication is to bo met by general tonics, and by the exhi- bition of small doses of some arsenical prepara- tion; and the second by the application of the red oxide of mercury ointment in a diluted form ; (one part to three), or the oxide of zinc ointment. The former remedy is the more suitable for the Bcalp or hairy regions of the body ; and the latter for the unprotected surface of the face and trunk. Eeasaics Wilson. PITYRIASIS VERSICOLOR (ir irvpoy, bran, and versicolor, of changing colour). — A synonym for phytosis versicolor. See Phytosis Versicolor. PLACENTA, Diseases of. — Synon. : Fr. Maladies du Placenta ; Ger. Kranklieiten dcs Mutterkuchens. — The frequency and importance of placental disease is hardly yet sufficiently recognised; and forty years ago, when the late Sir James Simpson published his memoir On Congestion and Inflammation of the Placenta, almost nothing was known on this subject. The placenta being the sole medium of vital Communication between the foetus and mother, [any deviation from its normal condition, by which its development may be arrested, and its physiological action impaired, must be of serious :onsequence. The principal diseases to which the placenta s subject are: — 1. Inflammation; 2. Conges- ion ; 3. Haemorrhage ; 4. Hydatidinous degenera- ion; 5. Fatty degeneration; 6. Atrophy; 7. Typertrophy ; 8. (Edema ; and 9. Calcareous leposits. 1. Placenta, Inflammation of. — Synon.; Tacentitis. — Acute inflammation of the after- irth is the sole cause of those morbid adhesions .hat occasion the most serious dangers of parturi- ion, namely, post-partum haemorrhage and in- ersion of the uterus. Moreover, it sometimes mses the death of the foetus by destroying the tructural integrity of the placenta. The dis- use is generally syphilitic in its origin. ; Symptoms. — The symptoms of placentitis are ) obscure that it is seldom detected until after ie birth of the child, when we find the placenta iherent. In many cases, however, this disease is attended y constitutional irritation or febrile disturbance ) a remittent character. A very usual symptom : placentitis is the return of morning sickness ■ the later months of pregnancy, together with dull aching pain, or a sensation of weight and .lness, over the hypogastric or iliac regions. The *76 PLACENTA, DISEASES OF. 12-H placental souffle will also be found intensified in sound, or abnormal in some other respect. Treatment. — The treatment most in use for placentitis is a mild alterative course of mercury conjoined with tonics, and followed by iodide of potassium. Severe local pain may be relieved by leeching, or by the application of oleate of mer- cury with morphia, or by iodated liniments. 2. Placenta, Congestion of. — This con- dition is occasionally met with after a pro- tracted labour, the placenta being then found engorged with blood, hard and tumefied, its external surface of a deep purple colour, and covered with a raised network of tortuous and congested vessels. Acute congestion, from the sudden engorgement of the placental vessels, may also arise at any period of pregnancy, from general plethora, or the recession of some acute inflammatory disease. It may also be occasioned bv the sudden check to the placental circulation from the death of the embryo. The diagnosis between congestion and inflam- mation of the placenta is impossible ; and the treatment is the same in both cases. 3. Placenta, Haemorrhage into. — Acute congestion of the placenta generally terminates by haemorrhage into either the deciduous or cellular (maternal) portion ; into the villous or vascular (fcetal) part of this organ ; or in some cases into the cellular interspace between these, thus constituting what Cruveilhier described as ‘apoplexy of the placenta.’ Haemorrhagic effu- sions of this kind are a frequent cause of mis- carriage. Occasionally, especially amongst the ill- treated wives of the labouring classes, placental hemorrhage is the result of external violence or shock. The effusion then generally takes place from the central external surface of the pla- centa, which is thus partially separated from the uterus ; but if the effusion be limited to a few ounces, gestation may go on undisturbed. 4. Placenta, Hydatidinous Disease of. — This consists in degeneration and abnormal development of the placental villi of the chorion, usually following, although occasionally produc- ing, the death of the foetus. In th ^Dublin Obstet- rical Transactions for 1874-9, the writer has related several instances of this comparatively rare disease. In most of these eases the hyda- tidiform mass was expelled from the uterus at the fifth month. See Mole. Symptoms. — The symptoms of this disease can at first hardly be distinguished from those of ordinary pregnancy. If, however, in addition to the signs that usually denote the death of the foetus in utero, the patient experiences occasional gushes of water, together with slight haemorrhage from the uterus, lasting for a short time, and recurring at irregular intervals, we may suspect the existence of hydatidiform disease in the pla- centa of a blighted fetus. The expulsion of these growths from the uterus is generally attended by severe haemorrhage. Treatment. — In the way of treatment, nothing can be done to arrest the progress of the disease, although chlorate of potasli has been suggested for thepurpose. But an attempt should 1202 PLACENTA, DISEASES OF. always be made to prevent its recurrence by im- proving the general health of the patient by alteratives and ferruginous tonics, especially any of the milder saline chalybeate waters, such as Ems, Kissingen, or Schwalbach, It has been recommended that we should bring on the expulsion of hydatidiform moles as soon as they are discovered. This, however, is in- advisable. Only a portion of the placenta may- be affected; or, as the writer has seen, the birth of a healthy living child may be immediately fol- lowed by the hydatidinous placenta of a blighted twin conception. Hence, we should let nature take her course, for in due time the morbid growth will be surely expelled from the uterus, rather Ban by unnecessary interference run the risk of lestroying a living foetus. 5. Placenta, Fatty Degeneration of. — This is a common disease. The late Sir James iimpson, Virchow, and Dr. Druitt, as well as tome earlier writers, have discussed the nature jf the affection, on which more light has been iince thrown by Dr. Barnes’s papers in the 34th and 36th volumes of the Medico- Ckirurgical Transactions , and by Dr. Braxton Hicks’ re- searches in the 14th volume of the Obstet- rical Transactions. The symptoms and treatment of this condition are so obscure, however, that it vill be unnecessary to dwell on it in the present vork. 6. Placenta, Atrophy of.— Atrophy of the placenta is an occasional cause of the death of the feetus between the sixth and ninth months of gestation. The uterine placental villi in such cases are arrested in their development, under- going a retrograde metamorphosis into an opaque molecular substance, generally accompanied by- fatty deposits in the umbilical terminal vessels of the foetal portions of the blighted organ. 7. Placenta, Hypertrophy of. — This is a much more rare pathological condition than that (ast mentioned. We sometimes, however, find the placenta greatly enlarged without any other apparent alteration in its structure, and in such eases the child, if alive, is usually diminutive and puny-, being stunted not only by the blood having been diverted from its nutrition, but still more by the compression of the terminal umbilical vessels. 8. Placenta, (Edema of. — Effusion of serum is another consequence of placentitis. In the few cases of this kind that the writer has seen, abortion occurred, and the placental villi w-ere enormously distended and bloodless, being filled with a serous fluid. In one instance, in addi- tion to the dropsy of the placenta, the umbilical cord was cedematous to an extraordinary extent. 9. Placenta, Calcareous Deposits in. — Cal- careous deposits are sometimes met with in cases of adherent placenta, being usually situated in the external or uterine surface, and in the decidual vessels. In some instances, however, the writer has found these deposits scattered throughout the whole substance of the afterbirth. Thos. Moke Madden. PLAGUE (n\-riyv, plaga. a stroke). — S t- non. : The Pest; Inguinal, Bubonic, Glandular, PLAGUE. Oriental, Indian, Pali, and Levantine Plague, Oriental Typhus; Septic Pestilence; Pr. la Teste ; Ger. die Pest. Definition. — A specific fever, attended by bubo of the inguinal or other glands, and occa- sionally by carbuncles. History. — The term plague is used by the older historians in two senses, (1) in a general sense, as applicable to the prevalence of diseases accompanied by great mortality, irrespective of their nature ; and (2) in a limited sense, as in- dicating the particular malady defined above. The earliest notice of the disease now designated plague is found in a work of Oribasius, the physician to the Emperor Julian (a.d. 361— 363). He quotes from Eufus (Alexander) of Ephesus, a writer who lived in the reign of the Emperor Trajan (a.d. 98-117), a passage from which it would appear that plague had been known as an endemic, and occasionally as an epidemic, in Libya (North Africa), Egypt, and Syria, from the end of the third or beginning of the second century before Christ. The first appearance of plague in Europe is referred to the 6th century of the Christian era. In the reign of the Emperor Justinian (a.d. 527-565) the disease underwent a development previously unknown. According to contemporary histo- rians, it broke out in Egypt, explosively, and presenciy spread thence to the neighbouring countries of Africa and Asia; invaded and ex- tended over the whole of Europe ; and generally became disseminated throughout the then known world, causing frightful mortality wherever it showed itself. From this period, it is inferred, plague became established in Europe, being sometimes more, sometimes less prevalent, for the 1,300 years following — indeed, until the ninth lustrum of the present century-. The great pestilence, most familiarly known as the black-death, which swept over the western hemisphere in the 14th century, causing an inconceivable mortality, aDd which has been designated black plague, although presenting several of the symptoms of bubonic plague, is held by some epidemiologists to have differed essentially from that disease. The black-death, according to these writers, was particularly characterised by a gangrenous inflammation of the respiratory organs, violent fixed pains in the chest, vomiting and spitting of blood, and a horribly- offensive and pestiferous breath, which could be perceived at a considerable dis- tance from the patient. Such symptoms dis- tinguished, these writers think, the disease from bubonic plague. Moreover, it is noted that while bubonic plague had had its apparent source in Egypt seven centuries before, black-death, accor- ding to contemporary writers, had its origin in Cathay- (Northern China), and issued thence to devastate the world. IVriters who regard black- death as a different malady- from plague, hold that the pestilential manifestation of the disease began and ended with the dreadful outbreak of the 14th century-, and that the malady has long been extinct. Other writers consider black-death to have been a modification of bubonic plague. But if this view be accepted, the extraordinary develop- ment and remarkable modification which the dis PLAGUE ease underwent in the 14th century, stand quite done in the history of the affection, and consti- :ute phenomena which would have to be regarded is indicative of a secular evolution of morbid Langes ( see Periodicity in Disease). This last- lamed view of the relation between black-death ind bubonic plague is not without a present in- terest. For Hirsch and others believe that the Mahamari of Northern India — the Pali, or Ju- lian plague, as the disease is also termed — - rhich has several times prevailed as a local epidemic since the commencement of the present entury, is a disease analogous to the black- Jeath of the 14th century . Probably these wri- ers would now include the more recently known Yunnan plague in the same category. In the loth century the countries in which ilague was habitually present or recurred at ntervals, included Northern Africa, Egypt, West- rn Arabia, Syria and Palestine, Asia Minor nd Mesopotamia, Persia, probably India and 'kina, and Europe generally. Throughout the 6th and 17th centuries there are almost con- nuous records, from year to year, of the pre- 3 nce of the disease, in greater or less activity, •-ithin this area of prevalence (Carl Martin, 'elermann's Mittheilungen, Juli, 1879)- During he latter half of the 17th century a remark- ole lessening of the area of prevalence of le disease began to take place. As regards urope, in the course of the twenty years 161-1681 plague disappeared from Italy, ngland, Western Germany, Switzerland, the etkerlands, and Spain. This lessening of area ntinued throughout the 18th century, the imber of serious outbreaks of plague also minishing, two only having occurred in that ntury, namely, (1) in 1703-13, (involving irkey, Hungary, Russia, Poland, Austria, Bo- mia, and Eastern Germany), and (2) in 1720- • (Provence). At the close of the first third of e 19th century, the area of prevalence of the sease had shrunk to the easternmost part of 3 Turkish Empire in Europe ; and in the year 41 plague ceased on the Continent altogether. While this change had been taking place in irope, a corresponding change had been mani- ted in the prevalence of the disease in its •oitats elsewhere. Before its complete cessa- n in Europe, plague would appear to have appeared fromNorthern Africa (except Egypt), m Mesopotamia, and from Persia ; the exist- ' '6 of the disease in Asia Minor, Syria, and testine came to an end in 1843; and in the ;.r 1844, with the cessation of the malady in - fpt, plague seemed to have become wholly 1 inct, and Europe to have got rid of a terror ’ ich had harassed it for ages. t is noteworthy that during the period of the l.gressive narrowing of the limits within which 1 gue prevailed, and until its disappearance, the t :ase manifested no abatement of those charae- tj sties, as well in respect to rapidity of course, ''he nature of the symptoms, and to its fatality, 1 ch had made it the dread of Europe and the i ant. The outbreak of 1665 in London, which P leded the disappearance of the disease from 1 land, and which is known as The Great Plague °\ ondon-, also the outbreak of 1720inMarseilles, v :h preceded the disappearance of the disease 1203 from France, have become historical from the fatality which accompanied them. Hardly, if at all, less terrible was the outbreak in Moscow in 1770, and the later outbreaks in Turkey, in Syria, and in Egypt. Even at the present day the traveller in Persia and Kurdistan comes upon communities the growth of which has been arrested, and the ruins of villages which have beer, depopulated, by the ravages of plague earlier in the century. Notwithstanding the disappearance of plague from its last-frequented haunts, certain epide- miologists, and notably Gavin Milroy in this countiy, having regard to the long intervals which had occasionally been observed between recurring epidemics of the disease, doubted its cessation. Their doubts were presently confirmed by the re-appearance of the plague in the Levant. This happened in 1853 (nine years after the presumed cessation of the disease in Egypt) in the Assyr country, Western Arabia, where a circumscribed outbreak occurred. Other local outbreaks followed at intervals in different places, in the order and countries here noted : — 1853, the Assyr district, Yemen, Western Arabia ; 1858-59, province of Bengazi, Regency 7 of Tripoli, North Africa ; 1863, district of Maku. Persian Kurdistan; 1867, the marsh district on the right bank of the Euphrates, south and west of Hillah ; 1870-71, Persian Kurdistan, in the district south-east of Lake Urumiah; 1871-73, Yunnan province, Western China; 1873-74, the marsh district on the left bank of the Euphrates, south of Hillah and the position of ancient Babylon. This outbreak proved to be the beginning of a manifestation of the dis- ease, which in the course of the years 1S74-75, 1875-76, and 1876-77, showed itself over an area extending from Bagdad on the north, to Suk-e-Sheyukh on the south, and from the banks of the Tigris and Shat-el-Hai on the East to the borders of the Syrian desert on the west. Hil- lah suffered from this outbreak in 1 876 (recorded death? 1,007), and Bagdad, both in 1876 (re- corded deaths 2,611) and 1877 (recorded deaths 1,672). The outbreak of 1873-74 on the Lower Euphrates was not the only appearance of plague at that period. Two other. outbreaks occurred in 1874, one in the Assyr district, Western Ara- bia (the scene of the outbreak of 1853), and another in the province of Bengazi, Regency of Tripoli (the scene of the outbreak of 1858-59 ). In 1876, in addition to the then prevalence of the disease in the district south of Bagdad and on the Lower Euphrates, plague broke out in the Shuster-Dizful district, Kkuzistan, south- eastern Persia ; and before the close of the year it had shown itself also in two villages of northern Persia, situated about twenty-five leagues from the south-eastern angle of the Caspian Sea. The same year also there was an outbreak of Malta- mart, in the mountainous district of Kumaun, North-western India, which did not terminate until the following year. In 1877 an outbreak occurred at Resht, the capital of the province of Ghilan, Persia, and in the surrounding district. Ghilan lies at the south-west angle of the Cas- pian Sea. The same year cases of a fatal bubonic febrile malady 7 occurred in the district of Baku, on the Caspian shore of Transcaucasia ; and aD 1204 PLAGIjE. outbreak of a non-fatal bubonic affection took place in Astrakhan and its vicinage, since recog- nised as a form of plague. At the beginning of 1878 plague was reported in the district of So- uj-Bulak, Persian Kurdistan; and in October the disease broke out at Vetlianka, a Cossack settle- ment on the Lower Volga, in the province of Astrakhan, Russia in Europe, and prevailed there and in the adjacent districts on both banks of the river, until February, 1879, with the excep- tion of an isolated case, or more than one, which was observed in the following month. Since this outbreak, when, after thirty-seven years’ absence, plague re-appeared on European soil, the disease has shown itself again (Feb- ruary-June 1879) in the Assyr district, Western Arabia, and there have been doubtful rumours of its presence in Persian Kurdistan. ^Etiology. — Plague is observed to bedeveloped under two principal sets of conditions, namely, (a) certain local states, physical or social, or both, as the case may be, affecting communities ; and (b) certain relations between persons sick of the disease and healthy persons. To these must be added (e) particular seasonal influences. (a) The local condit ions which favour the deve- lopment of plague were made the subject of care- ful study by a commission of the French Academy of Medicine, in 1844. The report of this com- mission, prepared by Prus, sums up and repre- sents the then existing knowledge on the subject. According to the commission, plague was a pro- duct of Egypt (where it was held to be endemic), Syria, the two Turkeys (Turkey in Europe and Turkey in Asia), and many other countries of Asia, Africa, and Europe; and the conditions ‘which determined and favoured’ the development (birth' of the disease among communities there, were : — dwelling upon allu- vial and marshy soils, notably such as were found near the shores of the Mediterranean, and on the banks of certain great rivers, the Nile, the Euphrates, and the Danube being specified ; a warm and humid atmosphere ; low, badly ventilated and crowded houses ; great accumula- tions of putrefying animal and vegetable matters in the vicinity of dwellings; unwholesome and insufficient food ; excessive physical and moral misery; and neglect of the laws of health, as well public as private. The recent, appearances of plague have served to correct some, and to confirm others of these conclusions of the commission. Plague is no longer endemic in Egypt ; but of late years, as already stated, it has broken out in several widely separated places of Africa and Asia. In these outbreaks (excluding from considera- tion for the present the outbreak in Astrakhan province), the disease appears to have been a local product determined by as yet entirely unknown conditions. The term 1 spontaneous ’ is frequently applied to such developments of dis- ease, but is best avoided as implying more than is warranted by our present knowledge. Again, the recent outbreaks have shown (and Tholozan has particularly' dwelt on this subject) that plague is, perhaps, as much a disease of the highlands as the lowlands. This is evidenced by its persistence, in Kumaun, on the Himalayan mountains, and among the mountains in Western Arabia and in Yunnan. The outbreaks in Persian Kurdistan in 1870-71, and in the province of Bengaziin 1873-74, took place on elevated table- lands. The outbreaks also of 1853 and 1874 in Western Arabia took place among the high- lands. But, if a less restricted topography must be assigned wherein plague may mamfest itself as a local product, so to speak, the later prevalences of the disease confirm folly the conclusions of the Commission of 1844 regarding other conditions of development which are not peculiar to any country or locality. The out- break of 1858-59 in the province of Bengazi followed upon four years’ drought and failure of crops, at a time when the greater part of the flocks and herds had been destroyed from want of food, and by a fatal epizootic which prevailed among them, plague breaking out when the population was suffering most from famine, and when the physical and social misery re- sulting from destitution was greatest. The same was, in effect, the state of things when plague appeared in Maku, in Persian Kurdistan, in 1863 ; but here it is noted also that the in- fected district was pervaded with the putrid emanations from the unburied bodies of cattle which had died from murrain. The outbreak of 1867 on the Lower Euphrates was confined to marsh-villages on the right bank of the river : and that of 1873-74, in the same district (the beginning of the greater development of 1874- 77), began in marsh-villages on the left bank of the river. The huts of the particular class of villages affected, writes W. H. Colvill, ‘ are on ground which is a foot or two lower than the surface of the water in spring ; and the ground is so saturated with water, that the refuse of the village is neither absorbed nor can it be eva- porated, for it acquires fresh moisture from the ground, and this refuse acquires the form of a bluish-black oily fluid which surrounds the huts and covers the paths, and stains the walls two feet from the ground ; and, in fact, the village is in such a state of filth that it requires to be seen to be believed.’ The outbreaks of 1S67 and 1873-74 had been preceded, according to Colvill, by the only two great inundations of the Euphrates which had occurred since 1831, theyeai of the then latest outbreak of plague in Bagdad The outbreak of 1870-71 among the highlands of Persian Kurdistan, had been preceded by a fatal epizootic among sheep, and ergotism among the people. Writing of one of these mountain- villages — and the account serves for all — Castald says : ‘ Whatever is most afflicting in poverty whatever is most revolting in filthiness, is aceu mulated, as if designedly, around these infectec dens, in the interior of which live, or rathei vegetate, from fifty to sixty men, women, ant children. The cultivation of some plots o ground in the neighbourhood furnishes thes unfortunates with insufficient nourishment The infected district escaped the famine wkic. at this time prevailed in Persia, but it may be question if the inhabitants escaped severe priva tion during the winter in which plague first ap peared. The outbreak of 1874, in the province f Bengazi, North Africa, occurred among the nom; die tribes occupying the Cyrenaic plateau at time when some of the favourite Arab campir- PLAGUE. rrounds had been converted into vast swamps iom heavy and protracted rains, and when the ,eople were reduced to the most abject misery and ,vere suffering from an extremity of famine, the ■esult of failure of their crops for three years in accession, consequent on drought. The outbreak if 1876-77 in the mountain-villages of Kumaun ook place among communities who are described is occupying houses in which cattle, grain, and hmilies are packed together under conditions of ilth not unlike those observed in the mountain- illages of Kurdistan. Of the conditions under vkich plague was observed in the great towns, Is in Bagdad and in Resht, as also on the Volga, hey were states of filth, in and about dwellings, uch as might be anticipated where no organised Scavenging had ever existed, and of crowded md badly-ventilated houses. But in Bagdad and he Mesopotamian towDS generally, the most nfluential condition in promoting plague was, iccording to Colvill and Cabiadis, poverty. babiadis, indeed, styles the disease, miseries inorhus, thus reproducing, in 1878, a name by ;vhich plague was designated by some in the Great Visitation’ of London, 1665, namely, ‘the Poor’s Plague.’ On the other hand, the communi- ies which suffered on the Volga were prosperous md believed to have plenty (on somewhat doubt- 'ul evidence, it must be confessed) ; but at the ime of the appearance of plague among them, hey were living under almost indescribable con- litions of filth accumulated about their houses, ind from which the interiors were not free. The local conditions which have been observed o be favourable to the development of plague ;ince the reappearance of the disease in 1853, t will thus be seen, are similar to those which vere observed before its disappearance from Europe and the Levant in 1844. (5) That the kind of relations maintained he- men persons sick of plague and the healthy exer- isedan important influence upon the propagation tf the disease, has been made clearly manifest in he recent outbreaks. The more closely and con- inuously the healthy were brought into associa- ion with the sick, the more certain were the former o suffer from the disease. Thus persons living a the same house with the patient w r ere pecu- liarly liable to suffer, while those who were rought only occasionally into contact with him ■las the physician) were rarely affected. And ere, again, a difference was noted between the ability of the physicians and of the surgeons nd their assistants to be attacked by the disease, he duties of the latter calling for more frequent nd protracted visits to the patients than the uties of the former, and they suffered to a greater stent. No doubt was entertained that the isease was, in ordinary phrase, caught from the ck by the healthy brought into association with lem; but there was no certain evidence that etual contact with the sick person was neces- jirytothe transmission, as the older doctrine of pntagion maintained. On the contrary, the evi- ence indicated that the transmission was chiefly fected through the healthy breathing the same tmosphere as the sick, that is to say, the atmo- bhere surrounding the sick person. There ould appear to be, in addition, evidence of trans- ission of the malady by the agency of clothes 1205 and bedding which had been used by the sick. The newer information obtained on this subject of the transmissibility of plague from those sick of the disease to the healthy, corresponds with the re- sults obtained on the same subject by the commis- sion of the French Academy in 1844, and both point to a close analogy between the modes of trans- mission of plague and of typhus, and between the habits of tho two infections. In plague, as in typhus, the liability of the healthy to contract the disease is mainly dependent on the constancy and intimacy of communication with the sick. In plague, as in typhus, the danger of infection appears to be principally proportionate to the fouling of the atmosphere surrounding the sick by the effluvium from his body and breath ; and in like manner either infection would seem to be peculiarly easy of destruction by free dilu- tion with air. Again, there seems to be no trust- worthy evidence to show that the danger of the propagation of plague by fomites (as the older writers have it), that is to say, by articles carry- ing the infection of the disease — such as cloth- ing and bedding — is greater in plague than in typhus. The condition for infection of articles of clothing and bedding was their very intimate use by, or association with, the sick. Evidence was entirely w ’anting of articles other than those mentioned, and under other conditions, being capable of communicating the disease to the healthy ; nor was there anything to confirm the assumption that the long array of articles con- tained in quarantine-regulations regardingplague were capable of retaining and conveying the in- fection. (c) Both tho sets of conditions here noted as affecting the development of plague appear to be influenced by seasonal changes. In Mesopo- tamia the disease, during its prevalence there, rapidly declines, and becomes dormant, with the setting-in of the hot weather in June (beginning to fall when tho temperature reaches 86° F., and ceasing abruptly at 113° F.), its activity re-awakening in winter, and gathering force with the advancing spring. Similar phenomena were observed in Egypt, whilst the disease pre- vailed in that country. In Constantinople, on the contrary, the disease was dormant during the colder months of the year, and became active during the hotter. The same w r as true of this country when the disease existed here, as is par ticularly observed in the season of prevalence of the epidemics which have ravaged the metro- polis. Here, as Wm, Farr, Ed. Smith, and, more recently, Buchan and Mitchell have shown, from the records of mortality, September was the month of greatest prevalence, the disease rising throughout July and August and falling throughout October and November. Further north (in Moscow, for example) the disease has prevailed as severely in the depth of winter as in the height of summer. Incubation. — The recent outbreaks have not furnished much additional information on this subject, but, such as it is, it tends to confirm the conclusion of the commission of the French Academy. This was to the effect that the disease had never shown itself among compromised per- sons after an isolation of eight days. L. Arnaud carefully studied the question in the outbreak of PLAGUE. 1206 1874, in the province of Bengazi, and from the facts ho then collected concluded that the mean time of incubation of plague was five or six days, and that the maximum duration did not exceed eight days. Hirsch, from the information he ob- tained at Vetlianka, relating to the recent out- break in the province of Astrakhan, concluded that the minimum period of incubation observed there was from two to three days, the maximum exceeding eight days, and that the average might be set down at five days. He notes, however, that very short or very long periods of in- cubation were seldom observed. Symptoms. — These are summarised here wholly from the writings of recent observers : W. H. Colvill and Giovanni Cabiadis (as made known by E. D. Dickson) in regard to plague in Meso- potamia ; Castaldi, in regard to plague in Mesopotamia, Persian Kurdistan, and Kesht ; L. Arnaud, in regard to plague in Bengazi (see Blue Book, ‘Plague,’ 1879); Doppner (official report); Hirsch ( Practitioner , ii. 1879); and W. H. Colvill and Payne (official report), in regard to plague in the province of Astrakhan. This course is taken, first, because the disease, as they describe it, is that which the present generation is called upon to consider ; and, secondly, because, generally speaking, the symptoms observed by them are similar to those described by the earlier writers on the subject. Plague occurred in three forms in the recent outbreaks, namely (1), an abortive or larval ; (2), a grave ( plague , as usually understood) ; and ( 3), a fulminant form 1. Abortive (larval) Plague.— This form is characterised by the appearance of buboes in the groins, armpits, and neck, as a rule pain- less, and unaccompanied by feverishness. At times, but rarely, the manifestation of the buboes is preceded and accompanied by a general febrile disturbance of the system, so slight as not to preclude the patient from moving about (ambulatory plague). At limes also, a bubo sup- purates ; but more commonly these swellings disperse in about fourteen days. The buboes are clearly distinguishable from the chronic glandular swellings observed in persons of a scrofulous tendency, or affected with any special diathesis. Cases of abortive plague were recorded in the greater number of the recent outbreaks of the disease of which we have detailed accounts, and were particularly observed preceding and following the outbreak in Mesopotamia in 1873-77, and preceding the outbreak in the province of Astrakhan in 1878-79. It is ques- tionable whether this form of the disease, un- accompanied by any marked febrile disturbance, is infectious. 2. Plague in its usual form. — The onset and progress of plague differ much in different cases, and at different periods of an epidemic. Most frequently, after a brief time of lassitude, ach- ing in the limbs and loins (sometimes a very painful aching), and shiverings, a febrile state commences; and concurrently with this, or from the second to the fourth day of its duration, buboes appear in the groins, the armpits, or beneath the angle of - the jaw. The febrile state is usually acute, and accom- panied with much, often severe, headache, and delirium or stupor ; the face being flushed ; the eyes red and turbid ; the skin hot ; the toDgue black, dry and fissured, or coated as with cotton wool, or pointed at the tip, with red edges andl thickly furred in the centre ; the teeth and gums covered with sordes ; and the thirst intense. The swelling of the glands increases, and is ac- ! companied by much, sometimes acute pain; and if the patient have lived on, suppuration may take place about the seventh day, at' which time, if not earlier, carbuncles or boils may appear. Of these symptoms, or groups of symptoms, it may be noted more particularly, that the disease is sometimes ushered in by vertigo, or convulsive tremor, or a peculiar, j absent, ‘ lost’ state, when the patient, if he be ’ seized from home, will be observed to make his way thither in a quasi-automatic fashion, with a strange staggeringgait ; or else the patient, whilst going about his ordinary avocations, is seen to become distracted, as if impressed with some inde- finable fear, which prompts him, if away from his house, to rush wildly through the streets until he reaches it, and then throw himself on the bed in a state of extreme restlessness ; while, in the gravest cases, the patient is attacked at the same period with vomiting of blood and a high febrile state. Cabiadis describes cases ushered in by a pro- longed regular shake, which persists from six hours to three days, the temperature of the body remaining nearly normal, and the patient not complaining of cold. This shake was invariably followed by coma, during which the patient sank rapidly. The pulse, in the febrile state, runs quickly up to 100-130 ; and the temperature of the body to 102-104°, and in the acutest cases to 107'6° Fahr. The end of the febrile state is marked by a sudden fall of temperature, the i thermometer descending sometimes as low as 93'2°Fahr. ; at the same time a profuse perspira- tion often occurs. Heat in the throat and in the epigastrium (inthe latter, as of burning char- coal there) was a not unfrequent complaint of the patients ; and at times a sensation likened to being stabbed by a knife in the breast has oc- curred. Nausea and vomiting of bilious matters were not uncommon (Arnaud) ; and vomiting of coffee-ground-looking matter was frequent at the beginning of the outbreak of 1873-74 on the river Euphrates. Constipation is the rule in the acute stages of the disease. It is some- times followed by diarrhoea, which has been regarded as a favourable sign. No noteworthy change appears to have been observed in the urine, either as to general appearance or quan- tity, unless it were mingled with blood; but Doppner describes its diminution and even sup- pression in severe cases at Vetlianka. Humor rhages were observed from the nose, the lungs, the stomach, the bowels, the vagina, and the urethra; and the cases in which they occurred all ended fatally. Occasionally the respiration is much hurried, but Arnaud states that such dis-j turbances of the respiration as he witnessed in Bengazi were of nervous origin— a nervous dys- pnoea preceding death. The prostration is ex- treme in some cases, and in a few instances m which this was observed consciousness was main- tained until just before the patient expired. Of the local signs, the appearance of the bufaei PLAGUE. not infrequently precedes tho symptoms of general disturbance. In some cases they aro first observed -within seven or eight hours after the febrile state has set in ; in other and more numerous cases they show themselves on the second, third, and fourth days of the attack, and rarely on the fifth. When the buboes appear first they are sometimes accidentally discovered, the patient having no previous suspicion that lie is affected; but more generally their appearance is preceded by pain in the glandular organs, at times sudden in accession, the patient exclaim- ing he has been stabbed in the groin, armpit, or elsewhere, as the case might be. The en- larged glands forming buboes are rarely nume- rous, and of a group only one is, as a rule, conspicuously enlarged, sometimes attaining a size equal to a turkey’s egg or an orange, while the others are but little enlarged. The swelling at times is very rapid. Suppuration is not often observed in the fatal cases, and so it happened that suppuration came to be regarded by the inhabitants of the localities where plague pre- vailed as a favourable sign ; while on the other hand, ‘flattening’ or subsidence of the swollen glands in the early days of attack was held as indicative of a fatal result. Boils and. carbuncles occur, but not very frequently. Petechia are often observed, most usually preceding a fatal issue; at times occurring comparatively early in the progress of the disease. Sometimes they are distributed generally over the body, at other times they are chiefly localised in the vicinity of the enlarged glands. They vary in size from the dimensions of a grain of millet to those of a lentil. They are at times so numerous that the skin assumes a livid hue, and the corpse has a blackened appearance after death. This appearance is so characteristic of the disease, says Cabiadis, that the maladj 7 might properly have been called, even in this day, black-death. The plague has a special physiognomy, having nothing in common with either typhus or perni- ■ cious fever in any of its forms, or with relapsing fever. ‘ The eyes are retracted within the orbits, but not surrounded with the blue circle which is seen in cholera ; the aspect is haggard, but without the fixity seen in typhous cases ; the ' facial muscles are relaxed as other muscles of ' l he patient, and do not present the wrinkles and contractions observed in a patient attacked with typhus or cerebral maladies ; the countenance of ’ the plague-stricken expresses apathy ’ (Castaldi). ‘ On coming up to a patient suffering from an attack of pernicious fever, you are struck with tho gravity of lrs case and the danger threat- . ening his life. The very reverse of this meets your eye when you see for the first time a case of plague. Even the worst instances of this malady are apt to deceive an inexperienced phy- sician, and make him fancy that the case is free from danger, w'hen in reality the patient has only a few hours to live. The first instance of plague seen by I)r. Cabiadis did not seem to him to be one of an alarming nature. The patient pooked stupified, as if intoxicated, and did not answer readily the questions put to him. He vomited blood, and had a small bubo in the right axilla, but the pulse and temperature were 1207 normal. The patient died a few hours after Dr. Cabiadis’ visit ’ (E. D. Dickson). 3. Fulminant Plague. — Cases to which this term is applied have been observed more particu- larly at the commencement of plague epidemics, but also during their course and towards their termination. These were cases which were struck down suddenly with illness and died in a few hours, without any of the characteristic indications of the disease — buboes and carbuncles, for example— having shown themselves. The conclusion that they were part of the prevailing epidemic — the infection having overwhelmed at once, as it were, the sufferers — appears justified by the prevalence, at the same time, of an inter- mediate class of cases, also very quickly ending in death, in which some traces of glandular swell- ings were observed, with profound disturbance of the nervous centres, convulsion or coma, and rapid formation of vibices and purpuric spots. The cases of the fulminant class which occurred at the beginning of the outbreak on the Lower Euphrates, 1873-71, were chiefly marked by vomiting of blood and setting in of a high febrile state concurrently. The natives had named these cases ‘ black- vomit’ before the actual nature of the disease became apparent (Castaldi). Mahamari (Pali or Indian plague) ; Yunnan Plague . — The recent descriptions of these forms of plague by Planck, Francis, Eocher, and Baber, do not present any such differences in the cha- racter of the disease as above described as to call for a separate aceeunt. The Plague ok the Yoloa, 1878-79. — Only one account of this outbreak has come into the hands of tho writer from the pien of an actual observer, and it merits a separate notice. It is contained in a report of Dr. Doppner. principal medical officer of the Cossack troops in the pro- vince of Astrakhan at the time, and is founded on personal observation of twenty-three cases seen by him when the outbreak was approaching its greatest intensity. His description of the symptoms presents them as forming two groups : —1. Violent headache (forehead and temples), pains in the limbs, slight shivering, followed by high fever, pulse from 100 to 120, sense of burning in the body and eyes, distension of the abdomen, and enlargement of the liver. These symptoms lasted two or three dajrs, and were in favourable cases followed by perspiration and recovery with general debility; but in the greater number, after an interval of two or three days, the fever returned, accompanied by delirium, sleeplessness, restlessness, a tempera- ture of 107’G°Eahr., dryness of tongue, fre- quent involuntary dejections, urine scanty and reddish. Death usually occurred in the second paroxysm (sometimes, but rarely, after a third) preceded by convulsions and a general prostra- tion of the vital powers. — 2. In other cases the patient was attacked suddenly with palpita- tion of the heart, irregularity of pulse, vomiting, vertigo, oppression of the chest, spitting of clear blood, pallor, an apathetic expression, with dulled eyes and dilated pupils. The patient then remained for two or three hours in a state oi extreme feebleness, followed by violent feverish- ness and delirium, suppression of the urine, and constipation. Maculae appeared upon the body ; 1208 PLAGUE. it exhaled a peculiar odour, something like that of honey ; and death supervened in a state of lethargy, with complete prostration of the vital powers. In neither form of the disease, at this stage of the outbreak, wero buboes a conspicuous symp- tom, and in the latter form they were rarely observed ; but buboes (inguinal and other) had characterised a series of non-fatal cases of abortive plague which had preceded the cases described, and during the decline of the out- break buboes were again observed. Death in the cases described occurred in from twelve hours to three days. Decomposition of the body always set in rapidly. [Dr. Z. Petresco, of Bucharest, who, under in- structions from the Roumanian Government, visited the seat of plague on the Volga, and reached the infected locality early in February 1879, received accounts of the disease from physicians who had witnessed it at Vetlianka subsequent to the period of time to which Dr. Doppner refers (November 17 (29) to December 4 (16)1878). He states thatthe predominant symp- toms were intenso headache, an acute febrile state (very rarely accompanied by delirium), and excessive prostration of vital force — these symptoms forming a ‘ triade semeiotique patho- gnomonique do la peste.’ He also states that, at the beginning of the outbreak at Vetlianka, cerebral and lymphatico-glandular disturbances were chiefly noted, the latter manifested by sub- maxillary, axillary, and inguinal buboes ; after- wards, at the height of the epidemic, graver indications of disorder of the nervous centres were observed, manifested especially by the headache, vertigo, feverishness, and collapse, the cases at times ending fatally in twelve hours ; lastly, during the decline of the epidemic pulmonary disturbance predominated (hemo- ptysis with symptoms of catarrhal pneumonia), inducing the medical men to diagnose the malady at this time as a croupal pneumonia, pneumo- typhus, or malignant typhus. — February 1880.] Diagnosis. — ‘ No other idiopathic fever, at- tacking a multitude of persons at the same time, is characterised by glandular swellings, by car- buncles, and by those severe manifestations of the nervous, sanguineous, and biliary systems which declare themselves in an attack of plague.’ — (Cabiadis, according to E. D. Dickson.) As regards perniciousfcver, with which the disease was confounded by some medical men in Meso- potamia, Cabiadis says no intermission has ever been observed in plague; no attack of plague has ever been cut short by the administration of sulphate of quinine ; and the expression of coun- tenance (see above), and general aspect of a plague patient are strikinglydifferent from those ofapa- tient affected with pernicious fever. At Vetlianka, intermissions, according to Doppner, were ob- served. Prognosis. — * Rapid suppuration of the buboes, even when accompanied until high fever, indi- cates a favourable termination ; all cases com- plicated with nervous, haemorrhagic, or bilious manifestations end fatally ’ (Cabiadis). Colvill is of op'nion that the -jecurreDca of diarrhoea in the course of plague, as seen in Mesopotamia, was a favourable sign. Relapses and Second Attacks. — Arnaui notes both relapses and second attacks in his account of the Bengazi outbreak, 1873-74, Age, Ddeation, &c. — Cabiadis and Colvill made an analysis of numerous cases of plague which came under their observation, from which the following particulars are taken in illustra- tion of the foregoing symptoms, and as elucidating other questions. Age. — Dr. Cabiadis noted the ages of 1,826 cases of plague observed at Hillah, in 1876, with the following result From 2 months to 9 years . 277 )» 10 years to 19 „ . 617 J* 20 „ 29 „ . 432 ft JO „ 39 ,, . . 292 » 40 „ 49 „ . 123 t J 60 „ 59 „ . 52 Ji 60 „ 69 „ . 18 >» 70 79 „ . 11 >» 80 „ 89 „ old man of 113(?)„ . 3 An . 1 Total .... Buboes and Carbuncles. l,82fi Cabiadis CoLmi 1,826 cases . 402 cases 'Buboes-.- In the Groin . . . 710 „ . 128 „ Axilla . . 466 „ . 109 „ Neck ... 98 „ = 19 „ , Crural region — „ , Several places 122 „ . 8 ” , not recorded . — ,, . 9 „ jy liUli ICUJIUCU. ■ )} • *7 j Carbuncles 36 „ . 9 Other manifestations. — Cabiadis. with respect to the 1,826 cases mentioned above, gives the following numerical statement of the numbers in which noteworthy special symptoms were ob- served : — Dependent on the I 'Coma in . . . 28 nervous centres 1 Convulsive shake 9 /Petechiae . . . 120 Epistaxis . . . 2 Dependent on the Haemoptysis . . 6 circulatory sys- - Haematemesis. . 27 tem. Sanguineous diar- rhoea . . . 14 -Menorrhagia . . 2 Dependent on the Bilious vomiting . 32 assimilative or- Bilious diarrhoea . 16 gans. Jaundice . . . 2 Duration . — Col vi 11 shows the duration of 531 fatal cases of plague as follows : — Days after Number of attack Deaths One day . 126 Two days . . SO Three „ . 105 Four „ . 76 Five „ . 60 Six „ . 26 Seven „ . 12 Eight „ . H Ten „ Twelve days . 14 . . . 9 Sixteen „ . . . 1 Twenty „ , . r PLAGUE. Mortality. — The mortality appears to have differed much in different places and at different periods of an epidemic. Colvill states, of the outbreak of 1874-75 in Mesopotamia, that the mortality in the first half of the epidemic in a village, was from 93 to 95 per cent, of those attacked, but that during the latter half of the epidemic the greater number of the attacked re- covered. The mortality in Bagdad throughout the outbreak in 1876 was, he states, 55'7 per cent, of the attacks (eases 4,585, deaths 2,556). Arnaud gives the mortality during the outbreak in Bengazi, 1874, at 39 per cent, of the attacks (cases 533, deaths 208). According to Cabiadis, the mortality at Hillah in 1876 was 52'6 per cent, of the attacks (cases 1,826, deaths 961). Hirsch estimates the mortality at Vet- lianka, on the Volga (Astrakhan) at 82 per cent of the attacks (cases 439, deaths 358) ; and Doppner states that at one period of the out- break there was a mortality of 100 per cent, (in other words all who were then attacked died), and at another, and later period, of 43 per cent. Anatomical Charactehs. — The recent out- breaks of plague have added nothing to our knowledge of the anatomical characters of the disease. The outbreaks occurred under circum- stances where anatomical investigation was out of the question. The information existing on this subject was obtained almost solely at the time of the French expedition into Egypt at the close of the last century and the beginning of the pre- sent; during the outbreaks of plague in Bes- sarabia, 1825, and in Moldavia and Wallachia (1828-29) ; and again in the outbreak of 1834- 35 in Egypt. The morbid alterations noted were ecchymoses of the coverings of the ner- vous centres, of the pericardium, the omentum, and the peritoneum ; enlargement and softening of the spleen ; punctated extravasations of blood in the mucous membrane of the stomach ; ecchy- motie spots in the mucous membrane of the in- testines;reddish-blackinjection of themesenteric glands; extravasation of blood — sometimes con- iiderable — into the cellular tissue about the kid- neys, the kidneys themselves being tumefied and presenting extravasation of blood in their tissue md in their pelves. The most constant andcharac- eristic changes were observed in the lymphatic ;lands. When buboes had been formed, the lands presented manifest signs of inflammatory ction in various degrees, as also at times the urrounding cellular tissue, which was, more- ver, frequently the seat of bloody extravasa- ions. The glands of the several cavities ’ere more or less involved in or partook of he morbid action conspicuously observed in the uboes ; and even where no buboes had formed, idications of considerable changes were found i the internal lymphatic glands. In some istances the affection of the glands would ppear to have been general throughout the ody; in others it would be limited to one or lore of certain groups, in addition to the more iperficial groups, as the bronchial, the medias- nal, the mesenteric, the lumbar, &c. The lands, as a rule, were found more or less en- rged, injected, and infiltrated with sanguineous aid. 1209 Treatjient. — (a) Curative. — The recent out- breaks of plague have thrown no positive light upon its curative treatment. In Bagdad and Hillah the plan of treatment mainly fol- lowed was the internal administration of car- bolic acid or of quinine, and the use of leeches and mercurial frictions to the buboes before suppuration. In some instances this plan was thought to have done good, in others it was useless, if not detrimental. In regard to plague, as to other grave general maladies, except those arising from paludal poisoning, curative treatment is at present only possible on general principles, both as regards the sys- temic and the local symptoms. The practice would appear to be the same in respect to the general symptoms as would guide the physician in the treatment of typhus ; in respect to the local symptoms, such as would apply to ordinary phlegmon. — (/3) Hygienic. — In the present state of our knowledge, more importance is perhaps to be attached to the hygienic treatment of the disease than to the curative. Most im- portant of all, perhaps, is the exposure of the patient to abundant, freely changing air; next is the use of cold or tepid sponging, as the temperature of the body and the state of the skin (as well as the sensations of the patient, if he be sensible) may seem to call for; together with the large administration of drinks (acid— ? mineral, or other) to combat the thirst, the judicious use of liquid food, and especially of stimulants when the dropping of the pulse, the coolness of the skin, and the ataxic condition of the patient call for them. Prevention. — The prevention of plague in- volves two sorts of considerations, the one re- lating to the removal of the conditions which favour the development of the disease ; the other to the limitation of the spread of the disease, the malady existing, (a) The condi- tions favourable to the development of plague have been already enumerated, and include all those insanitary states of houses, their sites and surroundings, which form the subject of public-health administration; also those states of poverty which have to be dealt with, not only as an economic but as a public-health question. Of these several conditions, the three which ■would seem most to call for special attention in this country, in view of impending plague, whether as regards private individuals or as re- gards local authorities representing communities, are over-crowding, defective ventilation of houses, wad. impoverishment, (b) In respect to the limita- tion of the disease, the malady being present, the first and most important consideration is the isolation of the patient under such circum- stances of aeration as are stated above, as well in the interest of the patient himself as of the community ; and the disinfection of articles of clothing, or bedding, used by him, and of the room he may have occupied. Local authorities have large powers enabling them to provide be- forehand, in a mode available for the use of the whole community, (Public Health Act, 1875, and the Metropolis Management Act, 1858, together with the Sanitary and Poor Law Acts relating to the Metropolis), hospitals for the isolation of cases of infectious diseases, such as plague, and (210 PLAGUE. apparatus and materials for disinfection ; and many authorities have already exercised these powers. See Public Health. But plague is the subject of special measures in this country, as in every country on the Continent and Mediterranean littoral, to wit, measures of quarantine. Quarantine aims at preventing both the introduction of the disease into a country, and the spread of the disease, if by accident it should happen to have been introduced, by the isolation for a longer or shorter period, not only of persons sick of plague, but, in addition, of all healthy 'persons who may have been exposed, directly or indirectly, to the infection of plague ; also by the isolation and disinfection of articles, described under the quarantine law, as susceptible of conveying plague-infection, coming from an infected dis- trict. Experience has shown that measures of quarantine against infectious disease are futile, if not impracticable for this country, from the impossibility of closing all channels of intro- duction, in consequence of the activity and magnitude of our commerce. But quarantine is retained in regard to plague and yellow fever, and has occasionally to be made use of to meet the requirements of other nations, who, failing the adoption of this system here, would be likely to impose disabilities on our shipping with refer- ence to the diseases named. Thus quarantine was revived in respect to plague, at the time of the recent alarm of the disease on the Continent. The doctrine of plague upon which the English Quarantine Act of 1825 is based, as well as the laws of foreign countries relating to the subject, is a traditional one, inconsistent in many re- spects with the later and more accurate observa- tions which have been made on the mode of spread of the disease. J. Netten Radcliffe. JSb b !S}(^ 1 strike) -" A hara_ mer-like instrument used in percussion, for strik- ing the surface of the body, either directly or indirectly. See Physical Examination. PLESSIMETER \ PLEXIMETEE J (irA r\ the phenomena probably vary, not with the den- *• ^ the effusion, but with states of the lung. DISEASES OF. 1217 may actually recede with an increase of fluid, and on the other hand it may rise upwards as with a diminution of fluid the re-inflated lung descends. For these and other reasons it is verv difficult to gauge the ebb of intrathoracic effu- sions, or accurately to ascertain their behaviour after tapping. In children, bronchial breathing and bronchophony often persist throughout. Dr. Bowditch says that he has been occasionally greatly embarrassed in deciding about reaccu- mulations. ‘ At times after the effusion has been withdrawn the chest remains as flat as ever, and often it never clears up in the lower part of the affected side ; but if it remains in this state without producing untoward symptoms, I have not tapped again, though a tentative as- piration could do no harm.’ In cases where the lung is unbound, gauging is of course the more easy. When the chest is quite full of fluid there may be silence throughout to ear and hand ; but even in such cases a faint or distant respiratory souffle is sometimes audible almost down to the base. Moreover, in most cases breathing more or less tubular, and some resonance on percussion, are to be heard over the root of the lung in the vertebra-scapular space. As air re-enters the lung, respiration is at first defective, and accom- panied by crepitant rales, hut it improves gra- dually, and reinforces itself as the lung expands and clears. In children silence on the affected side is less common, bronchial breathing and bronchophony persisting in them far more than in older persons ; but it is not by any means correct to say that bronchial breathing and bronchophony' always persist in the pleuritic effu- sions of children. Yet the pneumonia of children being mostly lobular the discovery in them of bronchial breathing and bronchophony is highly suggestive of fluid. In the other lung there is usually a slight general lowering of the percussion-note and compensatory breathing ; if the effusion be large enough to compress the op- posite lung, the percussion-note may he very markedly lowered. At times morbid sounds may be heard, even in the lung of the affected side. The gradual formation of a pulmonary fistula may in some cases be revealed some days or hours before evacuation, by the presence of liquid rales in the upper third of the affected side. Physical examination must be applied r.ot only to the investigation of the lung and of the contents of the pleura, but also to determine the position of those neighbouring parts which may be displaced, such as the liver, heart, spleen, mediastinum, and so forth. Pyopneumothorax . — This is a term applied to that condition in which, on perforation into some open channel, air finds entrance into an empye- matous cavity. At the same time pus is eva- cuated. The lung may in a measure expand, or in neglected cases may be irrecoverable ; and the chest-wall falls in more or less, according to the rigidity of the ribs in the individual. Dulness now gives way to clearer and lower notes, ex eept in such dependent parts as may still be occupied by effusion, and their pitch will varj according to the thickness and density of the false membranes within, and to the degree of pulmonary expansion. If the fistula be moderate in size, little or no blowing sound will bo heard. PLEURA, DISEASES OF. 1218 but two additional auscultatory signs may be obtained, which are alike in nature, but are dis- tinguishable as succussion and metallic tinkling. See Pneumothorax. Diagnosis. — The difficulties of diagnosis in pleurisy belong chiefly to the earliest and to the latest stages of the malady. In the earliest stage the pleurisy may be latent, and so beyond the possibility of diagnosis ; or a pain may bo felt, and this pain may be due to pleurisy, pleurodynia, or other causes. The pain is often referred to the loin or abdomen, thus leading to suspicion of mischief elsewhere. In the previous history a catching of cold, and the arthritic diathesis, would tell equally in favour of either view ; while prolonged anaemia and leucorrhoea would lead us to think of the latter. Unfortunately a comparison of local tempera- ture in the two sides seems untrustworthy, but the presence of fever would make us strongly suspicious of pleurisy. It must not be supposed that diagnosis in this early stage is unimportant. Few errors are more common than the attribution of pleuritic pains to pleurodynia ; the pain dis- appears as an effusion slowly accumulates, and mischief and peril, perhaps hardly remediable, may be the consequence. The careful observer will listen anxiously to the chest day by day, or more than daily, until a friction-sound be audible, and this once heard further mistake is impossible. Fever of course may be present with pleurodynia, and an immediate diagnosis would then be impossible, unless something cha- racteristic in the stitch and start on deep inspi- ration betray the real state of things to the practised observer. Neuralgic and inflammatory diseases of the walls of the chest are not likely' to give rise to any permanent misunderstanding. It is said that a pericardial may be mistaken for a pleuritic friction-sound, but the distinction can rarely be difficult. A difficulty is more likely to arise in distinguishing between a pericardial and a localised pleuritic effusion. Still this can hardly be insuperable. In rheumatic fever and in some ocher diseases pericardial may accom- pany or ensue upon pleuritic effusion, and when the latter is on the left side, and is abundant, the limit between the two may be beyond de- finition. The practical lesson is to remember the likelihood of pericardial effusion, and not to overlook it if it comes. In the later stages of pleurisy', when effusion is abundant, its diagnosis may be very difficult. Under ordinary circumstances complete and ex- tensive dulness with loss of all elasticity in the chest-wall, of respiratory sound, and of vocal thrill, make diagnosis easy ; and if there be re- sonance below the clavicle, its high-pitched cha- racter is very characteristic of fluid below. But there may be no such resonance, and the voice may' fail, or fail to setup thoracic thrill. More- over, vocal thrill and respiratory murmurs may- vanish likewise in intrathoracic tumours. Thus the diagnosis between exudations and pulmonary consolidations is sometimes difficult. In acute pneumonia the course of the fever, the expectora- tion, and other symptoms, help us to a decision. In pleurisy with moderate effusion, on the other hand, the limits of posterior dulness might be changed by a few forcible inspirations, such changes being probably due to a re-expansion of collapsed lung. Consolidated lung could not, of course, be thus altered. In both there may be tubular characters of respiration, whichare more easily distinguished in print than at times they may be in the patient. If segophonic we de- cide upon fluid, but if broncbophonic we have to distinguish as well as we can between the ‘ sniffling and metallic’ bronchophony (Walshe) of consolidation, and the duller and more dif- fused bronchial sound of pleuritic effusion. If the dulness and breath-sounds vary with the position of the patient, fluid is clearly present. Limited effusions, such as an encysted empyema, not large enough to bulge the intercostal spaces, to crush up the lung, or to displace other organs, are at times quite indistinguishable from a like extent of chronic consolidation, or of abscess in the lower lobe of the lung; such collections, though usually basic, are by no means always so, but, retained by adhesions, may occupy the upper and anterior region, any part of the middle 1 region, or strips, or irregular districts in anv direction. It may be said in general terms that a permanent very dull area remaining after an acute pleurisy or pleuropneumonia most pro- bably corresponds to an encysted empyema, but not always. In such cases fever may be entirely absent, and the general condition of the patient may not suggest disease. Still, such n collection of pus is pretty sure to work mischief sooner or later — years later, it may he — but the patient rarely escapes with impunity at last. The difficulties of distinguishing bulky effusions; from pulmonary consolidations are not often great. In the former the intercostal spaces may be bulged, and the moiety of the chest enlarged ; on the other hand it but very rarely happens that consolidation reduces the lung to silence, though this may be the case; in such a case the bulk of the half-chest would in all probability ba lessened, but so. on the other hand, may it be in a chronic pleurisy'. The fact is, many chronic cases can be diagnosed by the needle alone; and it should be noted that even with the needle more than one puncture or two should be made before deciding against fluid. Between intra thoracic tumours and large pleuritic effusions? difficulty is found only in those cases in whicl the tumour occupies precisely the half of tb< chest, but this is not very uncommon, especially in cases of aneurism. It must not be forgottei too that fluid effusion may accompany tumour in which case there maybe subtympanitic reson ance under the clavicle. In favour of fluid alon are the absence of enlarged veins ; the equalit of hydrostatic displacement of organs ; the at sence of signs of localised pressure, of pulse retardation, of inequality of pupils, and of pe euliar sputa. A curious pulsation, of uncertai explanation, is sometimes seen in empyema, an must not be mistaken for an aneurismal throl If fluctuation be certainly felt in the intercosti spaces, tho disease, in part at any rate, is a flui effusion. Sometimes a hepatic, biliary, rena or other subphrenic abscess, making its wa by a sinus, occupies also some part of tl pleural cavity. Here it may encyst itself, ail remain latent or quiescent for months or year, or it may excite an effusive pleurisy in tl PLEURA, DISEASES OF. remainder of the cavity, so that two effusions co-exist in one pleura. Such collections may of course form pulmonary fistulae, and pus from the same central source may in part issue from the urethra or rectum, and in part issue from the mouth. Such cases are often easy of dia- gnosis ; at other times they are more difficult, especially if there be no fistula in any direc- tion. When such pyogenic cysts contain air, but not by way of the lung, it may be sup- posed that they have originated in some per- forative disease of stomach or bowel. It is ob- vious that in these cases there will be little evidence of increased intra-thoracic tension. Dulness from disease below the diaphragm, but encroaching on the thoracic space, can often be displaced downwards by a deep inspiration. It is stated that in puncture, combined with the ise of the manometer, when the canula is in a cavity beneath the diaphragm, inspiration is ittended with an increase and expiration with i decrease of pressure, being the reverse of that vhich occurs when the canula lies in the pleura, in peripleuridc abscess tension is of course low md there is no pressure on neighbouring organs ; Dercussion-dulness is also less profound. It is ’aid that pus from cellular abscesses is of higher peeific gravity (1040) than from large cavities 11028-1030). : A haemorrhage into the pleura can be dis- mguished from a serous or purulent effusion, nlv by a careful survey of all the history and ymptoms ; the direct physical signs helping s but little. Large pulmonary cavities may 3 taken for encysted empyema with fistulous oening into a bronchus ; and here again, al- lough a pulmonary fistula rarely gives rise to ibular breathing, unless the opening be very rge, or communicate with a secondary cavity, ;t diagnosis by the direct signs alone might be lpossible. The history of the case, and the state ' the other lung would be important factors decision. In another class of cases the stinction between chronic phthisis and pleu- jsy may be difficult — in those, that is. in which ere is some old dulness and retraction of a rt of the side, with weak respiration and in- finite rdlcs, and more or less fever. The sence of lung-tissue in the expectoration, and e health of the other side, help to exclude ithisis. Fibroid phthisis, however, is not even is excluded, and is usually pleuritic in origin, children enlargement of the spleen, with ex- tsion upwards and backwards, has not in- quently simulated effusion at the base of the : lung. Finally, the intense distress and hopnina of very painful pleurisies — of dia- •agmatic pleurisy more especially — may simu- • 3 cardiac thrombosis. The state of the pulse i ne is usually sufficient to lessen the fears cf 1 physician. i’Ronxosis. — The prognosis of simple pleurisy, . rt from tubercle or carcinoma, is generally l ourable, unless the degree or kind of effusion i the chest endanger life. If not always I Durable, it is because simple inflammatory 1 rrisies seem sometimes to originate a process t chronic fibrosis, which thence invades the Happily such instances are rare, and in 61 ndividual case the chance of such an event 1219 : almost vanishes. In ordinary' inflammatory pleurisies, then, prognosis is quite favourable; in cases of effusion, where the effusion is moder- ate, it is favourable ; where the effusion is large, it is the less favourable the greater the quantity and the slower the absorption. Signs of hyper- semia and cedema in the working lung must be anxiously watched, especially if an empty radial, scanty urine, and other evidences of venous stasis be added. When the chest is full, pro- gnosis is unfavourable apart from operation. In severe and acute cases the other lung becomes cedematous and congested, bloody and frothy' sputa may appear, carbonic-aeid-poisoning will become evident in the blue lips and lethargic brain, the pulse will slip away, the heart fail, and the extremities grow chill ; or, again, dislo- cation of the heart and arrest of the pulmonary circulation may cause syncope by' asystole or thrombosis. Operation, however, raises the hope of recovery greatly — so much so as to put the chances largely in favour of rapid recovery in good subjects. The earlier the relief, the less the probability of refilling, the less the damage to the lung, and the better the hope of rapid amendment. In bad subjects prognosis will be the less favourable the more potent the adverse conditions ; and in pleurisies secondary to other diseases the prognosis will depend but partially upon any one element in the case. In old people operation is still useful, but especial care must be taken to draw off the fluid very slowly, and to watch the circulation. The conditions in them unfavourable to operation are still more unfavourable to absorption, or to any' kind of delay. In empyema the prognosis is grave ; unless operation be performed death is very pro- bable, either by syncope before the mattei escapes, or by exhaustion, chronic septicaemia or secondary' abscesses, during a long period ot incomplete drainage of the chest. If operation be submitted to, the prognosis is favourable, though a vast internal abscess with rigid walls cannot be but a fearful thing, and the illness will still be a long and an anxious one. Death can scarcely be said ever to be due simply to the operation, if carefully performed : and death, during or directly following the operation, though not unknown, is too rare to be an important fac- tor in our decisions or forecasts. On the whole, the earlier the operation is performed, after it is fairly indicated, the better the prognosis. Among the deferred dangers are amyloid disease, a rare event, but possible in cases of necrosed rib or other bone, or of very long and exhausting drain ; and phthisis or septic tuberculosis, happily made also rare by the density of the false-membranes. The presence of albumen in the urine alone does not necessarily preclude complete recovery, nor forbid prompt operation. The beariug of age and sex upon prognosis cannot as yet be decided. Experience indicates that it is more hopeful in eases under ten years of age and above twenty years. Dr. Bowditch says that full pregnancy is no bar to thoracentesis. The influence of dia- thesis on the progress of local diseases must Le estimated in all cases on general principles. As regards duration, an ordinary case of in- flammatory pleurisy will last from ten days to a month, according to the degree of effusion and [220 PLEURA, DISEASES OF. :he rate of re-absorption. Chronic cases ■with large effusions may last any length of time, rarely Less than three months. If tapped the fluid may, and very often does not return, or may not re- turn after a second tapping ; in such a case re- covery will he prompt. Empyemas, opened under the most favourable conditions, are often months and sometimes years before final closure, though it seems that the antiseptic operation and dress- ings will much shorten the average duration. If left to itself an empyema usually opens through the lung or externally. In the latter case the issue is most commonly about the fifth interspace an- teriorly. Drainage is thus very incomplete, and although some relief is attained, the patient nevertheless drags on with a permanent fistulous discharge, it may be for years, but recovery with- out operation is scarcely to be hoped for. Finally, it must not be forgotten that simple pleurisies may he the forerunners of phthisis. The occurrence or repetition of a pleurisy in a young person of delicate habit or origin is always an alarming thing, and the more so if not due to obvious causes. The experienced physician will call to mind many cases in which a pleurisy to all appearance wholly recovered from at the time, was followed before many months had passed by definite signs of phthisis. There is no evidence to show that all such pleurisies are tubercular in nature. Lastly, a decided attack of pleurisy, occurring in the course of pulmonary phthisis, always means or makes mischief, even if quickly got under. Treatment. — 1. Medicinal . — Dry pleurisy re- quires little or no treatment. In some cases, indeed, it may cause distress, as in chronic phthisis ; and if so, may be relieved by spongio- piline and laudanum, or by any similar sooth- ing measures. In the cases in which a trouble- some cough is caused by a patch of chronic dry pleurisy, the cough and pleurisy alike may be removed by the application of blisters. In acute pleurisy, however, much depends upon active treatment at the outset; in few maladies is early attention better rewarded, and in few is neglect more surely punished. Our great aim in the beginning is to diminish the pain, the inflam- mation, the fever, and the tendency to ex- cessive exudation. With or without treatment, as we have seen, the pain usually passes off in forty-eight hours, or thereabouts ; neverthe- less it is very acute while it lasts. In sharp cases, occurring in healthy persons, we maj r put on six to twelve leeches according to the age, sex, or condition of the patient, and these may bleed freely into a large poultice. This measure, if adopted at the very outset, dimi- nishes the pain, the fever, the exudation, and the duration of the case. When the bleeding has ceased the chest should be firmly bandaged, and as soon as the state of the leech-bites will allow of it, the affected side should be firmly strapped. This, by giving rest to the part, will favour re- solution and resorption. Constant respiration, on the other hand, favours effusion, as exercise favours it in inflammation of a joint.. If called to a case after the first brunt is over — say after a lapse of forty hours — it is better to omit the leeching, in order that the strapping may be applied at once. It must be carried out on the following plan, as laid down by Dr, Roberts, of University College Hospital : — Strips of a properly-adberent plaster spread on some thick material, from three to four inches wide and of sufficient length, are applied round the affected side from mid-spine to mid-sternum, or a little beyond. These are laid on over a variable extent of the chest, according to the requirements of the case, it being sometimes necessary to include the whole side. It is best to make the application from below upwards, and to fix the strips of plaster in an oblique direction rather than horizontally. The patient being directed to expire deeply, a strip is fixed at mid-spine and drawn tightly, firmly, and evenly round the side in the direction "of the ribs, that is, a little obliquely from above down- wards and forwards ; then another strip is laid on over this, also extendi ng from mid-spine to mid- sternum, but in the opposite direction to the first, that is, obliquely upwards and forwards across the course of the ribs ; the third should follow the direction of the first, overlapping about half its width, the fourth that of the second, and so on in alternate directions, until the entire side is included if required. Finally, it is often desirable to apply over the whole two or three strips hori- zontally, so as to form a superficial layer ; and, if necessary, one or two may also be passed from behind forwards over the shoulder, these being kept down by another strip fixed round the side across their ends. Dr. Roberts applies the strapping in all cases from the outset. The writer's experience is in favour cf early leeching in suitable cases, but it may be possible to com- bine the two remedies. This at the outset is far from easy, as a large poultice is almost an essential part of the leeching. Some physicians recommend that an attempt be made to snbdue the local inflammation by the application of ice, but the results of this method are not satisfac- tory. In addition to local measures, such medi- cines as the following are required : — A powder consisting of Pulveris ipecacuanhae compositi gr. v, and Pulveris antimonialis (James’s) gr. iij, is to be given every six or eight hours, for two or three days. In diaphragmatic and in other cases, in which pain is a marked feature, the subcutaneous use of morphia is also to be re- commended, in doses of one-eighth to one-fourth of a grain, or possibly more. The fever is rarely severe or protracted enough to require such vigorous antipyretics as quinine, nor is aconite a very safe remedy. It is better to give in addition to the powder, full doses of Liquoi ammonise acetatis (oij-Siv for an adult) ever} four hours, covered with a little milk; an alka- line effervescent being freely used also as f drink. Thus vascular tension is lessened, an: activity of the skin and kidneys is promoted In the earlier stages free purgation should b avoided, but it is well to call gently upon th alvine excretion by the use of mercurials an- salines. All solids must be withdrawn fror the dietary, and stimulants, as a rule, forbidder The alkaline effervescent or a cream of tartn drink, with acetate of ammonia mixture, are t be continued after the powders are withdrawi so as to keep up free excretion : for the sam purpose, and also to lessen chest-movement PLEURA. DISEASES OF. 1221 the patient must be kept closely to bed. For some days after the subsidence of the fever the appetite for highly nitrogenous diet must be neld in check, and it is desirable at this stage to lessen the amount of fluid in the dietary. Thus it is to be hoped that, as the patient’s general condition improves, the effusion in the chest may likewise fall. If this be not the case other remedies must be brought forward. Among the chief of these are blisters, which, if not pushed to full vesication, may be repeated fre- quently ; or the chest may be kept continuously ruder the effects of iodine, though this method s less successful than the blisters. At the same ime, or soon after, a pill may be administered twice daily, containing a grain each of digitalis (fresh leafj and blue pill. A grain of squill may be added, but squill has some tendency to disorder the stomach. The use of both blisters and mercury must, of course, be avoided if the kidneys be not sound, and mercury should be avoided in any case where a phthisical tendency 's suspected. Dr. Bowditch applies a solution f iodine (5ss in Spiritus etheris sulphurici yj), painting it on twice or thrice, or till burning is induced, and then reapplies it intermittently. He also administers iodide of potassium gr. v, thrice daily internally, and finds much help from this treatment. In vigorous patients free and repeated doses of some hydragogue pur- gative-such as Hunyadi water— may be tried before beginning the more tedious pills. Or the ointment of oleate of mercury may be. rubbed freely into the chest, and this may he used even in delicate persons, without fear, and in those whose sensitive skins are intolerant of blisters. Quinine may be added to the mix- lure containing iodide of potassium, or may nell accompany the mercurial course. But when 1 brief and gentle eliminative course of this kind is ended, it is well at once to turn to :he full tonic treatment, with such drugs as ron and quinine. Less active effusions in lelieate and anaemic subjects may need iron and bitters, cod-liver oil, and liberal diet from a :ery early stage, and such cases are common. It the same time such measures are not to be ised while the acuter stages are present — a irecaution too often forgotten ; for even in phthi- is a sharp intercurrent pleurisy must often be reated by salines, and perhaps a leech or two t first. These measures will generally succeed, a reducing not only an acute effusion of moder- te extent, but also many effusions of a more bstinate kind. If, however, the case resist he means prescribed, the effusion will probably icrease, and may need operative interference, as 1 60 commonly the ease in latent pleurisy. As a eneral rule, if an effusion rises above the angle f the scapula, and abides in this quantity or tore for two or three weeks in spite of adc- uate treatment, it must be drawn off, whether ; le patient be embarrassed by it or not. In ises where treatment by medicines has not been lirly tried, where the patient is in comparative ise, where the effusion is not above the spine the scapula behind nor above the mamma fore, and where the neighbouring organs re not seriously displaced, these operations ay give place to medicine for two or three weeks longer if desired. The writer, however, would advise the withdrawal even of a pint of fluid which had lain in the cavity for a month, as its continued presence, by soaking and com- pressing the lung, injures it, and destroys the absorbent power of the pleura and of its granu- lations. It is needless to add that if there be effusion in both pleural cavities, the amount in both must be considered as one quantity'. Be- fore resorting to operation, however, it is well to say that two more methods remain — the so- called ‘ thirst cure,’ which has some good effect in the treatment of serous effusion; and the jaborandi cure. The first method consists in the withdrawal of fluid from the diet, which should be as dry as possible, and consist of lean cold meat, stale bread and the like. All fluids are forbidden, except half a pint on the third day, and a pint on the seventh and eighth days. The effusion is said under this method to de- crease daily ; the method, however, is more painful than tapping, and could not be borne by all patients without injury. The second plan consists in tho promotion of profuse sweating, by means of jaborandi. Excellent results are said to have followed this method. The drug is administered as a liquid extract, 5j being given every three hours. If medicinal and dietetic means fail to remove a moderate effu- sion, or if the effusion already occupy the whole cr a great part of the pleural cavity, the cavity must be tapped without further delay. There should be no hesitation in tapping instantly any chest which is dull up to the clavicle, or which presents a small tympanitic space under the clavicle. The operation of removing fluid from the chest by tapping (paracentesis thoracis), seems to have been practised in early times, but has scarcely become familiar to us until the last quarter of a century. To Trousseau, of Paris, and to Di\ Bowditch, of Boston, the profession is chiefly indebted for anything like doctrine in this matter. Trousseau was probably the first physician to recognise the means, and the pro- priety of tapping in serous effusions. 2. Paracentesis thoracis. — Taking the opera- tion as agreed upon, we will now lay down the precise method of it. It may be a matter of doubt whether the fluid contents of the chest he serous, sero-purulent, or purulent. To ascertain this a hypodermic syringe may be passed through the wall of tho chest, and a sample of the fluid drawn away. In this way information is ob- tained as to the nature of the fluid, and its accessibility. Should the tap be dry, it can be repeated elsewhere more readily, and with less sens9 of failure, than the greater operation. Tho precise place of operation must, of course, be chosen with great care ; but, happily, there is plenty of margin for error. In an encysted empyema with thickened walls four or five punctures may be needed before pus be reached. If the issue be purulent two openings will be needed, when, after choosing the second with the greatest care, the first may be closed ; if the issue be serous, the complete emptying of the cavity is not necessary, and not always desirable. In cases of multilocular pleuritic effusion the emptying of one cavity only is of course an in- complete measure. Such cases are unsatisfactory PLEURA, DISEASES OF. 1222 at best, and can only be tested by repeated puncture. If there be no special reason to the contrary, the chest will be tapped on the lateral or poste- rior aspect, as there is thus less danger of in- terference with other organs. Reasons to the contrary may present themselves in the case of adhesions tying the lung to the side or back of the cavity, of lateral displacement of the heart in left-side effusions, of deformities in the individual, and so forth. The pointing of an empyema forward, however well-marked, is no in- dication for an anterior opening, as this pointing will recede when a posterior opening has been made ; nor is the faintly audible sound of respi- ration over the back of the affected side a reason for declining to operate posteriorly, fox - , such faint sounds are often conveyed to the ear when the cavity is full of fluid. Let a minute scrutiny then be made of the lateral and posterior aspects of the chest. Let any bulging of intercostal spaces be looked for, as at such a spot false- membranes are probably scanty or thin, and let the ribs be minutely examined, in order to ascertain that there is room enough between them for the insertion of a finger into the cavity, if this prove to be needful; or that, in any case, resection of a rib may, if possible, be avoided. The axillary line should be chosen in all cases in which the effusion is believed to be serous. If it should appear that the fluid is so limited or encysted that it does not gravitate to the bottom of the cavity, a tentative puncture must be made at the dullest spot, regard being had of course, to file position of neighbouring organs. If there lie no indication to the eonti'ary, we shall select the fifth intercostal space, a little in front of tie axillax’y line, as oxxr point of entrance, or the fourth space on the right side. The needle must now be gently forced through the skin, and then shot with a sharp sudden thrust through the remaining tissues into the cavity, the operator being careful to take the mid space, and tlnxs to avoid the periosteum of either rib, and the intercostal artei'y. If the skin be thick it is well to incise it with a bistoxiry before inserting the needle. There is no objection to freezing the skin beforehand, bxit it is rarely desirable. If the fluid drawn be clearly serous, and the patient be a child, or, the syringe capaeioxxs, it may be well, if time press not, to wait a day or two to see whether this small draught will set up absorption of the rest. Many sucli cases are on record. As a mile, how- ever, it will be needful to proceed to a further evacuation of the cavity. Eor this a special in- strxxment will be needed. We cannot enter into an account of the many instruments sold for paracentesis thoracis ; almost any one of them is satisfactory. They all consist in a fine trochar or perforated lance- headed needle, with an exhausting apparatus attached thereto . 1 Pumps of various makes are therefore adapted to the trocliars, by which the pressxire of the atmosphere or the choking 1 The hollow needles sometimes xised have many drawbacks. They may prick the long and cause cough or even let air into the pleural cavity, which, though not septic, prevents expansion o£ the lung. This, though not the only one, is a sufficient objection. by clots may he counteracted. These pumps are rather cumbrous, and they are liable to bo worked at an excessive pressure. The best exhaust in ordinary cases is a column of the fluid itself, which can be made longer or shorter, as the run of the fluid seems to indicate. This column is formed by attaching a long, fine india- rubber tube, at least four feet long, to the collar of the trochar, and its length is varied by eleva- tion or subsidence of the basin of water in which its distal end is placed. This tube has, of course, the action of a syphon, and by it alone, in the vast majority of cases, we can overcome the resistance of the atmosphei’e. The diameter of the tube should be small, or the fine cannlas now in use for paracentesis will not feed it; moreover, the slower the issue of the fluid the better. It is well to attach the tube to a short branch of the eanula issuing at a small angle from the side of the latter, and containing a stopcock; in such an instrument the trochar worts like a piston in the eanula, and can only be with- drawn to a point immediately beyond the opening of the lateral channel. The advantage of this arrangement is that on stoppage of the eanula the troclxar can at once be so pushed up as to clear it. If there be no piston-troclxar the eanula has to be cleared by wires— a fidgety process, and too often inefficient. It may be better indeed under such circumstances to close the wound and reintroduce it elsewhere ; thus less pain and annoyance is felt in tho end, and a better result obtained. As inflammatory serous effusions are certainly liable to turn into pus if septic elements be admitted to them in the smallest quantity, the instruments used must be scrupulously dis- infected and air excluded. If the distal end of the delivery tube be placed in water, and the tube be emptied by running tho finger down it, any bubbling will almost certainly point to wound of the lung. The cock should be turned when the patient is quiet and at tlxe beginning of lxis expiration. The fluid will run at first in a steady stream, afterwards in gushes corre- sponding to the inspirations. IVhen the fluid ceases to run, or coughing grows troublesome, the tube may be withdrawn ; for if the fluid be serous the presence of a remnant, or more than a remnant, of the effusion in the cavity is of no disadvantage; if it be seropurulent the cavity is certain to refill, and if it be laudable pus it will in all probability refill. On the other hand. 1 when the lung expands imperfectly, to exercise strong suction upon the mediastinum or on the abnormally vascular pleura is to run the risk of doing barm. The patient must neither lie nor sit erect, but a semi-reeumbent position should be taken, with tho shoxxlders raised upon pillows. If there be any tendency to syncope, an erect position will favour it, and a recumbent position is unfavourable to operation and to escape of fluid. The patient must be closely watched, and the stopcock turned on the least sign of faint- ness, but, happily, this is rarely seen. Cases are reported in which sudden death has occurred during paracentesis, or about the time of it. but cases of sudden death are not uncommon in pleu- ritic effusion, whether punctured or not. Aa anaesthetic is scarcely required for simple para- centesis. If the edge of the eanula present nc PLEURA, DISEASES OF. harsh ridge upon the trochar the stab is but little painful. It is -well, if there be no indication to the contrary, to inject one-fifth of a grain of morphia beneath the skin after the operation, to relieve any irritation either by cough or otherwise, and to secure subsequent rest. The stopcock of the instrument will, of course, be shut when the trochar is withdrawn, and the puncture promptly closed on withdrawal by the finger. It is well to keep the finger in apposition for a few minutes, and then to apply a simplo lint-pad with short strips of plaster. In favourable cases no second tapping is needed, and the heart tends to recover its position on the completion of the operation, moving three inches perhaps in the course of it; in other cases, even of serous effusion, the seve- rity of the pleurisy may have so fettered the lung that the readjustment of the parts is much more gradual, aud the space of the effusion is reoceupied but slowly by the unfolding lung and the yielding of the chest-wall and mediastinum. In this respect there is not much difference between serous and purulent formations, save, of course, that neglected cases are more likely to have become purulent. A rapid return to the normal of the physical signs is a very good omen, and in cases promptly dealt with is now happily our common experience. In cases which recover more slowly we get less help from the physical signs, the conditions within the chest being in a more stable state of perversion. In pletiro-pneumonia the lung may not he able to expand any more in cases of paracentesis for the pleurisy, so that only some ten ounces or so may be obtainable by falling in of the ribs. In two cases in which the present writer noted redupli- i cation of the second cardiac sound before tap- ping, this sign ceased at once on the emptying of the cavity. It is rather the rule than the excep- tion for some dulness to remain below the sca- pula, and this alone is no indication for repeating the operation. If there be any subsequent pain or elevation of temperature, these, under ordinary circum- stances, will prove to he transient. If the rise of temperature continue after the first day or two, the formation of pus is to be feared. The formation of pus, moreover, is net infrequently utended with a re-awakening of pain. If pus form, the cavity in all likelihood will soon refill, md pus will be detected on puncture. It is desirable, however, to draw oft' a considerable [uantity of a purulent effusion by ordinary tap- ring before proceeding to any further operation, jis in this way any danger due to the sudden ■mptying of the whole cavity b.v the radical ■peration is avoided. Soon after, or in one or two ays, according to the state of the patient, an pening must he made sufficiently large to per- j lit of the introduction of a sound. By means f the sound the extent and depth of the cavity ,rill he gauged, and the sound being directed to ie lowest point iu the axillary or infra-scapular ue an opening must be made upon it into the ivity, through which the latter will be drained ) the last drop. It is impossible to take too iuch pains to secure the perfect freedom of this pening, or to place it at the lowest point in the »vity. For this reason it is desirable to give 1223 an anaesthetic, that the operation may- be de liberately performed. Chloroform seems to put less strain upon the limited breathing powers than ether in these cases. If the patient be ol spare body, let the opening be taken below the spine of the scapula ; if stout and muscular, a more lateral operation will probably be pre- ferred, though drainage is more continuous aud thorough by a posterior opening, and the ribs are there less liable to fall together. After the pus has run out, the upper opening may be closed in the usual way. On no account let a drainage- tube be run through both openings, or it will act as a seton. It is of the greatest possible importance that all the instruments in use be disinfected, and it is desirable, if possible, to do the whole operation and dressings by the antiseptic method; and this is to be followed up by dressing under the spray. From the time of the operation, it has been stated, the temperature will fall rapidly to the Dormal ; if it rise again during convalescence the rise will be almost surely due to occlusion of the opening. To prevent this we insert a drainage-tube. False-membranes as thick as wash-leather may oppose themselves at first, aud the tube therefore, at first, should be propor- tionately large ; but these soon break down into curdy shreds, and the tube may be reduced in diameter, and must be gradually cut away, as secretion of pus diminishes. Injections of a simple or antiseptic character, into the cavity of empyema, are in the writer’s opinion to be avoided. They are rarely of use, they often increase irritation, and are sometimes attended with distressing or alarming general symptoms. Tho great secret is to secure free and complete drainage ; if this be attained the cavity will purify itself. This is as true of closing cavities as of freshly -opened cavities; for to inject sinuses, in the hope of procuring adhesion and closure, rarely succeeds and often does harm. In like manner to probe the opening of an empyema is generally a mistake. If the opening discharge for a long period, it may be well once for all to ascertain the length and direction of the sinus, but it is better to enlarge the opening if necessary, or even to make another, than to fret tho part by repeated explorations. Resection of a portion of a rib has been recom- mended by some surgeons, even as a part of the ordinary operation. If a neglected empyema have shrunk or discharged spontaneously, or if, after opening, the continuance of the discharge seem to depend on rigidity of the chest-wall and arrest of lung, then resection of a considerable portion of two or three ribs may carefully be considered. In this way closure of the cavity may be obtained, the spine and shoulders becoming distorted ; but such cases will become very rare as diagnosis and early operative relief are more generally understood. Id the exudations of tuberculous or carcino- matous disease, operation is often more than justified by the temporary relief given to the sufferer. If after the removal of a collection of pus and the establishment of free drainage the discharge becomes more offensive and the fever remains, the disease is probably tubercular ar.d the forecast of the worst. PLEURA, DISEASES OF. 122 1 Sometimes empyemas havo been treated by repeated aspirations, instead of by incision and continuous drainage. It is hopeless to attempt the cure of a aero-purulent discharge by this method, but a collection of laudable pus once removed by the aspirator has in rare cases failed to return. The chance of success by this method is too slight to be looked for with any confidence, and the repetition of these aspirations does not prevent the gradual condensation of the lung, nor the formation of a pulmonary fistula. There is no difference in method between the perfor- mances of these operations in childhood and in age, but in childhood recovery is generally more rapid and sure. Nor is there any difference of method in operating upon a case in which a pulmonary or other ill-placed fistula has already formed, nor is the performance of the operation much the less urgent in such cases, even if the bronchial opening be free and not valvular. It is desirable that after each cr any removal of fluid from the chest the re-expansion be as- sisted by respiratory gymnastics. The best method of obtaining this end is by graduated exercise ; by the inhalation of compressed air from one of the apparatus constructed for this purpose ; or by residence at high elevations. Means have been proposed by which the en- trance of air into an empyematous cavity under drainage might he prevented, and the lung thus helped to expand under inspiration. The per- manent need of absolute freedom in draining and dressing, however, must discourage the use of all complex apparatus, and if the operation be performed early and antiseptically it is marvel- lous how well the lung will recover itself. 3. Pleura. Air in. — Synon. : Pneumothorax; Er. Pneumothorax ; C-er. Luf thrust. Definition. — Pneumothorax, as its name im- ports, is the state in which the pleural cavity, normally' vacuous, or rather non-existent as a space, contains air or other gas without inter- mixture of liquid. If air or gas be present, together with pus, blood, or a watery fluid, we give to the resulting state the compound names Pi/o pneumothorax, H&matopneumothorax, and Hi/drapneumothorax respectively. The gaseous contents in these eases may precede the entry of the fluid or succeed it, and in the latter case it may perhaps be developed as a product of decom- position. These conditions, though not wholly unknown to the predecessors of Laennec, never- theless were first adequately distinguished and clinically demonstrated by him. JEtiologv. — Pneumothorax is a commoner event than would be supposed, were we to confine our attention to the cases which have received this name. It is often an incident in the course of other diseases, and of none more often than phthisis. Pneumothorax sometimes, but rarely, appears as a primary event and dis- appears again without further complication ; more usually it occurs as one result of wounds of the chest, of purulent pleuritis, of phthisis, or of some rarer disease, such as ulceration of the oesophagus or stomach, carcinoma and the like, which effects an opening into the cavity. If air be mechanically admitted to the cavity, lecomposition of its contents may add to the volume of that which was admitted. Even in those few cases in which pneumothorax seems ‘ idiopathic ’ — in which, that is, we find pneumo- thorax to be the first, the sole, and the last morbid state — we are almost bound to assume that this state is, in fact, secondary, and due to some perforation the cause and place of which escape our search. That such cases do occur is unquestionable; the most frequent cause being a strain, noticed or unnoticed at the moment. Id passing to the cases of more obvious causation, those due to wounds of the chest are the first to meet us, and need not detain us. That any wound perforating the wall of the chest and the pleura will permit air to be drawn by suction into the pleural cavity is obvious. Of the same kind, but of natural origin, is the pneumothorax which in empyema follows perforation of the lung with ejection of the pus upwards, or perforation of the chest-wall by natural ulceration outwards. In these cases of pyopneumothorax we have to deal, of course, with the presence both of pus and of air in the pleura. Pneumothorax, though occurring but in a minority even of the ulcerative cases of phthisis, yet is frequently met with as a com- plication. It occurs for the most part in the later stages of the disease, and often escapes observation ; less frequently it is met with in the earlier stages, and is then betrayed at once by its symptoms. Its occurrence may be aided or not by such a strain as a fit of coughing. That pneumothorax is not a more uniform result of ulcerative processes in the lung is due, of course, to the anticipation of a breach of surface by previous adhesive inflammation. Iu phthisis, happily, the perforation as a rule is minute, and. the quantity of matter escaping into the cavity small — so small as to he generally in- adequate to produce the physical signs of fluid contents. In other cases the escape is more abundant, or a more abundant effusion comes from the pleura itself, as a consequence of the resulting irritation. We then have to deal with an obvious hydropneumethorax, or pyopneumo- thorax. The opening by which air escapes into the pleural cavity may be, and often is, valvular, so that its entry during inspiration may not he balanced by its exit. In this way air may accumulate under pressure. If, as in empyema, the lung be already collapsed, this pressure is the less distressing; if the lung be wholly or in part open, the pressure adds to the de- gree of the sudden embarrassment due to rapid collapse of lung, and to encroachment upon the surrounding parts, including the opposite lung. Air thus entering the pleural cavity is often purified from septic elements by its filtra- tion through the lung, unless it pass through cavities and alveoli already charged with septic matters. In puncturing the chest-wall with a fine troehar, in cases of serous efiusion, the lung is sometimes wounded, and air escapes into the pleura. The accident is an untoward one ; but the air which thus escapes into the pleura is so cleansed by its passage through a healthy lung that, as a rule, it sets up no putrefaction, SEd is itself quickly absorbed. The puncture heals too rapidly to permit of any continuous transpi- ration, but the quantity suddenly admitted mav add a good deal to the suffocative distress of the PLEURA, DISEASES OF. patient A similar state of things is not uncom- monly seen in the practice of the surgeon, when an injury which breaks a rib also drives its broken point or points through the costal and pulmonary pleurae. It is said that in emphysema the bursting of dilated lobules may set up pneumothorax, and we may wonder that this event should be so rare. Perforation into the pleural cavity by cancerous or other destructive changes, either in the lung itself or such neighbouring organs as the cesophagus, the stomach, the bowel or connected ducts, is not very rare in cases of malignant disease ; and the entry of air and food into the pleura sets up suffocative and inflam- matory symptoms, which add greatly to the miseries of the last days of life. There are, no doubt, other ways of disease by which air may find its way into the pleural cavity ; but the above description, with little or no essential difference, will apply to all. Anatomical Chabactebs. — Under this head we have little to say in respect of pneumo- thorax, and we have not here to deal with the further appearances of hydrothorax or em- pyema. A patient would rarely die of simple pneumothorax ; for if death be mainly due to this, yet unless it occurred within the first few days it is probable that some degree of in- flammation would follow the disturbance. In the vast majority of cases, of course, the pneumo- thorax is secondary to some other disease, and any fluid or other products found with tho air in the chest may be due — not to the mere ad- mission of septic air into the cavity, but to the admission of decomposing tissue-elements into it. As concerns the presence of air alone, wo have only to say that in most eases — espe- cially in the eases in which air has reached the pleura by a valvular opening — the affected side of the chest may be visibly distended. In such a chest the pressure of the contained air may well have been not passive only but active, nnd on puncture the imprisoned air may escape with a hissing noise ; if the lung be wholly retracted, and the air contained under high pressure, the out-rush may be very strong — strong enough to blow out a candle. This air is usually deoxidised, and rich in carbonic acid ; if there be decomposing matters in the cavity, it is likely also to contain sulphuretted hydrogen. Neighbouring parts will be found more or less iislocated directly as the degree of compression of the contained air, and inversely as the amount ff adhesion limiting its extent. Bilateral pneu- 'nothorax is, of course, incompatible with life ; f it be found double we may be sure that one fide of it came on at the moment of death. Symptoms. — The symptoms of pneumothorax ire of course the more distinct, the less the symp- toms of the primary malady. In those rare cases n which pneumothorax comes on apparently as i primary disease — that is, in which the mode if entrance of air into the pleural cavity is dost obscure — we find the chief symptoms to ie dyspnoea and a sense of faintness, pain being less uniform symptom, and present only when he entrance of air is followed by irritation and uflammation from the fluid or solid matters which ecompany the gaseous. Aseptic air alone does 122A not set up inflammation, nor much irritation. Fever, in like manner, depends not upon the en- trance of air, but of the irritating matters accom- panying the air, and exciting inflammation. It may, like the pain, be considerable; it may not be present at all ; or, again, it may be lost in the fever of the primary’ malady, or show itself as a slight exacerbation of that fever. The dyspnoea, in part mechanical, in part probably reflex, is necessarily attended by increase of pulse-rate ; the two events being but different aspects of th9 same machinery. The degree of these accele- rations, as has been hinted, depends upon the amount of previous accommodation in the chest, and upon the amount, if any, of fluid and solid concurring with the gaseous escape. The escape of air with irritating matters suddenly into the pleural cavity of a person suffering but little from a phthisical ulceration, or of one surprised by an accident in the midst of health, will cause dyspnoea almost suffocative in degree, faintness, great acceleration of the pulse, and intense pain. If the affair be more serious there may also be symptoms of collapse, including a fall of temperature, cold extremities, ashen face, colli- quative sweats and chill breath. On the other hand, in pneumothorax occurring towards the end of phtliisis, when a pulmonary ulcer breaks into the pleura widely-adherent about a lung already half-obliterated, an attack of chest- pain may follow a bad fit of coughing, and be often put down, like the dyspnoea and the pulse- rate, to the fatigues and distress of a restless night. The patient’s general condition is not very markedly altered in such cases, and the pneumothorax is often overlooked. Cough and expectoration of course assume no proportions in simple pneumothorax ; but if pneumothorax be established on the bursting of an empyem3 into a bronchus, it is obvious that cough and expectoration will be the most prominent of the symptoms. It is well to remind the reader that emphysema of the skin may result from the same breach which causes the pneumothorax. Th & physical signs are as follows ; — The affected side, in well-marked cases, may be enlarged in girth and of a rounder form. It is, moreover, still in respiration, the half of the chest being fixed in the inspiratory’ position, or only dragged a little by the efforts of the accessory muscles. Air, like fluid, may press down the diaphragm, thrust the mediastinum aside, and change the place of the heart. And even if the admission of air be not through a valvular opening, and the admitted air be passive, yet. as Dr. Douglas Powell has shown, the elasticity of the opposite lung will dislocate the parts to some extent. In other cases, as in pyopneumothorax with retraction, the affected side often falls in so as to be of less girth than the sound side. In such a case, of course, there is no tension of the contained air. Vocal fremitus must be absent if the lung be wholly collapsed, or far removed from the wall of the chest ; if the lung be adherent in part to the chest-wall, vocal fremitus may be pro- portionally perceptible, and it may be possible to ascertain by other methods how far, if at all, the lung is adherent. Decubitus is usually on the affected side. Percussion gives us great assistance in the PLEURA, DISEASES OF. 1226 detection of pneumothorax, the sound being tympanitic everywhere where lung is not, by ad- hesion or repression, kept in contact with the chest-wall, and often extending beyond the nor- mal boundaries of the affected side. There is something about the loud, low-pitched and exten- sive (tympanitic) vibrations of the stricken chest in pneumothorax which is very characteristic. On the other hand, it is said that if the pleura be tightly distended by air under high pressure the percussion note may rise to positive dulness, and the presence of fluid will dull the percussion considerably or altogether, in districts which will vary with the quantity of fluid and the position of the patient. Iu pyopneumothorax, with a bronchial fistula, the sharp line between hyper-resonance and dulness may be changed after a profuse expectoration. By percussion with palpation the dislocation of neighbouring parts and organs may be ascertained. The auscul- tatory phenomena of pneumothorax are curious, and were known even to Hippocrates. If we confine ourselves to pneumothorax pure and simple, auscultation is generally almost negative ; in rare cases we may detect by a blowing sound the entrance and exit of air by a free opening, but in such cases fluid is always present as well. In them there may be faint amphoric breathing and a few resonant rales , especially near the shoulder-blade. The voice sounds in like manner; and the cough may be more or less amphoric. Vesicular breathing is never heard. In pneumo- thorax, there is often present the peculiar pheno- menon called the metallic ring. After death this metallic echo is always to be obtained, but during life the increased tension of the gas at the higher temperature may prevent it. In addition to this a very clear cracked-pot sound may be heard in some cases of pyopneumothorax wdth a wide fistula. The metallic tinkle of succussion, which was known to Hippocrates, consists in the echo of splashing or dripping fluid in the air- containing pleural cavity ; and indeed other sounds generated inside the patient, such as the heart-beat, cough, &c., may take this metallic resonance from the chest-cavity, and may betray pneumothorax or illustrate it. In the same case, at different times, such sounds may be heard, or may be inaudible — changes which are, perhaps, due either to mechanical conditions dependent, upon adhesions, the formation of false-mem- branes, the shape of the cavity, or the tension of the contained gases. See Physical Exa- mination. Diagnosis. — The diagnosis of pneumothorax by the signs and symptoms above named is not difficult, if the occurrence of it be sudden and the patient not too ill to resent examination. If the. presence of adhesions prevent the develop- ment of these symptoms, the case may be more obscure, but by so much the less serious. As, on the one hand, in an enormous moist cavity it is conceivable that metallic and succussion sounds may bo heard, so, on the other hand, pyopneumo- thorax, restricted by adhesions to small dimen- sions, might simulate a cavity. Indeed, diag- nosis might be impossible in such cases, but speaking generally, the dulness and retraction of the chest-wall over a cavity would assist the diagnosis. Distension of the stomach, wnth ele- vation of the diaphragm, or diaphragmatic her- nia, could scarcely be mistaken for pneumothorax by anyone who fairly took into consideration all the facts and history of the case. As empy- ema, especially in children, is liable to lead to purulent pericarditis, so may pyopneumothorax by perforative process have pyopneumopericar- dium added to it. Emphysema of the lungs gives rise to tympany sometimes as great as of pneumothorax. Emphysema, however, is always two-sided, and rarely dissociated from sibilns or other sign of open bronchial tubes. In eases of pyo- or sero-pneumothorax there may be great difficulty in determining the quantities of fluid and of gas respectively in the cavity ; as much as three quarts of fluid may co-exist with a great deal of resonance above it. Tapping alone could decide the matter, and in such a case would pro- bably be indicated. Prognosis. — This obviously depends so largely upon the causes and concomitants of the pneumo- thorax, that any general estimate of it is impos- sible. The tendency of air in the pleura is to absorption. The prognosis of chest-wounds, o: phthisis, of empyema, contains differences too wide for formulation. It is asserted that pneumo- thorax, by the sudden oppression of the lung, through the in-rushing air, may causo rapid and even sudden death. Treatment. — The treatment of pneumothorax in like manner must depend greatly upon the nature of the primary malady. In pyopneu- mothorax from empyema operation is the first necessity in a patient of sound constitution. Whether in any given case of phthisis pyopneu- mothorax should be dealt with by operation may become a question — but a question usually, of course, to be decided in the negative. In such cases opiates alone are our resource. Still, a case may be imagined in which the urgency of operation may outweigh its risks. In wounds of the chest-wall, or of the pulmonary pleura, the puncture rarely closes so soon as to imprison the air in a state of higher tension than the at- mosphere. Such a thing may occur, however, and the displacement of organs and respiratory distress may indicate that relief is urgently needed. If it be, a fine trochar may be inserted into the chest, and by means of a tube air may be permitted to escape through water until equi- librium is re-established. The hypodermic use of morphia is as valuable in soothing the pain and distress of pneumothorax as of like suffering elsewhere. Walshe recommends general bleed- ing, if admissible, or in any case free dry-cup- ping of the affected side. Among drugs he chiefly recommends musk, in five-grain doses, and very small inhalations of chloroform. 4. Pleura, Dropsy of. — S tnon. : Hydrotho- rax ; Fr. HydrotJwrax ; Gcr. Bmstwasscrsucht. Definition. — As the word implies, this is the term given to simple aqueous effusions into the thoracic cavity. Description. — Hydrothorax is not to be classed with the effects of inflammation, but with dropsies elsewhere, and is the companion in many cases of ascites and anasarca. In other cases it exists alone, hot is rarely confined to one side of the thorax, and perhaps never exists as a sole malady. We may say generally that it is liable PLEURA, DISEASES OF. to arise under the following circumstances : — when the whole circulation is so impeded that venous pressure is increased — as, for instance, in disease of the mitral valve or its orifice ; when venous arrest is due to some local causes, as for instance, to the pressure of localised swellings upon reins, or to venous thrombosis ; when the bronchial glands are enlarged ; when in renal disease the removal of water from the sjstem is checked; or, finally, when the quality of the whole blood is so deteriorated' by disease, or the circulation is so changed by cold, or other such general influence, that its serum tends to exude passively from the vessels. In the first and third cases we should expect to find dropsy in both pleural cavities, in the second case the transudation might be limited to one of them. On the other hand it is to be remarked that such transudations rarely stand at the same height in the two cavities, and indeed the contents of one of them is often so small in volume that the hydrothorax may seem to be unilateral. As a matter of experience hydro- thorax is chiefly seen in diseases of the heart and kidneys, in scarlet fever, in septic and ether diseases of the blood, and in the cancerous and other cachexias, whether there be local disease of the pleura or not. Diagnosis.— The diagnosis of hydrothorax and its measure are easy, except in a few cases where the effusions are restrained by adhesions. The luDg floats more readily than in pleuritic effu- sion, and the diaphragm often retains its normal relations. Treatment. — Hydrothorax in the majority or cases is not formidable in itself, and (being not uncommonly an event of the last days of life) is perhaps only noticed at the autopsy. Diuretics and hydragogue purgatives act more readily in hydrothorax than in inflammatory serous effu- 'sions. Still, if it increase so far as to harass the breathing or to add to the dangers of the disease, 'the fluid may be drawn away by a fine trochar without any fear of purulent change. It is well, however, to prevent the entrance of air into the chest, lest the fluid have in any degree an in- flammatory nature, as it may well have in scarlatina or nephritis, for instance. The opera- tion may be repeated a great number of times if re-accumulations make it necessary. The fluid, if wholly non-inflammatory, will appear as a ‘.greenish or yellowish transparent water, con- fining no clots nor coagulating in the vessel ; it will not contain corpuscular elements. The pre- sence of a corpuscular precipitate, or any troub- ling of the fluid, will at once suggest a degree of pleuritis. In heart-disease with much venous stasis the effusion is not rarely tinged with flood. If there be coagulation, however, the ift’usion is probably inflammatory. 5. Pleura, Haemorrhage into. — Synox. : Hemothorax. — Bloodstained effusions may occur, ns we have said, even in simple pleurisy, but nore commonly in such conditions as scurvy, ubercle, cancers, and the like. A purely san- guineous effusion is generally the result of founds of the chest or its viscera ; but it may Iso arise from within, as from rupture of the leart or of an aneurism, or from a bleeding aocer. The means of examination or treat- PLEURO-PNEUMONIA. 1227 ment of such cases, in so far as these are possible, may be gathered from the preceding sections. Haemorrhage into the pleura from di- rect extravasation may be left awhile, on the chance of reabsorption. If this does not seem on the way, a tentative puncture may be made. If the issue be ichorous, the patient will pro- bably become febrile, and the major operation be needed sooner or later. G. Pleura, Morbid Growths in. — The pleura enjoys no complete freedom from the inva- sion of sarcomatous or carcinomatous growths ; but the former class of growths are very rare, ex- cept as intrusions from neighbouring parts. Can- cer is found less rarely. The frequency of mam- mary cancer and the neighbourhood of the pleura to the breasts increases the danger of secondary mischief in the former part. Pleural mischief is, indeed, a common consequence of mammary cancer, and may be the fatal conclusion of a case. It occurs after or before operations of ex- cision. From the cancer in the wall of the chest simple inflammation often extends to the pleura, and produces the usual results. In other cases the cancerous growth is itself propagated to the costal pleura, and spreads from thence. The cancer is usually seen in the form of small flattened or rounded elevations, rich in blood- vessels. If septic matters escape into the pleural cavity its effusions may soon become putrid. It is said that a rapid degeneration of cells, either cancerous or tubercular, may give rise to a quantity of fat-droplets so great that a layer of fat may be seen to stand on the top of the serosity withdrawn by tapping. Blood, too, easily issues from highly vascular formations — whether cancerous, tubercular, or simply inflam- matory; and may be seen in the fluids after withdrawal. There is little to be said of the symptoms and signs of such cases that has not been said already under the more general heads of Lungs, Morbid Growths in ; Mediastinum, Diseases of ; and Pleurisy. The diagnosis of cancerous or other such masses from their own effusions or from simple effusions, let it be frankly repeated, is sometimes impossible without the needle. The prognosis in such cases will not depend upon the pleuritic changes alone ; and the only remark to be made on their treatment is that paracentesis, in the secondary effusions, is not wholly to be declined. Some such patients have obtained from repeated puncture not only a prolongation of life, but also great relief of suffering. T. Clifford Allbctt. PLEITBODYNIA (irAeupa, the side, and oSvvtj, pain).- — Synox. : Intercostal myalgia; Fr. Pleurodynia; Ger. Seitenschmerz. — A name for muscular rheumatism or cramp affecting the chest-wall. See Cramp ; and Rheumatism, Mus- cular. PLEUEO-PUEUMOmA. — This com- pound word signifies a combination of inflamma- tion of the pleura and of the lung itself. In all cases of acute pneumonia there is a certain de- gree of pleurisy corresponding to the inflamed lung; but it is of little or no practical significance, there being only some exudation on the pleural surfaces. Pleuro-pneumonia implies that the 1228 PLEURO-PNEUMONIA. two morbid conditions are actually associated in various degrees, giving rise to their respective pathological changes, and each thus influencing the symptoms and physical signs. Individual eases, therefore, present many diversities, in ac- cordance with the different ways and degrees in which the two diseases are combined. It may happen that they are associated from the first; or one may supervene during the progress of the other, in this way modifying its course, and not uncommonly rendering the diagnosis more or less obscure and difficult. It may be affirmed that the exact conditions present in the chest under such circumstances can only be positively deter- mined by adequate physical examination ; and it must be remembered that the pleuritic and pul- monary conditions will each tend to modify the signs produced by the other. No general rules can be laid down as to prognosis or treatment, but every case must be regarded on its own merits, in accordance with the principles laid down in the articles which treat of pneumonia arid pleurisy respectively. See Lungs, Diseases of ; and Pleura, Diseases of. Frederick. T. Roberts. PLEUBOTHOTOK 08 (n\e.vp66ev, later- ally, and vivos, tension). — A form of tetanic spasm, in which the body is bent towards one side. See Tetanus. PLICA POLONICA (base Latin).— Synon. : Fir. la Plique ; Ger. lVeickselzopf. — An alteration in the direction of the hair, attended with matting or felting, and resulting from neglect. See Hair, Diseases of. PLOMBliiEES, in Prance. — Simple thermal waters. See Mineral. Waters. PNEUMATOCELE (7rifd,u«i/, the lung, and a tumonr). — Hernia of the lung. See Lungs, Malpositions of. PNEUMOGASTBIC NERVE, Diseases of. — Synon. : Fr. Maladies du Kerf Pneumogas- trique ; Ger . Krankheitcn dcs Vagus. — Of all the cranial nerves, the pneumogastric has the most extensive distribution, supplying the pharynx, larynx, lungs, heart, oesophagus, and stomach, and even, in part, the intestines and the spleen. In some of the so-called functional diseases of the organs which it supplies, its action is conspicu- ously deranged. The symptoms of its disease are thus very extensive, and it will be well first to describe them generally, and afterwards to consider in detail those which merit separate description. Some of the functions of the vagus depend upon fibres of the spinal accessory which join it, but it is convenient to consider these in this article. The pneumogastric, it will be remembered, arises from the side of the medulla, between the glosso-pharyngeal above, and the spinal acces- sory below, and to the outer side of the hypo- glossal. The fibres of origin come from a tract of grey matter which is continuous below with the nucleus of the spinal accessory, and above lies, in the calamus scriptorius, between the hypo- glossal and internal auditory nuclei, while to the outer side of the upper extremity, and more deeply seated, is the nucleus of the glosso-pha- PNEUMOGASTRIC NERVE, DISEASES OF, ryngeal. The trunk of the nerve, after receiving fibres from the spinal accessory, and giving off some small branches (of which the most impor- tant is one to the external ear), passes down the neck, behind, and in the same sheath with, the carotid artery ; enters the thorax on the right side, over the subclavian artery, and, on the left, between the subclavian and the carotid ; passes through the thorax beside the oesophagus; and ends in branches to the stomach, spleen, and in- testines. The most important branches are the pharyngeal, which, with the glosso-pharyngeal, forms the plexus of the same name ; the superior laryngeal; the recurrent laryngeal, which passes back, the left around the arch of the aorta, the right around the subclavian artery ; branches to the oesophagus ; pulmonary branches which, by means of the pulmonary plexus, supply the lung ; and branches which form the cardiac plexus for the heart. ./Etiology. — The deep position of the pnenmo- gastric and its branches preserves it from some forms of damage, although its extensive course renders it liable to suffer from many causes. The nucleus in the medulla may be damaged by local softening, haemorrhage, or slow degeneration; but in all these cases other, adjacent, nnclei suffer ( see Labio-glosso-laryngeal Paralysis). The nerve, at its origin from the medulla, may be compressed by thickening of the meninges, growths from the meninges or bones, or aneur- ism of the vertebral artery. Affections of the nerve due to syphilis are almost always the result of meningeal disease in this situation. Other adjacent nerves commonly suffer at the same time. The trunk of the nerve is some- times, hut rarely, implicated in punctured or gunshot wounds ; incised and lacerated wounds damaging it are usually immediately fatal from lesion of the large blood-vessels to which it is contiguous. In surgical operations the trunk and branches of the nerve are occasionally in- jured. The trunk has been tied in ligature of the carotid, and divided in the removal of deep- seated tumours. In such operations in the lower part of the neck it is often also difficult to 3void injury to the recurrent laryngeal. In excision of an enlarged thyroid both recurrent lairngeals have been repeatedly excised, from the time of Galen down to the present. Sarcomatous and other tumours, and enlarged glands, may com- press or involve the nerve in almost any part of its course; and interference with its function es- pecially occurs from such disease in regions limi- ted by rigid structures, as in the upper part of the neck, near the skull, and in the upper part of the thorax. Aneurisms may compress the nerve or its branches ; and the recurrent laryngeals suffer from this cause with especial frequency, because they pass round large blood-vessels. The left suffers much moro frequently than the right, be- cause the arch of the aorta is more frequently affected by aneurism than the subclavian. Ac enlarged thyroid may compress the recurrent laryngeal nerves, and symptoms due to such com- pression may vary with the varying size of the tumour. The nerve is, in rare cases, the seat of neuromata. Neuritis of the trunk of the nerve, due to cold, is supposed to be an occasional cause of symptom*, but such cases are extremely rare. PNEUMOGASTRIC NERVE, DISEASES OF. Borne toxic influences, and especially the poisons of diphtheria and lead, may affect it, probably by acting on its central origin. Symptoms. — It must be remembered that the vagus nerve, besides containing motor fibres for the pharynx and larynx, is the chief afferent nerve for the respiratory centre. It contains acceler- ating and inhibitory fibres for this centre, but the former preponderate, so that experimental division of the nerve in an animal renders the respirations less frequent, but deeper, while sti- mulation of the divided (central) end quickens the respiration, and may even arrest it in tetanic standstill. The inhibitory fibres are contained chiefly in the superior laryngeal nerve, and their stimulation arrests the respiration in muscular relaxation. It is the inhibitory nerve of the heart; slight stimulation increasing the diastolic periods, and stronger stimulation arresting the action of that organ. On division of the nerve the cardiac contractions are accelerated. It has been said to contain trophic fibres for the heart and lungs, but this is not certain. The pneumo- gastric is an afferent nerve for the vaso-motor centre, the action of which is lowered by its stimulation, so that the arteries throughout the body are relaxed. It is the motor and sensory nerve for the oesophagus ; the sensory nerve for the stomach ; and partly also the motor nerve for the stomach and intestines. Symptoms due to paralysis of the vagus are more frequently met with than those which result from its irritation. Occasionally both are com- bined. Laryngeal spasm and vomiting are the irritative symptoms most commonly met with, but occasionally cardiac inhibition occurs. Czer- mak, for instance, was able to arrest his heart for a few beats at will, by pressing a small tumour of the neck against his pneumogastric. Concato had a patient in whom a similar inhibition could be caused by pressure on the right nerve. The in- creased frequency of pulse which corresponds to its paralysis has been several times noted, and has occasionally been associated with diminished frequency of respiration, although the laryngeal paralysis, also resulting, has often obscured the effect on the respiratory movements. Roux tied the trunk of the vagus with the left carotid ; in- stantly respiration was arrested, but the pulse was also retarded. The ligature was imme- diately relaxed, but the patient died in half an hour. Robert also tied the nerve with the caro- tid; the patient, who was conscious, immediately called out, ‘ I am suffocated ! ’ and his voice be- came hoarse. He recovered, but the hoarseness continued for six months. A good example of in- terference with the functions of the vagus has been recorded by Guttmann. A lad, after diphtheria, presented paralysis of the palate and of one ster- nomastoid. His respiration quickly became re- duced to twelve per minute, and very laboured, while his pulse rose to 120, and he died in a few hours. In many other cases a similar change in the pulse and respiration has been noted, and even a pulse-ratio of 160-200. In the face of these observations, and of experiments on animals, it is not easy to understand a fact said to have been observed by Billroth, who excised half an inch of one pneumogastric, which was implicated la a tumour, without any resulting symptoms. 1229 The important central relations of the vagus above alluded to cause derangement of its func- tion to form part of many so-called functional disorders of the central nervous system. Its nucleus forms part of, or is connected with, the respiratory centre, which is conspicuously dis- turbed in hydrophobia and some other diseases. The phenomena of ‘ Cheyne-Stokes breathing,’ or ‘ respiration of ascending and descending rhythm,’ are probably the result of lowered action of the respiratory or pneumogastric centre ( see Respi- ration, Disorders of). This symptom is met with in cerebral haemorrhage, uraemia, meningitis, and in some cardiac diseases. The central connections of the vagus, in the hemispheres, extend to, or are connected with, those parts which are concerned in emotion, and it is probably through the agency of this nerve that the heart’s action is affected in excitement and fear. In many epileptic fits the central representations of the nerve are the parts through which the consciousness is first af- fected, and hence the so-called ‘epigastric aura.’ A similar disturbance seems to be the cause of the globus hystericus and of the laryngeal spasm, which are conspicuous in some epileptic and hys- teroid seizures. The nerve is closely connected with the centre or nerves for equilibration, so that severe vertigo, on whatever dependent, is often followed by vomiting. The pneumogastric nu- cleus is contiguous to the internal auditory nu- cleus, and part of the auditory nerve, that which comes from the semicircular canals (the space- nerve of Cyon) is known to be concerned in equi- libration. In the vertigo which results from disease of this nerve, or of the canals (labyrin- thine or auditory vertigo) vomiting is very com- mon, and the nausea and retching of sea-sickness are probably due to the deranged action of the semicircular canals, in consequence of the motion affecting the pneumogastric centre. It is pos- sible that the connection of the vagus with the equilibrial nerves is by means of the cerebellum, diseaso of which so constantly causes vomiting, although this connection has not yet been traced. Conversely, gastric disturbance of the vagus is often accompanied by vertigo, especially when combined with pre-existent imperfect action of the auditory nerve. 1. Pharyngeal Branches. — The branches of the pneumogastric which enter the pharyngeal plexus supply the constrictors of the pharynx and the soft palate. Some have asserted that all the pharyngeal branches are derived from the spinal accessory; the pathological evidence that the branches to the soft palate are derived from this source is very strong, since when one vocal cord is paralysed from disease of the roots of the spinal accessory, the levator palati on the same side is always paralysed, and very often the tongue. See Palate, Paralysis of. (1) Paralysis . — ^Etiology. — The most com- mon cause of paralysis of the pharynx is disease of the origin of the nerve in the medulla ; such disease commonly also involves adjacent nuclei (see Labio-qlosso-laeyngeal Paralysis). Pa- ralysis may, however, result from meningeal disease outside the medulla, from disease of the bones of the base of the skull, but scarcely ever from disease outside the skull. It occasionally forms part of diphtheritic paralysis. 1230 PNEU MOG-AST R I C NERVE. DISEASES OF. Symptoms. — The chief symptom is difficulty in swallowing. Food lodges in the pharynx about the epiglottis, and small particles and liquids may enter the larynx. If the paralysis is limited to the superior constrictor, liquids may, it is said, be forced up into the nose by the contraction of the middle constrictor; but .'t is doubtful whether tins occurs unless the palate also is paralysed. The affection of one nerve causes only slight trouble in deglutition, no doubt because of the circular arrangement of the muscular fibres. Diagnosis. — The only conditions with wliicii paralysis of the pharynx can be confounded are spasm and organic diseaso. The writer once saw an elderly man with distinct pharyngeal para- lysis, who had been sent to an eminent surgeon because the difficulty in swallowing was supposed to indicate cancer of the throat. A careful exa- mination is usually sufficient for the distinction. (2) Spasm . — Spasm of the pharynx may be recognised by its paroxysmal character, and is almost always part of ‘functional’ nervous dis- ease. It forms part of the spasm of hydrophobia ; and occurs in hysteria, and in some other allied states. Individuals are sometimes met with who are unable to take food except when alone, so great is the amount of pharyngeal spasm which the presence of others induces. 2. Laryngeal Branches. — It will be re- membered that, of the two laryngeal nerves, the superior is the sensory nerve for the larynx, and also supplies motor power to the crico-thyroid muscle, which is the tensor of the cords ; while the recurrent laryngeal is purely motor, and sup- plies the other muscles. The motor fibres of both are derived from the spinal accessory. Of the muscles, the most important in regard to para- lysis are the chief abductor, the posterior crieo- arytsenoideus (which draws the postero-external angle of the arytenoid cartilago backwards, and so moves the processus vocalis outwards); the chief adductor, the lateral crico-arytaenoideus (which draws the postero-external angle of the arytenoid cartilage outwards, and thus the pro- cessus vocalis inwards); and the arytaenoideus (which approximates the two arytenoid carti- lages). Other muscles, acting at the same time, increase the power of closure. (1) Paralysis . — Only paralysis of the abduc- tors and adductors need be discussed in this article. That of the tensors and laxors of the vocal cords, although very important among laryngeal diseases, is always the result of local conditions, not of lesions of the pneumogastric nerve. A2xiotoGY. — Almost all diseases of the nerve- trunk affect the fibres to the larynx, the only exception being the diseases of the trunk below the origin of the recurrent laryngeal. Syphilitic and other intracranial disease, injuries, and pressure by tumours, all have this consequence ; and the motor paralysis is, necessarily, almost as complete in disease of the recurrent laryngeal as in that of any part of the trunk of the pneumo- gastric. In diphtheria the larynx is also some- times paralysed. Rheumatic paralysis is pro- bably always local. Diseases affecting the fibres of origin of the spinal accessory at the medulla, or its trink in the neck, or the recurrent nerve, usually, and diphtheria occasionally, cause para- lysis on one side only. Affections of the nucleus of origin of the nerve are usually bilateral: and the other common cause of bilateral paralysis is the implication of both reenrrents in growths in the upper part of the thorax. Diphtheria also sometimes causes paralysis of both nerves. Symptoms. — In complete unilateral paralysis the affected vocal cord is usually in half-abduc- tion, in the position assumed after death. Al- though there is loss of all movement, that of ad- duction is the obtrusive defect. In phonation the unaffected cord moves up to or beyond the middle line, while the paralysed cord remains motion- less; and the movements outwards in inspiration and inwards in expiration, are performed only by the healthy cord. The voice, under these circumstances, may be hoarse, or it may be little altered, the healthy cord being moved beyond the middle lme into sufficient proximity to the other to permit phonation. Complete approximation, such as is necessary for a cough, is impossible; and in the attempt to cough the patient only succeeds in driving air quickly' through the open glottis, and no sudden explosive cough is pos- sible. Sometimes, in complete unilateral para- lysis, the affected cord is not in semi-abduction, but is nearly up to the middle line. It is in the position for phonation, and so there is no defec- tive approximation in uttering vowel-sounds : but when phonation is over, and especially during in- spiration, the healthy cord is abducted, while the paralysed cord remains motionless. Thus the loss of abduction is the conspicuous defect. On what the difference in the position of the para- lysed cord depends, whether it is in abduction oi in adduction, is not quite certain. The position of adduction is seen especially in paralysis of the recurrent nerve. A plausible explanation, which has been suggested to the writer by Dr. Poore, is that the position of abduction is the early state, and that after a time, in some cases, the unopposed erico-thy'roid over-extends the cord, and so brings it into the middle line, just as in other organs, muscles, the opponents of which are paralysed, gradually, by' their tonic shortening, alter the position of parts to which they are attached. In paralysis from disease of the roots of the spinal accessory at the medulla, the affected cord is al- ways, as far as the writer has seen, in a state of partial abduction, a fact which harmonises with Dr. Poore’s explanation, since, in this case, the crico-thyroid will also be paralysed. When the cord is in the position of adduction, the voice is high-pitched. At rest there is no dyspncea, but on exertion the unabducted cord interferes with the entrance of sufficient air, and respiration be- comes stridulous and short ; but there is rarely, if ever, sufficient dyspnoea to render tracheotomy necessary. Bilateral paralysis is much less common. It may be due to central disease ; to diphtheria ; to pressure on both recurrent laryngeal nerves from tumours in the upper part of the thorax ; or to the injury of these nerves in the excision of en- larged thyroid. Two remarkable cases have been recorded (Baumler, Johnson), in which pressure on one recurrent laryngeal and vagus has caused paralysis of both vocal cords, in onecaso equally, in the other less on the side opposite to the tu- mour than on the same ride. Dr. Johnson snjj PNEUMOGASTRIC NERVE, DISEASES OF. ge 3 ts that the mechanism is probably an inhibi- tion of the central nucleus on both sides, by the pressure of the afferent fibres in the vagus. In bilateral paralysis the same difference in the position of the cords is met -with as in unilateral paralysis. Sometimes they are apart, in half- abduction, and sometimes approximated in ad- duction. In each case they are motionless. In the first instance the absence of the adduction for phonation is more conspicuous than the want of respiratory movement, and leads to the condi- tion being designated paralysis of the adductors ; in the latter the absence of the normal abduction on inspiration attracts chief attention, and there is said to be paralysis of the abductors. It is pro- bable that Dr. Poore’s explanation applies to these cases also. The difference between the two in their symptoms is very great. When the vocal cords are in abduction phonation is almost, or quite, impossible, and there is no closure of the glottis in cough. There may be no dyspnoea unless on very active exercise. When, however, the cords are near the middle line, the patient’s condition is very different. He is able to speak, but only in a high, stridulous voice. The most urgent symptoms arise from the absence of the , normal respiratory movements. Instead of being abducted in inspiration, the pressure of the air brings the cords closer together, while the cur- rent, in expiration, separates them. This in- : spiratory approximation of the cords constitutes a source of the gravest danger. When the pa- tient is at rest enough air may enter to prevent dyspnoea, but exertion brings on stridor and in- ; tense difficulty of breathing. The least swelling of the cords occludes the glottis entirely. This condition is one of great rarity, and is most commonly due to central disease. Slight impairment of adduction of the cords is a very common and much less grave affection, met with in general weakness, hysteria, and local in- flammatory diseases. It has been termed ‘ phonic paralysis,’ because in the slight effort of speaking the cords are not approximated, while in the stronger effort of the cough they are brought to- gether perfectly. It does not result from nerve- lesions. Ancestliesia of the larynx may result from disease of the superior laryngeal nerve, but is extremely rare from this cause. Lessened sensi- bility, bilateral, is not uncommon in central dis- ease of the medulla. (2) Spasm . — The common form of spasm of the laryngeal muscles is that of the adductors. The nuscles which close the glottis are far more powerful than those which open it, hence any ir- ‘itation of the nerves — direct, central, or reflex — auses closure. For this closure, since it plays ■n important part in many physiological pro- * esses, a central mechanism is provided, which 3 readily excited by T various means. In cough, or instance, it may be excited, not only from he special afferent nerves of the throat, larynx, nd hrngs, but also by those of the stomach, and ven, it is believed, by the branch of the vagus ’hick goes to the external auditory meatus, pasmodic cough may result from the simple ir- tability of the centre, as in hysteria ; and a pe- iliar barking cough is occasionally the result of iisturbat'.on in boys. In whooping cough, again, 1231 the glottis, after being closed, is imperfectly re- laxed, so that a sound accompanies the next inspiration. Simple laryngeal spasm, without implication of the expiratory muscles (laryngis- mus stridulus), occurs in children, in whom, in consequence of the constitutional condition known as rickets, the central nervous system is in a state of undtie irritability. In this the vaso-mo- tor centre seems to participate ; a child, on some exciting cause, as a start, a reflex impression, or on none, suddenly turns pale, is unable to get its breath for a few seconds, and then, the spasm relaxing, air is drawn through the slowly open- ing glottis with a crowing noise. Quite similar attacks may occur in adults. It may be accom- panied by distinct convulsive action elsewhere. In the paroxysms of epilepsy a similar combi- nation is seen ; the epileptic cry is the result of laryngeal spasm. Hydrophobia also is attended with a paroxysmal closure of the glottis. Since the closure of the glottis is the physio- logical effect of irritation of the afferent laryn- geal nerves, it is not surprising that spasm ac- companies a large number of laryngeal diseases, varying in its prominence according to the irri- tative nature of the disease, and the irritability of the reflex mechanism ; and, since the latter is most intense in children, we have in them a con- dition in which the slightest local catarrh gives rise to spasm. The attacks tend to occur es- pecially at night, when the reflex centres, re- leased by sleep from the control of the higher, are in their most active state. Spasm mayoccur, not merely from irritation of the laryngeal nerve, but from that of the vagus below (or by compres- sion by tumour), the afferent nerves from the lungs being sufficient to generate it. Reflex spasm is always bilateral in character. Direct spasm by irritation of the recurrent laryngeal usually involves only one vocal cord ; but in a few cases spasm so excited has been bilateral. This result can only be explained either by assuming the irritation of some afferent fibres, or by as- cribing it to the spasm of the arytaenoideus, which is a bilateral muscle (Krishaber). A very rare condition of ‘functional spasm’ has been described, in which spasm is excited by attempts to speak. It has been thought to be similar in its nature to writer's cramp. 3. Pulmonary Branches. — The effect of dis- turbance of the pneumogastric on the respiratory movements, and the reflex effect of disturbances of the afferent pulmonary branches, have been already described. The muscular fibres of the bronchi are innervated by the nerve, and their paroxysmal contraction in asthma is thought to be produced through its agency. It has been asserted that the plain muscular fibres, said to exist throughout the lung-tissue, are supplied by it (Gcrlach), and their contraction has been assumed to explain a peculiar form of emphy- sema, which has been observed in compression of the pneumogastric (Tuczek) ; but, since deep breathing of a costo-superior type was observed, it is possible that the effect is the result of the energetic respiration from the disturbance of the centre. The pneumogastric is commonly believed to contain vaso-motor fibres for the vessels of the lungs, but Brown-Sequard and Franck have separately shown that these fibres PNEUMOGASTRIC NEEYE, DISEASES OF. 1232 are contained, not in the vagus, hut in the sympathetic. Vascular lesions of the lungs have, however, been observed after section of the vagus. Michaelson noted rapid congestion and haemorrhage. It is possible that this may he of reflex origin. The congestion noted after lesion of the pons may also be produced through the agency of the sympathetic. In a case of haemor- rhage into the pons, fatal in two hours, the writer found intense congestion with extravasa- tion into the left lung, and haemorrhages in the left extremity of the stomach. After section of the vagus, animals die from chronic pneumonia, and hence the vagus has been supposed to be a trophic nerve for the lungs. But the changes have been accounted for by the entrance into the bronchi of food from the pharynx, in consequence of the obstructive paralysis of the oesophagus, and the paralysis of the larynx (Traube, Steiner). All admit that this is one cause of the pulmonary affection, but differ as to its adequacy in all eases. The ques- tion is still undecided. 4. Cardiac Branches. — The inhibitory effect of irritation, and acceleration of the heart's action, which results from lessened action of the vagus, have been before alluded to. The increased frequency has been several times observed in cases of local disease of the vagus in the thorax, compression by mediastinal tumours, &c. In a case of phthisis, for instance, in which the pulse was at first occasionally, and afterwards con- stantly, frequent (130-148), Meixner found the 1 eft vagus enclosed in a mass of enlarged glands in the upper opening of the thorax. The vagus is also the afferent nerve from the heart, and although we are normally unconscious of the cardiac action, some of the disordered sensations of disease are apparently produced through its agency. The subject of angina pectoris, and its relation to the vagus, are discussed in a separate article, but it may be here noted that in some anginal attacks the heart’s action is, for a time, arrested or retarded, and that in a few cases these symptoms have been found associated with organic disease of the cardiac plexus. Thus in a ease in which, during paroxysms of intense anginal anguish, the heart’s action was arrested for four or six pulsations, Heine found a tumour involving the cardiac plexus. In a case recorded by Blandin, anginal attacks were associated with a small tumour of the vagus. Further, there are afferent fibres from the heart inhibiting the action of the vaso-motor centre, and these are probably stimulated in some anginal seizures. After disease or injury of the vagus, the heart has been found in a state of fatty degeneration, and hence it has been thought that the vagus contains trophic fibres for the cardiac substance. 5. Branches to the Alimentary Canal. — The branches to the oesophagus are rarely diseased except in cases of affection of the nerve-trunk or of the centre. In very rare cases such disease has caused difficulty in swallowing, simulating stricture. Spasm of the oesophagus is more frequent. The vagus is the sensory, and in part the motor nerve for the stomach. Its fibres are very sensitive to any local irritation, and not rarely the seat of spontaneous neuralgia. Hun- ger is generally believed to be a pneumogastric sensation, and complete loss of the sensations of hunger and thirst were noted in a case of soften- ing of the root of the vagus from an aneurism of the vertebral artery (Johnson). Appetite, how- ever, is not always lost in animals when the pneumogastrics have been divided (Reid). In some cases of disease of the nerve, excessive appetite has been noted. This symptom, for it- stance, was noted in one case, in conjunction with dyspnoea, noisy breathing, and vomiting of unaltered food : post 'mortem , both pneumogas- trics were found atrophied (Swan). In another case of insatiable appetite, small neuromata were found on the nerve. It is possible that the polyphagia may be in part the result of the defective digestion of food. The pneumogastric is also in part the motor nerve of the stomach ; after its section the con- tractions of the organ are lessened, although not altogether arrested. Vomiting is probably produced through its agency, by varied reflex and central irritation. In the latter case (as in meningitis) the vomiting is sometimes extremely rapid. The writer has known paroxysmal vo- miting to result from the intermitting pressure of a tumour on the vagus ; and Boinet, having exposed the vagus in an operation in the neck, noted that whenever he touched the nerve the patient vomited. The vagus accelerates the contraction of the intestines, but no intestinal symptoms have been noted from its disease. General Diagnosis. — The chief symptoms on which the diagnosis of disease of the vagus, in any given case, would rest, are the laryngeal paralysis ; retarded respiration ; accelerated or retarded heart ; and vomitiDg. The diagnosis of the seat of the disease rests upon the range of the symptoms, and associated morbid pro- cesses. Disease of the trunk of the vagus is much less common than disease of its branches or roots. Paralysis of one vocal cord, for in- stance, is almost always tho result of pressure, either on the recurrent laryngeal, or on the roots of the spinal accessory at the medulla. Bilateral symptoms are usually due to central disease, or else (if slight) are of merely local origin. In most cases of pressure on the trunk and branches of the vagus the cause of the symptoms is distinct, the only exception being deep-seated tumours in the thorax. Pbognosis. — The prognosis is that of the cause of the disease, and is sufficiently discussed in other articles. Treatment. — Little can be said on the general treatment of the diseases of the pneumogastric, since it depends on the different conditions to which the symptoms are due, and which are de- scribed elsewhere. Central disease, and causes of pressure on the nerve are, as a rule, beyond the range of treatment. Whenever there is reason to suspect pressure on the nerve-roots (from the combination of paralysis of the tongue, palate, and one'vocal cord), iodide of potassium should be given, since this is more frequently due to syphilis than to any other cause. In laryngeal paralysis the local application of elec- tricity is sometimes useful, but more so in the weakness which depends on local causes than in that which is due to nerve-lesioDS. Injections PNEUMOGASTRIC NERVE. of strychnine are also sometimes useful, even, it is said, when its administration by the mouth is without effect. In central paralysis the treat- ment will depend on the indication given by the mode of onset regarding the nature of the lesion, whether softening or degeneration. In all spasmodic affections, sedative inhalations, especially chloroform, are useful ; and bromides will lessen the irritability of the nerve-centre. W. R. Gowers. PNEUMOGRAPH (* vetfiuv, the lungs, and ypiytii, I write). — An instrument for recording the movements of respiration. See Physical Examination. PNEUMONIA {■wvevp.tav, the lungs). — In- flammation of the substance of the lungs. See Longs, Inflammation of. PNEUMO-PERICARDIUM (ir vevp.a, air, ind TepucapStov, the pericardium). — A collection if gas in the pericardium. See Pericardium:, Diseases of. PNEUMOTHORAX (iri/evga, air, and liipa^, the chest). — A collection of gas in the tavity of the pleura. See Pleura, Diseases of. POCK. — A popular term for pustule, as ;liough a pocket or pouch in the skin tilled with ms. From the plural of pock is derived pox; .ence, small-pox, cliicken-pox, the great pox or lenereal pox, and so forth. PODAGRA (t roDs, the foot, and &ypa, a Seizure). — A common synonym for gout, as it jsually attacks the foot. See Gout. PODALGIA (ttoOv, the foot, and uKyos, ain). — A name for pain in the foot, due to any iuse, such as gout, rheumatism, &c. POINTS DOULOUREUX (Fr.)— Tender lints in connection with the affected nerves in niralgia. See Neuralgia. POISONOUS ANIMALS. See Venomous NIKALS. POISONOUS FOOD. — Under certain con- tions, various articles of diet, especially moat, gs, milk, butter, cheese, and honey, may be- mc possessed of poisonous properties, and is may arise from a variety of causeo, besides e introduction of known and specific poisons, oreover, certain kinds of animal food — fish iefly — may be possessed of definite toxic pro- rties. Food may be more or less poisonous — (1) from soundness, either from putridity or decomposi- n, and from disease ; (2) from the presence of r asites ; (3) from mouldincss, or presence of eterious fungi ; and (I) where the flesh is that 1 animals which have/eiZ on noxious or poisonous , nis ; and under this head may also he classed 1 sonous honey, which bees have gathered from ) sonous plants. (5) It may be of the nature of [ sonous fish, using the term fish in the popular : se. Parasitic diseases might strictly be said feome under head (1); hut as they are dis- used in separate articles, the preventive mea- ses to be adopted in the use of food infested 'A parasites will alone he treated o' in this f ;.e. See Cysticterci ; T;enia ; and Trichina. ’oisonous Vegetables. — Unsound or even 78 POISONOUS FOOD. 1233 rotten vegetables and fruits may be consumed, especially in hot summers, and become fertile sources of varied forms of poisoning. The symp- toms produced by the ingestion of large quan- tities of unsound fruit and vegetables are usually of a diarrhoeal character, not often of an alarm- ing severity, except in the cases of the young and feeble. They may, however, sometimes attain a fatal severity. The cause is usually obvious, and the treatment is simple — mild pur gatives, as rhubarb or castor oil, with or followed by opiates, to remove peccant matters from the intestines ; and stimulants, as ammonia or alco- hol, if there be much collapse. Poisonous Meat. — Tainted or putrid Meat. The obvious characteristics of good, sound flesh meat are that its colour is red — neither pale pink nor deep purple ; that it is marbled in appearance : firm and elastic to the touch, scarcely moistening the fingers ; having a slight and not unpleasant odour ; and that when exposed to the air for a day or two, it should neither become dry on the surface, nor wet and sodden. Sound meat is acid to litmus paper ; unsound meat may be neutral or alkaline. Meat may be tainted with physic administered to the animal. It is a common practice when a fat and valuable animal is unwell, to physic it, and if its recovery be not speedy to slaughter it. The meat of such animals may often be met with in our markets, and may induce illness from the physic with which it is contaminated. The effects of simple putridity are most varied. It is well known that some nations habitually eat, and even prefer, putrid in preference to fresh meat ; and the development of rottenness in eggs for the epicure is an art in China. There is no doubt that habit has much to do with the toler- ance of putrid meat — whether cooked or only partially cooked — by the stomach. But tainted game, and indeed all kinds of meat in which putrefaction has commenced, may, when taken, indubitably produce disease. This is chiefly of a diarrheeal character, preceded by rigors, and attended with collapse, and it may he convulsions and other signs of a profound affection of the nervous system. The effects of such tainted meat are slight as compared with those which are produced by the sausage-poisen, developed by a sort of modified putrefaction in certain German sausages. These sausages, when they become musty and soft in their interior, nauseous in odour and flavour, and acid to test-paper, acquire a highly poisonous character, and are frequently fatal in their effects. The symptoms produced by their use are gastric pain, vomiting, diarrhoea, depression, coldness of the limbs, and weak, irregular cardiac action. Fatal cases end in convulsions and oppressed respiration, death ensuing from the third to the eighth day. The nature of the sausage-poison, which is probably akin to that of putrid, and indeed all non-speeifically tainted meats, has been a matter of considerable controversy. Some have held that the toxic action is due to the develop- ment of rancid fatty acids ; others believe that a so-called catalytic body is produced, capable of setting up by contact a similar catalytic action. Others have regarded the sausage-poison as due to the formation of pyrogenous acids during the process of drying or smoking the sausages. The 1234 POISONOUS FOOD, recent discovery by Selmi of a class of poisonous alkaloids, termed ptomaines, developed during putrefaction of animal matters, on the one hand; and the discovery by B.illard and Klein, still more recently, that the fatally poisonous properties of ham prepared according to the American method, may be due to the presence of a parasitic bacil- lus, point to one or other of these two latter causes as the source of the effects of sausage- poison. Others have referred the effects to the pre- sence of a microscopic fungus — sarcina botulina. Poisoned Meat . — The poisonous nature of the flesh of animals which have fed on certain plants, for example, hares which have fed on certain species of rhododendron, pheasants on the calmia, &c., has been abundantly demonstrated, and need only be referred to here. The honey from bees which have garnered on poisonous plants, as the azalea, may likewise be deleterious; and the fact is of classical interest. The milk even of goats and other mammalia which have browsed on poisonous herbs has also proved poisonous. Diseased Meat .— The poisonous effects of meat affected with certain parasites — trichina, cysti- cerci, trematodes, &c., are referred to in the ar- ticles bearing these names. Great quantities of meat pass through our markets which is undoubt- edly the flesh of animals affected with disease — foot-and-mouth disease, pleuro-pneumonia, pig typhoid, the so-called scarlatina of swine, sheep- pox, &c. ; and it is a quite undecided point as to whether such flesh produces any injurious effects. To stop the sale of such meat would undoubtedly be to cut off large sources of our meat supplies. The evils attending the use of such diseased meat, when well cooked, have undoubtedly been exag- gerated ; but, on the other hand, there is enough evidence to show that the use of certain kinds of diseased meat is followed by serious results. Thus it is generally admitted that the flesh of animals which have suffered from pleuro-pneumonia and murrain, will give rise to boils and carbuncles. Braxy mutton may also produce disease when eaten. Trichina will produce trichinosis ; hy- datids the tape-worm ; &e. Poisonous Fish, Crustacea, and Mol- lusks. — Cases of poisoning by fish, Crustacea, and the so-called shell-fish of our islands are not unfrequently met with. Generally it is the ingestion of crabs, lobsters, and mussels which produces such results. These are usually of a distressing, rather than of a serious character, nettle-rash beiDg a common symptom. Occa- sionally, however, fatal results have ensued from the use of mussels. In tropical seas poisonous fish are more plentiful — the golden sardine, the bladder-fish, the grey snapper, &c. ; and these being eaten by larger fish, as the baracosta, perch, globe-fish, conger-eels, &c., the latter may become in turn poisonous. PREVENTIVE AND CURATIVE MEASURES. Good cookery, that is, exposure to a sufficiently high temperature for a sufficiently lengthened time, is undoubtedly the best treatment, short of abso- lute destruction, of unsound and diseased meat. So long as meat is high-priced, and the effects of diseased meat so little understood and so un- defined, it will be impossible to induce medical officers of health and sanitary inspectors to seize all the diseased and unsound meat which is daily POISONS. offered for sale. Notwithstanding all that ha- been said to the contrary, experienced observers are agreed that thorough exposure of the meat throughout to the temperature (140° Fah.) at which albumen is coagulated, is destructive to the parasites of flesh. Smoking is less effective. Salting is more effective than smoking ; but there is some evidence to show that salting may merely hold the life of organisms in suspense without entirely destroying their vitality’ ; and thus in the conversion of American salted pork into American hams in this country — a process of re-salting and subsequent drying— the specific germ (a bacillus) has been known to be again rendered harmful. It is not known whether efficient cooking entirely removes the deleterious effects of flesh affected with other than parasitic disease, as, for example, pleuro-pneumonia. The curative measures for the results of eating poisonous food cannot be specifically described. They are those which must bo arrived at on general principles. Symptoms are to be treated, and the powers of the patient sustained, until the deleterious matter is removed by excretion, or the trichina, e.g., has become encysted. Thomas Stevenson. POISONOUS GASES. See Carbonic Acid ; Carbonic Oxide ; Prussic Acid ; &c. POISONS. — Synon. : Fr. Poisons ; Ger. G-ifte. Definition. — There is no legal definition of the word poison, and the definitions usually pro- posed are apt to include either too much or too little. Generally, a poison may be defined as a substance having an inherent deleterious pro- perty, which renders it capable of destroying life by whatever avenue it is taken into the system. Substances which act only mechani- cally, such as powdered glass, are not poisons. In popular language, a poison is a substance capable of destroying life when taken in smr,.l quantities. A poison, then, may be defined as any substance which when introduced into the system, or applied externally, injures health or destroys life irrespective cf mechanical means or direct thermal changes. See Poisonous Food. Action. — PoisoDs may exert a twofold action. Their action is either local or remote, or both i local and remote. The local action of a poison is usually one of corrosion, inflammation, or an effect on the nerves of sensation or of motion. The remote actions of a poison are usually of a specific character, though some writers group the remote effects of poisons under two heads, and speak of the common and specific remote effects of a poison. The local actions of a poison of the corrosive class are usually so well marked; and so easily recognised, that the fact of its ad- ministration is obvious. Tlie same may he said, in a lesser degree, of the irritant prisons, espe- cially the mineral irritants ; but here the symp- toms often so closely simulate those of natural disease as to render the diagnosis a matter of great difficulty. An accurate acquaintance with the remote specific effects of the various common poisons is indispensable to the medical practi- tioner. The class of poison which has been ad- ministered or taken will thus be suggested tc his mind by the symptoms observed, and not | unfrequently the specific poison will be suspected POISONS. In this way tho physician may often be at once able to diagnose, from the symptoms alone, ti}e administration of strychnia, henbane, or can- tharides. Great care must be taken, however, not to draw a rash conclusion from the one symptom alone ; as, for instance, from the teta- nic spasms which are so marked a feature in .strychnia-poisoning. It is generally, but not universally, held that absorption is necessary in order that a poison should be able to exert its specific effect. Some, ; nevertheless, are of opinion that a poison may destroy life by an action on the nervous system before absorption has had time to take place. The facts in support of this view are, however, few, and open to doubt. Modifying Circumstances. — The usual ac- tion of poisons may be greatly modified — (1) by the largeness of the dose, and the state of aggregation, admixture, or chemical combination of the poisons themselves ; (2), by the part or membrane to which they are applied; and (3), iby the condition of the patient. Thus, for ex- ample, opium may be a medicament or a poison, according to the dose in which it is given ; and a dose of opium which may be beneficial to an adult in certain states of the system may be fatal to a young child, or to the adult when suffering, for example, from Bright's disease. All barium salts are poisonous, except the sul- phate, which is one of the most insoluble of all mineral substances. The simple cyanides ire highly poisonous, and the same may be said lof many double cyanides. But the double cya- hde of iron and potassium (potassium ferro- •yanide) is almost without action on the system. Che part or tissue to which a poison is applied must obviously greatly affect the activity of a ooison, owing to the varying rapidity with which .bsorption takes place through the cutaneous, mucous, serous, and other surfaces of the body, hirare may be swallowed in a considerable dose, rithout producing any appreciable effect, whilst small quantity of the same substance intro- duced into a wound will speedily prove fatal. It as been found that when a poison is slowly ab- orbed, so that it can be either disposed of in he system or again excreted more rapidly than . is absorbed, no poisonous results ensue ; but hen absorption occurs so quickly that the oison can neither he excreted nor destroyed in le system as rapidly as it is absorbed, the lecific effects of the poison are developed, urare, for instance, is absorbed by the gastric ucous membrane more slowly than it is ex- ited through the kidneys. But if the renal ■teries be ligatured, the poison accumulates in e blood, and the specific effects of the poison e developed, just as when curare is introduced to a wound. Idiosyncrasy has much to do with the poison- s or hurtful character of a substance. Thus rk, mutton, certain kinds of fish (notably shell- h), and fungi (see Mushrooms, Poisoning by), ve, under certain circumstances, and in certain .•sons, produced all the symptoms of violent itant poisoning ; whilst others, who have “taken of the same food at the same time, re enjoyed perfect immunity. More commonly who partake are affected, but with varying 1235 degrees of severity. Some persons are said, on good authority, to be capable of taking witli impunity such violent poisons as corrosive sub- limate or opium, in enormous doses, and this independently of habit, which is known to have such a large influence in modifying the effects of some poisons, notably of the narcotics. A tolerance of poisons is sometimes engendered by disease, so that a poison may from this cause fail to produce its accustomed effect. Thus opium is largely tolerated in tetanus, and in mania from drink : and mercurial compounds may in severe febrile affections fail to produce the usual constitutional effects of the metal. On the other hand, kidney-disease, by impeding elimination, may intensify the ordinary effects of a poison, and the like is observed when opi- ates are given where there is a tendency to cerebral congestion. Evidence. — In order to raise a valid inference in the mind of the medical attendant that poison has been administered to a patient, certain facts must be brought under his notice ; and with- out the concurrence of at least two or more of these, the actuality of poisoning cannot be main- tained. The sources of evidence in cases of suspected poisoning are the symptoms, the post- mortem appearances ; chemical analysis of articles of food or drink, or of the body and the excre- tions ; and experiments upon animals. The evi- dence derived from these sources being compared with the known properties and effects of various poisons in authenticated cases, will enable the physician to form a correct opinion as to the probable administration or not of a poison. The poisons most commonly administered are opium, prussic acid, arsenic in various forms, phospho- rus, oil of vitriol, and oxalic acid. It is rarely that the symptoms exhibited during life do not afford some clue to the cause of ill- ness ; and most frequently the symptoms are all that the medical attendant has to guide him to a diagnosis of the nature of the case, during tin- lifetime of the patient. Sometimes, however, persons are found dead as the result of poison, concerning the manner of whose death nothing whatever can be learned ; a suspicion of poison- ing arising from the circumstances under which the corpse is found. Here the aid of chemical analysis ought invariably to be invoked ; and fortunately in these cases the delay involved in making an analysis is of comparatively little moment. The effects may in the ease of many persons be either suddenly or slowly manifested ; hence we have acute and chronic poisoning. Cases of chronic poisoning are usually the re- sult of the repeated administration of small doses of lead, copper, mercury, phosphorus, or arsenic. All of these poisons are treated of in separate articles. The general conditions which should excite a suspicion of poisoning are the sudden onset of serious and increasingly alarming symptoms, in a person previously in good health, especially if a prominent symptom be epigastric pain; or where there is complete prostration of the vital powers, a cadaverous expression of the countenance, an abundant per- spiration, and speedy death. In all such cases the aid of the chemist is required, either to confirm well-founded, or to rebut ill-founded, suspicious POISONS. 1236 Classification. — Various attempts have been made to classify, poisons rationally. Perhaps the best classification, for the purposes of the medical practitioner, is that which groups poi- sons according to the more obvious symptoms which they produce. Our knowledge of the more intimate action of many poisons is still too slight to admit of any useful classification ac- cording to the manner in which they specifically affect the vital organs. Poisons may in the maimer indicated be clas- sified as:— 1. Corrosives; 2. Irritants ; and 3. Neurotics. It is perhaps at present pre- mature to attempt a systematic division of the last class. The class of neurotics embraces poisons so widely different in their action as opium and strychnine. 1. Corrosive Poisons. — Enumeration. — The action of one of the most typical of these poisons, corrosive sublimate, is fully considered under a special head ( see Mercury, Poisoning by). The most commonly administered corrosives are the mineral acids — sulphuric, nitric, hydro- chloric, and oxalic acid ; the alkalies — potash, soda, and ammonia; acid, alkaline, and corrosive salts — such as potassium bisulphate, potassium carbonate, zinc, tin, and antimony chlorides, and silver nitrate. Symptoms. — The mineral acids and the alka- lies have scarcely any remote effects on the system, their action being almost purely local. Some of the other corrosives enumerated may have, besides their local effects, a remote and constitutional action. The symptoms of corro- sive poisoning are marked and unmistakable, except when the patient is an infant. Imme- diately after swallowing the corrosive sub- stance, there is an acid, caustic, or metallic, burn- ing sensation felt in the mouth, fauces, gullet, and stomach ; and this speedily extends over the whole abdominal region. Vomiting is speedy, or may, rarely, be altogether absent. The vomited matters consist at first of the ordinary contents of the stomach, more or less altered by the action of the poison. In the case of mineral acids they are intensely acid, and cause copious effervescence when they fall upon limestone or marble. No relief is afforded by the evacuation of the stomach ; and later the vomits may be more or less mingled with altered blood, which may be dark, or even black; shreddy mucus, casts of the gullet or stomach formed by the shedding of the mucous membrane, and sometimes even the muscular wall of the oesophagus, are rejected. The abdominal pain is not relieved, but greatly aggravated, by pressure. The whole abdomen becomes distended, owing to the gases evolved by the action of the poison ; the diaphragm is pressed upon ; and intense dyspnoea may result, owing to pressure upon the thoracic viscera. When a mineral acid has been administered, there is little or no bowel action, and the urine may be suppressed; but in poisoning by the alkalies, and by the alkaline carbonates and sul- phides, there may be purging. The mouth, tongue, and fauces exhibit the local effects of the corrosive ; a yellow coating in the case of nitric acid; white at first, and as if covered with white paint, from sulphuric acid ; and whitish or brown and less thickly coated from I hydrochloric acid. Yellow or brown stains « - be observed on the skin, extending downwards from the angles of the mouth, and caused by the trickling of acid or other corrosive fluid from the mouth. Meantime the symptoms develop rapidly. The pain, thirst, dyspnoea, and dys- phagia increase. The patient, at first excited, with rapid, bounding pulse, becomes bathed in cold perspiration, the countenance becomes pinched, the pulse more rapid and thready. Enormous eructations of gas bake place, but these afford no relief. The patient may become more or less cyanosed ; but this will depend upon the amount of dyspncea. The intellect is usually clear to the last. Signs of collapse come on, and the patient may sink within a period varying from six to twenty-four hours. If recovery does not take place, death usually supervenes within a period of twelve to twenty- four hours. Very frequently, and more espe- cially in poisoning by oil of vitriol, the patient survives the first acute symptoms only to perish j months after, should not the aid of the surgeon be invoked and gastrotomy be performed, bv slow starvation, due to local injury to, and sui- sequent stricture of, the oesophagus. The use of bougies in these cases, to keep the gullet patent, seldom affords permanent relief. When nitric acid, or ammonia, is the poison taken, the vapours of the acid or of the ammonia may gain access to the air-passages and lungs, provoki ng inflammation, which is commonly fatal-i The dyspncea and chest-symptoms will be greatly aggravated in these cases, and may overshadow the more usual symptoms due to local action on the digestive canal. In poisoning by the camiq alkalies (potash and soda lyes) diarrhoea, with discharge of blood, is more common than the constipation observed in poisoning by the mineral acids. Entire suppression of urine, or anuria, is the rule in poisoning by corrosive sublimate. Oxalic acid in concentrated solution is un- doubtedly a corrosive and irritant poison. Very commonly, however, it kills by its depressing action upon the heart before symptoms of cor rosion have become prominent ; or the vomiting pain, and other more immediate symptoms o corrosive poison, are associated with a feebly pulse, clammy skin, nervous symptoms, aphon; i and speedy death, even within ten minutes of thj administration of the poison. To quote Chris tison’s language: — ‘If a person, immediate!; after swallowing a solution of a crystalline salt which tasted purely and strongly acid, is at tacked with burning in the throat, then wi: burning in the stomach, vomiting, particularl of bloody matter, imperceptible pulse, and ex cessive languor, and dies in half an hour, orstil more in twenty, fifteen, or ten minutes, I do nc know any fallacy which can interfere with th conclusion that oxalic acid was the cause c death. No parallel disease begins so abruptl and terminates so soon, and no other crystallic poison has the same effects.’ It must be adde that binoxalate of potash, and the soluble ex; lates generally, are as poisonous as the acid itsel Anatomical Characters. — The distinct iq between corrosive and irritant poisons is by r means well-marked ; and indeed corrosive poison when diluted, act as irritants. Hence wo sha POISONS. describe the 'post-mortem appearances of corro- sive poisoning under the bead of irritants. Diagnosis. — The diagnosis of corrosive poi- soning rarely admits of difficulty; and in any doubtful case analysis will remove all doubt. 2. Irritant Poisons. — Irritant poisons are of two classes — metallic irritants, and vegetable Lnd animal irritants, these latter being grouped ■together. Perhaps none of them, however, act ns pure irritants ; and the irritant symptoms which they produce are most commonly ac- companied by a well-marked effect upon the nervous system also. An irritant is a poison [which causes inflammation of the parts to which it is applied, usually the alimentary canal. By Jar the most important of the metallic irritant [poisons is arsenic {see Arsenic, Poisoning by). Other metallic irritants are the salts of anti- mony, zinc, and other metals. Elaterium, essen- tial oils, and gamboge may he cited as examples if vegetable irritants ; and cantharides of animal irritants. Irritant animal and vegetable foods are separately described. Sec Poisonous Food. Symptoms. — Irritants differ as a rule from .porrosive poisons in the greater slowness with which the symptoms are developed. Usually when an irritant is swallowed, after an interval — greater or less according to the specific character of the poison— a burning pain is felt, and sense jif constriction of the mouth, throat, and gullet, :peedily followed by sharp burning pain in the jspigastrium ; and this is increased by pressure — l mark which serves to distinguish the attack ;‘rom one of ordinary colie. Nausea, vomiting, ind great thirst ensue ; speedily followed by lain and sense of distension of the whole abdo- iuen, which is exceedingly tender, and perhaps 'isibly distended. Most commonly the vomiting s followed by purging, tenesmus, dysenteric tools, and often by dysuria. Should the loison not bo speedily removed from the system iy vomiting and purging, these continue un- elieved, and increase in severity ; and symptoms if inflammatory fever, or it may be of collapse, upervene. The pulse becomes rapid, small, and hready ; the countenance is anxious ; the skin 3 bathed in perspiration, now warm, and again old and clammy. The patient may never rally rom tho first shock to the nervous system ; lore rarely, having survived this, he dies in pnvulsions ; or he may perish of inanition after tore protracted sufferings. It must be borne in lind that those irritant poisons — such as diluted ilphuric acid — which, when taken in a more incentrated form, act as corrosives, may bring jout starvation, necessitating such operative rocedure as gastrotomy, by the injury which ley inflict upon the oesophagus and stomach, eath after the administration of an irritant .lison may, it is obvious, occur at very varying prods after th9 ingestion of the poison. Diagnosis. — Irritant poisoning may be mis- ken for various forms of natural disease. The seases with which it is most apt to be con- unded are — gastritis; gastric ulcer, with or ithout perforation ; peritonitis ; severe colic ; 'Oradic and Asiatic cholera ; and rupture of the iraach or intestines. A careful examination of I e patient, and the history of the case, will often move any doubt which may be entertained ; but 1237 a microscopic examination and chemical analysis of the ejecta of the patient will frequently afford the only means of clearing up the case during life. Too frequently irritant poison is not sus- pected until a post-mortem examination is made. In every case where a possibility of irritant poisoning is suggested, the aid of analysis should be invoked. For the diagnostic differences — so far as differences in symptoms are diagnostic — between irritant poisoning and the special dis- eases above mentioned, the reader is referred to the special articles in this dictionary. Anatomical Characters. — Tho post-mortem appearances in irritant and corrosive poisoning are corrosion of the mouth, fauces, gullet, and stomach, the mucous membrane being shrivelled, altered in consistence and colour, and more or less detached ; irritation and inflammation of the stomach and first portion of the small intes- tines; ulceration; and erosion. In corrosive poisoning the stomach may be perforated, the edges of the aperture being shreddy; and in the case of sulphuric acid tho viscera may be black- ened (altered blood) from the action of the acid upon the blood-pigment. The small intestines are implicated to a varying extent, or may alto- gether escape. The large intestine may be at- tacked, and this is more especially the case in poisoning by mercurial preparations. Arsenic exerts a specific effect upon the gastric mucous membrane. Remains of irritants may be de- tected in the intestinal canal, and be recognised by their physical, microscopical, and chemical characters. 3. Neurotic Poisons. — Enumeration. • — Under this head may be ranged a great number of poisons, having this in common, that the symptoms produced by them are more or less prominently affections of the nervous system. The class embraces pure narcotics, such as mor- phia ; chloral hydrate ; hyoseyamus ; digitalis ; strychnia ; prussic acid ; nitro-benzol ; phenol (carbolic acid); alcohol; aconite; belladonna, and many others. Symptoms. — These are necessarily of the most varied character. All that has been said already about the onset of symptoms, their character, and the circumstances under which they have appeared, must bo borne in mind in arriving at a diagnosis. Prussic acid produces its effects in the course of a few minutes ; or, it may be, seconds. The course of symptoms is very rapid ; and death may be well-nigh instantaneous. The symptoms are convulsions, great disturbance of respiration, with prolonged expiration, dilated pupils, and cyanosis. See Prussic Acid, Poisoning by. Morphia and opium, after a stage of excite- ment, produce deep comatose sleep, with slow stertorous breathing ; contracted pupils ; and clammy, perspiring skin ; all the other secretions being more or less suppressed. See Opium, Poisoning by. Aconite is diagnosed by the peculiar numbness and tingling of the skin which it produces. Belladonna, and its alkaloid atropine, widely dilate the pupils, and cause intense thirst, with mirthful delirium and spectral illusions. Alcohol in toxic doses produces profound in- sensibility ; and there is, moreover, always mort 1238 POISONS. sr less recognisable by circumstances which will be found described under Alcoholism. Nitrobenzol causes symptoms often undistin- guishablo from those of prussic acid ; but in con- sequence of its insolubility, and the slowness with which the liquid poison is absorbed by the gastro- intestinal mucous membrane, there is often a pro- longed interval between the administration of the poison and the onset of alarming symptoms. Chloral hydrate causes death after a stage of unconsciousness ; and there is scarcely any diffi- culty in ascertaining the nature of the case by the aid of the surroundings of the patient. Carbolic acid or phenol whitens and shrivels the membranes with which it comes in contact, and not only acts as a corrosive, but produces speedy narcosis, and greenish or black urine. The peculiar odour of phenol is always percep- tible, though not infrequently overlooked. Diagnosis. — It is impossible to enter fully into the diagnosis of each individual neurotic poison. The most frequent and important diag- noses have to be made in supposed cases of poisoning by opium, alcohol, and strychnia re- spectively. In opium-poisoning the equally contracted pupils ; the possibility of rousing the patient by means of external stimuli in all except the later stages — as, for instance, by flicking the feet, the application of the electric current, &e. ; and the moist clammy skin, may serve to prevent the case being confounded with one of apoplexy. In alcoholic coma there is great danger of mis- taking the nature of the case, in consequence of the frequency with which the alcoholic odour may be met with in cases where alcohol has been taken, either dietetically or medicinally, in mode- rate or somewhat immoderate doses. The very careful use of the stomach-pump can do no harm, and may not only save the patient if the case be one of alcoholic poisoning, but also serve to clear up the diagnosis. The tetanic spasms of strychnia will have to be differentiated from those of true (traumatic) tetanus. In this there is not usually any insuperable difficulty. Strychnia convul- sions are intermittent ; do not begin in the lower jaw ; are, as a rule, opisthotonic in character ; and do not affect the same groups of muscles as are implicated in true tetanus. See Opium, Poisoning by ; and Stbychnia, Poisoning by. Treatment.— Only the general principles of the treatment of poisoning can be indicated here. The treatment in poisoning by the most impor- tant special poisons is described in separate articles. The question of the use or non-use of the stomach-pump must be decided by the nature of the poison administered. Where one of the concentrated mineral acids, a caustic alkali, or other corrosive salt, oxalic acid in concentrated solution, or carbolic acid, has been swallowed, it is generally held that the stomach-pump should not be used, the danger of perforation of the gullet or stomach being considerable. In all cases where a non-corrosive poison has been taken, except in the case_ of prussic acid, where the course of the poisoning is too rapid to permit of the use of the instru- ment, the application of the pump is advisable and can do no harm. In cases of poisoning by opium and alcohol, the greatest reliance must POLYPUS. be placed jn evacuation of the stomach by aid. The corroding acids may be neutralise 1 by the administration of lime-water, or, still better, saccharated lime-water ; highly diluted solutions of the caustic alkalies ; or, failing these, the continuous use, in frequently repeated doses, of chalk, whiting, or the alkaline carbonates— sc! as to avoid dangerous distension of the abdomen! with carbonic acid gas. On the contrary, the caustic alkalies may be neutralised by the co pious imbibition of highly diluted acid liquids. Failing the use of the stomach-pump, or even! after the use of this, emetics may be administered to relieve the stomach of irritants. The promprl administration of an emetic is perhaps never inadmissible. The effects of corrosives and irri- tants must afterwards be met by general reme- dies, such as demulcents and oil to sheathe the mucous membranes, opiates to relieve pain, &cj The effects of oxalic acid cannot he avoided hy the administration of alkalies and alkaline car- bonates, for the alkaline oxalates are themselves highly poisonous. Chalk, whiting, and sola! !ej lime-salts precipitate oxalic acid as an iusohi lei calcium oxalate, and form the best remedies) No safe antidote is known for carbolic acid. Oil greatly allays the intolerable pain atten !i::g the local action of this acid. In prussic acid poison-, ing artificial respiration, persistently used, is our sheet-anchor, and may he supplemented hy galva- nism, alternate douches of warm and cold water, and other measures. After the use of the sto-- mach-pump to remove unabsorbed opiates, sti- mulating liquids containing tannin, such as strong black coffee, may he given ; the patient' must be kept awake by walking him about flicking the feet with towels, the application of the Faradic current, &c. Belladonna in full doses is in some respects antagonistic in it- physiological action to opium. Conversely opiates are regarded as direct antidotes to belladonna. On the same principle of counteracting effects, digitalis and aconite are counter-poisons, and lienee antidotes the one to the other. The hap. piest results have followed the use of full doses of chloral -hydrate in strychnia-poisoning; and chloroform may be freely inhaled to allay the tetanic spasms. In alkuloidal poisoning, except where a tetanising poison, such as strychnia oi brucia, has been given, the stomach-pump must be employed ; and emetics and tannin, in the form of tincture of galls, strong black coffee, 01 strong tea, should also be given, with the object of precipitating the alkaloid as an insoluble tan- nate. Thomas Stevenson. POLYDIPSIA (ttoXvs, much, and Siia thirst). — A synonym for excessive thirst; some times used for diabetes. See Polycbia; anc Thirst. POLYPHAGIA (voAus, much, and 1 eat). — A synonym for excessive hunger. S< Appetite ; and Pneumogastric Nerve, Disease* of. POLYPUS (iroXos. many, and rove, a foot) Synox. : Ft. Polype-, Ger. Polyp. . Definition. — This term is generally applies to any simple pedunculated growth, springing from a mucous surface ; but it is sometimes ex- POLYPUS. tended so as to include malignant pedunculated growths in similar situations. Varieties. — It is clear that no single de- scription will apply to each member of the class. Hence it will be sufficient to enumerate the principal varieties of polypus, a fuller account of most of which will be found in the article Tumours, and also in connection with the dis- eases of the several organs which they affect. 1. Polypi of the Nose. — These are of two varieties — the mucous and the fibrous ; both are j classed among the fibromata. Both are covered with ciliated epithelium ; the fibrous variety often involve the structures at the back of the pharynx, forming the so-called naso-pharyngeal \ polypus. 2. Polypi of the Ear. — Polypi of the ear resemble those of the nose, but present a variety of structure, as some spring trom the membrana tympani, others from the interior of the tympa- num. 3. Polypi of the Intestines. — These polypi are of much more frequent occurrence in the rectum than in any other portion of the intes- tinal tract. They are composed of tissue re- sembling that of the mucous membrane of the part, and are described amongst the adenomata. 4. Polypi of the Uterus. — These growths are of three kinds, namely: — (a) Cystic, which arederived from the ovules of Naboth ; (J) mucous or soft, resembling the polypi of the rectum; (c) hard or fibrous, the so-called fibrous polypus of the uterus. 5. Polypi in other situations. — Less com- mon forms of polypi, consisting of some modifi- cation of the mucous membrane from which they are derived, are found in the bladder, the larynx, on the gums, or sometimes in the sinuses commu- nicating with the nose. Malignant polypi present no special features which would enable them to be described as a class. Treatment. — Though polypi differ somewhat in structure, the treatment of the simple varieties of the class is the same — that is, if removal be considered advisable. Either the pedicle may be grasped and the tumour removed by avulsion ; or it may be divided at a stroke by some sharp instrument, or cut through slowly or rapidly by some form of ecraseur or ligature. In removing a malignant polypus a wide margin of healthy tissue must be taken away from around the pedicle. E. J. Gom.ee. POLYSARCIA ( rro\\js, much, and crop!, 3esh).— A term for excessive corpulence or pbesity. See Obesity. POLYURIA (irnAvs, much, and obpov, urine). Iynon. : Diabetes Insipidus ; Er. Polyuric ; Diabete r nsipide ; Ger. Zuclcerlosc Harnruhr. Definition. — A malady or group of maladies, ■haracterised by thirst, and a persistently ex- cessive flow of watery urine, which has a low pecific gravity, and contains no albumin or ugar. Attempts have been made to subdivide this pmp into smaller sections. One such section is Mydipsia or hydruria, having the characters boro specified as those of polyuria; another is POLYURIA. 1239 azoturia, where the solids, especially urea, are in excess of the normal amount ; and a third, anazoturia, where these are markedly deficient. The term polydipsia, referring as it does spe- cially to the symptom thirst, often used, puts the cart before the horse. Hydruria points to the dilute character of the urine rather than to its excessive quantity. Azoturia has been made to include all cases where urea is unusually abundant, even where the urine is scanty, as in fevers ; a condition totally averse from our notions of diabetes. Anazoturia very rarely occurs ; for, notwithstanding the low specific gravity of the urine in polyuria, owing to the large amount passed, the quantity of urea may, and often does, exceed that excreted in health. A form of polyuria, often slightly marked, has been described as ‘ phosphatic diabetes,’ on ac- count of the excess of phosphates passed. The separation of these cases into a distinct group is hardly necessary. Certain factors in the above definition require special attention, the better to mark off the malady so defined from other pathological states. Thus the flow must not only be excessive, but persistently so. This separates polyuria from conditions where there exists a merely temporary flow of an unusual amount. JEtiology. — Polyuria is limited neither by age nor by sex. 'It may exist in the new-born infant, and it may be found in the patient of seventy, but on the whole it is a disease of early rather than advanced life, whilst it is about twice as frequent in males as in females. Nothing is more marked in connection with the causation of polyuria than heredity. Perhaps the most extraordinary ex- ample of this is recorded by Dr. Gee, where the disease was directly transmitted through four generations. Sometimes one member of the family escaped, but the children were sure to be attacked. A newly-born infant, a member of this family, suffered from unusual thirst, so much so that water had to be given to still it. Beyond inheritance, nothing very definite can be said as to the cause and origin of polyuria. It is often connected with nervous affections or nervous excitement, and sometimes follows upon injuries to the head or disease of the brain. Drinking bouts too have been credited with giv- ing rise to the disease, as have drinking cold fluids, and sudden exposure to cold. Beyond these, no cause of any value can be assigned ; often in- deed the disease comes on without even such insufficient reasons as those given above, some of which have doubtless been assigned on the yiosj hoc principle. Symptoms. — Not much need be said regarding the clinical history of polyuria. When the result of accident or mental emotion, its onset is usually abrupt, anditmay end in like manner; sometimes as the result of intercurrent disease of a febrile kind. During its continuance thirst and watery urine are the two prime symptoms, for there may be little wasting, and the general health may be good. Occasionally there is increased appetite, as in one of Trousseau's patients, whom restaura- teurs would pay to stop away. In this patient, too, there was great toleranco of intoxicating liquors, whilst in others the opposite condition has been noted. Usually the bowels are con< POLYURIA. 1240 fined, and the skin dry, though neither happens invariably. Boils, to common in diabetes, are rarely seen; but purpuric spots sometimes occur, as does cedema, or that iaxness of subcutaneous tissue which often passes for oedema, in the later stages. As long as drink is supplied in plenty, the condition of the patient is very toler- able, were it not for the broken sleep caused by the incessant thirst and the desire to pass water ; but any attempt to restrict the quantity of fluid gives rise to intense discomfort, even causing the patient to drink his own urine. Ultimately this constant strain wears out the patient, and leads to death, if intercurrent dis- ease do not carry him off. Of the phenomena of polyuria, the urine alone requires special notice. It is inordinate in its quantity, and of a specific gravity little above that of spring water. In a case under the care of the writer, it remained persistently at 1,001 ; but it may rise to as much as 1,008 or 1,010. It is transparent ; almost like water ; of a faint greenish-yellow tint ; and with little taste, smell, or acid reaction. In quantity it varies with the amount of water consumed. If the patient is allowed to drink at will, the quantity passed roughly corresponds with that drunk, allowance being made for the watery vapour passing away by the lungs, and perhaps also by the skin. If the drink be restricted, more will be passed than is consumed, by the abstraction of water from the body. On the whole the quantity passed is greater than in ordinary diabetes, and may sometimes be measured by the pailful. Of the normal constituents of urine, urea, though rela- tively deficient in any specimen examined, is upon the whole in excess, sometimes enormously so. On the other hand, uric acid seems dimi- nished, hut this may depend on the difficulty of estimating it in urine so greatly diluted. Sul- phates and phosphates, especially the earthy salts of the latter, are usually increased, whilst the only abnormal constituent, if such it can be called, commonly found is inosite. Pathology. — As in the case of saccharine diabetes, our insight into the morbid processes concerned in the production of polyuria has been greatly aided by direct experiment. Bernard found that by pricking the floor of the fourth ventricle above the level of the ‘ sugar puncture ’ he could produce copious diuresis; and in certain animals injuries to the central lobe of the cere- bellum (the vermiform process of human ana- tomy) are followed by a like lesult. From this part of the nervous system the nervous influence seems propagated to the kidneys both by the splanchnics and spinal cord, but the exact course of the fibres has not yet been clearly demonstrated. Whether the nerves are merely vaso-motor fibres, section or paralysis of which would produce turgescence of the vessels of the kidneys, or trophic fibres, irritation of which would increase the activity of these or- gans, is not yet determined ; but in all probabi- lity paralysis of the vaso-motor fibres is the main factor in the production of hydruria. In the definition of polyuria given above dis- ease of i be kidneys was expressly excluded ; and after death, as far as the malady itself is con- cerned, nothing is to be found except increased vascularity. As a consequence of the disease, however, persisting over many years, and giving rise to frequent and severe distension of the bladder, when circumstances may prevent its being emptied with sufficient frequency, thicken- ing of the walls of the bladder, dilatation of the ureters, and sacculation of the kidney have been described ; but the accuracy of such observations as the results of simple polyuria have been questioned. Undoubtedly the most important lesions which hear on the disease are those which have befin ’found in the brain, especially in the neighbourhood of the fourth ventricle. These, besides the injuries already alluded to, comprehend tubercular and other forms of in- flammation, tumours of various kinds — glioma- tous and syphilitic, together with other local changes of different kinds. Diagnosis. — The diagnosis of polyuria, accord- ing to the defini tion already given, is easy. Itrests on these factors — thirst, and persistent excess of urine, coupled with the absence of sugar and albumin. It has further to be carefully distin- guished from mere temporary excess of eatery urine. Such an excess may occur where a .urge quantity of fluid of a diuretic kind has been swallowed, especially when there is little or no cutaneous transpiration. Again sudden flows of urine may occur about the period of early conva- lescence from fever, or yet again when a hydro- nephrosis suddenly empties itself. A 11 these are merely temporary and evanescent states. The total absence of sugar distinguishes polyuria from diabetes, though it is well known that the one state may pass into the other. In certain forms of Bright’s disease, especially those characterised by contracted kidney, the urine may he excessive and of low specific gravity; but in all of these albumin will be at least now and again found. Finally, polyuria is not to be confounded with such abnormal discharges of urine as may occur from time to time in what we call hysteria and its allies. Hero the nervous symptoms give a special feature to the malady ; nevertheless poly- uria has strongly marked nervous affinities. Prognosis. — This cannot be called favourable, for, whilst few actually perish from the uncompli cated disease, still fewer are cured of it, though a good many T get well. For some unaccountable reason, Trousseau looked upon polyuria as more dangerous than diabetes; hut ordinary experience cannot bear out this view. Probably its con- nection with tubercular disease in many cases misled him. Under such circumstances the tu- bercular disease would run its course just as disease of the nerve-centres would, altogether independent of the polyuria. Treatment. — As might he inferred from the account of the disease given above, the treatmeni of polyuria is far from satisfactory. If th e dis- ease can be assigned to any definite cause, we must look to that and deal with it, rather than with the excessive urination ; if not, it must he our endeavour to counterbalance the draining of the tissues, and the corresponding waste, by a plentiful supply of fluid and good nourishing diet. To relieve the kidneys from the unusual stress thrown upon them, diaphoretics have been recommended; at all events great care should he taken of the clothing so as to secure the patient POLYUKIA. from any risk from cold. Of medicinal remedies, that -which has been most lauded is valerian, especially by Trousseau, who gave it in enormous doses. Probably it, like other antispasmodic remedies, would be found of most service in cases allied to hysteria or similar neuroses. In one case under his care, the writer tried the whole range of antispasmodic remedies without effect. Opium and its alkaloids, though so ser- viceable in diabetes, are worse than useless in polyuria. They diminish the thirst and the urine, but they greatly increase the patient’s dis- comfort. Tonics, especially strychnine and iron, do good by improving the general health. In another case under the care of the writer, in a highly scrofulous subject, after every medicinal remedy had been tried in vain, change of air at the seaside was followed by almost complete disappearance of the polyuria. The importance of attending to the constitutional state is strik- ingly indicated in this case. Finally, in the hands of some the constant electric current has lone good, whilst it has equally failed in the ixperience of others. Alexander Silver. POMPHOLYX(7T0|Uifl>!r, abulia or bladder), "his term is applicable to the bullous affection o' the skin more commonly denominated pem- pligus, of which it is, in fact, a synonym. See Pemphigus. POUS VAE.OLII, Lesions of. — Synon. : Fr. Maladies de la Mesocephale; Ger. Krankheiten der Brucke. Introduction. — The pons is liable to a variety of affections, either by morbid processes having their primary seat here, or by secondary impli- cation from disease originating elsew r here, as by tumours of the cerebellum or base of the skull, or aneurism of the basilar artery. The position of the pons, its close relation to the vital centres of the medulla oblongata, the connection of the sensory and motor paths with the cerebrum and spinal cord on the one hand, and the cerebellum on the other, and the transit through it of many of the cranial nerves, render the symptomatology of pontine affections highly complex and diversified. Summary of Pathological Conditions.— Hcemorrhage in the substance of the pons is by no means uncommon, and may vary from a minute focus up to a complete disorganisation and rupture into the fourth ventricle. Embolism is not common; but thrombosis , from syphilitic or atheromatous degeneration of the basilar artery, is frequent, and is the origin of necrotic softening of an acute or chronic character. Hcemorrhage. — Haemorrhage into the substance of the pons, if of small extent, is net necessarily fatal ; but if it be of large amount, death occurs suddenly, or within a very few hours. Sometimes .there is a sudden onset of coma, with complete relaxation of the whole muscular system. The pupils are, as a rule, minutely contracted, and the 1 condition resembles profound narcotic poisoning. The temperature may rise to as much as 105° I'ahr. or more. Deglutition is difficult or im- possible; and death ensues from cardiac and respiratory paralysis, irregularity in the rhythm PONS YAEOLII, LESIONS OF. 1241 preceding the fatal issue. At other times, and of great signification in a diagnostic point of view, muscular spasms occur, either general or affecting one side more than the other, with dis- tortion of the face, either from paralysis of one side, or this combined with active spasm of the other. The occurrence of paralysis of one side of the face and of the limbs of the other side, so-called ‘alternate’ paralysis, is pathognomonic of the pontine seat of the lesion. Softening. — Acute embolic or thrombotic soft- ening of the pons, with or without loss of con- sciousness, may lead to death rapidly, with simi- lar paralytic symptoms; but days may elapse, or even months, after the first onset, with charac- teristic symptoms indicative of the position of the lesion, and death ensue either from gradual implication of the vital centres, or quite sud- denly. Localising Phenomena. — The symptoms most characteristic of lesions of the pons are a com- bination of paralysis of certain cranial nerves on the one side, and of the limbs on the other. The most common combination is paralysis on one side of the face and of the limbs on the opposite, the face being paralysed on the side of the lesion. The facial paralysis in this case re- sembles peripheral facial paralysis, both in the implication of the orbicularis oculi and degenera- tive changes in the muscles. The limbs may be paralysed as to motion only, or there may be a combination both of sensory and motor paralysis. Sometimes the motor paralysis affects one limb more than the other, and there may be a similar distribution of the anaesthesia. The alternate paralysis of the face on one side, and of the limbs on the opposite, occurs more particularly with lesions of the pons situated towards the pyramids, at a point where the facial roots have not crossed over to pass on to the opposite hemisphere. If the lesion be higher up, near the crus cerebri, the face and limbs may both be paralysed on the side opposite the lesion. Amongst other varieties the face alone may be paralysed, without affection of the limbs ; or one side of the face may be paralysed, and the other in a state of spasm ; or both sides of the face may be paralysed ; or one side of the face may be paralysed, and the limbs on both sides ; or both sides of the face, and the limbs on one side. Spasms in the limbs paralysed or in the others may occur ; and similar irritation of the sensory strands may be indicated by exeentric hyperaesthesia and paraesthesia. Along with the motor paralysis of the limbs, there is also a varying degree of vaso-motor paralysis, and a difference in temperature of the limbs of one degree or more. Next in frequency to affections of the facial nerve, with or without affections of the limbs of the variable character above mentioned, comes affection of the abducens or sixth cranial nerve. This gives rise to an internal strabismus, and usually of the eye on the same side as the lesion. There may be, therefore, paralysis of the face and abducens on the side of lesion, and of the extremities on the opposite side ; but cases have been recorded of paralysis of the abducens on one side, and of the face and limbs on the opposite ; 1242 PONS VAROLII, LESIONS OF. and also of paralysis of tlie face, abducens nerve, and limbs on the same side as the lesion. Defects in articulation are not unfrequently observed, depending on impaired mobility of the tongue, usually on the side of the motor paralysis of the limbs, but apparently sometimes on the other side. The fifth cranial nerve is also not unfrequently implicated. The sensory portion seems to suffer more than the motor. But cases have been recorded in which the motor portion of the fifth has been specially affected, leading to paralysis and degeneration of the muscles of mastication. The affection of the sensory division shows itself in more or less marked anaesthesia of the face, which may be general or limited to the area of distri- bution of some of the branches only. The tongue is not unfrequently affected on the same side, and tactile and gustatory sensibility impaired or abolished on the anterior two-thirds. The affec- tion of the fifth may occur on the same side as the lesion, with or without affection of the limbs, but it would appear also that anaesthesia of the face may occur, with implication of the ex- tremities on the side opposite the lesion. There is thus an extraordinary complexity and variability in the symptoms which may bo met with in connection with pontine lesions. Those which have been mentioned are the most common and most significant, especially if they occur in combination. Singly they have less value, and some of them, particularly defects in articulation, are not specially characteristic. But a combination of paralysis of the limbs on one side, either motor alone, or of motility and sensi- bility, and of the face on the other, is significant of pontine lesion. The addition of paralysis of the abducens adds to the certainty. Many other symptoms might be mentioned which have been noted in connection with lesions of the pons, especially tumours, which ought perhaps to be ascribed to interference with the functisns of neighbouring structures. As in other parts, however, tumours have been found invading or pressing on the pons without having given rise to any marked symptoms during life. But at other times, along with one or more of the previously mentioned symptoms, impairment of deglutition has been observed, due without doubt to pressure on the medulla oblongata. To pressure on the medulla oblongata should also be ascribed the irregularity and ultimate paralysis of the cardiac and respiratory movements, in connection either with tumours or with haemor- rhagic effusions into the pons itself. When a tumour presses forward in the direc- tion of the crura cerebri, the third cranial nerves may be implicated. Ptosis has been observed in such cases ; and external strabismus, from paralysis of the internal rectus, has also oc- curred, but comparatively rarely. Vertigo and disorders of equilibration have also been observed, but these may be attributed to an implication of the cerebellum or of its peduncles. Ataxic symptoms have, however, been described by Leyden as occurring in pontine lesions, with- out affection either of the cerebellum or of its peduncles. The writer has seen a case of very marked ataxy associated with anaesthesia of one side of the face, and of the limbs and trunk on the PORTAL OBSTRUCTION, opposite side, due probably to lesion on the right side of the pons. But the cases which have been recorded are not yet sufficient to establish any very definite propositions in regard to the exact causation or special characteristics of the ataxic disorders in question. In connection with tu- mours pressing on the pons, hearing may also be impaired or abolished in one or both ears. Im- pairment of smell has been observed on one side, when there has been ansesthesia of the face. This is probably due to the impairment of common sensibility in the nostril, intensified in some cases by the defective power of sniffing if the facial nerve is also paralysed. Albuminuria and glycosuria have occasionally been found in connection with diseases of the pons. It is very doubtful if any causal relation- ship has been at all satisfactorily established. Very often when albumin has been found, there is good reason to believe that it has been pre- existing, for lesions of the pons frequently occur in connection with chronic renal disease. Sugar has been found sometimes, and in other cases not. The same has been found in connection with lesions of other nerve-centres. So far, therefore, as facts go, the evidence in favour of a direct relationship between pontine lesions and glycosuria is at present extremely slender, and in need of further investigation. Diseases which encroach on the intracranial space produce the general symptoms of intracra- nial tumour, in addition to the special symptoms indicative of their invasion of the pons. D. 1'f.eeier. PORRIGO LARVALIS ( [porrigo , scarf, and larva, a mask). — Porrigo is an old-fashioned term, applied generally to eruptions on the scalp and face, whether exudative or desquamative; larvalis, masked, alludes to the covering of the face with an incrustation which conceals the features like a mask, such as is seen in a neg- lected exudative eczema of the face, an eczema pustulosum or impetiginodes. Pathologically, porrigo is an eczema. Sec Eczema. PORTAL OBSTRUCTION.— This is a condition of not uncommon occurrence, and calls for brief general discussion. Strictly speakiDg, portal obstruction implies that there is some direct impediment to the flow of blood in the portal circulation, either affecting the trunk of the vein before it enters the liver, or its branches in the substance of this organ. It must be re- membered, however, that any condition that in- terferes with the circulation beyond the portal divisions, whether in the hepatic vein, inferior vena cava, right side of the heart, or lungs, will retard more or less the flow of blood through the portal system ; and also that either of the tribu- tary branches of the portal vein may he affected alone. The portal trunk may be obstructed by direct pressure upon it, as by enlarged glands, a growth projecting from the liver, or a neighbour- ing tumour ; by changes in its walls, leading to constriction or complete closure ; or by blocking- up of its channel, as by a thrombus ( see Portal Thrombosis!. Cirrhosis is the most important disease which obstructs the portal circulation within the liver; but this result may also arise from accumulation of pigment and other causes. PORTAL OBSTRUCTION. Effects. — The effects of portal obstruction will depend on its seat, its degree, and the ra- pidity with which it is set up. They are merely those which necessarily follow mechanical venous congestion, namely, distension of the small vessels, which may end in changes in their walls and vari- cosity ; escape of serum; a catarrhal condition of mucous surfaces; haemorrhages; and, in course of time, permanent changes in organs and structures which are congested. Their localisation in this ease will correspond to the structures from which the portal vein receives its tributary branches. Hence any of the following conditions may re- sult in various degrees from portal obstruction ; — (1) Congestion and catarrh of the mucous membrane lining the stomach and intestines, with consequent disorder of the secretions ; dila- tation and varicosity of the small vessels ; or hae- morrhage into the alimentary canal. (2) Ascites, one of the most frequent and evident phenomena. (3) Enlargement of the spleen, either from mere accumulation of blood, or in chronic cases w’ith permanent increase and alteration in the splenic structure. (4) Congestion, followed by fibroid changes in the pancreas. (5) Haemorrhoids, it is generally believed. (6) After a while enlarge- ment of the superficial veins of the abdominal wall, owing to their communications with the portal vein; as well as of the veins within the abdomen, which are tributary to it. Several of the conditions mentioned are ob- vious on clinical examination during life; others are only evident on ‘post-mortem examination, although they assist in originating symptoms, especially in connection with the alimentary canal, such as those of dyspepsia, flatulence, and disordered bowels. Haemorrhage into the sto- mach or bowels is usually revealed by the oc- currence of hsematemesis or melsena, but it may prove fatal without any discharge of blood ex- ternally. It must necessarily happen that if the portal circulation is not properly carried on, the functions of the liver are proportionately dis- turbed. The signs of portal obstruction may set in with great acuteness, or very gradually. Those indi- cative of acute obstruction are the rapid develop- ment of ascites, returning speedily after para- centesis ; enlargement of the spleen ; and hsmor- rhage into the alimentary canal. It must be remarked that the most striking phenomena may disappear in chronic cases, after a time, without the removal of the obstruction, probably owing to the development of new channels, by which the blood is returned to the heart without passing through the liver. Diagnosis. — There ought to be no difficulty in recognising the signs of portal obstruction in marked cases ; and it might even be suspected before these signs are well-developed under certain conditions. The cause of the obstruction can only be made out by a consideration of each case in all its features. Treatment. — Rarely can anything be done directly to remove portal obstruction. The cir- culation may often be relieved to some extent by acting freely upon the bowels, especially by means of saline and hydragogue purgatives. Treatment directed to the effects of portal obstruction i3 frequently highly efficacious, and the most im- POST-MORTEM EXAMINATION. 1243 portant of these may be cured or relieved, even though their cause remain unaffected. The special treatment of these symptoms, and also of the conditions upon which portal obstruction depends, is described in other articles. Frederick T. Roberts. POSTAL THROMBOSIS.— Synon.: Por- tal Phlebitis; Pylephlebitis; Fr. Pylephlebite ; Ger. Pylephlebitis. Portal thrombosis may be divided into two kinds : ( A ) the Adhesive ; and ( B ) the Sup- purative. (A) Adhesive Portal Thrombosis. — Ad- hesive portal thrombosis is seen most commonly in cirrhosis of the liver, rarely as a cause of the cirrhosis itself. In the first case, it arises, not from an inflammation of the walls of the vessel, but from obstruction to the circulation. The thrombus itself is usually firmly adherent to the walls, tough, and of a red-brown colour, the vein being dilated. Symptoms. — The symptoms of portal throm- bosis are those of intense portal obstruction. There is ascites, rapidly developing itself, and, according to Frerichs, returning rapidly after removal by tapping. The veins of the walls of the belly become dilated. There may be hsema- temesis or a bloody diarrhoea. The spleen is greatly enlarged. Jaundice may or may not be present. Diagnosis. — The diagnosis of portal throm- bosis is a matter of great difficulty, the symptoms being very like those of cirrhosis, of which, in- deed, it is often a mere complication. Prognosis and Treatment. — The prognosis is always bad, no instance of recovery being known, and the treatment must be the same as for cirrhosis. (B) Suppurative Portal Thrombosis. — Suppurative portal thrombosis is commonly met with in connection with some morbid process, most often suppuration, in the parts from which the branches of the portal vein arise, as the intes- tines, of which very often the caecum is the seat, next the stomach, and the spleen. The vein is found greatly dilated, and filled with a dirty grey or reddish pulp, which, under the micro- scope, shows small round nucleated cells like pus- corpuscles. The liver itself shows, on section, the branches of the portal vein filled with a dif- fluent thrombus, so that the organ looks as if pervaded with abscesses. Symptoms. — The symptoms closely resemble those of abscess of the liver or of pyaemia. Traube thinks the diagnosis may be made if the liver and spleen be much enlarged, and if there be re- turning attacks of rigors with raised tempera- ture, while between the attacks the temperature is natural or only slightly raised, There must be also evidence of some suppuration, which mav involve the branches of the portal vein ; and pyaemia and endocarditis must be excluded. Often, however, all these signs fail. Prognosis and Treatment. — The prognosis is always bad ; the treatment must be the same as for abscess of the liver or pyaemia. J. Wickham Lego. POST-MORTEM EXAMINATION. Necropsy. POST-MORTEM WOUNDS. 1244 POST-MORTEM WOUNDS. — -Synon. : Dissection-wounds ; Er. Blessitres anatomiques ; Ger. Sectionwunden. Definition. — A variety of poisoned wounds, arising from the inoculation of a virus derived from the dead bodies of men or animals. Similar consequences may result from the in- oculation of the discharges from unhealthy in- flammations in living bodies, especially those arising from post-mortem poisoning. The condi- tions necessary for the production of adissection- wound are the virus, a means of entrance of the virus into the system, and a condition of body favourable to the development of the effects of the virus. Patholosy. — The Virus. Of the exact nature of the poison which gives rise to post-mortem wounds we know but little. The products of ordinary decomposition may cause local troubles, to be mentioned hereafter, but they never give rise to the graver forms of dissection-wound. The poison is present in greatest intensity in fresh bodies, and its virulence diminishes as de- composition advances. We have no evidence that it is the same in all cases, and as the effects vary greatly, we are justified in assuming that the poison also varies. The chief views held as to its nature are, that it is a product of a certain stage of ordinary decomposition; that it is the product of some special non-organised ferment ; and that it is of the nature of a minute organ- ism, which has the power of propagating itself in the living body. The first view is probably un- true, as the poison which gives rise to serious dissection-wounds is only found in tne bodies of patients who have died from some unhealthy inflammatory (infective) process. It is most marked in cases of septic peritonitis or pleurisj r , pyaemia, septicaemia, puerperal fever, diffuse cellulitis, erysipelas, or spreading gangrene. Tiie diminution of the intensity of the poison with decomposition is accounted for on thesecond theory, by supposing that the peculiar fermeut is destroyed by putrefaction ; and on the third theory, by the specific organism being destroyed by the growth of the ordinary bacteria of decom- position, it being a well-known fact that when two organisms are growing together in the same fluid, the stronger seems to overpower the weaker, to check its growth, and finally to lead to its destruction. Certain specific diseases, as glanders and splenic fever (malignant pustule), may be com- municated by inoculation from the dead body, but these accidents are not classed with ordinary dissection-wounds. Mode of entrance of the poison into the system. Whatever the virus may be, it only acts by direct inoculation. This most commonly occurs through an accidental wound or scratch during the post-mortem examination ; but a raw surface partly healed, or the fissures in chapped hands, or the small fissures so common at the margin of the nail, may equally serve as points of inocu- lation. In rare cases infection takes place through the unbroken skin, the hair-follicles seeming then to serve as the points of entrance. The further progress of the poison takes place either by soaking amongst the lymph-spaces of the cellular tissue, as shown by diffuse spreading cellulitis ; or by being carried with the stream in the lymphatic vessels, as in those cases in which the local affection is slight, and the first trouble is in the lymphatic glands. Prevention. — In order to prevent inoculation the following points should be attended to. Be- fore making a post-mortem examination of a dan- gerous case the hands should be carefully looked over. If any spot denuded of cuticle is found on the fingers, an india-rubber cot should ho applied, its base being bound round with string. If the whole hands are sore and chapped an india- rubber glove may be used. If no india-rubber cot for a finger is to be found, an efficient water- proof covering may be made at once with gutta- percha tissue and chloroform. If the hands are sound they may be well greased with carbolic oil (1 to 10), but, as this soon wipes off, the ap- plication must be repeated several times dur- ing the post-mortem examination. Accidental wounds arise almost invariably from carelessness — the assistant being as often wounded as the operator. There is scarcely any operation in a post-mortem which requires two to perform it, and an assistant should therefore be dispensed with. The most common acts of carelessness are — cutting towards instead of away from the left hand ; and letting the knife fall unobserved into one of the cavities, where it is concealed by blood or the viscera, and wounds the hands when next introduced. Wounds from ribs are amongst the most dangerous, as they bleed but little. To avoid these, when the bone-forceps has to be used, in cases of ossification of the cartilages, the ribs should he cut near the nipple line, and the skin folded over them whilst the viscera are being examined. In opening the hea 1 the saw is apt to slip, and to injure the hand holding the vault. To avoid this, either wvap the hand in a thick cloth, or hold the head with the left hand on the face, where it will be out of danger. Punctures during the sewing-up of the body have caused many deaths. These injuries are usually due to using too small a needle, which cannot be kept properly under control. A common packing needle sharpened is by far the safest instrument that can be used. In whatever way the wound is made the first essential of treatment is to make it bleed freely. If it is on the finger thi? may be done by winding a piece of string round it from the root to the tip : then wash it tho- roughly under a tap and suck it. Caustics are quite unnecessary if these directions are carried out. After a. post-mortem examination the hands should always be well washed in some strong antiseptic solution. The condition of body favourable to the de- velopment of the effects of the poison . — Nothing is more common than for two persons to be wounded at the same post-mortem examination, and only one to suffer from it. Sir James Paget has brought forward strong evidence for believing that constant exposure to the poison gives a cer- tain degree of ‘ immunity from the worse influ- ences of the virus,’ and that one dissection-wound protects the sufferer from another, at least tor some time. Anything which causes a depressed state of health favours the occurrence of post- mortem poisoning. Thus, we see it in students who have been some months resident in hospital POST-MORTEM WOUNDS. in nurses who are worn out with attending a had case, and in dissecting porters or others who in- dulge too freely in alcohol. Beyond these no special predisposing conditions are known. See Predisposition to Disease. Varieties. — It will be convenient to discuss the several forms of post-mortem wounds under distinct headings according to the following ar- rangement : — 1. Purely Local Affections. (a) Dissecting-porter' s icart, or anatomical tubercle.— Although not exactly a post-mortem wound, this affection must be mentioned here as beincr one of the effects of the irritation caused by the repeated application of putrid matter to the skin. It is seen only in those whose occu- pation brings them much in contact with decom- posing animal matter, and is of very rare occur- rence. Its seat is always at the back of the hand over the knuckles, or the joints of the fingers. It is characterised by a warty thickening of the skin, which may in some cases resemble epithe- lioma. In other cases the thickening of the cu- ticle may give the skin an ichthyotic appearance. The enlarged papillae are set closely together, and there is no true ulceration, but cracks and fissures may exist in parts, from which a serous discharge escapes. The growth tends slowly to spread. These warty growths are usually mul- tiple, and this, together with the want of any tendency to ulceration, will serve to distinguish them from epithelioma. Treatment. — In some cases a cure can be ef- fected by the constant use of wet dressing to soften the epithelium, combined with the application of a mixture of equal parts of glycerine and extract of belladonna. Should this fail, painting with strong tincture of iodine may berried, or, as a last resource, the application of some strong caustic. (b) The dissecting-room pustule. — This is al- ways the result of the inoculation of some poi- sonous matter into a slight abrasion or puncture. About twenty-four hours after inoculation the spot becomes red and itches. In another twenty- four hours a small drop of pus is seen raising the cuticle, and the part is intensely' tender. If the drop of pus be let out the pain is at once re- lieved. If no treatment be now adopted to pre- vent it, a small scab forms, under which pus again forms, and the redness and pain return as before. Each time that this happens the sore increases in size, till it may reach about one-eighth of an inch in diameter, and it then closely resembles in ap- pearance a small soft chancre. Without treat- ment the condition may continue indefinitely'. It is very seldom accompanied by any constitu- tional disturbance. The axillary glands may be tender, but suppuration is rare, except in un- healthy subjects. Treatment. — The small pustules can usually be cured simply by the application of water- dressing, so as to prevent the formation of a scab, and the shutting in of the pus. The treat- ment must be continued until it is soundly healed. If the smallest speck is unhealed it will relapse as soon as the dressing is removed. If, in spite of water-dressing it refuses to heal, nitrate of silver may be applied, or the ulcerated surface may be covered with iodoform. (c) Suppuration of the matrix, of the nail . — 1245 This arises from inoculation through one of those small fissures at the side of the nail popularly known as ‘ agnail’ or 1 hangnail.’ The inflam- mation extends rapidly to the matrix at the root of the nail. The dorsal aspect of the finger for half-an-inch below the nail is swollen, red, and acutely tender, and oil pressing over this area pus oozes out over the nail. The inflammation rarely extends over the whole matrix, so that the distal part of the nail is usually unaffected and firmly' attached, while the root is softened and loosened by the suppuration beneath it. The discharge has a strong, offensive odour of decomposition. This condition is extremely chronic, the irrita- tion being kept up almost indefinitely by the putrid discharge, which is more or less pent up beneath the nai. When recovery takes place the nail usually separates. Treatment. — The first essential of treatment is, if possible, to render the discharges aseptic. For this purpose the finger may be soaked in a concentrated solution of boracic acid, and dressed with boracic acid lint ; or pow'dered iodoform may be pushed with a piece of card beneath the swollen skin over the root of the nail. If these fail a strong solution of subacetate of lead (liquoris plumbi subacetatis, 1 part, spiritus rectificati 1, aquae 6) may be tried. If all these simpler means fail, the nail must be removed, and the raw surface, dressed with some mild antiseptic lotion, will quickly heal. ( d ) Suppuration of the hair-follicles. — This is a somewhat rare effect of post-mortem poisoning. About forty-eight hours after exposure to infec- tion a varying number of small pustules, each surrounded by a red areola, form on the hairy parts of the hands and wrists. On careful exam- ination each pustule will be seen to have a hair passing through it. As a rule these pustules discharge and dry up without causing further trouble, but in some exceptional cases they may be followed by constitutional symptoms or lymphatic inflammations. Treatment. — All that is necessary is to cover the part with cotton-wool, to hasten the drying of the pustules. (e) Boils. — Boils, which differ in no respect from those arising without known cause, may form as a consequence of exposure to post-mortem poisons. They probably start from inflammation of the hair-follicles. Treatment. — This presents nothing special. (/ ) Ordinary Whitlow. — Although whitlow is common amongst nurses and others whose duties oblige them to dress foul wounds, it is a very rare consequence of post-mortem wounds. It may', however, occasionally* be met with, and then present nothing special. See Whitlow. 2. Diffuse Inflammation of the Cellular Tissue, spreading 1 from the point of inoc- ulation. (a) Diffuse Cellulitis. — The seat of inoculation becomes in from twelve to twenty-four hours more or less red and irritable, and in this state it may remain for another day, at the end of which time a brawny swelling of a dusky red colour forms round it, and rapidly extends in all directions, but chiefly in the line of the lymph- stream. At the same time there is intense tension, burning pain, and severe constitutional POST-MORTEM WOUNDS. 1246 disturbance, high temperature, total loss of appetite, and possibly delirium. Red lines of inflamed lymphatic vessels may or may not be seen extending upwards, but glandular abscesses are rare, as in ordinary cellulitis. If unrelieved by treatment, sloughing rapidly follows the brawny swelling, first of the subcutaneous tis- sue, and afterwards of the skin. Treatment.— The only treatment in such case is free and early incision into the affected part. In one case which came under the observation of the writer the inoculation took place from a scratch from a broken rib which had penetrated a consolidated lung, and caused the formation of a foul abscess. Swelling in the finger com- menced on the second day, about 10 p.m., and at 11 a.m. on the following morning it had in- volved the whole finger and part of the back of the hand. Red lines extended from it a little way above the wrist. Two incisions were im- mediately made in the palmar aspect of the finger, and one on the dorsum of the hand, with the effect of at once arresting the extension of the process. In this case the attack commenced with slight nausea, but no chilliness or rigor; there was high fever and delirium on the third and fourth days. The constitutional treatment must be the same as in other cases of diffuse cellulitis. See Erysipelas. (4) Spreading Gangrene. — This is an intensi- fication of the preceding variety. A red, brawny swelling advances rapidly up the arm, quickly followed by gangrene of the subcutaneous cellu- lar tissue and skin. This condition is extremely rare as a consequence of dissection-wounds. A case occurred in 1S80, at University College Hospital, under the care of Mr. Heath, in which the patient’s life was only saved by amputation at the shoulder-joint.. It happened to a nurse from an accidental wound received whilst laying out the body of a patient who had died of puer- peral fever. Treatment.— T he treatment is the same as in other cases of spreading gangrene. 3. Inflammations chiefly affecting the Lymphatics. ( a ) Inflammation of the Lymphatic Vessels . — This usually commences from twenty-four to forty-eight hours after inoculation. The seat of inoculation may show scarcely any signs of in- flammation, or it may have developed into a small suppurating sore. The invasion of the lymphatic inflammation is marked by elevation of temperature, chilliness, or possibly a rigor. There is malaise and often nausea, with head- ache. Red lines are soon after observed running upwards from the seat of inoculation in the course of the lymphatic vessels. These lines are about one-eighth to one-quarter of an inch in width, and clearly defined. They are acutely tender. The lymphatic glands to which they lead are swollen and painful. If unrelieved by treat- ment suppuration frequently occurs in the lymphatic glands, or sometimes in the course of the vessels. Occasionally several lines may fuse together, giving the appearance of a band of cutaneous erysipelas. Treatment. — The bowels should be well opened. Stimulants in moderate quantities may be taken, good port wine being especially useful, I with strong beef-tea, milk, and eggs. If there is much fever quinine may bo of use in reducing the temperature. Locally, the whole course of the inflamed vessels is to be painted with a mixture of glycerine and extract of belladonna in equal parts, and the whole arm wrapped in hot fomentations, which must be frequently re- newed. This treatment seldom fails to arrest the progress of the inflammation, and ward off suppuration. If pus forms, either in the course of the vessels or in the glands, it must be let out as soon as it is recognised. (4) Abscess in the Lymphatic Glands. — This occurs either as a consequence of the previous condition or without any evident inflammation of the lymphatic vessels. It is frequently a com- plication of one of the local forms first described. The abscess forms either in the gland at the bend of the elbow or in the axilla, and presents no special features requiring description. The prognosis is not grave. Treatment. — The abscesses must be opened as soon as recognised, and, if possible, treated antiseptically. (e) Axillary Cellulitis This is one of the gravest effects of post-mortem wound. It fre- quently occurs in cases in which the local affec- tion at the seat of inoculation is so slight as to be scarcely recognisable. From twenty-four to forty-eight hours after inoculation the patient is seized with chilliness, and frequently a rigor; there is great depression; with nausea, or even vomiting, and headache. The temperature ra- pidly rises, reaching 104° or 105°, and there is frequently delirium. On examining the axilla some fulness, with acute tenderness, is recog- nised, and there is pain in moving the arm. The fulness soon extends to the front of the chest, in the region of the pectoralis major, and the veins of the region may become more clearly visible than natural. Later on there may be a blush of redness over the pectoral region, and with this there is oedema. If not relieved the swelling and redness may extend down the side of the chest, and show above the clavicle at the root of the neck. The constitutional condition assumes the ordinary characters of septictemia. There is muttering delirium, rapidly failing pulse, dry tongue, with sordes on the lips and teeth, pos- sibly diarrhoea, and the patient sinks intoa coma- tose condition and dies. Sir James Paget, in his well-known lecture on his own case, explains this condition by supposing that the lymphatic glands are first swollen, and the flow of lymph through them obstructed, and that the poison then extends backwards in the distended lymph- atics till it reaches the cellular tissue in which they arise, thus causing diffuse cellulitis, which, if not relieved, or if not speedily fatal, may extend to the whole area which sends lymph to the affected glands. If an incision be made early into the affected cellular tissue it will be found merely infiltrated with serum : later on the serum is turbid; still later the whole areolar tissue would be found in a sloughy condition, soaked in pus. Treatment. — The blood-poisoningaccompany- ing this condition is frequently fatal in spite of any treatment. The only hope for the patient lies in early recognition of the state of the part. POST-MORTEM WOUNDS. and in making free incisions. These incisions must thoroughly open up the axillary fascia, and if there is any suspicion of extension beneath the pectoralis major, another incision must be made two, or even three, inches in length, through the muscle. Thi3 is best made in the interval between the sternal and clavicular portions. The skin and fat only need be divided with the knife, the muscular fibres being separated with the handle of the scalpel to avoid haemorrhage. If these incisions are made with all antiseptic pre- cautions and the antiseptic dressing adopted, the patient’s chance of life is greatly increased. The constitutional treatment consists in free stimula- tion and abundant nourishment. Quinine may possibly be useful in large doses. 4. Septicaemia. — In some cases, which, for- tunately, are very rare, post-mortem wounds prove speedily fatal, with the ordinary symptoms of acute septicoemia. Local changes at the seat of inoculation may be entirely wanting. 5. Pyaemia. — Pyaemia may occur as a secon- dary complication of the forms of post-mortem wound which are accompanied by suppuration and sloughing; but it presents nothing special in such cases. See Pyemia. Marcus Beck. PCST-PHARYNGEAL ABSCESS. See Retro-pharyngeal Abscess. POSTURE. — In this article it is intended to point out the main practical relations of posture to the aetiology, diagnosis, and treatment of va- rious diseases. It not uncommonly happens that a patient assumes instinctively a posture by which his condition may be at once recognised, or which gives indications of importance as to his management. In other cases the practitioner makes systematic use of posture to assist him in his diagnosis, or to aid him in treatment. It should he mentioned at the outset that persons often present peculiarities with reference to pos- ture, which are of no practical significance, and are the result either of natural differences in in- dividuals, or of habit. For instance, some people can only sleep with the head raised very high, in an almost semi-recumbent position ; others lie with the head very low 7 , even level with or below the body. Many are unable to sleep on the back, or on one or other side, and especially the left side. The subject will be further discussed in its relations to the points mentioned above. 1. etiology of Posture. — As an immediate cause of disease, posture is chiefly important in ’ connection with occupation. For instance, many persons suffer from long-continued standing ; or, on the other hand, from sedentary occupations. The evil effects of the erect posture are evidenced by the development of varicose veins in the ; legs, and also by the occurrence of general fatigue and debility, displacement of the uterus, and ; other conditions, especially in young women ; and this subject has of late received considera- ble attention in relation to those employed in drapers’ shops. Those callings which entail con- stant or frequent bending forward of the body [ are often very injurious, and this may be aggra- vated by carrying burdens on the back and shoulders. Not uncommonly 7 persons injure them- POSTURE. 1247 selves by habitually bending forward while sit- ting, quite apart from occupation. Another il- lustration of the influence of posture in causing disease is where individuals have to work in constrained positions, such as colliers and mine- workers. The conditions thus induced are chiefly deformities of the chest, and certain diseases of the lungs, heart, and vessels. Posture is also of consequence in predisposing to certain affections under particular circumstances, or in modifying their effects. Thus the recumbent posture in low febrile and other conditions aids in the causation of hypostatic congestion and its consequences ; a similar position promotes the accumulation of morbid products in the bronchi in cases of acute bronchitis, which may cause further mis- chief ; and if an attack of pleurisy should super- vene when a patient is obliged to lie on his back, this will materially modify the way in which the fluid accumulates, for it tends then to collect posteriorly, and may cover the whole area of the chest in this aspect, while there is no sign of any fluid in front. Lastly, a peculiar posture in performing certain acts, such as writing, may have some influence in originating affections of the type of writer’s cramp. 2. Posture in Diagnosis. — As examples of postures spontaneously adopted by patients, which may give useful information in diagnosis, the following are the most striking. In many cases the posture indicates great debility, help- lessness, or prostration, and may thus afford im- portant information as to the general condition of a patient. An inability to lie down constitutes a prominent feature in certain forms of cardiac and pulmonary disease, in consequence of inter- ference with the respiratory functions, so that the patient is obliged to sit or to be propped up in bed, or sometimes even to sit up in a chair, to assume the erect posture, or to bend forward. Again, when anything is pressing upon the main air- tube — such as an aneurism — causing obstructive dyspnosa, the patient may instinctively lean for- ward, so as to take off the pressure as much as possible. In cases of unilateral lung-disease or pleurisy, the patient is often unable to lie on one or other side, especially the affected one ; while in affections of the heart it is frequently impos- sible for him to rest on the left side. As regards abdominal diseases, acute peritonitis is usually characterised by a very striking posture, the patient lying on liis back, with the knees well drawn up and bent, in order to relax the abdo- minal muscles. lie may also assume certain positions in other abdominal affections, on ac- count of their influence upon symptoms, such as pain or vomiting. In spasmodic painful attacks connected with this region, it is very common to see the patient bending forwards in a doubled- up position, and pressing upon the abdomen. In nervous diseases posture may be of value in diagnosis. Thus, it may reveal paralysis of dif- ferent parts ; in cerebral meningitis the patient often lies in a curled-up position, all the limbs being bent towards the body ; in spinal meningi- tis the head may be involuntarily drawn back- wards, in order to try to relax the muscles be- hind ; in cataleptic conditions any posture that is assumed is retained for a considerable or an unlimited time ; while in wry-neck the head is POSTUBE. 1248 turned to one side. Lastly, the position volun- tarily assumed hy a limb may give important information as to local diseases likely toinfluence it in this respect, such as those of the joints. The whole body may be distorted, as well as the limbs, in connection with diseases of the articu- lations. What has just been stated will supply hints as to how the practitioner might avail himself of alterations in posture in aiding him towards a diagnosis in certain cases. For instance, ob- serving the effect of such changes often gives valuable information in connection with pul- monary and cardiac diseases, as evidenced by the influence of the respective positions upon breathing, cough, the heart’s action, and other symptoms ; and the same may be the case in some abdominal diseases, as well as in nervous affections or in local diseases. Change of pos- ture is most useful, however, in connection with physical examination, the effects it produces upon certain physical signs being noted. In this way it is of essential aid in determining the presence of fluid in cavities, such as the pleura or peri- toneum; in distinguishing an internal aneurism from conditions simulating this lesion ; in detect- ing certain solid formations in the abdominal cavity; and for other purposes. Details on these points are given in other appropriate articles. It is also of importance to study the position of the patient in examining the chest ; and to remember that posture may materially influence physical signs connected with the heart. 3. Posture in Treatment. — Many of the pre- ceding remarks will afford suggestions as to the value of paying attention to posture as a thera- peutic measure, and it will at once be evident that if a wrong posture is the cause of any morbid condition, the first principle in treatment should be to rectify it. Besides, it will not un- commonly be found, advantageous to watch pa- tients, and to allow them to adopt, or assist them in adopting, such a position as their own sensa- tions dictate to be the most suitable for their condition. In order to illustrate further, how- ever, the benefits to be derived from posture, it may be well to point out some of the diseases in which its value is most strikingly exhibited. (a) Posture is of great importancewhen gene- ral rest of the body is required, or when there is general exhaustion or prostration of the system. The recumbent posture is clearly indicated under these circumstances, for it is the most restful of all, and involves little or no expenditure of muscular force. Hence in acute febrile diseases of all kinds, one of the first indications in treat- ment is to keep the patient absolutely in bed. This is also desirable where there is excessive fatigue or prostration from any cause. ( b ) In the management of affections connected with the respiratory organs, attention to posture is frequently of service. Here its influence as regards rest again comes in, for it may be of much consequence to make as little call as pos- sible upon the respiratory functions. Moreover, symptoms associated with the breathing appa- ratus are in many cases strikingly influenced by posture, such as pain, dyspnoea, or cough ; and the act of coughing may be materially assisted, and made more effectual as regards expectoration, hy the patient assuming a sitting or erect position The importance of the prone posture, or of bend- ing forwards, must be remembered when there is anything pressing on the main air-tube. _ (c) Posture often requires particular considera- tion in relation to disorders of the cardiac action, or to actual disease of the heart. Thus, in the syncopal state the patient should be placed hori- zontally, or even with the head at a lower level thin the body, so that the blood may more readily reach the brain, and thus life may be sustained. In this state, or when the heart is acting with extreme feebleness from aDy cause, raising the patient into a sitting posture has been known to cause a fatal result, and should be carefully avoided. On the other hand, there are conditions of the heart in which the patient cannot possibly lie down, and especially where there is much dilatation ; under these circum- stances it may be of the greatest service to have him constantly sitting up in a properly-con- structed chair, and the beneficial effects thus produced are sometimes almost marvellous. (d) In the treatment of aneurisms, whether in- ternal or external, posture, is frequently made use of with advantage. In the cure of this lesion in the chest or abdomen, rest is often an impor- tant agent, and on this account patients are kept in the recumbent posture for weeks or months, so as to keep the heart as quiet as possible, and also to limit the demand of the system for food, which is only given in a restricted quantity. Aneurism in the chest is one of the causes which may originate pressure on the air-tube, and on this account attention to posture may be re- quired in connection with it. In the case of aneurism in the limbs, posture is sometimes made use of to cure them, by causing pressure, as flexion of the knee for the cure of popliteal aneurism. (c) The influence of posture with respect to gravitation may often he recognised with advan- tage in the treatment of certain conditions. This is well exemplified by its effects on dropsical accumulations in the legs and scrotum. Abun- dant anasarca may frequently be got rid of com- pletely in a short time by keeping the legs in a horizontal position ; and oedema of the scrotum likewise may soon disappear when this part is propped up. The same principle is of essential importance in checking haemorrhage from a rup- tured varicose vein in the leg; and may also be made use of in the cure of varicose veins. The influence of posture upon dropsy may give use- ful information as to its cause, and as to the exact conditions upon which it depends. (f) As miscellaneous illustrations of the em- ployment of posture in treatment may be men- tioned the value of the recumbent position in sea-sickness, attacks of giddiness, megrim, and neuralgic affections about the head ; raising the head in comatose conditions ; the prone posture in the treatment of certain forms of spinal dis- ease; prolonged decumbency to restore a dis- placed uterus ; and various positions in which limbs are placed on account of local diseases, to relieve pain, to prevent muscular tension, t& promote the escape of pus, or for other pur- poses. . . (y) Lastly, it must be remembered that it is POSTURE. not uncommonly requisite to change the position of a patient more or less frequently, if he should be confined to his bed. For instance, it may be necessary to do this in lew febrile diseases, in order to prevent the occurrence of hypostasis at the bases of the lungs, or the formation of bed-sores on parrs subjected to pressure. This is also necessary in many cases of spinal or cerebral disease, and in very emaciated patients (see Ulcer). Change of posture is further use- ful in assisting the escape or expulsion of morbid secretions from theair-passages when they tend to accumulate there. Frederick T. Roberts. POUGUES, in Loire, Prance. — Alkaline chalybeate waters. See Mineral Waters. POULTICE. — Svnon. : Cataplasm; Fr. Cataplasms ; (ler. Erciumschlag . — Poultices are soft moist applications, usually applied hot, but occasionally cold They may be used merely as a means of applying heat and moisture ; or may contain some drug intended to exert a specific effect. Of the innumerable poultices formerly in use, only six are now officinal. Poultices may be arranged thus : 1. — The simple poultice, composed of linseed meal. The practice of using bread soaked in hot water as a poultice has deservedly fallen into disrepute, as it soon becomes sour and offensive. 2. Dis- infecting poultices, namely, cataplasma carbonis, and cataplasma sodae chloratae. 3. Sedative poultices, such as cataplasma fermenti, and cata- plasma conii. 4. The counter-irritant poultice — for example, cataplasma sinapis. 1. Simple Poultice. — The simple poultice, by its heat, causes a dilatation of the vessels of the part to which it is applied, and thus hastens '.he progress of inflammation, either towards re- solution or suppuration. It softens the cuticle, vnd relaxes the skin by its moisture, and thus 'avours swelling, and lessens tension and pain. In internal affections, such as bronchitis, pleurisy, or pericarditis, large poultices are frequently applied to the skin overthe inflamed part. They >enefit the patient, partly by their warmth, and wirtly by exerting an extremely mild counter- rritant effect, consequent upon the redness and ongestion of the skin which they produce. They re, however, somewhat troublesome ; they soon ecome cold and hard ; and if the patient be rest- >ss their weight causes them to shift, and frag- ents break off and drop into the bed, and there tying they cause considerable discomfort. For iplieation to external inflammations a few folds lint, soaked in hot water or any appropriate tion (sedative, stimulant, or antiseptic), covered ith oil-silk, and afterwards with a thick layer cotton wool, will be found to answer every irpose of a poultice, and to be much more eanly and less troublesome. Linseed-meal poultices applied to boils usually i use a fresh crop to spring up round the ori- tal boil, from the irritation they give rise to. icy should consequently never be used, wet racic lint being always substituted. In in- ■nal inflammations a poultice may often be vantageously replaced by cotton-wool only, ■ered with oil-silk and secured by a bandage, any counter-irritant action is required a few 79 POULTICE. 1249 drops of chloroform or turpentine may be sprinkled on the wool. Linseed-meal poultices are best made from meal from which the oil has been expressed, as the pure meal becomes rapidly rancid. The British Pharmacopoeia recommends the addition of a little olive oil. The following is a useful method of making a linseed-meal poultice ; — Heat the basin in which the poultice is to be made with boiling water ; then empty it and put into it again as much boiling water as may be necessary to make the required poultice ; sprinkle the meal into the water, stirring vigorously, till the proper consistence is attained ; lastly, stir in a small quantity of olive oil. By adopting this plan the poultice will be free from lumps. The poultice should then be spread with a broad spatula on a piece of rag. It must be of a uni- form thickness, and neither so thick as to be too heavy, nor so thin as to cool and dry too rapidly. A poultice should be changed every two or three hours by day, and every four at night, if the patient is sleeping. In all cases where there is free suppuration, a poultice is the dirtiest application that can be made to the wound. TVet. boraciclint should always be used instead. 2. Disinfecting Poultices. — Cataplasma carbonis is a horrible compound of wood-char- coal, linseed meal, and bread, and was formerly supposed to have some disinfectant properties. Both this and the cataplasma sod re poured into it, so that the stream is kept mre. But if, on the one hand, such decomposing hatters be either abnormally introduced from ■'ithout, or be generated in abnormal amount ■ ithin the body ; or if, on the other hand, the ormal process of elimination be in any way ob- U'ueted ; or if, still more, an abnormal excess of leone process concurs with deficient activity of le other, a rapid accumulation of these matters ikes place in the blood; and this, by providing a s pabulum requisite for the development of the ,)ison, supplies the very condition necessary for s morbific activity. Of the effectiveness of the introduction of itrescent organic matter, either in food, water, See his Paper on ‘The Predisposing Causes of Epi- tnics, in the Brit, and For . Med. Chir . Review, vol. xi., S3, p. 159. 1253 or air, the cholera epidemic cf 1848-9 afforded instances so ‘glaring’ that they here need only to be adverted to. Of the even more marked potency of the exces- sive generation of effete matter within the body, we have a typical example in the extraordinary pro- clivity of the puerperal female to suffer from the action of any septic poison to which she may be exposed. 2 Nothing can be plainer to the physio- logist, than that the return of the uterus, after parturition, to its non-pregnant condition, in- volves a rapid ‘waste ’ of its muscular substance, the products of which will be poured into the blood-current far more rapidly than they can be eliminated; this state continuing until the process is completed. The like condition exists in sub- jects of severe injuries, and of operations ; and not only do these exhibit a special proclivity to the action of specific poisons like scarlatina (the dis- ease only then declaring itself, although its germs must have been previously received and lain dormant), 3 but they show a peculiar liability to suffer from the ordinary septic poisons which have no effect upon the healthy carriers of them, erysipelas and adynamic ‘ surgical fever’ being thus communicable. 4 Excessive exertion, again, whether bodily or mental (such excess being marked by the feeling of fatigue) has always ranked among the most potent of predisposing causes ; and its action is clearly traceable to the same source, the abnor- mally rapid ‘ waste ’ of the tissues, whereby the blood-current becomes unduly charged with the products of their disintegration. 5 Ample evidence is afforded by army experi- ence, of the special liability of soldiers to zymotic disease, when on long and fatiguing marches ; and this especially in hot climates, where, the activity of the respiratory process being reduced by the high external temperature, the products of the ‘ waste ’ tend to accumulate in the blood- current. Of the predisposition induced by the accumu- lation of effete matter consequent upon obstructed elimination, none is more marked than that which results from overcrowding. The effect of defec- tive air-supply is not only to reduce the quan- tity of carbonic acid got rid of by expiration, 5 This proclivity was never more strikingly displayed than in the former experience of the Vienna Lying-in Hospital ; where a comparison of the mortality in the two sides of the institution, one attended by midwives, and the other by medical students, showed that an annual average of from 400 to 500 deaths out of 3,000 deliveries was distinctly traceable to the unclean habits of the latter, who were accustomed to come into the wards fresh from the dead-house. The enforcement of proper precautions soon lowered this excessive mortality to the standard of the other side. a Sir .Tames Paget, in British Medical Journal, 1864, vol. ii. p. 237. * Sir James Simpson in Edinburgh Monthly Journal, vols. xi. and xiii. 5 It is within the experience of everyone, that the sense of fatigue bears no constant proportion to the amount of exertion put forth ; and that whilst, on the one hand, anj obstruction to the eliminating processes (as by bad venti lation of the sleeping apartment) prevents its remova. by rest, an unusually severe and prolonged strain may be sustained without its induction, when the excretory apparatus is stimulated to increased activity, as in ‘ train- ing.’ And there is strong reason, therefore, for regard- ing this feeling as indicative of the degree in which the blood is charged with the products of nervo-muscular ‘ waste.’ PREDISPOSITION TO DISEASE. 1254 but also (which is probably of yet greater im- portance in relation to zymotic disease) to di- minish the normal oxidation of those, nitrogenous effete matters, of which (when thus metamor- phosed) it is the special business of the kidneys and skin to get rid. The accumulation of these within the body speedily makes itself manifest in the offensiveness of the halitus of the breath (the condensation of which show’s the presence of foetid matter) and of the cutaneous transpira- tion; and thus, although there may be no intro- duction of decomposing matter into the body, or specially rapid internal production of it, the blood-current becomes as effectually charged with the ‘pabulum of the zymotic poison as if this had been injected into it. 1 The strong predisposition to zymotic dis- ease induced by intemperance , which has been no less conspicuously manifested in the ex- perience of our Indian army, seems clearly traceable to the same source. For the habitual presence of alcohol in the blood-current un- doubtedly diminishes the oxidation of the ‘waste’ products, and thus occasions their accumulation in the system ; and this at a greater rate in hot climates than in cold, on account of the already reduced activity of the respiratory process in the former. Where, again, the rate of ‘ waste ’ is abnormally increased— as on the march of troops — the evil influence of alcoholic liquors is still more strongly manifested ; and this will be again aggravated by overcrowding in tents or barracks.- 1 Thus it has come about, that, while the average mortality of European troops in India under favourable circumstances does not exceed 30 per 1,000, it has been raised at particular stations through a long succession of years — solely by overcrowding in ill -ventilated barracks — to 75 or even 100 in the 1,000 ; whilst in certain Indian gaols, in which the air-space was actually at one time less than 100 cubic feet per prisoner, the mortality rose to an annual average of one in four. A most remarkable instance of the combined action of ’the two last-named ‘predisposing’ causes, resulting in the dowWe-charging of the blood with the pabulum most suited to the development of zymotic poison, was fur- nished by the terrible outbreak of cholera, which carried off one-eighth of the troops stationed at Kurrachee in 1846; no fewer than 464 deaths having then occurred out of a total strength of 3,746. Some of the troops (a) had recently come off a long and fatiguing march, but were well accommodated in airy barracks ; and their loss was at the rate of 96-6 per thousand. In another regiment (b), which had not been on the march, but was over- crowded in small ill-ventilated tents, the rate was 10S-6 per thousand. And in a third (c), which had made the march like a, and were overcrowded like b , the mor- tality was 218 per thousand, or at a rate actually exceed- ing their high rates added together. 3 Of this, Dr. Parkes’s experience as assistant-surgeon to the 84th Regiment in India, afforded a striking illus- tration. A large proportion of the men of this regi- ment were total abstainers, and the remainder were very temperate. Daring the year 1846-47, it was quar- tered for eight months in the healthy barracks of Fort St. George, Madras ; it then performed a march of be- tween 400 and 500 miles to Secunderabad, in a very wet and unhealthy season, through a country infested with fever and cholera ; and the remaining two months were spent in overcrowded barracks at Secunderabad. Yet the mortality during that year was only 13 in an average strength of 1,072, or at the rate of 12*1 per 1,000. Con- tinuing during the next year in the same overcrowded barracks, its loss was raised to 34*9 per 1,000; but this was less than half the average mortality of the troops quartered in the same barracks for fifteen years past. The 63rd Regiment, with which they had exchanged, though not specially noted for intemperance, had there lost 73 men in the first nine months of the previous year, or at the annual rate of 78 8 per 1,000 : and, having then inarched to Madras to take the place of the Slth, had so On the connection between famine and pesti- lence, it is unnecessary to enlarge ; but it affords the key-stone of our cumulative argument. For in whatever way it is to be accounted for, the fact is certain, that a state of general blood-con- tamination is produced by the accumulation of non-eliminated products of ‘ waste.’ In the Irish famine of 1847, the fcctid secretions from the skin, the rapid supervention of general putres- cence after death and its manifestation even pre- viously, and the frequent termination of life bv colliquative diarrhcea, all evidence the peculiar fitness of the body so conditioned for the de- velopment of a zymotic poison. And thus wo seem furnished with a scientific rationale for all that experience has taught as to the conditions of the spread of zymotic disease ; which, by giving greater definiteness and con- sistency to medical doctrine, will afford a surer and more positive basis for preventive hygiene, both public and individual. But whilst it is specially in establishing a pre- disposition to zymotic disease, and in aggravating the severity of its attacks, that the contamination of the blood-current by the accumulation of ‘waste ’ products most strikingly manifests itself, there can he no doubt that it lowers the healthy vigour of the body generally, and thus renders it more ready to be affected by any disease to which it may be constitutionally liable. Where any form of mal-nutrition exists — whether resulting from imperfect performance of the primary di- gestive processes, producing ill-made blood, or from imperfect conversion of blood into tissne — there must he premature degeneration and aug- mented ‘waste ’ ; and the rate of this augmenta- tion must tend to increase, if special attention be not given to the eliminating processes. Here are have the rationale of the fundamental importance of pure fresh air, as cool as it can be borne, to the scrofulous subject ; and of the remarkable cures sometimes effected in patients in whose lungs tubercular deposit has already commenced, by the hazardous discipline of a hardy out-door life. When any serious malady has occo cotab lished itself, the degeneration of tissue, as shown in the rapid wasting of the body, takes place with augmented rapidity ; and the necessity for the re- moval of its products is proportionately nrgen*, And this is not the less important when the pro- gress of the disease is stayed; for the purifica- tion of tho blood from the contamination it has received is absolutely essential to the establish- ment of those recuperative processes on which the final issue depends. Of the due elimination of the waste-products, their oxidation is the first and most fundamentally- important act; and of the direful consequences of past ignorance and neglect of this principle — evinced on a large scale in the overcrowding and had ventilation of hospitals, poorhouses, and gaols — their records too surely tell. Even now our practice is far from perfect in this particular ; and it ia -scarcely going too far to affirm that, not only the public, but the medical profession, have still much to learn as to the importance of an ample supply of pure manysict wtien the twe reriments met cu the nail, 'J be forced to borrow tho S4th’s dhoolica. PREDISPOSITION TO DISEASE. «ir, both for the prevention and the cure of disease. 1 William B. Carpenter. PREGNANCY, Diseases and Disorders 0 f # Stn’ON. : Pr. Maladies et Troubles de la Orossesse ; Ger. Krankheiten und Stohrungen dcr Schwangerschafts. Under this heading are included all those complaints which arise from the pregnant state, or which, occurring during gestation, are so modified, or exercise such an influence over it, as to require special treatment. The subjects of false pregnancy and concealed pregnancy will also be noticed. The principal conditions which demand consideration in this article are there- fore the following : — 1, vomiting ; 2, abortion ; 3, ptyalism ; 4, retroversion and retroflexion of the uterus ; 5, anteversion and anteflexion ; 6, em- bolism ; 7, extra-uterine pregnancy ; 8, pruritus of the pudendum ; 9, oedema of the labia and lower extremities ; 10, oedema of the upper extremities ; 11, haemorrhoids; 12, dropsy of the amnion; 13, cramps ; 14, eclampsia; 15, false, and 16, concealed pregnancy. See Fcetcs, Diseases of. The foregoing list of tho principal diseases . of pregnancy might be much extended if, follow- : ing the example of eminent obstetric authorities, we were to include jaundice, constipation, diar- rhoea, cardialgia, headache, insomnia, palpita- tion and hypertrophy of the, heart, rheumatism, I inflammation of tne uterus, &c. To these and most other diseases pregnant women are liable ; but not being in any way peculiar to pregnancy, or essentially modified thereby, they require no notice in this place. It would also be beyond the scope cf this article to refer to all those anomalous sympathetic dis- turbances of the nervous system, such as longings, morbid or depraved appetite, hysterical irrita- bility, nervous pains, odontalgia, &c., that some- times attend gestation, and which, unless exces- sive, may be regarded as symptoms, and not included amongst the diseases of pregnancy. 1. Vomiting. — The most common complaint of pregnancy is morning sickness, or nausea and retching, usually confined to the forenoon, and continuing from the third week after conception until the period of quickening. The sickness of pregnancy is generally attended by no loss of appetite or impairment of health, and may thus be distinguished from vomiting caused by gastric or other diseases. In some exceptional instances, however, this complaint assumes a graver aspect ; continues 1 The peculiar susceptibility of the nervous system of children often affords a most striking test of atmospheric .impurity that might otherwise pass unheeded. In the last century, trismus nascentium (a disease now rarely seen) «as one of the principal factors of the very high rate of infantile mortality which then prevailed. This disease (continued to be very fatal in the Lying-in Hospitals of Dublin, after it had almost disappeared from those of London ; and it was mainly by the attention to their ventilation enforced by L)r. Joseph Clarke, that the nortality of the infants born in them was reduced. The . lisease has continued to our own day, under precisely amilar conditions, in St. Hilda, and some parts of Iceland, n here two-thirds of ull the children born have lied in the first twelve days. Even in what would be iccouuted the well-ventilated dwellings of our own ( niddle and higher classes, obstinate cases of spasmodic nonp, recurring with the appearance of every tooth, are requently seen, which immediately yield on the removal 4 the little patients to the pure air of the country or he seaside. PREGNANCY. 1255 throughout tlie whole term of gestation ; harasses the patient by continual retching; and, as oc- curred in one case which came under the notice of the writer, may even cause death from ex- haustion. ^Etiology. — The aetiology of morning sickness is a subject on which much ingenuity has been wasted. For many years Smellies' theory pre- vailed. ‘ Perhaps,’ he says, ‘ this complaint ij chiefly occasioned by fulness of the vessels of the uterus .... (this) being stretched by the ovum, a tension of that part ensues, affecting the nerves of that viscus, especially those that arise from the sympathetic! maximi and communicate with the plexus at the mouth of the stomach.' Most of the diseases peculiar to women are now ascribed by some authorities to displace- ments of the uterus, which are regarded by Dr. Grailey Hewitt as 1 the almost universal cause of tho vomiting of pregnancy.’ The same writer —whose views, however, have been controverted by Dr. McClintock, Dr. Tilt, and others — insists that ‘it is the compression undergone by the uterine tissues (markedly by the nervous fibres at the seat of the flexion) which is the cause of the nausea and sickness.’ Treatment. — The treatment of this complaint depends on the period of pregnancy, the severity of the symptoms, and the constitution of the patient. In ordinary cases it may be prevented by the patient remaining in bed until the usual period for its return has passed over. Her diet should be light, and she should take as little fluid as possible, especially avoiding all warm drinks, such as tea. The bowels should be regu- lated by mild antacid aperients or effervescing salines. At the same time some of the so-called specifics may be ordered, such as oxalate of cerium in two-grain doses, or hydrocyanic acid, with infusion of calumba. It is unnecessary to refer to all the, generally useless, remedies which have been proposed for this complaint, in- cluding the dilatation of the cervix uteri, first- suggested by Dubois, and more recently recom- mended by the late Dr. Copeman, of Norwich ; the hypodermic injection of morphia ; chloral ; carbolic acid; and minute doses of ipecacuanha. In some cases of excessive vomiting occurring in plethoric patients, six or eight ounces of blood may be taken away with advantage. If, notwith- standing this, the sickness continues, and the patient is in danger of dying from exhaustion, the propriety of inducing premature labour be- comes a grave question. In no case should so serious a measure be resorted to without full deliberation and consultation. In all cases it should be deferred as long as possible, and in fixing the period for its performance regard should always he paid to the possible viability cf the feetus. 2. Abortion. — The expulsion of the feetus before the ordinary period of liability may result from diseases affecting either the mother or the ovum Amongst the former are constitutional syphilis, scrofula, fevers (especially the exanthe- mata), and general plethora ; and, according to Dr. R. Lee, ‘all the chronic diseases to which the uterus and its appendages are liable may also be considered causes of abortion.’ The ovuline causes are cystic or*other placental diseases, and PREGNANCY, DISEASES AND DISORDERS OF. 1256 3yphilis. It ,s unneeessai-y to discuss such a range of subjects here. See Miscarriage. 3. Ptyalism. — This is an occasional complaint of early pregnancy, butseldom requires any treat- ment. In exceptionally severe cases, salivation may be controlled by the application of tanno- glycorine and astringent gargles, especially chlo- rate of potash in infusion of bark; or, where those fail, by the application of a few leeches to the sub-maxillary glands. 4. Retroversion of the Uterus. — This form of displacement sometimes occurs in early preg- nancy, from pressure of the enlarging womb on the neck of the bladder, which, thus prevented from completely emptying itself, becomes so dis- tended that it gradually forces the fundus uteri downwards and backwards into the hollow of the eacrum, whilst the cervix is tilted upwards and forwards against the symphysis pubis. The symp- toms of this occurrence are difficulty in passing water, or even complete retention of urine, with tenesmus and powerless straining to empty the bowels. At the same time a sense of weight, or fulness, and bearing-down pains in the pelvis aro complained of. TiiRAT.MF.NT. — The treatment of retroversion during pregnancy must be prompt, as, if it be complete, it not only occasions considerable suffering to the patient, but also certainly ends in the premature expulsion of the foetus. In cases of slight retroversion, the displacement may be remedied by emptying the distended bladder with the catheter, supporting the uterus with a Hodges’ pessary, and keeping the patient lying on her face for a few days. In complete retroversion this becomes a matter of consider- able difficulty. The patient should be placed on her hands and kuees; the bladder emptied; and the fundus pushed up from the rectum by a couple of fingers of one hand, whilst with the other hand the cervix is pulled down. A well- bent pessary should be passed up into the pos- terior cul-de-sac of the vagina, and the recum- bent position rigidly maintained for some time. o. Anteversion and Anteflexion of the Uterus. — Anteversion and anteflexion of the uterus are very exceptional complaints during pregnancy. The patient complains of bearing- down pelvic pains, and on examination the os uteri will be found in the posterior cul-de-sac of the vagina, looking towards the sacrum, the fun- dus uteri pressing on the neck of the bladder, and occasioning at first incontinence of urine, which, as the displacement increases, changes to difficulty in micturition or complete retention. In anteversion, abortion is said to occur at an earlier period than in retroversion. Treatment. — The treatment consists in placing rhe patient on her back ; mechanically reducing the displacement ; and applying a cradle pes- sary. 6. Embolism. — A\ T e occasional!}', though, for- tunately, rarely, meet with cases of sudden death during pregnancy which cannot be accounted for by any cardiac disease, aneurism, or accident. In the pregnant state a strong predisposition to the formation of a fibrinous clot or thrombus exists, and this is increased by any circumstance that depresses the circulation, such, for instance, as the fainting that frequently attends quicken- ing. The thrombus may be carried array and become impacted in the pulmonary artery or elsewhere, at any subsequent period of gesta- tion, blocking the current of the circulation an! causing sudden death. There are no symptoms by which a thrombus can be recognised, until its presence is discovered after death. And the only lesson we can learn from the history of such cases is the necessity of watchfulness during gestation, to prevent the occurrence of any undue depression of the circu- lation. 7. Extra-uterine Pregnancy. — This is a rare condition of morbid gestation, generally the sequence of pelvic inflammation, extending to the Fallopian tubes, and rendering the passage impervious to the fertilized ovum. Hence mul- tiparae are most liable to it. Four varieties of extra-uterine pregnancy are described, namely, ovarian , interstitial , ventral, and tubal. The latter is most common. The early symptoms of ex-foe tat ion cannot be distinguished from those of natural pregnancy. But as the patient approaches the fourth month, she begins to complain of something unusual in her condi- tion ; and, later on, considerable dull pain and sense of fulness in the pelvis are experienced. On examination the os uteri will be found patu- lous, the cervix undeveloped, and a semi-solid tumour may be felt in Douglas’s space between the vagina and rectum. If, under these circum- stances, the sounds of the foetal heart are heard in an unusual situation, there can be no doubt as to the naturo of the case. In tubal pregnancy the cyst generally ruptures before the third month, and the patient dies undelivered, from shock and haemorrhage. In ex ceptional cases, however, the misplaced gestation may go on to the full term, and the foetus having then perished, after an abortive effort at expul- sion, it may be retained for many years without material inconvenience. Extra-uterine preg- nancy depends on causes entirely beyond the reach of medical treatment. 8. Pruritus of the pudendum. — Pruritus is occasionally a distressing result of the general hyperaesthesia and congestion of the generative organs during pregnancy, and consists in intense irritation, extending over the external orifice of the vagina, labia, and clitoris. The itching oc- curs in paroxysms which are most troublesome at night, and in aggravated cases wear out the patient, mentally and physically, from the loss of rest and constant irritation. In most cases this may be relieved by bromide of potassium in large doses, and the application of a strong solu- tion of borax or of nitrate of silver, or sedative lotions to the affected parts. 9. CEdema of the lower extremities. — (Edema of tho lower limbs, from the pressure of the gravid uterus on the veins, is a common complaint in the later months, and seldom re- quires any treatment beyond rest and aperients. Nor is the dropsical tumefaction of the labia, which occurs from the same cause, more serious. 10. (Edema of the face and upper extre- mities. — This is always an alarming symptom during pregnancy, foretelling uraemic convulsions, and, if attended” by albuminuria, urgently de- mands active treatment, such as depletion by PREGNANCY, DISEASES AND DISORDERS OF. 1257 (tipping over the loins, and strong saline purga- tives. In all cases and forms of dropsy during preg- nancy, the urine should be daily tested for albu- min; and if this bo found, the case must be treated as one of impending convulsions. 11. Haemorrhoids. — At all times women are more subject to this complaint than men, and during pregnancy, owing to the pressure of the gravid uterus on the hsemorrhoidal and internal iliac veins, comparatively few escape either in- ternal or external piles. As Smellie observed. ‘ the same method of cure may be administered as that practised at other times, though greater caution must be used in applying leeches to the parts.’ 12. Dropsy of the Amnion. — This condition is met with in some cases of abortion from hyda- tidinous or other placental disease. It also occurs from simple over-secretion of the amniotic fluid, and is then chiefly of interest as the cause of a condition to which the older writers at- tached great importance, namely, pendulous belly. This was regarded by Devanter as the ordinary source of obliquities of the uterus, and of difficult labour. Without discussing that, question, we must regard this condition as of some impor- tance, not only from the inconvenience it occa- sions, and which can only be palliated by an abdominal belt, but still more from the proba- bility of its leading to post-partum haemorrhage, from inertia of the over-distended uterus. Hence in these cases it is necessary to deviate from the ordinary rule of midwifery practice, by rupturing the membranes, the presentation being natural, as early as possible during labour. 13. Cramps. — Cramps in the legs, from uterine pressure on the large nerve-trunks at the brim of the pelvis, are common during the last months of pregnancy, and generally come on at night in the course of the anterior crural nerve, extending down into the calves and feet. In ordinary cases no treatment is required, unless friction over the seat of pain, and some aperient, can be so called. Where, however, as sometimes happens, the cramps become unusually severe and fre- quent, their recurrence may be prevented by the pressure of a bandage or elastic stocking. 14. Eclampsia. — This is, with one exception, the most serious complication of gestation. The true convulsions of pregnancy are sui generis in their nature, though they are usually, but erro- neously. classified as hysterical, epileptic, or apoplectiform convulsions. Hysterical convulsions, being nothing more than an attack of hysteria, accidentally affecting a woman in the early months of pregnancy, require no special treatment, nor any further notice. The so-called epileptiform and apoplectiform convulsions of pregnancy are identical in their character, and are influenced in their symptoms i by the constitutional state of the patient and the severity of the attack, rather than by any essen- tial difference in the nature of the disease. Symptoms. — The premonitory symptoms of convulsions are of considerable importance, as by their timely recognition, and the adoption of suitable treatment, the approaching attack may be often warded off. In the majority of cases, eclampsia is preceded by oedema of the upper extremities, face, and eyelids ; pains in the lum- bar region ; albuminuria ; and headache, vortigo, or peculiar irritability of temper. In asthenic eclampsia, the clonic spasms com- mence with twitching of tho muscles of the eye- lids, soon increasing in violence ; extend to every part of the body ; and recur at irregular intervals. In anaemic patients, throughout the attack, the face may be cool and pale, the eye glistening, and the pupil contracted ; but, gene- rally, as the convulsions recur more frequently, the impeded respiration induces symptoms of venous congestion : the faqe becomes livid ; the breathing stertorous ; the pulse full and labour- ing ; and thus the disease passes from the first into the second stage, or from the so-called ‘epileptiform’ into the so-called ‘apoplectiform’ convulsions. In plethoric women, however, the complaint commonly assumes the apoplectic character from the first, setting in by a violent convulsion, im- mediately after which the patient falls into a comatose state, the convulsions meanwhile re- curring at frequent but irregular intervals. After some time, under favourable circumstances, the convulsions cease, and the patient slowly re- gains consciousness. But, on the other hand, the coma may become more profound, the pulse more labouring, the respiration more embar- rassed, and the extremities colder, until at length ‘ the last sad scene of all ’ is closed by a violent and final convulsion. These convulsions may occur at any time of pregnancy, during labour, and within the puer- peral period. Pathology.- — The cause of eclampsia is a subject on which innumerable theories have at different times prevailed. The older British obstetricians regarded congestion of the brain as the general cause of this disease, and hence they relied on blood-letting for its cure. Next pre- vailed the opinion, founded on the views of Dr. Marshall Hall and Von der Kolk, that these convulsions are reflex actions, excited by uterine irritation acting upon the upper part of the spinal cord and medulla oblongata. Space does not allow of any consideration of these or the many other more recent conjectures on the causation of eclampsia. At the present time this disease is generally regarded as the result of ursemic blood-poisoning, it having been shown by Braunn, Frerichs, and others, that the convulsions of pregnancy are frequently associated with dropsy, albuminuria, diminished excretion of urea and. uric acid, and the consequent retention of these compounds iD tho system. That convulsive action may be occasioned by ursemic blood-poisoning is well known in other diseases ; and during pregnancy the same effect may be produced by the pressuro of the gravid uterus on the renal emulgent veins interfering with the functions of the kidneys. The influence of mental and moral impressions in causing convulsions has been remarked by all obstetricians. The fact of its being the patient’s first pregnancy has also some influence ; thus, of eight cases that came under the writer’s no* tice, five were primiparce. 1258 PREGNANCY, DISEASES AND DISORDERS OF. Teeatment. — Preventive . — In the treatment of the convulsions of pregnancy, whenever any of the premonitory symptoms already described, and more especially albuminuria, are observed, we should direct our efforts to the depuration of the blood, by cupping over the kidneys, and the administration of mild diuretics, saline purga- tives, and diaphoretics. At the same time we must endeavour to allay nervous irritability by sedatives, of which in these cases the best is bromide of potassium. Immediate . — During the convulsions precau- tions to prevent a patient from biting her tongue, or from injuring her person in any way, should in the first instance be taken. One of the most effectual means of shortening the paroxysms is cold affusion on the head and face. In the asthenic form of eclampsia, however, this re- medy should be used cautiously. In all cases the bowels should be unloaded by calomel and jalap, or by a drop of croton oil, or by the assa- feetida enema ; the head should be shaved and blistered, or ice applied, and at the same time sinapisms be put on the legs. In cases of sthenic convulsions bloodletting is — notwithstanding thedisusage into which this has now fallen— the only remedy of undoubted efficacy in subduing the convulsive action. If the patient be plethoric, and her pupils be con- tracted, we may, as a rule, bleed. If, on the contrary, the pupils be dilated, the condition of the brain may be considered as ansmic, and bloodletting would probably be out of the question. The amount of blood that may be taken from a plethoric woman suffering from eclampsia should be measured by the patient’s condition, and the effect produced, rather than by the quantity abstracted. In hysterical convulsions, if cold affusion does not suffice, the inhalation of chloroform or ether will generally cut short the attack. But in true puerperal convulsions, in which the writer has tried chloroform pretty extensively, it requires to be used with great caution, being contra-indicated whenever the circulation is depressed, or where there is any tendency to apoplectiform symptoms. In suit- able cases, however, he has found chloroform serviceable in- subduing the convulsions, and prolonging the intervals between them. Chloral was suggested by the writer several years ago. Opium was at one time largely prescribed in these cases ; so also was belladonna, originally introduced into practice by hi. Claussier up- wards of fifty years ago, and again recom- mended by recent writers. As a substitute for bloodletting, the tincture of veratrum viride is now employed by some American obstetricians. In the actual treatment of convulsions time is too important to be wasted in experimenting with these uncertain drugs ; though in the pro- phylactic treatment of convulsions during preg- nancy and after parturition, the writer has found small doses of belladonna beneficial in calming the nervous susceptibility so intimately con- nected with convulsive action. In every case of convulsions towards the end of pregnancy, our primary object should be to deliver the patient as speedily as is consistent with her safety and that of her child. 15. False Pregnancy. — Synon. : Pseudocyc- sis. — This is a subject of considerable interest in an obstetric as well as a medico-legal aspect. Spurious pregnancy is of more frequent occur- rence than is generally supposed ; nor is it con- fined, as some writers assert, to sterile elderly women of the upper classes, many cases of the kind having come before the writer in hospital and dispensary as well as in private practice. AUtiology. — With regard to the period of life at which pseudocyesis is most frequent, authori- ties differ. The writer has known it to occur in a girl of sixteen years of age, but the great ma- jority of cases are met with about the period of ‘ the turn of life,’ or between the ages of forty- five and fifty. The causes of pseudocyesis, be- sides those before roferred to, namely change of life, dyspepsia, and hysteria, are very numerous, including ovarian disease, uterine tumours and physometra, abdominal plethora and obesity, molar pregnancy, and cystic disease of the ovum. Molar pregnancy generally' terminates between the third and fourth months ; but if continued be- yond the latter period, the absence of the positive signs of pregnancy would show the true nature of the case. Symptoms. — The symptoms of spurious preg- nancy are occasionally so close an imitation of those of true gestation as to present great diffi- culties in their diagnosis. Most of the ordinary signs of pregnancy are simulated with extraor- dinary exactness in many cases of pseudocyesis. Thus we may have amenorrhcea, followed by irri- table stomach ; swelling of the mammae ; tur- gescence of the nipples ; and great and rapid enlargement of the abdomen, concurring in a woman who wishes to become pregnant. In cases of pseudocyesis, the last of these symptoms may be traced to an excessive deposit of fat in the omentum, or to tumour ; it may be caused by distension of the large intestines by accumulated faeces, or, more commonly, by flatus, constituting what the poor in Ireland graphically describe as ‘ a windy dropsy; ’ or it may bo due to dropsical effusion into the peritoneal cavity. If to these symptoms be added, as is gener- ally the case, some derangement of the patient's nervous system, we have the superstructure on which most cases of spurious pregnancy are built. As a rule those who suffer from pseudocyesis either fear or wish to be pregnant, and having as it were coached themselves up on the subject, apply their knowledge to their own fancied symptoms with such a morbid concentration of their thoughts on this topic, that they become monomaniacal on it, and deceive themselves as well as others. Few cases are more difficult to deal with in practice than those now under consideration, and seldom is the obstetric physician more unplea- santly' situated than when called in consultation to a patient who, having persuaded herself and those about her that she is pregnant, has made all the usual preparations for the expected event, and who, deceived by those anomalous periodic pains that sometimes occur in spurious ges- tation, sends for medical assistance under the impression that she is in labour. Cases of this kind show the necessity for much caution in pro- nouncing any woman pregnant. If the physician PREGNANCY. disregard the caution, and unfortunately fall in with his patient’s opinion, without sufficient ex- amination in a case of pseudocyesis, as soon as the true state of the case becomes obvious, he will probably be made the scapegoat for the mistake, and suffer all the odium of which a woman’s wounded pride is capable. Diagnosis. — The diagnosis of spurious preg- nancy is always a matter of much difficulty during the first months of the disorder. But, however closely the early symptoms of preg- nancy may be simulated, the positive signs of pregnancy after the fifth month cannot be coun- terfeited. And, even from the very first, in spurious pregnancy, it may generally he ascer- tained, on careful enquiry, that there is some- thing unusual in the symptoms — either some essential one is wanting, or else the symptoms which belong to one period of pregnancy manifest themselves at another, and commonly earlier, time than is natural. The value of auscultation as a means of dia- gnosis in these cases is doubtful. Even in the last month of gestation, the fact of the sounds of the foetal heart and placental souffle not being distinguished on auscultation, is no proof that the uterus may not contain a living child. Nor is the value of the positive evidence, derived from tho sounds of the foetal heart and placental souffle, as great as it is sometimes supposed to he. An experienced auscultator can with cer- tainty pronounce on the existence of a living child in vtcro from the auscultatory signs pre- sent. But all medical practitioners are not experts in this special subject; and we have seen sufficient proof that, by those who form a diagnosis, in such cases, from the presence or absence of any one sign of pregnancy, opinions are sometimes pronounced in haste, which have to be repented at leisure. A careful examination of the abdomen with both hands, will enable us to ascertain if there be any uterine enlargement, although not to distinguish between the enlargement caused by disease, and that occasioned by pregnancy. To do this, we must institute a vaginal exploration, to determine whether the conditions of the os and cervix uteri be what are usual at the corre- sponding period of pregnancy. In cases of pseudocyesis where the patient, being anxious to be thought pregnant, contri- butes to the deception by making her abdominal muscles so tense and rigid that it becomes im- possible to ascertain the size and position of the uterus, we may readily dissipate the phantom tumour, and overcome the action of the muscles, by the use of chloroform. If the abdominal or uterine enlargement be occasioned by flatus or by physometra, percussion over the tumour will afford an easy test. Treatment. — It is needless to add anything about the treatment of the cases we have been considering. Pseudocyesis is only an effect of certain morbid conditions, the recognition of which we have endeavoured to point out. The treatment of these causes will be found fully described in the articles on these several sub- jects. 16. Concealed Pregnancy. — Concealed preg- nancy is a subject so closely allied to pseudo- PRESSURE. 1259 cyesis, that a few words on it appear a suitable sequence to the foregoing observations. Of late years the concealment of pregnancy has become more common than was formerly the case. This is mainly attributable to the cheap and vicious literature which circulates so largely amongst the generally badly reared, and oftentimes sorely tempted, victims of seduction in our large cities, w'hose minds are thus familiarised with crimes of foreign origin, by which too often they seek what they falsely think a safe mode of escaping the penalty of their error. Hence it becomes essential for every medical practitioner to be prepared to meet cases of concealed pregnancy and attempted abortion under various disguises, and thus be enabled to detect and frustrate such crimes. So often has the writer detected preg- nancy in patients who applied for emmenagogues under the pretext of simple amenorrhcea, that he makes it a rule — especially in hospital prac- tice, where the class of persons above referred to are more likely to be met with — not to ad- minister any medicine of this kind until he has satisfied himself as to the true state of the case, though this should be done without any expres- sion of a doubt that might be unfounded. Thomas More Madden. PREMONITORY (pre, before; and moneo, I warn).- — This word is associated with symptoms which give an indication or warning of the advent or onset of certain diseases or seizures ; for in- stance, rigors, during the invasion of fever, and tho various nurse preceding an epileptic fit. PRESBYOPIA (7r0e<|/, the eye). — Impairment of the power of accom- modation of the eye, the result of progressive senile changes, in consequence of which the nearest point of distinct vision lies at more than nine inches from the eye. Distant vision may be perfect; but the eye, unaided by an appropriate convex lens, cannot see clearly objects less than nine or more inches from the eye. See Vision, Disorders of. PRESSURE. — This is an important subject from several points of view, but it will only be practicable in the present article to discuss it generally, without entering into details, and to offer suggestions for further consideration. 1. .ZEtiology of Pressure. — As one factor in the causation of various morbid conditions, pres- sure is not uncommonly of much consequence, and it may itself originate certain lesions. The pressure often comes from without, of which the following illustrations afford sufficient examples. General pressure upon the chest and abdomen preventing the movements of breathing, may lead to death from suffocation, to fractured ribs, or to other consequences. This sometimes happens, for instance, when a person is crushed in a crowff, or is buried in a fall of earth, although the head may be free. Hanging and strangu- lation are forms of violent pressure exercised on the windpipe and vessels in the neck. The pressuro of clothing is often very injurious in connection with the chest, especially that pro- duced by tight stays. This leads to contraction or distortion of the chest ; interference with thg functions of the lungs, heart, stomach, and other PRESSURE. 1260 organs ; displacement of organs ; or actual pul- monary disease. A familiar illustration of the effects of pressure is found in the development of corns and deformities of the feet, from wearing tight boots; and in the distortions of the feet artificially produced in Chinese women by means of systematic pressure applied in early life. In this connection may also be mentioned the wear- ing of tight garters, or other forms of local con- striction, which especially tend to interfere with the passage of the blood through the veins, and to develop varicose veins. Occupation may be the cause of pressure originating disease. Thus, prolonged sitting at various occupations has been supposed to set up sciatica. Direct compression upon any part of the body, by implements used in certain callings, may originate morbid condi- tions. For instance, pressure thus induced upon the sternum is liable to cause deformity of the chest; and when exercised upon the epigastrium, it has been suppose l to account for the local development of cancer of the stomach. Lastly, prolonged pressure from lying in one position for a length of time not uncommonly causes localised inflammation, gangrene, and bed-sores, in persons suffering from low fevers, paralysis, emaciation, and other conditions. See Ulcer. Pressure is often exerted by morbid conditions in the body itself, affecting other structures in the neighbourhood, and thus inducing secondarily various symptoms, pathological phenomena, or actual diseases. It may be more or less diffused, as in the case of an effusion of fluid into a serous cavity ; or concentrated upon a certain limited region or individual structure, as often happens with aneurisms and solid tumours. In this way movements may be interfered with, or more obvious effects may be produced, namely, displacement of organs and structures ; compres- sion of tubes, canals, hollow organs, or vessels, which may lead to their complete closure ; irri- tation and. inflammation, which may end in sup- puration or gangrene ; or actual destruction. The phenomena induced will depend upon the seat of the cause of pressure, and the structure which it affects. 2. Pressure in Diagnosis. — Patients may be couscions of a local subjective feeling of pressure, which in some instances may be of a certain value in diagnosis; but such sensations must never be regarded as reliable. The ob- jective effects of pressure are, however, often evident, and afford clinical signs of the greatest diagnostic value, as is frequently illustrated in cases of diseases of the chest and abdomen. Moreover, the practitioner can, by means of pres- sure with the fingers or hand, himself determine many points of essential value in the investiga- tion of numerous cases. Indeed, pressure is often an important part of palpation or manipulation, as employed in physical examination ( see Phy- sical Examination), and is especially useful in the following particulars: — By this means we are able to determine the existence and degree of local tenderness or hypersesthesia. Pressure also helps to reveal the presence of air or fluid in the sub- cutaneous cellular tissue. It is absolutely neces- sary for bringing out the feeling of fluctuation, degree of resistance, tension, and other sensa- tions ; while the effect of pressure in modifying certain physical conditions may be of great ser- vice in diagnosis, as may be exemplified by the influence thus produced in many cases upon an accumulation of faeces in the intestines. Pres- sure upon arteries or veins is employed with the view of observing its effects upon the local circulation, arteries, tumours and other morbid conditions ; and, in the case of the arteries, to determine the compressibility of the pulse. 3. Pressure in Treatment. — In this con- nection the first point to be noticed is the neces- sity of removing or avoiding any source of exter- nal pressure which is causing mischief ; and also of getting rid of internal pressure, if this is practicable. Pressure may frequently be em- ployed with advantage as a therapeutic agent. It may be thus tised in a more or less difftised manner ; cr concentrated on a limited surface. It may be practised by the fingers or hand; by means of plasters, bandages, elastic apparatus, and similar appliances, sometimes of an elaborate kind ; or by special surgical apparatus or appli- ances, such as the tourniquet, acupressure, the ligature, the clamp, or trusses of different forms. Pressure also constitutes one element in friction and shampooing. As regards the objects for which pressure is em- ployed, in the first place, it not uncommonly helps to relieve pain, which may be illustrated by the effects of manual pressure in subduing the pain of intestinal colic ; the relief often afforded to certain forms of headache bv applying a bandage or handkerchief tightly round the head ; and the beneficial results following the fixing of more or less of one side of the chest, by means of strapping or other agents, in cases of pleurisy or pleurodynia. Local pressure may also cure cer- tain forms of neuralgia. Agqin, direct compres- sion is sometimes employed to check symptoms produced by reflex influence ; thus pressure over the ovary may check vomiting, spasmodic or convulsive movements, and other phenomena connected with hysteria. Another use of pres- sure is to arrest the process of inflammation, which is exemplified by the practice of strap- ping the testicle in the early stage of orchitis. In relation to this point, a very important object for which it is employed is to promote the absorption of morbid accumulations and pro- ducts of all kinds, whether originating from in- flammation or other causes. Thus it helps to get rid of air: of fluid effusions, inflammatory or dropsical ; of fibrinous exudations ; and of thick- enings or indurations remaining after acute in- flammation, or resulting from chronic inflamma- tory process. Pressure is again frequently taken advantage of for its influence upon the blood- vessels. Thus it checks different forms of hemor- rhage, the kind of compression required varying with the precise form of bleeding. Elastic pres- sure, according to Esmarch’s method, has been found of great service in preventing bleeding during operations. In connection with arteries direct compression is also often employed for the cure of aneurisms. As regards the veins, pres- sure is of essential service in preventing the inju rious consequences likely to result from varicose dilatation of these vessels, and in giving them support ; while it is also made use of in the cure of this condition, especially in connection with PRESSURE. ;ertain operative procedures. In the case of the abdomen, pressure is often of much service to counteract the ill-effects of relaxed and flabby walls. It may also be used to excite contraction in the intestines, bladder, or uterus, under certain circumstances ; and to aid in the removal of accumulations in the bowels. Lastly, pressure is made use of in preventing certain forms of displacement of organs and structures ; and in attempting to cure the conditions upon which they depend, as is exemplified by the application of a truss in cases of hernia, and by some of the operations for the radical cure of this complaint. Frederick T. Roberts. PREVENTION' OP DISEASE. See Per- sonal Health ; and Public Health. PRIAPISM. — Synon. : Fr. Priapisme ; Ger. Priapismus ; li ut hen /cramp f. Definition. — A term generally understood to signify unduly occurring or unnaturally pro- longed erection of the penis, accompanied or not, as the case may be, by inordinate sexual desire. It is important to distinguish between mere turgescenee of the organ— false priapism ; and true priapism, or perfect erection. The former depends simply upon distension by blood, in- duced or permitted by relaxation of the walls of the blood-vessels and blood-spaces ; it may be associated with comparative flaccidity, and, though uncomfortable, is rarely painful. The latter requires for its production, not only distension by blood, but a certain kind and degree of ten- sion or contraction of the intrinsic muscular fibres of the trabeculae and sheaths ; it is cha- racterised by manifest rigidity, and if long con- tinued — as it may be for several days or even longer— may give rise to considerable suffering. Description. — Priapism, more or less pro- nounced, from time to time occurs in connection with various morbid affections of the general system, or of particular organs. Thus it usually, though not invariably, attends erotic mental de- rangement, It occurs frequently in tetanus and hydrophobia, and sometimes, occasionally even to a distressing extent, during recovery from the eruptive fevers. It has been noted in some cases of tumour or other disease of the cerebellum and pons varolii ; and in the earlier stages, or among the first indications, of certain diseases of the spinal cord, leading on to paraplegia. An over- loaded condition of the lower bowel, especially in conjunction with enlarged and irritable prostate, inflamed haemorrhoids, distension of the bladder, stone in t.he bladder, phimosis, urethritis, and other conditions, may be enumerated as not in- frequent local causes of troublesome, though transient, priapism, acting either by pressure on the blood-vessels, or by reflex nervous influence. It also occurs among the results of injuries of the central nervous system, as well as of the penis itself. Injuries of the spinal cord, especially in the cervical and lumbar regions, are liable to be followed by continued or recurrent priap- ism, or by turgescenee with flaccidity. Sudden erection, with emission, not infrequently attends .injury of the cervical spine. Numerous cases are on record in which, during violent coitus, or otherwise during erection, the penis itself has undergone injury ; and some portions or other of PRODROMATA. 1261 the sheaths of the corpora cavernosa, with the included blood-vessels, have been ruptured, or some blood-vessel has been ruptured, the sheaths remaining entire. In such cases extravasation of blood, followed by turgescenee of the corpora cavernosa, occurs ; and sooner or later the most persistent, and very often painful, priapism ensues. Treatment. — The treatment generally must depend upon the due recognition and treatment of tho condition on which the priapism depends. If of central origin, it is to this point that atten- tion must be directed. But it not infrequently happens that the local suffering is so considerable as to demand special measures for its relief. In some cases cold applications, in others warm or hot fomentations with anodynes, have proved most efficacious. Leeching has rarely been use- ful. Bandaging, masturbation, and sexual con- gress have often been tried ; but the result, as a rule, has been to increase rather than to mitigata tho evil. In cases in which extravasation of blood following injury is the cause, it may be necessary to make incisions, turn out any clots, and arrest further haemorrhage ; but permanent damage to the organ usually results, sometimes after prolonged suppuration, and sometimes even after risk to life. Among the medicines that have seemed more or less useful in various cases may be especially mentioned bromide of potassium, lupuline, cam- phor, hyoscyamus, and belladonna. Free purga- tion is beneficial in some cases. Arthur E. Durham. PRICKLY HEAT. — An eruption of minute pimples, which cover the skin more or less ex- tensively, and are attended with burning heat, and a most tormenting prickly itching. The affection occurs for the most part in hot cli- mates, and attacks principally those who are unaccustomed to extreme heat; hence it is often experienced by travellers in tropical regions. Pathologically it is a lichen, attended with great irritability of the skin, and from its dependence on heat of climate, has received the designation of lichen tropicus. This disorder will be found described under the head of Lichen. PRIMARY (primus , the first). — This word is either used to imply that a disease originates in an organ or structure from a local cause, such as primary pleurisy or peritonitis, or primary attacks ; or it is associated with the first mani- festation of a disease, such as the primary sort of syphilis, or primary cancer. It is also applied to the direct or immediate symptoms of a disease, as distinguished from those which may he produced secondarily or remotely. PROCIDENTIA (pro, downwards, and cado, I fall). — A falling down of certain organs or structures from their natural position, as of the uterus, rectum, or iris. See Prolapsus. PROCTITIS (irpwKrds, the anus). — Inflam- mation of the anus or rectum. See Periproc- titis ; and Rectum, Diseases of. PRODROMATA (j rph, before, and Spi/ios, a course). — A synonym for premonitory symptoms- See Premonitory. 1262 PROGNOSIS. PROGNOSIS. See Disease, Prognosis of. PROGRESSIVE MUSCULAR ATRO- PHY. — Synon. : Paralysis atrophica-, Cruveil- hier’s Atrophy ; Wasting Palsy; Fr. Atrophie musculaira ffraisseuse progressive (Duehenne) ; Ger. Muskelatrophie ; Muskellahmung. Definition. — A chronic wasting and Altera- tion in the structure of the muscular tissue, which may consist of (1) simple atrophy; (2) atrophy with granular degeneration ; (3) atrophy with fatty degeneration ; and (4) atrophy with (the so-called) waxy degeneration. -ZEtiology. — Progressive muscular atrophy mostly prevails among middle-aged persons and young adults, and the male sex is more liable to suffer than the female — in the proportion of about six to one. Consanguinity, or hereditary influence, is a powerful predisposing cause, and in the greater number of hereditary cases the atrophy becomes generalised. The principal exciting causes are excessive muscular exertion ; severe cold and wet — particu- larly when combined ; and diseases or injuries of the spine. When the disease follows cold and wet, the atrophy is commonly preceded or accompanied by neuralgic or supposed rheumatic pains, either in the muscles or in the course of their nerves. The disease is also not uncommonly a consequence of syphilis. In those cases that seem to be hereditary there often appears to be no other assignable cause. Pathology. — Progressive muscular atrophy does not originate, as was formerly believed, in the muscles themselves, but, as the writer hus shown, from functional or structural alterations in the nervous centres and their nerves. In fatal cases these alterations are of various kinds. They consist of atrophy of the nerve-cells and their processes in the anterior cornua of the opinal cord, commencing in pigmentary dege- neration, and ending frequently in their total disappearance. The blood-vessels are frequently dilated, sometimes to an enormous degree, and around them are generally found areas of gra- nular or fluid disintegration, of greater or less extent, and mixed with exudations, or compound granular corpuscles. Frequently there is an abundance of corpora amylacea. These morbid changes occur in both the grey and white sub- stance. Sometimes one and sometimes both of the anterior horns are reduced in bulk. The anterior nerve-roots are not unfrequently wasted to a greater or less extent, as Cruveilhier ori- ginally noticed. In some instances nothing re- mains of them but the neurilemma; in others the fibres are in process of partial disintegration. Anatomical Chaeactees. — The affected mus- cles suffer differently in their degrees of wasting, and present a variety of aspects. In the same muscle, bundles in different stages of atrophy may be seen by the side of others that are un- affected. If the wasting be extreme in all the bundles, a long muscle presents the appearance of a more fibrous cord or tendon, and a flat muscle may be reduced in a similar way to a kind of membrane. The atrophy may consist of only simple wasting, without any granular or fatty degeneration ; but in the majority of eases it is accompanied by both these alterations PROGRESSIVE MUSCULAR ATROPHY, of structure to a greater or less extent, and by variable changes in colour. The muscle is paler than natural, and sometimes quite colourless, or may have a faint yellow tint. Its consistence, in consequence of the increase of interfibrillar connective tissue, is greater than normal. Under the microscope the transverse and longitudinal strise are found to have disappeared to a variable extent and degree, or are even completely lost ; while the sarcous or muscular tissue is trans- formed into granules, which are sometimes so fine that they cannot be distinguished as separate particles. These granules are soluble in acetic acid. Granular degeneration or disintegration of tho muscular tissue may be the only structural alteration, but it is often accompanied or fol- lowed by fatty degeneration. This latter change, however, may make its appearance at once. In addition to this transformation of muscular tissue into fatty particles, fat-cells in great numbers are found between the fibres, sometimes in groups and sometimes in linear succession. These may increase in proportion as the mus- cular tissue is wasted, so that there may be no actual loss of volume in the limb. The waxy or vitreous degeneration appears to be confined to the voluntary muscles, and never affects all the bundles of a muscle. It consists of a peculiar transformation of the tissue into a colourless, glistening, and homogeneous sub- stance, in which the transverse and longitudinal stri® as well as the nuclei no longer exist. Although this kind of degeneration is more common after acute diseases, it is not unfre- quently found in progressive muscular atrophy, in which, indeed, all the three kinds of altera- tion above mentioned may exist, not only in the same person, but in the same muscle. Symptoms. — Progressive muscular atrophy dif- fers in many respects from the simple atrophy which is consequent on exhausting diseases or on paralysis, is always chronic, bnt of variable and uncertain duration. It is irregular and capricious iu its invasion. In most instances it first makes its appearance in the upper extremi- ties, especially on the right side. The muscles of the hand are generally those which are first attacked — the thenar eminence, then the hypo- thenar, and the interossei. When the interossei are much wasted, the hand presents the appear- ance of a bird’s claw, or what Dnchenne termed the main en griffe. The atrophy may extend up the limb, and then the flexors and extensors of the fingers, and often the muscles at the back of the forearm, become affected. The disease may also involve the muscles of the arms and trunk —the biceps, deltoid, triceps, pectoral, latissimi dorsi, rliomboidei, extensors and flexors of the head, sacro-lumbales, the abdominal muscles, and the muscles of respiration and deglutition. In some instances the atrophy begins in the muscles about the thorax, and proceeds to a considerable extent, while the arms may escape. In other instances it is limited to the muscles of the fore- arm. Occasionally it spreads to the lower limbs, but seldom begins there. A variety of alterations in the shape and position of the trunk and limbs is produced by this irregular wasting of the muscles, aid suei PROGRESSIVE MUSCULAR ATROPHY. alterations are characteristic of the disease ; for in ordinary atrophy following exhausting diseases the -wasting of the muscles is uniform. Loss of muscular power in the affected parts is one of the first symptoms, particularly after exertion or exposure to cold. The electric con- tractility of the wasted muscles is often slightly diminished. Still it is of great importance to note that the wasted muscles respond to the faradaic as well as to the voltaic current, unless the wasting has reached its final stage when healthy muscular fibres are almost wholly absent. The patient’s movements are awk- ward, and there is a certain loss of muscular co-ordination, in consequence cf the unequal wastin'! of the muscles, and the alteration in their relative force or antagonism. At an early period the affected muscles are subject to cramps, fibrillary tremors, and twitches. In some cases there is a variable degree of cutaneous anaesthesia, but usually the sensibility is unim- paired ; while in about half the cases more or less pain is experienced in the atrophied mus- cles, or before the atrophy commences. When the muscles of the face are affected its expres- sion is singularly altered, and the saliva dribbles from the mouth. The tongue is frequently shrunk and shrivelled from atrophy of its mus- cles, and articulation is imperfect ; in this case, however, such signs and symptoms are usually regarded as pertaining to a distinct disease (see Labio-Glosso-Laryngeal Paralysis). When the apparatus of deglutition is involved, cough is excited on swallowing liquids, which frequently escape through the nose ; when the muscles of respiration are much wasted, there is difficulty of breathing, and the patient commonly dies from some bronchial attack, in consequence of his inability to expectorate the mucus. Diagnosis. — This is usually made without much difficulty. The fact of the slow progress of the disease, with the successive implication of different muscles or groups of muscles, is very characteristic. It is distinguished from cases of paralysis followed by muscular atrophy, by the fact that there is no paralysis first, and atrophy after, as in these cases, but rather a weakness which increases pari passu with the atrophy. Then, again, in progressive muscular atrophy the muscles still respond to faradisation, whereas in post-paralytic atrophy this is very apt not to be the case, and we have instead to do with some form of the ‘reaction of degenera- tion.’ See Paralysis. Prognosis. — From what has been already said it is evident that progressive muscular atrophy is a malady of the gravest nature. The only pro- bability of effecting a cure, is when the disease , can be treated in its earliest stage, when the disorder of the nervous centres is merely func- tional, and before any organic lesions have super- vened. Treatment. — When the disease arises from the influence of damp and cold, or from over-exer- tion, these causes should, of course, be avoided. Warm clothing and warm baths — particularly the waters of Aix-la-Chapelle — are to be recom- mended. If there be reason for suspecting a syphilitic taint, iodide of potassium, or even mercury, if necessary, should be administered. PROSTATE, DISEASES OF. 1263 In other cases cod-liver oil, phosphorus, mineral tonics, and arsenic have been found useful. Rut galvanism in the early stages of the disease ha* proved tho most useful of remedies. The gal- vanic current should be applied to the spinal column, especially in the cervical region. When we consider that in the more advanced stages of the malady lesions of the spinal cord are in- duced, it is questionable whether the application of counter-irritants — especially blisters — to the spine, has had a sufficient trial. J. Lockhart Clarke. PROLAPSUS (pro, forward, and labor, I slip). — This word signifies that an organ or structure has fallen or slipped down, but implies a greater degree of displacement than proci- dentia ; so that the organ or structure may pro- trude through a natural or artificial orifice. The condition is of most importance in connexion with the rectum and the uterus. See Proci- dentia; Anus, Diseases of ; and Womb, Diseases of. PROPHYLACTIC f (trpb, before, and PROPHYLAXIS (pvAdcrtru >, I guard). These terms are used in connexion with treat- ment, and indicate the means employed for the prevention of disease. See Disease, Treatment of. PROSOPALGIA (irpbo'anruv, the face, and &Ay os, pain). — Prosopalgia signifies pain about the face. It may depend upon neuralgia of one or more branches of the fifth pair of nerves (see Tic-Dol’loureux). Its paroxysmal character, unilateral position, and anatomical localisation will indicate this form. Another form is of rheumatic origin. In this the pain is more or less constant, diffused about the face or forehead, and does not follow the course of a nerve-branch. Movements, and especially stooping, increase it. Occasionally such pain is of syphilitic origin, and is especially apt to occur in connection with the appearance of the secondary rash. Diagnosis. — In rheumatic prosopalgia the pain is diffused and increased by pressure. If it depend on syphilitic periostitis there will be ten- derness on pressure, and the parts will be swollen and less elastic than normal. There will also very likely be a certain amount of fever; and the pain will be increased at night. Treatment. — Muriate of ammonia in half- drachm doses, dissolved in half a tumbler of water, should be given every four hours. If there be any evidence of syphilitic infection, iodide of potassium should be taken, in doses of from ten to twenty grains every four hours. For the rheumatic form of face-ache five grains of iodide of potassium, with thirty grains of bi- carbonate of potash, should be given every four or six hours, after the administration of an aperient. This may be followed up by quinine or iron. Locally a mixture of equal parts of camphor, choral, and vaseline may be applied ; or a liniment containing chloroform, belladonna, and opium. Decayed teeth should be extracted. T. Buzzard. PROSTATE, Diseases of. — Synon. : Ft Maladies de la Prostate ; Ger. KranJckeiten det Prostate. 1264 PEOSTATE, It is not proposed in a work principally de- voted to medical subjects to deal at all fully with the affections of the prostate gland ; the present article must, accordingly, bo taken rather as an index to guide the practitioner in his dia- gnosis, than as anything approaching a complete disquisition on their pathology or treatment. General Eelations. — The points of practical importance in connection with the anatomy of the prostate are as follows: — In the examination of the rectum the healthy prostate is felt as a firm substance in the middle line, somewhat divided into two lateral lobes. The whole organ i3 about l|Tnch in width, with its apex opposite, namely, in the recumbent posture below, the apex of the pubic arch ; that is, about li inch from the anus, in a moderately thin subject, but much further in a very fat one. The whole gland is H inch in length, its posterior limit being usually about three inches from the anus — in other words, about the distance to which the forefinger can reach. From this it may be deduced that the trigonum vesica commences im- mediately behind it, and therefore that a fully distended bladder masks more or less completely the natural outline of the gland. It may thus also be gathered that the vesiculae seminales are beyond the ordinary reach of the finger, and that when these are infiltrated by disease, their apices, or perhaps only the vasa efferentia, can be detected. The practitioner should by no means neglect the digital examination of the prostate, as it will often yield information of the greatest value. The deviations from the normal type he may expect to meet with are — uniform or partial enlargement from simple hypertrophy, orfrom chronic or acute inflammation, inthe latter case possibly attended by a sense of fluctuation, due to abscess ; irregular hardness, most marked about the vasa efferentia, depending on a tuber- cular deposit ; the existence of small hard nodu- lar masses, ■which are calculi in the substance of the gland ; or the irregular enlargement caused by a new growth. It must be borne in mind that tumours or abscesses originating in neigh- bouring parts may surround the prostate and completely mask its outline ; thus the writer has met with a case of a large hydatid cyst be- tween the rectum and the bladder that rather closely simulated malignant disease of the pro- state, and effectually prevented its actual con- dition from being determined. It will not be forgotten that a certain degree of tenderness of the prostate does not imply a deviation from health, and that a more or less considerable enlargement in old age is so common as to be almost reckoned by some authors as normal. The effect of this enlargement on micturition will be mentioned further on. The copious plexus of veins which surround the prostate communicates fully with those of the penis and rectum ; and it is not unimportant, from a clini- cal point of view, to remember that these are thus connected not only with the systemic, but with the portal circulation. These veins may become the seat of phlebitis and its sequelae from various causes. The principal diseases of the prostate maybe considered in the following order : — 1. Prostate, Hypertrophy of. — The re- DISEASES OF. suits of Sir Henry Thompson’s observation* ( Clinical Lectures on Diseases of the Urinary Organs) were, that one-third of all men over fifty-five have some enlargement of the pro- state; but that a comparatively small numbei of these suffer any inconvenience from it; and that it usually begins between the ages of fifty, seven and sixty, though it may more rarely com- mence later. Very considerable enlargement ot the lateral lobes may cause no inconvenience ; but if the part which forms the floor of the pro^ static urethra, the so-called middle lobe, bo even slightly enlarged, difficulty in micturition is sure to result. It is thus easy to understand how a simple hypertrophy may reach enormous dimen- sions without giving rise to symptoms, while those which are caused by the enlargement of a prostate, which feels almost normal to the finger introduced into the rectum, may, on the other hand, be very severe indeed. Symptoms. — The symptoms are briefly these: The stream of urine becomes dribbling, and there is an obvious difficulty in emptying the bladder ; there is frequency of micturition, espe- cially at night and in the early morning ; per- haps a little pain before the act, but none afterwards ; and no alteration in the characters of the urine. If unrelieved, these early symp- toms are followed 1 r incontinence, depending upon over-distension of the bladder ; and, from the same cause not improbably, cystitis and dila- tation of the bladder, dilated ureters, and, per- haps, pyelitis and chronic interstitial nephritis. Patients with chronic hypertrophy of the pro state usually suffer from time to time from attacks of acute congestion, such as are de- scribed below. Anatomical Characters. — The structure of a hypertrophied prostate is but a slight modi- fication of that of the gland itself. Treatment. — In regard to treatment cf hy- pertrophy of the prostate it is only necessary here to give two words of warning. First, that most of the evils resulting from this condition depend upon the fact that the bladder is never emptied ; it is essential, therefore, that the patient’s powers in this respect should be ascer- tained without delay by catheterisation, and if it be discovered that a certain amount of residual urine remains, he should be taught to pass au instrument himself, and directed to do so at least once a day. Secondly^ cystitis has often been caused by setting up putrefaction of the urine by a catheter not surgically clean ; the simple precaution of lubricating it with carbolised oil prevents with certainty this catastrophe. The reader must consult surgical works as to the difficulties which an enlarged prostate offers to the introduction of a catheter, and the manner in which they may- be overcome. 2. Prostate, Congestion of — Congestion is a condition which follows on chronic hyper- trophy, and is commonly known as ‘ an attack of the prostate.’ Symptoms. — An old man, suffering from the symptoms above described, is suddenly seized — as the result of some indiscretion in diet, an exposure to cold, or some other apparently trivial cause — with complete retention, accom- panied by bloody urine, possibly a raised PROSTATE, DISEASES OF. 1265 temperature and quick pulse, and considerable local uneasiness. If the case do not improve, and especially if the urine be allowed to putrefy, the tongue becomes dry and brown, the pulse more rapid and more weak, and the patient passes into a low typhoid condition, which is not un- likely to end fatally. Treatment. — The treatment is in large mea- sure surgical, consisting in the proper passing of catheters; but scarcely less important is the careful regulation of the bowels ; and the ad- ministration of a diet sufficiently light, and yet not too lowering, together with, in most cases, a certain amount of stimulant, for it must be re- membered that the patient , is probably weak, and that death from asthenia is much to be dreaded. The writer would urgently insist on the importance of preventing putrefaction of the urine, which is the most fertile source of death in such cases; he can affirm from experience that this end may be attained by the thoughtful employment of antiseptic treatment, even in those cases in which it becomes necessary to keep the bladder empty by tying a catheter into the urethra. 3, Prostate, Chronic Inflammation of. — Synon. : Chronic prostatitis. — This is not an uncommon affection amongst young and middle- iged men. depending most frequently on a pro- longed gonorrhoea, in which the prostatic part rf the urethra has been involved. Symptoms. — The symptoms of this disease resemble rather closely those depending upon tone in the bladder, namely, frequent mictu- ition, with a feeling of heat and weight in the lerinaeum, and pain along the penis, extending o the tip ; there is also at times a little blood lasaed at the end of micturition ; and all the ymptoms are aggravated by exercise. Generally here are frequent nocturnal emissions. The line is cloudy, and on standing yields a mueo- urulent deposit. A rectal examination shows hat the prostate is enlarged, sometimes very .lightly, and seldom to any great extent ; it is Iways tender. The diagnosis can scarcely be ado without passing the sound. Treatment. — The treatment consists in rest, le administration of laxative medicines, and the ^plication of blisters or some other form of outer-irritation to the perinaeum; alcoholic imulants are to be avoided ; and the urine ould be rendered bland by alkalies and dibi- ts, as in cases of urethritis. 4. Acute Inflammation of the Prostate. — "xon. ; Acute prostatitis.— Acute prostatitis ly arise as the result of a gonorrhoea, or cys- is; from the irritation produced by calculi other mechanical cause ; perhaps sometimes opathically, or from exposure to cold or wet ; 1 from undue sexual excitement, or the too free i of alcohol if gonorrhoea be present. This y occur in men of any age, and is accompanied symptoms such as those depending on chronic animation, but much more intense ; the fre- 1 mey of micturition and pain during tho act i sing sometimes almost unbearable agony, and I dysuna amounting in some cases to complete i mtion, while the tenderness of the gland is | f great, a condition which makes an action of ' bowels very painful. Such cases may termi- 80 nate by becoming chronic; they T may undergo complete resolution ; or suppuration may occur ; in any case there will probably be some elevation of temperature, and in the event of the forma- tion of abscess there may be great and sudden rises and falls, accompanied by rigors and sweat- ings, with a dry, brown tongue, forcibly sug- gesting pyaemia. Prostatic abscess may burst into the rectum, bladder, or perinaeum. Treatment.- — The treatment of acute pros- tatitis consists in rest, and carefully-regulated diet ; diluent and alkaline medicines ; purga- tives; local blood-letting from the perinaeum, by leeches or otherwise (some French surgeons have recommended the application of leeches to the interior of the rectum) ; with hot fomentations, and morphia suppositories. If an abscess forms it may be opened through the rectum, but it is better to incise it through the perinaeum, as this plan is most likely to prevent tho formation of that most troublesome and almost incurable condition, a recto-vesical fistula. Abscesses sometimes form around the prostate (periprostatic). They are not so likely to in- volve the danger of the formation of a recto- vesical fistula ; and they should be treated by early incision. b. Prostate, Tubercle of. — This, though not a common affection of the prostate, occurs per- haps more frequently than is generally supposed, and is of great interest to the practitioner. It is usually a part only of a more or less general affection of the genito-urinary tract. Thus in cases where the epidydimes are hard and swollen, and the cords knotty from tubercular deposit, the finger introduced into the rectum will probably detect a hard nodule in one or both of the vasa efferentia. This, if seenyiosf mortem, is found to consist of a tubercular or cheesy mass, and if the condition have advanced further, the prostate itself may have become involved ; there may be either separate ncdules of tubercular deposit in a more or less advanced state of cheesy or, moro rarely, calcareous degeneration ; or the whole gland may have become hollowed out into an irregular cavity, filled in part with cheesy material, and discharging pus. Symptoms. — This disease may begin in child- hood, or in adult life. Its symptoms are most obscure. At first there are probably none at all, but as the disease advances, there will arise those of tumour of the prostate, together with those of abscess ; that is, there will be occasion- ally blood, and generally pus, in the urine; frequency and pain in micturition ; tenderness and swelling in the rectum, and so forth. Ab- scess from this cause has been known to burst into the peritoneum. Treatment. — The treatment can only be pal- liative, and must be directed to the relief of the symptoms as they arise ; but at the best it is most unsatisfactory. Occasionally it may be possible to open a tubercular abscess through the perinaeum, but it is open to doubt how far such a procedure is to the advantage of the patient. 6. Prostatic Calculi. — These are small bodies, generally multiple, formed in the glands of the prostate, usually late in life, but occasionally in comparatively young men. They probably begin as a deposit of animal matter. 1266 PROSTATE, DISEASES OF. but later are made up principally of phosphate, and partly of carbonate, of lime. They may pro- duce no symptoms at all, or they may project into the urethra, and give rise to great irrita- tion at the neck cf the bladder, and the symp- toms of vesical calculus* such will also be present if, as sometimes happens, they convert the whole gland into a single cavity, in which the calculi lie side by side. In this case they will be felt through the rectum, rubbing against one another ; and indeed prostatic calculi are, as a rule, to be felt in this situation. Vesical calculi of considerable size may be- come encysted in the prostate, and on the other hand prostatic calculi may find their way into the bladder. Prostatic calculi may give rise to abscess. If any treatment be required, it is purely surgical, and must consist in the removal of the stones by forceps, a lithotrite, or a perinaeal incision. 7. Prostate, Phleboliths of. — The patho- logist very often meets with phleboliths in the veins surrounding the prostate, the result no doubt of old phlebitis. 8. Prostate, Tumours of.- — The so-called fibrous tumours of the prostate are in all pro- bability simply local hypertrophies, and are composed principally of plain muscular tissue. Cystic disease is described as a pathological rarity, the gland being occupied by numerous cysts, containing serous or mucous fluid. Melanosis of the gland has also been observed. Cancer of the prostate occurs not very unfrequently, and is usually soft, though it is sometimes hard enough to be worthy of the name of scirrhus. The writer would speak with great caution of malig- nant tumours of the prostate ; such as he has himself examined have been cancers, with a very irregular arrangement of both stroma and epi- thelial cells. Tumours of the prostate may be at present considered as beyond the reach of surgical in- terference, though suggestions for their removal have been lately gravely made in Germany. 9. Prostate, Atrophy and Absence of. — Atrophy of the prostate is said to occur as the result of pressure, sometimes from an unascer- tained cause, or from simple senile decay. Con- genital absence of the prostate has also in rare cases been observed, but is of little clinical interest. R. J. Godlee. PROSTRATION (pro, forward; and sterno, I stretch). — This word signifies both the act of overthrowing, and the condition of being over- thrown, overcome, or depressed. In medical science it is generally employed in the latter sense ; and is used to express a condition of system in which the bodily energies as a whole, or the more active of them, have so completely succumbed to the effects of injury, disease, or powerful emotional influences, that they cannot be made to respond to ordinary stimuli. When prostration affects the whole system the patient is said to suffer from general prostration o f the vital powers. The principal forms of prostration of a single system, on the other hand, are — (1) muscular prostration, in which there is complete exhaustion of the voluntary muscles : and (2) I PRURIGO. nervous prostration , in which the nerve-centres, and especially those associated with the mind, are so completely overpowered that sensation and motion appear to be in a measure temporarily suspended. The causes, symptoms, and treatment of pros- tration in its several forms are more fully dis- cussed in other articles. See Collapse; Debi- lity ; Exhaustion ; Shock ; and Syncope. J. Mitchell Bruce. PROXIMATE CAUSES (proximus, near- est). — A synonym for the immediate or exciting causes of disease. See Disease, Causes of. PRURIGO (prurire , to itch). — Synox. : Fr. and Ger. Prurigo. Description. —Prurigo is the disease of itch- ing; but, as there are various forms of pruritus or itching of the skin, it becomes necessary to determine what, besides itching, constitutes prurigo. Pruritus is an excited state of the nerves of the skin, and as such, is associated with various forms of skin-affection, for example, with scabies, eczema, and urticaria ; but in these affections there is a difference in the cause of the disease. In scabies and eczema the cause lies in the tissues of the skin ; in urticaria, on the contrary, it is ; present in the nerves themselves. Hence urti- caria is denominated a neurosis, and prurigo is also a neurosis which leads onwards to a de- fective nutrition of the skin. What especially characterises prurigo is the combination of pruri- tus with an altered state of the skin, consequent on defective nutrition; and, as a rule.it may be said to be restricted to the elderly period of life, when nutritive power in general is weakenedj or exhausted. The quality of the itching in prurigo is not so much intensity, for the itching of chronic eczema and simple neurotic pruritus from reflex causes is often more severe. Its especial character is its pungency, which resembles a burning and gnawing of the flesh ; and also its mobility, sug- gesting the idea of animals creeping and eating their way through the substance of the skin. The degree of severity of the pruritus has suggested the names mitis and formicans — idle terms which ought to be abandoned; and as much may be said of the epithet senilis , inasmuch as general pru- rigo is necessarily a disease of an ill-nourishec skin, and especially of the kind of defective nu- trition which is incident to old age. If we take, as factors, an ill-nourished integu- ment, in an elderly person ; a dry, hard unevei skin, discoloured from irregular pigmentation fatless, and adhering loosely to the fascia be neath, suggesting the idea of leather or parch ment ; ar.d an irritable nervous system, we shal then have a case deserving the name of prurige Moreover, to this state of skin we must ad papules raised upon the surface, with heads tor, off by scratching, and capped with small blac; crusts of desiccated blood; and abrasions cause by fierce and incessant scraping with the nail All these conditions taken together constitu; a true case of chronic prurigo, a real pruritj senilis. A'arieties. — Frurigo is a general affection PRURIGO. the skin, but it is likewise met with occasionally is a local disease, in the integument around the anus .prurigo ani ; and in the folds of the clitoris, prurigo clitoridis. These latter cases are always accompanied with altered nutrition of the inte- gument, more or less condensation and hardening df the tissues, and thickening of the epithelium. The symptoms otherwise are the same as those of general prurigo, but are often remarkable for their intense severity. Pathology. —Prurigo is essentially neurotic in its nature; a feeble state of nerve-function gives rise to the altered nutrition of the in- tegument, and irritability of nerve-structures to pruritus. Prognosis. — The disease is obstinate and en- during, vexatious to the patient, and tending to aggravate general irritability, but not hazardous :to life. Occurring in old age, with a tendency to increase, it is apt to last for years. Prurigo cli- toridis is one of the most rebellious of disorders, and has a tendency to degenerate into epithe- lioma. Treatment. — The indications for treatment are to tranquillise the nervous system generally, jind to improve the nutrition of the tissues of he skin. For this purpose the digestive organs should be regulated ; a generous and nutritive diet enforced ; and recourse had to nerve-tonics :is well as to general tonics. Cod-liver oil is iften a useful remedy, and will be assisted by minia, strychnia, and phosphorus. Arsenic is indispensable. Sedatives are frequently required b relieve pruritus and procure sleep ; and for •his purpose the bromides and chloral hydrate ill do good service, or in some constitutions voseyamus and morphia. Violent exacerba- ons of pruritus are best controlled by single rge doses of quinia, namely, five to ten rains. Locally, the heat and shampooing of the irkish bath, frequently repeated and steadily usued, may bo regarded as curative in most ises. This should be succeeded by thorough '•unction of the skin with some bland unguent, 'ch as vaseline ; and a wash-leather covering iould be worn next the skin. Sponging with it water or hot decoction of poppy-heads will ieve the pruritus for awhile, and in some in- nces lotions of tar, and almond emulsion, with 'ax and hydrocyanic acid, are very successful. Erasmus Wilson. PRURITUS (j orurire, to itch). — Synon. : Fr. - '.irit; Ger. Jueken. Definition. — A form of perverted sensation of t skin, and most external parts of the mucous Lnbranes, characterised by itching. Etiology. — This symptom accompanies those s (-diseases which involve the uppermost papil- !• ' layers of the cutis, in which lie the ends of suory nerve-filaments. As a rule, it is absent in t |:e which attack the lower layers, for example, n t syphilitic rashes and leprosy. It may de- p l on any of the following causes : — ) Local irritation from rough clothing, pa- R *s (scabies, pediculi, pityriasis versicolor, * 1: 1 tonsurans and cirdnata), and unhealthy dis- d ges (saccharine urine, leucorrhcea). Perhaps “ winter pruritus of Hutchinson and Duhring, PRURITUS. 126,’ which is clearly in some way due to the local effects of cold, should be placed here. (2) Inflammations of the skin, including all forms of eczema, but especially the papular (lichen), psoriasis in the early stage, and, more rarely, pemphigus. It exists to a slight degree in roseola; and much irritation sometimes fol- lows the pustular rashes caused by croton oil and tartar-emetic ointment. Mucous patches and all forms of papular syphilide, if desquamat- ing, may itch. (3) Beflex irritation from distant organs, such as the uterus and stomach in urticaria, and the kidneys in Bright’s disease. (•1) The presence of certain substances in the blood, such as the bile-acids in jaundice, and copaiba. (5) Undiscovered causes, as in true prurigo and the lichen urticatus, or strophulus, of chil- dren (see Lichen ; Prurigo ; and Strophulus). Kaposi admits a pruritus cutaneus universalis as a true idiopathic neurosis. Symptoms. — Pruritus may be local or general, slight or severe, continuous or intermittent. It is generally most marked at night. It is usual to describe three special local forms. (o) Pruritus genitalium. — This form is chiefly found in women with uterine disease, such as a granular condition of the os uteri, or during preg- nancy, or at the change of life. Diabetes is a frequent cause, and should always be sought for. In men P, scroti ct penis depends on eczema or uncleanliness. Pruritus on and around the pubes should always suggest the presence of pediculi pubis. (/3) Pruritus ani. — This is usually connected, in adults, with piles, eczema, or profuse sweating ; and in children with thread-worms. (y) Pruritus senilis occurs in people at or over sixty, and most often depends on the presence of pedicidi vestimentorum, though in rare instances it seems to be a pure neurosis. Diagnosis. — It is essential to remember that pruritus is most often a symptom of external ir- ritation, and to search for the various causes enumerated above, especially animal parasites. The possible presence of the latter should not be ignored because of the social position of the pa- tient. Treatment. — For general pruritus, if no cause can be found, the two best remedies are tar and sulphur. Tar may be used as a lotion — for in- stance, the following: l)b Liquoris carbonis de- tergentis (Wright’s), ^ss; glvcerini, 5 j ; aquam ad jx. Sulphur maybe employed thus, as a bath : Ijb Potassii sulphidi, 5 iv ; aquae calidse, eong. xxx. Flannel should be removed from im- mediate contact with the skin. Carbolic acid with opium sometimes gives relief in the fol- lowing form : II Tincturas opii, 3 j ; acidi car- bolici, 5 j ; spiritus vinirectificati, 5 vj. Internal remedies, such as potassium bromide, strychnia, conium, and morphia, are of very doubtful value ; sulphate of atropia in 1 milligramme doses has proved effectual in a few cases of obstinate urti- caria. In pruritus genitalium extreme cleanli- ness and a borax lotion are the best remedies : 1)1 Glyeerini boracis 5 ij ; aquam ad 3 vj ; ft. lotio. For pruritus ani, a calomel ointment — such as: Ijl Hydrargyri subchloridi, 3 j ; adipis 1268 PRURITUS, jenzoati, 3 j ; ft. unguentum— is to be recom- mended. See Eczema; Phthiriasis; Scabies; and Urticaria. Edward J. Spares . 1 PRUSSIC ACID, Poisoning by. — Synon. : Fr. Empoisonnement par I'acide cyanhydrique ; Ger. Cyanwasserstoffsaurevergiftung. Prussic or hydrocyanic acid is one of the best known and most deadly of poisons. In the an- hydrous condition it is stated to kill with almost lightning-like rapidity 7 . Prussic acid is met with in commerce only in a diluted state. In this country two strengths of prussic acid are usual, t he Pharmacopceial acid, containing two per cent., and the so-called Scheele’s acid, containing about five per cent., respectively, of anhydrous prussic acid in aqueous solution. The soluble cyanides, more especially cyanide of potassium, largely used by photographers and by electro-platers, are common articles of commerce, and produce the same deadly results as the acid itself. The fatal dose of prussic acid is the equivalent of about one grain of the anhydrous acid. Anatomical Characters. — In persons who have died of prussic acid poisoning the eyes are glistening ; the extremities are blue ; the face is pale or livid ; and the lips are cyanosed. The blood throughout the body has frequently the peculiar odour of the acid, and is of a dull hue, with a peculiar bluish cast — a glimmering appearance. The stomach is sometimes red- dened, but not more than is common after other asphyxial modes of death. Symptoms. — In fatal doses tho symptoms of prussic acid poisoning set in very speedily; and in consequence of the readiness with which this poison is absorbed from the alimentary canal, and diffused throughout the circulation, the on- set of symptoms is reckoned by seconds rather than by minutes. Occasionally the patient may 7 be able to walk into an adjoining room, to com- pose himself in bed, or perform like actions ; but it is rarely that he will have time to dispose of the cup, glass, or bottle, in which the poison was contained before he is taken seriously ill. The symptoms may be divided into three stages. The first stage is very brief, and manifests itself by difficult respiration, slow cardiac action, with a tendency of the heart to stop in diastole, whilst its beats are irregular. There is disturbed cere- bration, and an awe-stricken aspect of counte- nance. This preliminary stage speedily ushers in the second or convulsive stage, the onset of which is occasionally signalised by a piercing shriek, though this is less frequently observed in man than in animals. With widely dilated pupils, the patient is suddenly thrown into violent clonic and tonic convulsions. The respiration is marked by shortness of inspiration, and prolonged efforts at expiration. The countenance becomes cya- notic. Vomiting is commonly observed ; and the urine, faeces, and even semen in the male are spasmodically evacuated. The patient now sinks down, probably in a state of unconsciousness, and with complete loss of muscular power. The convulsive stage speedily passes into the third, or, as it may be termed, asphyxial stage, with slow, gasping, stertorous respiration, extreme col- lapse, lose of pulse, and more or less complete 1 Revised by Dr. Alfred Songster. PSEUDO-HYPERTROPHIC PARALYSIS, paralysis of motion. Tho skin is cold, clammy and cyanosed. Death may be ushered in with irregular spasms. The onset of symptoms being rarely delayed beyond one or two minutes, death may occur within two or three minutes more. Power of volition is rarely continued in fatal cases for more than two minutes after taking the poison. Fifteen minutes is the longest interval which has been known to elapse between the taking of the poison and the commencement of symptoms; and then the patient recovered. Should the patient survive for thirty minutes good hopes may be entertained of recovery. The longest period which is known to have elapsed between the taking of the poison and death was one hour and a quarter. Diagnosis. — - This is rarely difficult. The foudroyant character of the illness, and the usually speedy death of the patient, coupled with the peculiar odour of the acid, and the finding of a cup or glass containing the remnants of the dose, seldom leave any doubt as to the nature of the case. Nitro-benzol poisoning closely simulates prussic acid poisoning, however, except that the onset of symptoms is generally much later in nitro-benzol poisoning than when prussic acid has been taken. Nevertheless, when crude bitter- almond oil, impure from the presence of prus- sic acid, has been swallowed, the close similarity between the odour of the oil and that of nitro- benzol may lead to error. Fortunately, the same treatment may be adopted in both cases. Prognosis. — This in all cases is very doubt- ful ; and no general rules can be laid down. Treatment. — Prompt inhalation of the fumes of ammonia should, if possible, never be neglected. The successive administration of a solution of the mixed per- and proto-salts of iron, followed by an alkaline carbonate, so as to convert the acid into an inert ferrocyanide, has been recommended on purely chemical grounds. There is, however, seldom or never time to admit of this elaborate treatment. A more practicable mode is to treat, the patient with alternate douches of warm (115° Fahr.) and cold water, so as to stimulate the respiratory 7 functions; artificial respiration may also be employed, together with friction ol the limbs. An emetic should be administered Faradaic currents of electricity to the cardiac region should not be neglected. Atropine if not, as has been asserted, a true physiologies antidote to prussic acid ; but, injected subcu| taneously, it may be of use as a respirator stimulant. Spite of all treatment, the patien usually succumbs. T. Stevenson. PSEUDO- (fcvS Jjv, false).— This is used as . prefix to various names of conditions, and signifie that they simulate certain diseases or condition which they really are not; for example, pseudo angina, pseudo-asthma, and pscudo-cytosis. PSEUDOCYESIS ( 1 pevSfjs, false, and mV' pregnancy). A syuonym for spurious pregnane; Sec Pregnancy, Diseases and Disorders of. PSEUDO-HYPERTROPHIC MUSCI LAR PARALYSIS. — Synon.: Lipomto s musculorum, luxurious-, Fr. Paralyste pseud hypertrophique ; Paralysis myosclerosique ; Ge Atrophia musculorum lipomatosa. PSEUDO-HYPERTROPHIC Definition. — This is a progressive muscular paralysis, appearing mostly in boys, in -which the ultimate fibres of the affected, muscles atrophy, j tut the muscles themselves appear to be hyper- .rophied, in consequence of the development of uterstitial fat and fibrous tissue. JEtiology. — Pseudo-hypertrophic muscular paralysis is a disease of boys, very few cases taring been observed in girls or in adults. In a large number of cases it begins in infancy, the .weakness becoming manifest at the time the jchild should begin to walk. In some instances it has been found to be hereditary, several chil- dren in the same family having been affected. .Nothing definite is yet known as to the direct causation of the malady. Anatomical Characters. — In the earlier stages of the malady, the muscles chiefly affected are those of the legs and lower part of the back, particularly the gastrocnemii, the posterior muscles of the thigh, and the erectores spinse. These muscles are enlarged, and they are felt to be firm and hard. This is not, however, due to true hypertrophy, for if a portion of the muscle bo removed during life by the emporte-piece , an instrument constructed by Duchenne for this purpose, the muscular fibres are found to ;’be atrophied, and much of the apparent bulk is seen to be due to an interstitial development of fat and fibrous tissue. Subsequently, the remain- ng muscles of the trunk, upper limbs, am.l sometimes even of the face become similarly af- ected, in most cases these muscles merely wast- ng without any apparent enlargement, but in ither cases the apparent hypertrophy being pre- eut in the upper as well as the lower half of the iody. In the later stages of the disease, the vhole of the voluntary muscles, including those vhich at first were enlarged, become more or ess wasted. The diseased muscles are found fter death to be composed in a great measure of rdinary fat-cells. The true muscular substance as to a considerable extent disappeared, and only few ultimate muscular fibres are seen running t intervals through the fat. Some of these ulti- late fibres retain their normal size and appear- nce ; others are much decreased in size, though ill showing the striation; only a few of the frophied fibres have lost their striation, and ecome granular. The diseased muscles also intain a considerable quantity of fibrous tissue, >me of which is probably the remaining sheaths muscular fibres which have undergone com- pete atrophy. There is less fat and fibrous tissue tho wasted muscles than in those which are leudo-hypertrophic, but the changes in the initi- ate muscular fibres are the same in both. Some doubt still exists as to the pathological :atomy of the spinal cord in this disease. Seve- 1 competent observers, such as Cohnheim and larcot, have failed to find any morbid changes the nervous system. Lockhart Clarke and pwershave, however, discovered important alter- ions in the spinal cord in a case of this disease. ie principal change was extensive disintegra- ® of tIlc Rrey matterat thecentreof each lateral If of the cord, and of the anterior commissure. Pathology. — It has been suggested by Fried- ch and others that pseudo-hypertrophic mus- ar paralysis is essentially the same disease as MUSCULAR PARALYSIS. 1269 progressive muscular atrophy, and this view is probably correct. The two diseases differ in this respect, that the former always begins in the lower limbs, the muscles of which are more exer- cised than the arms in children. The enlarge- ment of the muscles might be explained by sup- posing a compensatory growth in the early stages of the malady in those diseased muscles which have the most important functions ; and the pos- terior muscles of the legs and back have the important duty of keeping the body erect on the legs. It is a fact that the pseudo-hypertrophied muscles retain much greater power than the muscles which are merely atrophied. Symptoms. — The symptoms of a well-marked case of pseudo-hypertrophic muscular paralysis are very striking, and cannot easily be over- looked or mistaken. When the child is stripped, the muscles of the calves are seen to be lar- ger and firmer than natural, and the same apparent hi-pertrophy may be present in the muscles of the thigh, the glutei, the lumbar muscles, and others. Occasionally the muscles of the upper half of the body exhibit a similar increase in size, but much more frequently they are wasted, so that the emaciation of the upper half of the body contrasts strongly with the appa- rent excess of muscular development in thelower half. The next most obvious symptom is pro- tuberance of the belly. There is no abdominal enlargement, but the an tero -posterior curvature of the vertebral column in the lumbar region is much exaggerated, and the shoulders are thrown back. This unnatural curve is not caused by any disease of the vertebrae, for it entirely dis- appears when the patient sits or lies down. When the child stands, the legs are held apart, and the heels raised off the ground. He walks almost on tiptoe, as in talipes equinus, and with a most peculiar gait — a waddle, as if he needed to balance the body first on one leg and then on the other. Walking soon tires him. If he attempts to go fast he falls, and he is very easily knocked over. He can readily stoop so as to touch the floor, but generally has great difficulty in raising himself to the erect posture, using powerful muscular effort, and having to assist the move- ment by means of the hands placed on his knees. When sitting, he can recover himself from the bent position with comparative ease. The electro-contractility of the muscles is unimpaired. The general health of the patient is unaffected until the later stages of the disease. In many cases of pseudo-hypertrophic muscular paralysis there is some deficiency in mental power. Duchenne divides the progress of pseudo- hypertrophic paralysis into three stages: — In the first stage, lasting several months or even one or more years, there is merely weakness of the muscles, causing the peculiarities in the attitude, and in the mode of progression. Little or no enlargement of the muscles has taken place. During this stage proper treatment may bring about recovery. In the second stage the charac- teristic hypertrophy appears, and tho weakness extends to the muscles of the upper limbs. This stage may last for years. In the third stage complete paralysis of most of the muscles of the upper and lower limbs and of the trunk super- venes. The patient lies helpless, unable to change 1270 PSEUDO-HYPERTROPHIC PARALYSIS. PSOAS ABSCESS. his position. All the muscles, even those which were formerly hypertrophied, pass into a state of atrophy. The sufferer may live in this weak state until carried off by some intercurrent disease. Diagnosis. — Pseudo-hypertrophic muscular paralysis has such peculiar and well-marked characters that it cannot easily be mistaken. It is readily distinguished from the various forms of spinal paralysis by the evident enlargement and unusual firmness of the paralysed muscles of the lower limbs. From spinal curvature, depending on disease of the vertebral column, it differs in this respect, that the curve of the spine which is present in pseudo-hypertrophic paralysis disappears when the patient sits or lies down. Peognosis. — The prognosis is most unfavour- able. Teeatment. — This is only available in the first stage, before the hypertrophic symptoms are marked. Duchenne recommends localised fara- dization and shampooing, and he records two cases which were cured by these means. The writer has seen one case which had entered on the second stage, in which this treatment has completely checked the progress of the malady, and even brought about considerable improve- ment in the strength of the lower limbs. It is probable that the continuous current might prove useful. General tonic treatment is undoubtedly beneficial, but no medicinal remedies are known to have any special control over the disease. Alexander Davidson. PSOAS ABSCESS.— Synon.: Fr. Abcesdu Psoas ; Ger. Psoas abscess. Definition. — A variety of spinal abscess, formed by a collection of pus, confined by the fascial sheath of the psoas magnus muscle ; conducted by it beneath Poupart’s ligament ; and pointing in the thigh, in Scarpa’s space, ex- ternal to the femoral vessels. Such is the ordinary course taken by the pus in psoas abscess, although it is liable to a good many modifications. Thus, the matter may be arrested just above Poupart’s ligament, and the abscess occupy the venter ilii ; it may make its way into the inguinal canal, and out at the external ring, and simulate a hernia; or, again, it may point above Poupart's ligament, but in this instance the abdominal muscles and fasciae must have been perforated by ulceration. No real difference exists between the causes of lum- bar abscess and psoas abscess ; it is rather a question of degree, and of the position of the ulceration, and tho initial terms may be re- garded as topographical only. ^Etiology. — Psoas abscess is rarely met with before puberty, generally between that period and five-and-thirty years of age ; and would seem to be more common in males than in females. As a result of spinal caries the abscess is more liable to be of the psoas form, if the patient, during the early stages of the disease, has been able to get about. Anatomical Chaeactees. — Psoas abscess is generally a result of tuberculous osteitis, com- mencing on the anterior surface, and anterior portion of the cancellous tissue, or in the fibro- cartilages, of the lower dorsal or upper lumbar vertebra.* (see Spine, Diseases of). It may follow injury, however; and, moreover, may exist inde- pendently of diseased bone. The morbid process is one of ulceration and of suppuration. Tho tissues surrounding the affected parts become thickened, and confine the pus; whilst, from its sinking down, and from the j spreading of the ulceration, the abscess grows in bulk. More rarely, acute inflammation may occur in the substance of, or immediately be- j neath, the fascia covering the psoas muscle, as in psoitis and peripsoitis. The pus of the spinal abscess, having gained I the abdominal side of the diaphragm, passes into the body of one or other, or of both, psoas muscles ; arrives at Poupart’s ligament ; and i commences its downward course, this point be- ing called the ‘neck ’ of the abscess. When once it has passed this point it increases rapidly in size, its appearance being preceded by a bulging in the fold of the groin. Its subsequent course is inwards and downwards, following the line of the inner edge of the sartorius. It may, how- ever, lie over the adductors ; or may pass entire!' outwards ; the direction straight downwards is rare. Cases have been met with where it his i divided at the groin; where the matter passed the knee-joint, and pointedat thetendoAchillis; and where it has passed along the course of the | profunda femoris vessels. Sometimes the abscess does not pass beneath the crural arch, but by its expansion forms a well- ; defined globular tumour in the iliac fossa. In , other cases, the pus may find its way into the, inguinal caral ; into the intestine ; or, as is the case in children frequently, over the crest of the ilium, pointing in the buttock. Symptoms. — The earliest symptoms preceding psoas abscess are generally not well-marked. There is gradual weakness, loss of flesh, a pallid, complexion, and loss of appetite. Later on the limb becomes affected ; limping occurs during or after walking; and the action of the psoas muscle I becomes impaired. Subsequently a soreness, hardly amounting to severe pain, is experienced in the spine or in front of the thigh, aggravated by pressure ; or a swelling may appear in the lumbar region, since this particular abscess is merely a form of lumbar. The peculiar symp- tom of psoas abscess is essentially a fluctuating swelling benoath and extending below Poupart's ligament ; generally pointing external to the great vessels ; receiving an impulse on cough- ing; and disappearing, or partially disappearing, on the patient's assuming the recumbent psi- tion. It must, however, be remembered that the pus may travel along other channels, or may encroach upon other fascial sheaths than its usual one. Yet its persistence at its ‘neck’ will materially assist in its physical diagnosis. The contents of a psoas abscess are pus and tubercular matter, intermixed with flakes o( lymph, and particles of bone and fibro cartilsge. Diagnosis. — The chief point of difficulty id the diagnosis of psoas abscess is that of distin- guishing it from iliac or caeeal abscess. In the early stages it is always associated with spma. misehief in young subjects. It points below Poupart's ligament ; there is an inclination n! PSOAS ABSCESS. the trunk forwards, and some disturbance of the functions of the psoas ; and pain in walking is complained of. Iliac abscess arises in the loose areolar tissue of the iliac fossa, and in some cases may actually get into the sheath of the psoas. Sometimes the caries commencing in the lower lumbar vertebra may spread laterally, and rise above the crest of the ilium; and the pus, being discharged backwards, may appear to have com- menced with hip-joint disease, as the movements of this joint are impaired. It is important in such cases to place the patient under an anaesthe- tic, and make a most careful examination. Again, psoas abscess usually makes its ap- pearance in the groin very suddenly, owing to the giving way of some confining tissue. Medullary cancer may simulate psoas abscess ; particularly if the disease has invaded the spine, and caused a curvature of the lumbar vertebra. Aneurismal tumours, or blood which has escaped by the rupture of such tumours, may bo mis- taken for the disease, and particularly when such extravasation has found its way into the sheath of the psoas, and is non-pulsatile. Prognosis. — As a rule the prognosis of psoas abscess cannot be considered favourable. It is an advanced symptom of strumous dyserasia ; it rarely gets well of itself; it frequently impairs the functions of the spinal cord ; and it may terminate fatally by hectic or lesion of the lungs or bowels. Treatment. — The best method of treatment of psoas abscess is that adopted by Lister, of opening it by free incision antiseptically ; in- serting an adequate drainage-tube ; and dressing it with scrupulous care from first to last ( sec Antiseptic Treatment). The abscess may, however, open spontaneously, and no bad re- sults follow ; and, with great care, and the use • of the prone couch, the patient may recover. Good diet, cod-liver oil, iodides, and tonics ap- pear to be the most suitable internal remedies. Edward Bellamy. PSORIASIS I rub). — S ynon. : Fr. and Ger. Psoriasis. — This word expresses the effort to relieve itching ; hence the word psora, applied to the disease eczema by the Greeks, but in modern pathology restricted to scabies. The term has been adopted by the French and Ger- mans as the equivalent of the lepra of Willan, and is at present generally used in that sense. See Lepra. PSYCHOSIS. See Sycosis. PSYDRACIUM (dim. of ^uSpaues, blis- ters).— A small blister, or pustule, without in- flammatory base ; a cold pustule, in contradis- tinction to pblyzacium, or hot pustule. PTOMAINES. See Appendix. PTOSIS ( irrutris , a fall). — A drooping or falling of the upper eyelid, with inability to raise it, due to paralysis of the third cranial nerve. See Third Nerve, Diseases of. PTYALISM (tttuoAof, saliva).— A synonym for salivation, or excessive flow of saliva. See iiUYARY Secretion, Disorders of. PUBERTY, DISORDERS OF. 1271 PUBERTY, Disorders of. — Synon.; Fr. Troubles de la Puberte; Ger. Storungen det Pubert'dt. Of the various periods into which existence is divisible, certainly not tbe least important, in its pathological aspect, is that intervening between childhood and maturity, when the re- productive powers become developed, and which is known as Puberty. This epoch occurs earlier in warm climates, sanguine temperaments, and highly cultivated and luxurious states of society ; it is retarded by the opposite conditions ; and in these islands it generally commences between the ages of thirteen and fifteen in females, and a year later in males. Under the age of fourteen, a male is legally sup- posed incapable of committing a rape; and a female under twelve is deemed incapable of con- senting to sexual intercourse. By the Roman law, the period of the commencement of puberty was identical with that at which the individual became liable to military duty. Thus Adrian commenced his service at the age of fifteen. Puberty cannot, however, be estimated by age alone. Even in this climate, the period of the commencement of puberty varies widely ; thus the writer has seen instances of menstruation in children under ten, and has assisted at the de- livery of a girl of fourteen years of age. More frequently, however, puberty is postponed beyond the ordinary period, which may be also modified by family or hereditary peculiarities, and the influence of various diseases. In the first stages of life, the functional dif- ferences between the sexes are comparatively slightly marked ; but on the approach of puberty these suddenly become prominent, and so obvious does the influence of the uterine system become, that propter uterum est mulier is then almost literally the case. The accession of puberty in the male is at- tended by a characteristic alteration of the voice, from ‘the thin childish treble’ to ‘the deep manly bass,’ owing to the development of the pomurn Adami, and the elongation of the thyroid cartilage and thyro-arytaenoid muscle. About the same time occurs the growth of hair on the skin on various parts of the body. Before this there are observed the development of the male genital organs, the enlargement of the testes and other parts of the sexual apparatus, the se- cretion of the seminal and other accessory fluids, and the first outburst of the sexual instincts and feelings. So slowly do the successive changes, which mark the occurrence of puberty in the male, proceed, that they are not completed until full age has been passed. In the female, on the contrary, when puberty is reached, the individual passes at a bound, as it were, from childhood to womanhood, although the structural and functional changes involved in the transition are infinitely more complex and important than is the case in the other sex. Thus the enlargement of the external genital organs is accompanied with a still greater change of the internal organs of generation — the development of the uterus, ovaries, and mammae, and the commencement of that periodic sanguineous discharge per vaginam, the recurrence of which at regular monthly intervals marks the reriod 1272 PUBERTY, DISORDERS OF. within which woman is capable of reproduc- tion. The writer has found it less easy to discover the truedate of first menstruation than have some authorities whose tables are generally relied upon. In the great majority of cases the state- ments of those he questioned were so indefinite as to be practically valueless, and in only 497 instances did the writer get even any approach to accurate data on this point. Excluding all cases of so-called infantile menstruation, the re- sults of these inquiries may be thus summarised, the mean age being 15 : — Under 12 . . 4 menstruated for first time. At 12 . . 17 „ „ »> 13 . . >i ii ii a >> 14 . . 94 ii 11 fi ii ii 15 . . 1^8 „ „ „ „ ii 16 . . 10^ ii n a ii 17 - - 65 ii ii ii 11 ii 18 . . 10 ii ii ii ii Upwards of 18 1^ ii ii 11 ii Generally speaking, therefore, between the ages of thirteen and fifteen in our climate, the human female undergoes the change from child- hood to puberty ; the essential characteristic of this change consisting in a periodic sanguineous discharge, per vaginam, resulting from ovulation. The process of menstruation, from its commence- ment in ovarian congestion, resulting in the dis- charge of an ovum, its transmission along the Fallopian tube, its transit through the congested uterus, its expulsion thence, together with the disintegrated endo-uterine mucous membrane, and the consequent haemorrhagic discharge from the denuded uterus, is invariably productive of more or less goneral constitutional disturbance and mental irritation, so that no woman can be properly said to enjoy the mens Sana in corpore sano whilst menstruating. When this function lias become regularly established, the accompany- ing constitutional disturbance may be so slight as to bo practically unrecognisable. But on the first occurrence of ovulation, few, if any, escape somo sympathetic constitutional derangement, and more especially some one or other of the pro- tean forms of hysteria. Hence, under the guise of nearly every disease that may affect a girl at the age of puberty, whether it be spinal, cardiac, pulmonary, or any other disorder, the practi- tioner must look carefully that he has not to deal with some variety of hysteria, directly resulting from the complex process by which puberty is accompanied. Undue importance is attached to the non-ap- pearance of menstruation, as the supposed cause of all the ills that female flesh is heir to. In the majority of cases of delayed menstruation the amenorrhcea is the result of constitutional disease, to the rational treatment of which, and not to any utero-ovarian stimulation, should the efforts of the physician be directed. At the same time, the part played by the development of the reproductive system in the transformation scene from childhood to maturity, is unquestionably of the first importance. The morbid influence of the premature indulgence of the newly- awakened sexual appetites at the age of puberty, Mid tho many forms of disease by which the vice of masturbation is aveDged by outraged nature, are subjects the medical importance of which it would be difficult to exaggerate, and which it would he impossible to discuss in this article. Many of the ailments common about the period of puberty, are but accompaniments or fore- runners of tho functional and organic changes then commencing. More especially is this the case in the female sex. Hence the physician must bear in mind that the headaches, palpita- tions, symptoms of disordered nervous action, and many of the cases of haemorrhage from various organs which create so much alarm, are, as Sir Henry Holland long since observed, but evidences of ‘new balances struck in the allotment of the blood to different parts ; and in the course of such changes, congestions and discharges are prone to occur, the latter relieving or preventing tho former.’ It is hardly necessary to point out the necessity for careful diagnosis between symp- toms thus caused, and the evidences of actual disease ; for in the former, the active treatment required by the latter would be not only un- necessary, but positively injurious, by interfering with the progress of those natural functional or organic changes on the establishment of which these symptoms will cease. The circulation is now vigorous ; not only is the amount of blood in circulation greater during this period, but also its relative proportions of fibrin and red corpuscles are larger, and hence the roseate hues and plump outlines of early youth. It is sin-prising how well young persons at this period bear haemorrhagic discharges, with which the experienced physician will he slow to inter- fere, lest by their arrest he may bring on more serious consequences. Many of those cases of haemoptysis which excite so much alarm, as sup- posed evidences of pulmonary disease, and the subsidence of which is ascribed to the particular treatment adopted, as well r.s most cases of haematemesis occurring in girls about this epoch, aro merely symptomatic of the changes conse- quent on puberty, and require little or nothing in the way of repressive treatment. There are few practical subjects more neglected by physicians than the moral hygienic and phy- sical management of puberty. The effect of the evolution of puberty, as the occasional exciting cause of insanity, has been briefly alluded to by Dr. Maudsley and some other writers on mental disease. The influence of over mental stimulation during puberty, as an occasion of the increased proportion of nervous and cerebral disorders, is a subject of the greatest importance. At this period of life the present cramming system of education predisposes to insanity, the organ of the mind being goaded into premature activity, and overstrained in the effort to pass some com- petitive or other examination, deemed essential to entrance on official, commercial, or profes- sional life. Thus the mental powers are worn out and exhausted before they have attained their perfection. In another respect the modern system is hurtful to the mind; for now-a-days, when education is too often divested of that moral restraint and control formerly held to be essen- tial, ‘it proves injurious,’ as Dr. Copeland says. - not only in the way thus stated, but in giving rise to forced, unnatural, overreaching ambitions PUBERTY, DISORDERS OF. and unprincipled states of society; and these states, in proportion as they are developed, are the parents of crime, insanity, and suicide.’ Thomas More Madden. PUBLIC HEALTH. — In all civilised tountries laws are made with the intention of removing conditions which injure the health of the people. In the United Kingdom these laws are now very numerous, and almost every year new statutes regulating public healthare enacted. The general fault of the laws in this country has been their tentative and permissive character; powers are not infrequently given which there is no obligation to use, and which are therefore not used, and the wording of the Acts has sometimes permitted evasion. It may be believed that certain ambiguities of expression in the Acts were avoidable, but that they have arisen from the difficulty of determining the proper limits of the action of the State, i.e. to what point it is right to inter- fere with private property, with private enter- prise, and with individual responsibilities. These are difficult questions, for though it is undoubted that the community, as a body, has a just power of setting aside the rights of indi- viduals when necessary for the benefit of all its members ; yet it is obvious that such power must be exercised with great discretion, lest the right to property, and the incentive to labour and to self-improvement, should be endangered. Still it cannot be doubted that our sanitary laws have been influenced by an unnecessary timidity, and have been too much hampered by opposing opinions respecting the proper limits of these powers and rights. There are some writers who question whether the State has any right to interfere with individual action; but to this it seems answer enough to say that a community is, after all, nothing but a collection of individuals, whose united action is merely the individual action combined; that such union, as represented by the majority, is a necessity for the security of life and property, and in those cases is always enforced, and that there can be no reason why this combined action should not also regulate the important conditions of public health as well as ithe relations of property and the conduct of indi- viduals. Practically, also, there are conditions affecting the health of its menibers with which the community at large alone can deal, and with which, therefore, it ought to deal. It can also be ishown that this common action has already been productive of the greatest good in several cases, and is absolutely necessary in order to counter- act the ignorance, carelessness, selfishness, and avarice of men. Although there are many old statutes, and also provisions in the common law of England affeet- ng the public health, the sanitary legislation of England may be said to date from the passing of the Public Health Act of 1848 (11 and 12 Viet. '. 63). That Act was followed between 1855 ind 1872 by a variety of public Acts having unitary objects, besides others of local applica- ion. These public Acts have been now consoli- dated in the great Act of 1875 (38 and 39 Viet. . 55), an Act for consolidating and amending the Acts relating to public health in England. This PUBLIC HEALTH. 1273 Act is cited as the Public Health Act, 1875. It does not apply to Scotland or Ireland, which have their own Health Acts, nor to the Metropolis where former Kuisance Removal and Sanitary Acts continue in force. This statute repeals (except as regards the Metropolis and Scotland and Ireland in certain eases) no less than nine- teen Acts, 1 and affects sixteen others. It has not only consolidated but has improved the law, and in several cases has given increased powers to local sanitary authorities. In addition to this Act two others of impor- tance were passed in the session of 1875: the Artisans and Labourers’ Dwellings Improvement Act, 1875, which applies only to the Metropolis and to urban districts in England and Ireland having a population, according to the last census, of 25,000 and upwards. It gives powers to clear unhealthy areas, and to superintend and regu- late the rebuilding on such areas. It is likely to prove a very important Act, and doubtless will in time be followed by a statute dealing with smaller populations. In the same session an Act entitled ‘ An Act to repeal the Adulteration of Food Acts, and to make better provision for the Sale of Food and Drugs in a pure state’ (38 and 39 Viet. c. 63) — short title, ‘Sale of Food and Drugs Act’ — was passed. It repeals entirely or partially four Acts, and provides for the appointment of public analysts, and for the purchase and examination of food and drugs. [More recent Acts are (a) The Rivers Pollu- tion Prevention Act of 1876, to which reference will be made in the course of the present article ; (5) The Contagious Diseases (Animals) Act, of 1878, which confers certain powers for the pro- per keeping of cows and for the protection of milk against injurious influences ; and (c) the ‘ Pub- lic Health ("Water) Act’ of 1878, enabling rural sanitary authorities to require the provision of sufficient water-supply. In intention, at least, these Acts fill some serious gaps in the sanitary legislation of the country.] In the following article a general outline is given of the subject of Public Health. It is, of course, impossible to fill up the details, which require special works for almost every heading. But the outline will show the points which are especially deserving of attention, and which have to be considered both in legislation and in the practical performance of the duties of medi- cal officers of health. Condition of Open Lands , Forests, and Fivers. The drainage of land, so as to carry off water readily and thus to make both ground and air drier, has a great effect on public health. Ague, so common formerly in England, has greatly lessened, and dysentery, which so often went with it, has almost disappeared, in consequence of drainage. The movements of the ground-water which, by its rises and falls, influences the moisture 1 The only Sanitary Acts of previous sessions remain- ing unrepealed are the Bakehouses Regulations Act, the Baths and Washhouses Acts, the Labouring Classes Lodging Houses Acts, and the Artisans’ and Labourers’ Dwellings Act, 1SG8. PUBLIC HEALTH. 1274 and the amount of air in the soil, and, through these conditions, alters the amount and rapidity of decomposition therein, has been supposed also to influence health, and to be especially con- nected "with the development of typhoid fever and of cholera. A moist ground is also believed, on tolerably strong evidence, to be favourable to the production of destructive lung-diseases ; and there is no doubt that rheumatism and catarrhal affections are more common on damp soils. Although the influence of the ground-water in cholera is questionable, and it is not always active in the production of typhoid fever, it is certain that lowering the level of the ground-water when it is near the surface is often followed by the best results on the general health of the people, and in hot countries malarious diseases have been greatly diminished, even when the lowering of the ground-water has not exceeded a few inches. Land-drainage operations, as they influence public health, might therefore be undertaken by the State, but, practically, they have been carried on in this country by private and local enterprise, aided of late years by state loans on moderate terms of interest and repayment. In India this question of land drainage is of press- ing importance in water-logged and malarious districts, and it is one which in that country must eventually be met by the State, though its magnitude and cost will probably cause the question to be deferred as long as possible. The regulation of irrigation operations also may become an important matter of State con- trol if sewage irrigation farms increase in num- ber. These farms should not be situated near to houses (not within five hundred yards if pos- sible), and the lands should be properly prepared and drained so that there is no stagnancy of the water. If properly arranged it seems clear that sewage irrigation is not hurtful to the public health. Rice-field irrigation is more difficult to manago, as the water must rest longer on the ground, and underground drainage is less rapid. Rice fields, then, should be situated at a greater distance from houses. Up to the present time no law in England deals with the subject of land drainage in refer- ence especially to public health, for the Land Drainage Act of 1861 (24 and 25 Viet. c. 133) refers only to agricultural purposes. The regulation of forests ought to be con- sidered a state matter, as the climate of a country and, therefore, health are greatly in- fluenced by them. The removal of forests pro- duces a variety of direct effects. Greater movement of air over the earth is permitted : the soil is rendered hotter in all temperate and hot countries, colder in northern lands ; the air is drier everywhere, because the rainfall is lessened, the ground is drier, and the evapo- ration from leaves is lessened ; the ground is drier, because there is not only less rain but freer evaporation, and the roots of the trees no longer obstruct the movement of the ground- water, which flows off more rapidly. These direct effects have a varying sanitary signi- ficance, according to circumstances : for example, increased movement of air may be injurious, if malarious air be no longer kept away from a town, as is supposed to be the case with the Roman Campagna ; again, in hilly countries where the trees have been too much cleared off, there occurs aridity of soil as a rule, and greater rapidity in the amount of water passing into rivers during rains, and thus leading to floods. In this island the regulation of forests is not a matter of much national importance ; it is otherwise in Germany and France, where laws exist which restrain private action ; and in Italy, Greece, and Turkey the condition of the forests requires grave consideration as a matter of public health, as well as of climate and rain- fall. In India this is also the case, and there are several important sanitary aspects under which the operations of the Forest Department need to bo regarded. The regulations of rivers, such as the embank- ments, narrowings, deepenings, and removal of obstructions, have generally been concerned with little else than navigation or the prevention oi accumulations ; but they are equally important as they may influence the outflow of the land- water from their drainage areas, and in that way may affect the dryness of the soil. In this regard the condition of all watercourses is a matter of importance, and seems obviously a case for state control. It is not, however, usually included in the subjects of public health, and when any large watercourse is out of order, and inundations from the river or from the sea are dreaded, the Crown usually appoints, on the application of the proprietors of the adjoining lands, a Commission of Sewers, under the above Land Drainage Act, to consider what should be done. In another way the regulation of rivers is of importance. They supply the drinking-water of the community to a large extent, and freedom from contamination is, therefore, necessary. At present this is one of the most difficult questions of public health, and for some years a Eoyal Commission was engaged in enquiring into the causes and remedies of the pollution of rivers. The chief causes of contamination are the dirty water and sewage coming from towns, and the re- fuse of trade operations. The former can he best met by irrigation or by filtration through land, though the immense quantity of water to be purified, and the price or position of land, may cause difficulty. The admixture of trade refuse water presents, however, the greatest difficulty; to prohibit the flow into streams would some- times be to prohibit the trade works. 1 At pre- sent there is no settled standard of purity for either town or trifle water before its discharge into streams, and it is probable that the standard must vary with the place and trade, and most depend on the composition of the water as originally supplied, and the relation between its amount and the body of water into which it is discharged. Under the Public Health Act of 1S75 (clauses 6S and 69) a Sanitary Authority can protect any watercourse within its juris- diction from pollution with gas or with sewage, hut not from pollution by trade refuse. On the other hand, an Authority can be indicted by 1 A Government Bill brought in in the session of IS. 5 had to be withdrawn in consequence of the Urge interest* involved and in opposition to it. PUBLIC HEALTH. landowners or others for creating a nuisance or for inj uring the quality of the -water by dis- sharging sewage into a stream. In certain cases, as of the rivers Thames and Lea, special Acts restrain the pouring of sewage into them. It may be said on the whole that legislation with respect to pollution of rivers is at present hesitating, but that its general tendency is gradually to make the rules for preserving the purity of river water more and more stringent. [The Act of 1876 forbids putting into a stream or inland water — (1) any solid refuse of any manufactory, or any rubbish or cinders ; (2) any sewage, unless the best practicable means has been taken to render it harmless ; (3) any polluting liquid from any factory, unless it have been similarly made harmless. Proceed- ings under this Act can only be taken with the assent of the Local Government Board, who are to have regard to the industrial interests in- volved.] Conditions of Habitations. — In the case of a town of any size, the community is represented by the municipality or by a Board of Health or local Commissioners. In the case of country parts and villages that have no such special body, the Poor Law Guardians are cle facto the sani- tary authority. In the language of the Public Health Acts of 1872 and 1875, the former are I the Urban, and the latter the Kural Sanitary Authorities. Of conditions operative upon the health of i the individual and of the community, the one that fulls most conspicuously within the pro- vince of these public Sanitary Authorities, as of the Legislature which created them, is the condition under which people have their dwell- ing — the state and circumstances of their habi- tation, both in the particular and in the aggre- gate. So true is this, and so strongly is this consideration felt in practice, that it will be convenient to arrange the various subject- matters of the present article with the notion of condition of habitation in the foreground ; and to regard each subject as it principally con- cerns communities inhabiting a larger or smaller place, or as it concerns the particular habi- tation. Thus the general subject of public health will, with little exception, be here dis- j cussed under the three following divisions : — • I. Collections of houses forming cities and towns, that is, populations over two thousand porsons! II. Villages, that is, collections of houses, with populations of, or under, two thousand persons. TH. Separate houses. I. Cities and Towns. — The health of the in- habitants of English towns, as judged of by the annual rate of mortality, is not so good as that of the people of rural districts. The mean an- nual mortality differs in different towns from 20 or 21 to 35 and 36 per 1,000'of population, while during certain periods it may be much more. In rural districts the mortality is from 12 to 23 or 21 per 1,000. The causes of the difference are 1 There is no official definition of what constitutes a lovn or village, but the above is practically the best that xui be adopted. 127c various : in towns there is greater crowding, more of complete destitution, a higher degree of impurity in the air of the houses, a greater prevalence of infectious diseases, and greater exposure in unhealthy trades. The urban in- habitants are also on the whole more intem- perate, are less vigorous in frame, and have less active exercise in the open air than the rural population. In towns, however, it is especially the mortality of children under five years old which swells the death-rate, owing to the bad food and nurture, and the exposure to impure air of the children of the poor. In all cities there are districts, inhabited by wealthy people, where the mortality will bear comparison with healthy country places. It ought to be possible, there- fore, to raise the health of the inhabitants generally towards the standard of these favoured parts ; and the object of the local government should be, by thought and contrivance, to over- come, as far as may be, the difficulties that poverty puts in the way of health. Hygienic Conditions of Cities. — These are con ditions referable to : — - 1. The site and soil. 2. The arrangement and building of houses. 3. The water-supply. 4. The removal of refuse water and of dry refuse. 5. The removal of excreta. 6. The conservancy of the surface. 7. The supply of food, including the regu- lation of slaughterhouses and bakehouses. 8. The regulation of trades. 9. The arrest of infectious diseases. 10. The disposal of the dead. 1 1 . The supervision of nuisances. (1) The Site and Soil. — The sites of old cities were fixed by reason of war or commerce, or of vicinity to water-supply; when modern cities arise it is often in consequence of new indus- tries being developed, coal and iron, or cotton, or woollen works, and the site is determined by convenience of trade. In England new towns and villages spring up without regulation, and when they attain a certain size and some sort of municipal government is formed, it is often too late to attend to arrangement and construc- tion of houses and to proper preparation of the ground. It were to be desired that the Legislature should obtain for towns during their period of growth and extension, adequate atten- tion to such matters. In the case of old towns Local Improvement or Health Acts are often obtained, by which the errors of by-gone times are slowly and laboriously removed. In respect of the site it is necessary to dry the ground if it is at all damp, and to keep it from being contaminated by refuse and perme- ation of coal-gas. It is one of the advantages of sewering towns that the ground is thereby drained, and many sewers are now laid so as to facilitate the movement of the ground water as well as to serve as channels for house waters. For this reason alone every town ought to have either a system of sewers or deep drainage of some kind. There should be no cesspits or middens, or manure heaps, in uncemented holes ; every refuse of this kind ought to be removed and never allowed to soak into the ground. The PUBLIC HEALTH. 1276 ground ought in fact to be secured against every source of contamination. Paving of all streets and courts, so as to prevent surface impurities from soaking in, and great care in the construction of the public sewers, so that they may allow of no outflow, will keep the soil of a city free from those impurities which, under the influence of heat, water, and air, generate injurious effluvia that may be sucked into houses. It is neces- sary also to have rules about ‘ made ground.’ In- equalities in the surface of the ground are often levelled by filling in with refuse of all kinds; house and chemical refuse, and dredgings from rivers, with other rubbish, are sometimes used. Decomposition goes on in such soils, and even- tually, if not too foul, they purify themselves, but for this time is required. In the ‘ cinder refuse ’ of Liverpool, which is tolerably free from impurities, at least three years are re- quired for the disappearance of the more easily decomposed animal and vegetable matters. In other made soils it may be longer, and when soil is very impure, as in the case of old graveyards, it is uncertain how long it is before it would be safe to build upon it. Every made soil should be well drained, so that air and water may freely pass through it, and the best should have been laid down from two to four years before being built upon. The permeation of coal-gas from pipes is a point to be guarded against, and the ease of preventing this would be much increased by the use of subways, the objections against which are more theoretical than practical. With respect to the means of covering the sides of city streets for foot passengers good stone paving is essential; it not only hinders the evolution of effluvia from the ground, but it greatly increases the ease of cleaning the surface. In many Acts full powers are given for this ptirpose. (Public Health Act 1875, clauses 149- 150, and 42.) The question of the best kind of road for horse and carriage traffic is not quite so easily settled; there are four principal plans; maca- damizing, granite blocks, wood, and asphalte. As a mere matter of health the two last are preferable; there is less debris, greater ease of cleaning, and less noise. Both macadamizing and granite block roads soon get worn into fine mud, which is made up of finely comminuted stone mixed with droppings from horses, and the like. In wet weather this is washed into the sewers, which it aids in obstructing, and it forms a useless part of the sewage. In dry weather it becomes pulverised ; floats in the air and is one of the ingredients of city air, from which it is deposited as dust. Wood and asphalte break up much more slowly and are more easily cleaned both by rain and by washing. (2) The arrangement and building of houses. The arrangement of houses and streets in towns is influenced by many circumstances. A good return for money, facility of locomotion, and beauty are the chief considerations in new towns. In old cities questions of defence and of ma- terials have especially regulated the size and direction of t heir streets, and the height and com- pression of their houses. Many considerations will always influence the formation of streets, but a free passage of air to all parts of a town is a cardinal point, which should receive the utmost attention. The more numerous and the wider the streets are, the less impeded will be the air-flow ; in no case should a street be less in width than one and a-half times the height of a house. 1 There should be open spaces at the back of the houses, and all back-to-back building should be illegal. The erection of narrow lanes and alleys should be prohibited in all new towns, and the back courts so common in our older towns ought to be gradually removed. Additional open spaces should be provided at intervals ; and streets should be so arranged as not to form stagnant wells of air between the houses. Wide straight streets are useful for ventilation, and are best for the laying of pipes and tramways. Straight lines are by some not considered beau- tiful, but they are certainly most convenient. In all these points the law gave some power both in the Public Health Act of 1848 and in some later Acts, which granted permissive powers to sanitary authorities to purchase dwellings in order to improve streets, to set back houses when rebuilt, &c. These powers are continued in the Public Health Act of 1875, clauses 149-160. As regards existing towns power is given to urban authorities to make bye-laws regulating the width of new streets, provision for sewer- age, foundation of houses, spaces for air about houses, the drainage of buildings, and other points. So also a new provision in this Act orders that when only the front of a house in a street is taken down the urban authority may prescribe the line of the new building. Local Improvement Acts have also been obtained by some cities, giving larger powers of demolition and reconstruction, and the Artisans' Dwellings Act of 1875 strengthens these. As much, however, is left to local authorities in these matters, there will probably be no uniformity of action, and it seems important to make very stringent general rules on all these points. Moreover, as already said, due provision should be made beforehand for the proper construction of the many new towns which must needs spring up in the course of another century. The case seems clear for the community' at large to regulate matters so important for the general health, to a greater degree than has been yet done in any Act. 2 It is not possible to state with any precision the number of persons who may be located on an acre. This will depend in the main on the con- struction of the individual houses : but it may he laid down as a general rule that whatever be the size of the houses, the amount of ground not occu- pied by them in any given area should be con- 1 In some local Acts the width cf a street is fixed at the height of a house, but this is tco small. 5 As an instance of the necessity of this state inter- ference, the case of Liverpool may be cited. More than 70 years ago the Corporation was warned by the medical practitioners of Liverpool, that the houses then being erected, and their arrangement, must prove unhealthy dwellings. No regard was paid to this, and now Liver- pool will have to undo, at enormous cost, what might at the time have been put a stop to with ease. A P a P? 2 f/ Dr. Bussell, of Glasgow, in Public Health, March le <5, exemplifies the same thing in a most striding manner, b» the case of Glasgow. PUBLIC HEALTH. jiderably in excess of the amount actually taken np by houses. An important point to determine is the height of the houses. In England a large proportion of our towns consists of low brick houses; if these are not too crowded they give a good dis- tribution of the inhabitants and oppose little obstacle to the movement of air. When the houses are very lofty the air-currents must be much more impeded, and therefore the streets ought to be much wider, and open spaces here and. there more carefully provided. The con- struction of the separate houses cannot be altogether a matter of municipal control, but certain rules as to ground plan, foundations, and arrangement of closets, and the thickness of party walls, are in most towns enforced in respect of new houses. So in all houses, whether urban or rural, there should be means of ventilation for every room ; no inhabited room should have a borrowed light, but should have a window opening directly on the external air ; every window should open, and especially at the top ; every room should be of good height, not less than nine feet in the smallest, and ten and eleven feet in larger rooms ; the closets ought to be arranged in such a manner that, in addition to ventilation of the closet itself, there should be thorough cross ven- tilation into the open air between the closet and the rest of the house, and this is best accom- plished by having projecting portions of the building to contain the closets ; every house should be properly provided with closets in pro- portion to its population ; there should be proper water-supply, with easily inspected storage, if house-storage is permitted, and easy methods of carrying off the dirty house-water ; there should be proper arrangements for the collection and temporary storage of dry house refuse ; and house drains and pipes should be constructed and ventilated on tho principles that will pre- sently be set forth. All these matters are easy to regulate without interfering too much with the plans of the archi- tect, and have, in fact, been more or less dealt with in several Acts. In places with urban powers, indeed, bye-laws under the Public Health Act can be made to regulate the majo- rity of such points. (3) The Water-supply. In a town with sewers and water-closets it is generally considered that the supply of water per head daily should not be less than 25 gallons ; and if there are trades using large quantiti es of water, from five to ten gallons additional (reckoned per head of popula- tion) are wanted for the town. If there are no water-closets, from 14- to 20 gallons per head daily appears to be the amount usually consi- dered sufficient in large English towns. Many Acts, public and local, regulate water- supply. The sanitary Authorities of any place have had large permissive powers (under previous Acts, and now under the Public Health Act of 1875, clauses 51-07) as to constructing, or buying and maintaining waterworks, and building and eleansiDg public cisterns, fountains, &c., and powers are given also to protect watercourses or watersheds whence the supply is derived. The 1277 Public Health Act of 1875 has also increased, in some ways, the powers of the local authority, and in certain cases the powers of the Public Health (Water) Act of 1878 can be exercised in towns. In local Acts powers are also given to ensure proper fittings in houses, to carry out constant service, and other points of the kind. The following are the matters of chief im- portance in towns : — (a) The supply should be taken from sources capable of affording a quantity adequate to the present and proximate wants of the town, with such approach to constancy as may be attainable. In quality, 1 the great points are to ensure that the water is clear or is easily and completely freed from sediment by sand- filtration, and is well aerated, pleasant to taste, and without smell ; that it contains no inju- rious animal constituents, and cannot become contaminated with excreta of men or animals, or with foul water from houses ; that it contains no injurious amount of vegetable matter (not more than 2 or 3 grains per gallon) and that its mineral constituents are of moderate amount, not exceed- ing 60 grains per gallon as a maximum, and con- sisting of such mineral matters as are not likely to be injurious. With respect to lime especially, much discussion has taken place as to whether soft or hard water (from calcium carbonate) is best for a town ; the soft water is preferred for many trades and is probably best for health, though it has been found impossible to prove this by statistics ; it is certain that the in- habitants of numerous towns using a good chalk water have excellent health, and it would seem in fact that the question between water hard from calcium carbonate and soft water is not an important one. When water is hard from calcium chloride and sulphate it seems more in- jurious to health. The great point in choosing water is, in practice, its freedom from any chance of contamination with excreta, or with refuse matter from habitations. The sources of supply are natural lakes, arti- ficial lakes and gathering grounds, rivers, springs, and wells. In towns of any size superficial and shallow wells are always suspicious sources, as it is im- possible to secure them from foul overflows and soakages. Clause 70 of tho Public Health Act 1875 gives power to close wells, tanks, cisterns, or pumps if the water bo polluted. The duties of a medical officer of health should include the supervision of the sources of supply, so as to detect and prevent any possible con- tamination. (5) The water when supplied, except in the case of deep well waters, most commonly needs to be stored and filtered. The reservoirs of our towns contain from one to three months’ supply, or less if the supply is very constant. The reservoirs require to be well placed ; to be clear of trees, and protected from danger of anything being thrown .into them. The filters are usually made of sand about 3 feet in depth, and the water is passed through at the rate of from ^ to 1 gallon 1 Section 55 of the Public Health Act, 1S75, imposes on the Local Sanitary Authority the obligation of keeping the supply of water pure and wholesome in the case ot waterworks which have been purchased or constructed by them. 1278 PUBLIC to every sqaare inch of surface in 21 hours. The upper sand of the filters requires frequent clean- ing, and should be regularly inspected. This plan acts well, but constant supervision is neces- sary. ( c ) After filtration the water is distributed by means of pipes, usually by iron pipes, tarred or concreted inside, for the larger conduits, and then by lead pipes, or what is better, tinned-lead pipes for the smaller. Both iron and lead, and espe- cially the latter, are dissolved by some waters, and the question whether lead is so dissolved has often to be answered; in examining into this matter the water should be taken after it has been in contact with the pipes for some hours. Carried down by these pipes the water is either delivered at intervals to house cisterns, or, what is far better, is supplied on the constant plan without house-storage. If it be not possible to dispense with house-cisterns, they should be well made of slate or concrete, should be able to be easily inspected and cleaned, and their overflow pipes should always end in the open air, never go into any sewer. The greatest care should be taken that the cistern water shall run no risk of contamination by absorp- tion of foul air or by soakage into the cistern, which should be well covered to prevent dust getting in. If the constant system is in force it should be truly constant, for if the water is cut off at intervals, and the house-pipes are then emptied, air must be drawn into them and this air may be foul ; it has even happened that dirty liquids have been sucked into water pipes, as where a closet service-pipe has dipped into a choked closet-pan, and in this way excreta have not only passed into these house-pipes but have even got into the mains. Under a constant system and tmder an intermitting system alike, small service-cisterns are needed for water-closets and for kitchen-boilers, and precautions have to be taken with these cisterns equally with larger storage-cisterns. In fact too great care cannot be taken in thoroughly guarding water-pipes and cisterns in every way. The dangers con- nected both with the intermittent and constant systems have only been fully recognised during the last few years. The sources of contamination of drinking water are very numerous, and may affect the water at its source, in its flow, in the reservoir, or during distribution. If stored in houses it is especially exposed to risk ; and this is the grand argument for constant service, that the water may be de- livered immediately after filtration. The plan of cistern-storage, indeed, lessens those risks that are incidental to intermissions ; but this plan de- mands that cisterns be properly made and placed, and be regularly cleaned. For low-rented houses these conditions are very difficult of attainment, and therefore the constant service is peculiarly' adapted to the houses of the poor. Siphon- filters of animal charcoal placed in cisterns, filter the water immediately before use, and are much to be recommended. In all towns the service should be at high pressure, so that water may be carried to every flror and thus labour be spared, and the fresh- Qtsn of the water be secured. In towns where HEALTH. the water is not carried into the houses, but is fetched from ‘hydrants’ or stand pipes in the street, it has to be stored in the houses in buckets and runs many chances of impurity. A town requires water for public purposes, such as for public baths, washhouses, flooding and washing streets, flushing sewers, and putting out fires. Statutory powers are given for carry- ing out these objects. (4) The disposal of dirty house-water and dry refuse . — After being distributed and used in houses or trades, the water with the impurities ,’t has gathered must be carried out of the town. The inhabitants should have no difficulty in getting rid of their dirty water, or the same water will come to be used several times for cooking and for washing. Houses ought to have convenient sinks discharging by trapped pipes opening outside the house, not into a drain, but over a drain-grating. From hence it must go along pipes or sewers, and be disposed of at the outfall in some way. House-water, besides other impurities, invariably contains some por- tion of urine. It is not fit to be at once dis- charged into streams, but as its fertilising powers are small it is not well adapted for irri gation or precipitation. The best plan appears to be to filter it by intermittent filtration on a small area of properly prepared and drained ground, and then to carry it into the nearest stream. The dry refuse of houses consists of cinders and ashes, remains of food, dust from sweepings, and various other used-up articles of house life. In some towns there is little difficulty in disposing of this refuse. After being carted away it is sorted, and every article finds a sale. In other towns, however, the disposal of the house-refuse is a matter of difficulty and expense. In some places the dry refuse is placed every' day by the inhabitants in front of the houses and is removed by scavengers. In other cases there is storage of refuse on the premises ; if this is done every house should have a properly prepared dust- bin, well-paved to prevent soakage, well-covered so as to be kept dry, and so placed as to be convenient for the house as well as for the town-scavengers. In the building of any house the arrangements for the position of the dusUbin are almost as important as those for the closets. The removal ought to be frequent and regular, but the frequency has to be fixed by special circumstances. (o) The removal of excreta . — The excreta of the skin and lungs are got rid of by ventilation and washing, so that this heading refers only to the solid and liquid excreta. These average re- spectively (for both sexes and all ages) about 2) ounces avoirdupois of solid excrement and 40 fluid ounces of urine per diem. The excreta ought not to soak into the earth, or to remain near dwellings. The common privy and the * midden ’ of northern towns can- not be brought to fulfil these conditions. Id towns above 10,000 inhabitants it now seems clear that there is no possibility of using the earth or any deodorising plan, on account of the expense of transport. Therefore, for towns tw: PUBLIC HEALTH. 01 perhaps three plans only remain : 1. The dry plan -with frequent removal, with perhaps such dcodorisation as the ashes of the house may give —this is the so-called ‘ pail system’ in some one of its forms. 2. The water system, the excreta leing carried off from the house along drains and sewers, by the aid of water. 3. The air or pneumatic system of Captain Liernur, in which the excreta, unmixed with water, are sucked through pipes into a central reservoir by an air- pump, worked by a steam-engine. This plan of removal is as yet unfamiliar. It is now being fully tried on the Continent, and in after years there will be reliable data as to cost for original plant and for maintenance, as to certainty and efficiency of working, and as to returns from sale, all of which are now matters of doubt. It would not be possible to discuss here the relative value and the technical details of the pail and the water systems. Both are largely used in England. The former is used in towns where the barbarous cesspit and midden plans are abolished, and yet where proper sewers cannot be made, or water is deficient, or land cannot be obtained for irrigation or filtration; it has the disadvantage of keeping the excreta for some days near the house, and is sometimes attended with nuisances in the working, but, on the whole, it is capable of keeping a town clean when it is properly carried out, and it is an immense advance over the old midden sj'stem, which retained the excreta for long periods in the very midst of tho people. It is, however, j essential that the removal of the excreta should be frequent, that is, once a week or so — twice a week if practicable. After removal the excreta are applied at once to the land, or are made into poudrette. In some towns the house-ashes are thrown on a wire screen, so as to allow the fine ash to fall on the excreta — this is sometimes called the ‘ash plan in other cases deodorants are used. The ‘ Goux system ’ is to place some absorbent material round the interior of the pail to absorb the urine. The water system is more complicated, and probably more expensive, but if properly carried out is more effectual. If a town can make good sewers, and has water for flushing and land through which the sewer water can be passed by filtration or irrigation or both, the water sys- tem is the best for health. It is essential, however, that sew'ers should be well constructed, and should allow no deposit, and that they should be thoroughly ventilated. Deposits are prevented by having egg-shaped sewers with a proper fall, easy means of access for inspection and cleaning, and a regular flow ,of water with periodical flushing. The venti- lation of sewers, which is now enforced by law [clause 19, Public Health Act, 1875), is best ef- fected by having numerous openings — as many, n fact, as can be made — so as to allow constant ind free interchange between the sewer air ind the atmosphere. These openings may be by itreet-gratings or by special shafts, according to lireumstances. Ventilation through furnace chim- leys can be sometimes done, but is of no avail • or distant portions of the sewers. The open- ngs may, at certain points where the shafts >r gratings are near he uses, have to be guarded 1279 by trays of charcoal, through which tho sewer air passes. But in whatever way it is done, the rule must be to have the freest communication between the sewer air and tho general atmo- sphere. This free ventilation occasions no offence if the sewers are properly made and kept ; while, if the air of sewers at the ventilators is found offensive, the ventilation will at least have pro- vided against the more dangerous discharge of the foul air into houses. As a further provision against possible reflux or suction of the air of the public sewers into houses the following ar- rangement should be rendered imperative by law. At some point in the course of every house- drain, before it reaches the main sewer, there should be complete disconnection by means of (a) a ‘ siphon-trap,’ through which all the liquids of the house must pass, and which, therefore, must always be charged with water while the house is inhabited ; and of (6) an opening from the house-drain to the outside air, made on the house side of the siphon- trap, to provide for the escape of any sewer-air that may force the trap, as well as for the ventilation of the house-drain proper. If this were done the spreading of disease by town sewers would be impossible, and the greatest objection to them would be removed. The com- munity constructs the main sewers, but it would seem just that the owners of house property, who provide the house-drains and are obliged by law to connect them with the public sewer, should be compelled to put down one of the open-air traDS, which renders reflux impossible into their houses. Sewers have been objected to on account of the occasional spread of typhoid fever and diar- rhceal affections, and perhaps of cholera and diphtheria by their agency; but, if properly arranged, and with disconnection between the sewer and houses, there would be no danger ; and it is difficult in any case to seo how sewers can be displaced or be substituted by any other plan. The house- water must be carried off, and it is impure even if no excreta are allowed to flow in. Even if the pail or pneumatic plan be adopted, there must still be town sewers for dirty house-water, and all the precautions above alluded to must be enforced. Sewers, then, whether or not they receive the excreta of a town, are a necessity, and with proper construc- tion and management, they certainly ought to be solely beneficial to the public health. It is certain that when a town is well sewered the prevalence of enteric fever is lessened even to the point of extinction, and diarrhoeal affections have appeared to be more uncommon. Drying of the soil by sewers also lessens phthisis. It is a question of engineering detail whether the sewers carrying the house-water should also carry off the rain water. In some cases the 1 separate system ’ (that is, having different chan- nels for house and rain water) appears clearly the best. The sewer water is less in amount, more regular in flow from day to day, and richer in fertilizing properties. With regard to the disposal of the sewer water, three plans can be followed in the case of towns which cannot discharge at once into the sea or (without disobeying the Bivers Pollution Preven- tion Act of 1876) intoalarge river : first, precipi- tation at the outfall with a chemical agent such a! 1230 PUBLIC lime, aluminous compounds, phosphate of lime and alumina, clay, &e. A great number of chemical agents hare been proposed, and several clarify the water fairly, but none yield a deposit which pays the expenses either as manure or when burnt into cement. Precipitation must, however, be had recourse to when land cannot be obtained. Second, irrigation, one acre being sufficient for the excreta of about one hundred persons. Third, intermittent filtration, where one acre is sufficient for from 2,000 to 3,000 persons; the land re- ceives water six hours out of the twenty-four, and is deeply drained. In neither extended irriga- tion nor in filtration on a limited area is there any adequate profit, but still there appears to be some, and the purification is more complete than by precipitation. In some cases after filtration the water is passed over farm land, and this double purification appears to be very satisfac- tory. It appears certain that neither irrigation sewage farms nor filter-beds are hurtful to the public health when properly managed. (C) Tie conservancy of the surface area. — Tho cleansing of the surface area of towns is secured partly by powers originally given in a variety of Sanitary Acts, general and local, and continued with additions in the Public Health Act of 1875, clauses 42-50. These powers are large and on the whole sufficient. The sanitary im- portance of thorough surface-cleansing is ob- vious; the mud and dirt of towns and refuse of all kinds, wetted by rain and exposed to heat, soon decompose and give out. injurious effluvia, especially in narrow courts and lanes where the movement of air is impeded. The excellent effect on health of paving a town has been often observed. Public streets of all kinds can be easily kept clean, but want of paving and conse- quent foulness on private premises require to be Bought out. Under the above and other clauses in the Act the supervision of pigsties and stables is carried out and, generally, conditions which can give rise to nuisances injurious to health can be legally dealt with. (7) The Supply of Food , including the Regula- tion of Slaughter-, Cow-, and Bake-houses. — Avery important duty of a municipality is to supervise the food of the people. While the price and quality must be left to the ordinary operations of commerce, the responsibility of preventing falsifications, and of ensuring that the article shall not be injurious to health, must rest on the sanitary authority. The regulation of slaughter-houses and kn ackers-yards, directed by former Acts, is authorised afresh by the Pub- lic Health Act of 1875, clauses 166 to 170. Private slaughtcr-hotises are licensed, and can be visited and subjected to bye-laws. They are often constructed out of buildings intended for other purposes, are not fitted with proper appli- ances, and are generally placed in the densest part of the town. The evils attending them are gradually being removed by the efection of pub- lic slaughter-house's, where abundant air, water, good sewers and means of cleansing are provided. The custom of slaughtering in the country and then sending the meat to cities is increasing, and HEALTH. this again renders private slaughter-houses lea necessary. The transport of cattle and sheep to towns is a matter of very great importance as respects both the goodness of the meat and the comfort of the animals. It is a matter which should be dealt with in the Public Health Act, and should be under control to a certain noint. Space in the trucks, supply of water and food, length of jour- neys, and other matters, require regulation. Cowhouses are usually inspected by sanitary authorities, in pursuance of the powers of the Public Health Act, §§ 91-92, or of private Acts. In the metropolis they have to be licensed by magistrates. A certain cubic space is usually allowed to each cow (1,000 cubic feet should be the minimum), and cleanliness is enforced. The condition of small cowhouses and dairies, and of the water-supply and drains attached to them, requires more attention than it has received, as both enteric and scarlet fever are now known to have been spread by the agency of milk. [To these diseases must now be added diph- theria; and the suggestion that diseases of the animals themselves, as well as impurities re- ceived from water or air into their milk, are concerned in the production of milk-epidemics among human communities, will henceforth al- ways have to be kept in view. The foregoing requirement has been in a measure fulfilled by the Contagious Diseases (Animals) Act of 1878, which requires cowhouses to be licensed, and their sanitary condition at- tended to ; and requires precautions to be taken in dairies and milkshops against the contamina- tion or infection of milk. An Order of Council has been made respecting these various matters. It is observable that sanitary authorities are not charged with the duty of inspection under this Act, except in the ease of corporate towns ] Bakehouses are regulated under a special Act (26 and 27 Viet., c. 40) which was passed after long enquiry into the condition of the trado. By this Act the bakehouse is ordered to be kept in a cleanly condition, to be properly ventilated, protected from effluvia, and not to be used as a sleeping-place. The condition of the bakehouses disclosed by the enquiry referred to, was in the highest degree disgraceful and repugnant. The inspection of the chief articles of food takes place under the Public Health Act of 1875, clauses 116 to 119, in respect of meat, game, poultry, fish, fruit, vegetables, corn, bread, flour, and milk, and under the Adulteration and Licensing Acts in respect to other articles of food. The following are the chief sanitary points in each case : — 1. Meat. — Much doubt exists as to the extent to which the condemnation of meat exposed to sale should be carried. There is no doubt that meat sufficiently decomposed to be discoloured and to have a putrid smell, and meat with ab- scesses and suppurations, should be condemned, but the difficulty arises with meat apparently sound or not very obviously otherwise, but which is derived from diseased animals. Though opinions differ on this point, it _ may perhaps be said that meat derived from animals dead of inflammatory diseases and of epidemic PUBLIC pleuro-pneumonia may be used, but that beef from cattle dead of cattle-plague and anthrax (malignant pustule), mutton from sheep with small-pox and splenic apoplexy, and pork from pigs with earbuncular diseases, hog-cholera, hog- typhus, and scarlet-fever, should not be used, although it is not easy to give conclusive evi- dence as to bad effect in some of these cases. Cattle-plague meat, for example, has been largely used without injury. Opinions are much divided as to whether the flesh of braxy sheep, or of cattle dead of fooLand-mouth disease, should be used or not, but at present the evidence is rather against the view that such flesh is injurious. In the case of the parasitic diseases of animals the question is easier. It is of course highly dangerous to use pork with trichina. [Some recent experiences are pointing to trichinosis as a more common disease than had been suspected.] Cysticerci in pork, beef, and mutton should also, in the writer’s opinion, he a valid ground for not permitting the sale, though this view is not univer- sally or perhaps generally held, since as cysticerci are killed by a temperature of 160° Fahr., it is considered that good cooking removes all danger, and therefore that condemning meat for this cause is an improper restriction on supply. On the other hand, as it is impossible to secure that a sufficient temperature shall be applied, how can . it be possible to prevent the development of tape- worm if the sale is permitted ? The prohibition would probably not long affect supply, as the breeders and salesmen would take greater care iu preserving the cattle from parasitic infection ; and that this can be done, by supplying pure water and clean food, is shown by the experience of Upper India. Flukes in the liver do not constitute a valid ground of rejection of the meat, though the liver ought not to be eaten. Some very remarkable examples of an acute pecific disease of peculiar characters have re- ently been observed among consumers of meats lerived from the pig ; where the sole evidence f disease in the meat has been the presence of a ultivable bacillus. See Poisonous Food. Sausages when musty and strong-smelling hould be rejected, but, owing to the spices used, ecomposition is not easily made out. The pecu- ar ‘sausage-poison’ has not been identified. 1 Vheat-Flour and Bread. — The chief points ire to ascertain that there is no ergot, no fungi, or acari ; that alum has not been used ; and that her grains or mineral matter are not mixed 1th it. Under the Adulteration Act the following, nong other articles, may have to be examined : r dk, the chief falsifications in which are ad- tion of water or removal of cream. Falsifica- bn in other ways is not common. It may also improper for use, owing to the presence of ood, lacteal easts, pus and fungi. Butter', the 'sifications here are admixture with foreign 3, and excess of water or of salt. Cheese, which ty he decomposed, mouldy, or have copper ded to preserve it. Coffee, which may be trid or decomposing, or mixed with chicory, isted corn, &c. Tea, which may be deeom- ied, mixed with exhausted leaves, or with leaves , other than tea-plants, or with sand, iron ore, 81 HEALTH. 1281 colouring matters or facings. Cocoa, to which various starches may have been added, or the fat exhausted. Oatmeal, to which inferior barley or wheat- or maize-flour may have been added. Maranta arrowroots, to which potato starch or inferior kinds of arrowroot may have been added. Spirits, wine, and beer, in which there may have been addition or subtraction of spirit ; improper spirits, as methyl or other alcohols, added; addi tion of water, salt, sulphuric acid, ferrous sul- phate, lime-salts, lead, eoceulus indicus, hot spices, aloes, quassia, burnt sugar, &o.‘ Vinegar , the chief falsifications in which are the addi- tion of water and occasionally of sulphuric acid in excess of that permitted by law part.) In no case is an examination of food under the Adulteration or Licensing Act made to determine the quality of a pure food ; it is directed simply to detect the presence and amount of foreign- substances, or of decomposition and putrefaction. The law permits mixtures to be sold in some cases, if the admixture is stated on a label. (8) The Begulalion of Trades. — Trades are affected by the law under two points of view; 1st, irrespective of the nature of the trade, the place where it is carried on is regulated under tile Mines, Factories, and Workshops’ Acts ; and by the Public Health Act of 1875, urban authorities can make byelaws regulating offensive trades, such as blood and bone boilers, fellmongers, soap, tallow, and tripe boilers, &c. The object of the Factories and Workshops’ Acts, among other things (such as restriction of labour at certain ages), is to provide that the common conditions of health are not violated. This is a very necessary point, for many workshops are deficient in light and air, are badly ventilated, or are rendered unhealthy by gas burnt for light. Many small workshops are owned by men of small capital, who often sacrifice the health of workmen by compelling them to work under very unfavourable conditions. Happily the faults are usually easily remedied by a little common sense and simple appliances, and in this respect the Workshops and Factories Acts have done great good. One special fault in many workshops is, however, still common, namely, the burning of gas in large quantities in dark shops, without proper means of carrying off the products ; the very great influence of this condition on the lungs was long ago pointed out by Dr. Guy. 2. The other point in the regulation of trades is to prevent any of the processes being nuisances or injurious to the health, either of the work- people or the inhabitants of the surrounding dis- tricts. This is an extremely wide subject. Trades may annoy and inconvenience the public, as by offensive effluvia, black smoke, or acid vapour which destroys vegetation, yet may not be dis- tinctly injurious to health. On the other hand, without being notable nuisances in the above sense, they may be hurtful to health, especially those (and they are very numerous) which give rise to dust in the air of any kind. Cotton and 1 The examination of adulteration of beer is now so far more difficult as the law allows other bitters besides hops to be used, and it is understood there are numerous cheap bitters now used in place of hops. It is very de- sirable that tiie old taw allowing only malt and hops t? be used in the making of beer should be re-enacted. 1282 PUBLIC woollen debris, metallic vapours, filings and grindings, particles of size, clay, dry paints, and many other substances, come under this head. Much debate has taken place as to whether cer- tain gases, such as carbonic acid, chlorine, iodine, sulphuretted hydrogen, sulphurous acid, or the foetid vapours given off from catgut, gelatine, manuro and other trades, are or are not injurious to the health of the workmen, or persons living near the factories. In many cases the discus- sion is not closed, and fuller enquiries are neces- sary ; but at present it seems as if these gases and foetid effluvia, in such proportions as they are met with about factories, are not proved to be unhealthy (though their innocuousness cannot be asserted), however disagreeable they may be ; whereas there is no doubt that the inhalation of all solid particles, no matter whence derived, is highly inj urious. Phosphoretted fumes escaping into the air have affected the jaw-bones of per- sons exposed to them ; this happens now much less than formerly. The spread of infection by trade operations, as of anthrax among woolsorters, and of smallpox among paper-makers, has recently come to de- mand recognition. There is one article, the use of which gives rise directly and indirectly to a large amount of sickness, and the trade in which certainly requires regulation, if the public health is to be regarded. This is alcohol in its various forms. Owing to peculiar social customs, to the insufficient recog- nition of the immense amount of harm produced by excess of alcohol, and to a want of definition of what is excess, the laws of this country have not only legalized the sale of a dangerous article of diet, but have actually encouraged the sale, until an evil so gigantic has been produced that no one has yet suggested a reasonable remedy. Yet the salo of alcohol is so distinctly a source of disease and of injury to the State, that it must be considered by those who have charge of the Public Health, and in someway must eventually be restri cted. One source of the error seems to be that alcohol is regarded by the State, not only as a source of revenue, but as an indispensable article of refreshment. There is, of course, no question that the. public must be supplied with houses where they cau obtain proper refresh- ments, such as meat, bread, vegetables, milk, coffee, tea, or other articles of the kind ; and ‘ pub- lic-houses ’ were intended to supply articles of this description ns well as the alcoholic liquids which enter into the ordinary diet of most people. Yet, unfortunately, a system has grown up by which our public-houses have become only places where alcoholic liquors are sold, and this is defended on the ground that such liquids are re- freshments. The amount of temptation which has been put in the way of our working classes by the heedless multiplication of these grog-shops during the last forty years accounts for much of the drunkenness which so deeply affects our national life, and injures the health of the people. A remedy ought and must be found for this state of things, or else sanitary legislation will still pre- sent the absurd spectacle of raising up with one hand what it is smiting down with the other. lit; 1'he arrest of t/ee Contagious and Infections HEALTH. Diseases . — Small -pox, scarlet fever, measles, hooping-cough, diphtheria, enteric fever, typing and relapsing fever have to be dealt with. Among other contagious diseases also syphilis and gonorrhoea must bo included. Of late years, since the recognition of the fact that each of these diseases must have its own special cause, the prevention of the infections diseases has become much easier, although tho exact nature of the cause may be unknown. The general principles on which the prevention is based are — 1. The recognition of the places of origin and conditions of formation of the morbid agent, that is, whether it arises from processes going on in some of the structures of the human body, or in substances outside and independent of the body, with further question as to the nature of these substances, structures, or processes ; when these points are known.it is to be expected that the formation of the agent can be prevented or the agent can be destroyed. 2. The recognition of the means of spread of the agent, after its first formation, that is, whether it spreads by the help of the air, or is carried in drinking water, or in food, or is transferred directly from one person to another; so that when known the carriage of the agent may be stopped. 3. The early removal of the person affected from among the community, so that the risk of spreading in any way may be lessened. In the case of each of these diseases the pre- ventive measures are different, and it is impos- sible here to go into so large a subject as the prevention in each case. The measures include a continual supervision over the conditions of origin, introduction, and spread as far as they are known. Two points must, however, he specially noted. The isolation of persons ill with any disease which directly or indirectly can spread from one person to another is a necessary step in all cases. In the crowded houses of towns some diseases such as typhus, scarlet fever, measles, relapsing fever, &c., spread with great rapidity, and the only possible check is to remove the sick at the earliest moment from the houses, and to prevent persons ill with infectious diseases from expos- ing themselves in public places and convey- ances. For the first purpose sanitary authorities have powers (Public Health Act 1875, clauses 120 to 140) to remove persons ill with infection; diseases to a proper hospital in special convey- ances; to prevent sick persons frequentingpublii places or conveyances ; to destroy bedding o: clothing, and to disinfect rooms, houses, or cloth ing. Hospitals for infectious diseases can als< be built, and are now being constructed in man; towns ; it is desirable to make them simple cheap buildings of wood or iron, able to bj thoroughly cleaned, or after a tenn of years t be destroyed and replaced. These hospital should provide a cubic space of from 1,500 1 2,000 cubic feet with a floor space of from 12 to 140 feet; for each patient, and efficient seps ration between patients suffering from one an another infectious disorder. The freest ventilf tion, supply of water, and means of disinfectio are essential. Under the same Act a town is en powered to erect a proper place for disinfeettr PUBLIC HEALTH. clothing and bedding; and disinfecting chambers (heated by hot air, steam pipes, or gas, and in which a heat of 240° Fahr. can be reached) are now provided in many towns for the immediate disinfection by heat of all soiled clothes taken from patients with any of these diseases. The disinfection of the excreta or of discharges from the body, or of tho air surrounding sick persons, is also attempted and is evidently a proper plan to follow, though the results are at present uncertain. The spread of scarlet fever, | however, appears to be arrested by rubbing the ■ skin with carbolized or camphorated oil ; typhoid : fever is probably stopped by strong chemicals I added to the intestinal discharge ; and the spread [ of typhus has been also lessened and perhaps arrested by aerial purifiers, especially nitrous 5 acid fumes. Small-pox is prevented by vaccination, and for j this there are special Acts and a special organi- zation. The prevention of syphilis and gonorrhoea by periodizal inspection of prostitutes, and removal of them to lock hospitals when diseased, is only ; carried out in this country in certain military land naval stations, where the effect has been to lessen primary syphilis by nearly one-half, and to abate its virulence. The effects of the Conta- gious Diseases Acts upon the women, in respect not only of curing them but of influencing them for good and of reclaiming them, has been very .remarkable. In Germany, Franco, and Belgium precautions against venereal diseases have been carried out among the entire population for many years, with the effect of greatly lessening the amount and virulence of syphilis. As syphilis has a most pernicious effect upon the health of a very large number of persons, it ■ s most urgently to be hoped that the Legisla- :ure may before long deal thoroughly with this flatter and attempt to lessen syphilis, not merely in the army and navy, but among the lopulatioa at large. ' ( 10 ) The disposal of the Bead. — Two points are nvolved in the disposal of the dead both in towns nd villages. 1 . In this country where so many families live n single rooms, and where the custom of keeping he dead five or even six days before burial is jsual, it constantly happens that a corpse is kept or days in the room where all the family life is irried on. As decomposition, especially in some iseases, commences early, it cannot bo doubted lat an unfavourable effect on health must be ften produced. To avoid this detention, mor- lary chapels ought to be constructed in all iwns and villages, and to these all corpses tould be removed from the houses of the poor ithin thirty-six hours after death. Power has long been given (Public Health •ct of 1848) to the Sanitary Authority to pro- ‘,de mortuaries, and the Act of 1866 gave power remove, when necessary, corpses from rooms tere persons live and sleep. These powers are ntinued in the Public Health Act of 1 875, and rase 141 also now imposes on the local autho- rs the duty of providing mortuaries, if re- ared by the Local Government Board to do so. •ry little has as yet been done in this way, and 1283 England is in this respect far behind some of the Continental States. 2. The second point is the disposal of the corpse. The law of England now allows no burial-grounds in large cities, nor burial under churches, and consequently cemeteries are pro vided at convenient distances from towns. Theeo cemeteries ought to have a dry soil, so that tho ground water shall never rise high enough to wet the corpse or to float it up in the vault, as sometimes happens ; they should be as far from houses as practicable, and the minimum limit of 100 feet allowed by Government is much too little ; there should be good drainage, and the water should not run into any well or water- course from which drinking-water is taken; the site should be well ventilated and well planted, so that the roots of plants may absorb the de- composing matters. The kind of soil will, of course, depend on the locality; in many cases there is no choice, but if there be a choice a marly soil, not too stiff, but allowing free per- meation by air and free flow of water, should be chosen; gravelly soils act pretty well, but are said to form a compact mass round the body, which prevents access of air and moisture ; the lime and chalk soils act better, and especially if the soil is alkaline; very stiff clay preserves bodies longer than less compact soils. Bodies decay in very various times, according to soil, access of air, amount of pressure, &c. In some cases a corpse may be destroyed in three years ; but when ground has to be used over again, a period of from five to thirty years is allowed in different countries before tho second use. Bodies should be buried deeply (4 to 6 feet) in order to lessen the chance of contamination of the air, though it is supposed that when the graves are shallower, decomposi- tion is more rapid ; the graves should not be bricked, but the earth allowed to rest on the coffin. It has been proposed to use not coffins, but sheets or wicker-baskets, so as to let the earth at once come in contact with the body ; and, in fact, in many villages in England it was formerly the custom to carry the corpse in a coffin to the churchyard, but then to remove it from the coffin and place it in the ground in a sheet. If the coffin is not made too strongly it is probable that it does not much delay decomposition; so that this point does not seem very material. The decomposition of bodies occurs by putre- faction, with rapid disengagement of effluvia ; or by a sort of insensible decomposition, the pro- ducts being decomposed as rapidly as they are formed by the earth. In other instances the decomposition is by saponification. This last condition is said especially to occur if the earth is too closely pressed on the body, and gets too saturated with the products of putrefaction. As in some cases conveniently-situated and proper land cannot be obtained, a discussion has lately arisen whether burning, or, in the case of seaboard towns, burying the body in the sea, might not supersede burial in the ground. This article, however, is not the place to enter into this question. (11) The Supervision of Nuisances . — [Nuisances 1284 PUBLIC are defined in the Public Health Act, § 01, as being — (1) any premises, (2) any pool, ditch, gutter, -watercourse, privy, urinal, cesspool, drain or ashpit, (3) any animal, (4) any accu- mulation or deposit, (5) any over-crowded house, or part of a house — that are ‘ a nuisance or in- jurious to health.’ These words, as they occur here, must be read with reference to the general purposes of the Act, and will therefore include only things or conditions as above that are of a nature to injure health : mere disagreeableness or annoyance, though it may be a ‘nuisance’ at common law, not being enough to constitute a nuisance in the above cases. Moreover, (6) dirty* or unventilated factories and work-places, or any that are unnecessarily dusty, and (7) manu- facturing furnaces and the like that do not con- sume their own smoke, are, in this Act, included with nuisances under certain limitations. It is the duty of every Sanitary Authority 7 to cause inspection to be made of their district to discover nuisances ; and a certain procedure for the abatement of nuisances, and for the pre- vention of their recurrence, is appointed by the Public Health Act. For the performance of these functions the Authority is required to appoint one or more Inspectors of Nuisances, to whose office certain powers arc attached. [The work of nuisance-inspection, in its every-day con- cern with conditions injurious to health, cannot be properly performed without the constant and intimate relation of the Medical Officer of Health with the Inspector; and those districts are un- questionably best served as to sanitary inspection where the Authority has devolved on the Medical Officer the duty of instructing the Inspector and of supervising his work.] II. "Villages.— Although many of the earlier sanitary enactments had application to villages, it was not until the passing of the Public Health or Sanitary Act of 1872 (35 and 36 Viet., c. 79) that rural sanitary authorities were constituted. These authorities, namely, the Guardians of rural Poor Law Unions, can now exercise consider- able powers, and if properly set in action by their medical health officers and inspectors of nuisances (whom the authorities are obliged to appoint), a great effect must bo gradually pro- duced upon the rural labouring-class, whose condition has up to this time been almost en- tirely neglected. As the urban authority in towns, so the rural sanitary authority in country places may provide water for public use, may make public cisterns or baths, may T protect water- courses, may construct sewers and dispose of sewage matter ; must take care that no closet or privy is a nuisance; may clean ditches and re- move refuse, and may make regulations as to cellar-habitations and common lodging-houses. [Much increased power of securing proper water- supply in the particular house within rural dis- tricts has been recently given by the Public Health (Water) Act of 1S7S.] All powers pos- sessed by urban authorities as to trades, sale of unwholesome food, removal of nuisances, pro- viding mortuaries and hospitals for infectious diseases, are now also possessed by the Poor Law Unions (Public Health Act 1875, clauses 5 and 9). At present, however, except in those places HEALTH. where several rural sanitary authorities have united to appoint a first-class sanitary officer, little has "been done in English villages. The problem is, in fact, by no means an easv one, but it is being vigorously discussed, and I will be no doubt eventually solved by the officers of health of large areas, many of whom are men of great knowledge and distinction. The diffi- culty arises from the houses in the rural districts being, in a great number of cases, old, dilapi- 1 dated, unsuited for dwellings, and destitute of proper conveniences. When new houses are ; built, the sanitary authority can enforce certain | provisions, though it has far less control over building operations than is possessed by urban authorities. In the case of houses already built, ' however, its power is, from circumstances, even' more limited. There is very little money avail-j able for improvements ; the poor-rates are already often heavy, and guardians hesitate to increase' them. The small number of houses in villages! also, in comparison with the outlay needful to supply sewers and water, renders the cost per head relatively much greater than in town>. Progress, therefore, in rural districts must le slow, but yet it cannot be doubted that the pre-| sent condition will be gradually improved. In! addition to bad construction and dampness ofj houses, the most frequent sanitary defects on villages are as follows : — The water is too often 1 drawn from shallow wells or from small streams,; polluted by soaking, or from stagnant pools or) ditches, and its supply is limited. Often there are no means for carrying away the dirty house- water, and it is thrown on the ground and soaks into the soil close to and under the cottage ; the excreta are generally thrown into an ashpit near the house, or pass into a cesspit in the ground] into which they 7 gradually soak, polluting both ground and water. All sanitary appliances are; in fact, often wanting. Attempts are now being made to purify and then to guard the wells; td collect rain-water in proper tanks when othei sources are wanting ; or to store the water col- lected from the surface-soil of some area secun from drainage, manuring, or like impurities fa: recommended by Mr. Bailey Denton). For the disposal of the slop-water, open or partially closed surface drains leading to ditches, or under; ground drains that shall allow the water to flov into the soil, and other plans have been proposed It is, on any plan, important — but especially i shallow wells or the surface soil are to fumis! the drinking water — to carry off to a distanco al the slop)- water by drains of some kind. Forth removal of excreta (as sewers are generally on of the question) a pail system, with or withou the use of dried earth or charcoal, according t circumstances, has to be used. If the cottage have gardens, then tire simplest dry-earth plar with proper storage and the subsequent diggin into the gardens at intervals of not more tha three or four weeks, seems to answer well; ye it is very difficult to get peasants to attend eve to this simple matter. If the village be a lars one, then conjoint action in the procuring, dry ing, and distributing the earth, and in the r< moval of the mixed earth and excreta, answer well when care is taken. In other cases a pa system, with weekly or fortnightly removal PUBLIC without the use of earth or other appliance, can be employed, and may answer, as the manure has some value. These seem at present the directions in which the opinions of medical officers of health are tending where villages and labourers’ cottages are concerned, and where larger works cannot be undertaken. The object, of course, is to obtain by simple means, and. at not too burdensome a rate, the same results which are arrived at in towns by more costly plans, namely, to ensure pure drinking water, and to remove foul house- water and excreta; or, in other words, to ensure purity of the water, of the air, and of the ground. III. Houses. — The inside of a house is sup- posed to be beyond the control of the Public Health Authority, and is so to a large extent, but not altogether. The law takes cognizance of the existence of nuisance inside, as well as outside, a house ; and has special provisions for securing wholesomeness of habitation in the fol- . owing cases : — 1. Common lodging-houses have been regu- 'ated since the great Public Health Act of 1848, .he authors of which were evidently profoundly impressed with the great evils of overcrowding. 1 These houses are registered and inspected ; the number of lodgers is fixed ; and ventilation, and l 1 cleanliness, and water-supply are attended to (Public Health Act, 1875, clauses 70-89). A certain cubic space per head in the sleeping- rooms of these houses is generally fixed by the Authority. In the Metropolis (where Acts of 1 1851 and 1853, administered by the police, re- main in force) 240 cubic feet, in Dublin and many other towns 300 cubic feet, are required for each adult inmate. 2. Cellar-habitations. Since 1848 it has been unlawful to use cellar-habitations, unless they are in accord with certain conditions of space, height, window area, drainage, &c. In the Public Health Act of 1875, Clause 72 affirms these conditions afresh, and Clause 71 makes it ,iunlawful to use any cellar as a dwolling (that is, .a place where any person passes a night) which has been built or rebuilt after the passing of |the Act, or which was not lawfully in use when |the Act was passed. 1 With the supervision that has been given to tommon lodging-houses during the past thirty rears, they have become much healthier and noro decent habitations. During the same period the number of collar-dwellings in our owns has much decreased, and the condition of jhoso still used has notably improved. 3. 1 Houses let in lodgings’ or occupied by Members of more than one family. These are istinguished from common lodging-houses, where ommon occupation of a single room by persons f different families, or occupation for very short ;eriods, has been the distinction that one and nother authority have relied on to establish their 1 rmmon quality. The regulation of tenemented ouses, as the present class may conveniently be >rmed, dates from the Sanitary Act of 1866. I ,t present, by Clause 90 of the Public Health ict, 1875, Sanitary Authorities have various lportant powers conferred on them in respect HEALTH. 1286 of that large class of houses where two or more families live in the same house. But, for these powers to arise, the consent of the Local Govern- ment Board is required. 4. Overcrowding. The Nuisances Removal Act of 1855 (18 and 19 Viet. c. 121) empowered the Sanitary Authority, on the certificate of the medical officer of health or of two qualified medi- cal practitioners, to take proceedings before a jus- tice to abate overcrowding if the inhabitants consisted of more than one family. In the Pub- lic Health Act of 1875, clause 91 makes over- crowding, when dangerous to the health of the inmates, whether of the same family or not, a. nuisance to be dealt with as such under the Act. Some towns have also provisions in their local Acts, giving them the same authority, and in this way the immense evil of overcrowding is sought to be lessened. Tho question arises what is overcrowding, and usually the common lodging-house rules are taken, namely, an air- space of 300 cubic feet per head. But there is no legal amount, except in Scotland, where the General Improvement and Police Act of 1862 enacts that children under eight yeai’S of age shall have 150 cubic feet, and persons over that age 300. Obviously, the standard of space per person adopted as the minimum in the bedrooms of common lodging-houses, where the occupation is by night only, is too small for those who have to occupy the same room both by day and night, as is usually the case, where the question of over- crowding arises in the dwellings of the poor. It would be very desirable to raise the mini- mum (at all events for persons over ten years) to 400 cubic feet, and this is really little enough. The law, then, in these several ways acts di- rectly upon houses, and if any nuisance is re- ported, or if houses are found to be dangerous or unfit for habitation, further powers come into play. Although public authority does not extend to all the conditions which are next to bo passed in review, it will be convenient to consider to- gether the various CAUSES OP UNHEALTHINESS OF HOUSES. 1. Dampness . — Dampness arises from a damp soil, water rising into walls, rain beating through walls or coming from a leaking roof, or blocked water-pipes. Paving, concreting, damp-proof courses, hollow walls, &c., are the remedies. Damp houses are unhealthy, it would appear, by reason of the lowering of warmth, giving rise to catarrhal and rheumatic affections, and perhaps by reason of increased decomposition of organic substances from the constant excess of moisture. 2. Excessive coldness of air from draughts or from insufficient warming . — Although an airy house is the healthiest, there may be, not too much, but imperfect, movement of air, so that strong currents are caused ; or the temperature may be lower than is good for health, even if per- sons are well-clothed. The draughtiness is matter of construction, and is obviated by proper plans of ventilation. Then, as to warming. In towns, tho use of hot- water and steam pipes heated by a furnace common to several houses will, no doubt, soon supersede our present inefficient and expen- sive fireplaces, and since the supply of warmed PUBLIC HEALTH. !280 fresh air is a very simple proceeding when these pipes are used, not only will houses be better warmed, but better ventilated and less draughty. 3. Impurity of the air . — This arises from the following conditions : — impure air drawn from ground or basement into the house, or passing over impure earth or deposits ; air in house contaminated by effluvia from closets and pipes ; from combustion ; from respiration and skin- transpiration ; from uncleanliness of persons, clothes, walls, floors, and furniture. Each of these conditions has to be examined into and rectified according to the usual rules laid down in works of hygiene, A few remarks may, however, be permitted on some of the headings. The removal of respiratory impurities can only be accomplished by constantly removing the air of rooms and supplying fresh air. This is ventilation, which on account of the very mo- bile character of air and of the ease with which its currents are reversed, is a mechanical pro- blem of no little difficulty. The amount of air required for an adult, in order to keep the air free from any odour, is 3,000 cubic feet per hour ; the carbonic acid of respiration, which is taken as a measure of respiratory impurity, should not exceed "2 per 1,000 volumes of air. Practically, the amount most persons get is not more than 600 to 1,200 cubic feet per hour, if so much, and the air of their rooms smells fusty from organic effluvia. In cold times of the year, the entering air must be warmed, if such great changes are to take place as is implied in the supply of 3,000 cubic feet, or in the change of air in the air-space three, four, or even five times per hour. When warmed to nearly the temperature of the surface of the body (80° to 90° Eahr.) considerable movement of air is borne without difficulty, but if the temperature be much lower a correspondingly slighter movement is felt. Ventilation in this climate is therefore in- extricably mixed up with warming, and thorough ventilation of our rooms is impossible so long as we trust to radiant heat alone for warmth. The problem, therefore, which engineers have to solve in warming and ventilating our rooms, is what is the cheapest and most constant plan of introducing warm air, of a temperature under 90° or 95°, into our houses in cold weathor, the conditions of the problem being a supply of 3,000 cubic feet per head per hour, at a rate of movement imperceptible to the feelings of the persons in the room. The second point is connected with the impu- rity of the air from drains. The first thing is to be certain that the air of the house-drain is so thoroughly disconnect ed from the air of the town senders that no reflux from them is possible ; and, therefore, that if thero is any drain air polluting the atmosphere of the house it is not the air of the common sewer. That point having been settled, it will follow that drain-smell in the house must come either from the ground or from the house pipes or closets themselves. If from the ground, there is probably (if the ground itself he clean, or if the smell be of new pro- duction) a leaky pipe somewhere, and the air is penetrating through the interstices of the soil and is drawn into the house ; every house should have a plan of its drainage, so as to facilitate the search for a broken pipe. If not from the ground, the smell may be from some pipe in the house ; this arises from imperfect junction, especially when metal pipes are joined on to earthenware, or from the pin-hole eating- away of metal pipes. Or a drain-pipe may be choked (generally through ‘ settling’ at a joint occurring in an ill-laid and badly-bedded pipe), and decomposition be going on in its retained contents. Or there may be a clogged or im- perfect trap with the water either sucked out of it or becoming thoroughly charged with fcetid effluvia. In the latter cases, there is a presump- tion that the ventilation of the house-drain is not what it should be. In order to detect any of these conditions it is necessary that builders should alter all their plumbing arrangements ; at present they try to conceal everything, so that, without pulling a house to pieces, it is impossible to examine if pipes and traps are in order. Instead of this every pipe should be kept out of walls andabove ground, and if cased with wood, the case should be merely bolted, and not nailed. If a pipe must be carried underground it should he laid in a regular channel which can he opened ; but, as far as possible, all pipes should be above ground and open to sight, and none should run under houses. The sewage and foul water arrange- ments of our houses will never be satisfactory till these matters are attended to, and till the examination of every pipe about the house can be made without difficulty, and clogging or air and water leakage detected. In closets the chief points of leakage are the horizontal pipes and the traps. In all cases the soil pipe should be ventilated by a pipe carried to the open air at some point away from win- dows. Another matter to be guarded against, whether there be drain-smell or not about a house, is the immediate opening of the cistern overflow- pipe, or of the usual rain-water pipe, into the sewer or house-drain ; the co mm on practice is to open them into the sewer, perhaps with a sigmoid trap, which, however, is often dry at the top of them. Then sewer air passes up and enters the cistern, or rooms which happen to be near the top of the rain-water pipe. .Ill these pipes should open in free air over a grating, and if every householder would insist on the builder attending to these matters the chances of in- flow of sewer air into houses would be moch lessened. Another, third, point of importance is the way in which the products of gas-combustion are allowed to pass into the air of rooms. Nothing can be worse than the usual arrangement ; and, as gas-lights might be made a valuable means of ventilation if tubes were arranged to carry off the burnt gas, the present plan of chandeliers is not only hurtful, but involves an ignorant waste of useful force. 4. Impurity of the Water . — "Water delivered to a house may become impure on the premises, usually from uncleaned uncovered cisterns, ab- sorption of air from drains by the surface of the water, and sometimes by more direct leakage from pipes into cisterns. Lead may also be taken PUBLIC HEALTH. op. The remedies for these conditions are obvious. 5. Impurities from Uncicanliness of the House. Walls and ceilings all absorb impurities which are given out again to the air, and often become highly impregnated with organic matters. The chinks of floors allow matters to collect below them, and then impure air rises into the room. Or furniture . may harbour dirt, and thus con- tinually contaminate the air. The custom of re-papering walls without clean- ing the old paper, the decomposition of paste and paper on damp walls, and the use of arse- nical pigments, may disengage impurities. In the houses of the poor which are not regularly whitewashed, the half-crumbling plaster is often highly charged with animal material. These matters are to be avoided by original . good construction and by constant cleanliness. It is a great desideratum to make walls of im- permeable material, so that they may be washed without difficulty; but, at present, this is an expensive matter. If these various points, which are really ques- tions of purity of air and water, and of tempe- rature and movement of air, are properly dealt with, houses must ho healthy. These are con- ditions which are not difficult to secure if they are clearly understood and if their importance : is not underrated. The great point is to have the house-air pure, so as in no way to injure or depress the great function of respiration. While we look to the Municipality or Local i Sanitary Authority to keep the outer air pure, the task of doing the same for the house-air must necessarily fall on the inhabitants of the house. Vital Statistics. — The attention now paid to Public Health is in a large degree owing to the careful collection of the statistics of births and deaths, and of the causes of death, which have been tabulated in England for the last thirty-eight years. It may truly be said, indeed, that not only all Europe, but gradually the entire world, 'las been influenced by the work of the Registrar- General of England. "We are now able to de- ermine the limits of mortality and its causes vith some precision, and are being led towards nterpreting the causes of too high a death-rate. The chief vital statistics bearing upon public tealth are the determination of the birth-rate; f the general death-rate ; of death-rates accord- ng to sex, age, and disease; and of the health f classes of the community, as judged of by their xpectation of life at given ages. There are rnny other problems, but these are the most nportant. The collection of statistics of sick- ess, apart from mortality, has not been hitherto lccessful, on account of the difficulty of collect- 'g the data with sufficient accuracy. See Moe- 3) ITT. . The gross death-rate, without distinction of x or age, is that which is commonly used to press the health of a town or district. It is, course, to be understood that it is but an ,3mentary expression that should be accom- nied by further analysis of mortality accord- ? to diseases and ages, and by consideration of e birth-rate also, for the deaths of newly horn 1287 and young children form always a large item in the list. As far as it goes, however, the general death-rate is extremely useful. It is calculated on the population, which in England is ascer- tained positively by census every ten years, and in the intervals may be veryfairly estimated from a variety of data ascertained for the particular place or district. It was in view of gross death- rates in various districts of England that it waj assumed in 18-18, when the first Public Health Act was passed, that in this country the public health is nowhere satisfactory if the death-rate of the locality exceed 23 per 1,000 of popula- tion per annum. And under the provisions of that Act the General Board of Health consti- tuted by it was empowered to send an inspector to examine into the hygienic condition of any locality, wherein the number of deaths annually exceeded this iate. It would now seem that the number proper to be regarded as constituting a standard for such a purpose, might reasonably be lowered from 23 to 22 or even 21, but no legal or authoritative statement has been made of late years. See Moutality. Further investigation of mortality statistics according to age -and disease is, however, neces- sary to form a correct notion of the sanitary state of any district. Unexpected results are sometimes brought out, as, for example, that a general high death-rate may be owing entirely to an extremely high infantile mortality. The dis- eases which occasion the high death-rate will then also appear, and will indicate the directions for remedial measures. The child death-rate (that is, the death-rate at ages below five years, or even for every single year of the five, calculated on the population living at the several ages; or if that be not known, then on the gross population) is indeed most necessary to be known in every health-enquiry. Among the poor population of our large cities the deaths of children under five years of age may be found to constitute half of the total deaths at all ages, and occasionally in some had districts in unhealthy towns the deaths of chil- dren have reached 60 per cent, of the total deaths, whereas in all England the child death- rate (under five years) is but 40 per cent, of the total deaths, and in healthy districts and good families is below this, even below 30 per cent, of total deaths. In this way of reckoning, however, the excessive mortality of infants is obscured by an excessive mortality among older people ; and a better measure is to be found in the rate of annual mortality among 100 children under five years of age living in a community. Thus measured, it is found that there may die annually only four among the better classes, and from ten up to the immense mortality of twenty- six in the worst parts of our large towns. How wonderfully the child death-rate is in- fluenced by the high social position of the parents, which implies greater care of the chil- dren, is strikingly shown by Mr. Ansell's very useful tables of mortality among the upper classes. Of 100,000 children horn alive there are living at the end of their fifth year in all England 74,000 (in round numbers we may say that one quarter have died), among the ‘upper classes’ 12S8 PUBLIC HEALTH. (as defined by Mr. Ansell), 87,000 are living at the fifth year, while among the peerage not less than 90,000 are living. As a contrast, the writer would refer to a street in Liverpool, where he found the death-rate so high that only 10,000 children would be living at the end of five years out of 100,000 ; or 90 per cent, had died in five years. The determination of the diseases producing a given mortality is also a necessary part of all vital statistics, regarded as expressions of the public health. Tlio chief diseases causing mortality 7 under five years of age are diarrhoea and convulsions from bad food ; acute chest-affections from cold and exposure and vitiated air; and the contagious infantile diseases. The mortality from these causes is of course greater in amount among the children of the poor. Among older people phthisis and chest-affections, and from time to time outbreaks of infectious diseases, hold the first rank. The degree of prevalence of the infectious or so-called zymotic diseases must be always care- fully noted, but there are many other preventible diseases quite as worthy of attention, and espe- cially the acute and chronic chest-affections which are largely owing to removable unhealthy conditions of atmosphere and mode of life. The calculations necessary to bring out the re- sult are of the most simple kind if the data are known, namely, the number of the population, and of persons of various sexes and ages ; the number of deaths, the sex and age of the persons dying, and the diseases causing the mortality. ' The national census furnishes some of these figures, and the medical profession contribute the material for the rest. They bear, therefore, a very great responsibility ; for inaccuracy of ro- cord by them may greatly affect the action of the community 7 , taken on the faith of the accuracy of the statistics. Heretofore statistics of mortality alone have been available for the purposes of the sanitary physician and administrator, and their utility has been unquestionable. Such statistics, how- ever, are necessarily a very incomplete measure of the influences affecting the public health. When, in the future, it shall have become pos- sible to make proper record of all sickness, whether fatal or not fatal, further progress in the investigation of the conditions productive of disease, and in securing for the community the most healthful circumstances of life, will become practicable. The third statistical point to which reference has been made is the length of life a person of a given age may expect to live. This so-called ‘ expectation of life’ or ‘mean after-lifetime’ is the most exact test of the general health of a people. It is one, however, which can only be applied at long intervals, and by the aid of very accurate and numerous census and death lists. It is not, therefore, applicable as a daily method of determining the degree of health. It appears, however, that, at the present time, as compared with former periods, the expectation of life is improving in the chief European countries, and the mean age at death is also greater than formerly. PUERPERAL DISEASES. It is the office, then, of the statistician, by his study of the distribution of disease and the incidence of mortality, to guide towards an appreciation of the causes thereof, and to a better knowledge of the natural laws which influence public health : and it is the business of the sanitary legislator and administrator to give due recognition to those natural laws in their endeavours to maintain the health and to save the lives of the people. The struggle with disease and deatli is never-ending, but is not indecisive. It is remarkable how steadily public health has improved with each new advance in wise legislation. In no case has disappointment resulted, and in some instances the good results have been really surprising. Much still remains to be done, and many sanitary problems wait for solution ; but the rapid progress of late years makes us confident that greater effects still will follow as the knowledge of the causes of disease becomes more precise, and tho tech- nical means of prevention are more efficient!? applied. 1 E. A. Pabees. PUERILE ( pucr , a boy). — This word is as- sociated in medicine with the respiratory mur- mur when it is exaggerated, possessing the cha- racters heard over the lungs in a healthy child. See Physical Examination. PUERPERAL DISEASES. — The disease? associated with parturition, which fall for con- sideration in the present article, are:— 1. Puer- peral Convulsions ; 2. Puerperal Fever ; 3. Puer- peral Peritonitis ; and 4. Puerperal Thrombosis and Embolism. Certain other pathological con- ditions of equal importance, occurring during the puerperal state, are more conveniently dis- cussed under their several special names. See Pelvic Abscess; Pelvic Cellulitis; Pelvic Peritonitis; and Phlegmasia Dolexs. Puer- peral insanity is described in the article In- sanity, Varieties of. 1. Puerperal Convulsions. — Synon. : Puer- peral Eclampsia; Fr. Convulsions des femmes enceintes et en couclie ; Ger. Eklampsie in dtr Schwangerschaft und irn Wochenbdt. Definition. — A pccular kind of epileptiform convulsions, characterised by loss of conscious- ness and of sensibility, together with tonic and clonic spasms ; occurring in the later months of pregnancy, during labour, or after delivery ; and causing great danger to the lives of both mother and child. ./Etiology. — The frequent association of this disorder with albuminuria had till lately given rise to the belief that it is the result of uraemia. More recent observations, however, have thrown a doubt upon tips doctrine. Many cases have been observed in which albumen was present in large quantity without convulsions occurring; and others in which the eclamptic attacks took place without any albumen, or a mere trace only, being present. ! Traube and Rosenstein have referred tho causation of the convulsions to acute cerebral 1 This article, which was written by Dr. Parkes before his lamented death, has been revised, and a few pasoakis inserted, marked [ ], by Dr. George Buchanan. PUERPERAL DISEASES. anaemia, resulting from changes in the blood incidental to pregnancy, the watery condition of the blood being associated with increased tension of the arterial system. More recently, Dr. Angus Macdonald, of Edinburgh, has pointed out that he has discovered by post-mortem examination, extreme anaemia of the cerebro-spinal centres, with congestion of the meninges, without oedema. He attributes the convulsive attacks to irritation of the vaso-motor centre from an anaemic condi- tion of the blood, produced by the retention in it of excrementitious matters which should have been eliminated by the kidneys. Svmptoms. — Although frequently the convul- sions occur suddenly, no previous indications having been observed, still on inquiry it will generally be found that certain premonitory symptoms have been present. The most promi- nent of these is headache, sometimes very in- tense, generally frontal. Derangement of vision is another grave indication. An important sign when present is oedema, which may attract notice by puffiness of the face, especially of the eyelids, and should immediately suggest an examination of the feet and ankles, and of the urine. When the convulsive seizure occurs it cannot be mistaken. The eyes first become fixed, and rapid contraction of the muscles of the face occurs, with rolling of the eyeballs, the pupils being lost under the upper eyelids. The face becomes turned first towards one shoulder, then towards the other. The convulsions rapidly ex- tend to the other parts of the body ; after a short period of tonic contraction violent clonic spasms occur. The face becomes livid, the tongue is protruded, and, if care be not taken, it is lacerated by the teeth, colouring t he frothy saliva which has been emitted at the angles of the mouth. The thumbs become clenched in the palms, and violent jerkings of the arms occur, whilst the muscles of the face give rise to a variety of contortions. Sometimes involuntary evacuations of the bladder and rectum occur during the fit. There is total loss of consciousness and sensation. After a few minutes the symptoms gradually subside ; a longer interval occurs between the clonic muscular contractions ; the face loses its lividity ; and the breathing becomes more tran- quil. After the first fit has passed off the patient may recover her consciousness ; but if another occur with rapidity, and very little time elapses between the paroxysms, death may soon super- vene. Where there is a considerable time be- tween the attacks, it may be many hours or days before consciousness is restored, and recovery takes place. A remarkable feature of this dis- order is that when the patient becomes sensible, and is restored to health, she has invariably no recollection of what occurred not only during her illness, but for some time preceding the fits. The writer has observed the case of a woman whose puffy face attracted his notice in the City of London Lying-in Hospital the morning after her labour ; there was oedema of the ankles, and the urine contained abundance of albumen. Having remarked that it was a wonder she had lot had convulsions, he was summoned to find ter in this condition within a few hours. She »-s comatose for three days, and on subsequent 1289 inquiry she had no recollection of being taken in labour or of being conveyed to the hospital. This is by no means an exceptional case. Prognosis. — This depends upon the severity and frequency of the paroxysms. It is gener- ally considered that one in every three or four cases proves fatal. The mortality has probably diminished of late years, since indiscriminate venesection has been abolished, and other treat- ment. adopted. Treatment. — The treatment of puerperal con- vulsions depends greatly upon the period in re- lation to labour at which the eclamptic attack occurs. Generally the paroxysms in themselves are sufficient to provoke labour, and if this pro- ceed well, it should be allowed to take its own course ; officious manipulation is apt to increase the severity of the fits. Under some circum- stances, however, the induction of premature labour is necessary ; or it may be expedient to deliver as soon as possible when labour has commenced. Venesection, which used to be the universal treatment, is now very rarely adopted. There are, however, cases in which it is un- doubtedly called for ; in women of plethoric habit, with congested face, and full pulse, show- ing much arterial tension, it will probably be found of great benefit. Compression of the earotids, first recommended by Trousseau in the convulsions of infants, has been successfully adopted by Dr. Playfair in puerperal eclampsia. As soon as the attack commences it is well to administer an aperient, if possible. The treatment which has of late been found most serviceable is the administration of chloro- form, which not only modifies the force of the attacks, but appears in a marvellous way to diminish their frequency. It should be freely administered on the first symptoms of the attack, and its effect should be kept up until the fit has entirely subsided. Chloral alone, or in combination with bromide of potassium, may be administered by the mouth or rectum, often with great advantage. This may obviate the necessity of a further continu- ance of the chloroform inhalation. The hypo- dermic injection of morphia, which lias been condemned by some on account of the renal condition, has, nevertheless, been frequently found most efficacious, notwithstanding a large amount of albuminuria being present, and it is weU worthy of a more extended trial in pro- longed cases. 2. Puerperal Fever. — Stnon. : Childbed fever; Puerperal Septicaemia ; Fr. Fievre puer- perale-, Ger. Puerpcralfieber ; Kindbettficber. Definition. — A continued fever, occurring in connection with child-birth ; often associated with local lesions cf the uterus, vagina, or peri- neum ; and caused by the absorption of septic matter, not infrequently arising from the reten- tion of portions of placenta or membrane, or from a putrid foetus. ^Etiology. — Puerperal fever occurs not only epidemically but endemically, especially in lying- in hospitals ; and is communicable by contagion. Special sources from without are cadaveric matter communicated by the hands of the practitioner after making post-mortem examinations, and PUERPERAL DISEASES. 1290 septic matter conveyed by nurses on their hands or on sponges. Prolonged mental distress, and an impoverished state of the blood from want of food, predispose to it. Puerperal fever may be produced by the contact of other diseases, especially erysipelas, whicli in some respects bears a close analogy to it, a prominent charac- teristic of both being a peculiar diffuse inflam- mation ; in one the part affected being the skin and connective tissue, in the other the seat being the uterus, uterine veins, and peritoneum. Anatomical Characters. — These differ very greatly according to the duration of the fever, and the parts of the body affected by the dis- ease. In some rapidly fatal cases of a malignant type nothing has been found but a peculiar alteration in the blood — a great increase in the white corpuscles; a diminution in the red blood-cells ; an increase also in the fibrine and extractive matters, lactic acid and fat ; and fre- quently traces of bile-pigment. Generally, however, local lesions exist, and if these are seen after death, in the shape of lacera- tions in the genital tract, they will present an unhealthy appearance, their edges being swollen and cedematous. The uterine surface is generally found intensely inflamed, softened, and occa- sionally in a state of slough. The results of in- flammation may also be found in the veins, parenchyma of the uterus, and connective tissue around it ; as well as in the lymphatics, so large and numerous at this time, pus being frequently discovered in these vessels. The peritoneum is nearly always affected ; it may bo only congested in patches, but is generally universally so ; the intestines may all be glued together ; and the sac may contain more or less serum or sero-pns, with flaky lymph. Inflammatory swelling, softening, or abscesses may be found almost anywhere, in the uterine wall, ovaries, kidneys, spleen, liver, lungs, muscles, and connective tissue. Effusion into all the serous cavities may arise, and pus may be discovered around, or even within, the joints. An embolus may be found, a fragment of infected thrombus having escaped. Symptoms. — In no disease do the symptoms vary more than in this, depending upon the vio- lence of the fever, and the localities attacked by the poison. The fever generally originates within three or four days after delivery, though some- times later. Frequently there is, first of all, great depression, with headache; sometimes the first symptom is a rigor. The pulse becomes rapid and feeble, 130 or more per minute. The tem- perature rises to 103° Eahr., or higher. The skin is generally hot and dry. Vomiting fre- quently occurs early, the ejecta being like coffee- grounds, aud of a peculiar odour. Diarrhoea is often very troublesome, the evacuations being horribly fetid. The tongue soon becomes coated with a heavy fur, later on becoming dry and raspy ; and sordes appear on the lips. There is often acute pain, with tenderness and swelling, of the abdomen; but peritonitis with effusion may occur without any of these symptoms. Some- times the swollen, tender uterus can bo felt in the hypogastrium. The lochia are generally sup- pressed, and the secretion of milk arrested, though sometimes the mammie are hard and painful. As a rule the intellect is unimpaired, though low muttering delirium frequently precedes death. The breathing is short and hurried. Pneumonia, pleurisy, or pericarditis occasionally ensue. Jaundice or albuminuria may be present. The joints may swell and suppurate; and abscesses may form in any part of the body, sometimes in the eye. Course and Terminations. — The disease generally runs a rapid course, terminating fatally within a week. The pulse becomes more and more rapid and feeble ; the breathing mors hurried and panting ; tympanites sets in ; a cold clammy sweat breaks out ; finally hiccough, sub- sultus, and low muttering delirium come on, with frequently incessant vomiting; and the patient sinks from exhaustion. Treatment.— 1 . Prophylactic . — This is of the utmost importance. Keeping in mind the sources of the disease, it behoves the practitioner to avoid every means of communicating septie matter to the patient, either personally or by the nurse. If possible to arrange it, the genital organs should never be touched, for the purposes of examination or otherwise, without the hands having been first thoroughly rinsed in a solution of pure carbolic acid (1 to 20). All sponges should be permanently kept in a similar solution ; and all instruments, such as vaginal syringes or catheters, be thoroughly soaked in the same be- fore use. Instead of cold cream, a preparation containing 1 drachm of absolute carbolic acid to 2| oz. of benzoated lard should be employed for lubricating. The utmost care should be observed, to avoid the smallest piece of the placenta or membrane being left within the uterus. Subse- quently all washings or svringings of the genitals should be performed with a solution of carbolic acid (1 to 40). The practitioner should order all these preparations to be in the house previous to the expected time of delivery. 2. General . — The general treatment varies with the character of the disease. At first ac- tive antiphlogistic remedies maybe indicated: and in some cases local depletion by leeches, in others blisters. Drugs, such as veratmm viride (much employed in America), aconite, digitalis, or salicylic acid, may be useful in lowering the temperature. The internal administration of turpentine has been highly extolled ; this drug is often very efficacious when applied on hot flannel to the abdomen, or used as an enema where there is much tympanites. Opium, or morphia, is invariably demanded to subdue rest- lessness, allay pain, and induce sleep. Lauda- num, applied in poultices to the abdomen, is sometimes very grateful to the patient.. When, however, there is much tenderness and disten- sion, a paste composed of two parts of extract of belladonna to one of glycerine, brushed thickly over the whole abdomen, will be preferable. Quinine is often of great value in diminishing the fever ; it may be given in doses of 10 or 15 grains night and morning. Warburg's tincture may answer still better. The antiseptic douche should never be omitted; and a long vaginal tube should be employed, so as to ensure the fluid passing within the uterus. If used warm it is often very comforting, especially when the discharges are fetid. In cases of a more chronic type, where diarrhoea is a prominent symptom, tincture of PUERPERAL DISEASES. perchloride of iron in large doses, 20 to 30 minims, is sometimes very serviceable. One of the most important elements in the treatment of this exhausting disease is the frequent adminis- tration of nutritious food and stimulants — strong boef-tea, milk, eggs, champagne, or brandy— in small quantities at short intervals. In cases of obstinate vomiting recourse must be had to nu- trient eneraata. The most abundant supply of fresh air that can be admitted with safety should be secured. It is impossible to map out any distinct line ; of treatment for puerperal fever. Each case must be combated according to its individual symptoms, and demands constant attention ; for, though the disease is fearfully fatal, some of the most apparently hopeless cases recover. 3. Puerperal Peritonitis. — This, though one j of the most frequent complications of puerperal fever, sometimes occurs independently of it, other symptoms than those consequent upon the local inflammatory attack being absent. Anatomical Characters. — - The post-mortem appearances, associated with puerperal perito- nitis, differ only from those described in con- nection with puerperal septicaemia inasmuch as they are confined to the peritoneal cavity. There wiii probably be found an abundance of effused serum or sero-pus, and flaky lymph, intense con- gestion of the peritoneum, and the abdominal viscera will here and there be glued together. The uterus will pirobably be found preternatu- rally soft. Symptoms. — Generally within a week follow- ing delivery a well-marked rigor occurs, followed ' by febrile disturbance. The patient complains of acute pain in the lower part of the abdomen, • at first in one particular spot, but soon spreading over a larger area. The thighs become flexed on the abdomen to relieve the tension ; the belly : becomes much swollen, and excessively tender ; and there are generally much tympanites and obstinate constipation. The pulse is very cha- racteristic, being quick, wiry, and incompressible. Vomiting soon sets in. If the disease do not give way, the abdomen becomes more swollen and tense, and no pressure upon it can be borne. Everything that is taken is vomited ; the pulse becomes more rapid and feeble ; the tongue is dry and raspy ; the constipation gives way to diarrhoea ; the skin becomes clammy, and the extremities cold ; and the patient dies. Treatment. — Tho application of leeches to 1 the abdomen, immediately the tenderness is com- plained of, may be of much service in subduing the local inflammation, and allaying pain. Opium is the drug of all others to be relied upon. Hot fomentations and counter-irritants, such as tur- 1 Jentine, often give great relief. In the first stage a lopious enema of thin gruel with castor-oil, to ob- :ain a free action of the bowels, should be given. vVhere there is much tympanites, the addition of • urpentine may be of benefit in dispelling the latus. If vomiting prevent nourishment being aken by the mouth, it should be administered >cr rectum. 1. Puerperal Thrombosis and Embolism. Definition. — T he occurrence of a blood-clot u the right side of the heart or pulmonary ar- eries, either formed in situ or conveyed there PULMONARY VESSELS. 1291 from a distance by the blood-current, often giving rise to sudden death after delivery. Anatomical Characters, — The condition of the blood in pregnancy and the puerperal state renders it liable to form a coagulum, and this may occur in distant vessels. It is well known that in the later months of pregnancy the amount of fibrin in the blood is very greatly increased. Together with this a diminution in the volume of the blood from uterine haemorrhage produces a state of exhaustion, which causes a great pre- disposition to thrombosis. If, therefore, such having occurred in distant vessels, a portion of coagulum become detached, and be carried away till it reach the pulmonary arteries, embolism is tho result, and this is one of the great causes of sudden death occurring after parturition. It has been shown, however, that pulmonary thrombosis may occur independently of embolism; large, firm, decolourised coagula have been found, on post- mortem examination, occupying the right side of the heart and the larger branches cf the pulmo- nary arteries, which have evidently formed there, all traces of thrombosis elsewhere being absent. Symptoms. — These are common both to em- bolism and pulmonary thrombosis. In the great majority of cases, the patient is suddenly seized with severe dyspnoea ; she starts up and gasps for breath ; the face in some cases has been described as pale, in others livid. She feels she is dying, and calls out for air ; the pulse becomes almost imperceptible ; and generally death occurs very rapidly. In some cases, however, in which the clot is not sufficiently large to entirely obstruct the circulation in the lungs, it appears that ab- sorption may ultimately take place and recovery ensue. Dr. Playfair has published some cases which support this theory. Treatment. — In almost every case so rapidly fatal is the seizure that there is no time to think of treatment. When, however, the attack is not so terribly rapid in its termination, every effort must be made to rally the patient, by the admi- nistration of stimulants, such as brandy, ether, or ammonia, if at hand. The most perfect rest must be enjoined, so as to prevent the coagulum from becoming dislodged, and to promote its absorption. Dr. Richardson has recommended liquor ammoniae in large doses, with a view of dissolving the fibrin. Clement Godson. PUERPERAL IN SANITY. See In- sanity, Varieties of. PULLNA, in Austria. — Sulphated waters. See Mineral Waters. PULMONARY APOPLEXY— A term for a certain form of haemorrhage into the lungs. See Lungs, Haemorrhage into. PULMONARY DISEASES. See Lungs, Diseases of. PULMONARY "VESSELS, Diseases of. The vessels of the pulmonary circulation, more especially the veins, enjoy a considerable immu- nity from disease. Primary affections of these are of most exceptional occurrence, and the causes leading to their being secondarily involved are not numerous. It is not easy to account for this. The pulmonary arteries rarely present those 1 292 PULMONARY VESSELS, DISEASES OF. iiseased states which are of frequent occurrence in the arteries of the systemic circulation, and are not even as commonly affected as the sys- temic veins, with which they somewhat more closely agree in point of structure, and in the kind of blood carried by them. The portal vein, which is comparable to the pulmonary artery in other respects besides its plan of distribution, would appear to be similarly free. For these reasons affections of the pulmonary vessels are rather of pathological interest than clinical im- portance ; in the majority of cases they are not to be recognised during life, or, if so, are beyond the application of any treatment. The trunk of the artery, and especially the orifice in the right ventricle, is singularly liable to present congenital abnormalities, which are treated of in the article IIeaht, Malformations of. 1. Inflammation. — JEtiologt. — Arteritis affecting the pulmonary artery, whether acute or chronic, is of very rare occurrence. Previous to birth it seems to be more liable to exist than subsequently, and some of the congenital defor- mities of the pulmonary artery and its ralve are to be attributed to it. No satisfactory explana- tion has been offered of the greater tendency of the right heart and vessels to inflammation before birth, and of the left side and aorta sub- sequently. After birth it is almost invariably associated with such acute blood-diseases as pyaemia, or with those pyrexial states which are apt to assume a septic character, as scarlet fever. Very rarely cases are met with where no cause can be ascertained ; but it is said that whilst syphilis favours arteritis in the aorta, chronic alcoholism predisposes to its development in the pulmonary artery. Emboli, especially if of a putrid character, -which have become lodged in branches of the vessel, are very liable to set up inflammation in the contiguous walls. Anatomicau Characters. — These correspond with the usual characters of arteritis. The pro- cess begins in the sub-epithelial layer of the inner coat, and results in the formation of a variety of • connective tissue, which consists of fibres, fusiform fibre-cells, and homogeneous material ; these constituents being developed in varying proportions, and forming patches of grey gelatinous or semi-cartilaginous material. The formation of pus and abscesses within the thick- ness of the walls, and their subsequent rupture into tho lumen of the vessel, are practically unknown. The valves at the commencement of the vessel are the most frequent seat of inflam- mation, but it has been seen in the main trunk of the vessel. When the vessels have become much dilated, as from extreme mitral stenosis, the walls thus thinned are liable to undergo changes of a chronic inflammatory character (see Arteries, Diseases of). This state is only demonstrable after death ; during life it is not recognised, except the valves be affected, by any known signs or symptoms, and a diagnosis of its existence has not hitherto been attempted. Under such circumstances no plan of treatment can be laid down. 2. Degenerations. — (a) Atheroma. — This, as in the systemic arteries, occurs in two forms. The one form is a sequence of inflammation, when the patches of grey translucent material above- mentioned undergo fatty degeneration, and, as Virchow pointed out, tend to ulcerate, whilst similar patches in the aorta are more liable to calcify. The other form consists in a fatty dege- neration of the deeper layers of the intima with- out any previous inflammation, and occurring as part of a general atheroma of all the vessels. It is in vessels whose structure has been much altered by distension that atheroma is most fre- quently seen. Calcification of the atheromatous areas is not unknown. No symptoms are to be referred to this condition, though Dr. Walshe suspects that ‘ in some instances it aids in the production of pulmonary apoplexy.’ (b) Albuminoid degeneration. — This has been recorded as having been seen in the muscular coat of branches of the pulmonary artery. 3. Ulceration. — As already said, inflamma- tion of the vessel-walls very rarely extends to ulceration of the inner coat, but owing to the extreme frequency of ulcerative destruction of the lung-tissue, the intra-pulmonary branches of the vessels are constantly involved. Phthisis of whatever kind, abscess, or gangrene of the lungs, will each in their progress invade the vessels, the walls of which, though offering con- siderable resistance to the destructive process, sooner or later yield, and may be the cause of a fatal haemorrhage, though very frequently a loss of blood is prevented by blocking up of the vessels with coagula. 4. Dilatation and Aneurism, — A xatomical Characters. — Varying changes of abnormal dis- tension are not unusual, occurring in both sexes and in all ages beyond childhood, and are esti- mated as forming 3 per cent, of aneurisms of all kinds. The dilatation may affect the trunk uniformly ; and an extreme case has been re- corded where the circumference of the vessel at- tained 6 j inches, the normal average being taken at 3.) inches. Or, limited in extent, the bulging forms a sacculated, or, more rarely, a dissecting aneurism of the trunk or branches, from the size of a walnut to a pea, or even smaller, these latter being frequently multiple. The conditions which lead to these alterations in the normal calibre of the vessel are : — (a) Those causing a diminished resistance of their coats to the blood-pressure, especially if this be increased, which is often the case, by obliteration of some vessels, and con- sequent rise in tension in the remaining ones, or by general obstruction, such as mitral stenosis or emphysema would cause. (A) Those changes in the lung-structures which diminish the sup- port of the vessels, and so allow of their yielding. The results of arteritis and atheroma will furnish the first condition, and ulceration and destruction of the pulmonary tissue will provide the latter. The walls of true aneurisms may he thicker or thinner than those of the healthy vessel.and it is remarkable that their contents are never lami- nated coagula, even in the largest, but always fresh clots. An extreme case of distension of the pulmo- nary veins is recorded ( Dublin Journal. 18321, especially the left, where the vessels were di- lated to four times their normal size, owing to extensive obstructions at their openings into the left auricle. SrMETOiis. — When the main trunk of tb? PULMONARY VESSELS, DISEASES OF. pulmonary artery is the seat of an aneurismal tumour, there are the usual signs of pulsation and prominence in variable degrees, most marked to the left of the sternum in the second intercostal space ; over the same area a systolic bruit of a superficial quality is to be heard, not conducted above the sternum or clavicles ; and a systolic thrill is to be felt. There is also accentuation of the second sound, with the signs of hypertrophy of the right ventricle. Should the tumour be of any considerable size, it will give rise to those conditions which commonly follow an obstruction to the pulmonary circulation — namely, lividity, dyspnoea, cough, and general anasarca, with scanty, high-coloured urine. In an exceptional case pallor of the face was noticed. Pain behind the sternum, and headache also exist. Since the greater part of the artery is included within the pericardium, it is into that sac that rupture will probably occur. The small aneurisms of the intra-pulmonic branches give rise to no known symptoms until haemoptysis indicates their rupture. Diagnosis. — An aneurism of the trunk of the pulmonary artery may have to be distinguished from a similar affection of the aorta, or from a post-sternal tumour to which pulsation has been communicated. The tendency of pulmonary aneurism to extend to the left side, and the non- conduction of the bruit to the vessels at the root of the neck, with the coincident signs of pulmo- nary obstruction, are grounds upon which to found a distinction. Prognosis. — This is of necessity grave, what- ever the size of the lesion, and many eases of fetal haemoptysis are due to rupture of a small- sized sac. Treatment. — How far such treatment as gal- vano-puncture, the administration of iodide of potassium, &c., as pursued in aneurism of the systemic vessels, is applicable to similar affec- tions of the pulmonary artery, is unknown. For the treatment of the haemorrhage to which their rupture gives rise, see Bjemoptysis. 5. Stenosis. — A narrowing of the pulmonary artery may take place at the orifice in the conus arteriosus, or more rarely in the trunk or main branches. In the former situations it is com- monly congenital, the result of endocarditis or myocarditis, which, if developed within the first three months of foetal life, is almost invariably accompanied by some compensating lesion, such as intraventricular communication ; whilst if the affection of the heart ho subsequent to the third month of development, the circulation is carried on through a patent foramen ovale and ductus arteriosus ( see Heart, Malformations of). It is conceivable that stenosis of tlio conus arteriosus may be followed by secondary narrowing and closure of the pulmonary artery, and also that defective development of tho lungs may cause a narrowed vessel. The condition is very rarely due to any acquired change in the vessel-walls, although a case is recorded of stenosis of the artery from cartilaginous thickening and calcifi- cation of its coats. The calibre of the tube may be diminished by the pressure of tumours, such as an aortic aneurism or adenoid growths, or by tiie shrinking of cicatricial tissue in the adjacent lungs. 1 293 AVhen stenosis is developed at a very early period of foetal life, the artery remains exceedingly narrow behind the obstruction. AVhen it occurs late, the vessel may he of normal capacity, and if insufficiency co-exist with the obstruction, it may even he dilated (Lebert). Symptoms. — AVhatever be the cause of pulmo- nary stenosis, there will be a deficient supply of blood to tho lungs, producing dyspnoea, and the obstruction to the circulation will give rise to nil the signs and symptoms of general venous conges- tion, although to a less degree than in affections of the tricuspid orifice. Hypertrophy of the right ventricle, as evidenced by increased trans- verse measurement of the area of cardiac dul- ness ; a basic thrill ; a systolic bruit, of maximum intensity over the heart’s base, and conducted to the left of the sternum, but not audible along the course of the aorta and great vessels ; and a marked accentuation of the second sound — are the most important diagnostic signs of this condition. Cyanosis is not a characteristic, and does not occur unless there he extreme venous congestion, or a communication between the two sides of the heart. The association of constriction of the pulmonary artery, both congenital and acquired, with tubercular phthisis, has now been too fre- quently observed for it to be regarded as a co- incidence only, and their relation as cause and effect is generally admitted. Teeatment. — This affection is entirely beyond the reach of remedy. 6. Hupture. — Violent effort and great excite- ment have been followed by rupture of the pul- monary artery, either of the trunk or main branches ; it is said, even without previous dis- ease of the vessel (Chevers, 1816). But in the majority of recorded cases the coats were dege- nerated. Death is often instantaneous, hut very frequently is delayed, even some hours. Aneur- isms tend to burst sooner or later ; those of the trunk usually opening into the pericardium, while the intra-pulmonary dilatations commonly rup- ture into cavities in the lung. Ulceration, as said, is of very rare occurrence, but a case is recorded of its existence and extension through all the coats of the vessel, with a suddenly fatal termination. Rupture of the pulmonary veins has been recorded. 7. Embolism and Thrombosis. — The pulmo- nary artery is especially liable to become plugged, both by substances lodged in it from elsewhere, and by coagula originating in the vessel itself. Its re- lationship to the venous circulation explains this. Portions of broken-down clots developed in the systemic veins, from whatever cause ; the contents of hydatid and other cysts that have burst, into the venous current; fragments of cancerous and other new growths, all of which readily travel onwards towards the heart, pass into the pul- monary artery, in the branches of which they become lodged, according to their size. Once located, the plug will increase in size by the de- position on it of successive layers of fibrin, sometimes to such au extent as to obliterate all traces of the original obstructing substance. Oc- casionally very large thrombi are detached in the systemic veins, and are arrested in the trunk and main branches of the pulmonary artery. The causes of thrombosis of the vessel are various. 1294 PULMONARY VESSELS. The rare occurrence of inflammation or degenera- tion of the artery renders obstruction of the vessel from primary thrombosis very uncommon; but the development of clots iu the smaller branches, in association with pneumonia, phthisis, gan- grene, and other destructive Aing-diseases, is frequent. In certain septic states, in parturient women, and in conditions of extreme anaemia, es- pecially with diminished heart-power, when the blood is prone to clot in the vessels, the pulmon- ary artery is a favourite locality for this to occur. Thrombi may commence in the right ventricle, or, as would appear, sometimes on the semi- lunar valves, and extend into the trunk and, for variable distances, into the branches of the ves- sel. Such obstructions are frequently developed during the last hours of life, when the circula- tion is enfeebled and slow. See Embolism: ; and Heart, Thrombosis of. Symptoms.— The symptoms will, of course, depend upon the extent and completeness of the obliteration of the pulmonary circulation. If only the smaller branches be occluded, there may be no symptoms to be directly ascribed tc the obstruction. A very moderate dyspnma or slight haemoptysis would be equally attributable to the phthisis or other lung-state which had deter- mined the formation of the thrombi. In another class of cases, when larger branches are blocked, very marked dyspnoea is developed, with such symptoms as are conveniently grouped under the term ‘ anginal,’ such as pain in the prseeordia, a sense of great distress and faintness, palpitation, lividity, and extreme pallor, with cold sweats, but no loss of mental faculties, and an almost imperceptible pulse. The onset of such a condition maybe gradual or rapid; in the former case it depends on the slow increase in size of a small thrombus; in the latter, on the sudden lodgment in some branch of the artery of a solid substance that has entered the venous current. In some cases these symptoms are present to an extreme degree, and death follows in a few minutes ; in fact, this lesion constitutes one of the causes of sudden death. The appearances are not those of asphyxia, and it is usual to attribute the very rapidly fatal result to syn- cope or shock, as it would seem to be connected in some way with an arrest of the nerve-govern- ance of the heart. In that class of cases which do not terminate so quickly, it is usual to find that the symptoms abate somewhat, and may be followed at a variable interval of hours or days by a second or even several attacks, finally ending fatally. The post-mortem examination of such cases shows a thrombus of considerable extent, with indications of its having been formed at different times. Examination of the chest reveals no diagnostic signs. There is very likely to be a basic systolic murmur conducted along the course of the pul- monary artery ; but this is not constant. Diagnosis. — This is often very uncertain. The conditions in which thrombosis is usually met with, such as anaemic or parturient women, are those in which breathlessness, cardiac pain, and discomfort, and even a pulmonary hsemic bruit, are of frequent occurrence. The symptoms, when not of extreme rapidity, are very similar to those caused by stenosis of the pulmonary artery, PULSATION. which in itself is difficult to diagnose; and lastly, the suddenly fatal cases are almost iden- tical in their manifestations with rupture of the heart or of a thoracic aneurism, or even angina pectoris. The supervention of the above-detailed symptoms in a case of existing phlebitis, in a woman within twelve or fourteen days after child- birth, renders it highly probablethat they are due to a clot in the pulmonary artery. Prognosis. — This is to be looked upon as of the gravest character, if once symptoms arise which indicate the existence of a clot in the pul- monary vessels. The smallest plugs formed in branches which are being invaded by a progres- sive destructive change in the lungs, are pro- tective in character, and prevent or diminish an haemoptysis which erosion of the vessels might produce. Treatment. — In the most rapid cases death takes place before anything can be done; but in the less severe cases two points have to be attended to, namely, absolute rest, and free sti- mulation by brandy, ether, and ammonia, for by such means only can any hope be entertained of preventing an extension of the clot. Sinapisms over the cardiac region often afford relief. W. H. Allchin. PULMONARY MURMUR.— This word may be employed in two senses, namelv as sig- nifying, first, the respiratory sound heard over the lung; or, secondly, a bruit heard in connex- ion with the pulmonary artery and its valves. See Heart, Valves of, Diseases of ; Physical Examination; and Pulmonary Vessels, Dis- eases of. PULMONARY VALVES AND ORI- FICES, Diseases of. See Heart, Valves of, Diseases of ; and Pulmonary Vessels, Diseases of. PULSATION ( pulso , I beat). — Pulsation is a sensation of beating or throbbing, either ob- jectively appreciated by inspection or palpa- tion, or subjectively felt. It originates in the presence of a pulse or rhythmical rise and fall of blood-pressure, whether normal or abnormal, in connection with the part where it is situated. In most instances this is either the heart or some kirge blood-vessel; but in other instances the pulsation has a different origin, especially when the phenomenon is abnormal. As instances of normal pulsation may be mentioned the cardiac impulse; the arterial pulse generally; the pul- sation of the umbilical cord ; and the beating of the fontanelles. Abnormal pulsation may be referable (1) to dilatation of a blood-vessel, as in aneurism ; (2) to vascular dilatation and cardiac enlargement, as in aortic incompetence; (3) to vascular dilatation and cardiac excitement, as in exophthalmic goitre ; (4) to interference with the passage of blood through a vein, or even regur- gitation into it, as in the jugular pulse of tri- cuspid disease ; or (5) to the presence of a tumour upon a large vessel, conveying thenormal pulse unnaturally to the surface of the body, as in tumour of the pancreas or pylorus. Pulsatiou may also be present (6) in any part when it is the seat of inflammation, the small vessels being dilated; (7) in aneurism by anastomosis; and PULSATION. (3) in malignant disease of bone, which may closely simulate aneurism. With respect to the characters of this pheno- menon, it is of great practical importance to distinguish true expansile or eccentric pulsation from pulsation which is communicated only. In the former case the seat of pulsation expands rhythmically in all directions ; in the latter case it is moved in one direction only, that is, it rises and falls under the influence of tli6 motion con- veyed to it. The various pathological conditions which give rise to pulsation, and their treatment, are fully discussed under appropriate heads. J. Mitchell Bruce. PULSE, The. — S ynon. : Fr. le Fouls ; Ger. der Puls. — Each contraction of the heart, by throwing the contents of the left ventricle into the aorta, causes a sudden change in the ful- ness of the systemic arteries, which is manifested by elongation and dilatation of these vessels. When the finger is placed upon an artery, which vans on a resisting plane, such as the radius forms beneath the radial artery at the wrist, slight compression by the finger enables us to detect an increased hardness in the vessel at each cardiac contraction. It is this increase of i hardness, or fulness, or, in other words, this change in the distension of the artery', which constitutes the pulse. In feeling the pulse the finger slightly compresses the artery, and thus flattens it ; the cylindrical form is restored by I each pulsation. The amount of pressure required to flatten the artery completely, is the rough and ready way of estimating its fulness or tension, and is best performed by compressing the vessel with the index finger, whilst the middle and ring fingers, placed more distant from the heaTt. checkoff the pressure required to stop the blood- flow. The movement of the artery perceived by the finger appears in most cases to be simple, but when registered by the sphygmograph it is found to be a compound of three waves, called the sum- mit wave, the tidal wave, and the dicrotism. The summit wave, which caps the line of ascent of the trace, is due to the sudden vibration in the blood- column, following immediately on the lifting of the aortic valves by the discharge of the contents of the left ventricle. The tidal wave, or wave of impletion. or first secondary wave, as it is also called, is due to the distension of the arteries, following the increased pressure in the aorta and great vessels, from the reception of the ventri- cular contents. The dicrotism, or great secondary leave, is an oscillation of the blood-column, mainly, if not wholly, produced by the rebound of the blood from the closed aortic valves under the pressure of the aortic recoil. See Dicrotism. A pulse-trace (fig. 55) consists then in a line j of ascent, a to b, which ends in the summit wave, b, and corresponds to the first part of the ventri- cular systole ; from the summit wave the tracing falls slightly, till it is again raised by the tidal wave, c, due to the impletion of the vessel. After the tidal wave a more marked descent occurs, called the aortic notch, e, and the line again rises, into the dicrotic wave, d. The line of descent, PULSE. 1295 b to a 1 , is thus broken by two waves and two notches. The two waves have already been de- scribed ; of the two notches one precedes the tidal wave, and indicates a slight collapse in the arte- rial wall after the oscillation called the summit wave ; whilst the aortic notch preceding the dicrotism marks the fall in pressure in the arte- ries antecedent to the closure of the aortic valves. Fig. 55. Typical pnlse-trace. a to 5, line of ascent ; b to a\ line of descent ; b, summit wave ; c, tidal wave ; >n the chest and abdomen are not uncommon ; decomposition is said usually to set in early ; and there may be early post-mortem emphysema of the skin of the face and neck. The blood is generally dark, lake, and tarry, and sometimes peiuliarly viscid, and even in the heart it is often uncoagulated. Haemorrhages, varying in size from a pin's-head ecchymosis to large extravasations, are found in various parts. Ecehymoses beneath the peri- and endo-cardium, and in the cardiac tissue, often occur; also in the muscles, the connective-tissue planes, and the subserous and submucous tissues. In the lungs there are frequently haemorrhages , and congestive oedema, with partial collapse, is common. The spleen is usually enlarged, but not invariably ; its tissue is dark and pulpy, or may be completely diffluent. The liver is usually swollen, vascular, and somewhat softened, but haemorrhages are rare. The kidneys are often hyperaemic, and rarely there are extravasations in the cortex or pelvis. The stomach and intes- tines often present nothing abnormal. In the brain there are frequently scattered, punetifonn haemorrhages, and, rarely, large extravasations in the pia mater. Such are the general and constant conditions both in tho external and internal forms. In the malignant pustule itself the process extends deeply into the subcutaneous cellular tissue; the inner portion is haemorrhagic, and may he sloughing in the centre ; and haemorrhagic patches radiate into the surrounding tissue (Bollinger), which are extensively infiltrated with a semi-gelatinous blood-stained fluid. In the pulmonary form ecchymosis and gela- tinous exudation are sometimes found in the tissue of tho neck, especially surrounding the trachea, in the mediastinal glands, and in the lungs and pleurae. Occasionally the cervical gland may be swollen, and infiltrated with blood ; the cellular tissue surrounding them may be cedcmatous, and sometimes contains large haemorrhages. In the mediastinum is found a quantity of gelatinous fluid, sometimes blood- stained or mingled with small haemorrhages. Both pleural cavities usually contain serous fluid, often two or three pints or more. In the pericardium there is a variable quantity of fluid. The bronchial glands are swollen, sometimes greatly so, and may contain extravasations of blood ; and there may be large haemorrhages in their vicinity. The mucous membrane of the trachea and bronchi may be congested, and the scat of small blood-extravasations; they fre- quently contain frothy blood-stained mucus. From observations which the writer has recently made, there seems to be no doubt that the lesions frequently present in the larger bronchi correspond, both in their anatomical characters and in their relation to the constitutional in- fection, with the external malignant pustule; and that the virus, having gained entrance by a local infection of the mucous membrane, is con- veyed to the bronchial glands, and thence into the blood. The lungs may contain htemorrhagea into their substance, either scattered lobular patches, or more commonly wedge-shaped tracts at the periphery, and diffuse extravasations in the subpleural tissue ; hut in some cases the lungs appear natural to the naked eye. In this form the abdominal viscera often appear per- .fectly healthy. In tho gastro-intestinal form there is often some blood-stained serum in the peritoneal cavity. The mesentery and retro-peritonea 1 PUSTULE, MALIGNANT. connective-tissue are infiltrated -with, semi-gela- tinous fluid. The walls of the stomach, and parts of the intestines, are swollen and congested. In their submucous tissue there may he gelatinous blood-stained fluid or haemorrhages, which may form solid coagula beneath the mucous mem- brane. The entire mucous membrane is injected, or merely stained with blood. The intestines contain either blood-stained mucus or watery fluid, more or less mingled with blood. There may also, though much more rarely, be pustular and carbuncular foci in the intestines, which are said to resemble the malignant pustules of the skin. Microscopic Anatomy. — The most important point in the microscopic anatomy is the pre- tence of the bacillus anthracis in the blood and tissues, either diffused, or forming masses in the vessels and lymphatics. It is unnecessary to de- scribe here other more minute lesions. Flo. 70. Bacilli from the fluid exuded from the lung in a case of internal anthrax. X about 700 diam. n, lted blood-corpuscles, b and c, Large granular cor- puscles from the lung, d, Bacilli of various lengths, containing highly retractile granules, or fully formed spores. Symptoms and Course. — The symptoms of malignant pustnle vary greatly with the form of the disease. At least three distinct forms may be considered. 1. Malignant pustule or carbuncle proper, the form from which the names of charbon and an- thrax are derived. Usually it occurs as a pri- mary lesion due to direct inoculation ; very rarely secondarily to constitutional infection. The seat is usually either on the face, neck, hand, or arm — namely, those parts most exposed to ino- culation. At first a small red point or pimple appears within a few hours, or two or three days, after inoculation, and may be either painless, or at- tended by burning or itching. This rapidly ex- tends, so that in a few hours a large red swelling may be formed. Sooner or later a small papule appears at the seat of inoculation, and this vesi- cates at the summit ; the vesicle bursts and dis- charges a clear or turbid watery fluid, which is often deeply blood-stained. Beneath this there is a dark red. spot, which dries up, leaving a central dark brown or black eschar, seated on an angry, red, indurated base. This central eschar enlarges until it may reach the size of a shilling; sur- rounding it is usually a narrow ring of vesicles, 1305 and beyond this a livid red area and extensive brawny oedema. When the pustule is situated on the face, the entire side of the face, head, and neck may be involved in the red cedematous swelling. The lymphatic glands of the part are often greatly swollen. The complete develop- ment of the pustule depends on the length of time the patient survives. If recovery ensue, the central black eschar, on the raised, indurated, and inflamed base, may be well-marked at the end of ten days or later. The symptoms vary much. Even where the local condition is severe, constitutional symptoms may he slight or wanting ; or some slight febrile symptoms may bo present. But where the gene- ral system is involved, and the case takes an unfavourable form, the symptoms may still pre- sent great variety. There may be little fever, but great mental depression and physical ex- haustion, cold sweats, sometimes diarrhoea, fol- lowed by delirium and coma. The mind maybe clear to the last, only the increased prostration, embarrassed respiration, and cyanotic condition foretelling the fatal termination. In cases of external pustule, fever, which may be very high, usually predominates, and brain-symptoms are perhaps the rule in fatal cases. Death may occur in thirty or forty hours from the first appearance of the pustule, or be delayed till tho fifth or sixth day, rarely later. Healing of the pustule may take place by sloughing, or the eschar may simply separate and the wound granulate. Multiple carbuncles are said to occur after general infection from a malignant pustule, but they appear to he usually merely ordinary furuncles or carbuncles. The mortality in cases of external malignant pustule appears to vary in different outbreaks ; probably one in three is a safe estimate. Malignant anthrax cedema, without definite pustule, has also been observed in outbreaks of the disease ; it corresponds in the main with malignant pustule, and is usually rapidly fatal. The eyelids are the parts most commonly af- fected, hut it may occur elsewhere. 2. Internal anthrax differs greatly from ex- ternal, and may either be general, having no special lesion ; or accompanied by local affections, usually pulmonary, or gastro-intestinal. The symptoms common to these internal forms of anthrax vary much. The onset is often sudden, but sometimes gradual, preceded by a sense of depression and exhaustion, restless- ness, loss of sleep, vague sensations in the limbs, and sometimes cold perspirations. These symp- toms may last two or three days before more definite symptoms, but commonly only one or two days, or even a few hours. Whether after premonitory symptoms, or quite suddenly, acute symptoms may set in. There may be vomiting, shivering — amounting to distinct rigor or mere sense of chilliness — headache, and other symp- toms common to the onset of many acute dis- eases. But what is usually most noticeable is extreme physical prostration, often with great mental depression and anxiety, coldness of the extremities, embarrassed respiration, and usu- ally speedy collapse. The temperature is some- times high, reaching 105° F. or more, but mors commonly only slightly elevated; the rectal PUSTULE, MALIGNANT. 1306 temperature being 100° to 101°, whilst the axil- lary may be subnormal. In some cases delirium occurs early ; in others the mind is clear to the end. Vomiting may recur, but is not usually prominent. AmoDgst occasional symptoms of this form are sensations of numbness or ting- ling in various parts, particularly of the extre- mities. Death usually occurs in forty-eight to sixty hours from the onset of acute symptoms, but may be more rapid, or be delayed for five or six days. Owing to the absence of definite symptoms this form, 1 anthraccemia', has been little studied. More commonly the symptoms assume a more definite character, related either to the respiratory or digestive system. In the pulmonary form the symptoms may more nearly resemble those of acute bronchitis or of pneumonia. At the onset, there are usually some of the general symptoms just described. Some bronchitic sounds are heard over the lungs, especially posteriorly, and there may be patches of crepitation. Occasionally there is sore-throat and swelling of the glands in the neck, but not at all constantly. Cough may be slight or absent, and is rarely severe. Put even at this stage there is an amount of prostration and embarrassment of breathing, and tendency to cyanosis, out of proportion to the physical signs. These rapidly increase, the patient takes to bed, there is great prostration, difficult and laborious respiration, cyanosis and collapse, with or with- out wandering delirium. Death may occur in twelve hours, or be delayed from two to five days. Frequently there are intermissions or re- missions, followed by sudden relapse. In its general features intestinal anthrax is somewhat analogous to those already described. But early in the case there appear other symp toms — vomiting, sometimes dysphagia slight pain, uneasiness in the abdomen, colic, and diar- rhoea. The diarrhoea may bo from the first bloody, and may continue so. Bleeding from the mouth and pharynx sometimes occurs, and may persist. Tho general symptoms are those of extreme prostration, cyanosis, and collapse, often without elevation of temperature. Death may occur in twenty-four hours, or be delayed two or three days, rarely longer. There may be swell- ing of the neck, due to glandular enlargement and infiltration of the cellular tissue; and this may be a marked feature in the case. It is thus seen that in the internal form of anthrax the greatest variety is observed. Prognosis. — The prognosis in all these forms is extremely unfavourable. At the same time, it is stated that cases of milder and less fatal character sometimes occur. Diagnosis. — 1. Of malignant pustule proper. In the earlier stages diagnosis is very diffi- cult, except in persons who are known to bo ex- posed to contagion. At a later stage tho charac- teristic features of the pustule above described render the recognition comparatively easy ; and microscopical examination of the serum con- tained in the vesicles shows the presence of the bacillus. Moreover, inoculation experiments on guinea-pigs or mice will, if successful, usually readily decide it ; but no absolute conclusion can be drawn from failure. 2. Anthrax eedema without pustule is ex- tremely difficult to diagnose, except by a known cause of contagion, or the presence of the bacillus in the subcutaneous exudation. 3. Internal anthrax, especially the pulmonary form, also presents very few characters by which it can bo distinguished, unless there is some known source of contagion. In the later stages, if death is delayed three or four days, and acute inflammatory symptoms set in, the case is likely to be mistaken for acute pneumonia. 4. In intestinal anthrax there is also usually a known source of possible contagion, but not in all cases. When, however, the vomiting and purging have set in, the diagnosis from eases of irritant poisoning, especially by antimony or arsenic, must be difficult. Is tropical climates the distinction from acute dysentery or from yellow fever may be doubtful. Treatment. — In malignant pustule, the suc- cess of local treatment largely depends upon early diagnosis. As soon as any vesicle or pustule, likely to be duo to this poison, is discovered in a person known to be exposed to contagion, active local treatment should be adopted. Excision and cauterisation are the two most effectual remedies. If there is only a small pimple, a free crucial incision, and cauterisation with pure car- bolic acid, followed by dressing with carbolised oil or carbolic lint, is the course to pursue. The artificial leech may also be employed with ad- vantage- over the site of the crucial incision. When a distinct carbuncle, or rather eschar, has formed, free incision, followed by cauterisation, may be still employed with advantage. The caustics most available are carbolie acid and fuming nitric acid. The former is preferable. The statistics of recovery where this trear- ment is systematically carried out are highly encouraging. No other than general treatment appears to bo available in the internal form. The fact that carnivora suffer less readily than herbivora sug- gests the possible benefit of a largely animal diet in persons exposed to contagion. The in- ternal administration of quinine and of carbolic acid are strongly indicated in all forms ; and in- halation of air impregnated with carbolic acid might possibly be of value in the pulmonary form. In this form also, as death appears often to be due to compression of the lungs by pleural effusion, evacuation of the fluid should be tried. Stimulants, especially ammonia, ether, and alco- hol, are also indicated. Lastly, and chiefly, prophylaxis is bv far the most important point. Stringent regulations with regard to the destruction of the carcases and hides of affected animals would do more to stamp out the disease than any other measure. But as the disease is often imported from distant countries, by means of wool, hair, or hides, which retain the contagion for long periods of time, it is only by the thorough systematic disinfection of these, andthe destruction ofall the material which is knotvn to be infected, that the disease can be thoroughly prevented. Up to the present time (ISSIj'there is no enactment in England, evei in respect of animals known to have died of the disease, which enables anyone to interfere with such disposal of the carcase or the oflai as tne owner sees fit. It is greatly to be desired that PUSTULE, MALIGNANT, measures were taken to place the law in this respect on a similar footing with that in Ger- many and France. W. S. Greenfield. PUTRID FEVER. — A synonym for typhus fever. See Typhus Fever. PUTRID SORE-THROAT.— Sloughing ulceration of the throat from any cause, such as diphtheria, scarlatina, or syphilis. See Pharynx, Diseases of; and Tonsils, Diseases of. PYAEMIA (irvov, pus, and ac/j-a, blood). — Synon. : Purulent infection; Fr. Pyohemie ; Ger. Pyohdmie; Pydrnie. Definition. — A condition of blood-poisoning which gives rise to fever, accompanied either by severe gastro-enteritis and visceral congestions, or by certain local lesions, which are chiefly venous thrombosis, embolic abscesses in the viscera, acute suppurations of the serous mem- branes and joints, multiple abscesses in the con- nective tissue, and eruptions upon the skin. The disease is usually, but not always, sequential to a wound or injury. ./Etiology and Pathology. — The initiatory symptoms and the anatomical characters of pyae- mia arc such as point clearly to the introduction of some morbid material into the circulation, and not unnaturally gave rise to the idea, upon which the name of the disease was founded, that this material was pus. Several considerations formerly appeared to favour this belief, amongst which were especially these. Hunter believed that the lining membrane of a vein secreted pus. Now, as cases of pyaemia were found to be very commonly associated with phlebitis, and also with what were thought to be deposits of pus in the viscera, a very simple explanation of the dis- ease seemed to be that the inflamed vein secreted pus, which became mixed with the blood, and was carried by the circulation to some distant organ, wherein, being arrested, it formed the focus of a suppuration. Hunter observed that in cases in which an injury to a vein proved fatal, the coats of the injured vein were swollen and thickened, and its lining membrane was of an unusually red colour ; and he supposed that the fragments of fibrin and the softening clots often found in such veins were the products of an inflammation of their lining membrane, which in the one case was of an adhesive, in the other of a suppurative cha- racter. He believed that the coagula generally found in inflamed veins were the means whereby these inflammatory products were prevented from being carried into the circulation, and that if such coagula were not formed, pus se- creted by the inflamed vein might be mixed with the blood, and thus distributed. Hunter, though perfectly familiar with the secondary abscesses of pyaemia, does not seem to have connected them with the introduction into the blood of morbid material from a wound. That these abscesses were the result of an entrance of pus into the blood, and the arrest of pus-globules in the capillaries of the affected organ, was maintained by others, who thus looked upon the process as a mechanical trans- ference of pus-cells from one part of the body to another. These observers supposed that in PYAEMIA. 1307 healthy wounds the entrance of pus into the veins was prevented by the formation of a eoa- gulum, but that if this coagulum were not formed, or became broken down, pus entered the circulation, and gave rise to the secondary abscesses by its arrest in distant organs. This view was supposed to be confirmed by Cruveil- hier’s experiments, in which he injected mer- cury into the veins, and found that abscesses were formed in the first set of capillaries to which these veins were distributed, and that such abscesses were formed around a globule of mercury. Thus, if the injection w’ere made iDto the systemic veins, the abscesses were formed in the lungs; if into the portal veins, they were formed in the liver. But this explanation of the phenomena of pyaemia was soon found to be insufficient, and also to be incompatible with many facts since ascertained. Cases of pyaemia occur in which there is no primary suppuration from whence the pus could be derived ; there is no evidence that the lining membrane of a vein ever se- cretes pus ; the secondary abscesses of pyaemia are not deposits of pus, but true inflammations, and, if examined at their commencement, are found not to be purulent. Again, the first set of capillaries occasionally escape, and the secon- dary lesions occur in parts beyond them in the order of the circulation; and the position of the abscesses — as, for instance, in the lung, where they chiefly occupy the lower parts of the organ — is not explained by' the purely mechanical theory. Besides which, there are the general symptoms of systemic poisoning to be accounted for, and these are sometimes so severe as to kill the pa- tient before any secondary lesions are developed. Experiments upon animals show that the injec- tion into the veins of pus, or any material con- taining solid particles, is usually followed by the arrest of the solid particles in the first set of capillaries with which they meet, and a conse- quent obstruction of the capillary circulation ; but the result of this capillary obstruction varies according to the nature of the obstructing sub- stance. The injection of septic liquids filtered from solid particles, causes fever and other con- stitutional symptoms, varying according to the virulence of the poison contained. An examination of the symptoms of pyaemia will show that it consists of two series of mor- bid processes, the first series manifesting the general constitutional disturbance due to the systemic poisoning, the second having relation to the secondary lesions thereupon developed. Both analogy and morbid anatomy point to the pri- mary cause of these being the introduction into the blood of an animal poison, which at once gives rise to the first series or the general disease ; and we shall see that the secondary lesions are to be accounted for, either by a venous thrombosis, leading to a capillary embolism, or by a stagnation of the diseased blood and the changes which ensue thereupon. Of the exact nature of the poison which gives to the blood in pyoemia its infective character, we are in ignorance ; and it is better to admit this. Our powers of organic analysis are not yet sufficient for the isolation of the subtle but potent poisons upon which so many of the Epe- PYJEJHA. I *08 sifle diseases depend; and -we do not yet know what it is which gives to a pysemic clot its in- fective quality. It is certain, however, that the poison may be either generated within the body or introduced from without, and that there are predisposing causes which render a person pe- culiarly prone to its generation or reception. Of predisposing causes, impure air, and espe- cially that kind of impurity which results from the presence of decomposing animal matter, is doubt- less the most important. Thus the crowding together of a number of persons with suppurat- ing wounds, neglect in removing the discharges and excretions from sick persons, and imperfect drainage, are causes favouring the development of pyaemia. The puerperal condition is also a powerful predisposing cause. Disease of im- portant excreting organs, whereby effete ma- terials are retained in the blood, also renders a person more liable to pyeemia, as is often ob- served in cases of Bright’s disease ; and any great nervous depression (perhaps because of its influ- ence in diminishing excretion) has a like effect. Intemperance, and acute fevers, probably render their subjects somewhat more prone to pyaemia ; but it is a mistake to assert that chronic invalids, or persons in weak health, have any special lia- bility to the disease. Children, though by no means exempt from, are somewhat less liable to pyaemia than adults. Pyaemia, then, is caused by the entrance into the blood of an animal poison, which in the majority of instances originates in a wound, an injury, or a local inflammation ; but in some few cases it has been impossible to determine where the disease began. It is especially liable to follow certain dis- eases and injuries, and is the gravest danger of many operations. Thus, it occurs very frequently after compound fractures, and operations involv- ing the sect ion of a bone ; after i n juri es of the bones of the head, and in connection with acute necro- sis of the long bones from suppurative perios- titis ; also after wounds or injuries of veins; after parturition ; in connection with diffuse cel- lular inflammation, suppuration of the internal ear, and operations upon the urinary organs. Facial carbuncle is a disease peculiarly prone „o lead to pyaemia. Anatomical Characters.—' The morbid ana- tomy of pyaemia reveals two series of changes — the one depending upon the primary infection of the blood, the other upon the secondary effects of this. When the blood is very profoundly infected, the results of general blood-poisoning are often all that can be found ; the patient dies before the secondary affections can be produced. When the poison is smaller in quantity, or not much in excess of the eliminative powers, the secondary lesions predominate ; but in most cases changes of botli kinds are found. The wound, or the tissues at the site of the primary disease or injury, from whence the poison has entered the blood, are found in various conditions. There is often, but not always, sup- puration present, and the wound is bathed in foul and unhealthy pus ; or the wound may be dry, and discharging only a little thin ichor; or the cellular tissue may be infiltrated with sero- purulent fluid. The veins in the neighbourhood of the diseased tissues are often found blocked with coagula, extending a variable distance along their channels, and in different stages of disin- tegration. These clots may be soft and dark, or firm and adherent to the lining membrane of the vein, and partially decolourised ; or they maybe broken down in the centre to a reddish-yellow pulpy material, consisting of disintegrated fibrin. Sometimes the whole clot is thus softened, and the fragments of fibrin have been partly carried away into the circulation. Occasionally, but rarely, the clots contain real pua ; but the puri- form material found in the vessels is usually only broken-down fibrin, and the debris of cells. An abscess may, however, open into a vein, and thus pus may gain a direct entrance into its channel ; in such a case a coagulum, consisting of a mixture of pus and blood, is found in the vessel, and we have a true purulent clot. Sof- tening thrombi are found with especial frequency in connection with injuries and diseases of bone, as, for instance, in the sinuses of the dura mater after bruising of the cranial bones, or in consequence of caries of the bones of the ear ; or in the veins of an unhealthy stump, in which there is inflammation or necrosis of the bone. But it may be certainly affirmed that many cases of pyaemia occur in which no thrombi are found, and in which the most careful examina- tion fails to detect any morbid condition what- ever of the veins. It is necessary to point this out, because it has been erroneously asserted by some that phlebitis is an essential process in the disease. It is to be observed also that the pre- sence of pus is not a necessary element in the causation of pyaemia, as was once supposed; well-marked cases have been seen in which there has been neither wound nor suppuration for its origin. When a wound does exist, however, it is usually found in an unhealthy condition, and in this may probably be found the explanation of the spread of pyaemia by contagion. Healthy granulations do not allow the entrance of septic matter into the blood ; a wound may be bathed with foetid fluids of a most poisonous character, and yet none may be absorbed, as has been proved experimentally by Chauveau; but if the surface of the wound becomes unhealthy, the granula- tions no longer present a barrier to the absorp- tion of poisonous fluids. This is probably due. as Mr. Savory has suggested, to the dialvsiDg property of animal membranes. If, then, the secretions or exhalations of an unhealthy wound come in contact with another secreting surface, an unhealthy action may thereby be set up on that surface, producing a condition favourable to the absorption of septic material. This explains the prevalence of pysemia where a number of persons with open wounds are crowded together. A similar condition of wound may also be in- duced by neglect of other sanitary precautions, especially by the presence of decomposing ani- mal matter, and the escape of sewer-gas into the air surrounding the patient. In cases of acute pyiemia the morbid changes found post mortem are chiefly congestion and softening of the viscera, local stagnation and ex- travasation of blood, and a general blood-stain- ing of the tissues — conditions indicating profound changes in the state of the blood. In what these changes consist we are at present ignorant; but PYEMIA. osually the blood contains an excess of leuco- cytes, and its fibrin is diminished in quantity and lacks contractility. When the disease is not of this acutest form, but is of longer duration, there are developed those secondary lesions -which are especially characteristic of pyaemia. Most notable and commonest among these are the so-eallod ‘secondary deposits’ or ‘ secondary abscesses ’ of pyaemia. These are found most frequently near the surface of the viscera, and are the result of the obstruction of the terminal branches of the vessel supplying the part with blood. This obstruction is followed by engorge- ment and extravasation, by inflammation, and by rapid necrosis or suppuration. It is neces- sary more fully to describe this process before giving an account of the morbid anatomy of in- dividual organs thus affected. The obstruction may be caused in several ways. 1. It may be embolic. A portion of a dis- integrating clot may be carried into the circu- lation, until it meets with an artery too small to allow its transmission, or with the first set of capillaries in its route, wherein it becomes arrested. In this way a portion of the organ is deprived of its arterial blood-supply, and in consequence of the absence of the vis-a-tergo of the heart, regurgitation takes place from the veins into the capillaries, and even into the ter- minal arteries, giving rise to a venous engorge- ment of the affected region. The nutrition of the capillaries being interfered with by the lack of aiterial blood, their walls become altered or ne- crosed, and extravasation of blood takes place, the area of extravasation corresponding with the part supplied by the obstructed vessel. At the same time the vessels of the tissues immedi- ately surrounding the obstructed region become dilated, and so form a zone of intense hyperaemia. So far, this process is only what occurs in any case of embolism (as, for instance, when minute fragments of fibrin are detached from an inflamed mitral valve), but the importance of the process in pyaemia depends upon the changes which sub- sequently occur. Now the changes which occur in the tissues of a part the seat of embolism depend upon the character of the embolus. If the embolus come from a part which is gan- grenous, gangreue will usually occur in the tissue to which it is carried ; if the embolus be puru- lent, or come from a suppurating region, ‘ then the effect is a suppuration in the part implicated. This suppuration, however, is complicated with the embolic passive hyperaemia we have above described, so that the suppuration is incomplete, and consists rather in rapid breaking-down of the tissues than in the formation of a large num- ber of pus-cells, while the characteristic deep- purple congested zone around the affected spot is much intensified. Some describe this as a true sphacelus of the affected part, but there is no necrosis, and no foul decomposition of the patch affected in the suppurative form of embolic in- flammation. Lower degrees of inflammatory quality in the embolic clot induce similar but slighter inflammatory conditions, additional to the states described as due to the mechanical obstruction.’ There are all gradations among such degrees (Wilks and Moxtn). 1309 If, then, the embolus originate in a wound infected with the pyaemic poison, it sets up an unhealthy inflammation and rapid disintegra- tion of the tissues wherein it is arrested. The important difference, therefore, between pyaemic and other embolism consists in the fact that the pyaemic embolus is composed of infected clot. Virchow and others have maintained that this is the sole mode of production of the secondary pyaemic formations. This is incorrect, for, al- though such formations doubtless often have such an origin, they may also arise in a different manner. The embolic theory will not account for cases in which the first set of capillaries in the order of the circulation from the seat of injury escape, and secondary deposits are found in other organs beyond ; as, for instance, w'here they occur in the liver after an injury of the head, and the lungs are not affected. Neither does this theory explain the cases in which the joints only are affected, as in connection with gonorrhoea or scarlatina ; nor are the chronic cases in which only superficial abscesses occur thus explicable. It must be remembered, too, that the lesions in the lungs are found chiefly in the inferior parts of the organ, which is not what would be expected were their origin always embolic. 2. The capillary obstruction may be caused by a local stagnation depending upon the poisoned state of the blood. The infection of the blood interferes with the normal interchange between this fluid and the tissues, and produces a ten- dency to coagulation in the minuter vessels. This coagulation is especially prone to occur in organs or puirts of organs already congested, for where the circulation is slow the impurity will be the greater. In this way the greater frequency of the secondary lesions in the lower than in the upper part of the lungs is accounted for. When this form of thrombosis has taken place, the part so affected is in a condition similar to that above described as due to embolism, and the same series of changes ensues. It must be remembered, also, that the impurity of the blood interferes with the nutrition of the vessels, which thus easily allow of the extravasations that are so frequently found, not only in the viscera, but on the surface of the skin and mucous membranes. It is more difficult to explain the occurrence of the joint-affections, and the especial vulnera- bility of certain organs to the secondary inflam- mations of pyaemia. All that can be said on this part of the subject is that the poison of pyaemia selects certain organs and tissues whorein to ex- pend itself, just as that of rheumatism, syphilis, or typhoid fever does. The lungs are usually congested throughout, and are very prone to the secondary lesions. These are found chiefly near the surface and in the lower and posterior portions, and consist, in the early stage of the process, of small extrava- sations and patches of congestion ; the minuter branches of the pulmonary artery are herein found plugged with coagulum ; and haemorrhage, or inflammatory exudation, has taken place into the surrounding tissues. Thus we have a patch of pulmonary haemorrhage, or of lobular pneu- monia. Later on, the centre of this area of con- solidation is found in a state cf necrosis, ession of abscesses in the subcutaneous connec- I tive tissue of the limbs, and usually (after long suffering) recover completely. Such cases are .also sometimes seen in men’ (Paget). Occasionally, also, cases are seen of unusual duration, in which there are severe constitu- tional symptoms throughout. For the particu- lars of the following remarkable case of pyaemia after parturition, in which severe symptoms ex- tended over a period of five months, the writer is indebted to Mr. Pollock, who attended the patient with Sir Thomas Watson, Dr. Babington, and Mr. Headland: — Lady P. was confined on July 9, 1849. A few days after confinement there was slight phleg- masia dolens of one leg, which passed off in a fortnight. On August 8, she was attacked with violent rigors, fever, and sweating, with rapid pulse and great anxiety of countenance ; in fact, with well-marked symptoms of severe pvaemic fever. The rigors and sweatings continued with great severity for fifteen days, when she became slightly better, and was removed into the country. Early in September there was a recurrence of the symptoms, and these continued with varying severity till October 29, when she was attacked with acute pleuro-pneumonia. This subsided, but the rigors continued, and, in the latter part of November, Dr. AVatson diagnosed consolida- tion and secondary abscess of the lung. A few days afterwards a quantity of pus was expec- torated, and this was followed by rapid im- provement, and eventually by complete recovery, the patient being quite well when the present article was written. Diagnosis. — The chief difficulties in the diag- nosis of pyaemia arise from the occasional pro- minence of some local symptom, which masks the general disease. Probably the most common mistake is to regard a case of acute necrosis, with early joint-symptoms and rigors, as one of rheu- matism. Herein, however, there is an absence of the acid perspirations and the coated tongue of rheumatism ; the rigors are more frequently repeated ; and a careful examination will reveal mischief about the shaft of the bone as well as in the joint. When the chest-affection is severe, as in the pleurisy of children with disease of the in- ternal ear, it may be looked upon as the primary disease ; but a sudden attack of pleurisy occur- ring in anyone withotorrhoea, should at once give rise to a suspicion of pyaemia. The Liter stages of the disease may present some resemblance to typhus or enteric fever, but the history would give marked distinctions ; and in the majority of cases the diagnosis is sufficiently easy at any period of the disease. Prognosis. — The prognosis in all acute cases of pyaemia is very unfavourable. The great majority die, sooner or later ; either early in the disease, from the general blood-poisoning, or subsequently, from the gravity or exhausting character of the secondary lesions. Yet some few do undoubtedly recover, and these are they in whom the viscera escape, and the disease ex- pends itself upon the surface of the body, or runs a chronic course without involving vital organs. Puerperal pyaemia is less fatal than surgical. Treatment. — The unsatisfactory results of the treatment, and the great mortality of pyaemia, are the strongest reasons for taking every pos- PYiEMIA. Bible precaution for its prevention. A considera- tion of the causes •which predispose to, aud fa- vour the development of, the disease, will suggest certain prophylactic measures. Of these none are more important than to surround a patient who is suffering from an injury or operation, with an abundance of fresh air, and to carefully guard him from the exhalations of decaying or- ganic matter. Overcrowding, and especially tho accumulation of cases in which suppuration is going on, should be avoided. The careful drain- age of wounds is of the greatest importance ; for whether germs be admitted or not, one obvious way of preventing decomposition in a wound is to take care that nothing is left therein to decom- pose. The wound should be kept scrupulously clean, and the dressings changed sufficiently often to prevent the discharge becoming foul. Anti- septic dressings are very useful in this respect, and, whatever other advantages they may or may not possess, it is certainly desirable to apply to a wound a dressing which prevents the decomposition of the discharge, and the contamination of the surrounding atmosphere (see Antiseptic Treatment). The integrity and functional activity of the chief excreting organs should be inquired into in all cases of operation or injury, so that the accumulation of effete material in the blood may be guarded against ; and it should be remembered that the sudden change of condition that an operation or acci- dent frequently involves, may in itself seriously interfere with the action of the bowels and kidneys. When, however, pyaemia is developed, it must ! lie admitted that treatment has over it but i little control. The chief indication is to combat , the extreme depression which is always present, and to endeavour so to support the patient that he may be able, if vital organs escape, to pass Iliroughthe series of severe local affections that [may be anticipated. The satisfactory results obtained by Professor Polli, of Milan, from the indministration of sulphurous acid to animals into whom putrid injections had been made, have lot followed the use of this remedy in the human mbject ; yet there is reason to think it has some- imes done good, and to encourage us to give the mlphites in, at least, some of the more chronic ases. Probably, however, the most useful me- dicine is quinine, which sometimes produces larked benefit; it should be given in full and requently-repeated doses. The local affections must be treated on general rmciplcs. The secondary abscesses should be pened early ; and this is especially important 'ith regard to the joints, from whence the pus pould be evacuated directly we are sure of its sistence. When the infection appears to ori- mate in the inflammation of an accessible vein, te vessel should be divided between the heart id the inflamed part, in the manner recom- ended by Mr. Henry Lee. If symptoms of 'aemia occur in connection with inflammation a long bone, the question of amputation must considered ; and there are strong reasons for ! lie-ring that by this measure the disease may tnetimes be arrested. During the progress of 1 3 disease bed-sores must be carefully guarded linst, and the diet studiously adjusted to the | 83 PYLORUS, DISEASES OF. 1313 daily needs ; in fact, much will depend in this, as in the majority of serious disorders, upon careful nursing, judicious feeding, and the ob- servance of every hygienic precaution. J. Warrington Ha-ward. PYELITIS (irveXos, a vessel). — S ynon. : Fr. Pyelite ; Ger. NierenbccJcenentziindung . — Inflam- mation of the pelvis of the kidney. See Kid- neys, Diseases of. PYLEPHLEBITIS. — Inflammation of the branches of the portal vein, often associated with thrombosis. See Portax Thrombosis. PYLORUS, Diseases of. — The muscular fibres of the stomach are disposed in three layers. Immediately belowthe peritoneum theyare placed in a longitudinal direction; these are continuous with those of the oesophagus, and pass downwards over the organ, being continued to the duodenum ; they are collected into bands of considerable- thickness along the curvatures, especially the upper, and become stronger as they approach the pylorus. The middle layer surrounds the whole of the stomach, but to the left of the cardiac orifice the fibres are thin, and are replaced by those that are oblique. At the pylorus they form a thick band or ring, acting as a sphincter to the opening into the duodenum. The oblique fibres are continuous with the deep layer of the mus- cular coat of tho oesophagus. They arch over the fundus, but are quite lost towards the oppo- site end of the organ. The muscular coats of the stomach are formed of involuntary or un- striped fibres, being composed of elongated fibre- cells, which are united together by a sparing amount of connective tissue. The connective tissue is much thicker and stronger at the pylorus than at other parts of the organ, giving a great amount of firmness and strength to that region. The mucous membrane is also thicker, and the gastric tubes are wider than elsewhere. Most of these contain gastric cells, but are lined with conical epithelium to a greater depth than in the more actively secreting regions. Some anatomists have stated that in the human stomach, as in many of the lower animals, there are no pepsin-forming cells in this part; but in numerous cases the writer has been able to obtain an active artificial gastric juice from the mucou3 membrane covering it. The pylorus participates in the diseases of the stomach, which are fully described under that heading (see Stomach, Diseases of). As the outlet of that organ, however, the patency of the pylorus is of so great importance that its ob struction will be specially considered here. Pylorus, Obstruction of. — An obstruction to the passage of the contents of the stomach into the duodenum is not unfrequent, and may arise from very different pathological conditions. 1. The most common of these is the presence of a cancerous tumour at the pyloric end of the stomach. It usually surrounds the opening, and rarely spreads to the intestines. On micro- scopical examination the muscular fibres in tho vicinity of such tumours are sometimes found to he hypertrophied, the contractile fibres being en- larged and increased in number. More generally (314 PYLORUS, DISEASES OF. ■'lie cells are atrophied, although to the naked eye the muscular bundles may seem to be enlarged : 6omet‘imes the contractile cells are faint and small, in other cases they arc reduced to fibrous tissue, and no trace of the original structure can be discovered. This condition of the muscular tissue furnishes us with an explanation of the fact, that there is often great obstruction to the passage of the gastric contents into the duo- denum, where the pyloric opening seems only partially constricted, anditis to this loss of mus- cular contractility, and not to the mere narrow- ing of the opening, that vre must lookin order to understand how in many cases the stomach be- comes dilated from its incapacity to discharge- its contents. 2. The pylorus is sometimes nar- rowed by fibroid thickening of the submucous tissue. This morbid change may be confined to the opening only, or it may extend some dis- tance from the part chiefly affected, producing a hard, leathery condition of the coats. Tho same effect, although to a less degree, is produced by an obstruction of this kind as by cancer. The muscular bundles become hypertrophied, their contraction being embarrassed by the tough, fibrous tissue that surrounds and separates them. 3. The pyloric opening may be obstructed by an ulcer. This may arise either by its cicatrix pro- ducing a contraction, which leaves only a small opening through which the food has to find its way ; or, on the other hand, the muscular coat may have been destroyed by the ulceration, and the stomach may, in this way, be unable to force onwards its contents. 4. The pylorus or the duodenum may be constricted by the pressure of a tumour. Cases have occurred where a can- cerous gall-bladder has compressed these parts, but more generally the pressure is caused by glands enlarged by malignant disease. In a case which came under the notice of the writer, the opening was constricted by enlarged scrofulous glands occurring in a man affected with phthisis. 5. Adhesions may form between the duodenum or pylorus and the neighbouring parts, and in this way they may produce a difficulty in the pas- sage of the food from the stomach. A curious case fell under the writer's notice in which a man received a severe blow on the abdomen, which was followed by symptoms of obstructed pylorus. On post-mertem examination a portion of the upper part of the small intestine was found to be bent upon itself by the exudation of lymph into the mesentery close to its edge. Effects. — The effect of any considerable ob- struction at the pyloric opening is to produce a greater or less degree of dilatation of the stomach. The most prominent symptom is vomiting, occur- ring at irregtdar intervals, and usually several hours after taking food. Along with this we find heartburn, and other signs of indigestion; and a gradual loss of flesh and strength. The treat- ment must be directed to these effects and symp- toms. See Stomach, Diseases of — Dilatation. Samufx Fenwick. PYONEPHRITIS — Inflammation of the kidney, leading to the formation of abscess. See Kidney, Diseases of. PYOPNEUMOTHORAX— A morbid con- PYROSIS. dition of the pleural cavity, in which it contain* both pus and gas. See Pleura, Diseases of. PYRENEES. Ste Bagnebes-de-Bigorre ; Eaux Bonnes: Eacx Chaudes ; and Pah; and Climate, Treatment of Disease by. PYREXLA (vCp, fire, and I have). — This word is commonly employed as a synonym for fever; but it is applied by some pathologists to elevation of the body-heat from any cause. See Fever ; and Temperature. PYRMONT, in Germany. — Don waters and salt waters. See Mineral Abaters. PYROMANIA. — A name which has been given to insanity when the patient manifests a propensity to incendiarism. Its claim to be re- garded as a special form of insanity has not been established. See Insanity, Varieties of. PYROSIS ( nvpSu , I burn.) — Synon. : Water- brash ; Fr. Pyrosis ; Ger. Sodbrennen. Description. — Patients affected with water- brash experience a severe spasmodic pain at the epigastrium, which is often attended with a feel- ing of constriction, and after the lapse of a few minutes relief is afforded by the rejection of a quantity of watery fluid. The fluid is usually tasteless, without any smell, and seldom amounts to more than two or three ounces. Micro- scopically, it presents numerous epithelial scales from the mouth, and the writer has also found in it some gastric cells. It is neutral to test-paper, is not albuminous, and in one case in which he carefully examined it, it gave a dense precipitate with baryta, and a bulky pre- cipitate with nitrate of silver, soluble in nitric acid. Frerichs remarked that the fluid contains sulphocyanuret of potassium, and therefore be- lieved it was only saliva. But it is evident that it can scarcely be possible to obtain it entirely free from the salivary secretion, and therefore no great weight can be allowed to the observa- tion. Waterbrash is not necessarily connected with structural disease of the stomach, for the majority of those who suffer from it recover per- fectly. Again, in some cases the fluid rejected is evidently only saliva. In some persons affected with disease of the pylorus, the rejection of a tasteless fluid takes place, but this is neither accompanied nor preceded by pain. Pathology and .'Etiology. — Much differ- ence of opinion has been expressed as to the source of the fluid which constitutes water- brash. It has been referred to the oesopha- gus, stomach, duodenum, and pancreas. The pancreas seems unlikely' to be the organ from which it comes, for the fluid is unmixed with bile, and we should imagine a more violent effort would be required to reject it from a part so distant from the mouth. Again, the cesophagus is very intolerant to any collection of liquid in it, and it would only be by a spasmodic closure of the cardiac orifice that such an accumulation could occur in this tube. As regards the stomach, it seems improbable that the larger and more active end of this organ should be the source of the liquid, for any irritation should produce an acid, not a tasteless, fluid. At the pyloric end, however, there is a mass of tubes, lined PYROSIS. ehiefly with conical epithelium, whose office it is to secrete mucus, and as the only organic change that has been found along with water- brash is thickening at the pylorus, we may reason- ably conclude that this is the part whence the fluid is ordinarily derived. Waterbrash seldom occurs before puberty ; it affects females more than males ; and chiefly presents itself in persons of middle age. It is more prevalent in some countries than in others ; and is most general amongst those who subsist on food of a coarse and indigestible kind. Treatment.— All sources of gastric irritation should fee removed, such as every form of insol- uble or irritating food. Astringents, with or with- out opium, are the most efficacious remedies. They should be given in the intervals between diges- ion, so that they may act directly on the mucous QUARANTINE. 1315 membrane. Lime-water, bismuth, zinc, or other mineral astringents, or vegetable astringents, such as kino, krameria, logwood, or tannin, may be preferred ; but, on the whole, the writer has found the oxide and nitrate of silver the most efficacious. Unless there be some objection to it, opium may be combined with the astringents, as it both lessens the pain and seems to re- strain undue secretion ; or mercurial alteratives may be given, as their use is often attended with the best results. Samuel Fenwick. UYTHOGENIC PEVEB ( 7 rvdco, I rot, and yevviu, I beget). — A synonym for typhoid fever. See Typhoid Fevee. PYURIA (tvvov, pus, and oupov, the urine). — A name for a condition of the urine in which it contains pus. See Urine, Morbid Conditions of. Q QUARANTINE (quaranta, Italian, forty), irsox. : Fr. Quarantainc ; Ger. Quarantane. Definition. — The enforced isolation of indi- viduals and certain objects coming, whether by sea or by land, from a place where dangerous communicable disease is presumably or actually present, with a view of limiting the spread of the malady. The objects liable to quarantine include — on the assumption of their being apt to carry the contagion or infection of the disease — the luggage and personal effects of the indi- viduals isolated, certain articles of merchandise, and ships ; and, in land quarantine, carriages and other vehicles. Sometimes entire communities and districts are subjected to quarantine. History. — - According to systematic writers, quarantine had its origin in the fourteenth cen- tury, when the principle of isolation, applied ■ from a much earlier period to leprosy {mal de 1 SI. Lazare), began to be extended to pestilential diseases; and leper hospitals {lazarets), then •falling into disuse from the decline of the dis- ease, were converted to (as we should now say) juarantine uses. To this day quarantine estab- ■ishments retain the name significant of their original purpose — namely, lazarets. Fodere sug- ;ests that the period of forty days during which !t was customary formerly to enforce isolation, nd from which the designation quarantine is 1 erived, had its source in the teaching of Hippo- ■ rates, who, according to Pythagoras, attributed | special virtue for the completion of many things 1 > that period of time. The methodical establish- ient of quarantine dates from the sixteenth cen- iry, when the earliest doctrines of contagion, in ie original acceptation cf the term, were also rmulated. These doctrines, fantastic though, many respects, they now appear, still largely ihere to the practice of quarantine. Plague, we low understand the word {see Plague), was the disease against which quarantine was chiefly, indeed almost wholly levelled, until the beginning of the present century ; and the system is so imbued with the notions formerly held as to this malady, that it has -been found impossible to disembarrass it from them, in endeavouring to apply quarantine to other forms of disease. It is noteworthy that, as plague declined in Western Europe, and the area of its prevalence in the Levant became more and more restricted, the system of quarantine appears to have become more elaborate. Speculative notions, uncon- trolled by experience, and applied to the system, caused it to be overlaid with grotesque and puerile details. Notwithstanding, however, these drawbacks, the arbitrariness of the system, and the losses it inflicted upon commerce, without obvious proportionate gains, the advantages offered by quarantine in the protection of a country from pestilential disease appeared theo- retically to be so great, that neither administra- tive follies, nor the lessons as to its fallacies de- rived from experience, nor its general futilities, availed to bring about, the substitution of a more rational system of protection. Quarantine remained substantially unmodified from the termination of the last century to the fifth decade of the present, since which time it has undergone great changes, with a view of rendering the practice more consistent with ex- isting knowledge of the diseases to which it is applied, and of freeing it from the more prepos- terous detentions and practices which had be- come attached to it. Quarantine Acts. — In the present article we shall deal only with quarantine as it exists in this country. In Great Britain and Ireland quarantine, wdiieh is carried out under an Act of Parliament passed in the reign of George IV. (6 Geo. IV., cap. 78), has no longer a medical 1316 QUARANTINE. signification. It is practised, and that only to a limited extent, solely with a view of relieving our maritime commerce from disabilities which would else be imposed upon it by other coun- tries, ra which quarantine is regarded as an essential part of the public health administra- tion. The regulation of quarantine is not a func- tion of t he department of the Government which is concerned with the sanitary administration of the kingdom (the Local Government Board), but of the Privy Council, aided by the Board of Trade, the subject being dealt with as an inter- national commercial question. In what follows an authoritative official memorandum of the late medical officer of the Local Government Board (Dr. E. C. Seaton) on the subject is closely adhered to. The Quarantine Act provides for land quaran- tine and the quarantine of inland waters, as well as for maritime quarantine — internal and external quarantine, so to speak. It does not appear that internal quarantine has ever been enforced in this country since the Act was passed. Mari- time quarantine alone has been practised, and this has been applied to three diseases only, all of them infectious diseases offoreign origin, namely, plaguo, cholera, and yellow fever. Of plague there has been no question in English ports for the last thirty years or thereabouts, except a slight alarm in 1879, consequent upon an outbreak in south-eastern Russia, province of Astrakhan. Against cholera quarantine has not been enforced since 1858, its futility as a precautionary mea- sure in this country having then been abundantly manifested, yellow fever is the sole disease at present subjected to it in our ports, and this, as already stated, not from the medical necessity, but from the commercial exigency of the case. The only quarantine establishment now remaining in England — that at the Motherbank — is main- tained in respect of this disease. Infectious dis- eases habitually current in this country, such as small-pox, scarlet fever, &c., notwithstanding that the phraseology of the Quarantine Act covers any ‘ infectious disease or distemper,’ have al- ways been in practice exempt from quarantine, and dealt with under the general sanitary law of the kingdom. It appears to have been recog- nised that measures, primarily designed to pre- vent the introduction into the country of dis- eases only coming to us from abroad, and which involved international considerations, would be misapplied if used for the purpose of preventing the importation of diseases ordinarily existing here, the limitation of which, and not the ex- clusion, could alone be in question. The measures which have been substituted for quarantine against cholera — the only foreign epi- demic which at present much concerns the health of this country — consist in a ‘ system of medical inspection,’ the details of which are set forth in an Order of the Local Government Board, dated the 17th July, 1873. This plan differs from ‘ quarantine ’ in the following essential re- spects (a) It affects only such ships as have been ascertained to be, or as there is reasonable ground to suspect of being, infected with cholera or choleraic diarrhoea ; no vessel being deemed infected unless there has been actual occurrence of cholera or of choleraic diarrhoea on board in the course of the voyage. (6) It provides for the detention of the vessel only so long as is necessary for the require- ments of a medical inspection ; for dealing with the sick (if any) in the manner it prescribes ; and for carrying out the processes of disinfection. (c) It subjects the healthy on board to deten- tion only for such length of time as admits of their state of health being determined by medical examination. The measures for dealing with the sick under this Order are but an adaptation to a particular exigency of the principles of sanitary adminis- tration with regard to infectious diseases, which are in force under the general sanitary law of the kingdom. But though quarantine has no present practical existence in this country, except as regards vel- low fever, and all other infectious diseases are dealt with either under the general sanitary law of the country, or such modification of it as has been just described with regard to cholera, the machinery which is maintained under the Quarantine Acts, for obtaining information as to the existence of infectious diseases on board foreign-coming ships, is made available for deal- ing with all diseases of that kind, whether they are quarantinable or not. The quarantine ques- tions, as they are termed, which it is the duty of the Customs to put to the masters of all such vessels, embrace all infectious diseases; and, ia the event of any such disease not of a quarantin- able kind being found to exist on board, or to to have existed in the course of the voyage, the quarantine officer is required to detain the ves- sel and to forward the information with the least practicable delay to the sanitary authority of the port. In regard to cholera, moreover, both the customs and the sanitary authority have certain powers of detaining the vessel specified in the order of the Local Government Board above referred to. The provisions under Articles 12. 13, and 11 of the Order of the Local Government Board, as to the mode of dealing with persons who may arrive from abroad infected with cholera, will be better understood if a succinct statement be made of the ordinary provisions of the law with regard to infectious diseases in England. The authorities which have to administer that law, as now existing under the Public Health Act. 1875, are the urban, rural, and port sanitary authorities of the districts into which the whole kingdom is divided, and these authorities are empowered ; — (a) To pirovide hospitals or temporary places for the reception of the sick (section 131); (5) Where a hospital or place for such pur- pose is provided, to remove thither by order of any justice, on a certificate signed by a legally qualified medical practitioner, any person who is suffering from any dangerous infectious dis- order, and is without proper lodging or aecom modation, or lodged in a room occupied by more than one family, or on board any sitp or vessel (section 124) ; (c) To make regulations (to be approved by the Local Government Board) for removing to any hospital, to which the local authority is an- QUARANTINE. tilled to remove patients, and for keeping in suck tospital, so long as may be necessary, any persons brought within their district by any ship or boat, who are infected with a dangerous infectious dis- order (section 125); (d) To provide and maintain a carriage or carriages, suitable for the conveyance of persons suffering under any infectious disorder (section 123); (c) To cleanse and disinfect infected premises, and articles therein ; to destroy any bedding, clothing, or other articles which have been ex- posed to infection from dangerous infectious dis- order, giving compensation for the same ; and to provide all necessary means for the disinfec- tion of infected things (sections 120, 121, 122) ; (/) To take proceedings against (1) any per- son who, while suffering from any dangerous infectious disorder, wilfully exposes himself with- out proper precautions against spreading the said disorder, in any street, public place, shop, .nn, or public conveyance, or enters into any public conveyance without previously notify- ug to the owner, conductor, or driver thereof that he is so suffering ; or (2) any person who, being in charge of any person so suffering, so exposes such sufferer ; or (3) any person who gives, lends, sells, transmits, or exposes without previous disinfection, any bedding, clothing, •ags, or other things which have been exposed .o infection from any such disorder ; or (4) any owner or driver of a public conveyance, who Bhall not have immediately provided for the dis- infection of such conveyance, after it has to his knowledge conveyed any person suffering from a dangerous infectious disorder ; or (5) the owner of any house in which any person has been suf- fering from any dangerous infectious disorder, who shall knowingly let it or part of it for hire, without having previously disinfected it, and all articles therein liable to retain infection, to the satisfaction of a legally-qualified medical man ; or (6) any person who, showing for the purpose of letting for hire any house or part of a house, shall make false statements as to the existence of infectious disease therein, or within six weeks previously (the several acts here enumerated constituting offences liable to penalty under the Public Health Act, secs. 126, 128, 129); (y) To provide mortuaries, and to obtain the removal thither, by order of a justice, of the body of one who has died of any infectious dis- ease, which is retained in a room where persons live or sleep, or of any dead body in such a state as to endanger the health of the inmates of the house or room in which it is retained (secs. 141, 142); (A) To make inspection of their district, with a view to ascertain what nuisances exist calling lor abatement under the powers of the Act, and to enforce the provisions of this Act in order to abate the same (sec. 92) ; a provision which ex- tends to shipping — any ship or vessel lying in any river, harbour, or other water, within the dis- trict of a sanitary authority, being subject to the jurisdiction of that authority, in the same manner as if it were a house within such district ; (») Finally, to appoint a medical officer of health, inspector of nuisances, or several of those officers, according to the needs of the dis- QUINISM. 1317 trict, and other requisite officers, to aid them in the proper and efficient execution of tho Act (secs. 189, 190). The duties of the medical officer of health and of the inspector of nuisances, when (as is the case in the greater number of instances) the assent of the Local Government Board has to be given to their appointment, are set forth in Orders of the Board dated March 1880. The general powers above enumerated, if exer- cised duly and with reasonable diligence, aro held sufficient to provide for the exigencies which may arise in our ports from the introduction of infectious diseases by ships, whether the disease he current in this country or be of foreign origin not naturalised here ; hut iu the case of a non- naturalised disease, such as cholera, certain addi- tional securities are taken by the Order of the Local Government Board, 17th July, 1873, pre- viously referred to. The general powers, more- over, which are available against the importation of infections diseases by shipping, ar& available also, and have on occasions been used, against their exportation in like way to other places. The relative advantages of the system of medi- cal inspection and of quarantine as against cholera in the ports of Europe, underwent thorough dis- cussion at the International Sanitary Conference which was held in Vienna in 1871. A large majority of the delegates, including those from every State of the first rank except Erance, de- clared in favour of the former system. The minority, while adhering to quarantine, agreed to a system which would considerably diminish its stringency as heretofore practised. Haeby Leach. QUAKT.AN ( qvartus , the fourth). — A form of ague, in which the paroxysm returns after an intermission cf two days. See Intermittent Fevee. QUEENSTOWN, in South of Ireland. — Mild, not relaxing, winter climate. Southern ex- posure, with shelter. Mean winter temperature 44T° Eahr. See Climate, Treatment of Disease by. QUINISM.- — Syxox. : Cinchonism ; Er. Qui- nisme ; Ger. Cinchonism us. Definition. — A group of symptoms, chiefly connected with the nervous system, produced by the presence of quinine in the system. Axatohical Characters. — In the rare cases in man in which death has been due to quinism, post-mortem examination has revealed only con- gestion of the brain, liver, and lungs. In addi- tion to these, congestion of the spinal cord, kid- neys, stomach, and intestines has been found in experiments on animals. Symptoms. — Large doses of quinine, or smaller doses long continued, may produce two separate sets of symptoms, each independent of the other, according as they act locally on the intes- tinal canal, or upon the nervous system after absorption. It is to the nervous symptoms that the term cinchonism is usually restricted. Before considering these symptoms in detail, however, it may he advisable to mention the local effects of quinine upon the intestinal c-anal. These are, irritation, either of the stomach ol 1318 QUINISM, intestines, ■which manifests itself sometimes in vomiting, and sometimes in purging. Not un- frequently, also, small doses of quinine -will cause headache, independently of either vomit- ing, purging, or the nervous symptoms which are peculiar to cinchonism. This headache is probably caused reflexly by the irritant action of the quinine on the stomach or intestines, and may not depend on any special action that it exerts upon the nervous system after its absorp- tion. The nervous symptoms to which the term cinchonism is applied consist of affections of the hearing and sight, cephalalgia, and sometimes giddiness. Delirium, convulsions, and collapse are said to occur after very large doses. Noises are heard in the ears, the sounds being of a humming character, or resembling a distant waterfall, the ringing of bells, or the striking of a clock. These noises are accompanied by more or less deafness, voices being heard as if the speakers were at a distance. Sometimes the deafness becomes complete. It is usually tem- porary, but frequently lasts for several days after the quinine has been stopped, and has occasion- ally proved permanent. Affections of the sight are less common. They consist of occasional optical illusions, intolerance of light, amblyopia, mydriasis, and even blindness after large doses. Headache may sometimes be produced by small doses of quinine, without any affection of the sight or hearing ; and, on the other hand, the hearing may be very considerably affected with- out any headache occurring, although this is frequently present. The pain chiefly affects the top of the head and the temples. Occasionally a curious sensation is observed, as if the top of the head were coming off. This sensation is not accompanied by pain. Giddiness also comes on, so that the patient may have difficulty in stand- ing or walking, either after a single large dose, or after repeated or continued moderate doses. This is preceded by an affection of hearing, sight remaining unaffeetod. The giddiness is probably RABIES. partly due to weakness of the circulation, ia part to the action of quinine on the nerves and nervous centres. Experiments on animals have shown that quinine diminishes greatly the reflex function of the spinal cord, diminishes also sen- sibility, and, finally, paralyses the extremities. In some persons large doses of quinine cause a febrile condition unaccompanied by cephalalgia, but preceded by humming in the ears, disturb- ance of the mental faculties, and a slight rigor. In others, the cerebral symptoms have been so marked as almost to amount to a temporary mania. .The circulation is weakened by large doses of quinine, the heart becoming feebler, and the arterial tension diminishing. Not unfrequently fainting has been observed ; and therefore per- sons fully under the influence of quinine should be careful not to rise up suddenly. In some casse collapse and coma occur, occasionally ac- companied by convulsions. Treatment. — As a chemical antidote in cases of quinine poisoning, tannin or substances con- taining it should be given ; and to combat tho symptoms produced by quinine, already described, ammonia should he administered, and counter- irritation should be applied to the skin. Cold compresses to the head, leeches behind the ears, and purgatives may be employed when there is excitement or delirium. Alcohol and diffusible stimulants may he given if there is a tendency to collapse. T. Lauder Brcnton. QUINSY ( cynanche , sore-throat). — A popu lar synonym for acute inflammation of the tonsils. See Tonsils, Diseases of. QUINTAN ( quinius , the fifth).— A form of ague, in which the paroxysm returns after &n intermission of ninety-six hours. See Intebjut- tent Fever. QUOTIDIAN ( quotidie , daily). — A form of I ague, in which the paroxysm occurs at the same i hour every day. See Intermittent Fever B RABIES (rabies, rage or madness). — Synon. : Fr. la Rage ; Ger. Hundsvmth. Definition. — A non-febrile disease, due to a specific poison; and most frequently met with in the canine, feline, vulpine, lupine, and other species of carnivora; but communicable by ino- culation to all warm-blooded animals. It is accompanied by an inclination to attack other animals ; and is characterised by nervous dis- turbances, together with listlessness, uneasiness, wildness, cramps, paralysis, rapid emaciation, altered voice, quick course, and fatal termina- tion. -Etiology. — Various antecedent phenomena are supposed to be either the actual or predis- posing causes of rabies ; but we may say that neither climate, season, food, water, sex, genital excitement, pain, anger, age, nor breed, as far as we are able to judge, has the slightest effect in producing the disease. Many persons still adhere to the belief that rabies arises spontaneously in the canine, anc probably also in the feline, lupine, and vulpine species of carnivora ; although most, if not all, admit such cases to be extremely rare (Boer- haave, Hamilton, Gilman, Coleman, Renault, Haubner, Williams, Hill, &c.). Qthers (Maynell, Blaine, Youatt, Virchow, Gerlaeh, Roll, Bollin- ger, the writer and many more) believe that it never arises spontaneously, but that it is always RABIES. the result of tho introduction of the specific ani- mal poison into the system, either by a bite from * rabid animal, or by the absorption of the virus through the medium of an abraded surface. To prove beyond doubt, in any given case, that af- fected animals had never been bitten, nor placed in contact -with those already diseased, is ex- tremely difficult. Contagium. — The nature, composition, and the circumstances necessary for the production of this, as ■well as of most other animal poisons, is still a mystery. All -we know is, that it is a fixed virus, and therefore, can only be introduced into the system by inoculation. It seems to be more concentrated and abundant in the saliva than in any other part of the body; but we have reason to believe, it is present in the secretions and excretions (Roll, Hering), in the blood, and consequently in all organs and parts of the still warm body (Haubner, Eckel, Lafosse, Roll, Fleming, and others) ; although others (Breschet, Majendie, Dupuytren), from some cause or other failed to transmit the disease by inoculating with the blood of rabid animals. Whether tho poison is present in the saliva, blood, and other parts during the incubative stage is unknown. There is no evidence to show that dried virus is viru- lent ; and the contagium is found to be destroyed by ordinary influences, such as heat, calcium chloride, caustic alkalies, and concentrated acids. It is a disputed point whether the meat and milk of rabid animals are fit for animal food ; but few doubt the innocuousness of butter and cheese made from such milk. M. Galtier has recently (1881) found that the saliva of a rabid dog which has succumbed to the disease, or has been killed, does not lose its virulent pro- perties through mere cooling of the body. It is important, therefore, in examining the cavities of the throat and mouth after death, to guard against inoculation. The same observer has also found that the saliva of a rabid dog, obtained from the living animal and kept in water, con- tinues virulent for five, fourteen, or even twenty- four hours in the case of the rabbit. Water from which a mad dog may have drunk must, therefore, be considered dangerous for at least twenty-four hours. Although previous observations and ex- periments seem to prove that tho virus loses its potency as soon as the body is cold, or rigor 'mortis has set in, and it has therefore been as- sumed, a fortiori, that the flesh of rabid animals might be eaten cooked (Dr. Lecamus) or un- cooked (Decroix, Bourrel, &c.) with impunity, even if the mucous surfaces were injured, these statements must now be received with great re- serve. Animals that are inoculated with fresh (warm) saliva, blood, &c. do not in all eases contract the disease. Renault inoculated ninety-nine animals (horses, dogs, and sheep), and only sixty-seven became affected. Roll says that successful inoculations vary from 21 to 70 per cent., whilst from the bites of rabid dogs the proportion varies between 20 and 70 per cent., showing that the disease is comparatively less likely to follow from the natural (bite) than from the artificial (injection, &e.) introduction of the virus. This is probably due to the bleeding produced by the bite washing the poison out again, or to the bit - 1319 ten subject, the clothes, hair, &c. wiping the teeth before they pierce the skin. The recent researches of MM. Rasteur and Galtier seem tc show that the diluted poison of hydrophobia, injected into the blood of animals, acts as a pre- ventive of the development of the disease. It must also be remembered that the percentage — however the poison is introduced — is larger in carnivorous than in herbivorous animals or man, Fleming tabulates them thus : — ‘ Dogs and cats hold the first place in the scale of susceptibility ; then man and the pig; next ruminants, the sheep and goat being more susceptible than the ox ; and lastly the horse.’ It has been denied by some authorities (Betti, Girard, Vakl, Huzard, Dupuy, Lafosse, &c.), that the virus of other than canine and feline animals, or those which use their teeth as natural weapons of defence, is capable of transmitting the disease to others. But of late years, this has been proved by many(Bourrell, Eckel, Berndt, Youatt, Breschet, Majendie, Earle, and others) to be in- correct. Incubation. — The period of incubation in rabies ranges between extremely wide limits ; but the average period in any animal maybe said to be from three to six weeks. It is compara- tively shorter in young than in old animals. Spinola said that gestation prolongs it, and according to Fleming it appears sometimes to be hastened by excitement, anger, sexual irritability, terror, injury to the cicatrix, sudden changes of temperature, and other causes. Anatomical Characters. — The anatomical changes in rabies are by no means constant, nor do they at all equal what one would expect to find, judging from the symptoms presented during life. The following are the principal lesions found. The skin may be covered with mud, and wounded, especially about the lips. The visible mucous membranes maybe injected; the teeth fractured ; the tongue swollen, dark red, and wounded. The mucous membrane of the fauces, larynx, trachea, pharynx, oesophagus, stomach, and intestines may be swollen, congested, hyper- aemie, or may present haemorrhagic erosions, and signs of catarrh. The tonsils and salivary glands may be enlarged and vascular. The stomach usually contains some indigestible and foreign substances, such as pieces of wood, lea- ther, straw, hay, or iron. These, however, are rarely found in herbivorous animals. The small intestines are usually empty, or only contain r, mixture of bile and mucus. The solitary, agmi- nate, and mesenteric glands may be found en- larged. The spleen is frequently enlarged and congested, hence the disease has often been mis- taken for anthrax. The blood is dark-coloured, and coagulates with a soft loose clot. The kid- neys and bladder may be hypersemic, and the lat- ter is usually emptied and contracted. The lungs are generally gorged with blood. The vessels of the cerebro-spinal coverings may be congested, and serous effiisions in the cavities will be some- times observed. Williams says : ‘ On the lower surface of the medulla oblongata, at the origin of the seventh, eighth, and ninth pairs of nerves, the membranes are generally highly congested, thickened, softened, and matted together.’ The ltABIES. 1320 brain-substance may be soft and friable ; there is rarely congestion ; and, as a rule, the brain is pale and bloodless (Fleming! The microscopical changes have not at pre- sent been thoroughly worked out. Benedikt con- cludes, from examinations of numerous sections taken from various parts of the nervous centres, that the pathological process in this disease consists in acute exudative inflammation with hyaloid degeneration, which doubtless arises from the exudative infiltration of the connective tissue (Fleming). See Hydrophobia. Sysiptojis. — In the lower animals, the trains of symptoms are so marked, that they have given rise to the distinction of two different forms of the disease : one in which the nervous system is excited, hence the terms furious, wild, or ‘excited’ rabies; the other, where it seems to be depressed, and to which the names of ‘dumb tranquil,’ ‘torpid,’ or ‘ paralytic’ rabies have been given. Although this distinction is convenient for description, it must not be for- gotten that paralysis, in some form or other, usually sets in, sooner or later, in the excited form ; whereas in the latter it is rarely, and then only for a short time, preceded by any signs of excitement or inclination for mischief. In other words, the symptoms of rabies may be divided into three stages, namely, the premonitory, irri- tative, and paralytic. In the ‘furious ’ form, all three stages are well-marked; but in the ‘dumb’ form, only the first and last. The transition from one stage to the other is gradual and im- perceptible. The premonitory stage is characterised by an alteration in the manner and habits of the animal. Dogs, for instance, that are naturally friendly and docile, suddenly turn surly and bad-tempered, and as quickly return again to their former docile manner, showing more affec- tion than usual. Nearly all animals are rest- less, and frequently change their posture and position. Most are dull, lazy, languid, and seek seclusion from society by hiding themselves in dark and quiet places. Irritation at the seat of inoculation, demonstrated by rubbing, nibbling, or scratching the cicatrix, is frequently an early symptom. The appetite is lost, and in rumin- ants rumination is suspended. Sometimes a depraved appetite is present, evidenced in dogs and pigs by their eating all sorts of strange things, such as wood, iron, &c. ; and these, as well as sheep, often swallow their own faeces and urine ; whilst the latter have been seen to lick blood and even eat their wool. Carnivorous ani- mals and pigs frequently ‘gulp,’ as if trying to swallow something, or retch, as though to free their throat from some foreign body ; and vomit- ing sometimes occurs. The visible mucous membranes are red, and saliva almost always (except in horses) drivels from the mouth, due in all probability to dysphagia. The sexual organs of all species, except the pig (Haubner), are frequently excited in the early stage of this disease, and ungovernable salacity is present. The bowels are constipated ; the urine sup- pressed. These symptoms may hist from twelve to forty-eight hours, and then gradually pass either into the irritative, marking the ‘ maniacal ’ form, or into the paralytic stage, characteristic of tb ‘ melancholic ’ form. The irritative stage is distinguished by a pro- pensity to injure other animals ; by great uneasi- ness ; and by paroxysms of fury and excitement, with intervals of quietude and exhaustion. The increased restlessness, which marks the commencement of this stage, is manifested dif- ferently by various animals. They are con- stantly changing their position and posture. Dogs lie down in one place and quickly shift to another ; horses move their ears backwards and forwards, as though they were listening to some distant, sound. During the paroxysms dogs become excited; disturb their beds ; tear carpets, mats, or what- ever comes in their way; and bite their kennels, chains, other animals, and even their own bodies. They may lie quietly for a time, and then suddenly jump up with a peculiar howl; remain in the same posture for a time ; look vacantly' around them ; then suddenly walk for- ward as though following something ; and all at once snap at some imaginary object. The dog may obey its master’s call, although reluctantly, and look up pitifully', as though it did not wish to be disturbed. The tongue is swollen, and frequently dipped into water to cool it, although the poor creature cannot swallow any, and saliva hangs in strings from the angles of its mouth. The countenance is anxious and hag- gard. If the animal should succeed in escaping from its kennel at the early part of this stage, lie wanders forth ‘ on the march,’ apparently not knowing or caring where he goes. If any- thing comes in his way he immediately attacks it, and then resumes his journey'. The gait and carriage of the dog are at first natural, but as the nervous energy fails, he becomes unsteady and tottering ; the tail drops between his legs; his head is carried near the ground ; the abdo- men is ‘ tucked up ; ’ and the poor beast, which a few days previously was plump an 1 fresh-look- ing, is now comparatively a skeleton. Dogs generally endeavour to retrace their way back to their homes to die. Cats are very savage, arch their backs, lash their tails, and freely use their teeth and claws. Horses become very violent, frequently neigh, bite the bars and mangers, kick, paw, and endeavour to get loose. Cattle rarely, if ever, use their teeth, but bellow, paw the ground, butt and toss, frequently break- ing their horns. Sheep seldom, but goats often, use their teeth. Their natural timidity is re- placed by a pugnacious disposition, and they will even attack dogs. Pigs slaver at the month, bite their fellows and other animals, and become very wild. Poultry make stupid high jumps and other frenzied movements, peek one another, and chuckle frequently. The voice of all animals affected with rabies is altered in character, and is continually being exercised. In dogs, the cha- racter of the voice is one of the best diagnostic signs of the disease. It has a peculiar high-toned, croupy. ringing sound, as if the bark and howl were blended together. In the early part of this stage of the malady, the eyes are bright and glaring— especially in cats ; but as the disease advances, the bulbus oculi retracts in its ortit, and the membrana nietitaus is forced half ov«i RABIES. the cornea, giving the animal a horrible and for- 'orn appearance. At first the paroxysms are strong and pro- longed, but as the disease progresses they become -weak and short, and the periods of depression which intervene between the pa- roxysms are lengthened, until finally the animal has not power or strength to move his limbs, when th q paralytic stage may be said to have commenced. We now notice continual twitching aud convulsions of the muscles — even tetanus; and death soon takes place. The 'paralytic stage of the ‘ dumb ’ or ‘ torpid ’ form of the disease is marked by ‘dropping’ or paralysis of the inferior maxilla, rendering the animal unable to bite or bark. Although at the commencement of this stage there may be an inclination in the dog to leave its abode and ‘march;’ still it is less so than in furious rabies, and if he do go, the creature either quickly returns again, or seeks some secluded spot in which to die. The animal endeavours to remain quietly in a dark place, and takes little notice of what is going on around him. The tongue is swollen, livid, and hangs out of the mouth ; the saliva is tenacious and abundant. Paralysis of the posterior extremities soon sets in, and death quickly follows. When the tranquil form of rabies attacks other animals than dogs, it usually paralyses the posterior extremities. Duration and Termination. — Rabies gener- ally takes a rapid course, sometimes killing within forty-eight hours, aud rarely lasting more than ten days, although cases of canine madness have been reported to have lasted from fifteen to twenty days. The duration depends to a cer- tain extent upon the constitutional vigour of the animal. The termination is fatal in all animals. Diagnosis. — Marochetti and others have as- serted that rabies can be diagnosed a few days after inoculation, by the presence of a sub- lingual vesicular eruption, but there is no evi- dence to warrant us in believing this statement ; and Sir. Fleming remarks, ‘that it is much to be regretted that those who have seen these lyssi did not resort to inoculation with the contents of the vesicles to prove whether they really contained the morbific elements or not.’ The most characteristic symptom of the ‘ furious ’ form is undoubtedly the peculiar voice ; and of the ‘ dumb ’ form the dropping of the inferior maxilla. But since these symptoms only appear when the disease is comparatively advanced, we must take other symptoms into con- sideration, such as the behaviour of the animal, its physiognomy, inclination to bite, and to eat strange and indigestible substances. An ac- quaintance with the history of the case is neces- sary if we would avoid confounding it with other diseases. Epilepsy is distinguished from rabies by the sudden and complete loss of sense, champing of the jaws, foaming at the mouth, convulsions, cries, and rapid recovery. Distemper has sometimes been mistaken for rabies, from the fact that catarrh of the eyes and nose, giddiness, weakness, and emaciation are sometimes present in both diseases; and it is just this, with the fact that epilepsy is some- times a sequela to distemper, that undoubtedly 1321 led the late Mr. Grantley Berkeley, a professed authority on rabies, to state, ‘that dogs become utterly insane from distemper, and that if this disease be prevented by vaccination, hydro- phobia (rabies) will be decreased.’ It is scarcely necessary to say that such assertions are liable to cause great mistakes. Foreign substances in the fauces or pharynx, especially in the dog, may be distinguished from rabies by the history of the case, and by careful examination. Inflammation of the throat only presents one symptom of rabies, namely, inability to swallow. Gastritis and enteritis may be distinguished by the absence of the nervous symptoms, and by the pain produced on pressing the abdomen. Phrcnitis , especially in horses, may be con- founded with rabies ; but although the animals may be delirious, there is no inclination to do mischief, nor are they irritated by the presence of a dog or a person, and the course of the disease will soon decide the question. Tetanus in the dog has been confounded with Eibies, but this is such a rare disease in dogs, cats, cattle, sheep, goats, and pigs, as to call for no special mention. In horses such a mistake could scarcely happen. Anthrax. The pathological changes of rabies and anthrax, says Mr. Fleming, have at times lent some support to the idea that they were identical, or at least resembled each other. Al- though vertigo, and a disposition to fury, do in some cases accompany anthrax in the lower ani- mals (especially in the horse), the other symp- toms of anthrax, the rapidity with which it runs its course, and the pathological anatomy of the several diseases, will serve to distinguish one from the other. The presence of the bacillus anthracis in the blood is absolutely character- istic. Cattle-plague. The fits of delirium that now and again appear in this disease, as well as the great depression, apathy, and the unsteady gait, have a resemblance to those present in a certain stage of rabies. But this resemblance is very superficial. The existence of the plague in the district, and the appearance of the visible mu- cous membranes, and the other symptoms during life, as well as the pathological alterations after death, are sufficient to establish a distinction (Fleming). A ferocious dog has frequently been mistaken for a rabid one. There are no post-mortem signs sufficiently trustworthy or characteristic to enable us to form a correct diagnosis of rabies. The history of the case, however, together with the fact that foreign bodies are present in the stomach, and the mucous membrane of the fauces, larynx, and stomach congested, will materially assist us in forming a correct opinion. TREATMENT.-The curative treatment of rabies, so far as our experience at present goes, has yet to be discovered; and since the malady is” so dangerous to other animals and man, we think its cure ought not to be undertaken, except by experienced persons and under adequate restric- tions. The prophylactic treatment, however, de- serves our best consideration. If an animal has 1822 RABIES. been inoculated by a bite from a rabid animal or otherwise, the circulation in the part should be immediately stopped by a compress above it ; the wound thoroughly washed, sucked, or cupped ; and all parts that are supposed to have been in contact with the virus excised, and either the actual or potential cautery freely applied. In the lower animals, some of the wounds may escape our notice on account of the hair, and therefore even after the above precautions are taken, the subject must be treated as suspicious. Cows, sheep, and pigs, if the wounds have been promptly cauterised, may be used for food, provided they have been killed within twenty-four hours of the inoculation. If an animal is suspected of being inoculated from, or has been in company with, one affected with rabies, it should be kept in a secure place, and watched for at least four months, and then only allowed to go out muzzled, but it is preferable to destroy it. If such an animal has bitten any person, it should not be destroyed until it has been positively ascertained whether it is rabid or not. All affected animals should be killed at once and burned, or buried deep with quick-lime. The researches of AIM. Pasteur and Galtier suggest the advantage that may result from the intravenous injection of the diluted poison, for the purpose not only of pre- venting the disease, but, even after an animal has been bitten, of mitigating the severity of the symptoms. When a case of rabies has occurred, notice ought to be given at once to the local authori- ties, to prepare them for making and enforcing stringent measures to prevent its spread. No dogs ought to be allowed to enter public build- ings or conveyances, or to frequent the public streets or highways, without a muzzle, under the penalty of being seized by the police. If a rabid animal is at large, notice should be given of the fact to the neighbourhood as soon as possible. All kennels, chains, collars, and places with which a rabid animal has been in contact should be scalded and disinfected. George A. Banham. RACHITIS (^dx ,s - the spine). — A synonym for rickets. See Rickets. RAGATZ, in Switzerland. — Simple ther- nnd waters. See Mineral Waters. RAILWAY ACCIDENTS. Results of.— The results of railway accidents are, first, imme- diate, such as those which follow directly and continuously on the occurrence of the accident; and, secondly, indirect or remote, which follow at a later period, after an interval of apparent im- munity. The points of difference between rail- way injuries and those sustained in other ways, such, for instance, as by a fall from a horse or a carriage, are virtually those of degree. This effect is referable, firstly, to the great weight and impulse of the train, crushing perhaps com- pletely some portion of the body; secondly, in the caso of collision, to the sudden arrest of momentum of such ponderous bodies in more or less rapid motion, causing thereby violent vibra- tory shocks to the travellers. Thirdly, the occurrence being sudden and unexpected, the muscles are, as it were, taken by surprise, and RAILWAY ACCIDENTS, before contraction takes place, the ligament* at the spine are frequently strained or even torn. There is no time for preparation ; the whole is the work of an instant. Fourthly, in cases of injury to those who jump or fall from a train in motion, the gravity of the resulting injury de- pends on the rate of speed of the train at the moment ; on the part of the body which first strikes the ground, and the angle at which it is struck ; on the weight o'f the person ; and also on the nature of the ground. Accidents which happen to persons either get- ting into or out of trains not in motion, possess no special characters. It should, however, fcs mentioned that serious spinal injuries have oc- curred to persons sitting in a train not in motion, when, by a sudden unexpected jerk, a violent shock is sustained. It is, therefore, this violent and sudden cor,- motion of the system which constitutes the main feature in this class of injuries, a condition which does not obtain in cases where there is less sud- den violence. Most of the direct results of railway accidents are so obvious as not to need description here. They consist of various kinds of fractures, con- tusions, and lacerations, caused either by the force of the collision, or by crushing and grind- ing under the wheels of the carriages when the individual has been run over, or by fragments of splintered wood, iron, and glass, or by burns or scalds. These injuries either cause immediate death ; or the patient may ultimately succumb, or he may he permanently injured, or recover. Oc- casionally death results simply from fright ; the influence of intense fear on the minds, especially of persons suffering from, heart-disease, aneu- rism, and the like, being sufficient toeause death. The primary depression produced on the nervous and circulatory system continues and deepens; there is no power to rally; and a fatal result from syncope ensues. Direct results on the cerebro-spinal sys- tem. — The injuries following directly upon a railway accident are of considerable interest, both on account of the difficulty of arriving at a definite diagnosis, and because of the important issues dependent on the prognosis. They com- prise conditions of general shock and concussion, where the symptoms presented are principally subjective; and of local injury, such as fracture of the skull or of the spine, implicating the brain, the spinal cord, or their membranes, stretching or rupture of spinal ligaments, to a greater or lesser extent, injury to the pelvis, and other lesions. For a description of concussion of the core, and the localisation of lesions of the spinal cord. sec SrixAL Coed, Diseases of. Indirect results. — In this class of cases the extent of the injury is not evident at the time of the accident ; for instance, a person in a col- lision receives a shock of apparently a temporary character; recovers himself sufficiently to be able to assist his fellow-sufferers ; returns home; and resumes his usual avocations. After an interval of days, symptoms of spinal trouble show themselves ; the person experiences pain in this region, tenderness on pressure or on the application of a hot sponge, and inability tc RAILWAY ACCIDENTS, RESULTS OF. ].?•> sleep or to attend to business ; he hears noises in the ears ; and he feels a general exaltation of the sentient faculties. Cases such as these are frequently the subject of litigation as regards claims for damages against railway companies. Medico-legal questions in connexion with railway accidents.— In cases of claim for com- pensation for these injuries, it is of the highest importance that the medical men engaged should make themselves thoroughly acquainted with all the circumstances connected with the accident and its results. This applies to the medical attendant of the injured person, as well as to the medical officer examining on behalf of the company. It will, therefore, be well to refer to the general character of some of the fraudulent claims made upon railway companies. Fraudulent claims. — -There are three prin- cipal kinds of fraud practised, and sometimes with success, namely, first, by persons who, as may be subsequently proved, were not even pre- sent at the time of the accident ; secondly, by those who, though present and unhurt, yet simu- late symptoms of injury; and, thirdly, by those who, having sustained some trifling injury, wil- fully and intentionally exaggerate their symp- toms, in order to obtain an unfair amount of com- pensation. There are, therefore, certain points to which the medical man should attend, lest he should be led away by a well-planned history, and thus unwittingly be made a party to such transactions. Duties of the medical attendant. — 1. It is desirable to obtain in writing the patient's state- ment as regards the accident ; if possible ascer- taining, approximately, the rate of speed of the I rain when the accident occurred, the position of the person in the carriage, and whether other persons were present or not. 2. Note bruises or any sign of local injury on any part of the body. •3. Where injury to the spine is alleged, the investigation should be conducted as far as pos- sible according to the following systematic plan : — (1) Examine the spine by percussion, and by the application of a hot sponge. (2) Seek for any paralytic phenomena by — - (a) Measurement of limbs. ( b ) Comparative degree of surface sensibility. (c) Comparative amount of electrical irrita- bility of muscles. (d) The existence of spasm or tremor of the muscles of the spine and limbs. (3) Ophthalmoscopic examination must be made, in order to determine the existence or non-existence of local lesion, confirmatory or otherwise, of cerebral or spinal symptoms. This done, it becomes the duty of the medical attendant to form an opinion after satisfying himself on the following points : — a. Has the patient really been injured? 0. What is the nature of the injury ? y. Is the injury a possible result of the acci- dent as described? S. Is the train of symptoms consistent with the appearance of injury. He should also remember that the simulation of symptoms, such as spinal tenderness or mus- cular tremor, can frequently be detected by dis- tracting the attention, when pressure on the part previously complained of may be exercised with impunity, and the muscular tremors will cease. This, however, is not conclusive of imposture, for in hysteria, when the attention is diverted, the same occurs. Again, the existence of organic disease previous to the accident should be looked for, as it has happened that symptoms referable to disease — locomotor ataxy, for example — have been erroneously ascribed to injury. The urine should be examined in every case. As an instance where the truth of a patient's statements may be tested by the astuteness of the medical man, a case may be mentioned where the plaintiff, who had travelled up some fifty miles to London to be examined, stated among other symptoms that his urine continually drib- bled from him. The surgeon immediately asked to see his shirt, which had been worn at least six hours, when it was found perfectly dry and devoid of any stain of urine .' In another ease a man presented extreme spinal tenderness, even to the extent of complaining of pain when the part was blown upon with the breath. A sheet of paper being interposed, without the patient's knowledge, the effect was the same. Duties of the medical officer examining on behalf of the railway company. — The medical officer of the company should not con- stitute himself the agent of the company for settling the terms of compensation. The exa- mination should be made, if possible, in the presence of the patient’s medical attendant, anil should be conducted thoroughly, with tact, and without inflicting any unnecessary mental or bodily pain. A report of the case should be drawn up at the time, giving: — - 1. The patient’s account of the accident, and of his subsequent and present symptoms. 2. The present condition of the patient, noting particularly any objective signs of injury. 3. An opinion as to whether the symptoms complained of are likely to be the result of the accident, as to the probability of recovery, and at what period. As the plaintiff in an action has a right to a copy of this report, it should, of course, be worded with extreme care. The actual question of pecuniary compensa- tion does not concern either the medical atten- dant of the patient or the medical adviser of the company. They merely have respectively to bring forward facts in support of their opinions as to the value of symptoms, and how far they are dependent upon the injury. By an early investigation in such a manner as indicated, the practice of fraud would be ren- dered impossible, and by an accurate knowledge and statement of facts much conflict of medical opinion might be avoided. Unintentional exaggeration of symptoms. There are certain persons who, undoubtedly injured, without having any fraudulent de- sign, may yet unintentionally exaggerate their symptoms in consequence of the continual direc- tion of their minds to their sufferings, whilst an action for damages is pending. The suspense and anxiety, the examinations by the medical man, 1324 RAILWAY ACCIDENTS, and the repeated interviews with their solicitors, keep them in a constant state of nervous excite- ment. When, therefore, their claims are settled, it is natural that the relief they experience should frequently be attended by beneficial re- sults, or even complete recovery. See Feigned Diseases. Treatment.— The chief injuries received at the time of a railway accident being surgical, the treatment adapted for each particular case will be found in surgical works. Nevertheless there are some general points in the immediate treatment, to which any medical man present on such occasions would do well to attend. 1. Hcemorrhagc . — Death from haemorrhage should be prevented by promptly adopting pres- sure of some kind. If no tourniquet be at hand, or india-rubber band, a handkerchief tied round the limb and twisted tight with a piece of stick, will suffice for the time, or direct pressure by the finger. 2. Fractures. — Temporary splints may be im- provised out of cushions, newspapers, straps, and broken pieces of wood, &c., so that the injured may be removed witli as little pain as possible, and simple fractures may be prevented becoming compound. Simple dislocations should be reduced at once if possible. 3. Shock, collapse , and fright. — In the treat- ment of these conditions great caution is required to maintain the vital power until reaction sets in. The temperaturo of the body, the strength and rate of the heart’s action, together with the respiration, should be kept up by stimulants and warmth. Mr. Savory, in his article on Shock in Holmes’s System of Surgery, is careful to point . ut, however, the dangers of over-stimulation, whereby the flickering powers may be extin- guished altogether. J. Exposure to wet mid cold. — Every endea- vour should of course be made to prevent pro- longed exposure, by sheltering the injured as much as possible, and securing their early remo- val to any neighbouring houses. W. Rose. RALES (Fr., Rattles). — Certain adventitious sounds heard on auscultation, in connection with the respiratory organs, during the act of breath- ing, in various morbid conditions. See Physical Examination ; and Rhonchcs. RAMOLLISSEMENT (Fr., Softening).— This word is associated with all forms of soften- ing of t issues and organs ; but by English patho- logists it is generally used to denote softening of the central nervous system. Sec Softening. EANULA (ranula, dim. of rana, a frog). — A cystic growth in connection ■with the mouth, and having several modes of origin. See Mouth, Diseases of. RAPE. — Synon. : Fr. Viol ; Gcr. Eothzucht. Definition. — By the English law rape is de- fined as ‘the carnal knowledge of a woman for- cibly and against her will.’ General Remarks. — The crime of rape is punishable by penal servitude for life. The carnal knowledge of any girl under ten years of age is punishable in the same way ; and the carnal knowledge of any girl between ten and RAPE. twelve, under any circumstances, is punishable by three years’ penal servitude, since the law rightly considers that children under twelve can have no power to consent to sexual intercourse. Of cases of rape recorded by Casper, 73 per cent, were upon the persons of little children under twelve. Of 136 cases put upon record by this author, the ages were as follows : — From „ 12 „ 15 19 to 12 years of age, 99 cases. „ 1 ^ .. ,, 20 „ 18 .. „ 8 „ „ 25 „ „ 7 „ 47 „ „ 1 , For proof of the crime of rape it is not neces- sary that the force employed should have been of a violent physical kind. A mere threat of violence, or even of moral injury, is ‘force’ in the eyes of the law. The surreptitious adminis- tration of chloroform, ora narcotic, for the pur- pose of having intercourse with a woman against her will, is also force in the eyes of the law. The moral character of the woman is theo- retically, but seldom practically, beside the ques- tion ; and, provided force be used and the woman's consent be wanting, sexual intercourse even with a prostitute is legally ‘ rape.’ The punishment of the crime of rape was pro- vided for in the criminal code of Moses, who ordained that the ravisher of a betrothed dam- sel should die. The Roman law punished the crime with death and confiscation of goods, but provided the fol lowing saving clause : — Bapta raptoris, aut mortem., ant indotatas nup tias optet. Upou this, says Percival, there arose what was thought a doubtful case : ‘ Una node qui- dam duas rapuit ; altera mortem qptar, altera nuptias.' Many accusations of rape are false and trumped up, and are only brought by the woman when she finds that some sexual indiscretion is likely to bring her into trouble, or cannot be concealed by reason of her pregnancy. This being the case, stale accusations should be received with very great caution. Ths laws of Henry III. provided that the accusation should be made immediately, ‘ dim rcccns fucrit malefi - cium.’ By the old Scotch law no delay was allowed in bringing the accusation ultra unam noctem, and by the modern Scotch law a delay of three days is alone permitted. By the law of England no limit is placed on the time at which an accusation of rape may be made. An English jury is, however, naturally chary of giving cre- dence to a stale charge of rape. Some few years back a charge of rape was brought against a gentleman of position in one of the home coun- ties, by a girl with whom he had had connection some five months previously. There was no evi denee that the girl had offered any resistance, and as the accusation was brought only after pregnancy had become evident, and after ineffec- tual attempts had been made to extort money from the defendant’s relatives, and as the charge was evidently made at the instigation of an uncle who was a superintendent of police, and a cousin who was a lawyer, the case was dismissed. EAPE. It shows, we think, an imperfection in the Eng- lish law that it should be possible, under such circumstances, to prefer a charge of so serious a crime. The law for the substsnt.alion of a charge of rape i3 satisfied with proof of a minimum amount of ‘ carnal knowledge.’ The mere touch- ing of the vulva by the penis is carual know- ledge in the eyes of the law. The complete introduction of the penis into the vagina need not be proved, and still more is proof of emis- sion unnecessary. The Sion's of Eape. — From what has gone before, it is evident that there need be no signs whatever. If a girl be overawed by a threat and her vulva be touched by the penis, that is rape ; and, if proved, is punishable as such. On the other hand, the signs of rape may be very obvious, for example : — (n) The woman may have been heard to cry for help. (h) There may bo the signs of a struggle at the spot where the rape was alleged to have occurred. (c) There may be damage to the woman’s clothing, and bruises of various parts of her body — signs that she has been subjected to physical force. (d) The genital organs may be found injured ; the vulva bruised and perhaps bleeding ; the hy- men recently ruptured; and, in cases where the disparity in size between the man and woman is very great, rupture of the perinseum and mortal injuries to the vagina. («) Seminal spots may be found upon the woman’s clothing, which is a certain proof of a previous ‘intimate relation ’ with a male. Blood- spots also afford valuable evidence, but neces- sarily not so conclusive. Care must be taken not to confound menstrual fluid with blood. The concurrence of all these signs would amount to certain evidence of forcible connec- tion. It must be borne in mind, however, that violence may be done to the female organs in ether ways than by forcible connection, and the medical examiner should be upon his guard against inferring too much from the evidence afforded. He also should be on the look-out for facts which may rebut assertions made by the woman. Thus, signs of a previous pregnancy or the evidence of previous venereal disease (scars in the groin, sores upon the pudenda, or symp- toms of constitutional syphilis) may serve to disprove any assertions which might be made as to the woman’s virginity or previous chastity. To prove whether or no a woman be ‘ virgo Intacta ’ is next to impossible, and we can only state the probabilities for and against. Such a question, however, is quite beside the mark in many cases of rape ; but the presence of an unruptured hymen is an unlikely occurrence after forcible connection. An examination of the person of the supposed ravisher may afford Borne corroborative evidence. Blood or recent seminal spots upon the linen or clothing, and injury to the person or clothing, all afford their quota of evidence of a sexual act combined with violence. It is a matter of doubt whether the rape of a woman of fair size and strength be possible by 1325 an unaided man. If a woman be in the enjoy ment of her faculties she is capable of offering an amount of resistance which would be well- nigh insuperable ; and if she have offered a decent resistance, the person of the ravisher should bear evidence of it. Bape, as we have seen, is most often com- mitted on children of tender years. It is well to he on one’s guard against error with regard t'l the rape of little children. It must have corns within the experience of most members of the profession, and especially of those engaged in hospital practice, to have brought to them chil- dren suffering from a purulent discharge from the vagina, the mother at the same time alleg- ing that someone must have violated the child. It must be borne in mind that purulent dis- charges from the vagina are not uncommon in ill-fed, dirty, scrofulous children ; and that after some of the infantile acute specifics, sloughing of the pudenda is a rare, though recognised, occurrence. The case of Jane Hampson, set. 4, who died of sloughing of the genitals at Man- chester in 1791, should stand as an incentive to caution in these matters. The signs were con- sidered as those of defloration, and the coroner’s jury returned a verdict of murder against the boy who slept with her, but luckily for the mal9 child there occurred many other cases of slough- ing of the pudenda in Manchester before he was brought to trial, and as the doctor who was called to Hampson recognised and acknowledged his error, the boy was discharged. It was at one time a popular belief that connection with a virgin was a sure cure for venereal disease, and this has led, no doubt, to many eases of rape on young children. The presence of vene- real disease in one or both of the parties may be of value as evidence. Its presence in the woman and not in the man affords a strong pre- sumption against rape. The finding of spermatozoa within the vagina is proof positive of connection. But here, again, care must be taken not to mistake for sperma- tozoa the trichomonas vaginalis — a microscopic organism, not unlike a tadpole in shape, which has been described by M. Donne, as occasionally found in vaginal mucus. It must be remem- bered, also, that seminal fluid may eontaki no spermatozoa. Eape is occasionally effected with so much violence that death results. Ogston records the case of one Margaret Paterson, who was raped between Edinburgh and Dalkeith by two carters, who took her into their cart on the pretence of helping her on her journey. They forcibly held her down and repeatedly violated her person, and afterwards took stones from the road, coals, straw', prickly plants, &c., and forced them into the vagina. They then left her in a ditch, and she died in three days of her injuries. Post mortem the vagina and rectum were found lacerated and broken dowm into one passage, and the abdominal viscera in a high state of inflam- mation. The two carters were convicted and executed. It has been doubted whether pregnancy can follow rape, but there seem to be no sufficient grounds for this doubt. 'When called to a case of supposed rape the medical examiner must remember to take note 1326 RAPE, if every circumstance — the time that has elapsed since the alleged outrage, the mental state of the woman, her size and physical power as compared with that of the man, evidences of a struggle m the surroundings of the woman, or on her clothing and person. He should keep his mind open to receive any facts which may throw light on the moral character of the woman. He should accurately take note of the exact condition of the genital organs and linen ; should take possession of all stained linen for the purpose of chemical and microscopic examination ; and should re- move a portion of any discharge which may he found in the vagina for the same purpose. In drawing up a report, he should describe, as accu- rately and drily as possible, all facts which he may notice ; and should be carefully upon his guard against drawing any undue conclusions from those facts. G. V. Poore. BASH. — An outbreak of redness of the skin, or efflorescence ; called by the Greeks an exan- thema, or blossoming out. The word rash, or as it were ‘ rush,’ conveys the idea of suddenness, whilst in reference to development it is generally extensive. The best illustrations of the rashes and of the meaning of the term are erythema, the red rash ; roseola, the rose-rash ; rubeola, the crimson rash, generally known as measles ; scarlatina, the scarlet rash; purpura, the purple rash; and urticaria, the nettle rash. RATIONAL (ratio, reason). In conformity to reason. — A term applied to the mental state ; also to treatment when founded on scientific prin- ciples, in contradistinction to empirical treatment, founded solely on experience. See Conscious- ness, Disorders of; and Disease, Treatment of. REACTION. — "When any substance or in- fluence affects the organism sufficiently to cause appreciable physiological disturbance within it, it is said to have a. physiological action upon the body ; or, more briefly, to act or to have an action upon it. If the effect of such an influence have been well-marked, the organism does not simply return to the original or ordinary condition, or to what is called the ‘physiological balance,’ with the cessation of the influence; hut passes beyond it into a state characterised by pheno- mena?, which are, speaking broadly, the opposite of the former. The condition which is thus the effect or outcome of the action is called the re- action ; and the same name is also given to the process by which the primary effect passes into the secondary. The cold hath furnishes a fami- liar illustration of physiological action and reac- tion. The contraction of the superficial vessels, the pallor, the sensation of intense cold, and the fall of temperature, which are the immediate effects of the cold bath, are speedily replaced by such exactly opposite phenomena as dilatation of the cutaneous vessels, flushing of the skin, a warm glow, and a rise of temperature ; and in the same way the primary nervous stimulation gives way to a feeling of general calmness and com- fort. It is generally found that the phenomena cf action and reaction are in direct proportion to each other, unless the action be excessive, in which case reaction may not set in. In other instances the irritability or excitability of the organism, RECTUM, DISEASES OF. whether as a whole or in part, may be either unnaturally increased or unnaturally diminished, and the reaction he excessive or imperfect accord- ingly. Excessive emotional excitement, whether plea- surable or painful in nature, such as joy or fear, may similarly be followed by corresponding de- pression, by prostration, or even by death. In the reaction which follows severe injuries, espe- cially when they are met with under circum- stances of intense fear — for example, in railway accidents, both the bodily and the mental func- tions, so called, are simultaneously involved. The effects of reaction are also illustrated locally in the condition of wounds. Local re- action takes the form chiefly of inflammation, and is carefully studied by the surgeon, who finds in it a ready means of estimating the severity of an injury; the vigour of the system generally, and of the affected part ; or, it may be, the value of some particular kind of treatment. Reaction may itself call for treatment when it is either imperfect or excessive. Stimulation is demanded in the former case, for instance, by warmth, alcohol, or ammonia. When reaction is excessive, nervous and circulatory sedatives are equally indicated. J. Mitchell Brcce. EECEPTACUIUM CHYLI. Diseases of. The receptaeulum chyli is the dilated portion forming the commencement of the thoracic duct, which receives the contents of the lacteal vessels and of the lymphatics of the lower limbs and abdomen. It lies deep in the abdominal cavity, about the level of the first lumbar vertebra. The only morbid conditions which need he specially noticed in connection with it are dilatation and rupture. The receptaeulum has been found iu rare instances enormously dilated, and its walls thickened. It has also been known to burst as a result of this dilatation, with the escape of its contents into the peritoneal cavity, fatal perito- nitis being thus set up. It would bo quite im- possible to diagnose these conditions during life, and they have only been discovered on post- mortem examination. Frederick T. Roberts. RECRUDESCENCE (re-, again, and cru- desco, I become fresh). — The increase or exacer- bation of a disease or morbid process, after a temporary diminution ; for example, of fever o* inflammation. RECTUM, Diseases of. — Srxox. : Fr. Ma- ladies da Rectum ; Ger. Krankheiien des Afasi- darms. The diseases of the rectum may be con- veniently discussed in the following order: — 1. Congenital imperfections ; 2. Fistula in Ano ; 3. Malignant Disease ; 4. Polypus ; 5. Prolapsus ; 6. Stricture ; 7. Villous Tumour ; and 8. Ulcera- tion. Other diseases connected with the rectum will be found discussed under special headings. See Ants, Diseases of ; Defecation, Disorders of ; Hemorrhoids ; and Stools, Characters of. 1. Congenital Imperfections. — Malforma- tions of the rectum may be classed as follows 1. Imperforate anus, without deficiency of the rectum. 2. Imperforate anus, the rectum bema RECTUM, DISEASES OF. 1327 partially or wholly deficient. 3. Anus opening into a cul-de-sac, the rectum being partially or •wholly deficient. 4. Imperforate anus in the male, "the rectum being partially or -wholly de- ficient, the bo-wel communicating with the urethra or neck of the bladder. 5. Imperforate anus in the female, the rectum being partially deficient and communicating with the vagina. 6. Imper- forate anus, the rectum being partially deficient, and opening externally in an abnormal situation i>y a narrow outlet. 7. Narrowing of the anus. These imperfections can be remedied only par- tially or completely by surgical operations. 2. Fistula in Ano. — Description. — The loose areolar tissue around the lower part of the rectum is occasionally the seat of abscess, which bursts externally near the anus ( see Peri- proctitis). But instead of the part healing afterwards, like abscesses in other situations, the walls contract and become fistulous, and the patient is annoyed by a discharge from the open- ing. On introducing a probe it may pass through a small opening in the coats of the rectum into the bowel. The case is then called a complete fistula. When there is no external opening, the complaint is named blind internal fistula. The external orifice is usually near the anus, being indicated by a button-like growth with a central opening. The abscess before bursting may have burrowed to some distance, and the external orifice may be situated in the direction of the buttock or perineum. Fistula in ano arises also in other ways. It commonly originates in a phlegmonous abscess, the action of the sphincter muscle and the disturbance of defecation prevent- ing the closure of the sac. An ulcer just within tho external sphincter sometimes perforates the bowel, allowing the escape of feculent matter into the areolar tissue, and. thus leads to abscess. Ulceration induced by a pointed foreign body, as a fish-bone, may also induce a rectal abscess. In all these eases the inner orifice of the fistula is just within the external sphincter. Fistula occurs also in phthisical subjects, owing to tuber- cular ulceration of the mucous membrane of the rectum. The inner opening is sometimes found higher up the bowel, and there may be more than one, the sinuses being complicated. An anal fistula is an annoying complaint. The patient is troubled with a discharge which stains the linen, and with the escape of flatus. Fistula is a dis- ease of middle life, more common in meu than in women. Treatment. — The cure is by a surgical opera- tion. 3. Malignant Disease. — The coats of the rectum are subject to carcinomatous and sarco- matous disease. These growths invade the bowel to a greater or less extent, contracting the pas- sage irregularly, and sometimes almost closing it. Fungoid growths also spring from the coats and project into the bowel, blocking the passage. The degeneration and invasion of tissues mayreachthe vagina in the female, or the urethra and bladder in the male, and may even penetrate the perito- neum. Malignant disease may attack any part of the bowel, but generally appears in the lower part, within three inches of the anus. It is liable also to affect, though less frequently, the point where the sigmoid flexure terminates. Description. — The disease generally com- mences insidiously. Its early symptoms are often similar to those of simple stricture, and the real disease is not detected until a con- siderable change has taken place in the con- dition of the bowel. The patient is troubled with flatulency; has difficulty in passing his motions; and as the disease progresses, ex- periences pains about the sacrum, which gradu- ally increase in severity, and dart down the limbs. The stools become relaxed and frequent; contain blood; and in passing cause a scalding pain. Often also there is a thin offensive serous dis- charge. Loss of retentive power may ensue, from destruction of the sphincter, or of the nerve supplying the muscle. As the disease advances the patient loses flesh, and exhibits the blanched, sallow look, anxious countenance, and emaciated appearance commonly observed in persons suffer- ing from malignant disease. In consequence of communications established with the neighbour- ing passages, liquid feces escape from the urethra in the male and vagina in the female ; and at length the patient becomes hectic and exhausted, worn out by this painful and distressing malady. Complete obstruction may occur, and accelerate the fatal termination. There is great variety in the degree of suffering, and of constitutional derangement. The sufferings are in some in- stances excruciating, in others very slight. Ma- lignant disease usually occurs in middle life, but occasionally in the aged. It is more common in men than in women. Treatment. — Little can be effected by reme- dies in this terrible disease, beyond palliation of the symptoms, and ease from pain. The gene- ral health may be supported by tonics. The motions must be kept soft by medicines or by injections, and pain must be alleviated by chloral or morphia in suppositories or subcutaneous in- jections. In cases of obstruction, as well as in cases of severe suffering, life may be prolonged by colotomy. Excision of the diseased bowel has also been resorted to, but not with much success. 4. Polypus. — Polypus of the rectum occurs in two forms, the soft or follicular, and the hard or fibrous. Description.- — The soft polypus consists of an agglomeration of elongated follicles, covered with a distinct cylindrical epithelium, with a network of small vessels ramifying in it, and a peduncle which varies in length. The polypus is usually single, but several may exist. In children the polypus usually makes its appearance at the anus after a stool, resembling a small strawberry, being soft in texture, granular on the surface, and of a red colour. It has a narrow pedicle about the size of a crowquill, two or three inches in length, attached to the wall of the rectum. It produces no suffering, but causes a slight bloody discharge. The hard or fibrous polypus occurs in adults, is of a pear-shape, and has a peduncle more or less long and thick. It seldom bleeds, but occasions a slight mucous discharge ; and when the peduncle is long, the growth pro- trudes at the anus after stool. Treatment. — The treatment is very simple. For the soft polypus a ligature should be tied round the pedicle. This gives no pain, and the RECTUM, DISEASES OF. 1328 polypus comes away in two or three days. It Bhould not bo excised without the previous appli- cation of a ligature, as dangerous bleeding is liable to follow. The hard polypus may be re- moved by ligature or the ecraseur. 5. Prolapsus. — In relaxed states of the sphincter muscle and coats of the bowel, loose folds of mucous membrane are liable to protrude and require replacement. This protrusion and exposure of thickened mucous membrane, with or without internal haemorrhoids, has been erro- neously described by writers as prolapsus of the rectum. In the true prolapsus, there is much more than an eversion of the lining mombrane of the bowel. The gut is inverted ; there is a ‘falling-down’ and protrusion of the whole of the coats — a change analogous to intussuscep- tion, but differing from it in the circumstance that the involved intestine, instead of being sheathed or invaginated, is uncovered and pro- jects externally. .^Etiology. — Prolapsus is observed generally between the ages of two and four, but may occur later in life. In infancy it is produced by pro- tracted diarrhoea. The straining efforts to pass water in stone in the bladder also give rise to this affection in young subjects. In adults the descent results chiefly from a weakened condition of the sphincter and levator ani muscles. It is more common in women than in men, arising in the former from the parts being weakened in child-bearing. Young subjects generally outgrow this complaint by the period of puberty ; and common as is prolapsus in early life, it is rather rare in young grown-up subjects. Description. — The length of bowel protruded varies from an inch to six inches or even more. When not of any great length, the protrusion forms a rounded swelling which overlaps the anus, at which part it is contracted into a nock. In its centre there is a circular opening commu- nicating with the intestinal canal. An inversion of greater length forms an elongated pyriform tumour, the free extremity of which is tilted forwards or to one side. The protrusion may present the usual florid appearance of the mucous membrane ; or a violet, livid colour from conges- tion, consequent upon contraction of the sphincter. The mucous surface is often thickened and glan- dular, and sometimes ulcerated from friction against the thighs and clothes. Thickening of the coats of the bowel accounts for the difficulty in reducing the parts, and keeping them reduced afterwards, so often experienced in the treat- ment of these cases in children, the bowel being too large to be conveniently lodged in its natural position, and like a foreign body exciting the action of expulsion. An atonic or relaxed state of the sphincter muscle is shown by the facility with which one or two fingers can bo passed through the anus even in young children. Treatment. — In children irritability of the bowels and diarrhoea must be checked, and dis- ordered secretions corrected, by suitable reme- dies. In slight cases it will be sufficient to direct the nurse by steady compression to push the protrusion back into the pelvis. The relaxed state of the membrane may be treated with astringent injections of alum, or muriated tinc- ture of iron, used cold. If the bowel slips down when the child moves about, a rectal supporter may be worn. When the exposed surface is ulcerated, it may be painted with a solution of nitrate of silver, 20 grains to the ounce. The patient should bo made to relieve the bowels in the recumbent posture. In adults the anal aperture may be contracted, and the fall of the rectum prevented, by the application of the mineral acids or of potassa fusa to the mucous membrane near its junction with the skin. In more severe cases the complaint may be remedied by operation. 6. Stricture.— Stricture may be very limited in extent, and is then termed annular-, or the contraction may include a portion, more or less considerable, of the coats of the bowel. Above the stricture the rectum is commonly dilated and thickened, owing to a general hypertrophy of the bowel, particularly of the muscular coat. The mucous coat at this part is usually red from capillary injection, and ulcerated, and supplies an abundant purulent discharge. Often ulcerated apertures lead to fistulous passages, extending some distance, and opening externally near the anus or in the buttock, and in women in the vagina. The stricture is usually at the lower part of the bowel, from an inch and a half to two inches from the anus. It also occurs at the point where the sigmoid flexure terminates in the rectum. The disease originates in chronic inflammation of the mucous and submucous areo- lar tissue of the rectum. Women, in whom the disease is much more common than in men, have ascribed its origin to a difficult labour, during which the bowel was injured. Strictures of the rectum often also originate in the contraction consequent upon the healing of ulcers or wounds in the bowel, especially syphilitic. It is a dis- ease of middle life. Description. — The earliest symptom is habi- tual constipation, with difficult defecation when the motions are solid. As the contraction in- creases, the constipation becomes more obsti- nate, and the stools are diminished in calibre, and are often voided in lumps. A brown slimy fluid escapes with the motions, and there is a burning sensation after stool, and flatulent dis- tension of the colon. As the disease makes pro- gress and ulceration ensues, the discharges be- come purulent and bloody, and the sufferings are much increased. There is sometimes so copious a discharge as to mislead the practitioner, the stricture being overlooked, and the case treated as one of protracted diarrheea. The appetite may remain good, and the general health may be but little impaired but in the course of time the de- rangement of the digestive functions, the irrita- tion kept up by the disease, and the exhausting discharges firing on hectic symptoms. The appetite fails, the body emaciates, night-sweats become profuse, and the stricture directly or indirectly becomes the cause of death. This is sometimes hastened by a lodgment of hardened feces or some foreign body just - above the stric t-ure, so as to block up the passage, and occasion all the symptoms of internal obstruction. In patients with stricture small flattened excres- cences are usually observed at the margin of the anus. These cutaneous growths resemble ad- lapsed external piles, except that they are redder RECTUM, DISEASES OF. in colour, and are kept moist by the escape of an irritating discharge from the bowel. In many eases the interior of the rectum is abundantly studded with small excrescences or irregular growths of the surface, and folds of the mucous membrane, the result of chronic inflammation. Diagnosis. — A stricture in the lower part of the rectum can be easily detected by tactile examination. It must be borne in mind that the bowel is liable to be obstructed by disease of the neighbouring viscera, an enlarged or dis- placed uterus, fibrous tumours of this organ, an ovarian growth, pelvic hsematocele, excessively hypertrophied prostate, or hydatid tumour be- tween the bladder and rectum. Treatment. — The main object in treatment is to dilate the contracted parts sufficiently for the free passage of the motions, and this is to be effected by mechanical means — by the passage of bougies. Means must also be adopted to relieve the irritability of the part, and to ensure the regular passage of soft evacuations. Opiate suppositories at bed-time, castor oil, cod-liver oil, aperient waters, and local applications of solution of nitrate of silver, are the remedies required. In old inveterate strictures, wearing out the patient’s strength, the writer has recom- mended colotomy. ". Villous Tumour. — Villous tumour, a growth similar to that which occurs in the bladder, springs from the mucous membrane of the rectum, generally by a broad base ; is soft in structure ; and is composed of a number of pro- jecting papillae or villi. It is innocent in charac- ter, and is not apt to return after removal. Its chief peculiarity is a remarkable disposition to bleed. The villous tumour occurs only in adults, and is a rare disease. It should be removed by ligature if possible, or by the clamp-forceps. 8. Ulceration. — Description. — Chronic ul- ! ceration may arise from dysentery, tubercular disease, or syphilis. Dysenteric ulcers are exten- sive, and occur to persons who have been in | tropical climates, or exposed to hardships, and deprived of proper nutriment. The tubercular . ulcer is usually small in size, but indisposed to . heal. Syphilitic ulcers are large, deep, and ir- regular, and occur generally in women. It is a . question whether they are due to direct conta- gion, the mucous membrane of the bowel be- coming inoculated with matter from sores on the vulva, or in a more direct way, or whether the ulceration is the result of constitutional disease, fhe chief symptoms are a purulent discharge Tom the anus ; motions loose and mixed, or .'oated with a slimy fluid and streaked with blood ; soreness in defecation ; and occasionally tenesmus. The characters, position, and extent »f ulceration can be ascertained by examination vith the finger and with the speculum. Treatment. — The treatment depends on the ature and extent of the disease, and upon the onstitutional condition of the patient. In severe ises the patient should be kept in the recum- ent position. In extensive destruction of the aicous surface, with free discharges, especially hen originating in dysentery, vegetable astrin- mts, such as simaruba and krameria, combined ith mineral acids and opiates, are of great scr- ee in restraining the tenesmus and irritating | 84 REFLEX DISORDERS. 132S discharges. The nitrate of bismuth, with mag- nesia and anodynes, also affords great relief, and the sulphate of copper with opium may often be given with advantage. When the ulceration is consequent on constitutional syphilis or scrofula, the remedies appropriate to these dis- eases are required. The local treatment consists in the application of weak solutions of nitrate ot silver or sulphate of copper, and anodyne injec- tions with mucilage, or anodyne suppositories. T. B. Curling. RECURRENT DISEASES. — Disease- which have a tendency to return after theii actual or apparent cure or removal, either with out any obvious cause, such as cancer or ague or from some very slight cause, such as gout o.' rheumatism. EECU3EEUT INSANITY. See In sanity, Varieties of. RECURRENT LAEYN GEAL NERVE Diseases of. — See Pneumogasthic Nerve. Dis eases of. RED GUM.— An eruption of scattered red pimples on the skin of infants ; more scientifi- cally described as lichen urticatus. In infants the eruption has obtained the name of strophu- lus, from its presumed association with a dis ordered state of the bowels, accompanied with colic. The term ‘ gum ’ alludes to a resemblance between a pimple on the skin and the exudation of gum from a tree in the form of a drop, and is an illustration of the frequent reference to the vegetable kingdom in the nomenclature of skin- diseases. See Lichen; and Strophulus. Erasmus Wilson. REDUPLICATION. — -A doubling; a term generally used in reference to the sounds of the heart. See Physical Examination. REDUX (Lat., returned). — A term signifying the return of certain physical signs, after their temporary disappearance in the course of a dis- ease ; usually associated with crepitation in pneu- monia, and with friction in pleurisy and pericar- ditis. Redux signs are usually significant of a favourable tendency in a disease. See Physicai Examination. REFLEX DISORDERS. — These consti- tute a very varied group of affections, most of which are individually considered elsewhere, in separate articles. But it will be useful here to say a few words concerning them as a group, in order that the mutual relations of many appa- rently discordant conditions may thus be set forth, from the point of view of their origin or pathogenesis. Pathology. — The factors concerned in the production of a reflex disorder are in kind those which are needful for the production of a ‘ reflex action’ — though in the former case such causes act for an inordinately long time, or else with an intensity which is altogether unusual. In each case we must have (a) afferent impressions re- sulting from the influence of a foreign body or a pathological state (such as inflammation or ulceration), acting as an irritant upon afferent EEFLEX DISORDERS. 1330 nerves, either in some part of their course, or in their peripheric sites of distribution — whether such sites be situated upon the external surface of the body, or upon some part of one or other of the mucous surfaces within the body. Thus it happens that the determining cause may in some cases be associated with painful impressions, though in many other instances such impressions may be more or less completely absent. Occa- sionally mental emotions may take the place of peripheric impressions, as inciters of abnormal reflex phenomena. The next essential factor ( b ) is that the af- ferent impressions (painful or non-painful) pro- duced by the irritant or pathological state, should pass from the nerves, conveying them through a related nerve-centre, which, from one or other cause, chances to be in a state of exalted acti- vity; and thence ( c ) be reflected along one or other set of efferent nerves, so as to produce effects of this or that order. Yaiiieties.— As efferent nervesare distributed to glands, and to muscles (both involuntary and voluntary), reflex phenomena may show them- selves in one or other of two principal directions — that is, (1) by the modification of the quan- tity Or quality of some secretion, or (2) by the production of spasmodic contractions in certain muscles, either of the involuntary or of the voluntary type. In these ways, multitudinous and varied effects are apt to be produced on dif- ferent occasions, as may be gathered from the following brief illustrations. 1. Modified secretions . — The morbid effects belonging to this class of reflex disorders show themselves, for the most part, by a diminution rather than by an increase in the amount of the secretion of the gland whose functions are affected, as when irritation of some of the abdo- minal nerves leads to a suppression of the renal secretion, by setting up some form or mode of inhibitory influence. The action of cold upon the external surface of the body in producing an increased secretion of urine, is probably brought aoout by an augmented determination of blood to the kidneys, and not as a simple result of reflex action. The mental conditions of anxiety, fear, or terror do, however, often lead to an increased secretion of urine; and the increased secretion in these cases may be brought- about by simpler and more purely reflex influences. Again, precisely the same mental states may lead to an arrest of the salivary secretion, as well as to such an increase of the intestinal se- cretions as to produce loose evacuations or actual diarrhoea. Other instances might be included under this head, but they are all of them phe- nomena whoso precise mechanism is compara- tively obscure. Still in each case the mode of production of the phenomena would seem to conform to the type indicated. 2. Muscular spasms . — The morbid effects be- longing to this second class of reflex disorders are also variable in their occurrence, and more or less uncertain as regards their precise me- chanism. Still, reflex spasms, set up by some contiguous source of irritation, are met -with not unfreqwently in the urethra and neck of the bladder, in the sphincter of the vagina, or at the commencement of the oesophagus. They may also occur in the bronchi, or in portions of the intestinal canal; likewise in the ureters or in the gall-ducts, during tho passage of calculi along either of them. As an instance of a spasm engendered in in- voluntary muscular fibres, under the influence of a mental emotion or state, rather than a peri- pheric irritation, one may cite the sudden con- traction of the uterus in certain cases of abortion induced by fright, auger, or other powerful mental emotion. Again, acts of vomiting are pro- duced occasionally by certain sights or odours. In the voluntary muscles tonic spasms of a reflex character occur, especially in children or in females of a nervous temperament, in the form of contractions of some of the muscles of the extremities more especially, though at ether times the muscles of the jaw or some of the mus- cles of the neck may be the parts involved. See Spasm. Of infinitely more importance, however, are the multitudinous cases in which some sources of irritation, either within or on the surface of the body, occasion, in various more or less obscure ways, through the intervention of the great en- cephalic centres, convulsions or fits of one or other variety ( see Convulsions ; and Epilepsy). Here we have, as a result of the peripheric irri- tation, a whole series of spasms, partly tonic and partly clonic in character. It is worthy of note, too, that an irritant at the surface of the brain, in certain regions, is just as potential as an irri- tant acting upon the mucous membrane of the intestine. But another class of reflex muscular spasms still remains, to which an immense amount of importance is attached by some pathologists, namely, those which are brought about through the agency of vaso-motor nerves acting upon the contractile walls of 1 flood-vessels. It is well known that under tho influence of direct irri tation, vaso-motor nerves may cause small ar- teries and arterioles to contract to an extreme degree, and that this condition is apt to be fol- lowed by one of extreme dilatation of these same vessels. It is known also that under the in- fluence of emotions the calibre of the vessels in certain parts of the body is apt to vary greatly. Of this we have examples in the temporary pal- lor of the countenance produced by fright, and in the suffusion of the face and neck, from un- natural fulness of vessels of these parts, in the act of blushing. On the other hand it is assumed that, as a result of some abiding irritation in the intestine, in the bladder, or in other parts, reflex contractions of the arterioles in certain regions of the spinal cord (also of an abiding character) ; may be brought about, so as more or less com- pletely to annul the functions of this particular portion of the cord, and thereby ro lead to para- lysis of the lower extremities — that is, to para- lysis of the limbs chiefly' in relation with tho region of the cord affected. This is the generally assumed mode of production of a so-called ‘ re- flex paralysis.’ Others, however, imagine that, in certain cases at least, such a paralysis may be brought about differently — not by the reflex ac- tion producing a spasm of vessels in a part ol the spinal cord, but- by a spasm of die vessel* supplying the great nerves and muscles of the REFLEX DISORDERS. limbs affected. The anaemia, thus supposed to be induced in either case, is regarded as the cause of an ensuing paralytic condition. But the question as to the probability of the existence of ‘ reflex paralysis ’ need not be here discussed, since the arguments for or against the existence of such a paralysis which are applicable to one form of it are applicable also to another, and these are set forth in the article Spinal Coed, Special Affections of — Reflex Paraplegia. It is right here, however, to add that the late Dr. Meryon put forth an entirely different account of the origin of ‘ reflex paralysis.’ He assumed that the irritating body or process (that is, an influence slight in degree, but long-continued) gave rise to a determination of blood in related portions of the spinal cord ; that the continuance of this condition led to an overgrowth of con- nective tissue ; that this overgrowth caused pressure upon the imbedded nerve-fibres; and i hus induced paralysis in related portions of the body. This view is throughout based upon po- sitions of which no proof exists ; and if such a mode of production of paralysis, in response to local irritation, did really obtain, it would, by hypothesis, be by the establishment of a per- manent lesion, as a result of which we certainly should have no right to expect a fluctuation in the degree of the paralysis, in accordance with fluctuations in the amount or intensity of the local irritation, or a comparatively sudden ces- sation of the paralysis so occasioned, sequential to a cessation of the local irritation. Yet these are the assumed differential characteristics of a paralysis of reflex origin. It does not seem to be imagined by anyone that a local irritation is capable of engendering a condition of paralysis by any direct inhibitory process. The intervention of altered conditions of vaso-motor nerves and of altered states of vessels seems to be postulated by all. Yet some such direct influence may, perhaps, be more pos- sible in those related cases in which the starting- point or primary cause of paralysis is a mental state rather than a peripheric irritation — that is, in the aetiologically obscure cases described by Reynolds as paralysis dependent upon idea. See Spinal Coed, Special Affections of, No. 9. It is right here, also, to mention a class of phenomena which have some analogies to reflex disorders, that is, the numerous cases in which, as a consequence of irritation in one or other region, pain is felt in some more or less distant part of the body, as when a stone pressing upon the neck of the bladder causes severe pain at the meatus urinarius, or when disease of the stomach or of the liver causes a pain which is felt in the scapular region. H. Charlton Bastian. REFLEXES, Spinal. — See Spinal Coed, Diseases of; p. 1458. REFRACTION, Disorders of. See Vision, Disorders of. REFRIGERANTS ( refrigero , I cool). — D e- finition. — Remedial agents which lower the body-heat, either in health or in disease ; or which »ilay thirst, and impart a feeling of coolness. Enumeration. — The chief refrigerants are : — RELAPSING FEVER. 13S1 the whole class of Febrifuges ; Water ; Ice ; Effervescing drinks ; Acids ; and the juices or Fruits. Action. — As the name implies, anything may be ranked as a refrigerant which lowers the body temperature, and we may here consider in how far the drugs described under Febkifuges have the property of cooling down the healthy organism. Quinine and alcohol have but a slight and tran- sient lowering effect, and salicylic acid has none at all; and this is readily explained, if we believe that their antipyretic properties in fever de- pend on their destructive influence over the pro- toplasm of septic ferments. Refrigerants, however, are popularly held to be those drugs which relieve the thirst of the fever-stricken patient, by moistening his dry lips and cooling his parched tongue. Ice or iced drinks manifestly fulfil these indications; aud acids, which are often the most grateful of all, act very efficiently by directly stimulating the salivary secretion. R. Farquharson. REGIMEN (rego, I govern). — This word is not uncommonly used as synonymous with hy- gienic management. In a more restricted sense it is applied to the regulation of diet, both in health and disease. See Diet ; and Personal Health. REGURGITATION [re-, again, and g 2 irgiio, I swallow). — This word is technically applied to the reversal of the natural direction in which the current or contents flowthrough a tube or cavity of the body. Thus the food may regurgitate from the stomach into the cesophagus and mouth ; the bile from the duodenum into the stomach; and blood from the aorta or pulmo- nary artery into the ventricles, from the ven- tricles into the auricles, or from the heart into the veins, when the respective valves are incom- petent. See Heart, Valves of, Diseases of ; and Rumination. REHME (Oeynhausen), in Germany. — Gaseous thermal salt waters. See Mineral Waters. REICHENHALL, in the Bavarian Alps. Common salt waters. See Mineral Waters. REINERZ, in German Silesia. — Iron waters. See Mineral Waters. RELAPSE (re-, back, and labor, I slip). — The return of a disease, which has apparently ceased, during or immediately after convales- cence; or of a particular symptom in the course of a disease. Relapses are well exemplified in typhoid fever and acute rheumatism. RELAPSING FEVER.— Synon. : Famine Fever (Irish writers); Fr. Fievre a rechute-, Ger. Hungerpcst. Also many other names, according to the localities where it has prevailed as au epidemic. Definition. — A continued contagious fever ; characterised by absence of eruption, and a tendency to relapse at intervals of from five to seven days, and for an indefinite number of times ; and generally occurring as an epidemic. All medical writers, from the earliest times 1332 RELAPSING FEVER. recognise the existence of a relapsing form of continued fever ; hut this disease had until recent years been included under the general term ‘ Con- tinued fever.’ Even in the great Irish famine fever of 1847, many of the Dublin physicians did not sufficiently distinguish between typhus and relapsing fever ; and we find a statement often made that the fever relapsed into typhus, or that typhus relapsed into a form without spots. There is no doubt that typhus and relapsing fever co-existed at the time of the Irish famine, as they have invariably done at all times and places in seasons of great scarcity. Geographical Distribution-. — Northern Eu- rope seems to be the favourite habitat of re- lapsing fever. It has been met with in America, but not as an epidemic, having been imported from Europe, and not showing a tendency to spread. An epidemic outbreak occurred at Pe- shawur in the Punjab, and also in Egypt. Epi- demics have been more common in the British Isles than elsewhere. The most extensive epi- demics have arisen in Ireland in times of famine, and extended thence to England and Scotland. An epidemic was confined to Scotland in 1843, and another to London in 1868. JEtiology. — Predisposing causes. — - Males suffer more from relapsing fever than females, in the proportion of about 1'5 to 1. The disease is most common between the ages of fifteen and twenty-five. Season seems to have little effect, hilt it appears to be more prevalent in winter than at other seasons, because the other predisposing causes are more intense at that time of the year. All the causes which predispose to contagious zymotics favour more or less the prevalence of relapsing fever. The most powerful, however, are scarcity of food, overcrowding, and want of cleanliness. Exciting causes . — Relapsing fever is contagious, and has always been found, to spread in proportion to the facilities for communication. It has been transported from long distances by affected persons ; attacks attendants on the sick, and persons not predisposed when they are exposed to its contagion ; and may be communicated by fomites. It seems to act through but a short distance. The period of incubation is uncertain, sometimes being apparently almost absent, at other times stated to extend to fourteen or twenty- one days. Famine and its consequences, or famine alone, is a cause for the origin of relapsing fever dc novo. Some doubt the truth of this statement, but it is usually received by writers upon the disease. The evidence in favour of famine as a cause rests upon the 1 fact that after it has been absent for many years, it breaks out on each occasion under precisely similar circumstances ’ (Murchison). The circumstances preceding an outbreak are invariably failure of crops, and consequent famine. Relapsing fever, although usually prevailing among overcrowded persons in large towns, must not he considered to depend upon this condition, except so far as overcrowd- ing favours the spread of contagion. The over- crowding in towns during an epidemic results from the same cause as that producing the fever ; namely, the scarcity of food in the country, which drives people into the towns. Anatomical Characters.— These are no! marked, except where complications have caused death. The liver and spleen are both found en- larged in all cases, especially the latter organ. The digestive organs exhibit nothing particular, except in those cases where there has been leng deprivation of food, or where dysentery cr diarrhoea has accompanied or preceded the dis- ease. Certain small bodies termed spirilla have been found in the blood of patients suffering from relapsing fever; these bodies decrease as the paroxysms subside, and are absent during the intermissions. Spirilla were discovered by Ober- meier, of Berlin, in 1872, and the discovery was further confirmed by Engel in 1 873. Spirilla vary considerably in number in different cases and at different times. They are constant in size, and form spiral fibrils, of which the convolutions are extremely small ; the spiral form remains after all motion has ceased. Their movements are of three kinds — undulations passing along the whole fibril, flexions occurring at various points, and locomotive movements. These variations some- times give the bodies a circular appearance, a figure-of-8 shape, or an arrangement in long chains. Large colourless transparent cells, ir, some cases from two to four times the size ,.f colourless blood-corpuscles, are also found in the blood in relapsing fever. See Spirillum. Symptoms. — The invasion of the disease is usually, marked by rigors, frequently of a trivial character, amounting only to slight chilliness. This is followed by debility and giddiness; ex- treme weakness is not so marked as in the eariv stages of other forms of continued fever. There is headache, followed after a few hours by hot skin ; the temperature rises to about 105° F., or sometimes, it is stated, as high as 108°; the pulse rises to from 110 to 130, occasionally countirg 140 at an early stage of the disease. The tongue is covered with a moist creamy fur, which iu severe cases becomes brown and dry 7 in the centre, and in the worst forms becomes black all over. There is great thirst, as in all febrile diseases ; loss of appeti te ; some abdomi nal tende rness, espe- cially in the epigastric region ; occasionally nausea, and more rarely vomiting ; the bowels are usually confined, but in some cases diarrhoea prevails. In such cases the diarrhoea is of a dysenteric character, and is probably due to the dysen- teric tendency which usually prevails in time of famine, when relapsing fever is prevalent. The skin generally presents a jaundiced hue; and careful examination will detect more or less en- largement of the liver and spleen. There is great muscular and articular pain. The pain in the back is frequently of the most intense character. Headache is more complained of than in the other forms of fever. There is sometimes, but not as a rule, delirium towards the end of the first week. In from five to seven days from the invasion of the disease, the symptoms suddenly subside, and the patient quickly becomes con valescent, being for the time apparently well. This convalescence is frequently accompanied or preceded by a critical evacuation from the bowels, kidneys, or uterus, or by profuse diaphoresis. It may be permanent, but more commonly the patient remains well for a few days or a week, and then suddenly relapses, and passes through ah RELAPSING FEVEE. REMITTENT FEVEE. 1333 ihe symptoms previously detailed. There may be ji second or a third relapse, and even a fourth has been recorded. At no time during the progress of the disease is any specific eruption developed, although on the second or third day a reddish mottled rash has been met with, which, however, is irregular in its appearance, development, and duration, and usually terminates in desquamation. Purpuric spots have been sometimes, and suda- rnina very frequently met with. Complications. — Pulmonary complications are not so common in relapsing fever as in typhus or enteric fever. Bronchitis, pneumonia, and laryngitis may occur, especially bronchitis, but these complications are not severe. Cardiac, arterial, or venous affections are rare, with the exception of haemorrhages, which must be con- sidered as being connected with the purpuric ten- dency which usually prevails in times of scarcity. Nervous complications are more rare than in any other form of adynamic fever. Dysentery and diarrhoea in somo epidemics have proved to be most serious complications, and are of frequent .eeurrence whenever relapsing fever prevails. Abscess and other suppurative forms of inflam- mation are nor. common. In pregnant females attacked by this fever abortion usually occurs at in early stage ; and premature labour, with death of the foetus, and considerable danger to the mother, in the later stages of pregnancy. Death of the mother has sometimes happened from post-partum limmorrhage. Diagnosis. — Eelapsing fever is most likely to be mistaken for other forms of continued fever, and may be confounded with the eruptive fevers in their earlier stages, especially small-pox. It differs from typhus in having a higher tempera- ture and quicker pulse at the outset; in the absence of the specific eruption, of the extremely heavy aspect of the patient, and of the delirium jf typhus ; in the presence of extreme pains in .he back, vomiting, and jaundiced tinge of the ?km ; and finally in the sudden cessation of symptoms, and the tendency to relapse. It differs from enteric fever in the suddenness of its onset, enteric fever having a slow inva- sion ; the want of the marked and extensive daily variations in temperature ; the absence of the characteristic abdominal symptoms and eruption ; and the absence of the localised iliac tenderness and the peculiar diarrhoea of enteric fever. The tongue also serves to distinguish re- lapsing from enteric fever ; in the latter having a well-marked red tip and edges, in the former a light covering fur. Eelapsing fever at its com- mencement has been confounded with small-pox, on account of the extreme pain in the back and marked vomiting which accompany both these diseases, but the appearance of the specific erup- tion will soon decide the question. Pbognosis, Duration, Terminations, and Mortality. — The prognosis of relapsing fever is usually favourable, tile mortality being low, from 1'2 to 2 per cent, in London, up to 4 and 4o per cent., in other places ; the average rate being about 4 per cent. The chief causes influencing the rate of mortality seem to be the prior state of the patient, and the duration of the disease before medical relief is applied for. Purpuric symptoms, severe dysentery or diarrhoea, serious haemorrhages, or extensive chest-complications always indicate a grave prognosis. Treatment. — The treatment of the disease mnst be preventive and curative. The chief promoting causes of the disease being famine and contagion, the means for prophylaxis art- obvious. The active treatment must chiefly be directed towards the relief of symptoms, and sustaining the strength of the patient. The use ot quinine and mineral acids in the earlier stages, and a plentiful supply of light and nourishing food in the later, will be found sufficient. A considerable amount of the success of treatment must depend upon the dieting of the patient. It must he kept in mind that most of these patients have been in a state of starvation. It will he necessary, therefore, to carefully and gradually increase the supply of food. The food at first must he of a most digestible and fluid kind, which may gradually he altered to a diet of a more solid and general character. Dysentery has not infrequently been caused by the sudden feed- ing of patients suffering from relapsing fever in its early stages. Milk, light starchy puddings made with milk, thin custards, and finally chicken, chops, and general diet will be found the best course in this disease. Stimulants may be occa- sionally requisite, but are seldom necessary in any quantity, or for a length of time. T. W. Gremshaw. RELAXATION RELAXED }< re-, again, and laxo, I loose). — -These words signify a condition of looseness, and are used somewhat vaguely' in a variety of associations. Thus we speak of gene- ral relaxation, to express a want of muscular tone or vigor. Local relaxation refers to a con- dition of abnormal looseness of a part, as of the joints, muscles, the uvula, or the throat, which are then said to be relaxed. Another signification of the term relaxation is that of looseness of the bowels, as in diarrhoea. REMEDY ( remedium , a cure). — A remedy properly signifies a therapeutic agent which pos- sesses a recognised influence in preventing, re- lieving, or removing a particular morbid condi- tion. Thus vaccination is a remedy for small-pox ; quinine for ague ; mercury and iodide of potas- sium for syphilis ; and opium for pain. See Disease, Treatment of. REMISSION" REMITTENT y re-, again, and mitto, I send). — A disease is said to he remittent when it is characterised by periodical difninutions of symptoms, followed by exacerbations, as in re- mittent fever and neuralgia. The period during which the symptoms are in abeyance is called a remission. See Remittent Eever. REMITTENT EEVER. — Synon. ; Bilious Remittent ; Fr. Fievre remittente ; Ger. B'osar- tiges Endemisekes Either. Definition. — A paroxysmal fever of malarial origin, in which the paroxysms do not intermit, hut only, as the name implies, remit. General Observations. — Remittent fever is the most severe of the class to which it be- longs ; it is a more acute affection than inter- REMITTENT FEVER. 1334 : mittent fever, more severe in its symptoms, more rapid in its course, and the direct mor- tality is ten times greater than in any other form of malarial fever. It is commonly known in India as jungle fever, because it is in jungles there at certain • seasons of the year that it is most frequently contracted. It often obtains local names derived from places notorious for producing it, a practice productive only of con- fusion and misapprehension. It is sometimes said to hold a middle place between intermittent and continued fever; the more nearly it resembles the latter, the more dangerous it is. In other words, the less distinct the periods of remission, and the longer the stage of exacerbation, with its high temperature, and other disturbances of the system which characterise that stage, the greater is the risk of such blood- and organic changes as are incompatible with life. Remittent fever is usually seen in its gravest forms in hot climates, but has often been very fatal in malarial regions in temperate climates, as in Walcheren. This, in unhealthy countries, is often the first form of fever that attacks new-comers, but such are seldom exposed to second attacks ; in other words, there is in this type less ten- dency to a recurrence of the disease than in the intermitting form. It may be that the extremely energetic character of the symptoms in the remit- tent type is more effectual in destroying, alter- ing, or ‘ eliminating ’ the poison, than the milder intermittent attack. In 1865, out of 3,199 cases of remittent fever admitted into the military hospitals of Algeria, only 359 had second attacks; while out of 15,080 cases of intermittent fevers, 4,295 were re-admitted with the same type of fever ( Statistique Mcdicale de VArmee , 1865). The medical officers of our army in Spain ob- served that their men, on entering a malarial locality, generally suffered severely from the re- mittent form, while the inhabitants of the coun- try were only affected by the intermittent type. Survivors, however, who remain in the locality, become, like the inhabitants, only liable to the milder type of the disease. Aetiology. — Remittent fever is found when- ever its specific cause is generated in sufficient concentration to cause it. This will probably be found to correspond with the germ origin of intermittent fever (see Intermittent Fever; and Malaria). It prevails in the malarial parts of the Old and New World. Our armies have suffered from it both in temperate and hot cli- mates ; in the East and West Indies, and, with extreme malignity, on the West Coast of Africa. It is a common disease in the malarious parts of Italy; and the French army lias suffered much from it in Algeria. It is seen in the deltas of great rivers, in the terrain of India, in jungles, and in other districts iu the same country long left uncultivated. Anatomical Characters. — The morbid ana- tomy of remittent fever is the same as in inter- mittent fever; the. difference is only in degree. Congestion of the mucous coat of the stomach and duodenum, with softening, is more marked than in other types of malarial fever, as -well ns enlargement of Brunner s glands. The pig- mentary degeneration of the spleen and liver is more intense, often extending also to the brain and spinal cord, giving them a bronzed appear- ance. Symptoms.— Premonitory. — These are much the same as in a severe intermittent. Cold Stage. — The term is hardly applicable in this fever ; the patient is sensible only of a slight sensation of chilliness, which very rarely passes into rigors. Nevertheless, the thermometer indi- cates a temperature above the normal, and in the hot stage this quickly rises to 106°, 107°, and sometimes to 110° F. Hot Stage. — As this develops, the whole sys- tem is profoundly disturbed. There is the high temperature already indicated, which, when fully developed in the worst cases, approaches within three degrees of that in which the albuminoid constituents of the muscular tissue begin to co- agulate. This grave symptom is seen in its ut- most intensity in those who have exposed them- selves, perhaps after indulging in alcoholic liquor, to a powerful sun, without reasonable precau- tions. With this there is necessarily pungent heat of skin ; an intensely flushed face ; severe headache ; pain in the back and limbs ; quick respiration; a pulse of 120 or more; a foul, dry, and bile-tinted tongue ; a sense of oppression at the epigastrium, with fulness and tension in that region ; and violent vomiting, which brings do relief to the gastric oppression. This vomiting is one of the most distressing symptoms ; the quantity of fluid vomited far ex- ceeds what has been taken by the patient : at first it is colourless, then bilious, aDd sometimes bloody. In pernicious cases it closely resembles the ‘ black vomit’ of specific yellow fever. With the above symptoms there is an anxious counte- nance, and much restlessness. In this condition the patient remains from six to twelve hours. Then the more urgent symptoms abate ; the temperature falls two, three, or more degrees ; the skin becomes slightly moist, far short of the profuse sweating in an intermittent fever; headache sensibly diminishes ; and the nausea, vomiting, and epigastric tension either cease or sensibly abate. This is the remission, always anxiously looked for, not only as a relief to the patient, but as a precious time for treatment. In bad cases, when the other symptoms remit so little as to escape the notice of all but an expe- rienced observer, the thermometer wiil indicate at least an attempt at a remission. This lasts from two to twelve hours ; the longer it is, the more favourable is the prognosis. A feeliDg of chilliness then returns, quickly followed by the hot stage, with all its distressing symptoms. This is the exacerbation of systematic authors, which in its turn gives way to the remission. A morning remission in this fever is so in- variable as to be a point of diagnostic value, and it is an old rule in military practice so to time the morning visit as to insure seeing the patient while it lasts. The exacerbation usuallv returns about noon, and in severe cases lasts till midnight. Sometimes two exacerbations occur, one at noon, the other at midnight, with a slight evening, and more distinct morning, remission. The skin sometimes assumes a yellow ant, and if there be with this anything resembling black vomit, a false diagnosis of yellow fever may be made. The term ‘ yellow remittent- if .REMITTENT FEVER. eorrectly enough applied to such cases, but the resemblance between these and cases of specific yellow fever is only superficial. Hiccough is a troublesome symptom, and if it appears late in the disease, and continues during the remission, is not a favourable one. The bowels are usually constipated, but in pernicious cases the motions sometimes become very loose, bloody and offensive, a condition of evil omen. Jaundice is rare, although, as already said, the skin has often a yellowish tinge, more de- pendent on blood-changes than from an icteric cause. Hepatitis. — The only cases of suppurative in- flammation of the liver, occurring in the course of remittent fever, that have come under the writer's observation, were brought to Netley from the Gold Coast, where this serious compli- cation appears common. Delirium. — Except in men who have lived imprudently, and, in addition to the poison of malaria, have indulged freely in alcohol, active delirium is rare. Like in all malarial fevers, the symptoms and lesions in remittents point more to implication of the abdominal organs than of the nerve-centres. The urine is acid, scanty and high-coloured, rarely albuminous — so rarely, that its absence is a point of diagnosis between malarial remit- tent and specific yellow fever. During the hot stage the secretion of urea is greatly increased, but lessened when convalescence sets in. In two very severe cases treated by the writer in Liclia, there was profuse secretion of bloody urine throughout, which lasted until convalescence set in. The adynamic form of remittent fever is one of great gravity. It is becoming every day more apparent that in bygone years — and perhaps even now in India — cases of enteric fever have been, and are, mistaken for malarial remittent. The diagnosis is not so easy as it may appear to those who are familiar with enteric fever pure and simple, as seen intemperate climates. There are cases of a mixed nature, in which a thread of malaria, so to speak, runs through the symp- toms and obscures them. The term ‘ typho- malarial ’ has come into use in India to distin- guish this class of cases, which are as difficult to treat successfully as to diagnose clearly. French and Italian writers would apply their favourite term ‘ pernicious ’ to such cases, which are characterised from an early stage by great prostration ; brief and uncertain remissions ; a quick and compressible pulse ; a black and dry tongue, the teeth being covered with sordes ; rapid respiration ; epigastric tension and oppres- sion ; the bowels being loose, and the motions bloody, with a disposition to haemorrhage from the mucous surfaces generally. Such cases are often fatal, and post-mortem examination, in addition to the common lesions of malarial fever, reveals ulceration of Peyer’s patches. Duration. — The duration of a remittent fever is from five to fourteen days ; but, as in all mias- matic fevers, it is much affected by the action et remedies. In the worst forms death is rare before the eighth day. Diagnosis. — 1. From specific yellow fever . — 1335 Remittent is paroxysmal ; yellow fever is con- tinued. Remittent has a morning remission ; yellow fever has not. Haemorrhage from any source is exceptional in remittent ; in yellow fever it proceeds from mouth, nose, eyes, ears, bowels, and even the urinary passages. Even in the worst remittents albuminous urine is rare ; it is the rule in yellow fever. Over remittent fever the power of quinine is beyond question ; the drug is powerless in yellow fever. Death in the worst remittents is never seen before the eighth daj r ; in specific yellow fever it is common on the third day. The mortality rate in yellow- fever is often forty per cent, of those affected., that of remittent does not in ordinary circum- stances exceed four or five per cent., and is often less. Yellow fever is portable and contagious ; remittent is neither. Yellow fever has a special habitat of its own, and can only exist as an endemic disease in countries where the mean temperature does not fall below 7-° F. Lastly, specific yellow fever has never established a footing on the shores of India, where malarial remittent is an endemic disease. 2. Enteric fever, puro and simple, ought not to be easily confounded with remittent It is marked off by the difference in the thermometric curve : in enteric fever, the rise of temperature is slow; in remittents it attains its maximum in a few hours. There is also the characteristic eruption, the iliac gurgling, and the peculiar stools of typhoid, all absent in remittent. As mentioned above, the diagnosis is not so easy when the pe- culiar symptoms of malarial mask or obscure those of enteric fever. Still, due observation of the peculiar combination of symptoms will en- able careful practitioners to make a good prac- tical diagnosis, and to regulate their treatment accordingly. It may seem unscientific to speak of two specific diseases existing together, and as it were struggling for the mastery in the system. The writer’s belief is, that in the doubtful cases the real disease is enteric fever, the symptoms being merely modified by malaria, in the same way as they are in many other diseases. Prognosis. — This is favourable when the re- missions are distinct; when each succeeding ex- acerbation diminishes in force ; when the skin acts freely; and when the urine deposits the sedi- ment described as critical in intermittent fever as the attacks pass off. Faint and uncertain remissions ; a tendency to collapse at the close of an exacerbation ; the sudden setting in of dangerous complications ; the predominance of typhoid symptoms ; sup- pression of urine ; and a general disposition to htemorrhage from the mucous surfaces, are all signs of evil omen. Treatment. — After a large experience in the treatment of malarial fevers in some of the most unhealthy regions in the East, the writer desires to place on record the fact that he has never seen any but disastrous results from treatment based on the belief that remittent fever is an in- flammatory disease. The practitioner who keeps this in view, and acts on the principle of saving power as much as possible, will save more lives than the man who, alarmed by the violent dis- turbance of the system, attempts to calm it by lowering treatment • or the other, who, halting REMITTENT FEVER. 1336 between two opinions, seeks to cure his patients by an incompatible mixture of depressing and conservative remedies. With the reservations already given when treating of intermittent fever, no better combination of a purgative with quinine can be given, to begin the treatment, than Livingstone’s, described in the article on that disease ; but whatever be the purgative se- lected, it should be suited to bring away copious bilious discharges, which will greatly mitigate the vomiting, and it should be combined with quinine. A good formula is from 3 to 5 grains of calomel, compound extract of colocynth, and powder of scammony, with a drop or two of any aromatic oil ; this acts effectually on the whole tract of the intestine, usually without nausea or griping, and a like quantity of quinine may be added. Two courses are now open to the practitioner. One is to postpone the further administration of quinine until the first remission. In the other the exacerbation is disregarded, and qui- nine is given in full and effective doses at once. If the first plan be decided on, much may be done to promote the comfort of the patient, to lower the temperature, and thus to hasten the period of remission. In strong men, when the tempera- ture is high, exceeding 105° Fahr., with head- ache, violent action of the heart, rapid respira- tion, oppression and restlessness, drop doses of the tincture of aconite every quarter of an hour until ten or twelve doses have been taken, calm the patient, reduce the force of the heart’s action, assuage the headache, and sometimes in a marked manner relievo urgent and distressing symptoms. Used in this way, and its effects watched, aconite is a valuable and safe remedy, and, acting in the same way, it is as useful in specific yellow fever. It has also this great re- commendation, if cautiously used, that it leaves uo sting behind. When the temperature rises, as it often does, to 105-6° or 110°, more energetic means are callod for. The patient should be placed in a batli at 90° Fahr., which should be cooled down until the thermometer indicates a temperature 1-5° below the normal temperature of his body. T ho effect of this in calming the patient, reliev- ing the oppression, and checking vomiting, is often very striking. When removed from the bath the patient should be wrapped in a blanket. In adynamic cases, where the use of the bath is not deemed prudent, the same good effects may be brought about by spoDging the surface with water, the temperature of which is gradually re- duced as directed above. On the first appearance of the remission qui- nine must be given by the mouth, bowel, or skin. If there is no vomiting, by the mouth; if the remedy will not remain on the stomach, then it must be given by bowel or skin. Of the incon- veniences and occasional danger of the latter method, the writer has spoken in the article Intermittent Fever, to which the reader is re- ferred. If the hypodermic method is ever justi- fiable, in the face of thedanger of inducing tetanus in the manner described, it is in the grave and pernicious forms of this disease, when life is threatened, and time presses. If the remedy is given by mouth or rectum, at least half a drachm should be introduced into the system during the remission. It is in remittent fever of the urgent kind under notice that the Tinctura WaTburgi already mentioned (see Intermittent Fever) is most useful. As is now well known, the active ingredient in this remedy is quinine; and, if used as directed in the article referred to, it is as safe as it is effective. American physicians appear, in treating this disease, to follow chiefly the second plan mentioned, and trusting to the known property of quinine to diminish and not to increase temperature, they give it during the hot stage. The great difficulty here is the vomiting; during the exacerbation it is almost impossible to get anything to remain on the stomach. It must then be administered by enema to the extent of half a drachm, half the quantity being given in the same way three hours before the return of the exacerbations. Full doses of from 15 to 20 grains of the bromide of potassium at bedtime tend to calm restlessness and promote sleep. The above treatment must be persistently followed day by day until the fever is overcome. It will be seen from the above remarks that ob- stinate vomiting is not only a source of extreme and exhausting distress to the patient, but also one of the chief embarrassments of the practitioner. The means advised above are often effectual in checking it, and they may be supplemented by the use of ice when available, by external stimu- lants over the stomach, or by the application of cloths sprinkled with chloroform over the same region. Drop doses of Fowler's solution of ar- senic have been found by Bellot the younger effective in checking this distressing symptom in yellow fever, and the same remedy may pos- sibly be of use in cases resisting other means. But in the writer’s experience vomiting, as a rule, subsides with the other symptoms, when the exacerbations are controlled by quinine. AVhat was said, under the head of intermittent fever, of the daDger of pausing in the use of quinine, to treat this or thatcomplication.is most emphatically repeated here. On the first sign of collapse in any stage, re- course must be had to stimulants; white wine whey is an exeollont vehicle for the administra- tion of alcohol, if that be called for; good cham- pagne, if available, or the best Rhenish wine within reach, often answer admirably, and are keenly relished. Livingstone's party used bitter ale, and speak in praise of it as a stimulant grateful to the patient., ‘ frequently remaining on the stomach when all others are rejected.’ The large experience of such intelligent observers on such a subject is worthy of respect. It is hardly necessary to dwell on the necessity of sustain- ing the patient during the remission by a diet adapted to the irritable condition of the stomach. With one remark — one pregnant remark by the Rev. Horace Waller, the fellow-traveller, friend, and biographer of the illustrious Livingstone — we shall close this article; ‘One thing, however, must be strongly urged : it is that all notions about not being able to “ stand quinine,” that it “flies to the head,” and so forth, must be banished as utter nonsense. In Africa everyone can stand quinine ; there is scarcely a disorder there in which it is not positively required.’ Th* REMITTENT FEVER. RENAL CALCULUS. 1337 writer adds from his experience that this is as true of malarial regions in other parts of the world as it is of Africa. W. C. Maclean. REMOTE CAUSES. — This expression is used as a synonym for predisposing causes. See Disease, Causes of ; and Predisposition to Disease. RENAL CALCULUS.— Stnon.: Nephro- lithiasis ; Fr. Calcul renal ; Ger. A 'icrenstein. Definition. — A concretion formed by the de- posit of one or more of the solid constituents of the urine. It differs only in size from the gritty particles called ‘gravel’ ; it may be single, or there may be many ; it may be present in one or both kidneys at the same time ; and it occurs at all periods of life, from the foetus in utcro up to the extremest age. jEtioloqt. — The majority of urinary calculi are primarily formed in the infundibula or urini- ferous tubes of the kidney ; and are caused by precipitation, in the nascent state, of uric acid or oxalate of lime. This precipitation may be due to a real excess of the insoluble uric acid, or to deficiency of the water of the urine ; but the pre- cise form and proximate cause of the deposit are determined by the presence of a colloid matrix, composed of mucus or blood-globules, or other animal basis ( sea Calculus). Increase by gra- dual accretion goes slowly on until blockage of the duct occurs ; the calculus is then either floated by the urinary stream into the pelvis of the kidney and onwards through the ureter, or it becomes impacted in some part of its transit and develops into a full-formed renal stone, which, minute at first, may grow to enormous propor- tions. Varieties. — By far the most frequent variety cf renal calculus in this country is that composed of uric acid ; in the eastern counties, where stone is most common, it is very rare indeed to find in the adult any other primary form. Even in chil- dren, in whom oxalate of lime is not uncommon, uric acid is the most prevalent. It is thought by some pathologists that oxalate of lime forms the first starting-point even of uric acid stones, but this statement lacks proof. The sparing solubility of uric acid and oxalate of lime is pro- bably the cause of their greater frequency in calculi ; but other agents may occasionally be found to constitute the primary nucleus of renal stone, such as cystine, carbonate of lime, phos- phate of lime, either by itself or in combination with the ammonio-magnesian phosphate, form- ing what is designated the fusible calculus, and urate of ammonia or the mixed urates. The phosphates and urates, however, are more likely to occur as secondary than as primary deposits. Mixed or alternating calculi are frequently met with, in which are seen alternate strata or layers of uric acid, oxalate of lime, and phosphates, the latter generally constituting the external part. Pathological Effects. — The action of a cal- culus on the structure and condition of the kidney depends much on its size. At first it may pro- duce irritation and local congestion, possibly leading to actual inflammation, and even abscess within or external to the capsule. This may Happen when the stone develops in the tubular or secreting structure ; but when it remains and enlarges in the pelvis of the kidney, chronic pye- litis is more likely to ensue, with changes of an atrophic character. The pelvis dilates; pressure comes to be slowly exerted on the renal struc- ture, causing wasting, until but little secreting tissue is left ; and a large stone remains, occupy- ing the pelvis and branching into the calyces, in shape resembling a cauliflower, and with little covering beyond the capsule of the kidney. Symptoms. — The genesis of renal concretions is always unrevealed by symptoms ; their reten- tion and development up to a considerable size or in great numbers may be unsuspected and un- noticed ; and even their transit and escape through the urinary passages may be painless. Usually, however, there is some degree of lumbar pain, generally restricted to the side affected, spread- ing more or less to the front of the body, and down towards the groin and bladder. The pain is apt to be aggravated by exercise — especially by car- riage exercise, and it is liable on such occasions to become very severe ; so also w'hen, from any cause, it is disturbed in its bed, or makes a fruit- less attempt to enter the ureter (renal colic). "When a stone of some magnitude is passing down the ureter, symptoms of a very acute cha- racter usually ensue. The pain rises to intense agony in the loin, and along the course of the ureter down to the bladder and testicle ; fre- quently there is sickness or vomiting ; the patient is bathed in warm perspiration ; and he some- times passes into a state of fainting and collapse. The bladder is frequently irritable ; the urine is smoky from the presence of blood, or of elongated clots ; or almost pure blood escapes. These symptoms may come on suddenly; may last a few hours or a few days ; and may end as suddenly when the calculus reaches the bladder. The changes produced in the urine by renal calculus may be very slight. Haemorrhage is the most common and most characteristic ; some- times it is in quantity enough to render the urine smoky or like porter ; at other times it can only be detected by the microscope. When it exists in any palpable amount, albumen will, of course, be present too. Pus, mucus, and epithelium corpuscles will show themselves when the cal- culus has produced some degree of pyelitis. In long-standing cases a tumour may be felt in the situation of the kidney. The patient resting on his back, and the knees being drawn up, the surgeon with one hand behind presses the kidney forwards, and with the other in front presses it backwards below the margin of the ribs. He may thus, in young and thin persons — aided, per- haps, by the administration of ether — differen- tiate a renal stone from any of the usual kinds of renal tumours. Diagnosis. — Renal calculus may bo mistaken for various diseases : — 1. Bilious attacks, intes- tinal colic, or perityphlitis. The sickness and pain in the flank are present in all, but in ne- phritic colic the pain is apt to be more located in the loin, although this is by no means always so. The presence of haematuria will be conclu- sive. In typhlitis and perityphlitis there will be fever and local tenderness. 2. Obscure pain in the back, due to chronic lumbago or neuralgia. In these conditions the pain is generally across i 33S RENAL CALCULUS. the back, and not unilateral ; it is aggravated by- movements of the affected muscles ; and there is no lisematuria or other urinary complication. 3. Cancer or other renal tumour. Pain and hsema- turia are characteristic of both stone and cancer, but in calculus the health is generally good, while in cancer it is always deteriorated. In stone there is seldom any tumour, and when it does exist it must be of limited size and hard, whereas in cancer it is diffused and may be soft. Prognosis. — The frequent formation and escape of renal stones may continue for a great many years without any material injury to the general health. Even when blockage of the ureter takes place, leading to hydronephrosis and atrophy of the organ, or to nephritis or peri- nephritis with abscess, a fair measure of health may be preserved, provided the other kidney is in a healthy condition. When both organs are affected, or when complications arise, such as amyloid or tubercular disease, or chronic pye- litis, then the health steadily deteriorates, ema- ciation proceeds, with hectic and fatal exhaus- tion. Treatment. — -Bearing in mind that the large majority of renal stones are composed of uric acid, and that it is not difficult to form a correct diagnosis on this point, itwill be necessary chiefly to consider the treatment of this form of concre- tion. Preventive treatment consists in a rigid limitation as to the quantity of food taken. It is customary to condemn a free use of animal food and highly-seasoned dishes ; but it should be borne in mind that stone prevails largely amongst the poor, who seldom can indulge in animal food to excess, and it is not unfrequent in countries where no animal food is taken. Par more impor- tant is it, both as to food and drink, to observe a strict moderation as to the amount taken. In this way digestion and assimilation will be easy and perfect ; crude matters will not find their way into the bicod; the chemical conversion of uric acid will be complete ; and precipita- tion in the uriniferous tubes will be obviated. When the proclivity to uric acid calculi is de- cided, or when a small stone is known to exist, the free use of diluents and alkaline remedies is undoubtedly of importance. The waters of Vichy, Ems, and Neuenahr, taken freely at the springs, with or without baths, but with the great aid of change of air and mode of life, constitute the most efficient plan of treatment; but it must be admitted that in the majority of cases this good effect is only transient. Some high authorities recommend, in preference to the simple alkaline treatment, the use of those saline aperient waters whose chief ingredient is sulphate of soda, such as Carlsbad and Fried- richshall; and undoubtedly they have a most beneficial action, by promoting digestion and assimilation. But as with the alkaline remedies, whether natural waters or drugs, so with the salines, their action is evanescent. Leave them off and let the patient return, perhaps to a place whore calculus is frequent,, or to habits of care- less living, or to over- work, and the morbid ten- dency will almost certainly recur. If there are clear indications of the actual presence of a renal I stone, composed of uric acid, of moderate size and recent date, the solvent treatment, as described | RESISTANCE. by Dr. Wm. Roberts, should be fully carried oat. It depends for its success on the known solubility of uric acid and its salts in alkaline solutions of definite strength, the most efficient being about 60 grains to the pint; above and below this strength the solvent power diminishes. The patient, if an adult, should take 40 to 50 grains of the acetate or citrate of potash in 3 or 4 ozs. of water every three hours during the dav, and once at least in the r'ght; this plan should be continued for twc three months. During the treatment the urine should be frequently exa- mined, and if any approach to an ammoniaea! state should appear, the treatment must he sus- pended for a time. The effect of the treatment must be estimated by the diminution of lumbar pain, and by the escape of small calculi; no ill- effects are caused; seldom any indigestion; and no impairment of general health. Other drugs have been employed for the solution of uric acid, such as carbonate of lithia, phosphate of soda, tartrates and carbonate of potash and soda, and carbonate of limo. Some years ago the writer conducted some experiments with prepared chalk, and found that, when given to the extent of 20 to 30 grains in mucilage and mint water, three or four times a day, it had a most marked effect in quickly removing uric acid deposits, and it will have this effect even in the febrile state. It did not, in the quantities given, produce alkalinity of the urine, hut it acted distinctly as a diuretic. In the crisis of nephritic colic, narcotics are called for, in doses large enough and frequent enough to control the pain. If sickness is trouble- some, morphia may be administered subcutane- ously, and if there be vesical irritation, by sup- pository. If the agony he extreme and in pa- roxysms, chloroform may he inhaled occasion- ally; while the hot bath, anodyne fomentations, and stupes are useful aids to relieve and soothe. Surgical treatment of renal stone is coming prominently into notice at the present time. Incision in the lumbar region and removal of stone from the kidney is as old as Hippocrates; and when abscess and sinus exist, leading to a stone impacted in the kidney, or when a lumbar swelling is present which is obviously caused by a renal stone, an exploratory incision for its removal is clearly warranted, and has been suc- cessful in several instances. So, too, lies the en- tire extirpation of a kidney containing calculi, as well as for other diseases of the organ. For th» conditions which justify and call for these opera- tions, and for the steps to be taken in their exe- cution, the records of surgery must be consulted. Wm. Cadge. RENAL COLIC. — Srxox. : Xcphralgia calculo-sa ; Fr. Colique niphretique-, Ger. Xieren- schmcrzcn. — The name commonly applied to the symptoms which arise when a renal calculus either passes, or attempts to pass, down the ureter. Sec Renal Calculus. RENAL DISEASES. — See Kidneys, Dis- eases of. RESISTANCE. — The sensation recognised by the fingers, of the degree to which a part yields or resists when palpation or percussion i» being performed. Sec Physical Examination. RESOLUTION. RESOLUTION ( resolvo , I loose). — The re- turn of a diseased part to its natural condition ; ehiefly applied to the process of inflammation when it subsides gradually, and without the occurrence of suppuration or other unfavourable termination. See Inflammation. RESOLVENTS (resolvo, I loose). — Any- thing which. aids the absorption of effused pro- ducts may be included in this class of remedies ; the most efficient being, externally, counter-irri- tation and poultices ; and internally, mercury and iodide of potassium. Our knowledge of the precise mode of their action is still very vague. The subject of blisters and the like is considered under Counter-irritation.' It is generally held that mercury renders fibrin less cohesive ; and that iodide of potassium — in virtue, probably, of the free iodine which is separated within the blood — has a special affinity for albuminous bodies, and for that form of lowly organised fibrin which is so commonly deposited in the tissues during the more advanced stages of con- stitutional syphilis. It is difficult, however, to discuss this therapeutical heading from a strictly scientific standpoint, deriving its origin as it does from a past epoch, when pathological science was still in its infancy, and when very active modes of treatment were held to possess virtues which further experience has not confirmed. Free bleed- ing and blistering, combined with copious saliva- tion, were held in these days to have a most powerful influence in checking inflammation and removing its sequel® ; and we are only now learn- ing to assign to unaided nature the due share which she takes in effecting what we are accus- tomed to call the ‘cure’ of disease. R. Farquharson. RESONANCE ( resono , I sound again, echo). Resonance signifies the character of the sound yielded on percussion over the greater part of the chest, and, within wide limits, of the abdo- men also. The degree of resonance depends prin- cipally upon the proportion of air contained in the underlying cavities or organs. Vocal reso- nance is the voice-sound transmitted through the chest to the ear of the auscultator. It is increased or diminished in accordance with the physical conditions present in the chest-cavity. Hyper-resonance is a term used to signify un- due resonance over a given part. Deficient resonance is commonly called dulness. It is often used with the same comparative or localapplication as hyper-resonance. Sec Physical Examination. R. Douglas Powell. RESPIRATION, Disorders of. — A due performance of the function of respiration is es- sential to the well-being of the economy, and any derangement of this function is likely to be fol- lowed by more or less disturbance of the system, varying in degree and gravity, but often of a serious character. Moreover, the phenomena re- sulting from such a derangement are commonly of much significance with reference to diagnosis, prognosis, and treatment. Therefore, disorders affecting breathing demand attentive and care- ful observation and consideration in every case ; while their general study by no means receives the thought and attention which its importance RESPIRATION, DISORDERS OF. 1533 emphatically requires. In a short article it will be impossible to do more than give a very condensed summary of the subject, and to sug- gest points for the further consideration of those who are interested in it. The several forms of disordered breathing associated with particular diseases are indicated in their appropriate ar- ticles. Before considering the disorders of respiration, it will be well to call to mind the following points relating to the performance of the act in health. The average frequency of breathing is from sixteen to twenty per minute in adults, although this rate is easily disturbed temporarily by va- rious physiological conditions. The function is powerfully under the influence of the nervous system, and it is ordinarily carried on either by centric or reflex stimulation, without any con- sciousness of the act on the part of the indi- vidual, and independent of any voluntary effort. In ordinary respiration scarcely any movement or other sign of the act is observable to an on- looker, and the actual quantity of air changed with each breath is very small, amounting only to from 16 to 2.) cubic inches ; but in this respect also the act is very liable to be disturbed, while a person is able voluntarily, without any diffi- culty, to breathe more or less deeply, performing ‘ extraordinary respiration,’ and he may thus change large quantities of air, and call into play every part of his lungs. Remembering what respiration is intended for, the conditions required, for its proper performance in connection with the breathing-apparatus are, that there should be a sufficient supply of air suitable for the purpose, and an adequate passage for its entrance and exit; that there should be enough healthy lung- tissue; that the blood should pass freely through the lungs, and be within certain limits of a proper quality; that there should be no me- chanical impediment to the free working of the lungs, especially if suddenly called upon to do extra work ; and that the forces by which the respiratory movements are carried on, namely, the muscles, including the diaphragm, and the elasticity of the lungs and chest-walls, are equal to their work. If the act of breathing is watched and investigated, it will be found that normally expiration is rather longer than in- spiration ; but there is no striking difference be- tween the two divisions, the ratio being as twelve to ten in males, fourteen to ten in females. More- over, the movements are both thoracic and ab- dominal, the former being distinctly made up of expansion and elevation during inspiration, of retraction and depression during expiration, es- pecially when a full breath is taken. The inter- costal spaces in most parts, as well as the supra-elavicular fossae, seem to sink in during inspiration, so as to become more evident, this being more marked in proportion to the depth of the inspiration. It will further be noticed that the precise movements differ in different per- sons, and according to the extent of respiration. The lower ribs and diaphragm act principally in males and children during ordinary breathing ; in adult females the respiration is upper costal. In extraordinary breathing the movements are chiefly upper thoracic in all persons. Respiration is markedly influenced by physio- 1340 RESPIRATION, logical conditions, such as exercise, diet, sleep, and various ethers ; these must he remembered in considering its derangements. With these introductory remarks, the disorders of respiration may now be more conveniently studied. Aetiology and Pathology.— The numerous causes and conditions which lead to disturbances of respiration can be brought within well-defined groups, and it is desirable in the first instance to study them from such a general point of view. This, however, only gives a superficial insight into the subject, and does not indicate the kind of disorder that is produced by each cause, or how it acts, while many conditions act in more ways than one; and still further, in any individual case there may bo more than one, perhaps several causes at work, all of which ought to be recog- nised. These causes and conditions may be summarised in the following manner, and it will be seen that several of them act indirectly on the respiratory process : — 1. Conditions acting directly through the ner- vous system . — These include: — (a) Centric lesions in connection with the brain, involving the re- spiratory centre, either directly or indirectly, such as injury, haemorrhage, or a tumour. ( A ) Disease or injury of the upper part of the spinal cord, paralysing the nerves supplying the respiratory muscles, (e) Functional nervous disturbance, as from mere nervousness, emotion, hysteria, tiance, or chorea. ( d ) Conditions affecting im- mediately the nerves concerned in respiration, either irritating or paralysing them, especially the pneumogastric, recurrent laryngeal, or phrenic nerves. These nerves may be themselves dis eased, or affected by a neighbouring condition, such as a tumour, (e) Reflex causes, transmitted from the skin, as when cold water is dashed upon it; or from organs, as the stomach, intes- tines, or ovaries. It is important to remember that causes connected with the nervous system frequently aggravate disorders of breathing other- wise occasioned. 2. Abnormal conditions of the blood. — In this group are merely included conditions of the blood us a whole, and not any local derangement af- fecting the pulmonary circulation. They are : — - (a) Deficient quantity of blood, especially from a sudden or rapid loss, (A) Anaemia or hydrsemia. (c) Deficient aeration. ( d ) A poisoned, impure state of the blood in connection with narcotism, the anaesthetic state, pyrexia, the typhoid con- dition. uraemia, pyaemia or septicaemia, diabetes, and other diseases. 3. Functional disorders, or organic diseases, connected with the heart . — These are common sources of disturbance of breathing of various kinds, depending upon the intimate relation of the nerves and nerve-centres governing the heart and respiratory organs; upon the effects they produce as regards the pulmonary circulation; or sometimes upon their direct interference with the movements of breathing, by exerting pressure upon the lungs, especially the left, upon the left bronchus, or upon the chest-walls, particu- larly the diaphragm. This last cause is only noticed in cases of great enlargement of the heart, orof considerable pericardial effusion. The breath- ing, however, is frequently disturbed in connection DISORDERS OF. with disorders of cardiac action ; diseases of valves and orifices, especially the mitral and tricuspid: enlargements of the heart, particularly dilata- tion ; degenerations ; congenital malformations ; and clotting of blood in the cavities of the heart. 4. Abnormal conditions of the air inhaled.— The physiological effects produced upon the re- spiratory act by various states of the air in- spired are well known. These especially depeid upon its composition ; its temperature ; and its condensation or degree of pressure. From a clinical point of view these deviations have to 1c borne in mind, as they are more liable to be induced in certain diseases, and may also be made available for therapeutic purposes. 5. Conditions affecting the apparatus concerned in the respiratory movements . — These refer to the chest-walls and the diaphragm, and they in- clude : — ( a ) Certain painful affections, causing th9 patient to limit or modify the movements, such as the early stage of pleurisy, pleurodynia, or peritonitis. (A) Spasm or paralysis of the muscles, from any cause, (c) Organic changes, as undue softness or rigidity of the thoracic walls, cancerous infiltration, muscular atrophy or fatty degeneration, acute or chronic inflammation of the diaphragm. 6. Obstruction involving the main air-passages. This may be situated in the mouth, throat, larynx, trachea, or primary bronchial divisions, and is due to a variety of causes, which cannot he discussed here further than to state tint the obstruction may depend upon pressure from without; spasm or paralysis of the muscles of the larynx; some internal obstruction, whether from deposits, secretion, foreign bodies, or new growths ; or organic changes in the walls of the tubes, leading to their constriction. 7. Physical conditions independent of the respi- ratory apparatus, but interfering with it in various ways . — These may lie within the chest, as in the case of thoracic aneurism, or a mediastinal solid tumour or abscess. They act by compressing the lungs or heart, obstructing tubes, affecting nerves, or interfering with the moving apparatus. Or the cause of the disorder may lie in the ab- domen, such as excessive flatulence or tympa- nites, abundant fluid in the peritoneum, enlarged organs, ovarian tumours, or a pregnant uterus. They act mainly mechanically, by impairing the movements of the diaphragm. Breathing often becomes worse after food, in consequence of dys- pepsia leading to flatulent distension. 8. Conditions affecting the pleura. — Any ac- cumulation of air or fluid in one or both pleural sacs will necessarily tend to disturb respiration, as in pneumothorax, pleurisy, hydrothorax, or hsemothorax. It acts mechanically, and the de- gree of disorder will depend on the amount of the collection, the rapidity with which it takes place, the previous condition of the lungs, and other circumstances. Pleuritic adhesic ns and agglu- tinations also tend to embarrass respiration more or less seriously. 9. Morbid conditions of the lungs. — These have been left to the last, and it will be readily understood that all diseases of the lungs tend more or less to produce disorders of breath- ing. At the same time it must not be forgotten 1341 RESPIRATION, that these organs may be affected, even some- what extensively, under certain conditions, with- out any obvious respiratory disturbance. Pul- monary diseases act in various ways, of which the most important are by affecting the pulmonary circulation and the amount of blood in the lungs ; by interfering with the entrance or exit of air through the bronchial tubes ; by temporarily dis- abling or permanently destroying more or less of the pulmonary textures; or by influencing the respiratory act through its forces, and especially through the impairment or loss of the elastic force of the lungs required for expiration. Classification. — The arrangement of the nu- merous forms of disordered respiration is by no means an easy matter, and may be founded on different plans. Before giving that which seems to the writer to be a practical arrangement, he would urge the great importance of endeavouring to recognise in every case, by due investigation, what is the real nature of the deviation from normal breathing, and not merely to call it i‘ dyspnoea,’ or 'difficulty of breathing.’ More- over, it must be remembered that there may be more than one form of disordered respiration in the same case. The disturbance of breathing may be sudden, acute, or chronic ; and its several forms may be included under three main divisions, namely ; — 1. Deficient Respiration. 2. Dyspnoea or Difficulty of Breathing. 3. Peculiar Dis- orders. 1. Deficient Respiration. — This compre- hends the following: — (a) Slow breathing.— The frequency of the respirations may be notably reduced, without any other obvious disorder. Or this may be associated with marked shallowness of the movements, so that in extreme cases breathing seems to have almost or entirely ceased, and can scarcely be recognised even by the most delicate tests. These deviations are observed in various conditions or diseases affecting the nervous sys- tem, such as hysteria, trance, shock or collapse, narcotic poisoning, and some cases of cerebral disease. They are accompanied by impairment or loss of consciousness, real or assumed, and with other varying symptoms. Sometimes the breath- ing is slow but deep, and may then be sighing, stertorous, or attended with flapping of the cheeks in expiration ; this is noticed in apoplectic con- ditions. These disorders of breathing do not : obviously disturb the patient. ( b ) Restrained breathing. — By this is meant that the patient makes a voluntary and conscious effort to restrain or modify the act, because it produces or increases some painful or other mor- |bid sensation. It may he obvious at once to the observer, or may only be revealed when the patient is made to take a deep inspiration. The respirations are often increased in frequency, but .may be below the normal. The entire move- 'ments may be affected, or only those of either the , chest or the abdomen, or even only of one side if the chest. The early stage of pleurisy, peri- tonitis, and angina pectoris afford examples of liseases causing this disorder of breathing. (c) Shallow and feeble breathing. — The most striking feature in some conditions is the ex- feme feebleness and limitation of the act of re- DISORDERS OF. spiration. This has already been alluded to, as noticed in some eases of slow breathing, but the frequency is often much above the normal, and the class of cases now under considera- tion differ essentially from those previously men- tioned. The disorder indicates gradual cessation of the respiratory functions and pulmonary action, becoming more and more obvious, and gradually terminating in death. Little or no air is changed, and at last the breathing becomes a mere in- effectual gasp. This form of disturbance is ob- served in persons slowly dying from various causes; in gradual filling of the air-tubes in fatal cases of bronchitis ; and in cases of apoplexy or narcotism. It is often accompanied by rat- tling or gurgling rales, due to the presence of fluid in the air-passages, which become by de- grees filled up. It may follow certain forms of dyspnoea. ( d ) Ineffectual breathing .— The derangement thus named can only be recognised by making the patient attempt to draw a full breath. He may then have the sensation of an inability to do this, or to expand the chest properly. What is more important, however, is that this impairment of the respiratory act is often evident on objective examination, when it is seen that in certain conditions the most powerful efforts to breathe produce little or no result, and the movements are obviously more or less ineffectual, either as a whole, unilaterally, or locally. This may arise from various causes, such as paralysis or spasm of the muscles, rigidity of the chest-walls, dis- tension of the lungs in emphysema, pleuritic and other conditions interfering with their expansion, and certain morbid changes in these organs. Ineffectual breathing is frequently associated with some form of dyspnoea. 2. Dyspncea or Difficulty of Rreathing. — WTthout making too marked a distinction be- tween them, and remembering that they may be combined, there are certain forms of disordered breathing, usually characterised as dyspncea, which deserve separate recognition. (a) Obstructive dyspnoea . — This signifies that there is some obvious impediment or difficulty presented to the transmission of air through some part of the air-passages in respiration. The nature and severity of the disorder vary with the seat, cause, and degree of obstruction. Thus it may he that a swollen tongue, or enlarged tonsils or other throat-conditions, block up the passage more or less completely, and the patient breathes through the nose, often with obvious difficulty ; or if some air passes by the throat, it does so with much noise, especially when the patient is asleep. The most important form of obstructive dys- pncea, however, is that which is connected with the main air-tube, and it usually attracts im- mediate attention. It may be associated either with the larynx or the trachea, and in the for- mer case is liable to exacerbations. The gravity of the phenomena vary with the degree of ob- struction, but they are more or less of the fol- lowing kind. The patient is usually conscious of a difficulty in the passage of the air during respiration, referred to some spot, which may become very distressing ; the act of breathing is usually more or less laboured, and this may 1342 RESPIRATION, DISORDERS OF. culminate in a violent effort or struggle to breathe. The frequency of respiration is often below the normal, or at any rate it is but little increased, while the relative length of inspiration and ex- piration is disturbed. The difficulty may be experienced only during inspiration, or during both divisions of the act of breathing, but is usually most marked in inspiration, though occa- sionally during expiration. Various noises are produced by the passage of the air through the narrowed part, and with experience these become of great importance as indicating the existence and seat of obstruction. Signs of deficient aeration of the blood are liable to accompany this form of dyspnoea; and in acute cr sudden cases, or if the obstruction is very marked, there is danger of actual suffocation or apncea, which may occur rapidly or even suddenly. Physical examination will indicate that air does not enter properly into the lungs, as evidenced especially by recession of the lower part of the chest, par- ticularly marked in children, in whom this form of dyspnoea is likely to lead to most serious consequences. The obstruction may be situated lower down in the respiratory tract, either in one of the main bronchial divisions, or in the tubes distri- buted through the lungs, and then the character of the disorder merges in that of ordinary dys- pnoea, except that it is likely to be attended with various noises, and that the physical signs of deficient entrance of air into one or both lungs are evident. When there are objective signs of deficient entrance of air into the lungs, the condition is termed inspiratory dyspnoea. This, however, may also depend upon weakness of the chest-walls, and of the inspiratory muscles, as in rickets. (b) Excessive breathing — Ordinary dyspnoea . — Tins is the disorder usually met with in various degrees, and it implies that respiration is carried on in excess. The act may be too fre- quent, or too powerful, or both, so that more than the ordinary amount of air is changed in a given time. The movements of the chest are more or less free under different circumstances. In severe cases the patient is obviously distressed, and the act of breathing is laboured, and may be noisy. Then the aloe nasi are seen to work ; the patient cannot speak except in broken sentences, owing to want of breath ; and there may be signs of apncea. This form of dyspnoea is familiarly illustrated by the effects of undue exercise, such as running. Clinically it is associated in dif- ferent degrees with numerous conditions, such as nervous disorders ; fevers and other blood- diseases ; many cardiac affections ; conditions intei’fering with the action of the lungs; and various diseases of these organs, interfering with their functions, especially if acute. (c) Shortness of breath. — While associated with other forms of dyspnoea, this disorder frequently exists alone in various degrees, and it may be of much consequence in drawing attention to disease of a serious character. Shortness of breath signifies that the breathing becomes more or less hurried, and the individual becomes con- scious of dyspnoea, after making some effort, which ordinarily does not cause any such effects, such as walking ralher quickly or upstairs, sing- ing, coughing, or even taking a few deep breaths in physical examination of the chest. When at rest he may feel perfectly comfortable, and breath- ing is quite natural, but it is easily disturbed in the manner above indicated. This disorder is observed in general debility ; very markedly in anaemia ; in many cardiac conditions, especially degeneration ; in pleurisy frequently, and in many cases of chronic lung-disease, such as phthisis or emphysema. (i d ) Expiratory dyspnoea. — In the form thus designated the difficulty is experienced in expi- ration, which becomes prolonged and laboured, in some cases extremely so, the extraordinary muscles of expiration being called fully into play. The relative lengths of inspiration, expiration, and the pauses are thus deranged, and inspira- tion may become very short, even a mere gasp, There is often a sense of discomfort or even distress, and this is liable in certain conditions to be increased by exertion, or after taking food, or in certain postures. Expiratory dyspnoea may be a prominent feature in some cases of obstruc- tion of the air-tubes ; but is essentially connected with impairment of tho expiratory elastic force of the lungs in cases of emphysema, and of the chest-walls when they are rigid, these two con- ditions often going together. These conditions are frequently aided materially by blocking-up of the bronchi, as the result of bronchitis ; or by spasmodic contraction of these tubes, in connec- tion with asthma. (c) Orthopnoea. — This is almost always com- bined with one or more of the other forms of dyspnoea, and the term indicates that the patient can only breathe at all, or at any rate comfort- ably, when the body is in a more or less upright posture. In some cases it is sufficient if he is propped up ; in others he has to sit bolt upright in bed, or to bend forward ; in others still he .is obliged to sit up altogether in some kind cf chair, or even to stand, this being the only pos- ture in which breathing can be carried on. Cases of cardiac disease, of acute pericardial and pleuritic effusion, of acute pneumonia, of asthma, and of aneurismal or other thoracic tumours, afford illustrations of the causes of this disorder. (f) Paroxysmal dyspnoea. — This may be of various kinds, but as its designation implies, it signifies that the dyspnoea comes on mainly or entirely in fits or paroxysms. It is chiefly ex- emplified by paroxysms of laryngeal dyspncea ; by some eases of cardiac dyspnoea ; and, above all, by fits of bronchial asthma. See Asthma. 3. Peculiar Disorders. — It is scarcely prac- ticable to bring these under any definite sub- divisions, and it will suffice to notice the very curious and often indescribable disorders of breathing observed in certain nervous eases; the interrupted, jerky, sighing, or yawning respira- tion which may be present in various conditions ; and the peculiar disturbance which has been named Cheyne- Stokes respiration. This is rare, but may occur in connection with certain car- diac diseases, especially fatty degeneration; in- jury to the brain ; and cerebral haemorrhage. It is characterised by the breathing at intervals becoming by degrees more and more rapid and deep up to a certain point ; and then subsiding in the same gradual manner, until finally there is RESPIRATION, DISORDERS OF. a complete cessation of respiration, -with a dead silence, the pause lasting a variable time, and then the same series of phenomena being re- peated. Effects. — Many of the disorders of breathing ■which have now been considered are not attended with any obvious effects, and are practically of little or no consequence. Moreover, it must be noted that patients may become so accustomed even to marked derangements of the function of respiration, that they are not conscious of any injurious results therefrom. Most individuals under such circumstances, however, are conscious of more or less discomfort or other sensations, referable to some part of the respiratory appa- ratus. These are very unreliable and vague in their meaning; but there are effects which give important information in many cases, and which depend either upon the want of due aeration of the blood, or upon the interference with the general venous circulation which disorders of breathing so frequently induce. These will vary, not only with the nature of the disorder, but also with its degree, and the rapidity with which it is set up. Thus there may bo actual suffoca- tion, sudden or rapid, or a condition approaching more or less that of asphyxia or apnoea (see Asphyxia). Or a chronic state of venous con- gestion and venosity of the blood may be set up, indicated by a tendency to cyanosis, with en- largement of the superficial capillaries ; general chilliness and coldness of the extremities ; men- tal apathy or dulness, with headache and other signs of morbid blood-supply to the brain ; general languor, laziness, and muscular weak- ness ; dyspeptic disorders; changes in the urine; and other phenomena. In cases where the respi- ratory functions are chronically affected in chil- dren and young persons, in such a way that the blood is never properly aerated, growth and development are markedly impeded. Patients suffering thus may present a peculiarly stunted appearance. The features tend to become per- manently thick and coarse ; and the ends of the fingers and toes may become clubbed. In certain forms of dyspnoea the fat of the body tends to disappear ; while the muscles of respiration may become hypertrophied from excessive use. Treatment. — The indications to be fulfilled in treating disorders of respiration, and the measures by which these are to be carried out, must obviously present considerable variety in different cases, and it will only be practicable here to offer a few general hints on the subject. In the first place no treatment whatever may be called for in some instances ; while in other cases nothing can be of any service. The primary in- dication should always be to attend to the cause of the disorder, and by curing, removing, or alle- viating this, the disturbance may often be got rid of or materially diminished. This may be illus- trated by treatment directed to laryngeal ob- struction, ansemia, pleuritic pain or effusion, bronchitis, or cardiac derangement. By improv- ing the condition of the blood when ansemia is present, breathing is frequently much improved, even when there is some actual disease to dis- turb it, such as phthisis or cardiac disease. Attention to the condition of the air inhaled is m some cases of much importance, as regards its RESPIRATORY ORGANS. 1343 purity, temperature, degree of moisture, pressure, and other points. It must be remembered that some forms of dyspncea actuallyrequire an atmo- sphere which contains an excess of carbonic acid. Great advantage frequently arises from giving proper instructions to patients as regards posture, avoidance of exertion, diet, the act of coughing, or even the act of breathing itself. This is espe- cially important in certain forms of paroxysmal dyspnoea ; and any cause which is known to pro- duce any such attack should be carefully avoided. Moreover, the patient may sometimes be mate- rially assisted in the act of breathing by mecha- nical means. Not uncommonly active measures are called for, for the purpose of relieving some more or less urgent form of dyspnoea. For this purpose various means are indicated in different cases, such as venesection, or local removal of blood from the chest ; dry-cupping over the chest ; the internal administration of antispasmodios, stimulants, pulmonary sedatives, or other ap- propriate agents ; inhalations of different kinds, in the form of gas, vapour, or smoke; subcuta- neous injections of morphia or other active drugs; or the application to the chest of sina- pisms, hot poultices, fomentations, or turpen- tine stupes. Treatment may be urgently de- manded, directed to the asphyxial condition (see Asphyxia) ; and operative procedures, such as laryngotomv or tracheotomy, may be called for. in chronic cases, where the respiratory functions are imperfectly carried on, the condi- tions resulting therefrom must he remembered, and as far as possible obviated. Warm clothing is essential under such circumstances ; and, if practicable, a residence in a genial and warm climate is often of the greatest consequence. Frederick; T. Roberts. RESPIRATORY MURMUR.— The sound heard on auscultation over the lungs in respira- tion. See Physical Examination. RESPIRATORY ORGANS, Diseases of. The diseases which must be referred to in this article are those involving the special organs by which the function of respiration is per- formed. These organs comprise, first, the lungs, in which the process of respiration takes place ; secondly, those organs through which the air is brought into contact with the blood, that is, the air-passages, and the agencies by which the movement of the ait is effected ; and thirdly, indirectly, those organs by which the blood is brought into contact with the air, that is, the heart and blood-vessels. Frequency and Fatality. — General Etio- logy. — Before enumerating the several morbid conditions of the respiratory organs, it will be well to indicate the importance of this class of diseases— an importance which is due partly to the remarkable frequency with which they occur, and partly to the great fatality by which they are attended. On reference to the returns of the Registrar- General (Annual Report for 1880), we find his calculations showing that whilst during 25 years (1850-74) 50387 per million of persons living died of zymotic diseases, no fewer than 5840 died of diseases of the respiratory organs (in- RESPIRATORY ORGANS, DISEASES OF. 1344 eluding phthisis, and excluding the organs of cir- culation). This report further shows that the two great classes of diseases, the zymotic and respiratory, together accounted for almost one- half of all the deaths from every cause, includ- ing accidents. It must be remembered, further, that these figures represent only the number of deaths from respiratory diseases, and give but a rough indication of the number of instances of illness more or less grave from the same causes. When we come to investigate more closely the nature of these diseases, it is not difficult to account for the frequency of their occurrence. Complicated, delicate, and sensitive as the respi- ratory organs are in structure and function, in- cluding the pulmonary circulation, and the very important changes in the blood which occur in the capillaries of the lungs ; controlled by the nervous system, itself subject to a great variety of influences of a morbific character; dependent for the performance of the healthy act of respi- ration upon the continual movement of the me- chanism which admits air to the lungs, namely, the chest-walls and the respiratory passages ; affected also by the temperature of the air, subject ns it is to great variety, by its purity, liable as this is to be contaminated by noxious gases and impure particles, as well as to be damaged in its quality by alterations as regards dryness and moisture — it is easy to understand how the respiratory organs should become so fre- quently the seat of disease. Besides the more important influences to which we have referred, it will suffice to mention the effect that is exerted by such factors as occupation, age, sex, and cli- mate. These several aetiological points will be found fully discussed in the articles Climate ; and Disease, Causes of. The influences of inhe- ritance and diathesis also contribute powerfully to the causation of disease of the respiratory organs, more especially as predisposing elements in the production of phthisis, although the in- fluence of both can be traced in certain other morbid states, such as bronchitis, asthma, &c. General Pathology. — The respiratory organs are liable to the several forms of injury and of disease which affect the other organs and tissues of the body. The injuries, including wounds and the presence of foreign bodies, are chiefly of surgical interest. The chief diseases are: — 1, disturbances of circulation, including inflamma- tion and its effects ; 2, degenerations ; 3, new growths ; 4, malformations and malpositions ; o, deformities ; and 6, nervo-muscular disorders. 1. Disturbances of the circulation are found more especially in the mucous membrane of the air-passages, in the substance of the lungs, and in the serous coverings of these organs. Thus we have — as instances of inflammation, specific or otherwise — laryngitis and tracheitis (including croup and diphtheria); bronchitis, in its several and varied forms ; pneumonia, and pleurisy ; ulceration, which may occur in any part of the tract ; and gangrene, especially of the lungs. Congestion more generally affects the lung-sub- stance, but it is also to be met with in the mucous membranes of the passages. Haemor- rhage may occur from any portion of the air- passages, or from the substance of the lung itself, as the result of congestion, of tubercular disease and its effects, of disease of the heart and blood- vessels, and other causes. Examples of throm- bosis and embolism may be found in the pulmo- nary artery and veins. 2. Examples of degenerative disease are pre- sented by the indurations which the cartilaginous tissues of the larynx, trachea, and chest-walls undergo ; in the degeneration which is traceable in the air-cells in connection with emphysema; the pigmentary and calcareous changes found in the bronchial glands and lung-tissue ; and the caseous degeneration of inflammatory and new growths, such as tubercle. 3. The most important of the new growths are tubercle; malignant disease in its several forms, whether primary or secondary, extending from surrounding parts ; syphilis in its various stages, more especially affecting the larynx; and hyda- tids. 4. Malformations and malpositions of the lungs and air-passages are of rare occurrence, and are of most importance when portions of the lungs are undeveloped, as in atelectasis. 5. Deformities implicate most frequently the walls of the chest. 6. Lastly, there are the various nervo-mus- cular affections comprehended under the names of whooping cough, nervous aphonia, spasmodic cough, laryngismus stridulus, hiccup, spasmodic dyspnoea including asthma, paralysis of the laryn- geal muscles, of the walls of the chest, or of the diaphragm ; also pleurodynia and intercostal neuralgia. Although we have thus spoken of the several portions of the respiratory organs, and the dis- eases which affect them, as having, so to say, separate relations, we find no such isolation existing in the natural history of their diseases. Thus, for example, we seldom find inflammation of the lung in the absence of an affection of the pleura ; whilst when the like process affects the air-passages, it is rarely limited to one part, such as the larynx, trachea, or bronchi, without in- volving others, and it frequently passes on into the substance of the lung itself. Again one morbid process may be, and is very frequently, associated with others; thus inflammation may lead to degeneration of tissue, or vice versa ; new growths may give rise to obstruction of breath- ing, to inflammation, and frequently to hemor- rhage ; and nervo-muscular affections may he either the cause or the effect of similar disorder or disease. Here, too, we have to observe the relation between heart-disease and disease of the lungs ; likewise between morbid states of these organs and diseases of the abdominal organs. General Symptomatology. — The special symptoms of disease of the respiratory organs are founded essentially on disturbances which prominently affect their functions. Thus wo have; — 1. disorders of the respiration, as fully discussed in the preceding article. 2. There are also obstructions and consequent disturbances of the circulation, which cause (a) congestion of the superficial or deep-seated organs, including the heart itself, the cavities of which may become dilated ; and (6) haemorrhages, especially haemo- ptysis. 3. There occur disorders of secretions and morbid products, giving rise to varieties KESPIK AT OH Y OBGANS, DISEASES OE. of expectoration of more or less importance, as symptomatic of different forms of disease ( see If xpecto ration). 4. Cough is a symptom sel- dom absent, presenting many varieties. It is sometimes entirely referable to nervous disturb- ance, and of a reflex character ; whilst at other times it is the means by which secretions are expelled, which might otherwise accumulate, and lead to further embarrassment and distress (see Cough). The diseases of the respiratory organs are often attended by local and constitutional disturbance, as are diseases of other organs, such as pain, fever, wasting, and general debility, which will vary according to the nature of the morbid process and the part involved, as will be found fully described under special headings. Physical Signs. — The function of respiration is so intimately associated with physical condi- tions and mechanical actions, that the respiratory organs afford special materials for the applica- tion of the principles of physical diagnosis. The movements of air and the resonance of the voice i lirough the several classes of air-passages, and into the minute textures of the lungs, cause characteristic sounds which are readily recognis- able by the ear. These sounds become modified by the presence of disease, and afford charac- teristic evidence, by which its existence and na- ture may be determined. The size, the shape, and the movements of the chest-walls afford also available evidence in physical diagnosis. Valu- able information is afforded by a part that is re- sonant becoming dull, or by a part which should lie dull becoming resonant. For further informa- tion ou these points see Physical Examination. Treatment. — The diseases of the respiratory organs must be treated, whether for prevention or for cure, on those general principles which are applicable to the treatment of the diseases of other viscera; with such modifications as may lie called for by the special structure and func- tion of the organs themselves, and by any spe- cial features which disease affecting them may present. These general principles, and their particular applications, are so fully set forth in the articles which treat of the several diseases of the different parts of the respiratory system, that it is not necessary to discuss them again here. But seeing the extremo frequency with which disease of these organs occurs, and its grave re- sults, affecting alike the young and the aged, those who labour and those wiio pursue only pleasure, those who live in cabins and those w 7 ho live in castles — for tequo pulsat pede pauperum tabernas regnmque turns — we may enter a little more fully on the subject of their prevention. Preventive Treatment. — The principles which must guide us in this direction, independently of those which fall under the head of general hygiene, fully treated of in other articles, are : — 1. That a supply of uncontaminatcd air is essential for the prevention of lung-disease. . Impure air is found in the homes of the poor, and in their close and crowded workshops ; hut it also abounds in the assembly room, the ban- queting hall, and such-like places. The remedy for this evil will be found, when people are made to feel that pure air is as essential to health and life as is unadulterated food ; and when those who construct houses are convinced 85 1345 that they have no more essential duty to per- form than that of devising means ft>r the re- moval of impurities, and for the supply of wire air and pure water. 2. Pure air, however, can only be utilized by freedom of the respiratory movements. Many employments and trades involve constrained positions, which, no doubt, are often unavoidable ; but even in such cases a knowledge of the fact that such positions are hurtful, with a desire to remedy the evil, will frequently suggest means for its mitigation. Like results follow a very different source of restriction on the movements of the chest, namely, the use of stays and other articles of dress, which not only compress the chest- walls and prevent their free movements, bur even displace the contained organs. Much harm may also result from a practice which is called ‘ setting up’ or drill in the army. The recruit is required to ‘throw back the shoulders,’ an act by which the pectoral muscles are made to act as constricting bands. The drill sergeant aims at expanding and throwing forward the chest-wall, which he does not effect by merely throwing back the shoulders. This object can only be accomplished by teaching the person drilled to take a deep inspiration, and to carry the chest- walls forward. The frequency with which dis- eases of the lungs, and of the organs of circula- tion within the chest, occur in the army is a recognised fact, which may in some degree be explained by this objectionable system of drill. 3. In the prevention of chest-disease it is necessary to guard against vicissitudes of atmo- sphere and temperature. This fact is more readily admitted than its teachings are adopted. Most persons cannot entirely avoid exposure to these vicissitudes, but even in such cases counteracting influences are often practicable, and should al- ways be employed. Again, there are those who, not always from necessity, having respired heated air, perhaps for hours, suddenly expose the deli- cate respiratory mucous membrane to cold air. or the heated surface of the body to a chilling draught. Disease thus originated is within the knowledge of all of us, and all know that such results might have been obviated by forethought. Lastly, there is the necessity for protecting the organs within the chest by suitable covering. Suitable, for example, as is the dress worn by ladies during the day, the dress or rather the undress of many in the evening, would seem almost designed to leave uncovered and unpro- tected, both front and back, as much as possible of tho space which contains the lungs. Many instances of grave disease havo thus originated. The remedy is not far to seek, in resisting the objectionable rules of fashion. If more attention were given to obtain pure air for respiration, and to secure freer action of the respiratory organs, and if more precautions were practised in guarding against the effects of atmospheric changes, it is but a truism — which will not lose in force by being repeated here — to say that diseases of the respiratory organs would be infinitely less frequent in their occurrence than they are, and less serious in their results. Finally, if these remarks apply, as they do, to the strong and healthy, it is unnecessary to urge the absolute necessity of insisting upon theprac- 1343 RESPIRATORY ORGANS, deal suggestions which they convey in the case of persons whose respiratory organs are either constitutionally delicate by inheritance, or have been previously weakened by disease. Such are the chief victims of chronic lung-disease ; and in no class of disease is prevention so absolutely essential. R. Quain, M.D. REST. Therapeutics of. — In considering rest as a therapeutic agent it is requisite to under- stand its nature, the indications for its use, its varieties, and the ways of employing it. There are three ehief varieties : — 1 , Rest of the whole body by sleep ; 2, rest of the mind ; and 3, local rest of a diseased organ or inflamed part. Of any of these, but of the third in particular, the practitioner may direetly avail himself in the treatment of disease. The modus operandi of these varieties of rest consists in allowing the impaired, perverted, or lost functions of a part, or of the whole of the human frame, to be rein- stated by maintaining the equilibrium of demand and supply. Hence it is only by availing oneself of the physiological properties of the component parts of the body, that rest becomes a thera- peutic agent; and it must be borne in mind that physiological rest does not mean another variety, but rather that it regulates the employment of one or more of these varieties ; and that whether applied to the whole frame, to the mind, or to a localised part, it is the agent, in the guiding hands of the practitioner, which cures. 1. Best of the whole body and mind: repose in sleep. — This form of rest, which is so neces- sary to the well-being and the due perform- ance of the several functions of the human body, accomplishes two ends : — First, the arrest of further waste of nerve-force and tissue- metamorphosis — a checking or ‘diminution of chemical action’ (B. Jones); and, secondly, the repair of the used-up materials. Rest of sleep, in a healthy man, does not of itself restore energy to the weary limbs, or vigour to the exhausted frame — it does but place the patient in the best possible condition for nature’s recu- perative powers to exercise their sway without detraction or interruption. Sleep maybe looked upon as both a preventive of disease, and a curative means. The want of sleep and its attendant physiological processes of repair to the growing tissues of an infant — arising from whatever cause it may, such as teething, vesical calculus, flatu- lence, or worms — becomes of itself adirect cause of arrest of development and of wasting diseases, a-nd lays the seeds of future misery and early death. A healthy adult can for a time, with im- punity, do without much sleep ; but let it never be forgotten not only that the want of it acts as a great predisponent to the infection of fever and all contagious diseases, and, in fever, to diseases of the brain ; but also that in any disease, if carried too far, it becomes a cause of death. 2. Best of the mind: relaxation. — The light story, Ahe strains of music, the change of scene and society, are familiar to all as among the many ways by which rest is given to the over- worked brain and careworn mind. The waste of nerve-force attendant on long and deep thought, and the many strains put upon the brain in these days of emulation and hurry, must REST, THERAPEUTICS OF. be repaired, in like manner a3 muscular waste, by sleep and cessation from all mental work for a time. In too many cases has it happened that insomnia, the first indication of the disturbance of that equilibrium of the mental state compre- hended in the term ‘ 6anity,’ has ended, before long, within the portals of an asylum, in epi- lepsy, insanity, or idiocy. Hence, ‘in all diseases,’ writes Hilton, ‘of no matter what nature, of the cerebro-spinal system, when the evidence of disease is in deranged function, it becomes our duty to look upon and treat the altered nerve-substance as we do con- tusion and laceration of soft parts and congestion of organs, and to give the brain absolute rest, to rely on nature’s power to repair the injury or disturbance, and to avoid stimulants which excite rapid circulation, as much as possible. The brain disturbed in its vital endowment becomes un- equal to even its ordinary duties. It recovers itself slowly ; it then soon becomes fatigued from use ; and if claims are made upon it too soon after injury — that is, before structural and physiolo- gical integrity is re-acquired— the patient is very likely to suffer from serious disease of the brain. The brain requires absence from occupation, or rest, for its complete recovery’, and this should he in proportion to the severity’ and duration of the symptoms it presents ; in fact, the length of time which has been required by nature for the repair of the injury must be in proportion to the severity of the local injury; and the more severe the in- jury the longer the time required for perfect re- covery of the functions of the brain. If this prin- ciple were only adopted generally and the plan car- ried out, we should not witness so many chronic diseases of the brain.’ See Personal Health. 3. Local rest. — This, which may be called me- chanical rest, is well known to every surgeon to be an agent of supreme value in the treatment of wounds, fractures, displacements or inflamma- tion of joints : as it is obvious that every move- ment to which a wounded or inflamed part is subjected must act on the one h3nd like the repe- tition of the original injury, and upon the other like a continuance of the irritating cause. Tims rest is not only a negative advantage, as saving the patient from renewed injury or irritation, but a positive remedy, as it diminishes the heat of the body, reduces the pulse, and alleviates pain. Rest is of so much value in the treatment of inflammation, that in some instances no means will advance the cure without it, and numerous in- juries of the body’, externally or internally’, would do well with perfect local rest and nothing else. It was on this principle that Pott treated all fractures of the extremities, by relaxing the muscles which had been thrown into spasm by the fracture; and it is this principle that nature would teach, when we see, in hip-joint disease, immobility of the inflamed parts maintained by the vital anchylosis of the capsular muscles; when we notico the recti abdominis become hard and rigid in hepatic abscess or peritonitis; and when we find the fractured ends of a rib held together in a cylinder of ensheathing callus. To a physician mechanical rest is an invaluablo agent, and yet its benefits are not recognised in a practical way at all as frequently or as fully m they should be. BEST. THERAPEUTICS OF. 1347 Api- ligation. — The application of rest in dis- eased conditions of the different parts of the body is so varied, and the cases in which it should be employed are so numerous, that it would be im- possible to enumerate them all. In surgical prac- tice rest is constantly used in the treatment of injuries and diseases. Here we shall only deal with its employment in medical practice, and shall select a few examples, to illustrate its benefit in different regions of the body. A. Diseases of the respiratory organs. The obj ects of the treatment by rest may be stated to be (Roberts) : — 1. To maintain structures, which are actually diseased, orin danger of becom- ing so, in as quiescent a state as possible ; in short to try to produce mechanical rest, as is ordinarily done in the case of a diseased joint. 2. To check or limit the entrance of irritating gases— be they noxious, or simply of a different degree of tem- perature or humidity from that of the internal part with which the air comes in contact. 3. To quiet the circulation through theorgans, which are being placed in a condition suitable for repair. 1. Acute inflammation of the larynx and bron- chi— The patient is to bo placed m an equable and moderately high temperature, and the atmo- sphere impregnated with moisture; all speaking or using the voice must be forbidden, while the patient's wants may be made known by means of a slate and pencil (Hilton). Thus, not only is the breathing quieter and less frequent, but all irritation of cold and of di’y air prevented. ! 2. Acute capillary bronchitis.-— In this disease, while general rest is to be maintained, the indi- cations to relieve the congested right heart, and to remove the mucus which is causing the symp- toms of asphyxia, predominate; and physiolo- ; gical rest cannot in this instance be obtained by mechanical rest. Here relief is attainable by restraining with the one hand the outpouring of mucus into the small tubes of the lung, and getting rid of that which is already poured out, by means of alkalies and stimulating expec- torants ; and by maintaining, with the other hand, the forces of the circulation, and relieving the overloaded right heart, by liydragogue cathar- tics, diuretics, and diaphoretics. 3. Pleurisy . — In addition to keeping the pa- tient quiet, restraining breathing, and forbidding conversation, the most effectual way of employ- ing rest to the inflamed surfaces of the serous membrane, is by mechanically fixing the side with adhesive plaster, as we would do for an inflamed joint. The forms of pleuritis to which this is most applicable are : — Acute general pleurisy, seen early; dry pleuris} 7 of a small area; that accompanying pneumonia, the result t of a fractured rib ; and in the advanced stages of phthisis pulmonalis, where fits of coughing and pain are produced by stretching of those bands of organised lymph which bind the costal and visceral layers together. It is also applicable in [external fistula, and in pleurodynia. The plan proposed by Ur. Roberts, and which has answered remarkably well in the hands of the writer, is as follows ; — Apply two or three layers of plaster, cut in strips of about four inches, thus : the first strip is laid on obliquely in the direction of the ribs, the second across the course of the ribs, the dlird in the direction of the first, the fourth as the second, and so on until the entire side is covered, A strip is also passed over the shoulder, which is kept down by another fixed round the side across its ends. Each strip should be long enough to extend from the spine to the sternum. 4. Phthisis pulmonalis . — The stage at which mechanical rest becomes a decided therapeutic is that of breaking-down of the lung-tissue, and the formation of large cavities. Its application at an earlier stage is also useful in relieving the distress of breathing; but it seems most suit- able as a means of checking the short hacking cough, and the stitch-like pains, produced by stretching of those parts of the lungs which have been united by adhesive inflammation to the costal layers of the pleura. By means of strapping the upper part of the chest, corre- sponding to the disease, with diachylon spread on leather, and filling all the hollows previously with cotton-wool, so as to prevent all motion on inspiration or expiration, rest and quiet is ob- tained, and not only is cicatrisation encouraged, should such have commenced, but the risk of either haemorrhage by rupturo of an artery, or the laceration of the pleura pulmonalis and con sequent pneumothorax, is averted. B. Diseases of the heart and blood- vessels. — 1. Pericarditis. The mode of apply- ing rest in this disease must necessarily be different from that which obtains in pleurisy, as actual arrest or even limitation, to any degree, of the heart’s action — which theoretically and by analogy might be expected to be followed by the best results — would of course be out of the question. Rest must therefore be diffei’entlv attained, by general rest and quiet, and by phy- siological medication. The advantages of perfect rest in the horizontal position, are evident, as by it the attrition of the inflamed surfaces against oach other is lessened by some 17,280 beats in the twenty-four hours, and thereby the tendency to effusion diminished, and resolution encouraged. The medicine above all others to produce physiological quiet is opium. When not otherwise contra-indicated, and when care- fully watched, it is to be used freely, in grain doses every second or third hour, as it is remark- ably little liable to produce narcotism. 2. Internal aneurism . — For a long time, until recent years, this disease was looked upon as beyond the reach of medicines or cure. Valsalva saw the clue to treatment, and attempted to in- duce rest, and such a state of the general circula- tion that the aneurismal sac might be filled by the fibrin of the blood ; but the means he adopted wero not physiologically correct , and to Mr. Tufnell, of Dublin, is due the credit of having so modified the treatment as to obtain that rest which alone can cure the aneurism. Mr. Tufnell’s method may shortly be stated to be as follows: — The patient is to be placed in a bright airy room on a prepared bed or couch, on which he must be contented to remain for eight or ten weeks. He must thus lie in the horizontal position, and not even for a moment assume the erect posture. Accordingly the bed must be so constructed that the requirements of nature can be attended to without alteration of position. The diet is to be restricted to a minimum of solids and fluids. The patient’s mind is to be freed from 1348 EEST, THERAPEUTICS OF. all anxiety, and pain and sleeplessness relieved by opium. The object of these means is to give rest to the aneurism (1) by reducing the absolute quantity of blood circulating, without taking any of its ingredients from it by bleeding; (2) by rendering the blood hyperinotic; (3) by. diminishing the rate and force of the current through the sac. The horizontal position in a healthy individual makes a difference of at least twelve cardiac beats a minute less than in the erect position, and in disease this difference amounts to twenty or even forty beats. Taking it at the lowest rate of difference it is evident that in the horizontal position the blood circulates 17,280 times less through the body in the twenty four hours. The aneurismal sac is proportionately less often distended, and the threatened breach in the wall of the artery is averted by layers of fibrin deposited by the more slowly moving and concentrated stream. C. Diseases of the abdominal viscera. — In the therapeutic consideration of disease of these organs the principle of rest is not less plainly indicated than in the other parts of the body we have discussed ; and by neglect of so simple and yet so potent an agent all other treat- ment may signally fail to relieve or to cure. 1. Diseases of the stomach and intestines . — The whole basis of treatment often depends upon strict diet, and in some cases temporary total de- privation of food, enemata supplying the requisite nourishment. Local rest can best be obtained by the physiological action of opium upon the vermicular movements of the intestines, and by avoiding all irritants or purgatives. Opium may be required in full doses, so as to arrest all peri- stalsis ; and thus an inflamed or ulcerated sur- face is placed at rest, and nature is enabled to prevent perforation, and cure the disease. It cannot be too strongly stated that the injudicious employment of purgatives in threatened perfora- tion is not only unscientific, but the worst pos- sible practice, as it is almost sure to result in the death of the patient. This line of treatment by rest holds good in simple or cancerous gastric ulcer, Curling’s ulcer, typhoid ulceratioD, and that due to foreign bodies in the appendix vermiformis. The practitioner will find it also his best guide and indispensable aid to cure in perityphlitis, hepatic abscess, ileus, after operations for hernia, and in various other conditions. 2. Inflammation of the kidneys . — As the skin and bowels may vicariously perform many of the excretory functions of the kidney, the first indi- cation in acute nephritis is to relieve and rest that organ, by general rest, local depletion, and by calling vigorously upon the skin and intestines. In some cases where the equilibrium of secretion and excretion is thrown much out of balance, and where convulsions and dropsy point to an hydrsemic and toxsemic state, we should use vene- section as the readiest and most efficient means of attaining our object, of curing by rest. Conclusion. — The foregoing illustrations show the benefit of rest in its varied aspects, not as a remedy to the exclusion of others, but as a therapeutic agent by which nature is reinstated on the throne, so that she may again exercise her vital powers to restore order, give health, and maintain life, J. Mager Finnt. RESUSCITATION. RESTLESSNESS. — This signifies a con- dition of constant movement ; the movements being random and non-purposive, or only semi- purposive and fitful in character. The condition itself may be due to the most various causes. Thus it may be met with in children who are tho subjects of connate mental defects, and who ary scarcely over at rest during their waking hours ; or it may be seen for a time, and especially in ‘nervous’ people under conditions of extreme mental excitement. In various forms of delirium, or of mania, either subacute or acute, restless- ness also exists to a well-marked degree. Where it occurs in fevers to a notable extent it usually co-exists with delirium. Restlessness is likewise a prominent feature in patients who are suffer- ing from severe and abiding pain in almost any part of the body; or in those who have suddenly- lost large quantities of blood, either from the uterus or elsewhere. See Jactitation. Treatment.— -This being a mere symptom, dependent upon very many totally different un- derlying conditions, its treatment in each parti- cular case resolves itself into the treatment of the general condition upon which tho symptom is dependent. H. Charlton Bastian. RESUSCITATION {re-, again, and suscito, I stir up). — D efinition'.— The recovery from sus- pended animation or apparent death. In these conditions, of course all signs of circulation and respiration have disappeared, but usually the failure of one function has preceded the other. For the purposes of treatment we may regard as (A.) syncope those eases where the lips and mu- cous membrane are found pale and exsanguine ; and as (B.) asphyxia those where they are dark- coloured. A. Syncope. — Syncope may arise (1) from men- tal emotion, sudden pain, or shock; (2) from drugs and poisons, including anaesthetics, espe- cially chloroform ; (3) from haemorrhage, or any thing which reduces the due supply of blood to the heart; and (4) from fatty degeneration or dila- tation of that organ. T reatment. — Place the patient horizontally on his left side, with the pelvis and feet raised, Nria- ton has urged complete inversion of the body, but by its interference with the free action of the diaphragm this method may be injurious. The windows of the room should be opened ; the face fanned ; and a little cold water may be sprinkled on the forehead. Smelling salts being held to the nostrils, if natural breathing has not re- turned, begin Howard’s method of artificial re- spiration : — Position of patient. Face upwards; a hard roll of clothing beneath thorax, with shoulders slightly declining over it. Head and nock bent back to the utmost. Hands on top of head. Strip clothing from waist and neck. Posi- tion of operator. — Kneel astride patient's hips : place your hands upon his chest, so that the hall of each thumb and little finger rest upon tho inner margin of the free border of the costal cartilages, the tip of each thumb near or upon the xiphoid cartilage, the fingers dipping into the corresponding intercostal spaces. Fix your elbows firmly, making them one with your hips. Action of operator. — Pressing upwards and inwards to- RESUSCITATION. wards the diaphragm, use your knees as a pivot, and throw your weight slowly forwards two or three seconds, until your face almost touches that of your patient, ending with a sharp push which helps to jerk you back to your erect kneeling position. Rest three seconds ; then repeat this movement as before, continuing it at the rate of seven to ten times a minute ; taking the utmost care, on the occurrence of a natural gasp, gently to aid and deepen it into a longer breath, until respiration becomes natural. This method is said to keep the passage through the larynx free without the aid of an assistant or any contrivance for the purpose, and is recommended for that reason. Artificial re- spiration must precede the use of the stomach- pump, aud be continued until either the pulse or natural respiration returns. Keep up the temperature of the body by hot blankets or hot bottles. Stimulating the heart by galvanism has been recommended, but it is a doubtful remedy. It is not easy to make it produce general and effective contraction, such as would cause the ilood to move forward, and, failing to do this, it probably does harm by exhausting the irrita- bility of those parts which it does excite. Ether, or nitrite of amyl, may be held to the nostrils. A little brandy and hot water, eau de cologne and water, wine, or other stimulant, as sulphuric ether or sal volatile, is now to be given, with care that none of it enters the trachea. If swal- lowing is impracticable, inject warm fluids into '.lie rectum. In cases of syncope from loss of blood transfusion may be required. See Trans- fusion. B. Asphyxia, (a) Asphyxia Neonatorum. — The mouth and nostrils of the infant should be wiped dry ; and the body freely exposed, whilst the head is allowed to fall back over the hand which supports the nape. A few drops of cold water may be sprinkled upon the chest, and the face should be fanned or blown upon for one minute only. Next inflate the lungs by blowing into the nose and mouth ; and then squeeze the trunk. The body should now be immersed in water at 100°, from which the chest should be raised every half-minute and sprinkled with cold water. Sylvester’s method of artificial respiration is the best. Marshall Hall’s and Howard's methods may be used after the first inspiration has occurred, or together with mouth-to-mouth insufflation ( see Artificial Respiration). Experiments made by Dr. Champneys show that Hall and Howard’s methods of artificial respiration are absolutely useless as a means of directly inflat- ingthe lungs of still-born children; and also that Sylvesters method, and its modification by Bain and Pacini, introduce more air than any other method. (b) Asphyxia from. breathing noxious gases. The body should bo brought into fresh air ; arti- ficial respiration be at once commenced ; whilst an assistant should blow into the nostrils three or four times ; and hot blankets and hot water bottles be applied. (c) Asphyxia from mechanical obstruction of the air-passages. — The cause of obstruction must be removed, if possible, by adopting the inverted position of Howard’s method. Coins or plum- stones may thus dislodge themselves. In the 1349 absence of forceps, a button-hook or the handle of a tablespoon may be useful, especially in the removal of a lump of hard food. Laryngotomy or tracheotomy must be performed the instant the pulse becomes imperceptible at the wrist. (d) Asphyxia from poisons or anesthetics. — In the asphyxia of advancing coma from narcotics and anaesthetics, the breathing may stop from failure of the medulla and respiratory tract. In this case artificial respiration, by simply com- pressing the chest at intervals of five seconds, may suffice, but very often there is the mecha- nical obstruction in the larynx to be considered. If raising the chin and throwing the head back do not effect a free passage of air, Howard’s or some other method of artificial respiration should bo commenced (see Artificial Respiration). ft is well to understand that when the muscles of the larynx are paralysed, the glottis becomes valvular in action or partially so — that is to say, it permits air to pass outward freely, but only a weak current of air to pass inward. A strong current brings the sides together and gives riso to complete obstruction. This is chiefly caused by the drawing together of the relaxed arytaeno- epiglottidean folds of mucous membrane ; and in order to obviate this kind of obstruction, the folds should be tightened, by throwing back the head and raising the chin as far as possible away from the sternum. This will render it unnecessary to catch hold of the tongue with artery forceps, the treatment usually recom- mended. (e) Asphyxia from drowning. — In asphyxia from immersion in water there are two serious complications, namely, first, the presence of water and mud in the air-passages, and, secondly, the depressing effect of cold. With the view of more effectually removing the water from the air-tubes Howard gives the following rules : — Position of patient. Face downwards. A hard roll of cloth- ing beneath the epigastrium, making that the highest point, the mouth the lowest. Forehead resting on forearm or wrist, keeping mouth from ground. Position and action of operator. Place left hand, well-spread, upon thebaseof the thorax to the left of the spine ; the right hand upon the spine, a little below the left and over the lower part of the stomach. Throw upon them, with a forward motion, all the weight and force the age and sex of the patient will justify, ending this pressure of two or three seconds by a sharp push, which helps you back again into the up- right position. Repeat this two or three times, according to the duration of the emersion, and then resort to the method described in the treat- ment of syncope. The following rules have been published by the Royal Humane Society. They recommend the Sylvester method, but probably this and the modification by Bain, in which the anterior fold of the axilla on both sides is grasped with the clavicle and pulled upwards, are less useful than the Howard plan, which favours the patency of the air-passages. Directions for Restoring the Apparently Dead. I. — If from Drowning or other Suffoca- tion, or Narcotic Poisoning. — Send immedi- ately for medical assistance, blankets, and dry 1350 RESUSCITATION. clothing, hut proceed to treat the patient in- stantly, securing as much fresh air as pos- sible. The points to be aimed at are— first, and im- mediately, the RESTORATION OF BREATHING ; and, secondly, after breathing is restored, the pro- motion OF WARMTH AND CIRCULATION. The efforts to restore life must be persevered in until the arrival of medical assistance, or until the pulse and breathing hare ceased for at least an hour. Treatment to Restore Natural Breathing. Rule 1. — To maintain a free entrance of air into the windpipe, — Cleanse the mouth and nos- trils ; open the mouth ; draw forward the patient’s tongue, and keep it forward: an elastic band over the tongue and under the chin will answer this purpose. Remove all tight clothing from about the neck and chest. Rule 2. — To adjust the patient's position . — Place the patient on his back on a flat surface, inclined a little from the feet upwards; raise and support the head and shoulders on a small firm cushion or folded article of dress placed under the shoulder-blades. Rule 3. — To imitate the movements of breath- ing. — Grasp the patient’s arms just above the elbows, and draw the arms gently and steadily upwards, until they meet above the head (this is for the purpose of drawing air into the lungs) ; and keep the arms in that position for two seconds. Then turn down the patient’s arms, and press them gently and firmly for two seconds against the sides of the chest (this is with the object of pressing air out of the lungs. Pressure on the breast-bone will aid this). Repeat these measures alternately, deliber- ately, and perseveringly, fifteen times in a minute, until a spontaneous effort to respire is perceived, immediately upon which cease to imitate tho movements of breathing, and proceed to induce CIRCULATION AND WARMTH. Should a warm bath be procurable, the body may bo placed in it up to the neck, continuing to imitate the movements of breathing. Raise the body in twenty seconds in a sitting position, and dash cold water against the chest and face, and pass ammonia under tho nose. The patient should not be kept in the warm bath longer than five or six minutes. Rule 4. — To excite inspiration. — During the employment of the above method excite the nos- trils with snuff or smelling-salts, or tickle the throat with a feather. Rub the chest and face briskly, and dash cold and hot water alternately on them. Treatment after Natural Breathing has been Restored. Rule 5. — To induce circulation and warmth. Wrap the patient in dry blankets, and com- mence rubbing tho limbs upwards firmly and energetically. Promote the warmth of the body by the application of hot flannels, bottles, or bladders of hot water, hot bricks, &c., to the pit of the stomach, armpits, between the thighs, and at the soles of the feet. Warm clothing may generally be had from the bystanders. When swallowing has returned, a teaspoonful of warm water, small quantities of wine, warm brandy and water, or coffee should be given. Sleep RETRACTED ABDOMEN. should be encouraged. During reaction large mustard poultices to the chest will relieve the distressed breathing. II. — If from Intense Cold. — Rub the body with snow, ice, or cold water. Restore warmth by slow degrees. It is dangerous to apply heal too early. III. — If from Intoxication. — Lay tho indi- vidual on his side on a bed with his head raised. The patient should be induced to vomit. IV. — If from Apoplexy or Sunstroke.— Cold should be applied to the head, which should be kept raised. Tight clothing should be removed, and stimulants cautiously used. How soon should alcoholic stimulants be given? Certainly not until natural respiration has been induced, and in cases of narcotic poison- ing, not until consciousness has been restored. If, on the return of consciousness, the patient is in pain or faint, the inhalation of a few drops of ether or smelling ammonia is indicated. In their absence a few teaspoonfuls of brandy may be given. Hot tea and coffee should be the first refreshment swallowed, and in general it should not be pressed upon the patient, as vomiting is more exhausting than waiting a few hours for food. J. T. Clover. RETCHING- (A.-Saxon, hracan). — An in effectual effort at vomiting, sometimes accom- panied by the expulsion of gas from the stomach. Sec Vomiting. RETENTION ( re-, back, and teneo, I hold). This word is employed in medical science to imply that some material, whether solid or liquid, which ought to be discharged, is retained or kept back in a cavity or canal, either natural or artificial. Thus we speak of retention of urine, faces, menses, and bile ; and also of pus under certain circumstances. RETENTION OP URINE. — See Mictu- rition, Disorders of. RETINITIS. — Inflammation of the retina. See Eye and its Appendages, Diseases of. RETRACTED ABDOMEN.— The abdo- men as a whole presents under certain circum- stances more or less depression of its anterior wall, when it is said to be retracted, and this mar reach such a degree that the abdomen becomes boat-shaped, and its anterior boundaiy some- times seems almost to come into contact with the spinal column behind. The bony prominences of the crest and anterior angles of the ilium, the pubes, Poupart’s ligament, and the lower margin of the chest often stand out prominently. In some instances the retraction is partial, involving the lower part of the abdomen, while the upper part is enlarged. A retracted abdomen frequently renders itmoro easy to investigate by physical examination the contents of this cavity ; and it must be re- membered that the condition may be associated with diseases of abdominal organs which can thus be readily detected, or with abdominal tu- mours. It may, however, also itself give infor- mation of importance in diagnosis. The chief conditions under which a retracted abdomen may be met with, so as to be of clinical importance, an RETRACTED ABDOMEN. *s follows: — 1. In certain cases of disease of the brain or its membranes, and especially acute meningitis. 2. In some forms of intestinal colic, particularly that form associated with lead-poison- ing — the so-called painter's colic. 3. As a part of marked general emaciation from any cause, bnt especially that due to starvation, or to chronic diarrhcea from intestinal ulceration and other conditions. 4. In connection with chronic dis- eases of the oesophagus, stomach, intestine, or pancreas, causing obstruction in some part of the alimentary canal, so that food cannot be taken in, or is prevented from passing along. Here the retraction is also partly due to the general emaciation. 5. As one of the consequences of chronic peritonitis. It will be seen, from a consideration of the causes just mentioned, that retraction of the abdomen immediately results either from a spasmodic contraction of the intes- tines and abdominal muscles ; general wasting ; absence of food from, and contraction of tho alimentary canal; or peritoneal adhesions. It may be mentioned that marked temporary re- traction of the abdomen is sometimes noticed in connection with the act of breathing, in conse- quence of disordered action of the diaphragm. Frederick T. Roberts. RETRACTED CHEST. See Deformities of the Chest. RETROCEDENT [retro, back, and cedo, I depart). — A term employed in connection with certain acute diseases, when their prominent ex- ternal manifestations disappear or, as it were, go back. Retrocession is often associated with the simultaneous occurrence of internal disturb- ance. The phenomenon is observed in gout, rheumatism, certain skin-disoases, and the erup- tive fevers. RETROFLEXION (retro, back, and jlccto, I bend). — A form of displacement in which an organ is bent backwards upon itself. See Womb, Diseases of. RETRO-PHARYNGEAL ABSCESS.— Synon. : Post-pharyngeal abscess ; Fr. Ahces retro-pkaryngien ; Ger. Retropharyngeal Ahsccss. Definition. — A collection of pus in the loose areolar tissue which connects the pharynx with the muscles lying upon the vertebral column, namely, the longus colli and the rectus anticus major. -Etiology. — This is a somewhat rare affection, and is more commonly' met with in children than in adults, more particularly in those of astrumous diathesis. Idiopathic inflammation of this tissue, though usually assigned as one of the causes of the affection, is not often seen. More frequently tho inflammation, and resulting abscess, is a secondary disorder, dependent upon an inflamed condition and suppuration of a post-pharyngeal gland, or caries of some of the cervical vertebrae, or their cartilages. Amongst other causes, pyaemia has been noted ; and it has also been observed as a sequela to some of the acute fevers. Symptoms. — As in all disorders where inflam- mation plays a part, so here the onset of the disease is marked by increase of temperature and pulse, nausea, general restlessness and malaise, REVULSENTS. 1355 and already some amount of soreness of throat is complained of. The degree of pyrexia and constitutional disturbance will vary with the condition and constitution of the sufferer. Soon this soreness of throat develops into the true characteristic pain on making the attempt tc swallow, a symptom which is never wanting, and which goes on gradually, though slowly, aug- menting, till almost complete dysphagia is es tablished. Accompanying this, or at least soon after, is observed a peculiar stiffness of the neck, which, coincidently with the difficulty of swallow- ing, becomes more apparent with the progress oi the disease. A certain amount of swelling of the neck may also be observed, specially towards the angles of the lower jaw. Difficulty in breathing is another prominent symptom of the disorder, which, more particularly if the abscess be large, becomes greatly aggravated when the patient as- sumes the horizontal posture. On first looking at such a child with its embarrassed respiration, its anxious expression, its cyanotic lips and cheeks, one might well be excused for momentarily dia- gnosing the case as one of croup, were it not that, loud and hurried as are the respirations, they are not of a whistling character. Here also the voice is altered ; at first hoarse and indis- tinct, it assumes what is described as a snuffling tone, or a toneless voice. On inspecting the throat, a round swelling is observed in the pos- terior wall of the pharynx, occupying the centre of the pharyngeal space, or more to one side, whereby the cavity is greatly diminished in size. The mucous membrane presents a livid colour. On passing the finger over the root of the tongue and beyond the soft palate, this tumour will be felt to be either hard and tense, or soft and somewhat indistinctly fluctuating, according to the stage of the disease. When tho tumour attains an extraordinary size it has been seen to project in front of- the soft palate. A quantity of mucus usually fills the mouth. All attempts at swallowing are fruitless. Prognosis.— The prognosis is always doubt- ful. Most usually well-pronounced cases termi- nate fatally — invariably so if the disease depends upon caries of the vertebrse. Treatment. — Little can be expected in the way of arresting the disease. Usually it is well-pronounced before the physician is called to see the child, or it is some time before he can be quite sure of his diagnosis. Ice may be freely administered, and is most grateful to the patient. So soon as the presence of an abscess is distinctly established, surgical inter- ference must at once be had recourse to, and the abscess laid open by a well-guarded bistoury. Sustaining treatment is urgently demanded. Claud Muirhead. RETRO VERSION (retro, back, and verto, I turn).- — A form of displacement in which an organ is turned back. See Womb, Diseases of. RE-VACCINATION.— The operation of repeated vaccination. See Vaccination. REVULSENTS ( revello , I draw away). — This term dates from the time of the humoral pathology, and signifies therapeutical measures which draw the humours from the part affected, 1352 REVULSENTs. \ny detailed consideration cf such supposed effects could only be interesting from an his- torical point of view. R. Fahquharson. RHEUMATIC ARTHRITIS. — Synon. : Rheumatic Gout; Rheumatoid Arthritis; Fr. Rhumatisme noueux; Usuredes Cartilages ; Ger. Arthritis Deformans. Definition. — A disease of the joints, the essential nature of which is still unknown ; cha- racterised by chronic inflammatory and degene- rative changes, involving the various articular structures ; and leading to deformity. ^Etiology. — In a considerable proportion of cases, rheumatic arthritis follows ordinary acute rheumatism immediately, or it appears after an interval of several years, during which time ;hronic rheumatism of a milder degree may have b6en complained of. Persons of all ages may thus juffer, but the disease generally begins between •wenty and forty. It is commonly believed to ia more frequent in women, but this is doubtful. Depressing influences of all kinds, including acute liseases, frequent pregnancy, super-lactation, prolonged physical exertion, and mental distress, ■ire unquestionably predisposing factors. The iiseaso is hereditary. Tiie exciting cause is generally chill; but in many instances injury of a joint is the starting point of the morbid process. Anatomical Characters. — Two well-marked forms of this disease are met with, according as a single joint only, or several — perhaps all — of the joints are affected. In every respect the anatomical characters are identical in the two forms. Examined at an early stage of the morbid pro- cess, an affected joint is found to be enlarged; the synovial membrane, capsule, and ligaments being distended and stretched by a considerable amount of effusion. The synovial membrane is hyperoemic, swollen, and thickened; its fimbriae are enlarged and vascular ; intra-articular fibro- cartilages, ligaments, and tendons are vascular and softened; and the articular cartilages are partially removed, leaving a roughened, vascular, porous-like surface behind. In the more advanced stage of the process the effusion is considerably less, or may be completely re-absorbed ; and the capsule and ligaments are much thickened, or even partially calcified. The intra-articular structures, including fibro-carti- lages, ligaments, tendons, and articular cartilages, have disappeared in a great measure, leaving little or no trace behind. Peculiar pendulous bodies, consisting of masses of fibro-cartilage, are attached to the interior of the synovial mem- brane ; more rarely they are free. The articular cartilages, where their opposed surfaces are in mutual contact, are replaced by an ivory-like layer of bone ; whilst at other parts the surfaces present a pink colouration, with small spots of more intense hypersemia. The articular surfaces are variously altered in shape and size. Thus articular cavities are widened, and occasionally deepened, by enlargement of the circumference, in the form of ‘lips,’ or by the production of separate bony masses in the same situation ; whilst the heads of bones are enlarged ; present similar ‘ lips’ or sharp edges at their widened margins ; become RHEUMATIC ARTHRITIS, flattened at right angles to the axis of pressure; and thus preserve their relations with the cor- responding cavities. The shafts of the hones may be considerably altered in shape, increased in size, and altered in density. The associated tendons are frequently dislocated from their course beside the articulations, and atrophied or actually absorbed; and the corresponding muscles are similarly atrophied. Burs® in the neigh- bourhood of joints may he distended with fluid, and contain fibro-cartilaginous bodies. The ana- tomical changes in this disease frequently pre- sent a remarkably symmetrical distribution. Pathology. — A diversity of opinion still pre- vails upon the essential nature of rheumatic arthritis. The view most generally held at the present time appears to be, that it is a disease distinct from rheumatism and gout, with which it was confounded until the time of Ilaygarth (1805). Quite recently Mr. Hutchinson has shown that, in a certain number of instances, there is an element of gout in the disease, as evidenced by the family and personal history of the patient, and by the occasional presence of urates in the arti- cular structures post mortem. The writer’s ex- perience is almost entirely in favour of the strictly rheumatic nature of the disease, as was main- tained by Todd. In a large proportion of cases he has found that the morbid process started in an attack of ordinary acute rheumatism ; an observation which is entirely in accord with the account of the origin of rheumatic arthritis given by Dr. Adams, of Dublin, in his classical work on this subject. In numerous instances the family history is distinctly rheumatic. The writer has also found the heart diseased in a much larger proportion of cases than is usually stated in accounts of the disease. Finally, he has found that no lino can be drawn between acute and sub-acute cases of rheumatism; be- tween sub-acute and chronic cases of rheumatism; or between chronic rheumatism and so-called ‘ rheumatic arthritis,’ the latter being only a moro severe development of the former. Whatever, therefore, the essential nature of rheumatism may be, the writer holds that all the conditions named are expressions of one morbid process, which differ from each other chiefly in intensity and the manner of their evolution. Symptoms.— The symptoms of rheumatic ar- thritis iD its condition of full development arc exceedingly characteristic. The patient com- plains of pain and stiffness in connection with one or more joints ; and on examination these are found to bo swollen, more or less dis- torted, and tender. The history of these changes in the joints proves to be that, either in con- sequence of an attack of acute rheumatism, or not, first one and then others of the arti- culations became painful, tender, hyperaemic and swollen; that the resulting enlargement had not completely disappeared before the acute symptoms recurred ; and that, by a repetition of similar acute or subacute attacks, tho joints have reached their present condition. Thus the disease, whilst chronic in its course, consists essentially at first of recurrent acute, or sub- acute, attacks, which increase in frequency whilst their effects persist, and so finally become fusee as it were into a continuous whole. RHEUMATIC ARTHRITIS. The lucal symptoms and signs vary -with the particular joint affected ; but in every instance they are chiefly these — pain, tenderness, creak- ing on movement, impairment of mobility, en- largement, and deformity. The pain is generally distressing, and, by its continuousness and severity, may render the patient’s life miserable, especially as it increases at night and prevents sleep. It is aggravated by movement, and there is tenderness on forcible disturbance of !hs articular surfaces. Creaking or crepitation, audible and palpable, is a highly characteristic feature, which can be elicited and appreciated either by the patient or by the practitioner, and in the case of large joints may be so loud as to be audible at a distance. The mobility of the affected joints becomes more and more impaired as the disease progresses — at first on account of pain, afterwards in con- sequence of anatomical changes. Thus the vari- ous joints may become fixed by a ‘false’ (very rarely a ‘ true ’ ) anchylosis, so that the hands cannot be closed ; the wrists are immovable ; the arms can hardly be removed from the side; the jaws are fixed ; the head cannot be rotated : the patient may be unable to sit; and the knees, ankles, and toes may be similarly impaired in function. The variety of deformity is almost endless ; and the particular character it assumes depends as much on the joint involved, as on the nature of the process itself. Thus the knee, elbow, wrist, and knuckles may present considerable iutra- articular effusion, especially in the earlier stages; whilst the shoulder, hip, and intra-phalangeal joints exhibit more limited swelling and ‘drier’ signs. The terminal digital joints become cubi- cal or ‘ nodous ’ ; the middle digital joints become spheroidal in outline, or are partially dislocated backwards or forwards ; and the knuckles are the seat of a peculiar, oblique dislocation of the fingers towards the ulnar side. The lower ends of the radius and ulna project backwards, and give a full appearance to the dorsum of the wrist, which may be further increased by carpal and bursal enlargements. The elbow-joint is swollen; and bursal collections — fluid and solid — develop over the olecranon. The shoulder presents signs of wasting, rather than of enlarge- ment, due to atrophy of the deltoid and other muscles ; the head of the humerus at the same time lies unnaturally' forwards and upwards; and a corresponding depression is apparent behind. At the hip-joint the disease gives rise to flatten- ing of the buttock, shortening of the limb, and eversion of the foot ; enlargement can sometimes be felt in connection with the head of the bone and acetabulum ; occasionally the patient maybe not only lame but unable to sit, and must accordingly either stand or lie constantly. The knee is en- larged by the presence of considerable effusion in the earlier stage ; and when this afterwards becomes absorbed, local bony growths are easily felt, giving increased breadth to the patella, and forming sharp crests at the lateral margins of the articular surface of the condyles. The disease, as it affects the ankle and foot, does not require Jpecial description. At the temporo-maxillary urticulation rheumatic arthritis gives rise to obvious enlargement in front of the ears, and 1353 possibly to distortion or asymmetry of the chin. Prominent nodular swelling is the principal sign of the disease at the sterno-clavicular artieula tion. In the spine it produces rigidity chiefly, as well as pain locally and down the arms, and leads to stooping in various attitudes. The general condition of the subject of rheu- matic arthritis, when it is advanced, is one of debility and ansemia. The face is pale and ex- pressive of suffering; the complexion is muddy. The skin is peculiarly inactive, and rarely per- spires ; the patient looks pinched, and complains of a feeling of cold ; the extremities are often miserably cold and livid ; and the palms of the hands are damp or even soppy. Bodily activity is greatly impaired, by interference with the movements of the limbs ; in many instances the patient is completely crippled and bed-ridden. Even the voice and the hearing may be impaired, from involvement of the laryngeal and auditory articulations. The various bodily functions are feeble, and frequently deranged ; and although the mind may be active, the condition is rendered wretched in the worst cases by pain and helpless- ness. CoonsE and Terminations. — Unless the dis- ease be treated early, the course is essentially progressive towards deformity. Death from rheumatic arthritis is rare ; its other distressing effects have been -sufficiently indicated. Diagnosis. — The diagnosis of rheumatic ar- thritis necessarily depends upon the view enter- tained of its pathology. If considered a distinct disease, it is, as a rule, easily separated from gout by the entire absence of tophi in the joints and ears ; by the history of the disease ; and in doubt- ful cases by the absence of uric acid in the blond. Erom chronic rheumatism, as ordinarily defined, it is diagnosed by the amount of deformity pre- sent; but the writer holds that the two con- ditions are identical. Chronic synovitis of trau- matic or constitutional origin maybe occasionally mistaken for rheumaticartfiritis, but the presence of the latter disease in several joints, probably symmetrically, should remove all doubt. Rheu- matic arthritis of the hip and shoulder has pro- bably been frequently described as ‘dislocation’ and ‘ intracapsular fracture.’ Phogxosis.— The prognosis of this disease is favourable as regards life ; but unfavourable as regards cure, comfort, or ability to follow active bodily employment. The prognosis is much better in the rich, who can seek relief by change of climate in the earlier stages, than it is amongst the poor, in whom the disease must in a measure be allowed to pursue its progressive course. Treatment. — The treatment of rheumatic ar- thritis must be applied in two directions; first, to arrest, if possible, the morbid process, and, secondly, to relieve the distressing symptoms. In a large number of cases the second indication only can be fulfilled, for the disease is frequentlv too advanced, or the circumstances of the patient are too poor, to afford a prospect of cure. In the early stages of the disease much can be done by energetic treatment, which must be partly constitutional and partly local. If circum- stances permit, the patient should be advised to visit, according to the season of the year, either the baths of this country, of Germany, or of France 1354 RHEUMATIC ARTHRITIS, in summer ; or the Algerian springs, the French Riviera, or Italy in winter. Buxton, Bath, and Strathpeffer are the best home baths. Aix-les- Bains, Aix-la-Chapelle, Baden-Baden, and Wies- baden may be recommended from May till Sep- tember. The other places named, especially Hammam R’lrha in Algiers, are winter resorts. A voyage to the tropics or subtropics will suit other cases. The climate of Egypt proves bene- ficial in some instances ; and advantage may be taken there of the Eastern method of treating rheumatic affections by means of baths and rub- bing, which are undoubtedly' successful in some cases. See Mineral Waters. The most valuable internal remedies for rheu- matic arthritis aro cod-liver oil, iron, and arsenic. Cod-liver oil should be taken regularly if the digestion permit. Either iron or arsenic, or the two combined, should bo taken in full doses for periods of weeks or months, and their effect care- fully noted. Dr. Garrod especially recommends the syrup of the iodide of iron. The diet should be carefully ordered. Whilst all excess is avoided, as well as indulgence in malt liquors, wines, and rich indigestible dishes, a generous supply of mixed animal and vege- table food will be found to be most suitable. The clothing must bo warm, flannel or other woollen material being worn both summer and winter. The greatest possible care must be exercised to avoid cold and damp, in the choice of a residence and in the routine of daily life. The local treatment is to be considered of hardly less importance than the constitutional. On the first appearance of the disease, counter- irritation should be freely applied to the joints. The most convenient form is iodine paint, which should be used so freely that the skin becomes of a mahogany colour, and desquamation follows in a few days. The joints should be carefully protected by cotton-wool or flannel. Between the subacute attacks of the disease, efforts should bo made to restore the healthy nutrition of the affected joints. Whilst the internal treatment already indicated is persevered with, ora trial is given to guaiacum or iodide of potassium in ob- stinate cases, counter-irritation should be replaced by a method of less severe but systematic stimu- lation. The joints that can be easily reached should be thoroughly fomented night and morn- ing, by wrapping a piece of cambric or flannel around them, and sponging water over this, as hot as can be borne. After several minutes of such treatment the joint should be thoroughly rubbed, either with a stimulating liniment, such as the turpentine or acetic, turpentine liniment, with a mild mercurial ointment, or with some bland oil, such as cod-liver oil or goose-grease. The effect of such local treatment, if pursued steadily, is in the experience of the writer often remarkable, mobility being restored in cases where the joints have been useless for months. In very advanced cases, especially in old sub- jects, it is manifestly impossible to expect much improvement. Anodyne treatment is then chiefly called for, and a good deal can be done in this direction by well-chosen local applications, the preparations of opium being of course the most successful. The general health will demand sup- RHEUMATISM, ACUTE. port by a well-regulated diet, and the interna* treatment suggested above. J. Mitchell Bruce. RHEUMATIC FEVER. — A popular syno- nym for acute rheumatism. See EHECitATisir, Acute. RHEUMATIC GOUT. — A popular name for several kinds of chronic joint-disease, espe- cially rheumatic arthritis and chronic rheuma- tism. RHEUMATISM, Acute (|5e0/ia, a fluxion). — Synon. : Rheumatic Fever ; Fr. Rhumalisme ar- ticulaire aigu; Ger. Hitziger Gelenkrheumatismw. Definition. — An acute febrile disease ; caused by certain obscure climatic and diathetic in- fluences ; and characterised by pyrexia, sweats, and acute shifting inflammation of the joints and other structures. ./Etiology. — Predisposing causes. — Of the predisposing causes of acute rheumatism, the most important is inheritance, which can be traced in 27 per cent, of all cases. Previous at- tacks increase the liability to a return of the disease ; but there is a limit to predisposition from this cause after several attacks. The great majority of first attacks occur in persons under the age of thirty ; and the larger proportion of these between the ages of sixteen and twenty-five. At the same time, rheumatism is by no means uncommon either in children or in persons past middle life. Rather more males than females suffer; but, apart from other circumstances, the influence of sex is inconsiderable. Occupation and social position are important as predisposing causes; laborious outdoor occupations, in which persons are exposed to chills, poverty, and the many evils associated with these, contributing to furnish the largest percentage of cases. Cer- tain regions or districts, or even parts of dis- tricts, appear to deserve the name of ‘rheu- matic,’ from the number of residents who suffer from the disease, and from the probability that a person, otherwise predisposed to rheumatism, will be more likely to be attacked if he enter such an area. Determining causes. — The most common ex- citing cause of acute rheumatism is exposure tc cold and wet ; or, to express the same fact in other words, the disease has an intimate atiolo- gical relation to weather, season, and climate. Some apparent exceptions to this statement really accord with it; thus acute rheumatism is not uncommon in warm weather, on account of the frequency of chills from over-heating. Rheuma- tism may suddenly make its appearance after a sprain or other injury to a joint, which may also determine the distribution of the disease in the articulations. Similarly, the order of invasion of the several joints is due in some instances to the amount cf exercise to which they have been respectively subjected. Anattackof acuterheu- matism is occasionally referred to derangement of digestion, and of the functions of the liver, especially in subjects who have previously su;- fered. Indulgence in abundant rich or indi- gestible food will certainly determine a relapse in persons convalescing from the disease, and may possibly induce an attack in the predisposed RHEUMATISM, ACUTE. Depressing bodily or mental influences may ex- eite rheumatism under similar circumstances. Exhaustion by lactation, or by chronic uterine diseases, tedious convalescence, the puerperal state, and possibly simple despondency, may act in this way in different instances. Anatomical Chakactjsp.s. — The ■post-mortem appearances in acute rheumatism are, on the whole, remarkably negative, not so much on account of the absence of morbid changes in the affected parts, as from the slight degree to which these changes have advanced. On opening an affected joint, we find moderate hypersemia, with occasional ecchymosis, of the synovial membrane and fibrous tissues connected with the articula- tion ; a somewhat opaque, granular, swollen appearance of the synovial surfaces ; and a con- siderable amount of inflammatory effusion. This effusion is generally a thin, clear, alkaline, albu- minous fluid ; occasionally turbid, with flakes of fibrin and cell-products ; rarely purulent. The cartilages connected with the joint probably share in the inflammatory changes, especially if the process be severe ; and the associated soft parts, including the tendons and their sheaths, are very frequently hyperaemic, and the seat of effusion. A fatal termination in acute rheumatism is always the result of somo complication, inter- current disease, or injury; and in such cases the non-arthritic lesions are necessarily the most important. Of these the most frequent are congestion or inflammation of the lungs, and inflammation of the heart and pericardium. In- flammation of the pleura is much less commonly found; and in rarer instances inflammation of the peritoneum, larynx, testes, and renal tubules. When pyrexia has been great the solid viscera present granular degeneration, and are prone to rapid decomposition ; and in cases of hyperpy- rexia the blood is fluid. The blood has frequently been subjected to chemical analysis, but without any positive result of a pathological kind. The reaction of the liquor sanguinis is alkaline, as in health. The fibrin has been said to increase in amount to 1 per cent, instead of ’2 per cent. The amount of urea is not above the normal. Neither uric acid, lactic acid, nor any other ab- normal principle has been found in the blood during an attack of acute rheumatism. Patholoot. — T he pathology of acute rheuma- tism is still obscure, and in the present article it will be sufficient to enumerate the principal theories upon the subject. 1. Lactic acid theory. — Lactic acid accumu- lates in the body, and the symptoms are directly referable to the action of this poison upon the system (Prout, Todd, Richardson). . 2 . Xcrvons theory. — Chill of the peripheral parts of the body, especially of the skin and joints, causes disturbance of corresponding parts of the central nervous system ; and this gives rise to pain and vaso-motor (?) or trophic changes of the same peripheral parts, and to fever (Can- statt; Seitz). 3. Combination of 1 and 2. — Chill causes ac- cumulation or retention of lactic acid; this acts on the central nervous system ; and the dis- ordered nervous centres react upon the joints, &c. as in 2 (Senator). 135 6 4. Combination of 2 and 1 . — Chill disturbs the nervous system ; this disturbs nutrition gene- rally; lactic or some other acid is retained, and acts as a poison, as in 1 (Fuller). 5. Infective theory. — Chills are attended with the entrance of micrococci into the system, and endocarditis is the result. The joint-symptoms are secondary and embolic, as in pyaemic arthritis (Hueter). 6. Germ theory. — The disease is due to the presence in the blood of a vegetable organism of definite characters — Zymotosis translucens (Salisbury). 7. Malarial theory. — Rheumatism is duo to the presence in the system of a poison, which is of the nature of a miasm, entering from with- out. This miasm is generically allied to, but, specifically distinct from, the miasm of malarial fever (Maclagan). Without attempting to criticise these theories we may conclude that, whilst the true pathology of acute rheumatism cannot possibly be settled until the essential nature of fever is thoroughly understood, the most promising directions from which we may expect light to be thrown upon it are, first, the effect on the system of organic poisons, whether introduced from without, or produced within it as the intermediate products of nutrition ; and, secondly, the intimate relation of the nervous system to the body-heat, to the skin, and to nutrition. Under these circumstances it is impossible at present to estimate the respective significance and relative importance of the phenomena con- stituting the ‘ disease ’ rheumatism. But for the purpose of intelligible description, it is neces- sary that such of the phenomena as are only oc- casional in their appearance should bo separated from such as are constant ; and that the latter should be treated as the essential symptoms of the disease, whilst the former are regarded as complications. The constant phenomena of acute rheumatism, thus considered, are probably but three, namely, fever, sweats, and arthritis ; whilst inflammation of the cardiac structures, lungs, and serous membranes would be included under the head of the occasional phenomena or complications. This plan of description of acute rheumatism will be adopted in the present ar- ticle, for convenience’ sake only, and will imply no actual criticism of the theories of the pathology of the disease just enumerated; athough with several of them it necessarily cannot agree. Symptoms. — General description.— After suffering for a time from aching pains in the limbs and trunk, flying pains and stiffness in the joints, malaiso, chilliness, and sore-throat, the subject of an attack of acute rheumatism is seized with severe pain in one or more of his joints, experiences a chill or slight rigor, and is found to have several degrees of fever. The local and general symptoms quickly develop ; and a striking picture is presented by tho patient. He lies mo- tionless in bed, flat on his back, with every joint at rest and carefully guarded. The neck, back, and legs are straight; the arms folded across tho body, or extended along either side ; the eyes alone are moved, and follow the practitioner as he approaches the bedside. The face is found bedewed with perspiration ; and the rest cf the RHEUMATISM, ACUTE. 1356 body is profusely covered with sweat, which gives off a sour, acrid odour. The countenance is full, heavy, and expressive of a subdued feeliDg of pain and dread of movement; the complexion may le of a dirty, sallow colour, or even slightly jaun- diced ; and the cheeks are probably flushed. The affected joints prove to be swollen and red; hot to the touch ; remarkably tender ; and the seat of pain, which varies much in character and intensity. One joint, or several, or nearly every joint in the body, may be found in the condition just described. The patient complains of a feeling of illness, thirst, and anorexia; the tongue is foul and creamy ; the throat is somewhat sore ; and the bowels are irregular. The pulse is frequent, weak even to dierotism, and rather full. Respiration is somewhat ac- celerated ; and there may be slight cough. The urine is scanty, high-coloured, very acid, and loaded with lithates. The skin is covered with perspiration, congested, and warm ; and probably presents sudamina or miliaria in places. The patient’s mind is perfectly clear, and his atten- tion appears to be chiefly directed to the main- tenance of the affected joints in the most easy position possible. Until successful in this en- deavour he is restless and miserable ; and even if he have obtained temporary relief and have gone to sleep, he is liable to be suddenly aroused by involuntary spasm of the muscles connected with the affected joints. The pain is so severe when the disease is at its height, that sleep can- not be obtained. Such is the condition of a patient suffering from a fully-developed attack of uncomplicated rheumatism. For a period, which would appear to be perfectly indefinite, these symptoms con- tinue, varying considerably in intensity from day to day. Rut whilst the condition thus persists, the remarkable and characteristic fact is con- stantly observed in this disease, that the arthritic phenomena are at once transient and erratic, that is, that the rheumatism passes rapidly from joint to joint, the joints which were affected the one day being nearly well the next, and a fresh series swollen and painful. In this manner most of the joints of the limbs may have been affected in the course of a week, and the number of joints si- multaneously affected is very variable. There- after the disease may make a further invasion of joints previously involved, and that repeatedly. At last, the rheumatism appears to have ex- hausted itself ; no fresh joint is attacked ; and the parts last affected lose more or less completely the final traces, both objective and subjective, of the severe process which they have undergone, being for some time, however, stiff, feeble, and painful on movement. The patient now assumes a less constrained posture ; the other symptoms decline; the perspirations disappear; the counte- nance becomes more bright ; spirits and strength return ; tho tongue cleans, and the appetite is rapidly restored; the pulse falls in frequency; urine is passed in greater quantity, is less acid, aud no longer deposits urates ; and the tempera- ture falls to the normal. The patient being convalescent, a relapse of the disease by no means uncommonly occurs, after a few days or w'eeks ; and that in any de- gree, from a slight swelling, redness, and pain of a single joint, to a combination of the various symptoms, as severe as the first, or possibly more so. Analysis of symptoms. — Invasion . — In the great majority of cases the patient gradually ‘ sickens for’ acute rheumatism for several days before the symptoms are fully declared. He feels ill and out of sorts, chilly, indisposed to eat or work; sleeps badly; complains of slight sore- throat, aching pains in the limbs, and shooting shifting pains in the joints; and presents a sal- low, patchy complexion, and a dull, heavy yel- lowish appearance of the eyes. Altogether, the condition of the patient is very much that of the subject of a severe catarrh; the tongue, diges- tion, bowels, urine, and pulse presenting the or- dinary characters of moderate fever. On careful examination it is found that the pains are of two kinds. The first kind are by far the more severe, and consist of severe muscular aching in various parts of the limbs and trunk; whilst the second kind are of the nature of flyingpains in the joints or associated parts. The muscular aching ap- pears to be similar to, or even identical with the ‘break-bone’ pains which are familiar in common catarrh, and in the invasion stage of some erup- tive fevers. They are, therefore, not character- istic. The flying pains, which are, however, not always present — especially in first attacks, are actually situated in the articulations, forinstance the ankles, knees, or wrists, and are of the nature of sharp twinges, suddenly leaving one joint to return as quickly in another. Towards the end of the stage of invasion, these pains become less ‘shifting;’ and when, as the patient will say, they have ‘settled’ in one or more joints, the rheu- matism has passed into the second stage, that of the declared disease. Stiffness of the joints may also be present, especially in recurrent attacks. In the invasion period the skin does not yet present the perspiratory activity which is sc characteristic a symptom of acute rheumatism ; but rather a moistness, gre:isiness, or oiliness, with heat and some congestion. The tempera- ture is raised one degree or more. The sore- throat, which consists in pharyngeal catarrh, follicular tonsillitis, or even actual acute suppu- rative inflammation, is remarkably characteristic. The milder forms are soon lost in the more urgent symptoms. The duration of the stage of invasion of acute rheumatism varies greatly, the flying pains in the joints ‘ settling’ much more quickly in some cases than in others. In a small proportion oi cases the disease is so rapidly developed that the stage of invasion is wanting. The patient on waking in the morning finds one or more joints affected ; or he appears to be struck down during the day without the slightest warning; and in- stances are not uncommon in which persons, thus suddenly seized with acute rheumatism, have been removed to hospital, for supposed sprain or fracture of the limbs. In rarer instances the feverish symptoms of the invasion stage may be well-marked without any pains whatever. Declared disease. — 1. Phenomena eonneeted with the joints . — The physical signs presented t y a joint affected with acute rheumatism naturally vary much. The swelling is usually considerable, and is chiefly referable to effusion into the cavity RHEUMATISM, ACUTE. of the articulation, fluctuation being frequently discoverable. It is rare for the peri-articular effusion to be so abundant as to yield pitting on pressure. The amount of intra-articular effusion (as well as the pain) greatly influences the po- sition of the joint, but most joints are main- tained in a position a few degrees removed from extension. Careful examination will determine the increase and the disappearance of the swell- ing, as the joints are attacked and recover respectively. Pain is the most distressing of all the eymp- toms in uncomplicated rheumatism. It is always severe, and sometimes almost unbearable ; but it varies with the different joints, and with the degree and duration of their involvement, In degree it may be said to increase steadily for several hours ; it remains excessive for a time; and it then slowly and steadily declines. Its character is very differently described by different sufferers. When a joint is attacked by rheumatism, the first sensation felt by the patient is one of soreness on movement. As the condition develops, the soreness increases to an ache of a subdued, throbbing character. In the course of a few hours the ache ‘ works up’ into an intense pain, apparently associated with a feeling of cramp, the slightest movement of the articulation being almost unbearable. The severe pain now gra- dually declines — in some instances from the time the swelling reaches its height. After several hours the onty pain that remains is a distressing sensation as if the parts had been severely bruised ; and the effusion which accompanied the excessive pain having declined along with it, rest of the joint again becomes all-important, the very slightest movement being sufficient to restore the wearying ache. Finally, the pain completely disappears, and nothing remains be- yond. a feeling of stiffness and helplessness when the joint is moved. Whilst the course of the pain of an acute rheumatic attack is usually such as has been described, it is greatly modified by a variety of circumstances, such as the particular joint af- fected, the age and sex of the patient, the condi- tion of the nervous system, and the presence of certain temperaments. In some instances the pairs are increased at night. Tenderness is a constant and well-marked symptom of acute rheumatism. Reference has already been made to the effect of movement on the pain in its different stages, especially towards the end ; and to the characteristic posture and anxious expression of the patient, who suffers intensely from the slightest shake of the bed, or even a footfall on the lloor. Tenderness finally declines into the feeling of stiffness. The redness of a rheumatic joint is a simple pink blush of erythema, very rarely purpuric. Its intensity varies much with the deep or super- ficial situation of the articulation, and it is therefore most marked in connection with the joints of the hands and feet, the knees, and the ankles. Heat of the affected joint is a well-marked objective sign of acute rheumatism. The articu- lation feels decidedly warmer to the hand than the surrounding parts ; and this observation is eonfirmed by the thermometer. 1357 The electrical sensibility of the skin connected with an acutely rheumatic joint has been described by Drosdoff as being remarkably diminished, the area of nervous alteration cor- responding exactly with the area of redness, and its duration with the duration of the other local signs and symptoms. The favourite joints involved in acute rheuma trlsm are the larger articulations, especially the knees, ankles, wrists, shoulders, and elbows ; the hip joint less frequently than the others. The fingers come next in order of frequency ; then the toes ; whilst the remaining articulations are more rarely affected. Corresponding rather closely with the frequency of attack is the favourite order of invasion ; the ankles being more frequently the first to be in- volved, then the knees, and so on. In other instances it is observed that the disease passes along the joints of the lower limbs, including the hips, to those of the upper limbs ; frequently its distribution is symmetrical bilaterally ; whilst in some cases it is unilateral, the homologous joints of the upper and lower limb being simultaneously invaded. The smaller joints suffer, as a rule, towards the termination of the attack. 2. Disorders of neiylibouring muscles . — The muscular pains of the stage of invasion of acute rheumatism disappear in the declared disease, or are lost in the presence of more severe symp- toms. They are replaced, however, by pains in the soft parts of the limbs related to the affected joints, especially the muscular insertions and fasciae ; and even the whole limb may ache, with much stiffness and a feeling of utter powerless- ness. Painful twitchings are also common, espe- cially during sleep; and when the acute pain has passed off, marked muscular debility remains behind. 8. Temperature. — Acute rheumatism is at- tended by well-marked pyrexia, but this, like the disease as a whole, is variable in degree, course, and duration. The sudden invasion of the seve- ral joints, their speedy relief, the alternation of extreme bodily distress with comparative com- fort, and especially the variety of pyrexic dis- eases with which the rheumatism may he com- plicated, would hardly lead us to expect a typical temperature curve. In uncomplicated cases, however, the fever follows a tolerably definite course. Pyrexia makes its appearance at inva- sion ; it continues as long as the local symptoms preserve an acute or subacute character ; and with them it declines and disappears. The de- gree of the pyrexia, in the great majority of cases, is in direct proportion to the severity of the joint-disease. Mild local symptoms — that is, moderate pain, short duration of symptoms in any given joint, and a small number of joints affected, are accompanied by moderate fever, ranging from 99° to 102° Fahr. On the other hand, severe local symptoms — that is, severe pain, the full development of the several signs in the affected parts, and the simultaneous in- volvement of several joints, are attended by a temperature of 101° to 10-1° Fahr. In another, but very small class of cases, the temperature, whatever it may previously have been, rises rapidly to an alarming height, so as to be en- tirely out of proportion to the joint-symptoms, RHEUMATISM, ACUTE. i358 which either continue as before, or even dis- appear. This condition of hyperpyrexia is re- garded in the light of a complication, and as Bueh 'will be presently described. The type of the fever in uncomplicated cases is remittent, the thermometer rising - 25°, '50°, or D0°Fh. in the evening. The primary elevation of temperature at the commencement of the dis- easo is somewhat rapid; the decline or defer- vescence is decidedly more gradual, although it is generally irregular, being almost invariably broken by temporary rises, or interrupted by the supervention of some pyrexic complication. The occurrence of a relapse is marked by a return of pyrexia, which probably presents the same gene- ral characters as before. 4. Skin . — Profuse acid sweats constitute one of the characteristic phenomena of acute rheu- matism. The brow is covered with drops which trickle down the face; and the whole body perspires profusely, and is bathed in an atmo- sphere of wet steam. Although usually uni- versal, the sweats may sometimes be unequally distributed. It is doubtful whether any relation can be traced between the amount of perspiration and the hour of the day or night, the tempera- ture, or the pulse ; but it perhaps varies directly with the severity of the pain. The sweats con- tinue throughout the whole attack, making their appearance at an early date and disappearing gradually with the subsidence of the other symp- toms. They do not intermit in the striking way of the sweats of the hectic or septic states, un- less towards the end of a severe protracted at- tack, when the patient is greatly debilitated ; but at certain parts of the day the skin may be found to be perspiring less freely, or even to be per- fectly dry. The sweat of acute rheumatism pos- sesses a peculiar sour, acrid smell; and this is so powerful, and pervades so thoroughly the neigh- bourhood of the patient when the blankets are disturbed, that the diagnosis of the disease can frequently he made from it alone. Like the sweat in health, it is acid in reaction, rarely alkaline from decomposition. No other test can be readily applied to it clinically. The rheumatic patient may complain of the unpleasant, but never of the ‘ weakening ’ effect of the perspirations which is observed in hectic fever; on the contrary, he may describe them as bringing great relief to the bodily condition. In Rss acute cases the skin may present a shiny or greasy appearance, rather than actual perspiration. When the sweats are severe, sudamina make their appear- ance, especially about the trunk; and in some cases the skin is covered with a profuse eruption of miliaria. 5. Digestive system . — The tongue is covered with a thick, white, moist fur, which varies closely with the rheumatic condition, and serves as a ready indication of the same. The thickness of the coating is sometimes very great. Occa- sionally the tongue is dry ; very rarely brown, baked-looking, or cracked. The sense of taste is, in a greatmeasure,lost ; the mouth is parched; thirst is urgent and difficult to satisfy ; and the reaction of the saliva, or, more correctly, of the fluids of the mouth, is said to become acid. Ap- petite is lost, until the disease begins to decline, when hunger returns very early and urgently. Sore-throat occurs in some cases during the de dared disease, but is much less common than in the stage of invasion. Sickness is rarely present. Dyspepsia, attended with flatulence, is common, unless the most digestible food only be given. Irregularity of the bowels i3 characteristic of acute rheumatism, either constipation or diar- rhma being almost constantly present; and the two conditions frequently alternate. Diarrhoea is perhaps more common in first than in subse- quent attacks. The motions are dark and foul. Pains in the belly are by no means rare, and are frequently connected with diarrhoea, but they occur also in constipation ; and at times they are accompanied by attacks of distressing flatulence. 6. Circulation. — The circulatory symptoms proper to acute rheumatism are modified by complications affecting the heart in a very large proportion of cases. When no special circulatory complication exists, the pulse is regular, 80 to 120, full, sometimes hard, sometimes soft, or even dicrotic ; but it naturally varies much with the severity and stage of the disease. The effect of the various complications on the pulse will he presently described. 7. Respiratory system. — The frequency of the respirations in uncomplicated rheumatism is somewhat increased; slight cough is occasion- ally present; and under these circumstances a few dry rhonchi may be heard over the chest. On the other hand respiratory complications may be of a serious and even fatal character, and will demand consideration in their proper place. 8. Urine. — Throughout an attack of acute rheumatism the urine is scanty, high-coloured, and strongly acid ; and it deposits a quantity of urates. Albuminuria is rare. Quantitatively examined, the urine is found to contain an actual excess of urea, and a considerable (but probably only a relative) excess of uric acid, colouring matter, and sulphates ; the water is below the normal amount ; and the chlorides are diminished, although less so than in pneumonia. Lactic acid has never been found in excess. Any marked de- parture from these characters of the urine, espe- cially in the appearance of more than a passing trace of albumin, is to be considered as a com- plication of the rheumatism. 9. Nervous system.— As a rule, consciousness and clearness of intellect are preserved throughout. Delirium is very uncommon ; and when either delirium or stupor supervenes, it will generally be found that, in otherwise uncomplicated cases, the temperature has risen to an excessive degree. Very rarely the pyrexia remains moderate in these circumstances, and such cases have been described by the name of ‘ cerebral rheumatism.’ There is generally great distress of mind in acute rheumatism ; and in other than first attacks, the previous experience of its protracted course and dangers, and the recollection of the pains and other sources of bodily discomfort greatly affect the patient, and produce an amount of anxiety which is almost characteristic of the disease. Sleep is either impossible, or at best is constantly broken and unrefreshing, when the pain is severe. 10. Expresssion. — The debility or prostration, which forms an important element of fever from whatever cause, is present in acute rheumatism, but it is in a great measure obscured by the ex- RHEUMATISM, ACUTE. pression referable to pain, and to the effort to preserve an easy position. Towards the end of an attack, when pain is subsiding and movement is comparatively easy, the patient and the prac- titioner begin to appreciate the degree to which the bodily strength has been reduced. This loss is always great, and is sometimes extreme, vary- ing, of course, with the severity and duration of the disease. Varieties. — The description just given ap- plies to a fully-developed attack of acute rheu- matism, without complication, of indefinite but not protracted course, and of favourable termi- nation. It is only a minority of cases, however, that are of this nature. Occasionally the symp- toms are very mild or the attack very short, in which event the rheumatism is said to be sub- acute. Again, as nearly as possible every second case proves to be complicated with some affection of the viscera, especially the organs of circula- tion and respiration. These departures from the ‘typical’ course of acute rheumatism, as it is called for the sake of description, will next be considered. Subacute rheumatism. — Under this name are comprised a variety of cases of the disease, which, whilst of comparatively little severity, exhibit the greatest possible differences in their other clinical characters. Several well-marked groups of these may bo distinguished, and de- mand separate consideration. (a) Th e first group of subacute cases is one in which the duration of the disease is unusually short — probably from ono to three days. The number of joints affected is very small ; and the general symptoms appear to bo arrested before attaining any considerable severity. (b) In a second group of subacute cases, after exceedingly mild invasion-symptoms, a single joint only is attacked, with little pyrexia, whilst the skin presents a shiny or oily dampness rather than true perspiration. The rheumatism disap- pears in a few days ; or it shortly relapses in the same or in some other joint. Thisformof subacute rheumatism maybe difficult to diagnosefrom gout. ( c ) Widely different from the foregoing is an- other and the most common variety of subacute rheumatism. Such are many of the recurrent cases of the disease, and of the instances of first attacks in old subjects. It may be stated broadly that the first attack, or first and second attacks, of rheumatism are more severe than subsequent ones ; that the severity diminishes with each re- currence of the disease; and that persons attacked for the first time after middle life, suffer less than younger subjects. In all these cases, the pheno- mena connected with the joints, and the general symptoms, including the pyrexia and the sweats, are mild in degree, although by no means of short duration. In recurrent cases the patients are frequently the subjects of chronic heart-disease, in whom exposure to some of the determining causes of rheumatism has lighted up fresh endo- and peri-carditis, and therewith moderate fever and subacute rheumatism of the joints. The anxiety of the practitioner will be confined to the condition of the heart; but during the progress of the complaint, joint after joint may become painful, tender, slightly swollen, and red. ( d ) Lastly, there is a large and well-marked 1359 group of subacute cases of rheumatism in which the disease runs what may be called a latent course, and which occur especially in children. The joints are so slightly affected that the cha- racteristic signs and symptoms of rheumatism may bo entirely overlooked. Children frequently pass through an attack of acute rheumatism, without the true nature of the complaint being suspected by their medical attendant ; and in other instances the diagnosis is first made on the discovery of one or other of its familiar com- plications, notably heart-disease. The child is feverish, and complains of pain and tenderness in the limbs. Moderate swelling and redness of the affected joints pass unheeded in the full and high-coloured body of the patient ; and pain and tenderness in these subjects are either entirely disregarded, or referred to ‘growing,’ or to ‘a cold.’ Lastly, the sweats are much less profuse, or entirely wanting, the skin being hot with several degrees of fever. Whilst the disease in children runs this exceedingly mild course, and one which seldom exceeds a week in length, it is accom- panied, in a comparatively large proportion of cases, by acute cardiac disease — a fact which greatly increases the necessity for its early dia- gnosis. A more completely latent form of acute rheumatism has been described by Graves, in which articular symptoms are entirely wanting, whilst the other symptoms may be of the usual character and follow the usual course. When these four prominent groups of sub- acute rheumatism have been described, there still remain a large number of mild cases, which are too indefinite to be treated of in a general article. All possible varieties of the disease will be encountered in practice, according as, on the one hand, the ‘typical’ course is pursued, or, on the other hand, the disease assumes a subacute character. Course, Duration, and Terminations. — The course of acute rheumatism is extremely indefi- nite. The average duration of acute symptoms under expectant treatment has been estimated at nine days ; it is probably rather less under cer- tain other methods of treatment; audit is much prolonged by neglect. The entire duration oj an attack is much greater than this, and neces- sarily less definite, namely, two to six or even ten weeks ; and, speaking broadly, it increases with the age of the patient, up to middle age. Convalescence is generally protracted (before the health is perfectly restored) ; and it is very common to hear persons who have suffered from acute rheumatism state three or four months as the time they were ‘ ill.’ Convalescence is ac- companied by desquamation of the hands and feet, and perhaps of the body generally ; and may be marked by obstinate anaemia. In many cases stiffness, pain, and weakness remain in the joints and neighbouring muscles. The great majority of cases of acute rheuma- tism ultimately end in recovery, the proportion of deaths as the immediate result of an attack being only about four per cent. On the other hand, a large number of persons suffer from remote effects of the disease, many of which are not only distressing, but likely to lead to death. Of the immediately fatal cases, the larger pro- portion are associated with, if not actually du« RHEUMATISM, ACUTE. 1360 to, acute disease of the respiratory organs. The fatal eases which present cardiac disease, espe- cially acute pericarditis, are scarcely less nume- rous. Altogether it may be said that from a half to three-fourths of all cases of death during acute rheumatism are referable to acute cardiac and pulmonary disease, either separately or com- bined. It is doubtful whether acute rheumatism per se ever proves fatal — that is, whether any patient dies from excessive pain, sweating, and consequent exhaustion. Hyperpyrexia is the most common cause of death next to pulmonary and cardiac complications. In a small number of cases, meningitis, acute alcoholism, and other complications, to be mentioned presently, lead to a fatal termination. The remote consequences of acute rheumatism are, on the whole, more serious than the imme- diate effects. In a few instances the disease leaves behind it a condition of joints which passes into ‘ chronic rheumatism’ or ‘rheumatic arthri- tis.’ A more common effect is valvular disease of the heart, which, in the majority of cases, is referable to acute endocarditis occurring as a complication of rheumatism. It is impossible to estimate the number of cases of disease of the lungs, vessels, brain, kidneys, and other organs, which, in their turn, are caused by such heart- disease. It is also probable that the vessels suffer directly from the effects of rheumatism. When, in addition to these effects, we consider the remote effects of pneumonia and pleurisy, and of the other less common complications of rheumatism, as well as the liability to a return of the disease and its complications which seems to be engendered by a first attack, it is difficult to exaggerate the extent and seriousness of the ultimate results of this disease. Complications. — Acute rheumatism is fre- quently accompanied by certain other affections, which modify its course and greatly increase its gravity. The appearance of these complications is in every case anxiously apprehended ; and the prevention of the most serious of them is re- garded as the chief indication in the treatment of the disease. The principal are — inflammation of the heart and pericardium ; hypersemia and inflammation of the lungs, bronchi, and larynx; inflammation of the various serous membranes ; various nervous affections, such as chorea, me- ningitis, and mental derangement; erythema nodosum, and scarlatina ; albuminuria ; hy- perpyrexia; haemorrhages; and, lastly, various concomitant or intercurrent conditions. The relations of these complications to acute rheumatism are very various. The largest and by far the most important group, comprising cardiac inflammations, pneumonia, pleurisy, peri- tonitis, erythema nodosum, chorea, and menin- gitis, can only be described as having an intimate but obscure genetic relation to rheumatism. This relation is indicated in many ways, such as the frequency of their occurrence during an attack of acute rheumatism ; the comparative infre- quency of certain of them in any other connec- tion ; the manifest analogy that exists between the parts affected in some of them and the joints ; the direct increase of their frequency with the intensity of the general rheumatic symptoms, that is, of the cause of the disease ; the transient and migratory character which they may present, alternating as they sometimes do with each other and with the arthritis ; their occasional occur- rence before the joint-symptoms, or even with- out them, or in the person of a blood-relation of a rheumatic subject ; their amenability to anti- rheumatictreatment ; and, lastly, their occurrence in the course of acute rheumatism as a part only of a manifestly general disease. Other complications appear to be effects of rheumatism, such as albuminuria and mental disorder : and chorea is believed by some autho- rities to belong to this category rather than to the former. Scarlatina, dysentery, and profuse haemorrhages are perhaps related to it celiologi- cally. Lastly, such conditions as bronchitis, hyperpyrexia, and delirium tremens are to be considered as merely concomitant or intercurrent diseases. The chief of these complications must now be considered in detail, in the order of their rela- tive importance. 1. Cardiac complications. — These are by far the most frequent complications of rheuma- tism, being present in no fewer than fifty per cent, of all cases. The percentage of acute cardiac disease is, however, less than this — almost cer- tainly aljout one-third, the remaining cases being chronic, or chronic and acute cardiac disease com- bined. These numbers refer only to organic dis- ease of the heart, namely, endocarditis, pericar- ditis, myocarditis, and the effects of these, singly or in combination. But, besides inflammatory affections, there may occur functional disorders of the heart, characterised chiefly by palpitation, cardiac distress, and the presence of various ab- normal physical signs ; and, according to some observers, the latter class are of as frequent oc- currence as the former. The circumstances under which cardiac inflam- mation most frequently makes its appearance in acute rheumatism are — first, and specially, early age, rheumatic children rarely escaping disease of the heart, youths seldom, and the liability rapidly diminishing after the thirtieth year; secondly, severity of the rheumatic attack — with which the liability to cardiac complication in- creases in direct proportion ; thirdly, the female sex — women being more subject to rheumatic disease of the heart than men ; and, fourthly, neglect of proper treatment during and after the attack. The time of appearance of cardiac symptoms has been variously stated by different observers. As a matter of fact, they are generally discovered when the patient comes under observation ; they certainly begin most frequently in the first week of illness ; but they by no means uncommonly make their appearance in the second week, aud may occur at any period. Inflammation of the heart and pericardium are fully described under their appropriate headings (see Heart, Inflammation of ; and Pericardioi. Diseases of). The influence of the presence of cardiac complications on the course and pro- gnosis of an attack of acute rheumatism, is so im- portant as to alter the whole aspect of the case, and to prove the chief cause of anxiety. Affec- tions of the heart are by far the most common cause of death from rheumatism, immediate and RHEUMATISM, ACUTE. remote ; and even when they do not prove fatal, they constitute the most distressing of the remote affects of the disease. 2. Respiratory complications. — Diseases of the respiratory organs have been variously stated to occur in from one in every six to one in every sixteen cases of acute rheumatism ; and in the larger proportion of immediately fatal cases they are the direct cause of death. The most common is pleuro-pneumonia ; pleurisy alone the next ; then pneumonia ; and severe bronchitis, pul- monary congestion, and laryngitis are more rare. They may probably occur at any period of the rheumatic attack; but the most serious forms will necessarily appear towards the termination, for the obvious reason that they so frequently prove fatal. The supervention of acute respira- tory diseases is, as a rule, easily recognised by the appearance of their several symptoms and signs. 3. Hyperpyrexia. — This is one of the most alarming complications of acute rheumatism, but happily one of the most rare. The condition is fully described in another article (see Tem- perature). ^qoerpyrexia may occur at any period of the disease ; generally when the symp- toms are fully developed ; but even during con- valescence. The principal indications of the approach of hyperpyrexia, which it is of the last importance to recognise, are flushing of the face ; brightness and restlessness of the eyes ; an eager, excited expression and behaviour ; disap- pearance of pain and swelling from the joints, and arrest of the perspirations ; delirium ; and increase of the general symptoms of fever. On the occurrence of any of these symptoms in an otherwise uncomplicated case of acute rheuma- tism, the temperature should at once be taken, and the observation repeated every half-hour. If the body-heat, prove to be over 103°, and to be still rising, measures must be immediately adopted to prevent the hyperpyrexia, which is certainly threatening. 4. Nervous complications. — The reputed frequency of these complications has been greatly reduced since the discovery that the majority of the cases of so-called ‘ cerebral rheumatism ’ and ‘rheumatic meningitis’ aro really instances of hyperpyrexia. These cases being excluded, the frequency of cerebral disturbance, in uncom- plicated rheumatism, is not greater than in other pyrexial diseases. Cerebral embolism may occur from endocarditis ; meningitis is very rarely ob- served ; and a peculiar form of insanity has been described by German authors in connection with acute rheumatism. Delirium tremens occasion- ally supervenes when there is a history of alco- holism. Chorea bears a remarkable relation to acute rheumatism (see Chorea). Occasionally it appears during an attack; and choreic twit.ch- ings may thus be the prominent symptoms dur- ing the first days of the illness, especially in children. 5. Cutaneous complications. — In a small proportion of instances, acute rheumatism, or a condition which practically cannot be distin- guished from it, is associated with erythema nodosum ; sometimes the arthritic symptoms and sometimes the skin-affection being the first to appear, and the two conditions being further associated with some of the complications already 86 1361 mentioned. Urticaria is less frequently seen in the same connections. A remarkable condition, in which arthritic symptoms are associated with purpura, haemorrhages, vascular thromboses, and possibly ulcerative endocarditis, is known as peliosis rheumatica, or purpura rheumatica. See -Erythema ; Purpura ; and Urticaria. 6. Renal complications. — Albuminuria does not occur in more than ^ or 1 per cent, of all cases of acute rheumatism; and the so-called ‘rheumatic nephritis,’ has probably no real ex- istence. The frequency of albuminuria is not greater than can be accounted for by renal em- bolism, the probable existence of chronic cardiac and renal disease, the possible association oi scarlatina, and the presence of pyrexia. 7. Serous inflammations. — Peritonitis is a very rare complication, described chiefly bv French writers. Rheumatic ‘orchitis,’ or in- flammation of the tunica vaginalis, is occasionally met with. Rheumatic pleurisy and meningitis have been already referred to. 8. Gout. — When acute rheumatism attacks a subject of the gouty diathesis, its symptoms may bo considerably modified. The pain, swell- ing, and selection of particular joints have all a gouty character more or less ; and whilst the disease is more amenable to treatment directed against the gout, it has possibly a greater ten- dency to lapse into a chronic affection of the smaller joints. 9. Scarlatina. — Scarlatina may make its ap- pearance at any period during the course of acute rheumatism. The concurrence of the two dis- eases may occasionally be accidental ; possibly they mutually predispose to each other, by lowering the general health and increasing the liability to chill ; whilst some authorities hold that many of the ordinary complications of scar- latina, as well as the arthritis, are essentially rheu- matic, such as serous inflammations and nephri- tis. The occurrence of rheumatism as a com- plication of scarlatina is discussed elsewhere. See Scarlet Fever. Diagnosis.— Although acute rheumatism can generally be easily recognised, its diagnosis is sometimes a matter of the greatest difficulty. In the stage of invasion , it is most readily con- founded with the acute specific fevers, including influenza, and with catarrh, in which pyrexia and aching of the limbs are prominent symptoms. If sore-throat be comparatively well-marked, and the development of the joint-affection slow, the practitioner may be led to diagnose simple catarrh instead of rheumatism, and to make light of a complaint which is about to develop into a serious disease. In every doubtful case a cer- tain number of facts should be kept clearly in view, namely, the history of the attack; the pos- sible occurrence of previous attacks of rheuma- tism; the family history ; the absence of symp- toms characteristic of other diseases, such as eruptions or coryza ; the development of pain or tenderness in a definite joint, and acid sweats; and most important of all, the discovery of the signs of inflammation of the heart. In the second or declared stage, when one or more joints are involved, an entirely different group of diseases have to be diagnosed from rheumatism, namely, gout, ‘ rheumatic arthritis,' RHEUMATISM, ACUTE. 1362 gonorrhoeal rheumatism, pyaemia, glanders, and acute synovitis or arthritis of traumatic or dia- thetic origin. In doubtful cases the characteristic phenomena of rheumatism must be kept clearly in mind, especially the transient and erratic course of the arthritic symptoms, and the pro- bable presence of cardiac complications. Acute c/out may generally be diagnosed by the suddon invasion at night of a single joint — probably the great toe, in a man of middle or advanced age; by the severity of the pain, "which is relieved by the occurrence of a characteristic swelling of the part ; by the history of previous attacks of the same description ; and by the insignificant amount of constitutional disturbance attending the arthritis. The discovery of uric acid in the blood "will definitely settle the diag- nosis of gout. Pyemia is usually associated with an injury or pre-existing surgical disease ; and the fever has a markedly remittent character. Rigors are the rule, whilst they are the exception in rheuma- tism ; the sweats are distinctly intermittent ; the arthritis is neither transient nor migratory, but may advance to suppuration of the joints ; and the symptoms of blood-poisoning and extensive ani multiple visceral disease shortly supervene. Still it is a fact, which cannot be insisted upon too strongly, that cases of pysemia are frequently mistaken at first for acute rheumatism. Gonorrhoeal rheumatism may be recognised by being persistent, whether one or more joints be involved; by the typo and degree of the py- rexia ; by the absence of cardiac complications, as a rule; by the presence of conjunctivitis; and, most certainly of all, by the existence of a ure- thral discharge. Bheumatic arthritis may be distinguished by the characteristic deformity of the joints. For the diagnosis of glanders see Glanders. Ordinary synovitis is rarely multiple ; is per- sistent and not migratory; and has an appre- ciable cause, whether traumatic or diathetic. See Joints, Diseases of. The numerous difficulties which beset the diagnosis of sub-acute rheumatism, in children especially, have already been sufficiently dwelt upon. Prognosis. — In a disease which runs so un- certain a course, and which may bo complicated by such a variety of dangers, the prognosis is necessarily most uncertain. The proportion of fatal cases, and of cardiac complications, and the average duration of an attack, can easily be stated ; but in a given case there is at first no positive means of foretelling wdiat course the disease will run in any one of these respects. The prognosis must be specially guarded in per- sons worn out by mental or physical overwork or anxiety ; in young women of full flabby habit, with tendency to anaemia and disturbance of the uterus, stomach, and circulation ; and in women after delivery — all subjects in whom cardiac in- flammation and failure, and pulmonary complica- tions are to be apprehended. Ill-declared, ‘ weak’ symptoms, connected with the joints, indicating that the bodily strength and power of resistance are low, are less favourable than well-pronounced ‘ honest’ pains and a warm sweating skin, which generally point to a favourable termination as regards life. It must, however, be observed that the risk of complications in some degree increases with the severity of the local symptoms. The probability of cardiac complications de- cidedly declines after the first week, but the pos- sibility continues as long as fresh joints are being invaded. Rheumatism may be expected to run an exceedingly mild course in children, but the danger of cardiac complications is very great. In old subjects it may be safely assumed that the disease will end favourably. The superven- tion of pulmonary complications, especially in association with cardiac disease, or of hyper- pyrexia, should cause anxiety, as immediately threatening life. Remote danger from acute rheumatism is chiefly to be estimated by the occurrence of heart-disease, and by the nature of the same. Treatment. — The difficulties which beset an attempt to estimate the relative and absolute value of the different measures that have been proposed for the treatment of acute rheumatism, may be said to be at present insurmountable. Under the most favourable circumstances the number of carefully observed cases of any dis- ease, subjected to a particular treatment, must be very large, before a safe conclusion can be drawn respecting the result. The most favour- able circumstance for therapeutical observa- tions is manifestly uniformity of the course of the morbid process. This condition is as much as possible wanting in the problem before us. Rheumatism is a disease of indefinite duration, of infinite degree of severity, and beset with a number of complications. It is not always pos- sible to estimate the duration of the attack when the case first comes under observation. Lastly, many of the recorded cases have been treated by such complicated methods, that it is frequently quite impossible to eliminate the re- spective effects of the various drugs administered. In approaching the question of the therapeutics of acute rheumatism at the present time, these facte cannot be kept too clearly in view, for perhaps no disease has been alleged to have been success- fully treated by so many different remedies. 1. General treatment — When called upon to treat a case of acute rheumatism, the prac titioner must, in the first place, make certain special arrangements for the nursing of the patient. In addition to the ordinary measures proper in every case of an acute febrile disease which will probably prove of some duration, he must especially secure for the rheumatic patient perfect quiet, extreme gentleness of every ne- cessary movement, and the prevention or relief of the discomfort attendant on constant and profuse perspirations. Next to a good strong nurse, and perfect hygienic arrangements of the sick-room, a proper bed is of the utmost impor- tance in the general management of the case. The bed must be firm ; standing on a firm floor; sufficiently narrow; and placed in such a position as to be readily accessible from either side, and allow the attendants to reach any part of the limbs or trunk of the patient, without interfering with the position and comfort of the other parts. Further, the bed must be ‘made as a ‘ rheumatic bed ; ’ that is, a pair of blanket* must be placed between the sheets — the one RHEUMATISM, ACUTE. ever, the other under the patient, so as to absorb the profuse sweat, and diminish the risk of chill from dampness of the linen. The patient should be furnished with a long flannel bed-gown, made to fasten with tapes down the front and along the arms, so that the chest or any joint may be reached with the least possible disturbance. Arrangements must be made for collecting the urine and stools in bed ; and the use of a urinal and a bed-pan, or a properly arranged towel for these purposes, is impera- tive. These nursing arrangements being completed, the physician may turn his attention to the consideration of the therapeutics proper of the case. Two indications have to be fulfilled, namely, first, the relief of local symptoms which may be urgent; and, secondly, the reduction of the fever and the removal of the general distress. An effort must be made to secure these ends by separate measures, or by following some system that will effect both. The various measures at our disposal will now be considered, beginning with those which are at once the most simple, and the most urgently required. 2. Local palliative treatment. — Best . — The most ready and satisfactory measure of a local kindfor the relief of symptoms is the application of cotton-wool to the rheumatic joints. Cotton- wool is to be wrapped in some quantity around the parts, and secured by a moderately firm roller, or by a piece of warm flannel with the ends stitched together. The affected articulation is thus at once kept at rest and protected from cold and pressure ; whilst uniform support is obtained. The relief obtained by this simple arrangement is often remarkable. The joints should be carefully sponged with warm water and soap, or warm water slightly alkalinized by carbonate of soda, before this or any other application ; and the cotton-wool must be oc- casionally changed, especially if the perspira- tions be profuse. The principle of support and prevention of movement is more thoroughly carried out in a method of treatment which has found more favour with Continental than with English practitioners. This method consists in placing the joints in splints, as they become affected ; in bandaging them firmly ; or in encas- ing them in plaster of Paris. The results are said to be very satisfactory ; the pain being reduced to a minimum, the fever falling, and the course of the disease essentially shortened. Anodynes . — When the pain is severe, and relief is not to be obtained by simple rest and protec- tion, anodynes may be applied to the rheumatic joints. Opium in any of its ordinary forms, bella- donna and its allies, and other familiar anodynes, may severally answer best in particular instances. These substances may be applied on the surface of lint, secured and supported by a bandage; or the affected part may be lightly rubbed or smeared with the anodyne preparation in the form of liniment, and then wrapped in cotton- wool or flannel, as already described. Heat is generally grateful to acute rheumatic joints, but in many cases it is felt to be useless in the acute stage unless it be quite extreme. Thus simple warm fomentations may give relief ; but the patient may urgently demand their constant 1863 renewal, so that they may be almost scalding. There are obvious objections to such a plan of treatment. Extreme cold has been recommended by some authorities, notably Professors Esmarch and Hueter, in the form of ice. It is seldom used in this country. Blisters .— A favourite method of treatment with some physicians consists in the application of blisters to the rheumatic joints. The blisters, usually of cantharides, are intended to act less as counter-irritants than as ‘derivatives’ or ‘ eva- cuants.’ Dr. Herbert Davies, who introduced the blister-treatment in this country, contends that the rheumatic poison is especially abundant in the neighbourhood of the joints, and is actually separated with the blister-serum, and so re- moved from the body. In its original and com- plete form, the blister-treatment consists in applying a strip of cantharides plaster near every affected joint at the height of the inflam- matory stage. In some cases the amount of blistered surface may thus be enormous. The serum is encouraged to drain away, and the surface heals in due. course. It has been claimed for the blister-treatment that it relieves the pain, shortens the course of the disease, and lessens the tendency to cardiac complications. Of the first effect, there is probably little doubt; the other effects are questionable ; and statistics show that other methods of treatment are more efficacious in these respects. On the other hand, the danger of strangury, sloughing, and even pyaemia, and the substitution of another form of severe pain for that dispelled, must be mentioned as objections to its employment. Fcr these and other reasons, a modification of the blister-treatment has been proposed, probably at the sacrifice of the principle, namely, local blistering when a stimulant is demanded, in cases attended with much depression ; when the joint- symptoms are unusually severe ; when other less severe means have failed ; and when the condition threatens to become chronic. Leeches . — The local abstraction of blood by means of leeches, whilst it relieves pain, is very rarely called for, unless the arthritis be so severe and persistent as to threaten to lead to suppur- ation. Electricity . — It is said that, in some cases, marked relief follows galvanization of the rheu- matic joints. Indirect anodynes . — Certain lotions, of other than direct anodyne properties, have been re- commended as local applications, to produce a specific effect upon the rheumatic joints, and thus indirectly afford relief. The chief of these are alkaline solutions, especially solutions of the carbonates of potash and soda, sopped into flannel wrapped around the joints. They may be combined with preparations of opium. Their value is somewhat doubtful. 3. Medicinal treatment. — (a) Alkalies.— Before the introduction of salicylic acid the alkalies were in general use in the treatment of acute rheumatism. The alkaline method consists in the internal administration of sufficiently large doses of certain alkaline salts, such as the carbonates, citrates, tartrates, and acetates, to render the urine quickly alkaline ; m maintaining this reaction as long as the rheumatic symptoms RHEUMATISM, ACUTE. 1364 continue ; and in gradually allowing a neutral or an acid reaction to return by diminishing the dose as the disease declines. It is claimed for this method that as the alkalies begin to exhibit their action on the system, the whole aspect of the case becomes more favourable, the general dis- tress being alleviated, the temperature falling, and the local symptoms relieved ; that these favourable effects continue to become more and -nore marked, until the rheumatic condition has disappeared ; that the average duration of the attack is greatly shortened, not exceeding 6' 75 days in the acute stage, and 13'5 days before the disappearance of pain ; and that the propor- tion of complications is reduced as low as 2 per cent. only. In other words, it is asserted that in alkalies a direct antidote exists to the morbid influence (whatever that may be) which is the essence of rheumatism. The plan of administering alkalies varies con- siderably. Some practitioners give largo and frequently repeated doses, in order to obtain the speediest possible effect upon the system ; whilst others give a moderate amount, or otherwise modify the exhibition of the salts. Of the two plans the first is unhesitatingly to be preferred. To obtain the full effect of potash upon the system, not less than half a drachm of the bicar- bonate in an ounce of water should be prescribed at once, either alone or with citric acid in the effervescing form ; and the dose is to be repeated every four hours. An equal amount of the ace- tate of potash may be added to each dose, if a still more rapid and powerful action of the alka- lies be desired. The urine will probably become alkaline within twenty-four hours, and when once this effect has been obtained, it may very easily be kept up, by continuing the alkalies at longer intervals, which may be further increased as the symptoms decline. The effect of the drugs upon the patient must be carefully watched, and the amount and frequency of the dose varied accordingly, or its administration, if necessary, stopped. Finally, when the rheumatism is re- lieved, quinine may be added to the alkaline mixture ; and as convalescence advances, the potash may be entirely withdrawn. Constipa- tion occurring in the course of treatment may be relieved by combining the tartrate of potash and soda -with the bicarbonate instead of the acetate, tartaric acid being used to cause effervescence ; or if more obstinate, by a calomel and coloeynth pill. The alkaline influence upon the system maybe further increased, in a very agreeable way, by supplying the ordinary effervescing potash or soda-water as a drink, either alone, or combined with milk, or with fresh lemon-juice. The pa- tient may be encouraged to drink this in quan- tity, unless there be special indications to the contrary, such as cardiac distress. Should there be diarrhoea, lime-water may be substituted for the potash or soda-water. Should alkalies per- sistently cause purgation, their administration must be discontinued. The objections that have been raised to the alkaline treatment are chiefly two: first, that it is useless — an objection which is not supported by statistics ; and, secondly, that it is dangerous, an objection which only bears testimony to the power of the means employed, and suggests that the greatest care must be taken lest the exhibi- tion of alkalies should be overdone. ( b ) Modified alkaline treatment. — A modifica- tion of the preceding plan has been highly re- commended by Dr. Garrod, and consists in the administration of quinine from the very first, in combination with large doses of alkalies ; as much as five grains of the alkaloid (thus in the form of a carbonate) being given every four hours. (c) Symptomatic remedies.— The most obvious general remedies for the relief of symptoms are anodynes and apyretics. So much benefit follows the use of opium in some cases, by relieving pain and diminishing nervous irritability, that it has acquired a reputation even as a specific. Although formerly given in large and frequent doses, such as a grain every three or eight hours, either alone or combined with mercury, opium is now seldom employed in acuto rheumatism, except in the form of a moderate dose of Dover’s powder, or of a morphia draught at night, to relieve pain and induce sleep. For these purposes it is employed by most practitioners, including those who adopt what they call the purely expectant method of treatment. The effect of the opium must be care- fully watched, in the presence of the many com- plications which may possibly arise and contra- indicate its use. Apyretics. — The vigorous employment of apy- retie measures is unquestionably the method of treatment of acute rheumatism in greatest repute at present. It has been found that when the temperature is reduced by these means, the whole condition of the patient improves; the joint- symptoms decline; and the morbid process being apparently interrupted, the risk of cardiac com- plications is removed, at least for a time. Many apyretic remedies have been recommended, such as quinine, tartar emetic, veratrum viride, digi- talis, aconite, mercury, and various diaphoretics. The use of quinine has been already referred to. At the present time reliance is chiefly placed upon two powerful remedies of this class, namely, the cold bath or the wet pack, and salicylic acid. The cold bath is the most powerful and speedy method of reducing the temperature in acute rheumatism, but is seldom resorted to except in cases of hyperpyrexia. When this condition threatens, the cold bath or the wet pack is to be unhesitatingly employed, in the manner described elsewhere (see Temperature). If the symptoms be less urgent, cold sponging of the trunk may be sufficient to reduce the temperature. The use of salicylic acid, the salicylates, and salicin, introduced by Dr. Maclagan, constitutes the present routine treatment of acute rheuma- tism ; and the results obtained from it are cer- tainly more favourable than from any other method. Fifteen to 25 grains of salicvlate of soda, 20 grains of salicylic acid, or 15 grains of salicin, are given everyone, two, three, or four hours, until the temperature falls to the normal, after which the dose of the drug is reduced, so as to be simply sufficient to maintain the apyrexia for several days. The salicylates are best given in watery solution, variously flavoured; salicylic acid in milk, or combined with liquor ammonise acetatis; and salicin in wafers, or in solution. Different practitioners prefer the different form; RHEUMATISM, ACUTE. *f the active substance ; the salicylate of soda is probably most extensively used, being readily dissolved, whilst salicin is less liable to excite unpleasant symptoms. These are deafness and noises in the ears, delirium, cardiac depression, sickness, and collapse. Short of these effects, the salicylates reduce the temperature to the normal in the course of twenty-four to forty-eight hours, relieve the pain and other arthritic symp- toms, and markedly improve the condition of the patient generally ; the duration of the disease, and perhaps the risk of cardiac complications being thereby diminished. The average duration of acute symptoms under the salicylates is about three or four days. The principal drawback to the use of the sali- cylates is the fact that, whilst they cannot be continued for any length of time in sufficient loses to maintain apyrexia, without the risk of producing toxic symptoms, the rheumatism fre- quently returns as soon as their exhibition is stopped. Thus on the second or third day after the disease has been checked, the symptoms are jgain as severe as at first, and the risk of car- diac complications is again present. Whilst this objection is undoubtedly valid, it is still time that in a considerable proportion of eases no such relapse occurs, and that the patients are there- fore virtually relieved orcuredwithinforty-eight to sixty hours. If the salicylates fail or dis- agree, recourse must be had to alkaline treat- ment or to some other method. Certain practi- tioners combine the full alkaline method with the salicylates from the first; others prescribe the alkalies in diminished doses. Unfortunately Hntemia appears to be more marked, and con- valescence more slow, after treatment with sali- cylates. Hcrmatinic remedies may be considered to be xdicated by the great antenna which accompanies, Rnd yet more markedly follows, an attack of acute rheumatism. Dr. Russell Reynolds has recommended perchloride of iron in large doses ; end very favourable results have attended its administration, forty-three per cent, of all cases being convalescent in the first week. Alcoholic stimulants, in moderate doses, are indicated in a large proportion of cases of acute rheumatism, when the symptoms are severe and protracted. Resides this routine use of alcohol, a special virtue is claimed for its free adminis- tration, as in other fevers, by the school of Todd and his disciples, in preserving the strength and relieving the pain. Brandy may certainly he freely administered with advantage in eases attended with extreme depression, even to the amount of 24 ozs. per diem, especially in the event of car- diac failure. Tonics are indicated during convalescence; for example, quinine and iron, separately or com- bined either with alkalies or acids, and strych- nia. Tonics should not be commenced too early. ( d ) Empirical remedies. — Lemon-juice appears to havo proved successful in some eases, in doses of eight ounces or less in twenty-four hours. Since the course of acute rheumatism is now known to be indefinite, the number of carefully recorded cases treated by lemon-juice is insuffi- cient to permit a trustworthy inference to be drawn respecting its value. Similar doubts may 1366 be cast upon the alleged value of many other so-called remedies for the disease, such as pro- pylamine and trimethylamine , in 4- to 8-minim doses every two hours ; nitrate of potash to the amount of an ounce in the twenty-four hours; cynara or artichoke ; and the cyanides of potas- sium and zinc. Colchicum was formerly given extensively in acute rheumatism, but has fallen into disrepute since this disease has been sepa- rated from gout. It may, however, bo given with advantage for rheumatism in a gouty subject, to relieve pain. Guaiacum is useful in sub-acute lingering cases. Bromide of potassium has been found very useful in American practice, probably by relieving pain and restlessness. Calomel, in doses of 5 to 10 or even 20 grains, repeated for several nights, followed by saline purgatives in the morning, was highly recom- mended in some cases by the last generation of medical authorities, but cannot be said to be employed at the present day. The same remark applies to venesection. 4. Expectant treatment.- — Reference must here be made to the observations of Sir Wil- liam Gull and Dr. Sutton upon the course of acute rheumatism when treated by simple rest, and the exhibition of a placebo. The comfort of the patient is secured by ordinary means; and small doses of opium are given to complete this effect when indicated. The results have been remarkably favourable, but less so than those of several other methods of treatment, nine days being the average duration of acute symptoms, and the number of cardiac complications being very small. 5. Treatment of complications. — For an account of the treatment of the complications of acute rheumatism, the reader is referred to the respective articles on each of these in other parts of this work {sec Heart, Inflammation of; Lungs, Inflammation of; Pericardium, Diseases of; &c.) The plan of treatment which is being pursued for the rheumatism may have to bo temporarily suspended, or possibly completely changed, on the appearance of any of these complications. The treatment of hyperpyrexia is described in the article Hydrotherapeutics. The state of the bowels requires the most careful retention. Constipation must be relieved by any of the ordinary means ; and a purgative sometimes gives remarkable relief. Diarrhoea may be checked by lime-water or bismuth, or by a judicious dose of castor oil, according to its cause. The surface of the body must be regu- larly sponged with a very weak tepid solution of an alkaline carbonate. 6. Diet. — The proper diet in acute rheuma- tism is the same as that in most other kinds of fever. The patient must be fed at short and regular intervals, night and day, with the most digestible forms of nutritious food ; and may be encouraged to drink milk, or milk and soda- water occasionally. It, must not be forgotten, however, that in all probability the system is already overloaded with the products of imper- fect assimilation and transformation; that the digestive system is weak and irritable; and that the heart may be seriously affected by the ad- dition of much fluid or solid material to the blood. As the acute symptoms decline and appe- 1366 RHEUMATISM, ACUTE, tite returns, fish, milk-puddings, and shortly afterwards chicken, sweetbread, and other ‘light’ articles of diet may be allowed, and will be greatly relished. Meat must be strictly for- bidden until every rheumatic symptom has dis- appeared. Thirst is best relieved in the acute stage, as already stated, by aerated alkaline waters, either alone orin combination with lemon- juice or milk, the quantity given being regulated by the practitioner, and accurately recorded. 7. General after-treatment. — The general management of a case of rheumatism after the decline of the acute symptoms is scarcely less important than at the commencement of the at- tack. The patient should be encouraged to keep his bed for several days after the disappearance of the joint-symptoms ; and this advice becomes imperative when cardiac complications exist. Rest and comfort of body and mind must be se- cured at this period, for the purpose of quieting the action of the heart, and allowing the endo- carditic process which affects the valves, and which probably outlasts the articular process, quietly to subside. All attempts must therefore be avoided at completing the cure of acute rheu- matism within a certain small number of days. Even with these precautions the first day of sit- ting up generally proves an anxious time to the practitioner in cardiac cases. Locomotion must be forbidden for several days, and very gradu- ally permitted. When the patient is able to move about and go into the open air, the danger of a relapse during the first weeks must be care- fully kept in mind. Sudden and extreme changes of temperature are especially to be avoided ; and for this purpose the patient must be warmly clad, and studiously avoid draughts and expo- sure to cold in other forms. J. Mitchelu Bruce. RHEUMATISM, Chronic.— Synon. : Fr. Rhumatisme articulaire chronique ; Ger. Chron- ischer Rheumatismus. Definition. — A disease of the joints, of chronic course; referable to certain obscure influences ofa diathetic and climatic nature ; and characterised by various degrees of inflammatory and degener- ative changes in the articular structures. FEtiology. — The causes of chronic rheuma- tism, as far as they are known, are the same as those of the acute disease. The most powerful predisposing causes are inheritance, previous at- tacks of acute rheumatism, poverty, physical and mental depression, and laborious occupations en- tailing exposure to chills. For the last reason men are more liable to the disease than women. Chronic rheumatism is most common in middle life or advanced age, although by no means rare in young adults. Exacerbations of the symptoms are usually referable to exposure, and are accord- ingly most frequent or protracted in cold wet weather. Anatomical Characters and Pathology. — A variety of anatomical changes may be met with in chronic rheumatism, whilst iu the least severe form of the disease no definite changes in the articular structures can be discovered. In one Tarioty recurrent liyperaemia and effusion are found in connection with the synovial structures, and witli the articular and periarticular tissues RHEUMATISM, CHRONIC, generally. In the most severe cases the joiuta are enlarged and deformed, in consequence of anatomical changes which appear to bo identical with those of rheumatic arthritis. See Rheu- matic Arthritis. This disease is truly rheumatic in its nature, being intimately associated with acute rheuma- tism. In many of the best marked cases tha patient has previously suffered from the acuta disease, either immediately before or more re- motely; whilst in other instances one or more acute attacks occur in the course of the chronic disease. In yet another group of eases, a single member of a family will suffer from chronic rheumatism, ending in deformity, whilst his brothers and sisters arc, without exception, at- tacked with the acute disease. The predisposing and exciting causes are also identical in acute and chronic rheumatism. Indeed, in every par ticular the two forms of affection run into each other, and are inseparably associated. Symptoms. — The clinical characters of chronic rheumatism vary extremely in different instances. The leading symptoms of the disease are chiefly two, namely, pain and stiffness in connection with the joints and associated structures, recur- ring indefinitely for any length of time, aggra- vated by cold wet weather, and decidedly in- creased at night. More carefully investigated, the pains are found to have their seat in the joints, in the tissues of the limbs between the joints, or in both. Any or all of the articula- tions may be affected, but the site differs consi- derably’ in the different classes of the disease tc be presently described. The pain is of a severe, aching, wearying character, attended with a sense of heaviness and uselessness of the limb; it is relieved by rubbing, and by exposure to a cold atmosphere ; and is increased by slight warmth. Free use of the joint, although at first attended by much pain, often affords relief; whilst, on the other hand, severe exercise of the limbs during the day is liable to be followed by severe aching in the night. The affected joints also feel markedly dry and stiff, and creak on movement ; but exercise or rubbing may also remove these sensations. These symptoms may last indefinitely for years, either recurring at intervals, especially in the winter and spring seasons, or being persis- tent almost day aud night without intermission. Such are the essential characters of chrocicrheu- matism. Its other features are so variable as to permit of the formation of several well-defined classes or degrees of the disease, as follows : — 1 . First degree . — In this class of chronic rheu- matic cases the pain and stiffness just described are the only articular symptoms present Fo apparent anatomical change is produced, either iu the joints or in the associated parts. The subjects of this form of the disease may be other- wise well, vigorous, and long-lived, in spite of the severe pains by r which their rest is broken in cold wet weather. They may or may not bave, or have had, acute rheumatism. 2. Second degree . — In a more severe form ef chronic rheumatism, the pain is associated with obvious anatomical changes; and tho disease assumes the character of a recurrent subacute rheumatism, making its appearance at intervals RHEUMATISM, CHRONIC, for years. The articular phenomena consist of redness, tenderness, and swelling, the hands be- ing the favourite seat of the affection. These subacute attacks last for days ; and leave behind them a distinct amount of swelling, which may not have completely disappeared before the next invasion. The process may thus, in course of time, lead to considerable enlargement, or even deformity of the joints. 3. Third degree. — Chronic rheumatism of the most marked degree generally occurs in persons who either have had , or may afterwards h ave, acute rheumatism ; and is characterised by recurrent attacks of severe pain, tenderness, swelling, and hypersemia of one or more joints, which lead to marked enlargement and deformity. A single joint may be affected at first : but the disease gradually invades the others, both large and small, until the whole articular system is in- volved. After some years the subacute attacks follow so closely upon each other, and their local effects are so marked, that the patient is never free from distressing pain ; and the joints become anchylosed, dislocated, and otherwise disorgan- ised. At the same time the general nutrition is gradually impaired ; and the sufferer is anaemic, wasted, and debilitated. Chronic rheumatism of the most severe degree thus merges into, if it be not actually identical with, the class of disease known as ‘rheumatoid’ or ‘rheumatic’ arthritis. See Rheumatic Arthritis. It is necessary to understand that the division just made of the leading varieties of chronic rheumatism into three groups, according to its degree, has been employed for the sake of de- scription only. In a large number of instances the disease possesses certain characters both of the first and second degrees; whilst it is evident that cases belonging to the second degree may very readily advance into the third. Course and Terminations. — The disease, as its name implies, is essentially chronic, generally lasting throughout the life of the individual whom it attacks, and leading to various condi- tions of debility and deformity, according to the degree of its intensity. In many instances the patient is rendered unfit for work ; and such cases form a considerable proportion of the inmates of union infirmaries and other charitable institu- tions. Death as a direct result of the disease is rare. Complications. — Cardiac disease is met with in a considerable number of cases belonging to the third or most severe degree of chronic rheu- matism, being referable to endocarditis, which complicated the original acute attack. Dyspep- sia and calculous disorders are not unfrequently seen in the subjects of the less severe forms. Diagnosis. — If chronic rheumatism be re- garded as a distinct disease from ‘ chronic rheu- matic arthritis,’ it is only in its most severe form that it can be confounded with the lat- ter. A definite history of acute rheumatism ; the presence of cardiac disease ; and the non- involvement of such articulations as the jaw, the stemo-clavicular joint, and the spine, are consi- dered to be features which render probable the diagnosis of true chronic rheumatism from rheu- matic arthritis. But in the opinion of the writer, the two diseases are identical. RHEUMATISM, GONORRnCEAL. 1367 The pain, swelling, heaviness, weariness, and weakness associated with varix of the lower ex- tremities, sometimes resemble closely the symp- toms of the milder forms of chronic rheumatism. Physical examination at once removes all doubt. Prognosis.— T he prognosis of chronic rheu- matism is favourable as regards life, but very unfavourable as regards cure ; patients rarely losingtlie tendency to recurrenceof pain through- out the whole of their life. Within a short time of the commencement of the disease it will be easy to discover which of the principal forms it is likely to assume ; and the prognosis may be made accordingly. Treatment.— T he treatment of chronic rheu- matism consists in (1) the relief of pain ; and (2) the arrest of the rheumatic tendency, or the treatment of the disease proper. 1. Palliative treatment. — This chiefly consists in counter-irritation by iodine or cantharides ; the application of anodynes, such as preparations of opium, belladonna, and chloroform; or friction with various stimulating liniments, containing camphor, soap, turpentine, or acetic acid. Regu- lar warm fomentations night and morning, with very warm or even hot water, followed by rub- bing and the application of a stimulating lini- meut under warm rollers, is one of the most efficacious methods of local treatment, the pains being prevented or relieved, and the stiffness re- moved often to a remarkable degree. Altogether, whatever view may be taken of the pathology of the disease, thorough local treatment of the joints and limbs will generally be attended with decided relief. 2. General treatment. — The most successful treatment of the condition of system with which chronic rheumatism is associated, is removal of the patient from the variable weather of England, to the warm and settled climate of sub-tropical or tropical countries. In the case of the poor this is, of course, impossible ; and in them we have recourse to warmth of clothing and housing, as far as they can be secured, relief from mus- cular exertion, and the most nutritious and heat- producing diet that can be supplied, especially oils. To secure these necessary comforts, the chronic rheumatic poor have frequently to be admitted permanently into charitable institu- tions. Iron and cod-liver oil are the drugs best suited to support the general health. Courses of the mineral waters of Bath, Buxton, and Strath- peffer, in this country ; and of many foreign baths, such as Aix-les-Bains, Aix-la-Chapelle, Wies- baden, Baden-Baden, and Hamman R’lrha, prove invaluable in many cases to those who can afford to try them. The ordinary Turkish bath may also afford temporary relief, if properly employed. See Rheumatic Arthritis. J. Mitchell Bruce. KHEUMATISM, Gonorrhoeal. — Synon. : Fr. Arthrite blennorrhagique ; Ger. Tripperrheu matismus. Definition. — A form of inflammation of the joints and associated structures, the essential nature of which is unknown, occurring in the subjects of inflammatory discharge from the genito-urinary mucous membranes. .Etiology. — This disease, as its name implies J 368 RHEUMATISM, s generally referable to the presence of gonor- rhoea. It may originate, however, in any kind of inflammatory discharge connected with the urethra, such as gouty or traumatic urethritis or gleet. It is much more common in men than in women, apparently on account of the comparative immunity from gonorrhoea of the female urethra; but, on the other hand, an affection of the joints which strongly resembles it, is found in connec- tion with chronic uterine disease, or in the puer- peral state. Either a rheumatic or a gouty his- tory is frequently to be traced in the patient. Previous attacks powerfully predispose to the return of the disease on the recurrence of ure- thritis, even in a mild form. Amongst exciting causes the most important appear to be injury of a joint, such as sprain; and chill during the course of gonorrhoea. Persons who have suffered from the disease are frequently found to be, and to have been, peculiarly susceptible of urethral inflammation ; excessive sexual intercourse being regularly fol- lowed by discharge in such individuals. Anatomical Characters. — In recent cases of this disease the structures connected with one or more of the articulations are acutely inflamed. The cavity contains a variable amount of serous effusion, according to its form and size; the knee, for example, being considerably distended, whilst the digital joints are more moderately enlarged. The various component parts are hyperaemie and swollen ; and the peri-articular structures full or even cedematous. In more advanced cases the joints are found to contain either sero-purulent or purulent materials ; the cartilages may be eroded ; and finally the articulations may become completely disorganised or anchylosed. The cardiac structures are not affected. The eye may present the ordinary appearances of catarrhal conjunctivitis. Symptoms. — The disease, as ordinarily ob- served, commences at any period in the course of gonorrhoea — very frequently within a week of its appearance, but possibly not until it has de- generated into a slight gleet, or apparently dis- appeared. The patient is probably first aware of pain in the loins, or of swelling and pain in the soles of the feet, and very shortly these symp- toms involve the ankles. In other instances the knees or wrist-joints suddenly become painful, tender, and swollen — possibly after strain or exertion. At the same time the patient is fever- ish, suffering from malaise and anorexia; the tongue becomes foul; and the pain, helplessness, gonorrhoea, and general illness give rise to rest- lessness and depression. Along with, perhaps even before, the articular symptoms, conjunctivitis sets in, affecting one or both eyes, and although of a well-marked catarrhal kind, usually passes off in a few days with little or no treatment. The physical signs connected with the joints are generally well-marked, the parts being hy- peraemie and much swollen, both from intra- artuular effusion and from exudation around. The amount of oedema of the dorsum of the hand or foot when the neighbouring joints are iu- rolved by gonorrhoeal rheumatism, and of the sopor part of the subcutaneous surface of the tibia when tho knee-joint is affected, is often re- markable. The severity of the pain varies much. GONORRHOEAL. At times it is great, preventing sleep, especially as it is usually aggravated at night; in other instances it is extremely slight, and the con- dition is then more chronic in character. The pain is ‘gnawiDg’ or ‘aching;’ according to some patients, it is more severe before the swell- ing appears, according to others it is aggravated by the swelling. An important feature of the pains in gonorrhoeal rheumatism is that in some cases they are not limited to the joints, but involve the fibrous structures, especially ‘he loins, the plantar and palmar fasciae, the tendo Achillis, and the sheaths of nerves, such as the great sciatic. The muscles, or their aponeuroses, also appear to suffer; the fleshy parts of the arm, forearm, and thigh being occasionally complained of. Frequently indeed the patient declares that the pains are universal. Stiffness is also felt, particularly w£en a joint or limb lias been kept long in one position. Tenderness varies much, like the other phenomena, being exquisite in some instances, and entirely absent in others. Portions of the tendon-sheaths may be found swollen and tender. The heart and pericardium are very rarely, if ever, involved. Such is the usual appearance presented by a case of gonorrhoeal rheumatism within the first week of its appearance. Under favourable cir- cumstances the symptoms may decline; but in the majority of instances one joint after another is invaded by the morbid process, whilst those already attacked either slowly recover or con- tinue affected, the disease being thus protracted for several weeks or even months. Cases are met with in which all the joints of one or more limbs are simultaneously affected with gonor- rhoeal rheumatism, and have been so affected for ten or sixteen weeks ; certain of the articulations being but recently invaded, whilst others are slowh’ recovering from the attack with which the disease commenced. In this manner every joint in the body may be invaded, including the jaw, the sterno-elavicular articulations, and the spinal column. The class of case just described constitutes the most severe form of gonorrhoeal rheumatism. Happily, in most instances the disease is much milder, only one or two joints being affected, and the process either ending with a sharp pain- ful hurst of acute synovitis, or, on the contrary, lapsing into a state of chronic intra-articular effusion, with neither tenderness nor pain. When the disease is protracted, either in one or in many joints, the constitutional symptoms lose their acute character. There is little or no py- rexia; the appetite is fair; and the patient may even go about his work. But the health is gra- dually impaired, the patient being debilitated and depressed ; in the most severe cases he may be completely crippled, and reduced to a condition of great helplessness and wretchedness. Pathology. — Opinion is greatly divided upon the essential nature of gonorrhoeal rheumatism Three leading views may be mentioned. It is believed by some pathologists that ‘ gonorrhoeal rheumatism’ is nothing more than acute or sub- acute rheumatism, associated with gonorrhoea or other similar discharge. Other authorities recognise in the disease a mild form of pyaemia, RHEUMATISM, GON ORRHCEAL. the source of infection being usually the urethra. The third view is perhaps not inconsistent with either of the other two. It represents gonorrhceal rheumatism as a trophic or nutritive disorder, due to reflex disturbance ; the urethral inflam- mation affecting primarily certain centres in the spinal cord and brain, and the altered con- dition of these giving rise to the articular changes. According to both the pyaemic and the trophic or reflex theory of gonorrhceal rheumatism, the joint-affection may originate in a purulent dis- charge from any mucous surface, the urethra in- cluded. Thus j oint-disease has occasionally been observed in association with chronic uterine dis- charges, dysentery, and chronic bronchitis. It is beside the purpose of the present article to enter iuto a discussion of these theories. Cocese, Duration, and Tekhinations. — The variable course of gonorrhceal rheumatism has been already sufficiently indicated. The duration of the disease is quite indefinite, vary- ing from a few days to many months. The most unfavourable termination of the disease is anchy- losis of the joints, with hopeless crippling ; but this is rare. It never proves fatal directly. Diagnosis. — The diagnosis of this disease turns upon the existence of an urethral discharge, in association with articular inflammation. The occurrence of the latter in young male subjects should always rouse the suspicions of the prac- titioner as to the presence of gonorrhoea ; and he ought at once to ascertain, by careful inspection, the state of the urethra, never accepting, the patient’s statement on the subject. In some instances the history of a recent gonorrhcea may alone remain. The previous occurrence of one or more similar attacks in connection with gonor- rhcea will confirm the diagnosis. Ophthalmia in association with subacute articular symptoms ought immediately to suggest the presence of gonorrhceal rheumatism. Pbognosis. — The prognosis is generally fa- vourable. In young, healthy subjects, under care- ful treatment, the disease will probably shortly subside ; whilst it will prove protracted and ob- stinate under the opposite circumstances. Gonor- rhceal rheumatism increases in severity, and the prognosis is correspondingly more unfavourable, in subsequent attacks. Another point which should be seriously impressed upon the patient, by way of tvarning, is that the risk of the recur- rence of arthritis also increases with each expo- sure to gonorrhceal infection. Treatment. — The treatment of gonorrhceal rheumatism is still unsatisfactory. Whilst some practitioners endeavour to check the urethral in- flammation as speedily as possible, others strive to encourage the discharge. The former plan appears to be the more rational and the more successful ; and the treatment of the gonorrhoea should therefore be persevered with. The atten- tion of the practitioner will, however, be directed chiefly to the joints. If the local symptoms be severe, absolute rest is necessary, the patient being confined to bed, and the affected limb pro- tected by a splint in such a way that applications tan be made to the joints. Anodynes may be called for at first, such as poultices, fomentations — simple or opiated or a li nim ent, composed of RHEUMATISM, MUSCULAR. 1369 equal parts of extract of belladonna and glycerine. In other instances leeches may be tried; and blistering in others, where there is either great pain, unrelieved by anodynes, or persistent effu- sion. In subacute cases with little pain or gene- ral disturbance, strapping may be sufficient; and in a more chronic form of the disease friction of the joint and moderate exercise may effect a cure, for example, of the knee by walking. Internal treatment must be pursued simul- taneously. In acute cases free purgation should be obtained at first, and this should be followed by a course of alkaline salines, either alone or in combination with quinine. If the disease per- sist, iodide of potassium should be given, com- bined with alkalies or with iron, according to circumstances. In other cases mercurials effect a cure, especially if there be a syphilitic taint, which is not uncommonly the case. The diet must be carefully regulated in the different stages. In very chronic cases of gonorrhceal rheumatism, with threatening anchylosis, the patient should be sent if possible, to a warm watering-place, and be subjected to a thorough course of treatment both externally and inter- nally See Rheumatic Arthritis. J. Mm hell Bruce. RHEUMATISM, Muscular. — 3ynon. : Fr. Bhumatisme musculaire ; Ger. Muskelrheuma- tismus. Definition. — A disorder connected with fibro- museular structures; generally associated with the rheumatic diathesis ; and characterised by local pain and spasm, and a certain degree of fever. ^Etiology. — Muscular rheumatism is most frequently observed in the subjects of the rheu- matic diathesis. It occurs in both sexes, and at all ages ; children and adults being specially liable to rheumatic torticollis, and older subjects to lumbago and chronic muscular rheumatism of the limbs. The exciting causes are chiefly two ; first, exposuro to cold — above all, exposure of a muscular part to a ‘draught’ after exertion; and secondly, sprain or strain of the fibro- muscular structures. Muscular pain, tenderness, and spasms are also common in the invasion of acute rheumatism, and in gonorrhceal and chronic articular rheumatism. Anatomical Characters. — Mothing is known respecting the anatomical characters of muscular rheumatism, if, indeed, there be any discoverable change in the muscular or fibrous structures. Symptoms. — The disorder usually commences with slight febrile disturbance, possibly accom- panied by sore-throat. Either simultaneously, or in children after one or two days, pain is experienced in the region of some definite muscle or muscular mass, such as the sterno-inastoid or the muscles of the loins; and this speedily be- comes so severe as to constitute the leading symptom of the attack. The pain is present only when the affected muscle is thrown into action, so that it may be perfectly relieved by relaxation or rest of the parts involved. The slightest movement, however, from the position of relief is instantly attended with excruciating pain, of a peculiar spasmodic character, which persists until relaxation is again secured. Th« 1370 RHEUMATISM, constant effort to avoid pain gives rise to a feeling and appearance of stiffness, causing the patient to assume characteristic attitudes of the head, trunk, or limbs. Tenderness on grasping the muscle is occasionally well-marked. In some cases several of the joints may be affected with pain and stiffness. The constitutional symptoms of muscular rheumatism are generally those of mild pyrexia. The tongue is furred ; the appetite is impaired ; the bowels are confined; the pulse is somewhat frequent, full, and soft; and there is a feeling of malaise. In other instances these symptoms are extremely slight or altogether wanting, the patient suffering from nothing more than local pain. Occasionally there is catarrhal ophthal- mia. Muscular rheumatism usually persists for several days, and gradually declines, but in the milder cases it may last for weeks. One form of the disorder is essentially chronic, the patient suffering for years from pain in various fibro- muscular structures, especially those of the shoulder, arm, thigh, and leg, during cold, wet weather. Varieties. — The following local varieties of muscular rheumatism are recognised by special names : — 1. Muscular torticollis.— Synon. : Acute Wry-neck; ‘Stiff-neck’; Caput obstipum.— Here the sterno-mastoid muscle is chiefly involved, but any or all of the cervical muscles may be pain- ful. This form is most frequently observed in young subjects, and is often markedly recurrent. It is easily recognised by the fixed position of the head ; and has to be diagnosed from spas- modic torticollis, sterno-mastoid tumour, sprain, and spinal disease. 2. Pleurodynia. — The ftbro-muscular struc- tures of the chest- wall are the seat of rheuma- tism in this variety. Cough is a common excit- ing cause of the complaint, which is seen chiefly in adults. Pain is complained of in the chest- wall, usually on one side ; and in some instances it may be excruciating, and of a distressing spas- modic character. On examination it is found that a particular intercostal space, or the origin of the pectoral or serratus muscles, is the seat of localised tenderness ; and that every respira- tory act causes lancinating pain in the same situation. The respiratory movements of the affected side are restrained; but the ordinary physical signs of pleural, pulmonary, and cardiac disease are absent, as are also the points dou- loureux, which characterise intercostal neuralgia. If the movements of the corresponding ribs be restrained by plaster or bandage, the pain is effectually controlled. The direct constitutional disturbance is generally not great, unless sleep be prevented by pain. 3. Lumbago. — The muscular and fibrous structures of the loins aro here the seat of pain, most commonly the erector spinse, less commonly the latissimus dorsi, or other smaller muscles in the same situation, on one or both sides. As the muscles of the back support the body in the erect position, and participate in the various move- ments of bending the trunk in all directions, the patient may be compelled to remain at absolute rest in bed. More frequently he is able to go MUSCULAR. about, although with pain, or in a stooping atti- tude. The amount of febrile disturbance is gene- rally moderate. Lumbago is easily recognised by the character- istic muscular pain referred to the loins, greatly increased by bending, straightening the back, or by turning in bed; and by tenderness of the muscles on pinching, without acute defined ten- derness on pressure, as in abscess or neuralgia. At the same time it cannot be insisted upon too strongly, that careful examination of the back, of the abdomen generally', and of the urine, will alone prevent the practitioner from falling into the not uncommon error of treating cases of serious disease for simple lumbago. Renal cal- culus, lumbar abscess connected with spinal caries, perinephritis, perityphlitis, abdominal aneurism, disease of the rectum, uterus, or blad- der, and spinal meningitis, are the principal morbid conditions which must be borne in mind and excluded in every instance, before the dia- gnosis is settled. Pain in the loins is also a very common accompaniment of affections of the but- tock and lower limbs, such as sciatica, rheumatic affections of the hip-joint, and perhaps lameness from any cause. It is also very' frequently met with in gonorrhoeal rheumatism. 4. Cephalodynia. — Muscular rheumatism may affect the scalp, giving rise to a dull, aching kind of headache, on the brow or occiput, aggra- vated by movement, and occasionally compli- cated with tenderness of the eyeballs and oph- thalmia. 5. Dorsodynia. — Synon. : Omodynia; Scapu- lodynia. — These names are given to rheumatism involving the structures of the upper part of the back and shoulders. It occurs chiefly in persons much exposed to the weather ; and has to be diag- nosed chiefly from rheumatism of the shoulder- joint, and certain less common forms of neuralgia connected with the upper dorsal nerves and arms. 6. Abdominal rheumatism.— Muscular rheu- matism of the abdominal walls is occasionally observed, either alone or in association with lumbago. Diagnosis. — Speaking generally, muscular rheumatism has chiefly' to be diagnosed from neu- ralgia, and, as a rule, this can easily be done by the paroxysmal character of the latter, the tetio- logical relations, and especially the physical signs. The practical diagnosis of the chief local varieties has already been sufficiently indicated. Prognosis. — The prognosis of muscular rheu- matism is highly favourable. Under careful treatment recovery may be anticipated in a few days or weeks. But the disorder is one which is peculiarly liable to recur on exposure to its exciting causes. Treatment. — The treatment of muscular rheu- matism consists in remedying the constitutional condition ; and in relieving the local pain. _ At the very commencement of the illness, a hot air or Turkish bath may answer both these indications, and give immediate relief. The first indication will, however, be generally best fulfilled by free purgation, followed by alkaline salines, such as the bicarbonate, citrate, or acetate of potash, and acetate of ammonia. Iu more feeble subject! quinine may be given in combination with alka- RHEUMATISM, MUSCULAR. lies ; and iodide of potassium in protracted cases. The diet should be of the simplest tharacter. The best local treatment consists of absolute rest of the affected parts, which may be va- riously secured in different instances by confine- ment to bed, by strapping, or by plasters. Counter-irritants or anodynes, applied locally, give great relief, and for this purpose either a hypodermic injection of morphia, mustard poul- tices, cupping, warm opiate fomentations, or various liniments composed of extract of bella- donna and glycerine, opium, aconite, or chloroform and camphor, or of various combinations of these, may be ordered. Belladonna plaster gives at once relief and support in mild cases. The con- tinuous galvanic current occasionally dispels the pain and stiffness almost immediately. The affected muscles must be kept warm and care- fully protected from cold, especially in torti- collis. When rheumatism involves the muscles of the limbs, warm anodyne liniments are the best local application. Great care should be exercised to prevent the recurrence of muscular rheumatism, by wearing warm woollen clothing ; by avoiding exposure to damp and draughts; by attending to the diges- tion and the bowels; and by abstaining from severe, sudden, and awkward muscular efforts. In chronic or recurrent cases of the disorder, the patient should, if possible, visit some cf the English or foreign baths indicated in the article on Rheumatic Arthritis. J. Mitchell Beuce. RHINOSCOPY (^lv, the nose, and , I examine). — Synon. : Er. and Ger. Bhinoscopie. The practitioner is often called upon to explore the nasal cavities, either with the fingers or with instruments. In proceeding to seo the interior of the fossae, it must be borne in mind that the apertures of the nostrils descend lower than their bony floor ; therefore, after having thrown back the patient’s head, the nose should be elevated, and the nostrils dilated by means of dressing forceps. Owing to the narrowness of the fossae digital examination is difficult, but a knowledge of their anatomy will facilitate the introduction of instruments; and the finger can be passed through the mouth and behind the velum pendulum palati, to explore the margins of the posterior nares, and the naso-pharyngeal cavity. Rhinoscopy, or the optical examination of the cnoanie, may be either anterior or posterior. An- terior rhinoscopy is simply and easily conducted by means of a speculum, either in the form of a small aural speculum; or, better still, by Thudichum s nasal dilator ; and it will be found that reflected light, in most instances, answers better than direct sunlight. Posterior rhinoscopy must be employed to obtain a view of the deeper portions of the structures, and of the posterior aspect of the nares. Instruments and Method. — The instruments used, and the method of examination, are the same as that in laryngoscopy (see Laryngoscope, The), excepting that the mouth-mirror is directed for- wards and upwards, and placed beneath or be- hind the velum pendulum palati. By this means, EIBS, DISEASES OF. 1371 not only the nasal passages are brought under observation, but the structures in immediate re- lation with them. On proceeding to make a rhinoscopic examina- tion, the patient should be directed to breathe through the nostrils while the mouth is open, so that the velum may be flaccid, and the introduc- tion of the mirror facilitated. Some patients are unable to sustain this means of respiration, and in such cases, by causing the emission of nasal sounds, such as the French en, the velum is forced forwards and the palate drops. The velum may be pulled forward by means of forceps, but this operation is liable to cause spasmodic action of the palatal muscles, and it may take a long time before the parts become accustomed to the pro- ceeding. It is almost always necessary to use a tongue depressor, as more room is obtained, both for observation and manipulation. The best form of hand mirror is the ordinary larvngoseopic one, with the glass set at an oblique, and not a right angle to the handle ; and in using it, and looking at the reflection of the various structures at the back of the nares or vault of the pharynx, it must be remembered that only a perspective view can bo obtained, owing to the position of the parts. The structures which come under observation by the use of the rhinoscopic mirror are — the posterior surface of the soft palate and uvula, the posterior and part of the lateral portions of the septum of the nose, the turbinated bones, the nasal meatuses, the pharyngeal walls of the Eustachian tube and its orifice, the vault or roof of the pharynx, the lateral walls of the pharynx, and the upper portion of the posterior wall of the pharynx. The morbid conditions, for the inspection and treatment of which it may be requisite to uso the rhinoscope, are described in the articles Nose, Diseases of; and Phaeynx, Diseases of. Edward Bellamy. RHONCHAL FREMITUS. — A physical sign, appreciated by palpation of the chest, elicited by the act of breathing when certain secretions or other materials are present in the larger air-tubes or in a cavity. See Physical Examination. RHONCHUS (pe'yx“, I snore). — Ehonchi are sounds heard on auscultation when the air- channels are partially obstructed. The term is restricted by some authors to the so-called dry and more or less musical sounds produced in the bronchial tubes, for instance, sonorous and sibilant rhonehus ; the bubbling and crepitating sounds in chest-disease being spoken of as rales. By other authorities, again, all such sounds, whether sibilant or crackling, are described either as rhonchi or as rales , the terms being interchangeable. See Physical Examination. E. Douglas Powell. RHYTHM d>v8/j.bs, a measured movement). Tho relative proportion between the several parts of certain actions. In medical science it is generally applied to the movements of respira- tion, and to the action of the heart. See Physical Examination. RIBS, Diseases of. — See Chest-walls, ilis> eases of. RICKETS. 1372 RICKETS (A.-Saxon, ricg, the back). — Synon. : Rachitis; Er. Rkachitismc ; Ger . Eha- ckitis ; Englische Krankheit. Definition. — A general disease affecting the nutrition of the whole body ; arresting natural growth and development; perverting and delay- ing ossification ; retarding dentition ; causing the bones to become soft, and to yield to pressure, and the muscles and ligaments to waste ; and in many cases producing alteration of the brain, liver, spleen, and lymphatic glands. JEtioeogy. — R ickets is the consequence of slow impairment of nutrition, and the causes which produce it are principally : — bad feeding, foul air, damp cold rooms, want of sunlight, want of exerciso, and want of cleanliness. Of these, per- haps the first two have the greatest influence in causing the disease; for if the quantity of nu- tritive material introduced into the system be restricted by an improper selection of food, and if the oxidation of waste matters be hindered by an insufficient supply of fresh air, interference with nutrition is necessarily carried to a high degree. A pure bracing air will by itself do much in counteracting the effects of an improper dietary, for it has been noticed that injudicious feeding is less hurtful in country places where the air is dry than in large towns. This, how- ever, may be partly explained by the greater vigour of the digestive organs in the former case, enabling the child to derive nourishment from food which, under other conditions, would be innutritious. Some children are affected more readily and more severely by these causes than are others, for the more the strength of the child is reduced before the actual exciting causes of the disease come into play, the more quickly does the patient fall a victim to their effects. Therefore, all influences which impair the general strength, such as weakness in the parents, or, in the case of the child himself, an attack of acute disease, or even unusually troublesome dentition, must be looked upon as predisposing causes of the disorder. There is no proof that rickets is here- ditary. A tubercular family predisposition ren- ders the occurrence of rickets unlikely. Recently a distinguished foreign physician has attempted, by arguments drawn chiefly from morbid ana- tomy, to prove rickets to be invariably a conse- quence of inherited syphilis. But the reasons for rejecting this hypothesis are overwhelming. Anatomicai, Characters. — • The bones are affected in three ways : — growth is retarded ; the spread of ossification into parts still cartilaginous is interfered with ; and bone already ossified is softened. The growth of bone is not sompletely arrested ; it rather becomes irregular. There is considerable development of the cartilaginous epiphyses, and also of the fibrous periosteum ; but these parts ossify incompletely and slowly ; and as the normal increase in size of the medullary cavity continues in the usual way, the bone comes gradually' to consist less and less of osseous sub- stance, and more and more of, as yet, unossified matter proliferated at the circumference. It is in this way that the bones become soft, and not from any abnormal absorption of earthy' salts from bone already ossified. The process of cal- cification itself, besides being retarded, is ab- normal ; it has indeed been described as rather a process of petrifaction than of true ossification, On account of the softness of the long bones,' serious deformities ensue, as will be afterwards described. The flat bones become greatly thick- ened from proliferation of the periosteum. This is especially noticeable at the edges of the cranial bones ; and when ossification is completed, the sutures of the skull can be felt to be prominent In parts, however, and especially in the occipital bone, the osseous substance becomes thinned in places from absorption under the pressure of the growing brain. This condition, which is called ‘ craniotabes,’ can be detected by palpation. Cal- cification is very slow in the cranial bones, and the fontanelle often remains open long after the end of the second year. _ The liver, spleen, lymphatic glands, and kidneys are sometimes enlarged. The increase i n size is due, not to the presence of any foreign growth or deposit in these organs, but to irregular hypertrophy of their fibroid and epithelial ele- ments, conjoined with a deficiency in earthy salts - — an alteration analogous to the changes in the bones. The brain is enlarged from an increase of the neuroglia, not of the nerve-elements. The voluntary muscles are small, pale, flabby, and soft. Under the microscope their stria; are seen to be indistinct. The urine contains less urea and uric acid than natural, but more phosphates, especially phosphate of lime. Symptoms. — In most cases the symptoms proper to rickets are preceded by others which indicate a certain amount of interference with the diges- tive functions. There is occasional vomiting; the bowels are often relaxed ; and the motions are habitually loose, pasty-looking, and offen- sive. The beginning of the disease is marked by profuse sweating of the head, face, and neck; this is especially seen if the child fall asleep either at night or in the day. Almost at the same time he begins to throw off the bed-clothes at night. He will do this even in winter, and may be seen lying almost naked in the coldest weather. Later on, it is noticed that the child dislikes to be touched, and cries when danced about. He seems to be generally tender, and to dread movement of any kind. The occurrence of tenderness marks the commencement of the characteristic changes in the bones. The ends of the long bones enlarge ; the flat bones become thickened ; and all the bones lose their firmness and grow softer. These changes affect the osseous system as a whole, and lead to serious deformi- ties. If the child had been able to walk, he becomes unsteady on his legs, or even loses the power of walking altogether. He sits or lies about ; is drowsy in the daytime ; and at night moves his head restlessly from side to side, so as in many cases to wear the hair off the occiput. The flesh is soft and flabby ; the motions remain loose and offensive; and the child appears to be occasionally troubled with abdominal discomfort, for he may be found asleep in his cot. resting upon his hands and knees with his head buried in the pillow. The softness of the bones causes them to yield readily to pressure, and it is to this cause, and not to the force of muscular action, as was at one time supposed, that the deformities BICKETS. chiefly due. The long hones become bent and twisted. The direction of the bending depends upon the direction in -which the force of pressure is applied, and in the lower limbs will therefore vary according as to whether the child can ir cannot walk. Sometimes, however, if the disease begins before the child is able to support himself upon his feet, the lower limbs may escape de- formity altogether. They are usually in such cases particularly small and thin, with weak, flabby muscles, but the bones themselves are straight. Force of gravity is another cause of deformity of bone. Thus, in the humerus there is often a curve where the deltoid is inserted: this is produced in great measure by the weight of the hand and forearm when the limb is raised by the deltoid muscle. .The skull is elongated from before backwards ; the fontanelle is wide ; the sutures are thickened ; the forehead is high, square, and sometimes prominent ; and the head generally looks large. The face, on the contrary, appears small out of proportion to the head, for the growth of the facial bones is arrested. By palpation of tho occiput the condition named ‘ craniotabes ’ can sometimes be detected. It is an early symptom. Dentition is much delayed, and the teeth when cut are deficient in dental enamel, so that they decay rapidly. The spine is curved on account of muscular and ligamentous weakness ; and if this weakness he great, the natural posterior curve of the spine is so much exaggerated as almost to simulate angular curvature. It disappears, however, at once when the child is lifted up by the shoulders. Sometimes the spine is curved laterally. The deformity of the chest has the following characters : — The softened ribs sink in so as to present a groove passing downwards and out- wards on each side of the sternum. The bottom of the groove is formed more by the ribs than the cartilages, so that the enlarged ends of the ribs, looking like a row of beads under the skin, can be seen lying along the outer side of the groove. The sternum is forced forwards by this bending of the ribs, and the antero-posterior diameter of the chest is increased. The defor- mity is due to the pressure of the external air. In healthy breathing this pressure is overcome by the resistance of the thoracic walls, aided by the force of the inspired air. In the rickety child the resistance offered by the softened ribs is greatly reduced, and they therefore sink in at the parts where they are least supported. On ac- , count of the softened state of his ribs, the breath- ing of a rickety child is quick and laborious. The pelvis is pressed upon from above by the spine and the abdominal contents, from below by the heads of the thigh-bones ; and the direc- tion of these forces varies according to the posi- tion of the child. The general shape thus pro- duced Is triangular, and the pelvic cavity is often greatly narrowed. A rickety child is short for his age ; for his limbs, besides being bent, are stunted, growth in them being more or less arrested. His joints are largo, and loose from relaxation of the liga- ments. If the disease be severe, the child gets anaemic and wastes, and tho muscles become very flabby and small. His belly is big, even 13 ? 3 when there is no splenic enlargement, from shallowness of pelvis and flatulent accumulation. Such children give little trouble. They are quiet, and seldom cry if left alone. They are late in walking, late in talking, cut their teeth late, and in nursery phraseology are ‘back- ward children.’ Complications. — One of the chief characteris- tics of rickets is the intense sensitiveness to cold with which it is always accompanied; and it is to chills in different forms that a large proportion of deaths occurring in this disease must be attri- buted. A catarrh may affect the chest or the belly, and in either case the complication is a very dangerous one. A pulmonary catarrh in a young child should never be made light of, on account of its tendency to cause collapse of the lung ; and if the child be the subject of rickets, the danger is really Immi- nent on account of the softness of the ribs. If the chill affect the abdomen, as it is very apt to do, an intestinal catarrh is set up, and unless the diarrhoea be quickly arrested, the strength of the child becomes seriously reduced. Besides its influence in increasing the suscep- tibility of the body to cold, rickets also heightens the nervous impressibility of the child. This effect is not a common result of mere weakness, for in an ordinary case of malnutrition with wasting, the natural sensitiveness of the nervous system to external impressions is impaired. It must be therefore looked upon as a peculiarity of tho rickety state. Its effects are seen in the attacks of laryngismus stridulus and convulsions to which these children are so liable. Few cases of laryngismus occur in children who are not the subjects of rickets. Such patients usually have carpo-pedal contractions, and are liable to be con- vulsed upon the very slightest provocation. On account of the backwardness of the teeth in this disease, all nervous derangements are commonly attributed to dentition ; but in rickets dentition, although delayed, is not necessarily troublesome ; in fact the teeth, when they appear, are usually cut with singular ease. Another complication often met with in rickets is chronic hydrocephalus: the excess of fluid is however small. This complication is often sus- pected where it does not really exist. Diagnosis. — When the symptoms of rickets are well marked, the bony distortions themselves are sufficiently characteristic to make the nature of the disease unmistakeable. It is, however, of great importance to recognise the early symptoms of the disorder, so that by prompt treatment we may prevent the osseous and other changes taking place. It must be remembered that loss of flesh is a late symptom, and that a rickety child is not necessarily a thin one. If an infant pass the ninth month without any appearance of a tooth ; if his wrists enlarge ; and if on inquiry we find that he is subject to head-sweats at night, and likes to lie naked in his cot, the diagnosis of rickets may be made without hesitation. Weak- ness of the legs in a young child is often a source of anxiety to parents, and a medical practitioner is consulted because the child is twelve months old and cannot stand. In these cases the early signs of rickets will almost certainly be discovered Looseness in the joints is co mm on in cases of RICKETS. !374 rickets, ■where the symptoms of the disease mani- fest themselves at the end of the second year. The relaxation of the ligaments is not as a rule combined with much hone deformity, although it may be so. AVeakness of the legs from rickets is distinguished from essential paralysis by the fact that, aLthough there may be no power of standing, the child is yet able to move his limbs ; and that the muscles, although weak, are uot powerless. Prognosis. — The duration of rickets is depen- dent upon the duration of the causes which produce it. So long as the baneful influences under which the disease originated are in opera- tion, the morbid processes continue ; but when a better hygiene is adopted, and failing nutrition is restored, recovery begins. AVhen recovery takes place, the symptoms gra- dually become less intense and finally disappear. The enlargement of the joints greatly diminishes, and even the bony distortions become notably reduced, while the bones themselves become thick and strong. Growth, however, is not rapid, and if the disease have been severe, the child sel- dom readies the average height. AVhen the disease terminates fatally, it is usually through one of the complications which have been mentioned. Sometimes the child sinks and dies, apparently worn out by the intensity' of the general disease ; but even in these cases the immediate cause of death is usually as- phyxia, through the softened state of the ribs. One cause of the great mortality from bron- chitis in children is the frequency with which that complaint attacks rickety subjects, even a mild catarrh being seriously dangerous when the ribs are much softened. In estimating the prospects of recovery in any particular case, we must pay attention to the amount of chest-distortion ; and to the presence or absonce of disease of the glandular system. If the ribs he much softened, there is always cause for anxiety ; and if in a case of pulmonary catarrh there he great recession of the lower ribs in inspiration, the condition is a serious one. The presence of any complication, except per- haps chronic hydrocephalus, necessarily increases the gravity of the case. Treatment. — As rickets is the direct result of mal-nutrition produced by the anti-hygienic con- ditions in which the child has been living, our first care must he tc alter these conditions. AA T e must see that the living rooms are thoroughly ventilated; that the child is taken out regularly into the open air ; that he is warmly dressed ; and that his skin is kept perfectly clean by the abundant use of soap and water. AVe must next select a diet for the patient which is at once sufficiently digestible and nutritious. The term ‘digestible’ as applied to diet is a relative term. Food digestible to one infant is indigestible to another, and food readily digested by a child in his natural state of health becomes in- digestible to him when his stomach is temporarily weakened by teething or any febrile attack. It is not, however, sufficient that the diet should he digestible ; it must also be nutritious. Children kept too long at the breast frequently become rickety even although fed at the same time upon other and suitable food ; for the watery breast- milk, which forms the principal part of their diet, is sufficient by its bulk to satisfy their desire for food, without supplying the required nourish- ment to the tissues. Rickety children at the breast should at once be weaned, and if under twelve months old, should be fed principally upon milk guarded with liquor ealcis saceharatus, in the proportion of fifteen drops to the bottle- ful. They may take besides, broths, bread and butter, and occasionally the yolk of an egg lightly boiled or beaten up with milk. Instead of bread and butter, the milk may be thickened for some mea.s with Chapman’s wheat flour baked in an oven ; hut farinaceous food should be given with very great caution to these children, on account of their tendency to acid indigestion, which renders a starchy diet particularly likely to disagree. Under twelve months of age the child can seldom hear more than one teaspoonful of a farinaceous powder twice in the day. After the first year, strong beef-gravy, and flower of broccoli stewed, may be added to the diet. At sixteen or eighteen months old, a little mutton may be given, carefully pounded in a warm mortar. A mealy potato well boiled and mashed may be allowed, hut the effect of all farinaceous food is to bo carefully watched. The presence of flatulent pains is a sure sign that the proper quantity has been exceeded. The diet and general hygienic arrangements having been regulated, the secondary question of drug-giving has to be considered. Before adopt- ing tonic treatment, it is important to improve the condition of the bowels. A dose of castor oil or of rhubarb aud soda should be given to clear away undigested food, and afterwards a few grains cf bicarbonate of soda witha drop of tincture of opium in a little aromatic water will soon remove the offensiveuess of the motions. Citrate of iron may then he added to the mixture, and the child should begin at once to take cod-liver oil. The dose of the oil should he small at first (m. xv— xx), and while it is being taken, the motions should be watched for any appearance of oil in the stools; if this occur, the dose is too large and must be diminished. As convalescence advances other medicines may he given ; and iron wine, quinine, decoction of oak hark, reduced iron, and Parrish's food are all useful. So long as the previous directions have been attended to, the exact tonic used is of comparatively little moment : but cod- liver oil should never be omitted from the treat- ment. Lime has been strongly recommended by some authors, hut according to the writer’s expe- rience is of little value unless combined with iron as in Parrish's food, in which ease it is pro- bably not to the lime that the benefit is to be attributed. It may onee more be repeated that in rickets the success of treatment is in direct proportion to the conscientiousness with which the rules relative to diet and general manage- ment have been carried out ; and the mother should he made to understand that the chi Ids recovery depends upon her own watchfulness and care. The bone deformities can bo prevented to a certain extent, by hindering the child from walk- ing while the hones are still soft The bowing of the legs is often owing to the child's getting upon his feet before the hones have become RICKETS. sufficiently consolidated to bear the weight of the body. In these cases light well-padded splints which project below the feet will be the best safeguard. When the ligaments of the joints are loose and weak, the joints may be much strengthened by a well-fitting silk elastic sup- port. After the tenderness of the body has subsided, the child should be well shampooed, especially along the spine, both morning and evening. With regard to the complications : — diarrhoea and pulmonary catarrh must be treated upon ordinary principles. A good flannel bandage very much diminishes the tendency to relaxation of the bowels, and is of further value in retarding the too rapid descent of the diaphragm, and so in diminishing to a certain extent the recession of the chest-walls during inspiration. The uervous complications are best treated with bromide of ammonium or of potassium. Laryngis- mus stridulus is often cured at once by bathing the whole body three times a day with water of the temperature of 60° Fh. Eustace Smith. RIGIDITY ( rigidus , cold, frozen, stiff). — - Stnon. : Fr. Bigidite; Ger. Starrlicit. — This term implies the existence of a more or less fixed con- dition in parts that ought to be freely movable. It is a state met with principally in the limbs, where it is dependent upon certain unnatural conditions of the joints or of the muscles, either separately or in combination. It may, however, occur iD the trunk as a whole, or in the neck, owing to the existence of tetanic or tonic spasms in muscles, due to one or other of various causes. The valves of the heart, and the arteries, when stiffened by fibrosis, are said to be rigid. Again it is a term commonly applied to a condition of the 1 os uteri ’ during parturition, in certain women, in whom the orifice of the womb does not dilate co-ordinately with the increase in force of the uterine contractions. The term is also sometimes used in connection with the features. Marked ligidity of a limb at this or that joint often results from joint-disease. Perhaps more fre- quently, however, rigidity in a limb is primarily dependent upon altered functional or nutritive conditions of its muscles, which may or may not be associated with actual paralysis implicating the same parts. Numerous cases exist in which, without the existence of paralysis, or with a comparatively small amount of it, tonic .spasms occur in the muscles of a limb, so as to entail rigidity (see Spasm). This may be met with, for instance, in hysteria, and in the early stages of some spinal diseases, more especially in primary lateral sclerosis. More frequently still, however, rigidity is found in association with distinct paralysis. For many years a distinction has been made between two kinds of rigidity associated with paralysis ; the one of which, known as ‘ early rigidity,’ is apt to supervene soon after the onset of a cere- bral or spinal paralytic affection ; whilst the other, known as ‘ late rigidity,’ comes on rather :u old cases in which mere paralysis with flac- cidity of muscles may have been previously pre- sent, The former is now believed in many cases RIGOR. 1875 to have a tendency to pass into the latter form ; and where this latter becomes well-developed, it is commonly associated with a secondary or with a primary sclerosis of the corresponding lateral column of the spinal cord, even though the initial paralysing lesion may he in some portion of the motor tract of the opposite cerebral hemisphere (see Spinal Coed, Introduction to Diseases of). In early rigidity we have to do with mere func- tional changes in the muscles, and the condition itself of rigidity is not constant; it intermits from time to time during the day, and commonly disappears during sleep. But in late rigidity, associated with extensive secondary degenera- tions in the spinal cord, the nutrition of the nerves, as well as of the muscles and their ten- dons, appears to suffer, and that, for the most part, in an irretrievable manner. This more severe condition of rigidity is associated with actual shortening of muscles or tendons, and in this stage but little, if any, difference exists between the degree of rigidity of the limbs by night and by day. See Motility, Disorders of. H. Charlton Bastian. RIGOR. — Stnon. : Shivering-fit ; Fr. Frisson ; Ger. Frostanfall. Symptoms. — This state is characterised by the following phenomena — There is general shiver- ing, the tremulous movements not infrequently being so great as to cause chattering of the teeth. The face wears an expression of great discomfort, or even of distress. The complexion, especially on the lips and beneath the nails, is blue and livid. The tongue is moist, although thirst is felt. The fingers are shrivelled and ‘dead;’ the skin dry and corrugated (cutis anserina ) ; and the cutaneous sensibility dimi- nished. The respiration is quickened and shal- low. The pulse is frequent, small, and firm. The temperature of the general surface is raised, although a sensation of cold — sometimes of severe cold— often referred to the back or the abdomen, is present. The extremities, however, as the fingers, ears, and nose, may be colder than natural. With these maybe combined other symp- toms, such as headache, nausea, vomiting, and the special pains in the back or the limbs, which are proper to the different species of fever ; hut delirium is rarely present. Pathology and .Etiology. — Rigors are the result of the disturbance of some, as yet undeter- mined, nervous tract, which, however, is clearly connected with, if not indeed the same as, the great co-ordinating centre in the medulla for the respiratory, cardiac, and vascular movements, and which must, further, be in intimate relation with the thermotaxic centre, if such exist. One of the exciting causes of this disturbance may be the existence of some abnormal differences between the temperature of the surface and that of the interior of the body. This suggestion of Liebermeister, at any rate, supplies an answer to one or two perplexing questions. It enables us to understand how it is that a man already in the grasp of a serious disorder, the temperature of whose body is raised, and is rapidly rising, has yet the same sensation of cold as a healthy man whose external temperature is below the normal, and whose nervous and vascular system* 1376 EIGOE. are merely reacting in a perfectly natural man- ner under one of the commonest conditions of animal life, for in each case the surface is colder than the deeper parts, and thus gives rise to a sensation of cold. It gives a “plausible solution of the paradox that the greater the absolute heat of the body as a whole, the more acute is the sensation of cold ; and it establishes on a scientific basis the empirical belief in the value of rigors as marking the access of disease, when it is seen that their presence is a proof that increased tissue-change, as shown by the in- creased production of heat— the very essence of fever — has already begin. The early diagnosis of fevers, whether idio- pathic or symptomatic, is often greatly facili- tated by the careful study of the phenomena of the initial rigors. Putting on one side the cases in which a local cause may be found to exist, very violent rigors occur chiefly in connection with the following diseases Malarial fevers, relapsing fever, variola, scarlatina, erysipelas, pyaemia, and croupous pneumonia. They are less marked in typhus and enteric fever, pleu- risy, catarrhal pneumonia, and bronchitis. It must, however, be remembered that, in apprais- ing the value of any nervous symptom, such as rigors, the personal factor is of extreme importance, and that general rules derived from averages are here more than ever misleading, if applied indiscriminately to individuals. An additional argumentfor their central origin is found in the well-known fact, that in children and in persons of unstable nervous equilibrium — for example, epileptics — convulsions are a fre- quent result of the same causes which produce rigors in other cases. Eigors occur under the following conditions : — 1. In health, when a more or less extensive part of the surface of the body is chilled by external cold. Indeed the chilling of even a very small extent of skin is sufficient to produce them. 2. From irritation of a sensory nerve, and espe- cially in connection with some mucous surface. Thus rigors are an everyday result of the pre- sence of irritating matters in the stomach or bowels, of catheterism. and of the passage of biliary or renal calculi. 3. With the access or the exacerbation of some local disease, espe- cially if it be one which is to end in the forma- tion of pus. Eigors occur, not only at the be- ginning, but also during the progress, and with great violence just before the bursting of an abscess. Thrombosis in veins is also attended by rigors. The writer himself once experienced very violent rigors in connection with extensive thrombosis of the veins of the left arm, due to a prick received at a ■post-mortem, examination, although no suppuration whatever took place during the whole course of his illness. 4. At the beginning of idiopathic and symptomatic fevers, that is, when the fever has already begun, and the increased heat-production in the viscera has destroyed the natural balance be- tween the temperature of the interior and of the surface of the body. Although for practical purposes it is conve- nient to distinguish these different modes of origin of rigors, they are essentially identical ; that is, in each we have the effect of irritation RINGWORM. of a, certain kind conveyed by afferent nerve* to some central tract or organ. Treatment. — Warm, mildly stimulating drinks and external warmth are always grateful to the patient, and perhaps shorten the duration of the attack. Tincture of aconite, in 5-minim doses, has the reputation of preventing the occur- rence of rigors from local sources of irritation, and may perhaps be useful when they arise from more general or from constitutional causes. Nitrite of amyl also has been employed, appa- rently with some measure of success. But the only effectual treatment is that of the diseased condition with which they are associated, and this can rarely be begun with advantage before the termination of the rigors or ‘cold stago.’ Until that period has arrived it is at best useless to attempt any internal medication; even quinine is of little or no avail in this stage of malarial fever, and often seems merely to ag- gravate the sickness, headache, and general dis- comfort, which are the usual concomitants of rigors. J. Andrew. RIGOR MORTIS (Lat. The stiffness of death). — Synon. : Fr. Bigidite eadaverique ; Ger. Todtenstarre.— The stiffening of the muscles after death, due to coagulation of their plasma. See Death, Signs of. RINGWORM.— Stnon. : Tinea ; Fr. Teigne- Ger. Bingunirm. Definition. — A disease of the hair-follicles and hair, of a circular figure, and spreading in the form of a ring. Etiology. — Eingworm is essentially a dis- ease of the nutritive period of life ; it is con- tagious, and sometimes communicated to the adult, particularly to women : in the latter case appearing on the unhairy parts of the body, such as the neck, the shoulders, the chest, and the arms. It is very generally taught and believed that the cause of tinea is the growth and de- velopment of a fungus-plant; that the disease is propagated by means of sporules, which are accidentally conveyed from one person to an- other; and that the subsequent folliculitis and other pathological processes result from the irritation caused by the parasitic fungus. That the disease does not become universal, instead of being sporadic, is explained by the admission that the spores require a favourable, that is. a morbid soil for their evolution and growth. The writer of this article entertains, however, a different opinion, and believes that the folliculitis is con- sequent on a depressed state of health of the in- dividual ; that the follicular epithelium is, there- fore, imperfectly developed : and that the phyti- form growth' is a proliferation of the granular elements of the immature epithelial cells and of the hair-cells — a degeneration, in fact, of their component elements. Description. — Eingworm of the scalpis recog- nised by loss of hair in one or numerous patches of a circular or oval figure, and of an average diameter of half an inch or an inch. The base of the patch is somewhat elevated ; more or less papulated, from prominence of unhealthy fol- licles; coated with a furfuraceous desquama- tion ; roughened by the stumps of hair broken a: RINGWORM. different lengths ; and sometimes covered with a matted stratum of withered and discoloured hair. There is rarely any redness or inflammation of the patches, their prominence being due to dis- tension of the follicles with dry epithelial exuviae, and accumulation of furfuraeeous desquamation. Occasional^, however, the patch is bordered by an inflammatory ring, and the latter is some- times surmounted with minute pustules. On the scalp it destroys the hair, which loses colour and texture, appears like tow, and breaks off close to the follicle. In chronic cases a peculiar scurfi- ness — ‘ diffuse ringworm ’ — is the result. On the body it forms red, slightly raised rings, which may present a concentric arrangement. Anatomical Characters. — A microscopic ex- amination of the epithelium of the follicles and of the hair, detects in the substance of both a phytiform structure, which is identical in ap- pearance with that of mucedinous fungi, consist- ing of mycelium andsporules, and growing and proliferating like a vegetable fungus {sec Epi- phyta) ; and this parasitic fungus has received the name of trichophyton. Hence, ringworm is regarded as a parasitic disease, and its contagion is supposed to reside in the sporules of the epi- phyte, which, it is presumed, are communicated from one child to another by the agency of combs, brushes and the atmosphere itself. The permeation of the shaft of the hairs by the trichophyton renders them brittle ; they break off close to the aperture of the follicle ; and when this occurs over the whole surface of the patch, the ragged stumps suggest the idea of having been eaten off by the grub of a tinea or moth. Hence the terms tinea and ringworm applied to the disease ; the grub being presumed to devour the hairs from the centre towards the circumference, and so to give rise to the ring or circular figure of the patch. Looking to the scurfiness of the patches, Willan adopted the term porrigo for its designation ; for example, porrigo tonsurans and porrigo scutulata ; the latter from the shield-like figure of the patches. Its growth by the circumference, creeping as it were into the surrounding skin, suggested the term herpes tonsurans ; and the discovery by Gruby of a fungus-structure commends the term phy/osis as a generic title. A variety of ringworm is known as lcerion. See Kekion. Pathologically, tinea is a chronic folliculitis with some degree of infiltration of the skin ; it • is propagated from a centre to neighbouring fol- licles, and constitutes a thickened disk with thickened margin. On the scalp, where the fol- licles are large, the former prevails and the dis- ease becomes chronic ; whereas on the non-hairy skin, where the follicles are small, the inflamma- tion subsides within the area, and travels on- wards by the circumference. The folliculitis of ringworm rarely exceeds in pathological manifes- tation the production of a papule with congested and infiltrated base ; but in certain constitutions it may give rise to a vesicle, and even to a pustule ; the latter more particularly where the strumous diathesis prevails. The more pathognomonic characters of tinea are evinced by an excessive accumulation of laminse of epithelium within the follicles, and by a disorganised condition of the hair ; the epithelium as well as the hair being 87 1377 penetrated and filled with the mycelium and sporules of the trichophyte. In the shaft of the hair the trichophyte is seen in the form of stems branching from point to point, or rows of glo- bular sporules ; whilst the envelope of the hair is oftentimes composed exclusively of sporules. Diagnosis. — The diagnosis of ringworm in its fully developed state is by no means difficult. The circular and oval disks, and stumps of broken hair, are pathognomonic of tinea of the scalp ; whilst the circular, red, and elevated rings of tinea annulata on the non-hairy skin are equally so. Only two affections approach it in appear- ance, namely, dry eczema and area; but in eczema capitis, which is often furfuraeeous, there are no stumps of broken hairs, the hairs being unaffected, and the disease is more chronic, or there may be a previous history of eczema, or evidence of its presence on other regions of the body. Alopecia areata or porrigo decalvans ex- hibits a total loss of hair on a smooth spot, with no other morbid affection of the skin than simple atrophy. See also Kehion. Prognosis. — The prognosis of ringworm is twofold: — Is it contagious ? Will it last long? To which wo must answer that it is contagious wherever that state of health exists which is favourable to its development; and, secondly, that its duration will be governed by the age, as well as by the powers of constitution of the patient. It is very rarely met with in infancy and never in the adult; and, left to itself, it has a natural tendency towards cure. Nevertheless, it is sometimes prolonged for several years, and may interfere very seriously with the education of children afflicted with it ; while, in general, it is kept up by defective hygienic conditions and unsuitable diet. Treatment. — The t reatment of ringworm must be constitutional as well as local : constitutional to improve assimilation and nutrition ; and local to stimulate a feeble tissue to a more vigorous and healthy function. The constitutional reme- dies must consist of generous diet, fresh air, and exercise; ordinary tonics, and especially arsenic in nutritive doses — for example, two or three, minims of liquor axsenicalis, or their equi- valent of other arsenical preparations, with the meals, three times a day. The best local treat- ment is moderate friction with the iodide of sul- phur ointment, diluted with two-thirds of ben- zoated lard, night and morning ; daily brushing with the hair-brush ; and no washing. Where the iodide of sulphur ointment proves irritating, the nitric oxide of mercury ointment, diluted in similar proportion, may be substituted. Tinea annulata of the body should be pencilled with the liniment of iodine daily, until the rings are arrested; and the same liniment may be applied to suspicious spots cn the scalp, or as an addi- tional stimulus to the scuta themselves. The parasitic theory of the disease has led to the use of sulphurous acid and perchloride of mercury under the name of ‘ parasiticides ’ ; but these remedies have no special advantage over those already named; and the corrosive sub- limate is dangerous unless employed with great care. In the French school, avulsion of the hairs, called ‘ epilation,’ is the practice commonly 1378 RINGWORM. adopted * the process of tearing out the hair boing followed by the use of a weak solution of corrosive mblimate. This practice brings to mind that terrible French remedy the pitch-cap, and is utterly unnecessary for cure. See Epi- phytic Skin-Diseases; and Tinea. Erasmus Wilson. RIPPOLDSAU, in the Black Forest, Germany. — Mixed iron waters. See Mineeal Waters. RISUS SARDONICUS or SARDONIUS ( risus , a laugh ; and sardonius, connected with, or caused by, the herb sardonia or sardoa, that is, belonging to Sardinia). — A peculiar expression of the face, in which the features are distorted by spasm of the muscles, so as to present the appearance of a painful grin or laugh. It is usually observed in tetanus. See Tetands. RODENT ULCER. — Synov.: Fr. Cancroide , Ger. Epithelialkrebs.— Rodent ulcer must be re- cognised as a kind of tumour ; but its exact posi- tion amongst other forms of new growth is still not definitely decided. Hence, in this work a special article is devoted to its consideration. Most authors agree in classing it amongst the epitheliomas. Clinical Characters. — Naked-eye appearances. A distinguishing feature of most rodent ulcers Is the fact that ulceration follows pare passu with .lew growth, the result being that, as in the case of lupus, instead of the formation of a swelling or tumour, an actual diminution of the size of tho part occurs. Another characteristic of the dis- ease is, that whilo it often makes its appearance at a period of life which might be considered early for an epithelioma, it runs a course of ex- treme chronicity, and rarely, if ever, affects the lymphatic glands. Many eases last for twenty or thirty years, interfering but little with the general health, and at times in part undergoing a process of feeble cicatrization. Rodent ulcer begins as a pimple, usually on some part of the face, and most frequently on the side of the nose or about the eye. After remaining quiescent for a long time, perhaps years, ulceration occurs, and continues to spread with great slowness, involv- ing in its course every structure that it meets. Thus in time huge caverns are excavated in the face ; the eyeball may be destroyed ; the nose and upper jaw may disappear; and, not unfrequeutly, if the disease reach the forehead, the dura mater is exposed, and the brain is seen pulsating at the bottom of the cavity. The appearance of the ulcer is characteristic: the surface is glistening, and is covered with very imperfect granulations ; it has an uneven level, and is mottled with yel- low and red ; the margin is very slightly raised, and somewhat indurated, has a purplish pink colour, and is often considerably undermined. The discharge is thin and purulent. Capillary haemorrhage not unfrequently occurs, but more severe bleeding is rare. A section through the edge shows the narrow margin of new growth, in which alone the characteristic structure is to be made out. Death may occur from old age or other causes independent of the disease ; from an at- tack of erysipelas or meningitis, or from maras- ROSEOLA. mus induced by the constant worry and dis- charge. Microscopical Appearances. — Many tumoure which approach somewhat nearly the condition above described will be found on examination to exhibit the structure of a lobular epithelioma ( see Cancer) ; but the most typical ones will usually exhibit something like the appearance represented in fig. 119, facing p. 204. Beneath the epidermis, and imbedded in a varying amount of stroma, consisting of more or less well-developed fibrous tissue, are large, roundish, and irregular masses of densely-packed epi- thelial cells of small size, the circumferential ones taking an oval shape, while the deeper ones are circular. There is, as a rule, no tendency to the formation of globes ; but, in some cases which have run a typical course, imperfect nests have been found ; the so-called prickle-cells are. as far as the writer has observed, never seen. The cells are smaller than those usually seen in an epithelioma, and suggest the origin of the growth from the sweat-glands, a view which is favoured by the fact that the epithelial masses occasion- ally assume a more or less distinctly tubular arrangement. Strenuous advocates are found in support of, and in opposition to this theory of the primary source of rodent nicer, and the same may be said of other hypotheses, such as that it starts from the hair-follicles or the sebaceous glands ; but, in default of stronger evidence than is at present forthcoming, it would he unwise to dogmatise upon the question. The reader will find some of the literature of the subject in the late Mr. Charles H. Moore's book on rodent cancer, in Dr. J. Collins Warren’s monograph on rodent ulcer, and in the various communications to the Pathological Transactions ; but in German writ- ings he must search under the head of Epithelial Cancer, to which class rodent ulcer has always been consigned. Prognosis. — The prognosis in a ease of rodent ulcer may he implied from what has been said of its clinical features. Treatment. — The obvious treatment is free removal by the knife in the early stages. Mr. Moore was a strong supporter of the plan of removing even very large ulcers; he was in the habit of proceeding with the knife as far as pru- dence would allow, and applying chloride of zinc paste to any parts it was considered unsafe to re- move. This treatment in his hands and in that of others has been followed by very marked success. R. J. Godlee. ROISDORF. in Germany. — Mixed alkaline table waters. See Mineral Waters. ROME, Central Italy. — Moderately warm, moist, fairly calm, sedative winter climate. Mean temperature, winter, 46 75° Fahr. Prevail ing winds, tS.E. and N. Sec Climate, Treatment of Disease by. ROSALIA ( rosa , a rose). — A rose-coloured rash ; a term formerly applied to scarlatina and rubeola, before these rashes were clearly differ entiated. ROSEOLA (rosa, a rose). — Syxon. : Fr. Roseole, Ger. Roseola. — This affection, the name ROSEOLA. of which is derived from its crimson tint of colour, is one of the exanthemata or rashes of the skin, and in common parlance is called ‘ rose-rash.’ In general characters it resembles a mild form of measles, and has consequently received the name of ‘ false measles.’ .IEtiology. — The cause of this exanthem is feverish excitement, resulting from heat and exhaustion ; hence it is frequently epidemic in hot weather. Although allied in appearance with measles, it cannot be regarded as contagious. Frequently it is symptomatic. Description. — Eoseola ordinarily assumes the form of a punctated rash, more or less suffused, but it sometimes occurs in small erythematous blotches, which spread by the circumference and form, rings. In the latter cases it is only distinguishable from erythema by its roseate colour. The exanthem forms part of a slight febrile attack, attended with weariness, lassitude, nau- sea, and prostration ; and is accompanied with more or less redness of thefauces. and sometimes [ with swelling and tenderness of the submaxillary glands and occasionally of the neighbouring lymphatic glands. The exanthem has a course of tour or five days or a week, and then disappears, leaving the patient convalescent; and, like its congeners the exanthemata, it begins with the head, then travels downwards to the trunk of the body, and is last perceivable on the arms and legs. It is rarely of sufficient force to he followed by exfoliation of the epidermis. Varieties. — Besides those objective terms i which liken roseola to measles, it has likewise been called after tho seasons when it commonly occurs, R. cestiva and R. autwmnalis. Other terms, such as R. 'punctata, corymbosa, maculosa, orbicularis, annulata, and papulata relate to varieties of its pathological characters. An exanthem, identical in appearanco with idio- pathic roseola, is met with in secondary syphilis; the punctated rash which is associated with con- tinued fever is likewise a roseola ; whilst other forms, which have been observed associated with variola, vaccinia, gout, rheumatism, and cholera, I may he regarded as erythemata resulting from venous hyperEemia, Diagnosis. — The diagnosis of roseola has been sufficiently illustrated by the above description —a punctated rash, corymboid like measles, but sometimes orbicular or annulate like erythema ; its special pathognomonic characteristic being its crimson or rose colour. Prognosis. — The prognosis of roseola is fa- vourable ; the feverish disturbance subsides in a few days or a week. Tho prognosis of symptomatic cases necessarily varies. Treatment. — Rest and repose together form nn important element in the treatment of roseola. A mild purge may be necessary to regulate the digestive organs, and may be accompanied with effervescent salines. Locally, the skin should he anointed with some soothing and un-irritat- i mg oily substance, such as vaseline, olive oil, or benzoated lard. Erasmus Wilson. ROSE-RASH. — A popular name for roseola. See Roseola. ROTHELN. — The German synonym for ru- ROUND-WORMS. 1370 bella ; frequently employed by English practi - tioners. Sec Rubella. r 1 ROUND-WORMS. — In respect of their form the various species of nematoid entozca more or less resemble earth- worms, and, consequently, are collectively called round-worms ; but the term is by many persons restricted to the large lumbricoid parasites which infest man and several of the lower animals. Description. — The human round- worm (Ascaris lumbricoidcs ) varies much in size, the males measuring from four to seven inches in length, and the females usually from nine to fourteen inches, though an instance has been recorded from America where a female measured seventeen inches. The general structure of the worm was long ago investi- gated by Cloquet, Owen, Dujar- din, Busk, and others; but the most modern and important addi- tions to our knowledge of its anatomy are due to the writings of Eberth, Bastian, Schneider, and Leuckart. In the matter of deve- lopment, the writings and labours of Nelson, Thomson, Kolliker, Meissner, Richter, Davaine, and Heller are particularly noteworthy. The precise manner in which the essential act of fertilisation is ac- complished in nematoids carries with it no practical issue, but ex- periments with the mature ov-a have an important bearing on questions of sanitation and infec- tion. Verloren, Vix, and others have reared intra-chorional em- bryos of various nematode species in water; and the writer himself has watched the development of the eggs of Ascaris lumbricoidcs , in fresh water, through all the stages of yelk-segmontation up to the stage of an imperfectly organ- ised, coiled embryo, subsequently keeping the ova alive in this con- dition for a period of three months. Dr. Davaine pushed the facts of development much further. He kept the ova alive for upwards of five years. He administered some of these five-year-old embryos to I rats, and had the satisfaction of finding a few of the eggs in the rodents’ faeces, with their con F ' % lumbricoi- tai ? e . d embryos still alive, but des ; male, with striving to escape the shells. As exserted spi- a general result it may be said (origiSl) " S1ZS ^at t ' 10 em bryos escaped their shells ; but only in the case of early embryonal stage of growth, did the gastric juice of the experimental animals act upon the shells, and thus liberate the contents of the ovx 1380 ROUND- Tf yet more practical importance are the obser- vations of Holler, respecting a •post-mortem ‘find’ made in May, 1872. In the small intestines of a lunatic he discovered eighteen specimens of very young round-worms ; all of them being referable to the species in question (A. lumbricoides). They severally measured from i to i an inch in length. Now, as Heller himself has pointed out, between the embryos as they appear at the time of their expulsion from the egg and the smallest round- worms hitherto seen in the human subject, we have, as regards size, an immense gap to bridge over. This 1 find ’ of Heller’s, therefore, tends to make it appear almost certain that the common round-worm completes its life-cycle without the necessity of having to pass through the body of any intermediary animal bearer. The truth of this conclusion, moreover, is borne out by nu- merous facts, which have come to the knowledge of the writer. In one instance brought under his notice, a local endemic of roundworm-hel- minthiasis was clearly traceable to drinking water from a filthy stream, into which sewage- deposits flowed. The further treatment of this subject, in reference to public health, will be found more fully discussed in the writer's second memoir ‘ On the Dispersion and Vitality of the Germs of Entozoa,’ read before the Association of Medical Officers of Health ( Medical Times and Gazette , 1871, p. 215). The Ascaris mystax is described in the article Ascakjdes. Symptoms. — The symptoms superinduced by round-worms, and the practical management of cases, more immediately concern the physician and practitioner; but in England, the disorder is, speaking relatively, not very prevalent. In some countries round-worms in the human sub- ject are extremely frequent, this being especially the case in tropical regions, as in India, in China, in Central America, and, according to Dr. Dyce, still more notably in the Mauritius ( Medi- cal Gazette, 1834). Whilst, in British practice, we seldom encounter more than one, or, it may be, several spe- cimens in each patient, it is no uncommon ex- perience abroad to en- counter several scores in a single bearer. Now and then from one to several hun- dred specimens have FlO. 72 . Ascaris mystax ; male fieen removed from a £. a AteS^rt KatUral ***• but such instances are compa- ratively rare in England. Marshy and low-lying grounds, in the neighbourhood of dwellings, are eminently productive of round-worms, hence their comparative abundance in some parts of Holland, and in the lake-districts of Sweden. Dr. Brandt, of Oporto, informs the writer that lumbricoids are very common in Portugal, affect- ing something like 75 per cent, of the children, who frequently pass large numbers by the mouth as well as by the anus. Many remarkable phenomena result from the presence of these large worms in the human sub- ject. Ordinarily, the symptoms bear a close •WORMS. resemblance to those arising from thread-worms, but the results are commonly of a graver charac- ter. As stated in the writer’s published lectures (Worms, p. 113), they give rise to colicky and shooting pains about the abdomen, followed generally by more or less dyspepsia, and ac- companied with nasal itching, nausea, vomiting, and even diarrhoea. Sometimes, also, there is cerebral disturbance, attended with general rest- lessness and convulsive twitchings during sleep. In severe cases, amaurosis, catalepsy, convulsions, erotomania, and death by enteritis or by per- foration of the intestine, have been known to occur. These worms have a remarkable ten- dency to grope about the intestinal canal, as if seeking a new abode, and thus it is that they not unfrequently make their way into various and, so to speak, unsuitable parts of the body, where they cannot thrive. Amongst other strange situations, they have not unfrequently been found in the gall-duct, in the cavity of the thorax, and especially in the parietes of the abdomen. This habit of wandering often proves fatal to them. Any foreign solid body in the intestine, with a suitable hole in it, is sure to attract their attention, and to form a sort of worm-trap. Thus these parasites have been strangled by metallic buttons, by ‘ hooks and eyes,’ by an open-topped thimble, and by other miscellaneous foreign bodies accidentally or purposely swallowed by their human bearers. Numerous cases, many of them fatal, have appeared in journals during the last half-century. The writer’s treatises on Entozoa (1864) and Parasites (1879), as well as Davaine's Trade (1877), abound with references of this kind, and since these books were published other notable cases have been placed on record. Amongst fatal instances occurring in this country, the cases by Blair (Edinburgh Medical Journal, 1861) and Rogers (Lancet, 1848) deserve mention. An interesting example of perforation and conse- quent abdominal abscess, followed by successful treatment, was also recorded by Sheppard (Bri- tish Medical Journal, 1861). A case very similar to this has been orally communicated to the writer by Dr. Reginald Pierson, of Leipzig, the patient, a soldier, having come under his care during the Franco-German war. Children appear to be more liable to harbour large numbers of these worms than grown per- sons. Kiichenmeister refers to a case where a child passed 103 worms, and to a second in- stance where another child was infested by up- wards of 300 ; whilst, in Gilli's yet more strik- ing case the child voided no less than 510 worms (Giorn. d. Sci. Med. di Torino, 1S43). In a case communicated to the writer by Dr. Mackeith, of Sandhurst, Kent, the patient, a child of only five years, passed upwards of 300 worms, most of them having been expelled in consequence of appropriate treatment with santonine and aloetic mixtures. One of the specimens mea- sured 15 inches in length. The sympathetic nervous symptoms are often most serious. Hy- steria, catalepsy, chorea, epileptiform seizures, paralysis, loss of sight, deafness, mental de- fects, eclamptic fits, convulsions, maniacal ex- citement, and other obscurer phenomena, have ROUND-WORMS. been recorded as due to the presence of these worms. That these affections have in most in- stances been exclusively duo to the presence of the parasites, is proved by the fact of the frequent and immediate disappearance of the symptoms following the expulsion of the worms. The writer is indebted to Dr. H. Cooper Rose for particulars of a case, in which a child only fifteen months old suffered from severe convul- sions, the symptoms entirely disappearing after the expulsion of upwards of a score of these lumbricoids. Cases of the most violent delirium, and even of complete idiocy, have entirely re- covered upon the employment of suitable vermi- fuges ; whilst in instances whero the presence of the worms has either been overlooked or disregarded, a fatal result has ensued. In the standard work by Davaine, numerous instruc- tive references, with particulars of the cases, are fully recorded ; whilst the writer’s introductory work supplies many others. In this connection, also, an interesting and instructive paper by Assist.-Suxg. G. D. D. Goopta appeared in the Indian Medical Gazette, and London Medical Becord, 1871- From observations made at the dispensary at Tangail, he concludes that lum- jricoid worms may be an exciting cause of suicide. Such deaths are more common among the Mussulmans than the Hindoos. Round- worms were found by Goopta in twelve out of eighteen bodies of suicidal hanging, that is, in about 67 per cent. The greater number of those who committed suicide were of the age it which the worm is frequent. When, by reflex action, the worms bring on irritation, the suf- ferers turn peevish and low-spirited, and can scarcely withstand any trifling reprimand or cor- rection. To them these insignificant causes be- come so painful, that they immediately resolve to relieve themselves by suicide, the hanging- method being generally adopted. Diagnosis. — The diagnosis of round-worm is usually a very simple matter, because the patient is sure sooner or later to pass one or more para- sites, even though he or she may not have taken medicine. In cases where only one worm exists its presence is rarely suspected, and in those instances where the existence of these worms is overlooked, although many happen to be present, it often turns out that they are lodged in the sto- mach instead of occupying their more usual seat, namely, the small intestines. In all obscure cases of dyspepsia and the like, especially if there be colic, it is well for the practitioner to make a microscopic examination of the faeces. In cases of chronic vomiting, especially if there be hse- matemesis, the contents of the stomach should be carefully scrutinised, for in this way, as the writer himself has found, the ova of the lumbri- coids may be detected, and the true nature of the case will at once become apparent. On the other hand, the practitioner should exercise the greatest caution lest he give encouragement to the notion of parasitism (so often erroneously entertained by hypochondriacal subjects), without fully going into the history and other particulars of any given case. Treatment. — When once we are satisfied as to Lhc presence of round -worms, their expulsionis ne- cessary , and, fortunately, not very difficult of exe- 1331 cution. Of the many vermifuges recommended, none are equal to santonine, which in the case of children may be administered in the form of powder, in doses of two to four grains, mixed with sugar and sprinkled on bread and butter, and followed by a saline cathartic, or a large spoonful of castor-oil. Many prefer to mix the crystalline powder with the oil itself, or to com- bine it with two or three grains of the resin of scammony. The plan of giving the drug over night, followed by a morning cathartic, is objec- tionable to some extent, since it leaves abundance of time for the santonine to exert its physio- logical action, which is not the purpose in- tended. For adults from five to ten or even fifteen grains are often employed on the Conti- nent ; but the writer has seen evil effects from the larger doses, and considers it imprudent to administer more than five grains once a day for three days in succession, combined with castor-oil. If larger doses are given the effects should be carefully watched, as this drug has been known to produce tenesmus, spasms, and even haemorrhage. The writer has several times noticed giddiness, with more or less mental con- fusion, as the result of moderate dosing with santonine. In all cases it is as well to tell the patient that vision is apt to become tempo- rarily impaired; and that the daylight, as well as all objects looked at, may appear yellow, or, in rarer cases, blue or green. The urine almost alway s acquires a deep yellow or red tinge, which is alone sufficient to alarm some patients. For- tunately these physiological phenomena quickly disappear. Perhaps, as regards the employment of santonine, it is as well, in the case of young persons, to follow the advice of Kjichenmeister, who remarked that we ‘ should never administer more than eight grains in two days, divided into closes of two grains each twice a day.’ Amongst the various other remedies employed, aloes, scammony, jalap, calomel, sulphur, and turpentine hold a prominent place ; but their utility as vermifuges is for the most part due rather to their drastic properties than to any specific action on the worms themselves. As a lumbricifuge, no remedy is equal to santonine, which, however, may be combined with, or fol- lowed by, any one of the above-mentioned drugs with advantage. If santonine and turpentine be employed, they should be combined with castor- oil. Dr. Pockles, of Holzminden, recommends the powdered root of male fern in conjunction with ordinary purgatives ; whilst kamala and kousso are spoken of favourably by others. In doses of from one to two drachms, the kamala powder has proved effectual in the hands of Drs. Mac- kinnon,Ramskill,andLeared. The South .African fern-powder, or ‘payna,’ so much employed by the Kaffirs for tape- worm, has also been recom- mended ; but its lumbricifuge virtues are probably inferior to those of kousso and male fern, which latter drugs ought, in the writer’s opinion, to be employed only in cases of taenia. According to Davaine, the so-called ‘varec,’ or Corsican moss, which is procured from various species cf sea- weed, is much employed in France, but the re- sults obtained are variable, probably owing to adulteration. Dr. E. J. "Waring speaks favour- ably of several Indian remedies. Thus the zet-ei 1382 ROUND-WORMS, or theet-tsce, the black varnish of the Burmese, is said to be a most efficacious lumbricifuge, and the Burmese also employ a fungus, or worm- mushroom, called thanmo , which, according to Dr. Packman, has considerable anthelmintic power. The inhabitants of Java, and the Chinese living at Macao, employ a worm-fruit termed ciy-tlum, obtained from the plant quisgualis indica. There is also a small annual, vernonia anthelmintica , extensively distributed throughout Hindostan, the seeds of which, according to Waring, are held in the highest repute amongst the people of Southern India. Many other drugs having drastic and anthelmintic properties are employed in Eastern countries ; but of all the various remedies none is so satisfactory as san- tonine, combined with or followed by purgatives, and continued for several days in succession. See Ascarides ; and Lumbricus. T. S. CoBBOLD. ROYAT, in France. — Muriated alkaline waters. See Mineral Waters. SUBBING SOUND. — A synonym for fric- tion-sound. See Physical Examination. RUBEFACIENTS {ruber, red, and facio, I make). — A class of counter-irritants which pro- duce simple redness of the skin. See Counter- irritants. RUBELLA (dim. of Btibeola). — Synon. : Rubeola sine catarrho ; Raise Measles ; German Measles ; Epidemic Roseola; Er. Eougeole ; Ger. Rbtheln. Definition. — A specific eruptive fever, the rash appearing during the first day of the illness, beginning on the face in rose-red spots, extend- ing next day to the body and limbs, subsiding with the fever on the third day, and not preceded by catarrh or followed by desquamation. .ZEtiology. — Propagated by contagion, rubella occurs in epidemics, often of limited extent, but with sporadic offshoots. It has a long period of incubation, mostly a fortnight, the extremes being from six to twenty-one days. Hence a difficulty in tracing the source of personal infection; this is increased by the slight and transient nature of the illness allowing patients to mix freely with others. One attack is preventive of a recurrence, but is not protective against either measles or scarlet-fever, nor do attacks of either of these diseases in any way modify the liability to this one ; it is as distinct from them as is chicken- pox from small-pox. During epidemics of measles or of scarlet-fever mild and irregular cases of botli are not unfrequontly mistaken for this ex- anthem ; well-marked outbreaks of it are often attributed to measles, while slight attacks of scarlet-fever are miscalled rotheln, and a hybrid disease imagined which bas no existence. Very young infants seem less suscept ible than older children ; a child at the breast has been known to escape when the mother and other children in the family have been attacked. Adults not un- frequently suffer, as many persons escape attacks in childhood; sex makes no difference. The disease is contagious, even before the rash is thrown out, and it continues to be so for some RUBELLA. days, or it may be weeks afterwards. Second attacks are rarer than in scarlet-fever, but the rule against them may be less absolute than for measles. Rbtheln is seldom fatal ; when a mor- tality is reported as high as 3 per cent, of the attacks, measles is present. Symptoms. — Slight fulness of head, heaviness, pain, or giddiness is felt, with aching of the tack or limbs, and a little tenderness of the throat, for twelve hours or a day before the rash appears. Very often the rash is first seen with surprise, as the feeling of illness has passed or may have es- caped notice. Some enlargement of the lymphatic glands in the neck is an early sign, most marked in children. There is redness of the fauces and uvula, less mottled than in measles, not so in- tense as in scarlet fever; the tonsils are full and smooth; there is no ulceration. Sometimes an odour, as in measles, attends the rash. The eyes are suffused, but there is little or no coryza; the lids are somewhat swollen and irritable ; the face is flushed, and the cheeks are red or full be- fore the appearance of the spots. These are bright red, raised, rounded, with clear skin between them, but they soon coalesce ; not grouped as in measles, the spots are more prominent than in scarlet- fever, and there is not the finely-diffused redness of the neck and chest observed in that disease. Moreover, the rash is already fading from the face and upper part of the body while extending to the limbs, so that it is less intense on the third day. It leaves some itching, or a very fleeting yellowish tinge, but no discoloured mottling of the skin, and no desquamation. However little illness is felt at the beginning, a continuous rise of temperature commences with, or just before the rash; it may reach 102°-3°, or be only 2° Fahr. above the normal; with rest in bed this may fall one degree by the end of the second day, but is evenly maintained as the eruption pro- ceeds, and subsides with it on the third day. During the following week it is readily disturbed, either raised by exertion or depressed by fatigue or chill. At this time recrudescence of the rash has been observed. Slight catarrhal signs not unfrequently come on after the rash has faded, the eyelids are sticky, the nostrils stuffed, the throat sore, or some cough begins. Exposure, or want of care at this time may determine serious disturbance of health, generally with pulmonary complication. The urine is often high-coloured in the early part of the illness, the chlorides are increased but there is no albuminuria, nor has this ever been known to follow. In some few cases tran- sient complaint of the throat or of fatigue has been made a week before the rash, or epistaxis has occurred ; fulness of the small cervical glands is often felt, but no constant intermediate symp- toms are found, and any feeling of sickness is without fever. Diagnosis.— The sudden onset of this form of rubeola without previous sneezing or cough dis- tinguishes it from measles, to which it is much more nearly allied, as well by general characters as by the kind of rash, than to scarlet-fever; but the spots are more evenly distributed at wider intervals, each with an areola of its own before coalescence, and not in groups with a common areola ; there is no gradual rise of temperaturs .RUBELLA. before the rash, nor the sudden fall afterwards, both characteristic of measles. The small lym- phatic glands in this ailment are palpably en- larged down the sides of the neck, and perhaps behind the ears, but not specially at the angle of the jaw, as in scarlet-ferer. The rash on the second day may look like that of scarlet-fever, or the red flush of scarlet-fever at first sparsely distributed, or with prominent red papillae, may lead to mistake ; but the sudden onset is much more marked in scarlet-fever when, should the rash appear as early, yet it is more intense on the third day, especially on the neck and chest ; moreover, the fever persists till the fifth day, even when not greatly elevated; there is also the state of the pulse and tongue, and the pro- minence of throat-symptoms. Sometimes it is not till the second or third week that the kind of desquamation, and possibly signs of renal irritation, or the occurrence of other cases, complete the diagnosis. The length of interval between successive cases is also a distinction. Roseola is not contagious ; it occurs in red points or spots, not raised above the healthy skin be- tween ; there are no throat-symptoms, no en- larged lymphatic glands, or fever. Erythema affects parts of the skin only : attention restricted to the character of the eruption often leads to error. Pathology. — As in most infectious diseases, particles given off from the sick, chiefly by the breath, attach themselves to the mucous surface of the throat or air-passages, and either multiply themselves, or produce a morbid change in tho material around them ; this morbid matter enter- ing the lymphatics is at first arrested in their glands, and thence enters the blood. Fora time some of this may be deposited again at the point from which it started, or the amount be too small to produce that arrest of nerve-tone which permits the dilated vessels and increased com- bustion of general fever. A special effect on the vaso-motor nerves of the skin is necessary to produce the turgidity of the rash, and this not of the momentary character of a passing irrita- tion. Local irritation of the sympathetic in the neck, starting from the mucous membrane, may determine the early appearance of the rash on tho face. The skin generally has not the intense vascular injection, with the exudation that results in detached epidermis, as seen in scarlet-fever, nor do the congested vessels of the papillae leave such dilated meshes as after measles. Whether any special microzyme is associated with rubella there is no histological research to show. Prognosis. — Recovery is so much the rule, that were it not for the mischief any febrile dis- turbance may exeito in weakly children, and the risk of pulmonary disease from premature ex- posure, all cases of rubella might be expected to do well, In severe eases the throat must be looked to, and in all cases the chest examined. We must bear in mind that infection persists for a month, and that two months may elapse before health is quite restored. Treatment. — Rest in bed for three days, and confinement to the house for a week, is almost all that is required ; the fever demands no secretion to be increased for its mitigation, nor any special means for its control. Dilute acids may be given RUPTURES. 1383 for relaxed throat ; and tonics, such as bark oi iron, during convalescence. William Squire. BFBEOLA. — A synonym for measles. See Measles. BUMINATION ( ruminn , I chew again.) — Synon. : Fr. Rumination ; Ger. Wicderkaucn . — Rumination, which is the normal method of digestion in a large class of animals, occurt occasionally in the human subject. In the cases recorded the return of the food usually took place about a quarter of an hour after the meal had been finished. The regurgitation seems to have been produced by the contractions of the muscular coat of the stomach, assisted by those of the diaphragm and abdominal muscles. The food is usually stated to have had no acid taste, and therefore could not have un- dergone any digestion. Dr. Copland recommends that the meals should be deliberately and care- fully masticated. As to medicinal treatment, he had found benefit from ipecacuanha and aloes twice a day, and a tonic draught one hour before dinner. Samuel Fenwick. RUPIA. (pi-nos, dirt or filth). — Synon. : Fr. and Ger. Rupia. — A term applied to the crusts formed by the desiccation of purulent and ichor- ous discharge, over the foul sores or ulcers of syphilis and lupus. Description.— The crusts of syphilitic rupia vary in thickness and extent. Sometimes they are flat and rugged, and sometimes prominent ; and they are generally marked on the surface by concentric lines, which indicate the peripheral growth of the ulcers which they conceal. Their colour is grey, sometimes brown, and more or less mottled with black, from admixture of blood with the purulent secretion. When of large size and flat they suggest the idea of an oyster-shell imbedded in the skin ; at other times they aro conical in shape, like the shell of the limpet. This latter variety results from the desiccation of the discharges poured out by a pustule in course of centrifugal growth, and the consequent superaddition of fresh layers to the under sur- face of the original crust. Rupial crusts found in lupms are harder, and never so large as those of syphilis. They differ also in pathological structure, being concretions of epidermal substance, instead of mere desic- cated masses of morbid secretions. Treatment. — The treatment of these two forms of affection is that of the diseases which they separately represent, namely, syphilis and struma. Syphilitic rupia is chronic syphilis in a state of ulceration, and calls for the treatment applicable to that disease. Iodide of potassium will heal the ulcerations, and then the crusts of rupia will fall off of themselves. It is better to avoid removing them artificially, as they consti- tute a natural covering to the ulcers whilst the latter remain in existence. Erasmus Wilson. RUPTURES ( rumpo , I break). — Synon. ■ Fr. Ruptures; Ger. Risse. — The subject of rup ture of organs generally has been thoroughly dis- cussed in the article Perforations ant> Ruptures 1384 RUPTURES. io which ihe render is referred ; and the considera- tion of this lesion in connection with particular organs is fully entered upon where this is re- quired, as in the case of the heart, stomach, and other important viscera. The general meaning SALIVARY GLANDS. of the word is so evident that it needs no defi- nition. In addition to its obvious meaning, the word is used in a popular sense as a synonym for hernia, which is spoken of as a rupture. See Hernia. Frederick. T. Robert*. s SACCHORRHCEA (T SCLEROSIS. Spinal | Spinal Cord, Special Diseases of. Disseminated or Multi- locular Sclerosis. SCLEROSTOMA (s, hard, and ariyea, a mouth). — A genus of strongyloid parasites in which may be placed the species of human ne- matode sometimes called strongylus quadriden- tatus after Siebold, dochmius duodenalis after Leuckart, or, more commonly, anchylostomum duodenale after Dubini, Dies- ing, and other helmintholo- gists. This helminth gives rise to a special form of tro- pical anaemia which is notun- common in Brazil, where it is designated oppilagao, or cangago. As in Europe the parasite is most frequently called the Anchylostomum, so also the disease occasioned by its presence is often called Anchylostomosis. Without doubt C. von Siebold's nomen- clature is the best, zoologi- cally speaking ; but it has been found more convenient to treat of the parasite and its disease in this place. Description. — The male parasite measures about one- third of an inch in length, *'Vofaa S U the female being very nearly (A), and female (b) half an inch. The Hunterian x 5 diameters. Museum contains specimens of this entozoon contributed by Dr. J. E. da Silva Lima, of Bahia. Symptoms and Diagnosis. — In persons affected with this disease, according to the late Dr. Wueli- erer, there is extreme pallor of the visible mucous membranes, with excessive weakness, dyspnoea, palpitation, and a tendency to syncope. Drop- sical effusions supervene, and death sometimes follows from dysentery and diarrhoea ; but the loss of blood consequent upon the suction-wounds of the selerostomes is the real cause of the malady, whether the attacks prove fatal or not. When the symptoms just mentioned occur many person resident in a warm country, the presence of these parasites will naturally be suspected. In such cases anthelmintics should be administered, followed by a careful inspection of the faeces, in which the worms or their ova may be found. Histoby. — The worm was first discovered by Dubini at Milan, and seems to be tolerably commcn throughout Northern Italy ; but, according to Pru- ner, Bilharz, and Griesinger, it is still more abun- dant in Egypt. The ‘ Egyptian chlorosis,’ as the disorder is also sometimes termed, has been de- scribed in the standard works of Kiichenmeister and Davaine, and also, with great care, by Leuc- kart (Die Mensch. Par., s. 455 et seq.), who closely follows Griesinger (Archivf. physiol. Heillc., 1854). The writer has carefully gone over the late Dr. Wucherer’s admirable memoir on this subject, and only refrains from quoting his statements at greater length from want of space (‘Ueber die Anchylostomumkrankheit, tropische Chlorose, oder tropische Hypoiimie,’ Deutsches Archie fur Klin. Med., 1872, ss. 379-400). The estimable author not only supplied the writer with abundant materials for confirming what others had already made out respecting the structure of this worm (Entozoa, p. 361); but he supplied the specimens which formed the subject of the excellent illus- trations given by Dr. Weber in the Path. Soc. Trans, for 1S67 (vol. xviii., p. 274). Numerous prior observations made by Wucherer in the Gazcta -IT d tea da Dahia are included in the memoir above quoted, and they have been re- ferred to in the writer’s recent work ( Parasites , 1879, p. 2\Zet scq.). When Wucherer announced, through Dr. Jobini at the Rio Academy, his dis- covery of the Egyptian chlorosis in Brazil, his views as to the true cause of the disorder met with opposition. The general opinion was that the Anchylostomata were not the primary and necessary cause of this tropical ansemia, but rather a co-operating agent in its production. Against this view Dr. Wucherer afterwards very properly protested (Gazcta, January 15, 1868). In the meantime, says Wucherer, ‘ Dr. Le Roy de Mericourt, prompted by my first communi- cation, had invited the physicians of the French colonies to seek for anchylostomes. Drs. Mo- nester and Grenet, at Mayotta (which lies about 12° S. lat. to the north-east of Madagascar), ascertained the presence of entozoa in hy po- lemics. Dr. Grenet sent the duodenum and a portion of the jejunum of an hypoaemic corpse to Le Roy de Mericourt, who compared tho anchylostomes with Davaine's description, and recognised them as examples of A. duodenale. In the year 1868 Dr. Rion Keraugel found anchy- lostomes in the bodies of hyposemies in Cayenne. Thus (adds Wucherer) the occurrence of anchy- lostomes in hyposemies has been authenticated by Pruner, Bilharz, and Griesinger, in Egypt ; by myself, Dr. Moura, Dr. Turinho, and other physicians, in Brazil ; by Monesiier and Grenet, in Comorens ; and by Rion Kerangel in Cayenne. It thus also appears, from the wide separation of these several localities, that the anchylc- stomrs, it duly sought for, will be found in manT SCLEKOSTOMA. ether countries.’ Dr. Wucherer was correct ; end what has since been unwisely called Tunnel Trichinosis is merely another name for the same disease, which recently caused so much havoc among the workmen in the St. Gothard tunnel. This outbreak was specially investigated by Professor Perroncito, of Turin, and by Dr. Bugnion of Geneva. The memoir by Perroncito (Osserv. El-mint, relative alia Malattia sviluppa- tusi en demica — R. Accad. dei Lir.cei, 1S79-8U), is idustrated with figures of the larval anchylo- stomes. Figures of the adult worm are given by Bugnion in his memoir, with a valuable biblio- graphy ( Revue de la Suisse Romande, May and June 1881). More recently Dr. Perroncito lias communicated to the Academie des Sciences h s observations on a like outbreak amongst the miners of St. Etienne. Treatment. — Perroncito gives the following t xceben : advice as to treatment : — ‘The strength should bj sustained with food easy of digestion, very nourishing, aided by the best tonics and re- cmstitu-nts, whilst we proceed at the same time ti destroy the worms which constitute the funda- mental cause of the oligaemia. None of the pa- tients subjected to treatment with the best anthel- mintics, with a good meat diet and rich wine, need succumb, unless the anpemia has arrived at that extreme degree in which the organic powers cease to regenerate the blood ; and still less, if at the same time they take preparations of iron and bitters.’ He adds : ‘ The ethereal extract of male fern appears to me most adapted to kill the different species of parasites ; only it must not be supposed that one or two doses will be sufficient to liberate the intestines from thou- sands and perhaps millions of helminths that live on chyle and blood.’ Prof. Perroncito men- tions the case of a young St. Gothard patient, with large quantities of anchylostomes, combined with not a few anguillulse and some ascarides, who was treated with male fern so successfully that even the ‘ first draught ’ occasioned great relief. This was followed by santonine and the nourishing diet above recommended. The pa- tient’s strength rapidly increased, and he was afterwards perfectly restored to health. In many other cases under Perroncito’s care the same excellent results followed. This success has been acknowledged by Dr. Bugnion in his admirable paper published in the Brit. Med. Jour, for March 12, 1881. Like Wucherer, Dr. Perroncito had to encounter much opposition. The tunnel disease was referred by his oppo- nents to any cause rather than the true one. At length, says Dr. Bugnion, the parasitic character of the malady was irresistibly recog- nised when ‘Dr. Sonderegger had treated a young engineer of the works. The patient showed all the symptoms of Egyptian chlorosis ; and after having taken santonine with calomel, evacuated the anchylostomes in large numbers.’ The writer has encountered similar opposition in re- spect of certain destructive animal epidemics, which he has found to be caused by strongyloid and other parasites. Further confirmation of the truth of Perroncito's determinations was afforded by cases under the care of Professor Biiumler, Dr. Schonboehler, and Dr. Damur respectively. Particulars of these cases are SCROFULA. 1399 given by Dr. Bugnion, who also concludes hia interesting paper by the surprising statement that ‘in the report published in June 1880 by Dr. Sonderegger, who was retained by the Federal Government, of the bodies in 117 cases of death only a single examination was made.’ The conduct of the authorities of Airolo in re- fusing the necessary post-mortem inspections was certainly most reprehensible. T. S. CoBBOLD. SCLEROTIC, Diseases of. See Eye and its Appendages, Diseases of. SCORBUTUS. — A synonym for scurvy. iS*« Scurvy. SCRIVENER'S PALSY. — A synonym for writer’s cramp. See ’Writer’s Cramp. SCROFULA (scrofa, a sow). — Syn'on. : Fr. Scrofule ; Ger. Scrofeln . — If we would raise the true doctrine of scrofula we must build upon the foundations of the ancients. The Hippocratic choirades (xoipdSes), struma vera, or glandular scrofula, should ever be the criterion or note of what is scrofulous. Guided by this principle, we may extend the use of the word scrofula far beyond its ancient limits, without any fear lest the mean- ing of the term should become proportionally vague and indefinite. In the first place, struma vera will be to us the sign of a present and an- tecedent strumous diathesis, or special disposition to this form of disease. In the next place, upon the strumous diathesis, thus signified, will be found to depend many forms of disease other than glandular. And for this very reason, because the meaning of the word scrofula can be thus widened, it becomes highly important that the criterion, note, or principle itself should be well defined and understood. I. Struma Vera: Scrofulous Lymphatio Glands. Anatomical Characters. — Matthew Bailiie writes thus : ‘ The most common morbid affec- tion of the absorbent glands is scrofula. In this case the glands are frequently a good deal en- larged, and sometimes feel a little softer to the touch than in a healthy state. When cut into, they sometimes exhibit very much the natural appearance ; but it is more common to find that some of them contain a white, soft, cheesy matter, mixed with a thick pus : this is the most decided mark of a scrofulous affection.’ But this cheesy change is a late stage of the strumous affection. Scrofulous glands, which are only potentially, but not actually, cheesy, present to the naked eye very much the natural appearance, as Bailiie says. If we take a chain of lymphatic glands, all somewhat enlarged, but only some of them cheesy, we should expect to find the earlier stage of the strumous lesion in the glands which look most natural. These ap- parently natural lymphatic glands, therefore, are those which we choose for examination first of all. Virchow taught that the primitive strumous lesion consisted in a simple hyperplasia of tha gland-tissue. But to Schiippel (1871) belongs the merit of having proved that a scrofulous gland is indeed a tuberculous gland. In the earlier stage of the lesion, the gland is studded SCROFULA. 1400 n-ith microscopic tubercles, possessing characters described in the article on tubercle. And the sub- sequentchanges, cheesy and other, which thegland undergoes, are due to changes in the tubercles. [See Scrofula by Mr. Treves, Lond. 1882.) Symptoms. — In the living person strumous lymphadenitis may be distinguished from what we may call genuine lymphadenitis. The first character of the scrofulous disease consists in an excessive irritability or inflammability of the glands, constituting what Thomas White long ago called an ‘ inflammable diathesis.’ Vulnerability is a word employed by Virchow to signify the same peculiarity, which may as- sume two forms : namely (i.) that the inflam- mation is much greater in a scrofulous per- son than in a healthy person, under the same conditions; and (ii.) that glands, wdiich in a person not scrofulous, would not inflame at all under the circumstances, in a strumous person do inflame. Another character of the scrofulous disease consists in its obstinacy, intractability, pertinacity. Once enlarged, ihe strumous gland remains enlarged for a long time. The reason of this lies in the nature of the scrofulous inflamma- tion and its products. A genuine lymphadenitis, in a healthy person, will resolve, suppurate, or organise in a short time. In struma vera, reso- lution, suppuration, and organisation take place very slowly, even when they take place at all. Commonly the inflammatory products remain, where they were produced, inert and passive, and sooner or later undergo the cheesy change. Hence the intractability of strumous lymphadenitis. II. Antecedent Scrofulous Lesions. — Lymphatic glands do not enlarge spontaneously. There is always some antecedent lesion which sets up a change, similar to itself, in the asso- ciated glands. Of all tissues of the body, the lymphatic is the most embryonic, the least dif- ferentiated or organised. For this reason it is also the most plastic of all tissues, and endowed with most potentiality. A venereal sore causes a venereal bubo, cancer causes cancer, and so forth. Let ns inquire into the characters of the lesions which precede and cause the strumous or tuberculous lymphadenitis. In general, these primitive lesions are also inflammatory. And inflammations being com- monly the result of injury, we might expect these primitive inflammations to be usually seated in those parts of the body which are most directly subject to injury. Such is the ease. The skin, the mucous membranes, the subcutaneous connective tissue, the bones, and- the joints are the most frequent seats of the original scrofulous disease. Occasionally the primitive lesion affects the solid secreting glands, especially the kidneys and the testicles. The distinguishing characters of these primi- tive lesions are those common to all strumous inflammations, and those peculiar to the special inflammation. 1. The common characters of scrofulous inflammation have already been partly enumerated with respect to the lymphatic glands. Functionally, vulnerability and obstinacy mark the primary as well as the secondary lesions. Structurally, the chief peculiarities are found in the inflammatory product. This, when fresh, is rich in cells, which are much larger than the corpuscles of a genuine exudation, and which consist of a dim glistening protoplasma, and a large nucleus, either single or double ; in short, epithelioid cells. Scrofulous exudation is either infiltrated, diffused, and assuming no particular shape ; or it is tubercular. And lastly, it is re- bellious, and resolves, suppurates, or organises slowly and imperfectly. The defective vascu- larity of strumous products will account in part for thpse peculiarities. 2. The special charac- ters of scrofulous inflammations can only briefly be alluded to. In the skin, the most character- istic lesions are those which the French school have called scrofulides. The common dermatitis, or eczema, is modified when it occurs in a scro- fulous person : eczema impetiginodes, in parti- cular, often shows the characters of vulnerability, obstinacy, and recidivity, and of an exudation rich in cells. Impetigo of the eyelashes (tinea tarsi), and otitis externa are common strumous diseases. In the mucous membranes scrofulous inflammations possess similar characters. The secretion is sticky, rich in cells, and tending to form scabs. The mucosa, according to Rind- fleisch, is infiltrated with an exudation, some- times so copious that the corpuscles form a com- plete layer beneath the epithelium, and reach deeply- into the submucosa. Actual tubercles may form, and intractable ulceration may follow upon the exudation, whether diffused or tuber- cular. Ophthalmia, coryza, ozsena, angina faucium, otitis interna, laryngitis, bronchitis, enteritis, pyelitis, cystitis, vaginal and vulvar catarrh, are common forms of strumous inflam- mation of mucous membranes. In the connective tissue scrofulous disease possesses the same cha- racters, which need not be narrated again ; slow cold abscesses, which will neither discharge nor disperse. Besides abscesses, local exudations, which are equally obstinate, but which go no further than a chronic oedema or induration, are often present in the subcutaneous tissue of scro- fulous persons ; the lips and eyelids are affected thus with especial frequency. Scrofulous arthri- tis, osteitis, and periostitis are described under their appropriate articles. Lastly, the lungs, kidneys, and testicles may be the seat of primi- tive strumous disease. III. Tertiary Scrofula.— We have traced struma backwards from the secondary lympha- denitis to the primary lesion. We must now assert that scrofulous disease may be dissemi- nated over the whole body, in a manner precisely similar to the dissemination of cancer in its last stage. This disseminated or tertiary scrofula is nothing else than general tuberculosis. The tubercular dyscrasia, approached from our pre- sent point of view, is tertiary scrofula. See Tubercle. IV. The Scrofulous Diathesis. — Strumous lesions imply the existence of a strumous dia- thesis, or special disposition to strumous disease. Upon this topic we will ask three questions: How may the strumous diathesis be recognised? What is the strumous diathesis in itself? and What are its causes ? 1. The strumous diathesis may be detected in two ways — directly or indirectly ; it may be mani- fested by the patient himself or by his kindred. The latter or indirect means of discovering SCROFULA. icrofula depends upon a fact in aetiology, to wit, the strongly hereditary nature of this dia- thesis. 1. Struma manifests itself in the patient him- self, in the first place, by means of the charac- teristic lesions which have been already enume- rated; and secondly, by means of the phlegmatic temperament. Now the doctrine of tempera- ments, however true we may feel it to be, seems to lie beyond the power of exact definition. With regard to the phlegmatic or lymphatic temperament more particularly, we may say that its chief characters seem to consist, structurally, in a defect of blood, and an excess of serum, lvmph, or phlegm ; and functionally, in languor. But although scrofula is especially common in the phlegmatic temperament, the phlegmatic tem- perament does not necessarily imply scrofula; and, moreover, scrofula maybe met with in san- guineous and melancholic temperaments. So that, as was afore said, it is not possible to lay down any definite rule upon this topic. ii. Struma, manifesting itself in the kindred of a person, may be deemed a proof that the person akin possesses the same diathesis. In the first place, his kindred may be known to have suffered from strumous diseases. In the next place, a great mortality in the family would probably be due to the strumous diathesis, since no other diathesis can compare with it in highly hereditary character, and in the large number of dependent fatal lesions, occurring at all ages. 2. Of the intimate nature of scrofula we know very little. When we ask what that property is which serves as bond of union between the dia- thesis and its manifestations, and between those manifestations among themselves, we cannot say more than that scrofula is a special form of constitutional weakness, debility, or degeneracy of mankind. We do not know what determines the special form, nor what are the relations between struma and other degenerate habits, such as bronchocele, leprosy, cancer. The scrofu- lous debility or defective vitality manifests itself chiefly in two ways. First, in a defective power of resistance to external influences ; hence the vulnerability of strumous persons. Next, in a defective power of growth and development ; a defect which shows itself not only in the inflam- matory process (constituting obstinacy, intrac- tability), but also in the delayed or defective growth of some or all parts of the body. This opens up the whole topic of malformations, con- genital idiocy, delayed developments ; but at pre- sent experience hardly carries us any further. 3. ./Etiology is another weak part of the doc- trine of scrofula. In this place it is not possible, and under any circumstances it would hardly be profitable, to do more than set down a few general propositions. Whatever lessens health and strength tends to beget scrofula ; and tends to beget it, not so much in the enfeebled person himself, as in his offspring. Once produced, struma is highly hereditary. The latter two propositions, taken together, express the fact that the scrofulous diathesis is commonly con- genital. Among the anti-hygienic conditions in the parent, which tend to manifest themselves as scrofula in the child, must be mentioned con- stitutional syphilis, and the age of the parents SCURVY. 1401 at the time of conception, either too advanced or too youthful. Congenital scrofula does not often show itself during the first year of life. From the second year onwards, during the whole period of growth and development, strumous diseases are very common. After middle life they become less common ; yet a strumous person may mani- fest his diathesis even in extreme old age. Treatment. — The treatment of scrofula is preventive and curative ; and relates, moreover, to the strumous disposition and the dependent structural lesions. The prevention of the dis- position clearly consists in avoiding the predis- posing and exciting causes thereof. Its cure is to be sought in carrying out the rules of health: fresh air and sunlight are especially needful (see Personal Health). Iodine, once thought to be a specific, has much sunk in repute; cod-liver oil ought perhaps to be reckoned foocl rather than a drug. The cure of the local lesions does not only relate to the sundry lesions themselves, but is also a means of preventing further development of the disease. Cure and prevention thus go hand in hand. The treatment of the primary local inflammations will be found in the appro- priate articles. With regard to the glandular abscesses and phlegmonous scrofulides — the chief sources of general tubercular infection — it would seem to be more reasonable to favour an out- ward discharge of the matter, than to strive to promote its absorption. Scrofulous bones have been removed with the same intention. S. J. Gee. SCURF. — A popular name for the furfur or bran-like exfoliation which forms at the roots of the hair. It is also called dandruff. It is com- posed of the normal desquamation of the epi- dermis of the scalp, with the addition of the epithelial exuviae thrown off by the hair- follicles. See Pityriasis, SCURVY. — Synox. : Scorbutus ; Fr. Scorbut ; Ger. Scharbock. Definition. — Scurvy is characterised clini- cally by intense general debility; sponginess and swelling of the gums ; ecchymoses, closely resembling bruises, about the thighs and legs ; a brawny hardness about, and sometimes a con- traction of, the muscles of the calf; pearly con- junctivae ; and a sallow aspect somewhat akin to mild jaundice. From a pathological point of view the disease is characterised by effusion of a semi-organisable fibrinous material in the tissues of the gums, between the strise of the muscles of the thighs, legs, and sometimes (but comparatively seldom) of the arms, and also between the periosteum and the bones of the extremities, and occasion- ally of the ribs; ecchymoses sometimes found about the thoracic and abdominal aortie and the alimentary canal ; and a generally blanched con- dition of all the tissues. ./Etiology. — Scurvy is, in an eminent degree, cosmopolitan. It may prevail in a mild or severe, an intermittent or endemic form, in any lati- tude, in any country, or among any variety of the human race, inasmuch as the predisposing and exciting causes may exist anywhere under certain circumstances. War, famine, shipwreck, or any other accident or exigency that deprives SCUKVT. 1402 human beings for a length, of time of fresh vege- table food, is sufficient to introduce scurvy into a community. Although very vaguely described by Hippocrates and other early writers, there is no doubt that in semi-civilised and savage countries scurvy was endemic. Most military historians, who have chronicled the sanitary circumstances of armies from the thirteenth century to the date of the last American war, speak of its ravages, and in the early months of the Crimean War the French lost more men by scurvy than by the guns of the enemy. It has also from the earliest times been a chief foe to sailors, and until the beginning of the seventeenth century, it constituted a formidable item in the mortality list of the navy, in this as in other countries. In the spring of 1810, an outbreak of the dis- ease occurred among the prisoners at the Mill- bank Penitentiary, and was confine! exclu- sively to the military sections of the inmates, whose diet differed in one important respect from that of the other convicts. The last ex- tensive outbreak on land, other than those that have arisen in consequence of war, occurred in Ireland during the potato famine in 1847, when th« inhabitants suffered severely. Since, how- ever, the prophylactic properties of a vegetable diet have been understood, scurvy, except in times of war, has — unless under very exceptional and always preventable conditions — ceased to assume formidable proportions either ashore or afloat. It is indeed in civilised communities very rarely found on land. It is almost extinct in the Eoyal Navy, owing to the introduction of lime- and lemon -juice, and also to the greater variety in the scales of diet ; and during tire last eight years it has diminished in the .British Mer- cantile Marine, by from seventy to eighty per cent., in consequence of legislative enactments that secure a proper quantity and quality of antiscorbutics to the crews of all long-voyage ships. Cases of the disease are still seen occasionally at the Seamen’s Hospital at Green- wich, usually associated with some other disease, as dysentery, ague, etc. ; hut in some instances clearly caused by carelessness, either on the part of the captain in serving, or on the part of the crew in not taking, the lime-juice provided. Pathology and Anatomical Characters. — Although the aetiology of scurvy is so well under- stood, yet we are still in ignorance of the pre- cise nature of the alterations of the blood and tissues which precede aud accompany the deve- lopment of the disease. The most important contributions hitherto made to our knowledge of the pathology of scurvy are those of Mr. George Busk and Dr. Garrod. The former, in a series of analyses made of the blood drawn from scorbutic patients, showed that there was a con- siderable diminution of the red blood-corpuscles, an increase in the amount of fibrin and albumen, and no deci'easo in the amount of potash salts. Dr. Garrod observed that in scorbutic diets potash existed in smaller quantities than in anti- scorbutic ones, and was led to determine the amount of that substance in the blood and urine of a patient suffering from scurvy, and he found it considerably diminished. From this observa- tion, he brought forward the theory that scurvy depended upon a deficiency of potaRh in the system. The fact that potash is diminished in the urine of patients suffering from scurvy, has been confirmed by Ralfe and others. But it is doubt- ful whether the disease is produced by a de- ficiency of that base in the system, since the administration of large quantities of beef-tea, containing more potash than in the ordinary anti-scorbutic dietary of the Seamen’s Hospital, fails to exercise a curative effect, and it is not till the patient obtains lime-juice or potato that he recovers. Dr. Buzzard considers that, although the organic acids and potash separately do net represent the requisite material, it is to be found in the chemical combination of the acid and the base. Dr. Balfe, from observations founded on the effect which the withdrawal, for a considerable period, of all fresh succulent vege- tables and fruits has on the urine of healthy persons, and from the analyses of urines from patients suffering from the (disease, states that the ‘ primary alterations in scurvy seem to depend on a general alteration between the various acids, inorganic as well as organic, and the bases found in the blood, by which (a) the neutral salts, such as the chlorides, are either increased relatively at the expense of the alka- line salts; or, (6) that these alkaline salts are absolutely decreased. This condition produces diminution of the normal alkalinity of the blood, and he suggests that this diminution produces the same results in scurvy patients as happens in animals when attempts are made to reduce the alkalinity of the body (either by in- jecting acids into the blood or feeding with acid salts), namely, dissolution of the blood- corpuscles, ecchymoses and blood-stains on mucous surfaces, and fatty degeneratiou of the muscles of the heart, the muscles generally, and the secreting cells of the liver aDd kidney.’ The most marked morbid changes of scurvy are the cedematous, spongy, and occasionally ulcerated gums ; the bruised-like condition ol the legs ; and the brawny hardness, confined usually to the gastrocnemius and hamstring muscles. On cutting these across, tough fibrinous effusions are found packed between the muscular strise, giving the cut surface a streaky appear- ance. If tbe anterior surface of the tibia be examined, the same kind of effusion will be often found between the periosteum and the bone. It would appear that the effusion is due, not to the degenerated condition of the vessels, but to a chemical alteration of the blood. In severe cases the ribs will sometimes be found detached from the cartilages, and old frac- tures occasionally become disunited. Beyond a general anaemic condition, and occasional eeehy- motic spots about the pleura and pericardium, the contents of the thorax present no special appear- ances. In examining the abdominal viscera, at- tention should be directed to the spleen, which is usually friable, and often rotten and pulpy ; to the external coats of the intestines, in which patches of effusion will frequently be found; and to tbe mucous coat of the large intestine, which if, as is frequently the case, the disease be com- plicated with dysentery, will be studded with ulcers of varying depth, which have, however, en- tirely lost their dysenteric character, and becomi SCURVY. ragged along the edges, ill-defined, but not, as a rule, very much excavated. The body is not always badly nourished, and the cheeks are usually puffy on account of the swollen gums, hut local or general dropsy is seldom present. Symptoms. — -The most striking features of scurvy are a complexion of sallow, dull, leaden nue, analogous only to that of a patient who has been for a long time subject to attacks of some form of remittent or intermittent fever, or to that of a person recovering from jaundice; pearly- white conjunctive ; puffy and sometimes bloated cheeks; gums spongy, bluish-red in colour, swol- len sometimes to such an extent as to hide the teeth both in front and behind, and tending to bleed; teeth more or less loose, some already lost ; tongue clean and pale ; no special charac- teristic about trunk and upper limbs (though the latter are now and then slightly ecchymosed) ; shortness of breath, but no other chest-complica- tion ; no abdominal tenderness or anything ab- normal as to the functions of the abdominal or- gans ; thighs and legs usually presenting a more or less bruised appearance, particularly justabove and below the knee; brawny indurations of the hams and calves of the legs, often painful and tender ; and the effusions above described may be so dense and abundant as to fix the legs in a semi-flexed position. Node-like swellings are also often observed over the tibia, owing to effu- sions between the periosteum and the bone. There are also usually a large number of spots and patches, very much like those of purpura, scattered indifferently about the lower limbs. There is sometimes considerable oedema about the ankles; but in uncomplicated scurvy, pitting on pressure anywhere is the exception rather than the rule. The bowels are more or less con- stipated, appetite is good, and there is no thirst. The breath has a peculiar offensive odour, and this may be aggravated by ulceration or slough- ing of the gums, or necrosis of the jaw. General debility varies in degree, but may be excessive, with weak voice, and some tendency to fainting, if the patient is put or kept in a sitting position. Ho feels more or less general aching, and a sen- sation of contusion in the legs. The skin is dry and harsh, and desquamates over the legs. Heart and lung sounds are normal. The urine is free from albumin, of normal specific gravity, with abundant chlorides ; urea, phosphates, and po- tash are said to be deficient. Complications and Sequeue. — Simple scurvy is now rarely seen inland (except in times of war or famine), and not very often afloat. It still, however, complicates diseases or accidents that occur at sea to a considerable extent, and so pro- longs convalescence almost indefinitely. A sailor, for example, goes out from England to Calcutta, and shortly after arrival in the latter port is attacked with dysentery or intermittent fever, fractures a limb, or becomes syphilitic. He re- mains in India a very short time, ships in a convalescent and enfeebled condition, lies up before the ship has been at sea many days, and probably does little or no work during the entire passage. The berth that he occupies constantly (and with very little change of clothing) is pro- bably wet, his food scanty and unvaried, and his lime-juice or other antiscorbutics (as he cannot 1403 go to fetch them) served out irregularly, or per- haps refused when given. Under such circum- stances, scurvy soon begins to ‘ colour’ the ori- ginal disease. The intestinal canal in cases of dysentery, the spleen in cases of ague, buboes and chancres in syphilis, are all attacked, so to speak, scorbutically. Wounds, scratches, ulcers, or any other breaches of surface will not heal, and fractures sometimes become disunited; so that, as a consequence, the recovery of the patient after his arrival is deferred (solely on account of the existence of this scorbutic condition) for several weeks or months. In fact, all processes of repair, internally and externally, appear to be arrested, and no advance is made until the scorbutic symptoms have entirely dis- appeared. Hemeralopia is sometimes associated with scurvy, and it may be considered that night- blindness is induced by scorbutic conditions, in- asmuch as this affection has decreased pari passu as scurvy has diminished in the British Mercan- tile Marine, and is now seldom complained of by sailors. In bad cases haemorrhage may take place from mucous surfaces. Nausea and vomit- ing may also occur. The sequelae of uncomplicated scurvy are, practically speaking, nil, for the patient, when properly treated, makes a rapid and complete recovery, leaving no trace of the disease behind. There appears, however, to be little doubt that one illness renders the patient less able to resist successfully future attacks of the disease, if placed under the same predisposing conditions. Several instances are recorded of old sailors, who have been the subjects of two or three attacks; but these have been generally complicated with some other disorder, delirium tremens being occa- sionally superadded. Diagnosis. — The diagnosis of scurvy cannot be difficult if the symptoms described above exist, and a dietetic history is carefully made out. As Parker records, in a very valuable paper published on that subject in the second volume of the Bri- tish and Foreign Medico- Chirurgical Review, ‘ it may be confidently asserted that an invariable antecedent of every case of scurvy is a deficiency or absolute want of fresh vegetable food.’ This important item of information being established, the spongy gums, and the bruised-like condition of the lower limbs (this latter condition not being connected with any history of accident or injury), with great general debility, should be sufficient to determine the nature of the disease. For even in mild cases the condition of the gums is quite unlike that produced by mercury. Moreover, the mercurial feetor is absent, but a foetid, earthy odour exists. Nor has the dull blue margin seen in the gums in cases of lead-poisoning any resemblance to the scorbutic condition. Scurvy might be occasionally confounded with purpura, as in some cases haemorrhagic spots only exist about the legs, with no ecchymoses or hardness round the calf and hamstring muscles. But the condition of the mouth, the absence of severe cachexia, and, as Niemeyer remarks, the compa- rative absence of epistaxis, hsematemesis, hsema- toma, and bloody evacuations from the bowels in scurvy, will aid at once to settle the diagnosis. The disease is now, under ordinary circum- stances, rare among women and children. The SCURVY. 1401 possibility of its existence should not, however, be overlooked. Ur. H. G. Sutton read at the Clinical Societ} 7 , in 1871, notes of two cases of acute scurvy in women, but no particulars as to dietetics are given. Dr. Dickinson had under his care at the Children’s Hospital, Great Ormond Street, a girl, ten years of ago, who was the sub- ject of genuine uncomplicated scurvy, whose diet had for some months consisted chiefly of bread and butter, with no meat, and little or no milk. Single cases are also occasionally noted by phy- sicians, caused for the most part by pursuing strictly a scorbutic regimen, for the purpose ol' combating some other obstinate disorder. Prognosis. — Scurvy existing apart from other maladies is not a fatal disease. The patient may be seen in a state of excessive prostration, with feeble pulse, whispering voice, and a ten- dency to syncope, unless the recumbent position be rigorously maintained ; but a few days’ rest, under favourable conditions, and proper treat- ment, produce a marvellous change, which re- sults in a steady and very satisfactory convales- cence. But before this prognosis is given, care should be taken to ascertain that the scurvy does not cover any other chronic or organic dis- ease. Dysentery, syphilis, and the various forms of intermittent fever, are undoubtedly its worst complications, and either of these maladies will, even under favourable circumstances, prolong convalescence considerably. The duration of the disease is limited only by the vitality of the causes that produce it, for as long as the scor- butic diet and other predisposing conditions exist, so long will the disease maintain the mastery, and progressively increase in severity. M. Villemin, writing on the causes and nature of scurvy, in the Gazette dcs Hopitaux , 1874, says, as the result of experiences gleaned during the siege of Paris, that scurvy is a contagious disease, and should ba classed with typhus. It is impossible, in face of facts recorded both as to sea and land scurvy 7 , to subscribe to this opinion, and it is difficult to understand on what grounds such a dictum can be based. Treatment. — If the patient, w'hen firstbrought under notice, be so ill as to be unable to walk or stand, great care should be taken that the recumbent position is adopted and maintained. Many severe cases of scurvy have been lost by the neglect of this apparently simple precaution. The patient, in the absence of the nurse, sits up in bed, and has a sudden attack of syncope, from which he never recovers. Having regard to this, let the patient be undressed carefully, and washed (without a bath), any wounds or abra- sions being covered with simple water-dressing. The direct treatment of the disease is almost purely dietetic, starting upon the principle that want of fresh vegetable diet has been the ex- citing cause of the illness. So the diet should consist of mashed potatoes ; any variety of green meat (the Cruciferce being perhaps the best) ; oranges, pears, apples; and, as a convenient anti- scorbutic, lime- or lemon-juice at the rate of from three to four ounces daily 7 , mixed with about eight times its bulk of water, sweetened to taste, and used as a drink. Solid animal food should be given at least orce a day, and in liberal quan- tity. as soon as it can be properly masticated. Begin in bad cases with beef tea, mutton broth, milk, eggs, fish and minced meat, in fact, any and all varieties of nutritious animal food, in con- junction with the vegetable diet ; for the appetite is usually good, and the digestive powers almost unimpaired. If great prostration exist, brandy, in small and frequent doses, must of course be given ; but as a general rule, very little is re- quired. Malt liquors are undoubtedly antiscor- butic, and it is well to give a pint of ale or porter daily if no dysenteric complication exist. Milk is also to a certain extent antiscorbutic, and should be given freely 7 . Sir James Paget re- lates of a surgeon that he lived for nineteen years, engaged in active practice, on milk and bread- stuffs exclusively, and at the end of that time only was attacked with scurvy. As regards therapeutics, little or nothing net! be done. All active treatment, general and local, is em- phatically wrong. The administration of mer- cury 7 to scorbutic patients (through errors of diagnosis) did, in former years, an enormous amount of mischief, and, even in the presence of chest-complications, all counter-irritants to the skin must be avoided. Chlorate of potash, in the form of a mouth-wash, or given inter- nally, probably 7 assists to cleanse and purify the gums and mouth ; and if old ulcers or open sores exist upon any part of the body, lint, wetted with weak lime-juice, is said to promote a healthy surface. But whether any complication be internal or external, no processes of elimina- tion or repair will advance satisfactorily until the scorbutic symptoms disappear. If no grave disorder beyond the scurvy exist, recoveiy is very rapid, and few diseases are so eminently satisfactory to treat. The gum-swellings recede, and the ecchymoses on the legs begin to disap- pear after two or three days of treatment ; and the brawny tenderness of the muscles of the lower limbs diminishes daily, the fibrinous effu- sions causing it being steadily and quickly ab- sorbed. Dysentery is the most common compli- cation of scurvy, and is usually tedious 7 and troublesome. A fair trial should be given to the treatment above recommended, excluding malt liquors, and substituting a small allowance of brandy, and as a rule the dysentery and scurvy will disappear together. The antiscorbutic treatment proper to combat the advent of this disease is sufficiently indi eated in the ( above remarks, for it will be plainlj seen that scurvy is due to the absence of certain necessary ingredients in diet. "When these in- gredients cannot be given in the usual form, the mostconvenient substitutes are lime-juice, lemon- juice, and in a minor degree citric acid. Garrod recommends salts of potash, and John Morgan, of Dublin, thinks that phosphorus is deficient where scurvy exists. But the great mass of evi- dence, collected during the last fifty years, goes to prove that lime- and lemon-juice contain, in natural combination, the best and most conve- nient prophylactic elements against scurvy. Its use in the Royal Navy has, since the close of the last century, been chiefly instrumental in driving the disease out of the service; and legis- lative enactments passed in 1867, whereby a proper and genuine supply of juice was secured to all British sailors, have resulted in the deereaw SCURVY. M scurvy in our own Mercantile Marine by from 70 to 80 per cent. Single cases are, of course, occasionally met with afloat, for the disease, al- though almost entirely preventive, will never be practically exteinnnated from the merchant navy until legislators, snip-owners, and ship- masters are convinced that it is commercial economy to send to sea only healthy men. Scurvy will, of course, always be liable to occur in times ot' war and famine ; and among any class of the population the possibility of its existence in single cases, in consequence of dietetic de- ficiencies, should never be overlooked. Hakey Leach. SCYBALA (oKv&a\ov, dung). — Faeces in the form of hard rounded lumps, whether discharged or retained in the intestine. See F;ecf.s, Examina- tion of. SEA-AIR; SEA-BATHS; S E A- V'OYAGES. — The physiological and therapeu- tical effects of sea-bathing cannot be separated from those of sea-air; for it is impossible to take sea-batlis without being under the influence of sea-air; and the stay at the seaside alone, without sea-bathing, produces on many consti- tutions all the effects which are usually ascribed to sea-bathing. Residence at the seaside, that is, the influence of sea-air, is to be regarded as a special kind of climatic treatment, while the action of the sea-bath is analogous to the stimu- lating forms of the cold-water treatment. As the sea-air and the s%a-bath owe part of their properties to the constitution of sea-water, it will be well to begin with the latter, then consider the characters and influences of the sea-air and the sea-bath, and add some notes on seaside watering-places, and on sea-voyages. Sea-water. — Temperature . — The sea-water is of more equable temperature than the surrounding air. It is, as a rule, warmer than the atmosphere in winter, and cooler in summer ; although on chilly days in summer, especially after a series of hot ones, the temperature of the sea-water is often higher than that of the air. Th6 variations of the temperature of sea-water from night to day, and from one day to another, are much less than those of the air. It would, however, be erroneous to assume, as is sometimes done, that the tem- perature of the sea-water near the shore is the same at different times of the day. The writer has often measured it at the Riviera, and the south coast of England, and has repeatedly found it, at one f.m. and two f.m., from 5° to 7° Fahr. higher than on the corresponding mornings at seven or eight a.m. As to the different seasons, the sea-water reaches its highest temperature in summer much later than the air ; and as it loses its heat less rapidly than the latter, it is mostly warmer in autumn and winter than the sur- rounding air, and gives off warmth to the latter. During the sea-bathing season, namely, from the end of May to the beginning of October, the tem- perature of the sea-water at the coasts of Eng- land, the north of France, Belgium, Holland, and Germany, varies in general from about 56° to 72° Fahr., while in the Bay of Biscay and in the Mediterranean it is considerably higher. Constituents.— Sea-water holds in solution a SEA-AIR, SEA-BATHS, &c. 1405 large amount of salts, varying somewhat in different localities, and slightly even in the same place at different times. The Mediterranean is richest, with about 2| to 3§ percent. ; whilst the water at the coasts of the British Channel and German Ocean varies from 2£ to 3£ per cent. The water of the Baltic, owing to the large number of streams which enter it, is much less salt, containing only about £ per cent. Five- sixths of all the salts are chlorides of sodium and magnesium, whilst the remainder consist of the sulphates and carbonates of lime, magnesia, and potash. Sea-air. — The sea-air, and the air at the sea- shore, are considerably influenced by the con- stant evaporation taking place from the sea, and also by the temperature of the sea. Owing to these circumstances, the sea-air contains in general more moisture, relative as well as ab- solute ; and is more equable in temperature, the summer being less hot, and the winter less cold at the seaside than at inland places in the same latitude ; the day also may be regarded as less warm in summer, the night as less cool in winter. A very important fact is the comparative purity of the sea-air from organic admixture and inorganic dust, while the occasional presence of a greater or smaller amount of saline particles cannot be regarded as a disadvantage. The amount of ozone is greater ; that of carbonic acid smaller. The variations of the barometer are greater, but more regular in their occurrence, and this possibly exercises a.beneficial influence on the functions of life. The greater density of the atmosphere, which means a comparatively large amount of oxygen in a given volume of air, is often con- sidered as one of the principal causes of the stimu- lating effect of sea-air; but Frankland’s and Tyndall’s experiments on combustion render the usual reasoning on this point, with regard to combustion and tissue-change, rather doubtful. Nor is the fact to be overlooked that the air at the sea-shore is mostly in greater agitation than the inland air ; and by this circumstance is probably to be explained the experience of Benecke (‘ Sea-air and Mountain-air,’ Deutsch. Arch./. Klin. Med., vol. xiii. p. 80, 1874), that the same body of hot water loses its heat more rapidly at the sea-shore than at various eleva- tions in Switzerland, varying from 3,000 to 6.000 feet above sea-level— an experience from which we may infer that living bodies likewise give off more heat at the sea-shore than in elevated inland regions. The physiological effects of sea-air may be designated, with Braun ( Curative Effects of Baths and Waters, English edition, 187-5, p. 253), as ‘powerful stimulation of the change of substance, both retrogressive and formative, expressed in a striking increase of urea, and decrease of uric acid and phosphoric acid in the urine, in the greatly increased requirements of food, and in the rapid and considerable increase of the weight of the body.’ A certain power of re- sponding to the increased stimulus of the sea- air is, however, required of the constitution ; for the increased tissue-change necessitates an increase in the ingestion of food, and in the processes of excretion of the products of retro- gressive tissue-change. If the digestive and i40G SEA-AIE. SEA-BATHS. SEA-VOYAGES. Assimilative organs be unablo to satisfy the former demand, various digestive disturbances arise, the appetite fails, and emaciation is often the consequence. In many of these conditions greater benefit is derived from mountain health- resorts, where the demands made on the constitu- tion are less great, and where less food is required. If the excretory functions be imperfect, as is the case in so-called ‘bilious’ individuals, and in some undefined gouty tendencies, headaches, giddiness, constipation, or other symptoms usu- ally called ‘ biliousness,’ make their appearance, and sometimes render the removal from the sea-shore necessary, though the use of aperient remedies, reduction in the amount of food, and especially of stimulants, and active exercise at some distance from the sea, often suffice to correct this defective elimination and its con- sequences. In many cases of this kind, however, courses of mineral waters, especially the alka- line, saline, or common salt springs, ought to precede the stay at the seaside. See Mineral Waters. Sea-batlis. — The sea-bath may be regarded as a powerfully stimulating cold-water bath, modified in its action by the saline ingredients ; by the admixture of mechanical particles, or- ganic as well as inorganic; by the varying degree of motion through the waves ; and by the alternation in the exposure of a part of the body to the waves and to the air. We have already discussed the temperature of the sea- water, and the saline ingredients; but the temperature of the surrounding air, and the degree of motion in the air, also exercise a modifying influence on the effects of the sea- bath. The motion of the water varies con- stantly, according to the size and force of the waves, and the effect of the bath to a great degree depends on this point. When the waves are in any degree powerful, the upper part of the body is exposed to the coming, the lower to the receding wave, and the cutaneous nerves are not only influenced by the cold, but also by the force of the water, and by the sand and other substances mixed with it. In a quiet sea these influences are considerably lessened. The alternation of exposure to the water and the air, likewise occasioned by the waves, is peculiar to the sea-bath, and is another source of con- stantly changing impressions on the cutaneous nerves. Bathing-season, and Rules for tjsing it. — The season for sea-bathing varies according to the climate of the locality. Thus it extends on the Mediterranean shores from May to October and even November ; on the shores of the English Channel and German Ocean from J une to Sep- tember and the beginning of October. The time of the day for sea-bathing must depend on the individual, on the weather, and on the tide. Delicate persons ought not to bathe with a perfectly empty stomach ; but also never after a full meal. The duration of each bath is to be regulated according to the constitution of the batter, the force of the waves, and the tem- perature of the water. Weakly persons ought not to remain in the water over half a minute to five minutes, but immersion for one and two minutes is in many such cases all that is useful and permissible, while stronger individuals may remain from five to ten minutes. The bather, we may say in general terms, ought to leave the water as soon as the reaction manifests itself. In many cases, the warm sea-water bath may be recommended with advantage, when the cold sea-bath is forbidden. Indeed, courses of bath- ing in warm sea-water are not sufficiently used in a systematic way, though the medical prac- titioner possesses in them a gentle, manageable, and efficacious means of treatment daring winter as well as during summer. They are in their action analogous to warm common salt-baths ( see Baths ; and Mineral Waters). Unfortunately the arrangements are still very defective at many localities. Some physicians at seaside places are beginning to make more extensive use of them, and with excellent results. The tepid swimming-bath of sea-water we may regard as intermediate between the warm-bath and the bath in the open sea, and likewise as very useful in appropriate cases. With due care it' can be employed also in winter. It offers the advantage of the combination of one of the most perfect modes of muscular exercise, with exposure of the skin to the influences of the sea -water bath. The physiological effects of the sea-baths are similar to those of the sea-air. Abstraction of heat and stimulation of the cutaneous nerves lead to increased tissue-change, retrogressive as well as productive. Increased appetite and in- creased weight of body are usually observed in those who are benefited by sea-baths; while loss of appetite, headache, digestive disturb- ances, and loss of weight are often observed in those who are unable to bear the shock, or the increased demand on the body, or who remain too long in the bath, or take it too frequently. Cases not suited for Sea-bathing.— Persons affected with diseases of the heart, or of the blood- vessels and lungs, with organic diseases of the nervous system, with enlargement of the liver, or with other organic diseases of the abdominal viscera, ought to avoid bathing in the open sea, which may produce most injurious effects, such as violent palpitation and dyspnoea extending over many months, sleeplessness, total loss of appe- tite, and great emaciation. Old persons, and persons with feeble circulation, whether from age or otherwise, ought to avoid bathing in the open sea. excepting on warm days, and with a very quiet sea. Cases to be benefited bt Sea-bathing.— Sea-bathing is useful in many conditions con- nected with weakness or atony of the skin, such as tendency to profuse perspiration, or to taking cold at every change of temperature, or exposure to wind or draught. In scrofulous complaints, long-continued re- sidence at the seaside promises more than other climatic agents ; but, as we have to deal with constitutional defects, and as our aim must be to alter the constitution, two. three, or even more years are often required. In many cases, judicious courses of sea-bathing, the use of warm sea-water baths, and sponging with sea- water, assist the climatic element of seaside residence. Education at schools situated at the seaside offers, in scrofulous children, the greatest advantages. SEA-AIR, SEA-BATHS, SEA-VOYAGES. 1407 Id muscular rheumatism, the moderate use of the sea-bath combined with sea-air is useful. In more recent rheumatic joint-affections the sea-bath is mostly injurious, whilst the more gentle action of the sea-air, combined with the use of warm sea-water in local and general baths, is frequently beneficial. Persons affected with so-called nervous rheumatism — a term which is applied sometimes to hysterical cases, sometimes to spinal irritation, and also to rheumatism combined with nervous weakness — often derive benefit from the gentle use of the sea-bath, and still more from the sea-air. In some functional diseases of the nervous system, the sea-bath forms an excellent remedy, if it be adapted to the individual case; for in- stance, in hysterical paralysis and other forms of hysteria, in the milder forms of diphtheritic paralysis, and in nervous dyspepsia. It must, however, be borne in mind that many persons, with a tendency to neuralgia, nervous asthma, hysterical convulsions, and other forms of hys- teria, are unable to stand prolonged residence at the sea, especially at the Riviera. In such cases, mountain climates are generally more advantage- ous, during summer and autumn. In many forms of anaemia, when it does not depend on organic disease of the heart and blood-vessels or other viscera, but on direct loss of blood or its con- stituents, on confinement, grief, and imperfect food, on slow and imperfect development, sea- air exercises a good effect. Hence the benefit obtained in many cases of amenorrhcea, chlorosis, and allied complaints. Often, however, the demauds made by the sea-air on the constitution are too great, and the invalids lose weight; whereas they gain on mountains of moderate elevation. In chronic pneumonia, in the remains of pleuritic effusion, and in phthisis, the sea-air, by its purity and its more equable temperature, is useful ; but as wind is in most cases to be avoided, sheltered localities are essential. Sea-bathing is in this class of cases hazardous. The beneficial effects in whooping-cough, when the first stage is over, are well known. Regarding asthma, nothing can be said with certainty ; some cases of nervous asthma are benefited at the seaside, while others are aggravated ; on the whole the writer’s experience is more in favour of elevated regions than of the seaside. Whenever the effect is not yet known, the recommendation of seaside residence or mounta m-air must be re- garded as a trial ; only in complications with heart-disease, the injurious effect may be re- garded as certain. The advantage to be obtained in tendency to catarrh we have already men- tioned. In addition to the conditions named, there are many which cannot be designated by the name of any disease ; but which are only states of weakness, manifesting themselves in various ways, as inability to sustain mental or bodily efforts, tendency to abortions, to leucorrhcea without any disease, &c. In such states of weakness the stimulating effect of the sea-air, combined with the grand aspect of the sea, are found eminently useful. Seaside Watering-places. — England is re- markably well provided with seaside places, and the different localities offer considerable variety with regard to climate. The east coast, which may he designated as drier and more bracing, is especially to be recommended from the middle of June to the middle of October. The principal places on the east coast are, beginning with the north, Tynemouth, Redcar, Saltburn-by-the-Sea, Whitby, Scarborough, Eiley, Bridlington, Cro- mer, Yarmouth, Lowestoft, Aldborough, Dover- court, Walton-on-the-Naze, Southend, Margate, Broadstairs, Ramsgate, Heal, and Dover. On the south-eastern and southern coast, which may be regarded as intermediate between the eastern and the south-western coast, we have Folkestone, Sandgate, Hastingswdth St. Leonards- on-Sea, Eastbourne, Seaford, Brighton, Wor- thing, Littlehampton, Bognor, the Isle of Wight, Bournemouth, and the Channel Islands. These places differ considerably with respect to the soil on which they lie ; the position — close to the sea or on a cliff; the aspect; and the con- figuration of the locality itself and the surround- ing country. Even different parts of the same place offer different advantages. Thus the lower part of Folkestone, near the lower Sandgate road, is sheltered from the north, by the cliff, while the houses on the cliff itself are more or less freely exposed to the winds from all quarters, and therefore preferable during the summer months. Hastings with St. Leonards is remarkably sheltered from the north, north-west, and to some degree from the north-east winds, and is through this, and through the influence of the sea, some degrees warmer during the late autumn and the early winter months — we may say till February — than closely adjacent but less sheltered places. In the Isle of Wight, the Undereliff, with Ventnor and Bonchurch, is shel- tered by the hills from north and north-east winds, like Hastings, and more so ; and has during winter a more equable and a higher tem- perature than other parts of the island. The Undercliff is therefore more adapted for climatic treatment during the colder part of the year ; whileSandown, Shanklin, Cowes, Ryde, Alum Bay, and Freshwater are more suited for sea-bathing and climatic purposes during the warmer months. Bournemouth is sheltered as well by the configu- ration of the hills as by the pine-woods, which serve as a protection from violent winds. On the south-western coast, which may be regarded as somewhat moister and more sedative, Swan- age, Weymouth, Sidmouth, Budleigh Salterton, Dawlish, Torquay, Teignmouth, and Penzance are the principal sea-bathing places, amongst which Torquay may he regarded as the most important winter health-resort. On the North Devon coast we may name Lynmouth, Hffa- combe, and Minehead ; on the Bristol Channel, Weston-super-Mare, Portishead, and Clevedon ; on the Welsh coast, Tenby, Aberystwith, Pen- maenmawr, Llandudno, Rhyl ; and in Lancashire, Westmoreland, and Cumberland, Grange, shel- tered by configuration, Southport and Blackpool. Fleetwood, St. Bees, and Silloth. Scotland likewise offers abundant localities for sea-bathing, the most frequented of which are Nairn on the east coast, Rothsay in Bute, Ardrossan near the firth of Clyde, and the Isle '.f Arran on the west. 1408 SEA-AIR, SEA-BATHS. SEA-VOYAGES. Ireland is even richer, ^vith Bray and Kings- town, near Dublin ; Duneannon and Tramore on the south coast; Rostrevor and Fortrush further north; Bundoran in the north-west ; Kilkee in the south-west; and Queenstown, a sheltered and warm, but moist, climatic health-resort in the south, where are also Youghal and Bally- cotton. On the north coast of France, Calais, Boulogne, St. Valery, Treport, Dieppe, Etretat, Fecamp, Havre, Trouville, Deauville, Villers-sur-Mer, and Dinard, are the most favourite resorts; on the south-west, Arcachon and Biarritz ; and on the south, Marseilles, Cannes, and Nice. The west and south-west coasts of Italy possess many good localities for sea-bathing for those requiring, or at all events bearing heat, such as Bordighera, Alassio, San Remo, Castellamare, Sorrento, and the islands of Capri and Ischia. On the coast of Belgium, Holland, and Ger- many the most important localities are Blanken- berghe, Ostend, Scheveningen, Borkum, Norder- ney, Baltrum,Langeroog, Spikeroog, Wangeroog, DaDgast, Cuxhaven, Wyk, and Westerland. The coasts of Norway, Sweden, and Denmark offer likewise good opportunities for sea-bathing, combined with bracing soa-air, from July to September. Sea-voyages. — Sea- voyages have from remote antiquity formed a mode of treatment in chronic diseases, especially of the respiratory organs, and have more lately been much recommended in the treatment of consumption and scrofulous affec- tions ; but the different influences to which the invalid is exposed on long sea-voyages are but little appreciated in their details by the majority of the public, or by medical men. The essential advantages which are generally ascribed to sea-voyages are the enjoyment of perfectly pure sea-air, abundance of light, and free exposure to the sea-breezes ; absence, or at all events great limitation, of bodily exertion ; and the probability of psychical repose. The un- initiated frequently regard these advantages as more or less fixed and, so to say, measurable qualities, and speak of sea-voyages in the same way as of sea-bathing, cold-water treatment, mineral-water cures, or mountain climates. The advantages of sea-voyages are, however, by no means fixedqualities, and they are often mixed up with unfavourable influences, such as bad weather, sea-sickness, improper food, &e. In every-day life it is an acknowledged fact, and not less so in all climatic cures, that the house in which the invalid lives exercises a most powerful influence on his chance of regaining and maintaining his health ; and that the house alone often mars the effect of the best adapted climatic change. In the same way the floating house, the ship, with its arrangements, forms one of the most impor- tant elements in the compound agent ‘ sea-voyage.’ The arrangements of ships, however, are no- toriously often very imperfect, and the narrow cabin never stands comparison with a good bed- room, the only counterbalance to this drawback often being that the invalid is forced to be the whole day long on deck, that is, in the open air, in order to escape from the confined state of the cabin. By this circumstance alone, however, the majority of the more serious cases ought to be excluded from sea-voyages in ordinary shipg, as they cannot be easily moved from the cabins to the deck, and vice versa. The hygienic conditions of the ship, the space allotted to each passenger, the ventilation of the rooms, the arrangement of the decks, must in every case be a matter of care- ful enquiry ; but it would require too much space to enter into the details in this place. There are iron and wooden ships, steamers and sailing vessels. The iron ships have the advantage of being easily kept clean and free from smells, but they are apt to become very hot under the influence of the tropical sun. The sailing vessels can be kept more free from smoke and dust ; but they are dependent on wind, and if they meet in the tropics with perfect calms (doldrums), the pas- sengers may have to endure intolerable heat for several days and possibly weeks. The combina- tion, therefore, of sailing power for ordinary con- ditions, with steam to be used only incase of need, would appear to possess the preference for ships to be used for therapeutic purposes (invalid ships). A second point of paramount importance for every delicate person is the food, and. in this re- spect again the ship-life on long voyages is less advantageous than the life in well-supplied health- resorts or at home. Although the food on first- rate ships is now much improved, compared with former times, yet it is impossible to offer the same variety, or the same delicate cooking, as in first-class hotels or private establishments. A certain amount of monotony in food is scarcely to be avoided, and invalids with a delicate appe- tite ought therefore not to attempt long sea- voyages, excepting under very favourable cir- cumstances, as, for instance, on large privato yachts provided with good cooks. Sea-sickncss, or rather the degree of liability to sea-sickness, depends on peculiarities of con- stitution, which are only to be recognised by ex- posure to the influences of the open sea in differ- ent states of agitation. Sec Sea-sickxbss. We have given, under the head of sea-air, the prominent qualities of sea-climates ; but the most cursory consideration of the climatic conditions to be encountered in a long sea-voyage, shows that there must be great differences between the physiological and therapeutical influences of sea- climates in latitude 50° and in latitudes 15° and 5°. The air in the tropical regions has a much higher temperature and a larger amount of absolute moisture ; the atmospheric movement is, as a rule, though by no means always, slighter ; the baro- metric pressure is somewhat less in the tropics than in the temperate zones ; and the daily and annual variations of atmospheric pressure are greater in the former than in the latter. There is also a difference between the same degrees ot latitude on the north and south of the equator, the temperature in the southern hemisphere, for instance, being somewhat lower than in the northern, but these differences are comparatively small. The effects of the climatic conditions of sea-life in different latitudes on the constitution are very complicated. "We will here only point tr. a few facts, namely, that in some delicate consti- tutions the functions of life are performed more easily under the influence of greater heat; that many delicate persons can eat and digest better, are able to take more exercise, sleep better, and SEA-AIR, SEA-BATHS. SEA-VOYAGES. 1409 their mental functions are more active under the same circumstances ; but that in the majority of average persons continued great heat produces lassitude, a tendency to diarrhoea and other diges- tive derangements, and imperfect sleep. Further, that in most individuals the bodily temperature rises above the natural heat (in general about Fahr., and in some persons as much as 2° and 3° Fahr.) ; and that pulmonary haemorrhage occurs more frequently under high than under ordinary degrees of heat. Morbid states accompanied with pyrexia and with a tendency to pulmonary haemorrhage ought therefore not to ‘be exposed to tropical heat. The climatic conditions- to be met with in different voyages through the same regions vary at different seasons, but they vary still more in voyages through different seas, especially ac- cording to the longitude and latitude. Our knowledge of different sea-climates, that is, of the different climatic conditions in different parts of the ocean, is as yet not perfect. Hr. Faber, in a communication ‘ On the Influence of Sea-voyages on the Human Body,’ Practitioner, March 1876), shows that the equability of sea-climates is by no means so complete as is generally assumed ; and that great changes in temperature and atmo- spheric movements occur not rarely on successive days, and even on the same day. Therapeutical Uses. — The opinions of differ- ent writers on the therapeutic value of sea- voyages in the treatment of disease vary con- siderably. In the last century Gilchrist revived the practice of sea-voyages, and strongly recom- mended them in cases of phthisis. In more recent times Jules Rochard, the well-known French climatologist, has collected a large body of evidence from the French Navy to dispel the faith in sea-voyages ; but we must bear in mind that the hygienic condition in which the sailors used to live were not perfect, and are no doubt inferior to those of well-arranged private ships of the present day. Dr. Walshe, on the other hand, is in favour of well-planned voyages. The majority of physicians entirely, or almost entirely, confine themselves to diseases of the respiratory organs in recommending sea-voyages ; but their therapeutic field is no doubt much larger, and the result is probably more generally favour- able in some other complaints. 1. Phthisis . — The writer has had the oppor- , tunity of witnessing the effects of sea-voyages of two to seven months’ duration, in twenty-one cases of phthisis in the first or the beginning of the second stage. Of these twenty-one cases ten benefited considerably, six remained stationary, five became worse. The voyages were all either to the Cape of Good Hope and. back, or to Aus- tralia and New Zealand and back, between the months of September and May. Of the five bad results three occurred in patients who went to Australia and India and back, with scarcely any rest on land ; they seemed to have gained in the first part of the journey, but more than lost the gain in the latter part, apparently from dislike of food, from the monotony of the life, and from exhaustion. In seven cases of phthisis in the second stage the result of sea-voyages was favourable only in 2, indifferent in 2, bad in 3 tascs. In 4 cases in the third stage the result 89 was bad in 2, indifferent in the two others, which latter were stationary or ‘ quiescent’ cases. The writer has also notes of 4 cases of phthisis in the first and the beginning of the second stage, where long summer voyages (namely, from three to five months) with whalers to the northern seas, wero tried, the result being favour- able in 3 cases, unfavourable in 1, apparently through inability to bear the want of variety in food. 2. Laryngeal and bronchial catarrh and asthmst^ In simple chronic catarrh of the larynx sea- voyages, or cruising in yachts from this country to the Mediterranean, to the Azores and Ma- deira, had very good results in 8 cases out of 9. Satisfactory was also the effect of a similar plan in 7 cases of chronic bronchial ca- tarrh. In a tendency to bronchitis from pulmo- nary emphysema the benefit was likewise evident in 7 cases out of 8, but here the effect was, from the nature of the circumstances, less permanent,. Of 6 cases of asthma, 2 cases of a bronchitic kind were benefited; 2 of a nervous character aggravated ; and 2 were neither better nor worse. Eight cases of hay-asthma were, while on the high seas, quite free, but those who returned while the complaint was still in season, were immediately attacked. 3. Scrofula. — In 9 cases of scrofulous affections (caries of bones, affections of joints, glandular swellings and ulcerations) one or several long sea-voyages were tried ; in 6 of them the effect was quite satisfactory, in 3 less decided. 4. Vesical disease. — In 3 cases of irritable bladder sea-voyages on yachts in warm climates have likewise proved useful. !>. Cardiac disease. — Decidedly injurious was the effect of sea-voyages in 5 cases of dilatation of the heart, combined with chronic bronchitis. In 2 cases of enlargement of the liver, connected with weakness of the heart, the result was like- wise unsatisfactory. 6. Shin-disease. — Chronic eczema was, in d cases out of 6, aggravated by sea-voyages. 7. L’eri'ous disorders. — In 4 out of 6 cases ol mental irritability, long sea-voyages, especially in yachts, had favourable results ; in the oth the mental condition was aggravated ; in the 6th great improvement of the mental state was obtained, but this was accompanied by considerable exhaus- tion, from inability to take a sufficient amount of food. Of 3 cases of melancholia 2 were ap- parently cured, the third remained uninfluenced. In 4 cases of locomotor ataxy, in the earlier stage, cruising in comfortable yachts in the Mediterranean, with occasional landing, during the autumn, winter, and spring months, has been very’ beneficial ; in two of these the disease has apparently been arrested, by persevering with this course during five and six years. 8. Dipsomania. — Finally, the writer has tried long sea-voyages in yachts in five cases of dipso- mania, stimulants having been entirely excluded from the dietary. In one of these cases the re- sult appears to be permanently good ; in the four others it was good for the time with regard to the state of the body’ as well as of the mind, but there were relapses, which in two of the cases have led to several repetitions of the trial, each time apparently with more lasting, but as yet 1410 SEA-AIK, SEA-BATHS, &c. aot permanent, result. Well-arranged sea-voyages deserve therefore, at all events, a place in the management of this most terrible affection. Conclusions. — From a comparison of these ex- periences with those of other observers, the writer is inclined to infer that, under favourable cir- cumstances, sea-voyages of not too long duration may be rendered beneficial in the early stages of phthisis. The voyage to Australia and New Zealand and back, after a stay of a few months in these climates — Hobart’s Town, in Tasmania, for instance — specially recommends itself. The in- valids referred to left in the second half of Sep- tember, or in October or November, and' returned in May or June. In this way the more unfavour- able seasons of England are avoided, and instead of the short and sunless days, long and bright ones are obtained. To go to Australia and to return immediately has proved exhausting in several instances. Another good plan is to go to the Cape of Good Hope, and ascend in easy stages, by diligence and bullock-carts, to the higher regions (Bloemfontain, for instance), and to return after a stay of three or four months or more. This plan, however, is rather expen- sive ; and it requires a considerable amount of bodily strength, and the inclination to stand a certain amount of roughing with regard to accommodation and food. The voyage to the northern seas requires a peculiar mental disposition, and would, under the present conditions, be resorted to only under ex- ceptional circumstances ; but it has been very beneficial in the three cases of early phthisis mentioned— all of them possessing a satisfactory fund of strength, combined with love of sea-life and a good digestion. The combination of yachting in the Mediter- ranean, and residence at one or several of the health-resorts of those regions, or with a visit to Upper Egypt, has repeatedly proved successful in cases under the observation of the writer, not only in pulmonary invalids, but also in cases of mental irritability, exhaustion, chronic rheu- matism, and gout. This plan, however, is some- what expensive. In hay-asthma sea-voyages during the season of the aomplaint are to be recommended; but in other forms of asthma the result is uncertain, and the advice should not be given without con- sideration of all the circumstances. In some forms of mental irritability, and in the earlier stages of locomotor ataxy, sea- voyages, and especially yachting, in the subtropi- cal regions, offer many advantages, particularly during the colder and damper seasons of our climate, as it allows of the combination of the enjoyment of sun, light, and pure air, with rest of body and mental repose. In slighter forms of .mental irritability or overwork shorter voyages ,are often sufficient, and even preferable ; and the voyages to Madeira, to the West Indies, or to Brazil and the Biver Plate, may thus be recommended during the colder season. Dipsomania and other morbid passions may ! be treated with great, advantage by sea-voyages sand yachting, provided that stimulants and the other injurious influences which the weak per- ■son is unable to resist, can thus be entirely re- moved. SEA-SICKNESS. The time may come when we shall have Mero- peut icsh ips, speci ally arranged for different classes of invalids. If would, for instance, not be wise to mix those suffering from dipsomania with sick persons to whom a moderate amount of stimu- lants is useful. CIRCUMSTANCES COUNTER-INDICATING SeA-VOY- ages. The circumstances which render it neces- sary to avoid sea-voyages are: — 1. Unconquerable sea-sickness. 2. Great temporary or permanent weakness and exhaustion. 3. Permafient delicacy of appetite, with ina- bility to become accustomed to a certain mono- tony of food, or to a certain coarseness in the preparation of food. 4. Inability to bear the glare of the sea, as it occurs in tendency to glaucoma. 5. Persistent sleeplessness while at sea. 6. Dilatation and weakness of the fibres of the heart, with or without valvular disease. 7. Enlargement of the liver, especially when caused by dilatation of the right ventricle. 8. Advanced stages of consumption, unless the affection be quite stationary. 9. Morbid conditions -with a tendency to pyrexia. 10. A tendency to haemorrhage. It is the influence of great heat that ought to be avoided by the two classes of cases last men- tioned. A voyage through tropical seas, espe- cially in sailing ships, might prove dangerous in such subjects, from the possibility of being becalmed. 11. A tendency to epilepsy or maniacal fits. This ought specially to contraindicate sea-voyages to tropical climates. For further information regarding sea-voy- aces, reference may be made to The Ocean as a Health-resort , 1 S80, by Mr. William S. Wilson ; and further to a treatise on sea-voyages, by Dr. Faber of Stuttgart, which is issued as a part of Von Ziemssen’s Handbueh dcr AUaemcinen Thera pic. Hermann Weber. SEA-SICKNESS. — Synon.: Fr. Mai it mrr ; Ger. Scckrankhcit. Definition. — A peculiar functional disturb- ance of the nervous system, produced by shock, resulting from the motion of a ship. The most prominent symptoms are a state of general de- pression, giddiness, vomiting, and derangement of the bowels and of the urinary secretion. Pathology. — The immediate, cause of sea-sick- ness is referable to the shock, or series of shocks, to the nervous system, produced by the motion of a ship. A precisely similar condition may fre- quently be induced by any forcible motion for which the individual is unprepared, or to which he is unaccustomed, as the motion of a swing. The nervous system is taken unawares, and is unable to adapt the emissions of nerve-force to the unexpected demands made on it. The mo- mentary displacement of the viscera, especially the stomach, the unusual impression on the vision, and the feeling of insecurity, further con- tribute to die general shock. The action of the heart and of the arteries is deranged through reflex influence, causing giddi- ness from anaemia of the brain, and diminished SEA-SICKNESS. teripheral circulation. The stomach is also af- fected through reflex action, rendering it intole- rant of the presence of any substance, and caus- ing the gastric juice to be actively secreted. The acid secretion acts as a direct irritant to the stomach, and prolongsthe sickness. At length habit enables the nervous system to adapt itself to the new condition of motion, and to overcome the disturbing influence ; shock consequently ceases to be produced ; the reflex derangements of the circulation and viscera, giddiness, nausea, and other disorders, are no longer called forth ; and convalescence ensues. It is not within the scope of this article to notice the many theories which have been adduced to account for sea- sickness, but most late writers attribute it to reflex nervous disturbance. Dr. Chapman's theory is, that there is an undue amount of blood in the nervous centres along the back, producing an abnormally large number of exciting impulses, which cause a copious secretion of mucus in the stomach and bowels, vomiting, and coldness of the extremities from contraction of the minute arteries. Some persons are totally insusceptible to the shock producing sea-sickness. Constipation is probably the result of the want of the gastro-biliary juices and mucus in the bowels, these being vomited; and the diminution of urine may be accounted for, in part at least, by the increased secretion of mucus and saliva. Anatomical Characters. — The writer has only had the opportunity of taking notes of one autopsy in a case of ordinary sea-sickness, in which the patient died suddenly. The appear- ances were those of death by simple syncope, there being no organic disease present. The brain, however, was not examined. Symptoms. — Sea-sickness may be divided into the stages of (1) Depression, (2) Exhaustion, (3) Reaction, and (4) Convalescence. The early symptoms are sudden giddiness, slight at first, but increasing with the motion of the vessel ; and a sense of weight and un- easiness at the epigastrium, speedily followed by nausea and vomiting. At first any food that may have been in the stomach is rejected; and afterwards acid, greenish-yellow, gastro- biliary secretions, often in large quantity, with mucus. Diarrhoea is sometimes present, but constipation is more usually the rule throughout. Tho flow of saliva is increased, while the urinary secretion is lessened. Appetite is lost, even the sight or smell of food being loathsome. The secretion of milk is frequently arrested in nursing women ; in others the menstrual flow is aug- mented. Sea-sick patients are always worse in the morning. Women suffer more severely than men as a rule, while old people and young chil- dren are but slightly affected, or escape alto- gether. In the majority of cases a favourable reaction takes place without further symptoms, the vomiting and nausea cease spontaneously, a ravenous appetite succeeds, and the patient feels well. In other instances great exhaustion super- venes rapidly or gradually The patient feels miserably helpless. He suffers from coldness of the extremities, thirst, headache, and spasmodic pain in the stomach, and complains of numbness of the surface of the body. There is frequently 4 great tendency to heavy sleepiness ; and vomit- 1411 ing of gastro-biliary fluids, sometimes mixed with striae of blood, takes place whenever they collect in the stomach. A semi-comatose condition, from which the patient is with some difficulty roused, is sometimes met with in very severe cases, and requires assiduous treatment. In these prolonged cases reaction may assume a febrile character, with a rapid pulse, flushed face, hot skin, and urine containing lithates ; and convalescence is slow. An occasional but rare form of sea-sickness is swooning, but without vomiting or any other symptom. The patient lies motionless and almost deathlike for a variable period. This state is not without danger. Another form is frontal head- ache, neuralgic or anaemic. Complications and Sequels.— Fainting and hysterical attacks are the most common compli- cations of sea-sickness in women. Pregnant women occasionally abort. A weak and irritable condition of the stomach, resembling subacute gastritis, or a state of general debility, may remain for a long time. Duration-. — The ordinary duration of sea- sickness in long voyages is from three to five days, but it may last for weeks. Prognosis. — This is almost invariably favour- able, yet death, although extremely rare, may occur from syncope or from exhaustion. Treatment. — It may be premised that there is no known means of preventing sea-sick- ness in those susceptible of it. The majority of cases get well spontaneously, but there are many which will require systematic treatment, espe- cially in long voyages. Measures should be taken to counteract the nervous shock, and to sustain the system during its continuance. _ Diet before embarking should be light. Fresh air is a powerful element in the treatment, to obtain which the voyager should remain on deck whenever the weather permits, or in a deck-room. The temperature of the body should be main- tained by wrapping up in shawls, and hot bottles applied to the feet if necessary. The faco may be bathed occasionally with eau de Cologne, and the vapour of ammonia inhaled through the nose. In the early stages alkalies are indicated, to counteract the irritant effects of the acid gastro- biliary secretions, together with diflusibfe stimu- lants frequently administered. A draught may be given, consisting of bicarbonate of soda, grains 10-20, ammoniated tincture of valerian, rn.xv, chloroform, niiii-v, dissolved in half a drachm of rectified spirit, _mueilage of acacia, 3jss, and cam- phor water to jj. Such a draught may be given every two hours, or, omitting the mucilage, it may begiven in effervescence with citric acid. Chloro- form is valuable as a sedative to the stomach, as well as being a general stimulant. Other use- ful drugs are Hoffman’s anodyne, hydrocyanic acid, and, in prolonged cases, bismuth. Iced champagne is often valuable. Ice sucked slowly allays thirst, and relieves vomiting. A full dose of opium sometimes acts like a charm, through the rest which it procures, or morphia may be injected subcutaneously. Hydrate of chloral is also a valuable narcotic. More recently nitrite of amyl and nitro-glycerine have been success- fully employed in some instances. External sedative applications over the stomach 1412 SEA-SICKNESS. do good, such as a liniment composed of equal f iarts of belladonna, chloroform, and camphor iniments; and a binder rolled firmly round the body is useful. When the patient is in his berth he should lie on his back, -with his head low, as immovable as possible. Notwithstanding the vomiting, food should be pressed on the patient; and, lest exhaustion occur, light semi-fluid food is the best, such as arrowroot, given frequently in small quantities. Afterwards toasted bread, with beef-tea or chicken broth, and when these are borne, boiled fowl, pickled meats, or corned meat with pickles, may be tried. Acids at this stage aid digestion, which has become weakened through the vomiting of so much gastric juice and bile. Beer ancl alcoholic drinks should be avoided in the earlier stages ; but at a later period, claret, champagne, or brandy, or stout, may be allowed with benefit. Diarrhoea and other symptoms should be treated on general principles. For short voyages the best that can be done is to remain on deck when possible, avoid alcoholic drinks, and follow the general directions above given. Dr. Chapman recom- mends the application of ice along the spine, in order to lessen the nervous currents by its seda- tive influence; and this treatment is occasionally successful in arresting the vomiting. J. DE ZoUCHE. SEAT- WORM. — A synonym of the small thread-worm, or oxyuris vcrmicularis. By prac- titioners the small and troublesome entozoa here referred to are more frequently spoken of as ascaridcs, thotigh, as explained elsewhere, the expression is not correct. The term seat-worm is suggestive, inasmuch as the presence of these parasites is apt to give rise to irritation in the neighbourhood of the anus ; hut it is somewhat objectionable and misleading, since it tends to favour the view still very commonly entertained and taught by medical men, that the rectum and sigmoid flexure of the colon constitute the true habitat of this entozoon. The ctecum forms the ‘head-quarters’ of the seat-worm, and the know- ledge of this fact has an important hearing upon the method of treatment to be pursued. Sec Ascakides ; Oxyuris ; and Thread-worm. T. S. COBBOLD. SEBACEOUS FOLLICLES, Diseases of. — Synon. : Fr. Maladies des Follicules sebaces; Ger. Krankheiten der Talgdrusen. The sebaceous follicles of the skin are sub- ject to disease depending both upon internal and external causes. Those follicles which are attached to hairs, and those which are isolated, show little difference in this respect. Enlargement or hypertrophy of the follicles is often seen, and appears to arise chiefly from internal causes, occurring either at a particular stage of development, or from some general alteration of nutrition, such as follows a parti- cular diet or excess of particular kinds of food. This form constitutes acne punctata, an affection in which the affected portion of skin appears covered with black spots; these being the open- ings of the enlarged sebaceous follicles, choked with plugs of sebaceous matter, the outer ends of which become blackened. The plugs or co- SECRETIONS AND EXCRETIONS. medones, when examined, are found to consist of solid fatty matter (sebaceous secretion), closely packed epithelial scales, and minute rudiments of hairs. The parasite Demodcx folliculorum is often present, but does not appear to exercise any influence on the disease. Not unfrequently an imperfectly formed hair occupies the centre of the mass. Acne punctata occurs in those parts of the body where there are numerous rudiments of hairs, and where hairs grow commonly, though not uniformly, in the male sex. Hence it is con- fined to the face, neck, and upper part of the back and chest. When inflammation is set up in hypertrophied follicles suppuration follows, and we hare acne suppurativa. The condition called lichen pilaris is sub- stantially the same as hypertrophic acne, being produced by over-growth of cells in the sheath of the hair and the sebaceous follicle. See Acne. J. F. Payne. SEBORRHCEA {sebum, fat, and £e'w, I flow ). An ungrammatical synonym for stearrhcsa. See Stearbhoea. SECONDARY ( secundus , the second). — In contra-distinction toprimary, the word secondary is used with the following significations. .Ftio- logically it implies that a disease is not local in its causation and origin, but is manifested as a secondary lesion — either as the result of some general or constitutional condition, or of an affection which has previously involved some other structure or organ, it may be in a remote part of the body. It also signifies the later manifestations of a disease, as distinguished from those which occur at an early period, as in the case of secondary syphilis or secondary cancer. The term is, moreover, applied to symptoms, when they are more or less remote from the seat of mischief, or are only indirectly set up by the disease with which they are associated. Frederick T. Roberts. SECRETIONS AND EXCRETIONS, Disorders of. — Although the derangements affecting the chief secretions and excretions of the human body are considered in detail in other parts of this work, it may serve a useful purpose to deal with them from a general standpoint, as there are several facts which apply to them col- lectively. Those that have principally to be borne in mind are the secretions poured into the alimentary canal — namely, the saliva, gastric juice, bile, pancreatic juice, and intestinal secre- tions ; the milk ; the urine ; and the sweat. Of secondary importance, from a clinical point of view, are the various mucous secretions, the tears, and the semen ; the serous secretions have also to be remembered. It is assumed that the physiological distinction between a secretion and an excretion is understood. Varieties of Disorder. — 1. Secretions and excretions are very liable to chaity s m quan- tity. A definite amount of each of these should be formed during the twenty-four hours, vary- ing within recognised limits, and influenced by certain physiological conditions. The quantity produced, however, often deviates from the healthy standard, in the direction either of .a 1 SECRETIONS AND EXCRETIONS, DISORDERS OF. txfliss, or (b) deficiency. In the former case the amount of the secretion formed is often far above the normal, or what is needful for its pur- pose ; in the latter case various degrees of defi- ciency occur, culminating in an absolute sup- pression of a particular secretion or excretion. 2. Changes in quality are also frequently no- ticed, and these may be associated with changes in quantity, or they may exist alone. The quali- tative changes include the absence or deficiency of one or more of the normal chemical ingre- dionts of the fluid ; excess of either of these ingredients ; absence, deficiency, or imperfection of formed organic elements, as in the case of the semen ; or the presence of adventitious and ab- normal ingredients. It may also be mentioned here that the quality of secretions is often modi- fied by admixture with excess of mucus or with morbid products. 3. Another disorder affecting certain secre- tions and excretions is interference with their escape by the normal channels, so that they are retained. This applies particularly to those which have one or more special ducts for their exit, liable to be obstructed in various ways. The escape of the bile, pancreatic juice, urine, paro- tid secretion, milk, and other fluids may be thus prevented. 4. Allied to the deviation just noticed is that in which a secretion flows in some abnormal direction. As illustrations may be mentioned salivary fistula, in which the parotid secretion escapes through an opening on the outside of the cheek ; external biliary fistula, or the open- ing of the gall-bladder in various other direc- tions ; vesico-vaginal or vesico-reetal fistula, where the urine passes from the bladder into the vagina and rectum respectively ; and closure of the lachrymal duct, so that the tears flow over the cheeks. In this connection allusion must also be made to those cases in which a reservoir of some secretion ruptures, and thus its contents escape. For instance, the gall-bladder may give way, or the urinary bladder, the bile or urine consequently escaping into the peritoneum. JEtiology. — The causes which produce one or other of the disorders of secretion just indicated are as follows : — 1. Alterations in quantity and quality are often immediately induced by ner- vous disturbance. The influence of the nervous system upon the act of secretion is well known, and it may be centric in origin, as in the case of strong emotion ; direct, when the nerve influenc- ing a particular secretion is irritated, compressed, or otherwise disturbed ; or reflex, due to some remote irritation affecting such a nerve. The effect of neuralgia upon the secretion of the tears, saliva, and perspiration, is often very striking. 2. Similar disorders frequently depend upon derangements affecting the local circulation in the secreting gland. This is well exemplified in the case of the urine, which is abundant and watery as the result of active congestion of the kidney; deficient, concentrated, and otherwise abnormal when these organs are. the seat of venous congestion. The bile is also considerably modified in quantity and quality by portal con- gestion. 3. General conditions of the system materially affect secretions, from various causes, Weh as pyrexia, plethora or anaemia, shock or 1413 collapse, and the typhoid condition. Moreover, they may be disordered in connection with dis- eases which produce marked effects upon the general system, such as phthisis. 4. Functional derangements of the glandular structures which form different secretions are very common, and may be due to many causes. Amongst others may be mentioned a want of due and proper stimulation; excessive or too frequent stimula- tion ; injurious habits which affect certain secre- tions ; and want of tone or imperfect nutrition of secreting tissues. Such causes frequently operate injuriously in relation to the secre- tions poured into the alimentary canal. The sweat is affected by neglecting cleanliness of the skin. 5. Organic diseases of the glandular structures necessarily modify secretions more or less, either temporarily from acute disease, or permanently from some chronic mischief, which may ultimately entirely check a secretion. These diseases are of different kinds, and cannot be specially indicated here, but they all tend to alter or destroy the secreting structures. C. The secretions generally may be affected by cer- tain abnormal elements which accumulate in the blood. Under such circumstances, however, some excretions become the special channels for the elimination of these elements, and thus are liable to be seriously deranged. Thus in diabetes, whatever its pathology may be, the accumulation of sugar in the system leads to the characteristic changes in the urine observed in this disease, while at the same time the cutaneous excretion is diminished. It may further be remarked here that if the elements which ought to be removed by a certain excretion are not thus eliminated, they may find their way by other channels, and thus modify the quality of other fluids. This is exemplified by the elimination of urea in other directions when it is not excreted by the kidneys. 7. A secretion may be properly formed, but it is in manycases subsequentlymodified by admixture with morbid products derived from surfaces with which it has to come in contact, such as excess of or unhealthy mucus, or pus. Also, in the case of the stomach, the habit of taking large quantities of water or other fluids may so dilute the digestive secretions, as to make them unfit to perform their functions properly. 8. With regard to the causes which impede the escape of secretions, these are either of a mechanical nature, the duct being obstructed by something lodging in it, such as a calculus or plug of mucus, or being pressed upon from the outside ; or due to organic disease, narrowing or closing the channel or its orifice ; or possibly occasion- ally to muscular spasm or to paralysis of the duct. Such conditions may be temporary or per- manent. The discharge of secretions in abnormal directions is the result of organic lesions, either congenital or acquired, by which the unusual channels and communications are formed. Effects and Symptoms. — Disorders affecting secretions and excretions are often directly ac- countable for a variety of sj-mptoms, as well as for certain definite morbid conditions, and these effects are usually readily explained. 1. With reference to their quantity, secretions and ex- cretions must be regarded as mere liquids of a particular kind, and symptoms may therefore 1414 SECRETIONS AND EXCRETIONS, DISORDERS OE. simply depend upon their amount. Eor instance, deficiency or excess of saliva and buccal mucus will cause respectively dryness of the mouth, or a mere or less profuse flow of saliva; an abun- dance of gastric juice may account for acidity and acid eructations ; the quantity of the secretions in the alimentary canal often aids in the causa- tion of diarrhoea or constipation; and variations in the amount of the cutaneous excretion give rise either to undue sweating, or to dryness of the shin. 2. Certain actions are frequently influ- enced by disorders of secretion. Mere alterations in quantity may affect t.haee actions. Thus, pro- fuse salivation causes frequent spitting or swal- lowing ; abundant secretion in the air-passages ex- cites coughing and expectoration; excess of fluids in the stomach or intestine may cause vomiting or purging respectively ; a free secretion of urine renders micturition more frequent. But, apart from the quantity, the quality of a secretion may further influence these actions. Of this we have a striking illustration in diabetic urine, which is in itself irritating, and excites the bladder to empty itself. The bile is another example, for undoubtedly this fluid has an irritating effect upon the intestine, and may also increase the secretions of this canal, so that in these ways excess of bile may be a cause of diarrhoea, while its deficiency is an important element in many cases of constipation, owing to the want of its stimulating action upon the intestinal wall. 3. Each secretion, as distinguished from an excre- tion, has certain definite functions to fulfil, and a number of symptoms may be due to the fact that a particular secretion fails to perform its functions. This may arise from the fact that it is suppressed or deficient in quantity ; abnormal in quality, and therefore inadequate for its work; or for some reason or other does not reach the place in which this work is carried on, as when a duct is obstructed, or a fistula allows the escape of a secretion, so that it is lost. Symptoms arising from this cause are mainly observed in connection with the alimentary canal, and they are of extremely common occurrence, as well as of varied character. Many of the symptoms in dyspeptic cases are to be thus explained, and a knowledge of the physiological uses of the dif- ferent digestive secretions will indicate the de- rangements to be anticipated when one or other of them is unequal to its work. It must be remembered not only that these secretions are concerned directly in digesting the food, but that some of them also prevent fermentation and decomposition, and their imperfect action in these respects may originate important symp- toms. Under this heading the lacteal secretion may be alluded to. Deficiency in its quantity, or imperfection in its quality, often renders it unfit to fulfil its function, that is, the proper nourish- ment of the infant who is supposed to live upon the maternal milk. 4. If certain secretions or excretions are seriously cheeked or altogether suppressed, or if they are retained in any part, so that they become subsequently absorbed, ob- vious effects on the entire system are produced, which may be of a very serious character. Thus, in tho case of the bile, jaundice and its accom- panying phenomena are evident; in connection with tho uriDe we may have dropsy or uraemic symptoms. Impaired cutaneous excretion also produces effects upon the system, although these are not so marked. 5. What may be regarded as the secondary effects of disorders connected with secretions must also not be forgotten. If their escape be prevented, they are liable mechanically to produce important lesions. Thus they often lead to distension of hollow organs, such as the bladder or gall-bladder. Moreover, they may at the same time excite irritation and inflammation, especially if, as in the case of the urine, decom- position take place, with the formation of irri- tating products. By these combined effects, important organs may ultimately be completely disorganised, such as the kidney or liver. Re- tention of milk in the mammary glands is one important cause of inflammation and abscess in these organs. When certain secretions or ex- cretions find their way into abnormal situations they may also originate more or less serious con- ditions. Thus if urine or bile escape into the peritoneum, acute peritonitis will be set up. Teeatment. — Without entering into any de- tails, it will suffice to indicate in this article the principles upon which disorders of the secretions and excretions are to be treated. 1. Any obvious cause of such disorders must be rectified or got rid of at the outset, if practicable, as, for in- stance, injurious habits, neuralgia, and many other causes. 2. When secretions are abnormal in their formation, either as regards quantity or quality, means are often within reach for cor- recting these errors. This may not uncommonly be effected by acting upon the general system, by means of tonics or other suitable agents, and thus indirectly influencing sceretion ; but there are also special therapeutic agents employed for their immediate offects upon particular secre- tions or excretions, such as the gastric juice, the bile, the urine, and the sweat. With regard to quantity, remedies are used to diminish this when excessive, as well as to increase it when deficient. It may be mentioned here that mea- sures for augmenting certain secretions, and es- pecially excretions, are often resorted to for other therapeutic purposes, when they are not in any way abnormal. Care must be taken not to carry measures for promoting the formation of secre- tions too far, otherwise in the long run they axe liable, by over-stimulation and in other ways, to do far more harm than good. This applies parti- cularly to those cases where there is organic mischief affecting the glandular structures, and interfering with their formation. Secretions and excretions are often materially influenced in quantity and quality by acting upon the circula- tion in the organs which form them, either di- rectly or indirectly. 3. It may be practicable to treat some disease which originates a disordered secretion, and thus to influence it. This may be illustrated by diabetes, and by diseases of parti- cular organs, the secretions of which are affected. In this way marked effects are sometimes pro- duced. 4. When certain secretions are wanting or very deficient, especially the gastric ittice and bile, their place may be supplied by administer- ing the important elements of these secretions, or by making them artificially. The elements of the pancreatic juice are also now frequently given in different forms. Thus the want or de- SECRETIONS AND EXCRETIONS, fluency of these fluids in the digestive process may often be entirely made up for. An impor- tant use of some of these substitutes, at present much in vogue, is that introduced by Dr. Wil- liam Roberts, by -which the food is artificially digested in different degrees before it is taken fcv the patient. 5. The symptoms which disor- ders of secretions give rise to often need special treatment, -whether they be of a local or general character — for instance, c-oustipation, diarrhoea, flatulence, jaundice, ursemia, and oiher pheno- mena. G. In many cases attention has to be directed to the prevention of an accumulation of a secretion or excretion, or to its removal if it have accumulated. This, may be illustrated by retention of the milk in the mammary gland ; and of the urine in the bladder. The effects of any such accumulation also need to be recognised in treatment, such as dilatation of an organ, inflammation, or rupture. 7. Operative proce- dures may be required in some cases, either to remove an accumulation which cannot otherwise be got rid of ; or to cause a secretion to pass in its proper direction, in those cases where there Is an abnormal communication or fistula, or a closed passage, such as an obstructed lachrymal duct. It must be remembered that there are many disorders of secretions and excretions which are merely temporary, and which need no treatment whatever. Frederick T. Roberts. SEDATIVES ( sedo , I ease or assuage). — Synost. : Fr. Sedatifs; Ger. Bcruhigcnde Mittcl. Definition. — Therapeutic measures which exert a soothing action upon the system, by diminishing pain, lessening functional activity, or tranquillising disordered muscular movement. Sedatives may be divided into the following groups : — 1. General Sedatives.— -Constitutional seda- tives, like stimulants, widely overlap other thera- peutic divisions. The type of all soothing action assuredly must be a full narcotic, an anaesthetic vapour, or a subcutaneous injection of morphia, either of which renders the sufferer temporarily oblivious to any excruciating agony, such as that of biliary or renal colic. In fact, general seda- tives must be looked for exclusively in the nar- cotic and anaesthetic class ; and if the constant consumption of vital energy by disease be not com- pensated by sleep, we prescribe opium, chloral, or hyoscyamus. 2. Local Sedatives. — Under this heading we must place extreme cold, which, applied either in the form of ice, or more effectually by the ether spray, deadens the sensibility of the skin, and prevents the prick or cut of a slight opera- tion from being felt. Next come aconite, opium, belladonna, veratria, and blisters, which soothe by a direct action on the sensory nerves, or by influencing the circulation of the parts around. These are useful in neuralgic or rheumatic pain, or in the acute suffering of superficial inflamma- tory conditions. Again some substances may be regarded as sedatives, in virtue of their power in allaying the excessive itching of prurigo and other chronic skin-affections. Hydrocyanic acid, eirbolic acid, chloroform, borax, and chloral are tmong the best remedies for this purpose. 3 Pulmonary Sedatives. — Pulmonary seda- SELTERS. 1415 tives are also deserving of mention, and, passing by emetics and nauseants, which undoubtedly depress the breathing power, we find that vera- tria, Calabar bean, prussic acid, and several other drugs directly tend to paralyse the respiratory centre, on which action the greater part of their poisonous influence seems to depend. 4. Spinal Sedatives. — Spinal sedatives have precisely an opposite effect to spinal stimulants, and it has been amply proved that Calabar bean, gelsemiuum, bromide of potassium, and methylconia powerfully lower reflex excitability through the cord and the great ganglia of the brain. 5. Stomachic Sedatives. — Irritable condi- tions of the mucous membrane of the stomach, giving rise to pain, vomiting, pyrosis, and other symptoms, are commonly met with, and require a considerable variety of treatment. If gastrodynia fails to yield to bismuth, soda, or hydrocyanic acid, recourse may be had to small doseS of nitrate of silver or of arsenic; or blistering over the epi- gastrium may produce the desired effect. If vomit- ing be the prevailing symptom, hydrocyanic acid again proves useful, carbonic acid in the form of effervescing draughts, or minute and oft- repeated doses of nux vomica or ipecacuanha. Combined with this, we must take especial care to enjoin a mild and unstimulating dietary, of which milk and lime-water should form the prin- cipal ingredients. 6. Vascular Sedatives.— Vascular sedatives have the power of lowering the heart's action ; and emetics and tobacco do this by the general depression following nausea and the act of vomit- ing. Other drugs, however, act directly on the heart itself, either by paralysing the muscular tissue of which its walls are composed, or by a more special influence over its nerve-supply. Slowing of its action may be effected either by stimulation of the inhibitory branches of the vagus, or by interference with the sympathetic ganglia which work in the opposite direction ; and experiment has not in all cases made it quite clear what is the true explanation. But what- ever the exact physiological explanation may be, we have some practical rules for our guid- ance in the use of these remedies, and more es- pecially of digitalis, which, cardiac tonic though it be, is also a true sedative to that organ. Vlien the heart-muscle is weak and languid, it3 contractions are necessarily less efficient than in health; and in order to perform its allotted amount of routine work in propelling the blood, its cavities must fill and empty more rapidly than usual. The result of this is seen in the hurried, feeble, and often irregular pulsations of the organ ; and digitalis, by bracing up the mus- cular fibres, and giving increased tone, renders its action more efficient, and enables it to take more prolonged periods of repose. Other cardiac sedatives are aconite, veratrum viride, colchi- cum, and hydrocyanic acid, but they’ are seldom used for this purpose, although aconite, whether through its action on the heart, or on the small vessels, is very effective in early inflammatory conditions. R. Farquharson. SELTERS, in Germany. — Muriated alka- line table-water. See Mineral "Waters. 141 C SEMEIOLOGY. SEMEIOLOGY ( , I make rotten or putrid; I make fester or mortify.) — This word is nsed with some vagueness. It has been employed in both the senses indicated by the derivation, that is, either as merely synonymous with putrid, or as signifying some special or even specific virulence in decomposing matter. The confusion will be better understood by referring to the definition of Septicemia. There is no doubt the word had better he abandoned, and putrid used in its 6tead ; or else that it be clearly understood to have no meaning beyond putrid. Marcus Beck. SEPTICEMIA ( oTiiTTiKbs , putrid, and alua, blood). — S ynox. : Pr. Septicemie ; Ger. Septir cdrnie. — This term properly means the condition produced by the entrance of septic matter into the blood. Great confusion has, however, been caused by using it to signify two entirely distinct conditions. The first of these cannot be better defined than in the words of Dr. Burdon Sanderson, in his Lectures on the ‘In- fective Processes of Disease ’ {Brit. Med. Joum., Dec. 29, 1877). He says: ‘What I mean by septicemia is a constitutional disorder of limited duration, produced by the entrance into the blood-stream of a certain quantity of septic material. It must, therefore, be regarded, not so much as a disease as a complication, differing from pyaemia, not only in the fact that it has no necessary connection with any local process, either primary or secondary, but also in the important particular that it has no develop- ment. Pyaemia is a malignant process which goes on and on to its fatal end : but in the case of septicaemia, inasmuch as the poison which produces it has no tendency to multiply in the organism, there is no reason why the morbid process should not come to an end of itself, un- less either the original dose is fatal, or 3 second infection takes place from the same or another source.’ The process here described is merely poisoning by the absorption of the chemical products of putrefaction. It is no mere an in- fective process than the poisoning that would result from the application of arsenic, mercury, or any other inorganic substance to a raw surface. On the other hand, Koch of Berlin, Davaine, and many others include under the term septi- caemia all those cases of general infection from a wound in which no metastatic inflammations are present. Koch especially describes as septi- SEPTICAEMIA. eaernia in mice a disease in which, as the result of the inoculation of an infinitesimal dose, the animal dies within a certain period, without the formation of any secondary local centres of in- flammation. The blood, however, is so com- pletely impregnated with the poison that merely scratching the ear of another mouse with a needle dipped in the opened heart of the first, is sufficient to start a similar process in that animal, and so on indefinitely. In this case the process is truly infective, and the poison multi- plies in the body of the animal. The poison lias been shown by Koch to consist of a distinct form of microscopic organism. These two conditions must be kept distinct if we are to avoid confusion. In both forms the development of the poison is associated with putrefaction, in the first necessarily, in the second accidentally. The former is an inevitable con- sequence of the entrance of the products of putrefaction into the circulation ; the latter can only occur if the specific organism, which is the cause of it, should happen to find a place amongst those which are necessarily associated with all putrefactive changes. The latter also, although usually originating in conjunction with what we ordinarily speak of as putrefaction, can be trans- ferred from animal to animal by inoculation, without the intervention of any putrefactive pro- f cess whatever. If, therefore, we use the word septic as mean- ing no more than putrid, the two conditions indicated above, at present often indiscriminately spoken of as septicaemia, may be defined as fol- lows : — Septic poisoning . — The effects produced by the absorption of a poisonous dose of the chemical products of putrefaction. Septic infection . — An infective disease caused by the entrance into the blood, and by the mul- tiplication therein, of a specific organism most commonly developing in wounds or cavities, the fluids of which are at the same time in a state of putrefaction. It must be understood that this article is merely intended to indicate the meanings of the word septicamia. The fuller discussion of the subject comes under Pyaemia. See Pyemia. Marcus Buck. SEPTUM COBDIS, Deficiency of. See Heart, Malformations of. SEQUELAE ( sequor , I follow).— Conse- quences or sequels. This word is applied to symptoms or morbid conditions which either remain or supervene after various diseases have run their course; such as renal disease after scarlatina, paralysis after diphtheria, or cardiac disease after acute rheumatism. SEBOUS CYST. — A cyst containing serous fluid. See Cysts. SEBUM / In physiology the ls< l md portion of the blood, which separates after coagu- lation, is named the serum , and this is taken as a type of fluids of more or less similar composition, consisting of a watery solution of albumin with certain salts. In pathology ws have to deal with serum outside the blood-vessels, either as a mere dropsical accumulation, cr as a SEBOUS MEMBRANES. 1421 consequence of inflammation. It may be thug met with in the cellular tissue under the skin or a mucous membrane, and in other parts; in serous cavities ; in certain organs, as the lungs and the ventricles of the brain; or as a discharge from the surface of the skin, as in cases of eczema. Its precise composition varies considerably under different circumstances. Clinically serous fluid is, as a rule, of most importance on account of its mechanical effects, when it accumulates in quantity in various parts, and these effects may be most serious. Its presence can usually be detected by objective or physical examination. The treatment required will be either that for dropsy or inflammation, modified by local consi- derations, according to the principles laid down in other special articles. FREDERICK T. BoBERTS. SEBOUS MEMBRANES, Diseases of. Synon.: Maladies du systemc sereux ; Ger. Krank- heiten der Serbscnhaute .— These constitute an important class of diseases, and although they are discussed under /he headings of the several serous membranes, it will be advantageous to consider them generally, according to the plan followed in the case of the mucous membranes. These membranes line closed cavities, except the peritoneum in the female, which communicates with the uterus through t.heFallopian tubes, and thus with the exterior of the body. They consist of a basement-membrane, covered with epithe- lium, usually of the scaly variety, and a sub- serous cellular tissue underneath. In addition to their more obvious function, of allowing free movement for organs, they are intimately con- nected with the absorbent system, the vessels of which freely open on their surfaces. Fibro-serous membranes constitute a variety in which there is an outer fibrous covering, lined by a serous layer, of which the pericardium is an example. These introductory remarks will clear the way for the consideration of the nature and causes of the diseases of serous membranes, which will now be pointed out. 1. Injury. — The serous membranes are liable to be injured from without, chiefly as the result of wounds pienetrating the cavities which they line, hut also by fractured bones, especially in the case of the ribs and skull. It is believed that a severe external contusion may affect an underlying serous membrane. Another impor- tant cause of injury to these structures is some perforation or rupture taking place within the body (see Perforations and Ruptures). They are frequently more or less injured in various operations. Any kind of injury to this class of membranes was formerly regarded with great dread, and operations in which they were in any way interfered with were considered highly dangerous ; more recent experience has, however, shown that mere damage to a serous membrane is not serious in itself. More or less grave con- sequences are liable to follow, from haemorrhage ; from the admission of air, especially if it con- tains septic matters; or from the escape of solid or liquid materials into a serous cavity. In ad- dition to their direct effects, these often set up inflammation, which may prove fatal. 2. Inflammation. — Serous inflammations are 1422 SEROUS MEMBRANES, DISEASES OF. of common occurrence, and without entering into details, their causes may he thus summarised: (a) Some injury from, without including that set up by fractured bones, (h) Perforations and ruptures within the body, the inflammation be- ing then mainly due to the materials which gain access into the serous cavity, (e) Mechanical or chemical irritation of any kind. Many cases be- longing to the former groups would come under this one; as well as those in which inflammation is set up by necrosed bone, diseased organs, and tumours, or as the result cf over-distension of a serous membrane. This class would also include those cases in which a serous inflammation is purposely excited by the injection of certain chemical" irritants. The occurrence of peritonitis from the entrance into the peritoneum of mate- rials from the uterus may also be mentioned here. (d) Morbid growths in connection with a serous membrane. These deserve separate mention, though they likewise act by causing local irrita- tion. ( e ) Extension of inflammation from other structures. In this way the morbid process may pass from one serous membrane to another. Serious forms of inflammation may probably ex- tend to the serous membranes by means of the lymphatics. (/) Certain general states of the system, in connection with low fevers, Bright's disease, and other affections, (q) Causes acting upon the general system from without, such as cold, when the inflammation is said to be idio- pathic. Different serous membranes present dif- ferent degrees of liability to be affected by one or other of the causes mentioned; and these pro- duce different effects, according to their nature. Cases of serous inflammations present much diversity as regards their severity and rate of progress, and the morbid changes are thus mate- rially influenced in their character, as well as by the cause of the inflammation, the particular membrane affected, and other circumstances. In general terms they may be grouped as acute, subacute, and chronic in their origin and course; but those which are more or less acute at first often leave behind permanent morbid conditions. Taking an ordinary case of an acute serous in- flammation, running a regular course, it presents the following more or less obvious stages in its anatomical characters : — (u) Increased vascula- rization, consequent redness of the membrane, and sometimes small haemorrhages, accompanied with dryness, loss of polish, opacity, and swell- ing. ( b ) Deposit of organisable lymph or fibri- nous exudation upon the surface, containing a variable number of cells, (c) Effusion of fluid into the serous cavity, more or less of the nature of serum, but also containing a variable propor- tion of fibrin and cells. (r not, nyunphomania, when developed, is an intirely distinct disorder from the last-named mnplaint, and is generally connected with 90 physical irritation or disease of -sbme part of the sexual organs. Frequently it is associated with subacute endometritis or ovaritis, resulting in irritation and congestion of the erectile struc- ture of the internal, as well as of the external, generative organs. In these cases pruritus of the vulva generally exists ; and the local hyperms- thetic condition is followed by structural disease in the affected parts, hypertrophy of the nymph* and clitoris, vaginismus, and chronic follicular vulvitis. The moral, hygienic, and medical treatment of these conditions is discussed in other articles in this work. Here it is only necessary to add. that in the treatment of no forms of disease is the exercise of the highest qualities of the physi- cian more required than in the management of erotomania and nymphomania. In these case? he must act on the religious and moral as well as on the physical constitution of his patients he must seek to turn tho perverted current o' thought into better channels ; insist on healthy occupation of mind and body; and clearly poin'. out the physical ill-health and mental debase- ment which surely await on sexual abuses. At the same time the judicious practitioner will endeavour to strengthen the physical powers by tonics ; to diminish general plethora hy saline purgatives, to remove local congestions by appro- priate treatment; and to lessen nervous irrita- bility by the bromides and other nerve-sedatives. Generally such patients are idle and over-fed, and require work and abstinence, and in addressing these persons their medical attendant may well re-echo the advice given to Falstaff by his quon- dam friend Prince Hal, and desire them to ‘ Purge, foreswear sack, and live cleanly.’ With regard to local treatment in cases of nymphomania, all that need be said is that, vaginal examinations, being likely to increase the irritability of the hypersesthetic parts, should, as a general rule, be altogether avoided ; or, at least, should be resorted to only in exceptional instances, and when absolutely indispensable. At the same time, however, it is obvious that where nymphomania is the result of local disease, neither moral nor general medical treatment can be of use until the topical exciting cause is re- moved. It may be admitted that, in certain exceptional cases and with suitable restrictions clitorideetomy is a useful procedure. Insanity .—' The effect of sexual disorders on the mental functions can be only very briefly alluded to. The fact is certain that insanity in women is frequently connected with functional derangement or organic disease of some portion of the utero-genital organs. Indeed in both sexes, although less obviously in men, reflex irritation from the soxual system has, probably, much to do with the causation of insanity. In the insane there is usually a peculiar insensibility to the ordinary symptoms of disease, resulting from the impaired nutrition and lowered vitality of the nervous centres and nerves of sensation. Therefore, in such cases, in the absence of the usual evidences of sexual disorders, the existence of these diseases is very likely to be overlooked. During the last few years several instances of mental derangement, of hysteria approxi- mating to insanity, and of other forms of 1426 SEXUAL FUNCTIONS (FEMALE), aervous disturbance arising from ovarian causes, have come within the writer's observation. In some of these cases the nervous disorder had existed for a considerable time before its local exciting cause was suspected. And, more than once, the writer has seen this ultimate recogni- tion and treatment, of obscure uterine or ova- rian disease in a woman, who had been for years in a lunatic asylum, followed by the resto- ration of mental as well as physical health. The ordinary occurrence of menstrual irregu- larities, and especially of amenorrbcea, in the early periods of insanity, is recognised by nearly all writers on this subject; and there seems a general concurrence of opinion as to the direct connection between suppression of the menses and mental derangement in many instances. One of the most remarkable cases of this kind is that of a girl, mentioned by Pinel, who ‘ from the age of ten years was in a state of incoherence from suppression of the catamenia. One day on ris- ing from bed she ran and embraced her mother, exclaiming, “Mamma! Iam well.” Theeatamenia had just flowed spontaneously, and her reason was immediately restored.’ Puerperal mania , — Puerperal mania is another instance of the influence of uterine or peri-uterine causes in disturbing the nervous system. The setiology of this disease is very complicated, and it must be ascribed to the combined operation of several distinct factors. Foremost amongst these is the local condition of the denuded uterus dur- ing involution ; and the shock and exhaustion consequent on parturition under conditions of mental depression, as shewn by the fact that twelve out of twenty cases that came under the writer’s notice occurred amongst unmarried pa- tients in the Lying-in Hospital. Any circum- stances that occasion- suppression of the lochia or of the mammary secretion at this time, when the nervous system is in a state of peculiar tension, and the physical powers lowered, act directly as exciting causes of puerperal mania. Alcoholism . — Uterine and ovarian disorders must also be reckoned amongst the predisposing causes of intemperance. The craving for alcohol in women of all classes, may frequently be dated from the first painful menstrual period, when stimulants are often forced by foolish mothers into reluctant lips. The pain of dysme- norrhoea being thus relieved, at the next epoch the girl naturally, and no longer unwillingly, seeks similar solace, until, finally, the victim of dysmenorrhoeal alcoholism becomes a habitual, and perhaps an incurable, drunkard. Cardiac disorder . — Of the cases of supposed heart-disease in nervous women, which daily come before those connected with any large hospital, in the greater number of instances the cardiac complaints are the result of hysteria, originating from chronic uterine or ovarian disorder, on the cure of which all the cardiac symptoms will subside. It is needless to dwell further here on the functional irregularities — palpitation, dyspnoea, and other symptoms of the same kind — which are thus connected -with over- stimulation and irritation, or disease, of the female sexual system. General health .— The consequences of pre- mature or excessive indulgence and abuse of SHAMPOOING. the sexual appetites on the general healtn. claim merely a passing notice in this article. At no former time was it so necessary as at present for medical practitioners to recognise the evidences of these abuses and excesses ; to which are due a large and increasing proportion of the disorders, mental and physical, by which human life is embittered or its duration shor tened. The pathological results of these abuses, acting through and upon the nervous system, and the long train of maladies thus occasioned, must be familiar to every experienced physician who encounters in his practice the cachectic and debilitated victims of the excesses referred to. To these causes must be mainly ascribed the failure of physical stamina, the liyperaes- thetic nervous condition, and the want of mental power and determination, noticeable amongst too many of the youth of the present day. Thus the evils resulting from this wide-spread sen- suality, the effects of which are now seen in our hospitals and lunatic asylums, have attained such proportions as to be a subject of national as well as medical importance. With respect to the constitutional relations of chronic disorders of the female sexual organs. Dr. Harnes very truly observes ‘ that disorder of the sexual organs cannot long continue without entail- ing constitutional disorder, or injuriously affect- ing the condition of other organs.’ The most com- mon of the chronic complaints peculiar to women are subacute endometritis and cervicitis. Next in frequency are the functional disorders occa- sioned by ovarian congestion and irritation. And, thirdly, in this connection are the various dis- placements and flexions of the uterus. The two first of these in all cases react on the general health. And even in the third, where local symptoms and local treatment obviously claim most consideration, the secondary consequences of the uterine dislocation often require attention, after the displacement or flexion has been me- chanically remedied. Thomas Moef. Madden. SEXUAL FUNCTION’S IN THE MALE, Disorders of. — Disturbances of the most important sexual functions in the male are described under the following headings, to which the reader is referred: — Impotence; Masturbation ; Spermatorrhoea ; Sterility in the Male ; and Testes, Diseases of. SEXUAL ORGANS, Diseases of.— The diseases of the several sexual organs in the male and female will be found described under their special headings. See Penis, Diseases of ; Testes, Diseases of; Ovaries, Diseases of; Vagina, Diseases of; Womb, Diseases of; Ac. SHAKING PALSY. — A synonym for paralysis agitans. See Paralysis Agitans. SH AMPO OIN G.-Syxox.: Massage ; Knead- ing ; Medical rubbing ; Fr. Massage; Ger. Mas- siren. Definition'. — A process of treatment by rub bing, which consists in deep manipulation. Applications. — The shampooer grasps the part, and by squeezing it laterally in the palms of his hands in a peculiar manner, in which the muscles of the thumb are brought into vigorous SHAMPOOING. ase, exerts a compressing force upon the deep muscular structures by a kind of kneading pro- cess. Muscular contractility is thus stimulated, and the circulation increased, so as to produce a corresponding increase of temperature. By frequently repeating this process, the nutri- tion of the limbs operated upon is increased, and the flesh becomes much firmer, with a corre- sponding increase in muscular power. In India, where shampooing appears to have been an ancient practice, it is employed to restore en- feebled and debilitated muscles, exhausted by the heat of the climate. In England shampooing has of late years been much more generally used, and since the introduction of the Turkish baths, where trained shampooers are always in attend- ance, it can be more readily obtained. Uses. — In infantile paralysis, if the limbs af- fected are shampooed for half-an-hour twice a day by a competent nurse, in addition to the use of galvanism and of warm clothing, the process of recovery — to which there is always a natural tendency — will be materially facilitated. In the more severe forms of paralysis, iu the adult, less benefit can be expected from shampooing, though the warmth and circulation in paralysed limbs are improved by its use. In limbs weakened by the long-continued use of mechanical supports for any surgical purpose, shampooing is found to be of great service in improving the muscular strength, and restoring a healthy and vigorous circulation. As employed by Dr. Weir Mitchell, and de- cribed by Dr. Playfair ( Lancet , 1881, I. p. 857. and II. p. 991), shampooing appears to be of great value also in the systematic treatment of nervous prostration and hysteria. William Adams. SHINGLES ( cingulum , a girdle). — A popu- lar name for herpes zoster. See Hekfes ; and Zoster. SHIVERING. See Rigor. SHOCK. — Synon. : Fr. Choc ; Ger. Skoh ; Wimdstupor ; WwidschrecJc. Definition. — A condition of sudden depression of the whole of the functions of the body, due to powerfulimpressions upon the system by physical injury or mental emotion. Its more obvious manifestations are signs of lowered activity of the cardiac, respiratory, and sensorial functions; and reduction of the surface temperature. General Description. — If a person be unex- pectedly subjected to the influence of extreme terror, if a large bone or joint be shattered, or an important viscus injured, the entire system re- ceives a profound impression, and its functional activity is more or less stunned. The whole body appears to sympathise with the injury in- flicted on one of its parts ; thepatient is prostrated by an indescribable sense of bodily anguish and oppression ; he feels sick and faint ; is seized with tremor ; totters or falls ; the surface becomes pale, cold, and covered with sweat ; the expression of countenance is vacant, yet anxious ; and the respiration and circulation are weak and ir- regular. Shock varies in degree, from the most trifling amount, which rapidly disappears, to that pro- SHOCR 1427 dueing instantaneous death., as in the case of lightning stroke, or of a severe blow on the epi- gastrium. The intensity of shock depends on the nature and extent of the injury producing it: on the co- existence of internal or external haemorrhage ; and also upon the age, habits, temperament, and idiosyncrasy of the individual, and his mental condition at the time of the injury. Direct violence applied to the brain or spinal cord pro- duces shock in the most intense form, but in such cases, which are beyond the scope of this article, the symptoms due to the local lesion predominate, and are of course the more important. Shock is usually immediate in its effects, but sometimes these may be for a time deferred by intense mental preoccupation or excitement. ; Nature,’ as Hunter said, ‘ does not feel the in- jury.’ The soldier during the excitement of battle may be unconscious for a time of the severity of his wound, but presently he is re- called to a sense of danger, and the depression which ensues will be increased in proportion to the previous excitement. ./Etiology. — Intense mental impressions, such as extreme terror, or apprehension of death or mutilation, are capable of producing shock in persons of excitable nervous temperament. Some individuals are so readily affected, that a certain degree of shock may- be induced by the most trifling lesion, or even by the sight of an injury inflicted upon another. It may be stated generally, however, that whatever is calculated to produce psychical de- pression, will aggravate the shock induced by other causes. Wounds, for instance, inflicted on the soldiers of a beaten army, or on those in a closely besieged town, are often followed by greater shock than are wounds of a similar severity occurring under different circumstances. Injury is the chief cause of shock. As a rule the more extensive the injury, the nearer it is to the centre, and the more it assumes a crushing character, the greater will prove the amount of shock. The crushing of a fiDger or bruising of a testicle often occasions severe shock ; so also do extensive burns and scalds. Intense pain, without serious organic lesion, is capable of producing shock, as may be witnessed during the passage of a gall-stone through the duct, or of a calculus through the ureter. Loss of blood associated with the injury greatly augments the degree of shock ; and it may be impossible to separate the symptoms due to the more direct physical impression from those caused by the haemorrhage. Shock is, however, independent of the presence both of pain and of haemorrhage. During the operation of castration a patient, while under the influence of chloroform, and in the absence of haemorrhage, may present all the symptoms of profound shoek, the moment the cord is divided. After disarticulation at the hip or shoulder joints, and in other great opera- tions, the patient may present features of shoek, altogether independently of either pain or loss of blood. Ovariotomy, especially the opening of the abdomen, is said to be occasionally attended by shock ; but it does not occur after ovariotomy, except when the operation is severe and pro tracted, or associated with haemorrhage. SHOCK. 1428 The frequency of shock after operation has diminished since the introduction of anaesthetics, but chloroform itself may occasion some of its symptoms; and it is by no means unlikely that fatal accidents during chloroform-administra- tion may be due to the combined depressing influences of the shock and the anaesthetic. Injuries extensively involving the bones and joints are prone to induce shock. The tempera- ture has been observed in some instances to fall during the sawing of the bone in amputation. Kailway accidents, happening as they do very suddenly, and occasioning great alarm; acute peritonitis caused by the escape of irritating sub- stances into the abdominal cavity, as in perfora- tion in typhoid fever; the strangulation of a hernia ; or a sudden and severe intussusception, may each and all bo attended by symptoms of shock in a more or less intense degree. H athoxog y. — I t is still difficult to explain the modus operands by which any kind of physical injury, of sufficient severity, implicating any por- tion of the body, may produce the set of pheno- mena known as shock. The story told by the symptoms is one of depression of the whole vital functions, associated with all the evidences of a diminished circulation of blood in those portions of the periphery which we can examine during life. The integument is blanc-hed and shrunken ; the pulse is thready or imperceptible ; the veins are collapsed ; and open wounds, unless involv- ing large arterial trunks, bleed slightly or cease to bleed; while the lowered temperature, as registered in the axilla and mouth, marks a co- incident diminution of tissue-metamorphosis. That the brain suffers from a similar privation of blood is indicated by the enfeebled pulsation of the carotid arteries ; by the anaemic condition of the retinal vessels, as shown by the ophthal- moscope ; and by the mental torpor and feeble irritability, conjoined or separate, which consti- tute invariable features of the condition. IIow far the chaDge is shared by other organs it is at present impossible to say, but, awaiting further investigations, the facts already known are suf- ficiently definite and constant to guide us in the direction of a rational pathology. The manifestations of inadequate blood-supply to the tissues in general are almost identical with those of haemorrhagic asthenia ; but no heemorrhage has taken place, and tve must seek the blood which has left the anaemic parts in some other vascular territories. If we make a post-moricm examination in a case where death has forestalled nature’s effort at reaction, one striking phenomenon is revealed, namely, an enormous distension of the abdominal vessels governed by the splanchnics. Into this capacious set of vessels has been diverted a great mass of the blood destined for other regions; and being thus practically withdrawn from the general circulation, it has produced a useless congestion of the abdominal viscera, at the ex- pense of the nutrition of the rest of the system, while the weakened heart contracts feebly but hastily upon the scanty supply which now passes through its cavities. Physiologists have taught us the probable cause of this. Long since it was demonstrated that stimulation of the central end of the divided depressor branch of the vagus, in the rabbit, produces an immediate lowering of the blood- pressure in the arteries of the head, neck, and extremities; this effect coinciding with, and de- pending upon, a dilatation of the abdominal arteries, and a consequent derivation of the blood- flow in the direction of least resistance, or to- wards the abdominal viscera. If, however, the splanchnic nerves be cut, the reflex circuit is broken, and the balance of the circulation becomes restored, or nearly so, although the irritation of the depressor nerve be continued. The experiment of Goltz, of directly paralysing the splanchnic of a frog by sharply striking the abdomen, was fol- lowed by the same result as is the reflex paralysis of the same branches through the depressor nerve ; and it is likely that the severe shock caused in man by a severe blow on the epigastrium, owes its origin to a similarly induced paralytic dilatation of the visceral arteries. Lor the pre- sent we may thus accept, as the most plausible interpretation of the symptoms of shock, a sudden dilatation of the abdominal vessels, attributable to an inhibitory influence exerted upon the splanchnics, through the medium of a special re- flex centre, which is in more or less direct com- munication with the sensorium, and with all parts of the body. Much, however, remains to be done. It has been shown that when a rabbit is narcotized by chloral, stimulation of the central end of the divided sciatic nerve will induce a lowering of arterial pressure, corresponding closely to that initiated by stimulation of the de- pressor branch ; and in all probability a similar experiment upon any nerve containing afferent fibres would be followed by the same result But if, on the other hand, the same stimulation be performed while the animal is paralysed by curare, it is remarkable that the effect is reversed, the vessels controlled by the splanchnics contract- ing, and the general arterial tension being con- sequent^’ increased. These observations are in the highest degree suggestive, and may hereafter form the basis for a plan of treatment of shock, that will be a landmark in surgical therapeutics. Symptoms. — The symptoms of shock are of two kinds— namely, first, those due to a stun- ning or blunting of the vital powers, aptly styfed Wundstupor by the Germans ; and secondly, those attributable to mental terror, anxiety, and agitation — Wundschrcck. These may exist together, or separately, or one may pass into the other. 1 .Pure or torpid shock, as distinguished from the latter form, which may be termed ‘ erethitic shock,’ is manifested, if only slight in degree, by transient symptoms. The patient becomes pale and faint ; complains of nausea; trembles; and experiences a sense of oppression, confusion, and anxiety: the surface becomes cold and moist ; beads of sweat form on the brow ; and the limbs may be unable to support the weight of the body. The duration depends much on constitutional pecu- liarity ; the symptoms either passing off in a few minutes, or lasting for an hour or two. If the shock be severe, the patient immediately after the receipt of the injury is stunned ; liis senses and consciousness are benumbed ; the counte- nance and the surface generally become deadly pale, and are bathed with sweat; the a ni manor 14 US) SHOCK. jf the face is replaced by a mingled expression of torpor and anxiety ; from time to time mus- lular contractions and uneasy movements of the oody may occur, but usually there is an absence of voluntary effort ; the eyes are dull, vacant, and motionless, and the pupils are usually di- lated ; the temperature — an important index to the severity of the shock — ranges from one to ttvo degrees or more below the normal, and is much lower when there has been severe .loss of blood ; the respiration is remarkably slow and irregular — faint, scarcely perceptible, inspirations alternating with deep sighs ; and the pulse may be almost or quite imperceptible at the wrist, very weak, insufficient, and very rapid. The patient is conscious, but he sees and acts as through a mist, and cannot realise his position ; urgently questioned, he replies slowly and with evident effort ; his voice is weak and hoarse ; he may complain of coldness and numbness of his limbs, but appears scarcely sensible of pain. There may be nausea, and even vomiting ; and relaxation of the sphincters, with involuntary dis- charge of faeces, is occasionally observed. The fall of temperature in shock, excluding cases of injury to the brain and spinal cord — where it is greatest of all — is proportionately greater, other things being alike, in injuries extensively involving bones and joints, in burns and scalds, and in the cases where there has been considerable loss of blood. It is greater in amount in men of forty than in those of twenty. During the War ot the Commune a number of ob- servations were taken, and the average tempera- ture varied from 96'5 to 97'5°, the lowest tem- perature observed being 93'5°. The fall was greater after shell- than bullet-wounds ; and amongst the insurgents than in the regular troops. 2. In the shock with excitement — restless or ere- ihitic shock — symptoms of anxiety and restless- ness predominate. This form is often witnessed in association with previous haemorrhage, or when there is great pain, as in crushing injuries of important parts, and in burns or scalds. In- dividual idiosyncrasy, however, has an important influence upon the condition. The ordinary symptoms of shock, such as pallor, cold surface, frequent pulse, and feeble respiration are present. The patient in addition betrays a marked and unceasing restlessness, tossing about in bed. and throwing his arms and head from side to side ; his consciousness is but little impaired, yet he pays no heed to questions ; nothing seems to com- fort or quiet him ; he appears as if overwhelmed by some indescribable anxiety and oppression, of which he vainly struggles to rid himself. Vomit- ing and painful eructations are usually present in such cases. There is often considerable tremor, and sometimes the case will pass into well- marked delirium tremens. The torpid may pass into the erethitic form of shock ; or shock with excitement may lapse into a torpid condition, which is always a change cf bad omen. Duration.— Shock, unless it be the result of serious or fatal injury, is generally recovered from speedily and completely. It may be quite gone in fifteen minutes or half an hour; or it may continue five or six hours, or longer, and then pass awaj’. The erethitic or restless form of shock does not continue so long as the torpid. The less important the vital lesion ; the less it has been complicated with loss of blood ; th6 greater the power of the individual; the less his nervous susceptibility ; and, finally, the more efficient the treatment, the shorter will prove the duration of the shock. Terminations. — Recovery or reaction takes place readily from the milder forms of shock, especially when aided by suitable treatment. Prom the more severe, it is more difficult and protracted ; or the case may end more or less rapidly in fatal collapse. When the reaction proceeds favourably, the pulse becomes stronger and fuller, the respiration deeper, and the bodily warmth returns. The mind appears to awaken to the exercise of its faculties, to shake off its oppression, and to appreciate the nature of the previous injury, and of the existing circum- stances ; and both the mental and physical equi- librium are by degrees restored. Vomiting is often an early symptom of recovery. The reaction is not always steady. Fluctu- ations may occur ; and relapses after an im- provement often occur once or twice, each time, however, with diminished severity. When the torpid form of shock passes into the erethitic, the condition becomes one termed ‘ prostration with excitement’ ; the respiration is hurried, the skin hot, and the face flushed. There are great thirst, headache, and scanty urine, with restlessness, tremor, incoherence or delirium, and sleeplessness ; and death from exhaustion fre- quently follows, preceded by a haggard, "wild expression of face, a pulse that cannot be counted, subsultus, and hiccough. After severe shock symptoms of excessive re- action are not uncommon ; and their gravity will vary with the intensity of the previous shock. Complications and Sequel.®. — The compli- cations which may arise are those due chiefly to loss of blood, or peculiar to the form of injury received. From ordinary uncomplicated shock recovery is usually perfect, but occasionally, es- pecially after railway shock, permanent deterior- ation of health follows, or some impairment of a special sense ; or the mental vigour or temper of the individual may be changed for the worse. In these cases organic changes in the nerve- centres have probably supervened. In drunkards the shock of injury very often terminates in or- dinary delirium tremens. Pre-existing organic disease, especially of the heart or kidneys, renders persons more suscep- tible of the effects of shock, and shock more dangerous and severe. Diagnosis. — The phenomena of shock bear some resemblance to those of concussion and of syncope. Concussion is usually distinguished from shock by the predominance of intellectual disturbance over the circulatory symptoms ; and syncope is in most cases marked by its more transitory duration, and by its origin in loss of blood, or in other of the well-known causes of the condition. Shock, however, may co-exist with either concussion or syncope. Prognosis. — This mainly depends on the na- ture of the injury, and the physical and mental power of the individual, Otherwise, the longer the shock endures, the feebler the manifestations 1430 SHOCK. of life, and more especially the lower the tem- perature falls, the more unfavourable becomes the prognosis. A fall of temperature below 96° nearly always presages a fatal issue. It is a very unfavourable sign when no rise of tempera- ture takes place in four or eight hours after the receipt of injury. Extreme feebleness of pulse and respiration, marked tremor, profuse cold sweat, singultus, a feeling of impending dissolu- tion, and involuntary evacuations, all indicate gravity of the case. Tbeatment. — The objects of treatment in shock are to sustain the lessened vitality, but not to over-stimulate it ; and to moderate subse- quent reaction when it is excessive. To apply external warmth is the first and plainest indication, as it is one of the best ap- peals to the misdirected circulation. Hot water bottles and hot blankets may be applied to the extremities ; hot turpentine epithems and sina- pisms to the precordia ; and turpentine may be rubbed along the spine with advantage. If the patient cannot swallow, an alcoholic stimulant may be injected into the rectum; and ammonia may be inhaled, or subcutaneously injected. Slap- ping the hands and feet promotes recovery in some cases, but this measure is inefficacious in cases of severe injury, or those accompanied by great loss of blood. In profound shock, unaccompanied by loss of blood, the breathing must be carefully watched, and failure guarded against by artificial respira- tion. The phrenic nerve may be usefully stimu- lated by electrodes placed along its course in the neck, and in the epigastrium. If the external jugular vein be gorged with blood, it may prove advantageous to open it, and thus relieve the stagnation of the venous circulation. Where shock lias been accompanied by severe haemor- rhage, transfusion in extreme cases should be re- sorted to. As soon as practicable, nourishment must be administered, as well as stimulants. Tincture of belladonna has been given in half- drachm doses every hour in some cases, with the view of stimulating the cardiac action, and helping to contract the paralysed arterioles. The use of calabar bean lias been recommended, on account of its power to diminish the venous accumulation in the abdomen, by causing con- traction of the veins. If shock be associated with excitement, which should be regarded as a sign of want of power, the patient always requires support; and opium, or, when this drug is not desirable, henbane or chloral, may often be given with advantage. Au ice-coil to the head allays excitement and promotes sleep. In the torpid form of shock narcotics are inadmissible. Should inflammatory reaction take place, a regulated- diet, rest to mind and body, a gentle mercurial purge, when the secretions are deranged, and in young ple- thoric subjects the cautious administration of antimony, or a local blood-letting, are the chief means to be adopted. Throughout the treat- ment caution should always be exercised not to strain the action of remedies too far. The question of operation in shock may oc- casionally be difficult to solve. As a rule a pa- tient suffering from severe shock should never be operated upon ; unless, indeed, bleeding be I SIALAGOGUES. going on, or the arteries and nerves are much exposed and lacerated from the violence of the injury. When an operation appears to be com- pulsory no anaesthetic is required. It is better, however, to await partial reaction whenever it is possible to do so. William Mac Coemac. SHORTNESS OP BREATH. See Rg- spibation, Disorders of. SHORT-SIGHTEDNESS. See MAopia ; and Vision, Disorders of. SIALAGOGUES ( , saliva, and S.ya, I move). — S ynon: Fr .Sialagogues-, Ger .Speichel- treibende Mitteln. ' Definition. — Remedies which increase the se- cretion of saliva. Enumebation. — The principal sialagogues are Dilute Acids, Ether, Ginger, Rhubarb, Horse- radish, Iodide of Potassium and other iodides, Jaborandi, Mezereon, Mercury and its salts. Mustard, Tobacco, Physostigma, Pyrethrum, and Pebbles. Action. — There are two essential factors in the secretion of saliva ; the first is the activity of the secreting cells in the gland, the second is a sufficient supply of nutritive material to them, from which they may form a secretion. This nutritive material, though it may be derived di- rectly from the lymph-spaces around the cells, must be ultimately supplied by the blood circu- lating through the glands. Usually, therefore, when the gland is in action, the supply of blood is greatly increased, the arteries dilating, and the blood flowing rapidly through them. Some drugs, such as physostigma, will stimulate the secreting cells, while they contract the blood- vessels; and under these circumstances, although the secretion may begin actively, it soon comes to a standstill from want of material. The se- creting cells may be excited to activity, by sub- stances which stimulate the nervous structures within the gland itself, as, for example, calabai bean (physostigma) ; by stimuli proceeding di- rectly from the encephalon, as seen in salivation occurring from the mere idea of savoury food; and by stimuli applied to the mouth and exciting the gland reflexly. Nausea is almost always accompanied by salivation, and substances which cause nausea almost invariably cause salivation, the irritation of the stomach causing reflex sali- vary secretion. The stimulus here passes up the afferent nerves to the medulla, and travels down the efferent nerve to the gland. Sialagogues are divided, according to their mode of action, into two classes ( 1 ) topical or direct ; and (2) specific, remote, or indirect siala gogues. The names direct and indirect are com- plete misnomers, just as they are in the case ol emetics, and they ought to be discarded, inas- much as the so-called ‘direct’ sialagogues are those which do not act directly on the gland, but on the mouth ; and the ‘ indirect ’ are those which do act upon the gland, affecting either the nervous structure contained within it, or the nerve-centres directly connected with it. The topical sialagogues are dilute acids, ether, ginger, rhubarb, horseradish, mezereon, mustard, pebbles, pyrethrum, and tobacco. The rcmcit SIALAGOGUES. eiaiagogues are iodide of potassium and other iodides, jaborandi, mercury and its salts, physo- stigma, and tobacco. Topical sialagogues excite secretion of salira reflexly, the afferent nerves being the lingual and buccal branches of the fifth, and the glosso- pharyngeal nerves. The afferent nerves, through which nauseants probably excite the salivary secretion, are the vagi. Of remote sialagogues, iodide of potassium probably acts upon the gland-structures, but upon which part has not yet been determined. It may, however, also act reflexly, by stimu- lating the sensory nerves of the mouth, as it is excreted in the saliva, and the taste of it is often persistent. Mercury probably acts partly by affecting the gland-structures, and partly by affecting the mouth. Jaborandi, physostigma, and tobacco appear to affect the terminal branches of the secretory nerves in the glands. Uses. — Saliva is useful in keeping the mouth moist, and thus facilitating mastication, deglu- tition, and the movements of the tongue in speaking. By moistening the fauces it also pre- vents or lessens thirst. A pebble placed under the tongue, or masticated, will keep up a slight flow of saliva, aDd may be useful for these pur- poses. Where this is insufficient, dilute acids are employed (see Acids). As the flow of blood to the glands is greatly increased through secre- tion, sialagogues have been used as derivatives, to lessen inflammation, congestion, and pain in other parts of the head, as in tooth-ache, ear- ache, and inflammation of the ear, nose, or scalp. Saliva has also, however, a digestive power upon starch, and increase of the flow may be advantageous in imperfect digestion of this sub- stance. When swallowed, the saliva stimu- lates the secretion of gastric juice, and increased salivary secretion therefore tends to aid gastric digestion. To attain this object it is best to chew a piece of ginger or of rhubarb. T. Lauder Brunton. 8IBBENS. - — This term, derived from a Scotch word, signifying ‘ kindred,’ is suggestive of a disease prevalent in families, and presumed to be a form of chronic syphilis. SIBILANT BALE, or RHONCHUS : SIBILUS ( sibilus , whistling). — A variety of dry rale or rhonchus, of a whistling or high- pitched musical character, usually produced in the smaller divisions of the bronchi. See Physi- cal Examination ; and Rhonchus. SICILY. — A warm, moist, winter climate. Climate of base of .(Etna more variable than N. coast. See Climate, Treatment of Disease by ; and Paleemo. SICK HEADACHE. — A popular synonym for megrim. See Megrim. SICKNESS. — A common name for vomit- ing. See Vomiting. SIGHT, Disorders of. See Vision, Dis- orders of. SIGNS OF DISEASE. See Disease, Symptoms and Signs of ; and Physical Exami- BATION. SIXTH NERVE, DISEASES OF. 1431 SINGULTUS (Lat. sobbing, hiccup). — n synonym for hiccup. See Hiccup. SINUS (Lat.). — Pathologically, sinus means a narrow track of variable length, leading from a chronic abscess to a free surface. See Abscess. SINUSES CEREBRAL, Diseases of, See Meninges, Diseases of. SINUSES, NASAL, Diseases of. Si* Nose, Diseases of. SIXTH NERVE, Diseases of. — The sixth nerve, or abducens oculi, confers motor power on the external rectus muscle of the eyeball, and its morbid states of excessive or defective function are indicated by corresponding spasm or paralysis of that muscle. 1. Spasm of the external rectus.— This condition is very rare, except as a consequence of some change in the visual functions of the eye. The external rectus may then habitually overact, causing divergent strabismus. Permanent con- traction occurs when there is complete paralysis of its antagonist, the internal rectus. Spasm may occur from irritation of the nucleus or fibres of the sixth nerve, as in meningitis of the base. The symptoms are inclination out- ward of the affected eye, and consequent diver- gent strabismus. The treatment is that of the cause on which it depends. Sec Strabismus. 2. Paralysis of the external rectus. — JEtiology. — The common causes of this condition are cold, acting possibly on the nerve-fibres within the muscle, but more probably by giving rise to inflammation around the trunk of the nerve ; syphilis, by causing growth on, or exuda- tion round, the nerve, or meningeal thickening ; meningitis; pressure on the nerve by aneurism or tumour ; and organic diseases of the pons. Transient or permanent paralysis sometimes accompanies sclerosis of the posterior columns of the spinal cord (locomotor ataxy) ; its cause is obscure. Symptoms.— Paralysis of the external rectus causes inability to move the affected eye out- wards, and hence convergent strabismus, and homonymous diplopia when looking at an object on the affected (say left) side of the middle line, the images becoming more distant as the object is moved to the left, but parallel, and on the same level, so long as it is on the level of the eye. When looking up or down as well as out, the second image slants, the two being nearer together at the lower end, and the second image the lower of the two when looking up and out. On looking down and out, the two images are nearer together at the top than at the bottom, and the second image is on a higher level than the other. There is erroneous projection of the field of vision. Diagnosis. — Paralysis of the sixth nerve ia easily recognised, except when slight in degree. In the latter case it may often be detected by a careful search for the diplopia, or by the secondary deviation of the sound eye in the same direction when that eye is covered and an object fixed by means of the weak muscle. See Strabismus. Prognosis. — The prognosis is most favourable when the paralysis is due to cold or svuhilis : least .432 SIXTH NERVE, DISEASES OF. favourable when due to meningitis or tumour. When associated with ataxy, it is usually re- covered from, but a return is common. Treatment.— When the complaint is of rheu- matic origin, the treatment should consist of hot fomentations to the temple ; counter-irritation by blisters ; and iodide of potassium and tonics internally. If of syphilitic origin iodide of mercury or of potassium should of course be given. In spinal mischief, strychnia and arsenic are useful. In obstinate cases, faradization, or the interrupted battery current, may be applied to the muscle through the eyelid, or to the temple to produce a reflex effect. The direct applica- tion to the muscle through the conjunctiva is too painful. W. R. G-owees. SKIN, Diseases of. — S ynox. : Fr. Maladies de la Peau ; Ger. Hautkrankheiten. Definition. — Cutaneous diseases may be de- fined as an aberration of the skin from the standard of health, evidenced by an alteration in its appearance, qualities, sensibility, functions, and relations to the rest of the organism. Classification. — The ancients classed diseases of the skin according to colour, roughness or smoothness, and bulk. At the present time we shall find no better classification for all practical purposes than — (1) diseases of the circulation-, (2) of nutrition ; and (3) of sensibility. This ap- plies to the skin in general; but the compound nature of the skin — consisting as it does of a pigment-organ, the rete mueosum ; a homy covering, the epidermis ; an apparatus of sebi- parous and sudoriparous glands; and a special outgrowth of the derma, the hair — requires an expansion of this classification, so as to include specially the diseases of these separate parts. Hence a very simple subdivision of diseases of the skin, founded on*the anatomical struc- ture of the organ, would be, besides diseases of the skin in general — (4) diseases of the retc mueosum ; (5) diseases of the epidermis; (G) diseases of the glandular apparatus; and (7) diseases of the liair- follicles and hair. 1. Disease, of the Circulation. — Diseases of the cutaneous circulation are manifested by hypersemia, and principally by inflammation; and inflammation, according to its origin from ordinary constitutional causes or from blood- poison, admits of a division into common inflam- mation and specific inflammation. Common in- flammation is represented by eczema, erythema, pemphigus and anthrax ; and specific inflamma- tion by the exanthemata, syphilis, and elephan- tiasis. The four examples of diseases of common inflammation above mentioned may be taken as types of so many groups of cutaneous disease, for example, eczematous, erythematous, phlyc- tenous, and anthracoid. The eczematous group comprises eczema, scabies, lichen, and impetigo; the erythematous group, erythema and ery- sipelas ; the phlyctenoid group, miliaria, pem- phigus, and herpes; and the anthracoid group, ecthyma, hordeolum, furunculus, and anthrax. In like manner, treating specific inflammation according to the same method, we have an ex- anthematous group, composed of rubeola, scar- latina, and variola ; a syphilous group presenting SKIN, DISEASES OF. itself in the forms of erythema, papule, tubercle, ulcer, and gummated tumour ; and an elephantous group, which includes the macular, tubercular, anaesthetic, and mutilating forms of elephan- tiasis. 2. Diseases of Nutrition. — Diseases of nutri- tion are consequent on aberration of nutritive function, sometimes in the form of dystrophy or altered nutrition, sometimes as atrophy or ab- sence of nutrition, and sometimes as hypertrophy or excessive growth. Under the head of dys- trophic affections are to be included — lepra or psoriasis, struma or scrofula, lupus, lymphoma, xanthoma, and epithelioma ; under that of atro- phic affections — dc-rmatoxerasia, ichthyosis, sau- riosis, striae atrophicae, morphcea, and scleriasis ; and under the head of hypertrophic affections — spilus, verruca, cornu, clavus, angeioma, fibroma general and partial, and mycosis ; general fibroma including spargosis or elephantiasis Arabum; and partial fibroma, molluscum, and cheloma. 3. Diseases of Sensibility. — Diseases of in- nervation comprehend pruritus, prurigo, derma- talgia, neuroma, which are examples of dys- aesthesia ; with hyperssthesia and anaesthesia. 4. Diseases of Pigmentation . — Disease of the rete mueosum, the seat of the colour of the skin, constituting ehromatopathia and a group of chromatopathic affections, has its principal seat in the rete mueosum, and is manifested by excess of pigment, termed melasma or melanopathia ; deficiency of pigment, termed achroma or leuco- pathia; and aberrations from the normal standard of colour, as in xanthochroia or excess of yellow, and cyanopathia, or the presence of blue pigment in the skin. To this group must also be added the leaden or slate-coloured hue of the integument, produced by the chemical operation of nitrate of silver on the superficial portion of the corium, named melasma tinctum and argyria. 5. Diseases of the Epidermis and Nails . — Diseases of the epidermis and nails constitute an epidermic and onychopathic group of affections of the skin, the former of these being remarkable for the presence of a phytiform growth within its structure, as in tinea or ringworm, and lavas — the so-called nosophyta ; and the latter embrac- ing all the varieties of disease of form, texture, colour, and bulk of the nails. 6. Diseases of the Cutaneous Glands. — Diseases of the glands of the skin and their functions constitute a group of steatopathic affections, and another of idrotopathic affections. Of these, the former includes steatorrhrea or excessive secretion, comedones or impacted secretion, mol- luscum contagiosum scu adenosnm or hyper- trophy of the sebiparous glands, encysted tu- mours resulting from dilatation of the follicles with sebaceous secretion, and sebaceous horns consequent on the desiccation of inspissated sebaceous matter, exuded through an aperture of the cyst. The idrotopathic affections compre- hend excess, deficiency, and alteration of cuta- neous perspiration, represented by the terms liyperidrosis, anidrosis, osmidrosis or feetid per- spiration, chromidrosis or coloured perspiration, haemidrosis or sanguineous sweat, and inflamma- tion of the sweat-glands. 7. Diseases of the Hairs and Hair-folliclcs — Diseases of the hair-follicles and hair are rs- SKIN, DISEASES OF. presented by affections of the hair-follicles proper, for example, folliculitis, acne, gutta rosacea, sycosis, and favus ; and by special affec- tions of the hair, comprehending alteration of quantity, colour, and structure. iETiOLOsr. — The aetiology of cutaneous diseases embraces most of the causes ■which give rise to disease of other organs *of the body ; the only special characteristic of the skin being its peri- pheral distribution, and its consequent exposure to friction and to the action of the atmosphere. Like other organs it is dependent for its health upon healthy nutrition and innervation. When nutrition is defective in infancy and youth, the skin loses its powers of resistance ; it becomes abnormally sensitive to the action of irritants from within and from without; and it is conse- quently prone to eczema, lichen, struma, and acne. Hence derangements of digestion and cutting of teeth are common causes of eczema in infants; struma is often developed for the first time with the appearance of the permanent teeth ; and acne accompanies the active development of the hair at and after puberty. Thus, in considering the aetiology of diseases of the skin, we may take as a starting-point a weak organ, whatever the causes of that weakness of organ may havo been, and then endeavour to discover the agency of the exciting cause. A weakly parent may become the mother of an ill-nourished infant, or may be unable to supply it with congenial food ; a weak and sensitive skin follows; and then a variety of excitants, operating on a skin so predisposed, may give rise to an eczema. Or, if in place of a weakly parent we assume a faulty digestive apparatus, the skin may equally bo the sufferer, and then an accidental malassimilation will become an exciting cause of eczema, erythema, or urticaria. In like manner an external irritant, such as friction, may promote the development of an eczema. The cause may, however, be in itself so potent as to develop an exanthem in an other- wise healthy skin, as in the exanthematous fevers. Disturbances of innervation may be associated with discolouration of the skin, as in Addison's disease ; or with eruptions, such as herpes. Next to malassimilation and specific poisons as causes of cutaneous disease, defective nutrition is evinced in ichthyosis, achroma, alopecia, and lupus erythematosus; and aberration of nutrition in struma, lupus, lepra vulgaris, and in the various forms of hypertrophy, general and partial. Poisonous articles of food may produce skin- eruptions. Thus urticaria follows the use of cer- tain kinds of fish, more especially mussels, or of other indigestible substances. Certain drugs, too, have a specific action on the skin, giving rise to various forms of rash ; for example, the salts of iodine and bromine, cubebs, copaiba, and quinine. Borax has recently been said by Dr. Gowers to produce psoriasis ( Lancet , 1881 , vol. ii.). As a summary of the aetiology of cutaneous diseases, they may be said to be the product of a feeble organ, induced by debility or derange- ment of constitution ; and the therapeutical corollary will follow — restore power to the con- stitution, the organ will recover, and the disease trill cease. 1433 Symptoms. — The semeiology or symptomato- logy of cutaneous diseases is principally mani- fested by alteration of the colour, texture, and sensibility of the skin. Change of colour may proceed from abnormal circulation, giving rise to various tints of red, ranging from scarlet to livid; or from aberrations of pigment. Change of tex- ture is evinced by abnormal hardness or softness, thickness or thinness, roughness or smoothness, swelling or prominence, or solution of continuity in the form of cracks or ulcers. Colour. — (a) The brighter tints of redness pro- ceed from active hyperamia , while the duller, the purple, and the livid are the consequence of pas- sive hyperemia. The brightest of the hues of red- ness are met with in erythema, urticaria, eczema, and scarlatina; the tint of roseola, rubeola, and the syphilodermata trenches on the purple ; while the lrypersemia resulting from venous congestion is livid and almost black, as we see evinced in morbus ccerulms, in chilblain, and in anthrax. Angeieetasia and ntevi are scarlet, crimson, purple or livid, in correspondence with the activity of circulation through their blood-vessels ; and effusions of blood into the cutaneous tissues, as in purpura and ecchymosis, range between crimson and black. It is essential to distinguish between a redness which is transient and one which is permanent; between that which maybe regarded as a pathological blush, such as erythema and urticaria, that which indicates a superficial in- flammation, as in the case of eczema and ervsipe- las, or a deeper inflammation, as in the instance of furunculus and anthrax ; and in the case of permanent redness, a state of angeieetasia or a vascular nsevus. (b) Changes of colour from aberration of pig- mentation are commonly restricted to the rete mucosum, and range in hue from the whiteness of achroma, through the yellow and brown stains of lentigo and chloasma, to the deepest black of melasma. Altered pigmentation is also met with in the tissue of the corium ; as in the yellow tints of xanthoma, the black deposits of melasma, the chemical stain of oxide of silver, and the mechanical colouration of tattoo. Texture. — Alterations of texture of the skin are discoverable by the touch as well as by the eye. Infiltration of the cutaneous tissues commu- nicates to the hand a feeling of density and thickness; this may always be observed in eczema, where it gives rise to slight swelling, but is most conspicuous in erysipelas, and in the tumescent forms of erythema. Similar infiltration, together with hyperemia and hypertrophy, produces the various forms of pimples, tubercles, and tumours of the substance of the skin. IVe must, however, except from this cause the tubercles of urticaria, which are consequent on muscular contractility; and those of chronic syphilis, elephantiasis, lupus, lymphadenoma, and epithelioma, which are due to the formation of a new tissue. In chronic eczema, in the lepra of the Greeks, and in dif- fused lichen planus, the skin is sometimes found as hard and dense as leather, from infiltration ; and in this state it not infrequently cracks and breaks, so as to produce chaps or rhagades. The skin is apt to be roughened in chronic eczema by hypertrophy and exfoliation of the epidermis, and most conspicuously so in lepra vulgaris; 1434 SKIN, DISEASES OF. while a state of congenital roughness of the skin is pathognomonic of xeroderma and ichthyosis. In alopecia universalis the skin is morbidly soft and smooth ; and it is likewise smooth and thin, from defect of nutrition, in alopecia areata. The texture of the skin is also rendered abnormal by the prominence of the follicles of the skin in the form of papulae, as in a cutis anserina resulting from vascular congestion and infiltration instead of from muscular spasm; by the production of vesicles and sero-pustules, the consequence of exudation ; by surface exudation giving rise to crusts of various thickness — all of these states being common to eczema ; by the hypertrophic laminse of epidermis generated by the congested blotches of lepra vulgaris ; and by the ulcers of lupus, syphilis, and elephantiasis. It is impor- tant, therefore, to discriminate between variation of texture due to alteration of the skin in its whole or in its parts. Thickness and condensa- tion may proceed from infiltration solely, from infiltration with active hypertemia, from infiltra- tion with hypertrophy, or from the development of a new and abnormal tissue : it may be re- stricted to the derma proper, or it may spread to 1 he subcutaneous tissues ; or the alteration may bo one involving separately the papillse, the glands, or the fibrous or other tissues of the corium. Sensibility. — Altered sensibility may present itself as an excess or defect of sensibility, itching, tingling, pricking, heat, chill, or actual pain. Diagnosis. — The diagnosis of cutaneous dis- eases is governed primarily by the physiognomy of the affection, aided by corroborative evidence supplied by the history, constitution, age, dura- tion, cause, regional distribution, symptoms, &c. ; in a word, by all the information which patho- logy and experience have brought to bear on the subject. Prognosis. — The prognosis of cutaneous dis- eases is in general favourable. They are vexatious to the patient, sometimes on account of their ugli- ness, at other times from the teasing itching, or even pain, by which they are accompanied; but they are rarely fatal. Indeed their gravity is regulated by their cause, and by the constitution of the patient, rather than by their own intrinsic qualities. The most universal of cutaneous dis- eases, eczema, originates in malassimilation ; and its cure or persistency will depend on our po-wers of restoring assimilation to a healthy standard, and this again will be governed by the circum- stances and position in life of the patient. Ery- thema, and especially urticaria, are due to a state of constitution, and in themselves are simply a symptom of constitutional disorder. Sufferers from pemphigus sometimes die, because pem- phigus is often a symptom of asthenia and ca- chexia ; and anthrax, which occasionally kills by' pain alone, is, in general, only fatal from con- stitutional complication. In specific inflamma- tion of the skin the prognosis turns upon the curability of the major disorder — of the rubeola, the scarlatina, the variola, the syphilis, or the elephantiasis ; and these are all curable, saving accidental complications, except elephantiasis, which must be regarded as an incurable disease. In the dystrophic affections — the Greek lepra, struma, and epithelioma, medicine is placed at , SKIN, BRONZED. the mercy of a feeble constitution ; and although we may do much to improve, we cannot profess to cure. The same may be said for the rest of the nutritive affections ; we can cure some, such as ichthyosis, hut we must fail signally in our attempts to cure others, because we possess no direct means of renovating a faulty constitution, or of giving strength -and energy to a feeble organ, and thus restoring its normal function. The neuropathic affections, again, present to us the problem of cure of a disordered nervous system; if that disorder be simply functional or due to derangement of general health, we shall probably succeed ; if the alteration in the nerve- tissue be organic, we must necessarily fail. Treatment. — The treatment of cutaneous diseases divides itself naturally into constitu- tional and local. Sometimes the constitutional treatment is alone essential, as in non-nlcerative syphilis; at other times local treatment only is required, as in the chronic forms of eczema, termed psoriasis by Willan and Bateman ; but in general a judicious combination of the two is necessary. The aim of therapeutical treatment should be to restoi^ healthy function and normal vital power ; and the recovery of these will fre- quently prove sufficient to accomplish the cure of the local affection, if the latter have been shielded in the meantime by soothing applications. Mild tonic aperients, succeeded by tonics, especially by quinine, iron, and arsenic, constitute the spe- cial treatment of the whole family of inflamma- tory affections of the skin. Where the restora- tion of the nutritive power of the skin is a primary indication, as in non-inflammatory lepra vulgaris, and ia every instance in which the nutrition of the skin is to be amended, arsenic may be regarded as a specific remedy. The local remedies for cutaneous diseases are alleviative, stimulant, and caustic. Alleviative remedies, such as the oxide of zinc ointment, are especially adapted to the inflammatory affections, headed by eczema ; chronic eczema and lepra vulgaris or psoriasis require the stimulating help of the mercurial ointments and tar; while lupus and epithelioma necessitate the employment of caustics, such as nitrate of silver and potassa fusa. Besides these, which are the essential re- medies, there are others adapted for special pur- poses, which are mentioned in connection with the different diseases to which they are appli- cable. They consist principally of absorbent powders and lotions ; lotions to relieve pruritus ; and sulphur applications for scabies. The several diseases of the skin are fully dis cussed under their respective headings. Erasmus Wilson. SKIN, BRONZED. — A form of pigmentary discolouration of the skin, embodying a reddish tint, in lieu of the yellow and green hues which are met with in lentigo and chloasma, and the absolute black of melasma. When the com- plexion is darkened by the action of the atmo- sphere and of the sun. it is said to be bronzed ; and the term ‘bronzed skin’ has become familiar also in consequence of its application to the melasma of the skin in Addison's disease. Bronzed skin, again, calls to mind the copper colour of chronic syphiloderma, in which the melasma is SKIN, BRONZED. modified by red and yellow. In alliance with Addison's disease, melasma mnst not be regarded as specific, but simply as the ordinary melasmic change of colour of the disordered skin, of which the ‘ bronze ’ tint is an accidental modification. See Addison’s Disease ; and Pigmentary Skin- diseases. Erasmus Wilson. SKIN, DISCOLOURED. See Pigmentary Skin-Diseases. SKIN-BOUND DISEASE.— A popular bynonym for Sclerema neonatorum. See Sclerema Neonatorum. SKODAIC RESONANCE. — A peculiar high-pitched resonance, found chiefly at the ster- Rc-clavicular region of the chest, in some cases of pleural effusion. See Physical Examination. SKOLIOSIS(cnco\il>s,crooked). — A synonym for curvature of the spine. See Spine, Diseases and Curvatures of. SKULL, Diseases and Deformities of. — Synin. : Fr. Maladies da Crane-, Ger. Krank- des Schddcls. — The principal diseases and deformities of the skull will be discussed in the lo. lowing order : — 1. Changes of shape ; 2. Vari- ations in size ; 3. Meningocele and Hernia Cere- 1 r; . 4. Cephalhoematoma ; 5. Inflammation ; 6. Pickets; 7. Craniotabes ; 8. Syphilis; and 9. Tumours. i . Changes of shape.-The shape of the skull not only varies much amongst the different races of mankind, but in each race variations are to be found, sometimes depending upon, sometimes independent of, disease in the individual. A glance at any extensive collection of crania is sufficient to indicate how much larger some skulls are than others, in proportion to their width ; how in some the vertical diameter is pro- portionally great, in others small ; how some hare wide cheekbones, some depressed noses, and others projecting jaws. The old classification of Blu- menbach has now been superseded by the nume- rous and minute observations of recent investi- gators. Eor a short account of the methods of craniometry now in use, and of the present tran- sitional state of the science, the reader is referred to the ninth edition of Dr. Jones Quain’s Anatomy, vol. i. p. 80, where he will also find references to most of the important works upon the subject. The skull is seldom perfectly symmetrical ; the asymmetry beiDg usually more marked behind than in front. This is shown not only by a coarse examination of the exterior, but by referring to the differences between the sulci and foramina on the two sides, which are so commonly met with. A familiar illustration is afforded by the fact that the nose is rarely if ever exactly in the mid line of the body ; but much more striking deviations from perfect symmetry may occur, as, for instance, in a case recently reported by Mr. Pearce Gould to the Pathological Society, in which one half of the cerebellum was absent, and there was a cor- responding deficiency of the cerebellar fossa on the occipital bone. Many savage races pro- duce abnormalities of the shape of the skull, by the application of external pressure during SKULL, DISEASES OF. 1435 early infancy ; and a similar result has been supposed to be consequent on the method of wrapping up the heads of children that is adopted in some parts of France. A marked asymme- try of the skull accompanies that rare disease, ‘hemiatrophy of the face,’ supposed by Mr. Hut- chinson to be related in some way to morphoea, There are also recorded cases of hypertrophy of the tones of the face and skull. A re- markable instance of this disease, or rather o( the development of enormous hyperostoses, was shown by Mr. Hutchinson, in His recent lectures on Surgical Affections of the Nervous System, at the Royal College of Surgeons. Here the hyperostoses appeared closely confined to parts which were supplied by branches of the fifth nerve. Some of these hypertrophic cases are, no doubt, examples of exostosis, others of inflamma tory enlargement. An uniformly thickened skull, depending presumably, though not certainly, on the latter cause, may be either porous like can- cellous bone, or dense and heavy like ivory. There is in the museum of the College of Surgeons an example of both varieties, each of which measures in many parts no less than ^ in. in thickness ; in the porous variety the sutures are usually more or less completely ossified. The writer has seen a case in which, without apparent cause, the growth of one half of the lower jaw appeared to be arrested about the age of puberty, which gave a peculiar inequality to the face. Remarkable deformity of the skull may result from the con- strained position in which the head is held by patients suffering from torticollis. 2. Variations in size.-The size of the skull is also subject to considerable variations in different races. It is somewhat larger, on the average, in men than in women. Amongst individuals also there are very great differences. Great intellects have sometimes been associated with large crania, but oftener there has been no such relationship, and not unfrequently the opposite has been tho case. Far greater, however, are the modifications of size, which depend upon pathological condi- tions and defects of development. Some of these are briefly as follows : — a. Microcephalic idiots . — Amongst this class of idiots, which must be made to include the cretins, the skull is remarkably deficient in size. Micro- cephalic skulls may be caused by a too early union of the sutures, in which case the want of development of the brain may be looked upon as a result of this synostosis ; or there may be a normal condition of the sutures as regards union, but both the brain and the skull remain undeveloped. The low forehead and animal face which are characteristic of this condition, give a remarkably unpleasing appearance to the child. The amount of idiocy depends upon the size and structure of the brain, and the development of the convolutions. See Cretinism. b. Ancncephalic monsters . — This class exhibits a more or less complete deficiency in the develop- ment of the cranial bones, as well as of the brain. The great variety of abnormalities which may be met with will be found described in the article Brain, Malformations of. c. Hydrocephalic infants . — These infants have skulls of a size proportionate to the amount of fluid which is present, and they may thus some- SKULL, DISEASES AND DEFORMITIES OF. 1436 times reach enormous dimensions. See Hydro- cephalus, Chronic. In this connection must be mentioned that extremely rare disease in children— hypertrophy and. sclerosis of the brain, which involves a cor- responding increase in the size of the skull. See Brain, Hypertrophy of. 3. Meningocele and Encephalocele. — Closely related also to hydrocephalus are the cases of meningocele and encephalocele. It may briefly be stated here that they involve the exis- tence of a deficiency at some point of the skull, through which the membranes of the brain, con- taining cerebro-spinal fluid, or indeed some part of the brain itself, may protrude. The most frequent seat of this disease is the occipital bone, and the next in frequency the nasal part of the frontal bone, but tumours of this nature have been met with in other situations. It is of the highest importance to diagnose these two kinds of tumour from those developed in the bones of the skull or outside them; mistakes in diagnosis have not unfrequently led to most disastrous results, as, for example, when a meningocele has simu- lated a polypus of the nose, and its removal has been undertaken. If patients who have suffered from meningocele or encephalocele recover — a most rare occurrence — a small hole may remain in the bone which presented the deficiency, or Tie opening may be completely obliterated. 4. Cephalheematoma. — True cephalhaema- toma is a collection of blood between the perios- teum and the skull. It occurs congenitally, usually on the right parietal bone, but often on the left, and as a rule varies in size from an inch to two inches in diameter ; and it is surrounded by a hard, well-defined margin, which ultimately is composed of bone. It is probably in most eases, if notin all, the result of mechanical violence during delivery. An exactly similar condition is often seen as the result of a contusion in later life. If left alone a cephalhaematoma generally disappears. If suppuration have taken place incision becomes necessary. See Cephal- hematoma. The term cephalhaematoma might equally well be applied to collections of blood between the dura mater and the skull. Such effusions are probably always traumatic, and result from the rupture of a meningeal artery or vein. If serious results do not immediately follow from pressure on the brain, considerable thickening of the dura mater may be set up, accompanied by the symp- toms known as those of pachymeningitis. See Meninges, Cerebral, Inflammation of, Simple Traumatic. 5. Inflammatory Diseases. a. Inflammation of the diploe and its veins . — In cases of injury to the skull, whether of the nature of fracture or of simple exposure in a scalp-wound, inflammation of the diploic veins is not uncommon, if the wound be allowed to putrefy. Under such circumstances if the outer table be removed, the whole diploe and its veins are found to be filled' with pus, or on applying a trephine to a bone thus affected, the pus may be seen to exude from the divided veins. The dura mater, under such circumstances, may be affected, or pus may collect between it and the bone. Pysemia, with its characteristic concomi- tant symptoms, is tho frequent, if not the invari- able, result. It is not assumed that in this affec- tion the outer and inner tables of the skull escape, but it is only in the diploe that the pathological process is obvious to the naked eye. The only treatment that has been suggested — trephining — does not offer any hope of alleviating the symptoms. b. Chronic osteitis. — This may affect the bones of the skull without apparent cause, but in the majority of cases depends upon the syphilitic taint. Sometimes all the bones of the skull become thickened and enormously massive, the surface being much roughened and often worm- eaten. At other times irregular hyperostosis may be the result. Considerable thickenings of some of tho cranial bones, the result of an im- perfect vascular osseous deposit, are found in some infants affected with congenital syphilis. These are mostly met with about the fonta- nelles, especially on the frontal and parietal, and sometimes the temporal bones. The irregular hyperostoses are mostly the result of local peri- ostitis; in fact, they are ossified nodes. Chronic osteitis is the cause of the falling-in of the bridge of the nose or the massive condition of the same part, which gives such a characteristic appear- ance to a child suffering from congenital syphilis. The treatment must be directed against the constitutional taint, if any is to be discovered. c. Caries. — Chronic osteitis can hardly be con- sidered apart from caries, which, again, in the majority of cases, depends upon syphilis, though more rarely on the strumous diathesis. It is usually caused by the penetration of a superficial ulcer into the deeper structures, or by the sepa- ration of the periosteum, resulting from perios- titis. It is frequently associated with more or less chronic osteitis and necrosis. One of the most frequent seats of caries of the skull is the fore- head, as a sequence of tertiary syphilitic ulcera- tion ( corona Veneris). Another common seat is the hard palate, which is often perforated as the disease advances. Caries may occur in the occipito-atlantal articulation (Pott's disease), followed by a train of symptoms which will be found discussed in other parts of this work. Caries of the temporal bone, either of the petrous or mastoid portions, frequently follows otitis media, and is not uncommonly the intermediate stage between this disease and meningitis or cerebral abscess. Beyond precautions for maintaining cleanli- ness, little or nothing can be'done to relieve this condition by the surgeon ; and with regard to other cases of caries of the skull, whether con- sidered pathologically or clinically, nothing can be added which does not apply to the same disease in other parts of the body. Caries of the occipito-atlantal articulation is well treated in the early stages by the actual cautery. d. Necrosis. — Necrosis of the skull not unfre- quently depends upon a traumatic cause, such as scalp-wounds or burns; but here again the syphi- litic form is exceedingly common. It may also de- pend upon disease cf the middle ear. Simple trau- matic necrosis leads to the separation of a seques- trum in the usual way. Syphilitic necrosis often depends upon some form of ulceration, or upon periostitis, and maybe accompanied by extensive SKULL, DISEASES ANTD DEFORMITIES OF. caries and chronic osteitis. The separation of syphilitic sequestra is generally a remarkably tedious process ; and they are, moreover, often surrounded by little or no reparatory callus, so that after their removal it is no rare occurrence to find the dura mater pulsating over a large area at the bottom of the -wound. At the same time this rule is not invariable ; it is common to find great thickening if necrosis of the bones of the orbit occur, which may cause permanent dis- placement of the eyeball. The writer has seen a large piece of the body of the sphenoid sepa- rated as a sequestrum, including the sella tur- cica, and removed through the nose without the slightest evil result to the patient. Necrosis is not unfrequently met with affect- ing the bones of the face. Thus a part or the whole of the upper or the lower jaw may die, and be separated as a sequestrum. Necrosis of the jaws often depends on inflammation set up by carious teeth. Another cause, happilynotnow frequently met with, is the poisonous effect of the fumes of phosphorus in persons employed in the manufacture of this substance, and in that of lucifer matches (see Phosphorus, Poisoning by). The same remarks apply to the abuse of mercury. But besides these more special causes, necrosis of the bones of the face may depend upon those more general states which are sup- posed to stand to necrosis of other bones in the relation of cause and effect ; such as fevers and the like. The amount of thickening round a necrosed upper jaw has not unfrequently led to its removal in mistake for a tumour ; it is, there- fore, of the highest importance to examine all swellings in this region with great care. Treatment. — If the membranes be left ex- posed, some protection must be provided for the cranial contents ; otherwise the treatment of ne- crosis of the skull must be conducted on general principles. Sequestra in the mastoid process or around the tympanum should be carefully dealt with, on account of the danger of setting up meningitis, which any surgical interference in- volves. In dealing with necrosis of one half of the lower jaw it must be remembered that, un- less sufficient callus have been thrown out before the removal of the sequestrum, the other half will lose its support and assume an altogether unnatural and almost useless position, leaving the patient in a condition in which he can hope for but little relief from surgery. e. Periostitis . — Periostitis of the skull has been already referred to. It may depend upon syphilis or struma — most, commonly the former, and gives rise to what are known as nodes. The inflam- matory subperiosteal effusion may be fluid or solid (soft and hard nodes) ; and it may undergo true or spurious suppuration or ossification, or may be completely absorbed. The most common position for cranial nodes is the frontal bone. As in the case of periostitis elsewhere, nodes are the seat of characteristic nocturnal pain, which is ex- tremely distressing and exhausting to the patient. Treatment.— The treatment in any case is by the administration of iodide of potassium ; the effect of which is most marked, however, in syphilitic cases, the pain being usually removed in two or three days. If suppuration occur, in- sision is required. 1437 6. Rickets. — In a rickety infant the skull looks large; though it maybe questioned whether this does not depend on a deficient development of the bones of the face. The frontal and parietal eminences appear too prominent ; the fontanelle.s remain patent much longer than in a healthy infant ; and in some cases the anterior fontaneila may be unclosed as late as the fourth or sixth year. The skulls of rickety children have a peculiarly massive feel ; they are sometimes long in proportion to their width, conforming to the shape known as dolieoceplialic. For a more detailed account of this and other conditions see a paper by S. J. Gee, M.D., in vol. vii. of the St. Bartholomew’s Hospital Reports , on'The shape of the head looked at from a medical point of view.’ The head of an adult who has been the subject of rickets in his childhood, has often a very characteristic appearance ; an apparently large square skull, with a prominent forehead towering above a diminutive and pinched-up face, giving to the individual a decidedly intel- lectual aspect. Craniotabes occurs occasionally in rickety skulls, but, as will be afterwards shown, we do not yet know how far, if at all, it depends upon the constitutional condition. 7. Craniotabes. — By this term is meant the occurrence of spots of remarkable thinness in the skull, such that an indentation may be produced by the pressure of the finger. True craniotabes, as opposed to the gelatiniform degeneration of the outer table (Parrot), attacks the inner aspect of the skull. For its production an undue soft- ness of the bone appears to be necessary, to- gether with the occurrence of pressure, either from within or from without. It is rarely found congonitally, and then affects the anterior part of the skull. It is common in syphilitic infants under one year of age, and then affects usually the posterior parts of the parietal bones. These positions, it will be noticed, are those most sub- jected to pressure under the two conditions mentioned. Craniotabes has been, by some ob- servers, associated with rickets, but the relation of the one to the other is at present doubtful. It disappears as age advances, and requires no special treatment. See M. Parrot, Revue Men- suclle, 1879, p. 769 ; and Dr. Barlow and Dr. Lees, Pathological Transactions, 1880, p. 236, and 1881, p. 323. 8. Syphilitic affections.— From the fore- going observations it will be seen that syphilis, congenital or acquired, has much to account for amongst diseases of the skull. It may cause periostitis, with consequent nodes ; chronic osteitis, with consequent hypertrophy, local or general; caries ; necrosis ; and craniotabes. As a general rule, it may be stated that syphilitic affections of bone are amongst the later manifes- tations of this disease. The inflammatory forms are usually accompanied by severe nocturnal pains, and they may be expected in most cases to yield to the administration of iodide of potassium. 9. Tumours. — It is necessary to refer in the briefest possible way to the tumours of the skull. Primary growths may spring from the diploe, or from the inner and outer tables of the cranial bones. Perhaps the most common are exostoses, 1438 SKULL, DISEASES OF. and some of the various kinds of sarcoma, either of which may reach an enormous size. The former may assume various characters. A remarkable instance of one presenting the appearance of a horn will be found described in the Path. Trans. vol. iii. p. 149. These alone, and then only in cer- tain cases, admit of removal by the surgeon. In connection with the bones of the face, tumours of the antrum or of the upper jaw, of various kinds, and tumours of the lower jaw, are not uncommon. In the latter position the various forms of epulis — myeloid, fibrous or malignant, and cystic tumours are frequently met with. Exostoses often grow from the jaws and the orbit, and in connection with the latter the different kinds of odontoma must be mentioned. Secondary tumours of all kinds may affect the skull ; thus more than one in- stance is on record of a pulsating growth, occur- ring secondarily to a similar growth in the thy- roid gland. Of these secondary affections the commonest are those which affect the skull by the direct extension of tumours from within or without ; for example, the epitheliomata of the scalp or mouth, or rodent ulcer of the face. E, J. Godlee. SLEEP, Disorders of. — Synox. : Fr. Troubles du Sommeil ; Ger. Stbhmngen dcs Schlafes. — A proper amount and kind of sleep is needful in order that the body may be main- tained in a state of health. But the actual amount of sleep taken and necessary for persons in health varies, within wide limits, according to age, the soundness of the sleep itself, and indi- vidual idiosyncrasy. Age is a very important modifying factor. Thus an infant may sleep for twenty hours out of the twenty-four, and young children up to the age of ten commonly sleep for fourteen or at least twelve hours. In children from ten to fifteen years old, the duration of sleep usually varies between twelve and ten hours. In persons from fifteen to twenty-five the period should not sink below eight hours ; from the latter age on to fifty it may fall to seven hours ; and after thisage about the same amount of sleep is required by the majority of persons, though some find six hours sufficient, and a few can (without apparent in- jury) take habitually even as little as five hours’ sleep. The instances in which a duration of sleep habitually less than this is needed, are altogether rare and exceptional. Soundness of sleep, too, is subject to much in- dividual variation. In childhood and in early life, sleep is commonly mere profound than it is in adults, and much sounder than in old age. But over and above these variations incident to age, there are individual differences. Some persons are naturally ‘ light ’ and others 1 heavy ’ sleepers. As a rule, those who can do with a small amount of sleep belong to the latter category. And similarly in regard to amount there are indivi- dual differences ; some persons are able to do with a comparatively small amount, while others seem to require to sleep decidedly beyond the average periods above stated. The disorders of sleep, — that is, the variations outside the above limits— belong td three prin- cipal categories, in the first of which may be ranged all those cases where sleep is excessive in SLEEP, DISOEDEES OF. amount; in the second those in which it is defec- tive in soundness or in amount; and in the third those in which it is unnatural in character. I. A m ount of sleep excessive. — This oc- curs commonly in more or less demented persons or in idiots, whose brain-activity i3 below the usual level. Such persons, when their natural wants are satisfied, are apt, like the lower ani- mals, to sleep away a large portion of their time. But some individuals of notable intellectual power may occasionally, even in a state of health, though after greatly prolonged labours with previous deprivation of rest, continue to sleep soundly for twenty-four or even thirty-six hours. In many brain-affections, and in some cases of blood-poisoning, a condition of unnatural sleep bordering upon stupor may be present for many days. Obscure cases in which sleep is prolonged for weeks, or even months, are occa- sionally met with in this country. This rare condition only supervenes in persons of an obviously ‘ nervous ’ temperament, and the state itself seems generally to be a kind of trance allied to catalepsy. On the West Coast jf Africa a curious endemic disease occurs known as the ‘sleeping sickness’ (see Gore, Brit. Med. Journal , Jan. 2, 1875), the aetiology and pathology of which is altogether obscure. It begins with a swelling of the cer- vical glands, together with an increasing ten- dency to sleep. The somnolence becomes more and more constant, until at last the patient can- not even be aroused to take nourishment. The disease lasts from six to twelve months, and is generally fatal. See Teaxce. II. Amount of sleep defective. — Under this head we have to do with two kinds of failure — a defect of quality ( disturbed or restless sleep); and a defect in quantity ( [wakefulness , insomnia, pervigilium). These two defects often co-exist, though in many cases we may have the former condition existing alone. (a) Disturbed or restless sleep. — This is a most common complaint, apt to occur in persons of all ages, and under the influence of many different causes, some of the most frequent of which are these ; — indigestible food, or food of excessive or unaccustomed quantity, taken not long before going to bed; painful conditions of any kind; discomfort induced by undue cold or excessive heat; mental excitement or worry; prolonged overwork (mental) ; over-fatigue (bodily) ; fe- brile conditions ; inflammations ; gouty states of the system ; imperfect action of the liver : exces- sive haemorrhages ; acute and chronic illnesses of various kinds ; the state of convalescence from many acute diseases. Lastly, sleeping in a novel or uneasy condition, or in the midst of unaccustomed noises, may also he mentioned as a not unfrequent cause. Under any of these various conditions sleep may be fitful and dis- turbed, the persons often starting or turning about uneasily, dreaming much, and from time to time waking under the influence of dreams of a distressing or oppressive character. In one of the most extreme of the latter conditions, especially when it has been evoked by indiges- tible food, the state known as nightmare is in- duced. See Nightmare. SLEEP. DISORDERS OF. 1439 Treatment. — The treatment of disturbed sleep must of course vary widely according to the nature of the influences under which it has arisen. These may at times be easily corrected, but in other cases where the disturbed rest is depend- ent upon pain difficult to annul, or upon some acute or chronic disease, it may be impossible or extremely difficult to ensure sound sleep, not- withstanding the best directed efforts to correct or neutralize the disturbing causes in operation. It may then be necessary to hare recourse to the measures recommended under the next heading. (h) Insomnia or wakefulness. — Under this head we ma} T have either complete or partial insomnia. The condition is complete when the person gets no sleep at all for night after night, as in acute mania, delirium tremens, in those suffering from some very severe pain, or in persons under the influence of profound grief or mental anxiety. On the other hand we may have partial insomnia of different kinds. In the one set of cases the per- sons who suffer from it may lie awake for long periods (one to several hours) before being able to get to sleep at all, and then sleep may be more or less sound and continuous till morning. In other cases patients do not experience so much difficulty in getting to sleep, though after they have slept for one, two, or more hours they awake and cannot again fall asleep ; they lie awake often in a state of mental depression, or even actually tortured by gloomy or horrible forebodings. Various cases are on record in which absolute insomnia has lasted not only for days but even for weeks, interrupted only by mere snatches of 6leep during brief intervals. In this whole class of cases, however, the suf- ferers themselves are apt to form exaggerated estimates of the amount of their wakefulness, and to become more or less hypochondriacal upon the subject. Treatment. — In many of these cases the art of the physician is very severely taxed. When- ever it is possible, insomnia should be corrected by a studious attention to the general health and habits of the patient, and by endeavouring to ensure the presence, as far as possible, of the physiological conditions which favour sleep. Mental repose, bodily comfort, a sufficient degreo of warmth, a certain amount of fatigue, com- bined with perfect quietude, are essentials. To ensure the first of these conditions it may be needful to prohibit all study for some hours before retiring to rest. An evening walk, so as to induce a certain amount of bodily fatigue, is often beneficial where it can be had recourse to. A cup of warm beef-tea,, gruel, or some weak stimulant, just before going to bed may also have a salutary influence, and the former may be repeated, or taken preferentially, during the night. Monotonous sensorial impressions (sounds or gentle frictions) ; or a monotonous dwelling of the mind upon certain uninteresting imagi- nary sights or verbal repetitions are, again, not unfrequently found to act as provocatives of sleep. Where such measures are unavailing, recourse must be had to hypnotics and sedatives, such as bromide of potassium, chloral, opium in one or other of its forms, morphia by mouth or sub- cutaneously, hy«.scyamine, Indian hemp, &e., in doses appropriate to the age and condition of the patient. In the more urgent cases the doses of such hypnotics may have to be repeated till sleep is procured ; but in many of these urgent conditions the sedative influence of packing in the wet sheet must not be forgotten. Where hypnotics are had recourse to, it is of great im- portance to see that their use is not continued after the need for them has passed. Abrupt dis- continuance is often most inadvisable, but rather a gradual diminution of the dose, with or without the knowledge of the patient. III. Sleep unnatural in character. — Under this head we have to do with various un- natural conditions, in which the abeyance of func- tion characterising sleep is more partial than that which normally exists. In disturbed sleep the physiological condition pertaining to sleep is generally less profound than it should be, just as in other cases of unusually deep sleep (akin to stupor) such a condition is generally more pro- found than natural. In the cases to which we now refer, however, sleep is partial in its area ; portions of the brain that are usually involved in the physiological condition peculiar to sleep remain exempt, so that the sleeper exhibits powers which sleep usually annuls. Hence we may have somniloqiiy or sleep-lalking ; and som- nambulism or sleep-walking. In those who exhibit the former phenomena, dream-thoughts are capable of evoking correlative acts of speech, and such persons will sometimes allow a listener to hold a sort of conversation with them, of which in the waking state they recollect nothing. This dream-conversation may be more or less coherent. Dreams themselves, too, vary much in their coherency in different individuals. In some persons whose sleep is to that exten' unnatural, powers are displayed which even sun pass those of the waking state. Mathematical problems have been solved during such sleep ; poems and music have been composed and written out, which have altogether surprised the same person when awake. The writer has re- cently seen a young lady liable to what may be termed 1 singing fits,’ in which she would lie for hours incapable of being aroused by ordinary means, singing without intermission songs, hymn3, and portions of operas in promiscuous succes- sion, but in a manner very decidedly excelling that of which she was capable w T hen awake. In all these states we have to do with a morbid condition of sleep, partial in its area, and in which there is the farther peculiarity that certain faculties are in a condition of exalted activity. The alliances here are intimate with the condi- tions that have of late been studied under the name of ‘ hypnotism,’ but which were formerly included under the term animal magnetism (see Magnetism, Animal). The same remark applies to somnambulism also. Here the morbid sleeper possesses an unwonted power of calling his muscles generally into activity in response to his dream-thoughts. Sight in relation to the dream may be good, though unrelated visual impressions are not taken cognizance of. Muscular sense- impressions also are freely acted upon, but the sleep-walker may be quite deaf to all ordinary auditory impressions. 1440 SLEEP, DISORDERS OF. Treatment. — These are to he regarded as dis- tinctly morbid conditions, and the persons mani- festing them may often be cured by attention to the general health, and the use of remedies cal- culated to give tone to, and allay the irritability of the nervous system. A line of treatment, in fact, not very dissimilar from that to which one would have resort in convulsions or epilepsy, will often suffice to cure these minor manifestations of nervous disorder. Finally sleep may be disturbed by certain phenomena occurring to the person in this con- dition, which, though scarcely to be spoken of as disorders of sleep, ought at least to be mentioned under this head. One of minor significance is snoring, which at times may be so loud as to awaken the sleeper ; but another of far greater significance is the tendency to the occurrence of convulsive or epileptic attacks, which in some patients occur only during sleep. II. Charlton Bastian. SLOUGH (Sax. Slog, afoul hole or hollow). — The dead material resulting from gangrene, ulceration, or low forms of inflammation of soft tissues. A slough may be in the form of a mass, as in gangrene; or in shreds, as in ulcers and unhealthy wounds, which are then said to be sloughing. See Gangrene ; and Ulceration. SMALL-POX.— Synon. : Variola ; Fr. la pelite Verole ; Gcr. Blattern. Definition. — An acute specific, infectious dis- ease, characterised by sudden and severe fever, which after forty-eight hours is followed by an eruption of pimples on the forehead, face, and wrists, gradually passing over the body. Thi3 eruption is followed by a fall of tempera- ture, and in from ten to fourteen days it passes through the stages of vesicle, pustule, and crust; it also appears on certain mucous membranes, and is sometimes complicated with haemorrhage into the skin, and from the mucous surfaces. ^Etiology. — When, where, or how small-pox arose is not known It certainly appeared in Europe in the sixth century. It arises now from contagionand frominoculation. It affects all races of men, every age, and both sexes. No climate is free from its ravages. It rages with special virulence where it appears for the first time, and in such cases may carry off whole tribes. It is exceptionally severe among negroes and the in- habitants of warm climates generally. Its sub- jects are unvaccinated or badly vaccinated per- sons, extensive observation having shown that in proportion to the efficiency of vaccination is the rarity and mildness of small-pox. As a rule it attacks the same person once only, but there are exceptions to this rule. Some few — of whom Morgagni, Boerhaave, and Diemerbroek are said to have been examples — are insusceptible of small-pox. Anatomical Characters. — Small-pox is the result of a specific morbid poison, which, after a period of incubation of about thirteen days, pos- sibly sometimes less, manifests itself by high fever and an eruption on tho skin. The erup- tion is sometimes preceded by rashes of an ery- sipelatous, scarlet, or measly character, chiefly SMALL-POX. seen on the lower abdomen, the groins, and the upper and inner part of the thighs, along the sides of the chest and about the axillae. Sometimes they are seen upon the face and neck, and occasionally they cover the body. They are distinguished from the haemorrhagic rashes by the absence of blue-black spots, and are usually associated with the milder cases. ‘As regards the skin-eruption, the papules are due, in the first instance, partly to punctiform hy- peraemia of the cutis, over which the epider- mic cells, andmore especially those of the super- ficial portion of the rete mucosum, become swollen. By degrees, serous fluid is poured out into the substance of the affected epidermis, raising the homy layer from the swollen group of cells below, but detaching it imperfectly, so that a number of small irregular intercommuni- cating serous cavities are produced. But soon suppuration occurs in tho subjacent rete mu- cosum, and the pus-corpuscles then rapidly diffuse themselves, and the pock is converted into a pustule. The umbilicated character which is so common is due to the presence either of a hair or of a sudoriparous gland, the connection of which with the subjacent true skin has not yet been destroyed. The suppurative process need not implicate the true skin below ; but not unfre- quently it involves and destroys it to a greater or less depth, and is prolonged inwards along the hairs or glands. Under the former circum- stances the pustule leaves no permanent trace ; under the latter a depressed cicatrix results, presenting numerous pits upon its surface.’ (Bristowe, Theory and Practice of Medicine.') Post-mortem examination shows nothing be- yond external appearances, special to small- pox, except a trace of eruption on the larynx and vocal cords. The blood is in most cases imper- fectly coagulated, and in black cases not at all. In the latter ecchymoses of the mucous and serous membranes will be found. Pleuritic effusions and pneumonic consolidations are some- times found, but the most common lung-compli- cation is broncho-pneumonia. In variola hsemor- rhagica pustulosa haemorrhage is generally found in the substance of the lungs, heart, kidneys, and liver. Symptoms. — Small-pox may be described under six forms:— (1) discrete; (2) confluent; (3) haemorrhagic pustular; (4) malignant ; (5) in- oculated ; (6) small-pox after vaccination and re- vaccination (modified). (1) Discrete. — In the discrete form the disease begins with rigor, fever, lumbar pain, headache, and sickness, with copious perspirations; fol- lowed by an eruption on the forehead, face, and wrists. This is usually most abundant on these parts, next most abundant on the hands and feet, and least so on the limbs and trunk. The eruption is followed by a remission of the general symptoms, and a fall of temperature, which continues until about the eighth day, which, in this article, is always the day of disease. Be- tween the third and the eighth days the pimples appear on the extremities and the trunk, and change into greyish-white vesicles, circular, flat- tened, depressed in the centre, and surrounded by a red ring. During this time also vesicle* may be seen in the mouth and the upper part of 1441 SMALL-POX. the pharynx and larynx, and there will he some soreness in these parts. On the eighth day some of the vesicles become pustular, lose their central depression, and become globular, whilst the red- ness which surrounds them becomes more marked. With this change the temperature rises, and the general symptoms return ; but these are of short duration, for the pustules either dry up rapidly and form scales, or burst and form scabs ; the temperature falls by about the tenth day ; and the patient is then convalescent, fatal results being extremely rare, except in unvaccinated children under one year. When the crusts have fallen, and the desquamation which follows them is complete, there will often be pitting. (2) Confluent. — -In this form the initial symp- toms are essentially the same as the former, but more severe. The eruption appears about the same time, and in the milder varieties is dis- crete until the disease has reached the vesicular or the pustular stage ; but in the more severe forms it is confluent from the first, and instead of showing distinct closely packed papules, the whole face is swollen, presenting the appearance of a tense elastic mass. When the eruption is well out the temperature falls, and the general symptoms remit, but to a less extent than in the discrete variety, and this remission continues until about the eighth day. Up to this time more or less delirium is present in many cases, and it is sometimes maniacal and suicidal in cha- racter: drowsiness and stupor sometimes bike its place, and occasionally alternate with it. On this day, the eighth, the vesicles begin to be- come pustular, the areola to deepen, the tem- perature to rise, and the general symptoms to return. At the same time the face becomes extremely swollen; the eyelids close from cede- matous swelling ; saliva flows copiously from the mouth ; the glands, and the subcutaneous tissue of the neck and lower jaw enlarge; and the early delirium usually disappears. One of three things may now take place: — (1) the disease may go on regularly to the eleventh day; (2) the development of the pustules may cease, the face remaining flat, of an opaque white colour ; or (3) haemorrhage may take place into the skin beneath the vesicles, and from the mucous mem- branes, that is, may become haemorrhagic pustular. In either of the last two events death is almost in- variable, and often rapid. Inthe first the swelling of the face increases for the next three clays, during which time the vesicles become pustular, and the hands and feet swell. There will be increased sore-throat, increased salivation, great thirst, sleeplessness, delirium, rising temperature, and occasionally laryngitis. On or about the eleventh day the temperature and the general symptoms will have reached their height, the pustules will discharge their contents, and crusts will form. After this, in favourable cases the temperature will begin to fall, and the symptoms of the so- called ‘ secondary fever ’ to decline. By the four- teenth day crustation will be complete on the face, where it is most commonly found, the general symptoms will have disappeared, the temperature will have become normal, and convalescence es- tablished. In unfavourable cases it is about this time, the eleventh day, that death usually occurs. It is preceded by low delirium, variable tempera- 91 ture, subsultus, involuntary motions, and occa- sionally haemorrhage into the skin and the pus- tules. When the crusts, which in this form are often retained many weeks, fall off, and when the desquamation is complete, there is pitting, which, at first of a reddish-brown colour, in process ot time becomes white. (3) Haemorrhagic, pustular, or vesicular. — This form of small-pox constitutes the connect- ing link between the confluent and the malignant. With the latter it is often confounded, and hence true malignant has sometimes been said to end in recovery. It is characterised by haemor- rhage into the skin beneath the vesicles or the pustules. There are generally petechise, some- times ink-spots, and often subcutaneous haemor- rhage. Recovery is very rare. Death may take place in the vesicular or the pustular stage. (4) Malignant. — S vxon. : Variolanigra ; Va- riola hcBmorrhagica ; Black Small-pox ; Purpura variolosa.— This form is invariably fatal. Its distinguishing features are haemorrhage into the skin, and irregularity in the form of the erup- tion. The illness commences with the ordinary symptoms, but accompanied by marked lumbar pain, prsecordial anxiety, and coldness of the extremities. This is followed, about the third or fourth day, by ecchymosis into the conjunctive, and a purpuric or scarlatiniform rash, sometimes covering the whole body, but most marked over the lower abdominal region, and the upper and inner part of the thighs, in which rash large and small dark blue, deep violet, or black spots are seen. The ordinary eruption is sometimes entirely absent, or when present is very meagre and much modified. In the majority of cases it is limited to a few scattered vesicles, more often found on the fingers and toes than elsewhere. With these appearances there will often be found on the skin hard tumours, of variable size, of the same colour as the spots ; and from one or more of the mucous surfaces there will be bleeding. Death some- times takes place as early as the third day, most commonly on the fifth, rarely later than the seventh. The temperature usually fluctuates about 102°(Fahr.), sometimes reaches 104°, and is sometimes nearly normal during the whole course of the disease. The mind is almost always clear throughout. This form of small-pox has received so little mention of late years, although it is well described by Sydenham, that the writer thinks notes of a few cases will be use- ful set. 24, unvaccinated. Condition on fourth day : — Very restless, pulseless ; losing blood from vagina ; repeated vomiting ; some papular eruption with ink-black spots ; bruise about the size of a shilling over the insertion of the right deltoid. Mind clear. Fifth day : — Patient called the nurse, who had just left the bedside, on immediately returning to which she found the patient dead. J. W., set. 28. One fair vaccination-mark and one bad. Illness com- menced with lumbar pain and vomiting. On the fourth day : — Face red and swollen ; papular eruption on hands, and general erythematous rash, with spots like leech-bites ; haemoptysis ; temperature 100-4°. Mind clear. Sixth day: — Left eye black ; blue spots on face; hsematuria; haemoptysis; feeble pulse; temperature 99°; death. J.L., set. 23, three good vaccination-marks. 1442 SMALL-POX. On fourth day : — Anxious and restless, with general scarlatinous rash, most marked over the groins and lower abdomen, of a brick-red colour, with many lead-coloured spots; face natural, except for conjunctival ecchymosis and bruised eyelids ; lead-coloured spots on the sides of the trunk and borders of the axilla; petechiae on legs ; a few vesicles between the shoulders ; mind clear; temperature 101°; continued much the same until the morning of the seventh day, when haemoptysis occurred, and the patient died ; tem- perature 98‘0°. This form of small-pox occurs at all ages, and in both sexes. It is never found in well-vaccinated subjects under fifteen, nor in those who have been efficiently revaccinated about that age. (5) Inoculated. — On the second day of in- oculation a pimple rises, which by the fourth has developed into a vesicle, and by the seventh or eighth into a pustule, when the patient has rigors, swelling and pain in the axillary glands, and more or less fever, followed on the eleventh day by the ordinary small-pox eruption (Bristowe), which passes through the usual stages. The in- oculated pustule attains full development on or about the eleventh daj', and by the fourteenth there will be a crust. The characteristic of the disease thus induced is its mildness. It pro- tects from small-pox in the same degree as first attacks of that disease protect from second attacks. The objections to it are (1) that small- pox so induced is infectious; and (2) that it is sometimes fatal. (6) Small-pox after Vaccination and He- vaccination. (a) After vaccination . — Speaking generally it may be said that good vaccination protects from small-pox, and that when it does not protect absolutely' it renders the disease milder, the disfigurement less marked, and re- duces the mortality directly as the efficiency of the vaccination and revaccination. Persons under fifteen years of age with two good cicatrices are very rarely the subjects of severe small-pox, and if they contract it, death is almost, if not quite unknown. After this age, however, certain, chiefly' inefficiently vaccinated, persons become again susceptible, and the disease in some of these is occasionally severe. Post-vaccinal small-pox may be described under the following three forms : — (1) In one class of cases there is more or less feeling of illness, headache, slight fever, possibly some lumbar pain, followed on the third day by a sparse eruption of papules, which abort and soon disappear. (2) In another class there are severo initial symptoms, followed on the third day by an eruption of papules, and a remission of the fever. On the fifth day the papules will have become vesicles, which in a day' or two dry up without any recurrence of fever, leaving the patient convalescent at the end of a week. (3) In a third class the initial symptoms are very severe, sometimes indistinguishable from those of confluent small-pox, and they last forty-eight hours, after which an abundant eruption comes out, the whole face swelling as in severe con- fluent. The temperature now falls, and the dis- ease in some cases will abort at this stage ; in others it will go on to the vesicular stage and then abort, the patient becoming convalescent about the end of a week, without any recurrence of fever. In the case of adults who have beea vaccinated only in infancy, and in children who have been badly vaccinated, the disease may run an unmodified course and end fatally. (b) After revaccination (successful). Small- pox, after this, is practically unknown. Daring the epidemic of 1871, 110 persons were engaged in the Homerton Fever Hospital in attendance upon the small-pox sick ; all these, with two ex- ceptions, were revaccinated, and all but these exceptions escaped small-pox. The experience of the epidemic of 1876-77 was of the same kind, all revaccinated attendants having escaped, whilst the only one who had not been vaccinated took the disease and died of it. So, in the epi- demic of 1881, of SO nurses and other attendants of the Atlas Hospital Ship (small-pox) the only person who contracted small-pox was a house- maid who had not been revaccinated. At the same time a single efficient revaccination about puberty is not, in the writer’s opinion, an effec- tual protection, even against death, for all time. Coursk, Termination, Complications, and Sequel®. — In the discrete form of small-pox the great majority of cases recover; half of the confluent cases die about the eleventh day, and the malignant cases invariably die. In small-pox modified by vaccination the course of the disease will depend upon the quantity and quality of this, as shown by the marks. If these be of the best kind, three or four in number, and in a pa- tient under fifteen, the disease is invariably mild. In some, however, who have passed puberty, the best primary vaccination loses in power; but nevertheless, it almost invariably modifies the disease, and when death occurs it is usually due to some accidental complication. Of complications, laryngitis, bronchitis, pneumonia, and in particu- lar broncho-pneumonia, are the most common. Glossitis occurs occasionally. On two occasions the writer has met with cerebral symptoms, which were shown after death to depend upon cerebral haemorrhage. Aphasia with right hemi- plegia he has seen twice; and once a condition like dementia, shown after death to depend upon thrombosis of the basilar artery. In the cases of cerebral haemorrhage the eruption was not fully developed, hut at the time of death they did not seem likely to become cases of extreme confluence. One was in a girl twenty-one years of age, with two good vaccination-marks ; and the other in a boy of eight with four fair marks. In both cases the event occurred in patients who suddenly became dangerously ill, and the seriousness of whose illness could not be as- cribed to a small-pox which was by itself mild. It may be that this would he found to be the immediate cause of death in other cases, if post-mortem examination were more frequent and complete. It has been said that small-pox is occasionally complicated with scarlatina or measles ; and Dr. Murchison, Professor Monti of Vienna, Dr. Theodore Simon of Hamburg, Mr. Marson. late of the London Small-pox Hos- pital, and others have published cases in support of this. There is no doubt that eruptions in- distinguishable from those of scarlatina and measles, appear in many cases of variola ; but whether the presence of such eruptions, which are hut one symptom, constitute evidence uper SMALL-POX. ivhich to maintain the co-existence of two speci- fically distinct diseases — an opinion which has the support of Trousseau ( Clinique Medicate, vol. i. 'p. 32, edition 1868) — may be doubted. Pregnancy has been said to be a grave com- plication of small-pox. It is certain, however, that many pregnant women recover without in- jury ; lut abortion in confluent cases is often fatal, on account of the attendant bleeding. Of sequelae the most common is pitting. Mania and dementia are occasionally seen. Erysipelas, ab- scesses, gangrene of the extremities, particularly the tips of the hands and feet, enlargement of the glands of the neck, conjunctivitis, iritis, perfor- ating ulcer of the cornea, are not uncommon, and then occasionally one or both eyes may be de- stroyed. The specific small-pox eruption, however, never appears on the corneal conjunctiva. The changes which take place in the eye are late in ■.he disease, and in all probability due to defective nutrition. Otitis, parotitis, orchitis, and ovaritis occur sometimes ; and pyaemia occasionally. Diagnosis. — This cannot be made with cer- tainty until the eruptiou appears. Fever, head- ache, lumbar pain, and vomiting during the time of an epidemic of smdl-pox, should arouse sus- picion ; and should these be followed after forty-eight hours by an eruption of papules on the forehead, face, and wrists, the diagnosis may beconsidered certain. The difficulty of exact diag- nosis depends on the fact that in many cases all the main features are not present together, and that one begins to trust to the existence of some one prominent symptom. Fever with headache, oackache, and vomiting may occur in continued fevers ; but the later appearance of the eruption, and the fact that it is not found in the situations in which that of small-pox occurs, ought to nega- tive the idea of small-pox. Small-pox is occasion- ally preceded by eruptions which simulate those of measles, scarlatina, or erysipelas, and these eruptions are associated with fever and other symptoms of constitutional disturbance. If the disease be small-pox, the eruption will change within twenty-four or thirty-six hours, or will show signs of malignancy. Pyaemia, glanders, and acute rheumatism with a pustular eruption, may also be mistaken for small-pox, but attention to the history of the case will be enough to enable one to form a correct opinion. So far as erup- tion alone may lead to error, the point for diag- nosis turns on the query, Could the eruption have reached, or would it not have gone beyond its existing stage, if the disease on which it depended were small-pox ? Of eruptions unat- tended by general symptoms, syphilides, acne, eczema, erythema, and urticaria are most fre- quently mistaken for small-pox ; but mistakes of this kind may in most cases be avoided by a careful consideration of the history. Lumbar pain is found with fever in pneumonia, but phy- sical examination of the chest ought to settle the question; moreover, there is no- eruptiou beyond occasional herpes. In lumbago there is no fever. Labour-pains are unattended by fever ; more- over, they usually come on gradually and in the belly first, and are not constant. It must be borne in mind, however, that pregnant women, when suffering from small-pox, may have labour- pains and the initial symptoms of small-pox con- 1443 currently. Cases of black or malignant small- pox will present little difficulty ; but if scarla- tina, measles, and typhus prevail at the same time, there will be gieat difficulty in arriving at an exact diagnosis as to which form of malig- nant fever exists in the case under observation. The diagnosis from chicken-pox has been treated of in that article. See Chicken-pox. Phognosis. — This will have been gathered from what has preceded. Small-pox is most fatal in unvaccinated children under five, and in adults over thirty. At these periods of life half or more may die. The lowest mortality in the unvaccinated occurs from ten to fifteen. The discrece form is rarely fatal in adults, but it is so occasionally when it occurs in unvaccinated children. Half of the confluent cases will die. and of the malignant all, and nearly all children under one year, whatever form the disease may assume. As regards vaccination in prognosis, it may be stated generall}’ that the unvaccinated will die at the rate of about 50 per cent., the badly vaccinated at the rate of about 26 per cent., and the well vaccinated at the rate of about 2’3 per cent. See Vaccination. Treatment. — There is no specific for small- pox, its complications or sequela;, and the treat- ment is therefore to be conducted on general principles. The following are points of im- portance : — (1) The patient should be placed in a large, well-ventilated room. He should be fed at intervals on easily digestible food, such as milk, beef-tea, chicken broth, and eggs beaten up ; and occasionally, according to habit, a little wine or spirit may be given. He should be per- mitted to drink iced water or iced lemonade as he pleases. He should have a feather-bed, the sheets ought to be of the softest material, and the coverings light ; and there should be two beds in the room, in order that the patient may be changed daily. (2) Two competent nurses should be obtained, one to attend the patient by day, the other by night, and these should never for a moment lose sight of him. (3) The hair should be cut short. (4) Heat of skin should be relieved by cold-water sponging, and the swell- ing of the eyelids and other painful parts by the constant application of cold compresses. (5) To relieve itching olive oil may be used, or, what is better, vaseline, which applied as a dressing to the face will facilitate the removal of scabs : and to destroy the disagreeable odour, some kind of deodorant, such as sanitas powder, should be sprinkled about and over the patient’s face and bed. (6) To procure sleep, opium ; or some form of alcohol, diluted with warm water, mav be given. (7) Salivation should not be inter- fered with, but the mouth should be kept clean, and sedatives avoided during its continuance. (8) When delirium is marked, in addition to the nurse there should be an attendant, one accus- tomed to deal with lunatics, and of some bearing if possible. Mechanical restraint should be avoided, and the ‘strait jacket’ and ‘tying down’ strictly forbidden. The patient ought not to be left for one moment alone, otherwise he may have to be looked for wandering along some street, or drowned in the nearest water- course. He should never be argued with, and never flatly contradicted. If he should imagine 1U4 SMALL-POX. tiis attendants are bent upon injuring or killing him, they should be changed. If he be excited by the mere presence of others, as may happen in hospital wards, he should be treated by himself in a dark room. Should he persist in getting out of bed and putting on his clothes, in walk- ing about his room, or in sitting over the fire, he should be permitted to do so, for to the fretted and fevered patient moving about is a relief. In maniacal delirium chloroform may be administered. (9) The eyes should be carefully watched, and in severe cases an ophthalmic surgeon should be consulted. (10) About the eleventh day laryngitis often supervenes, and for this tracheotomy should be performed when there arises distinct difficulty of breathing. Although in the majority of such cases the patient dies, the relief from suffering is so great that the operation should be performed. (11) When crusts begin to form about the nostrils they should be removed, and generally the pa- tient should bo kept in bed until suppuration under the crusts has ceased and the skin is healed. (12) Abscesses should be opened when they appear, and a water-bed should be ordered at the same time. (13) The patient may be dis- charged safely when the crusts and scales have disappeared, and not less than six baths have been given, at intervals of two days. Such is the general treatment of confluent small-pox ; in the discrete kind little is needed ; in the malig- nant none is of any avail. The prophylaxis of small-pox is discussed under Vaccination. Alex. Collie. SMELL, Disorders of. See Nose, Diseases of; and Olfactory Nerve, Morbid Conditions of. SNAKE-POISONS. See Venomous Ani- mals. SNEEZING, Excessive. — Syxon. ; Fr. Coryza spasmodiquc ; Ger., Nieselcrampf. Definition. — An affection characterised by frequent and uncontrollable attacks of sneezing, out of all proportion to the nasal secretion. ^Etiology. — The causes of excessive sneezing may be broadly classified as extrinsic and in- trinsic. Extrinsic causes include especially va- rious vegetable substances in the form of pow- der, of which tobacco-snuff is the type, and the pollen of certain plants ( see Hay Fever). The intrinsic conditions in connexion with which the affection occurs vary considerably. In some cases it is associated with whooping-cough and asthma, and it is not uncommon in gouty persons. It is sometimes a symptom of the hysterical con- dition, and not unfrequently associated with dis- ordered menstruation, or some other derange- ment of the sexual functions. It has been met with in pregnancy, and even during more than one pregnancy in the same person, ceasing in the intervals, and has been supposed to replace morniDg-sickness (Barnes). In some persons a bright light or intense colour is sufficient to determine an attack of sneezing. Symptoms. — The morbid sneezing has no special .characters. It is distinctly a reflex act, being excited usually by some slight impression on the •fifth nerve. A slight catarrhal condition of the SOFTENING. nasal mucous membrane is common. The secre- tion has been thought to be, in some cases, of a specific character, analogous to that of hay fever. Treatment. — The attack itself maybe usually cut short by a strong impression on some branch of the fifth nerre; when this fails, a mustard poultice to the back of the neck, or an emetic, may be employed. Atomised astringent nasal inhalations, or the vapours of creasote or iodine are useful. The immersion of the head in cold water has been recommended. Any irregularity in the functions of the genital or other organ’s must be attended to ; and iron, quinine, and arsenic, if not otherwise objectionable, are useful in removing the liability to the complaint. See Catarrh ; and Hay Fever. W. E. Gowers. SNUFFLES. — A popular term for the condition in which a nasal discharge exists in- children suffering from congenital syphilis. See Syphilis. SODEN, in Taunus, Germany. — Common salt waters. See Mineral Waters. SOFTENING. — Syxon. : Fr. EamoUisse- ment ; Ger. Erwcichung. — A term of pathological significance, implying that an organ ortissuehas a degree of consistence less than that which is natural to it. This is a condition which occurs in various organs or parts (1) as a result of pathological changes during life ; and (2) as a consequence of different post-mortem influences. (1) Intra-vitam softening. — With regard to the first order of changes, the brain and the spinal cord are the organs in which these condi- tions are most common, and in which it is apt to assume its most typical characters ( see Brain, Softening of ; and Spinal Cord, Softening of). It occurs also in the osseous system (see Boxes, Diseases of). The liver and spleen may like- wise be softer than natural, and so may the mucous membrane of the stomach or intestines, or the tissue of the heart. In nearly all such cases the principal cause of this diminished con- sistence is a fatty degeneration or infiltration, associated with more or less of serous infiltration (see Fatty Degeneration, and the diseases of the several organs mentioned). This pathological condition is the reverse of those conditions of induration known by the name of sclerosis in some organs, and cirrhosis in others. Sec Scle- rosis. (2) Post-mortem softening. — The softening due to the definite pathological processes just referred to as occurring during life, has to be clearly discriminated from certain softenings which may supervene after death as a result of traumatisms or mere post-mortem changes. Thus the tissue of the brain or of the spinal cord, in some parts, may be diminished in consistence, and rendered more or less pulpy, owing to its Laving been bruised during the operations neces- sary for exposing these organs to view. The same organs likewise diminish in consistence by mere lapse of time after death, and the more quickly in proportion to the heat of the weather. In the stomach also post-mortem softenings are most prone to show themselves, should the oKnn contain gastric juice at the time of death. Here we get softening first, and afterwards solution of SOFTENING. the mucous membrane and other tissues of the organ. See Stomach, Softening of. H. Charlton Bastian. SOLIS ICTUS (Latin).— A synonym for sunstroke. See Sunstroke. SOMNAMBULISM. — Sleep-walking. See Sleep, Disorders of. SOMNILOfiUT. — Sleep-talking. See Sleep, Disorders of. SOMN OLEN CE. — An unnatural drowsiness or disposition to sleep. See Sleep, Disorders of. SONOROUS BALE. — A variety of dry rale or rhonehus, of a low-pitched character, resembling snoring and similar sounds, and pro- duced in the larger air-tubes. See Physical Examination ; and Rhonchus. SOPOR (Lat.).— An unnatural deep sleep, from which the patient can only be roused with difficulty. See Consciousness, Disorders of. SOPORIFICS (sopor, heavy sleep).-SYNON. : Fr. Soporifiques ; Soporativcs ; Ger. Einschla- fernde Mittel. — A synonym for hypnotic agents. See Narcotics. SORDES (Lat., filth).— Definition.— Crusts which form upon the lips and teeth of persons suffering from extreme exhaustion. Description.— Sordes occur commonly in what is called the typhoid state, whether this be due to typhoid or puerperal fever, pneumo- nia, or any like disease. They appear first as .bin, light-yellowish crusts upon the prolabia, generally in close proximity to the teeth; gradu- ally increase in thickness and in area ; and, changing their colour to brown, or even black, at length extend to the adjacent surfaces of the teeth. They seldom or never cover those por- tions of the teeth which are hidden by the lips, but spread over their exposed surfaces ; so that, as the patient lies with slightly parted lips, they bridge over the interval in the form of a narrow band upon the middle of the incisors of the upper jaw. When the lips are more widely separated, the sordes do not extend, unless in conditions of extreme exhaustion, over the whole of the exposed surfaces of the teeth, but form two ridges, corresponding with the margins of the upper and lower lips. Sordes are composed of various schistomycetes, mingled with debris of food and epithelium. Micrococcus occurs almost constantly ; bacillus subtilis frequently ; and the writer has found, each in a single instance, sarcina ventrieuli and spirochseta plicatilis. Pathology and TEEATMENT.-These organisms, which are of constant occurrence on the papil- lary surface of the healthy tongue, are easily dislodged from the smooth lips and teeth. Eut in conditions of great prostration, especially when the prostration is associated with delirium, the slight frictions necessary for their removal are not made, and they obtain so firm a hold that they can only be removed by careful and re- peated cleansing. Such cleansing may with ad- vantage be performed with a piece of soft rag, or ft brush dipped in a weak solution of Condy’s fluid. II EKE Y T. Butlin. SPASM. 1445 SORE-THROAT. — A popular name for various affections of the pharynx, larynx, and tonsils. See Larynx, Diseases of; Pharynx, Diseases of ; Throat, Diseases of ; and Tonsils, Diseases of. SOUFFLE (Fr.). — A soft, blowing sound. The term is applied either to the respiratory murmur heard over the lungs; or to certain murmurs heard in connection with the heart or blood-vessels. See Physical Examination. SOULZMATT, in France. — Alkaline table- water. See Mineral W aters. SFA, in Belgium. — Iron waters. See Mine- ral Waters. SPAIN, Southern. See Malaga ; and Climate, Treatment of Disease by. SPANB3MIA (avavbs, rare, and ai/ia, blood). — A condition of blood, in which the amount of its solid constituents is below the normal, the blood then appearing thin. See An/Emia ; and Blood, Morbid Conditions of. SPAS. See Mineral Waters. SPASM. — Synon. : Fr. Spasme; Ger. Krampf. Definition. — A name given to abnormal con- traction, occurring either in muscular organs, in single muscles, or in groups of muscles. 1. Spasm of muscular organs. — Concerning spasms of organs not much requires to be said here. We may cite as instances those spasms which occur in the pharynx in hydrophobia ; the contractions of the oesophagus in cesophagismus and in some cases of hysteria ; the painful con- tractions of the intestine which are presumed to occur in certain cases of colic ; of the lower end of the rectum in tenesmus ; of the bladder or of the urethra in certain cases of inflamma- tion with irritability ; of the vagina in vaginis- mus; of the uterus in rare cases of sudden abor- tion resulting from shock ; possibly of the heart in certain diseases of that organ; of the vessels in various regions of the body, and on various occasions, from over-action of vaso-motor nerves ; of the bronchial tubes in certain cases of asthma and hay-fever ; of the glottis in laryngismus stridulus, and in pertussis ; as well as of the gall- ducts or ureters under conditions of irritation, either direct or reflex. In reference to many of these conditions the reader may refer to special articles in which they are considered. All are due to excessive nervous stimuli, maintaining conditions of muscular contraction, which are unusual both in degree and in duration. These spasms are, therefore, tonic in type, and in almost all the cases cited it is involuntary mus- cular fibres that are involved. 2. Spasm of single muscles or of groups of muscles. — The next class of spasm is that which affects the striped or voluntary muscles. They are divisible into two main categories, that is, into tonic spasms, in which the contractions are uninterrupted, and clonic spasms, in which con- tractions and relaxations occur in quick succes- sion ; the former being typified by cramps, and the latter by convulsions. Under tonic spasms, we may have cramps of brief duration, affecting a single muscle, such as 1446 SPASM, the diaphragm in hiccup ; or of prolonged dura- tion, as in tho sterno-mastoid in certain cases of wry-neck. The tonic contraction may affect several muscles at the same time, as in lock-jaw, or the painful cramps which occasionally occur in the calves of the legs, or in other parts of the body. Such local spasms occur also in the con- ditions known as tetany, in conjugated deviation of the eyes, and in writer's cramp ; likewise in spasmodic spinal paralysis, in hysterical para- lysis, and under various conditions of irritative organic disease implicating motor nerves, or motor centres or tracts, either in the spinal cord or in the brain. More general tonic spasms occur in catalepsy, in tetanus, and in strychnia- poisoning. This whole class of tonic spasms is supposed to be due to irritation, mechanical or chemical (nutritive), operating directly , either upon motor centres or upon the fibres conveying motor inci- tations in some part of their course between the brain and the muscles. In other cases, however, tonic spasms are of reflex origin, and the cause of irritation operates in or upon sensory sur- faces, nerves, or centres. Clonic spasms are also of various kinds. They may be limited to single muscles, such as the orbi- cularis palpebrarum ; or they may aflfectparticular groups of muscles, such as those of one side of the face, or the muscles of the lower jaw on both sides, or certain of the abdominal muscles, or some of the foot muscles, as in ankle-clonus. In other cases elouie spasms may be more general, taking the form of unilateral or of bilateral con- vulsions. The latter also may be irregular or of co-ordinated type. See Convulsions. Where clonic spasms are much slighter in degree and in range, affecting some muscular fibres and that to a small extent, rather than entire muscles in a more marked manner, we have the production of tremors, which may be either fine or coarse, local or general. Transition conditions exist, connecting all these various manifestations more or less closely with one another. They constitute, indeed, one great assemblage of related though apparently heterogeneous phenomena, which have mostly received separate consideration under their re- spective names. Though it is desirable that their fundamental relationship should have been thus briefly pointed out, no practical end would be achieved by dwelling further upon the group as a group, upon the physiological meaning or origin of the several forms of spasm, or on their therapeutic treatment, which will be found de- scribed under separate articles. Sec also Moti- lity, Disorders of. H. Charlton Bastian. SPASMODIC. — Synon. : Fr. Spasmodique ; Ger. Krampfhaft. — A descriptive epithet applied or applicable to conditions or diseases in which spasms, and mostly those of the tonic class, are met with as prominent or essential constituents ; for example, spasmodic croup, spasmodic asthma, spasmodic stricture. See Spasm. SPECIFIC. — When applied to a disease, the word specific signifies that such disease is pro- duced by a Special cause, and has special charac- SPECTROSCOPE IN MEDICINE, ters, for example, syphilis and the eruptive fevers. When applied to a remedy, it implies that the substance has a distinct and definite effect in the cure of a certain disease, such as mercury in syphilis, or quinine in ague ; or that it acts upon a particular organ, as ergot upon the uterus. SPECTACLES, ITses of. See Vision, Dis- orders of ; and Strabismus. SPECTROSCOPE IN MEDICINE.— As one of the instruments of research in prac- tical medicine the spectroscope is of quite recent introduction ; and, as yet, it can hardly be said to have taken a place amongst those of general application. It has been of service to the phy- siological chemist, in the analysis of the tissues of the body; and for the detection of blood- stains, and perhaps of poisons, it promises to be of value to the practising physician. It is towards a more complete knowledge of the na- ture of animal and vegetable pigments that it would seem to be of most use. Description. — The application of the instru- ment depends on the principle that all matter, in whatever condition — solid, liquid, or gaseous — possesses the property of absorbing certain of the rays of light by which it may be illuminated, and reflecting others. This being granted, if the spectrum be taken, that is, the series of compo- nent colours into which a light— whether sun, gas, paraffin, or electric— may be split up in its passage through a prism ; and if there be intro- duced between the source of light and the prism the material to be investigated, there will be pro- duced certain definite and characteristic modi- fications of the spectrum, in the form of dark bands of various intensity and position. Such are called absorption-spectra, and are those re- ferred to here. The mechanical arrangement required to at- tain this object consists of (n) a glass prism, so placed as to give a minimum deviation of the refracted rays ; between which and the observer is (b) a small telescope through which the re- fracted rays pass to the eye ; and on the distal side of the prism, between it and the source of light, is (c) a tube, carrying next to the prism a double-convex lens, and at the other extremity (rf) a slit, the margins of which are constricted by accurately and movably adjusted knife- edges. Tho length of this tube, called the colli- mator, is equal to the focal length of the convex lens. The whole apparatus may be carried on a stand, so arranged that the telescope may move round the prism as a centre, and the angle it makes with the collimator recorded on a scale. A simpler instrument has been constructed by Browning, which can be carried in the pocket. By an ingenious arrangement the instrument has been adapted to the microscope, forming the microspectroscope , and is then applicable to the examination of very minute quantities. But in this case there is no telescope, the spectrum formed by the prism being viewed directly. Applications. — In the greater number of cases where the spectroscope is applicable to medicine, it is for the examination of fluids, although 6olida and morbid gases have also been investigated. For fluids it is sufficient to arrange the instrument SPECTROSCOPE IN MEDICINE, to that the spectrum of a gas or paraffin flame is obtained, and then to place a test-tube (a flat one is best) between the slit and the light. Some practice is required in adjusting the instrument, regulating the size of the slit, excluding extrane- ous light, and obtaining the most suitable degree of dilution and thickness of stratum of the fluid to be examined. The positions of the absorption- bands are most conveniently recorded by refer- ring them to the standard Frauenhofer lines of the solar spectrum. Certain precautions require to be borne in mind in regard to the absorption-spectra. Thus it appears that every substance has not its own spectrum, entirely distinct from that of any other, but that many bodies, very different in nature, possess the same spectrum, as carmine and oxyhemoglobin ; it is by the behaviour of the spectra, under the treatment of the fluids with reagents, that the spectroscopic results come to be of definite value, Again, the same substance may give different spectra according as it is in a solid, fluid, or gaseous state; or so- lutions of the samo body in different media may give different absorption-bands. 1. Blood. — Haemoglobin, both in the oxidised and reduced condition, is easily recognised by its spectrum. The former shows the dark lines in the yellow and green regions of the spectrum, the one next D being darker and more strongly marked than the other, which is near to b. Reduced haemoglobin, on the other hand, gives but one dark band, in a position between the two of oxyhsemoglobin. The spectrum of blood is identical with that of haemoglobin, of which of a grain may be detected by the spectro- scope ; but ‘ there does not appear to be any probability of our being able to decide by this means whether the blood is or is not human ’ (Sorbv). Carbonic acid and many other gases, such as carbonic oxide, or coal-gas which contains seven per cent, of CO, nitrous oxide (NO), and sul- phuretted hydrogen (SH 2 ), and the cyanides of hydrogen, potassium, &c., nitrite of amyl, iodine, &e., all possessing an affinity for hsemo- globin, show characteristic absorption-spectra ; and investigation by the spectroscope of blood treated with these reagents, helps to explain the poisonous characters that most of these bodies possess, and show it to be chiefly due to their combining so closely with the haemoglobin that the latter ceases to be an oxygen-carrier ; whilst CO 2 is very loosely combined, and is easily sepa- rated by mere exposure of the reduced haemo- globin to the air. The various derivatives of haemoglobin, such as haematin, both acid and alkaline, haematoidin, and haemin, all give characteristic spectra, by which they may be recognised. It is necessary to be acquainted with the spectra of these bodies, as well as of oxy- and re- duced haemoglobin, since in many of the situa- tions in which blood is sought for — as in urine, vomit, fluid of cysts, and stains on clothes — it has undergone changes into one or other of these derivatives. Ammonium sulphide is the most convenient agent for reducing haemoglobin ; and in examining any fluid for this body, it should always be employed, since it is by the SPECULUM. 144? behaviour of haemoglobin under its influence that it may be identified and distinguished from carmine. In the investigation of blood-stains, their age, as well as the character of the material in which they are found, must be considered. Distilled water, glycerine, or dilute solution of ammonia or nitric acid may be used to dissolve out the stain, with the result of giving a solution of haemoglobin or haematin, which may be enclosed in an ordinary microscopic cell and examined with the microspectroscope. 2. Bile. — It is said that fresh human bile yields no spectrum, but that when diluted, or if hydrochloric or nitric acid be added, an ab- sorption-band appears at F, which is due to j. pigment known as urobilin. This spectrum may be regarded as a test for bile. 3. Urine. — Healthy urine gives a spectrum with an absorption-band at F, identical with that of urobilin, which behaves on treatment with reagents in the same manner as the spectrum of that pigment, and hence it may be regarded as a normal colouring matter of the urine, and ab- sent in some diseases. Other pigments appear, from the spectra given, to be present in certain diseased states and in pregnancy. Sugar and albumen are not to be detected in the urine by the spectroscope. 4. Faeces. — On spectroscopic examination the band of urobilin is presented. See The Spectroscope in Medicine, by Dr. MacMunn, and Dr. Thudichum's researches in the Reports of the Medical Officer of the Privy Council. W. H. Allchin. SPECULUM (Lat.) — Synon : Fr. Speculum ; Miroir ; Ger: Speculum ; Spiegel. Definition.— An instrument adapted for ex- ploring the several channels and deeper-seated parts of the human body. The chief of these are the ear, the eye, the nose, the mouth, the throat, the rectum, and the vagina. For each of these there are specially adapted instruments. Description. — Specula are made of various materials, and in a variety of shapes. The spe- culum is intended not only to permit and facili- tate inspection, but also to dilate the canals and to expose parts, in order that they may be treated surgically, or have medicaments applied to them. For this reason a cylindrical speculum will not always answer the purpose ; we have, therefore, bivalve and trivalve specula, and many other forms. On account of the friability of glass, other material has not infrequently to be used, such as white polished metal or wood ; the latter is objectionable, as it has no reflecting power ; but when it becomes necessary to apply the actual cautery through a speculum, a substance must be employed that is a non-conductor of heat and non-friable, such as wood. Vahieties. — Aural specula. — Of these there are several forms, and some are known under the name of ‘ auriscopes.’ Some have a trum- pet-shaped opening, which facilitates the in- troduction of light, and greatly increases the illuminating and reflecting power. There are also bivalve aural specula with a screw lever, and others with handles attached so as to sepa- rate the blades. 1448 SPECULUM. Eye specula. — These are known by the name rf eyelid retractors and ophthalmoscopes, both of which are really specula for examining the eye, though not generally classified as such. See Ophthalmoscope. Nasal specula. — There are several of these, the great purpose they have to serve being that of dilating. One, known as Elsberg’s, is three- bladed. Throat specula. — Specula for examination of the throat are generally called laryngoscopes. See Laryngoscope. Bectal specula. — These are cylindrical, bi- valve, or trivalve. The cylindrical are made on the principle of Pergusson’s vaginal speculum, but with an opening so as to expose the wall of the rectum at whatever part it be adapted to. The valvular forms are made of white metal. Vaginal specula. — Of these there are many. Perhaps the most useful is that known as Fer- gusson’s, which is cylindrical and made of glass, with a coating of mercury behind it, so as to give it reflecting power, and backed by vul- canized india-rubber. An improved variety of this is of a tapering form, so as to admit more light. See Womb, Diseases of. Sims’ duck-bill speculum is of great use in retracting the peringeum and dilating the vagina, when space is required for operation, as in vesico- vaginal fistula. Then there are bivalve and tri- valve metallic specula. Wooden cylindrical spe- cula are always used when the actual cautery is applied, for reasons already mentioned. For the ordinary purposes glass is the preferable mate- rial, as it is unaffected by caustics. The uses of specula will be found described in connexion with the diseases of the several organs to which they have reference. Clement Godson. SPEECH, Disorders of. — Synon. : Troubles du Langage; Ger. Siohrungen der Sprache. — De- fects of speech are very various in their nature, degree, and mode of causation. They are capable of being classified from several different points of view. We shall not attempt to do more in the present article than point out the nature and relations of the several kinds of defects, which will, in almost all cases, be found to have re- ceived consideration under their own proper headings. -ZEtiology and Pathology. — Disorders of speech may depend upon (1) congenital, or (2) acquired defects of the brain, or of certain of its nerves and sense-organs. 1. Congenital defects. — The most frequent and important of these defects is deafness, which entails mutism, so that the individuals thus afflicted are known as ‘ deaf-mutes.’ It must, however, be borne in mind that this condition of mutism or dumbness may also be brought about by absolute deafness occurring from any cause after birth, but before the child begins to talk ; or even after it has learned to talk, up to the fifth or seventh year. In cases of the latter type, the child soon, when without the accustomed guidance derived through the sense of hearing, forgets how to speak and becomes dumb. In addition to this class of SPEECH, DISORDERS OF. cases, there are those of congenital idiocy with- out deafness, but in which the child never learns to talk or articulate in the proper sense of the term {see Idiocy). There are also other cases allied to the last, in which, owing to some intra-cranial lesion occurring either before, during, or soon afterbirth, the child’s subsequent mental condition is greatly impaired, as well as its motor power. In these most deplorable cases the child may never be able to speak in any distinct or articulate fashion, it may not be able to walk or even stand, or it may only be able to accomplish these latter acts imperfectly. In some of these children there is evidence of the existence of a hemiplegic condition, with arrest of growth of the paralysed limbs. Such patients are also frequently subject to one-sided fits ; but it is not certain whether in these cases the inability to speak is especially prone to occur in those who are congenitally paralysed on the right side. In some of the less severe examples of this latter type which have come under the writer's observation, speech has been merely deferred — the child has not commenced to speak till the fourth, fifth, or even the sixth year. See Dumbness. 2. Acquired defects . — Among acquired defects of speech we have troubles of various degrees and kinds, which may come on at any period between infancy and old age, and which, as regards dura- tion, may be temporary or permanent. The great variations in the extent and nature of these defects is due to the fact that the impeding con- dition or lesion may act (1) upon parts of the brain concerned with the genesis of thought, and of the will to speak, (2) upon some part of the nervous channels or centres concerned with the actuation of speech, or (3) upon the peripheral nerves and organs concerned with articulation and vocalisation. Thus it happens that acquired defects of speech may, in one set of cases, be associated with the most marked alterations in the intelligence or previous mental condition of the patient, whilst in others they may be repre- sented by mere defective articulation or vocalisa- tion. In briefly referring to the principal varie- ties, we will pass from the simple to the more complex types. Proper vocalisation is essential for the pro- duction of normal speech ; where it alone is de- fective we have to do with various kinds of apho- nia, which may be due to very different causes {see Voice, Disorders of). Again, articulation as a mere motor act may be interfered wi(h or per- verted in diverse modes. "Where speech-move- ments are incoordinate, we have such common defects as stuttering or stammering {see Stam- mering) ; or else those less marked perversions of speech- movements which are met with in some cases of chorea. Again, where the movements concerned in speech are more simply defective, we have that indistinctness of articulation and blurred utterance which, in various degrees, is so commonly associated with different forms of paralysis due to cerebral disease. To this kind of defect the name ‘ Aphemia ’ is now commonly applied. It presents itself under many various conditions, and with different degreos of com- pleteness. It may show itself in its most ex- treme form in ‘ labio-glosso-laryngeal paralysis, SPEECH, DISORDERS OF. or in ether forms of bulbar disease. This blurred or difficult articulation is also one of the signs met with in general paralysis of ttie insane and in disseminated cerebro-spinal sclerosis. Again, it occurs in association with hemiplegia caused by different lesions in various parts of the brain, between the medulla below and the cerebral cortex above. As a rule it is most marked and most persistent in hemiplegia due to disease of the pons Varolii, while in lesions higher up it is apt to be slight and more transitory, especially where such lesions exist on the right side of the brain. It is evident, indeed, that this kind of defect is specially prone to occur where there is damage to the first parts of the outgoing tract leading from the left cortical auditory word- centre, or to any lower parts of the same tract, or when there is damage to the actual motor centres for articulation situated in the medulla oblongata (see Brain as an Organ of Mind, 1880, p. 618). Damage to the. upper part of these tracts, however, so long as it is situated above the level of the left corpus striatum, gives rise to a form of this aphemic defect which is commonly known as aphasia (see Aphasia). The writer’s most recent investigations have led him to the conclusion that this condition may, in reality, and in full accordance with modern doc- trines as to the strict localisation of cerebral func- tions, be induced by damage in parts of the cor- tex comparatively remote from the ‘third frontal convolution ’ (op. cit. p. 680). Such forms of speech-defect may exist without obvious mental impairment, and it is worthy of note that they may sometimes be induced without coincident hemiplegia, by over-work, either literary or clerical, or under the influence of great excitement. Related to speech-disorders of this type are the other more complex and extremely varied defects of speech classed under the head of amnesia. These are often associated with grave meDtal and volitional defects. The writer has recently come to the conclusion that they are especially apt to occur in association with lesions involving tho supra-marginal lobule, the angular gyrus, and the posterior part of the upper temporal con- volution, that is to say, the convolutions which bound the upper end of the 4 Sylvian fissure ’ (op. cit. p. 683). These are parts of the cortex which, according toFerrier, have much to do with visual and auditory impressions. They would accordingly be concerned with the appreciation, on the one hand, of printed and written charac- ters, and, on the other, of spoken words ; and seeing that such parts of the cortex must also afford the starting-points for volitional incitations to acts of writing, reading, and speaking, it can easily be understood how much damage to the brain in these regions may interfere with intel- lectual ‘ appreciation,’ as well as with intellec- tual ‘ expression.’ Finally, in this relation, reference should be made to certain forms of speechlessness occa- sionally met with in hysterical females, or in the insane of both sexes, in which there may be a deficiency of will to speak, dependent upon per- verted cerebral action, either without or with a discoverable basis of actual morbid changes. In such cases, also, there may be no apparent motive ; or the speechless condition may, in the SPERMATORRHCEA. 1449 insane, stand in direct or indirect relation to certain delusions. Teeatment.— The treatment of these various defects of speech will, of course, depend upon their causes and associated conditions. Reference must, therefore, be made to the several special articles in which the different forms of such defects are considered. H. Chablton Bastlan. SPERMATORRHCEA ( Px, in the upper cervical region and in the medulla. He then, as he has since, found ascending areas of degeneration occupying the superficial portion of the lateral columns, which were traced upwards into the restiform bodies. It would seem possible that the fibres which undergo degeneration in this latter case correspond with those of the direct Pig. 86.— P. Showing descending areas of degeneration : a. in inner part of anterior columns ; l. in lateral columns (mid-dorsal region). Case of paraplegia, from oomplete transverse softening in upper dorsal region. U. Showing descending degenerations in case of right hemiplegia , from extensive softening of left corpus striatum. (Twice natural size.) the seat of lesion. Or if, as so frequently hap- pens, we have to do with a total transverse lesion, represented for instance by a focus of softening extending through the whole thickness of the cord in the upper dorsal or in some other region (so that the patient suffers from complete para- plegia), we should then find large areas of secon- dary degeneration in each lateral column below, as well as smaller areas in the inner part of each anterior column (fig. 86, P). The areas in both situations become less extensive as they descend, and gradually wear themselves out in the lower part of the lumbar swelling (see Med.-Chir. Trans, vol. 1., pi. x.). It was stated by Bouchard, and has been commonly repeated by succeeding writers, that the areas in the anterior columns do not appear beyond the mid-dorsal region, but this, as the writer pointed out in 1867, is cer- tainly not the rule. In such a case as that last cited, namely, one of paraplegia due to a total transverse lesion in the upper dorsal region, there would he found above the seat of lesion certain ascending degenerations — the principal of which would be situated in the posterior columns, though others smaller and less commonly known are to be met with in the outer part of the lateral columns (fig. 87, P). The ascending degenerations in the posterior columns are often strictly limited to the so-called ‘ columns of Goll.’ Situated on each side of the posterior median fissure, they together constitute a median wedge-shaped patch, whose apex extends for- wardstothe commissure, and whose base is at the posterior surface of the cord. This band of dege- neration reaches upwards to the medulla, though the exact course of its fibres through this region is uncertain. Nothing definite, indeed, is known as to the functions subserved by the fibres com- posing the ‘ columns of Goll.’ It seems clear, how- ever, that, under certain conditions, the areas of ascending degeneration in the posterior columns may be differently arranged, and not completely limited to the ‘ columns of Goll,’ since in a case with a lesion of some kind in the mid-cervical region (whose nature is not known because, un- fortunately, this part of the cord was not pre- served) the writer long ago found such areas as Px P Fig. 87. — P. Showing ascending areas of degeneration: p, in columns of Goll ; and l, along outer border of lateral columns, in middle of cervical swelling. Case of paraplegia, from complete transverse softening in upper dorsal region. Px. Different arrangement of ascending areas in poste- rior columns in upper cervical region. (See Trans oj Med.-Chir. Soc., vol. 1., 18G7, pi. ix.) (Twice natural size.) 1 cerebellar band,’ located by Flechsig in this situation. Such fibres would be afferent in func- tion, but would probably only constitute a small part of the afferent fibres going to the cere- bellum. (Nothing is known at present as to any band of efferent or motor fibres entering the cord from the cerebellum, and none such may exist. The cerebellar influence upon the motor tract — of whatever nature — may be expended upon certain centres situated in the pons varolii, or even in the corpora striata.) In these areas of degeneration, in addition to the changes already mentioned as occurring in the nerves themselves, other processes take place. There is, for instance, a very distinct but secon- dary overgrowth of the connective tissue through- out the diseased area, as well as an abundant development of large granulation-corpuscles, pre- cisely similar to those met with in ordinary foci of softened nerve-tissue. The granulation-cor- puscles are closely packed amongst the meshes of the connective-tissue overgrowth and the atrophied nerve-fibres (see Med.-Chir. Trans., vol. 1. pi. xi. figs. 19, 20). In preparations which have been immersed in bichromates or in chromic acid, these corpuscles do not become stained to anything like the same extent as the healthy nerve-tissues ; hence the areas containing them remain pale, and are consequently to be traced with the greatest ease in spinal cords which have been immersed for a week or two in these fluids, 1462 SPINAL COED, though when they were in the fresh state no such areas may have been detectable, even on the most careful examination, by the naked eye. (14) New growths in the substance of the spinal cord itself are not very common, nor, on.account of the limitations of space within the spinal canal, do they ever attain a very large size. For this situation a growth equalling a hazel-nut in bulk would he esteemed large. In regard to the nature of the growth, this is, of course, a matter of purely pathological interest, since the clinical signs and symptoms which a growth in the spinal cord is capable of causing would not vary with its nature, but would be wholly dependent upon its situation and its rate and manner of increase. Cancer occurs within the spinal cord almost solely as a secondary extension from a similar growth pre-existing in the dura mater or in the vertebrae, or possibly in more distant parts. In altogether exceptional cases it may occur primarily in the spinal cord. Gliomata, sarcomata, and myxo- matam ay also occasionally be met with, either in pure or in blended types. Tubercular or scrofu- lous nodules are also apt to occur, either alone or in combination with a tubercular meningitis. Syphilitic gummata may likewise be found in the substance of the cord, though their presence in this situation is not so frequent as it is in asso- ciation with the spinal meninges. (15) Atrophy with degeneration of ganglion-cells is apt to occur as a secondary process with ex- treme frequency in portions of the grey matter of the cord which happen to be more or less im- plicated by other contiguous pathological changes. But in two or three distinct diseases the ganglion cells of the anterior cornua, in different parts of the cord, are prone to be suddenly overtaken by an stiologically obscure and altogether inexplicable failure of nutrition, which speedily reveals itself by entailing an atrophy of the particular cells affected. This, for instance, occurs as the ana- tomical basis of ‘ infantile paralysis,’ and of the similar form of paralysis now known to occur (though more rarely) in adults. In these diseases whole groups of contiguous and functionally-re- lated cells are affected simultaneously, and as the atrophy progresses, there is generally evidence of a secondary overgrowth of the neuroglia sur- rounding such nerve-cells, in the anterior cornua. To assume that this process is inflammatory in type, as the terms ‘cornual myelitis’ or ‘acute anterior polio-myelitis’ imply, seems to the writer altogetherunwarrantable. Inflammation does not limit itself to individual tissue-elements, and the slight overgrowth of the contiguous neuroglia may well be a secondary process of simple hyper- plasia. This latter process is indeed less evident where, as in ‘ progressive muscular atrophy,’ the initial and mysterious atrophy of individual gan- glion-cells occurs more slowly and more sparsely. Cells, here and there in particular groups, -undergo in this affection the atrophic process, leaving others around them for a time as healthy as ever. Yet, as the disease progresses, the ranks of the healthy cells become gradually thinned in an altogether irregular manner ; and this atrophy of nerve-cells, as it occurs, speedily entails, for reasons to be set forth in the next section, a corresponding atrophy of functionally related muscular fibres. , DISEASES OF. § 7. Trophic Relations between different Tissues and different parts of the Spinal Cord. — Irritation of the posterior cornua, or of the posterior roots of the spinal nerves, may give rise to various pustular or vesicular eruptions in related portions of the skin, often associated with neuralgic pains in these same regions. In other cases, with lesions in some parts of the grey matter, ulceration or actual sloughing of certain related tracts of skin are easily deter- mined — especially under the combined influence of continued external pressure and frequent irri- tation from urine or faeces, as in some cases of paraplegia. Degeneration or destruction in any way of the great ganglion-cells of the anterior cornua, or of the anterior roots of the spinal nerves (either within or outside the cord), gives rise, in the course of two or three weeks, to atrophy of the muscle-fibres with which such cells or nerve- roots are in relation. Wo thus get an atrophic paralysis, associated with the electrical ‘reaction of degeneration.’ Certain diseases affecting the grey matter of the cord (in ways and sites which cannot be pre- cisely defined) are also apt to be associated with chronic diseases of the joints. Sometimes com- paratively unimportant, they lead in other in- stances to great atrophy of the articular ends of the bones, and possibly to dislocation with utter destruction of the joint, as in some cases of loco- motor ataxy. Atrophy, with brittleness of bones, may also be metwith in the same orin allied cases. The fact of the existence of these trophic troubles in association with such lesions, may be admitted wholly irrespective of the explanation of their pathogenesis. Whether they are due to altered states or influences transmitted by or- dinary motor and sensory nerves in relation with such tissues, or to altered influences through cer- tain purely hypothetical ‘trophic nerves, Ties alto- gether outside the fact of the mere co-existence of the several trophic troubles with the several lesions — which is the point of more immediate interest for the practitioner of medicine. § 8. General Symptomatology, and General and Regional Diagnosis. — Taking them in con- junction with some of the simpler principles of nerve-physiology, the practitioner has to make use of the various kinds of data above enume- rated in the investigation of the precise nature of every case of disease of the spinal cord which comes before him. Under the word ‘ nature’ we include, of course, both sides of the diaguosis that has to be made, namely, the regional and the pathological. The practitioner is compelled to interpret the patient’s symptoms, and the various signs he is able to recognise for himself, by the aid of such data when he attempts, for instance, to ascertain what parts of the cord are damaged, and in what order they have been implicated. He may wish to know whether the posterior or the lateral columns are specially involved ; whether the grey matter is much damaged; and, if 60 , whether the damage more particularly affects the anterior cornua or other parts. Again, he may wish to know whether the anterior or the posterior spi- nal nerve-roots are specially involved; and, if sa SPINAL COED, whether they are merely irritated or more severely damaged, and -whether they have been simul- taneously or successively affected. For the pre- sent we shall concern ourselves with this aspect of the problem only, though it will subsequently be shown in our account of the several diseases of the spinal cord what light the coexistence of certain groups of these facts throws upon the other aspect of the problem, namely, upon the question of the pathological nature of the lesion. Some of the facts already cited have, however, to be translated into their clinical equivalents, and to be supplemented by others derived more exclusively from the clinico-pathological study of spinal diseases, in order to form a series of data more immediately useful in the interpreta- tion of the phenomena of diseases of the spinal cord in their regional relations. Regional Diagnosis. — We already possess a number of valuable clinical data available for throwing light upon the regional side of the problem of diagnosis. It must be borne in mind, however, that the regional diagnosis of diseases of tho spinal cord is itself a twofold problem. It involves a consideration : (a) of the transverse area involved ; and ( b ) of the longitudinal situa- tion and extent of the disease in such areas. (a) Diagnosis of the transverse area in- volved. — The facts to be tabulated under this head may be set down in the order of their rela- tion to different component parts or regions of the spinal cord. (1) Anterior roots of spinal nerves. — Irritation of these may give rise to various forms of twitch- ing or to tonic spasms in related muscles. Great pressure upon or destruction of the anterior roots will give rise to local paralysis in the related muscles, followed in the course of a week or two by marked atrophy, and the establishment of the electrical ‘reaction of degeneration’ (see Pa- iulysis, Motor). There will also be an abolition of reflex excitability of these muscles in response to skin-irritation, or from blows upon or stretch- ings of their tendons. (2) Antero-latcral columns. — Increasing pres- sure upon or disease of these columns gives rise to paresis, gradually deepening into motor para- lysis of parts deriving their nerve-supply at or below the seat of lesion. When the disease occurs in the lateral column more especially, there may be twitcliings or Btartings in the muscles below, or well-marked spasms, and possibly painful cramps. There may also be great exaltation of the superficial and deep reflexes, if the manifestation of the latter is not hindered by pre-existing spasms. Motor paralysis exists to some extent, but without any appreciable impairment of sensibility. No marked wasting of muscles, or diminution in electrical reactions, usually occurs. (3) Grey matter. — (a) Of anterior cornua . — Disease of these parts causes motor paralysis, with atrophy, loss of faradic excitability and of reflex excitability in related muscles — as in cases of disease of the anterior roots of spinal nerves. (b) Of posterior cornua and central parts . — Damage of these regions of grey matter will, ac- cording to its completeness in transverse extent, cause more or less delay or defect in the trans- DISEASES OF it 63 mission of painful impressions, and perhaps in- terfere also with other modes of sensibility. Some trophic lesions in skin and joints may also be met with (see'§ 7). At different levels in the cord special centres (represented in both anterior and pos- terior regions of grey matter) in connection wit b definite functions, may be interfered with tv morbid conditions implicating the grey matter (see below § 9 [1-10]). (4) Posterior columns. — The results of disease confined to this situation (more especially to the ‘ root-zones ’) will be — ataxy or signs of inco- ordination of movements ; interference with im- pressions of touch, pressure, temperature, and of ‘ muscular sense ’ ; abolition of knee-reflex ; and diminution or loss of sexual desire. (5) Posterior roots of spinal nerves. — From ir- ritating lesions there will arise lancinating or other pains in the skin and deeper textures of related portions of the limbs, and possibly trophic skin-lesions. Pressure or destructive lesions will give rise to loss, in various degrees, of different modes of sensibility, superficial and deep ; and diminution or abolition of the superficial and deep reflexes in related regions of the body. § 9. (b) Diagnosis of the longitudinal si- tuation and extent of the lesion. — This is a consideration distinctly secondary to the other, since at whatever longitudinal level the disease may be situated, its clinical characters will al- ways be qualified by the part or parts of the transverse extent of the cord that may bo in- volved. Here we have to depend in the main upon the signs indicative of the implication of particular sensory and motor nerves, whose exact relations with different portions of the spinal cord are, of course, known. Such signs may con- sist of some excess or defect of sensibility, of motilit}’, or of reflex action. We are accustomed also to obtain informa- tion of a more general kind from the fact that special centres in connection with different viscera, and functions situated at different longitudinal levels in the cord may be more or less deranged. To this portion of the subject it will, indeed, be found most convenient to give attention in the first place. Evidence from perverted activity of spinal centres. (1) The lateral columns in the upper cervical region contain the motor paths for the muscles of respiration, so that section or disease of them at a lower level interferes with the movements of respiration on the same side of the chest (tho- racic muscles) ; whilst, if the lesion reaches as high as the fourth and third cervical nerves (the origin of the phrenic) the diaphragm itself also becomes paralysed, and the movements of respiration must therefore almost cease. (2) Again, the upper cervical region of the cord, if it does not contain actual centres con- nected with the excitation of the heart’s action, is at all events traversed by certain channels for the transmission of cardiac stimuli (whose point of exit from the cord is, with sympathetic fibres, lower down). Thus different lesions in this upper cervical region of the cord may, according to their nature 1464 SPINAL CORD. DISEASES OF. and extent, greatly interfere with the heart’s action, as well as with the respiratory movements. The frequency of the pulse may be either notably accelerated or retarded; whilst the respiratory movements may be slower or much quicker than natural, and also extremely irregular and per- verted in rhythm. (3) The lower cervical and upper dorsal re- gions of the cord also contain the so-called ‘ cilio- spinal centre,’ or the fibres emanating from it. These pass outwards with the fibres of the an- terior roots in the above-named regions, and thence into the cervical sympathetic. Irritation of them causes dilatation of the pupil on the same side, whilst section or other destructive lesion causes contraction of the pupil. (4) The vaso-motor nerves for the side of the head and neck arise in similar regions of the cord, and leave it in the same manner. Irrita- tion of them produces contraction of the blood- vessels ; section, severo compression, or destruc- tion causes dilatation of the blood-vessels of these regions. See Sympathetic System, Disorders of. (5) Generally it may be said that section of one half of the cord or destruction of it for any extent longitudinally, causes at first paralysis of blood-vessels in the lower parts of the body on the same side— this vaso-motor paralysis carry- ing with it in the same parts an increase of temperature and an exaltation of sensibility. In a short time, however, the vaso-motor paralysis (and with it the increase of heat and sensibility) passes away, owing to the vaso-motor centres in parts of the spinal cord below, and to the peri- pheral vaso-motor centres, adapting themselves to act independently of those in higher parts of the cord and of the supreme regulating centre in the medulla oblongata. (As a rule the higher vaso- motor centres control those lower down, but after temporary paralysis even the peripheral vaso-motor centres seem to resume control over related blood-vessels.) (6) Tho movements of the stomach and intes- tines. generally are certainly influenced by the cord in different regions, so that in various cases, under perversions of this normal spinal influence, we may get vomiting, diarrhoea, or obstinate con- stipation — as direct results, that is, of morbid changes in certain parts of tho cord in which intestinal sympathetic fibres have their roots. The exact situations of these centres and paths of stimulation are, however, only vaguely known. In the grey matter of the lumbar swelling of the cord there are aggregated a number of centres having to do with important functions, which may be variously interfered with by dis- ease. These centres are those which regulate— (7) the evacuation of the rectum ; (8) the evacu- ation of the bladder ; (9) erection and ejaculatio seminis ; and (10) the contractions of the uterus. In each case the spinal centre constitutes an independent reflex centre, provided with its af- ferent and efFerent nerves, but in each case also there is more or less of connection between the spinal centre and others in the cerebral hemi- spheres. There must therefore be double sets of internuncial fibres for each centro traversing the whole length of the spinal cord and medulla; partly for the transference of afferent impressions from each centre to the brain, and partly for the conduction of efFerent impressions in the reverse direction. In the case of the uterine centre these cerebral connections are of comparatively slight importance ; since, with a complete transverse lesion in the cervical or even in the upper dorsal region, the process of parturition may still be successfully accomplished. So long as the spinal mechanism is complete and perfect, parturition may take place without the need of cerebral co- operation. Our subsequent remarks will, there!' re, refer principally to the other three lumbar centres. Complete transverse lesions occurring in any part of the dorsal or cervical regions will, of course, entirely cut off all the above-mentioned lumbar spinal centres from connection with, and therefore from any voluntary control by, the cerebral hemispheres. But various limited local lesions in particular transverse areas of the cord (though such areas cannot at present be definitely specified) may produce similar results, so far as the cerebral control of any one or two of the lumbar centres is concerned. According as the sever- ance of these lumbar spinal centres from cerebral correlation and control is complete or partial, one or other of the following results would be produced : — Name of Complete Severance from Cerebrum Incomplete Severance from Cerebrum Centre Afferent and Efferent Internuncial Fibres Afferent Internuncial Fibres Only Efferent Internuncial Fibres Only Rectal centre Unconsciousness of need, and in- ability to prevent evacuation Result. — Constipation, ■with in- continence of faces after an aperient Unconsciousness of need and therefore no attempt to re- strain evacuation Consciousness of need to evacuate, with no ability to restrain the act Vesical centre . Unconsciousness of need, and in- ability to prevent micturition Result. — Reflex evacuation in gushes at intervals Unconsciousness of need and therefore no attempt to re- strain micturition Consciousness of need, but inability to restrain mic- turition Sexual centre . — Diminution or absence of sexual desire. Erections and emis- sions, if they occur, wholly dependent upon the spinal reflex mechanism With simple destruction of fibres, nearly same results as *et down in previous column ; but with irritation of afferent fibres there might be great in- crease of desire (satyriasis or nymphomania) Feelings of desire, but no erection in response. Erection and emissions, if present, purely through spinal reflex. But with irritation of efferent fibres there may be persistent erections, mostly without desire SPINAL COED, DISEASES OF. The rectal and the vesical spinal centres are each composed of two parts with their separate afferent and efferent nerves — one in relation with a sphincter muscle, and the other in relation with detrusor or expulsive muscles in functional opposition with the former. These several nerve- fibres, both afferent and efferent, are probably all contained in the sacral nerve-trunks — that is, they both reach and leave the lumbar swell- ing as constituents of these nerve-trunks. De- struction or irritation of either of these sets of fibres, or of one of the centres, will necessarily interfere to some extent with the working of this particular centre, so that its functions may be interfered with in several different ways. There may be various degrees of irritability of the bladder or rectum, or various degrees of paralysis of these organs. In cases of paralysis of the bladder, especially when owing to lesions implicating its spinal centre, the urine soon becomes foetid and alka- line, and inflammation (alone or with ulceration) is most apt to be set up in its mucous mem- brane. The details as to the modes of disturbance of :he genital function, where disease implicates its lumbar centre or the afferent and efferent nerves in connection therewith, are both less known ind of less clinical importance than where it in- volves the internuncial fibres between this centre •md the cerebrum. Again, should the lumbar portion of the cord beeomo affected in a preg- nant woman so as to involve the uterine centre , unless the contents of the womb were thrown off during some initial period of irritation, this organ would be quite incapable of expelling the foetus and its accessories. Evidence from implication of particular sen- sory or motor nerves. 1 10. The more precise indications concerning the longitudinal implication of the spinal cord are, as already stated, derivable from the level at which alterations in sensibility or in motility (either voluntary or reflex) are to be detected. The more closely the lesion approaches to what is called a ‘total transverse lesion,’ the more distinctly will signs of this order reveal them- selves. It is important, too, to recollect that the fibres of different sensory roots are to some extent dispersed through cutaneous surfaces over- lying the muscles supplied by the corresponding motor roots. In regard to sensibility, the upper limit at which the trunk is affected is often sharply de- fined by the presence of a feeling of constriction, of pain, or of numbness (‘girdle sensation’) en- circling the body. This sensation is generally supposed to be due to irritation of the roots of the nerves as they traverse the posterior columns (or perhaps outside them) at the upper level of the lesion. This symptom may of course be absent, but in many cases of paraplegia it is well-marked. Then again the muscles which are paratysed can generally be pretty well defined, so that a re- ference to the nerves by which they are inner- vated will also enable us to fix upon the region of the cord from which they proceed. Thus we obtain indications as to the upper level of disease in the motor tracts. 1465 These latter indications are, however, by no means so distinct as many might suppose, because the majority of limb and trunk muscles receive fibres from more than one motor root, as Preyer and Krause showed long ago. And the view subsequently indicated by E. Eemak that func- tionally related or synergic muscles are repre- sented 'together in the anterior horns of the spinal cord has been confirmed and extended by Ferrier and Yeo {Proceed, of Royal Soc., March 24, 1881, p. 12), by their experiments on the functional relations of the motor roots. They find that stimulation of individual roots of the brachial and crural plexuses result, not in mere unrelated contractions of various muscles, but in highly co-ordinated synergic contractions, lead- ing to definite movements. But as the 1 muscles thrown into action by each root are innervated inmost cases by several nerve-trunks,’ the result ‘of section of each motor root would therefore be paralysis of the corresponding combination, not necessarily, however, of the individual mus- cles involved .... whilst weakened, they might yet act in other combinations in so far as they were supplied by other roots.’ Different com- bined movements which have been found to be dependent upon particular motor roots are citel by the authors in this valuable paper. The integrity of those reflex actions which can be elicited either in health or in disease, depends, of course, upon the integrity of the entire nervous arcs concerned (that is, upon integrity of in-going fibres, centres, and out-goingfibres). Thus though the impairment of a reflex may not necessarily be due to central causes, its presence, on the other hand, clearly shows that the grey matter and other regions of the cord which must be traversed by its stimuli are not impassable ; whilst its exaltation will indicate the probable existence of some central change, by which the grey matter in question is rendered more excitable, or else by which it is cut off from cerebral inhibitory influences. § 11. For practical purposes it will be well here to group together the various indications as to longitudinal localisation to which we have referred — classifying them as they are related to one or other of four imaginary segments of the spinal cord. (a) Cervical region of the cord. — This corresponds externally to the space between the occiput and the upper border of the 1th cervical spine (8 th cervical nerve). The 1st, 2nd, and 3rd cervical spinous pro- cesses are respectively opposite the origins oi the 3rd, 4th, and 5th cervical nerves. The phrenic nerve (motor nerve of the diaphragm) arises from the 4th, or from the 3rd and the 4th oervical nerves. Opposite the 3rd cervical spine (level of 5th cervical nerve) the cervical swell- ing of the cord begins ; whilst it ends opposite the 7th cervical spine (level of 1st dorsal nerve). Disease of ‘his region may involve interference with respiration, and possibly weakness of voice; interference with the heart’s action — pulse very frequent, or the reverse ; flushing or pallor of the head and neck ; continued priapism (with crushing lesions) ; augmentation of temperature in the body generally (hyperpyrexia) ; and marked contraction or dilatation of the pupil. I4G6 SPINAL COED, The innervation of the shoulder, arm, and hand muscles is derived from spinal nerves between the 6th cervical and 1 st dorsal inclusive ; those supplying the ulnar side of the hand and fore- arm arising from the lower level, that is, from the upper part of the next region. (6) Upper half of the dorsal region of the cord. — This corresponds externally to the space between the 1th cervical spine (ls< dorsal nerve ) and the ith dorsal spine ( 6th dorsal nerve). The results of disease here are apt to be these : — The ‘ scapular reflex ’ may be abolished, calling into activity as it does the last two or three cervical and the first two or three dorsal nerves ; the intercostal muscles are paralysed at different levels; a ‘girdle sensation’ is felt at different levels ; there may be prominence of certain verte- bral spines, and possibly tenderness on pressure or on tapping over them ; the ‘ epigastric reflex ’ may be abolished, depending as it does upon the spinal cord at the level of the 4th to the 6th or 7th pairs of dorsal nerves; and priapism (with crushing lesions) may occasionally be met with. (c) Lower half of the dorsal region of the cord. — This corresponds externally to the space between the upper border of the 5th dorsal spine (' Ithdorsal nerve) and the lower border of the 10 th dorsal spine ( space below 12th dorsal nerve). Disease here may give rise to the following symptoms : — The ‘ abdominal reflex’ maybe abo- lished, depending as it does upon the integrity of the cord between the levels of the 8th dorsal and the 1st lumbar nerves. Paralysis of lower intercostal muscles or of abdominal muscles may possibly occur, in addition to paralysis of the lower extremities. ‘ Girdle sensation ’ may be felt at different levels (the umbilicus correspond- ing with the 10th dorsal nerve, and the ‘ ensi- form area’ with the 6th and 7th dorsal nerves). There may be prominence of certain of the lower dorsal spines, with possible tenderness. Id) Lumbar region of the cord. — This cor- responds externally to the space between the lower border of the 10th dorsal spine ( just below 12 th dorsal nerve), and the upper border of the 2nd lumbar vertebra. Here the symptoms are Paralysis, not im- plicating the abdominal muscles, hut limited to more or less of those of the lower extremities.' No ‘ girdle sensations’ around the trunk. Three superficial reflexes may he abolished, namely, the ‘ cremasteric,’ which depends upon the integ- rity of the cord in the upper lumbar region ; and the ‘ gluteal ’ and the ‘ plantar,’ both of which seem to he dependent upon the integrity of the lower part of the lumbar region of the cord. A deep reflex may also be abolished, namely, the so-called ‘ knee-jerk,’ which is de- pendent upon the upper lumbar region of the cord. ‘ Anklo-clonus ’ may he met with when diseaso affects the upper or mid-lumbar regions of the cord, but not where the lower lumbar region is implicated. Loss of sensibility about the perineum and anus (if not due to disease of nerve-trunks), is indicative of disease of the pos- terior columns in the lower lumbar region. Ab- solute paralysis of the bladder and rectum may be present, with tendency to inflammation and ulceration of the former organ. DISEASES OF. In the clinical data above given are included the majority of the facts upon which the reyiona diagnosis of diseases of the spinal cord most in all cases he based. In them also will be found the explanations, so far as they can be given in moderate compass, of the sy7nptoms met with in different diseases of the spinal cord. An obvious advantage will be found to have resulted from this somewhat lengthy preliminary discussion, if, as it ought to do, it tends to give the prac- titioner a more thorough insight into the nature and relations of the several diseases of the spinal cord, at the same time that it aids him in their diagnosis. Although it is true that the groups of symptoms presented in different diseases of the spinal cord, considered individually and collectively, afford the materials upon which a regional diagnosis must ho founded, it is no less true that a part of the symptomatology (namely, that comprised in the mode of origin and the mode of establish- ment of the disease, together with what may be gathered from the patient’s state general^-, from his family history and from his personal history) constitutes the basis upon which a pathological diagnosis has to be arrived at. Again, although the arrival at a regional diagnosis is often spoken of, and may seem to he a process altogether distinct from that involved in the arrival at a pathological diagnosis, yet, as a matter of fact, in the investigation of many individual cases of spinal disease, it will he found that the one problem is not settled first, and the other after- wards, but that both are tentatively considered more or less simultaneously. Thus, certain em- pirically known pathological conditions may afford at once a ready explanation of a given group or sequence of symptoms, as in ‘infantile paralysis,’ in ‘ locomotor ataxy,’ or, in a more general sense, in angular curvature of the spine. Here, therefore, the pathological diagnosis goes hand in hand with the regional diagnosis, and in working them out each gathers additional confirmation from the establishment of the other. Sometimes, however, as in the case of traumatic injuries (including stabs, and fractures with dis- locations of vertebrae), the pathological diagnosis is at once obvious, and the regional diagnosis alone requires to he settled in detail. For the above reasons it has been necessary to tabulate in this article certain ‘ Pathological data concerning the Spinal Cord’ (§ 6), though it would not be found specially advan- tageous were we to follow out this part of the subject further, and attempt here to set down the more general clinical data and dcduciic-ns of pathological import, necessary to be borne in mind for the arrival at a pathological diagnosis, in order to form a series of facts and deductions comparable with those already given in elucida- tion of the problems of regional diagnosis (§§ 8-11). These other problems will be dealt with, as far as possible, in the descriptions of the several diseases of the spinal cord. H. Cha.ri.ton Dastixv SPINAL CORD, Special Diseases of. — In order that the mutual relations of the dif- ferent diseases of the spinal cord may he the more readily appreciated, their names are her* SPINAL COED, SPECIAL DISEASES OF. let down in groups, and they will be severally considered in the same order, which is one based upon their causes and nature, rather than upon alphabetical considerations. This list will, there- fore, in addition serve as an index to tho pre- sent article The names of the different diseases now to be described are printed in block type ; while the names of those diseases which are dis- cussed separately in different parts of the work (to which the reader is referred), are printed in small capital letters. I. Diseases of the Spinal Cord dependent upon known organic changes : — I. Concussion of the Spinal Cord ; 2. Punc- tured or Gun-shot "Wounds of the Spinal Cord ; 3. Sudden Crushing Lesions of the Spinal Cord ; 4. Slow Compression of the Spinal Cord ; 5. Au- remia of the Spinal Cord ; 6. Hypersemia of the Spinal Cord ; 7. Inflammation of the Spinal Cord; 8. Heemorrhage into the Spinal Cord; 9. Softening of the Spinal Cord. 10. Infantile Paralysis; 11. Acute Spinal Paralysis of Adults; 12. Acute Ascending Para- lysis; 13. Chronic Spinal Paralysis; 14. PitO- oefssive Muscular Atrophy; 15. Pseudo- hypertrophic Paralysis. 16. Locomotor Ataxy ; 17. Spasmodic Spinal Paralysis; 18. Amyotrophic Lateral Sclerosis; 19. Multiple or Disseminated Sclerosis. 20. Tumours and New Formations of the Spinal Cord; and 21. Malformations of the Spinal Cord. II. Diseases dependent upon unknown or imperfectly known organic changes: — 22. Tetanus; 23. Tetany; 24. Torticollis; 26. Writer’s Cramp ; 26. Spinal Irritation ; 27. Eefiex Paraplegia ; 28. Intermittent Para- plegia ; 29. Hysterical Paraplegia ; 30. Para- plegia dependent on Idea; 31. Neurasthenia Spinalis ; and 32. Toxic Spmal Paralysis. In addition to these diseases, dependent upon changes limited to the spinal cord, other affec- tions should here be mentioned, in which the spinal cord is implicated (in modes more or less known) together with the cerebrum in one or other of its regions. These ccrcbro-spinal affec- tions are as follows: — 1. General Paralysis of the Insane ; 2. Cerebro-Spinal Sclerosis ; 3. Paralysis Agitans ; 4. Hydrophobia ; and 5. Chorea. For an account of the diseases dependent upon morbid changes in the membranes of the spinal cord, see Meninges, Spinal, Diseases of. 1. Spinal Cord, Concussion of. — Synon. : Commotio Medulla Spinalis ; Fr. Commotion de la Moelle Epiniere ; Ger. Erschutterung des Eiick- enmarks. .Etiology. — This condition is met with prin- cipally in persons who have fallen from a height, or in those who have been present in a railway collision. In these cases the brain is apt to suffer as well as the spinal cord, and it is not always easy to unravel the respective symptoms due to shock of this or that great segment of the cerebro-spinal system. Anatomical Characters, — In many of these cases there are, in all probability, no morbid thanges that would be discoverable. In others, 1467 however, minute extravasations of blood, or actual ruptures of the nerve-tissue, may occur — and this sometimes even to a marked extent, as in a case seen by the writer. An example of slighter lesions is recorded by Sir Wm. Gull, in which small extravasations of blood were found in the anterior and posterior cornua as well as in the posterior columns of the cord. In neither of these cases was there any external or visible injury ; but in each paraplegia was produced immediately after the fall that determined the lesions in the cord. In addition to haemorrhages into the substance of the spinal cord itself, there is in these cases tho possibility of the occurrence of meningeal haemorrhages, pressing upon the cord or its nerve-roots; and within a day or two after the occurrence of the concussion itself, there is the possibility of some local and sub- acute inflammation being set up in the mem- branes of the cord. Symptoms. — In the great majority of these cases no complete paralysis is induced, even at first. There may at most he paresis of one or more limbs, general prostration, nausea with occasional vomiting, a rapid and possibly ir- regular or intermittent pulse (especially after the least exertion), with occasional startings and twitchings of the limbs, whose sensibility may be diminished, exalted, or unaffected. The temperature will probably be at first depressed, as a result of shock, though subsequently a febrile elevation may continue for somo days. The tongue may be furred, the appetite bad, the bowels constipated ; whilst in regard to micturi- tion there may he either some delay and difficulty, or, on the contrary, an irritability of the bladder, with difficulty in retaining its contents after the desire to micturate is once felt. With this thero is often general restlessness, nervousness, and insomnia. In more severe cases of concussion, even where there is no complication resulting from appre- ciable lesions, the shock to the system {see Shock) may be more profound, and there may he paralysis of limbs, lasting perhaps for some days, and then rather suddenly disappearing. Diagnosis. — The questions to be determined are, whether, looking to the symptoms presented by the patient, there is likely to be any organic lesion or change in the spinal cord or its mem- branes ; or whether we have to do with mere functional perturbations induced by the shock or blow to which the patient has been subjected. In the absence of definite paralysis, or even with its presence for the first few days, the answer to this preliminary question will often be shrouded in doubt. To come to a definite opinion as to the precise nature of the change which a spinal cord, deemed to be damaged in some way after a concussion, has undergone, lapse of time and several examinations of the patient are often required. In many cases in which compensation for an injury is claimed a further complication appears. Here it is that the difficulty arises as to how much the symptoms experienced, or said to be experienced, may be due to an excited imagina- tion, and how much to causes independent of the imagination, whether voluntarily or involun- tarily aroused. It must be conceded that symp* SPINAL CORD, SPECIAL DISEASES OF. toms of injury are undoubtedly feigned by un- scrupulous persons; and it seems also equally clear that, even unknowingly to the patient, the excitement consequent upon the accident, the details heard concerning the injuries of others, combined with the inquiries of doctors and cf sympathising friends, tend to keep up and to exaggerate symptoms in many nervous patients, over and above those which may have resulted from the shock. Such patients also may make a more speedy recovery subsequent to trial snd compensation, than they had been making before the trial, and yet they may not have been in any sense impostors. It is true that such persons, however, do not recover quite so quickly as those others who for their own unscrupulous ends have been previously exciting their imagina- tions in a voluntary manner. Prognosis. — In only the severest cases of concussion or shock is there actual danger to life ( see Shock). Where, however, great pros- tration is induced, and especially in those who may previously have been suffering from heart- affections, or from a very excitable nervous system, life may be speedily brought to a close ; or at most such patients may not survive a severe concussion more than a day or two. Severe concussions of the cord may also form the starting-points of many and varied deviations from health, which may not begin to show them- selves for weeks, or perhaps even months, after the initial shock. Among such sequels, which have come under the writer’s notice, may be mentioned the following; — Loss of flesh with general failure of nutrition, epileptiform fits, progressive muscular atrophy, lateral sclerosis of the spinal cord, a slowly increasing paraplegia (of uncertain pathological basis), and caries of rertebrs followed by angular curvature and paraplegia. In other and slighter cases, time and rest, with suitable medical treatment, may be ex- pected to lead to perfect recovery, sometimes speedily, but sometimes only after protracted periods of impaired health. Treatment. — In the first instance, symptoms of shock have to be combated by the employment of warmth and stimulants. In subsequent stages, rost in the recumbent position must be enjoined for a time. It is of the first importance to make sure that the patient does take complete rest, and is kept free from excitement during the first few days after any concussion accident, and that he gets sound sleep at night, under the influence of bromide of potassium, or of this together with chloral. If the condition of restlessness, with disturbed sleep, can be checked, then a mitiga- tion of other symptoms may be expected to fol- low. The application of ice to the spinal column may at times be desirable ; or pain . must be re- lieved by the subcutaneous injection of small doses of morphia. Later on tonics, with a simple nutritious diet and plenty of fresh air, together with rest, will be needed for the complete resto- ration of the patient. 2. Spinal Cord, Punctured or Gun-shot Wounds of. — Synon. ; Acute Traumatic Lesions of the Spinal Cord ; Fr. Plaies ct contusions de la Moellc Epiniere ; Ger. RiicJcenmdrhszerreissungen. ^Etiology and Anatomical Characters. — Punctured or gun-shot wounds of the spinal cord are commonly made with knife, dagger, sword, or bullet. In each set of cases, the wound in the spinal cord will be associated with perforation or rupture of some of the membranes, and also with haemorrhage, either between them or into the substance of the cord. The arches of the vertebrae or their articular processes and some of the ligaments connecting them may be more or less damaged, and a wound commonly exists through the contiguous skin and muscles. In the cord itself, there may be either a clean-cut wound through certain of its columns and parts, or a broader crushing lesion. In each case more or less blood may be effused upon and below the cut surfaces of the cord. At later stages, there may be signs of inflammation of the membranes, as well as cf local inflammatory softening of the substance of the cord. Symptoms. — The signs and symptoms con- sequent upon wounds of this kind are subject to endless variations, in accordance with the dif- ferent regions of the cord involved, the actual extent of the wound in its substance, and the possible presence of varying amounts of effused blood. These wounds often involve only a por- tion of the transverse area of the cord. It is indeed in this class of cases more especially that hemiplegia spinalis and hemiparaplegia are met with. Thus where a unilateral lesion exists in the mid or upper cervical region, both arm and leg are paralysed, so that the state known as hemiplegia spinalis is produced ; but where it occurs in the dorsal region, the one leg only is paralysed, and we have what is known as hemi- paraplegia. The essential peculiarity in the latter eases is that on the side of lesion there is complete motor paralysis in the limbs or limb below; whilst on the opposite side, the limbs or limb, and the trunk up to the middle line, are more or less completely anaesthetic — sensitiveness to im- pressions of touch, pain, temperature, and tick- ling being alike abolished. Other minor peculiarities are these : — On the side of motor paralysis , there is also vaso-motor paralysis, which carries with it, as consequences, (a) an elevation ot temperature (from lj° to 2° Fahr.), and ( h ) a hyperssthesia for all modes of sensibility (owing in part to hyperemia in the limb and cord). Surrounding the body, at the level of the upper margin of antesthesia on the side of sensory defect, there is usually a narrow girdle of hyperesthesia ; whilst below this level, on the side of the lesion, there is a half band of hemiannesthesia — whose depth varies with the longitudinal extent of the lesion. (The complete zone of hyperesthesia is probably due to hy- peremia of nerve-roots, and of the grey matter of the cord immediately above the lesion ; wh ; le the half-zone of antesthesia is dependent upon destruction of the nerve-roots, and of the spinal cord for a certain extent.) If bed-sores occur, they are met with on tho side of sensory paralysis ; whilst in one or two cases signs of a joint-affection (in the knee prin- cipally) have occurred on the side of motor paralysis. There seems no reason for expecting SPINAL COKD. SPECIAL DISEASES OF. 1469 any special muscular atrophy or diminution of fnradaic irritability on the side of motor para- lysis, except in those muscles whose nerve- eupply comos from the portion of the anterior iornua actually destroyed by the lesion. In many cases, especially at first, there is paralysis of the bladder and of the rectum, or there may be incontinence of urine. Later on these troubles tend to diminish. Nothing definite is known in regard to the condition of the skin-refiexes and tendon-reflexes in these states. Where anomalies exist in regard to the extent of decussation of the pyramids (Flechsig), the above-described effects of unilateral lesions of the cord would also undergo corresponding variations. In gun-shot wounds, whether occasioned by pistol or rifle, splinters of bone may be de- pressed at times, so as to compress and irritate the cord, and thus the symptoms may be made to approximate more closely to wounds of the next category. After a few days the symptoms may be com- plicated by those of spinal meningitis, or ex- tended by the spread of an inflammatory soften- ing of the cord above and below the seat of lesion. Diagnosis. — The primary cause of the patient’s condition is generally only too obvious. It may be clear that we have to do either with a punctured or with a gun-shot wound in some region of the spine ; but subsequently many, and often very difficult, questions require to be solved. It is of first importance to learn whether the cord itself is really damaged, or whether the symptoms are in the main caused by epi-dural or sub-arachnoid haemorrhages (see Meninges, Spinal, Haemorrhage into). In the former case there will be evidence of complete or partial interruption of conduction in the cord, to or from all parts below the seat of lesion, and not of a mere local implication of nerve-roots. If it seem probable that the cord itself is damaged, we have to determine whether it is completely cut across, or only partially damaged — and if the latter to what extent. These questions must be decided in the main by reference to the signs given in Introduction, § 8 . Should the case be seen for the first time several days after the injury, an exact diagnosis as to the amount of damage to the cord itself is often greatly obscured by the existence then of certain secondary pathological conditions — more especially localised inflammation of the meninges, or secondary inflammatory softening, extending perhaps above or below, or in both directions, from the original wound. A process of softening may also extend transversely through the whole substance of the cord, even where only a unilateral lesion had previously existed. Prognosis. — This, as a rule, is bad in all cases of traumatic injury of the spinal cord; and the gravity of the case is usually the greater the higher the wound happens to be situated in the cervical region. Wounds of the dorsal or lumbar region of the cord are rather less serious, so far as life is concerned. The degree of recovery from paralysis of limbs will greatly depend upon the nature and extent of the wound. A clean-cut wound may bo filled up by the growth of a kind of cicatricial tissue ; but it has not yet been accurately determined whether the nerve-substance of the cord can be reproduced in man. There seems, however, reason for supposing that some amount of reparation of nerve-tissue may take place in the cut spinal cord even of man — especially in early life. Treatment. — Absolute rest, with cold appli- cations, and possibly local blood-letting, will be needed in the first instance. Subsequently, when immediate danger from shock and from tho spreading of local inflam- mation has passed away, the patient must be treated upon the general principles applicable to all cases of paraplegia — which principles will be found set forth in (9) Spinal Cord, Softening of. 3. Spinal Cord, Sudden Crushing Le- sions of; Fr. Compressions brusques de laMoeUe Epiniere; Ger. Riickenmarksquchchunpen. .Etiology and Anatomical Characters. — The above form a class of wounds sufficiently distinct to need separate treatment. This kind of damage to the cord may be produced by the sudden giving-way of a carious vertebra in any part of the spinal column ; more rarely from a heavy blow on the back, which does not fracture the spine; or, in a modified form, from the burst- ing into the spinal canal of an aortic aneurism, after its erosion through the vertebrae. But in the majority of cases such wounds of the spinal cord are the results of forms of external violence which cause fracture and dislocation of vertebrae, in some portion of the spinal column between the upper cervical and the upper lumbar region. When this occurs displacement of vertebrae, even to a slight extent, especially in the dorsal re- gion, in which the spinal canal is narrowest, is sufficient to produce severe pressure upon, or crushing of, the spinal cord. The membranes may not be torn across, but the substance of the cord itself may be greatly compressed or reduced to a blood-stained semi-fluid mass of pulp. Afte » some hours there are obvious signs of a com mencing inflammatory reaction in the membranes ; and above and below the seat of lesion similar changes are apt to be set up in the spinal cord itself, which may go on to tho production of a variable amount of inflammatory softening. The patient may die, however, before any of these latter changes have been established. Symptoms. — These vary much, according to the region of the cord involved. Still, in spite of differences thus dependent upon the seat of injury, there is a certain general similarity in the symptoms produced by all crushing lesions of the spinal cord. They are usually of this nature : — Complete paralysis, both motor and sensory, of parts below the seat of lesion ; in addition to severe pains in the back, girdle pains surrounding the body at the upper limit of sensory and motor paralysis ; increased heat or possibly undue coldness of the body through- out the paralysed parts ; complete paralysis of bladder with retention of urine, gradually giving place to incontinence ; paralysis of intestine, extremely obstinate at first, but subsequently complicated with involuntary evacuations after 1470 SPINAL CORD, SPECIAL DISEASES OF. the administration of purgatives ; extinction of all reflex actions at first. In the course of two or three days, if the patient should survive, other general symp- toms become well-marked, owing to the es- tablishment of a local meningitis, together with some amount of traumatic myelitis. Amongst vnese we have general fever, with an increase of the ‘girdle sensation,’ and of pains in the limbs; twitehings in the limbs or in particular muscles ; and also a general increase m reflex actions for a time. The above-mentioned complicating patholo- gical processes may gradually subside, but there will still be danger to life from the supervention of severe cystitis or of extensive bed-sores, to- gether w'ith one or other of the various sequelae to which such conditions are apt to give rise. The additional symptoms and variations met with, according as the crushing lesion occur.? in different regions of the cord, are as follows. (They increase in number the higher the lesion occurs in the spinal cord. See Introduction, § 11.) When it is situated in the lumbar swelling we have, in addition to the limitation of the para- lysis to the lower extremities, and a more or less complete extinction of related reflex actions, the appearance of rapid atrophy in the paralysed muscles, together with the manifestation of the electrical ‘reaction of degeneration.’ The blad- der and rectum are apt to be completely para- lysed. AVith the lesion in some part of the dorsal region we have sensory and motor paralysis of the trunk up to a certain level, with an absence of the rapid atrophy and before-mentioned elec- trical reaction in the muscles of the lower extre- mities, though some atrophy and the presence of this reaction may occur in one or more of the trunk muscles. In addition (and notably with the lesion in higher parts of the dorsal region) there may he some weakness of voice, some interference with the movements of respiration (especially with those of expiration), as well as marked and continuous priapism. The super- ficial and deep reflexes may he depressed or exalted, according to the condition of the grey matter below the seat of lesion. AVith the lesion in the lower cervical region the upper extremities are partly paralysed, both as regards sensation and motion ; the movements of respiration are much more gravely interfered with (expiration especially), whilst inspiration is of a purely abdominal type ; the voice is not- ably weak and feeble. Continued erection of the penis is more frequently met with; and in some cases a remarkable hyperpyrexia super- venes, in which the temperature before death may rise to 108°-112° Fahr. Should death not occur in this way, it is very apt to supervene in the course of a few days, by gradual failure of respiration, which grows worse than it was in the early days of the affection, owing to the se- condary myelitis which becomes established, im- plicating the cord and nerve-roots at a level higher than the original wound. The pulse is often much interfered with, but variously ; it may be slower or much more frequent than na- tural; it may be small, irregular, and frequent; or full, regular, and infrequent in its beats. There may also he signs of paralysis cf the sym- pathetic vaso-motor nerves supplying the neck and head, perhaps to a more marked extent on one side than on the other. AVhere the lesion occurs in the upper cervical region of the cord complete paralysis of the trunk and of all four extremities may be recog- nised, if death does not occur too suddenly to allow even this to be observed. The sudden death, so apt to occur in these cases, is due to the fact that in them the diaphragm is paralysed, as well as the other respiratory muscles. AVhere the lesion does not involve the whole of the roots of the phrenic nerve, and where the shock has not been too abrupt and violent, life (with ex- tremely difficult respiration and almost complete loss of voice) may be prolonged for a few hours. An admirable series of cases illustrating these crushing injuries to the spinal cord is to be found in Ollivier’s work (3me ed., t. i., p. 253 et scq.). Diagnosis. — If the existence of fracture and dislocation of vertebrae can be substantiated, the probabilities are always in favour of the pre- sence of a crushing lesion in the spinal cord. Otherwise after a very severe fall or blow upon the hack, doubts may be at first entertained as to whether we have to do with the effects of concussion alone, or with this plus some amount of crushing of the cord or of haemorrhage upon or beneath its membranes. The subsequent course of the symptoms may, however, in a day or two, enable us to resolve these doubts. Prognosis.—' Tho prognosis in lesions of this kind, as already indicated, is much graver than in the case of mere punctured wounds of the cord — these being oftener slight and partial in their transverse extent. Death may occur im- mediately ; or at any time during the first week ; in the main from failure of respiration and of the heart’s action. It is only in exceptional cases, and where the lesion is in the dorsal or lumbar region, that life is prolonged for several weeks or months. Such lesions are probably too severe to admit of anything like thorough repair with proper nerve-tissue. Paralysis, therefore, of a more or less complete kind, is lasting. But even where life is prolonged for a few months, it is ultimately lost, owing to the establishment of sloughing bed-sores and ulcera- tive cystitis, followed perhaps by blood-poison- ing, extensive meningitis, or other complications. Treatment. — In many of these cases treat- ment is useless and death inevitable. In those which are of a less urgent nature, the possibility (faint though it may be) of bringing about some slight relief by trepauning, with the view of ele- vating any depressed fragments of the vertebral arches, should not be lost sight of. Except, in- deed, for tho fact that parts surrounding the cord are damaged, so that rest in one position is often indicated, the treatment of these cases after the first urgent symptoms have abated does not differ from that which is appropriate in other well-marked cases of paraplegia, where there is a tendency to the formation of sloughing bed- sores, and to the establishment of cystitis. See (9) Spinal Cord, Softening of. 4. Spinal Cord, Slow Compression of. SPINAL COED, SPECIAL DISEASES 05. Synon. : Chronic Traumatic Lesion of the Spinal Cord ; Fr. Compression lente de la Moelle Epi- nierc ; (in part) Paraplegie douloureuse des ean- cereux ; Ger. Lang same Compression des RiicJccn- rnarks. JEtiology and Anatomical Characters. — The most frequent causes of the set of symptoms grouped under this head are to he found in dis- sases of the vertebrae, and especially simple in- flammatory cr scrofulous caries of the bodies of the Tertebrae (leading to angular curvature , or ‘ Pott’s Disease ’). Still, ether kinds of disease of the vertebra may also be productive of slow compression of the spinal cord, and of that form of localised softening of the organ -which is so commonly met with in this class of cases (the so-called ‘compression myelitis’). Among these may be mentioned cancer of the vertebrae, either primary or secondary ; also exostoses projecting into the spinal canal, or more irregular thicken- ing of the bones in this situation. In cases of vertebral caries, a tough, yellow, scrofulous growtli often infiltrates the posterior vertebral ligament, and thence spreads to the dura mater, here producing thickening and irregular fungosi- ties which may press injuriously upon the spinal cord — more especially upon its antero-lateral columns. In these cases the organ may be dis- tinctly softened opposite, and perhaps for a very short distance above and below, the site of com- pression. At first such softening is principally apparent in the columns above mentioned; but in cases of longer duration it may involve the whole thickness of the cord, and be followed by the usual ascending and descending ‘ secondary degenerations (§ 6, [13]).’ The softened matter itself is an almost bloodless fluid or semi-fluid pulp, either of a whitish or dull yellowish-white colour, and there is generally no undue vascula- rity of the immediately adjacent portions of the cord. In certain crises of slow compression no such softening of tho cord is produced ; there is rather a slow atrophy or disappearance of the nerve- substance as the pressure increases, together with a sclerosis of what remains. This may occur, for instance, where the cord is pressed upon by some exostosis, or by irregular growth and thickening of the inner surface of the spinal canal, such as occurs occasionally in one or other of the cervical vertebrae. It has long been known that no constant rela- tion exists between the amount of angular cur- vature and of paralysis in different cases of ver- tebral caries. Paralysis may be absent where curvature is most marked. On the other hand, with no curvature and with only a slightly marked projection of one or two vertebral spines, paralysis may yet exist to a well-marked degree. This is due to the fact, that in such cases the cord is only very rarely compressed by the bones, whilst it is frequently more or less pressed upon by the yellowish growths which protrude from the inflamed or carious vertebrae, or which produce thickening and infiltration of the dura mater at the seat of disease, and changes of this sort may be well-marked even where no angular curvature is appreciable. Again, where angular curvature is present, the posterior surface of the bodies of the vertebrae, 1471 corresponding with the angle, is often bent, rough, and eroded, and the cord over it is apt to become softened, though there may be no compressing growths or thickenings of the mem- branes. Thus it happens that the paralysis in these cases may be variously produced. And seeing that it is often due to pressure by inflammatory- products rather than to pressure or irritation from the diseased bones themselves, we may the better understand the fact that occasionally a great improvement may set in and become esta- blished in regard to the paralysis, although the angular curvature of the spine, and therefore the distortion of the spinal canal, remains as obvious as it ever has been. In addition to slow compression of the cord resulting from diseases of the bones of the spine, a somewhat similar condition may be induced by the various kinds of tumours of the meninges, or by hydatid growths implicating these parts (see Meninges, Spinal, Diseases of ; Tumours). Con- fined within the narrow limits of the spinal canal, such tumours, even though of smaE size, may soon come to exercise a very injurious amount of pressure upon the spinal cord. Symptoms, Course, and Terminations. — W e shall point out some of the distinguishing cha- racteristics of the paralysis which is often asso- ciated with vertebral caries, and afterwards refer to the peculiarities met with where meningeal tumours exist. In vertebral caries with commencing pressure upon the spinal cord, the symptoms will be different, according to the part of the column implicated. The affection is frequently ushered in by an abiding pain in the spine and parts adjacent, often supposed to be ‘rheumatic’ in nature. Such pains commonly disappear when tho patient is in the recumbent position, except dur- ing the acts of sneezing or coughing. They are commonly induced by particular kinds of move- ments, which are more or less difficult on this account. There is also some weakness in the lower part of the body and in the lower extremities. The mere ‘ weakness’ may continue for weeks or even months before there is anything like actual paralysis ; though at last this may show itself somewhat abruptly. The patient now becomes unable to stand, though lie can still move his legs slightly whilst lying in bed. At this stage sensation is little, if at all, interfered with; but there may already be some increase in the readi- ness with which the knee-reflex manifests itself, and ankle-clonus may also be easily attainable. Next there may be startings of the limbs, and commencing rigidity of the muscles when pas- sive movements are attempted; followed after a time by a more marked rigidity (which, when present in the calf muscles, will prevent tho manifestation of ankle-clonus and of the knee- reflex). Later, if pressure increases, and espe- cially where a complete transverse softening becomes established, sensibility in its various modes becomes implicated. At this period the exaltation of the reflexes often diminishes. For a time the degree of impairment of sensibility and the freedom with which knee-reflex and ankle-clonus may be obtained fluctuates. Mean- while, painful spasmodic contractions of the legs 1472 SPINAL CORD. SPECIAL DISEASES OF. (with flexion of hip and knee joints) become habitual, persisting through day and night with only rare intermissions. Although there is some general wasting of the muscles, together with a flabby condition when they are relaxed, they still react almost normally to the faradic current. The skin is often dry and scurfy. The temperature of the limbs is gene- rally slightly lower than normal. At the first onset there may bo for a few days a difficulty in voiding the urine, but this power soon returns and often continues long after the limbs have become powerless. The bowels are perhaps somewhat constipated, but there is no incontinence of faeces, unless diarrhcea super- venes from any cause, or except when the reflex activity of the bowel is greatly exalted under the influence of aperient medicines. The above condition of things may last long without much variation. But after a time there will be a gradual mitigation of the symptoms, or the reverse. In the latter case loss of voluntary control over the bladder and rectum appears ; and (especially when sensibility of the body and limbs becomes impaired) the tendency to the formation of sloughs and gangrenous bed-sores becomes increased. With these conditions other complications, such as cystitis, blood-poisoning, (See., may appear and greatly aggravate the con- dition of the patient, helping to bring about a more speedy termination. In the case of tumours arising from the meninges, the onset of the affection may also be very gradual at first, though, perhaps, rather suddenly intensified at last. Here, however, the pressure very often comes upon the cord from behind, or it may at the same time impli- cate one or both lateral regions of the cord. At first, therefore, we commonly get variously-im- paired sensibility and neuralgic pains, or pains mixed with startings and cramp-like contrac- tions in certain muscles, occurring in those par- ticular regions of the body or limbs which are in relation with the nerve-roots slightly pressed upon and irritated by the new growth. Great differences exist in different cases in regard to the degree and persistence of the initial pains. Subsequently these same nerves and the cord itself may become more severely pressed upon, and then loss of sensibility over the field of distribution of the nerve-roots is met with, to- gether with loss or impairment of sensibility in all or some parts of the body whose nerve-supply is from the cord below the compressed region. With this a minor amount of motor paralysis also occurs, which, however, subsequently be- comes more marked, and ultimately complete. When this takes place we have all the signs and symptoms met with in a case of total transverse softening of the spinal cord at the level impli- cated (see Spinal Cord, Softening of). This change is, in fact, commonly established by the persistence and increase of pressure due to the new growth. These are the broad outlines of the symptoms met with in such cases, which, of course, are subject to innumerable variations in individual cases, in accordance with differences in the region of the cord affected, together with the rate of growth, mode of incidence, and size of the tumour. In cancer of the vertebrae, also, we have much the same grouping of symptoms; the prelimi- nary pains being here especially severe (see Charcot’s Lemons, t. H., ed. 3, p. 86). Diagnosis. — In the paralysis associated with vertebral caries the diagnosis depends upon the recognition of this causal condition, which, in the early stages, is often a matter of some diffi- culty. Much will depend upon the existence of pain in particular regions of the spine, or radiat- ing therefrom ; of pain which is relieved by the recumbent position, and greatly aggravated by coughing, sneezing, or stooping movements of different kinds (see H. Marsh in Brit. Med. Journ., voL. i. 1881, p. 913). And yet in the absence of signs of caries, or of a scrofulous habit of body or history, or of an exciting cause for caries, in cases where there may be little or no prominence of vertebral spines, and even no pain from firm pressure or the application of a hot sponge, we may be helped in our diagnosis of the existence of caries by the distinctive cha- racters of the paralysis itself, namely, its impli- cation of motility principally, the exaggeration of the tendon-reflexes, the more or less marked rigidity of the legs, and the continuance of con- trol over the bladder and rectum. In cases of the latter type, or where there is only a slight prominence of two to four vertebral spines, it may be difficult, however, to establish a diagnosis between caries and cancer of the bodies of the vertebr®. It is true that a rounded prominence of several vertebral spines is met with in cancer more frequently than the angular projection commonly associated with caries; yet this single character will not always aid us ; we must look also to the presence or absence of severe pains, to the clinical grouping of symp- toms generally, and to the history of the patbnt. The diagnosis of the other causes of slow com- pression of the cord to which reference has been made (exostoses or meningeal tumours), is usu- ally a matter of extreme difficulty. We must be guided by probabilities based upon other asso- ciated states or conditions that may be recogni- sable in our patient, and also by the mode of onset of the affection. Prognosis. — Wo can only speak in general terms concerning the prognosis of the rather miscellaneous conditions which form the subject of this article. Cancer of the vertebrae or of the dura mater, compressing the cord, is the most serious of them all. The progress of such cases is usually both rapid and extremely painful, so that the end comes inevitably before many months have expired. In vertebral caries associated with compres- sion of the cord, the prognosis is extremely un- certain. Under suitable treatment many of these cases practically recover more or less fully. The process of caries is arrested, the spoiled vertebrae are strengthened and bridged over by growth of new bony tissue (though, of course, the angular curvature of the spine remains), whilst recovery from the paralysis may be more or less complete. This latter kind of recovery takes place occasionally even after paralysis, with almost persistent contractions of the lower ex- tremities, has existed for from twelve to eighteen months or even longer. SPINAL (JOKD. SPECIAL DISEASES OE. 147fl In other cases, of exostosis, hydatids, or men- ingeal tumours, compressing the spinal cord, the prognosis will depend upon the part of the cord involved, upon the rate of increase of the symp- toms of compression, and upon the extent to which a secondary myelitis or softening is es- tablished. The disease in these cases, in spite of stationary periods, or even those of slight im- provement, is more or less continuously progres- sive, though it may last for many months, or, occasionally, even for a year or two. Some of the complications or accidents incident to the para- plegic condition ultimately bring the patient’s life to a close. Treatment. — Rest in the recumbent or in the prone position is, of course, absolutely essential in cases of vertebral caries or of cancer of the vertebrae. In addition to this in many cases of vertebral caries, some form of Sayre's jacket may be needed, in order more effectually to secure absolute immobility of the affected portion of the spinal column. This, however, would have to be reserved for the more chronic cases or stages ■ — for those in which local treatment was no longer considered to be necessary or desirable. In cases of paraplegia associated with verte- bral caries, the patient’s general health requires the utmost attention during the period in which we are endeavouring to check the disease by the influence of rest. Good nutritious food and cod-liver oil will be required, combined with steel wine or the syrupus ferri phosphatis. In some eases iodide of potassium (together with iodide of iron or small doses of bichloride of mercury) seems to do good. In regard to local measures, counter-irritation of some kind is generally had recourse to, either in the form of flying blisters near to and on each side of the portion of the spinal column which is affected, or else by the renewed application of moxas or the actual cautery to these regions. The latter more severe measures are still re- commended by some authorities, though the experience of others, amongst whom was the late Sir Benjamin Brodie, is against their employment, as being of little or no use, and therefore adding needlessly to the sufferings of the patient. The writer is strongly inclined to think that all the good which moxas or the actual cautery are in- tended to bring about, may be as effectually achieved by the aid of flying blisters applied to the spine from time to time. In the case of an hydatid tumour pressing upon the spinal cord, and also situated in part out- side the vertebral spines, tapping might bring much relief. In the majority of the other con- ditions comprised within the limits of this article, little can be done to cure the condition which is the cause of the spinal disease, so that it would only remain for us to treat the paraplegia and its attendant conditions upon the general principles applicable to them, which are fully considered under (9) Spinal Cord, Softening of. 5. Spinal Cord, Anaemia of. — Anaemia is not to be considered as the basis of any ordinary or common disease of the cord ; or, in other words, there is no definite group of symptoms the existence of which is likely to be recognised more than once in a lifetime in any actual pre- 93 sent patient, which would justify the diagnosis ‘anaemia of the cord.’ First, the writer would repudiate the notion that antsmia or chlorosis, as a mere blood-disease, is capable of producing, on the side of the spinal cord, any set of symptoms which can be marked off from those characterising the condition as a whole. In these diseases the functions of all the organs are impaired by reason of the impoverish- ment of the blood. The brain and spinal cord, on account of the delicacy of their functions, will, of course, suffer to a notable degree ; and when general debility is extreme, a paresis of the lower extremities may be notable beyond that of other parts of the body', because tile legs in stand- ing or in walking have to support so great a weight. Where anything more than such pa- resis exists —that is, where there is actual para- plegia, such symptoms are not to be explu.nd' by a mere anaemia of the cord. Other causes are to be looked for. Jaccoud’s whole group of paraplegics dyscrasiques will probably disappear before a more thorough knowledge of the actual mode of causation of these and many other obscure forms of paraplegia. Secondly, embolism and thrombosis of spinal arteries will produce temporarily 5 * 7 , and in quite- limited regions of the cord, a condition of anaemia. Such local anaemia would probably soon be rectified by the establishment of a collateral circulation; and in the event of this not taking place, local ‘softening’ of the organ would en- sue. A paralysis owning such an origin would not, therefore, be spoken of as resulting from ‘ anaemia of the cord.’ Thirdly 7 , pressure upon parts of the cord will occasion anaemia and ultimately softening, but the symptoms in a case of this sort will depend mainly upon the pressure itself interfering with, the functions of the nerve-tissue thus affected. Beyond the conditions above referred to, there is the possibility that definite groups of para- lytic symptoms may be occasioned by anaemia induced by mere functional spasm of the arteries iD certain regions of the cord — spasm, that is, which persists day after day. This is supposed by Brown-Sequard to be the condition existing in the cases of so-called 1 reflex paralysis ’ ( see 27, Keflex Paraplegia). If such a condition of persisting arterial spasm be possible, and an actual cause of paralytic symptoms, we may well ask whether it too ought not after a time to lead to actual softening of the cord. There will still remain a very few 7 exceptional cases, in which a condition of real anaemia of the spinal cord is brought about in man, just as it has been brought about in some of the lower animals whose abdominal aorta has been tied or compressed. When the blood-supply is thns suddenly cut off from the lumbar region of the cord in animals, their hinder limbs become para- lysed almost immediately, and continue paralysed as long as the blood-supply of the cord happens to be arrested. But if, after a mere brief interval, the blood is again allowed to take its natural course, the temporary paralysis disappears completely in a very short time. A condition of this kind seems to have occurred in a patient, formerly under the care, of Sir W. Gull, who suddenly became para- plegic, app irently owiDg to an abrupt arrest of SPINAL COED, SPECIAL DISEASES OF. :474 file blood-current through the abdominal aorta, is was indicated by the cessation of the femoral and other pulses in the lower extremities (see Guy's Hospital Reports, 1857, p. 311). The man continued paraplegic for months, and only recovered when the collateral circulation became, after a time, pretty fully established. In a very few other cases referred to by Erb, in which paraplegic symptoms were associated with an obstruction of some kind in the abdominal aorta he thinks that these symptoms, supervening as they did rather less suddenly, may have been in great part due to the deficient blood-supply to the muscles and nerves of the lower extremities, rather than to ansemia of the cord — to a peri- pheral, that is, rather than to a centric anaemia. 6. Spinal Cord and its Membranes, Hy- pereemia of. — -This condition again is more fre- quently talked of than it deserves, looking to the small amount of positive knowledge we possess upon the subject. Hypersemia of the cord must be either passive or active, that is, it must be a result of me- chanical congestion or of arterial determination. Mechanical Congestion. — In obstructive heart- disease extreme congestion of the spinal cord may exist for months without producing any distinct symptoms of disease of the spinal cord. A constantly congested spinal cord would doubt- less perform its functions in a less vigorous man- ner than natural, but such effects would be slowly evolved and comparatively obscure. After a long time the effects might become more marked, owing to the overgrowth of connective tissue within the organ. We may indeed have the starting-point of a general sclerosis of the spinal cord under such conditions ; but this secondary change, when only slightly marked, may, even in the spinal cord, produce no definite symptoms. General mechanical congestion of the cord is probably more frequent and more easily brought about than a congestion involving parts of the organ. From various causes there may be undue pressure upon certain veins, which directly or indirectly convey blood away from special re- gions of the cord and its membranes. Such an event cannot, however, be regarded as a likely cause of a congestion productive of morbid spi- nal symptoms, if we consider the absence of dis- tinct symptoms resulting from extreme general congestion of the cord ; and also the fact of the very free anastomosis of all the spinal veins. Active hypercemia may in its origin be of two kinds — ‘reflex’ or ‘inflammatory.’ ‘Keflex’ hypersemia of the cord and its mem- branes is possibly a phenomenon of great fre- quency, manifesting itself locally in certain regions — the seat of the process varying according to the conditions under which it arises. It might be immediately caused by vaso-motor paralysis, implicating certain vessels of the cord and their branches ; and would thus involve an increased afflux of blood to the tissues contained in the corresponding vascular t erritories. We know that such an increased afflux of blood may exist in other tissues for some time without inducing tissue-changes of an appreciable kind (Brown- Sequard). It is fair to suppose, moreover, that any symptoms induced by such increased afflux of blood to certain regions of the cord would be indicative of exalted rather than of depressed function (for example, hypermsthesia, actual pains and spasms, or increased reflex excitability, rather than their opposites). In weak and irritable states of the nervous system it is quite possible that such vaso-motor paralysis, and also vaso-motor spasms inducing localised anaemias, may manifest themselves in spinal vessels, as they do in cutaneous vessels by familiar flushes or pallors. If occurring in the skin, however, these would be temporary phenomena, and not capable of producing the symptoms of an abiding disease. How frequent such reflex local hyperaemias (whether brief or prolonged) may be in the spinal cord, and in what precise manner they are excited, we do not know. Suppression of the menses or of htemor- rhoidal fluxes, the prosence of worms in the intestine, the prolonged incidence of cold and wet, or severe concussions of the spine, any or all may operate in this particular manner — but for proof that they do, as matter of fact, we may look for evidence in vain. The subject of ‘ inflammatory hypersemia’ will bo briefly considered under the next heading. In this case, in addition to changes in the vascular system, the effects of the inflammatory process as a whole have to be taken into account. Even in the first stage of inflammation something prior to and beyond the mere ‘ active ’ conges- tion has to be thought of. From what is said above, it may be seen how shadowy is our present knowledge concerning the existence of any definite sets of symptoms which can be ascribed to non-inflammatory hypersemia of the cord and its membranes, either general or local. 1 7. Spinal Cord, Inflammation of. — S ykox. - Myelitis; Myelitis Acuta; Softening of the Spinal Cord (in part); Fr. My elite; Myilitt aigue ; Inflammation cle la Moelle Epinierc ; Ramo- lissemcnt de la Moelle Epinierc (in part) ; Ger. Myelitis; Rucke n ma risen tzundung ; Erweichung dcs Riickenmarks (in part). Nature, /Etiology, and Pathology. — To speak definitely on this subject, in the present state of knowledge, is extremely difficult. This is due to several causes. In the first place, it is owing to the fact that so much uncertainty exists in the m ; uds of many eminent patholo- gists and physicians as to what ought rightfully to be included under this term ; and, secondly, because by a very large number of writers the term is understood and used in the vaguest ‘ The view in regard to congestion as a cause of definite morbid symptoms on the side of the brain and of the spiral cord has been entertained for the last six- teen years at least by the present writer, and the above article (6) has been in manuscript for nearly three years. It seems necessary for him to make this statement to pre- vent further misunderstanding arising from the fact that his name appears ns one of the authors of a paper on ‘Congestion of the Brain,’ in Dr. Reynolds's System of Medicine, in which a much more important r6le is at- tached to Congestion as a producer of definite morbid symptoms. The present writer was. however, only the author of the sections on * Pathology ' and ‘ Morbid Ana tomy ’ in the above-mentioned, article, and was not, pre- vious to its publication, aware of the views entertained by the accomplished editor of the work in question in regard to the supposed great clinical significance o( Congestion when it exists in the hrain. SPINAL COKD. SPECIAL DISEASES OF. 1470 manner, but 'with, a manifest tendency to com- prise under it the largest possible number of affections of the spinal cord. Critical dis- crimination seems to have been, and still to be, in abeyance -with many who describe or report cases of disease of the spinal cord. They set down as instances of ‘ myelitis ’ not only all cases in which the substance of the spinal cord is softened, but still more all those in which it is indurated — and, no less impartially, those in which it is merely degenerated. (1) The notion that common ‘softenings’ of the spinal cord are of inflammatory origin has persisted with little alteration, although for nearly twenty years pathologists have been inter- preting altogether differently the mode of pro- duction of apparently similar 1 softenings ’ of the cerebrum and cerebellum. Can it be that ‘ soft- ening’ as it occurs in the majority of cases in these latter organs is of non-inflammatory origin; while in the majority of apparently similar cases occurring in the spinal cord, the process is really inflammatory in its nature ? (2) Then, again, without adequate cause, the very localised changes occurring in and around the great ganglion-cells of the anterior cornua, in ‘acute’ and ‘chronic spinal paralysis,’ and in ‘ progressive muscular atrophy,’ have been set down as inflammatory in their nature, and new names have been given to these affections, tend- ing to ratify this view as to their origin. Thus they are spoken of by some as cases of anterior r polio-myelith, or more briefly, and, so far, better, as cases of cornual myelitis. But localisation of an inflammatory process to great ganglion-cells and their immediate surroundings, at present con- stitutes a rather unintelligible process to many pathologists. And mysterious as these par- ticular changes are, from the point of view of their aetiology, on any hypothesis that has yet been started, it is at least simpler, and more harmonious with the nature of the observed conditions themselves, to regard them as of a degenerative type. If the slower and more isolated changes characteristic of ‘ progressive muscular atrophy,’ are to be placed in this category (and in regard to them there is abso- lutely no evidence either clinical or pathological that can be adduced in favour of an inflammatory origin), then also it becomes easy to believe that under some at present imperfectly defined con- ditions, a change of the same kind may set in more rapidly in these the most specialised of all the anatomical elements met with in the spinal cord, so as to produce the more acute affections above referred to. The slight secondary over- growth of neuroglia often occurring around the degenerated ganglion-cells, does not in the least militate against this view as to tho pathology of the process ; a similar secondary change occurs also in the process next to be referred to, and will be found to be easily explicable without the necessity of having recourse to the ever-ready and fashionable hypothesis of inflammation. (3) ‘Secondary degenerations’ of the spinal cord have indeed, in spite of their name, and of what is known as to their origin, been erroneously regarded of late by some writers as inflamma- tory changes (Ziemssen's Cyclopadia, vol. xiii. p. 769). When nerve-fibres are cut across, those portions which are severed from their connection with certain ganglion-cells are no longer able to preserve their nutritive integrity. Simulta- neously throughout their whole length fatty degeneration affects their white substance. Myo- line breaks up, and becomes disintegrated as it does in non-inflammatory softenings in the brain; and very speedily granulation-corpuscles begin to form abundantly throughout the changing area. But though fatty degeneration thus occurs simul- taneously in all the cut fibres of the band, the vascular supply of this tract of tissue has not been altered. Since the blood in the diseased area is not utilised by the nerve-tissues proper, except to a very small extent, a large excess of nutriment is placed at the disposal of the neu- roglia, and this undergoes a well-marked hyper- plasia. Thus a band of tissue-change is pro- duced in which some of tho characteristics of softening are blended with those pertaining to a patch of sclerosis. In brief, we have effects resulting from a primary fatty degeneration of the nerve-fibres, and a secondary hyperplasia of the neuroglia ; and from first to last there is not the least reason for believing in the existence of an inflammatory process. (4) If we turn now to ‘ sclerosis ’ of the cord of primary origin, we again meet with processes which are commonly regarded and described as forms of ‘ chronic myelitis' This nomenclature is objectionable as applied to the processes in the spinal cord, just as it is in its application to like processes occurring in other organs, as the liver, the lungs, or the kidneys. Fibroid over- growth, which forms the basis of so many ex- amples of ‘cirrhosis ’or ‘sclerosis’ in different organs and tissues of the body, is a process pa- thologically intermediate between inflammation, on the one hand, and degeneration on the other. Thus, what were formerly named ‘interstitial inflammations,’ are now the ‘non-inflammatory hyperplasias’ of some pathologists, and tho ‘ fibroid degenerations ’ of others. It would seem that the view as to the inflammatory nature of such processes is erroneous, if we look either to what is known concerning their modes of ini- tiation, or to the actual nature of the changes themselves (which agree in every particular with those of infiltrating new growths) ; it would seem, moreover, not less erroneous if we look to the clinical history of the affections themselvc -3 in which these scleroses occur. It conveys, therefore, an altogether erroneous implication to speak of such mere fibroid overgrowths as so many instances of ‘ chronic myelitis.’ Thus, it will be seen that the writer attri- butes to inflammation a far more restricted role. in the production of morbid conditions of the spinal cord than is customary. The various forms of so-called ‘chronic myelitis’ he would exclude from that category. lie would do the same for the set of changes known as ‘ secondary- degenerations ’; and also for those which ar e characterised by more or less acute atrophic processes implicating the great ganglion-cells of tho anterior cornua. Of the processes above referred to in order, there remains, therefore, only the class of ‘ soft- enings ’ of the spinal cord. That many of theae 1473 SPIRAL CDltD, SPECIAL DISEASES OF. are of a simply degenerative type (due to dis- turbances of blood-supply), and that, in the great majority of cases, these are the instances iu which ‘ softening’ appears to occur as a pri- mary process, the writer feels assured. On the other hand, it seems clear that in many cases changes, truly inflammatory in their origin and progress, may terminate in the production of states of ‘ softening’ of the cord, which are indis- tinguishable by naked eye from the softenings of degenerative type, and which can as yet also be very imperfectly discriminated by the micro- scope. These latter inflammatory softenings very rarely occur as primary pathological states ; they are met with rather as secondary changes. Thus we may get inflammatory softenings spreading (a) around and from wounds or other traumatic lesions of the spinal cord; or (6) starting from some blood-clot or tumour situated in or pressing upon the substance of the cord. It is not by any means clear, however, that all the forms of softening which arise in the latter manner should be regarded as of an inflamma- tory nature ; and much room for doubt also exists as to the real pathogenesis of many cases of so- called ‘ compression myelitis ’ (p. 1471). Another cause of true inflammatory changes in the spinal cord ( myelitis peripherica) is to be found (c) in spinal leptomeningitis ( see Me- ninges, Spinau, Diseases of ; Leptomeningitis). Suppuration is clearly a process of inflam- matory origin, and might therefore be expected to occur occasionally in the midst of ‘ soften- ings ’ which result from inflammation. In the light of what has been said above, the follow- ing statement by Erb is of considerable in- terest. * Actual suppuration occurs very rarely,’ he says, ‘ in acute myelitis. When abscess of the cord does form, it is generally secondary to a severe traumatic lesion or to suppurative menin- gitis. In spontaneous myelitis, on the other hand, suppuration is exceedingly rare, and has only been observed in a very few cases.’ Thus suppuration is met with just in those forms of softening (‘myelitis’) which are undoubtedly of inflammatory origin ; and, on the other hand, it is not met with in the ordinary cases of primary or spontaneous softening, here assumed to be of non-inflammatory nature. In instances other than those above men- tioned, suppuration rarely occurs in the spinal cord. Small disseminated abscesses may, how- ever, be found in pyeemic cases, as they are in the brain and in other organs. One other condition requires to be referred to here, and that is the so-called acute central Tiiyelitis, described originally by Albers, and after- wards studied by Hayem (see Archives de Physio- logic, 1874, p. 603). These are cases in which apparently spontaneous ‘ softening ’is met with, implicating in the main the central grey matter, and that often through a considerable extent of the cord. At times, however, the softening ex- tends beyond the grey matter, so as to involve more or less of the surrounding white substance, when it has been termed myelitis diffusa. Con- siderable obscurity still prevails in regard to the setiology of these affections. In some cases, such a change has been met with as part of an infective process, in which minute vessels in the grei matter of the cord have been found obstructed with micrococci. Occasionally, moreover, in certain at present imperfectly known condi- tions, minute thromboses may, as Dr. J. Hamil- ton has shown, occur throughout the spinal cord, and more especially in its grey matter, and thus lead on in the main to the production of a central softening (see British and Foreign Review, April 1876, p. 447). In this latter case, the patient was suffering from pyelitis, and it is supposed that there may have been some blood-poisoning. Still it was not ascertained that the multitudes of minute thrombi were either associated with or caused by micrococci in the vessels. It appears probable, however, that if from any cause minute widespread obstructions of small vessels occur in the spinal cord, soft- ening would take place principally in the grey matter, owing to its greater vascularity. IV e should thus get that particular distribution of this change which is met with principally in cases of so-called ‘ acute central ’ or ‘ diffuse myelitis.’ A careful study of the two cases of this disease recorded by Hayem has by no means sufficed to convince the writer that they ought to be regarded as having had an inflammatory origin. Neither the symptoms nor the mode of onset of the disease lend any distinct support to this view; nor do the results of the elaborate examination, to which the spinal cords were submitted by this accomplished observer, at all satisfy the writer that the pathological condi- tions mot with were inflammatory either at their commencement or in their subsequent progress. See Spinal Cord, Softening of. Symptoms, Course, and Terminations.— From what has been said it will be seen that true inflammatory conditions of the cord are only with extreme rarity of primary origin, and that they occur, for the most part, as secondary complica- tions in association (a) with wounds or injuries of the cord ; ( b ) with foreign bodies in its sub- stance ; or (c) with spinal leptomeningitis, either simple or tubercular. The supervention of a real myelitis in the course of either of these diseases of the spinal cord would perhaps be associated with an exaggera- tion of the already existing febrile condition; with an increase in the amount of paralysis, and in the degree of interference with sensibility: possibly also with more pain, restlessness, and spasms. Myelitis may become associated with more or less of distinct suppuration, and almost certainly goes on to the formation of well-marked foci of softening. These may remain limited in site, but occasionally they have a distinct tendency to spread above and below the original seat of injury or disease. Such depots would probably undergo subsequent changes, very similar in kind to those prone to occur in foci of non-inflamma- tory softening. Diagnosis. — All that can be said under this head has been referred to above in connection with the symptoms characterising the superven- tion of myelitis. Prognosis. — The gravity of any wound or lesion of the spinal cord, or attaching to the presence in it of blood-clot or tumour, is, of course, greatly SPINAL COED, SPECIAL DISEASES OF. 1477 Increased by the supervention of inflammatory changes about their immediate confines. Again.; the fact that an inflammation of the spinal me- ninges is complicated with similar changes in the substance of the spinal cord itself, cannot fail greatly to aggravate a case of simple spinal lep- tomeningitis. For, even should recovery from the acute affection take place, the actual degree of abiding paralysis, ataxy, or impairment of sen- sibility would much depend upon the degree in which the substance of the spinal cord had been itself implicated. Treatment. — The amount of power that we possess in controlling an inflammatory condition of the spinal cord is probably not great. Little '.{ anything is at present to be done with mere drugs. The patient should, if possible, lie in -he prone position, or, failing this, on his side, with absolute rest. The advisability of abstract- ing blood locally by cupping or leeches should be entertained, and must depend much upon the amount of local pain or tenderness. In some cases it seems to be of service. Or we may trust rather to the application of cold externally, in the form of ice-bags, along the spine. At the same time the patient should be kept upon spoon diet, with a sparing amount of stimulants ; and the bowels should be relieved by the aid of copious warm enemata, which may also act usefully as de- rivatives. The limitations circumscribing our efforts at direct therapeutics must be compen- sated as far as possible by attention to the state of the general health, and by the most careful and assiduous nursing, in the hope that the morbid process may after a time abate, and that, in the absence of collateral complications, the patient may make a more or less complete recovery’. 8. Spinal Cord, Heemorrliage into. — S y- non. : Hamatomydia ; Hcematorrhagia Medulla spinalis; Spinal Apoplexy ; Fr . Hematomyelie; Apoplexie de la Mcelle Epiniere ; Bes hemorrka- gics intrarachid iennes ; Ger. Riickenmarksapo- plcxie; Spinalapnplexie. .ZEtiology and Anatomical Characters. — Haemorrhage into this organ is a comparatively rare event. It occurs under three different con- ditions, namely — (1) as a result of concussion or violence; (2) as a secondary event, consequent upon a definite pre-existing morbid condition ; and (3) as a primary event, or local pathological accident. We are here specially concerned with haemor- rhages into the spinal cord belonging to the third of these categories, and may in a few words dis- miss the other two. (1) Traumatic haemorrhages, small in extent, may, as already stated, occur in almost any region or part of the cord as a result of some severe concussion (see Spinal Cord, Concussion of). Again it may occur in the grey matter, and even in the white substance to a smaller extent, close to and as an appanage of wounds of the cord. In each of these cases symptoms due to the hsemorrliage itself would probably bo ob- scured by the general set of symptoms resulting from the concussion or injury’. (2) Secondary haemorrhages are, however, more closely connected, from the point of view of symptomatology, with those forming the special subject of this article. During the growth of cer- tain soft tumours in the cord, a rupture of some of their vessels may take place, so as to cause haemorrhage either into the growth itself, or else into contiguous regions of the cord. Such an event would be signalised clinically by the sud- den exacerbation of the symptoms previously existing. But a combination of greater import- ance, though one of considerable obscurity, con- sists in the co-existence of a ‘ central my’elitis ’ of the grey matter of the cord through more or less of its extent, together with a central haemorrhage of nearly similar extent. The existence of any such ‘central myelitis’ as an independent dis- ease of the cord seems to the writer very doubt- ful. It is at least equally probable that the haemorrhage has been primary, and that the ‘myelitis’ or softening is of secondary origin around the blood-clot. It need not be denied, of course, that in other cases haemorrhage does occur occasionally into the midst of a focus of softened tissue in the spinal cord, just as it occurs occasionally under similar conditions in the midst of softened brain-tissue. (3) Primary haemorrhages differ as regards the amount, the site, and the distribution of the blood effused, in different cases. In connection with scorbutic states, and also independently of these, small haemorrhages may occasionally occur into the substance of the cord, without pro- ducing any distinct symptoms. But, at other times, a comparatively large quantity of blood may be effused into the cord, and then it occurs almost invariably into the central regions of the grey matter, through which it may extend for a variable distance. When the quantity is smaller, the blood may be effused into the grey matter of one side only. Though this kind of haemorrhage is, in con- tradistinction to the others, spoken of as primary, yet it is almost invariably preceded by some pathological changes in the vessels of the cord. These constitute the predisposing conditions, and the actual rupture takes place, rarely, when the person is at rest, or, more frequently, under the influence of some distinct exciting cause — such as muscular exertion of one kind or another. Primary haemorrhage, though rare, is most prone to occur in persons between the ages of twenty and forty, and not with increasing fre- quency as age advances. This constitutes a further notable difference between haemorrhages into the brain and those of the spinal cord. Symptoms. — These are necessarily subject to great variations, according as the haemorrhage takes place into the cervical, the dorsal, or the lumbar region. The kind of variation thus in- duced may be gathered by reference to the Intro- duction, § 11. Here it is of importance to set forth the pe- culiarities (both as regards mode of onset, and nature of the symptoms) which belong to haemor- rhage as compared with other pathological con- ditions of the cord. First, its tendency is to take place suddenly and without warning; and, se- condly, for the blood to be effused into the grey matter for some distance, thus giving rise to a characteristic grouping of symptoms. There may, therefore, be a sudden onset of pain in the back (possibly severe); followed almost immediately SPINAL CORD, SPECIAL DISEASES OF. 1478 by complete motor and sensory paralysis of the legs and trunk up to a certain level, together with complete paralysis of the bladder and rec- tum. At first there may be an abolition of all reflexes, and possibly a lowering of temperature in the legs; though after a day or two — should the injury be in the dorsal or lower cervical region of the cord — there may be increased heat of legs, owing to vaso-motor paralysis, and a return with some exaggeration of various re- flexes. Rapid atrophy, with the appearance of the electrical ‘reaction of degeneration,’ occurs in all muscles that are in immediate functional relations with the portions of the cord damaged. Cystitis, together with sloughing bed-sores and all their consequences, tend to occur early, and that often in spite of all precautions that may be taken. Where the haemorrhage invades pretty fully, but is limited to, the grey matter of one half of the cord, we may have groups of symptoms that take the form of hemiplegia spinalis or hemi- paraplegia. See (2) Spinal Cord, Punctured or Gun-shot Wounds of. Diagnosis. — -The absolutely sudden onset of the paralysis, which may be complete in the lower extremities in tho course of a fewminutes ; (especially when associated with a sudden pain- ful sensation in the back, or one which radiates into the limbs); as well as the almost complete and sudden loss of sensibility in the paralysed parts, form a group of symptoms which are typically distinctive of hsemorrhage into the grey matter of the cord. The condition most likely to be confounded with it is a large hemorrhage outside the dura mater, causing compression of the cord. Here tho onset would also be sudden, but almost in- variably associated with some mechanical injury or shock. The paralysis of motion too would gene- rally be much more marked than the interference with sensibility. The subsequent progress of such a case would further tend to separate it from a case of intra-medullary haemorrhage, since (even with a severe meningeal haemorrhage in the cervical region) if the patient should sur- vive the first effects of the lesion, the symptoms might be expected soon to grow less aud less urgent, and recovery may be more or less com- plete. No such amelioration is, however, to be expected in the case of a well-marked haemor- rhage into the grey matter of the cord, in the cervical region or elsewhere. On the side of the brain embolism is capable of initiating paralytic symptoms with as much suddenness as a haemorrhage, but in the spinal cord, for reasons previously stated, this does not occur (see Introduction, § 6 (8)). It does, however, happen occasionally that a process of softening— probably caused by throm- bosis — has its occasioning conditions initiated suddenly. When this occurs paraplegia sets in almost as abruptly as if it were occasioned by haemorrhage ; but then it is usually an incom- plete paraplegia, and, for a time at least, unac- companied by loss of sensibility. In the course of a few days, in such a case, sensory paralysis may supervene, and the motor paralysis may become more complete. In the exceptional cases of paraplegia of sudden onset due to this cause, there is generally no initial pain in the back, though there may be pains and burning sensa- tions in the limbs. Phognosis. — Where the haemorrhage is at all large, so as to extend through the grey matter for the distance of an inch or more, the prognosis is always grave. Very few of such cases recover. They are, in fact, liable to be aggravated by the establishment of a secondary process of softening in the grey matter, which may slowly extend both above and below the blood-clot as well as around it. Should this softening reach far into the cervical region, or should the haemorrhage itself implicate this part of the cord, the patient may not survive more than a few days. But if the primary and secondary pathological changes are limited to the lumbar or to the dorsal region of the spinal cord, the fatal event is usually brought about more slowly, after an interval of weeks or perhaps even of months — and then commonly from the occurrence of sloughing bed-sores, together with cystitis and other accompaniments of a severe paraplegia. In the case of small haemorrhages limited to some fractional part of the transverse area of the cord, and of slight longitudinal extent, the prognosis is of course much more favourable, and there is no reason why partial recovery, at least, may not occur. Treatment. — In the treatment of a case of spinal hsemorrhage, should the patient be seen immediately after its occurrence, absolute quie- tude, with rest in the recumbent or prone pos- ture, should be ensured. Bleeding, either local or general, is useless. Purgatives also are contra-indicated. Should the pulse be full, and the heart’s action excited, decided benefit may be derived from ten-minim doses of tincture of digitalis, in com- bination with 15 or 20 grains of bromide of potas- sium, given for the first three doses at intervals of three or four hours, and subsequently every six or eight hours for two or three days. These drugs will also favour sleep, and exercise a gene- ral calmative influence. Position and rest are perhaps the means to be principally relied upon to prevent a recurrence or continuance of the haemorrhage; such mea- sures may be supplemented by warm applica- tions to the feet and calves of the legs; though the patient should in other respects be kept perfectly cool. Ice to the spine may be applied, but is of doubtful utility. Spoon diet should be strictly enjoined for a few days at least. The patient's urine will require to be drawn off by catheter, and extra precautions ought to bo taken to ensure its antiseptic cleanliness. After a day or two, if the bowels have not been moved, a laxative should be administered, since, as in many other forms of paraplegia, there may, at first, be obstinate constipation rather than incon- tinence of faeces. Subsequently, the case requires to be treated in all respects like any other very bad case of paraplegia — extra precautions being observed throughout, in order, as far as possible, to guard against the onset of bed-sores and cystitis. Fuller details concerning such treatment will be found under the next article, Spinal Cord, Softening of, since this is by far the most common cause of paraplegia. tiFlNAL. UOKD. SPECIAL. DISEASES OF. 9. Spinal Cord, Softening of. — Synon. : Non-inflammatory, white, or simple softening; Myelomalacia-, Mollitics Medulla spinalis; Acute Myelitis (in part); Compression Myelitis (in part) ; Fr. Ramollissement de la Moclle Epmiere ; Uer. Erweichung des Riickemnarks. Nature of Change. — The writer has already intimated ( see Myelitis) his opinion that far too large a share is assigned to inflammation in the pathogenesis of diseases of the spinal cord. This mistake is particularly obvious in regard to acute inflammations. It has long been the fashion to speak of almost every focus of ‘softening’ that occurs in the spinal cord as being the result of an ‘ acute myelitis ’ ; and we find even Erb (in Z-iemssen's Cyclopedia, vol. xiii.) putting for- ward, as characteristics of an inflammatory soft- ening, peculiarities which certainly ought not to be regarded in such a light — and this although he seems otherwise strongly inclined to hold a similar opinion to that above expressed. Whilst admitting that a true myelitis is not distinguish- able macroscopieally, in the great majority of cases, from a simple or non-inflammatory soften- ing, Erb adds a statement to the effect that the 1 microscopical examination can alone furnish con- clusive evidence.’ Jn the opinion of the writer, however, such evidence as that which is cited by Erb (foe. cit. p. 470) is quite inconclusive. It is evident, indeed, that we are still almost as destitute of microscopical as we are of macro- scopical characters, of a trustworthy description, for enabling us to decide whether any given focus of softening has been of inflammatory or of simple Don-inflammatory origin. Such re- searches as those of Hamilton {Quart. Joarn. of Micros. Science, Oct. 1375) and others must be prosecuted further and multiplied before any certain means of deciding such a question will exist. In the present state of knowledge, therefore, it would appear that the ‘ non-inflammatory softenings ’ of the cord are represented by the primary and apparently idiopathic ‘softenings’ which frequently occur in this organ. ^Etiology and .Pathogenesis. — Concerning the setiology of non-inflammatory softening of the spinal cord, it is impossible to speak posi- tively. The disease presents itself as a spon- taneous or idiopathic affection, sometimes with- out apparent cause or definite antecedent condi- tions of any kind, but at others as a sequence of one or other of various known and common ante- cedent conditions. Thus in certain cases the symptoms set in more or less suddenly after some great bodily fatigue; in others after extreme sexual ex- cesses ; or they may occur during the period of convalescence from certain acute fevers, such as variola, typhus, and other exanthemata, or after rheumatic fever. During the first week or two after childbirth there is likewise a liability to such symptoms ; and also in the later stages of syphilis. These different conditions may act very variously in contributing to bring about a focus of softening in the spinal cord, and nothing more than conjectures can be advanced in regard to its pathogenesis in the several cases. Again, the symptoms indicative of a primary softening of the cord may set in after the action 1479 of other conditions, regarded by some as excit- ing rather than as predisposing causes. Of these the following may be enumerated; — Prolonged exposure to cold and wet ; sudden suppression ol the menses or of other accustomed fluxes ; vio- lent emotional disturbances; or the existence ot some inflammation in one or other of the pelvic organs, such as the uterus or the bladder and urethra (instances of the latter class being some of the cases formerly supposed to be of ‘ reflex ' origin). In regard to these ‘ exciting causes,’ all that is certainly known is, that softening of the cord seems to set in not unfrequently in persons who have been subjected to one or other of them ; but in what precise mode either of them is related to the subsequent softening, nothing very definite can be said. Something, nevertheless, may be advanced by way of suggestion — with the view more especially of giving some direc- tion to the investigations needful for clearing up this subject. Spinal and cerebral softenings probably own a similar mode of origin. Of the obstructions of vessels which so largely determine cerebral non-inflammatory softenings, it is those due to thrombosis rather than to embolism which inter- vene in the main for the production of corre- sponding conditions in the spinal cord {see In- troduction, § 6, (8) and (9)). It is well known that the causes of thrombosis are principally three, and that in different cases, now one now another of them may be most in- fluential ; whilst in other instances two or more of these causes may co-operate. These three causes are (a) thickenings, irregularities, or de- generations of the inner coats of the vessels ; (5) slowness of blood-current ; (c) peculiarities in the chemical composition of the blood, rendering it more than usually prone to coagulate. The thrombosis may take place in the arteries or in the veins, and the plexiform arrangement of the spinal vessels which oxists, together with the slowness of their blood-current, may favour the occurrence, as well as the spread of the process when it has once been initiated. Thus a process of coagulation, beginning, perhaps, in some very small vessel, may gradually extend so as to involve larger and larger branches, and thereby increase the area of the cord which is deprived of its proper blood-supply. And it is especially worthy of note, in this connection, that the blood-supply of the lower end of the cord (where primary softenings are most common) is peculiar and easily interfered with. To this important point Dr. Moxon has recently called attention {Brit. Med. Jour. vol. i., 1881). In short, the ana- tomical conditions existing in the cord, both on the arterial and on the venous side of its circula- tion, are probably of a kind distinctly to favour the occurrence of thrombosis ; and, if there were space for it, we might attempt to show some- thing as to the respective modes of action of the very different exciting and predisposing causes which have been previously enumerated, as seem- ing to be in relation with primary softening of this part of the nervous system. Anatomical Characters.- — In regard to their distribution or extent in the cord many varieties of softening exist. These have beon commonly recognised, though they have been mostly de SPINAL COED, SPECIAL DISEASES OF. 1480 scribed under corresponding designations as so many varieties of ‘ myelitis.’ Thus, we may have a ‘ complete transverse softening,’ involving the entire thickness of the cord for a variable longitudinal extent, either in the lumbar, the dorsal, or in the cervical region. Or the softening may be more limited to certain subdivisions of the cord in one or other of these regions — and then constitute an ‘ incomplete transverse soften- ing.’ Thus it may, in one set of cases, princi- pally affect the anterior columns and grey mat- ter ; in another set the posterior columns and more or less of the grey matter. Or the soften- ing may be central, and almost confined to the grey matter through a considerable extent of the cord, as in ‘diffuse central softening;’ when this change involves the white columns as well as the grey matter for a considerable extent, we have what, is called ‘diffuse softening’ of the cord. When a small focus of softening exists which only involves part of the transverse area of the cord, and that for a very limited extent, we have a ‘ circumscribed softening’ of the cord ; and where many of these small foci are scattered through different parts and regions of the organ, wo havo what is known as ‘ disseminated soften- ing.’ An accidental damage during the opening of the spinal canal must not be confounded with the results of pathological change. In a spinal cord bruised in the manner indicated the nerve- substance may be softened and diffluent, and somewhat rescmblo a patch of real pathologi- cal softening. Examination with the microscope, however, would show, amongst the fragments of myeline from the broken nerve-tubules in the former case, an entire absence of the large granulation-corpuscles, which are, on the con- trary, invariably present in a patch of real pathological softening. If there were, after such an examination, still room for doubt, this might be resolved by the fact that the softened nerve- matter in a patch of real softening of the cord, has its specific gravity lower by 3-5 degrees than that of other healthy portions of the organ, whilst iu the patch of merely bruised nerve- substance it would not be appreciably lower than normal. The normal specific gravity of the spinal cord varies commonly from 1033— 1041 in different individuals — the higher figures being most frequently met with in elderly per- sons. The modes of estimating the specific gravity have been discussed by the writer in Journ.of Ment. Science, vol. xi. 1866. Where the process of softening has gone on to its final stages — in a case, for instance, of ‘com- plete transverse softening’ — the whole substance of the cord in the affected site is reduced to a rather dirty-looking milky fluid, which, when the membranes are cut across, flows out so as to leave a complete gap in the cord-substance for an extent, it may be, of one to three inches. Symptoms, Course, and Terminations. — The symptomatology of this disease presents an ex- tremely wide range, i n accordance with the vary- inff extent and sites of the softening in the cord, as existing in different patients. In ‘circumscribed’ and ‘ disseminated soften- ing,’ for instance, the symptomatology would be excessively variable in different patients, and, especially in the latter class of eases, it might be extremely difficult to arrive at a diagnosis. The symptoms could, in fact, only be interpreted by the light of the general principles applicable to the regional and pathological diagnosis. Again, incases of ‘diffuse central softening’ the symptoms — except for the fact that they set in gradually rather than abruptly — would bear a close resemblance to those of haemorrhage into the spinal cord, where the blood is effused into the central grey matter for a certain extent (see No. 8, Spinal Cord, Haemorrhage into). There is some doubt, indeed, whether these latter cases may not occur principally as epipheno- mena sequential to a primary central softening. The symptomatology of ‘ incomplete transverse softenings’ of the cord, is for the most part ex- emplified by the second stages of various forms of so-called ‘ compression myelitis ’ — cases, that is, in which the anterior regions of the cord more especially are, in one set of cases, principally pressed upon either by tumour, or by the inflam- matory products associated with vertebral caries (‘ Pott's Disease ’) ; whilst in another set the pos- terior columns and posterior grey matter may undergo a similar softening, under the influence of the pressure of a new growth impinging upon the cord from behind. Cases of this type, how- ever, may easily and do often merge into ‘ com- plete transverse softening ’ (commonly known as ‘complete transverse myelitis ’). Both complete and incomplete forms also often occur in the cord, quite independently of pressure. Of these states it 'will be well, for the sake of brevity, to confine our attention principally to ‘complete transverse softening.' In a case of complete transverse softening in- volving the mid-dorsal region, the temperature in the axilla usually varies between 98° and 100°F., though with an extension of the pathologi- cal process, or towards the close of the disease, it may rise to 101°, 102°, or even higher. Mean- while the lower extremities themselves are often distinctly cold to the hand — the temperature being in some cases more or less subnormal. It is important to note this, because it might have been supposed that hyperaemia and a slightly elevated temperature would exist, owing to the vaso-motor nerves of the limbs being paralysed. The motor paralysis of the lower extremities is absolute, and the abdominal muscles are also powerless. The feet, as the patient lies in bed, are extended and often inverted, so that the great toes cross one another. The skin after a time tends t.o become dry and scurfy. The muscles feel flabby to the hand, but they waste only to a slight extent, and continue week after week to show only a small amount, if any, of diminution in the degree of their irritability to faradaic and to galvanic currents. The sensibility of the limbs is completely abo- lished both for tactile and painful impressions, as u r ell as for differences of temperature and tick- ling. A like abolition of sensibility exists over the trunk up to the level of the ‘ ensiform area ’ whilst above this level the sensibility becomes quite natural. Though the upper limit of anaes- thesia may be quite sharply defined, yet in these cases of complete transverse softening there if often no distinct ‘ girdle-sensation.’ SPINAL COED, SPECIAL DISEASES OF. The muscles of the lower extremities may show some slight irritability when they are for- cibly tapped, and when the soles of the feet are strongly tickled there may he very slight move- ments of the toes ; but beyond this there is often an entire absence of all reflex movements — there is no ankle-clonus, no knee-reflex, and a similar absence of the cremasteric and abdominal re- flexes. 1 In the initial stages of the affection, however, and especially when the softening is not completely transverse, all these reflexes may be extremely well-marked fora time, though they tend gradually to diminish. For the first ten days or a fortnight there is often complete retention of urine, but after this time, when the lumbar region of the cord again becomes capable of manifesting to some extent its centric functions, the initial retention gives place to incontinence of urine. This fluid may be discharged at intervals of two to three hours in small quantities, owing to the occurrence of reflex contractions of the bladder whenever it attains a certain degree of fulness. The passage of a catheter, however, in these cases will often show that the bladder is never completely emptied — two to four ounces remaining after the reflex contractions. Unless special precautions are taken, the urine, in such patients, speedily becomes am- moniacal, and more or less loaded with mucus. The bowels are usually constipated, and re- lieved only after the administration of aperients or enemata. At these times there is generally incontinence of faeces — the patient having no power of controlling the reflex actions concerned in defecation when they have once been strongly excited. The actual passage of the motion is moreover often unfelt. Under the irritative influences emanating from the seat of softening during the period of its establishment, a small bed-sore may begin to form, often amenable to treatment. Later on, sloughs are apt to form upon the heels, over the malleoli, and in other situations habitually ex- posed to continuous pressure. But the most fre- quent site for intractable sloughing bed-sores is over the sacrum. Inflammation of the mucous membrane of the bladder is at last set up ; and the inflammation may extend up one or both ureters, so as to implicate the pelvis of the kid- ney, when minute abscesses may also form in the kidney itself. Under the influence of these various conditions the patient’s appetite and strength gradually fail ; emaciation proceeds ; and death after a time may come from sheer exhaustion, aided, perhaps, by some intercurrent inflammatory affection of the lungs. Other modes of death are pointed out in the section on Prognosis. Diagnosis. — The recognition of this disease at the bedside often presents considerable difficul- 1 In one recent case in which paraplegia had existed for over three months, in consequence of a complete trans- verse softening in the upper dorsal region (with the above-mentioned clinical signs), the writer was much struck with the extremely pallid appearance of the grey matter through the whole length of the cord below the seat of softening. The absence of the reflexes maybe in part due to such condition of the grey matter, and this itse'f may be caused by a spasm of its vessels in some u ay induced by the lesion above. Some amount of spasm may also exist in the vessels of the limbs, whose tempera- lure Is often rather sub-normal. 1481 ties. We must be guided partly (a) by the patient's history and state ; partly ( b ) by the mode of onset of the disease ; and partly (c) by the symptoms of the fully established affection. (a) The points in regard to previous history which are of principal significance are referred to under the head of lEtiology. In regard to (i) mode of onset, this is usually not abrupt and sudden ; there is rather a slow increase of para- lysis during a week, ten days, or a fortnight. Still, it is a fact that softening of the cord (ap- parently due to thrombosis) does occasionally cause a sudden incomplete paralysis, though such paralysis increases subsequently in the manner above stated. Such a case must not therefore be confounded with haemorrhage into the cord, merely by reason of its absolutely abrupt onset. The extent to which the diagnosis turns upon ( c ) the nature of the symptoms of the fully-estab- lished affection, cannot be very definitely defined except in some cases. When the softening is slight and partial, it gives rise to no distinctive symptoms; hut where there are clinical signs cf the existence of a complete transverse lesion, the chances are that the lesion itself is, if not a pri- mary, at all events a secondary softening. In regard to the regional diagnosis of soften- ing of the spinal cord, the following points require to he borne in mind : — The indications as to the transverse area in- volved, and as to the upper limits of the change in the spinal cord, are wholly derivable from the presence or absence of the various signs and symptoms which have been set forth in the Introduction, § 8, (a), and § 11. The attempt to ascertain the lower level of the lesion, and consequently its longitudinal extent in the cord, is always difficult, and often cannot he achieved with any success. The indications are all obscure, uncertain, and apt to fail. This is especially the case if we attempt to base an opinion on the fact of the existence or absence of superficial reflexes (see § 5, (ft) ). Thus, complete transverse softening may exist in the upper dor- sal region, and extensive secondary degenera- tions may have been produced, yet for week after week there may he a complete absence of all the reflexes (superficial and deep) dependent upon the cord below the upper dorsal region. This the writer has lately ascertained by re- peated clinical examinations of cases whose na- ture has been subsequently verified post mortem. Pbognosis.— T he prognosis in a case of para- plegia must always involve a twofold problem: — (1) as to the duration of paralysis, or the pro- bability of recovery ; (2) as to the danger to life. (1) The chance of ultimate recovery from para- lysis would vary inversely with the size or extent of the lesion existing after the first ten days or a fortnight — that is, by the time soften- ing has been unmistakably established, and when the chance of such an event being warded off by the establishment of a collateral circulation no longer exists. But where a reinstatement cf blood-supply does take place, all symptoms of paralysis may gradually disappear in the course of some weeks, or, it may he, months. (2) Danger to life is brought about in many ways, and a fatal result may be entailed (a) by a gradual extension upwards of Ihe process of 1482 SPINAL COItD. SPECIAL DISEASES OF. Boftening (especially where it exists in the lower cervical or upper dorsal region) so as to involve paralysis of the diaphragm, or an extreme inter- ference with the heart’s action. ( b ) Inflamma- tion of the bladder, followed by implication of other portions of the urinary tract, may lead on to death after the paralysis has lasted for some months, (c) About the same period extensive bed-sores may form, and the patient may, after a time, die exhausted, or from blood-poisoning, (i d ) The supervention of an intercurrent pneu- monia may lead on to a fatal result ; or (e) the end may come from the extension inwards of the process of sloughing, so as to lead to the esta- blishment of a rapidly fatal spinal meningitis. Still, in some cases the patient may remain paralysed for a very long time before a fatal ter- mination is brought about. Treatment. — Our power to deal with the soft- ened condition itself of the spinal cord is ex- tremely small, whether it may have been caused by thrombosis or by compression. Luring the early stages probably the less that is done in the way of active interference the better. The prin- cipal indications are that the patient should have absolute rest in bed, and for the first few days at least a rather sparing diet ; spoon diet being de- sirable where distinct elevation of temperature exists. The secretions should be regulated, and the urine, if necessary, drawn off by a thoroughly clean catheter smeared with carbolised oil. Seda- tives, such as bromide of potassium, either alone or in combination with chloral, may be needed at night, for a time, so as to ensure sound and re- freshing sleep. Should the patient’s general health be weak or deranged, as is so often the case, every effort must be made to improve it by means of an easily assimilated but generous diet, gradually increased, and by the exhibition of suitable tonics, with or without small doses of cod-liver oil. It is far better to trust to such general means than to the supposed influence of phosphorus, or any other drug. To expect any of them to have a direct influence in restoring softened nerve-tissue is vain; and any good that may be achieved by drugs alone is probably brought about either by their power of regulating some of the principal functions of the body, or by improving its nutri- tive processes generally. Still scarcely any morbid condition exists in which more constant care and vigilance are needed than in the paraplegic stale, in order to correct or ward off its numerous incidental troubles or complications. One of the first points claiming attention in the early stages of a case of paraplegia is to take such measures as will stave off the occurrence of bed-sores as long as possible. These precautions are especially needful where the paraplegia is complete, and. where loss of sensibility exists. The patient should at an early stage of the dis- ease be placed upon a water-bed ; and those forms are most suitable in which there is a canal through the centre for the passage down- wards of the evacuations. The patient must be kept scrupulously clean and dry ; and no folds of the bed-clothes must be permited to piress against the skin. If possible, the patient should aot l>e allowed to lie habitually upon his back, but occasionally in a prone or lateral po: it mu The skin over the sacrum especially must be carefully watched, and on the least sign of a patch of undue redness there, it should be rubbed once or twice a day with a mixture of equal parts of olive-oil and spirits' of wine. If it becomes actually abraded it should be dress ed with zinc ointment, smeared over a piece of soft lint. For the first fortnight or more there may be complete retention of urine, which then requires to be drawn off night and morning by catheter. Luring this period great care should be taken in regard to the cleanliness of the catheter em- ployed, and only instruments which have been smeared with carbolised oil should be used. Care- lessness in this respect will tend to bring on cys- titis at an early date, with alkalinity of urine, and may thus quite prematurely aggravate the bladder-troubles. As soon as the bladder begins to empty itself again, in a reflex manner, at intervals throughout the day, the use of the catheter may be discontinued, as long as the water which comes away continues to be clear and acid. During this period of incontinence it will be necessary to draw off the urine from time to time for the purposes of examination. As before stated, the bladder never completely empties itself. After this state of things has continued for some weeks, the urine at last gene- rally becomes alkaline, ammoniacal, and more or less mixed with mucus. At this stage the blad- der should again be emptied once or twice daily, and washed out each time with 6 to 8 oz. of quinine solution (2 grains to the ounce, with enough of dilute sulphuric acid to dissolve it); or with a 1-2 per cent, solution of the new drug, ‘ resorcin.’ This will prove the best means of warding off or of mitigating inflammation of the bladder ; and thus perhaps of preventing its extension to the ureters and kidneys. In regard to the bowels, purgatives will pro- bably be required from the first, as without their use there will be no evacuation. Some- times a simple enema will suffice. Scybals tend to accumulate in the large intestine, unless its contractility can be aroused occasionally by a large injection, consisting of three pints of warm thin gruel, together with half an ounce of spirits of turpentine and an ounce of castor oil. Where the disease has reached the chronic stage, and when death is not inevitable, the mus- cles should be faradised or galvanised three times a week, with a view to maintaining their nutrition, and in old and extreme cases of this sort, good results seem occasionally to have been obtained by passing fine needles through the skin into the muscles, and then connecting these needles, one after another, with the negative pole of a voltaic battery of suitable strength, the positive pole being applied at the same time to the back, or to the limb above the transfixed muscle, by means of a damp sponge, in the usual way. This method, recommended especially by Dr. J. E. Morgan, is only suitable where there is also loss of sensibility. When in the final stages of paraplegia large and sloughing bed-sores have formed, they will require the most constant care and attention. Poultices may’ be at first needed till the sloughs 1483 SPINAL COED, SPECIAL DISEASES OF. nave separated, and afterwards the wounds must be variously dressed according to their condition. An ointment composed of ten grains of carbolic acid to one ounce of vaseline may be employed ; or more stimulating applications may be needed. Sometimes the iodide of starch paste forms a suitable dressing. 10. Infantile Paralysis. See Infantile Pa- ralysis. 11. Acute Spinal Paralysis of Adults. — Synon. : Poliomyelitis Anterior Acuta ; Acute Inflammation of the Grey Anterior Horns ; Acute Atrophic Spinal Paralysis ; Fr. Paralysie spinale atrophique aigiie\ Ger. Poliomyelitis Anterior Acuta ; Acute Spinallahmung bci ilrwachscnen. This is essentially the same disease as that known as infantile paralysis (see Infantile Paralysis), though presenting certain differences from the fact of its occurring in adults. Its existence, however, was not distinctly recognised till about the year 1865, when illustrative cases were published almost simultaneously by Du- chenne and Morritz Meyer. Now that observers have been on the look-out for it, it has proved to be one which is by no means uncommon, although it is very much rarer than the similar affection in infancy or early childhood. The disease is more difficult to recognise in adults, because in them other affections occur with which it is quite possible that it may be confounded. aEtiology. — The aetiology of this affection in adults is just as obscure as it is in children. Sometimes it manifests itself without any assign- able cause ; whilst at other times there is the possibility that exposure to wet and cold, some shock or blow, or some antecedent acute febrile illness may have had to do with its origin. Symptoms. — It will principally be necessary in this place to point out the manner in which the group of signs and symptoms characteristic of the disease in infancy becomes modified when it occurs in the adult. The first set of differences is due to the minor irritability of the nervous system in the adult., as compared with that of the young child. The initial febrile symptoms may be so slight as to escape notice ; convulsions have never been met with; and preliminary head-symptoms are gener- ally very slight. Some headache, or mental dulness, may be present ; and vomiting occurs not unfrequently. Paralysis then sets in speedily— it may bo within a few hours — and is more or less wide- spread. The muscles are flaccid ; reflex actions are abolished or greatly diminished. In the course of a few days, generally, improvement as regards motor power sets in, and very slowly pro- gresses. It may go on continuously to complete recovery in the course of a few months; or, as often happens, such recovery is only partial. In the latter case certain muscles or groups of muscles remain paralysed, and in them a rapid atrophy occurs. When tested electrically, these muscles exhibit the ‘ reaction of degeneration.’ The affected parts are cold, and sometimes more or less cyanotic. There is no impairment of sensibility ; and no interference with the func- tions of the bladder or rectum. All the characters mentioned in the last para- graph accord with those which present them- selves in infantile paralysis, but later on differ- ences again show themselves. One of the cha- racteristic features in the child is arrest of growth in the parts affected, so that the limbs or parts of limbs paralysed remain more or less abortive. This, of course, cannot occur in the adult ; and also owing to the fact that the joints are stronger, the secondary deformities (often so serious in the child) are not met with to the same extent in adults. Prognosis.— This is not a disease dangerous to life. Complete recovery not unfrequently takes place, and that too, as tho writer has re- cently seen, where the paralysis may have been widespread, affecting all the limbs for a time, and leading to marked atrophy in the muscles of the lower extremities. In other cases, there is left in particular parts a chronic remainder of paralysis with atrophy, just as we find to be the case in children. Diagnosis. — The mode of origination of the disease; the fact that the paralysis is purely motor, and accompanied by no interference with sensibility ; the fact that after the first few days at least the functions of the bladder and rectum are not interfered with ; and also that in later stages there is atrophy of muscles, and tho exist- ence of the electrical ‘reaction of degeneration’ — these constitute a group of conditions which, taken as a whole, is thoroughly distinctive. The disease with which it is most liable to be confounded is that about to be described, namely, (13) Chronic Atrophic Spinal Paralysis. The points of distinction will, therefore, be given under it. ‘ Progressive muscular atrophy,’ if we bear in mind its very chronic onset, is much less liable to be confounded with the present disease, as also if we recollect that in it atrophy makes its appearance before paralysis rather than after, and that the electrical reactions are notably different. The fact of the absence of spasms, the diminu- tion of reflexes, the non-interference with sensi- bility and with the sphincters, together with the abrupt origin of the disease, suffice to separate the acute spinal paralysis of adults from all other affections of the spinal cord. Treatment. — This disease must be dealt with on precisely the same principles as those which are applicable to the corresponding affection in young children. Kepetition is, therefore, here unnecessary. See Infantile Paralysis. 12. Acute Ascending Paralysis. — Synon.: Paralysis Ascendens Acuta ; Landry's Paralysis ; Fr. Paralysie ascendante aigue ; Ger. Paralysis ascendens acuta. Definition. — A mysterious affection of the spinal cord, first definitely described by Landry in 1859 ; characterised on its clinical side by the existence of a progressive paraly’sis, advancing rapidly from below upwards, so as finally to implicate parts dependent for their innervation upon the medulla oblongata ; characterised also on its anatomical side by the most puzzling absence of any appreciable pathological change. On account of the latter peculiarity, the dis- ease ought not tobedescribed in the presentplace, but rather to constitute the first of Class II. 1484 SPINAL COED, SPECIAL DISEASES OF. But this disease, together ■with ‘ acute spinal paralysis’ and ‘chronic spinal paralysis,’ have such an amount of similarity from a clinical point of view, that it seems very desirable for their descriptions to follow one another, so that mutual alliances as well as differences may be the more distinctly appreciated. -Etiology and Patholoqt. — The causes and pathogenesis of this affection are just as ob- scure as those of the disease last referred tc. Exposure to cold, and emotional disturbances (with or without suppression of menstruation in the female) have been observed occasionally as precursors. Occasionally, too, this disease has supervened during convalescence from some pre- vious acute febrile malady. Syphilis is thought by a few (but on no sufficient evidence) to have something to do with the pathogenesis of this affection. Westphal, again, is inclined to believe in the possibility of some toxic influence — though this also is little more than a mere supposition. The disease seems principally to occur in persons between the ages of twenty and forty, and to be decidedly more frequent in males than in females. Although the brain and spinal cord of those who have died from this affection have now been frequently examined by skilled observers, the results have hitherto been entirely negative, so far as morbid anatomy is concerned. Symptoms, Course, and Terminations. — About the prodromata there is nothing distinc- tive — they may be absent. When present there may, for a few days, or even for a few weeks, be a slight febrile condition from time to time, with a sense of weariness, and more or less numbness in the limbs, especially in the tips of the fingers and in the feet. The disease then more definitely declares itself by a marked weakness of the lower extremities ; soon to be followed by actual paralysis, which, as in the ‘subacute and chronic spinal paralysis,’ shows itself first in the distal portions of the limbs, and gradually approaches the trunk, so that in the course of two or three days the para- lysis of the lower extremities becomes complete. The trunk muscles are next and soon impli- cated in a similar manner. The patient can no longer sit up or turn in bed. Eespiration be- comes more and more affected, and defsecation is interfered with, through weakening of the abdo- minal muscles. Next, though sometimes after a distinct inter- val, the upper extremities become implicated ; though here again the paralysis first involves the distal portions of the extremities, and thence gradually spreads (after a period in which mere paresis exists), till the whole limbs become com- pletely powerless. The paralysed limbs, both upper and lower, are lax, and show no trace of contraction. Though the muscles are flaccid, they do not undergo a marked amount of atrophy, as is the case in ‘ s*mte spinal paralysis.’ In accordance with this latter peculiarity, there is the further striking characteristic that the electrical reactions of nerves and muscles continue perfectly normal. This seems now to be a well- attested fact, and it has been verified by good observers even after complete paralysis (without atrophy) has existed for several weeks. Sensibility is scarcely, if at all affected; nor. as a rule, are pains complained of in the paralyse! parts. The nutrition of the skin is not impaired, 60 that there is no tendency to the formation of bed- sores. Coldness and cyanosis do not seem to bo characteristics of this affection. The sphincters are usually not at all affected. Constipation is often marked, anddefaecationmay be rendered difficult owing to paralysis of the abdominal muscles. In regard to reflex actions, these — especially the skin-reflexes — may not be much affected at first, but may be abolished later on. Existing information is defective concerning ‘ tendon-re- flexes ’ in this affection, and the writer has made no observations on the point himself. As a rule there is no febrile elevation of tem- perature. At the stage above indicated, in nearly one- third of the recorded cases, or it may be even before the arms have become much implicated, the disease becomes arrested, and after a brief interval recovery of power begins to manifest itself — usually in a reverse order, so that power is regained first over the arms, then over the trunk, and subsequently (in the course of several weeks) over the lower extremities. But in the remaining two-thirds of the cases, after the arms have become paralysed, the dis- ease still progresses so as to affect the cervical muscles, the diaphragm, and finally the muscles innervated by the motor nerves of the medulla. Thus, in its later phases the disease is charac- terised by a greatly increasing difficulty in re- spiration; great weakness invoice; extreme ra- pidity of pulse; and possibly by inequality of the pupils. Finally, increasing paralysis of the muscles concerned with articulation and degluti- tion sets in ; and, owing to the augmenting dif- ficulties of respiration, death may arrive at any moment by asphyxia. This climax of the disease may be reached in the course even of three or four days ; on the other hand, it may not be reached until as many weeks have elapsed. Whenever the disease has advanced so far as seriously to implicate the medulla, recoveries are comparatively rare. In quite exceptional cases the disease may pur- sue a reverse order throughout; implicating the nerves of the medulla first, then those of the cervical region of the cord, and so on. The cele- brated Cuvier is said to have died from the dis- ease, progressing in this very unusual manner. Prognosis. — Nothing can be added concern- ing prognosis beyond what has been above indi- cated in speaking of the course and terminations of the disease. It seems the rule that, the more rapid the progress of the disease, and the earlier the medulla is affected, the more is a fatal ter- mination to be feared. Still, even in the most acute cases, improvement may take place. Diagnosis. — So far as the established disease is concerned, we have in this affection, in ‘ acute spinal paralysis of adults.’ and in sub- acute forms of ‘ chronic spinal paralysis ’ mala- dies that present certain well-marked points of similarity. In each we have to do with simple motor paralysis, with no fever, no tenderness or pains in the spine, no pains in the limbs or con- SPINAL COKD. SPECIAL DISEASES OE. 1485 tractions, and with no incontinence of urine or faeces, or tendency to the occurrence of bed-sores. ‘ Acute ascending paralysis’ differs from, both these affections, however, in the important fact that rapid atrophy does not set in in the paralysed muscles, and that the electricial reactions in no way differ from those met with in healthy nerves and muscles. In the very acute cases, of a few days’ duration only, these distinctions would be worthless, as sufficient time would not have elapsed to make it possible for either of them to occur. In such rapid cases, therefore, the distinctly progressive character ot the disease is that which will serve to distinguish it from the more severe cases of ‘acute spinal paralysis,’ in which the paralysis sets in simultaneously throughout the whole of the parts affected, and often with a pretty distinct initial febrile dis- turbance. Then, again, there is the fact that this latter disease has no tendency to involve the medulla, and is only very rarely fatal. It is in the diagnosis of the more slowly evolved forms of ‘ acute ascending paralysis,’ from the similarly progressive eases of ‘chronic spinal paralysis,’ that the development of rapid atrophy of the muscles, together with the ‘ reaction of degeneration ’ comes to be distinctive of the latter affection. Then, again, in ‘acute ascend- ing paralysis,’ there is a longer persistence of reflex actions, and a far greater tendency to the manifestation of symptoms showing that the medulla oblongata is involved. Treatment. — -The absence of any known pathological substratum for this disease makes it extremely difficult to lay down any directions for treatment. It would appear that we have to do with a simple alteration of the molecular condition of the spinal motor nerve-centres, un- accompanied by any known inflammation or irre- gularity of vascular supply. Under these circumstances, the patient should be put upon a nutritious but easily assimilable diet, with a fair amount of stimulants ; and, further, we may endeavour to induce a change in the nutritive and functional activity of the spinal cord, by having recourse to frictions of the skin or gentle shampooing of the limbs, together with brief daily applications of weak faradic currents to many of the affected muscles. From drugs, perhaps the best chance of bene- ficial results may be looked for from combina- tions of iron and arsenic, or from the cautious use of small doses of strychnia. Iodide of potas- sium would probably be useless. Sulphur baths should be had recourse to in the more chronic cases. 13. Chronic Atrophic Spinal Paralysis. ■Synon. : Subacute and Chronic Inflammation of the Grey Anterior Horns ; Poliomyelitis Anterior Subacuta et Chronica-, Fr. Paralysis generals spinale anterieure subaigue ; Ger. Subacute Spi- nallahmung Erwachsener ; Subacute Spinalpara - lysie. Nature, .^Etiology, and Pathology. — This disease was described by Duchenne in 1853, and then again more completely in 1872, as a more or less rapidly advancing motor paralysis, as- sociated with atrophy of the muscles affected, »nd loss of their faradic excitability. He believed the disease to be dependent upon a chronic degeneration occurring in the grey anterior horns, and this view is supported by the few examinations as yet made of persons who have been the subjects of this affection. The pathological changes in the anterior horns have been associated with atrophy of the anterior nerve-roots. The c-auses of the malady are at present almost wholly unknown ; but it occurs princi- pally in individuals between the ages of thirty and fifty years. As with other chronic spinal affections, so here, there has often been one or other of the following events occurring some little time before the onset of the disease : — Exposure to cold and damp, some shock or con- cussion, venereal excesses, or great fatigue in- duced by other causes. But what share the pre-existence of one or other of these conditions may have had in initiating the disease cannot at present be defined. Symptoms. — In the subacute cases, paralysis may become developed (usually in the lower extremities first) in the course of a few days or weeks ; at the same time there may be some very slight initial febrile disturbance, and pos- sibly some shooting pains in the back and limbs. In the more chronic cases, the latter symptoms may be absent, and the onset of paralysis is very much slower. There may be at first mere paresis, felt most in the ankles and knees ; but gradually (often after many months) this deepens into distinct paralysis of certain groups of muscles, or of the entire limbs. The muscles are flabby and progressively waste ; at the same time they cease to respond well or even at all to the faradic current, and become more sensitive to the voltaic. There may also be notable fibrillar twitchings in the muscles undergoing this atrophic process. Sensibility is unaffected. Skin and tendon reflexes are abolished. The temperature of the affected limbs is lowered ; and the feet especially are apt to be cold and cyanotic. Soon the arms become affected in a similar manner, and here the paralysis may first affect either the extensors or the flexors. It may remain more or less limited to certain groups of muscles, or may gradually extend so as to implicate the whole limb. The distal parts are usually, however, more completely involved than the proximal. In the arms the same kind oi phenomena occur as in the lower extremities, and there is a similar absence of rigidities or contractures. There is no tendency to the formation of bed- sores, and the nutrition of the skin seems to be unimpaired. The rectum, the bladder, and the sexual organs are usually quite unaffected. After a time, the excessive reaction of the wasted muscles to the galvanic current decidedly diminishes ; though in the earlier stages of this affection the electrical ‘reaction of degenera- tion ’ exists with all its characteristic details. Prognosis, Course, and Terminations. — In the subacute cases, after a month or two, improvement may gradually begin to manifest itself; and in exceptional instances this may go on slowly, but steadily, to complete recovery. In 1486 SPINAL CORD, SPECIAL DISEASES OF. other of these cases, however, certain muscles or groups of muscles do not undergo the same improvement as the others ; they may continue paralysed, and become more and more atrophied. In the more chronic cases, recovery is scarcely to be looked for ; though after the symptoms have developed to a certain extent, it occasion- ally happens that no further advance is made. Such patients may remain in much the same condition for years. In another class of cases the malady proves more continuously progressive, so that after implicating the upper and lower extremities severely, the morbid process may extend to the tipper cervical region of the cord, so as greatly to interfere with respiration ; or it may even extend to the medulla, so as to involve the tongue and pharyngeal muscles, and more or less interfere with the functions of articulation and deglutition. In such cases death is liable to occur through asphyxia or slowly progressing exhaustion. In the majority of cases of this disease, more or less complete recovery cccurs, though it may be only after two to four years. Diagnosis. — This malady bears a closer resem- blance to the 1 acute spinal paralysis ’ of adults than to any other affection. The two diseases are naturally distinct in their modes of initiation, but as established diseases (that is, in their later phases) they would be very difficult to discrimi- nate from one another in the absence of definite information as to modes of onset— and such in- formation is often not to be obtained. It is the abrupt commencement of the paralysis over a wide area of the body that is met with in, and which is so distinctive of, ‘ acute spinal para- lysis’; whilst in the subacute forms, and more especially in ‘.chronic atrophic spinal paralysis,’ we have to do with a distinctly progressive spread of the disease from part to part. In regard to the discrimination of these sub- acute and chronic forms of spinal paralysis from some other varieties of spinal cord disease, the reader may refer to what has been said concern- ing the grounds on which the diagnosis of ‘ acute spinal paralysis ’ is to be made ( see (11), Acute Spinal Paralysis of Adults). In ‘ amyotrophic lateral sclerosis ’ the upper extremities may be paralysed, wasted, and flaccid as they are in ‘ chronic spinal paralysis ’ ; but then in the former disease there would be the characteristically different combination of para- lysis without wasting, but with more or less rigidity in the lower extremities. For the distinguishing characters of ‘acute ascending paralysis’ see the account of that affection, in the preceding article. Treatment. — Possibly counter-irritation to the spine in the early stages may do good, and should certainly be tried. Local bleeding would probably be useless. A nutritious and easily digestible diet, tonics, and rest are essential in the early stages, together with a thorough super- vision of the general health. Later on, electrical treatment by the voltaic current must be had recourse to, and must be perseveringly continued for long periods, until the muscles again begin to respond to the faradic current. The electrical treatment is what is principally to be relied upon, and except in the subacute cases it may be com- menced almost from the first, should the patient happen to come under observation during the early stage of the malady. Sulphur or brine- baths seem at times to do much good. 14. Progressive Muscular Atrophy. See Progressive Muscular Atrophy. 15. Pseudo-hypertrophic Paralysis. See Pseodo-hypertrophic Muscular Paralysis. 16. Locomotor Ataxy. See Locomotor Ataxy. 17. Spasmodic Spinal Paralysis.— S ynox.: Paralysis spinalis spastica ; Primary Sclerosis of the Lateral Columns ; Idiopathic or Primary Lateral Sclerosis ; Pr. Tabes dorsal spasmodique (Charcot); Ger. Spastische Spinalparalysie ; Pri- m'dre Skleroseder Scitenst range des Ruckcnmarks; Primare Lateralsklerose des Ruckcnmarks. This is one of the most recently-recognised of the diseases of the spinal cord. It was described first by Erb in 1875, and within a few months of the same time in a thorough and indepen- dent manner by Charcot. Although these ob- servers indicated with precision the probable pathology of the disease, they were not able to verify their anticipations by the examination of any patient who had died from (or whilst sutfer- ing from) this complaint. This last step has been recently accomplished in this country by Dr. Dresehfeld. But even before the disease was distinctly de- scribed, its probable existence and principal fea- tures wore in part anticipated by Tiirek and by Charcot — both of them being guided more espe- daily by the clinieal effects produced by ‘ secon- dary degenerations ’ in the lateral columns, as occurring in association with hemiplegia. zEtiology and Pathology. — The disease is distinctly more common in males than in females : it occurs in the majority of cases in adults from twenty to fifty years of age. Erb and others have also described spasmodic forms of paralysis occurring in children, which may possibly be instances of this disease. The writer has' met with it once in a child of about ten years of age, but then the lateral sclerosis seemed onlv to form a prominent part of what was really a ‘ multiple sclerosis ’ of cerebro-spinal type. In some cases the disease appears indepen- dently of any appreciable predisposing or excit- ing causes ; but, in other instances, falls or other traumatic influences seem to be distinctly connected with its origin. On rare occasions exposure to wet and cold has seemed to have had some influence over the. genesis of this, as well as over so many other forms of spinal dis- ease. Anatomical Characters. — In the only un- doubted case which has yet been investigated poll mortem, namely, in that of Dr. Morgan, where the spinal cord was examined by Dr. Dresehfeld ( British Medical Journal, January 29, 1S81, p. 152), the following pathological conditions were observed : — ‘ The cord, when examined in the fresh state, showed to the naked eye no abnormality, except softening in the lowest dor- sal region. After hardening in bichromate of SPINAL CORD, SPECIAL DISEASES OF. 1487 Rmmonia. sections of the cord showed already to the naked eye one light-coloured patch in each lateral column ’ — and this throughout the cervi- cal, the dorsal, and the lumbar regions of the cord. This hand of morbid tissue, presenting all the typical characters of a sclerosis, occupied the greater portion of the lateral columns, hut without implicating the grey matter or extend- ing quite to the surface of the cord. The anterior and the posterior columns were perfectly healthy. The microscopical characters of primary sclerosis in the spinal cord are briefly described in the article on ‘multiple sclerosis.’ See (19) Mul- tiple Sclerosis of the Spinal Cord. The occurrence of the slight softening in this case was an accidental complication, otherwise the lesions actually found agreed very perfectly with Charcot’s scientific predictions as to the probable pathological changes peculiar to this affection of the spinal cord. Symptoms. — This disease often sets in almost imperceptibly, and the symptoms continue to develop themselves in a very slow and gradual manner. Patients begin to complain first of mere weak- ness of the lower extremities, and this continues to increase till a well-marked condition of paresis exists. There is great difficulty in getting up- stairs, and the feet begin to drag even when the patient walks on level ground. This paresis may soon be associated with more or less of muscular twitchings, often more marked in the morning, but sometimes more especially at night, and of a painful character. Soon an actual stiffness of the muscles of the legs begins to manifest itself, which becomes apparent principally when pas- sive movements are attempted, or even when the patient seeks himself to move the limbs. At last some amount of rigidity of muscles may be more or less continuously present, so as greatly to interfere with locomotion, or in some cases even to prevent it altogether. In the early stages of the disease, ankle-clonus can be elicited with the greatest ease, and the knee-jerk is found to be distinctly exaggerated on both sides. When one of these patients is in the sitting posture, commencing pressure on the toes of one foot, as in the act of rising, will at once initiate the characteristic tremors of ankle- clonus. All such signs, however, will probably diminish as the rigidity becomes more marked. Whilst the patient is able to walk he often exhibits a typical ‘ spastic gait.’ The legs are generally kept close together, owing to a spas- modic contraction of the adductors of the thighs; the toes trail or are dragged along the ground ; and then , when the heel is beginning to be brought down, a spasmodic contraction of the calf muscles may take place, tending to raise the patient upon his toes and almost throw him forward. In this way a mixed and very irregular kind of walking is necessitated, partly to be accounted for by mere powerlessness, and partly by the occurrence of strong muscular spasms. In some instances, either owing to variations in the amount of the spasms, or it may be to the great weight of the patient, this spastic walk is not well-marked. In all cases, however, it is quite different from the ataxic gait ; and when standing with feet close together, no increase of unsteadiness or feeling of vertigo is occasioned when the patient closes his eves. Sensibility is little, if at all, affected ; still, in some instances it is apt to be slightly impaired. In one case, at present under the writer’s care, ability to recognise differences of temperature was for a time greatly lessened ; and although tactile sensibility is scarcely at all interfered with, the patient has frequently complained cf a diminished power in appreciating the exact posi- tions of his legs. Skin-reflexes are often nor- mal, but occasionally they may be slightly in- creased. The muscles do not atrophy, and their elec- trical reactions continue to be almost normal ; whilst, according to Erb, that of the nerves is slightly but distinctly lowered to both currents. Sexual desires are not affected, but sexual dis- ability may be occasioned to a variable extent — partly owing to weakness or actual paralysis, and partly to mere spasms of muscles. Micturi- tion is often scarcely at all interfered with ; there is nothing like incontinence of urine or of faeces, though there may be an obstinate amount of constipation. No vaso-motor or trophic disturbances in the limbs are usually present. As the disease progresses (it may be very slowly, and in the course of years) the muscles of the trunk become affected, so that weakness and spasms (often of a very painful character) occur in the abdominal and back muscles. After a time the arms also may become implicated, and in the same fashion as the legs, excepting that when permanent contractions of the muscles come on, they mostly fix the arm to the side, whilst the forearm is pronated and half-flexed, and the fingers and wrist are strongly flexed. In rare cases the disease is limited to one side of the body, beginning, for instance, first in one leg, and then extending to the arm on the same side, so as to present a kind of hemiplegic dis- tribution. Just as rarely, too, the disease may first affect the two upper extremities, and then extend down the trunk, so as ultimately to in- volve the lower extremities. During the development of the disease shiver- ing fits, affecting the muscles of the jaws as well as almost all the muscles of the body, may occur from time to time, lasting for half an hour or more, and though quite unaccompanied by any changes of temperature, they may, nevertheless, be provoked by cold. Sometimes, however, such attacks occur spontaneously; or they may spread from some accidentally initiated ankle-clonus, or other well-marked spasm. Persons suffering from this disease often re- main in an almost stationary condition for a series of years, at any particular stage of the disease that may happen to have been attained. Ultimately, however, there is a tendency to com- plete paralysis of the parts affected, with perma- nent contractures — the legs at this stage being often immovably fixed in a condition of rigid extension. As a rule, pains are not complained of at any stage of the disease, though some patients suffer much from painful eramplike con- tractions, occurring either in tbe lower extremi ties, or else in some of the abdominal muscles. Complications. — So long as the morbid procesi 1488 SPINAL CORD. SPECIAL DISEASES OF. remains limited to the lateral columns, no other symptoms present themselves. Should it, how- ever, invade the grey matter in particular regions of the cord, then characteristic complications are apt to arise, and it may also be said that the gravity of the disease becomes very distinctly increased. The way for a fatal termination may then be paved through the gradual increase, for instance, of bladder-troubles; or through the oc- currence of severe bed-sores, and collateral events to which they may give rise. Another possible extension of the sclerosis is to the posterior columns, so that we may get a variable mixture of the symptoms pertaining to ‘ spasmodic spinal paralysis,’ and to ‘ locomotor ataxy.’ It should be borne in mind, however, that such a complicated clinical grouping some- times develops in the reverse order. Usually in patients suffering from this disease, there is no association with cerebral symptoms, nor is there any tendency to the springing up of cerebral complications. Still, in one case under the writer’s care a subacute maniacal condition became developed ; whilst in another case dia- betes to a slight but tractable extent has mani- fested itself. In both instances, however, there happens to have been a marked hereditary pre- disposition to the occurrence of insanity and of diabetes respectively. Prognosis. — As hinted above under the head of complications, so long as the disease-process remains limited to the lateral columns, as it does in the great majority of eases, ‘ spasmodic spinal paralysis ’ carries with it no danger to life. Such patients may survive for an indefinite time, even though for years after permanent contractures have become established they may have been absolutely confined to bed. Still Erb speaks of two cures, and of decided improvement in some other cases, and is inclined to think that this affection may prove a little more amenable to treatment than some of its congeners. Diagnosis. — The grouping of symptoms met with in this disease is so characteristic, that there ought to be no difficulty in recognising it. In no other affection of the spinal cord have we the combination of a gradually progressive paralysis beginning in the lower extremities, associated with muscular twitchings and rigid- ities; greatly exalted tendon-reflexes; no im- pairment of sensibility and no pains ; no wasting of muscles or other trophic changes ; and no interference with the functions of the bladder and rectum. The real difficulty arises in the recognition of the complex forms of the disease, or of com- binations of this 'disease with others, then coming under observation for the first time. This, for instance, is the case where we have to do with a combination of posterior and lateral sclerosis, in which, in order to arrive at a diagnosis of the existing condition, the observer must be able to recognise the respective effects or modifications that may result from the combination of the t.wo diseases. Another difficulty of the same kind arises when the symptoms of the disease are complicated by extension of the sclerosis to the grey anterior horns, the characters of which will be next described under the head of Amyotrophic lateral sclerosis. Again, when ‘multiple sclerosis’ affects iu the main the lateral columns, the real diagnosis can only be arrived at by the recognition of symptoms which could not be produced by a mere affection of the lateral columns. Thus the writer has at present under his care a little girl, ten years of age, first brought to him on account of head-symptoms, which suggested the possibi- lity of intracranial tumour, but in whom, after a few months, sisrns of lateral sclerosis have be- come developed in a very typical manner. She now presents the most characteristic spastic gait, being frequently raised quite upon the points of her toes as she walks. There is also great exaggeration of th6 tendon-reflexes, and no im- pairment of sensibility. The case seems clearly one of ‘ multiple ’ or ‘ cerebro-spmal sclerosis.’ Treatment. — In the treatment of ‘ spasmodic spinal paralysis,’ as in that of locomotor ataxy, we must use such means as are most likely to be of avail in checking the causal process of sclerosis in the columns of the cord. The general health of the patient, and the regula- tion of his mode of life, must receive our most careful attention. Sound sleep must also be ensured, as far as possible. Nitrate of silver has been praised by some; but the writer believes that, on the whole, more good is to he obtained from iodide of potassium in eight- or ten-grain doses, either with or with- out liquor arsenicalis. Small doses of cod-liver oil also seem to do good. There is no particular indication for electrical treatment in this disease: but stimulation of the skin and subjacent parts, by frequent frictions and shampooings, may be of service, and so also may sulphur baths. There are mostly no pains to be allayed; but occasionally painful cramp-like contractions of the muscles cause much distress to patients suffering from this disease. These pains are difficult to relieve, though good may be done, in some cases, by the extract of calabar bean in increasing doses. For the rest, any accidental accompaniments of the malady must be treated upon the general principles applicable to the management of other spinal affections. ‘ Nerve- stretching ’ might be beneficial, as in certain cases of locomotor ataxy, though there is room for doubt on this point. 18. Amyotrophic Lateral Sclerosis. — Sv- non. : Fr. Sclerose laterals amyotrophique. This is an extremely interesting and rare affection, which might perhaps be regarded as a mere variety of the ordinary lateral sclerosis; still it is a variety which pursues a very distinc- tive course, and constitutes a disease much more formidable than its prototype, since it seems almost invariably to lead to a fatal termination in two or three years. Pathoi.ogy, and Anatomical Charactees. — The peculiarity of this form of lateral sclerosis lies principally in the fact that it commences in the cervical region, and soon spreads to the contiguous anterior horns of grey matter ; thence, after more or less of an interval, it extends in two directions : — (a) downwards, so as to involve the dorsal and lumbar lateral co- lumns, and also the contiguous anterior cornua of grey matter ; and (b) upwards, so as to im- SPIN All CORD, SPECIAL DISEASES OF. 1489 plicate the upper cervical region of the cord and the medulla oblongata in a similar fashion. Thus it will be seen that there are three peculiarities about this form of lateral scle- rosis; ('l)that it begins in the cervical region of the cord, and subsequently affects the lumbar portion ; (2) that it does not remain limited to the lateral columns, but soon spreads to the contiguous anterior cornua, where it leads to destruction of the great motor ganglion-cells ; and (3) that it almost invariably extends up- wards also, so as to involve the medulla ob- longata, and thus to gradually bring about the death of the patient. Symptoms, Course, and Terminations. — Being marked by the anatomical characters above de- scribed, it will be easily understood that patients suffering from this disease present an admixture of such signs and symptoms as may be met with separately in ‘lateral sclerosis,’ in ‘progressive muscular atrophy,’ and in ‘ bulbar paralysis.’ We have, in fact, the following typical grouping and sequence of symptoms : — 1. Paresis, gradually increasing to actual pa- ralysis of the upper extremities, and soon asso- ciated with distinct muscular atrophy, fibrillar twitekings, &c. Any movements that can be executed are weak, and associated with tremors. More or less marked rigidity of muscles, and finally actual contractures occur, in which the arms are fixed close to the sides of the body ; the forearms are semi-flexed and pronat.ed, whilst the hands and fingers are strongly flexed. 2. After an interval of some months, a similar group of symptoms becomes developed in the lower extremities. Again, we have paresis gradually increasing, with muscular tensions, exaggerated tendon-reflexes, and an increasing amount of rigidity of the lower limbs, w r hich are usually fixed in the extended position. At a later period in the lower extremities, as com- pared with the arms, a process of muscular atrophy sets in, with development of the ‘reac- tion of degeneration,’ and fibrillar twitekings in the affected muscles. During the whole of this time, there is little or no interference with sensibility. There is usually no implication of the sphincters, and no tendency to the formation of bed-sores. 3. In the last stage of the disease, there is evidence of extension of the morbid process upwards to the upper cervical region and the medulla. Signs of bulbar paralysis present themselves in the usual way, by paralysis with atrophy of the tongue and lips, and by progressive weakening of the muscles of the palate, pharynx, and larjmx. The phrenic nerve has also gene- rally become involved, and when weakness of the diaphragm is added to weakness or actual para- lysis of the other muscles of respiration, this all- important function becomes more and more im- paired, and thus a fatal termination may at any time be easily brought about. Increasing dif- culty of articulation and deglutition may have existed for some months before death. Prognosis. — As already indicated, the prog- nosis is bad ; the disease usually advances to a fatal termination in from one to three years. Diagnosis. — In the early stages, when amyo- trophic latenl sclerosis affects the arms only, it 94 is characterised by its gradual, painless onset 4 the absence of impairment of sensibility, tha fact that weakness sets in first, and that twitch- ings and tensions of muscles soon declare them- selves, either before or after themuscular atrophy becomes very obvious. This combination is already sufficiently distinctive, in the absence of pain iu the back, tenderness over the spine, oi any other evidence of vertebral disease. When the disease advances to its second and third stages, the picture becomes gradually more and more distinctive, and easily' to be separated from all other affections of the spinal cord ; especially if we are duly impressed by the nega- tive symptoms, namely, the absence of sensory impairment, of bladder-troubles, and of bed- sores. Treatment. — Little success has hitherto at tended the treatment of this disease. The indi- cations are to endeavour to arrest the process of sclerosis, partly by the most assiduous attention to the general health, and partly by the adminis- tration of iodide of potassium, either alone or in combination with arsenic or small doses of bi- chloride of mercury. In the early stages fara- disation should be had recourse to • sulphur or mineral baths may be tried ; and, if possible, residence in some high and bracing health-re- sort, or at all events in a climate where much time may be spent in the open air. In later stages little can be done, except by general treatment. 19. Multiple Sclerosis of the Spinal Cord. Synon. : Disseminated Sclerosis; Insular Scle- rosis; Multilocular Sclerosis; Fr. Sclerose en plaques disseminees ; Ger. Multiple Sklerose des Ruclcenmarks. Nature and AEtiologt. — Nothing approach- ing to an adequate recognition of the characters and importance of this disease was made anterior to the year 1866. Then, and in the two or three subsequent years, the malady may be said to have been identified and characterised by Vulpian and Charcot, but more especially by the latter and his pupils. It is a disease produced by the development of patches of scleros : s (overgrowths of neuroglia') of varying size and shape, throughout the spinal cord, and also in different parts of the brain. Clinically the disease is met with under the most diverse forms, according to the different sites and sizes of the patches of sclerosis occur- ring in different cases. These different forms of the disease are divisible into three partially dis- tinct types, according as the morbid changes and symptoms occur in and are referable (1) to the spinal cord alone ( spinal type); (2) to tho cerebrum alone ( cerebral type); or (3) to the brain and spinal cord ( cerebro-spinal type). As the dominant symptoms of the disease are often those of the spinal type, even where there is also an extension of the morbid process to the cere- brum, it will be most convenient to speak here in the main of the ‘ cerebro-spinal ’ type. It is, moreover, both more frequent and a more cha- racteristic malady than either of the simpler forms. In regard to the aetiology of the disease, little can be said. It may occur with or without the SPINAL CORD, SPECIAL DISEASES OP. 1490 predisposing influence of a neurotic tendency. It ■a at least as common in females as it is in males ; and though rarely occurring in children under ten years of age, it is perhaps most com- mon between the ages of ten and thirty years. Beyond the age of forty it again becomes exces- sively rare. Amongst the exciting causes, exposure to wet and cold would seem to t ike the first rank. After this come traumatic influences of various kinds, mental shocks or troubles, great fatigues from mental or bodily labour, and finally the state of convalescence from several acute dis- eases, such as typhus, cholera, variola, or other specific fevers. It has, indeed, been said to occur sometimes as a sequence to severe and long- continued hysteria; but in some of such cases at least it would seem to be far more probable that the early and obscure symptoms connected with this affection were those which were re- garded as hysterical. ‘Hysteria’ may be produced or simulated in many ways, but as itself a pro- ducer of organic changes its rule is assuredly open to grave doubts. Anatomical Characters. — The patches of sclerosis which constitute the anatomical basis of this disease, do not differ in their essential nature or in their appearance (macroscopic or microscopic) from the similar overgrowths of the neuroglia that occur in locomotor ataxy and in primary lateral sclerosis. On the cut surface of the spinal cord, medulla, or other portion of brain, the foci of sclerosis mostly reveal themselves as greyish, greyish- red, or semi-gelatinous yellowish patches, differ- ing principally by reason of slight contrasts in colour, from the dead white of the more healthy columns of the cord, and from the natural ap- pearance of the grey matter. The tissue of the patches may either be level with, project slightly above, or sink slightly beneath, the general cut surface of the cord. The same differences also exist in regard to those patches which involve the external surface of the cord — they may at times, when the new growth is excessive, rise slightly above the surface ; whilst later on, when shrinking has occurred in the cirrhotic patch, some amount of superficial depression may be met with. The patches vary much in size; in the spinal cord they range from a mere pin’s head to that of a large pea, or of a bean ; whilst in the cere- brum or in the cerebellum they may attain still larger dimensions. In the spinal cord the patches occur in all parts of its longitudinal extent, and they may occupy very variable portions of the transverse area of the cord. Some involve principally the lateral, others the anterior or the posterior columns of the cord ; or portions of the grey matter, either alone or in conjunc- tion with one or more of these columns, may be implicated for a variable extent, transversely and longitudinally. Patches of different sizes, and varying in their transverse extent, occupy different levels of the cord, and may thus occur in an irregular series throughout the organ. These spinal foci of sclerosis, again, may be associated with patches of the same kind dis- tribute! through the medulla, pons, and cerebral peduncles, in part superficially and in part within their substance. Similar patches may he found in variable number, and quite irregularly distributed, through other parts of the cere- brum, as well as through the cerebellum. In regard to the microscopical characters ot these foci of sclerosis, certain differences are met with in different cases, principally depen- dent upon the age, or stage of formation, of the patches. Without going into minute details, it may be said that there is in all cases a hyper- plasic overgrowth of the neuroglia which natu- rally exi-ts around and between the nerve-ele- ments. The nature of this change becomes quite distinct when properly prepared sections of the cor! have been tinted. The new tissue takes the staining fluid freely, and when the circum- ference of a patch (especially some small onei is examined, it becomes obvious that numerous thickened processes of neuroglia connect it with the healthy tissue around. It is by the hypei- trophy and gradual fusion of these circumfer- ential prolongations that the morbid growth pro- gressively encroaches upon the previously healthy portions of the cord. As this mere interme- diate tissue grows, it presses upon and con- stricts the nerve-fibres and nerve-cells, so as to cause atrophy of the latter and a partial atrophy of the former. For there is reason to believe that the nerve-fibres do not wholly dis- appear ; in these patches of primary sclerosis (as in the case of ‘secondary degenerations’) it is the white substance of Schwann which disappears, whilst the axis-cylinders, or a considerable num ber of them, persist. In the new tissue itself we find the usual granular or very finely fibrillar matrix, containing minute spherical or ovoidal plastides, also branched cells, and occasionally a few granulation-corpuscles. The latter are met witli especially during the earlier stages of a patch of sclerosis ; just as corpora amylacen or colloid bodies may be found in older patches. The walls of the capillaries as well as of arteries and veins are generally greatly thickened, and the vessels in a patch of this kind may be both numerous and large; in other cases, however, the number of vessels existing in the patch is by no means so conspicuous. It is well known that the adventitia or outer coat of the vessels in these patches is specially apt to become thickened, and that this sort of over-growth may extend inwards, so as to cause fibroid dege- neration of the middle coat and even of the intima. It is probable that proliferation also takes place from the inner surface of the intima (an endarteritis), and that occasionally, owing to this cause, a thrombosis may be brought about. Certain it is that the writer has on several occasions found the larger vessels of a patch of spinal sclerosis blocked by an old and firm thrombus. Pathogenesis. — With reference to the starting point of a patch of sclerosis something may be attributable to general causes or tendencies, such as exist in scrofulosis, in syphilis, or in other cachectic states of the system. Still, a general tendency of this kind to hyperplasia can only be adduced as a very partial explanation, since not unfrequently disseminated sclerosis maybe met with in the absence of any cachexia ; and. more- ov;r patches of sclerosis may occur in the nervous SPINAL COED, SPECIAL DISEASES OF. 1491 system only, or to no notable extent in other organs of the body. This, therefore, would indi- cate the existence of something, or of some pro- cess, of an abnormal kind taking place in the spinal cord and brain, and again not uniformly through them, but in foci situated here and there. It is no explanation, as some seem content to sup- pose, merely to say that the abnormal processes are ‘ chronic inflammations ’ ; since whether it is or is not advisable to speak of the changes by this name, we should still have to ask what is the cause of such local departures from healthy nu- trition. Doesthe process begin in the connective- tissue elements themselves? or is there some primary change in the small vessels (possibly of the nature of endarteritis) leading to obstructions and a sequential overgrowth of the neuroglia? It would seem pretty certain, at all events, that the change in the nerve-elements proper follows the overgrowth of the neuroglia — as certain, in- deed, as that throughout a band of ‘ secondary degeneration’ the order of these changes is exactly reversed. There fatty degeneration and atrophy of the nerve-fibres are the first evonts, and these are followed by hyperplasia of the neuroglia. See Introduction, § 6, (13). One of the most interesting facts, in connec- tion with these patches of primary sclerosis, is to bo found in the circumstance that they them- selves rarely lead to bands of descending ‘secon- dary degeneration’ in the anterior or lateral columns, or of ascending degeneration in the nosterior columns. The fact itself has been long observed, and always regarded as rather surpris- ing. The writer believes it to be explicable by the fact previously mentioned, that the bulk of the axis-fibres remain, so that the nerve-fibres below the seat of lesion (or above in the ease of the posterior columns) are not absolutely cut off from the nerve-cells which exercise a ‘ trophic ’ influence over them. Some nerve-tremors may still pass along the damaged fibres in the sclero- tic patch, 1 and thus the nerves in the parts be- yond do not degenerate as they would do if the fibres had been absolutely cut across. Some fibres may be completely strangled and then ab- sorbed, and in such a case the continuations of these nerve-fibres would degenerate. In the final stages of a sclerotic patch this kind of sequence is apt to occur ; so that towards the end there may be the tendency to the occurrence of some amount of secondary degeneration, even though the degenerated fibres may not constitute a very compact band. Symptoms. — It can easily be understood, from what has already been said, how much the symp- tomatology of this disease is liable to vary in different cases, according to the varying situation, extent, and order of evolution of the morbid patches. That it is possible to assign anything like a definite symptomatology for this affection, is due to the fact that there are certain seats of election in which the patches of sclerosis are specially apt to occur. The sites affected with special frequency are the lateral columns of the cord, the medulla, and the pons ; and it is with 1 In support of this, there is the fact mentioned by Charcot, that an optic nerve which was affected through lt3 whole thickness by sclerosis was yet capable of per- forming its functions. the occurrence of patches of sclerosis in these situations that we have the following set of correlated symptoms pertaining to the ‘ cerebro- spinal’ type of the disease. A slowly ensuing paresis of the lower extremi ties begins, first in one limb and then after a time it involves the other. During this time the paresis develops into a more and more marked paralysis, though the sensibility of the limbs re- mains almost completely unaffected — nothing more than a temporary numbness being com- plained of in the majority of cases, whilst light- ning-like pains and girdle-sensations are alto- gether absent. After an interval, first one and then another upper extremity may become weak and subsequently more or less paralysed. During theso early stages of the disease more or less distinct remissions of symptoms may occur from time to time. Meanwhile a most typical sign soon shows itself in the paretic or semi-paralysed limbs, in the form of a marked trembling or shaking of those muscles or parts of a limb which are called into voluntary action with any intensity, although these phenomena immediately subside when the voluntary exertion ceases. The invo- luntary movements consist either of extremely well-marked tremors, like those met with in some cases of paralysis agitans, or else of move- ments of greater range, more resembling those of chorea. Later some paresis of the trunk-muscles may gccut, as well as of those of the neck ; and this mav be followed by a similar affection of the tongue, lips, and facial muscles — possibly, also, of those of the palate, pharynx, and larynx. When a patient affected in this manner, who has been pre- viously lying perfectly still inbed, is told to endeav- our to situp, shakings and tremors begin in almost all parts of the body, and the scene is strangely changed until all voluntary efforts cease and the recumbent position is again assumed. The same kind of thing is seen when movements of par- ticular parts of the body are attempted : thus when, in the sitting posture, the patient attempts to hold up one leg, tremors of it immediately begin; ask him to take hold of something or to squeeze a dynamometer, and the upper extremity called into action at once begins to shake; request him to put out his tongue, and immediately irre- gular protrusions of the organ occur, associated with twitchings about the angles of the mouth and even in other parts of the body. The act of walking may cause, in more or less advanced cases, tremors of the legs, arms, trunk, head, and neck — all at the same time. Movements of slight intensity occasion either no shakings or merely tremors of a very fine kind. The latter are seen in the early stages of the disease, when writing is attempted. Almost each letter registers a number of fine tremors, mixed here and there with greater irregularities. In more advanced cases, however, the movements are so disorderly that writing becomes either impossible or wholly illegible. Just as there is no loss of ordinary sensibility, so we find that patients remain fully conscious as to the positions and movements of their limbs, and that closure of the eyes occasions no increased uncertainty of their movements ; nor, 1492 SPINAL CORD. SPECIAL DISEASES OF. when in the standing position, are they rendered more giddy or more unsteady by such a pro- ceeding. Up to this stage there may be no distinct in- terference with the functions of the bladder or the rectum. The tendon-reflexes are, however, generally distinctly exaggerated ; ankle-clonus may be obtained with readiness, and the knee- jerk is often more pronounced than usual. There is no tendency to the formation of bed-sores ; no wasting of muscles ; nor is any alteration in their electrical excitability met with. After variable and often long periods, the affected lower extremities, which have become more and more paralysed, may in some cases show signs of commencing bar-like rigidity. The limbs, as the patient lies in bed, are closely drawn together, and in a condition of rigid extension, which is generally increased when any attempts to move them are made. At first this condition of the limbs ensues from time to time, in the form of paroxysms lasting for an hour or two. But, after a time, the attacks are both more frequent and longer, so that ultimately the condition of rigidity becomes permanent. Contractions of the arms are less common, and when they occur they become fixed at times in a different position from that met with in simple lateral sclerosis (see Spasmodic Spinal Paralysis) ; that is, like the lower extremities, in a condition of extension, and closely drawn to the sides of the body. At this period ankle-clonus can often be elicited with the greatest ease, and the movements of the one leg may extend to the opposite lower extremity, and may indeed set up more or less of general tremor throughout the body. Exposure to cold, or irritation of the skin m various ways, will also often suffice to set up this general tremor, which, as Brown-S6quard showed, may commonly be caused to cease in- stantly by a forcible flexion of one of the great toes. With the cessation of the tremors conse- quent upon this manoeuvre, the limbs may also be left for a time in a supple and flaccid condition. The manifestation of tremors of the tongue, lips, and face is of course a sign that the medulla oblongata is affected; and when this occurs, simultaneously, or very soon after, other evi- dences of the implication of the medulla and of contiguous portions of the cerebrum may be met with. Articulation may become more or less affected, the speech being rendered slow, hesi- tating, and measured, syllable by syllable ; or it may be jerky in character — becoming especi- ally thick and blurred in the later stages of the disease. The power of swallowing is less fre- quently impaired, but in advanced stages it is apt to be affected. Nystagmus is very frequently met with. Dip- lopia, or actual paralysis of the ocular muscles, is rare. Amblyopia not unfrequently exists ; perhaps, in one eye only. Actual blindness is very rare. Vertigo, sometimes to a marked extent, is no uncommon symptom ; and as the cerebrum be- comes more and more affected, a condition of well-marked hebetude, or actual dementia, gradu- ally becomes pronounced. This betrays itself externally by a blank, expressionless aspect of the face ; the patient becomes childish in manner, hia memory fails, he takes interest only in trifles, laughs constantly also at the merest trifles, or, on the other hand, is very easily moved to tears. During this condition of things a subacute maniacal condition may supervene ; or the patient may develop ‘delusions of grandeur’ precisely similar to those met with in 1 general paralysis of the insane’ — examples of which the writer has recently seen in two of his own patients. In other cases persons suffering from this disease mav lapse into a profoundly melancholic condition. At this stage, too, apoplectiform or epileptic form attacks are particularly apt to occur from time to time. After such attacks, of whichever kind, the limbs on one side of the body and the face are left more or less paralysed ; and where the attack has been epileptiform in character, the convulsive twitchings are often limited to this one side of the body. As Charcothas pointed out, these attacks are precisely similar to those which occur in general paralytics, or in cases of old hemiplegia with descending sclerosis. They answer to the so-called ‘ congestive attacks,’ but, as Charcot contends, they do not seem to he associated with any new appreciable lesions of a ‘ gross ’ order. Such epileptiform attacks may be brief, or they may last for hours ; or, off and on, even for days. In all of them the tem- perature begins to rise almost at once — without any initial period of depression — and may even reach 104° in a few hours, or in a day or two. The temperature then begins to fall again ; or should it continue to rise to a still higher point, the attack is very apt to terminate fatally. Every attack of this kind leaves the patient in a manifestly worse condition, both bodily and mentally ; and perhaps in one of them at last death may occur. Varieties. — The symptomatology of this dis- ease is likely to be considerably modified in differ- ent cases, but principally in two directions, pro- ductive of complications of the same kind as those which are also apt to occur in ‘ spasmodic spinal paralysis.’ In each disease there may in some cases be a special affection of the posterior columns, in one or other region of the cord, bring- ing with it more interference with sensibility, and an admixture of other symptoms pertaining to locomotor ataxy. It is, perhaps, principally in these cases that the ‘crises gastriques' t pains, vomiting, and occasionally diarrhoea) are also met with. In other instances there may bean ex- tension of the sclerosis to the grey matter of the anterior cornua in one or other region (as well as to other parts of the grey matter), leading, amongst other phenomena, to muscular atrophy in related regions of the body. In either of these ways the symptoms of the original diseaso may be complicated, and, to a certain extent, obscured. Many other differences also present themselves in special cases, owing to the varying situations in which the morbid patches make their first ap- pearance. In a fair proportion of the cases the disease seems to reveal itself first in the brain rather than in the spinal cord. Terminations. — After pursuing a very slow course for years (often five to ten), the miserable sufferers from this disease may at last be carried off' in various ways. Death may take place it one of the apoplectiform or epileptiform attacks SPINAL CORD, SPECIAL DISEASES OF. occurring either in patients who are merely slightly demented, or in those who are otherwise actually insane; or, at last, in cases in which there is great interference not only with articu- lation hut also with deglutition, the functions of the heart or of respiration may also become affected, and may thus lead on to a fatal termination. In other cases, after the disease has lasted for years, and when the grey matter of the cord has become seriously involved, accidents may super- vene similar to those which occur in the final stages of many cases of paraplegia. The bladder .nay become paralysed, and after a time inflam- mation and ulceration may be set up, followed by secondary inflammation of the ureters or kidneys. Or bed-sores may form, sloughing may go on extensively, and the patient may at last die exhausted, or from the supervention of blood-poisoning or some acute inflammatory disease. Diagnosis. — In its early stages the diagnosis of this disease may present very considerable difficulties. This is especially the case when the morbid process begins in the cerebrum. Here for a time there may be nothing distinctive, and we have to wait for the further development of the disease before anything like a positive diagnosis is possible. Similarly, where the disease begins only with spinal symptoms, it is often extremely difficult to diagnose it with certainty in its very early stages. The important characters in the more typical forms of the disease are the youth of the patient, the paresis gradually increasing, first in one and then in the other lower extremity, with no alteration in sensibility or in the elec- trical irritability of the nerves or muscles. When ankle-clonus becomes easily obtainable, and when, moreover, the peculiar tremors and disordered movements on voluntary excitation of the muscles are met with, together with the absence of any such tremors in the condition of rest, and some amount of paresis or of similar symptoms in one or both upper extremities, the diagnosis of the ‘ spinal ’ type of this disease can be no longer difficult or doubtful. By far the most typical cases, however, are those of the ‘ cerebro-spinal ’ type, in which, with such symptoms as are above indicated, there are also some others due to disease of the medulla or pons — such as have been indicated in speaking of the symptomatology of the disease. In these cases the disease is really quite distinctive; so that even when the patient is seen at this stage for the first time, the malady ought to be easily recognised. Chorea is the affection with which it is most apt to be confounded ; but the absolute cessation of all tremors anddisorderedmovements in multiple sclerosis when the patient is at rest, and their immediate re-initiation (mainly in the parts moved, but also often to some extent in others) on the occurrence of voluntary efforts, is a thoroughly distinctive characteristic. Paralysis agitans ought to be distinguished from disseminated sclerosis with even more ease. It is scarcely ever met with in persons under the age of thirty-five, just as multiple sclerosis is only rarely met with in persons beyond such an age. The movements of paralysis agitans •re only to a slight extent exaggerated by volun- 1493 tary exertion of the parts ; and such movements, in the form of fine tremors, do not cease to any- thing like- the same extent under conditions of rest. There is generally no shaking of the head and neck in paralysis agitans. Mercurial poisoning with tremors can be easily distinguished, on inquiry into the history of th« patient, and the mode of onset of the disease. In those more irregular cases of multiple sclerosis, in which there is either an implication of the posterior columns of the cord, or of the grey matter in some region or regions, the dia- gnosis of the complex nature of the affection must bo based upon the general principles applicable to the regional diagnosis of spinal cord dis- ease. Phoonosis. — Absolute cure of this disease is scarcely to be hoped for. The most that lias been done, hitherto, as a result of treatment, has been to bring about more or less distinct re missions, and also to delay the progress of the disease. Death usually occurs in from five to ten years, in one or other of the modes already indicated. Treatment. — Many drugs have been tried, but hitherto with little or no positive result, in the treatment of this affection. Nitrate of silver has seemed to do good in some cases, especially in the early stages. But the writer is much more disposed to trust to iodide of potas- sium in eight- or ten-grain doses three times a day, with or without moderate doses of perchlo- ride of-mercury or of liquor arsenicalis ; com- bining the use of those drugs with cod-liver oil and a good nourishing diet. From time to time, however, the above medicines should be omitted, and simple tonics taken in their place. In the early stages of the disease, sulphur baths and shampooing of the limbs may be of service ; and in all cases it is of great importance to see that the patient obtains sound sleep, since in this, as in all other chronic spinal diseases, the patient’s downward course is sure to be greatly hastened where refreshing sleep is not obtained. No distinct indications exist for the treatment of this affection by electricity, and no advantages have as yet been recorded from its use. The complications of the disease, which may occur in its later phrases, must be treated in accord- ance with the general principles applicable for this as for other spinal affections. Every effort must be made to preserve the general health of the patient, as this will probably be found to be the surest means of arresting or holding in check the progress of the disease. 20. Spinal Cord, Tumours of. — S vnon.: Intra-medullary Tumours; Fr. Tuncurs de la Moellc ; Tumeurs rachidiennes ; Ger. Krank- haften Gesckwillste des Ruckenmarks. ^Etiology and Anatomical Characters. — Tumours originating in the substance of the spinal cord may be regarded as belonging to two classes, according as they represent (a) mere local accidents in the form of perverted tissue- changes ; or ( b ) such local accidents developing under the influence of a distinct general state, such as syphilis or scrofulosis. (a) Of the purely local overgrowths, the most typical, and perhaps also the most fre< 14S4 SPINAL COED. SPECIAL DISEASES OF. quently occurring fire gliomata. The considera- tion of these growths comes in natural sequence to that of sclerosis affecting different regions of the cord. In such a tumour we have an exu- berant overgrowth, as Virchow and most other pathologists suppose, starting from the neuroglia of a certain portion of the cord. At first the growth infiltrates and substitutes itself in the place of a certain amount of nerve-tissue; but it soon grows excessive in quantity (spreading in area perhaps at the same time), and thus comes to exercise a more and more marked com- pression upon the remaining tracts of nerve- tissue composing the cord at the same level, within the narrow and unyielding boundaries of the spinal canal. These gliomata are often- times extremely vascular. They are liable to undergo a certain amount of central softening ; and into their substance, especially in the soft- ened feci, haemorrhages are very apt to occur. Softening of nerve-tissue may also, at a certain stage, take place around the growth, and thence may extend for a variable distance above and below. Other tumours of an allied nature, such as sarcomata and myxomata , also at times develop, either in their pure types or with blended characters, within the spinal cord. They pre- sent few intrinsic peculiarities in their manner of affecting the cord. They rarely attain any large size ; indeed the limitations of the spinal canal only permit of much increase in one direc- tion. And elongated growths are occasionally met with. To a considerable extent, such tu- mours have an infiltrating mode of growth, though their boundaries are apt to be rather more defined than are those of gliomata. In regard to the causes of these tumours, almost nothing more definite can be said than that they seem, at times, to find occasion and conditions suitable for their initiation after some blow upon the spine or concussion of the spinal cord. (6) Of the growths which tend to occur in the spinal cord (as occasionally in other parts of the body) under the influence of some general disease or diathetic condition, two are especi- ally to be named. These are scrofulous growths (‘tubercular’), and syphilitic gummata. The former are generally small, varying in size from a mustard seed to a pea, and only very rarely attaining the dimensions of a hazel-nut. Next to gliomata they are the new growths most fre- quently met with in the substance of the spiual cord. When small, they may occur in associa- tion with a cerebro-spinal tubercular meningitis ; but at other times they are found, and especi- ally the larger growths, existing independently of any acute inflammation of the meninges. In this latter case, the tumours may be combined with a certain amount of adjacent and secondary softening of the substance of the cord. Syphilitic gummata, originating in the cord itself, occur only with the greatest rarity. They are more frequently found starting from the meninges, and then they may press upon or actually grow into the nerve-substance. Cancer is believed not to occur primarily in the substance of the spinal cord, though it may grow into its substance, or seriously press upon it, when originating either in the meninges or it the vertebra. Symptoms, Course, and Terminations — T he difficulties of diagnosis are almost always very great in the case of tumours of the spinal cord, because in their early stages, and occasionally for prolonged periods, they aro associated with slight and somewhat vague symptoms. Independently of the variations in different cases, consequent upon the longitudinal situation or level of the tumour in the spinal cord, the symptoms to which they give rise in various parts of the body may be more or less vague anomalies of sensibility in different regions, associated with a certain amount of weakness, often not amounting to actual paralysis. Growths from the meninges, or from the vertebra, pressing upon the spiual cord, are not quite so apt to run a latent course for any length of time, since they are rather more prone to involve the anterior or the posterior roots on one or on both sides— at first irritating them, and subsequently causing paralysis from pres- sure. Thus localised numbness, pains, or anaes- thesia, either alone or associated with twitch! ngs, cramps, or paralysis, confined to certain parts of the body, are rather more common incidents during the growth of extra- than of intra-me- dullary tumours. Still the diagnosis between these two classes of tumours may be impossible. Sclerosis, in its ‘insular’ form, especially when the patches are few or close together, may also present symptoms almost inseparable from the first stage of some intra-medullary tumour. The important fact is, however, that sclerosis in the cord tends to become more and more generalised, and thus gives rise to a propor- tionately widening range of symptoms ; or else it limits itself to special columns, and thus becomes associated with more special sets of symptoms. With any of these tumours of the spinal cord, the symptoms are, after a time, liable to undergo a sudden and grave increase, owing to the occurrence of a haemorrhage into its sub- stance and perhaps into adjacent regions of the spinal cord, or else owing to the commencement of a process of secondary transverse softening. Beyond these possibilities of sudden grave aug- mentation of symptoms, the course of intra- medullary tumours is also apt to be marked by peculiar exacerbations and remissions from time to time, in association with periods of altered growth or vascularity of the tumour itself. Diagnosis. — The very gradual onset of the symptoms in cases of tumour of the spinal cord, is a point of great importance in the diagnosis of these conditions. Thus, for instance, we eliminate arachnoid or intra-medullary haemor- rhages, and also the numerous class of cases of softening of the spinal cord, with other affec- tions having a more or less abrupt origin. The diagnosis of tumour of the cord as distinct from its compression by disease of vertebra (where there is also generally a slow evolution of paralytic symptoms), must be based in part upon the absence of any evidence of vertebral disease. The diagnosis from meningeal tumours has already been referred to under the head cf symptoms ; and so also has the diagnosis from SPINAL CUED. SPECIAL DISEASES OF. 1193 mere Bclerosis of the spinal cord, in which the connective-tissue overgrowth is not sufficiently bulky to amount to an actual tumour. If the arrival at a diagnosis as to the existence of a tumour of the spinal cord is a process beset with difficulties, these by do means cease when, passing from the primary, we have to approach the secondary question as to the nature of the growth presumed to exist. Put little is possible in this direction. It is true that, with a history of pre-existing syphilis, even without the evidence of other simultaneous manifesta- tions, we should be warranted in assuming it to be even more than possible that an existing growth was syphilitic in nature, and in treating the patient accordingly ; and that all the more because this is about the only kind of new-growth as to which we have distinct evidence of its amenability to the influence of remedies. The presumptions in favour of the tubercular or scrofulous nature of a supposed new-growth in the spinal cord, would rarely carry with them more than a moderate amount of cogency. Still, occasionally the general habit of the patient, together with the fact of the existence of scro- fulous enlargement of glands, or of some forms of phthisis, might give more or less probability to such a conclusion. Beyond this not much can be done in the way of diagnosing special kinds of tumours. We might be guided in our opinion as to the possible existence of a sarcoma by the presence of one or more of such growths in other parts of the body ; or failing this, we may recollect that primary cancer affecting the spinal cord is almost unknown, and that gliomat.ous tumours are, next to the tubercular or scrofu- lous, those which are most frequently met with in the cord itself. Prognosis. — The prognosis in all these cases is bad. Life, it is true, may last for months or even years, but the tendency is for the primary affection to set up other secondary accidents, in the form either of haemorrhage or of softening. Thus, paralysis is rendered more complete, and the way is paved for an ultimate fatal termi- nation, through the intervention of cystitis and renal mischief; by way of bed-sores with ex- haustion and blood-poisoning ; or by extension of softening upwards to the cervical region and the supervention of respiratory paralysis. Treatment. — In the case of the existence of a syphilitic tumour in the spinal cord, we may attempt (and with some expectation of success) to treat the causal morbid condition with large doses of iodide of potassium, either alone or in combination with bichloride of mercury. But in almost all other cases little can be done in this direction, and we are reduced to the necessity of dealing with the paraplegic state, and its atten- dant conditions, as best we can, and also of at- tending to the general health, with the view of arresting the progress of the disease, and keep- ing its possible complications in check. See section on Treatment, in Spinal Cord, Soften- ing of. 21. Spinal Cord, Malformations of. — Va- rious conditions are comprised under this head which are of little or no interest to the practi- tioner. Tho spinal cord may be absent, imper- fectly developed, or double. Again, cases occur in which the spinal cord is either unduly long or unduly short, or in which it may present some trifling lack of symmetry. One of the most in- teresting of these latter conditions is due to the fact recently discovered by Flechsig of the pos- sible non-uniform distribution of the pyramidal tracts upon the two sides of the cord, so that the amount of decussation of the motor fibres, not only in different individuals but also in the two halves of the same cord, may be quite un- equal. In the latter case an asymmetrical de- velopment of the antero-latoral columns on ths two sides would be met with. Congenital dilatation of the central canal oj the Spinal Cord ( Hydrcrrachis interna , or Hydro* myelus), though an interesting pathological con- dition, does not reveal itself by any distinct symptoms during life. Confusion is, however, apt to arise between this mere unimportant congenital anomaly, and the existence of cavities in various parts of the grey matter of the cord, more or less centrally situated, which are to be regarded as remainders or products of some pre-existing pathological changes. These latter conditions have received much attention, and the various forms have been described under the name, originally given by Ollivier, of 1 Syringomyelia.’ Here, again, we have to do with matters of exclusively patholo- gical interest. Congenital dilatation of the central canal in its most developed form is apt to be connected with spina bifida. See Spina Bifida. II. Diseases of the Spinal Cord depen- dent upon Unknown, or very imperfectly* known, Organic Changes. 22. Tetanus. See Tetanus. 23'. Tetany. See Tetanv. 24. Torticollis. See Wry-Neck. 25. Writer’s Cramp, &c. See “Writer’s Cramp. 26. Spinal Irritation. See Spinal Irrita- tion. 27. Keflex Paraplegia. Synon. : Urinary Paraplegia (in part); Fr .Paroplegie reflexe ; Paraplegie fonctionnelle ; Ger. Reflex Paralysis spinalis. General Eemarks. — Some practitioners be- lieve that paralyses of various kinds are brought about purely by reflex influences. They would include under this category some of the cases of paralysis of separate muscles, such as the ocular ; some cases of paralysis of one or both arms ; or some of the cases of paralysis of one or both lower extremities. It is the latter class of cases with which we are now specially concerned, though much of what is to be said in the present article may, mutatis mutandis , be consi- dered applicable to the whole class of so called ‘ reflex paralyses.’ Those who believe in the frequent existence of this form of paralysis are considerably less numerous than they were twenty years ago, when the notion of its frequency and importance was warmly espoused by Brown-Sequard ( Lccts , on Paral. of Lower Extremities, 1861), and when 1496 SPINAL COED, SPECIAL DISEASES OF. the morbid anatomy of the spinal cord was still very imperfectly known. The number of com- petent observers was smaller, whilst the difficulty in detecting morbid changes in this organ was much greater then than it is now that we are accustomed to employ more elaborate methods for its preservation and for its examination. Yet one of the strongest of the arguments brought forward in favour of the existence of ‘ reflex para- plegia ’ was the absence of discovered lesions in the spinal cord in a class of cases reported upon by Stanley in 1833 (Med.-Ckir. Trans., vol. xviii. p. 260) in which paraplegia was associated with various morbid conditions of the urinary organs — cases, in fact,' of the so-called ‘ urinary para- plegia.’ And the main support for the opinions of those who still believe in the existence of a class of reflex paraplegias, now also lies in the absence, in certain cases of paraplegia terminating fatally, of any actually-discovered lesion. .Etiology and Pathogenesis. — The inter- pretation of the paralyses of this class put for- ward by Brown-Sequai'd is as follows : — That an irritation, operating upon certain sensory nerves, produces impressions which, after impinging upon the properly related grey matter in the spinal cord, are thence in part reflected aloDg vuso-motor nerves regulating the calibre of cer- tain blood-vessels which supply either (a) the portion of the spinal cord in relation with the paralysed parts, or else ( b ) the great nerves or the muscles themselves of the paralysed parts. In either case this reflection of impres- sions resulting from irritation of sensory nerves, upon such special groups of vaso-motor nerves, is supposed to lead to a persistent spasm of the vessels which they innervate, so as to cause a continuous anaemic condition, either of certain vascular territories in the spinal cord itself, or else of the related nerve-trunks and muscles. In either case, too, the nutrition of the parts involved in this anaemia is supposed to suffer — so that their functions can no longer be carried on or only in a very imperfect manner — and thus a more or less complete paralysis results, which is capable, however, of being mitigated from time to time, ot actually intermitting, or indeed of being ab- ruptly cured, according as temporary diminutions or a complete disappearance of the original ex- citing cause may lead to a diminution or to an actual cessation of the supposed profound anaemia produced by the supposed spasms of vessels. These are the theories upon which the doctrines of ‘ reflex paraplegia ’ are based. Among the sources from which the initial irri- tation is supposed to proceed, almost all parts of the body, internal as well as external, are included. Thus irritative impressions, it is thought, may emanate from almost any part of the urinary tract— from the urethra to the kidney ; in other cases similar impressions may emanate from some portion of the female genital organs; in others from the intestinal canal, owing to the presence of worms or some such persistent causes of irritation; in others from some portion of the thoraoic organs ; or, as it seems to be held, from irritated sensitive nerves in almost any part of the body, whether situated near the surface or deep amongst the tissues. The assemblage of symptoms supposed to cha- racterise these forms of reflex paralysis presents nothing like a distinctive mode of grouping. And of the several components of the group put for- ward by Brown-Sequard in 1861 ( loc . cit., p. 33), as pertaining to one of the most typical varieties, viz., ‘ urinary paraplegia,’ none can now have any pretensions to be regarded as distinctive, except- ing the alleged tendency of the paralysis to vary in degree with variations in the malady on which it is supposed to depend, together with its ten- dency to spontaneous or easy cure coincidentally with or soon after the cessation of the urinary troubles, whatever they may have 1 een. In harmony with this latter character also are the alleged facts that speedy cures have been brought about of eases of paraplegia, especially in chil- dren, after the expulsion from the alimentary canal of tape- worms or round-worms ; or, of cures of the same disease in adult females after the cessation of some uterine inflammation; or of cures of a paralysis of ocular muscles after the removal of some carious tooth which had previously been exercising an irritative influence upon branches of the dental nerve. It would be improper and useless to deny the existence of such eases ; they are theoretically possible. On the other hand, the writer is com- pelled to believe, after a very extensive expe- rience, that, if they exist, they can only occur as extremely rare events. Although it is theoretically possible that an irritation of a sensory nerve may be reflected on vaso-motor nerves, so as to lead to arterial spasms in certain territories of the spinal cord or in cer- tain groups of muscles, neither proof nor even analogy exists in favour of the view that such a condition of spasm could be maintained for days or even weeks. Nor, if it could occur for these prolonged periods, and to such an extent as to annul some of the most important functions of the spinal cord during this time, is it at all clear that the nutrition of the cord in the affected regions would not he seriously interfered with by such prolonged anremia ; and if so the assumed speedy resumption of healthy functions after the disap- pearance of the vascular spasms would constitute another difficulty, since such speedy recovery would be incompatible with the theory upon which the explanation of the disease is based. Again, it is almost certain that many of the eases formerly supposed to belong to this cate- gory of ‘ reflex paralysis ’ had no right to figure therein. Cases of diphtheritic paralysis have been proved to belong to a different category; and there is good reason to believe that in other instances the. morbid conditions really existing as causes of the paralysis have simply been over- looked, either because the appreciable changes wore only slightly advanced at the time of the patient's death, owing to the brief duration of the illness, or because of the want of a thorough examination of the cord, conducted with all need- ful aids, care, and expenditure of time. It seems clear, therefore, that the opinions of those who believe in the existence of ‘ reflex para- lysis,’ and of ‘reflex paraplegia’ in particular, stand much in need of farther support. Well- observed and well-recorded instances of the disease are urgently wanted, if reflex paraplegia is to retain its elaim to a place in our nosology. SPINAL COED. SPECIAL DISEASES OF. 1497 28. Intermittent Paraplegia. — Synon. : In- termittent Spinal Paralysis-, Fr. Paralysie Spinal Intermittente ; Ger. Intermittizender Paralysis Spinalis. — Very few cases of paraplegia of this type have been recorded, and it must also be a condition of extreme rarity. The earliest recorded example was made known by Eomberg, and as this, both in its nature and its course, seems to have been a typical instance, it may be cited here. ‘ A woman, sixty-four years of age, after being quite well the day before, was suddenly attacked with paralysis of the lower extremities and of the sphincters. Sensibility was unchanged, conscious- ness clear, the temperature cool, pulse 80, small and empty, no pain in the spinal cord. The next day there was an astonishing change in the condition. The patient could walk again and void urine voluntarily, and only complained of weakness in the legs. The following morning there was paraplegia again, which had set in at the same hour as it had done two days before. A third paroxysm was awaited, which also set in at the appointed time, although without para- lysis of the sphincters. Quinine effected a rapid cure.’ Two other cases are cited by Erb. In one of them there were also three attacks before cure took place under the influence of quinine ; but in the other, observed by Hartwig, attacks of in- termittent paralysis seem to have gone on for many months. It is worthy of note that in the two former cases there is no statement that the patient had previously suffered from ague ; whilst in that of Hartwig, although the man had been afflicted with tertian intermittent fever five years previously, for a few weeks, there is no mention made of the recurrence of any other symptoms of this type, even during the period that the patient continued subject to the attacks of intermittent paraplegia. We know absolutely nothing as to the real cause or intimate pathology of such attacks. Any future cases, therefore, deserve to be ob- served and recorded with the greatest care. Meanwhile it should bo remembered that the cases already observed seem to have proved ex- tremely amenable to the influence of quinine and of arsenic. 29. Hysterical Paraplegia. See Hysteria. 30. Paraplegia dependent on Idea. — Na- ture and .ZEtiology. — This is a form of para- lysis, of purely ‘ functional ’ type, ccasionally occurring in neurotic impressionable persons, and yet not dependent upon any ordinary hys- terical condition. Attention was first called to such cases by Dr. Eussell Eeynolds, who cited, amongst others, a typical instance in which a young lady, whilst attending to a paraplegic father, amidst the additional anxieties consequent upon straitened circumstances and the fatigues incident to teaching in order to obtain the bare necessaries of life, became at last, under the influence of long-continued strain, together with an abidi ng fear (inspired by actual physical weak- ness) that she herself was becoming paralysed, reduced de facto to this condition, as the final outcome of a slowly-increasing weakness (see British Medical Journal, November 6, 1869). Pathology. — Such a condition n.ay occur quite independently of hysteria, and be just as free from anything like conscious simulation or de- sire to exaggerate. We cannot say positively that the state is induced by what is called ‘inhibi- tion,’ or by definite vascular spasms such as are supposed to form one of the pathological bases of the class of so-called ‘ reflex ’ paralyses, and yet both these modifying influences over the func- tional activity of the spinal cord may be in part operative when imagination, continuously excited in some one direction, has a tendency to pervert the functional activity of this portion of the nervous system. The same conditions that exist as more lasting states in these cases, probably exist temporarily, under the influence of suggestion, in hypnotised persons. See Magnetism, Animal. Symptoms. — There is a paralysis of motion in the lower extremities, more or less complete, often partial, and generally without implication of sensibility. There is unabated control over the bladder and rectum. Dr. Eeynolds points out that, while such patients may be wholly incapable of lifting a foot from the bed, they often find themselves able to turn or sit up without any assistance. And in slighter cases, though they may be un- able to stand for a moment, such patients may yet be able to move the legs in any direction while in the recumbent position. Diagnosis. — The character of the paralysis, and its limitation in range, is thought to be of importance. But still more important is the esta- blishment of the fact of the pre-exislence of long- continued fears or fancies (in a person of deli- cate or neurotic temperament), of such a nature as to be in accordance with the patient’s now- present condition, combined with the absence of all signs positively indicative of any struc- tural defect in the spinal cord. Where such a condition exists (as it may) as a mere complication of an actually existing structural disease, the diagnosis becomes either impossible or extremely difficult. It is, iu fact, only possible after prolonged observation and experience as to the course of the symptoms. Prognosis. — The prognosis is extremely good if the nature of the malady be divined, and a right course of treatment adopted. Under such circumstances, an almost complete cure may easily be brought about in a week or ten days ; but, failing this recognition, the morbid condi- tion, may, it is said, under ordinary treatment, persist for an almost unlimited period. Treatment. — The practitioner must inspire the patient with confidence that the malady is curable, and surround her (or him) with cheer- ful, hope-inspiring attendants and influences. At the same time, with the view of supporting her confidence (if for no other reason), he should faradise the muscles of the apparently paralysed limbs daily, or have recourse to frictions or shampooings combined with passive movements. He must make the patient attempt to stand or walk, with the necessary support ; administer opiates, or bromide of potassium with chloral, to procure sleep, if necessary ; and carefully seek to restore the patient’s general health and nutri- tion. In this class of cases especially, it would 1498 SPINAL COED, SPECIAL DISEASES OF. seem probable that the influence of ‘suggestion,’ if hypnotism could be induced according to Braid’s method, might be capable of producing an almost immediate cure. See Beaidism. 31. neurasthenia Spinalis. — Synon. : Func- tional Nervous Weakness of the Spinal Cord. Nature and FEtiology. — Under this name, descriptions have been given of a combination of symptoms not unfrequently met with in males as well as females, but more especially in the former. They are supposed to represent a condition of extreme nervous debility, coming on obscurely, or at all events not as a sequence of some previous severe illness or shock. Still the symptoms met with often approximate closely to those pertaining to a state of con- valescence from some serious febrile illness ; and are not at all unlike some of those which may follow concussion of the spinal cord. Such symptoms when occurring independently are most prone to show themselves in those who are naturally of a neurotic temperament. They may be excited by over-fatigue of various kinds, especially when this has been coupled with dis- turbed sleep for some time. Prolonged exercise cr over mental work may have been the particular exciting causes of fatigue; though perhaps much more frequently this is to be found in sexual excesses (of a natural or unnatural order), either extending in the form of habitual indulgence over a considerable period, or as more isolated but marked excesses. At other times, symptoms of neurasthenia spinalis set in without obvious provocatives of either type. Pathology. — Concerning the actual cause of spinal neurasthenia little or nothing can be said. Sometimes there may be the co-existence of dis- tinct cerebral symptoms of an analogous type ; though on other occasions the symptoms are more purely spinal. This malady is perhaps capable of being induced by mere altered mole- cular states and actions of the tissue-elements of the spinal cord. A kind of persistent ‘fatigue condition ’ exists, so that their nutrition cannot bo properly maintained. Although some may imagine the existence of some more than usually' antemic condition of the spinal cord, of this, as a fact, there is no evidence. To speculate upon other modes in which such a set of symptoms might be brought about, would in the present state of our knowledge be of little service. There is, however, the possibility- that this morbid con- dition may be due in the main to a functional disease of the cerebellum— especially if the views of Eolando, Luvs, and others, as to the functions of this great organ, should prove correct even in part. Symptoms. — A feeling of utter weakness and prostration induced by even the smallest amount of muscular exertion, is the central symptom, though this is usually associated with coldness, and more or less numbness of the extremities. Pains, too, may be felt in the muscles of the limbs and in some parts of the back, though there is commonly no tenderness over any part of the spine. These symptoms may be unusu- ally distinct after any activity of the genital function, and they may then be associated with extreme wakefulness, or sometimes with pro- tracted inability to sleep. Occasionally, and especially when this latter symptom is not present, the patients may present a florid and fairly healthy appearance, strangely at variance with the extreme debility complained of. Diagnosis. — The points of greatest impor- tance are the existence of extreme weakness, with no evidence of anything like actual para- lysis, or indeed of any symptoms which would indicate an actual structural disease of the spinal cord. This being so, and diabetes being also eliminated, we may oftentimes (and especially where the existence of one or other of the above- mentioned exciting causes has been established) pretty confidently conclude that we have to deal with what is here named ‘neurasthenia spinalis.’ Prognosis. — A relief of this condition is ulti- mately to be looked for under the influence of rest aDd suitable treatment ; but in regard to the rapidity with which any such amelioration of the patient’s symptoms is to be brought about, great differences exist in different cases. Weeks, months, or even years may be required before a natural amount of vigour is restored. Treatment. — Eest, especially in the direction of previous excesses, is the first and indispen- sable requisite. Every effort should be used to obtain regular and sound sleep. The action of these potent restoratives should he supplemented by a generous and easily assimilable diet, to- gether with a moderate amount of stimulants. Ilypophosphites of the alkalies with iron and small doses of strychnia (which may be con- veniently given in the form of a syrup) often prove decidedly beneficial. An abundance of fresh air is desirable, and especially that of ele- vated and bracing mountain situations. Daily- frictions and shampooing, aided by stimulating saline baths, may also prove to be of much use. 32. Toxic Spinal Paralysis. — Under this name it will be right to refer to a class of cases of paraplegia produced by poisons of various kinds. It constitutes a somewhat heterogeneous group, concerning which our knowledge is still very defective — in the main, because such cases are happily of rare occurrence. Of the toxic agents taken into the body, and capable of entailing a paraplegia, some are minerals, such as arsenic and lead ; others are of vegetable origin, such as aconitia, conia, veratria, prussic acid, ergot, and alcohol ; whilst others again are of animal origin. In the majority of cases, their action as ‘causes’ is not sufficiently potent to lead to paralysis as any- thing like an invariable effect. They need the concurrence of other favouring circumstances, probably in the main intrinsic ; but under the combination of conditions thus resulting, a para- plegia may be induced — in actual modes, how- ever, that may differ considerably 7 among them- selves. It is only in this attenuated sense that the above-mentioned poisons are to be regarded as ‘causes’ of paraplegia. They ought perhaps, from this point of view, to he considered as pre- disposing rather than as exciting, and in no case as proximate, causes of paraplegia. This holds good, for all that we know, con- cerning the fitful and irregular manner in which SPINAL COED, DISEASES OF. arsenic, lead, or alcohol (and probably to a simi- lar extent other toxic substances) give rise to paraplegic symptoms in those who have taken them to excess. Thus, according to Tanquerel des Planches, out of 200 cases of lead-poisoning, ia only fifteen did the paralysis implicate the lower extremities ; and in only one of these did it occur as a distinct paraplegia. This case might, therefore, have been due to a fortuitous combination of conditions — in short, it might have been a coincidence rather than a definite result of the taking of lead. Again, in regard to arsenic, it is true that in certain cases Orfila observed paraplegic conditions in dogs which had taken large quantities of this drug ; but such symptoms would seem to be met with only occasionally as a result of acute arsenical poisoning in man, and perhaps with equal rarity in those who habitually consume large quantities of this substance. Probably the mode of action of alcohol as a cause of paraplegia is very nearly as general and ill-defined, yet Dr. Wilks goes so far as to speak of an ‘alcoholic paraplegia,’ resulting from excesses in spirit-drinking. Alcohol, like many poisons, when taken in undue quantity, may deteriorate the nutrition of the body generally; it may spoil the integrity of its more delicate tissues, and thus interfere with the discharge of some of its finer functions. In this way, through general spoiling and degeneration, the way may be led on to the development of special changes favouring paralysis, now in this and now in that part of the nervous system. If either one of a group of possible morbid changes, induced upon such a basis, chances to affect principally the lower part of the spinal cord, a paraplegia may be induced. The principal justification, however, for speaking of such a state as an ‘alcoholic paraplegia,’ probably lies in the fact that here (as indeed in all cases of toxic para- lysis) the first therapeutic indication is to be found in the renunciation of the harmful agent. The notion has recently been advanced by Moxon, that a certain class of poisons, which own the common property of being ‘ depres- sants of the circulation,’ have a tendency to paralyse the hind legs rather than the fore legs of animals. In this group are included aconitia, conia, and — doubtfully — veratria, chloral, and prussic acid. He is of opinion that these drugs act by causing further impediments ‘ to the ex- ceedingly and peculiarly difficult blood-supply of the caudal end of the spinal cord’ ( British Medi- cal Journal , April 2,' 1SS1, p. 498). It should be borne in mind that extreme feebleness of blood- current is of itself a common cause predisposing to the occurrence of thrombosis both in arteries and in veins, and that such a condition may intervene in some of these cases of poisoning, and lead to the development of paraplegia. This would enable us to account for the otherwise inexplicable fact of the maintenance of the para- lysis long after other effects of the poison have passed away. H. Charlton Bastian, SPINAL IRRITATION". — Syxon. ; Ra- thialgia ; Fr. Rackialgie ; Ger. R'uckgratschnicrz . Definition. — Notwithstanding the doubts that have been entertained by many authorities, both SPINAL IRRITATION. 1499 British and foreign, spinal irritation is an affec- tion which has a real existence and deserves a special name. Although spinal irritation maybe, like other affections, allied with, or caused by, various organic or functional nervous diseases, the name ought to be kept for a special spinal complaint, chiefly characterised by a morbid excitability of the sensitive nerves of the spine, manifesting itself by spontaneous pains, and by tenderness under pressure, or when the affected parts are moved. AEtiology. — Rachialgia is more common in certain countries than in others— more so, par- ticularly, in Great Britain, Ireland, and the United States than in Continental Europe. This probably accounts for the fact that this affection was first studied and described by a number of Irish and American writers. Sex is an impor- tant setiological element : out of 304 cases col- lected by the two Griffins and by Hammond, there were only forty-two men. The writer has seen it in three men only out of more than fifty cases. It occurs chiefly in girls between fifteen and twenty-five. As regards other causes the most important are: — excessive walking or driv- ing; violent movements of the spine, or a blow upon it; abuse of sexual intercourse ; masturba- tion ; and severe diseases, such as typhoid fever, scarlatina, fever and ague, dysentery, and diph- theria. Anatomical Characters and Pathology. — In simple rachialgia there is no organic altera- tion that the naked eye can see, or the microscope can show. At most a congestion is sometimes found. Still organic affections of the spine and its fibrous tissues may give rise to the functional affection we are now studying, so that a necropsy may show pathological alterations of various kinds in the fibrous and bony tissues of the spine. As regards the physiological pathology of spinal irritation, the symptoms belong to two distinct groups, one composed of local morbid manifestations, and the other of those which are distant. As regards the first of these groups, it in- cludes. tenderness and the various kinds of pain ; there is, in a measure, similitude between the symptoms and those of neuralgia. The tender- ness especially is often similar to that which is detected in some points of a nerve attacked with neuralgia. Still there are differences (especially as regards the kinds of pain) which prevent a complete assimilation of rachialgia with a com- mon neuralgia. The group of symptoms appear- ing at a distance from the spine, is composed of reflex or direct effects of irritation of the spinal nerves. Among these symptoms we find referred sensations, muscular spasms, increased tonicity, contraction of blood-vessels, trembling, altera- tions of secretion and nutrition, inhibition of the heart, &c. Dr. Quain communicates to the writer his con- viction that spina] pain and tenderness exist more often as transmitted or referred phenomena con- nected with morbid states of the mucous mem- brane than is generally recognised. Thus he finds pain present over the posterior cervical region in cases of congestion or follicular disease of the mucous membrane of the pharynx and adjacent parts. In the dorsal region the like pains and tenderness are constantly found in cases of gas- SPINAL IRRITATION. 1500 trodynia, associated, it may be, with morbid states of the mucous membrane of the stomach. In the lumbar and sacral regions similar condi- tions are traceable in connexion with disordered states of the mucous membrane of the intestines, or of the urinary and genital organs. As we find extreme sensitiveness of the retina in cases of disease of the conjunctiva — or as we find pain at the end of the penis in cases of stone in the bladder — so may we have many of these other reflex or referred troubles in connection with distant disorders. Symptoms. — Spinal tendcmesi. — This is the essential and only constant feature of rachialgia. Its existence, however, might not he found out if questions were merely asked, or a cursory examination were made, as the symptom may be slight and localised in one vertebra, and the patient may not he aware of its presence. It may be found in any part of the spine, and cor- respond to only one, to many, or even to all of the vertehrse. "When very limited, tenderness exists more frequently at the lower part of either the dorsal or the cervical regions, less often in the latter. The symptom is elicited in two ways — by pressure or movement. "When the ten- derness is slight, pressure will succeed in show- ing its existence, while a movement might prove ineffectual. It is essential to he extremely cau- tious in making pressure, as not only a consider- able and lasting pain may result from sudden and great pressure, hut very serious convulsive paralytic or psychic manifestations may be pro- duced. The writer has seen cases in which attacks of catalepsy, of tonic, clonic, or choreic movements, of temporary (and in one case of prolonged) paralysis of the lower or upper limbs, of exophthalmos with mental disorder, &c., had been caused by heavy pressure on the cervical or dorsal vertebrae. Usually the place where pres- sure gives rise to the greatest pain is the spi- nous process. Sometimes, however, the disorder is unilateral, and then the seat of greatest tender- ness is the transverse process. Very frequently myalgia co-exists with rachialgia, and then the muscular masses so attacked, on one or on the two sides of the spine, are very tender under pressure. There is often hyperaesthesia of the 6kin itself, and the writer found this so great in one case that any unexpected touch, or even a gentle breath of air on the skin, made the patient (a strong and courageous man) scream out. The tactile hyperaesthesia in that case was so great that the two points of the aesthesiometer, which on the spine are felt by a healthy person only when distant one from the other at least an inch and a half, were distinctly recognised when distant less than a line, that is, when almost touching each other. In a number of cases sensi- bility is morbidly increased in every nerve-fibre of all the tissues of one or more vertebrae and of the neighbouring parts. There is no absolute relation between the pain caused by pressure and the constant spontaneous pain existing in many cases, as there may he considerable ten- derness without any, or with very little, spon- taneous pain, and there may he only moderate tenderness although a constant or almost con- stant severe pain is complained of. Tenderness is often discovered by movement of the spine performed voluntarily or involun- tarily by the patient, or produced, for diagnosis’ sake, by the physician. Generally, however, the pain thus generated is somewhat different from that due to pressure on the spiuous processes, and is chiefly, if not only, sn increase of the constant spontaneous pain. Pains referred to the periphery of the body, or to internal otgans. are often associated with local tenderness developed by pressure. These transmitted pains, as well as the local pains caused by pressure, may last for hours — nay, for days, showing how carefully the examination for tenderness should be made. It is well, when we have to deal with hysterical or timid patients, to judge of the degree of tenderness more from the sudden and involuntary movement of the spine, when we press upon it, than from the patient’s statements as regards the degree of local or referred pains felt. The amount of blushing of the face when a tender spine is pressed upon, is also a means of appreciating the degree of ten- derness, especially when the affected part is in the lower third of the cervical region, or the upper third of the dorsal region. Spontaneous spinal pain. — This symptom is less important than tenderness, because it is not constant, and also because it often exists in organic spinal complaints. It is increased in most eases by pressure on, or by movement of, the spine. According to Dr. Hammond’s obser- vation it is found in about one case out of three of spinal irritation. The writer believes that its frequency is much greater. It is quite vari- able in its character and degree. It may con- sist only or chiefly in a feeling of heaviness, of coldness, of heat, of pricking, or of itching. In many cases it increases, and in some it de- creases, when the sitting or standing posturo is assumed. Lying flat on the back usually diminishes, but sometimes increases it. Its seat is generally at the point where the spinal nerves emerge from the spine, resembling in this re- spect a neuralgic pain. Visceral functional disturbances. — Rachialgia is often followed or accompanied by various func- tional disorders, more or less directly caused by it. The stomach and the heart are the parts chiefly affected ; but other viscera (the liver, the kidneys, or the bowels) are also sometimes af- fected. Vaso-mofor disturbances. — These may appear anywhere, but the face exhibits them more often and more intensely than other parts. They con- sist chiefly in alternations of great paleness and flushing. 'Motor disturbances. — A fixed contraction of some muscles, especially in the fore-arm, has beeu pointed out by Mr. Teals. Dr. C. B. Radcliffe says that this contraction does not disappear during sleep. This slight rigidity increases when an effort is made to loosen it, A great variety of other motor disturbances may ap- pear in this affection, as will be mentioned here- after. The symptoms of rachialgia necessarily vary with the different regions of the spine. 1. Cervical Region. — Spinal irritation in very frequent in this region, although less so than in the dorsal. Of 301 cases collected by the two SPINAL IRRITATION. Griffins, and by Dr. Hammond, the affection was confined to the cervical region 71 times, and it occupied parts or all of the cervical and dorsal regions in 82 cases. More than elsewhere, pres- sure on the spine, when the disorder is in the neck, will produce referred sensations. For in- stance, pressure on the two upper vertebrae may cause pain in the forehead; pressure on the third and fourth vertebra a pain in the pharynx ; and on the last cervical a pain behind the sternum. According to the best observers, especially Still- ing and the two Griffins, the following symp- toms have been noticed in eases of cervical spinal irritation: vertigo, headache, psychical disturbances, insomnia, nightmare, neuralgic pains in the head, face, neck, shoulders, chest, and upper limbs, contraction of flexor muscles in the fore-arms, clonic spasms, fibrillary move- ments in the shoulders and arms, disturbances in phonation and deglutition, dyspnoea, spas- modic cough, fainting, and palpitation of the heart. 2. Dorsal Region. — This is the region most frequently attacked, although the united statis- tics of the brothers Griffin and Dr. Hammond do not clearly establish this point. The stomach is the principal seat of disturbance in dorsal rach- ialgia. It shows its irritation by pain, pyrosis, eructations, nausea, and vomiting. Palpitation of the heart is not rare ; but dyspnoea and cough are less frequent than in cervical rachialgia. So are neuralgic pains, involuntary movements, and tonic spasms. 3. Lumbar Region. — Rachialgia is rarely localised in the lumbar region. Dr. Hammond has seen it fifteen times, and the two Griffins thirteen times. The writer has only seen it four times out of more than fifty cases. It manifests itself or is accompanied by the following symp- toms : neuralgia in the lower limbs, myalgia in the lumbar and abdominal regions, painful spasms of the vesical or anal sphincters, uterine and ovarian pains, with or without menstrual dis- turbances, disorders of motility, such as tonic or choreic movements in the lower limbs, pseudo- paraplegia, &e. 4. General Rachialgia. — It is assuredlyquite rare to find every vertebra tender. The writer has seen it but twice. But it is not so rare to find cases in which almost every part of the spine is affected. The two Griffins have seen it in fifteen cases out of a hundred and forty- eight. Hyperasthesia is then usually greater than in localised rachialgia. The pains produced even by the gentlest pressure on one spinous process usually extend to the whole vertebral column. The various symptoms pointed out as due to localised spinal irritation are present liere together, and show themselves in the four limbs, the head, the neck, the trunk, and the internal organs— especially, however, in the heart and the stomach. Diagnosis. — The symptoms of spinal irrita- tion are so characteristic that it is only in cases of complication of this affection with another that doubts might arise. A sprain of the spine, intense congestion of the cellular tissue and of the muscles, and inflammation of the parts close to the spine, involving the fibrous tissue binding together the vertebra, and due to some trau- 1501 matie cause, will certainly give origin to the local and sympathetic symptoms of spinal irritation, together with those due to inflammation or con- siderable congestion. There cannot be a mistake. Two distinct morbid states, then, follow a blow or some other traumatic agency on the spine. In the same way we find hysteria co-existing with spinal irritation. Indeed, it is extremely rare to find that hysteria, beginning by any symptom, will not soon be accompanied by some degree of spinal irritation; and, on the other hand, in almost all cases of genuine spinal irritation, more or less marked hysterical symptoms will appear, so that these two affections almost, always are, at least partly, blended together. The sin- gular and rare affection described by Trousseau under the name of tetany , can hardly be mis taken for rachialgia, not only because the most important symptoms of spinal irritation are ab- sent or very slight in tetany, but also because in this last aftection the muscular contraction is generally accompanied by trembling, anaes- thesia, and a feeling of great fatigue. Tetanus, and the organic affections of the spinal cord and its meninges may be put aside, as although there may be 'spinal tenderness in some of those affec- tions, especially in meningitis, the other symp- toms clearly establish their existence, and not that of mere rachialgia. The same may be said of Pott's disease, or other morbid structural alterations of the vertebra. Prognosis. — It is impossible to agree with those physicians who take a light view of spinal irritation. If an American practitioner has, as he states, cured 133 patients out of 156, he has been exceptionally fortunate. Although a cure can often be obtained, and sometimes very quickly, this affection, when at all powerful, will frequently resist treatment, or reappear after a temporary cure. The writer would say, he, rever, that many patients refuse to submit to the most energetic means of treatment, and that, there- fore, we cannot know what would have been their fate under better means than those used. Still, death is never caused in a direct way by this affection. Its worst feature is that it ren- ders the patient most miserable from pains, weak- ness, and the various functional disorders it pro- duces. Treatment. — In this affection, as well as in all functional disorders, anaemia exists so frequently, and participates so certainly in the production, or at least in the persistence, of the symptoms, that the writer can easily accept the statement of some physicians, that certain remedies, such as iron, quinine, the mineral acids, alcoholic stimu- lants, cod-liver oil, arsenic, andnux vomica, have been used successfully against rachialgia. Indeed, some of these means — one or another, according to special circumstances — ought almost always to be used. The writer’s own experience does not confirm that of Dr. Hammond as regards the beneficial effects he attributes to zinc. Internal remedies taken by the mouth are certainly less important than external ones, or medicines used by subcutaneous injection. As regards this last means there is no doubt that injections of morphia or atropia under the skin, especially when made near the focus of pain or tenderness, are of great service, not only for a time against 1602 SPINAL IRRITATION. these symptoms, but also frequently against the affection itself. The writer employs with more benefit the following substances together than one of them alone in such cases, as well as in cases of neuralgia : sulphate of morphia, from § to | a grain, sulphate of strychnia, from jb to L- of a grain, and sulphate of atropia from ^ to ^ of a grain, beginning with the minimum dose, and reaching quickly the maximum one, if the increase can be borne. When the pain or tender- ness is localised in a small part of the spine, the writer has obtained great relief from the use of an ointment of aconitia, two grains ; veratria, four grains; and lard, two drachms. Every counter-irritant, including galvanism (if we can look upon it in such a way), has been used with benefit in some eases. Applications of ice and of the actual cautery will be found to be the best. Ice may be employed, finely pounded, as a kind of poultice, applied on a large surface and cn the bare skin, or in frictions on the two sides of the spine, and by either process only for three to six minutes, twice a day. If there be no success by these means, the application of a very hot piece of flannel on the principal seat of pain is advis- able, followed after five minutes by the applica- tion of ice according to one or other of the two above methods. When the whole spine is tender or painful, each of its three regions should be treated, one after the other. Next, if not first in importance, is the use of the actual cautery, after the following rules : — First, the instrument must be at white heat ; secondly, it must have a very small surface; thirdly it must be applied quickly although firmly ; fourthly, it must make, on each day of application, three or four cauterisations on each sideof the spine, and these irritations must extend over two or three inches in length ; fifthly, the operation is to be re- peated every day for eight or ten days, care being taken that the instrument be passed each time on unaltered skin. The writer uses a Paquelin cautery, with which there is, on account of the above rules, neither great pain nor a sore pro- duced. The outer layer of the skin dries up and becomes brown, but there is no blister or ulcer or purulent discharge. This is a most valuable means ef treatment, especially when the pain and tenderness of the spine are intense. If all the means already mentioned have failed, or even when they have not been tried, and when the patient is attacked in a great extent of the spine, and is quite submissive and willing to do as she is told, absolute rest of the tender and painful parts is to be employed. In Hilton’s valuable work on Rest and Pain , the rules are given which must be followed in such cases. The words absolute rest express exactly what is needed. It would be worse than useless to make a patient with spinal irritation lie down, and stay in bed for two, three, or four weeks, if he or she were allowed to turn in bed, or to move the spine at all at the affected part. If the rest of the part is really absolute and constant, a cure is almost always obtained after a few weeks. So long as the difficult treatment lasts, every attention must be paid to the nourishment, to the state of the bowels, and to the occupation of the mind of the patient. It need not be said that Other means of treatment (especially subeuta- SPINE, DISEASES OP. neous injections against pain), are to be used during the period of rest. Fresh air must be admitted to the room as far as the season allows. The muscles of the limbs (which are to be left without voluntary movement) are to be gently galvanised several times a day. so as not only to improve their nutrition, but to act also on the general circulation of the blood. On getting out of bed, when it is ascertained that both pain and tenderness have disappeared from the spine, the patient must for a time (a week or more) be most careful to avoid moving the parts much which have been affected. The writer cannot con- clude this article without referring the reader to a lecture of one of the ablest physicians of oor time, Dr. S. Weir Mitchell, of Philadelphia, in which rules not essentially different from the above are given. See ‘Rest in the Treatment of Nervous Disease,’ in A Series of American Clini- cal Lectures, vol. i. No. 4, New York, 1875. C. E. BrOWN-SeQU A RD. SPINE, Diseases and Curvatures of. — Synon. : Fr. Maladies et Courburcs du Rhachis ; Ger. Krankheiten and Kriimmungcn des Riick- grates. General Remarks. — T ho vertebral column isa complex anatomical structure, consisting of large masses of bone, chiefly cancellous, forming the bodies of the vertebrae ; large flat discs of fibro- cartilage placed between the bodies of the ver- tebra; ; and connecting ligamentous structures. On either sideof, and behind the vertebral canal, in which the spinal cord is placed, are the ob- lique articulating, and the spinous processes, with which are connected the large group of muscles, whereby the various movements of the spinal column are regulated, and the erect posi- tion of the body maintained. All these structures are liable to special forms of disease, such as are met with in other parts of the body where similar structures exist. Hence a certain analogy may be traced between the most ordinary forms of disease which c.oa ir in the spinal column, and the joint-diseases of the ex- tremities ; but the absence of articular cartilage and synovial membrane between the bodies of the vertebra, destroys much of the analogy Nevertheless, in the ordinary form of disease ot the spinal column, or ‘ Pott’s disease,’ we havo as its chief characteristics, caries and necrosis of bone, with ulceration of the intervertebral car- tilage, accompanied by suppuration. The liga- ments are, as in other parts of the body, especially liable to the rheumatic form of inflammation. The muscles are especially liable to paralytic and spasmodic affections, such as occur in the muscles of the extremities, and other parts of the body. The spine is also very liable to various forms of curvature. Other forms of disease, such as tubercular deposits, cystic and malignant growths, are occasionally met with, but do not require special description in con- nection with the spinal column. The diseases of the spinal cord and its membranes are described in other articles. The only affections, therefore, which demand special consideration in this place are (1) Potth Disease ; and (2) Lateral • Curvature. 1. Pott's Disease of the Spine. — S ynon.: SPINE, DISEASES AND CURVATURES OP. 15t3 Spinal caries ; Fr. Mai vertebral de Pott ; Ger. Pott’sche Krankkeit. Definition. — A destructive disease of the 6pinal column, depending upon ulceration of the intervertebral cartilages ; generally associated with caries and necrosis of the bodies of the ver- tebra ; and named after the distinguished sur- geon Percival Pott, who first described its pa- thological characters. Anatomical Characters. — The disease may commence either in the intervertebral cartilages, or in the bodies of the vertebrae. In the majority of cases ulceration of one or more interver- tebral cartilages occurs, as the result of subacute inflammation ; and the adjacent surfaces of the bodies of the vertebra become destroyed by caries and necrosis. When the disease com- mences in the bones, primary necrosis occurs in one or more of the bodies of the vertebrae, as it is observed to do in other situations where cancellous bone exists in large masses. In a later stage, the osseous and cartilaginous struc- tures are all involved in the destructive pro- cess, and a chasm is formed in the anterior part of the spinal column, which subsequently be- comes bent upon itself, the spinous processes projecting posteriorly so as to produce the dis- tortion described as angular curvature of the spine. The angular form of tbo projection is most marked in the dorsal region, in consequence of the natural curve of the spinal column in a posterior direction, and also from the length of ihe spinous processes. In the cervical and lum- bar regions an opposite condition obtains, and an obtuse posterior, rather than angular, projec- tion occurs ; and this may be absent, even in cases ot' extensive disease. If the case proceed favourably towards a curative termination, the destructive processes become arrested, and a healthy reparative pro- cess is established, terminating in bony anchy- losis between the bodies of the vertebra, which have become approximated after the loss of structure. Ossification also proceeds along some of the ligamentous structures passing between the laminie, as well as between the spinous pro- cesses. Thus the resulting angular, or posterior, projection becomes a persistent deformity — a deformity essential to the cure of the case. IEtiology. — Pott's disease of the spine may be either of local or of constitutional origin. When local, it results from injury, and the vio- lence may be either direct or indirect. Cases traceable to direct violence are of more frequent occurrence in adult life, for instance, the fall of earth from the roof of a tunnel upon the back of a man, in the stooping position ; the fall of a sack of wheat upon the back of a person passing under it ; or a fall from a ladder. The evidence .of direct injury is not so easily obtained when the disease occurs in childhood, but occasionally we see spinal curvature deve- loped in robust and healthy children, who have never had any previous illness, and whose family history is unexceptionally good. In such eases we can hardly doubt that some slight accident, met with in boisterous play, must have been the immediate cause of the disease ; and, in some in- stances the writer has obtained undoubted evi- dence to this effect. The immediate symptoms are slight and transient, but in the course of a few months conclusive evidence of the existence of disease is developed. Indirect violence frequently gives rise to Pott’s disease of the spine, and in all probability lays tbe foundation of the mischief in the greatest number of cases, although the accident, as a pro- ducing cause, cannot be traced in every instance, especially when the disease occurs in childhood, as it most frequently does. The kind of acci- dent alluded to is a rick or twist of the spine, as, for example, when a child imitating the clown in a pantomime, turns head over heels, or when a boy is taken up by the arms, and swung round by a man on to his back in play. The latter occurred to a boy who was for several years under the writer’s care; the immediate symptoms were not severe, and passed off in a short time, but disease of the spine was gra- dually developed, with external abscess, through which portions of necrosed bone came away; the boy ultimately recovered. A fall out of bed has frequently been known to lay the foundation of spinal disease, and in many of these accidents there is no evidence of direct injury to the spine. In young adults, a rick or twist of the spine received in wrestling, and in the rough game of foot-ball, or by a fall from a horse, has been known to precede the development of disease without any direct blow upon the spine. In all these cases, the injury done to the articulation is in all probability hy laceration of the ligaments, just as in severe sprains at the knee and ankle- joint; and when such an injury occurs in a person of marked strumous constitution, the destructive inflammatory processes of ulceration and caries usually follow, as they do at other articulations, when both local and constitutional causes are combined. When of constitutional origin, disease of the spine is generally developed in children in whom we have sufficient evidence of a strumous consti- tutional condition, frequently associated with a consumptive family history; still cases are often met with where we have no such indications, but in which the disease has been developed during a condition of induced constitutional debility, that is, after an attack of scarlet fever, measles, or whooping-cough. In this class of cases we have the absence of any history of a local in- jury, either direct or indirect, and the disease appears to depend essentially upon the constitu- tional condition of the patient. Symptoms and Diagnosis. — 1. Early stage. During the early stage of Pott’s disease of the spine, that is, before the production of angular curvature — a stage which usually occupies a period of from six to nine months — the symp- toms are often so ill-defined, that an accurate diagnosis cannot be formed. Turn symptoms, namely, pain on motion, and pain on percussion over the spinous processes, have been too gene- rally relied upon as indicating the existence of disease ; but both these symptoms are frequently absent when disease exists, and are also pre- sent in an exaggerated form when there is no disease, so that their diagnostic importance is uncertain. Still, when present in conjunction with other symptoms, they are often of mate- rial diagnostic Talue. A certain amount of fixity SPINE, DISEASES AND CUEVATUBE3 OF. 1504 in a portion of the spinal column, that is, a want of flexibility in the stooping position, is of importance as showing a condition of reflex mus- cular contraction, similar to that which exists at tho hip- and knee-joints, in the early stage of disease. There are some regional peculiarities of impor- tance in reference to diagnostic symptoms ; and the special symptoms present, with more or less distinctness in different regions, may be grouped in two classes, namely— (а) Pain occasioned by certain movements, in which particular muscles attached to the ver- tebrae which are the seat of disease, are called into play ; and pain occasioned by percussion over one or more spinous processes. (б) Attitudes assumed by the patient to avoid piain on motion. In the upper cervical region, a constrained and fixed position of the head, to avoid pain on motion, always exists in the early stage of spinal disease; and the child finding a difficulty in keeping the head in the erect position, acquires the habit of supporting the chin by the hands, the elbows frequently resting on a table or chair. This attitude is of great diagnostic value. Occa- sionally in this region the disease is ushered in by obscure cerebral symptoms, resembling those of subacute meningitis. In the lower cervical and upper dorsal regions there are no very distinctive symptoms, but in children there is not unfrequently a troublesome cough, sometimes supposed to be a mild form of whooping-cough, probably depending upon irri- tation of the recurrent laryngeal nerve. In the middle dorsal region the absence of symptoms in the early stages of Pott’s disease is most marked, probably from the comparative immobility of this portion of the spinal column, motion in any direction being very limited; and probably also from the absence of any muscular attachments to the bodies of the vertebrae. Local piain, and pain on percussion, are sometimes present. The patient moves about slowly and cautiously, and sometimes sits with the arms extended, the hands resting on a chair, to re- lieve the spine of the superincumbent weight and the effect of pressure at the seat of disease, as well as to assist in breathing. In the lower dorsal and upper lumbar regions , the early stage of disease is characterised by pain experienced in the various movements in which the psoas muscles are brought into play, such as the stooping position, putting on stock- ings, lacing boots, or lifting even a light weight from the ground ; the act of going up and down stairs; any attempt to rise suddenly from the horizontal to the sitting or standing position, especially in the morning after a night's rest ; any attempt to twist the body round suddenly when lying down, as in the act of turning suddenly from the back to the stomach. In this region also may be mentioned as a diagnostic symptom the attitude assumed by the patient in the sit- ting position, as described in the cervical and upper dorsal region. 2. Advanced stage. — In the second stage of Pott’s disease, that is when angular curvature is developed, any previous difficulties of dia- gnosis which may have existed are cleared away, and we know the disease has existed probably from six to nine months, and that a loss of substance in the intervertebral cartilage and bone has occurred. But exceptional cases, ip which diagnosis may be doubtful, occasionally occur in two situations, namely, when a posterior projection of the spinous processes takes place, either of the seventh cervical and first dorsal vertebrae, or of the eighth or ninth dorsal ver- tebrae — situations iu which it may be said that-a spurious form of angular curvature may exist, as an exaggerated condition of the naturally prominent spinous processes existing in these situations. The projection of the spinous pro- cesses may he accompanied with such symptoms as local pain on pressure or percussion, pain ex- tending along the shoulders and down the arms, leading to the suspicion of the existence of dis- ease. When occurring in girls, the symptoms in these cases are generally due to hysteria ; but as in some cases disease is subsequently developed, the diagnosis should he. cautiously given, and any treatment based upon it cautiously fol- lowed out. The projection of the spinou6 pro- cesses of the seventh cervical and first dorsal vertebrae may often be traced to a natural con- formation and family peculiarity, as we see in some short-necked and round-shouldered girls. This condition often occurs, in a more marked degree, in adults, and is increased by a thicken- ing and hypertrophied condition of the cellular tissue, possibly also by fluid in a bursa ; in such cases the neuralgic pains which accompany it are due to a gouty or rheumatic-gouty tendency. Course, Duration, and Terminations. — The progress of Pott’s disease of the spine is extremely variable, hut as a general rule, within a period of from six to nine months from the commence- ment, angular curvature is produced. If the case proceed favourably, without external abscess or paralysis, the disease becomes arrested, and bony anchylosis takes place in about three years. When abscess and paralysis occur, the period of recovery is frequently prolonged to five or seven years. The subject of psoas and lumbar abscess will be found treated of elsewhere. See Lumbar Abscess ; and Psoas Abscess. Becovery from the incomplete form of pa- ralysis which occurs in these cases, usually takes place in about two years. When the disease does not terminate favourably in bony anchy losis, death occurs ; usually preceded by abscess, paralysis with meningitis, and inflammatory softening of the cord. In children the mortality is probably about one in twenty, and in adults about one in five cases. Prognosis. — The prognosis in Pott's disease of the spine will be much more favourable in children than in adults, but in both it will be unfavourable in proportion to the rapidity with which the disease pursues its course, and also in proportion to the evidence of a strumous or tubercular diathesis; a large proportion of cases occurring in children and young adults having a phthisical family history. Treatment. — The treatment of this disease must be both constitutional and local. The con- stitutional treatment is of importance, because in a large number of cases in which this disease occurs, there is evidence of a strumous or tuber SPINE, DISEASES AND CUKVATUKES OF. 130fi *nlar diathesis, indicating the exhibition of cod- j'ver oil 'with hypophosphite of lime, iron, and other drugs of the same class. The local treatment, especially, varies very much according to the age of the patient and the region in which the disease is seated, the prin- ciples being essentially recumbency, counter-irri- tation, and mechanical support. With regard to the local treatment in the first stage, that is, pre- vious to the production of angular curvature, a stage which usually lasts from six months to a year, if the disease can be diagnosed, absolute recumbency should be insisted upon ; and coun- ter-irritation in some form or other, such as by blisters, the actual cautery, issues, or moxas, is also generally useful. Mechanical support to the spine in any form is not indicated in this stage. In the second stage of the disease, that is, when angular curvature has taken place, absolute re- cumbency should still be insisted upon for a pe- riod of from one to two years from the probable date of the commencement of the disease. This is more especially necessary when disease occurs in the cervical or upper dorsal regions, as there is not only a greater tendency to paralysis, and danger to life in this situation, but when dis- ease takes place in the upper dorsal region, and recumbency is not carried out, the ultimate de- formity is always much greater than it need be. Absolute recumbency contributes not only to the arrest of disease, but to a diminution of the ultimate deformity. When this disease occurs in infancy, or in young children, in any region, absolute recum- bency must be insisted upon, the child living and being carried about in a spinal tray made of basket-work with a mattress inside. When dis- ease occurs in the cervical or upper dorsal re- gion, extension by the head may be combined with absolute recumbency, and this was first introduced by Mr. Fisher, who used a rack-and- pinion extension movement. The writer has adopted this principle with great advantage in a case of cervical caries, with partial paralysis, but he employed the weight and pulley attached to the upper extremity of the plane on which the patient was kept day and night. As the case improves, in the course of one or two years, partial recumbency with mechanical support, that is, recumbency for about half the day, may be substituted for absolute recumbency, and this is especially applicable to cases of disease occurring in the middle and lower dorsal regions, when the disease is not extensive, and appears to be running a slow or chronic and favourable course. As to the kind of support, a piece of thick gutta-percha applied and moulded to the back, whilst the child is lying on its stomach, and retained by a bandage passed round the body, answers very well for hospital practice. A better kind of support is made of thick leather, blocked on a plaster of Paris cast of the back, with elastic in front. The plaster of Paris jacket applied during suspension, introduced into this country by Professor Lewis Sayre of New York in 1877, is very useful, espe- cially in hospital practice, where any rules laid down are certain to be disregarded. The principle of applying a form of support to the 95 spine during the progress of disease, whilst the patient is suspended by the head, is novel, and has been very useful, but must be employed with caution. It secures immobility, relieves un- due pressure, and diminishes the consecutive or compensating curves, in many cases to a greater extent than can be accomplished by horizontal extension ; and plaster of Paris is a very useful material for the purpose, easily obtained, and can bo applied by any surgeon. The disadvan- tage, however, of not being able to remove it foi washing purposes is very great, and the liability to the production of sores from pressure and friction, is also an objection to its use. The material which has now to a great extent su- perseded the plaster of Paris is the poroplastic felt, which is applied, when softened by steam, whilst the patient is suspended, and being buckled on in front, can be removed as often as required. Partial recumbency with mechanical support, in some modified form, must be continued in all cases occurring in childhood, long after disease has ceased; and in some cases, in which the re- sulting deformity threatens to be considerable, even until the completion of growth. 2. Lateral Curvature of the Spine. — Defi- nition'. — A deformity or contortion of the spine, in which the bodies of the vertebra deviate laterally in a horizontal direction, with or with- out a corresponding deviation of the apices of the spinous processes. TEtiology. — The causes of lateral curvature are both local and constitutional, and as one or other of these causes may predominate, so the cases admit of being arranged in three classes. Class 1 .— Cases in which the constitutional largely predominate over the local causes. Class 2. — Case3 depending upon constitu- tional and local causes in about equal degrees. Class 3. — Cases essentially depending upon local causes acting mechanically, so as to disturb the equilibrium of the spinal column. In cases belonging to the first class the spinal curvature generally occurs under twelve years of age. Occasionally it is met with as a congenital affection. Many cases occur in infancy or early childhood, that is, under three or four years of age; but the majority between seven and ten years of age. "When congenital, spinal curvature is sometimes associated with osseous malforma- tion, but it also occurs without any such compli- cation. The cases included in the first class can frequently be traced to an hereditary predisposi- tion, lateral curvature occurring in two or three generations, and several members of the same family are frequently affected. The children usually exhibit signs of constitutional debility, and the local causes of curvature cannot be traced, except in infancy, when the children are nursed always on one arm. In the second class the spinal curvature gene- rally occurs between the ages of twelve and six- teen. Hereditary tendency is not usually trace- able. These cases may be arranged in two sub- divisions, (a) cases defending upon induced con- stitutional or general debility , combined with local causes acting mechanically ; and (b), those clearly of a ricketty character. (a) The local causes are the long continuance of certain bad positions, such as standing or SPINE, DISEASES AND CURVATURES OF. 1506 one leg; the long continuance cf the sitting and stooping position ; sitting cross-legged ; occupa- tions which render the long continuance of some particular position necessary, such as needle- work, book-folding, ironing, nursing children, and carrying heavy weights. ( h ) The second series includes cases of lateral curvature of a rachitic character, associated with the general rachitic conformation of the skeleton. In the third class spinal curvature generally occurs previous to the completion of growth. These cases are essentially unconnected with any constitutional affection or hereditary predisposi- tion, and frequently co-exist with the natural amount of muscular strength. As local causes, in addition to habits and occupations above re- ferred to, may be mentioned the effects of a wooden leg, and inequality in the length of the legs from any cause, such as would disturb the equilibrium of the spinal column. Anatomical Characters. — In the so-called lateral curvature of the spine, the spinal column does not yield in a purely lateral direction, as a flexible column would bend, but presents the appearance of a spiral twist, owing to the bodies of the vertebrae turning round in a di- rection of horizontal rotation, so that their an- terior surfaces are directed laterally along the convexity of the curvature. In a severe case this rotation commonly extends to a quarter of a circle in the centre of the curve, and diminishes from this point to the two extremities, so that the vertebrse, unequally turned upon themselves, cease to correspond in their natural relations to each other. This deviation of the bodies of the vertebras does not necessarily correspond to, nor is it always indicated by, any lateral deviation of the apices of the spinous processes, although such deviation generally exists to some extent. In all cases, however, the internal deviation of the bodies of the vertebrae is much greater than the deviation externally of the apices of the spinous processes. In all cases of confirmed lateral curvature, whether slight or severe, structural changes exist, varying in degree according to the severity and duration of the curvature. The structures affected aro the intervertebral fibro-eartilages, the bodies of the vertebrae, and the oblique arti- culating processes. All these suffer simply from mechanical pressure, arising from the unequal distribution of the weight of the body. The fibro-cartilages and the bodies of the vertebrae suffer from unequal compression in the concavity of the curve, and become more or less wedge- shaped. The articular facets on the oblique ar- ticulating processes, which form the only direct articular connections between the separate bones of the vertebral column, undergo important struc- tural changes at an early period of the formation of lateral curvature, that is, as soon as it becomes confirmed. These articular facets become altered in their direction and aspects, according to the ' extent of the lateral deviation, or rotation, of the bodies of the vertebrse. In the lumbar region, where the articular facets are naturally nearly vortical in direction, looking inwards and out- wards respectively, they gradually assume, in a severe case of lateral curvature, an oblique di- rection, looking obliquely upwards and down- wards. Mr. Alexander Shaw first directed at- tention to these changes in the oblique articulat- ing processes which, as he observes, receive the weight of the body in the act of leaning to one side, and are the only bony structures which check the lateral movements of the trunk ; and when any such position is long persisted in, the articulating processes, which are soft and imper- fectly formed at the age of puberty, become wasted by absorption, as the result of unequal pressure. The joints of the articulating pro- cesses being situated posteriorly as well as late- rally, the spinal column cannot yield in their direction, without wheeling partially round. Hence the rotation of the bodies of the vertebrae becomes confirmed, together with the other structural deviations described. The ligamentous structures, including chiefly the short ligamentous bands passing between and connecting the bodies of the vertebras and the intervertebral cartilages, and also the short articular ligaments connected with the oblique articulating processes, become adapted to the alterations in the bones, and in the articulating surfaces. It is an error to assume that in con- firmed curvature the ligaments are relaxed, and elongated on one side, and contracted on the other, as generally described ■ although in the physiological condition described as ‘ weak spine,' with an inclination to lateral curvature, a con- dition of muscular debility and general liga mentous relaxation undoubtedly exists. The muscles have not been shown to exhibit any structural changes in the early stage of lateral curvature of the spine, except in those rare instances in which the curvature depends upon partial paralysis. In the late stages, or in adult cases of long standing, the spinal muscles havo been found much wasted, pale in colour, and in more or less advanced stages of fatty degene- ration. In the early stages of curvature an increased prominence of the spinal muscles is observed on the convexity of the curve, whether in the dorsal or the lumbar region ; but this does not depend upon any spasmodic or active muscu- lar contraction. The muscles are simply dis- placed, or pushed outwards, by the angles of the ribs in the dorsal region, and the transverse processes of the vertehrte in the lumbar region, which are thus displaced as a part of the rotation movement described. Other structural changes exist in the ribs, which become distorted and altered in shape, so as to lead to deformity of the chest, characterised by a prominence and flattening of the ribs, which become bent at their angles on the side of the convexity — usually on the right side, and a de- pression of the ribs on the side of the concavity. Anteriorly, the symmetrical form of the chest is completely' destroyed ; the sternum becomes very oblique, its lower extremity projecting ; and the cartilages of the ribs corresponding to the side of the concavity of the curve — usually the left — are prominent, and bent upon themselves. The oblique diameter of the chest, therefore, is in- creased, but its capacity is altogether diminished, causing considerable disturbance in the relative position of the heart and lungs, and giving rise to functional derangement of these organs. The pelvis also becomes distorted in lateral SPINE, DISEASES AND CURVATURES OF. curvature, but only in one class of cases, namely, those of rachitic origin, in which the evidence of general rickets is unmistakably present. In all other cases of lateral curvature of the spine, the pelvis is of its full natural size, and well- formed. Symptoms and Diagnosis. — Lateral curvature of the spine is generally supposed to be indicated by a lateral deviation of the apices of the spinous processes, but such deviation may exist either as a functional or as a structural condition. It may be seen in a case of weak spine with muscular debility and ligamentous relaxation, such as is frequently met with in quickly growing girls ; or it may co-exist with' rotation of the bodies of the vertebras in confirmed lateral curvature. The evidence of rotation of the bodies of the vertebrae precedes the lateral deviation of the apices of the spinous processes in many cases, whilst in others the two conditions co-cxist, and appear to take place simultaneously ; but rotation of the bodies of the vertebra may proceed to a considerable extent, the bodies moving horizontally through a quarter of a circle, with only very slight devia- tion laterally of the apices of the spinous pro- cesses. It is therefore the evidence of rotation we must look for in cases of commencing structural curvature, and not the lateral deviation of the apices of the spinous processes. Rotation of the bodies of the vertebrae is always evidenced by a posterior projection of the angles of the ribs on one side, and depression on the other, in the dorsal region ; and a corresponding posterior projection of the transverse processes of the vertebra on one side, and depression of the other in the lumbar region. Upon these condi- tions alone can the existence of rotation of the bodies of the vertebra be determined. Course, Duration, and Terminations. — The progress of lateral curvature is extremely vari- able, tending naturally towards a process of spontaneous arrest in some cases, and in others to a progressive increase, with proportionate de- formity. The course depends very much upon the form and situation of the curvature, especially whether it assumes the character of the so-called ‘ single ’ or ‘ double ’ curve ; descriptive terms which, though not anatomically accurate, are suffi- ciently so for practical purposes. The cases which naturally lead to spontaneous arrest are those in which a double curvature exists, one in the dor- sal, and the other in the dorso-lumbar region, the two curves being about equal in length ; whilst the cases in which a progressive increase of cur- vature and deformity is certain to occur, are examples of the so-called long single curve, frequently involving the whole of the dorsal, together with a portion of the lumbar region, or the whole of the lumbar and a considerable portion of the dorsal region. In cases of double curvature with a marked irregularity in the length of the curves, increase will also certainly occur, but to a less extent than in the long single curves. With regard to the duration and terminations of lateral curvature, these have already been described in the observations made in reference to the course. Prognosis. — The prognosis will be unfavour- able in proportion to the early age at which the spinal curvature commences, and the evidence of 1507 I constitutional causes with hereditary tendency ; and also in proportion to the inequality in the length of the curves, when double, or in cases of so-called long single curves. The prognosis will be favourable in proportion to the absence of these conditions. Treatment. — -For practical purposes all cases of lateral curvature of the spine may be arranged in three classes: — 1. physiological curves ; 2. commencing structural curves ; and 3. confirmed, structural curves. 1. With regard to the treatment of cases in the first class, 'physiological curves , no mechanical treatment by any form of spinal support should be given, but reliance placed entirely upon physiological means, such as gymnastic exer- cises, partial recumbency, and attention to the general health. In some cases an elastic brace attached to stays may be of use. 2. In the second class, commencing structural curves , these form the only curable cases of late- ral curvature, and in their treatment the writer recommends a combination of mechanical sup- port, gymnastic exercises, and partial recum- bency. By this combination of physiological and mechanical means, the further progress of curva- ture will be arrested, and the best opportunity afforded for recovery from such slight structural damage as may have already occurred. 3. In the third class, confirmed structural curves , mechanical support of some kind must be resorted to, and continued during the period of growth, with the hope of preventing increase, and obtaining some improvement in the curvature ; but confirmed lateral curvature, whether slight or severe, with its adapted series of structural changes, is essentially an incurable affection. The most efficient retentive spinal support is that form of instrument made with a pelvic belt, and spring plates attached to vertical bars at the back, without any mechanism requiring alteration by the surgeon. In some favourable cases, the stronger spinal instrument-, with steel plates attached to levers, and adjusted by racli- and-pinion movements, may be used with ad- vantage. Sayre’s plaster-of-Paris jacket has been largely employed in these cases ; but, from what the writer has observed in the practice of others, he disapproves of its application, on the following grounds : that it fails as a curative agent, the gain in height by extension being quickly lost ; that it weakens the spinal muscles by its constant use, and hinders gymnastic exer- cises ; that it restrains respiratory movements, and prevents active exercise ; that it is an unne- cessary restraint at night ; and that it interferes with bathing and cleanliness. Another form of support has been recently introduced — the poro- plastic jacket, which when softened by steam is applied in the same way as the plaster-of-Paris jacket during suspension, and is free from the disadvantages of the latter, as it can be removed at night, or at any time, for the purpose of gym- nastic exercises. It acts as an efficient and light retentive support in many cases of incurable curvature. In this class of cases mechanical support, in whatever form it may be employed, must be combined with partial recumbency' and gymnastic exercises during the period of growth ; but after this period little good will be derived, 1508 SPINE, DISEASES OF. except from mechanical support, when a disposi- tion to increase of curvature exists. When there appears to be no disposition to increase of cur- vature, all mechanical support should he discon- tinued, attention being paid only to the general health. Wm. Adams. SPIRILLUM (dim. of spira, a twist, a curl). This is the name given to the most important of the genera belonging to the tribe of Spiral Bac- teria ( Spirobacteria , Cohn). The three genera of this tribe are closely related to one another, as may be gathered from the citation of the charac- ters by which, according to Cohn, they are to be severally distinguished. He describes them as follows : — Vibrio, ‘ filaments short, light, sinuous ’ ; Spirillum, ‘filaments short, spiral, rigid’; Spiro- chete, ‘filaments long, spiral, flexible.’ The alli- ances between the two latter genera especially are found to be so strong that many naturalists sink the latter generic name, and include all such species under the one genus Spirillum. The interest attaching to these organisms, from a medical point of view, is due to the fact that one of them, as originally discovered by Ober- meier, is very frequently found in the blood of relapsing fever patients, during the first pa- roxysms of the disease (see Relapsing Fever). This organism is generally known as Spirillum Obermcieri, though some speak of it by the name of Spirochete Obermcieri. In length it equals the breadth of 2-5 red blood-corpuscles (see Fig. 88). It is quite indistinguishable in size, Flo. S8. Spirillum Obermeieri, amongst red blood-cor- puscles. (After Koch.) x 700. in general conformation, and in the character of its movements, from another form originally described by Ehrenberg as Spirochete plicatilis, which is to be found in some infusions, in stag- nant fresh or salt water, and (as Cohn has dis- covered) in the mucus about the teeth of some persons wholly free from fever of any kind (see Sobdes). Some regard the presence of Spirillum Obermcieri in the blood as clear evi- dence that it is the cause of relapsing fever; others look upon its existence there as a mere epiphenomenon— believing, as the writer is in- clined to do, that it appears as a consequence rather than as a cause of the morbid processes constituting the fever. 1 H. Charlton Bastlan. 1 Dr. Vandyke Carter of Bombay has of late succeeded In reproducing the disease by inoculation, incertainsmall monkeys. But, for suck a method, there was a large proportion ot failures, viz. six, in twenty-one trials. Dr. SPLEEN, DISEASES OF. SPIRO PITTITE. See Spirillum. SPIB OMETER (spiro, I breathe, and pirpor, a measure).— Synon. : Fr. Spirometre ; Ger. Spi- rometer. Definition. — An instrument for measuring the vital capacity of the chest. Description. — The object of the several in- struments that have been designed for this purpose, is to measure the total amount of air expelled from the chest by the deepest expiration following upon the deepest inspiration. All our knowledge of spirometry is derived from Dr. Hutchinson's exhaustive paper in the Medico- Chirv.rgical Transactions of 1846. The instrument designed by Hutchinson consisted ol a mouthpiece and tube communicating with a gasometer of registered and graduated capacity, into which the patient breathed. A very convenient and accurate spirometer has within the last few years been introduced by Mr. Lowne, which works on the principle of the anemometer. The advantage of this instrument is its portability. Dr. Waldenburg describes and figures, at page 202 of his work Die Pneumatische Behandlung, 4'c., a spirometer identical in principle with Hutchinson’s, but more elaborate, and capable of being employed for the purpose of inhalation of compressed or rarefied air. Results. — The chief results of Dr. Hutchin- son’s labours may he thus summarised. The vital capacity varies according to height, weight, age, and disease. (1) Height. There is an increase of 8 cub. in. in vital capacity for every inch in height between 5 ft. and 6 ft. Thus the vital capacity of a healthy person at 5 ft. to 5 ft. 1 in. being 174 cub. in., at 5 ft. 4 in. it would he 174+ 32 = 206 cub. in. ; at 5 ft 8 in. 238; &c. (2) Weight. Excess in body-weight is asso- ciated with diminished capacity in the proportion of about 1 cub. in. per lb. excess. (3) Age. From thirty to sixty years the vital capacity decreases nearly li cub. in. per year. (4) Disease. The spirometer furnishes a very accurate standard of health or of the extent of disease, as regards the chest, the vital capacity in lung-disease diminishing from 10 to 70 per cent. R. Douglas Powell. SPITTING OP BLOOD.— A popular sy- nonym for haemoptysis. Sec Hjemopttsis. SPLEEN, Diseases of. — Stnon. : Fr. Mala- dies de la Rate ; Ger. Krankheiten der Mila. — In the Nomenclature of Diseases published by the Royal College of Physicians of London, in 1869, the diseases of the spleen are classified under Carter, in reference to this. Eays (Medico-Ctiirvrg. Trans., 1S80, p. 125) : — ‘ The discrepancies indeed, in my experi- ments are marked enough to render it doubtful if the spirillum itself does represent the contagion proper, at. 1 not rather some other agency which at certain periods is associated with it.’ A similar doubt was expressed by Dr. Murchison, who, when referring to the disappearance of the organisms from the blood before the crisis of the fever, their absence during the intermission, and their re- appearance with the relapse.of fever, said (Patti. Trans. 1875, p. 317) : ‘ It seems difficult to account for their appearance and annihilation twice over, except on the supposition that the soil was suitable for their develop- ment during the febrile process and unsuitable whan the febrile process was complete.’ SPLEEN, DISEASES OF. diseases of the digestive system. Hut the spleen, which is the largest of the structures known as • ductless glands,’ is not immediately concerned with the processes of digestion, and its develop- mental origin shows it to be unconnected with the digestive organs, although it lies in the abdomen. Its diseases ought rather to be classified with those cf the other ‘ductless glands,’ namely, the thyroid, the thymus, and the supra-renal capsules. It is now generally admitted that the fimctions of the spleen are intimately connected with the work of sangui- fication, through certain special chemical pro- cesses (metabolic) giving rise to an assemblage of transformations of proteids, associated in some way, still unknown, with the metamor- phoses of the blood-corpuscles. The spleen is most probably one of the seats of formation of the white blood-corpuscles, and of destruction of .he red. It is in fact a blood-lymph-gland ; and the most important indications of splenic disease ire derived from the constitutional state due to extreme anaemia. This anaemia is characterised by the mucous membranes appearing pale and bloodless, the complexion and general surface waxy, earthy-like, or sallow ; there is great debility and gradual wasting, characteristic dys- pnoea, a tendency to haemorrhages, general ana- sarca and dropsy, — phenomena which are due to tho poverty of the blood, justly referable to some morbid condition of the spleen, and now generally recognised by the name of splenic cachexia. Another important function of the spleen, in connection with the other ductless glands, ought not to be lost sight of in the study it' its diseases, namely, that it acts as a diver- ticulum for tho accommodation of a relatively large quantity of the blood, upon which those active metabolic processes take place which con- stitute a special function of the spleen. Its anatomical structure eminently fits it for this. After every meal it is in a' state of more or less congestion or hypereemia, which reaches its maximum about five hours after the taking of ,ood, and it then returns to its normal bulk. Its yielding capsule and its veins, remarkable for their large calibre and great distensibilitv, even when the distending force is small, sufficiently explain the rapid physiological and morbid congestions with which the organ is affected, as well as the rapid subsidence of splenic en- largements. The ductless glands, and especially the spleen, vary so much in magnitude within healthy limits, that it is difficult to state their usual weight and dimensions. The spleen may, however, be stated to range in weight in the adult from four to ten ounces avoirdupois ; but in eases of enlargement weights as high as 18 lbs., 20 lbs., and even 40 lbs. are on record. In atrophic states the writer has weighed it as low as half gn ounce. In relation to the body its normal weight is about 1 to 350 or 400 up to the age of forty ; and as age advances, the rela- tion becomes as 1 to about 700. It usually measures about 5 inches in length ; 3t) inches from the front to the posterior edge; and 1^- inches in thickness. Its bulk averages from 9 J- to 15 cubic inches ; and its specific weight is about 1 0G0. In the following paragraphs the diseases of the 1609 spleen will be shortly noticed mainly in the order in which they have been named in the nomen- clature of the College. 1. Acute Inflammation. — Svxorr. : Splenitis. As a primary affection acute inflammation of the spleen is of rare occurrence in this country. It has been known, however, to result from blows, or other kinds of accidental violence; but such injuries are more apt to cause rupture of the organ. It is mainly to the occurrence of haemor- rhagic infarctions that splenitis is due, with more or less consecutive suppuration. These infarctions occur during the course of contagious fevers ; in blood-poisoning, such as pyaemia ; and in valvular diseases of the heart, where vegetations of fibrin form on the valves, leading to embolism. Such infarctions are generally well-defined accumulations of fibrin in more or less rounded masses when limited and in the sub- stance of the organ, but generally wedge-shaped when involving larger portions. The base of the wedge is towards the periphery, where it may cause an elevation of the capsule, the apex being directed towards the hilus of the spleen. The infarctions vary in size from a pea to a hen’s egg ; and are at first of a dark brown or brownish- red colour, and quite hard. Colour, however, is soon lost, and they become yellowish-white. A margin of acute inflammatory reaction is often well-marked round their boundaries. Under such circumstances the spleen is enlarged, and of a deep purple colour ; its tissue so soft as to be easily broken down — about the consistence of coagulated blood. Pus may form, generally in one or more abscesses containing each a variable quantity ; or the whole spleen may be converted into a bag of pus. Splenic abscesses have been known to open externally, into the left thoracic cavity, the stomach, the transverse colon, and tho cavity of the peritoneum, where circumscribed peritonitis generally forms a limiting sac for tho pus. Splenitis may also terminate by the infarc tion caseating, or becoming a mass of fibro- cellular substance, which, gradually shrinking up, leaves a cicatrix-like contraction on the capsular surface, in which calcification may oc- cur. These fibrinous infarctions in the spleen cor- respond to the areas which mark the terminal divisions of the branches of the splenic arteries, commencing to deposit beyond where they break up into the hair-pencil-like small twigs known as penicilli. Secondary splenitis is generally the result of pyaemia or blood-poisoning, ending in abscess. Such pymmic blocks or infarcts resemble the simply fibrinous infarcts in shape, but they are more irregular, because the process tends to extend beyond the limits of the area of the terminal twigs of the blood-vessels; and they rapidly proceed to suppuration, with inflammation of the capsule of the spleen which covers the base of the infarct, and probably due to its very septic properties. In such eases there seems to be some spontaneous local coagulation of the blood in the splenic vessels — the blood itself being morbid, as in contagious fevers such as typhus — without any evidence of embolism. Symptoms axb Physic at. Signs. — The symp- toms and physical signs of splenitis are mainly due to the presence of, and changes associated with, infarcts. The hyperaemia and inflammation SPLEEN, DISEASES OF. *510 cause tlie whole gland to swell. In cardiac diseases, with embola from valvular vegetations, these infarcts are generally numerous, and the swelling is therefore proportionally great, with tumefaction and some pain in the left side : and probably there is ascites and dropsy. Such splenitis may go on even to suppuration, without marked local symptoms. The enlargement of the spleen — sometimes called ‘splenic tumour’ — can generally be recognised by palpation, aided by percussion. Its form is that of the spleen ex- aggerated ; and the lobulation or notching of its swollen anterior edge can sometimes be felt through the wall of the abdomen, if the patient he thin. The enlarged gland, growing, as it were, out from beneath the ribs on the left side, can sometimesbetraeed extending lowdown, asfaras, and even into, the pelvic region, well over beyond the right side of the lima alba, and backwards towards the spine, where its margin can be separated from the mass of dorsal muscles. Its lower end can also generally be felt as a rounded edge. The tumour is movable in all directions by manipulation, change of posture, and by the act of respiration, when adhesions do not fix it. Weight and uneasiness, rather than local soreness, are present. The splenic cachexia exists ; and there may occur hsemorrhages from the stomach and bowels towards the fatal end of such cases, often so profuse as rapidly to hasten dissolution. Diagnosis. — The diagnosis of enlarged spleen, resulting from splenitis due to one or other of the causes referred to, requires the exclusion of lardaceous disease ; malignant or other tumours about the cardiac end of the stomach or tail of the pancreas ; such swollen conditions of the spleen as exist in Hodgkin’s disease ; an enlarged left lobe of the liver ; and renal, omental, or supra-renal growths. 2. Hypertrophy. — Simple enlargement of the spleen occurs under a great variety of circum- stances ; but true hypertrophy, uncomplicated, and in its simplest form, is a rare occurrence, in which nothing abnormal is to be seen in the spleen or in the blood. Enlargement with hy- peroemia (congestion of the spleen) occurs as a result or concomitant of pyrexia in many specific fevers — notably in enteric and malarious fevers, erysipelas and puerperal fever, pyeemia, and acute tuberculosis. The capsule of a spleen so enlarged appears very tense. The gland feels plump and elastic ; but on section its substance is generally soft, pulpy, almost liquid, very full of blood, and of a dark colour. Sometimes, however, it is so firm that a more or less smooth or coarsely gran- ular surface is shown on section, with an abun- dant new formation of small lymph-cells and nuclei, many of them contained in large mother cells (compound splenic corpuscles), and seen especially in the splenic pulp and vein. This condition constitutes the nearest approach to true hypertrophy, iu which, with an increase in the quantity of diffuse granular matter, the enlarge- ment is' due less to hyperemia simply than to increase of normal structural constituents. Thus the organ may attain two or three times its natural size ; but the enlargement is only tem- porary, and subsides as the pyrexia subsides. Such simple hypertrophy sometimes results from long-continued or mechanical hypersemia, follow- ing any obstruction to the portal circulation, or obstructive valvular disease of the heart. The hypertrophy consequent on malaria being fully described in another article (see Malahia), there only remain to he noticed two special forms of splenic hypertrophy, one named by the College of Physicians as a subvariety — namely (a) leucocyth&mia or leuktemia ; and the other (b) a peculiar enlargement originally described by Dr. Hodgkin, hut which has not been named by the College as a substantive disease. It is, however, an affection which presents such very striking peculiarities, that it requires a distinct appellation and description. a. LeucocythtBmici. — Leucocythsemia is fully described under its own heading; but a brief account may be given of the disease in the pre- sent article. It has a much more extended pathology than is implied by a mere hyper- trophy of the spleen, although the enlargement of the spleen is almost constant. The disease is one sui generis, in which the number of the white corpuscles of the blood is greatly increased, with a simultaneous diminution of the red. It is generally brought about by chronic exhausting diseases, exposure to cold and wet, or such serious acute diseases as typhus fever, pneu- monia, puerperal fever, or affections of the lym- phatic glands ; and it is almost always attended by enlargement of the spleen. The condition is generally associated with cough, diarrhoea, epistaxis, haemorrhagic effusions, and furuncu- lous or pustular eruptions. The increase of the colourless corpuscles of the blood, which with the enlargement of the spleen are the prominent characteristics of this disease, does not seem in any case to have occurred alone. Other and variable morbid states are always associated ; or some change-producing event in the constitution, such as happens during the period of gestation and the process of parturition, precedes or co- exists with the augmentation of the colourless blood- cells. The largest spleens are found ia connection with this disease. There is a true hypertrophy of the organ in all its parts, so that its substance on section appears to be quito natural, although sometimes paler than usual (as all the organs are), and sometimes having a peculiar smooth lustrous appearance. Lymphatic structures also are to be sometimes seen in sepa- rate or conglomerate masses in its substance. These are composed mainly of adenoid tissue, like a congeries of splenic corpuscles or Halpig- liian bodies. The liver is frequently' enlarged and pale. Affections of the lymphatic glands sometimes also predominate ; especially in such cases as Virchow has described, where a lym- phatic diathesis prevails, and there is a progres- sive inclination of the lymphatic system to the formation of lymphatic elements, while lym- phatic gland-tissue tends to grow beyond itspre- existing boundaries. The liver, in such cases, as well as the spleen, contains numerous accumula- tions in whitish granules, or some kind of lymph tissue. This constitutes lymphamia, or the lym- phatic form of leueocythasmia ; the other being the splenic. It may also be associated with an increase in the medulla of the bones. The causes which bring about this form of hypertrophy of the spleen, with its attendant changes in thf SPLEK.Y, DISEASES OF. blood, are yet obscure; still there is sufficient evidence to show that some acute inflammatory processes may lay the foundations of tho morbid state. Tho writer has seen the lymphatic form of the disease follow so conspicuously after expo- sure to cold and wet, as to leave no doubt of the relation of the diseaso to the exposure in the connection of effect and cause, the inflammatory swellings of the lymphatic glands commencing immediately after the exposure. There is also evidence to show that the disease may exist in a latent, masked, or subacute form for an un- known period, till the occurrence of some more acute disease, or change-producing period like child-birth, unmasks the constitutional state, after which the disease rapidly proceeds to a fatal issue. In females four cases out of teu have had their first beginnings rendered obvious after pregnancy. Symptoms. — In the majority of cases intense ‘splenic cachexia’ prevails, with tho usual physical signs of splenic tumour. Weight and fulness of the abdomen are the chief subjective local sensations; but transitory pains are fre- quently experienced there. Ascites and anasarca are usually also present. The surface of the body is pale ; vomiting, diarrhrea, or constipation may prevail by turns ; and jaundice is not infre- quent ; but diarrhoea to a considerable amount is by far the most frequent and dangerous com- plication, and the most difficult to arrest or con- trol. Haemorrhage occurs generally as epistaxis, or from the gums. The course of leueocythae- mia is usually chrome, and an extreme degree of emaciation is the result ; but it is uot till towards the fatal issue that febrile phenomena set in, the type of which is usually hectic. In the diagnosis of this disease it is necessary to examine the blood microscopically, in order to demonstrate the varied increase of the colourless blood-cor- puscles and diminution of the red. A single drop of blood is sufficient for this purpose, most conveniently obtained by a needle puncture of the patient's finger, the resulting drop of blood being examined under a magnifying combination of at least 250 diameters. The colourless cor- puscles will then bo seen to form at least a sixth, a fourth, or nearly a half of the whole number of corpuscles. A proportion of one white to ten red, or even as many as one to three, is not uncommon — an increase which gives to the blood a paler and more opaqiie appearance than is natural. In splenic leuksemia the white corpuscles are larger and more granu- lar than normal. The red corpuscles may be reduced to one half, or one quarter, of the nor- mal amount. As leukssmic blood decomposes, Charcot discovered that it contained microscopic, colourless, elongated, octohedral or spindle- shaped crystals, insoluble in water, but soluble in acids and alkalies, which he and \ ulpian regarded as proteid bodies. Prognosis. — Hitherto no instance of cure is known. All the cases have progressed to a fatal termination in about fourteen months — the mini- mum duration being about three months, and the maximum about four j'ears. Death takes place gradually by asthenia and exhaustion ; or rapidly from htemorrhage or diarrhoea. b. Hodgkin's disease . — Tho other form of 1511 splenic hypertrophy is that which has been de- scribed by the name of ‘ Hodgkin's disease.’ It is also known as lymphadenoma. It is charac- terised by a peculiar white deposit or growth in the spleen, in addition to mere hypertrophy ; which is sometimes also seen in the liver, kid- neys, and lungs. An enormous enlargement of the lymphatic glands throughout the body, accompanied during life by a remarkable anaemia and disposition to subcutaneous oedema, arc usually the earliest phenomena. The groups of glands in the order of their most frequent in - volvement are the cervical, axillary, inguinal, retro-peritoneal, bronchial, mediastinal, and me- senteric. The new growth is at first limited to the glands, blit eventually advances beyond their capsules, so that the enlarged giants be- come confluent in lobulated masses, which may invade and infiltrate adjacent tissues. The dis- ease differs from leucocythsemia in this respect, that there is no marked increase in the white corpuscles of the blood; nor has it anything to do with lardaceous disease. The enlargement- of tbe lymphatic glands appears as the primary affection, and consists in a general hypertrophy of every part- of the glands ; but the exact nature of the defined white bodies which pervade the spleen is not clearly made out. Their growth commences in the Malpighian bodies. They arc similar to what are found in the liver, lungs, and kidneys ; and are composed mostly of lym- phoid or adenoid cells imbedded in the stroma, similar to the structure of a lymphatic gland. See Lymphadenoma. Symptoms. — These are indicative of general ill-health — paleness and sallowness of complexion preceding all other signs. Weakness gradually increases, the patient begins to totter on his legs, and at last is unable to walk. Sexual appe- tite is lost ; and emaciation progresses, with marked antemia, a pale sclerotic, and a feeble pulse. The legs finally become osdematous. Prognosis. — The disease is eminently malig- nant, death usually taking place through derange- ment of tire functions of the lymphatic system. 3. Lardaceous Disease. — Albuminoid dis- ease is rarely limited to the spleen, but usually also affects the liver, kidneys, and sometimes the intestinal villi in the same patient. The trabe- cular interspaces, but more commonly the ]Mal- pighian sacculi, are filled with the new material, so that each corpuscle looks like a sago-grain. The spleen sg affected is usually enlarged, and is specifically as well as absolutely heavier than in health. Sec Albuminoid Disease. A lardaceous spleen implies a long-standing cachexia, and in its most intense form is seen after protracted caries and necrosis of bone, es- pecially when associated with scrofula or syphilis ; or even after external injury which leads to protracted bone-disease. Hence the question is still undecided whether lardaceous disease arises from such local sources, or is a constitutional or general diseaso. 4. Cancer. — Cancer of the spleen is extremely rare as a primary lesion. It chiefly occurs as an infective process, following generally cancer of the stomach or other viscus ; or as generally dis- seminated encephaloid growths. 5. Hare Diseases. — Here it is only necessary i 51 2 SPLEEN, DISEASES OE. io mention hydatid disease, tubercle, and the 3plenic enlargement occasionally occurring in congenital syphilis. Treatment. — Treatment of these diseases of the spleen by medicinal remedies is extremely uncertain, as can readily be understood from what is known of their pathology. All sources of mechanical congestion must if possible be removed or relieved. Saline purgation may be useful for this purpose ; also compound jalap powder, with rhubarb, and sulphate of iron may be taken in such quantities as will produce three or four stools in the twenty-four hours. The iodides and bromides of potassium have also been recom- mended. The biniodide of mercury, in the form of an ointment, rubbed into the skin, has also had a beneficial effect in reducing simple splenic enlargement when not otherwise complicated. In the chronic hypertrophies, such as leucocythce- mia and Hodgkin’s disease, improvement of the general health is all that can be arrived at, by the employment of tonics, change of air, and atten- tion to the hygiene of the patient. Sec Leuco- cyth/Emia ; and Lymph adenoma. William Aitken. SPLENIC FEVER. Sec Pustule, Malig- nant. SPLENIZATION. — A morbid state of the lung, in which it somewhat resembles the spleen in colour and consistence. Sec Lungs, Compres- sion of. SPORADIC ( (r7r64w, I scatter). — This term is used in connection with the occurrence of diseases occasionally, and in an isolated manner, amongst individuals; as distinguished from those diseases which appear endemically or epidemi- cally. See Disease, Classification of. SPORADIC CHOLERA. Sec Choleraic Diarrhoea. SPOTS. — A popular name for eruptions on the skin. See Eruption ; and Macuue. SPOTTED FEVER. — A popular name for typhus fever. See Typhus Fever. SPRAT'S, Therapeutical Uses of. Sec Inhalations. SPUTUM ( spuo , I spit.) See Expectoration. SQ.UAMJE {squama, a scale). — Scales. A synonym for scaly diseases of the skin. See Scaly Eruption. SQUINTING. A popular name for stra- bismus. See Strabismus. STADIUM (Latin, a stage). — A period or stage in a disease, as in fever ; for example, stadium increment i, stadium convalescents. STAGNATION OF BLOOD.— Local ar- rest of the circulation. See Circulation, Dis- orders of ; and Inflammation. STAINS. — This word, as applied to the skin, is synonymous with ‘ maculae.’ See Macula. STAMMERING.— Synon. : Fr. Begaic- ment; Ger. Stottern. Definition. — Under the head of stammering, in its broadest sense, are included many different STAMMERING. forms of defective articulation, such as the in- ability, congenital or acquired, to pronounce cer- tain letters or certain combinations of letters, the tendency to hesitate or stumble in utterance or to transpose letters or syllables, and the habit of interjecting meaningless sounds or words into the pauses which occur in the course of continu- ous speech. But the term is generally used, at any rate in English, as synonymous with stultcr- ing, to imply a spasmodic affection of the organa concerned in speech, in virtue of which the enun- ciation of words becomes suddenly checked, and a painful pause ensues, not infrequently marked by a prolongation, or a repetition in rapid se- quence, of the particular literal sound at which the check arises. ^Etiology. — Stammering is to some extent hereditary, although a large number of stam- merers are certainly free from hereditary taint. It is sometimes imitative. The defect rarely, if ever, shows itself before the age of four or "five years. Usually it comes on from this time up to the period of puberty. But it may originate at any age ; sometimes after febrile disorders ; some- times in connection with nervous affections, such as epilepsy, hysteria, and tabes dorsalis ; some- times it attends mere temporary failure of health ; sometimes it appears in connection with soreness or irritation of the mouth ; sometimes it is induced by simple nervousness or excitement. In many of these cases the stammering is temporary only, and disappears with its cause. And as a general rule confirmed stammerers have their infirmity aggravated under similar circumstances. Occa- sionally, on the other hand, stammering ceases during the presence of illness. It is a curious fact that men stammer in much larger proportion than women. Cases of persistent stammering, arising in childhood, sometimes recover in the course of time ; and, as a general rule, some im- provement takes place after the attainment of maturity, and especially as age advances. Description. — It has often been maintained that stammering occurs only in connection with the enunciation of the explosive consonants, that it never attends the utterance of the vowels, and that it never manifests itself during the acts of whispering and of singing. All these statements, however, though founded on fact, axe more or less inaccurate. For though it is at the explosive consonants b, p, d, t, hard g and k, that stammerers for the most part come to grief, stammering is by no means uncommon during the articulation of the continuous consonants, such as v.f th , s, sh, y, w, in, n, and even occurs when vowel-sounds are being produced; and though it is certainly rare for patients to stammer when whispering or singing, there are exceptions to this rule. When stammering takes place in connection with the explosive consonants, the barriers by whose sudden opening after complete closure the several consonantal sounds are produced, instead of separating, as they should do, remain spas- modically closed; and the patient struggling to overcome the spasm, either remains, foravariable but short time, absolutely voiceless, or overcoming the resistance fitfully, utters the consonantal sound in a series of two or more successive puffs. In the utterance of b and p it is the lips which STAMMERING. 1513 remain closed ; in the utterance of d and t it is the barrier formed by the tongue, whose tip is pressed against the superior incisors or anterior part of the palate ; in the production of hard g and k it is the barrier formed by the pressure of the dorsum or root of the tongue against the posterior part of the palate. In pronouncing the continuous consonants, the barriers at which the distinctive sounds are pro- duced are not in absolute or uniform contact; and the consonantal sounds are continued during the passage of air through the constricted oral channel or through the nose. When, therefore, stammering attends their pronunciation, it is not due to any spasmodic closure of the parts engaged, but rather to their fixation in the natural position they have assumed, and to the frequent association therewith of more or less rhythmical attempts to close them or to separate them more widely from one another. The resulting sounds therefore either come to a full stop, or are simply prolonged or drawled, or are repeated. In the utterance of the vowels the mouth and its appendages play only a subordinate part, and a free passage is maintained for the passage of air through the mouth. It is at the rima glot- tidis that the fundamental sound is produced, and it is mainly to spasm of this part that vowel- stammering is due. JBut the hitch in utterance may also originate in the respiratory apparatus, and not infrequently stammering depends on a sudden inspiration or expiration, or on an arrest of the respiratory movements. It will thus be seen that stammering may be caused by spasm of either of the three mecha- nisms concerned in the mechanical production of speech ; namely, the mouth, wherein words are articulated ; the larynx, where phonation is effected ; and the respiratory apparatus, which regulates the supply of air to the organs of speech and of music. At the same time there is no doubt that stammering is far more frequently connected with spasm of the muscles of articu- lation than with spasm of the larynx or of the respiratory muscles, and that, of the three, respi- ratory spasm is the least common. Not infre- quently, however, the different varieties of spasm are associated in s greater or less degree. The degree and character of stammering differ largely in different cases. Sometimes it is no- thing more than a scarcely perceptible hitch in the enunciation of a particular letter; sometimes it is so severe and continuous that the patient becomes almost unintelligible. The most dis- tressing cases are those in which the spasm ex- tends to parts unconnected with speech, it may be to nearly the whole muscular organism. In such a case the spasm commences, let us assume, at the base of the tongue ; the mouth opens widely, and remains in that position; the muscles of ex- pression work convulsively ; the glottis contracts; respiration becomes arrested; the face becomes congested and the veins dilated ; violent spas- modic movements involve the trunk and limbs; and only after some time, either when the pa- tient becomes exhausted or he resolutely- restrains his attempts to articulate, does his paroxysm come to an end. A stammerer of this kind is a truly pitiable object. Fortunately for him, however, these severe paroxysms are not always present ; they increase in number and intensity under excitement or nervousness; and, on the other- hand, may be replaced to a large extent in ordi- nary quiet conversation by merely slight hitches or drawls or reduplications of letters. A condition allied to stammering, to which the name Aph- thongia has been given by Fleury, has been occa- sionally observed. It seems to be tire product of in- tense excitement, and of temporary duration only ; and to be characterised by powerful spasm of the muscles supplied by the hypoglossal nerves, inclu- ding the sterno-hyoid, sterno-thyroid, and thyro- hyoid muscles, which comes on whenever an attempt to speak is made, and totally prevents speech. Pathology. — The pathological explanation of stammering is obscure. There is no reason to believe that it depends on any discoverable ma- terial lesion, either of the organs concerned in speech, or of the nervous mechanism which con- trols them. It appears to be allied to a series of spasmodic affections, which have been especially studied by Duchenne, in which complex co-ordi- nated movements (facility in the execution of which is only attained by long practice) are con- cerned; such, for example, as scrivener's palsy, and the recurrent spasms which occasionally compel the skilful pianist or violinist, and the practised swordsmau, to give up their pastime or avocation. Speech is pre-eminently' an act of this kind. It is slowly and laboriously learnt in early childhood ; and ease and accuracy of arti- culation are the result only of long and con- tinuous practice. We are born with tho capa- city for speech, but articulate speech itself is the outcome of careful education. For its suc- cessful performance it is necessary that three distinct and complex mechanisms — the respira- tory, the phonetic, aud the articulatory — shall act with precision and in exact concordance; that the lungs shall be expanded at suitable inter- vals, and to a suitable degree, and that the force of expiration shall be regulated with nicety; that the rima glottidis shall be opened or closed according as surd or sonant letters are to be produced, and that the tension of the cords shall be accurately adjusted to the pitch of the musical tones required to be produced; and that the movements of the lips, jaws, tongue, and soft palate shall be accurately adjustable for each literal sound, and capable of passing from one set of adjustments to another with rapidity and smoothness. Of all these co-ordinated move- ments, those connected with articulation are the most various in their grouping, the most rapid in their changes, and the latest learnt. It is natural, therefore, that the hitch or spasm inter- rupting speech should occur mainly in connec- tion with these, andmainly, if not exclusively, at the instant of passing from one literal sound to an- other; that is to say, at the moment of transition from one set of muscular combinations to an- other set. It is natural too that the laryngeal or the thoracic spasm should occur rather in association with articulation than at other times; inasmuch as the movements are more various and intricate during articulation than they are during ordinary respiration, or even than they are in the production of musical notes, as in <514 STAMMERING. singing. In the last case the laryngeal changes, though extremely delicate and exact, are mainly of one kind only, dependent, namely, on varia- tions of tension in the vocal cords. Treatment. — In dealing with cases of stam- mering it is necessary in the first place to coun- teract, or cure, if possible, any affection of the mouth or throat, or any general disorder that may be present, -which are frequent causes of temporary stammering, or of aggravation of habitual stammering. Assuming, however, that the patient is in other respects in absolutely good health, -what can be done ? Many kinds of medical treatment have been practised, and even operative measures ; but, as far as the writer knows, without beneficial result. The only methods, indeed, of any real efficacy, are edu- cational methods. Tho patient should he taught to practise slow and deliberate utterance, and whenever the tendency to stammering occurs in connection with any letter, to check himself momentarily by voluntary effort, and then to try again, rather than to struggle against his defect. Ho should, moreover, be taught to accustom himsolf so to regulate the admission of air into his chest during speech, that his utterance may never fail for want of breath. Further, con- sidering that excitement and nervousness always aggravate stammering, he should learn, as far as possible, either to avoid speaking under theso conditions, or to restrain excitement and nervousness, or so to control himself as to speak with special care and deliberation when he is thus affected. These measures should not only be observed in ordinary conversation, hut be habitually and systematically practised in read- ing aloud ; and especially those sounds, or those combinations of sounds, or those transitions from one sound to another, which are most difficult for him, should he made file subject of care- ful and constant study. By suc-h means habitual stammering is occasionally cured, or if not cured, so far kept in abeyance that an occasional momen tary pause in speech is the only surviving indi- cation of it that the practised ear can detect. More frequently, however, the stammerer re- mains a stammerer, either because he has nover had the patience and determination which, are necessary to carry out the line of treatment above indicated, or because his infir- mity is one for which treatment is unavailing. By taking advantage of the well-known fact that stammering almost always disappears during singing, many stammerers have been able to counteract their defect by intoning. This method has proved of special efficacy in the cases of clergymen and other public speakers. J. S. Bristows. STAPHYLOMA (aratpvJeii, a bunch of grapes). — Synon. : Fr. Slaphylome ; Ger . Sta- phyloin . — This word was applied by old writers, in the jargon which was once supposed to he scientific, to any limited protrusion of the tunics of the eyeball. It was first used to denote the protrusion which occurs in the circum-corneal sclerotic zone, as a consequence of localised in- flammation of this region. The tissue affected by the inflammation in such a case becomes softened, yields to the intra-ocular tension, and SSaTIoTIGS, medical. projects ; but being restrained by bands of lymph, or by thicker portions of its own struc- ture, from projecting uniformly, the prominence becomes more or less sacculated ; and the most prominent portions, being thinner than the rest, and permitting the dark pigment of the interior of the eye to show through, present an appear- ance which may be compared to that of a minia- ture bunch of purple grapes — a real or fancied resemblance from which the term ‘staphyloma’ was derived. This form has more recently been termed ‘ staphyloma of the sclerotic,’ to distin- guish it from ‘ staphyloma of the cornea,’ which is the protrusion left when the corneal tissue has been destroyed by ulceration, either wholly or in part, and the resulting cicatrix, formed of iris-tissue coated over by lymph, yields to the pressure of the fluids within the eye and be- comes prominent. Corneal staphyloma is de- scribed either as partial or complete, according to the amount of cornea which is replaced by cicatrix. Staphyloma posticum is a phrase, applied to that protrusion of a circumscribes portion of the sclerotic, in the immediate vicinity of the optic nerve, which occurs in some cases of my- opia ; and which, by increasing the elongation of the eyeball, increases also the degree of the short sight. It would he highly desirable ti abandon the term ‘staphyloma’ in favour or ‘ protrusion,’ with sncli appended words as might serve to indicate the place and nature of the change. Sic Eye and its Appendages, Diseases of. II. Brudenell Carter. ST Aft V ATI OY (Sax. Stearfian, to perish). This term is generally applied either to depri- vation of food, or to the series of phenomena to which such want gives rise. The word is often used synonymously with fasting, which, how- ever, may be more accurately applied to volun- tary starvation. Sec Fastinci. STASIS (erraa, I stop). — Local arrest of the circulation. See Inflammation. STATISTICS, Medical. — This term signi- fies the collection of numbers respecting healthy and morbid processes, and respecting disease and death ; the application of arithmetical and algebraical operations to such numbers ; and the deduction of conclusions therefrom. But little use of statistical methods was made in medicine before the present century ; and much of the progress that science has recently made is largely to be ascribed to the direct use of such methods in pathology, aetiology, and therapeutics, and to the indirect influence they have had in promoting accuracy of thought. The value of statistics depends upon the eom- pleto uniformity of the facts observed, and upon the accuracy with which the observations are made. It may be well here to remember the words of Rousseau, quoted by M. Louis : ‘ Je sais que la verite est dans les choses et non dans mon esprit qui les juge, ct que mains queje mets du mien dans les jugements que fen portc , plus )c suis sur d'approchcr de la verite.’ In England much use of statistics has recently been made in tho investigation of the causes of disease among communities. See Morbid nr; STATISTICS, MEDICAL. Mortality; Periodicity in Disease ; and Public Health. G. B. STEARRHCEA (trre'ap, fat, and pia, I flow). — S ynon. : Steatorrhoea. Definition. — A flux of the fatty secretion of the skin. By an ungrammatical combination of the Latin sebum with the Greek verb, it is some- times written seborrheea. IEtiology. — A n ill-nourished or debilitated condition of the skin must be regarded as the cause of this affection ; the debility being some- times temporary, as in young persons, and sometimes permanent, as in the elderly. Description. — L ike other secretions, that of the sebum of the sebaceous glands and follicles is liable to excess. It is sometimes diffused over the surface, forming a greasy stratum, and some- times accreted in laminae of various extent. This is the stearrheea simplex, an affection most commonly met with on the face. The excessive secretion in its normal state is colourless, but occasionally it is stained with melanie or biliary pigment ; lienee the terms stearrheea nigricans and stearrheea favescens. Sometimes, as in elderly persons, the epithelial element of the secretion prevails over the fatty element, and in that case it is apt to adhere closely to the epidermis. In the latter case the concretion may be accompanied by excoriation, and sometimes by asthenic ulceration, of the skin. Diagnosis. — S tearrhoea is so obvious in its nature as to be unlikely to be confounded with other affections of the skin. It is sometimes associated with acne ; and, in certain cases of excessive accumulation, has been denominated ‘ ichthyosis.’ Prognosis. — S tearrheea is an affection which admits of immediate relief, and is generally cur- able. In elderly persons, however, it is some- times the precursor of epithelioma of the skin, or of rodent ulcer. Treatment. — The abundant use of soap as a detergent, followed by the application of a lotion of lime-water with oxide of zinc and calamine, very speedily exerts a favourable influence on the skin. Concretions may be softened previously to removal, by pencilling with olive oil, or by inunctions with vaseline. And where the encrusting laminm are incorporated with the epidermis, a cold starch-poultice, made as starch is ordinarily prepared, may advantage- ously precede other curative operations. In both young and elderly persons it will be necessary to improve the general health, which is usually defective. And it may be found desirable to conclude the treatment by the ad- ministration of three minims of liquor arsenicalis three times a day, as a neuro- and nutritive tonic. Erasmus Wilson. STEATOMA ( ariap , fat, and 6gbs, like). — - Synon. : Er. Steatome ; Ger. Steatom. — An athero- matous cyst. Sec Cysts. STEATOZOON (oreap, fat or sebum, and (aov, an animal).— Theterms Steatozoon and En- tozomi folliculorum were given by Sir Erasmus Wilson to the microscopic animalcule called by STERILITY IN THE FEMALE. Idl5 Gustav Simon Acarus folliculorum, and by Owen Demodex folliculorum. See Acabus. STENOSIS ( nrevia , I constrict).— A con- striction, narrowing, or stricture of an opening or a tube ; for instance, mitral or aortic stenosis, in the heart ; and stenosis of the oesophagus. STEECOEACEOU3 ( stercus , dung). — Fmcal; a term generally applied to vomited matter, when it presents the characters of feces See Vomit. STERILITY IN THE FEMALE. — Synon. : Barrenness; Fr. Sterilite , Ger. Un- fruchtbarkeit. Definition. — Want cf the power of reproduc- tion in the female. Frequency. — In the general community the proportion of childless marriages seems to be about 1 in 8, or 8o; among members of the peerage 1 in 6T1. Whether Kehrer be correct in estimating that the husband is in fault in at least oue-fourth of the cases of sterilitas matrimonii remains to be proved. Doubtless he is nearer the truth than those who attribute the sterility in nine cases out of ten to some fault in the wife, because whilst the comparatively rare cases of male impotence are readily enough recognised, and also the rarer cases of asperma- tism, the cases of azoospermatism , where an azoic semen is ejaculated, are for the most pare altogether overlooked. The possibility that the cause of the childlessness may be found in the male must, therefore, always be borne in mind. But we confine ourselves here to the considera- tion of sterility iu the female. See Ihpotency , and Sterility in the Male. ./Etiology. — For generation the essential pro- duct in the female is the ovum; and in her reproductive apparatus we find (i.) oviparous organs for its production; (ii.) oviducts for its transmission ; (iii.) an ovigerent organ or nest in which the ovum is hatched; and (iv.) copula- tive organs for the reception of the semen, the spermatozoa of which constitute the essential con- tribution of the male. In a married woman in whom the generative function is iu abeyance, the sterility may be primitive or acquired. In the former case we have to do with a female who has never borne a child; in the latter the woman may have borne one or more children, but has for some years ceased to conceive. Iu either case we search for the fault in one or more of these four planes of her sexual apparatus. I. Faults in the ovaries. — The ova are developed iu the ovaries, and the conditions which interfere with ovulation — that is, the regu- lar ripening of an ovisac, and the discharge of an ovum — diminish or destroy the possibility of con- ception. Such conditions are found in ; — 1 . Absence or imperfect development. — Cases of absence or defective development of the ovaries are rarely met with, except in women in whom the rest of the sexual apparatus is also anoma- lous. 2. Displacements. — One or both ovaries may be found displaced. Instead of lying at the level of the pelvic brim, they have fallen into the pouch of Douglas. In this position, though the ripening and dehiscence of the ovisacs may le 1518 STERILITY IN duly taking place, the discharged ova are not received into the free extremity of the Fallopian tube. The displaced ovary, moreover, is ex- tremely likely to be the seat of some degree of inflammation. 3. Inflammation. — Oophoritis, acute orckronic, lessens the conception-power in various ways. It may lead, 1st, to destruction of the follicles, so that no ova are produced ; 2ndly, to condensation of the stroma, so that the regular ripening of the ovisacs is impeded ; 3rdly, to deposits on the sur- face, which prevent the dehiscence of the ovisacs ; or, 4thly, to adhesions of the ovary, in situations which hinder the entrance of the discharged ova into the oviducts. 4. Degenerations. — The neoplastic degenera- tions to which the ovaries are most liable are the cystic; and all the varieties of eystomata, as well as the fibromata, the sarcomata, and the carcino- mata, are commonly attended with sterility. Where both ovaries are affected the sterility is absolute, from the complete loss of function in the organs ; and even where only one is affected, tho disturbance in the relations of the pelvic organs, caused by the growing mass, is likely to prevent impregnation. See Ovaries, Diseases of. II. Faults in the oviducts. — The Fallopian tubes or oviducts serve not only for the recep- tion of the discharged ova, and their transmission downwards to the uterus ; they serve also for the upward transit of the spermatozoa. In most cases it is probably somewhere in their canal, perhaps towards the free extremity, that the male and female elements come into union. 1 . Absence. — Defective development of the Fallopian tubes is usually associated with other abnormalities of the sexual apparatus, especially with rudimentary conditions of the uterus. 2. Inflammation. — Inflammatory changes may be found affecting either the external serous covering, or the internal mucous lining. In the former case sterility results from adhesions, which lead to displacements of the free extremities, so that they are not in a position to receive the ova discharged on the bursting of an ovisac ; or from bands which constrict the tubes, and so occlude their canal. In the latter, changes in the se- cretion may prejudice the vitality of the sperma- tozoa or ova ; or the thickenings, polypoidal cr other, may obstruct the canal; or complete atresia may be produced, and their permeability be thus entirely lost. See Faixopian Tubes, Diseases of. 3. Degenerations.— The tubes are rarely enough the seat of neoplasms; but when such do develop in their walls, occlusion of their canal and con- sequent loss of function may ensue. ill. Faults of the uterus. — In the process of reproduction, the uterus serves as the receptacle or nest, in which the fertilised ovum is carried during the period of incubation. In its prolife- rating mucous membrane tho chorionic villi take root; through its expanded blood-vessels the foetal blood is brought into relation with the maternal ; its walls grow in correspondence with the increase in size of the ovum ; and its largely developed muscular fibres are the main agents in the ex- pulsion of the ovum when it is finally hatched. It plays such an important part in the female economy that the name of it is often used as sy- nonymous with tho sexual apparatus ; and some THE FEMALE. of its morbid conditions are among the com- monest causes of sterility. 1. Defective development. — First, it may be an- sent al together, or represented merely by a fibrous nodule. Secondly, it may be small, having under- gone arrest at some stage of its growth, and re- maining infantile, juvenile, oradolescent. Thirdly, it may be bieornuous — retaining the trace of its original duplicity by the presence of a septum running through the body alone, or running through both body and cervix, perhaps through the vaginal canal as well. Fourthly, it may be unicornuous — only one of the halves of the organ having been developed, while the other tube may be obliterated, or attached as a rudimentary by- horn to the better developed tube. Fifthly, a more frequent malformation is found in a conical form of the cervix, which is not infrequently compli- cated with, sixthly, narrowness of the os. This last condition may exist by itself, forming a well- recognised cause of sterility, and furnishing some of the cases in which a most satisfactory cure can be accomplished. 2. Displacements. — First, descent of the uterus is found as the predominant morbid condition in some cases of sterility, but this is more frequently associated with the deviations auteriorly or pos- teriorly. Of these, secondly, the antrotersions, flexion and version, are very frequent among women who have never conceived at all ; thirdly, the retroversions, flexion and version, are more common in women who have given birth to one or more children, and have subsequently re- mained sterile. The flexions, in particular, form a very clearly recognisable and often remediable cause of sterility. 3. Changes in size. — The retrogressive changes which occur in the uterus after labour sometimes go on morbidly, and in one group of cases leave the organ in a condition of, first, super-involution. The uterus may be reduced to a little tube which only admits the sound for half an inch. Even when the degree of super-involution is less, and it still measures two and a quarter inches in length, it is apt to cause amenorrheea and sterility. In another group of cases the uterus remains hyper- trophied in a condition of, secondly, sub-involu- tion, which is inimical to conception ; and when conception does take place in such a uterus, abortion is liable to occur. 4. Inflammation. — Among the commonest causes of sterility must be ranked the inflamma- tory changes to which the uterus is so liable, whether the process have affected mainly the ex- ternal, middle, or internal coat ; and in many of the cases where some other condition tending to sterility is present, inflammatory changes come in to increase the difficulty, and to cloud the prospects of recovery. First, perimetriiis is usually only an element of a more general pelvic peri- tonitis, which often leaves behind it fixations and displacements of the uterus, preventing conception or promoting early abortion. Secondly, mcsomc- tritis, leading to thickening of the walls of the organ, produces an expansion of its cavity and disturbance of its function. It is rarely possible to dissociate it from, thirdly, endometritis, which is attended also with dilatation of the cavity, but which is further mischievous from the deleterious influence of its abnormal secretions on the life STERILITY IX THE FEMALE, ind progress of the spermatozoa, and from the difficulty with which a fertilized ovum gets healthily engrafted on its surface. Moreover, in certain cases of long standing, some of the uterine entices may become more or less occluded, a re- sult which is more especially apt to ensue in the external orifice when caustics have been applied to the cervical canal. 5. Degenerations. — First, 'myomata., or fibroid tumours, are found in a considerable proportion of barren women. Whether sub-peritoneal, in- tra-mural, or sub-mucous, they interfere in many ways with conception, and give a proclivity to miscarriages or dangerous, labours when concep- tion has occurred. Secondly, sarcomata have usually their seat in the uterine cavity, and seem to be an absolute bar to impregnation. Thirdly, carcinomata have been sometimes met with in tho pregnant uterus ; but these are commonly seated in the cervix, and it is usually only in an early stage of the mischief that conception can occur. See Womb, Diseases of. IV. Faults in the external organs. — In various ways the organs which serve for the recep- tion of the spermatic fluid may be so affected that their copulative function is disturbed or de- stroyed, and the patient remains sterile. 1. Malformations. — Occlusions of the labia are rare ; but the vaginal canal may be impervious, firstly, from abnormal conditions of the hymen ; secondly, from atresia in some part of its course ; or, thirdiy, from complete absence. Even it will be found that in certain cases where tho rest of the generative apparatus seems to be well-developed, a preternatural shortness of the canal is found in some sterile women, from whom the semen es- capes immediately after it is thrown into the cavity. 2. Injuries. — The injurious influences of a bad labour on the reproductive power of a woman may be found, first, in an undue •patency of the canal, usually from extensive rupture of the perinseum ; secondly, more frequently from at- resia, partial or complete ; or, thirdly, from fistu- lous formations, leading to communication with the neighbouring cavities. 3. Infiammation. — In its acute stages, inflam- mation of the pudenda and vagina produces, first, dyspareuma ; in its more chronic forms it may be productive of, secondly, unhealthy discharges, which endanger the vitality of the spermatozoa ; or it may lead, thirdly, to occlusions of the labia, or of the vaginal orifice or canal. Partly of inflammatory origin is the condition, fourthly, of vaginismus, which is not an uncommon cause of impossible connection. 1. Degenerations. — The various neoplasms oc- cur with rarity in the vaginal canal ; but in the pudenda — sometimes from their bulk, sometimes from their sensitiveness — they interfere with con- nection, as in cases of elephantiasis labiorum or of urethral caruncle. Diagnosis and Prognosis. — Investigation into a case of sterility may require that we satisfy our- selves as to the fertilizing powers of the male, and the due fulfilment of the marital function. Occasionally some concurrent disturbance in the functions of tho sexual apparatus of the female, or of the neighbouring organs, may enable us to make a close guess at the cause of her barren- STEKIL1TY IN THE MALE. 151? ness ; but we can only arrive at a true conclusion by a careful physical examination, having in view such a vidimus of causes as we have given. Some of the conditions, such as the more pro- nounced malformations, or imperfect develop- ment, make us regard her as hopelessly sterile : others, such as uterine flexions and stenosis, and some vaginal occlusions and injuries and tender, ness, wo may undertake to treat with good hops of fruitful result. See Vagina, Diseases of. Treatment. — In commencing tho treatment of any case we must bear in mind that moibid conditions may be present in more than one of the planes of the sexual system, and that we must begin with the removal of tho obstacle that lies nearest the surface. Urethral caruncles and other sensitive structures in tho vulva must be cut off or cauterised. Contractions of the vaginal orifice or canal must bo stretched ; and where there is complete atresia an aperture must be formed and kept patulous. Stenosis of the uterine orifices may be overcome by temporary dilatation with a tangle-tent, which the writer has more than once seen followed by impregnation. Where such dilatation fails, the os may be di- lated more permanently, by tearing it with an instrument like a pair of long dressing-forceps, the blades of which are forced apart after it has been passed into the cervix ; or by dividing the cervix at both sides, or in one or other lip, with a liysterotome. The deviations of the uterus must be rectified ; versions, after replacement, being usually retained by some modification of Hodge's pessary; flexions demanding in addi- tion the use of an intra-uterine stem. The stem- pessary of zinc and copper introduced into tbe interior, is tho best means of stimulating to its full function the imperfectly developed uterus, and the uterus which has withered from super- involution. Morbid conditions in the interior of the uterus require direct applications to its cavity. And, as in a large proportion of the cases, some inflammatory mischief complicates the other morbid condition, it is often helpful to the cure to make the patient use hot douches and baths, and the internal remedies which tend to remove the effects of inflammatory action. It is to the beneficial influence which the waters of Ems, Aix, Kissingen, and other spas exert on chronic metritis, that their reputation for curing sterility is mainly due. In cases where the natural method of getting spermatozoa brought, into relation with the ova has failed, success is said to have followed the introduction of seminal fluid by means of a fine syringe and tube into the cavity of the uterus— a line of treatment legitimate, it may be, but only to be followed in quite exceptional circumstances. Alexan der Russell Simpson. STERILITY IW THE MALE. — Synon. : Fr. Sterilite ckez I’homme ; Ger. Unjruchtbarfceit dcs Manncs. — Sterility in the male has been con- founded with impotence, no distinction having been drawn between inability to procreate and incapacity for sexual intercourse. A man may, however, be subject to sterility, independently of impotence. See Impotence. Description. — Sterility may arise from the fol- lowing causes : — 1. malposition of the testicles 1518 STERILITY IN THE MALE. 2. obstruction in the excretory ducts of the tes- ticle ; 3. impediments to the ejaculation of the seminal fluid; or 4. aspermatismus or non-ejacu- lation. 1. Malposition of the testicles. — -A testicle which does not pass into the scrotum is nearly always small in size, and often undeveloped, not having undergone the enlargement and change in structure 'which takes place at puberty. A testicle thus detained fails in some animals, us well as in man, to secrete a fertilising fluid ; and a male with this defect on both sides, though, often potent and efficient for sexual intercourse, is incapable of impregnating the female. Many striking cases illustrating this point have come under the notice of the writer, cases of persons with retained testes, who have married without their wives becoming pregnant, and in whom the fluid emitted in coition has been destitute of spermatozoa — azoospermatism i. 1 The facts which have been adduced as opposed to the conclusion that cryptorchies are sterile, are chiefly instances in which they are reputed to have procreated children ; but it is remarkable that as yet no case has been found in which a retained testicle has been fully proved to be capable of secreting a fertilising fluid. Spermatozoa have been found absent in every case of retained testicle, without exception, in which search has been made for them. 2. Obstruction . — The lymph exuded in the cavity and walls of the excretory duct of the testicle in epididymitis, is liable to produce ob- struction of the canal. This may be only tem- porary, the lymph becoming absorbed under treatment. Where the obstruction is complete and permanent, an induration is left in the tail of the epididymis; and when this exists on both sides, sterility is the result. Many curious cases of sterility from this cause have fallen under the writer’s observation. 2 They show the great importance of steadily prolonging the treat- ment of epididymitis, until the enlargement and induration of the part have disappeared. The excretory duct of the testicle is liable also to be interrupted by tubercular deposits in the epi- didymis. Sterility from this cause in persons with double tubercular disease of the epididymis is not uncommon. 3. Urethral impediments. — A close stricture in the urethra so completely interrupts the pas- sage of the seminal fluid, that in ejaculation it regurgitates into the bladder, where it mixes with the urine. This is a condition which is remediable by the cure of the stricture. 4. Aspermatismus. — Sterility sometimes arises from a cause which has been expressed by the term aspermatismus. Thus, it is essential to the complete performance of the sexual act, that the local excitement should culminate in the reflex action of expelling the collected semen. Unless this takes place coition is unsatisfactory and fruitless. There are cases of men who never experience ejaculation, even after prolonged coi- tus, though they are subject to nocturnal emis- sions. This appears to arise in some instances from defective sensibility in the glana penis, 1 For detailed e viilence on this subject, see Treatise on j Diseases of the Testis , by the writer. ■ Vide lib. cit. i STERTOR. which the writer has endeavoured to correct by the application of the acetum cantliaridis to the glans, and by electro-magnetism. In one case of non-ejaculation, the nerves proceeding to the glans appear to have been destroyed by a syphi- litic ulcer on the dorsum penis, or to have been compressed in its cicatrisation. Conclusion'. — The question may ariso whether a man who has the inclination and power tc copulate, but who is nevertheless sterile, is justi- fied in contracting marriage. That a man who is unable to fulfil the command, ‘ to be fruitful and multiply,’ is right in disappointing the hopes and perilling the happiness of a woman cannot, in the writer's opinion, bo maintained ; and he has felt it his duty to give advice in accordance with this opinion. T. CuKLING. STERNUTATORIES ( sternuo , I sneeze). Synon. : Errhines ; Fr. Sternutatoires ; Ger. Lies- mittel. Definition. — Remedies which cause sneezing and produce an increased secretion from the mucous membrano of the nose. Enumeration. — The principal sternutatories are Tobacco Snuff, Veratrum album, Euphor- bium, and Ipecacuanha. Actions and Uses. — The action of these drugs is simply one of stimulation and irritation of the part to which they are applied; and the slight amount of gentle excitement furnished by snuff has ensured a very wide popularity for this preparation of tobacco. White hellebore causes almost uncontrollable sneezing when incautiously inhaled, and powdered ipecacuanha-root is well known to cause exces- sive irritation in exceptional cases. No use is now made of these therapeutical actions, and it seems hardly necessary to retain the term ster- nutatories any longer in our nomenclature. R. Faequharson. STERTOR (sterto, I snore). — Stnon. : Fr. Sterteur; Bonflement; Ger. Schnarc/ien; Bocheln. Definition. — A term commonly applied to sounds in the throat resembling snoring, which occur in the apoplectic and like conditions. In this article the writer would extend the name to other sounds formed in any part of the respi- ratory passages or mouth by the movements of the air, under the like circumstances. Varieties. — Several varieties of stertor may he recognised, as follows : — 1. Nasa l. — X asal stertor arises from approxi- mation of the ate nasi towards the septum by the ingoing air, as in the act of sniffing. 2. Buccal. — This form of stertor is due to vibrations of the lips, and puffings and flappings of the cheeks during inspiration or expiration. 3. Palatine. — Arises from vibrations of the soft palate, whether the breath passes through the mouth or the nose. 4. Pharyngeal. — Pharyngeal stertor is caused by the lolling back of the base of the tongue iuto near contact with the posterior wall of the pharynx. 5. Laryngeal. — This variety is referable to vibrations of the chordae vocales. 6. Mucous. — Mucous stertor is a term which STEKTOK. uuiy be g'.veu to the bubbling of air through mucus in the trachea or larger air-tubes. /Etiology. — One or more of the varieties of stertor, in varying degrees of intensity', may oc- cur in any of the following morbid conditions, namely Suffocation ; epilepsy ; convulsions in children ; the death-agony ; fractures of the skull, and concussion of the brain ; bronchitis — - particularly that of the old, sudden oedema of the lungs, and large haemorrhages from the lungs; great exhaustion ; chloroform-poisoning, drunken- ness, and opium-poisoning ; drowning, and all conditions in which mucus or fluid exists in the lungs ; and all forms of sopor, whether natural or the result of accident or disease. Description. — The general phenomena of stertor are those of suffocation. A patient may be found lying in a state of complete unconsciousness, with a congested, tur- gid, and expressionless face ; usually dilated and fixed pupils ; insensitive conjunctives ; a hot and perspiring skin; throbbing arteries; a full and bounding pulse ; and, lastly 7 , noisy breathing, the direct result of mechanical interference with the passage of air into or out of the lungs, whether arising from contractions of theorifices, and vibra- tions of the soft parts of the nose, lips, cheeks, palate, pharynx, and larynx, or from mucus in the trachea and bronchial tubes. When the obstruc- tion to the breathing is only slight, but long- continued, the face may be of a dusky pallor, and there is an entire absence of turgidity and con- gestion. Pathology. — All the varieties of stertor, whether manifested singly or in combination, have been usually regarded, especially in the cass of apoplexy, as symptoms essentially and mysteriously connected with the primary 7 disease. This is not the true account of them. Whatever may be the original cause, these symptoms only indicate a varying amount of obstruction to re- spiration, sometimes so great as to be fatal in itself, but only as a secondary and, so to speak, accidental consequence of the primary disorder. Stertor is, in fact, ‘suffocation.’ In its effects it may be compared with croup, and being equally dangerous it may equally require relief. But even buccal stertor, which many authors have looked upon as of so grave importance, may not (infrequently be observed in ordinary sleep ; and the writer has seen recoveries from apoplexy, in which at different times all the forms of stertor have been present. Stertor in apoplexy being, then, apoplexy plus suffocation, the whole subject, as regards diagnosis, prognosis, and morbid ana- tomy, must be approached from a new point of view. The congested and turgid face, the noisy breathing, the rales in the chest, the throbbing arteries, and the full and bounding pulse, which are the generally received symptoms of sthenic apoplexy, and which have been regarded as in- dicating the adoption of venesection and active remedies, are neither more nor less than signs of suffocation. Immediately upon the removal of obstructions to the breathing, all these symptoms disappear, and with them the necessity for active treatment. Long ago Heberden and Eothergill questioned the propriety of bleeding in such cases, and the latter thought that these violent symp- toms arose from an exertion of the vires vites 1519 to restore health ; whereas they really indicate a struggle to overcome an impediment to respi- ration and circulation. Directly this impediment is removed, all is quiet in apoplexy, and the prae titioner is enabled to judge of the real state of the case — which side is paralysed, whether the nerves are losing or recovering their power, and what evidences exist as to greater or less interference with the functions of organic life. Treatment. — In stertor, as in strangulation, we must proceed at once to remove the impedi- ment to free respiration. Nasal stertor. — This maybe relieved by press- ing upwards the tip of the nose, or by keeping the nares open by the handle of a common salt-spoon. Laryngeal stertor . — This never appears dan- gerous enough to warrant tracheotomy, which alone would remove it. Buccal, pharyngeal, palatine, and niveous stertor . — These varieties of stertor arc readily treated by placing the piatient comfortably on one side, and. affording support by well-arranged pillows. In this position the buccal and palatine stertor, if any remain, will be too feeble an impediment to require further attention. The tongue drops to the side of the pharynx, and leaves plenty of room for the ingoing air. The mucus or fluid, too, whether resulting from these or other forms of stertor, drains away into the lowermost lung, thus preventing the formation of large foam-vesicles in the trachea (the ‘ death- rattles ’), which are always dangerous respiratory impediments. Care should be taken to keep the neck rather straight, as, if the chin be brought too near the sternum, the thyroid cartilage presses upwards and backwards, and piushes the base of the toBgue towards the back of the pharynx. In the management of mucous stertor it must be observed that, after a time, varying from one day to three or four, the lower lung becomes filled with mucus, though the patienx is still breathing quite placidly. If at this stage the patient he turned over on the other side, the mucus begins travelling across the trachea into the opposite lung; is caught on its passage by the ingoing air ; and is whipped into foam, which at once blocks up the larger air-tubes of the only lung that can work, and so instant distress and danger result. If the life of the patient be not at once destroyed, still the additional shock re- duces very much the chances of ultimate reco- very. Under these circumstances change of posi- tion should always be tentative, and time for some return of nerve-vigour should be allowed before it is attempted. This warning applies with equal force to all cases where mucus or fluid obstructs the air-passages, as in drowning and bronchitis. In drowning, it may he re- marked that the water, on entering the lungs, becomes quickly inspissated with mucus, forming a milky foam, which can only be slowly eva- cuated by the application of Dr. Marshall Hall’s or other process of artificial respiration. See Artificial Besfiration ; and Besuscitaticn. Hubert L. Bowles. STETEOGEAPH {arrfios, the chest, and ypaepw, I write). Definition 7 . — An instrument for recording thf movements of the chest. 1520 STETHOGRAPH. The indices in stethometers are adapted to record maximum expansion at anyone point. Dr. Sanderson’s ‘ recording stethometer,’ described and figured in the Handbook to the Physiological Laboratory , consists essentially of a tympanum, on one side of which a knob is fixed, for appli- cation to the chest-surface. This tympanum is in communication with a second tympanum by means of an air-tube, and the fluctuations of the second tympanum are recorded by a writer upon a revolving surface of paper. By means of this instrument, prcperly adjusted, the respiratory movements of the chest at any point can be re- corded, as regards both depth and rhythm. R. Douglas Powell. STETHOMETER (itt~)6os, the chest, and (Uerpor, a measure). — Synon. : Pr. Stethometre ; Ger. Stethometer. Definition. — An isntrument for measuring the mobility of the chest, and of its several parts, during respiration. Description. — Various forms of stethometer have been designed. Dr. Sibson's ‘ chest-measurer ’ consisted of a simple arrangement by which a rod, attached by a movable rack to an index, might bo applied vertically in succession to dif- ferent parts of the chest (see Sibson's Collected Works , vol. ii.) Dr. Qnain’s stethometer con- sists of a cord attached to an index working on a graduated dial (London Journal of Medicine, Oct. 1850). Expansion on the two sides may be measured and compared by means of the double tapes, or the soft metal cyrtometers, held so that the ends overlap in the median line. A more elaborate instrument is that of Dr. Ransome, who has with it made valuable observations on the respiratory movements ( Med.-Chir . Trans- actions, vol. lxiv. p. 185). R. Douglas Powell. STETHOSCOPE () desires of a person who seeks his pleasure in the gratification of his palate. Consequently, one of the most common causes of atonic dyspepsia, more especially amongst the richer classes of society, is to be found in the undue frequency of meals. Every practitioner is consulted by per- sons complaining of dyspepsia produced by food, in some shape or another, being taken every two or three hours, under the supposition that they are suffering from debility. In reality, the feel- ing of exhaustion from which they suffer arises from the stomach never being allowed a sufficient period of repose. It is called into renewed ac- tivity by the introduction of fresh food before the last meal has been passed into the duodenum. Imperfect digestion is the necessary consequence, and only a small portion of what is eaten is dis- solved and reaches the blood. On the other hand, atonic dyspepsia constantly arises amongst the poor from an imperfect supply of food, or from the food not being of a nutritious nature. The out-patient rooms of our public institutions are daily frequented by females who are existing on tea and a scanty supply of bread, and who could be readily cured by a more generous diet. An immoderate use of alcoholic liquors seems chiefly to favour the production of inflammatory gastritis ; but the writer has constantly seen those who had habituated themselves to such indulgence become the victims of feeble digestion as soon as they have abandoned the use of stimulants. It is, however, much better that persons who are unable to take stimulants in moderation should suffer from dyspepsia than subject themselves to the innumerable other evils arising from drunkenness. Imperfect mastication is a com- mon cause of this complaint. The writer has found that only 19 per cent, of those who were not dyspeptics confessed to the habit of eat- ing very quickly, whilst amongst the sufferers from gastric disorders '51 per cent, were in the habit of imperfectly masticating their food. Persons who live chiefly on liquids, such as tea and soup, are more liable than others to feeble digestion. In all probability the mucous mem- brane becomes relaxed, and the gastric juice is too much diluted to dissolve the food with the requisite rapidity. Insufficient exercise is an- other very common cause of the complaint, and those w r ho lead indolent and luxurious lives pay the penalty in the shape of dyspepsia. Consti- pation is another common cause of this form of indigestion, and it is partly by producing this symptom that sedentary occupations exercise such a prejudicial influence. As the gastric fluid is secreted from the blood, it is evident that a normal amount and quality of the latter must be necessary for the perfect performance of the digestive process. Consequently, we find that the digestion becomes feeble in all cases of ansemia, however this condition may have been produced. Numbers of cases are constantly pre- senting themselves in the out-patient depart- ment of every hospital in which the symptoms of atonic dyspepsia are maintained by long- standing leucorrhoea or other discharges. The nervous system controls, not only the secretion of the gastric fluid, but also the muscular action of the organ. Any deviation, therefore, from its STOMACH. DISEASES OF. 1525 normal state is apt to be attended with an alte- ration in the secretion and motions of the sto- mach. In the more acute disorders of the brain we often have an excess of acid secreted ; but whenever the nervous system is enfeebled, the functions of the digestive canal are weakened in a corresponding degree. Symptoms. — The invasion of atonic dyspepsia is always gradual, and in a large proportion of the eases the symptoms replace those of acute or chronic gastritis. There is seldom any severe pain, but the patient often complains of a feeling of fulness and distension after meals, which begins shortly after eating, and lasts for an hour or two. In other instances there is a sen- sation of constriction, produced by flatulence, which affects the lower part of the chest, and is relieved by eructation. Occasionally, the pain radiates to the shoulders, or passes down the left arm and hand, so severely as to simulate angina pectoris. It is distinguished from that complaint by its coming on shortly after food, and not after exertion. In other cases the constriction is ac- companied by dyspnma, arising, no doubt, from the movements of the diaphragm being impeded through its being pushed upwards by the dis- tended stomach. In men of advanced age who are inclined to obesity there may be considerable embarrassment of the pulmonary and cardiac functions from this cause, especially where any unusual exertion is undertaken after a meal. It is, perhaps, unnecessary to say that in hysterical persons, and in those whose nervous systems have been unduly excited by alcohol, there is often a shrinking from the slightest touch upon the skin. In these conditions the tenderness is gene- ral ; it is not increased by deep pressure, and is often most loudly complained of w'hen the hand is applied to a part distant from the stomach. Vomiting rarely presents itself, excepting as the result of some t emporary error in diet, or as an accompaniment of hysteria or phthisis. Eructa- tions are generally complained of ; but, instead of the acidity that accompanies catarrhal in- flammation of the stomach, only gas or small portions of undigested food are returned. The appetite is generally deficient; in some cases there is a craving for various indigestible sub- stances, but this is not so common as in the inflammatory affections of the stomach. Some- times there is an aversion to all food. The tongue is usually broad, flabby, indented by the teeth, but not red, pointed, or injected, as in gastritis. Thirst as a rule is absent. The large intestine corresponds in the feebleness of its functional power. The bowels are consequently constipated, the stools disordered, and, in many cases, they contain largo portions of undigested food. The most common appearance is of pieces of fibre-like tissue that have escaped the action of the stomach, often mistaken by patients for worms. The urine is usually pale and of low specific gra- vity. If it deposits lithates, the sediment is pale in colour ; more generally oxalates or phosphates make their appearance. A long continuance of imperfect digestion produces loss of flesh and strength, but this is never to the extent that oc- curs in the organic affections of the stomach. The pulse is slow and feeble. The heart is especially apt to be affected with palpitation. Often the patient complains of a sudden tumbling sensa- tion, as though the heart had turned over; at other times the palpitation comes on after exer- tion, and relief is obtained by stooping, or some other change of posture. Some are chiefly tor- mented at nights. They are awakened at two or three o’clock in the morning with violent and irregular palpitation. Such cases occur most frequently in the old, and often indicate a fatty condition of the organ. The skin is cold and clammy ; and irregularities in the circulation, producing coldness of the hands or feet, are con- stant sources of complaint. The nervous symptoms constitute the most distressing manifestations of the disease, more especially when the affection itself arises from an exhausted condition of the nervous system. The patient awakes at two or three in the morn- ing, and is unable to sleep for many hours, when perhaps he falls into a troubled and unre- freshing slumber. There is often great irrita- bility of temper, gloom obscures the mind, or the patient is incapable of concentrating his mental powers, or he becomes feeble and irre- solute in character. Diagnosis. — Atonic dyspepsia is not likely to be confounded with the painful affections of the stomach — namely, ulcer and cancer. It is, how- ever, a point of great practical importance to distinguish it from an inflammatory affection of the mucous membrane. This is the more difficult because these conditions so often replace each other in the progress of a case of chronic dys- pepsia. The chief differences are as follows. In atonic dyspepsia there is no epigastric tenderness, which is usually present in gastritis. There is no pain excepting what may easily be referred to flatulent distension ; and acidity and heartburn are much more rare in the former. Vomiting, again, is unusual in atonic dyspepsia; common in gastritis. The tongue is broad, flabby, .and tolerably clean, and forms a striking contrast to its injected tip and edges, and thick coating in the latter affection. The urine is pale, depositing oxalates or phosphates, in a feeble state of the stomach ; high-coloured, and loaded with lithates. when the organ is inflamed. Treatment. — The first and most important point is to remove, as far as possible, all the causes of the disease. It is evident if a patient is eating too frequently, or masticates his food imperfectly, or leads an indolent and luxurious life, all drugs must be unavailing to remove his disease, so long as he maintains it by an erro- neous system of living. Again, the food should be of such a nature as will require the least pos- sible exertion on the part of the stomach. Thus, lightly-cooked mutton, chicken, or game is more easily digested than beef, pork, or lamb. Eoast meat is more digestible than boiled. Soups and broths should be avoided, as well as any large quantity of hot tea or coffee. In bad cases vegetables had better be omitted from the die- tary for a time ; but as soon as the patient im- proves they should be again employed. Great mischief is often done by forbidding fora length of time all vegetable food ; for, although the fla- tulence and other symptoms may be thereby re- lieved, the general health soon suffers. In many cases it will be found useful, where we are forced 1526 STOMACH, DISEASES OF. to forbid vegetables, to order one or two table- spoonfuls of lemon juice daily. This may be either tal^en diluted with water, or squeezed from the lemon over the meat. When there is much tendency to acidity, light puddings and farinaceous food must be sparingly used, but otherwise they generally agree well. Pastry and new-baked bread should be avoided in all cases. When a person of middle age and inclined to obesity is troubled with feeble digestion it is better that he should avoid potatoes, spirituous liquors, sweets and fatty substances ; and that ho should use dry toast instead of bread, and a simple but varied, diet. A dinner-pill of rhu- barb, ipecacuanha, and ginger may be given to aid digestion, accompanied by a nervine tonic, such as strychnia or tincture of nux vomica, combined with nitro-hydrochloric acid. Innumerable remedies are recommended for this form of indigestion, but in order that they should be usefully employed, it is necessary to ascertain the cause from which the imperfect secretion of gastric juice has arisen. In a large proportion of the cases the feeble condition of the mucous membrane has resulted from previous inflammation. There is a second class where, although the gland-structure is normal, the blood is deficient in quantity, or is abnormal in quality. In a third the defect originates with an exhausted condition of the nervous centres. Each of these states requires a separate medici- nal treatment, and, although one often merges into, or is associated with, another condition, yet the features of one or other appear more pro- minently in each case that comes under our notice. Where the feeble digestion has arisen from a relaxed state of the mucous membrane produced by previous inflammation, the tonic should be of an astringent character. It is in such cases that the nitric, nitrohvdrochloric, or phosphoric acid, either alone or in combination with bitter infusion, is required. Acids are best given when the stomach is empty, so that they may directly affect the vascular system of the organ. If me- tallic preparations are preferred, the perchloride of iron may be used. Notwithstanding the ad- verse opinions of many authors, the writer has often found pepsin very valuable in these cases. The pepsina porci is the best preparation, and it may be given along with capsicum or ipecacu- anha before, not after, meals. One reason why pepsin so often proves inefficacious is that it is not administered in sufficient doses. In cases of feeble digestion in young children or aged per- sons, much benefit will sometimes result from the addition of pepsin, in larger quantities than usually prescribed, to milk, warmed and left to stand a short time before being taken ; or pep- tonised food may be ordered in seme cases. See Peptonised Food. AVhere the dyspepsia arises from anaemia, re- course must be had to iron. If it is con- nected with excessive menstrual discharge or leucorrhcea, the writer has often found the phos- phate of iron and manganese a useful prepara- tion. In other cases it may be combined with quinine. The saccharo-carbonate and the am- monio-eitrate are very valuable and unirritating salts. It is a good plan in these cases ta alternate the steel with other tonics, and as liberal a diet should be given as can be easily digested. Where the nervous system is chiefly in fault, preparations of nux vomica and phosphorus, or those of zinc and arsenic, are chiefly of use. Zinc may be given as a valerianate along with quinine, or as a superphosphate in combina- tion with iron. It is in this class of cases that preparations of silver, such as the nitrate and oxide, are chiefly valuable. The colon is usually as atonic as the stomach, and therefore the bowels require attention in almost every case that comes beneath our notice. All severe purgatives should be avoided; for nothing so increases the feebleness of the diges- tion as the indiscriminate employment of this class of drugs. Salines, such as the sulphate of magnesia and the various mineral waters, must be especially prohibited. The most useful aperients are rhubarb pill, combined with nux vom : ca or belladonna. When there is no affection of the rectum, the extract of aloes answers well ; or if this part is irritable some mild aperient, such as senna electuary, may be employed. AVhero a slight amount of acidity is present the compound rhubarb powder of the pharmacopoeia, or an occasional dose of soda and rhubarb, is most suitable. 4. Stomach, Atrophy of. — Analogy would lead us to expect that the structure of the sto- mach would be liable to atrophy, since this change is so often met within the kidney, liver, and other glandular organs ; and this expectation would be strengthened if we considered the great func- tional activity of the gastric mucous membrane, and its especial liability to inflammatory changes. We find that atrophy of portions of the gland- structure of the stomach is exceedingly common, although sufficient usually remains intact to en- able the organ to perform its functions. From his own investigations the writer is led to be- lieve that a certain amount of anatomical change occurs in every person after he has reached the middle period of life, when the necessity for a superabundant supply of nutriment has ceased. It takes place first in the pyloric region, and tends gradually to extend as age advances. Caution is required in the investigation of such changes in the case of the stomach, lest the effects of post-mortem digestion should be mis- taken for those of disease. In both the mucous membrane is attenuated, and the structure de- stroyed ; but in the former it is soft, and can he readily detached by the slightest pressure of the finger; in the latter it is firm, adherent, and usually pale and anaemic. Microscopically, in post-mortem solution, the surface is uneven ; in atrophy it is smooth, and the openings of the tubes are sharp, defined, and often enlarged. On a section being made, in the former the tissue is seen to be reduced to a mere mass of cells and fat ; in the latter the lower ends of the tubes are often enlarged and loaded with cells. Anatomical Characters. — In atrophy of the stomach the mucous membrane usually escapes post-mortem digestion; it is thin, smooth, and firmly adherent to the subjacent coats. Micro- STOMACH, DISEASES OF. scopically, in the earlier stage of the disease the solitary glands are enlarged, and filled -with cells and nuclei. The gastric tubes, and some- times the subjacent muscular fibres, are dis- placed by theso bodies, -which are scattered every- where through the membrane. The tubes adhere firmly to each other, hut they still contain normal cells. Later in the disease the solitary glands appear empty in their centres, but sur- rounded by thick layers of nuclei ; the tubes can no longer be traced throughout their whole extent, but can only be recognised as bulbs filled with fatty cells, or as lines of cells, whilst the whole tissue is obscured by fatty and granular matters. In the last stage the solitary glands have disappeared, and the tubes are replaced by fibres. In some cases observed by the writer, although the mucous membrane was very thin, it was so fatty that 33 per cent, was removed when digested in ether. These anatomical changes seem to produce a concomitant decrease in func- tional power, Tost-mnrtem, digestion seldom oc- curs, even in the summer, and in one case in which the writer performed artificial digestion with the whole mucous membrane, only six- tenths of a grain of albumen was dissolved, and in two others the albumen was only softened. When a similar experiment was performed with the stomachs of persons who had died of other diseases, four grains of albumen was the average amount dissolved, the remainder being softened and translucent. Symptoms and Causes. — Atrophy of the sto- mach presents itself clinically in three different forms : — 1. We find it combined with inflammation of some of the other coats of the organ, and proving fatal by the exhaustion of the patient. A man, thirty-nine years of age, was admitted into the London Hospital, under the care of the writer, in 1873. Some enlarged lymphatic glands of the axilla had existed for twelve months, and for six months he had suffered pain immediately after eating, attended by vomiting shortly after meals. AVhen admitted, the vomiting occurred daily, and he brought up an intensely acid fluid. This gradually subsided, but he lost flesh and strength, and died from exhaustion. On post-mortem exa- mination, all the organs proved to be healthy, excepting the stomach, the coats of which for some distance from the pylorus were greatly thick- ened, whilst the mucous membrane was exten- sively atrophied throughout the whole organ. Cases like this are mentioned by most authors on diseases of the stomach, and are usually quoted to show how slight may be the anato- mical changes sufficient to produce death. But when the microscope is brought to hear upon the point, the atrophy of the glandular structure is found to be very extensive, so much so that if an equal amount of morbid change were to present itself in a closely-packed glandular organ, as, for example, in the kidn-ey or liver, it would he at once recognised and its importance acknowledged. 2. The second class includes a large number ( f the casps known as 1 idiopathic anrnmia,’ and, in all probability, the morbid alterations re- eult, not from inflammation, but from degene- ration. The writer has met with some marked 1527 cases corroborating this statement. Dr. Hand- field Jones quotes a case of ‘ extreme anaemia,’ in a man aged sixty-two, in which there was general atrophy of the stomach {Morbid Con- ditions of the Stomach, p. 108). Sappey men- tions the case of a young man, aged thirty- two, who had died in a state of marasmus, in whom almost all the pepsiniferous glands had been destroyed, excepting those in the py- loric region. It is evident from these cases that a considerable proportion of those suffering from idiopathic ansemia are really the subjects of atrophy of the stomach. There is not much emaciation, for the pancreas, liver, and absorb- ing apparatus of the intestines are capable of digesting and taking up the fat. But the heart, like the other tissues, becomes loaded with fatty matter ; and it has therefore often hap- pened that the general feebleness and evident want of blood have been attributed to this state of the centre of the circulation, and the patient has been said to have died of ‘ fatty heart.’ 3. There is a third class of cases in which atrophy of the stomach occurs, without any very especial symptoms during life pointing to the organ thus seriously diseased. The writer care- fully examined the structure in fifty-seven per- sons who had died of cancer affecting various organs of the body. Fifteen of these were fe- males, who suffered from cancer of the breast, and of these 75 per cent, presented well-marked atrophy of the glandular structure of the sto- mach. In twenty-four there was disease of the uterus, and gastric atrophy was present only in three of these; whilst no case occurred amongst persons affected with malignant disease of the glands, bones, or skin. It is evident, therefore, that the atrophy of the stomach only accom- panies certain forms of cancer. In those cases of cancer of the breast where the microscope dis- closed atrophy, the mucous membrane was much attenuated and its weight diminished ; in one case it only weighed 360 grains, the average weight in females dying from other diseases being 720 grains. The amount of pepsin con- tained in the gland-structure was, in every ease in which it was tested, remarkably deficient. The diminution in the weight of the mucous membrane in these cases was not thp result of a general wasting of the body, for in cancer of the uterus the average weight was 660 grains. The co-existence of this serious disease of the stomach with cancer of the breast, supplies us with an explanation of the fact, that many cases die some time after an operation has been performed, in whom there has been but a trifling reappearance of the malignant growth, and no great amount of discharge or of bleeding, to account for the gradual loss of flesh and strength. The writer has seen different cases of this kind, and has remarked that the cancerous tumour is usually slow in its growth, liable to contract, and that eventually nodules form in different parts of the skin. The dyspeptic symptoms are limited to failure in appetite, ofteu a disgust for animal food, and flatulence, accompanied by a gradual loss of flesh, strength, and colour. Diagnosis. — Atrophy of the stomach can only be diagnosed by the exclusion of all other dis- STOMACH, DISEASES OF. 1528 eases that tend to produce anaemia. Hemorrhage and other discharges must, of course, be strictly inquired for, and it must not be forgotten that bleedings may be going on in the digestive canal without havdng attracted the observation of the patient. It must be also remembered that anae- mia very often occurs from merely temporary failure of the digestive powers, at the com- mencement and termination of the catamenia. When we meet with a case of progressive anae- mia in a person of middle life, we should also examine the blood in order to exclude leukaemia. In this disease, as is well known, the white blood-cells are greatly increased in number, whilst the writer has found in atrophy of the stomach a diminution in both kinds of cells. Where we find the above diseases absent, no dis- colouration of the skin, and no signs of malig- nant disease, we may fairly suspeet the presence of gastric atrophy. This suspicion would be strengthened if the patient were affected with cancer of the breast, or a hard malignant tu- mour of any other organ. Treatment. — The most important point in treatment is the regulation of the diet. As there is usually a great distaste for animal food, the ingenuity of the practitioner is often severely taxed to discover some form of food likely to furnish albumen to the system which the patient can be prevailed upon to take. The articles of diet that usually agree best are mutton, fowls, game, soles, whiting, haddock, and oysters. It is often necessary to order that the meat should be beaten up, or minced, so that it may be swallowed quickly. Milk and eggs, where they agree, are invaluable, and in the later stages soups and animal broths may be substituted for solid food. The writer has often recom- mended specially prepared beef-tea, which may be composed of extract of beef that has been digested by means of pepsin. Some patients object greatly to the taste of it, and it is a useful plan to give it mixed with ordinary beef- tea or chicken-broth, or with a proportion of invalid turtle-soup. In some cases gluten bread and gluten chocolate answer well. Other ar- ticles^ diet, composed of starch and sugar, are usually more readily taken, and more easily digested. As regards medicines, steel in all shapes is beneficial. It may be combined with strychnia, quinine, or other bittors, according to the cir- cumstances of the case. Arsenic may be used with advantage, but it will be found a good plan to alternate it with other tonics. Pepsin is often prescribed, but it does not produce much benefit. Acids are often valuable, the most useful being the hydrochloric and phosphoric. They are best given, it is said, shortly after a meal. Change of air, travelling, and freedom from the cares of business, are generally of more use in retarding the progress of the disease than any drugs we can prescribe. 5. Stomach, Cancer of. — Malignant disease of this organ is much less common than simple ulceration, but nevertheless the stomach is more frequently the seat of cancer than any other organ in the body, with the exception of the uterus. It is almost always primary, unless it arise from an extension of disease from seme neighbouring organ. Secondary malignant affec- tions of the stomach are exceedingly rare. AStioeogy. — The tendency to gastric tancer increases with the age of the individual. Dr. Brinton collected 605 cases, and found the average age at death to be fifty ; the greatest liability being between sixty and seventy. It is very rare below thirty, and up to forty tho liability is scarcely equal to one-fifth of the whole. Males seem to be twice as liable to gastric cancer as females, and although the accuracy of this statement has been called in question, the writer’s own experience tends to confirm it. In a large number of cases there is a history of hereditary transmission, and so com- pletely is this established, that the mere fact of more than one member of a family having suf- fered from cancer, would lead us to diagnose its presence in a doubtful case. Neither anxiety, poverty, nor intemperance seems to influence the development of the disease. Anatomical Characters. — All the varieties of cancer of the stomach are here met with, but scir- rhus is by far thre most common. According to the researches of Dr. Brinton, it constitutes 72 per cent, of all the cases. N ext in order of fre- quency he places the medullary form, which amounts to 18 per cent. Colloid cancer is much more infrequent, excepting when in combination with seirrhus. These different forms are, how- ever, very often combined with each other. Thus we meet with seirrhus combined with medul- lary or colloid cancer. Microscopically the new growths present the ordinary appearances cha- racteristic of the forms of the disease to which they belong. Cancer seems generally to begin in the submucous tissue, and spreads from thenco to the other coats. The muscular structures vary in appearance in different cases. In some tho normal tissue has been completely destroyed, and what appears to the naked eye as muscle proves to be, under the microscope, a mass of cancer cells and fibres. In other cases we find, even at some distance from the disease, the muscular bundles much increased in thickness, and the contractile fibre-cells greatly enlarged, with very prominent nuclei. Again, the pressure of the new growth puts a stop to nutrition, so that the muscular bundles seem to be reduced to a mere mass of fibrous threads. Of equal in- terest are the changes produced in the mucous membrane. Over the tumour the glandular tissue is generally destroyed, and nothing but cells and fibres represent the original texture. But in every case examined by the writer exten- sive disorganisation of the glandular structures has been found at a distance from the original disease. This is most marked in seirrhus, where we meet with the intertubular spaces filled with fibres, the tubes being atrophied, and often re- duced to mere bulbs filled with fatty cells. AVhere the softer varieties of cancer form the main portion of the disease, the tubes are every- where apparent, but are unusually loaded with cells, whilst between and below them nucleated cells are everywhere profusely scattered. This destruction of the glaudular structure in can- cer of the stomach is in marked contrast to what we find in cases of simple ulcer, fer in STOMACH, DISEASES OF. this the normal condition of the tubes can be readily seen at a very short distance from the edge of the sore. Cancer tends in the majority of cases to attack the orifices of the stomach, and here again is another point of difference between it and simple ulcer. Its most frequent seat is at the pylorus ; according to Dr. Brin- ton 60 per cent, of all the cases being located in this region. In 13 per cent, it affected the car- diac orifice, the fundus being scarcely ever pri- marily attacked. It always has a tendency to spread in a transverse direction, so that an annular stricture is a common result. When it affects the pylorus, it scarcely ever impli- cates the duodenum; and, on the other hand, it seldom appears at the cardiac orifice with- out spreading to the lower end of the oeso- phagus. Symptoms. — The symptoms of gastric cancer usually show themselves very insidiously. The patient complains of slight disturbance of diges- tion, acidity, flatulence, or want of appetite. It has been stated that in the majority of cases there has been no previous liability to dyspepsia. No certain rule can be laid down respecting this point. In many of the cases observed by the writer, dyspepsia has been present for years, whilst in others there have been no symptoms of gastric derangement, and the first signs of the cancer have occurred whilst the patient seemed in perfect health. In some the fatal illness has been ushered in by hsematemesis ; but this is uncommon. Pain is one of the most prominent symptoms. At first it is only slight, and is often described as a dull, gnawing sensation, but, as the complaint progresses, it assumes a more neuralgic character. Generally, it is referred to the epigastrium ; in other instances to the back, or to the hypochondrium. It is or- dinarily increased during digestion, but, unlike the pain of ulcer, it is often equally severe when the stomach is free from food. The pain of cancer lias been said by some authors to be occasionally of a colicky character. This, probably, arises from a co-existing atony of the colon, for the writer has seen cases where this kind of pain was quite relieved when pro- per attention was directed to the large intes- tine. There is generally tenderness on pres- sure over the seat of the cancer, but it is not so localised, nor so severe, as in simple ulcer. Unless the pylorus is obstructed, there is rarely much complaint of acidity or flatulence. This arises from the fact that the absence of ap- petite prevents the patient from indulging in any large amount of food. W r hen the growth affects the pylorus, the same symptoms are pro- duced as in obstruction of this opening from any other cause (see Pylorus, Diseases of). A’omiting is a very general symptom, having occurred, according to Dr. Brinton, in 87 per cent, of his cases. It varies greatly, according to the part of the organ affected. In disease of the cardiac orifice it is almost always present, and arises partly from the co-existing affection of the (esophagus. When the body of the organ is alone implicated, it may be entirely absent, but in pyloric contraction it usually takes place at a lengthened interval after food. Loss of appetite is almost always present, and it shows itself, not 1529 only in the later stages, but at a comparatively early period in the disease. The loss of appetite is most marked in scirrhus, and it often forms a useful diagnostic sign, for in simple ulcer the appetite is generally unaffected. The tongue is usually dry, but thirst is seldom much com- plained of. The bowels are often confined in the earlier stages, from the imperfect muscular action of the upper part of the canal, but as the disease progresses diarrhoea frequently occurs, and tends to enfeeble the patient. The most strik- ing feature of the disease is the steady and often rapid loss of flesh and strength that accom- pany it. We meet in the post-mortem room with no other examples of such extreme emaciation as are encountered in bodies after death from this disease. No case ever runs its whole course without this symptom manifesting itself. The lips become pale, and the skin often of a greenish, or slightly jaundiced hue. How are we to explain this cachexia, which seems always to occur in gastric cancer, although it is often not even marked in the malignant affections of other organs ? No doubt, where there is a rapidly growing tumour, the wasting of the blood and the co-existing dischage from the seat of the disease, are sufficient to account for it. Where, as in scirrhus, these conditions are often absent, the chief cause of the loss of appetite, the failure in strength, and the change 'n colour, is the atrophy of the glandular structure of the stomach, which, as already pointed out, usually accompanies the disease. The pulse is ordinarily soft and feeble, for in this, as in other forms of cancer, an enfeebled condition of the heart, arising from a softened, fatty state of its muscu- lar tissue, is commonly present. If fever is ex- cited by the occurrence of any losal inflammation, the pulse is, for a time, increased in force and frequency'. Although the above are usually th9 symptoms of gastric cancer, the practitioner must not expect them to be always present. He may be called to a middle-aged or elderly man, in whom a rapid loss of flesh, strength, colour, and appetite are the only indicati ons of the fatal disease under which he labours. The patient may assert that he has neither pain, nausea, flatulence, nor, in fact, any symptom pointing to a derangement of his gastric functions. The mere loss of ap- petite and strength in an elderly person should be sufficient to awaken suspicion, and demand a most careful exploration of all the abdominal organs. Couese and Dubation. — Cancer of the sto- mach destroys life more rapidly than a similar affection of almost any other organ in the body, and it has been calculated that the average duration of the disease is about one year, the maximum being thirty-six months, whilst the shortest period in which life is destroyed from the first symptoms being noticed is only one month. The encephaloid form is most rapid in its course, because its growth is quicker, and the neighbouring organs, such as the liver and lymphatic glands, are more often implicated. Colloid cancer is the slowest in producing death, and most of the more chronic cases have con- sisted of this form of malignant tumour Severe haemorrhage is more rare than iu simple ulcer, but there is a greater tendency to a constant STOMACH, DISEASES OF. 1530 Dozing of blood from the ulcerated surface. The blood, thus slowly effused, is acted upon by the gastric juice, and when vomiting occurs, it is rejected like ‘ coffee grounds.’ This appearance of the vomited matter used to be considered as pathognomonic of cancer, but it is now known that it only arises from the blood being slowly effused, and may, therefore, present itself in other forms of gastric disorder. Peritoneal per- foration is more rare than in simple ulcer ; but we more frequently meet with communication between the stomach and other organs, such as the colon. In such a case there may be sterco- raceous vomiting, or diarrhoea maybe excited by the gastric contents finding their way into the large intestine. Marked relief of the symptoms of cancer may be temporarily afforded by such a perforation, although this is not common. In still more rare cases adhesions occur between the stomach and the parietes of the abdomen, and an external opening is produced. As the disease progresses, other symptoms are generally observed. In some cases ascites occurs; in others cederna of the legs; in others jaundice is pro- duced by the pressure of the enlarged glands on tho gall-ducts, or by the implication of the liver itself. Physical Signs . — Tho chief and most impor- tant physical sign presented by gastric can- cer, is the presence of a tumour. Dr. Brin- ton calculated that it is present in 80 per cent, of all the cases, and probably this estimate is not far from the truth. It is usually well-de- fined, hard, and nodular; and not unfrequently isolated nodules can be felt in its neighbourhood. The sound on percussion is generally more or less tympanitic. The tumour is usually found iu the epigastrium, or in the right hypochondriac region, more rarely near the umbilicus. As a rule, it is fixed, and does not move downwards with the respiration ; but in some instances, where adhesions had not formed, it has been dragged downwards by the weight of the stomach, and has presented itself as low as the liypogas- trium. It is most readily discovered when the pylorus, or the smaller curvature, is the part affected. Where the cardiac orifice is the seat of the mischief, the growth may be so deeply situ- ated that, unless it is of large size, it may elude discovery. There are certain chances of error as regards a tumour caused by gas- tric cancer, against which we should be on our guard. Thus the swelling may arise from a feculent collection in, or from disease of, the colon. Again, cases are given where the stomach was found filled with string, hair, or cocoa-nut shavings, and in each case a tumour existed during life. The rectus muscle, when in a state of tension, may give rise to the sensation of a tumour, and it is only by altering the position of the patient that the mistake can be obviated. The size of the stomach in gastric cancer varies according to the orifice affected, and in this way may prove a useful aid in diagnosis. When the pylorus is obstructed, the organ is Bsuallv enlarged; when the cardiac orifice is narrowed, the organ becomes decreased in size, and we derive less assistance from tho examina- tion of the vomited matters than might be expected. In dilated stomach they are in a state of fermentation, and contain sarcin® and torulae. Occasionally there are portions n f cancerous masses, but, as a general rule, these are too much decomposed to afford satisfactory evidence. In one case observed by tho writer, a number of particles of the intestine, with the villi attached, were discovered by the microscope in the rejected fluids, showing that the can- cerous mass had invaded the duodenum. In some instances of doubtful cancer, the fluids vomited become quite solid when boiled with liquor po- tass® ; and this may prove a useful indication iu certain cases. Diagnosis. — In the earlier stages, and before the existence of ulceration, gastric cancer may be readily overlooked. We are apt to consider a person who complains of pain at the epigastrium, flatulence, and other symptoms of indigestion, as merely suffering from dyspepsia. The loss of appetite is, however, generally a more promi- nent symptom in the early stages of cancer than in dyspepsia, and if the patient be a person of middle age, and is rapidly losing flesh, the pro- gress of the case should be most narrowlv watched, and the abdomen frequently explored for any appearance of tumour. The chief diffi- culty in diagnosis is to distinguish cancer from simple ulcer; and it is often requisite to watch the case for some time before a decided opinion can be formed. As a general rule, the pain is more severe, more increased by food, and more relieved by vomiting, in cases of ulcer than of cancer. On the other hand, it is less fixed to one spot, and is more neuralgic in cancer. The vomiting is more immediate after food, when the cardiac orifice, and is longer delayed, when the pylorus is affected by cancer than in cases of simple ulcer. The fluids rejected in chronic ulcer contain no fragments of mucous membrane, although these may be present in acute cases, and the rejected matters do not solidify when boiled with liquor potass®, as they sometimes do in cancer. In one doubtful case the writer ventured on the diagnosis of a simple ulcer, from finding in the fluids vomited a short time after eating a large amount of peptones. The patient, against all expectation, perfectly recovered. Severe h®matemesis should lead us to suspect ulcer, frequent ‘coffee-ground’ vomit incline us to the diagnosis of cancer. Loss of flesh and strength, although present in both cases, is much more rapid and decided in cases of cancer ; and, in like manner, where we can find no evidence of hamorrhage from any organ, great pallor of the lips and throat should lead us to suspect it. Again, as cancer seldom appears in those below thirty-five years of age, and quickly destroys life, we should decide in favour of simple ulcer if the symptoms occurred in a young person, and had lasted for many years. The presence of a tumour, in case proper pre- cautions have been used to prevent mistakes on this point, will settle the question in favour of cancer. In doubtful cases, the distinction between a tumour of the stomach and colon may be some- times assisted by the plan adopted in the fol- lowing case. A pitient was admitted into the London Hospital with a hard tumour below the left hypockondrium. As his symptoms did no! STOMACH, DISEASES OF. 1531 definitively point to gastric cancer, there was much difference of opinion as to the nature of the disease. The lowest edge of the tumour was first marked out with ink on the skin, when a considerable quantity of soap and water, well frothed, was injected by the rectum. The edge of the tumour was raised two or three inches, but its note on percussion was not clearer than before. As soon as the bowels had acted freely, the patient was requested to drink a pint of effervescing liquid, and now the edge of the tumour descended considerably, and the note on percussion became more tympanitic. From the injection into the colon raising the tumour, it was plainly not connected with the intestine, whilst from the percussion note becoming clearer after the drinking of the soda water, it was evident that it overlay, or was in some way connected with, the stomach. In all doubtful cases the stomach-pump should be used. Prognosis. — The prognosis of any case of gas- tric cancer is always unfavourable. It is bad in proportion to the rapidity of the progress of the case ; the early occurrence of the vomiting ; the frequency of haemorrhage ; and the evidence that other organs, such as the liver, are also impli- cated. Treatment. — There is not much to be ex- pected in the treatment of this disease. Inas- much as we are unable to check the progress of the malady, all our efforts must be directed to the relief of symptoms, and to support, as well as we can, the strength of the patient. Good and well-selected food, rest, and a fair supply of stimulants, often, for a time, appear to afford new strength to those overpowered by the dis- ease. If the body of the stomach be the part affected, the indications for treatment are the same as in simple ulcer. "When the pylorus is narrowed, the same plan must be pursued as when stricture- of that opening has occurred from any other cause. Cardiac obstruction often brings with it the greatest misery to the patient. He is tormented with hunger which he is unable to appease, and death gradually approaches by starvation. In such cases the writer has in vain tried the application of ice-bags, belladonna ex- ternally and internally, and the hypodermic in- jection of morphia. So long as nutritive ene- mata can be borne they should be given, and if diarrhoea is produced by them small doses of laudanum may be mixed with them. In a case of this kind in the London Hospital, great relief was afforded by the passing of a narrow gum clastic tube into the stomach, and pouriDg through it liquid food. After the tube had been used for a little time the patient was able to take liquids, and gained considerably in weight ; but eventually the opening became so constricted that the tube could not be made to enter the stomach. 6. Stomach, Concretions in. — Concretions in the stomach are composed of various indigest- ible substances that have been swallowed, such as hair, paper, cotton, cocoa-nut fibre, &c. They chiefly occur in idiots and lunatics. In some of the cases recorded a tumour has been observed during the life of the patient. Concretions of this kind may give rise to perforation, but more generally they set up inflammation of the mucous membrane, followed by peritonitis. 7. Stomach, Contraction of. — Contraction of the stomach may be general, or confined to one part. When general, the stomach is uniformly reduced in size. This condit ; on is the result of long-continued abstinence from food. Thus, in disease of the oesophagus or of the cardiac orifice of the stomach we meet with it, and sometimes to such an extent that the organ is contracted to the size of the intestine. Again, when vomiting has been excessive and long-continued, as in acute gastritis, a diminution in capacity is ob- served. In all these cases, although the organ appears to be so much reduced in size, it readily assumes its normal dimensions when artificially distended. The stomach may be generally les- sened by the contraction of a cancer or ulcera- tion situated in the smaller curvature. The lessened capacity may be partly due to the small amount of food that could be retained on ac- count of the constant vomiting, but it is chiefly owing to the drawing together of the orifices, which in extreme cases may be separated from each other by a very small space. Partial con- traction of the stomach may result from the puckering up of the coats of the organ by the cicatrisation of an ulcer. Cases are recorded in which the stomach was divided, by the contrac- tion of a cicatrix, into two distinct pouches, com- municating with each other by a very narrow canal. Where the contraction occurs in the pyloric region, the contents of the stomach can- not be forwarded iffto the duodenum, and hyper- trophy of the muscular structure, together with dilatation of the fundus of the stomach, is generally the consequence. See Pylorus, Dis- eases of. 8. Stomach, Dilatation of. — This may occur either in an acute or chronic form. (1) Acute dilatation. — This form is exceed- ingly rare, and has attracted but little atten- tion until of late years. The earliest case on record is that of a lady mentioned in the fourth volume of the Pathological Transactions , by Dr. Miller and Dr. Humby. She had been under treatment for piles shortly before her ill- ness, and the abdomen had been observed to have increased in size. She was attacked with vomiting of immense quantities of fluid. The vomiting ceased four days afterwards, and the abdomen was found to be greatly enlarged. After death the cause of the abdominal distension proved to be the stomach, which was so much dilated that it was capable of holding. 10 pints of liquid. Dr. H. Bennett, of Edinburgh, relates a similar case, and attributes the dilatation to a large quantity of effervescing liquid the patient had swallowed to allay his thirst. Dr. Hilton Fagge, in the Guy's Hospital Reports (vol. xviii. Third Series), describes two cases that had fallen under his notice, and also mentions that two similar cases had been observed at Guy’s Hos pital during fourteen years. Diagnosis. — The signs of the dilatation, ac cording to Dr. Fagge, are : — ‘ 1 . A rapidly in ■ creasing distension of the abdomen, which is unsymmetrieal, the left hypoehondrium being STOMACH, DISEASES OF. 1532 full, while the right hypochondrium is compara- tively flattened. 2. The existence of a surface- marking descending obliquely towards the umbilicus from the left hypochondrium, and corresponding with the dragged-down lesser curvature of the stomach, this line appearing to descend with each inspiration. 3. The presence of fluctuation in the lower part of the abdomen. 4. The occurrence of splashing when the dis- tended part of the abdomen is manipulated. 5. The presence of a uniformly tympanitic note over a large part of the distended region, when the patient lies flat on his back. Above the pubes, on the other hand, there may be dulness on percussion, simulating that of a distended bladder.’ Treatment. — -There is no doubt that the treat- ment recommended, and in one case employed, by Dr. Fagge is the proper one, namely, to empty the distended stomach as quickly as pos- sible with the stomach-pump ; and to maintain life by nutrient and stimulating enemata. (2) Chronic dilatation. — .Etiology, — The most common causes of dilated stomach are con- ditions that prevent the egress of the digested food into the duodenum. 1. Cancer affecting the pylorus is the most usual cause. It may pro- duce obstruction at the duodenal opening, either by the formation of a hard scirrhous ring, or by the projection inwards of fungoid growths. 2. The narrowing of the pylorus arises in some cases, not from malignant disease, but from fibroid thickening taking place below the mu- cous membrane ; or more rarely thickening of the mucous membrane alone suffices to narrow the opening into the duodenum. 3. A simple ulcer near the pylorus, or the cicatrix of a healed ulcer, may cause the obstruction. 4. The pressure of tumours upon the pylorus or duo- denum externally may prevent the due evacua- tion of the contents of the stomach. The tu- mours are usually of a malignant nature, but, more rarely, the same effect may arise from enlarged scrofulous glands. 5. The stomach may be displaced by adhesions, or the pylorus so dragged downwards that dilatation results. 6. The stomach may become dilated from paralysis of its muscular coat, produced, as in a case given by Dr. Wilks, by injury to the splanchnic nerves ; or, as in an instance which occurred to the writer, from a fibroid change in the muscular coat. A certain amount of dilatation is by no means uncommon as a result of chronic catarrhal gastritis. Anatomical Characters and Pathology. — When we lay open the abdomen, the stomach is found to be greatly increased in size, often so much so that it appears to fill the whole cavity. The greater curvature lies below the umbilicus, in extreme cases even as low as the pubes. The position of the pylorus varies according to the nature of the co-existing disease. Sometimes it is tied down by adhesions to its original site; at others it has been dragged downwards by the weight of the enlarged organ, and is situated at a much lower level. When the stomach is laid open, it is found partially or wholly filled with a dark-coloured frothy fluid, the amount of its contents being often enormous. The rug* are effaced by the constant stretching, and the mucous membrane presents a level surface, which is generally more or less softened by the action of the acid contents upon it after death. Microscopically, the glandular structure is found to have suffered from the long-continued stretch- ing. In one case the writer found the tubes visible, but widely separated from each other, the gastric cells being large and fatty. In another case the destruction had proceeded still further ; a large proportion of the tubes had been destroyed, and were replaced by fibrous tissue, the muscular tissue being also thin and fibrous. In other cases the muscular structure proves to be in a state of hypertrophy, this con- dition being usually most distinct in the pyloric region. Symptoms. — As, with the rare exceptions be- fore noticed, where the dilatation occurs sud- denly, the stomach only slowly enlarges, the symptoms manifest themselves very gradually. They are preceded by those of the malady which gave rise to the dilatation. Thus, the patient may for many years have suffered from the severe pain after food and vomiting indicative of ulceration ; or frequent attacks of waterbrash, or flatulence and acidity, may have led to the suspicion of fibroid degeneration of the pylorus. Unless cancer should co-exist, there is seldom much complaint of pain, but a sensation of weight and fulness is usually experienced. More generally, attacks of heartburn present themselves, and a scalded feeling of the stomach and oesophagus annoys the patient. In some, there is a constant sense of craving referred to the epigastrium. Vomiting is almost always present, although it may be absent for consider- able intervals. It does not occur, as in gastric ulcer, shortly after food, nor is there usually any complaint of nausea. The patient feels full and uncomfortable, often has a sensation as if fermentation were going on in the abdomen for two or three days, until he gets relief by the evacuation from the stomach of an enormous quantity of liquid. In other cases, the vomiting occurs more frequently, most generally at night, or towards the morning. He experiences great relief for a few hours or days, as the case maybe, until the fluid again collects in sufficient quantity to produce discomfort. There is no great amount of straining during the attacks of vomiting, and if the abdomen be examined as soon as the act is terminated, the stomach is still found to be full. It seems, indeed, as if the contents were only partially pumped off by the action of the diaphragm and the abdominal muscles, the stomach itself being quite passive. In some casos hsmatemesis occurs, but this is rare, unless cancer be also present. The characters of the vomited matter are peculiar ; usually they are of a more or less dark brown colour, very sour, edging the teeth and scalding the throat of the patient. When the liquid is allowed to stand, it soon becomes covered with a thick scum, and deposits a thick brown sedi- ment. Chemically, it is found to contain various acids produced by the decomposition of the food. Microscopically, we meet with sarcinse and torul* in great abundance, intermixed with particles of partially digested food, and with mucus. In a few cases, bile is evacuated, but STOMACH, DISEASES OF. this is an uncommon circumstance, and espe- cially where there is a narrow stricture at the pylorus. Acid eructations are very common, and often more distressing to the patient than any other symptom. Thirst is usually complained of, and an excessive secretion of saliva is frequently remarked. The tongue has nothing characteris- tic. The appetite is bad where cancer co-exists, but in other cases it is good, often voracious. The bowels are almost always constipated, and the stools hard and knotty. The urine is usually acid, and often deposits an abundant sediment of lithates. The nutrition of the patient soon suffers, and loss of flesh and strength always accompanies the disease.- Death eventually takes place by exhaustion, being not unfrequently pre- ceded by swelling of the feet and legs. Physical Signs . — The abdomen is perhaps dis- tended, and covered with enlarged and tortuous veins. The shape is characteristic, the upper curvature of the stomach being visible as it stretches across between the false ribs, the epi- gastrium being hollow instead of prominent, and the abdomen much fuller on the left than on the right side. "When, as is so often the case, the mus- cular coat is in a state of hypertrophy, the ver- micular movements may be seen through the stretched and attenuated integuments. The movements are slow and gradual, proceeding usually towards the right side of the body. They are almost constant, but can be quickened by the application of cold or by galvanism. Too great stress must not be laid upon this symptom. Vermicular movements are visible in the parts above the stricture, whenever any portion of the gastro-intestinal tube is contracted. The sounds on percussion vary as the dilated sto- mach is full of air or of fluid. The tympanitic sound is best heard when it is only partially full. By changing the position of the patient, we are enabled to show that the fluid gravitates in the enormously dilated organ. By lowering the head and raising the hips and legs, we may generally define the lower boundary of the stomach, by the clear sound which is thus exchanged for a dull one on percussion. Bam- berger asserts that, by placing the stethoscope over the stomach whilst the patient is drinking, we can hear the fluid fall into the distended cavity. This, in the writer’s opinion, is of little value, for he has distinctly heard the passage of food through a stricture of the cardiac opening, where the stomach was smaller than normal. Diagnosis. — With ordinary care, a dilated stomach is not likely to be confounded with any other abdominal disease. The chief points to bear in mind are — the large extent over which there is a tympanitic sound; the irregular dis- tension of the abdomen ; the hollowness of the epigastric region; the fulness of the left side of the abdomen; the vermicular motion apparent over the dilated organ ; the peculiarity of the vomiting; and the large amount of fluid thus evacuated of an acid character, presenting under the microscope torulae and sarcinse. The dia- gnosis of the cause of the dilatation must be determined by the history of each case. Treatment. — The indications for treatment are sufficiently evident, but unfortunately they are most difficult to meet. 1 333 a. It is evident that it is a matter of th* first importance to keep the stomach as empty as possible, so as to allow of its contraction. This can only be effected by giving small quantities of liquid food at a time, and frequently. But it must not be forgotten that if the patient fails to fill the long-distended organ, a sensation of faintness and craving will be induced that will tempt him to set at defiance all our directions Consequently, we may be often obliged tc give way to his solicitations, and allow food of a solid character. The main point, however, is, as much as possible, to restrict the supply of food. In bad cases the writer finds it a good plan to order nutrient enemata, as well as small quantities of food by the mouth. See Enema. The plan of washing out the stomach, by means of a stomach-pump, with Vichy water or a strong alkaline solution, has not been so successful i.i th6 bands of tho writer as he expected. In one case it had no appreciable effect in giving relief; and in another the patient complained so much of it that he was forced to abandon its use. b. The muscular action of the stomach must be as much as possible facilitated. The writer has used galvanism, but with no ultimate benefit. Elastic abdominal belts may afford support to the overloaded organ. What, however, is always more or less beneficial is to keep up a free action on the large intestine by enemata. Injections of gruel and barley water, mixed with castor oil and turpentine, answer the purpose best. c. Symptoms must be relieved as they arise. The subcutaneous injections of morphia are in- valuable for the relief of pain. In some cases chloral answers better, but, on the whole, it is inferior to preparations of opium. One of the most distressing symptoms is acidity. This is best relieved by a combination of bismuth with magnesia or soda, or by lime-water given fre- quently. Sir William Jenner recommends the hyposulphite of soda to relieve the acidity. Others have recommended carbolic acid and creasote. The plan the writer has often adopted with suc- cess is, to restrict the patient to a diet from which all starch and sugar are carefully excluded. Thus, at breakfast we may give weak coffee, dandelion coffee without sugar or milk, and lime-water, always with gluten bread. Th6 other meals, which should be frequent and very sparing, may consist of soup or animal broths, or — if it be thought advisable to allow solids — of mutton, game, chicken, or fish. No vegetables should be permitted, and the patient should be restricted to gluten bread or almond cake instead of wheaten bread. With such a diet, assisted by cod-liver oil, patients for a time may improve greatly, and gain both flesh and strength. In persons affected with dilated sto- machs from atrophy of the muscular coat, lasting benefit may be obtained ; especially if the com- plaint be recognised, and treated in a decided way. 0. Stomach, Fibroid Thickening cf. — This condition has received various names, such as ‘ cirrhosis of the stomach,’ ‘sclerosis,’ ‘plastic linitis,’ &c. Allusion has been made in another article to thickening of the coats of the stomach I of a similar nature to that affecting the pylorus, STOMACH, DISEASES OF. 1534 and usually producing hypertrophy of the mus- cular layer, narrowing of the opening into the duodenum, and eventually dilatation of the organ ( see Pylorus, Diseases of). Such cases, although not common, are every now and then met with, and in many instances the thickening of the 6ubmucous tissue extends for some distance from the pylorus, producing a tough, leathery condi- tion of the coats. More rarely the thickening occurs in other parts than at the pyloric end. Thus, in one case of caries of the spine, the stomach was attached to the spinal column by a dense layer of connective tissue, which slso involved the coats of the organ. Over the mass was a large ulceration with thickened base and edges. But apart from these local thickenings, we occasionally meet with a form of the disease, in which the coats of the whole organ are im- mensely hypertrophied. ^Etiology. — Males seem to he more liable to this complaint than females, and it occurs at an earlier period of life than cancer. Dr. Brinton states that, whilst the average age of cancer is fifty, that of fibroid thickening is only thirty- four. Mechanical injury seems in some instances to have produced this disease. Anatomical Characters. — On opening the abdomen, there are almost always found signs of general peritonitis, either acute or chronic. In some cases a thick layer of lymph overlies and unites the various organs ; in others only fluid, mixed with flakes of lymph, is discovered. The stomach is round or oval in shape, smooth on the surface, firm to the touch, and forming a tumour in the epigastric or hypochrondriac region. When cut into, its walls do not collapse ; and its cavity is often so much reduced in size as to be capable of containing only a few ounces of fluid. The thickness of the walls varies greatly, but in some instances they have been described as upwards of an inch. As a general rule, they are thicker at the pylorus than elsewhere, but the opening into the duodenum is not necessarily' constricted, although such is not . infrequently the case. The coats are of a dirty grey colour, but the distinction between them can be readily made out. The chief seat of the thickening seems to be in the submucous tissue; but the muscular layers, as well as the connective tissue between the muscular bundles and the subserous structure, are allmuch increased in thickness and density. The mucous mem- brane is thrown into folds or elevations, or stud- ded over by small projections, most of these appearances being probably the result of the diminished capacity of the organ. Microscopic- ally, the mucous membrane is usually found healthy. All those who have examined such cases have come to the same conclusion, namely, that the connective tissue alone is universally increased in thickness, and that there is an absence of any indication of cancer. Symptoms. — In a case observed by the writer the symptoms followed immediately after the receipt of an injury to the epigastrium; but usually they have come on insidiously. There is generally pain in the epigastrium, increased by fcod, in some instances shooting into the back and shoulders. The tumour formed by the thickened stomach is almost always tender on pressure, but not remarkably so, unless peritonitis is present. Vomiting is a general symptom ; in some it occurs directly after food, in others the fluid re- jected is thin, like saliva. Towards the close of the disease vomiting of blood is not unfrequent, but, unless ulceration occur, there is an absence of the coffee-ground fluid so constantly marked in cancer. The appetite is always bad, and decreases as the disease advances; the bowels are usually confined. There is loss of flesh and strength ; the pulse is feeble towards the end cf the case ; dropsy, both of the peritoneum and lower extremities, generally shows itself ; and the patient dies from exhaustion, or is cut off by the occurrence of peritonitis. The duration of the malady varies greatly. In some cases it has been known to last for many j-ears, whilst in others tho patient has died in a few months. Physical Signs . — In almost every instance a tumour has been observed during life. It is generally situated in the epigastrium, but may present itself in either hypochondrium. In one patient it was supposed, from its situation, to he a cancer of the spleen. It is smooth upon the surface, more or less tender to the touch, and usually movable from side to side. On per- cussion, the sound is not perfectly dull, as in the case of a solid tumour. Diagnosis. — This complaint may be con- founded with cancer, or with foreign bodies in the stomach. It must be most difficult, if not impossible, to diagnose the more acute cases from cancer. The smoother surface of the tumour, and the non-affection of the liver or other organs, are the most likely points ou which stress may he laid, to distinguish between the two diseases. In the chronic cases of fibroid thickening, the long duration of the illness, the less constant pain, the vomiting directly after food, the loss frequent occurrence of coffee- ground vomiting, and the absence of the history of a family predisposition to cancer, may afford some grounds for a diagnosis. To distinguish these cases from foreign bodies in the stomach, we must remember that the latter are found chiefly in idiots and in the insane, or in hysteri- cal females. The writer has long been in the habit of distending the stomach in all doubtful cases, by making the patient drink freely of soda water; and in one instance where thecoatsof the stomach were much thickened, he succeeded bv so doing in proving the case to be one of fibroid disease. The note on percussion became more tympanitic, and the lump descended, hut in the case of a foreign body in the stomach no change would be effected by such a manoeuvre. Thickening of the walls of the stomach may, as just said, closely simulate cancer. It is neces- sary therefore that we should he on our guard against such a mistake. Although fibroid thick ening of the stomach is ver}' rare, yet we should not be too hasty in giving a settled opinion until the presence of a tumour, attended by other general and physical signs, leaves little doubt as to the correctness of the diagnosis. Treatment. — Careful attention to diet is the most essential point in the treatment of this disease. The diminution in the size of the stomach is sufficient to show that only small STOMACH. DISEASES OF. 1535 quantities of food can be retained, and the im- paired condition of the motor apparatus indi- cates the necessity that the nourishment should consist only of liquids. Milk and animal soups seem best fitted for such cases. Opium is almost th9 only medicine likely to be of value ; but occasional leeches, and small blisters, frequently repeated, to the epigastrium, tend to relieve the sufferings of the patient. .0. Stomach, Gangrene of. — It is supposed by many modern authors that ulcerations of the stomach are produced by the solution, by means of the gastric j uice, of small patches of the mucous membrane that have been deprived of their vita- lity, and become gangrenous. Such may no doubt be the case, when the m'orbid condition is con- fined to merely isolated patches of the stomach ; but where acute gastritis coexists, there is a com- plete suspension of the secretion of gastric juice, and the writer has in such cases seen the edges of the slouuhing tissue still remaining attached to the neighbouring healthy structures. Where there has been great depression of strength we occasionally meet with sloughing, to a consider- able extent, of the mucous membrane of the stomach, both in the inferior animals and in man. Cases of sloughing of the stomach occurring in the human subject have been recorded by various authors. Dr. Habershon mentions one in which, along with diseased kidneys and pneumonia, there were several sloughs at the lesser curvature of thestomach, ‘ the longest two inches in length and about one in breadth, black and slightly raised ; a section showed that the slough was situated in a sort of cup of slightly thickened tissue. Two smaller sloughs were situated near to it.’ The most ordinary form of gangrene of the stomach is where it occurs in cancer of the organ. A large mass of sloughing tissue is found connected with a malignant ulceration, often of large size, and generally situated towards the pyloric end of the organ. Treat:, ient. — Gangrene of the stomach is be- yond treatment. 11. Stomach, Hernia of. See Stomach, Mal- positions of. 12. Stomach, Hypersemia of. — The mucous membrane of the stomach is frequently found to be congested after death, where there has been but little evidence of disease during life. ^Etiology and Anatomical Characters.— Gastric hypersemia may arise from different causes. If an animal be killed when fhsting, the lining membrane of the stomach is found to be pale and anaemic ; but if death should occur whilst digestion is going on, the ves- sels are seen to be filled with blood. The same thing is observed in the human subject, and serves to explain the frequent occurrence of a congested state of this organ after death. In other instances the increased vascularity is the result of a lavish employment of alcoholic stimu- lants during the later hours of life. The most extreme degrees of hypersemia of the stomach are met with in cases of diseased heart, more especially when the mitral valve has been con- stricted. When we open the stomach we are at once struck with, the dark, purple condition of its lining membrane, the appearance of conges- tion being most evident iD the pyloric region and terminating abruptly at the end of the •oeso- phagus. The rugse seem thick and prominent, and the whole surface is covered with a layer of tenacious mucus. Spots of extravasated blood present themselves, some being softened on their surface, as though they had been acted upon by the gastric juice. There is, however, seldom any of the general softening character- istic of the action of the gastric juice after death, and the surface looks raw and uneven after the removal of the adherent mucus. The whole stomach has a thickened, fleshy feeling, and is, in reality, considerably increased in bulk. In three males who died of heart-disease the average weightof thegastric mucous membrane was found to be 1,026 grs., and in three females it amounted to 800 grains. As the average weight in fifteen males, who had died of other diseases, was 864 grains, and in thirteen females 530 grains, it is evident that the bulk is greatly increased in hypersemia. Microscopically, sections of the stomach have an opaque appearance, from the quantity of blood and serum they contain, but, after being for some time macerated, they are more transparent. In some cases the tubes can be readily separated from each other, and are normal ; but in others they are of unusually large size, and distended with cells and granular matter. The blood-vessels are always enlarged, and in long-standing cases the coats of the veins are thickened. The capillaries surrounding the ori- fices of the tubes, where the backward pressure of the blood must be chiefly felt, on account of their want of support, are especially dilated and engorged with blood. Long-continued congestion produces the same effect in reducing the secre- tion of the stomach, as it does on that of the kidneys and other glandular organs. The secre- tion of acid is evidently lessened, for in some instances phosphates have been found in the con- tents of the stomach, and, as a general rule, the mucous membrane does not present the appear- ance of post-mortem solution. But the formation of pepsin is also impaired. The writer made an artificial gastric juice from the mucous membrane of three males dying of heart-disease, and found only 2'9 grains of albumen were, on the average, dissolved, whilst the average amount digested by the mucous membrane of persons who had died of other maladies was 4 grains. In the case of three females a still smaller amount of solvent power was displayed. In one only 2 grains were di- gested, and in the other two scarcely any effect was produced upon the albumen. There can be, therefore, no doubt that long-continued conges- tion of the gastric mucous membrane not only produces anatomical changes, but also diminishes the characteristic secretion of the organ. The question may be asked why hypersemia is more intense in the pyloric than in the more actively secreting portions of the organ? In all proba- bility it arises from the fact that the vessels of the stomach perforate the muscular coat ob- liquely, before they pass upwards between the tubes to the surface. The circular fibres must compress these vessels during their contraction; and the veins, from the greater tenuity of their coats, and from their not being protected by STOMACH, DISEASES OK 1536 surrounding fibrous tissue, must feel the effects of the compression more than the arteries. But the transverse muscular fibres are comparatively thin and weak in the larger portion of the stomach, and become firmer and stronger as we approach the pylorus. Consequently, the veins are moro liable to compression during the more energetic motions of this region, and the effects of the congestion are here more appreciable. 13. Stomach, Hypertrophy of the Walls of. See Stomach, Eibroid Thickening of. 11. Stomach, Inflammation of.— Stnon. : Gastritis; Fr. Gastrite ; Ger. Gastritis. All the coats of the stomach may he simul- taneously inflamed, but this is rarely met with, and the cases in which it occurs are referred to under other headings {see Stomach, Fibroid Thickening of). Usually the mucous mem- brane is alone the seat of the disease, and it has of late years been the custom to describe this as ‘gastric catarrh.’ This term is objectionable, as catarrh is so generally applied to the inflamma- tion of mucous membranes of a much more simple anatomical structure. It, should be borne in mind that the mucous membrane of the stomach is in reality an expanded gland, the elements of which have a greater functional activity than those of any other secreting structure in the human body. The injuries inflicted upon it by disease are therefore in no way analogous to those suffered by an ordinary lining membrane, but tend to lessen or altogether destroy the function of an organ of primary importance to the well-being of the individual. In addition to this, the anatomical changes are not always of the same character, but seem to the writer in certain cases quite distinct from those ordinarily produced by catarrh. Inflammation of the mu- cous membrane of the stomach will therefore be described under two forms, namely, (1) Catar- rhal ; and (2) Erythematous gastritis. It will he also necessary to consider the disease according as it occurs in an acute or chronic form. (1) Acute Inflammation — Acute Gastritis. ./Etiology.— Acute catarrhal gastritis is most common in persons of middle and advanced age, aud it more frequently affects females than males. Sometimes it occurs in gouty and rheumatic subjects, and is relieved when the disease ap- pears in the joints. Again, it presents itself in those who suffer from disease of the heart, emphysema of the lungs, cirrhosis of the liver, aud other disorders that have a tendency to keep up a congested condition of the digestive tract. Under these circumstances it often proves very dangerous, and snaps the feeble thread by which the patient clings to life. The most com- mon causes are, however, errors in diet; various indigestible substances, such as cheese or shell- fish, being especially liable to produce it. Above all, an immoderate indulgence in spirituous liquors is apt to set up this form of inflammation, not infrequently laying thereby the foundation for other and more serious morbid changes. Acute erythematous gastritis is more generally met with in children and in j'oung persons, and constitutes a considei'able number of the so- called ‘ gastric ’ and 1 remittent ’ fevers, so com- mon at this period of life. It also presents itself in scarlet fever and other eruptive disorders, and although it usually passes off without provoking any local symptoms during the fever, it never- theless constantly leaves a liability to a frequent recurrence of the disorder. Considering how often the recurrence takes place, it is strange that so little attention has been attached to the circumstance. A similar morbid condition of the stomach often makes its appearance in the last stage of phthisis and other exhausting disorders, and adds greatly to the danger and sufferings of the patient. Anatomical Charactebs. — In catarrhal gas- tritis the stomach is usually contracted and empty. The lining membrane is covered with a tenacious or thready mucus, beneath which it appears irregularly congested. It is softer than usual; and often presents numerous small hae- morrhages. These are most commonly met with in the pyloric region, are round or oval in shape, and frequently superficially ulcerated. Micro- scopically, the pits on the surface of the mem- brane are found to be swollen, prominent, and their vessels are much congested. On section, the gastric tubes are seen to be greatly dis- tended with large granular cells, which, by their increased size and number, bulge outward the basement-membrane, so as to produce an irre- gular outline. The solitary glands are greatly enlarged. We meet with the most perfect examples of acute erythematous gastritis in scarlatina. In the earlier stages there is no increased secretion of mucus, and often but slight injection of the sur- face, whilst at a later period the mucous mem- brane may be even paler than usual. Microsco- pically, the gastric tubes are much distended by granular and fatty matters, so that the cells are quite obscured, and in many cases these seem to be reduced greatly in number. Casts of the tubes are in some instances met with in the contents of the stomach. It will be observed that the morbid appearances, which are strictly analogous to those of the skin in scarlatina, differ from those produced by catarrh, in the amount of mucus not being increased, and in the tubes being distended by an albuminous fluid, instead of by an increased growth of the cells them- selves. It is therefore analogous to an erythe- matous affection of the skin, with which, indeed, it is associated in scarlatina ; whilst the catarrhal form is analogous to the eczematous and other inflammations of the cutis, which are charac- terised by a more abundant formation of the cel- lular elements. Symptoms. — The catarrhal form of gastritis is sometimes preceded for a few days or hours by a feeding of general weakness ; in other cases the attack comes on without warning. There is sel- dom any complaint of pain in the region of the stomach, although a sense of fulness and uneasi- ness is not uncommon. Vomiting is always pre- sent, and constitutes one of the most charac- teristic signs of the disease. At first any re- mains of the previous meal are rejected, but afterwards a thick, glairy mucus is expelled, attended with violent retching. The tongue is foul, and the breath often offensive, from the co- existence of oral catarrh. There is an absence of STOMACH, DISEASES OF. appetite, or a positive aversion to all food. The bowels are confined ; the urine, which is often pale and copious before the attack, becomes scanty and high-coloured during its continuance. The pulse is rarely quickened, and the tempera- ture of the skin unaltered. There is almost always headache, the pain chiefly affecting the forehead and eyes, and being accompanied by intolerance of light and sound. In erythematous gastritis, on the contrary, pain at the epigastrium is a prominent symptom, excepting when the disease accompanies eruptive fevers. It usually comes on directly after food, sometimes shooting into the shoulders, or down the left arm. In phthisical cases a feeling of rawness in the oesophagus and stomach is more generally complained of. The pain is associated with tenderness on pressure over the pit of the stomach. In children there is usually an ab- sence of pain, but the tenderness is well-marked. Vomiting is as general as in the catarrhal form, but the matters rejected seldom contain much mucus. Nausea is present where vomiting is absent, and in the slighter cases forms the chief ground of complaint. Thirst is almost always troublesome ; the tongue is at first red and in- jected, but in a day or two is apt to become dry and glazed. Diarrhoea generally accompanies the disease, the stools being foetid and unhealthy. The pulse is quick, often out of all proportion to the severity of the other symptoms. The tempera- ture of the skin is increased, especially in children. Both these forms of gastritis generally sub- side, but in other cases the disease shows a tendency to become chronic. In both there is a diminution, or entire cessation, of the secretion of the stomach. This does not arise from any deficiency in the amount of pepsin in the tubes, for the writer has found the mucous membrane after death capable of forming an active artificial gastric juice. In all probability, the secretion of acid is arrested, or its flow into the stomach prevented, by the swelling of the orifices of the tubes or of the pits into which they open. The result, however, is that fermentation occurs in any food that may be placed in the organ ; the inflammation is thereby kept up ; and largo quantities of torulae, mixed with food or mucus, are rejected by vomiting. Diagnosis. — The vomiting of aeute catarrhal gastritis, attended, as it so frequently is, by headache, is apt to be confounded with the gas- tric irritability of brain-disease. In affections of the brain the vomiting occurs more directly after food, and is often unattended by nausea. The tongue may be clean, whilst the pulse is quick, the skin hot, the bowels obstinately con- fined, and other symptoms are present pointing to some brain-lesion. In gastritis the nausea is more complained of : the tongue is foul ; the pulse, in the catarrhal form, but little quickened ; the skin comparatively cool ; the bowels often re- laxed ; and there is a history of previous at- tacks, or of some dietetic error or co-existing visceral disorder. Acute erythematous gastritis may at first closely simulate typhoid fever, espe- cially in children. It is, however, distinguished from it by the gastric symptoms being promi- nent from the onset ; by their sudden occur- rence ; by the rapid, not gradual, rise of the 97 1537 temperature ; by the red, injected tongue ; and by the spleen not being enlarged. The fall in the temperature, and the absence of eruption and of diarrhoea, serve to prevent mistakes after the first week of the illness. Prognosis. — When gastritis is uncomplicated, the prognosis is favourable, but it is otherwise if it take place in the course of some serious chronic disorder. Treatment. — The general principle to be kept in view is to afford the stomach as perfect phy- siological rest as possible. In severe cases, therefore, it is best to let the patient abstain entirely from all food for twenty-four or forty- eight hours, allowing him to suck only a little ice, in order to allay thirst. If there be much exhaustion, or if the attack be a protracted one, the strength may be supported by nutrient enemata. Sometimes the subcutaneous injection of morphia assists in giving rest to the inflamed organ. In acute catarrhal gastritis, especially when it is attended with portal congestion, or has arisen from excessive indulgence in spiri- tuous liquors, we can often put a stop to the attack by calomel. Five grains may be placed on the tongue, and be followed by a saline aperient, or a second dose may be administered the following day. When there is diarrhoea or much exhaustion, it is a good plan to give a grain every few hours. In the slighter attacks effervescing liquids often give great relief to the patient. In the earlier stage of erythematous gastritis, nitrate of potash or muriate of am- monia, along with hydrocyanic acid, is generally of benefit ; the bowels being at the same time re- lieved by some mild aperient, or by an enema. In both forms the practitioner should be on the watch, lest the symptoms should be kept up by fermentation. This is readily determined by placing a drop of the vomited matters, mixed with a weak solution of iodine, under the micro- scope. Torulie, if present, will bo detected by their brown colour, round or oval shape, and their tendency to the formation of chains of cells. In case of fermentation, carbolic acid, creasote, or sulphurous acid may be prescribed. The glycerine of carbolic acid, in doses of ten or twelve drops, is to be preferred, combined with tincture of belladonna or solution of morphia. In other cases the sulphurous acid seems to answer better. Occasionally the vomiting appears to persist from exhaustion. When this is suspected to be the case, stimulants must bo had recourse to, and the writer has seen champagne stop sickness at once, when all other remedies had been fruit- lessly tried. It is in such circumstances that the hypodermic use of morphia is so valuable ; a single dose often giving sleep, and allowing the stomach sufficient repose to recover its normal tone. When there is much epigastric tenderness, the application of a few leeches is often of great value. This is chiefly the case where the attack has occurred as a complication of some other gastric disorder, such as ulcer. In obstinate cases of catarrhal gastritis, dry-cupping may be used with benefit. In the erythematous form we always find warm external applications use- ful, such as poultices of linseed meal, with or STOMACH, DISEASES OF. 1538 without mustard, hot fomentations, and in some eases stimulant or opiate liniments. When it is considered advisable to allow food, it should he in the form of liquid. It should be given in small quantities at a time, and he often repeated. In catarrhal gastritis all sac- charine and starchy fluids should he avoided, on account of their tendency to ferment. It is hest to restrict the patient to chicken-broth, or mutton or beef-tea, or milk mixed with soda, Vichy, or Seltzer water. In the erythematous form, where there is less tendency to fermenta- tion, barley-water, arrowroot, or other farina- ceous food mixed with milk, may be used. It often happens that condensed milk is tolerated where cow’s milk is rejected. (2) Chronic Inflammation ; Chronic Gas- tritis. This is, perhaps, the most common disease met with in practice, and comprises all the forms of chronic gastric derangement usually described under the head of ‘ inflammatory dyspepsia.’ It is almost always of a catarrhal nature, for when signs of erythematous gastritis present them- selves, it will generally he found that the latter affection is an acute attack supervening on chronic changes of a catarrhal nature. ^Etiology. — Men are more subject to chronic gastritis than females; and amongst the working classes, the writer found it was most frequent in men between forty and fifty, and in women between fifty and sixty. In a large proportion of the cases that occur in early life it is an here- ditary disease, and the mother is much more apt to transmit it than the father. It often results from attacks of acute inflammation. Persons of a full habit of body are more especially liable to chronic gastritis, and it is in such that the com- plaint usually proves especially rebellious to t.roatment. Of alL causes, errors in diet are most apt both to induce it, and to maintain it when once it lias been lighted up. Thus, a too free supply of animal food is one of the most potent causes, and equally so is the habit of too fre- quent repetition of meals, without allowing a sufficient interval between them. This habit of eating too frequently is greatly kept up by the craving which is so common a symptom of the disease. Imperfect mastication is another com- mon cause: hut, above all, the immoderate use of alcohol occupies a prominent place. It is strange how frequently we discover signs of chronic gastritis after death, where no particular complaint has been made of any derangement of the digestive organs. This is more especially the case where cirrhosis, chronic congestion of the liver, diseased heart, and other disorders tending to obstruct the portal circulation, are present. In like manner, it is apt to occur whenever any ex- cretory organ is performing its office imperfectly, as in chronic diseases of the kidney, or when constipation, or inactivity of the skin exists. It is very common in gouty subjects, and in fe- males who suffer from catamenial derangements. It is often met with in persons who have died of phthisis and other wasting disorders. Anatomical Ciiakacters.— The mucous mem- brane of the stomach is covered with a layer of .greyish -white, tough, transparent mucus, which ibrmly adheres to the surface. On its removal an abnormal amount of vascularity becomes apparent, the veins being large and prominent. The surface is often of a grey or slate colour, and not unfrequently numerous hiemorrhagic ero- sions present themselves. This is more espe- cially the case where long-continued congestion has been kept up by cardiac or hepatic disease. In other cases the surface is strikingly uneven, being studded over with numerous little pro- minences, separated from each other by shallow furrows. This condition is named ‘mammilla- tion.’ More rarely, small polypoid formations project from the membrane. The whole mem- brane is firm and tough, and can be stripped away from the subjacent structures in flakes of considerable size. These anatomical changes are more common in the pyloric region than in the more actively secreting portions of the orgaL. Microscopically, in the slighter cases the ana- tomical changes may be limited to enlargement and thickening of the small pits on the surface, together with dilatation and congestion of the blood-vessels. Hut when the disease has been of long standing, a section shows the glandular structure itself to have participated. The secret- ing tubes are closely united together, and to the subjacent coats ; their basement-membrane is greatly thickened ; and they are distended with cells and granular matters, which often project like little lumps from their orifices. At a later stage the tubes become atrophied, and onlyafew fatty cells remain to point out their former site : or their free ends are obstructed, whilst their lower ends are dilated into a flask-like form. The grey pigment may be deposited either between the tubes or in the cells themselves. The soli- tary glands are generally enlarged, and tend to atrophy the tubes by their pressure. Patches of thickened layers of epithelium may remain at- tached to the surface, showing that a condition may exist in the stomach analogous to squamous diseases of the skin. Symptoms. — There is a great difference amongst authors as to the symptoms produced by chronic catarrhal gastritis. This, no doubt, in part, arises from the fact that simple and uncomplicated cases are so rarely fatal, and that we have, therefore, hut few opportunities of verifying the diagnosis by 'post-mortem examina- tion. But it also depends on the symptoms of other co-existing affections being so often de- scribed along with those arising from the de- ranged stomach. There is seldom much com- plaint of pain, excepting it be a sense of fulness and oppression at the epigastric region after food. When there is acidity, the patient ofteu experiences a severe burning from the stomach to the throat. In such cases temporary relief may he afforded by food or stimulants, on ac- count of the introduction of fresh aliment ex- citing the stomach to increased action, so that the decomposing remains of the previous meal are either neutralised or hurried through the pylorus. There is generally a certain amount of tenderness at the pit of the stomach, which is most evident in the cases in which congestion of the liver is also present The appetite is variable, being usually lessened, but in other cases a crav- ing for food is experienced. Nausea is a common symptom, but vomiting, in the ordinary run of STOMACH, I Cdsos, is not so frequent as might be expected. When the affixstica Das been induced by drunken- ness, a rojoction ci mucus in the early morning lakes place, aud iu gouty subjects this forms a most distressing symptom. Acid eructations, and a sour taste in the mouth, are commonly com- plained of. These probably arise from particles of undigested food remaining entangled in the mucus, setting up acetous fermentation in the saccharine and starchy articles of diet. The writer prevailed upon a number of patients who were suffeiing from this symptom to excite vomit- ing in the early morning by drinking warm water, fn every case a quantity of thick, ropy mucus was rejected, and intermixed with it were por- tions of partially digested food. In some the r.mount of fluid rejected was so large that the conclusion could not be resisted that the muscular coat had been enfeebled by the inflammation, and had been thus unable to completely expel its contents. Thirst is often present, and, as a general rule, is most complained of towards even- ing. The bowels are usually confined, but where the catarrhal condition has extended to the in- testines, frequent attacks of diarrhoea take place. The urine is high-coloured, depositing lithates ; but as the inflammatory condition subsides, it may become of low specific gravity, alkaline or slightly acid, and may deposit pale-colourcd lithates or phosphates. Where the oral cavity is, as is usually the case, also inflamed, the throat presents a red, congested appearance. The tongue is large, indented with the teeth, and if the liver is simultaneously congested, is coated with a thickened epithelium of a brown or yellow hue. If the catarrh have extended to the salivary - glands, the surface of the tongue becomes dry, or is covered with a white, creamy mucus. If the duodenum be affected, the patient is liable to jaundice from obstruction of the biliary passages ; more generally the results of imperfect lacteal absorption are shown in the loss of flesh, dry- ness and harshness of the skin, and imperfect nutrition of the hair and nails. The pulse is ordinarily slow, full, and regular. A short cough is often complained of, from coexisting laryngeal irritation. The temperature is seldom increased, excepting towards evening, and the patient often complains of coldness in the ex- tremities. The nervous system almost always suffers. There is great watchfulness, or the patient wakes after a few hours of broken and disturbed slumber. Attacks of headache are frequent, the pain affecting chiefly the forehead and eyeballs. It is necessary to notice two important varie- ties of the complaint, both on account of their practical importance, and also from the little at- tention they have received from authors. In one class of cases the prominent symptom consists in the rejection of an enormous quantity of mucus. This may occur almost constantly, vast amounts of glairy or of blood-stained mucus being re- jected. In other instances the vomiting occurs only every few days, mostly after breakfast ; and, from the quantity expelled, it would almost appear as if a gradual accumulation took place between each attack, until the stomach was excited to get rid of it. There is often no nausea preceding the vomiting, and but few gastric 1 SEASES OF. 1530 symptoms between the attacks. This form of gastric catarrh is most apt to occur in females, but it may also affect the other sex. The second variety appears to be an eczema of the stomach ; at any rate, the catarrh of the mucous membrane replaces a similar catarrhal condition of the skin, and is often relieved as soon as the latter reappears. In many cases the condition may he attributable to a gouty diathesis, of which both the skin-affection and that of the stomach are but the expressions. Still, this alter- nation between the disorder of the skin and ato- mach is not infrequently witnessed in practice. Diagnosis. — The only disease likely to lead to mistakes in diagnosis is atonic dyspepsia ; but we may meet with very rare cases of chronic catarrhal gastritis that are difficult to distin- guish from ulceration and cancer of the sto- mach. Where, as occasionally happens, a cer- tain amount of haematemesis presents itself, the diagnosis between this disease and ulceration requires care. But in catarrh, there is usually some co-existing disease of the heart or liver, or some disorder of menstruation ; there is an absence of pain, or, if pain be present, it is relieved, not increased, by food, as in the case of ulcer. Again, the vomiting is less excited by food; the epigastric tenderness is slight and diffused, not confined to one particular spot, as in ulcer. Cases are sometimes mistaken for cancer. The pain, however, in gastric catarrh is slighter; the tenderness comparatively trifling; and the hsematemesis never excessive or long- continued, as in cancer. On the other hand, in the latter disorder there is a more rapid loss ot flesh and strength, and more pallor of the lips and complexion. The discovery of a tumour iu the epigastric region, or in some other organ, would remove all doubts as to the real naturo of the malady. Treatment. — The first point in treatment is to discover, if possible, the cause of the dis- ease. It is useless to attempt to relieve an inflammation of the stomach, so long as the veins of the organ remain in a state of con- gestion produced by a disease of the heart or lungs. Cases that had been ineffectually treated for months with purgatives and tonics, yield at once to rest and digitalis, prescribed on account of the discovery of a dilated heart. In other instances, chronic Bright’s disease, by preventing the due elimination of the effete matters, gives rise to the gastritis ; and, under such circum- stances, treatment directed to the relief of the original affection yields more satisfactory results than that which would be ordinarily prescribed for inflammatory dyspepsia. Constipation will be often found to have preceded the gastric symptoms, which have been produced by the food being too long retained in the stomach, from the diminished muscular activity of the whole canal. Here a regular action of the bowels is the main indication for the relief of the gastric catarrh. There is often, as before mentioned, a craving for food every two or three hours, set up by the presence of mucus in the stomach. Numbers of cases prove rebellions to treatment, because the patient persists in seeking temporary relief by frequently cramming the stomach with food, or because he keepc the 154C STOMACH, DISEASES OF. mucous membrane in a state of excitement by stimulants, taken under the idea that debility is the cause of his sufferings. In the majority of very obstinate cases, ono or other of these habits requires to be overcome, before other treatment can be made available. The mere removal of the cause producing the disease is often sufficient to ensure its cure, but in other instances we are forced to employ other means. The chief indication in the ordinary run of cases is to take off any increased pressure upon the venous circulation. In any glandular structure we can only effect this object by lessening the amount of blood flowing to it, or by increasing She rapidity of the circulation through the organ by stimulating its secretion. The first of these objects in the case of the gastro-intestinal tract is accomplished by purgatives, which drain away a large quantity of the liquid portions of the blood which has to pass through the vena portae. In young and vigorous subjects, therefore, sa- lines, such as the sulphate of magnesia, the tar- trate of soda, or the mineral waters of Pullna or Friedrichshall, may be employed. These may be assisted by small doses of mercurials, given every second or third night. The salines should not be too long continued alone, as they are apt to enfeeble the muscular powers of the canal. After a short period, it is necessary to combine them with a tonic, such as quinine or calumba, or with sulphate or phosphate of iron. In moro feeble subjects, or in those who have previously suffered from atonic dyspepsia, it is better to relieve the congestion by stimulating the biliary secretion. For this purpose, taraxacum or chamomile may be employed, assisted by a pill each night, con- taining podophyllin or blue-pill. In another set of cases, where the patient is not robust, both objects may be attempted at once — by the administration of soda and rhubarb. in the day, assisted by an occasional dose of blue pill at night, or by a course of the Carlsbad water every morning. It has been before remarked how readily fer- mentation is set up, whenever the secretion of the gastric juice is lessened or arrested. This circumstance must he borne in mind in the treat- ment of this as well as of other gastric disorders. As soon as the more urgent symptoms of chronic gastritis are subdued in any case, tonics, such as iron, calumba, or quinine, along with acids, may be nsed to obviate the enfeebled state of diges- tion that always results from the long continu- ance of the inflammation. The treatment of cases where immense quan- tities of mucus are vomited must be conducted on a different principle. Here the venous sys- tem is iu a state of passive congestion, and no active inflammation of the mucous membrane is in progress. We must use astringents, the best of which are bismuth, nitrate or oxide of silver, oxalate of cerium, kino, tannin, and opium. Purg- ing makes the patient worse. In order to ob- viate the ill-effects of the astringents it is neces- sary to give each night a pill of podophyllin and creasote, or of nux vomica and aloes, or some other similar preparation. The disease has been relieved by placing around the abdomen a fold of flannel dipped in dilute nitro-hydrochlorie acid, and covered with india-rubber cloth. Eczema of the stomach is most difficult to treat satisfactorily, probably because it depends on the general state of health. It is best re- lieved by moderate doses of solution of potash, taken a little before the time when the scalding pain is expected, assisted by a pill, every night, of podophyllin and creasote. As soon as the urgent symptoms have been overcome, benefit may be expected, either from the compound iron mixture, or from quinine combined with ammonia. Flannels dipped in a solution of common washing soda, and covered with india- rubber, may he applied over the epigastrium with benefit; or a liniment of croton oil may be employed. The latter must he used with great caution, as, from the unusual irritability of the skin, the eruption is apt to be very severe. Theoretically, it might be expected that a fari- naceous diet would not be suitable in these cases ; inasmuch as it is apt to set up fermentation. It is better to confine the patient to sparing meals of mutton, chicken, game, or fish along with bread. Vegetables and fruit should be at first avoided, but may be freely used as soon as the more urgent symptoms have subsided. The breakfast is the most difficult meal to manage, for tea and coffee are apt to disagree and increase the mis- chief. Dandelion coffee is often very useful in such cases. It is made by boiling the roasted and dried root of the taraxacum with a quarter of its weight of the best coffee. Where this cannot he readily obtained, the succus taraxaci of the Pharmacopoeia may be taken, along with weak coffee. If milk does not disagree, it may he nsed, mixed either with lime-water. Seltzer, or Vichy water. Alcohol should be avoided, hut if from long habit or other circumstances its use is necessary, a small quantity of weak spirit and water should be substituted for wines. 1 5. Stomach, Malposition of. — The stomach may he displaced congenitally ; or as a resuit of accident or disease. In congenital displacement the stomach may he situated on the right side of the body, the fundus pointing to the right hypochondrium, the pylorus to the left. But, as in such cases it will he also found that there is a similar mal- position of the heart, liver, and spleen, no mistake in diagnosis is likely to occur. As a congeni- tal condition, the stomach may occupy the left pleura, through a partial arrest of development of the diaphragm. It may be also situated in the left pleura, owing to a rupture of the diaphragm. It is said that such a state has given rise to a mistake in diagnosis between it and pneumo- thorax of the left side. In both there is a clear sound on percussion, and a gurgling produced by motion of the body. Besides this, the pressure of the distended stomach has been seen to displace the heart, and produce dyspnoea. Bamberger has pointed out that in protrusion of the sto- mach into the left pleura the respiratory sounds can be heard in the upper part of the left lung; the clear note on percussion becomes duller after food ; and any metallic sounds that may present themselves are unconnected with the breathing of the patient. The dyspnoea of congenital dis- placement is only occasional, not persistent, and it will be found to have existed for years, id STOMACH, DISEASES OF. stead of occurring suddenly, as in pneumothorax. When the hernia has resulted from an accident, it is usually accompanied by vomiting of fluid containing sarcinse, and by other signs indicating that the stomach does not get freely emptied of its contents. The organ may be displaced down- wards by the weight of a tumour situated in its coats. This is more especially the case with the pylorus, which is generally the seat of such a morbid change. Under these circumstances, the pylorus maybe so depressed as to occupy the right iliac region, or it may have fallen still lower, snd be united by adhesions to some of the pelvic viscera. In some cases the stomach is found in the contents of large umbilical and scrotal herniae. An interesting case of this nature is recorded by the late Mr. Moore ( Transactions of the Medico- Chirurgical Society, vol. xlvi.), where a stomach, so enlarged as to be capable of containing a gallon and a half, was situated in the sac of an umbili- cal hernia. There were several sloughs on its inner membrane, and in one spot a perforation had taken place, the size of a sixpence. When a stomach is much dilated, in case no adhesions have been formed between it and some of the neighbouring organs, it is displaced downwards by the weight of its contents. As a result of this, the umbilical region is much distended, whilst the epigastrium is hollow and sunk in'* wards, so that a distinct prominence can be often discovered, stretching between the lower part of the left hypochondriac region and the other side. 16. Stomach, Morbid Growths in. — The stomach is liable to all the forms of morbid growth that are met with in the other structures of the body. Excepting the breast and uterus, no part is so frequently the seat of malignant disease. All the varieties of cancer attack this organ, and not unfrequently they are combined. Thus we meet with scirrhus and encephaloid, or scirrhus and colloid, in the same tumour. Scirrhus is by far the most common, constitut- ing, according to the researches of Dr. Brinton, three-fourths of the whole number. Its most usual seat is the pylorus or the lesser curvature, and here it forms a tumour that rarely invades the duodenum, but tends to surround the organ. When a section is made at an early period of the dis- ease, the distinction between the different coats is readily seen. The peritoneum and the tissue directly beneath it are thickened, the muscular structure is of a grey colour, and much increased in bulk, the bundles of fibres being divided from each other by firm septa of connective tissue. The mucous membrane covering the tumour may appear to the naked eye to be healthy. Sooner or later ulceration takes place, and a deep exca- vation results, with thickened elevated edges, and with a base not unfrequently covered with fungoid projections. Microscopically the tumour presents the ordinary appearances of scirrhus. The muscular structure is usually in a state of degeneration near the cancerous structure, even when it has not been invaded by the disease. The mucous membrane has been more or less dis- eased in all the cases the writer has examined, even at a distanco from the tumour. The tubes were generally united to each other, and were, 1541 in many places, in a state of atrophy or of fatty degeneration. Encephaloid cancer has affected the stomach in about one-tenth of the cases recorded, accord- ing to the inquiries of Dr. Brinton. It forms soft, quickly-growing nodules, which project below the peritoneum, or elevate the mucous membrane. It seems generally to commence, as scirrhus does, in the submucous tissue. When ulceration occurs, numerous fungoid masses, which are often very vascular, project upwards. The muscular coat is more completely destroyed in the neighbour- hood of the tumour than in scirrhus, and the mucous membrane is generally diseased in all parts of the organ. The tubes are not, however, so much atrophied as in the harder form of cancer, but are usually distended with cells, and the subtubular and intertubular spaces are occu- pied by cells of various sizes. Colfoid cancer is generally associated with scirrhus. The structure feels softer than when- scirrhus is present alone, and consists in part of a gelatinous material contained in round or oval spaces bounded by connective tissue. Dr. Brin- ton calculates that only 9 per cent, of all the cases of cancer of the stomach are composed of colloid uncombined with scirrhus. Villous cancer presents a mass of elongated processes, which, under the microscope, seem to be composed of fibrous tissue loaded with cancer- cells, each usually possessing a loop of blood- vessels. All the villous projections that are found on the mucous membrane of the stomach, are not, however, necessarily malignant, some being of the nature of fibrous papilloma. See Stomach, Cancer of. Lipoma, sarcoma, and adenoma are also occa- sionally met with in the stomach. Tubercle is very rare, and only found where there has been general tuberculosis. 17. Stomach, Neuroses of. — The subject of gastric neuralgia has been already partially dis- cussed (see Gastraxgia), and it has been pointed out that it rarely occurs independently of symp- toms indicating some disorder of the digestion. The writer has, however, met with it as a perio- dical affection unattended by any gastric disease. These cases occur chiefly in females of a nervous temperament, are worse at the catamenial pe- riods, and yield to treatment of a tonic character. Hyperesthesia of the stomach is a very common accompaniment of various gastric disorders. Its presence in a measure accounts for the very great degree of suffering experienced in many cases of ulceration, and it often confers upon a ease of atonic dyspepsia an amount of pain that leads the practitioner to suspect his patient is affected with some grave organic disease of the organ. This increased sensibility of the stomach often leads to mistakes in the treatment of gastric ulcer, by inducing us to persevere with liquid diet and opium long after the sore has completely healed. In hyperesthesia of the stomach iron occupies the most important place as a remedial agent, and may be combined with quinine, strychnine, or other bitters. Arsenic, in doses of three or four minims of Fowler’s solution, gradually in- creased and given directly after food, is often exceedingly useful. The nitrate and oxide of 1542 STOMACH. DISEASES OF. silver are favourite remedies with many prac- titioners, but the writer has found them less useful than the tonics before mentioned. As soon as it can be borne, porter or bitter ale will be found beneficial. In the majorit.yof eases change of air and a carefully regulated diet are more efficacious than drugs. Spasm . — Spasm of the stomach is a frequent complaint, and chiefly occurs in females who are subjects of atonic dyspepsia. The attacks mostly occur after a meal of an indigestible character ; but in other instances a single mouth- ful of food, taken after a long fast, may pro- duce it. In the former case the painful spasm probably arises from the stomach becoming over- distended with flatus, which it has been unable to expel, on account of a spasmodic contraction of the cardiac orifice. In the latter the organ is most likely distended by flatus, and the en- trance of food excites a contraction which the exhausted muscle is unable fully to execute. During the attack relief may be obtained either by a subcutaneous injection of morphia, or by a draught containing opium combined with chloro- form or other, or with some essential oil, such as mint or cinnamon. The treatment between the attacks must be conducted on the principle laid down for atonic dyspepsia. See Stomach, Atony of. Paralysis of secretion.— It now and then oc- curs that the power of the stomach to secrete appears to become paralysed, just as we occa- sionally find to be the case with the kidney, and probably with other organs of the body. Vomiting . — One of the most important of the neurotic affections of the stomach is where vomit- ing is habitually present, without any other signs leading us to suspect disease of the sto- mach itself. Deference is not made here to the cases where the vomiting accompanies preg- nancy, or uterine or brain disease, but where it occurs without any nausea. It chiefly presents itself in hysteria and phthisis, and in the latter disorder is, according to the writer's observation, most frequently met with where the apex of the right lung is chiefly affected. Hysterical vomiting comes on whilst the patient is eating, or almost immediately after the meal is fin- ished. A person will leave the table suddenly, reject what has been taken, and often complain again of hunger. What is vomited is not sour, and seems to consist only of food in the state it had been in just before being swallowed. There is no pain, and although the flesh and strength are reduced, it is not to the extent that might have been expected. In all probability, therefore, only a part of what is taken is returned, for in severe cases the symptom is present whenever an at- tempt is made to take food. Various methods of treatment have been putin force, and in many cases without any success. Electricity has been strongly recommended, whilst morphia, hydro- cyanic acid, aconite, bismuth, oxalate of cerium, nitrate of silver, and innumerable other remedies have been employed. According to the writer's experience the most useful plan is to adminis- ter a dose of morphia and solution of potash a few minutes before food. In other case<=, he has tried ice for the same purpose. The food should be of a digesti b'e nature, but sol ds agree better than liquids, although nstances are given where the irritability of the stomach has been overcome by small quantities of liquid food given every half-hour. In very obstinate cases all food must be abstained from, and life supported for a few days by nutritive enemata. Cases occasionally present themselves in which symptoms of disease of the spinal cord follow affections of the stomach. In such cases vomit- ing has been excessive and frequently recur- ring; pains, evidently of a neuralgic character, have first attacked the feet and extended up- wards; and as the pains have subsided, para- lysis has gradually crept on. The treatment found most successful has been the employment of sedatives so long as the pain continued severe, followod by the use of electricity and mineral tonics when the paralysis alone remained. The valerianate of zinc combined with quinine is often very efficacious in restoring the patient to health. In other cases strychnia, quinine, and iron have been employed, either alone or in com- bination. 18. Stomach, Perforation cf. — With the exception of a few rare cases where the coats of the stomach have been penetrated by me- chanical injuries, or by the extension of disease from some of the neighbouring organs, per- foration is the result of simple or cancerous ulceration. In the majority of the cases of ulcer- ation, the peritoneal covering of the stomach inflames as the disease approaches it, and the organ becomes attached to some of the adjoin- ing parts. In this way a barrier is formed against an opening being made into the peri- toneal cavity ; and, as the ulceration deepens, its base is formed of the structures to which the coats of the stomach adhere. It has been calculated by Dr. Drinton that 70 per cent, of the simple ulcers situated at the posterior sur- face, are closed in by union with the pancreas or liver. But when this safeguard does not exist, the extension of the ulceration outwards finally reaches the peritoneum, this thin membrane sloughs, and a portion of the contents of the stomach escapes into the peritoneal cavity. Sud- den and violent peritonitis is immediately set up, which is almost always followed by fatal consequences. In some cases, instead of the contents escaping from the stomach, a mere leakage occurs through the peritoneum, which is sufficient to produce inflammation of the serous membrane. Hence it may happen that, instead of general peritonitis, circumscribed inflammation is set up by the perforation, and an abscess follows, bounded by the neighbouring organs, which have become closely united to each other and to the stomach. Some cases are recorded, where an abscess thus formed was evacuated through the lungs by perforation of the diaphragm, the pus exciting in its passage gangrenous pneumonia or pneumothorax. The writer has known the gush of pus from the abscess produce sudden death by suffocation ; and in a few cases placed on record an external opening has taken place, and a gastric fistula has been established. Occasionally, the stomach adheres to the colon, or even to a coil of the small intestine, and an extension of the ulcer STOMACH, D brings about a communication between these organs. Ulcerations situated in the anterior surface of the stomach are most apt to per- forate the peritoneum, as the greater mobility of this region lessens the chance of adhesions taking place. Simple ulcerations are more apt to penetrate the serous sac than those of a can- cerous nature, as adhesions are much more apt to occur in the case of the latter. Perforation again takes place more readily in the 3 T oung than in those of more mature age, and it is especially liable to affect females. More than half the cases amongst females occur between the ages of fourteen and thirty, but in the other sex the effects of age are not so strongly marked. Symptoms. — In cases of chronic ulcer, the symptoms produced by the perforation are pre- ceded, for a more or less lengthened period, by pain, vomiting, or hsematemesis. But in young persons the occurrence of perforation often takes place with startling suddenness, and the pain comes on when the patient believes herself to be in perfect health. In most cases careful inquiry shows that there has been previously slight uneasiness after food, flatulence, or other signs of disordered digestion. It is, however, impor- tant to recognise the fact, that this terrible accident occasionally occurs where there has been no previous complaint of ill-health, and that aoy sudden and severe pain in the abdomen in a young person should never be treated lightly. In a large proportion of the cases admitted into a hospital, purgatives or stimulants have been previously given, and it has occasionally hap- pened that castor oil, or some other medicine, has been detected in the peritoneal cavity on examination after death. The first symptom of peritoneal perforation is a sudden aDcl severe pain in the abdomen, and this is not necessarily referred to the region of the stomach. It is quickly followed by retching or vomiting; and when the patient is seen by the practitioner, the symptoms of general peritonitis are present in a marked degree. The patient lies upon his back, with his knees raised, dreading to make the slightest motion, speaking only in a slow and guarded manner, and breathing quickly and carefully, lest the action of the diaphragm and abdominal muscles should increase his suffering. The face is pale, and expressive of pain and anxiety; the whole abdomen tense, and so ex- cessively tender that the slightest pressure is dreaded; the pulse is quick, small, and com- pressible; the extremities are cold; and the bowels obstinately confined. The patient may either sink in the stage of collapse, or the pulse may recover its strength, the extremities regain their warmth, and death may occur from peri- tonitis some days later. One well-authenticated case has been recorded where recovery took place ; and, on the patient subsequently dying from a fresh perforation, the results of the former pene- tration of the abdominal cavity were observed. Several cases which are related as recoveries from perforation, have been recorded of late years in the public journals ; but the evidence that they really were so seems to be insufficient. When perforation of the colon takes place, the pain is often very severe, from tire co-existence of peritonitis ; and the sudden appearance of 1SEASES OE. 1543 faeces, or of foetid gas in the vomited matters, indicates the presence of an opening into the large intestine. In other cases, the communica- tion between the organs appears to be of a val- vular kind, so that severe diarrhoea may occur from the entrance of the gastric contents into the gut, without any appearance of faeculent matters in the fluid rejected from the stomach. Where perforation of the diaphragm has oc- curred, there has usually been severe febrile action, with great pain in the side or epigastrium, followed, after an interval of some time, by the symptoms and physical signs of pneumothorax or gangrenous pneumonia. Diagnosis. — Peritoneal perforation is most apt to be confounded with colic, or the passage of a biliary or renal calculus. In all these cases there is the occurrence of sudden and severe excru- ciating pain of the abdomen, often attended by vomiting, and all may be accompanied with great depression. In perforation, however, the patient lies in the recumbent position, with the legs drawn up ; whilst in the passage of calculi or colic he is restless and tosses about. In the former, the pulse is rapid, and there is intense abdominal tenderness ; in the latter the patient often seeks, by pressure over the seat of the pain, to relieve his suffering, and the pulse is but little quickened. In perforation, there is often a history of symptoms indicating gastric ulcer ; in colic, not infrequently, an account of previous attacks of a similar description. Treatment. — The only chance the patient has of escape from death is in the most perfect rest, both of the whole body and of the diges- tive canal. Food and drink of every kind must be forbidden, and even enemata should be avoided. A full dose of opium must be administered, as much as 2 grains, and a smaller quantity re- peated every three or four hours subsequently. Cold applications externally have beeD recom- mended, but it will be generally found that warm fomentations give more relief If im- provement take place, it will be better to support the strength of the patiert for some time by nutrient enemata, than by tood given by the mouth. 19. Stomach, Softening off —There are few stomachs examined after death, more especially during the warmer months of the year, that do not show some signs of softening. When this change is only slight, the surfaces of the rugse alone seem softened, and have a semitransparent appearance. When it is more extensive, the whole of the liningmembrane covering the fundus has a smooth, thin, translucent appearance, and is either readily detached by the finger, or forms a slimy mucus overlying the subjacent coats. Where the process has proceeded still farther, the muscular and peritoneal layers are soft and pulpy ; and occasionally the organ is perforated, and the contents are found in the cavity of the peritoneum. More rarely still, the softening affects the neighbouring organs, the oesophagus or diaphragm being perforated ; and the gastric contents may be found in the left pleura. The nature of this process has given rise to no small discussion. John Hunter, who first remarked its occurrence in healthy persons who had beer 1544 STOMACH. DISEASES OF. killed by accidents, attributed it to the action of the gastric fluid upon the stomach after death. Some pathologists of eminence, -whilst admitting that softening may result from post-mortem solu- tion, contend that certain forms of this condition occur during life, and differ in their character from cadaveric changes. Rokitanski distinguishes two primary forms of softening : one a disease of infant life, called gelatinous softening, in which the whole fundus is converted into a greyish, transparent jelly, and which is usually an accom- paniment of brain-affections. The other, in which the parietes of the stomach are converted into a dark-brown pulp, occurs either in brain-diseases, or as a sequela of typhus, pyaemia, acute tubercu- losis, acute cancer, and other diseases. One chief cause of difference in the appearances of these forms is the state of the blood-vessels. In the first the pallor arises from the anaemic condition of the lining membrane ; whilst in the latter the dark- brown colour is probably dependent on the action of the acid upon the blood contained in the dis- tended veins and capillaries. Notwithstanding theauthority of the distinguished pathologist just named, it is generally believed at the present day that all the various forms of softening are merely the result of post-mortem digestion, and that the differences in appearance between them are but the effects of the varying amount of acid that may exist in the stomach at the time of death. Certain circumstances have been found to favour the occurrence of post-mortem softening of the stomach : — 1. The condition of the atmo- sphere at the time of death is one element. It was in summer that the cases occurred that first attracted the attention of Hunter, and it is found that the extent of softening which occurs in cold weather is comparatively trifling to what is ob- served in the warmer months of the year. This is what might have been anticipated, for we know that heat is requisite in order that arti- ficial digestion should proceed quickly. 2. The amount of the contents of the stomach exercises a considerable influence. When death has oc- curred whilst the stomach is empty, little or no softening occurs, but if it contain food the mu- cous membrane is sure to present some indica- tions of change. 3. The nature of the contents of the stomach is still more important in de- termining the amount of softening. It is well known that the presence of an acid in the gastric juice is requisite for the performance of diges- tion, and we consequently find that there is the greatest extent of change where there is a large amount of acid in the contents of the stomach at the time of death. This fact has been inge- niously used to explain why the post-mortem changes are so extensive, as remarked by Roki- tanski, in brain-disease and in the case of chil- dren. It is believed that an unusual amount of acid is secreted in cerebral affections, as we know is the case in certain irritations of the liver and kidney; and as the food of children is mostly composed of milk, it is assumed that the lactic acid resulting from its decomposition, united with the pepsin contained in the stomach, forms a digestive fluid possessing great activity. 4. The condition of the stomach as regards the amount of pepsin stored up in it exercises a considerable influence upon the chance of its soft- ening. It has been elsewhere shown that in typhoid fever, chronic atrophy, and chronic liy- peraemia, the amount of pepsin stored up in the gastric mucous membrane is very small, and it is in these disorders that we meet with very little alteration in the organ after death. 5. An- other point, which has not attracted sufficient notice, is that the texture of the organ varies in different cases, and that some more readily yield to the solvent action of the gastric juice than others. To prove this the writer placed in an artificial digestive fluid equal portions of three human stomaclis. The first was normal ; the second in a state of fatty degeneration ; whilst, in the third, the tubes were replaced by fibrous tiss i,e, and the blood- vessels were much congested. After a few hours’ digestion the first piece was found reduced to a pulp; the second was gelatinous, and of a yellow colour ; the third formed a black, opaque mass, quite unlike the others. Here, it will be observed, the colour and appearance of the different specimens varied; and in many cases, as for example in children, the softness of their healthy mucous membrane greatly determines the rapidity and completeness with which the gastric fluid acts upon it. To ascertain if this was correct the writer placed in some artificial gastric fluid four pieces of stomach. The first was taken from a healthy dog and was soft ; the second from a healthy human subject ; the third and fourth from females who had died from cancer of the breast, and the mucous membranes of whose stomachs were extensively atrophied. After three hours’ digestion at 100°, the first broke up into fragments ; the second was reduced to a pulp ; whilst the third and fourth showed only a little softening on their surfaces, hut were in other respects unaltered. The completeness with which the first two were dissolved was found, from other experiments, to have partly arisen from the acid being imbibed by the tissue, and coming into contact with the pepsin stored up in the gastric cells, which were absent in the dis- eased structures of the third and fourth speci- mens. But the question arises, whether soften- ing of the mucous membrane of the stomach ever occurs without post-mortem solution ? This must be answered in the affirmative. During the con- tinuance of the cattle-plague the animals affected were killed, and in some cases the stomachs were immediately removed and brought to the writer. In each case the mucous membrane was very soft, and presented, under the microscope, the usual appearances of gastritis. Again, in certain dis- orders — as, for example, in cancer of the uterus — the writer has always found the gastric mucous membrane very soft, where there was no appear- ance of cadaveric change. This softness probably arises from imperfect nutrition, and is analogous to the fatty heart so commonly met with in such cases. Fatty degenerations of the stomach are by no means uncommon — for instance, the whole membrane has been found in this state in a case of gastric ulcer ; and we can scarcely suppose that an organ in such a condition can have the same firmness as when the glandular texture is in a perfectly healthy state. 20. Stomach, Ulcer of. — .Etiolost. — The age of the individual is allowed by all observers STOMACH. DISEASES OF. 1545 to be one of the chief predisposing causes of gastric ulcer. Where the functions of the sto- mach are most actively performed, as in child- hood, it is scarcely ever met with, Dr. Brin- ton having been only able to find two cases out of 226 in children below ten years of age. It becomes gradually more frequent as age ad- vances. Females are more liable to the dis- ease than males, in the proportion of three to one. The chief preponderance of liability amongst females occurs at the commencement and the cessation of the catamenia. In both sexes, want of food, mental anxiety, and other depressing conditions, have been referred to as tending to produce the disease in question. Many authors regard intemperance as one of the most potent causes. Although the writer has certainly seen the symptoms of gastric ulcer follow a too free use of alcohol, yet he has been greatly surprised to find how rarely the stomach has presented any signs of disease, beyond those of catarrhal gastritis, in a considerable number of persons who had died of delirium tremens. Some have affirmed Riat tuberculosis is a common predis- posing cause, whilst Dr. Brinton has remarked that persons affected with phthisis are not more liable to gastric ulcer than other persons. The writer has found the ordinary ulcer rare in such cases, but superficial ulcers near the pylorus are by no means infrequent, and are probably the result of the acute erythematous gastritis, to which attention lias been directed, as tending to complicate the later stages of pulmonary disease (•wee Stomach, Inflammation of). If we sum up tho chief causes, we find the conclusions con- firmed to which morbid anatomy directs us. Ad- vanced age, which gives rise to fatty and fibroid degenerations, both of the tissues and the blood- vessels, is the chief predisposing influence of gastric ulcer. In like manner, syphilis and tu- bercular affections, which lead to ulcerations of the skin, by diminishing the reparative powers of the system, seem also to induce gastric ulcer- ation. In addition to these all conditions that lead to chronic catarrhal gastritis, suctqas uterine affections, and diseases of the heart and liver, have also a decided tendency to set up the dis- ease. Anatomical Characteks and Pathologv. — Ulcerations in this organ are of frequent occur- rence, being present, according to the researches of Dr. Brinton, in about 5 per cent, of the deaths arising from all causes. The ulcers are usually round or oval, varying in size, as a gene- ral rule, from the diameter of a fourpenny-piece to that of a half-crown. They have been found to destroy life when so small that the most care- ful search was necessary to ascertain their exist- ence, and, on the other hand, they may be met with many inches in diameter. When of recent formation, the edges are sharp, and the sore looks as if a portion of the mucous membrane had been punched out ; but when it has lasted for some time, the edges are hard, callous, and ad- here to the subjacent tissue. The diameter of the ulcer usually lessens from above downwards ; so that in case the peritoneum has given way, the perforation may be a mere chink. The base of the ulcer may be formed either of the muscular coat or peritoneum, or of some of the neighbour- ing organs — such as the pancreas, liver, or spleen— which have become attached to the stomach by adhesions. Microscopically, in recent cases the writer has generally found the tubes around the ulcer healthy, with the exception that a few blood-globules are extravasated amongst them. In older cases, the surrounding tissues are matted together, and the tubes are com- pressed and atrophied, whilst the newly-formod fibrous tissue closely unites the edges of the lesion to the parts below and around them. But the mischief is always confined to the neigh- bourhood of the ulcer, and we never discover a general atrophy of the secreting structures of the stomach, as in malignant disease. At the most, the mucous membrane presents the signs of fatty degeneration, or the usual appearances of acute or chronic catarrhal gastritis. Where the ulceration is spreading, the tubes immediately around it may be seen to be more or less emptied of their secreting cells, whilst their basement membranes have fallen together. Still further off may be remarked tubes only partially filled with cells, and the mucous membrane is consequently thin and soft. Gastric ulcers are most common in the pyloric region, being chiefly situated on the posterior surface, and near the smaller curva- ture. When two are present, it is not unusual to find them opposed to each other, as though they had been both produced by the same irrita- tion. When an ulcer exists in the duodenum, it is very common to find one also in the stomach. There has been much difference of opinion as to the method by which gastric ulcers are pro- duced. Some authors are fond of pointing out that sores of this character are confined to the stomach and duodenum, where an acid secretion comes in contact with the tissues ; whilst in the remaining parts of the small intestine they are rarely discovered. Hence it has been assumed that they are dependent, in some way or another, upon the solvent action of the gastric juice. But it should be remembered that the ulcera- tions are very rare where the power of secretion is most active, and where it remains longest in contact with the mucous membrane — namely, at the fundus ; and also, that they are extremely uncommon in childhood, when the gastric func- tions are most energetically performed. Instead, therefore, of the presence of the gastric juice being the cause of the stomach being so espe- cially liable to ulceration, may not the rarity of ulcerations in the small intestines be rather due to the greater development of the lymphatic system in them, which obviates the ill-effects of any temporary congestion, and to the fluid na- ture of the contents of this portion of the canal ? We have not here space to discuss the various hypotheses that have been invented to account for the production of gastric ulcers ; but we may fairly allow that, like ulcerations on the exterior of the body, they must originate from very different causes. 1. They may be produced by the sloughing of portions of the mucous membrane arising, from general debility. Such cases have been dis- covered in persons broken down by syphilitic disease, kidney-affections, and other exhausting maladies. We see analogous cases of sloughing STOMACH, DISEASES OP. 1546 of the mucous membrane of the oral cavity in a similar state of health. 2. The death of small portions of the mucous membrane has been attributed to embolism of the arteries of the stomach. Against this, as a common cause, is the fact that the gastric ulcer is generally single, and that we constantly fail to discover ulcerations where numerous emboli can be proved in the vessels of the other prin- cipal organs of the body. It is probable, how- ever, that some rare cases are to be attributed to this cause. 3. The perforating ulcers so commonly met with in young persons were attributed by Koki- tanski to haemorrhagic erosions of the mucous membrane, produced by catarrh. His opinion seems to be supported by the fact, that these ulcers are most frequently present where catarrh is most common, namely at the pyloric region ; and also that their occurrence is usually pre- ceded only by symptoms indicating a slight at- tack of catarrhal gastritis. 4. Dr. Copland pointed out how often the arteries of the stomach were diseased, where an ulcer was present, especially in old people. The truth of this remark the writer can confirm, from the microscopic examination of a number of spe- cimens ; and to this circumstance we must also attribute much of the difficulty experienced in the cicatrization of gastric ulcers. Where the arte- ries are healthy, it will be often found that the veins are thickened and tortuous, and it need not be pointed out that the effect of a similar condi- tion is daily seen in the production of ulcera- tions of the lower extremities. 5. Probably not less powerful in setting up these ulcers in the aged are the fatty and fibroid degenerations of the mucous membrane, so often discovered on microscopical examination. It seems reasonable to suppose that in tissues thus altered, a slight irritation would be sufficient to set up an ulcerative process. When a small and superficial ulcer of the stomach heals, only a slight scar is left ; but where it has been of large size, and has pene- trated more deeply, the organ may be puckered up by the cicatrix, and considerable change of shape may be produced. The ulceration may, on the other hand, produce death by laying open a blood-vessel ; by perforating the perito- neum or some of the neighbouring organs; or, in more rare cases, by giving rise to abscess of the liver. Symptoms. — Pain is by far the most constant and prominent symptom of ulcer of the stomach. At first, it is only a feeling of uneasiness after food, but as time goes on it increases in con- stancy and severity. It commences shortly after food, and persists" during the whole period of digestion, or until the contents of the stomach are rejected by vomiting. In some cases it begins as soon as food has been taken, but more generally an interval of fifteen or twenty minutes elapses before it is complained of. The pain is usually relieved by the recumbent posi- tion, but in some the patient finds relief by bending the body over a chair or by lying on one side. The writer has seen eases of large aleers, in which there was little or no pain, the sore being apparently insensible to irritation, as is sometimes seen to be the case in old ulcers of the legs. The pain is referred to one spot, which is usually situated in the epigastrium, but more rarely it affects the left hypochon- drium or the umbilical region. In a consider- able number pain is experienced in the back, usually at a place between the last dorsal and the first lumbar vertebrae, or rather a little to the left side of this region. It is not uncommon for the pain to increase for a few days, and then gradually to subside. These exacerbations the writer has chiefly observed in very chronic cases. They probably point to an extension of the ulcer- ation, for they not infrequently precede haemor- rhage and perforation. In almost every case we meet with tenderness on pressure over the seat of the sore. This may be so great that the patient is unable to wear his clothes moderately tight; in others it requires a careful search to discover the sore spot. The tender part is, as a rule, opposite the place to which the pain is referred, and can often be covered by the finger-end. General tenderness is no test of an nicer, as it is often present in congested liver, gastric catarrh, and other complaints of the epigastric region. It is necessary to be careful in testing for the exist- ence of a gastric ulcer by the finger, for a very slight pressure often suffices to bring on a par- oxysm of pain, even when the stomach is empty of food. The tender spot may be situated in the epigastrium, in the hypochondrium, or near the umbilicus, but it is most generally in the first- mentioned locality. Vomiting, although often present, is a much more variable symptom. It seldom occurs directly after food, as is often the case in cancer, because the cardiac orifice is rarely the scat of simple ulcer. It is preceded by nausea, not infrequently by a copious flow of saliva, and it relieves the pain by freeing the stomach of its acrid contents. The tongue may be perfectly clean, or may be thickly coated. As the abnormal appearances of the tongue in dyspepsia arise from an extension of gastric catarrh to the mucous membrane of the mouth, a perfectly clean tongue is present, if tho ulcer is unattended by gastritis. Flatulence is not a common symptom, inasmuch as the amount of food taken is limited, on account of the pain produced by it. Extreme acidity occa- sionally presents itself, but it is not so common as the statements of some authors would lead us to imagine. The appetite is seldom much affected, especially in the young. Patients often remark that they could and would eat freely, were it not for the dread of the pain. The bowels are generally confined. The stools are knotty, and in many cases contain mucus. There is nothing characteristic about the urine. It is usually clear, and is passed frequently, and in unusually large quantities. Whenever the disease has lasted for some time there is a loss of strength and energy, arisingfrom imperfect nutrition, from the frequent attacks of pain, and from the vomiting. The duration of gastric ulcer varies greatly. In some eases the sore seems to heal rapidly ; whilst in others the symptoms often subside and re- appear, so that the patient remains an invalid for years. Chronic cases in old people are often very difficult to cure, and great patience and per- severance are required in order to obtain ever STOMACH, DISEASES OF. »n alleviation of the symptoms. The symptoms produced, by haemorrhage and perforation are elsewhere described. See Hj;jiatemesis ; and Stomach, Perforation of. Physical Signs . — In a recent case of gastric ulcer we can expect no assistance from physical signs, but where the disease has lasted for some time evidence of adhesions may be detected. Ad- hesions may be suspected, when it is found, by auscultation and auscultatory percussion, that only a small portion of the stomach is in ap- position with the abdominal walls, and more especially if this part is the tender spot, and does not vary its position with different states of distension of the organ. Again, if the stomach is found to be of considerable size when empty, and its extent not increased by food, we may suspect that its motions are trammeled by adhe- sions. The microscope affords but little assist- ance in the detection of gastric ulcer, because the extension of this disease is usually very slow, and we therefore have little chance of discover- ing portions of the mucous membrane in the vomited matters. Treatment. — The main indication, where the symptoms of ulcer of the stomach are urgent, is to give to the affected organ as perfect a state of rest as is possible. The patient must be placed in the recumbent position, unless it produce pain, and must retain it strictly. In the more chronic cases, or when the more severe symptoms have subsided, a limited amount of exercise may be permitted, lest the gene- ral health become deteriorated by confinement. In urgent cases mere position is not enough, and physiological rest must be insured. It is, therefore, often necessary to interdict the use of all food, and to keep up the nutrition of the body by nutritive enemata. In less severe cases it is only necessary to confine the patient to liquid food, taken in small quantities and fre- quently. Milk must form the basis of diet, and it can be either taken alone, or, if there be much acidity, mixed with lime-water or with Seltzer or Vichy water. In some cases butter- milk agrees, where sweet milk produces vomit- ing. In others the concentrated Swiss milk is more readily digested. But sometimes milk in all forms disagrees, unless it be mixed with some farinaceous material, such as arrowroot, sago, tapioca, or corn-flour. As the patient im- proves a more nutritious diet may be prescribed, such as beef tea, mutton broth, chicken broth, eggs, maccaroni, or light puddings. Vfhere the patient is young and otherwise healthy, leeches are often of great service. Some practitioners have objected to their use, but the writer has often seen them of signal benefit. It is seldom neces- sary to apply more than six at a time, and they may be repeated from time to time, as the case requires. In others dry-cupping answers a good purpose. "Where there is reason to object to the effects of the leeches, a bladder filled with ice and applied to the part often affords relief ; but, in general, hot poultices and fomentations are more useful. In long-standing cases great benefit is often derived from repeated small blisters, or from the application to the epigastrium of tartar- emetic ointment or croton oil. The most valuable remedy in all cases is opium. It relieves pain, 1547 I controls the action of the muscular coat, and re- | strains the secretion of the stomach. It is best given in doses of one or two grains, once or twice a day, shortly before food. It is a common prac- tice to apply morphia hypodermically, but tnis in some cases produces vomiting, and must, there- fore, be used cautiously. Besides this, it must be remembered that the sedative, when taken by the mouth, is more directly applied to the ulcer- ated and tender surface. The vomiting is a most distressing symptom, and tends to prevent the healing of the sore. The fluids rejected should be often examined by the microscope. If torulae or sarcinae are present, recourse must be had to carbolic acid, creasote, or sulphurous acid; at the same time a small blister should be applied to the epigastrium. "When a large quantity of mucus is discharged, the case is best treated with full doses of bismuth, magnesia, and morphia, or with oxalate of cerium. As soon as the more active symptoms subside, it is necessary to ad- minister tonics. Some preparation of iron may be selected ; the saccharo-carbonate or citrate answers the purpose best. When the case is still more chronic, prepara- tions of silver, copper, and zinc have been recom- meuded. The nitrate of silver is, in the opinion of most authors, to be preferred, whilst others have looked upon it as inert in the doses usually given. The writer has certainly seen great benefit from both it and the sulphate of copper ; but, on the other hand, he has seen mischief result from the administration of these salts at too early a period. As the bowels are almost always con- fined in gastric ulcer, it is necessary to promote their action by castor oil, small doses of aloes, or enemata. In the more acute stage of the dis- ease all irritating aperients must be, of course, carefully avoided, and the bowels should be re- lieved only by injections. 21. Stomach, Vessels of, Diseases of. — The blood-vessels of the stomach are frequently diseased, and their morbid conditions no doubt play an important part in the production of ana- tomical changes in the other structures of the organ. Dr. Copland, many years ago, drew attention to an atheromatous state of the ar- teries as frequently present along with gastric ulcer, and the same remark has since been made by Virchow. From repeated examinations of cases of chronic gastric ulcer with the micro- scope, the writer can confirm the truth of these statements. He has constantly found the ar- teries thickened and enlarged in the neighbour- hood of the ulcer. Not unfrequently the vessels, as well as the other textures of the organ, are in a state of fatty degeneration, the condition being in some degree analogous to what is ob- served in fatty degeneration of the heart, in connexion with obstruction of the coronary ar- teries. Where the arteries are healthy in gas- tric ulcer, the veins of the mucous membrane are generally thickened and dilated, display- ing a state like that so constantly remarked in the veins of the lower extremities where ulcers have been long existing. In cancer of the stomach the smaller arteries in the neigh- bourhood of the malignant growth have been often found greatly thickened. This condition 1548 STOMACH, DISEASES OF. 5eems to bp. an important one in determining ■•he future progress of the malignant growth, as leading to its being imperfectly supplied with blood, and. its consequent sloughing. But an abnormal state of the smaller arteries of the stomach is also met with where there is no other disease. There has been much dispute whether a similarly thickened condition of the arteries in contracted kidney is a result, or merely a co- existing state, of other morbid changes. The occurrence of thickened arteries in the stcmach without, as well as with, other structural altera- tions, seems to show the opinion of those to be correct who hold that the arterial changes in atrophy of the kidney are not necessarily the result of the other abnormal states. Affections of the veins of the mucous membrane of the stomach are constantly present in heart-disease, and in cirrhosis of the liver. In such complaints we usually find the vessels much dilated and the coats thickened. Samuel Fenwick. STOMACHICS ( a-ri/xaxos , the stomach). Synon. : Fr. Stomachiqiics ; G-er. Magenmittel. Definition. — Substances which increase the functional activity of the stomach. Enumeration. — The most important stomach- ics are Alcohol, Acids, Alkalies, Aromatics, Bit- ters, Arsenic, Pepsin, and Strychnia or Nux Vomica. Action. — In the act of digestion the stomach has the threefold function of secretion, move- ment, and absorption. By an abundant secretion of gastric juice some of the albuminous consti- tuents of the food are quickly digested ; and this digestion is aided by the movements of the stomach, which mingle the gastric juice with the food, and aid solution by breaking up the particles. From the stomach, also, absorption of some of the products of digestion goes on. Some stomachics, such as alcohol and dilute alkalies, increase the secretion of gastric juice ; pos- sibly also bitters, and small doses of arsenic. Dilute acids, given after meals, and pepsin supply the essentials of gastric juice when secretion is leficient. It is not improbable that the peri- staltic movements of the stomach are increased uy strychnia and nux vomica. We want ex- periments on the action of drugs which increase absorption. It is also probable that some of the good results of bitters are due to their pre- venting abnormal processes of fermentation in the stomach. T. Laudeb Bbunton. STOMATITIS (iTrifia, the mouth). — Synon. : Fr. Stomatite ; Ger. Mundschlcimhaut- cntzundung. Definition. — Inflammation of the mouth. "Varieties. — Stomatitis is chiefly met with in infants and young children. It presents itself under three varieties : — 1. Follicular; 2. Ulcer- ative; and 3. Gangrenous. 1. Follicular Stomatitis. — This form of in- flammation of the mouth is very apt to arise when children are recovering from the eruptive fevers. But it may also be met with in com- paratively strong children, both in connection with severe dental irritation, and also originat- ing in a true herpes of the mouth, analogous to, and sometimes associated with, herpes labialis. STOMATITIS. Follicular stomatitis has its origin in the follicles of the mucous membrane, which become inflamed, and exhibit spots of white exudation. There is, however, no breach of surface. The name of aphtha is often, though incorrectly, given to simple, or follicular, stomatitis ; and the term thrush is popularly applied to both complaints {see Aphth.e ; and Thrush.) Follicular stoma- titis is not a serious complaint, though it in- dicates a weak state of health and a faulty nutrition. The little patient swallows with dif- ficulty. There is an increased flow of saliva; the mouth is hot and tender ; the sub-maxillary glands are swollen ; and the bowels are dis- ordered. 2. Ulcerative Stomatitis. — This is merely an advanced form of the preceding variety. The inflamed follicles break and form small ulcers, covered with a greyish or yellowish slough. These ulcers may remain separate and distinct, or several may coalesce to form one larger ulcer. Sometimes the ulcerative process spreads rapidly. This is especially apt to be the case when the disease is situated on the gums. In a severe case the bases of the teeth and the alveoli may be exposed. Treatment. — The treatment of these two varieties of stomatitis must be conducted on the same principles, and may, therefore, be given under the same head. It is necessary to put the child in a favourable hygienic condition, and to regu- late its diet. If it be at the breast, inquiry should be made as to whether it is fed regu- larly, and only at proper intervals. This should be insisted upon. If the milk evidently disagree, the infant must be weaned. In some cases, however, it may be enough to supplement the mother’s milk with some suitablefood. 'With older children attention must be directed to the nutri- tious quality of their food, and to the regularity of their meals. If it be possible for the child to have a change of air, this alone will often have a most beneficial effect. Small doses of grey powder, or of rhubarb and magnesia, should be given to regulate the bowels ; while at the same time chlorate of potash and bark should be pre- scribed. Subsequently a course of cod-liver oil. or of the syrup of the iodide of iron, or of Parrish’s chemical food, will be useful. Locally, the mouth should be washed with some simple detergent. Borax is the most valuable; but when, as not unfrequently happens, there is some feetor of the breath, a little tincture of myrrh, or Condy’s fluid, may be used with advantage. 3. Gangrenous Stomatitis. — Synon. : Cart- er um oris; Noma. — Occasionally, but very rarely, we meet with a much more formidable variety of stomatitis, arising out of the ulcerative form, and supervening upon measles, or some other debili- tating blood-disease. In ennerum oris one cheek, generally near the angle of the mouth, becomes swollen, red, brawny, and shining. The whole thickness of the cheek is affected by an acute inflammation, which runs on rapidly to gangrene. The internal surface is the seat of a deep foul ulcer, and the little patient can hardly open his mouth. Gradually the redness passes into livid- ity; and a black point appears, which is soon the centre of a large slough When this separates. STOMATITIS. the teeth and the interior of the mouth are ex- posed to view. Treatment. — Everything must be done to support the patient’s strength by milk, beef-tea, wine, and stimulant medicines. The mouth should be syringed frequently with warm water, or with a disinfectant mouth-wash. The cheek must be covered with a poultice or a fomentation until the slough separates, and then the raw sur- faces must be dressed with a stimulating lotion — for example, of carbolic or nitric acid, or of sulphate of zinc. If the gangrenous inflammation threaten to spread, the edges must be thoroughly touched with strong nitric acid. Indeed some consider it well to treat the ulcer inside the cheek in this manner from the commencement. In order to do this effectually it will be neces- sary to administer an anaesthetic. But, in spite of all that can be done, gangrenous stomatitis is a very fatal disease. W. Faielie Clauke. STONE. — A popular name for calculus. Sec Calculus. STOOLS, Characters of. — The physical, chemical, and microscopical examination of eva- cuations from the bowels, or ‘ stools,’ have been fully considered in the articlo Faeces. There remain to be described here certain characters which the stools possess in special diseases. Owing to the extreme variety in appearance, quantity, consistency, colour, and composition which healthy motions present, their charac- teristics in disease are of doubtful significance, and it is but rarely that a diagnosis depends on their investigation, unless it be for the dis- covery of such bodies as entozoa, gall-stones, pius, or other objects accidentally swallowed, and occasionally pus or blood. In a few diseases only do the evacuations pre- sent features of sufficient constancy to be in any way distinctive, and even then it is rather as an element in the diagnosis, than as being actually pathognomonic, that they are to be considered. As might be expected, these maladies are amongst those in which there exists some serious lesion of the gastro-intestinal tract, or of its tributary glands. The following may be referred to in this category : — ■ Cholera. — During the stages of the onset, crisis, and reaction of Asiatic cholera, the stools present a successive series of changes in colour, consistency, and composition. During the pre- liminary diarrhoea the contents of the bowel are voided in a semi-formed, pappy, and increasingly fluid condition, with a progressive alteration in colour from the normal tint to almost colourless- ness. During the algid stage about 50 to 100 ounces are discharged, in 10 to 20 portions, of a rice-water or whey-like appearance, inodorous, and wholly wanting in bile-pigment. The ex- creta on standing deposit whitish floeculi, con- sisting of epithelium, fungi, granular debris, and crystals of salts, chiefly phosphates ; occasionally a few blood-corpuscles are seen. The supernatant fluid is alkaline ; and it contains a large propor- tion of chloride of sodium, and a little albumen. When the stage of reaction sets in, the stools become coloured, at first greenish, and they then STOOLS. 1549 generally assume the normal colour and consis- tency as the diarrhma becomes less profuse. In this stage they are sometimes very fetid. Dysentery. — In this disease, more than in any other, are the stools diagnostic, especially if with their appearance their odour be taken into ac- count, as they are peculiarly fetid, or even gangre- nous. The frequency of the stools is very great, amounting sometimes to hundreds in the day, but a few drachms being voided on each occasion. Considerable variation is met with, dependent on the severity, type, or stage of the case ; but the first discharges, and perhaps the only ones in mild cases, consist of pale yellow masses of glairy mucus, often specked with blood, ar.d with or without a small quantity of pale, feculent matter. The microscope reveals a few leucocytes and free nuclei, with blood-corpuscles, enclosed within the structureless mucus. In later stages, when there is suppuration of the mucous membrane, small red lumps, of an appearance like raw washed meat, are seen in yellowish or reddish albumi- nous fluid. These masses consist of red blood- corpuscles, imbedded in a stroma of viscid mucus, with pus and epithelial cells and granu- lar debris. Sometimes the stools consist chiefly of blood; at other times pus predominates; and when the disease is of a very malignant cha- racter, large gangrenous portions of the bowel are voided with a brownish serous fluid. The mucus is sometimes expelled in a form resem- bling masses of boiled sago. It is said that a partial diagnosis of the extent of the disease may be made by a study of the characters of the stools. Enteric fever. — Previous to the establishment of the intestinal ulceration in typhoid fever, the stools consist of brownish masses, more or less formed ; but subsequently what is often re- garded as a characteristic appearance is pre- sented, namely, pale yellow semi-fluid pea-soupy evacuations, of an alkaline reaction, and offen- sive odour. On standing, the motions deposit a yellow flocculent sediment of particles of food, granular debris, fungi, epithelial cells, and crystals of triple phosphates. The fluid has a sp. gr. of 1015 ; and contains 4 per cent, solids, chiefly albumen and chloride of sodium. Not infrequently blood is found, and sometimes por- tions of Peyer's patches that have sloughed off. The diagnosis between typhoid and tubercular ulceration of the bowels is not to be made with any certainty from the appearance of the stools. For although the above description applies to the evacuations in many cases of enteric fever, in others they are much more consistent, and even clayey. Identical discharges are met with in tubercular disease of the intestines. Pancreatic disease. — In those morbid condi- tions where the pancreatic juice is not secreted, from destruction of the gland, as in cancer, or when the secretion is prevented gaining en- trance into the bowel from occlusion of the duct, it has long been known that the stools are liable to contain fat in variable quantity, occurring in the form of loose drops, or lumps, or smeared over the fseces, or discharged free from feculent mat- ter, constituting a stearrheea. This condition is much more likely to be met with when the bile Is prevented from flowing into the duodenum, 1550 STOOLS, although the existence of such obstruction is not a necessity. And further, it must be admitted that fat has been found-wanting in the stools when there has been marked pancreatic disease. It must not be forgotten that healthy evacuations contain a small quantity of fat, which may be considerably increased if the amount ingested be excessive. Hence fat in the stools cannot be re- garded as absolutely indicative of disease of the pancreas, though very often associated with it. Owing to the frequent association of diabetes with disease of the pancreas, such as cancer or atrophy, fatty stools are often met with in that disease. Hepatic disease.-It is only in affections of the liver in which there exists some interference with the flow of bile into the intestine, that the stools present a characteristic appearance, namely, a want of colour, varying from a pale yellow to a whitish- clay tint, in proportion to the degree of exclusion of the bile. Such evacuations are almost always unformed and of ‘porridge-like’ consistency ; rarely in the form of pale scybala. From want of bile their odour is invariably offensive ; and they may be even putrid in cancer of the liver. Since haemorrhage from the mucous surface frequently complicates icterus, the faeces are sometimes blackened from blood. In a few recorded cases of hepatic disease, where the pancreas has been unaffected, fat has been found in the stools, sometimes in largo quan- tities. Fever.-In the general febrile state, when there is no primary affection of the digestive organs, the motions are diminished in quantity, and as a rule drier, though very frequently unformed. The colour is generally darker, due probably to the increased destruction of blood-corpuscles, and increased elimination of bile-pigment; and the odour is more offensive than in health. Other diseases. — In other affections of the chylopoietic viscera the characters of the alvine discharges are so variable in quantity, colour, consistency, odour, and composition, that no general remarks can be made and no diagnostic indications recorded. Sometimes in grave dis- eases the motions are not to he distinguished from those in health, whilst a trifling change in diet or habitation, or a slight catarrh, may be accompanied by the discharge of faeces differ- ing in many respects from the normal. The fact is that no standard can be taken, so numerous and frequent are the disturbing causes. Severe constitutional diseases of a chronic character, as rickets and scrofula, where the general nutrition is seriously affected, and the blood much alteredin quality, are very frequently characterised by stools which are pale in colour and fetid in odour. The deteriorated quality of the intestinal secretions, and consequent imper- fect digestion of the contents of the bowel, will account for this. The significance of blood in the motions has been explained in the article Helena. Pus in any considerable quantity, and espe- cially if free from admixture with faeces, may be taken to indicate the rupture into the bowel of an abscess, since the inflammatory conditions of the canal, such as enteritis and dysentery, are cot accompanied with very extensive pus-pro- STKABISMUS. duction. The contents of pericacal or perirectal abscesses are usually extremely ill-smelling. See also Kothnagel, Zeits. f. Klin. Med., iii., P- 241. TV. H. Allchin. STRABISMUS. — Stxon. : Squint; Fr. Strdbisme ; Ger. Strabismus; Schielen. Definition. — A condition in which the two eyes are not directed to the same point in space. Description. — Squint is commonly either (1) convergent, or (2) divergent ; but (3) there may be a deviation either upwards or downwards. When one eye appears to be normally directed, and the other to deviate, it is convenient to dis- tinguish the former as the working, and the latter as the squinting eye. The extent or degree of strabismus, or, as it is more usually called, the magnitude of a squint, is expressed in terms of millimetres. In con- vergent or divergent squint it is customary to measure the distance between an imaginary ver- tical line bisecting the palpebral fissure, and another imaginary vertical line bisecting the pupil of the deviating eye. In an upward or downward squint, the distance between the hori- zontal diameter of the pupil, and an imaginary horizontal line bisecting the palpebral fissure, would give the measurement required. 1. Convergent strabismus. — This is seen under two principal forms ; (a) that which de- pends upon paralysis or paresis of one of the external recti muscles, permitting the antagonist internal rectus to exert a preponderating influ- ence upon the position of the eye; and that which depends upon excessive development of both interni, in consequence of an error of refraction, whether (5) hypermetropia, or (c) myopia. (a) Paralytic convergent strabismus. — Thisform of strabismus is met with in all degrees, from the slightest weakening of the affected external rectus to complete paralysis. IEtiology. — Paralytic convergent strabismus is primarily a nerve-affection, in which, how- ever, the muscle concerned will after a time he liable to undergo degenerative changes. The strabismus usually commences somewhat sud- denly, in persons of adult age. and often rapidly increases in degree ; the paralysis, which at first was only partial, becoming complete. In the great majority of cases it is associated with syphilis ; but it is also met with as a result of impaired nutrition or degenerative change in the nervous centres, consequent upon anxiety or over- work. In some of the syphilitic cases, it appears to he due to central mischief, such as gumma or arterial occlusion; in others to pressure upon the trunk of the sixth nerve by periosteal thick- ening or other morbid growth. Diagnosis. — In pronounced eases, the diagnosis is easy; and depends upon the fact that, even when the working eye is closed or covered, the squinting eye cannot he directed outwards by voluntary effort. If the paralysis, although con- siderable in degree, is not complete, the eye cannot he directed outwards as far as usual ; if the paralysis is complete, the pupil cannot be carried external to the middle line of the palpe- bral fissure. “When the affected muscle is only slightly weakened, the nature of the condition may not he at once apparent from the limitation of movement ; and the degree of deviation mat STRABISMUS. be so slight that it is not easy immediately to i pronounce ■which eye is affected. This doubt may be removed, and the existence of paresis made manifest, by the following tests. The surgeon should stand in front of the seated patient, and should hold up before him, in the middle line, and at a convenient reading dis- tance, some small object, telling him to look at it steadily. By his own hand, or by a piece of ground glass, the surgeon then cuts off' the view of the object first from one of the patient's eyes and then from tie other, watching their movements as he does so. When the object is concealed from the squinting eye, the other one, seing already rightly directed, will remain sta- tionary to continue the act of seeing, and the squinting eye will also remain stationary; but, when the object is concealed from the working eye, the other, or squinting eye, being wrongly directed, and not receiving th6 image of the object upon its yellow spot, will make a slight outward movement in order to take up correct fixation. At the same moment, the working eye, behind the obstruction, will execute an inward movement of somewhat greater ampli- tude than the outward movement of its fellow. Let it be supposed that there is slight weaken- ing of the right externus, producing slight in- version of the right eye. When the object is screened from the right eye, the left still sees it clearly and sharply, and both eyes remain at rest. When the object is screened from the left eye, the right receives the image upon a point of its retina internal to its yellow spot, and sees it only indistinctly. The right eye, therefore, makes an excursion outwards, sufficient in amount to bring the image of the object upon its yellow spot, and to enable it to see better ; but the motor impulse by which the necessary movement, of the ex- ternal rectus is called forth, is conveyed at the same time to the internal rectus of the left eye, as a result of the habitual association of the two eyes and of their muscles in the act of looking towards the right ; and the sound muscle, under a given motor impulse, contracts more vigorously than the weakened one. The result is that the excursion inwards of the working eye is larger than the excursion outwards of the squinting cne ; and in this way the fact of paresis of the right externus is rendered manifest. This form of strabismus is at first attended by distressing double vision, which often produces giddiness, but which diminishes in time, as the patient learns to neglect or mentally to suppress the image of the squinting eye. The smaller the deviation, the more distressing will be the double vision ; because, the nearer to the yellow spot is the image of the squinting eye, the more definite will it be, and the less readily will it be distinguished from that- of the other. In cases of very slight deviation, the equality of the double images renders it difficult to tell the true from the false, and leads the patient into fre- uuent error with regard to the position of the object looked at. TnEATitEirr. — The treatment of paralytic stra- oismus is primarily that of the syphilis or of the nerve-exhaustion upon which the paralysis depends ; but it is also necessary to endeavour to minimise the inconveniences of the double 1551 vision while it continues, and to provide against permanent degeneration of the paralysed muscle from disuse. The former indication may be ful- filled by covering the squinting eye with a patch, or with an opaque glass in a spectacle frame ; and, as the double vision is only troublesome when the eyes are directed to the side of the affected muscle, it is often sufficient to render opaque, by grinding or otherwise, the outer half of the glass which covers the affected eye. The nutrition of the muscle may be preserved, when the paralysis is incomplete, by systematic volun- tary endeavours to call it into action; these endeavours being made three or four times a day for a few minutes at a time. For this pur- pose, the working eye should be closed or covered, and the squinting eye should be directed as much as possible towards the outer side. When the paralysis is complete, so that the eye cannot be carried beyond the middle line of its eyelid- opening, it is necessary to exercise the affected muscle by localised electric currents, after the manner of Duchenne. In cases where there is no response to induced currents, those of a cell battery will sometimes be found effectual. Ths exercise by electricity should he repeated at short intervals, such as every two or three days, until the nerve-function is beginning to be re- stored, so that the muscle can again be exercised by the wilL In cases of paralytic strabismus of old stand- ing, it is sometimes necessary to have recourse to tenotomy of the contracted intemus, before the eye can be restored to its correct position. It may be laid down as a general principle that every case can be cured, by combined tenotomy and volitional or electrical exercises, as long as the paralysed muscle will respond, in however small a degree, either to the will or to one form or other of electric current ; but that, where the eye does not move outwards in obedience to the will, and where neither induced nor battery cur- rents produce contraction of the paralysed muscle, no good is to be expected from either operative or medicinal treatment. (5) Convergent strabismus due to excessive de- velopment of both interni. — .-Etiology. — As a re- sult of errors of refraction, about 90 per cent, of this class of cases are due to flat-eye or hgger- metropia. The flat formation of the eye requires, for acute vision of near objects, a strenuous ac- commodation-effort ; and this, by the intimate as- sociation which exists between the nerve-centres governing the accommodation muscles, and those governing the interni, produces a corresponding effort of convergence. As soon as a child who is born with flat eyes begins to take careful notice of near things, his accommodation muscles and his internal recti are both called into frequent and energetic exercise ; and the consequence is that the interni become excessively developed in re- lation to their antagonists, the externi, so that the normal, or resting position of the eyes, in- stead of being one of parallelism, becomes one of convergence. The result of this is that the child would receive double images, of equal intensity, of all objects situated either nearer to him, or farther from him, than the point at which the convergent optic axes would meet if pro- longed. Let us suppose that this point is one foot STRABISMUS. 1552 distant from the eyes ; and that the child wishes to look at an object which is eighteen inches dis- tant. He cannot do this with both eyes, because the externi are unable to overcome their more powerful antagonists. If, however, he combines the right externus with the left internus, as in the act of looking to the right with both eyes, he becomes able to fix the object correctly with his right eye ; and if ha combines the left externus with the right internus, as in the action of look- i ng to the left with both eyes, he becomes able to fix the object correctly with his left eye. But as, in either case, both eyes start from a position not of parallelism but of convergence, the effort which carries the right eye from its convergent state to the middle of its palpebral fissure will carry the left from its convergent state to one of much greater convergence, and vice versd with the left eye ; so that, while one' eye is directed to the object of vision, the other is rolled far inwards. In this way, the image is received upon the yellow spot of the working eye, and upon so peripheral a portion of the retina of the squinting eye that it is easily neglected by the consciousness, and ceases to be a source of con- fusion or embarrassment. Diagnosis. — The state of things in ,an ordi- nary case of squint beginning in childhood is the following. In a state of rest, as when the attention is not directed to any object, or during sleep, or under an anaesthetic, the eyes are equally convergent ; but as soon as any object is looked at, one eye fixes this object and the other rolls inwards. If the degree of flatness is alike in both eyes, and if the muscles in both are of equal power, sometimes one will be the squinting eye and sometimes the other ; and in most cases this condition obtains for a time. The squint is then said to be ‘ alternating.’ Generally speak- ing, however, it is for some reason easier to work with one eye than with the other; either because it is flat in a less degree, or because its accommo- dation muscle or its external rectus is stronger than the corresponding muscle of its fellow ; and then this eye is used in preference to, and gradually supersedes, its fellow; becoming always the working, while that is always the squinting eye. The squint is then said to bo ‘ permanent.’ Treatment. — It would appear at first sight, from the rationale of the affection, that the squint which depends upon flat- eye could always be prevented, or even cured, by the habitual use of convex spectacles ; but, as a matter of fact, the balance of power between the externi and the interni becomes deranged at so early a period of life, that spectacles could not be applied until too late. In every pronounced case of stra- bismus, it is necessary to perform tenotomy of the interni, sometimes only of one but far more frequently of both ; and the only question to be considered is that of the time most favourable for the operation. In determining this question, the points chiefly to be taken into account are the state of vision, and the age of the patient. When a squint be- comes permanent, the vision of the habitually squinting eye frequently becomes impaired, appa- rently as a result of the continued mental sup- pression of the image which it receives ; and in a person who is suffered to grow up to adult age squinting, this impairment of vision often falis little short of blindness, and admits of no remedy. No change is discoverable, generally speaking, by the ophthalmoscope ; but the power of re- sponding to impressions upon the retina seems to be lost. On the other hand, as long as the squint is alternating, and each eye is used by turns, the sight does not usually suffer. The immediate effectof tenotomy of one or both interni is to release the eyes from their position of enforced convergence, and to diminish the power of the interni to rotate them inwards. The divided muscles soon acquire new attach- ments farther back upon the eyeball than their former ones, so that their power is permanently diminished, and this diminution may even be in excess, so as to leave an undesirable preponder- ance of the externi, and a corresponding tendency to eversion. The surgeon, even by the best planned operation, cannot absolutely determine the future position of the eyes. That determination has to be effected by the muscles themselves under the guidance of vision ; and a perfect result after a squint operation, by which is meant the restora- tion of parallelism when at rest, without im- pairment of the power of volitional convergence, can only be obtained by an instinctive re-arrange- ment of the muscular forces concerned, a re- arrangement mainly brought about by efforts to avoid double vision, which is often the immediate result of an operation. While, therefore, it is always possible to remove by tenotomy a coarse and manifest malposition, it is only possible to obtain a perfect result when the recti muscles are well-developed, when the acuteness of vision is equal or nearly so in the two eyes, and when the power of attention to visual impressions is sufficiently active to render double images dis- tressing. The muscular development and the power of attention are both deficient in early childhood ; and hence, so long as vision does not suffer, it is better to defer operating for squint until about eight years of age. As long as the squint is alternating, there is no fear that the vision will suffer, and it is then safe and desir- able to wait ; but, as soon as the squint becomes permanent, it is necessary to test the vision of the squinting eye from time to time, and to provide for this eye being exercised every day, by keeping the other closed or covered for short periods. If, in spite of such exercise, the vision of the squint- ing eye is found to be undergoing progressive deterioration, the operation should be performed without delay, at however early an age ; and the parents should be warned that it may perhaps be necessary, for the attainment of perfect har- mony of movement between the two eyes, to operate again at some future time. It will sometimes happen that a child is first brought for advice at an earlier age than eight, in whom the squint has already become per- manent in one eye, and in whom the vision of that eye has already begun to suffer. In such cases, it is best to devote a few weeks to endea- vours to improve the vision of the squinting eye by compulsory exercise ; and if these endeavours should be in any degree successful, to continue them as long as improvement under their em- ployment is perceptible. If no improvement STRABISMUS. ihould be produced, the operation should be per- formed -without further loss of time. (c) The convergent squint of short-sighted people. — This is not a very common affection, and depends upon the fact that, spectacles to afford distant vision not having been worn, the ex- tend, which produce the approximate parellelism of the optic axes required for distant vision, have not been exercised ; while the intend have been constantly exercised in producing conver- gence for the vision of near objects. The former muscles, therefore, have been suffered to fall into a condition of feebleness from disuse, while the latter have undergone abnormal development. In such cases the eyes are usually equally con- vergent, such a position giving single vision of near objects; while double vision of distant ones is not irksome, on account of the indistinctness with which they are seen. Treatment. — When the convergent squint of of a short-sighted person is of small magnitude, it may sometimes be cured by wearing glasses which correct the short-sight for distance, and call upon the external recti to take up their proper function. More frequently, however, they fail to respond ; double vision is produced ; and tenotomy, followed by the use of the spec- tacles, is required. Such cases usually turn out perfectly well. 2. Divergent squint. — This is nearly always a consequence of defective vision of the squinting eye, which wanders outwards for want of guid- ance from visual impressions. It may also follow from unskilfully performed or excessive opera- tions for the core of convergent squint. Treatment. — The operation for divergent squint is not a mere tenotomy, but requires the shortening of the internal rectus of the squinting eye, or its advancement to a point of attachment nearer to the corneal margin; and the results of such an operation are less under command than those of tenotomy. The muscle may not attach itself firmly in the new position, or the connect- ing medium may stretch after a short time. The operation may be undertaken more hope- fully, the better the vision of the divergent eye; and it is often very successful. It is neverthe- less most prudent, in every instance, to prepare the patient for the possibility of failure, or of only partial success. It is in no case likely that the defect will be increased by failure of the operation ; and, as the chief motive for its per- formance is usually the improvement of appear- ance, it may be uhdertaken with propriety in almost every case. 3. Complex squint. — The forms of strabis- mus in which the deviation is either upwards or downwards are not sufficiently numerous to be brought under any general rule. They depend either upon spasm of the muscle producing the deviation, or upon paralysis or paresis of its an- tagonist ; and every case must be investigated and treated upon its merits, by tenotomy or elec- trisation, or both combined, according to the par- ticular circumstances. Various irregular forms of strabismus are also seen, in the course of certain acute and chronic diseases of the nervous system, which entail loss or impairment of mus- cular co-ordination, such as meningitis and loco- motor ataxy; but such forms are usually easily 98 STRANGULATION. 1553 to be distinguished as symptoms of the general disorder, requiring no treatment or considera- tion apart from it. In chronic diseases, such as locomotor ataxy, it may be conducive to comfort to exclude the squinting eye from vision, for the purpose of obviating the inconveniences inci- dental to double images. R. Brudenell Carter. STRANGULATION ( strangulo , I choke). In pathology this term is employed to express either the process or the condition of constriction of a tube, when it is so complete that the passage of the contents is prevented. See Hernia ; and Intestinal Obstruction. STRANGULATION as a Mode of Death ( 'strangulo , I choke).— Synon. : I’r. Strangula- tion ; Ger. Erwiirgung. Definition. — The act and effect of constric- tion of the neck and air-passages by means of a ligature or manual pressure (throttling). Death results essentially from asphyxia. IEtiology. — Strangulation is chiefly homi- cidal, but it may be suicidal or accidental. Ac- cidental strangulation may occur in a variety of ways, as in the case of a child from tightening of a cravat round the neck, from the end catch- ing in the wheel of a perambulator; in the case of a drunken woman by fixation and tightening of her bonnet-strings ; and in the case of a cripple by a rope attached to a weight accident- ally becoming tightened in front of the neck. it was at one time doubted whether suicide could be effected by strangulation, owing to the fact that the hands relax when insensibility comes on, rendering it impossible to keep up sufficient tension on the ends of the ligature. But when the ligature is wound more than once round the neck, or some method is adopted by which the ligature can be tightened like a tour- niquet, as by the insertion of a piece of stick which catches behind the ear or elsewhere, it is quite possible ; and numerous instances are on record of suicide so effected. In most cases, however, the presumption is in favour of homi- cide, and in all cases of strangulation by manual pressure this may be looked upon as certain. Signs. — In addition to the general indications of asphyxia ( see Asphyxia), there are special signs of strangulation which vary with the de- gree of force employed, and the amount of resist- ance offered by the victim. To strangle an individual of normal strength, and in full possession of all his faculties, is barely possible, without causing evident signs of violence on various parts of the body. The existence of injuries of this kind is valuable evidence of the mode of death. Very often cranial injuries are found, from the individual having been first knocked down by a blow on the head. Ecchv- moses, abrasions, and other signs of mechanical violence are generally to be found in various parts of the body. If the strangulation has been effected by manual pressure, the front or sides of the neck exhibit bruised marks, corresponding to the thumb and fingers, with, perhaps, curved excoriations corresponding to the nails. The re- lative size of the marks produced by the thumb and fingers, and the direction of the nail-marks, 1504 STRANGULATION. indicate the way in -which the pressure has been exerted, and whether with the right or left hand. When a ligature has been empleyed, a mark is left on the neck, which varies with the nature of the ligature, and the way it has been disposed. Usually it is a transverse, shallow furrow; single, double, or multiple, according to the number of folds ; and continuous, or interrupted in places. The bottom of the groove is generally pale, and not parchmented as in hanging, owing to the pressure not being kept up so long as to lead to dessication. Eechymoses in the course of the groove are met with more frequently than in hanging, owing to the great violence frequently exerted. Very commonly punctated eechymoses are visible on the conjunctivas, face, neck, and chest. They are considered by Tardieu to be more fre- quent in strangulation than in asphyxia from other causes, or from overstraining, which like- wise may lead to them. In the subcutaneous cellular tissue, and in the fasciae of the muscles above and below the hyoid, extravasations are frequently found, as well as on the external sur- face of the thyroid cartilage and trachea. The lungs vary as regards their vascularity, but on the surface it is common to find pseudo-membranous patches, which are due to the rupture of some of the superficial air-cellsand collection of air-bubbles under the pleura. In the substance of the lungs congested patches, or apoplectic extravasations, are often found, varying in size, according to Tardieu’s description, from half a franc up to a five-franc piece — extravasations, therefore, much larger than those usually found in suffocation. Treatment. — The treatment of asphyxia from strangulation is that of asphyxia in general. See Artificial Respiration ; Asphyxia ; and Re- suscitation. D. Terrier. STRANGURY (arpay a drop, and oipoy, urine). — Synon. : Stillicidium urines ; Fr. Stran- gurie ; Ger. Harnstrenge. Definition.— A condition characterised by a frequent and urgent desire to pass the urine, which is voided in drops or in very small quan- tities, with a sense of painful spasm in the peri- neum, and often with no feeling of relief. iETiOLOGY.— Strangury occurs under such a great variety of circumstances that it can be regarded only in the light of a symptom. It is found in nephritis or intense congestion of the kidney, however induced ; and thus becomes a symptom after the administration of large doses of turpentine, or the use of cautharides, either internally or in the form of a blister. It like- wise occurs in acute or chronic inflammation of the bladder, prostate, and urethra; in hyper- trophy of the prostate ; in cancer and other tumours, and in stone of the bladder; and in advanced stricture of the urethra. Treatment. 1. Preventive treatment . — Stran- gury may be prevented from following the appli- cation of a blister to the surface of the body, by allowing it to remain on but for a short time, following it by a poultice, or by sprinkling the skin of the part with powdered camphor. 2. Curative treatment. — Regarding strangury -as but a symptom of some other morbid condi- STROPHULUS. tion, wo must consider it as we should cough, headache, or dropsy, and treat it with a view to removing the condition on which it depends. With regard to relieving the more urgent local symptoms, warm hip-baths and fomentations, hypodermic injections of morphia, and supposi- tories of morphia or of belladonna, may be used with advantage. STRATHPEFFER, in Ross-sRire. — Sul- phur waters. See Mineral Waters. STRICTURE ( stringo , I bind). — A contrac- tion of a tube, duct, or orifice ; for instance, of any part of tlio alimentary canal or of the uri- nary passages. See Urethra, Diseases of. STRIDOR: STRIDULOUS ( strideo , I creak). — Stridor is the name given to a peculiar noisy form of breathing, produced in the larynx ; varying greatly in its character — being either harsh, musical, or crowing ; and due to various forms of obstruction. Ttie term stridulous is applicable to the respiration, the cough, or the voice, when they possess the characters of stridor. See Larynx, Diseases of; Pneumo- gastric Nerve, Diseases of; and Voice, Dis- orders of. STROKE. — A popular synonym for an at- tack of apoplexy or sudden paralysis ; but also used in the compound words, sun-stroke, heat- stroke, and wind-stroke, to indicate the effects of these agents. STRONGYLU3 ( OTpoyyvKos , cylindrical). Synon. : Fr. Stronglc ; Ger. Pallisadenwurm. — A genus comprising many species of nematoid worms. The large kidney-worm, sometimes called Eustrongylus gigas, has only once been found in the human body. The case was un- doubtedly genuine, and the specimen is still preserved in the museum of the Royal College of Surgeons. See Sclerostoma. STRONGYLUS DUODENALTS. See Sclerostoma. STROPHULUS ( errpiipos , a twisting of the bowels, or colic). — Synon. : Pr. Strophulus : Ger. Schalknotchen. Definition. — A papular eruption of the skin in infants ; referable, as the derivation of the word implies, to derangement of the bowels. Description. — The eruption is a lichen, a form of folliculitis, rarely extensive, and unassociated with constitutional symptoms. Its principal seat is the face, but it may also be dispersed over the trunk of the body and limbs. Its duration will ho influenced by the nature of its cause. Some variety in colour, duration, and cause has given rise to several names applied to the eruption. It is sometimes ephemeral, and has been termed S. eolations ; sometimes the pimples are pale or shining, hence 5. albidus and S. Can- didas. More frequently they are red and in- flammatory, and either dispersed or aggregated, S. confertus ; and occasionally an interpapular hypertemia or inflammation gives rise to the variety known as S.intertinetus. When associated with dentition this trivial rash is termed ‘ red gum ’ and ‘ white gum ’ ; whilst under conditions of aggravation it is prone to run into eczema. STROPHULUS. Treatment. — The treatment of strophulus is one of attention to the general health and con- dition of the infant. A few doses of magnesia and rhubarb, and even a grain of calomel, may sometimes be found useful, but in general a dis- creet attention to the food, with rest and warmth, will be all that is necessary. Locally, the rash should be dusted oyer with fuller’s-earth powder, or sponged with a lotion of lime-water and oxide of zinc, with or without calamine. Erasmus Wilson. STEUCTUEAL DISEASES. — Diseases attended by recognisable anatomical changes, as distinguished from functional diseases. See Disease, Classification of. STRUMA 1 , . . , ,, STRUMOUS / ( struma > a scrofulous swell- ing.) — Synonyms for scrofula and scrofulous. See Scrofula. STRYCHNIA, Poisoning by. — S ynox. : Fr. Empoisonnement par la Strychnine ; Ger. Strychninvergiftung. — The seeds of Strycknos nux vomica, commonly known as nux vomica, as well as several other plants, owe their powerful toxic (excito-motor) properties to an alkaloid, strychnia ; and in a minor degree to another alkaloid, brucia, which is said to produce the same physiological effects as strychnine. Strychnia is a white crystalline substance, very sparingly soluble in aqueous liquids, to which, however, it communicates an intolerably bitter taste. It is more freely soluble in acid and alcoholic liquids. When mixed with flour and sugar, and coloured by admixture with either soot or Prussian blue, strychnia forms the basis of several well-known forms of ‘ vermin-killer.’ Spite of its repulsively bitter taste, strychnia has been administered with homicidal intent in such liquids as infusions of tea and cocoa, and in other media. Anatomical Characters. — The anatomical characters after death by strychnia-poisoning are very ill-marked, and at most consist of some congestion of the vessels of the spinal cord; and even this may be wanting. Symptoms. — Except when taken in the form of pill, strychnia and all substances containing it produce an immediate and intensely bitter taste, which is also at the same time of a quasi-metallic character, and is very persistent. Since the fatal dose — half a grain of the alkaloid — is small, and the poison is readily soluble in the acid gas- tric fluid, its physiological effects are, as a rule, not long delayed. They may be unmistakable after the lapse of two minutes ; but commonly they are not well-marked till five, ten, or even twenty minutes after administration. They begin with a stage of restlessness, excitement, and a vague sense of impending peril. The special senses, too, are often preternaturally sharpened. A feeling of chokiDg or impending suffocation en- sues ; then there is a trembling of the whole body ; jerkings of the head; and often, in a moment, the whole body becomes stiff and rigid, assuming a bow-like form, (opisthotonos), i.e., arched for- wards and resting perhaps on the head and heels only. The muscles even of the chest and abdo- men are tense and fixed, so thatrespiration is im- peded, giving rise to more or less cyanosis. The STRYCHNIA, POISONING BY. 1555 feet are either ineurvated or excurvated. The angles of the mouth are drawn down, so as to give rise to the well-known risus sarclonicus of tetanus. Attempts to administer medicine by either cup or spoon have been known to result in the patient’s biting the cup or spoon in two, in consequence of a violent spasmodic closing of the jaws. During the paroxysm, and indeed throughout the intoxication, the cerebral faculties are unimpaired, and the convulsions are purely of spinal origin. The pupils are dilated. In a few minutes, and often in half a minute, the muscular tension relaxes, and there is a complete remission of the spasms. The patient lies ex- hausted, and bathed in perspiration ; the rapid pulse of excitement falls in frequency ; respira- tion becomes more normal ; and the dusky lividity of the countenance passes off. This remission is, however, of no long duration. A gentle touch, a footstep, even a breath of air impinging on the patient, results in a new crisis; and often with a wild, despairing cry, a renewed convulsion, simi- lar to but more intense than the preceding one, is ushered in. The patient rarely dies during the first or second paroxysm, but the alternation of convulsions and quiet is repeated again and again till death ensues, usually in half an hour or an hour; or in non-fatal cases the fits become less and less frequent, less in- tense, and eventually cease. Death takes place commonly during a paroxysm, from asphyxia ; but it may also occur in the intervals between the paroxysms, from exhaustion. Diagnosis. — The characteristics of strychnia- coDvulsions are so well-marked, as already de- scribed, that there is little likelihood of the nature of the case being overlooked; and the only disease with which strychnia-poisoning can readily be confounded is tetanus — traumatic, idiopathic, or hysterical. In the hysterical form of the disease, as described by some writers, the well-marked hysterical symptoms, the closed or half-closed eyes, the desire to be fanned, and the incomplete remissions of spasm, servo for diagnosis. Except in the history there is nothing to distinguish between the traumatic and idio- pathic forms of the disease, so that what is here stated with regard to the diagnosis between strychnia-tetanus and traumatic tetanus, ap- plies also to the idiopathic form. In traumatic tetanus the muscular symptoms begin with pain and stiffness of the neck and jaws, gradually passing into spasms ; and the jaw is one of the earliest parts affected. The strychnia-symptoms, on the other hand, develop rapidly, and begin in the extremities, or a general convulsion at once seizes the whole body. Moreover, the jaw is usually last affected, and its muscles relax first. The strychnia-relaxation is complete, or rarely almost complete ; whilst in traumatic tetanus there is permanent muscular rigidity, and no complete remission of spasm. Strychnia- tetanus is an affair of minutes, or at most of half a dozen hours ; whilst traumatic tetanus never kills within twelve hours, and generally ex- tends ovfer a few days. In strj-chnia-poisoning the most trivial movement or touch will set up a convulsion ; whilst during the spasms firm grasp- ing of the hands, and hard rubbing of the rigid muscles, will often afford grateful relief. This 1556 STRYCHNIA, POISONING BY. distinction is not marked in traumatic tetanus. An analysis of the urine by Stass’s method, which often affords certain indications of strychnia, and may be made in a few minutes, will, in doubtful cases, at once remove all uncertainty as to the nature of the disease. Prognosis. — The prognosis is at all times doubtful. The patient’s life cannot be considered safe till the convulsions clearly exhibit marked decrease, both infrequency and intensity. Treatment.— Should the convulsions have already set in, the use of the stomach-pump is out of the question. An emetic of warm water with mustard, or carbonate of ammonia, should be given without a moment’s delay. The patient should be touched as little as possible, and absolute quiet observed in the sick-room. Ex- cellent results have ensued from the administra- tion of large doses of bromide of potassium ; even half an ounce in one dose has been given. The salt serves the double function of rendering the poison insoluble, and counteracting its physio- logical effects. The gastric irritation produced by such large doses of the bromide as are neces- sary militates against its use. Chloral in full doses, and the anaesthetic administration of chloroform vapour, are the best remedies. The free use of chloroform not only alleviates the pain and allays the spasms, but allows time for the elimination of the poison from the system. Nitrite of amyl has been recommended by Dr. Barnes. Strychnia-poisoning more often ends fatally either from the lateness with which re- medies are applied, or their non-application, than from their inefficient character. Thomas Stevenson. STUPE (stupa, tow.) — A synonym for a fomentation. See Fomentation. STUPOR (Lat.). — S tnon : Pr. Stupeur ; Ger. Stupor ; Stumpfsinn. — A partial loss of con- sciousness. See Consciousness, Disorders of. STUTTERING. See Stammering. STYPTICS ( this way can be traced to obvious pathological causes. Thus, a morbid process may extend directly along blood-vessels, lymphatics, or other tissues ; or a morbific agent may be convoyed by the blood or lymph from one part to another ; or a secondary lesion may be produced by direct nervous influence. There are other cases, how- ever, in which the connection is not so evident, but it is quite intelligible that organs which are physiologically related may be sympathetically disturbed in pathological conditions. The sym- pathetic disturbance may bo indicated by mere pain or other subjective sensation ; by functional derangements, as of secretions or actions ; or by positive organic lesions. The occurrence of such phenomena in corresponding parts on both sides of the body, when a disease has commenced on one side, is sometimes very curious, especially as regards organic lesions. As illustrative of the associations in which the word ‘ sympathetic’ is employed may be mentioned sympathetic 'pain, sympathetic headache, sympathetic cough, sympa- thetic vomiting , sympathetic bubo. Frederick T. Robebts. SYMPATHETIC SYSTEM, Disorders of. — S ynon.: Fr. Maladies du Nerf sympathique-, G-er. Krankheiten der Ncrvtis sympatkicus. Introduction. — This subject can only be treated in a brief and tentative manner, owing to the fact that a wide basis of positive know- ledge does not exist. The physiology of the different departments of the sympathetic system of nerves is now only beginning to shape itself, whilst on the side of pathology and morbid anatomy there is even still less of definite know- ledge. Thus it happens that for the most part only conjectures, often very insecurely based, are current, or can be said to exist, in regard to the dependence of definite sets of symptoms, or distinct diseases, upon disordered actions or morbid changes occurring in one or other part of the sympathetic system of nerves. These problems are now, however, receiving the atten- tion of many workers, so that before long it is to be expected that our knowledge on this impor- tant subject will have become both more exten- sive and more definite. We shall, therefore, in the present article, confine ourselves to some general remarks concerning the anatomical rela- tions and the functions of the sympathetic system of nerves ; to the modes in which disorders of SYMPATHETIC SY'STEM, DISORDERS OF. 1570 its several parts may arise ; and to little more than a mere mention of the various morbid con- ditions, which may be principally or in part occasioned by defective or otherwise abnormal activity of one or other department of this great system of nerves. We shall thus be enabled to indicate some of the best established facts or relations in this direction which have already acquired a clinical importance, and also to indi- cate the directions in which further advances are to be looked for. Whilst the sympathetic system of nerves, with its double ganglionated cord and great ganglionic plexuses, is to a certain extent an independent nervous system, its roots nevertheless penetrate deeply into the cerebro-spinal axis. The two nervous systems are connected, on each side of the spinal column, by means of double sets of filaments, passing between each of the sympa- thetic ganglia and the respective anterior spinal nerves with which they correspond, as well as with most of the nerves attached to the medulla oblongata. The fibres in all these filaments of communication are partly afferent and partly efferent. Thus, just as ingoiug or centripetal impressions, instead of being reflected from some of the sympathetic ganglia, may pass on to spinal and medullary centres, so may motor or inhi- bitory impressions pass outwards from these cerebro-spinal centres, so as to modify the sub- ordinate motor or secretory influences, emanating from some one or other of the sympathetic ganglia themselves. From the ganglionated cord on each side of the spinal column, numerous internal branches are given off, which unite with one another, with those of the opposite side, and often with filaments of the pneumogastrie nerves, so as to form great plexuses with or without well-marked ganglia, with which the various glandular organs and hollow viscera of the body are in connection by means of afferent and efferent fibres. On the course of these visceral nerves many smaller ganglia, constituting subordinate centres, are to be found. The sympathetic nerves are conducted to and ccme from the viscera, principally upon and along the course of the blood-vessels. Some of the nerve-fibres on the visceral blood- vessels, and a much larger proportion of those on vessels going to other parts of the body, belong to a special set of the sympathetic fibres, which, from the nature of their functions, are known as v aso-motnr nerves. Some of these fibres must have ‘afferent’ functions for the conveyance of impressions to vaso-motor centres ; while others of them will transmit ‘efferent’ impulses ; the two sets together serving to regu- late the calibre of the blood-vessels, and conse- quently the amount of blood flowing through the different vascular territories. These vaso-motor nerves are connected with small ganglia distri- buted along the length of the blood-vessels, from which, in response to afferent impressions, motor stimuli may issue to such vessels and their branches. Such peripheral ganglia are, hotvever, in subordinate relation with spinal vaso-motor centres, situated along the whole length of the cord, and these in their turn are dominated by » still higher regulating centre, situated in the medulla oblongata (near the lower extremitv or the fourth ventricle), which appears to be in re- lation with all the vaso-motor nerves throughout the body. Modern observations would seem to show that there is another vaso-motor centre in the cerebral cortex ; and this is believed by Benedikt, Meynert, and others to be situated in the hippocampus-major. The nature of its relations with the medullary centre are as yet uncertain. Other fibres of the sympathetic system are mixed up on the vessels with those haviug a vaso-motor function. These others vary in function and in numerical proportion, ac- cording to tlie nature of the organ to which the vessels are proceeding. Thus to and from the liver, the pancreas, the salivary glands, and other allied organs, would proceed nerve- fibres, regulating the secretory and other vital actions taking place in the tissue-elements of the several organs ; also from and to such organs there would proceed afferent and efferent fibres for rousing and regulating the activity of the contractile tissues in their respective gland- ducts. Again, there would lie on intestinal arteries, in addition to vaso-motor fibres, many other sympathetic fibres for the innervation of the muscular layers of the intestine, and many also for the different glandular elements of its mucous membrane. Lastly, in such an organ as the bladder, vaso-motor nerves, and nerves for the supply of its own proper muscular tissues, would exist in abundance, while those in rela- tion with glandular elements would be compa- ratively scarce. Whether over and above these different kinds of sympathetic fibres, others exist of the so- called ‘trophic’ type, seems at present to be ex- tremely doubtful. If. therefore, we consider the functions of tho sympathetic system of nerves as a whole, we find that it has to do with the degree of contrac- tion of the pupil ; with the calibre of the blood- vessels generally; with the activity of all the glandular organs ; with the movements of all the hollow viscera, and gland-ducts ; and pos- sibly in some special manner with the nutrition of all the tissues. And inasmuch as the nerves pertaining to this system, if not both the nerves and ganglia, are to be found iu all parts of the body, it is to be expected that its functions may he more or less locally deranged, or its struc- ture more or less damaged, by almost every form of disease, be it local or general. Every local inflammation must be associated with a per- verted activity and deranged structure of sym- pathetic nerve-fibres in the inflammatory focus ; whilst every fever will entail widespread and varied perversions in the functions of this sys- tem of nerves throughout the body. Owing, however, to the fact of the intimate structural relations existing between the sympathetic and the cerebro-spinal nervous system (see Nervous System, Diseases of), it is more especially in diseases of the spinal cord and of the brain that we are accustomed to meet with definite sets ot signs and symptoms referable to disordered or arrested action of portions of the sympathetic system. In the present article, therefore, the disorders of the sympathetic system will be very SYMPATHETIC SYSTEM, DISORDERS OF. briefly considered as they occur: (1) in associa- tion with diseases of the spinal cord and brain ; and (2) independently of affections of the cerebro- spinal nervous system. 1. Diseases of the sympathetic system in connection with the cerebro-spinal system. (a) The spinal cord. — Lesions of the cervical region of the spinal cord may be associated with extreme contraction or extreme dilatation of the pupil on one or both sides ; with in- creased heat and redness, or the reverse, of the aead and neck; with perverted respiration; with perverted action of the heart ; and possibly with an exalted febrile heat of the whole body {see Spixal Coed, Diseases of, § 9). Though we regard these phenomena as signs of disease in this particular portion of the spinal cord, it is none the less true that such phenomena are due to altered activities in those root-portions of the sympathetic system of nerves which take origin in, or traverse, this region of the cord. This is shown by the fact that similar sets of symptoms are produced by injuries, tumours, or other morbid processes implicating the cervical sym- pathetic itself. It will be well to cite here the phenomena commonly associated with irritation or paralysis of the cervical sympathetic nerve, on account of their importance as diagnostic indications. The signs dependent upon irritation of the cervical sympathetic in its oculo-pupillary fibres are — dilatation of the corresponding pupil with sluggish action, widening of the palpebral fissure, prominence of the eyeball, feeling of tension in the eye (as in glaucoma), and a scanty secretion of tears and mucus ; whilst in its vaso-motor fibres they are — lowering of temperature of the side of the face and head, diminution of sensibility, an absence of perspiration, with (if the irritation continue) a tendency to slight atrophy of the side of the face. The signs of paralysis of the cervical sympathetic in its two sets of fibres are the direct opposites of those above cited, so that it is not necessary to enumerate them. Of these signs, those dependent upon irritation or para- lysis of the oculo-pupillary fibres are usually much more constant and durable than those which depend upon irritation or paralysis of the vaso-motor fibres. These latter signs are, for reasons at present unknown, often transitory and fitful. Sometimes there may be signs of paralysis of oculo-pupillary fibres co-existing with signs of irritation of the vaso-motor fibres, or vice versa. It has been definitely determined that injury in the lower cervical region of the cord, and as far down as the level of the second dorsal nerve, may give rise to the oculo-pupillary signs of one or other kind ; and, on the other hand, that damage to the cord in these same parts, or as low down as the fourth dorsal nerve, may give rise to the above-mentioned vaso-motor signs. When the dorsal and lumbar regions of the spinal cord are the seats of disease, other groups of phenomena will doubtless, after a time, be more fully recognised as results of irritation or paralysis of those roots of the sympathetic sys- tem which have their origin in or which traverse these particular regions of the spinal cord. It is therefore important to bear in mind the place of 1571 origin and the distribution of the different inter- nal branches from the lateral sympathetic cords, which proceed from these regions to the different glandular organs or hollow viscera. Diarrhoea, sickness, obstinate constipation, sexual defects, and bladder-troubles, are among the symptoms which have such an origin, as well as undue heat or unnatural coldness of the lower extremities. (5) The brain. — In different portions of the brain some of the signs and symptoms of disease are also referable to direct or indirect inter- ference with the functions of the sympathetic system of nerves ; but they constitute (apart from vaso-motor derangements, which are very common and often well-marked) far less distinc- tive aggregates, owing to the fact that the sym- pathetic system of nerve6 has a much less exten- sive relation with the brain than with the spinal cord. In this direction, however, and in connec- tion especially with diseases of the medulla oblongata, we have to bear in mind the occa- sional occurrence of diabetes, polyuria, or albu- minuria ; also of some cardiac and respiratory derangements. 2. Diseases of th.e sympathetic system proper. — Where disease exists in the ganglia of the sympathetic system itself, or where it in- volves them, we get groups of symptoms more clearly referable to disordered activity of this system of nerves alone. These will differ in particular cases, according to the nature of the morbid change, that is, according as it is destructive or merely irrita- tive; and according to the number or particular combinations of ganglia and fibres affected. Tho ganglia and related plexuses may either be im- plicated by intrinsic morbid processes, or may be variously involved from without by morbid processes having their origin in other adjacent tissues. a. Intrinsic changes. — The principal intrinsic morbid processes which have been hitherto re- cognised post mortem in some one or other of tho sympathetic ganglia are : — pigmentary degene- ration; cirrhotic overgrowth of their connective tissues, with or without secondary atrophy (the ganglia in such cases being either smaller or larger than natural) ; a highly congested and varicose state of their blood-vessels ; effusion of blood into their substance ; new growths start- ing from their substance ; and fatty degenera- tion, with more or less marked atrophy. It is unnecessary to repeat here the statements re- lating to the pathology of such changes, which have been made under Nervous Ststem, Diseases of. b. Extrinsic disease. — Different parts of the sympathetic system may become involved in new growths or in abscesses ; or they may be simply pressed upon by aneurismal or other tumours occurring in contiguous regions of the body. _ Besides the pathological conditions already enumerated, it should be borne in mind that in altered blood-states, whether cachectic or of fe- brile origin, we commonly have, and especially in the latter class of cases, a greatly perverted activity of the sympathetic system throughout tho body' — as evidenced by the altered vascular conditions, increased tissue-metamorphosis and 1572 SYMPATHETIC SYSTEM, body-heat, together with 'the perverted activity of most of the glands in the body. See Fever. But to what extent the actual structure of glandular or blood-making organs may be per- verted by primary or secondary morbid changes in related portions of the sympathetic system, we have yet to learn. Waxy degeneration of the liver or spleen may, for instance, be a result of certain perversions of the normal life-processes taking place in the elements of these organs, pri- marily induced by changes in the quality of the blood, such as occu-r in many cachexias. But whether this altered blood acts directly upon the tissue-element, and brings about the struc- tural change known as waxy degeneration ; or whether cachectic states of the system entail upon the sympathetic centres a perverted nutri- tion, and a consequent perverted influence upon the tissue-elements of related organs, whereby they, being at the same time fed only by im- poverished blood, lapse into those lower modes of vitality which result in the degenerative change above-mentioned, are unsettled questions, well worthy of consideration. These remarks, with suitable modifications, are applicable as regards the possible instrumentality of related portions of the sympathetic system, in causing other varieties of morbid change in other organs of the body. The principal disorders other than those due to structural diseases of the cord and of the brain, in which derangements of the sympathetic system of nerves exist, or are believed to exist, and in which such derangements have either wholly or in part a causal relationship to the principal signs and symptoms of the respective disorders, are as follows: — epilepsy; convulsions; migraine (hemi- crania); exophthalmic goitre; unilateral liyperi- drosis ; progressive facial hemiatrophy ; angina pectoris ; asthma ; diabetes ; Addison’s disease ; gastralgia ; enteralgia (colic) ; neuralgia coeliaca ; neuralgia spermatica ; and uterine neuralgia. (See ‘ Phys. and Pathol, of Sympath. Syst. of Serves’ by Eulenberg and. Guttmann, 1879.) Among the affections more doubtfully or partially related to disorders of the sympathetic we may mention glaucoma; neuro-retinitis; progressive muscular atrophy ; pseudo-hypertrophic paraly- sis ; locomotor ataxy; diphtheritic paralysis; and so-called ‘reflex paralysis.’ In the special articles on most of the first group of affections, the reader will find references to the dependence of such conditions upon disorders in one or other department of the sympathetic system. 1 H. Charlton* Bastian*. SYMPTOM 1 See Dxsbask SYMPTOMATOLOGY / ’ Symptoms and Signs of. SYNCOPE (ffny/coTr?/, a faint). — Synon*. : Fainting ; Fr. Syncope ; Ger. Ohnmacht. Definition. — A state of suspended animation, due to sudden failure of the action of the heart. JEtiolooy. — Syncope may be due to any con- dition which interferes with the action of the heart, whether acting (, I carry with). — S y- non. : Febris coniin.ua. SYNOCHTJS (rrvvexu, I hold or keep to- gether). — Synon. : Febris continens. Synocha and synoclius are now obsolete terms, which were used for many centuries as epithets of two distinct types of fever, hut in different senses at different periods. A complete history of their varying meanings would occupy much space ; a few illustrations of it only need, be given. Syno- cha does not occur in Galen’s extant writings ; and Synochus is by him contrasted with wupe-rbs trwtxvs, and defined to be a fever whose course is steady and uniform from its beginning to its end. Under it, in his Method. Medend., lib. ix., cap. iii. he admits three varieties, namely, 1, when the temperature remains steady ; 2, when it rises steadily; and 3, when it falls steadily, during the whole course of the fully established disease. The meaning of the term has no refer- ence to the duration of the fever. ir uperbs svvex’hs, on the contrary, is a fever with paro- xysms and remissions. Galen, Dejinit. Med., 186-7. In the second edition of Stephen Blancard’s Lexicon, a.d. 1717, from which the etymology given above is taken, synocha is a continued fever, of several days’ duration, with paroxysms SYPHILIS. and remissions, attended by remarkable heat, and sometimes putrid. It may he either quo- tidian, tertian, or quartan. By this he seems to mean that exacerbations may take place on those days, hut the fever is remittent not inter- mittent. Synochus is a continuous fever ( febris continens), often lasting several days, unattended, by serious symptoms, and is either simple or putrid, according to its severity. Linnaeus, in 1763, and De Sauvages, in 1768, both define synocha to be a fever not lasting more than a week, synochus one not lasting more than two or three weeks. Cullen, in 1785, dissatisfied, hesa 3 's, with the previous use of the words, gives to them a special meaning of his own. In his nosology synocha is a fever with very high temperature ; a frequent, strong, hard pulse; red urine; and very little disturbance of the sensorium. Synochus is a contagious disease, in which the fever combines the symptoms of synocha and of typhus ; begin- ning as synocha, towards the end it becomes typhus. With this variety of meaning it is not sur- prising that the same disease is placed under synocha by one author, under synochus by another. As the further uso of these terms, apart from their incongruity with modern sys- tems of classification, can only perpetuate this confusion, they may be allowed to become ohso lete. James Andrew. SYNOVIAL DISEASES. See Joints, Diseases of. SYPHILIS (etymology uncertain. Per- haps from avv , with, or ervs, a swine, and tpiKia, I love; or from cri C.) in the axilla, and even less under the tongue, having been observed ; but the temperature 'of the inte- rior of the body is generally very high, reaching 10i°Fahr. (10° C.), and sometimes much more. In peritonitis a low general temperature may be present for days, even if the peritonitis super- vene in the course of typhoid fever. With the collapse caused by alcoholic intoxication great depression of the general temperature occurs, when the patient is exposed to cold and wet; and in a case of carbolic acid poisoning, which came under the observation of the writer, the temperature fell as low as 93'92° Fahr. (3I'4° C.). A temperature of 7 1 '6° (22° C.) has been observed in sclerema neonatorum. In chronic diseases of the respiratory organs, not of an inflammatory or tuberculous nature, as well as in chronic heart-disease, the temperature is generally found somewhat below normal; and the same is the case in chronic nephritis, more especially in those cases accompanied by general dropsy. In cases of the latter kind we even sometimes see a febrile temperature, caused, for instance, by tubercular disease of the lungs, be- come considerably abated, if not entirely re- versed, when chronic kidney-disease supervenes; as also when intestinal ulceration becomes more prominent, or leads to peritonitis. 2. Elevation. — Elevation of the general temperature, as part of the febrile process, is the most prominent symptom in most diseases of an infectious origin, as well as in diseases of an inflammatory nature. In both an in- creased production of heat, no less than a dis- turbance of the regulation of the temperature, is the effect of the presence in the blood of some foreign substance, acting injuriously on the nervous system, and causing altered chemical processes. Modern theories give a more and more prominent part in these actions to organised bodies (fungi, bacteria), which, in themselves or, possibly, by products of their own life-changes, or by the changes which they cause in the fluids of the body, are assumed to be the cause of the febrile process, and thus of the increased tem- perature. The proper balance of the heat-forming and heat-destroying processes may also be disturbed by other influences acting upon, and by primary diseases of, the nervous system. When the body is subjected to external cold, after it has been fatigued by exercise, and already cooled by per spiration — if, for instance, a cold bath were taken under such circumstances, a rigor, with rapid rising of the temperature may follow ; but, no local disease becoming developed, the tempera- ture quickly goes down again amid protuse perspiration, and the whole attack may TEMPERATURE. 1600 over. Or a disturbance of the heat-regulating functions of the nervous system may be caused by the irritation of some nerve-filaments, as by a gall-stone passing the biliary duct, or a stone passing the ureter or the urethra, and a febrile attack 'will follow. The rigor, leading to a high fever of an evanescent character, which may follow the introduction of a catheter (urethral fever), sometimes belongs to the same group of cases. But generally, in cases of this last kind, the nervous system is already in an abnormal state through the previous disease of the kidneys or bladder. The functions of the nervous system may further be deranged by in- jury; and a rise of temperature has not only been observed in injuries to the brain, but, in a most excessive degree, sometimes after injury of the cervical part of the spinal cord, when temperatures of 110° to lll°Fahr. (43‘3° to 44°C.) have been observed (B.Brodie, H. Weber, Teale, and others). In tetanus a very high temperature may occur, rising still higher a little after death ; as much as 112-55° Pahr. (44’75° C.) was reached in a case observed by Wunderlich. An alteration of the heat-regulating functions of the nervous system may be brought about by a considerable external heat acting upon the body, especially when com- bined with moisture of the air. In cases of sun- or heat-stroke, it is quite common to see the tem- perature of the body rise to 108° Fahr. (42-2° C.) and more ; and it would seem probable that a febrile elevation of temperature, if going on unchecked for a considerable time, by causing exhaustion of the nervous system, may lead to hyperpyrexia. Thus it is not very uncommon to see the temperature rise excessively in infectious diseases, especially scarlatina, towards the close of life (proagonic hyperpyrexia) ; and the tempe- rature may, in such cases, even rise a little more immediately after death. This is due to the losses of heat being greatly reduced after the stoppage of the circulation, the heat- production going on in the interior for a time ; and the gradual failure of the circulation probably also takes a great share among the causes of a proagonic hyper- pyrexia. Hyperpyrexia sometimes comes on m the con- valescence from acute rheumatism, even after the fever has entirely subsided, and when the patient is on the point of being discharged from the hospital. An excessive rise has occurred and caused death in severe cases of hysteria ; and in hysterical patients hyperpyrexia has occasionally been observed without any of the other symp- toms which in other cases usually accompany so grave a phenomenon. Cases of this kind are extremely suspicious, and in some of them it was discovered how this hyperpyrexia was simu- lated. Thus the patient has driven up the mer- cury by rubbing the bulb of the thermometer between the folds of her night-dress ; whilst in other cases the high elevation of the mercury has been brought about by means of poultices, or by the patient having lowered the top of the in- strument, so that the column of mercury began moving by its own weight. This, however, is not possible with a thermometer of the thin bore which English thermometers now generally have. A very high temperature, to which the pulse and respiration and the other symptoms do not correspond, must always arouse a suspicion that the rise of the mercury has been artificially pro- duced, and the verification will be easy if the physician carefully watch the mercury as it rises, or by taking the temperature in the rectum or vagina. The very important part which the nervous system plays in regulating the blood-heat, is also seen in the great liability of the temperature easily to deviate from the normal range during convalescence from acute disease, when the weak- ness of the nervous system, brought on by the previous illness, will show itself in this no less than in other alterations of function. This can frequently be observed in convalescence, not only from the specific fevers, but also from pneumonia and other acute febrile diseases, when trifling external influences may cause a considerable rise of the temperature, which, however, is generally of short duration only, but which, in the case of specific fevers may cause apprehension lest a relapse be comiDg on. In a somewhat different manner, and more lasting, a slight sub-febrile elevation of temperature may be observed in the convalescence from acute rheumatism, where it may persist for weeks without any joint- or heart-symptoms being present. Significance of Abnormal Temperature fob Diagnosis and Prognosis. — The mainte- nance of the heat of the body at a certain range being so insured, any deviation of the general temperature from the normal standard, however slight in degree, and unless of a very transient nature or brought on by evident external causes, is to be taken as a sign of disease. Such de- viation may be of a variable degree, along with symptoms which, in part, are the consequence of the abnormal temperature, such as an ab- normal rate of pulse and respiration, and ner- vous symptoms. The whole range of deviation within which life can well be maintained is com- prised between 90° Fahr. (32-3° C.) and 110° Fahr. (4 3 '4° C.). A temperature approaching either end of this range indicates a condition of extreme danger, which is already great with a temperature of 95° Fahr. (35° C.), or beyond 106'5° Fahr. (41'5° C.). With reference to the goneral condition of a patient who presents an abnormal temperature, a few distinctions may be conveniently tabulated : — 1. Temperature below the normal : — a. Temperature of collapse, below 97° Fahr. (36-2° C.) b. Subnormal temperature, 97-98° Fahr (36-2-36-7° C.) 2. Normal temperature: 98 0-99‘5 t ’Fahr.(36'7- 37-5° C.). 3. Temperature above the normal : — a. Subtebrile temperature, 99-5-100-5° Fahr. (37-5-38 05° C.). b. Febrile temperature of moderate degree, 100-5-102° Fahr. (38 05-3S-S8 0 C.), morning; 102-2-103° Fahr. (39°-39-44° C.), evening. c. Febrile temperature of high degree, 102 '5° Fahr. (39-2° C.), and more in the morning; 105-106° Fahr. (40-6-411° C.) in the evening. d. Hyperpyrexia, 105-8-107"5° Fahr. (41-42° C.) and more. Extremely dangerous. Single Observations. — Near the ends of this scale a single observation of the temperature TEMPERATURE. of a patient may at once decide the prognosis. Thus a temperature below 93° Eahr. (33‘88° C.), or above 1 08° Eahr. (42'22° C.) is almost always fatal, although cases have been recovered by active treatment in which the latter point has been exceeded by several de; rees. No less valu- able may single observations be for diagnosis, chiefly in a general way, in showing that there is disease when, perhaps, no other symptom points to it, but also for the diagnosis of a special disease in some instances. Where there are other symptoms of disease, the discovery of an abnormally high or a febrile temperature may at once give quite a different aspect to a case, as, for instance, when a patient who has been suffering for some time from a trouble- some cough, but in whom the most careful ex- amination of the chest could not detect any lung-disease, is found to have pyrexia. The sus- picion that there is commencing phthisis may thereby bo at once confirmed, or aroused for the first time. Or, again, in a case where the patient simply complains of dyspepsia and lassitude, the thermometer may give a degree of heat which would not have been expected either from the looks of the patient, or from the temperature of his hands or chest, and the attention may thereby at once be directed to the possibility of the case being one of typhoid or some other specific fever. One reservation must be mado with regard to single observations in patients who have not been kept at rest for some time before, for example, in patients who have walked to the physician’s house, or who had to undergo a journey to the hospital. In such cases the tem- perature may be somewhat altered by the fatigue ; and it is quite common to find the first tempe- rature in a patient, immediately after his admis- sion into the hospital, considerably higher than after a few hours’ rest, or, if he have been ex- posed to cold, much lower than what would otherwise correspond to his condition. Systematic Series of Observations. — But of much greater value than isolated observations of temperature is the regular and continued watching of the course which the temperature takes in a disease. Many diseases present a de- viation from the normal temperature showing a typical course as regards the duration, as well as the daily fluctuations, of the abnormal tem- perature. Tho course of its temperature being part of the natural history of a disease, the study of this is of great importance for diag- nosis. Types of Pykexia. — First, it is the mode of rising of the temperature which varies, and by which some diseases may be distinguished. In some diseases a contraction of the peripheral arte- ries takes place at the onset, which, by diminish- ing the peripheral circulation and the giving off of heat, leads to a rapid rise of the internal tem- perature, and is accompanied by a sensation of cold. In pneumonia, therefore, and other diseases com- mencing with a rigor, the temperature rises ra- pidly and. continuously to a height of 104° Eahr. (40° C.) or more ; whereas diseases with a more gradual beginning show simply a slow elevation of the normal range, both morning and evening temperature becoming gradually higher, and the usual daily fluctuation being maintained. Thus, | 101 1601 in typhoid fever the temperature rises every day about 2° Eahr. ; but the temperature going down again in the morning, the maximum of abou! 10o°Fahr. is only attained on the fifth or sixth day. At the height o f a disease the temperature may fluctuate round an average temperature ’of about 103° Eahr. (39‘d° C.) or more, whilst it shows the same daily course as in health, that is, being lowest in the morning and highest in the evening. The range of this daily fluctuation may, however, differ considerably in different diseases ; and according to the extent of the daily fluctuation, three types may be distinguished. When the daily fluctuation of an elevated temperature shows only the normal difference, or even a smaller difference, between the morning and evening temperatures, we speak of continuous, or, more correctly, sub-contmuous pyrexia ; when the difference is greater than the normal, the remission having a tendency to a low tempera- ture, and the exacerbation, on the contrary, to a considerable rise, the pyrexia is called remittent-, and, thirdly, when the remissions reach the normal, or recede even below it, we have the intermittent type of pyrexia. A continuous elevation of temperature is ob- served soon after tho commencement of a disease, and during its height. Considerable remissions, or even intermissions, of the febrile temperature are principally ob- served in the decline of some acute diseases, and in chronic inflammatory diseases, especially of a tubercular nature, or in chronic syphilitic affections, the remissions generally becoming more marked as the exhaustion of the patient increases. Tho intermittent type of pyrexia is most typi- cally shown in malarial diseases, in which the elevation of temperature may follow a quotidian, tertian, or quartan type. The same also some- times occurs in chronic tubercular disease of the lungs. Pyrexia of a remittent type may present a peculiarity which is worthy of note, as being of some diagnostic value. Whereas in the great majority of cases the daily fluctuation fol- lows the rule of health, the exacerbation taking place in the evening, we sometimes meet with cases where this order is reversed, the rise taking place in the morning, and the remission occurring in the evening. This ‘inverse type ’ as Traubo called it, of the daily fluctuation of a fe- brile temperature has been observed insome rare instances in typhoid fever ; more frequently in cases of chronic lung-disease; whilst in doubtful cases of inflammation of the lungs it has some significance as to the disease belonging to tho class of phthisis. Slight deviations in the maximum daily rise of a febrile temperature occur sometimes in this way, that the height is reached in the mid- dle of the day, or that the exacerbation takes place in the night, or that two or more consider- able elevations, instead of one only, take place in tho twenty-four hours. Such occurrences, which have been observed in typhoid fever and in phthisis, can, of course, only be found out by the observations of the temperature being repeated with sufficient frequency. A more frequent ap- plication of the thermometer will also be neces- TEMPERATURE. 1602 sary iri some cases of ague, where the attacks are not well-marked, or occur in the night, in order correctly to judge of the case. The decline of the elevation of temperature, at the termination of a disease, may be gradual, the daily fluctuation, however, taking place as usual; or it may be rapid, by a continuous sinking of the temperature to, or somewhat below the normal, in the course of from twelve to thirty- six hours, or even in six to eight hours, as in relapsing fever. The latter mode of termi- nation of a fever is called crisis, whereas the former is designated lysis. A crisis may some- times be accompanied by symptoms of collapse, and, in some rare instances, by acute delirium, which, however, generally passes off within a day or two, and is not of bad omen provided the general condition of the patient remain good. Symptoms of this kind, as well as a more considerable elevation of the temperature just previously to its fall, or a great irregularity in the course of the temperature preceding it, may be called perturbatio critica. It would ap- pear that diseases caused by the action in the system of some foreign substance — as, for instance, some infective agent, its action being of a limited duration — have a tendency to a critical defervescence. Diseases, on the contrary, in or by which an organ has become materially altered, as by an injury, or in the course of an infectious disease of longer duration, show a slow decline of the pyrexia, with a tendency to a re- mittent type. The repair of the damaged struc- tures taking some time, the decline of the pyrexia is slow, and the defervescence by lysis. Examples of the former mode of defervescence are furnished by acute pneumonia, erysipelas, typhus, relapsing fever, and measles when not complicated by more serious inflammation ; the latter type is shown by typhoid fever, in which the specific process produces deep alterations in the glandular structures of the intestine, which persist for some time after it has terminated. The same is observed whenever an organ is altered by an inflammatory process, be this of a traumatic or of an infectious origin. The ancient physicians believed that a crisis took place with preference on certain days, as, for in- stance, the seventh day of an illness ; but more extended experience, gained by means of the thermometer, has shown that, although a change or a termination of a disease take place at a certain definite period, the latter is not bound to one particular day. See Crisis. Any irregularity of the course of the tempe- rature in a disease in which, as a rule, it runs a very regular and definite course, is indicative of some disturbance or complication, and its early detection is therefore important for diagnosis, no less than for prognosis and treatment. On the approach of death the temperature in many cases gradually sinks; but instances are not of rare occurrence in which, on the contrary, especially in diseases with high fever, a con- tinuous rising takes place towards the fatal termination, reaching sometimes hyperpyrexie degrees. 1 i ctvi ral sconce the temperature is more easily ii tin ■noed by external causes, as well as by in- ternal changes, and the approach of a relapse or j complication being at once indicated by a rise of temperature, the continuance of regular thermo- metrical observations in the first period of con- valescence is of very great importance; the more so as convalescents are sometimes not sensible to changes, which at first only show themselves in an alteration of the temperature. Treatment. — Abnormal states of temperature ought not, as a rule, to be considered as objects of treatment by themselves, all the concomitant symptoms, in fact the whole state of the patient, having to be taken into consideration, in order properly to treat a case of febrile disease. Rut there are exceptional cases in which the state of the temperature at once urgently requires a symp- tomatic treatment. Such are, for instance, cases of hyperpyrexia in sun- or heat-stroke, in which the most energetic means ought at once to be applied to reduce the temperature. As the expe- rience of American physicians has shown, life may in such cases sometimes be saved by con- tinually rubbing the surface of the body with large pieces of ice, using at the same time stimu- lants by the rectum or subcutaneously. A rapid abstraction of heat by rubbing with ice, or cold bathing with affusions, may also be the only means of saving a patient in whom, in the course of acute rheumatism, hyperpyrexia has set in; and a case published by Dr. Wilson Fox in which the temperature reached 110° in the rectum, is very instructive in showing that external cooling may be successful, when even very large doses of quinine (120 grains had been given in six hours), had been administered without effect. The same plan must be followed in hyperpyrexia occurring in the course of other diseases. Complications, such as pneumonia, do not contraindicate this treatment, the success of which is, however, de- pendent upon the possibility of rousing the ner- vous system, and upon the circulation remaining sufficiently active. An abnormally low temperature requires the external application of heat, which will be ma- terially assisted by warm stimulating drinks or injections, using eventually subcutaneous injec- tions of ether or of tincture of musk, to stimulate the action of the heart. Apart from such exceptional cases, the treat- ment of the abnormal suites of the temperature must be subordinated lo the general treatment of the case. In many cases the abnormal tem- perature being dependent upon some local cause, • the removal of the latter will make the abnormal temperature also disappear, or at least reduce it — an experience with which surgeons are quite familiar. Rise of temperature being, however, the chief and most important symptom of pyrexia, leading of itself to serious consequences, especially by weakening the heart's action, it becomes neces- sary in many cases of protracted febrile disease, besides the general or special treatment which the case requires, to treat the febrile temperature symptomatically. It has now been shown by an overwhelming experience that the course of the specific fevers, such as typhus, typhoid, scarla- tina, although it cannot be cut short, can yet materially be influenced, by keeping the febrile temperature artificially down, by means of cold baths or wet packing, and by antipyretic medi- TEMPERATURE. cines. And it is very important not to wait in u. case with continuous high temperature until symptoms of failure of the heart’s action — a weak pulse, cold extremities, cyanosis, and congestion of the lungs, and muttering delirium — show them- selves, but to try to prevent these symptoms by keeping down the temperature. Patients treated early on this principle will be found much less frequently to pass into that state, to sleep more soundly, and to retain their appetite ; bedsores and other serious complications being of much rarer occurrence ; and it has been established that the mortality in specific fevers has by the antipyretic treatment been considerably dimi- nished, and that convalescence also is quicker than in cases treated on the expectant plan. In the symptomatic treatment of pyrexia in acute disease, and especially in the continued fevers, it is best to follow the principle laid down by Liebermeister, than whom no one has had more experience in these matters. Starting from the fact that a febrile elevation of temperature, of a remittent type, is much better supported by the patient than a temperature of even a lower degree, but which has a more continuous course, the object he has in view is, by the anti-pyretic treatment, to increase the remissions that nor- mally take place every day, and to prolong them as much as possible. Comparative experiments have shown that external cooling by baths, and other means, as well as antipyretic medicines, are of greatest effect at those times of the day when the temperature spontaneously has a tendency to decline. In order to attain the greatest anti- pyretic effect with the least frequent repetition of baths, the most suitable time for the latter, according to Liebermeister, is the night; and the antipyretic medicines may be given to assist and prolong the effects of the baths. As regards external cooling, by far the most effective means are cold baths of 60° to 70° Fahr. (15° to 20° C.), and about ten minutes’ duration. More agreeable to the patient are baths of about 95° Fahr. (35° C.), gradually cooled down by the addition of cold water to 70° Fahr. (20 C.), or less, but their duration must be longer to have the same effect as the former ( see Hydro- therapeutics). Cold wet-packing is less effec- tual, but may replace baths in patients of small volume (see Cold, Therapeutics of). Quinine, in order to derive the greatest effect from its use, ought to be given in one large dose, 20 to 40 grains, in the evening, its action being slow and passing off slowly. Salicylic acid, on the con- trary, and its soda-salt, which produce a fall of the temperature much more quickly, but also much less durably, are best given in a dose of 60 to 120 grains in the night or towards the morning. Heither these medicines nor cold bathing must, however, be used in a routine way, many things having to be taken into account in their use and in judging of their effect, as the time of the day, the severity of the case, and, not least, the in- dividuality of the patient. C. G. H. Baumleb. TENDERNESS. — This word, in relation to medical and surgical practice, usually implies that pain, in various degrees and of different kinds, is elicited by pressure, as distinguished TENDERNESS. 1603 from the sensation which is felt spontaneously by the patient. The term might conveniently be made to include all painful sensations elicited by any physical disturbance of a part, as, for instance, the movement of a joint, or the pres- sure of its structures against each other. The like observation applies to any irritation of the mouth or throat, when these parts are the seat of disease accompanied by tenderness ; as well as to other mucous surfaces. Tenderness is a symptom often of great im- portance, and it claims the careful attention of the practitioner. It is often present when there is no complaint of pain on the part of the patient; while, on the other hand, it is by no means a necessary accompaniment of spontaneous pain ; its very absence is frequently of much conse- quence in diagnosis. In an investigation for the purpose of eliciting tenderness, care is required, especially in certain cases ; and the examination should be made with gentleness and restraint, so as not to give the patient unnecessary pain, or to produce other effects, which might prove serious in some instances. It may be that only a slight touch can be borne, but pressure may be gradu- ally increased, if necessary, until tenderness is produced ; it must be noted what degree of pressure is needed to cause the sensation. The observer must thus endeavour to fix upon the structure in which the tenderness is located; ns well as to measure the intensity of the feeling. Its limitation in extent must also be determined. The patient can often give useful information as to its exact character. Care, however, is neces- sary to guard against being misled by malin- gerers, hysterical persons, or those who have imaginary ailments ; and also not to mistake tenderness for mere hypersesthesia of the skin. For this purpose it is of much help, among other points, to watch the patient’s expression of coun- tenance whilst pressure is being made. Hys- terical patients may seem to suffer acutely when slight pressure is made ; but if this be gradually increased, while their attention is diverted by conversation, it is found that the suffering is net real. It must also bo remembered that some persons are much more sensitive than others. Value in Diagnosis. — Without attempting to treat the subject exhaustively, a few hints may be offered as to the diagnostic relations of ten- derness, and as to the more prominent diseases and conditions in which the presence and degree of this symptom are of essential service in in- dicating their existence. When pain is complained of, the presence or absence of tenderness, and its degree, may be of signal value in diagnosing the kind of painful sensations to which it belongs. For instance, it may be affirmed, as ?. general rule, that the pain of inflammation is accompanied with tenderness, and especially so if the condition is superficial, has ended in suppuration, or involves nerves. On the other hand a purely neuralgic pain is on the whole free from tenderness, and is not un- commonly relieved by pressure, although there are certain localised ‘ tender points ’ in some forms of this complaint, and these are also of signifi- cance. Hence, when pain is evidently seated in a particular nerve or nerves, pressure may de- termine whether they are actually involved in 1604 TENDEKNESS. some inflammatory mischief, or merely function- ally disordered. Again, the pain of muscular rheumatism, -when not inflammatory, is often relieved by pressure ; while spasmodic muscular pains are usually thus greatly alleviated, so that pati ents of their own accord press upon the affected part. In this way a very obvious and decided dis- tinction is frequently afforded between spasmodic and inflammatory conditions involving the ab- dominal structures. Further, in connection with tumours and growths, those which are of a malignant nature are often accompanied by pain and tenderness, while those which are benignant may be said to be, as a class, free from such symptoms. Marked tenderness may be an im- portant sign of destructive changes, such as those which occur in some diseases of joints, or as a result of the pressure of an aneurism or other tumour, where there is at the same time spontaneous pain. Very limited and obvious ten- derness may indicate the seat of a foreign body, lodged in the soft parts or irritating them, es- pecially if it should be pointed, as, for instance, a needle. It must be remembered, in the next place, that tenderness may be a valuable diagnostic sign, when there is no complaint of pain on the part of the patient. For example, it may reveal joint-disease, not previously known to exist, the writer has found this symptom of great as- sistance in recognising the presence and situation of obscure limited disease in the abdomen, such as cancer, ulceration, or suppuration. It may also lead to the discovery of undetected suppu- ration. In the case of children who are too young to complain, but who, on account of their crying, may be supposed to be suffering, an unusual manifestation of pain during their ex- amination must be carefully looked for and attended to, as useful information may thus be obtained. It may be mentioned that general tenderness is in some instances a striking symp- tom of commencing rickets in children. In the case of ulcers, in order to determine their con- dition for purposes of treatment, it is worth while to notice whether they exhibit tenderness, as well as its degree. Some ulcers are indolent, and scarcely at all sensitive ; others are extremely irritable, and cannot be touched. These illustrations will suffice for the general diagnosis of tenderness, and it now remains but to point out some of the complaints in which this symptom is peculiarly prominent. Amongst these may first be mentioned superficial inflam- matory affections, such as acute erythema or erysipelas, and also any condition ending in sup- puration. Peritonitis is usually attended with remarkable tenderness, either generally distri- buted over the abdomen, or localized, according to the seat and extent of the disease. Here, how- ever, it is necessary to guard against being misled by certain hysterical cases, in which there is intense hyperesthesia of the skin covering the abdomen, but the distinctions already pointed out should prevent any mistake in diagnosis. Gout affecting the joints is generally’ accom- panied by exquisite tenderness, much more than in other forms of articular disease, although affections of the joints generally give rise to tenderness. Hysterical patients are again liable TENDONS, DISEASES OF. to mislead the practitioner in this direction, as they sometimes seem to be intensely tender about a joint, when there is really nothing the matter with it. There is also a peculiar complaint met within these subjects, called ‘ spinal irritation,’ in which exquisite tenderness is experienced along the spine, or over some of the spinous pro- cesses (see Spinal Irritation). Amongst other conditions which are attended by peculiar ten- derness may be mentioned corns and bunions ; neuromata ; certain stumps after amputation ; boils ; whitlows ; and many affections involving such sensitive structures as the eyo, or the matrix of the nails. Treatment. — In the first place', of course, the disease with which tenderness is associated must be treated independently of this particular symptom, although it may afford useful indica- tions. For example, it may reveal suppuration, when an incision will give vent to the pus, and relieve the tenderness. For the nervous and hysterical conditions in which tenderness is a prominent symptom, general treatment directed to the particular condition present is essential. When a part is really tender, all pressure must be avoided, or even, in some instances, the mere touch of such articles as clothing or bed-clothes. For instance, in cases of acute inflammation of joints, or in peritonitis, it is of great service in treatment to raise the bed-clothes by means of cradles, so that they do not come into contact with the patient. Hot and cold applications, anodynes, and allied agents may be employed locally with good effect in many conditions for the purpose of diminishing undue sensibility. Sec Hysteria ; Pain ; and Spinal Irritation. Frederick T. Koberts. TENDON-EEFLEN. — Sec Spinal Cord, Diseases of; page 1458. TENDON'S, Diseases of. — Svnon. : Fr. Ncdadics des Tendons; Ger. Krankhciten dcr Schnen. Although simple in their structure, and per- forming a purely mechanical function of a passive kind, tendons and tendon-sheaths are liable to a considerable variety of diseases. In some instances these diseases are primary, and origi- nate in the fibrous and synovial structure of the parts involved ; whilst in other instances they are secondary to morbid conditions of the mus- cles, joints, and fascia; with which the tendons are connected. The primary injuries and diseases alone call for notice here. Injuries. — Tendons are subject to a variety of injuries as the result of violence, such as partial or complete rupture of the tendon proper ; rup- ture of the sheath ; dislocation ; incised wounds; and, most common of all, sprain of its fibres. Inflammation.. — Inflammation of a tendon and its sheath may be traumatic in origin, but it frequently makes its appearance without obvious cause, and then constitutes one form of whitlow (see Whitlow). Certain effusions into the syno- vial sheaths may be regarded as of a chronic inflammatory nature. ’Rheumatic affections. — Of greater fre- quency and importance are the affections of ten- dons and tendon-sheaths, which occur in aeuts and chronic rheumatism, in rheumatic arthritis. TENDONS, DISEASES OF. tad gonorrhoeal rheumatism. These will be found fully described in the several articles on those subjects. In acute rheumatism, and in the early stage of gonorrhoeal rheumatism, the involvement of the tendon-sheaths may give rise to nothing J more serious than pain and stiffness; but in protracted cases of the gonorrhoeal affection, and in rheumatic arthritis, permanent changes may result, including contractions, adhesions, calcifi- cation, and even complete destruction. Gout. — The tendons and their synovial sheaths are by no means an uncommon seat of gouty deposit. This condition is probably best marked in the extensor tendons of the hand, giving rise to a characteristic form of rigidity, or false an- chylosis of the finger-joints. Ganglion. — This affection is usually a local dilatation of a tendon-sheath, or a cystic forma- tion in connection with it. In the opinion of the writer it is especially common in rheumatic subjects. See Ganglion. Deformities. — The most obvious and the most common deformities involving tendons are of tho nature of contractions, such as give rise to club-foot and distortions of the fingers. As a rule, these are the result of some of the morbid con- ditions already referred to, but in other instances they are of more obscure origin. Thus, in the so-called ‘ Dupuytren’s contraction of the palmar fascia,’ a highly characteristic deformity of the fingers and palm of the hand results from a kind of stricture of the sheaths of the flexor tendons of the fingers and wrist, due to shorten- ing of tho fibres connecting them with the palmar fascia. In several cases of this nature the writer has found marked thickenings of the extensor tendons also, where they are in relation with the inter-phalangeal joints. Hew growths. — Various new growths of a fibrous, cartilaginous, osseous, or malignant nature have been found in connection with tendons. SiHPToiis. — The symptoms connected with diseases anl injuries of tendons are chiefly of an objective and easily recognisable kind. The most obvious of these is impairment of move- ment of the tendon in its sheath, and of the as- sociated muscles and joints. In its slightest degree, such impairment amounts only to stiff- ness ; hut when it is more marked, it may take the form of rigidity, or even complete loss of lunetion. Deformities may then very readily arise in connexion with the joints, such as un- natural flexion or extension, or actual disloca- tion ; whether referable to shortening of the tendon, to constriction of its sheath, to pro- longed d’suse of the joint, or to wasting of the associated muscles with over-action of their opponent groups. Similar results may follow rupture, wounds, or destructive ulceration of tendons. Traumatic, rheumatic, and goutv effusions into tendon-sheaths give rise to swellings along their course, which are easily recognised if the anatomical relations of the parts be remembered, but which are probably often mistaken for intra- articular disease. Localised swellings on ten- dons, such as ganglia, nodules, and new growths, present unmistakeable characters. The chief subjective symptoms connected with TESTES, DISEASES OE. 1605 the diseases of tendons are pain and a feeling of stiffness. Both of these symptoms vary greatly in different instances, and neither is perhaps characteristic of affections of these structures, apart from the associated muscles, bones, and ligaments. Treatment. — The treatment of diseases of tendons, where it is not of a strictly surgical nature, is fully described in the several articles in this work, to which reference has been made. J. Mitchell Bruce. TENESMUS (rewu, I stretch), — Synon. : Er. Tenesme; Ger. StuMzwang. — A certain group of morbid sensations referred to the anus and its vicinity have been thus named. There is a feel- ing of fulness and weight, with frequent or con- stant inclination to go to stool, and straining during the act of defecation, little or nothing being passed, and that often of the nature of slimy mucus or blood, while no sense of relief is experienced afterwards. Tenesmus is a common symptom in cases of dysentery. It may also he associated with local diseases about the lower part of the rectum or anus, such as piles, fistula, or malignant disease. Other sensations are often present at the same time. Treatment. — Any local cause of tenesmus must he removed or cured, if practicable. The sensations are best relieved by local applications of heat or cold, or by the use of small enemata containing laudanum, or of suppositories of morphia or extract of belladonna Frederick T. Roberts. TEPLITZ, in Bohemia. — Simple thermal waters. See Mineral Waters. TERMINATIONS OF DISEASE. See Disease, Terminations of. TERTIAN ( tertius , the third). — A term applied to a form of intermittent fever, in which the paroxysms return on the third day, or at an interval of about forty-eight hours. See Inter- mittent Fever. TERTIARY ( tertius , the third). — This word is usually associated with the advanced forms of syphilitic disease. See Syphilis. TESTES, Diseases of. — Synon. : Fr. Mala- dies des Testicules ; Ger. Rrankheiten der Roden. The diseases of the testes will he discussed in the following order: — 1. Abnormalities of de- velopment ; 2. Hypertrophy ; 3. Atrophy ; 4. Injuries ; 5. Acute Inflammation ; 6. Chronic Inflammation ; 7. Hernia Testis ; 8. Cystic Disease; 9. Fibroma ; 10. Chondroma; 11. Ma- lignant Disease; 12. Teratoma; and 13. Neu- ralgia. 1. Abnormalities of Development.— (a) Absence. There maybe complete absence of the testicles. The subjects of this imperfection, if they attain the age of puberty, present the or- dinary characteristics of eunuchs. As the com- plete gland is formed from two distinct parts, the failure or arrest of development may he limited to either part, separately from the other. Thus cases are described where a well-developed vesi- eula seminalis and vas deferens have been found, without any trace of a testicle ; and others, 1606 TESTES, DISEASES OE. where a testicle existed with complete or partial absence of the tas deferens. ( b ) Excess. — - Supernumerary testicles have been described, and men not unfrequently believe themselves to be so gifted. The mistake has arisen from the presence of encysted hydroceles, or of fatty or fibrous tumours of the cord, or of an old epiplocele. There is no well-authenti- cated case recorded of the presence of more than two testicles. ( c ) Malposition. — The testicles, which are de- veloped in the abdomen, immediately below the kidneys, are at birth, or shortly after, lodged in the scrotum. This change of position is fre- quently described as ‘descent of the testicle,’ an obvious misuse of words, if regard be paid to the usual position of the foetus in the uterus. The testicle may be retained in the abdomen, or in the inguinal canal ; or may pass through the inguinal canal into the perineum, and be lodged between the bulb of the urethra and the anterior part of the tuber ischii, or over the ex- ternal pillar of the ring into the subcutaneous tissue of the upper part of the thigh ; or may pass through the crural canal to the upper and inner part of the thigh-, or, if it has passed into the scrotum, may be rotated, so that the epidi- dymis is in front and the testicle behind. More rarely it has the long axis transverse instead of oblique ; or it may be completely inverted, so that the globus major is below, the globus minor above. Eetention in the abdomen or inguinal canal may be the result of adhesions from intra-uterine inflammation, or of disproportion between the gland and the orifices through which it has to pass, or of some constricting band. The passing through the crural canal to the thigh, or through the inguinal canal to the perineum or thigh, must be the result of some unusual attachment of the lower end of the gubernaculum. Malpo- sition in the scrotum must be caused by some abnormality in the development of the cord. The consequences will vary with the position. If the testicle is retained in the abdomen, the corresponding half of the scrotum remains un- developed, and the gland is always much smaller than normal. Sometimes there is an arrest of development, or it undergoes fatty or fibrous degeneration, or if otherwise normal, does not secrete a fertilising fluid. This seems fairly established by numerous observations, both in men and the lower animals, where the testicle has been abnormally retained in the abdomen. One case, however, has been recorded by Hutch- inson, where the observer, to whom the retained testicle was submitted for microscopic examina- tion, stated that he found numerous sperma- tozoa. When the testicle lies at the internal inguinal ring, the epididymis is frequently found partly in the badly-developed scrotum, into which also extends the processus vaginalis. As the com- munication between this and the peritoneal cavity is usually maintained under such conditions, in case of peritonitis with peritoneal effusion there may be distension of this process, so as to greatly simulate a hernia, and render an exploratory examination necessary. Retention of the testicle in the inguinal canal is more liable to complications than retention in the abdomen. It is often accompanied by inguinal hernia; is more exposed to injury; and when enlarged at puberty, or by inflammation, may cause severe pain from constriction by th6 surrounding parts. Inflammation of a testicle retained in the in- guinal canal has been mistaken for strangulated bubonocele, or for a bubo. Careful examination of the scrotum should, therefore, be made in doubtful cases. Retraction can usually be distinguished from retention of the testicle by the state of develop- ment of the corresponding half of the scrotum. The perineal or femoral position of the gland is not of necessity attended with any bad re- sults. A testicle, however, so situated, is usually smaller than normal and is more exposed to in- jury. This is especially the case in the perineal position. Treatment. — If retention of the gland in the inguinal canal be attended with any incon- venience, operative interference may succeed in placing it in the scrotum. But if this should fail from shortness of the cord, extirpation would be necessary. When in infants retention of the testicle is complicated by an inguinal hernia, the use of a truss is not to be recom- mended, as it will prevent the possible descent of the testicle, and the hernia not infrequently spontaneously subsides. If the retention of the gland be permanent and cause inconvenience, it is better to remove it at once. If the gland have passed through the crural canal, nothing can be done to remedy the malposition ; but wheu it has passed through the inguinal canal into the perineum or the thigh, an attempt may be made to place it in the normal position. lu an adult, such a proceeding would be hopeless, from the non-development of the scrotum. In infants, the attempt has been twice made at the London Hospital, by Curling and James Adams. Both cases died, and in the second, in which alone a post-mortem examination was allowed, acute peritonitis was found, which had extended from the pervious processus vaginalis. With antiseptic precautions, however, better results might be anticipated. Mr. John Wood has successfully transplanted in an infant a testicle from the perineum to the scrotum subcutaneously. When a band of tissue in the perineum, probably the gubernaculum, had been divided with a tenotomy knife, the gland could be pushed up to the inguinal canal, and from thence into the scrotum, where it was retained by a harelip-pin passed above it as in acupressure. This method, when practicable, would be unattended with danger. Hut as some- times the unaided efforts of nature draw the gland from the perineum up to the irguinal ring, where it is comparatively safe frominjury, and more favourably situated for any attempt at removal to the scrotum, it is advisable always in infants to allow time for such a possible modi fication, which might moreover be encouraged by electric stimulation of the cord. Of malpositions in the scrotum, that where the epididymis is in front, and the testicle proper behind, is alone of any practical importance. In any operation for hydrocele or haematocele o! TESTES, DISEASES OF. lh*i tunica vaginalis, the position of the testicle ought first to be ascertained. (d) Arrest of Development . — This sometimes occurs after the testicles have passed into the scrotum, sothat these glands remain permanently in their infantile condition. No general cause has been discovered for this abnormality. 2. Hypertrophy. — When only one testicle has been retained in the abdomen, the other some- times attains an unusually large size. Such cases of, as it were, compensating development, are, however, the exception and not the rule. 3. Atrophy. — Wasting of the testicle may result from inflammation, or from lesions of the spinal cord caused by injury or disease, or sub- sequently to injuries of the head. It may also be produced by early and excessive venereal ex- citement ; or by deficient blood-supply, due to aneurism or other causes. It is frequently found associated with varicocele. 4. Injuries. — These glands are greatly pro- tected from accidental violence by their mobility, and the laxity of the surrounding structures. Immediate death has resulted from severe con- tusions of the testicle, probably from reflex in- hibition of the action of the heart. Contusion and wounds require appropriate surgical treat- ment. 5. Acute Inflammation. — When acute inflam- mation attacks the body of the gland solely or chiefly, it is called orchitis-, when the epididymis, epididymitis. For the comparatively rare cases in which the vas deferens, or this duct along with the ofher structures of the spermatic cord, is affected, w'thout the testicle being implicated, the bar- barous hybrids, deferenitis and funiculitis have been coined. ./Etiology. — Acute inflammation may be caused by direct violence, or by the extension of inflam- matory processes from the mucous membrane of the urethra. It may also occur, though rarely, as a sequela in small-pox or in pyaemia. It is not infrequently a concomitant of parotitis or mumps. Of these varieties, the most frequent is gonor- rhoeal epididymitis. This was at one time re- garded as an instance of 1 sympathetic inflamma- tion.’ Careful examination will, however, always prove that the vas deferens is also affected, though sometimes in so slight a degree that its participation in the inflammation might easily escape notice. This form is, therefore, due to direct extension of the inflammation of the ure- thral mucous membrane. Orchitis associated with mumps has been generally regarded as an instance of ‘ sympathy,’ or 1 metastasis.’ Kocher, however, considers it to be the result of ure- thritis. According to this experienced observer, the disease commences as stomatitis, by which the parotid, or sometimes the submaxillary and neighbouring lymphatic glands become infected. The morbid material is carried by the blood t.o the kidneys, and in its course through the urinary passages sets up cystitis or urethritis, and thus the orchitis results. The question cannot, however, be regarded as finally decided. Orchitis and epididymitis sometimes occur in rheumatic or gouty subjects. Occasionally cases are met with in which no exciting cause can be dis- covered. 1007 Symptoms. — Tho symptoms of orchitis are local pain and swelling, with, in cases of or- chitis sometimes, and in cases of gonorrhoeal epi- didymitis frequently, redness and tension of the corresponding part of the scrotum. Severe lum- bar pain is in some cases felt, especially by labouring men, who apply for relief on account of some supposed sprain or injury, being either ignorant of, or attaching no importance to, the affection of the testicle. This is probably due to inflammation of the lumbar lymphatic, glands, with which the lymphatics of the testicle freely communicate ; but it may possibly be an example of ‘ referred sensation.’ Prognosis. — The prognosis is good. The in- flammation usually subsides speedily, and leaves the gland in a healthy condition. Atrophy sometimes results after inflammation associated with mumps, or caused by severe contusion. Chronic induration of the epididymis may per- sist; but after some months it usually disap- pears. Stricture of the epididymis, or of the vas deferens, is very rare. Suppuration does not occur except in pyaemia, or after small-pox, or in strumous and very enfeebled persons. Treatment. — Iiest in the recumbent position, with the scrotum supported by a crutch-pad, and the application of ico locally, are in ordinary cases sufficient. Where rest is impossible, well ad- justed strapping of the part affords considerable relief, and promotes absorption of the products of inflammation so rapidly as not infrequently to necessitate the re-application of the strapping within twenty-four hours. Attention to diet and avoidance of all violent exercise will be re- quisite. In moro protracted eases, mercury, taken in small doses internally, or applied locally by inunction, or on strapping, will be found of benefit. The practice, recently recommended by some eminent surgeons, of puncture or incision of tho ordinarily inflamed gland, is, according to the v-riter's experience, never necessary. If sup- puration, however, occur, a free incision should be made as early as possible. 6. Chronic Inflammation. — Chronic orchitis may sometimes be the result of an acute attack, but is much more frequently induced by syphilis, struma, or gout. (a) Syphilitic Orchitis . — Description.- — This may occur in young children who are the subjects of inherited syphilis, in the form of hard nodules in the testicle. In adults it belongs to the tertiary stage of the disease, but is very often symme- trical. It is usually painless, the patient being frequently ignorant of its existence. The gland is enlarged, very hard, insensitive to pressure, and often nodular in form. Treatment. — This form of orchitis is usually very amenable to treatment, but has a tendency to recur. Iodide of potassium combined with mercury in small doses internally, when it can be tolerated, and strapping locally, will in most cases produce rapid disappearance of the disease, for a time at any rate. Atrophy may sometimes result : and in some cases suppuration, with the formation of troublesome sinuses, may occur. In one case under the notice of the writer, which was complicated by an inguinal hernia, the gland had, after very prolonged and unsuccessful treat- ment, to be removed, as the use of a truss caused TESTES, DISEASES OF. 1608 great pain, and the non-uso of it led to a dan- gerous descent of the hernia. ( b ) Strumous Orchitis .— In most systematic works on surgery tubercular disease of the testicle is given as a distinct affection, but the descriptions of it are very confused, no two being in perfect agreement. This is partly because at one time the presence of caseous matter was regarded as evidence of tubercle, and partly because in many cases microscopic examination of the gland after its removal can alone determine the nature of the disease. Tizzoni and Gaule have, therefore, proposed to substitute the term ‘phthisis’ for ‘tuberculosis’ of the testis, since in this organ, as in the lungs, tubercular and non-tubercular processes, either separately or concurrently, run the same course. Symptoms. — -Tubercular disease of the testis is not rare in young children, and usually com- mences in the body of the gland. It occurs, how- ever, much more frequently after puberty, and i hen commences, in the majority of cases, in the epididymis ; the body of the gland and the vas deferens becoming subsequently infected in the progress of the disease. A nodular swelling is found either in the gland or in the epididymis, which is usually only slightly, if at all painful, and runs an indo- lent course. After a longer or shorter time, this softens down into an unhealthy pus ; adhesion and perforation of the superjacent structures ensue ; and a fistula is formed. This condition may continue for a long time, but usually the disease extends to the rest of the glandular appa- ratus. Sometimes the testicle is very much enlarged. The vas deferens, if affected, may 7 either be uniformly thickened, up to the inguinal ring ; or present a number of distinct round or spindle-shaped enlargements. The prostatic portion of the duct and the vesicula seminalis are frequently similarly affected. Digital exami- nation of these parts, through the rectum, ought therefore always to be made. Treatment. — The treatment of strumous or- chitis consists in careful attention to diet and hygienic conditions ; in the use of cod-liver oil and iodide of iron ; and in the protection of the part from accidental injury by a suspen- sory bandage. Abscesses should be opened as early as possible, and any fistula either laid open by incision or dilated by laminaria, and treated with stimulating lotions, such as nitrate of silver, of the strength of five grains to the ounce. In favourable cases the disease may be arrested, but in many cases removal of the gland becomes necessary 7 . If the epididymis and the vas deferens are much involved, the gland, by obliteration of its duct, is functionally useless; and as there is always considerable risk of in- fection of the system generally, early removal of the gland is, in such cases, to be recommended. If the prostate and vesicula seminalis have be- come affected, this would, of course, he useless. There is another form of caseous orchitis, not of tubercular origin, in which the intertubular lymphatic spaces of the testis become filled with a new growth of lymphoid tissue, by which the seminal tubules are ultimately compressed and destroyed. This may become transformed partly into fibrous tissue, but in the greater part usually undergoes fatty degeneration, forming caseous masses, which subsequently 7 break down into cr,rd-like pus. The symptoms are very similar to those of the tubercular disease, but there is not the same danger of general infection of the system. (e) Gouty Orchitis . — Chronic orchitis from gont can be diagnosed by the history of the patient, and yields readily to the ordinary treatment for gout, but is very apt to recur. 7. Hernia Testis. — This morbid condition was formerly known as ‘ benign fungus of the testis.’ Description. — It consists of a fungous pro- trusion from the scrotum, of a red or yellowish- red colour, and varies from the size of a pea to that of a small egg. There are two varieties, which may be distinguished as superficial and deep. The superficial form springs from the visceral layer of the tunica vaginalis, and is very comparable to the fungous granulations occa- sionally met with in cases of suppuration, or in wounds of the synovial sheaths of tendons. In this the tunica albuginea is intact, but probably altered in structure. In the deep form the tunica albuginea has been perforated, and the protruded mass consists largely of seminal tubules. It cannot be regarded as an evidence of any special disease of the gland, as it may occur, but by no means necessarily, after any form of orchitis in w 7 kich there has been suppu- ration. Treatment. — The treatment consists in well- adjusted pressure upon the protrusion ; with the occasional application of caustics, such as nitrate of silver or red oxide of mercury 7 . Freeing the margins of the opening from adhesions, and bringing the thus liberated integument over the protrusion by means of sutures, is usually very successful. When the precedent inflammation has been due to some specific cause, the appro- priate constitutional treatment must also be em- ployed. S. Cystic Disease. — Cysts are frequently found in the testicle, either separately or asso- ciated with other growths. Description. — In true cystic disease or sim- ple cystoma, the whole or part of the body of the testicle is replaced by a closely aggregated mass of cysts, of very variable size. Some are so minute as only to be visible on microscopic examination, while others may attain to the dimensions of a pigeon's egg. When only part of the gland is so affected, healthy glandular substance is found at the periphery, enveloping the cystic growth. The cysts have no proper wall, and are lined witli shallow cylindrical epi- thelium, which is sometimes ciliated. They are filled with either clear watery, or sometimes very viscid, fluid ; or with atheromatous matter, re- sembling the contents of a sebaceous cyst. Very frequently nodules of cartilage are found inter- posed between the cysts. The disease usually occurs in adults, but one ease has been recorded where the enlargement was first observed at the age of three months. The structure seems to indicate very clearly the origin of the cysts to be from retention within the rete testis. There is. another form of cystic disease, where the cysts are separated by a considerable quan- TESTES, DISEASE3 OF. 1 GOO tity of gelatinous connective tissue, and often contain polypoid ingrowths, which sometimes completely fill their cavities. The tumour is often as large as a child’s head. This form is regarded as cystic adenoma of the gland. Cysts of the epididymis have been described in the article on Hydrocele. Symptoms. — Cystic disease of the testicle is usually attended with very little pain. The tumour is of an oval form, either with a smooth surface, or with irregular elevations ; and does not attain a very considerable size, being gene- rally about as large as a goose’s egg. There is an indistinct sense of fluctuation, unequal at dif- ferent parts. Diagnosis. — Cystic disease has sometimes been mistaken for hydrocele or hsematocele. The form of the tumour, its relatively greater weight, the absence of transparency, and the impossibi- lity of detecting the body of the testicle at any part, distinguish it from hydrocele. The distinc- tion from hsematocele is in some cases more difficult. If exploratory puncturo be considered requisite, a full-sized instrument should be used, as the fluid may be so viscid as not to flow through a small cannula. Treatment. — Castration is the only remedy for this condition. 9. Fibroma. — Fibrous tissue is found in ab- normal quantity in atrophy of the testis, in chronic orchitis, and associated with new growths. By fibroma of the testicle, however, is meant a new formation of fibrous tissue to a considerable extent, without any other important change. In structure it resembles fibrous tumours of the uterus. It so rarely occurs, however, as to prac- tically be devoid of clinical importance. 10. Chondroma. — Cartilage, usually of the hyaline, but sometimes of the fibrous variety, is found in association with many new growths in the testicle. Pure chondroma is comparatively rare. Description. — This form of tumour of the testis occurs as disseminated nodules, con- nected by fibrous tissue ; or as elongated masses with branching processes. By compression of the seminal tubules, it leads to dilatation of other parts of the tubules ; and by invagination of the walls of such dilatations, the growth often seems to be in the interior of a tubule. Careful exami- nation, however, will always prove it to be of extra-tubular origin. It similarly invades the lymphatics, and through them has a great ten- dency to infect other parts of the system. It is ofteD associated with myxoma ; and sometimes, though rarely, it develops into bone. It can only be diagnosed with any certainty when the tumour has attained a large size, and is then characterised by the hardness and slow growth of the mass. Treatment. — Castration is the only treat- ment; and in consequence of the tendency of this disease to invade other organs, the rule laid down by Mr. Curling is the best — ‘ to recom- mend an operation without unnecessary delay, in all cases of large sarcocele w'hich do not give any indication of yielding to treatment.’ 11. Carcinoma and Sarcoma. — These are classed together, because, though histologically of very different origin, the distinction between them in any individual case is often impossible, except by microscopic examination of the tumour after removal. Even then the distinction is sometimes impossible, if we may judge from the description of recorded eases of mixed sarcoma and carcinoma. The latter originates in the epithelial struc- tures of the gland, and is almost invariably of the encephaloid variety. Scirrhus is said by all writers to occur sometimes, and so-called speci- mens are in many museums. According to Butlin, however, many of these are probably examples of fibrous sarcoma. Encephaloid cancer usually commences in the body of the testis, by the formation of one or more nodules. Some- times the epididymis is first attacked. Very rarely is there general infiltration of the gland. In an early stage of the disease the gland is hard, from tension of the tunica albuginea, but when this has been destroyed in the progress of the growth, the mass is soft, and there is often distinct fluc- tuation. This may be unequal at different parts, from the presence of cysts. The growth is usually painless, but in some cases there is acute pain, either locally or in the lumbar region. The chief aids to diagnosis at this period are the rapidity of the growth, the enlargement of the blood-ves- sels of the cord, and the age of the patient. For while encephaloid cancer has been met with in young children and old people, still the vast ma- jority of recorded cases have occurred between 20 and 40 years of age. If the tumour attain a very large size, the scrotum may slough, and a bleeding fungus pro- trude. The disease has a great tendency to in- vade other parts of the system, and especially at an early period the lumbar lymphatic glands. This may lead to oedema of the lower extremities, from pressure on the abdominal veins. The inguinal glands generally escape infection, ex- cept in some eases where the scrotum has been involved in the disease. Secondary growths have been found in the mesenteric glands, liver, spleen, and lungs. Sarcoma originates in the connective tissue of the testicle, and sometimes develops in both glands simultaneously. With microscopic exa- mination two varieties can be distinguished, the round and the spindle-celled. The latter grows more slowly, and both are often associated w r ith cystic and cartilaginous formations. The symp- toms are very similar to those of cancer. Sarcoma sometimes commences in the tunica vaginalis, and is then usually accompanied with extravasation of blood into the sac. The wwiter has met with two such eases, where the shape of the tumour, the complete absence of pain, the history of gradual enlargement, and the very distinct fluctuation were suggestive of hoemato- cele. Exploratory examination, however, proved them to be cases of sarcoma. Castration was performed, and the testicles were found to be only slightly affected by the disease. Both cases died within a short period after the operations, from secondary affection of other organs, accom- panied by similar haemorrhages. Melanoma of the testis was formerly regarded as a form of cancer, but is now considered to be sarcomatous. It is extremely rare, and in the few recorded cases of it, similar growths were found in many other organs of the body. 1610 TESTES, DISEASES OF. Diagnosis. — As a general rule it may be stated that sarcoma occurs most frequently under ten and after forty years of age ; and that the epi- didymis is more frequently the primary seat of the disease, and, when secondarily involved, is attacked at an earlier period than in cancer. The distinction in any individual case must, however, be very uncertain, and is of little im- portance. Prognosis and Treatment The prognosis is very unfavourable in both, as recurrence of the growth in other organs after the removal of the tumour is the rule to which there are but few exceptions. Castration is the only possible treat- ment for both diseases. 12. Teratoma. — The testis, like the ovary, may be the seat of cysts, containing hair, skin, bones, &c. The cysts are sometimes within, sometimes upon the gland. The more complex cases may be best explained as resulting from the inclusion of a second fertilised germ ; while the simpler cases may be due possibly to the accidental grafting of the germs of such tissues on the rudimentary testicle. The history of a congenital tumour will suffieo to direct atten- tion to any such case. Tlioy are very rarely met with, and castration is the only suitable treatment. 13. Neuralgia and Irritability. — The tes- ticle is sometimes the seat of very acute per- sistent or periodically recurring neuralgia. This must he distinguished from hypersesthesia or irritability of the gland, which is occasionally associated with varicocele, or may be the result of self-abuse, excessive venery, or even of un- satisfied sexual excitement. Neuralgia may be due to some local cause, to varicocele, or to indura- tion of some part of the glandular apparatus from precedent inflammation. It may also be sym- pathetic, as in renal colic, or where the digestive system is disordered. Occasionally no cause can be discovered, and we have to assume that it is due to some affection of the central nervous system. Treatment. — When of local origin, the treat- ment of neuralgia of the testis must be directed to the removal of the cause ; and if all other methods fail, and the pain he severe enough to warrant it, castration may he required. When due to affections of other parts of the body, the treatment must be regulated accordingly. Hyperoesthesia of the gland usually yields in time to tonics, and attention to ordinary hygienic conditions. Jeremiah McCarthy. TETANUS. — Synon. : Lock-jaw; Fr. Te- t dnos ; Ger. Starrkra.mpf. Pathology and JEtiology. — Our knowledge regarding the pathology of tetanus is very limited, but the symptoms which characterise this affection are undoubtedly referable to an abnormal influence of the nervous centres which control the action of the voluntary muscles. Dr. C. Allbutt and other observers have described the pathological changes in the spinal cord, after death from tetanus, to consist of intense conges- tion of the tissues, with structureless exudations, especially in the grey matter ; it is difficult to determine, however, whether these changes are the causes, or simply the effects, of the abnormal TETANUS. nerve-action which characterises tetanus. Most of us have formed some conception of the nature of this disease, from the analogy which exists between the effects of poisonous doses of strych- nia and the spasms of tetanus ; but we have no grounds whatever for supposing that the ttvxIus operandi of nux vomica on the nervous system is the same as the cause, whatever it may be, which induces tetanus. On the other hand, there is much in the phenomena presented by some instances of traumatic tetanus, to lead us to think that the violent contraction of the muscles in this disease is due to irritation set up in the peripheral distribution of a nerve, and that this hyper-action once established is con- veyed along the nerve to the spinal cord, excit- ing by' reflex action the muscles near the injured nerve to a state of spasm. The irritation subse- quently extends, and so the whole length of the spinal cord becomes implicated, a slight impres- sion on the skin producing general tetanic con- vulsions. In support of this theory as to the origin of the disease, a few cases have been re- corded in which division of the principal nerve, or in other instances the stretching of a nerve leading from a wound, has completely stopped an attack of tetanus. And in some cases the writer has certainly seen tetanic spasms com- mence as if by reflex action ; for instance, after tying a large bleeding pile, the patient, within thirty-six hours of the operation, complained of spasms of the sphincter ani muse'e, and although the ligature was instantly removed, nevertheless the disease ran a very rapid and fatal course. On the other hand, the circumstances of tetanus, when considered in all their bearings, point to some influence at work which is different in its nature from that of ordinary reflex action. It is the exception rather than the rule for the muscles in the neighbourhood of the wounded part to be first involved in the disease, as they probably would be if it arose from a purely reflex action; it matters not where the seat of the injurymay bo, in by far the greater number of cases the muscles of the face are affected before those of any other part of the body. In numerous instances of tetanus the writer has noticed, for twenty-four or forty-eight hours before spasms of the muscles have set in, that the patient’s face has presented a pinched appearance, which is very characteristic of the disease, depending on rigidity of the muscles of expression. Various groups of muscles are sub- sequently involved, in the following order— those of mastication, the neck and back, the muscles of respiration, and lastly, those of the extremi- ties. So generally is this the order in which the muscles are implicated, that the writer is dis- posed to think that, whatever the pathology of the disease may be, the morbid influence which produces it commences in the medulla oblongata, and extends to the spinal cord. Lastly, the writer has met with many severe cases of teta- nus among persons in whom it was impossible to discover any wound or abrasion of the skin or mucous membranes of the body, 1 and in in- 1 In the surgical wards of the Mayo Hospital, Calcutta, within a period of five years, S3 cases of tetanus were treated. Of these, 44 cases were traumatic, and 24 di*i. Of the remaining 39 idiopathic cases, 10 died. TETANUS. glances of this description it is difficult to account for the symptoms of the disease on the theory that it depends on reflex action. It seems very certain that local circumstances and meteorological conditions greatly influence the occurrence of tetanus. In the tropics, the disease is far more frequently met with than in other parts of the world. It is seldom absent from the Calcutta Hospitals, and in some sea- sons appears to prevail as an epidemic. It is, in fact, a matter of common observation in Bengal, that after sudden changes of temperature cases of tetanus appear among surgical patients ; so that, while admitting that in many instances of teta- nus wounds are the immediate cause of the dis- ease, we cannot overlook the fact that a chill is frequently an immediate antecedent. The disease attacks persons of all ages ; it occurs occasionally among infants immediately after birth, but more commonly commences a few days after the re- mains of the umbilical cord have separated from the child’s body. Men are more subject to te- tanus than women. In the tropics the disease is by no means uncommonly seen among horses, especially after they have undergone the opera- tion of castration. Symptoms. — Tetanus almost invariably com- mences, in man or the lower animals, whether it is of traumatic origin or otherwise, in rigidity of the muscles of expression. In the course of a few hours the muscles of mastication and of the head, neck, and back become involved, so that the patient experiences difficulty in opening his mouth, or in moving his head from side to side ; and deglutition is impeded by spasmodic con- traction of the pharynx. The rigidity of one or more of the groups of muscles above referred to is constant throughout the whole course of the disease ; but in addition to this, from time to time these muscles are thrown into the most frightful spasms ; in this way the patient’s body is some- times bent like a bow, the whole weight of the trunk being supported on the back of his head and heels. The abdominal and thoracic muscles are also implicated, and hence the patient’s belly is tense and hard, and the walls of his chest expand imperfectly in the effort of breathing. The muscles of the arms and legs are often extremely rigid, and convulsed in a most violent manner ; they are the seat of ter- rible pain. The interval between the paroxysms of spasm of the affected muscles is very uncer- tain ; sometimes the cramps last only for a few seconds, at other times for five and even ten minutes. The most dangerous cases of tetanus are evidently those in which the muscles of respiration are principally involved, for death is generally caused in this disease by the inter- ference with the respiratory process, the chest being, as it were, compressed in a vice (Watson). In consequence ot the condition of the muscles of the neck and thorax, the sick person is unable to speak, but his intellect generally remains clear up to the last, nor are the other functions of his body materially deranged. The patient suffers much from hunger and thirst, which he is unable :o alleviate; and, above all, he longs for sleep, which is frequently denied him in consequence of the recurring spasms. The surface of the skin is bedewed with perspiration ; and the pulse rises 1611 and falls with the intensity of the spasms, and the duration of the disease. Course and Duration. — Tetanus is one of those maladies which run a definite course, al- though its duration is not so precisely defined as that of some other diseases ; in some cases it may kill the person affected in the course of a few hours, but in the greater number of in- stances patients die of tetanus from the seventh to the eleventh day after the commencement of the disease. If they survive the twelfth day, the malady, as a rule, gradually subsides ; and the patient may usually be pronounced cured in twenty-five days from the commencement of the attack ; but he often suffers for many weeks subsequently from rigidity of the muscles which have been involved in the tetanic spasms. Prognosis. — The writer has for some time past relied much on the thermometer, not only as a means of forming a prognosis, but as indicating to some extent the treatment to be followed in tetanus. Doubtless in some of the worst in- stances of this disease the thermometer fails us ; for if the muscles of respiration are very much affected, as they are in the most severe cases, the process of combustion within the body is so much interfered with that its temperature is not kept up to the degree it should be, in proportion to the violence of the muscular action. Never- theless, as a general rule, in instances of tetanus, so long as the thermometer indicates that the temperature of the patient’s body is under 101 3 Fahr., we may remain easy regarding the issue of the case. If the mercury rises in the instrument beyond 101°, there is impending danger ; and if it reaches 103°, the case is one to cause us the greatest anxiety. After death from this disease the writer has found the temperature of the body to rise as high as 107°. Treatment. — One of the most remarkable facts connected with tetanus is the almost incre- dible amount of Indian hemp and opium which persons suffering from it will swallow, without producing their poisonous effects on the system. The writer has prescribed these drugs in very large doses, but has failed to satisfy himself that they influence for good the progress of the malady. He has also given the Calabar bean a fair trial in tetanus ; but unless it be pushed to the extent of rendering the patient collapsed, the tempera- ture of his body falling perhaps to 91° or 95°, and the pulse being hardly perceptible at the wrist, he has found that this medicine hardly affects the spasms of tetanus in severe cases, whilst in the milder forms of the disease there is no neces- sity for resorting to such a dangerous means of cure. In fact, we know of no system of treat- ment which will cut short the progress of a case of tetanus, and, therefore, the indication is to employ all our efforts to keep the sick person alive during the illness through which he is passing. As means to this most desirable end, we must feed him, and, if possible, secure him at least some eight hours’ sleep during the day. TVith respect to food, the patient must be made to swallow about four ounces of milk every four hours ; one egg, or half an ounce of the juice of raw meat, being mixed with the milk, morning, noon, and evening. If the pulse indicates great exhaustion, beef-tea and brandy 1G12 TETANUS, may be given as an enema, in addition to the above-mentioned food. In cases of tetanus the teeth are often so firmly locked together that it is necessary to insert one’s fingers between the closed jaws and the cheeks, and pour the milk into the cavity thus formed ; the liquid will trickle between andbehindthe patient’s teeth, and pass down his throat. Some of it may occasion- ally run into the trachea, and cause considerable spasm, but the writer has never seen any more serious result follow from this. If the patient can swallow with comparative ease, arrowroot maybe mixed with the milk; a man can live very -well on a diet of this description for some twenty-five days. With reference to drugs, the writer knows of no medicine which procures sleep so well as the hydrate of chloral in cases of tetanus. It should be administered in 40-grain doses (to an adult) at bedtime ; and in severe cases of the disease (the temperature of the patient's body rising to up- wards of 101°) an additional 30 grains of chloral should be given at mid-day. However serious the case may seem to be, we should rigidly adhere to the plan of treatment above described, the urgency of the symptoms not causing ns to deviate from our attempts to make the patient swallow a sufficiency of food, and of the hydrate of chloral, to enable him to struggle through the malady from which he is suffering. C. Macnamaba. TETANY. — Synox. : Tetanilla; Idiopathic muscular spasm ; Ur. Tetanos intermittent. Tetany is a neurosis originally described by Dance in 1831, and more or less fully described since tinder many names, especially in France. It is probably much more common in that country than in England, where it is very rarely met with. It is mostly a comparatively trivial and temporary malady. HStiology. — The disease is associated with no recognised organic changes in any part of the nervous system, and much uncertainty prevails in regard to its causation. It occurs mostly between the ages of 15 and 30 years, though it may show itself in older people, as well as in young children, and even in infants. It occurs in either sex, but is more common among females. Persons of a neurotic temperament, or those whose constitutions have been disturbed or Weakened from many causes, are specially liable. Teething, the establishment of menstruation, chronic diarrhoea, lactation, the state of conva- lescence from many acute diseases, are all con- ditions which predispose to this affection; whilst exposure to cold, and emotional disturbance seem to act as the most common exciting causes. Symptoms. — The morbid manifestations con- sist, in the main, of tonic spasms, frequently re- curring for brief periods in one or other part of the body, painful in character, and unaccompanied by less of consciousness. The attacks in different individuals vary widely, the spasms being some- I imes quite local, and sometimes involving many different regions of the body. In the slighter kinds of attack, a numbness and ;ingling is felt in the fingers and toes, which speedily become fixed in tonic spasm. As the spasms strengthen, they may extend to higher TETANY. parts of the limb, and become painful. The fingers are drawn together and slightly flexed, the thumb is bent into the palm, and the wrist slightly flexed. The toes also are drawn to- gether and towards the sole, the big toe being drawn under them. The dorsum of the foot is arched and the heel pulled up, whilst the leg and thigh are more or less rigidly extended. One or more of the limbs may be affected in this way, or if all are implicated, it may be simul- taneously or successively. This condition of things lasts for a few minutes, or even for an hour or two, accompanied often by severe pain along the nerve-trunks, and by some diminution of sensibility in the parts affected. When the attack is about to terminate formication sets in, as at the commencement of the spasm. After variable intervals the attacks are renewed, it may be in an hour or two, or only after several daj’s. Such paroxysms may be frequent during several months ; and, according to Trousseau, so long as a tendency to recurrence of the spasms exists, they may always be excited anew by simply ‘ compressing the affected parts, either in the direction of their principal nerve-trunks, or over their blood-vessels, so as to impede the venous or arterial circulation.’ On the other hand, the application of cold to the parts affected fre- quently arrests the spasms for a time. In the more severe forms of tetany, the attacks may begin in the way above indicated in the upper extremities, next in the lower extremities, and then, whilst diminishing in the parts first affected, they may extend more or less generally to the trunk muscles. The contractions are invariably more or less painful. The spasms may even spread to the facial muscles, so that the jaws may be firmly clenched, and speech greatly embarrassed. If the muscles of the larynx are involved, as well as those of the chest and abdomen, extreme dyspnoea may be induced. Still there is no loss of consciousness. These attacks may be of brief duration ; or they may be extreme in degree, long-continued, and frequently repeated. In such severe cases there is slight elevation of temperature, with greatly quickened pulse, and a furred tongue. After some weeks or months the paroxysms usually become less severe, less frequent, and finally cease altogether. Diagnosis. — The diagnosis must be based upon tile progressive character of the at tacks ; upon the fact that they begin in the upper and lower ex- tremities, and after a time completely intermit; upon the absence of all loss of consciousness during the attack; and upon the fact of the possibility of reindneing the paroxysms by pres- sure upon the nerves or vessels of the parts affected. These characters will suffice to distin- guish the affection from tetanus, epilepsy, and hysteria. Pbogxosis. — The prognosis is usually favour- able, the complaint gradually subsiding after a few months. Still, in very exceptional cases, tho patient may die asphyxiated during one of the extremely severe attacks. Treatment. — The treatment of tetany should in the main be directed to the improvement of the patient’s general health, and the diminution of all debilitating conditions or causes of irri - TETANY. .ation. At the same time, we must endeavour to lessen the general mobility of the nervous system, by seeing that the patient obtains re- gular and sound sleep, as well as by the adminis- tration of the bromides in suitable doses, in combination with valerian, musk, conium, or other antispasmodic remedies. H. Charlton Bastian. TETRASTOMA EEHALE (rlrpa, four- fold; ari/ia, a mouth; and ren, a kidney). — A form of entozoon found on one occasion in the urine of a patient by Lucarelli, and described by Delle Chiaje. See Entozoa , by Dr. Cobbold, Bond., 1861. TETTER. — Tetter is an old Saxon word, equivalent to the French dartre. Tetter is de- fined to be ‘a tickling and itching scab,’ and may be taken to signify a chronic inflammation of the skin, attended with desquamation and itching. In this sense the term is popularly applied to patches of chronic eczema, and espe- cially to those of psoriasis ; but it is altogether too indefinite in its meaning for scientific use. Erasmus Wilson. THALAMUS OPTICUS, Lesions of.— Svnon. : Fr. Maladies dcs Ccmchcs optiques; Ger. Kranklieiten dcr Sehhiigel. Introduction. — Diseases of the optic thala- mus vary in their symptomatology according as the lesion is strictly limited to the ganglion itself, or implicates also neighbouring structures. In the former case it is apparently well es- tablished, by numerous recorded cases, that lesions, such as apoplectic cysts, or areas of softening, may exist without producing any discoverable symptoms, either in the domain of motility or sensibility, general or special. This is more particularly the case when the lesions occupy the convexity or ventricular aspect of the optic thalamus. But more frequently diseases affecting the optic thalamus implicate also, directly or indirectly, the corpus striatum, internal capsule, crus cerebri, or corpora quadrigemina. Owing to the community of vascular supply between the corpus striatum and optic thalamus through the opto-striate arteries of Duret, embolism or rupture of these vessels leads to conjoint destruction, more or less extensive, of both ganglia, as well as rupture, or pressure on the fibres of the internal capsule. A haemorrhage or embolism in this region produces hemiplegia of the opposite side of the body. But that the hemiplegia cannot be due to the lesion of the optic thalamus is clear from the fact that such lesions may exist without any motor paralysis whatever. It is, therefore, more logical to attri- bute motor paralysis, when it does occur in con- nection with lesions of the optic thalamus, to implication, direct or indirect, of the corpus striatum or the motor fibres of the internal capsule. Localizing Phenomena. — It is a question whether, apart from considerations as to causa- tion, there are any symptoms specially charac- teristic of haemorrhages in the region of the optic thalamus. Among other symptoms noted are clonic or THALAMUS OPTICUS, LESIONS OF. 1613 tonic spasms of the paralysed limbs in a con- siderable number of the cases. These, however, though, according to Bastian, occurring in about three-fourths of the cases, cannot be regarded as pathognomonic, for similar spasms may occur from lesions elsewhere, as in the cortex, centrum ovale, and pons. Nor is it true that lesions of the optic thalamus specially cause paralysis of the uppei extremity, as has been contended by Saacerorte and others. The leg may suffer quite as much ; and indeed when the motor paralysis is asso- ciated with anaesthesia, the affection of the leg is frequently much more pronounced than that of the arm or face. The occurrence of anaesthesia on the paralysed side is more constant and more enduring when the lesion invades the optic thalamus and its neighbourhood, than when it is confined to the ganglia of the corpus striatum. This is owing to the fact that the posterior fibres of the internal capsule are directly injured, and not merely pressed on, as in the latter case. The anaesthesia may extend to the special senses as well as common sensibility, but more frequently the tactile sensibility only is distinctly im- paired. The reflex cutaneous excitability is also greatly diminished, as has been shown by Crichton Browne (IFest Riding Asylum Reports, vol v.). The paralysed limbs are frequently also affected with unsteadiness, tremors, or choreic-like spasms, intensified on volitional efforts. This affection, termed post-hcmiplegic chorea (Weir-Mitchell, Charcot), is generally- if not invariably associated with a greater or less degree of impairment of sensibility in the affected limbs. It is doubtful how much, if anything, can be assigned to the lesion of the optic tha- lamus itself in the causation of these symp- toms. But for regional diagnostic purposes, they may be regarded as significant of lesion of the optic thalamus and its immediate neigh- bourhood. When the lesion involves only the posterior fibres of the external capsule, lying external to the optic thalamus, the result is hemiamesthesia, general and special, of the oppo- site side of the body. The power of movement ma_v not be apparently affected. If so the leg is, in general, relatively more affected than the arm. But, though the motility is retained, the muscular sense is lost, so that the patient is unaware of the state of contraction of the muscles or the position of the limb, and requires the aid of vision in guiding its movements. Cases have been recorded by Hughlings Jackson and others, which render it in the highest degree probable that lesions of the posterior aspect of the optic thalamus, and region of the corpora geniculata, cause hemiopia towards the side opposito the lesion, from paralysis of both retin® on the corresponding side. A similar result ensues from direct lesion of the optic tract, however, aod also from sever- ance of the medullary fibres of the occipito- augular region. Hence hemiopia alone, with- out other symptoms, cannot be taken as abso- lutely diagnostic of lesion of the posterior aspect of the optic thalamus. Conjoined with affection of the other forms of sensibility, however, it points to lesion in this region. 1614 THALAMUS OPTICUS, LESIONS OP. Tumours of the optic thalamus, in addition to the general symptoms of intracranial growths, though sometimes these even seem to have been wanting, produee either no special symptoms, or such a variety as to render the regional diagnosis very uncertain or altogether impossible. The symptoms may be those indicative of lesion of the internal capsule, both its motor and sensory strands ; or they may be such as have been observed in connection with lesions of the corpora quadrigemina. It will thus be seen that, in respect to the regional diagnosis of diseases of the optic thalamus, we are obliged to rely on a combina- tion of symptoms, not one of which can be re- garded as absolutely depending on the optic thalamus itself, and our localisation is at best only approximate. Treatment. — The treatment of diseases of the optic thalamus comes under the head of treatment of cerebral disease in general. D. Ferbieb. THERAPEUTICS (depaneva, I attend. — Synon. : Pr. Therapeutique ; Ger. Therapie. Definition. — The science and art of heal- ing. Introduction, — Therapeutics is the most es- sential part of medicine, for although other parts of medical science are interesting to the practi- tioner, it is the cure of disease which the patient seeks. Therapeutics may be divided into two classes — the therapeutics of fancy, and the thera- peutics of fact. In order to cure disease with certainty, the practitioner must know what the nature of the disease is, and what the action of his remedies will be. When these are posi- tively known, therapeutics becomes a science, but when either is uncertain, it is simply an art. Its principles may hereafter become a science, but its practice must always remain more or less an art, and be dependent for suc- cess upon the skill of individuals. For the symptoms which ought to indicate to the practi- tioner the nature of the disease may be wrongly interpreted by him, or, as it is usually termed, he may form a wrong diagnosis, and thus be led to apply wrong remedies. The idea in the practi- tioner’s mind may correspond more or less exactly with the condition of the patient, or may not have the slightest resemblance to it ; and it is only by careful comparison and experiment that their agreement can be ascertained. An absurd fancy of the practitioner will lead to absurd treatment, and the therapeutic results will not be satisfactory. Histoky. — In all ages of the world’s history we have had the therapeutics of fancy and the therapeutics of fact running side by side, and, in proportion as the latter has predominated, has treatment been improved. In primitive times the imagination of physicians was busy with fancies regarding the nature, the causes, and the cure of disease. The nature of the disease was sometimes supposed to consist in the posses- sion of the body by an evil spirit, which caused the morbid symptoms, and the cure consisted of various incantations and exorcisms. At other times the disease was supposed to consist in alterations of the fluids or of the solids of the THERAPEUTICS. body, cr of the formative principle which per- vaded them. It was supposed that in disease the juices left their proper places in the body, or became disproportioned in quantity, or that the atoms and pores of the solids became altered, so as no longer to allow of free atomic motion. At other times, again, morbid conditions were attributed to fermentation, with production of alkalies or acids in the body; and later on, when the contractile power of muscular fibre was recognised, diseases were supposed to be due to spasm or atony. Equally fanciful qualities were attributed to medicines, some being reckoned hot, some cold, some astringent, some opening and some closing the pores, some contracting and some relaxing the muscular fibres, and some being supposed to cure disease because there was some external resemblance between them and the organ of the body affected. Principles. — T he u n sat i sfactory results of su cb fanciful therapeutics have led some, in all ages of medicine, to a more or less experimental thera- peutics. Physicians saw men suffering and dying all around them, and could not wait for exact knowledge. They therefore applied themselves to tentative therapeutics, giving first one thing and then another in the hope of doing good, and col- lecting the results of these experiments on their patients, for the guidance of themselves and others in subsequent cases. The results thus obtained, showing that a certain drug was useful in a certain disease without the reason of this utility being known, constituted empirical thera- peutics. In order to obtain a broader basis than that afforded by the observation of any single man, some have collected numbers of cases from various observers, and have analysed and tabu- lated them. The results of this method con- stitute statistical therapeutics. But it is liable to great fallacies, inasmuch as cases which are very different are tabulated, for convenience’ sake, under the same name, and the results are, therefore, rendered untrustworthy. The problem placed before the practitioner in the treatment of any one case is rendered ex- ceedingly difficult, not only by reason of the complexity of the bodily mechanism itself, but by the manifold alterations to which it is sub- ject in disease, and the variations produced in the action of a drug by alterations in dose, by differences in the original constitution of the patient, and further differences superinduced by the disease. So complex, indeed, is the problem, that it is impossible to unravel it by any Dum- ber of observations in disease, and it can only be solved by making ourselves acquainted with a few of the conditions at a time. This can only be done by experiment upon animals, for human life is too valuable to allow of the necessary sacrifice. By experimental physiology, the func- tions of the various parts of the body and their relations to each other are being gradually ascer- tained ; in experimental pathology diseases are induced artificially, in order that we may dis- cover the alterations produced by them in the functions; and in experimental pharmacology, drugs are administered in order to determine the part of the body which they affect, and the nature of the alterations which they produce in its function. The problem being thus simplified, THERAPEUTICS. tho practitioner may hope to recognise, from the symptoms of the patient, the orgar affected by disease, the nature of the disturbance in its function, and to apply frith some degree of suc- cess a remedy which will counteract such disturb- ance. This constitutes rational therapeutics. Great advances have of late years been made in this direction, but it will be a long time yet be- fore we can hope to attain such exact knowledge as we desire, and at present our therapeutics must be to a certain extent empirical. When directed towards the removal of the cause of the disease it has been called pathogenetic therapeu- tics. When this cannot be recognised, or cannot be removed, the treatment is directed to those parts of the organism on which the cause of disease acts, so as to lessen or remove the symp- toms which it would otherwise produce. This is symptomatic therapeutics. And when we can neither remove the cause nor relieve the symp- toms, but are forced to trust to the vis medicatrix vaturcp, and try to maintain the patient’s strength byfoodand nursing, we have expectant treatment. This might perhaps also be called expectant the- rapeutics, for although in its narrowest sense we generally understand by this term cure by means of medicines, in its wider acceptation it includes nursing, climate, and measures of treatment, such as regulated exercise, regulated gymnastics, friction, massage, the application of heat, and cold water. T. Lauder Brunton. THERMOMETER, Clinical (deppri, heat, and pirpo v, a measure). — Synon. : Fr. Thermo- metre-, Ger. Thermometer. Definition. — An instrument for measuring different degrees of heat or cold. Description — The thermometer was invented by Galilei, about 1603, but it was Sanctorius (1561-1636) who first had the idea of investigat- ing the temperature of the human body in health and disease. The substances made use of in the construction of thermometers are mercury, first used by Fahrenheit ; a coloured fluid — such as alcohol; or air. Any of these substances, en- closed in a fine exhausted glass tube, expanding at one end into a globular or cylindrical bulb, represents a thermometer. On applying heat or cold to the bulb the contents expand and rise, or contract and descend in the tube. The extent of the rise or fall can be expressed in a number of a scale, which is engraved on the stem or on a separate piece of white glass, or on a strip of paper fixed to the stem, and enclosed with it in a wider glass tube. The thermometers used in this country and in the United States are graduated with Fahrenheit's scale, whereas on the Continent of Europe the Centigrade or Celsius scale is now r everywhere used for medical and scientificpurposes, the Reau- mur scale falling more and more out of use. The difference between these three scales is this, that in the centigrade and Reaumur scales the melt- ing-point of ice is marked zero, and the boiling- point of water (or rather tho heat of the steam of water boiling at an atmospheric pressure equal to 29-02 inches of mercury) marked 100° arid 80°, respectively; whilst Fahrenheit marked the former by 32° and the latter by 212°; 180 degrees of the Fahrenheit scale are, therefore, THERMOMETER, CLINICAL. 1615 equal to 100° centigrade and 80° Reaumur, and the relation of the three scales to each other is, therefore, as F. C. R. 9:5 ; 4 One degree of F. = § C. or |R. ; one degree C. = |F. In converting degrees of the Fahrenheit scale into centigrade degrees, it must, however, be borne in mind that zero of the C. scale corre- sponds to 32 of the F. scale ; 32 must, therefore, be deducted in converting a certain degree of the F. scale into the corresponding degree of the C. scale, and 32 must be added when C. degrees are to be expressed by the corresponding degrees of F. The formulae for these conversions are, therefore ; — x deg. F. = (,r- 32) x § deg. C. x deg. C. = (x x §) + 32 deg. F. For instance : 99'5 F. = (99 5 — 32) x § = 67’5 x 5 = 37-5 C. 39 C. = (39 x f) + 32 = 70 2 + 32 = 1 02-2 F. It will be convenient, for quick reference, to give the corresponding degrees of the Fahren- heit and centigrade scales in that range with which human physiology and pathology are con- cerned, side by side : — Fahr. Cent. 95'0 35'0 Fahr. Cent. 104-0 40 0 960 35'55 96-8 36-0 97-0 36-11 98-0 36-66 98-6 370 990 37-22 9a - 5 375 1000 3777 100-4 38-0 1010 38-33 101-3 38-5 1020 3888 102-2 390 1030 39-44 103-1 39-5 104-9 40-5 105-0 40-55 1058 41"3 1060 41-11 106-7 41-5 107-0 41-66 107-6 42-0 108-0 42-22 108-5 42-5 109-0 42-77 109-4 43-0 110-0 43-33 111-2 44-0 112-1 44-5 113-0 45-0 In thermometers for clinical use the degrees on the scale ought to be divided into fifths. Thermometers ought to be carefully compared from time to time with a standard thermometer, as they are liable, after a certain time, to give abnormally high indications, owing to the bulb gradually contracting a little. In England they may be sent for comparison to the Kew Obser- vatory. Of great convenience for clinical use has been the introduction of self-registering mercurial maximum thermometers. It is not without in- terest to notice that a self-registering thermo- meter by a small piece of iron being introduced into the tube, had been used by Currie, at the end of the last century ; but just as Currie and de Haen’s work with the thermometer had been entirely forgotten for half a century, so were self-registering thermometers only used again in medicine some time after the ordinarv ther- mometer had been re-introduced into clinical practice by Baerensprung, Traube, and Wunder- THERMOMETER, CLINICAL. 1616 lich. Casella -was the first who constructed a registering clinical thermometer, by introducing a small quantity of air into the tube, and thereby separating a small part of the mercurial column from the rest. Instruments are now made in which the index — that is, the small separated part of the mercurial column — is prevented from falling back into the bulb, or in which an index is only formed each time the mercury rises out of the bulb. In using an instrument of this kind, the index, it need hardly be said, must be shaken down below 95° or 90° before the thermometer is applied to the patient. Another principle has been followed in the construction of very sensitive instruments for special researches on temperature, namely,, that of the thermo-electric apparatus. The electric current, which is produced in a circuit composed of two different metals, when their point of con- tact assumes a different temperature from that of the other ends, or again the changes which a galvanic current shows when the resistance of a part of the circuit is altered by a change of temperature acting on it, can be measured by a galvanometer inclosed in the circuit. Gavarret, Ileidenhain, and other physiologists have used the thermo-electric pile in physiological investi- gations in animals. J. S. Lombard and Hankel have applied it to observations in man. Quite recently a convenient form of thermo-electric apparatus for clinical purposes has been devised by Redard . The apparatus constructed, on the last-mentioned principle, by 0. W. Siemens, for measuring deep-sea temporatures, might also easily be adapted for clinical purposes. A self-registering apparatus for continuous observations, on the principle of an air-thermo- meter. has been constructed by Marey ; and it would seem as if the desideratum of a clinical thermograph, automatically registering the changes of temperature on the surface of the body during a certain time, were near being satisfactorily realised in the instrument brought out by Mr. W. D. Bowkett ( Lancet , July 1881). For measuring surface-temperatures, mer- curial thermometers of special shape, namely, a long cylindrical bulb coiled up in one plane at a right angle to the stem, have also been con- structed. A thermo-electrical apparatus, or Bow- kett’ s instrument, is however more sensitive and more convenient for that purpose. Applications of the Thermometer. — The object we generally have in view with clinical thermometry being to examine as nearly as pos- sible the temperature in the interior of the body, or the blood-heat, which is less variable than that of the surface (see Temperature), the localities most suitable for applying the thermometer would be the natural cavities, or the openings by which a thermometer might be introduced to a certain depth into the interior of the body. In the rectum, vagina, or bladder, the tempera- ture is not subject to the ordinary changes acting from without, and the time required for taking an observation with the thermometer in any of these localities, would be only such as is ne- cessary for raising the temperature of the mer- cury to that of the surrounding mucous mem- brane. This time might be materially shortened by previously heating the thermometer to a de- gree a little below that to be expected in the body. "With this precaution an observation of the temperature in the rectum or vagina will not take more than half a minute. The case is very different if we take the tem- perature in a cavity of the body which is not always closed, such as the mouth; or in the axilla, which can be formed into a closed cavity only by placing the arm closely against the chest. Here the time required for an observation is much longer, because the temperature of the mucous mem- brane of the mouth, or of the skin of the axilla, begins itself slowly rising after the closing of these cavities, until it is raised to that of the deeper tissues which are not exposed to the loss of heat from without. Whereas nine to eleven minutes on an average are required for an obser- vation of the temperature in the mouth, ten to twenty-four may be necessary for the mercury to become stationary in the axilla. The time varies also according to the state of the general circu- lation. It will be found much longer in persons with a weak circulation, for instance, in a casecf heart-disease, than in the case of a vigorous patient with a good circulation and with febrile heat. It is evident that, as was first pointed out by Liebermeister, the time for an observation in the mouth or axilla can be materially shortened, not so much by previously heating the thermo- meter, as by, previously to the introduction of the latter, keeping the mouth or axilla closed for ten to fifteen minutes. These cavities will then have assumed a steady temperature, and the time required for the observation will only be that necessary for raising the temperature of the mercury and the glass to the temperature of the surrounding parts. It is, therefore, a good plan if the patient had been lying on one side to turn him over to the other, or to make him lie on one side for a time before the thermometer is intro- duced, and then to put it into that axilla which had been closed by the position of the patient. If the skin of the axilla be very wet with perspi- ration, it ought to be wiped dry before applying the thermometer. For practical purposes the rule generally re- commended in observations being taken in the axilla, to leave the thermometer until the mer- cury has remained stationary for five minutes — a rule which naturally applies to self-registering no less than to ordinary thermometers — secures sufficient accuracy, and this rule should be given to nurses and attendants to whom the observa- tions are left. Especially in obscure cases, in which much depends upon the discovery of even a trifling elevation of the temperature above the normal standard, which may be of great impor- tance for diagnosis, this precaution ought never to be omitted ; and for observations requiring scientific accuracy, as, for instance, when the effect of some drug on the temperature of the body is being studied, the observations ought to be made by the physician himself. For various reasons the axilla is the locality most suitable, and, therefore, generally used f )r thermometrical observations. In very young or restless children, however, as well as in veiy ema- ciated adults, axillary observations would become untrustworthy. In such cases, or where patieuis THERMOMETER, CLINICAL. are in an insensible state, or under special cir- cumstances — for instance, when a great diver- gence exists between the axillary and the inter- nal temperature, or when doubts arise as to the cor- rectness of an axillary observation — the rectum, or eventually the vagina, may be used for apply- ing the thermometer, and with a self-registering thermometer this can be done without unneces- sarily uncovering the patient. In using the rec- tum, great care must be taken not to let a small instrument slip into it, and in restless children to prevent the instrument from being broken. This is best prevented by placing the patient on his side, and while the thermometer is kept in situ with one hand, letting the other one rest on the hip of the patient, in order to be able at once to arrest any turning movement which he might happen to make. The thermometer ought to be introduced about two inches deep into the rectum ; and may, before being taken out, be gently pushed forward a little more, in order to bring the mercury in contact with a fresh part of the mucous membrane, which has not been cooled by the bulb of the thermometer. When large masses of faeces fill the rectum, the thermo- meter passing into them may indicate a somewhat lower temperature than when in contact with the mucous membrane. Other places of application, such as the in- guinal fold, or the fold of skin between the thumb and the second metacarpus, may be used for special, but are quite unsuitable for general, clinical purposes. For observations made with the thermometer see Temperature. Thermometrieal Records. — It is extremely useful to register the thermometrieal observa- tions in a case of disease on a chart, and to con- nect the marks bylines; the curves which are thus formed being quite typical in many dis- eases. On the same chart may be entered, also by marks and lines, or otherwise, the numbers of the pulse and respirations, as well as remarks concerning other symptoms, or the treatment. The use of the thermometer for estimating the temperature of rooms, and especially of wards, is fully described in other appropriate articles. See Nursing ; and Personal Health. 0. G. H. Baumler. THIRD NERVE, Diseases of. — The third nerve is purely motor in function and supplies the levator palpebrse superioris, the superior inferior and internal recti, the inferior oblique, the ciliary muscle, and the sphincter of the iris. It arises from the surface of the crus cerebri by a series of fasciculi, which pass to a nucleus of grey matter lying on the posterior portion of the floor of the third ventricle and beneath the aqueduct of Sylvius. The anterior part of the nucleus in the floor of the third ventricle inner- vates the ciliary muscle ; the middle part, be- neath the anterior extremity of the aqueduct of Sylvius, supplies the sphincter of the iris ; and the posterior part of the nucleus innervates the extrinsic muscles of the eyeball (Hensen and Vcelckers). Morbid states of the third nerve show them- selves as spasm or paralysis in the muscles sup- plied by it, that is, of the eyeball, the upper eyelid, the iris, and in the ciliary muscle. 102 THIRD NERVE, DISEASES OE. 161’ 1. Spasm. — Spasm is never met with at the same time in all the muscles supplied by the third nerve. It occurs in isolated ocular muscles, especially in the internal rectus, in conditions ol irritation of the trunk and nucleus of the nerve, as in meningitis, in hysteria, also in hyper- metropia, and in paralysis of the antagonist muscle. When extreme the eyeball is turned in- wards, and cannot be moved out. Clonic spasm of the muscles occurs in ‘ nystagmus.’ The eta vator of the upper eyelid is occasionally spas- modically contracted, so that the eye cannot be shut, but remains widely or partly open (lag- ophthalmos). Slight contraction of this muscle occurs in cases of long-continued paralysis of the orbicularis palpebrarum. Spasm of the muscle is chiefly due to reflex causes, especially to neu- ralgia of the fifth nerve. Spasm of the sphincter of the iris produces contraction of the pupil, sometimes to very small dimensions (myosis). It may be a congenita’ condition, but also results from irritation ol the trunk of the third nerve ; from stimulation, central or reflex, of the nucleus ; or it is se- condary to paralysis of the dilator fibres sup plied by the sympathetic. It may result from excessive (associated) efforts at accommodation. It is, however, most frequently met with in loco- motor ataxy, and is associated with loss of reflex action. The condition is described more fully in the next section. Spasm of the ciliary muscle may result from the other causes of irritation of the nerve-trunk, or from excessive efforts at accommodation in hypermetropia. Its effect is to produce a fixed accommodation for near objects. Treatment. — The treatment of the central causes of overaction of the third nerve commonly resolves itself into that of the primary condition. Where no cause is obvious, rest is most impor tant, and efforts at accommodation should cease; tonics and counter-irritation, and sometimes in- jections of morphia, may be employed. Atropia will overcome spasm of the sphincter pupillm or of the ciliary muscle. The cold douche to the eyeball is useful in spasmodic lagophthalmos. 2. Paralysis. — ^Etiology. — The commonest cause of paralysis of the third nerve is some affection of its trunk in its passage through the membranes at the base of the brain, the orbital fissure, or within the orbit ; due either to rheu- matic inflammation of the nerve-sheath, or to syphilitic inflammation of the nerve or mem- branes. Less frequent causes are diseases of, or adjacent to, the inner part of the crus cerebri through which the fibres pass and from which they emerge (haemorrhage or softening of the crus, aneurism or growth in the interpeduncular space), basilar meningitis, and aneurism of the termination of the internal carotid. It is also met with as a result of diphtheria, and in asso- ciation with disease of the spinal cord, especially locomotor ataxy. Occasionally all the muscles supplied by the third nerve become paralysed, together with the other orbital muscles — the ophthalmoplegia ex- terna of Hutchinson. In such a case the writer has found a degeneration of the nerve-cells of the nuclei of these nerves. Symptoms. — Paralysis may affect some or all 1618 THIRD NERVE, DISEASES OF. the fibres of the third nerve. When complete the upper eyelid is dropped and cannot be raised, and can be moved only outwards, and a little outwards and downwards ; after a short time it is always turned outwards. The pupil is in a mid-state between contraction and dilatation, and cannot be made to contract by light ; power of accommodation in the eye is lost by paralysis of the ciliary muscle. Each part supplied by the nerve may be paralysed separately, by affection of the special branch of the nerve after it leaves the main trunk. When the levator palpebrae superioris is affected, ptosis or dropping of the eyelid alone results. An attempt is made to raise the eyelid by excessive contraction of the corresponding half of the occipito-frontalis. Double ptosis is often seen in elderly persons, without other evidence of nerve-weakness. In paralysis of one of the three straight muscles supplied by the third nerve, there is strabismus, with defective movement in the direc- tion of action of the affected muscle, and double vision, the distance between the two images in- creasing as the object is moved in the direction of action of the affected muscle. When the in- ternal rectus is paralysed, slight power of move- ment inwards still remains from the superior and inferior recti. There is divergent strabismus and crossed diplopia ; when looking upwards and inwards the images approach at the top, when looking downwards and inwards they approach at the bottom. The patient carries his head turned towards the side of the affected muscle, to avoid the double vision. When the superior rectus alone is paralysed, the movement upwards of the affected eye is diminished, and the eye deviates a little outwards; there is crossed dip- lopia in the upper half of the visual field, the image formed by the affected eye being higher than the other, the two diverging above, the dif- ference in height being greater in looking out- wards and upwards, while the difference in obliquity is greater on looking inwards and up- wards. When the inferior rectus only is affected there is defective movement, with crossed dip- lopia, on looking downwards. The second image is below that of the healthy eye, the distance between them being greatest on looking down- wards and a little inwards. The images are not parallel, but diverge at the bottom, and the difference in obliquity increases on looking in- wards and downwards. The inferior oblique is very rarely affected alone. In paralysis of the sphincter pupill* the elasticity of the structure maintains the pupil at middle size, and it can be further dilated by atropia, hut all power of contraction beyond the middle size is lost. When the ciliarymuscle is paralysed, the power of accommodation is lost., the far point of vision remains the same, but the near point is rendered much more distant. The remarkable loss of reflex action of the iris which occurs in association with locomotor ataxy is usually accompanied by myosis. Not only does the pupil not contract on exposure to light, hut, if small, it does not dilate on stimu- lation of the skin (Erb). The associated con- traction on accommodation is usually preserved t(ArgyH-Robertson). Sometimes this is lost, and THIRST. the ciliarymuscle is also paralysed — the ophthal- moplegia interna of Hutchinson. These symp- toms may also occur in cases of old syphilis, apart from spinal disease. They probably de- pend on localised degeneration in the nuclei of the third nerve. Diagnosis. — Paralysis of the third nerve is generally obvious ; it is only the slighter para- lyses of separate branches supplying the ocular muscles which are sometimes not easy to recog- nise ; and, for this purpose, a careful exami- nation of the double images is often necessary. The diagnosis of the cause is less easy. Rheu- matic paralysis succeeds exposure to cold, and is often attended by much pain; in syphilis other cranial nerves are often affected indepen- dently ; in meningeal and spinal disease there are the respective distinctive symptoms ; in disease | of the crus there is hemiplegia of the opposite | side, coincident in onset with the affection of the third nerve; in interpeduncular disease the affec- tion of the third nerve may precede the hemi- plegia, and both third nerves commonly suffer. After diphtheria the ciliary muscle is usually alone affected. Prognosis. — When due to cold or to recent syphilitic mischief, or after diphtheria, the prog- nosis is good if proper treatment can be secured. In cases of organic cerebral disease it is less favourable, and is subordinated to that of its cause. In association with spinal disease the ultimate prognosis is unfavourable, for, although the early attacks are usually recovered from, the affection commonly recurs. Treatment. — In rheumatic paralysis from cold, hot fomentations, counter-irritation by blisters to the temple, small doses of iodide of potassium, and tonics are the most useful. When of syphilitic origin large doses of iodide of potas- sium usually suffice to effect a cure. If associated with spinal mischief, strychnia, iron, and arsenic are occasionally of some service. In intracranial disease — tumour, aneurism, or meningitis — the treatment is that of its cause. After diphtheria tonics are alone necessary. In paralysis of the sphincter pupillse and ciliary muscle, occa- sional instillation of a small quantity of Cala- bar bean, by stimulating locally the paralysed fibres, does good, and has been said to be bene- ficial in affections of other branches of the nerve. In the paralysis of the ocular muscles electricity is sometimes of use, applied through the eyelid to the affected muscle, small electrodes being used, and the eye so turned as to bring the muscle as much as possible within reach. One electrode may he placed on the muscle, the other on some indif- ferent part or on the temple, or both electrodes may be placed over the muscle. The voltaic current slowly interrupted is the more useful; the negative pole should be placed on the muscle, the positive on the temple. Faradisation is of less service; the feeble strength which alone can he used is, so to speak, absorbed by the orbicu- laris. The application of the continuons current in the neighbourhood of the orbit sometimes produces slight temporary improvement. W. R. Gowers. THIRST.— Synox. : Fr. Soif; Ger. Durst.— Thirst is a sensation indicating a necesei f j on THIRST. the part of tho system for an increased supply of water, as appetite shows there is a need for the introduction of food. Although the sensation is referred to the back of the throat, it is not a purely local feeling, as is proved by the fact, well-known to physiologists, that it cannot be allayed by the swallowing of water, unless the fluid reach the stomach and be absorbed. It is always present in febrile disorders, an increased supply of liquid being required both to reduce the heat, by promoting the evaporation of mois- ture from the skin and lungs, and also to wash away the products of the increased tissue-changes that accompany these complaints. In like man- ner it is always present when much fluid has been abstracted from the system ; thus, it shows itself after all surgical operations attended by haemorrhage. It is a prominent symptom in cholera and diarrhoea, in which diseases large quantities of serum are rapidly removed from the gastro-intestinal circulation, and it is equally so in diabetes, where fluid is largely excreted along with sugar by the urinary organs. A crav- ing for cold and acid drinks presents itself in acute gastritis, the intensity of the thirst being perhaps due to the incessant vomiting, which prevents fluids remaining long enough in the stomach to be absorbed. In chronic gastritis thirst is usually present, and is chiefly com- plained of towards evening. It forms a useful diagnostic sign where there is a difficulty in dis- tinguishing between this disease and mere atonic dyspepsia. Treatment. — Thirst is relieved by the agents usually recognised as refrigerants, such as water, barley-water, toast and water, and similar drinks ; sucking small pieces of ice ; effervescing drinks ; freely diluted acid drinks, especially those made with vegetable acids or phosphoric acid, alone or combined with a little aromatic bitter ; the juices of fruits, or these made into drinks. Care has often to be exercised in the employment of these apparently harmless agents, and their con- sumption has to be checked, otherwise patients will take them to excess, and may thus do them- selves considerable injury. Samuel Eenwicr. THORACENTESIS (0<$paj, the chest, and kcvtIu, I prick). — A synonym for paracentesis thoracis, or tapping of the chest. See Paracen- tesis ; and Pleura, Diseases of. THORACIC ANEURISM.- Under this head are included aneurisms of (A) the intra- thoracic aorta ; (B) the arteria innominata ; (C) the pulmonary artery ; (D) the coronary arteries ; and (E) the heart. The last two forms have been fully treated of under their re- spective articles, and will not be further referred to here. See Coronary Arteries, Diseases of ; and Heart, Aneurism of. A. Aneurism of the Intr a- Thoracic Aorta. This may be most conveniently discussed in its clinical aspects under two heads, namely, (1) aneurism of the arch , and (2) aneurism of the descending thoracic aorta ; whilst the former may be subdivided into aneurism of (a) the ascending, ( b ) the transverse, and (c) the descending portion. Relative frequency. — Of seventy-six cases THORACIC ANEURISM. 1819 analysed by the writer, including fourteen treated by himself, the seat of aneurism, single or multiple, stated in the order of relative fre- quency, was as follows : — Single : ascending por- tion of arch, thirty; transverse portion, seventeen ; descending thoracic aorta, ten; ascending and transverse portions of arch, nine; transverse and descending portions, two ; entire arch, two; de- scending portion, one; thoracico-abdominal aorta, one. Multiple : ascending portion of arch and descending thoracic aorta, two; ascending por- tion of arch and abdominal aorta, two. (1) Aneurism of the Arch. — The different parts of the arch of the aorta must be consi- dered separately. (a) Ascending yiorfion.-Aneurisms arising from one of the sinuses of Valsalva, within the range of the valves, rarely attain a size larger than that of a billiard-ball. They are saccular and not unfrequently pedunculated, communicating with the aorta by a small orifice. They further exhibit a remarkable tendency to descend in the progress of growth, involving in their course the heart or the root of the pulmonary artery. By their position they are sheltered from direct in- flux from the ventricle, whilst they are exposed to the maximum force of reflux from the aorta. "When, however, the orifice is partially or entirely above the level of the valves, the main pressure sustained by the sac is that of efflux from tlm ventricle ; hence the direction of growth is up- wards. Aneurism of the portion of the vessel immediately above the level of the valves is especially prone to advance towards the right side, forming a tumour visibly projecting, or detectable by palpation and percussion, in the vicinity of the right nipple. It may be fusi- form or saccular, true or false ; it usually at- tains a large size ; and, when fusiform, not un- frequently extends over a great portion, or even the whole of the arch. The direction of growth may, however, be backwards or to either side ; the aneurism in its progress implicating the oesophagus, the pulmonary artery or one of its branches, the superior vena cava, or either auri- cle ; it is in such cases usually saccular, and of comparatively small size. Aneurisms of the extra-pericardial portion of the ascending aorta usually tend forwards and upwards iu the line of main blood-pressure, projecting at the right margin of the sternum above the fourth costal cartilage, and occasionallylikewise into the root of the neck, involving the arteria innominata. They may, however, grow backwards and to the right, implicating the right bronchus or lung, or the superior cava ; directly backwards, pressing upon the oesophagus or the bifurcation of the trachea; or, projecting mainly towards the left side, they may involve the left branch of the pulmonary artery, and the left bronchus or lung. Symptoms and Signs. — - Aneurism of the sinuses is rarely attended with very definite symptoms; indeed only when it presents at the anterior wall of the chest. Owing to its position within the pericardium, and its close proximity to the heart, the symp- toms produced by aneurism in this situation mav be readily confounded with structural or valvular disease of the heart itself. The acoustic signs are, for the purposes of diagnosis, no less indefinite • 1620 THORACIC because, from the position of the aneurism close to the orifice of the aorta, a murmur produced by it, whether of influx or of efflux, may be easily mistaken for one of the same rhythm caused by obstruction or inadequacy of the valves. The difficulty of diagnosis is further increased by the usual co-existence of atheroma with dilatation of the first portion of the aorta, relative incompe- tency of the valves, and dilated hypertrophy of the left ventricle. The ordinary symptoms are those of palpitation and derangement of the rhythm of the heart, from affection of the car- diac plexus. But the diseases just mentioned may, in the absence of aneurism, give rise to similar phenomena. The existence of venous stasis and congestion of the upper half of the body, viewed in conjunction with tumultuous and irregular action of the heart, and in the absence of discoverable cause of venous obstruction at a higher point in the chest, would, however, war- rant the presumptive diagnosis of aneurism at the root of the aorta, implicating the right auri- cle or the termination of the superior cava ; and if with these symptoms were associated systolic murmur at the base, not transmitted in the course of the aorta, or a double murmur, a positive diagnosis to the above effect might be made. Were the diastolic murmur preceded by a distinct second sound, valvular inadequacy from dilata- tion of the aorta, without valvular disease, would be thereby indicated, and the diagnosis of aneurism pro tanto sustained. Symptoms of ob- struction of both cavae, namely, general venous congestion, and engorgement of the liver, would in the foregoing connection justify the special diagnosis of pressure upon the sinus of the right auricle. The symptoms of pressure upon the other chambers of the heart are those only of doranged rhythm and circulation, such as may be due to various causes inherent in the heart. Systolic murmur in the pulmonary artery may result from the pressure of an aneurism on the root of that vessel. Communication of an aneu- rism with one of the chambers of the heart is usually effected by an aperture not more than two to three lines in diameter. It is the result of progressive absorption, and the symptoms are scarcely to be distinguished from those of ante- cedent pressure. The physical signs are more characteristic ; they consist in a loud murmur, systolic or diastolic, of a ‘booming’ or ‘splashing’ character, accompanied by thrill, traceable from the root of the aorta in the direction of abnormal influx, and not transmitted in any of the ordi- nary lines of valvular murmur. If two murmurs exist, they are fused or converted into a con- tinuous rumble. Sudden transfer of the seat of greatest intensity of such a murmur, from the aortic area to some other point of the precordia, would be conclusive, not only as to the irruption of an aneurism into one of the chambers of the heart, but likewise as to the date of its occur- rence. Aneurism of the ascending aorta, external to the pericardium, is occasionally latent, but ordi- narily it is characterised by very definite symp- toms and signs. A large fusiform aneurism of this portion of the vessel, or engaging the en- tire arch, equally expanded, not in contact with the anterior thoracic wall or pressing inconve- ANEURISM. niently upon any of the adjacent organs, may he virtually latent ; exhibiting no symptom of aneu- rism except vague neuralgic pains darting over the chest, shoulders, arms, and back, and no sign but exaggerated double sound. Pointing externally, or in persistent contact with the chest-wall, an aneurism may be readily identified by the cir- cumstance that it presents a second centre of pulsation and sound. The ordinary pulsation is systolic, expansile, and diffused (though not always equally) over the entire surface ; but a second and minor impulse of diastolic rhythm may likewise exist. The former is in many cases accompanied by tactile thrill. The acoustic signs consist either in two sharp accentuated sounds, nearly alike in character, and corresponding in rhythm to those of the heart ; or in a single or double murmur of blowing or ‘ booming’ quality. There is likewise absolute dulness, with suppres- sion of respiratory sounds and of vocal fremitus, to the extent of the tumour. Pressure upon the superior cava is character- ised by venous congestion, limited to the upper half of the body : whilst actual communication with that vessel is evinced by cyanosis to the same extent ; extreme engorgement with pulsation of the jugular veins ; a buzzing systolic murmur, with intense thrill, at the seat of communication and transmitted into the veins of the neck. Accord- ing to Dr. Mahomed, in cases of arterio-venous aneurism inspiration alters the markings of the sphygmograph, by diminishing the volume of blood in the artery. Pressure upon the main bronchus is indicated by diminished or suppressed respiration, with normal percussion-sound, in the correspondinglung;and occasionally by ‘whiffing’ or ‘jerking ’ inspiratory sound. Diminished re- spiration throughput either lung, with inequality as between its upper and lower portions, would indicate pressure, but unequal in degree, upon the primary bronchus and its superior secondary branch ; whilst partial or complete suppression confined to the upper lobe would show that the superior lobular branch was alone implicated. Passive pneumonia, from occlusion of the pulmo- nary vessels, is a frequent result of the pressure of an aneurism upon the bronchi. It is worthy of notice that consolidation of lung-substance so pro- duced is especially characterised by the absence of vocal fremitus. Bronchitis may likewise arise from mechanical irritation ; and where present may, in greater or less degree, mask the physical signs of aneurism. The sudden irruption of an aneurism into one of the bronchi is indicated by copious discharge of florid blood from the mouth and nostrils, and is instantly fatal by syncope or asphyxia. An opening established into the pulmonary substance is followed by ‘leakage’ of blood, or repeated but limited haemoptysis. Pressure upon the pulmonary artery is necessarily attended with engorgement of the right chambers of the heart, and general venous congestion ; and the establishment of an opening into that vessel, with sudden and urgent dyspnoea without spasm or stridor, extreme con- gestion of the lung, and haemoptysis. Death is rapid in such cases ; but should an opportunity for physical exploration be afforded, a 1 buzzing' systolic hum might be detected in the second and third left intercostal spaces, close to the sternum THORACIC ANEURISM. Pressure upon the oesophagus is indicated by dys- phagia, referred by the patient to a corresponding point of the chest. Dysphagia due to the pres- sure of an aneurism is remittent, and varies in some degree with posture — traits by which it is distinguished from that produced by cancer. Dysphagia from volvulus of the oesophagus may, ncwever, exhibit similar variations. (6) Transverse 'portion.— Aneurisms of this Dortion of the aorta are usually fusiform : they involve mainly its anterior and superior wall, pushing forward the upper end of the sternum, projecting into the neck, compressing the left innominate vein, and modifying, in many eases, the circulation in the primary arteries and their branches. They likewise frequently press back- wards upon the oesophagus and trachea, the pneumogastric or sympathetic of either side, or the left recurrent nerve. Owing to the back- ward courso of the left extremity of the arch, aneurisms arising from this portion of the vessel rarely appear in front. They project above the left clavicle, involving the innominate vein, the pneumogastric, sympathetic, or recurrent nerve of the left side, and occasionally all three ; or posteriorly in the left scapular region. Symptoms and Signs. — Pressure upon the left innominate vein is accompanied by visible en- gorgement of the thyroid, left jugular, subcla- vian, brachial, and superficial thoracic veins and their tributaries, with cedema of the left arm. The circulation in the carotid or subclavian artery of one side is often diminished or suppressed by the lateral pressure of an aneurism, or by clot- formation in the sac. Pressure upon the trachea is indicated by clanging or metallic cough, and stridor ‘ from below,’ that is, loudest at the upper part of the sternum, and distinctly audible over the lower cervical and upper dorsal vertebrae. The symptoms of aneurismal pressure upon the sympathetic, pneumogastric, and recurrent nerves are most frequently exhibited on the left side only. Thosi? due to implication of the sympa- thetic or its cilio-motor roots are manifested in the pupil on the affected side. They consist in dilatation or contraction of the pupil according to the degree of pressure ; the former from irri- tation, and the latter, which is the more usual phenomenon, from paresis of the nerve. Laryn- geal stridor, huskiness or loss of voice, and harsh metallic cough, in the absence of local disease of the larynx, are eminently diagnostic of pressure upon either recurrent nerve. By means of the laryngoscope the vocal cord on the side of disease, and in rare cases the cords on both sides, are seen to be fixed during breathing and vocalisation, from unilateral or bilateral paralysis of the ab- ductor muscles of the larynx. Dr. George John- son holds that unilateral paralysis is distinguished by slight huskiness of voice, with stridor on full inspiration; and bilateral paralysis, by permanent dyspnoea and stridor. Paroxysmal dyspnoea or fatal asphyxia may result from collapse of the arytaenoid cartilages in such cases. Pressure upon either 'pneumogastric is especially characterised by paroxysms of remittent spasm of the glottis, which may be suddenly fatal ; but, where the recurrent nerve is not likewise implicated, persis- tent stridulous breathing, aphonia, and metallic eough are not exhibited. The writer has oeca- 1021 sionally witnessed urgent laryngeal and bronchial spasm from the pressure of an aneurism, engag- ing the root of the lung, upon the pulmonic plexus exclusively. The physical signs are identical with those already described in connection with aneurism of the ascending portion of the vessel. (c) Descending portion. — Aneurism of the left curvature and descending portion of the arch involves the. left recurrent nerve in nearly every instance. In the progress of growth it passes into the root of the neck ; backwards towards the left scapula ; or backwards and outwards into the substance of the lung. Symptoms and Signs. — These include symp- toms of pressure upon the recurrent or pneumo- gastric nerve, as well as the subclavian or inter- nal jugular vein ; a pulsating tumour in the left interscapular space, which may attain very large proportions ; and signs of congestion and consoli- dation of the upper and back part of the left lung. In the last case the aneurism, being involved in the pulmonary structure, may afford no specific evidence of its existence. The physical signs differ in no respect from those which characterise aneurism of the other portions of the arch. (2) Descending Aorta. — Aneurisms of the upper portion of this division of the vessel rarely attain a large size. They maj'pass upwards and to the right side, implicating the trachea and oesophagus ; or directly to the right, stretching the oesophagus or thoracic duct, and ultimately opening into one of them, or into the right pleura. In a case which came under the writer's notice, the trachea and the oesophagus were simultane- ously perforated, and death occurred by luemor- rhage into both. The aneurism may advance to the left, and ultimately prove fatal by rupturo into the left pleural cavity ; it may erode the vertebrae and ribs, and point in the left infra- scapular region ; or it may advance towards the anterior wall of the chest, displacing the heart, and involving itself in the substance of the left lung. Aneurism of the lower part of the vessel usually extends into the abdomen, constituting the thoracico-abdominal form of the disease. It may displace the heart forwards, and the liver downwards; it may likewise extend backwards, eroding the vertebrae, and pointing in the lower dorsal or the lumbar region on the left side. Finally, an aneurism in this situation may prove fatal by simultaneous hajmorrhage into the left pleural cavity and left retro-peritoneal space, or into the vertebral canal. Symptoms and Signs. — To what has been al- ready stated on this subject it is only necessary to add, that progressive absorption of the ver- tebrae is indicated by fixed and boring pain re- ferred to a particular point of the vertebral column, which is tender to pressure, and whence not unfrequently radiating or ‘ nipping ’ pains extend round the chest. Forward displacement of the heart by an aneurism would be charac- terized by violent impulse, simulating that of cardiac hypertrophy (the distinction would rest upon the presence of the special symptoms and signs of aneurism) ; a remarkable derangement of cardiac impulse, constituting the ‘double jog’ of Hope ; with absence of the positive signs of 1622 THORACIC hypertrophy. Pressure upon the thoracic duct is very rare ; it would he indicated by the symp- toms of mat-assimilation, wasting, and inanition, — symptoms which are foreign to aneurism under its ordinary forms. The physical signs of aneurism of the de- scending thoracic aorta are ordinarily limited to a sharp sound, single or double, audible over the dorsal vertebrae and somewhat to the left ; and, more rarely, perceptible impulse. The existence of murmur is exceptional ; when present, murmur i3 all but invariably single and post-systolic, and is inaudible in the erect posture. Duration- and Terminations. — The duration of aneurism of the intra-thoracic aorta may vary from a few days to several years. Death is most frequently caused by rupture of the sac into various parts ; or by gradual exhaustion from insomnia and inanition. Of seventy-one cases of aneurism in this situation tabulated by the writer, including twelve observed by him- self, twenty-six were fatal by rupture of the sac ; namely, into the pericardium ten — all being aneurisms of the ascending aorta; into the left lung or pleura five — four being of the transverse, and one of the descending thoracic aorta ; into the trachea four — three of the transverse, and one of the ascending aorta; into the right lung or pleura three — two of the ascending, and one of the descending thoracic aorta; into the left bronchus or oesophagus three — two of the de- scending thoracic, and one of the transverse aorta (in one of these an opening existed both into. the left bronchus and the oesophagus) ; ex- ternally one — the aneurism having arisen from the transverse aorta. Death may also result from asphyxia, intercurrent inflammation of the lungs or pleura, or from coma. B. Aneurism of the Arteria Innominata. Aneurism involving the innominate artery may be mistaken for aneurism of the aorta, at or near the first curve of the arch. Symptoms and Signs. — Those which are most distinctive of innominate aneurism are the early appearance of pulsating tumour above the right clavicle, accompanied by arterial obstruction on the right side; displacement of the trachea and larynx to the left ; and pulsation with sound, localized at the right sternoclavicular joint and immediately above. Diminished circulation in the right carotid and subclavian arteries at an early period of the disease, and the reduction or arrest of pulsation in the sac by digital pressure upon these vessels, afford the most constant and least equivocal evidence of innominate aneurism. The early occurrence of neuralgic pains in the right side of the neck, the right shoulder and ear, followed by oedema and partial paralysis of the right arm, are likewise suggestive of inno- minate, as distinguished from aortic aneurism. The symptoms of nerve-pressure on the right side, as exhibited in the larnyx and pupil, are usually well-pronounced in this disease. Tho physical signs are in no respect different from those of aneurism of the arch. Concurrent im- plication of the aorta is ordinarily determined with tho greatest difficulty, and occasionally a positive diagnosis in this respect cannot be made. If pulsation and sound of maximum intensity exist at the level of the second costal ANEURISM. cartilage, or an inch auda-half below the sternal end of the clavicle, whilst the pulse-tracing of the right radial artery exhibits imperfect aneu- rismal characters, the aorta may be considered as involved in the disease. C. Aneurism, of the Pulmonary Artery. Aneurism of the main trunk or primary branches of the pulmonary artery is unknown ; but aneu- rism and ectasia of the secondary and subse- quent branches have been repeatedly found in connection with cavities in the lungs, and aro recognised as the ordinary source of fatal haemo- ptysis in the third stage of phthisis. Cavities confined to one lung with walls condensed by fibroid growth, and either stationary or in pro- cess of secondary ulceration, are those which are most favourable to the formation of pulmonary aneurism or ectasia. In the walls or trabeculae of such cavities the branches of the pulmonary artery remain pervious; their coats, already thickened by chronic inflammation, and weak- ened by degenerative changes, expand under vas- cular pressure, where least supported, and form an aneurism, globular, fusiform, or semi-fusi- form, according to the extent and degree of their structural change and denudation, or a simple ectasia. These ultimately give way by rupture or erosion, and severe haemorrhage into the cavity and connected bronchia is the immediate result. Active ulceration of an existing cavity is usually attended with partial thrombosis of adjacent vessels. Hence, in such cases haemoptysis is seldom copious, and death results from ex- haustion produced by repeated small haemor- rhages. In the process of primary and active excavation of lung-tissue the vessels are com- pletely blocked, and haemoptysis, even to a small amount, is exceptional. See Haemoptysis. Symptoms and Signs. — Of a special kind there are absolutely none. Copious haemoptysis iD connection with cavity would be eminently suggestive of pulmonary aneurism. Of twelve cases of fatal haemoptysis in the third stage of phthisis, tabulated by Dr. Douglas Powell, a ruptured aneurism or ectasia of a pulmonary branch was found to be the source of haemor- rhage in eleven instances. Treatment. — The treatment of aneurism will be found described in the articles Abdomixai Aneurism; and Aorta, Diseases of. The cura- tive treatment of aortic or innominate aneurism should be directed to the single object of effect- ing consolidation of the contents of the sac. With this object in view three methods have been pursued, either separately or conjointly, namely, the 'postural and dietetic ; the medicinal ; and the surgical. As complemental of the first plan of treatment of thoracic aneurism, an occa- sional blood-letting by venesection, to the amount of eight to ten ounces, for the purpose of reducing arterial tension or venous engorgement, may be demanded. With a view to causing or promot- ing deposition of fibrin in the sac several agents have been used, namely, acetate of lead, in doses of four to eight grains; iodide of potassium, ten to thirty grains ; and aconite, fivo minims of the tincture thrice daily. Ergotin has been used hypodermically by Lungenbeck. Each of these agents has been credited with success in the treatment of aneurism. But, as spontanecuj THORACIC ANEURISM. cure has been occasionally -witnessed under favourable circumstances as to diet and rest, where no medicine had been given, a more than promotive influence, by retarding the circulation and reducing vascular pressure, can scarcely be assigned to the medicine used, where rest and restricted diet have been observed. Galvano- puncture of the sac has been practised with success. Deligation of the common carotid artery, or of that vessel and the subclavian, may be followed by the most favourable result, in cases where pressure upon these vessels has been found to control pulsation in the sac. For details of the surgical treatment see Aneurism:. The 'palliative treatment of thoracic aneurism is discussed in the article Aorta, Diseases of. A few leeches applied from time to time in the vicinity of the sac, or a hypodermic injection of morphia, will relieve the pain and repress the inflammation caused by excentric pressure. Thomas IIayden. THORACIC DUCT, Diseases of. — Synon. Fr. Maladies du, Canal tlioraciqve ; Ger. Krank- lieiten dcs Cactus thoracicus. — The thoracic duct is the main trunk belonging to the absorbent system, by means of which the chyle from the lacteals, and the lymph from the lym- phatics (except that from the right side of the chest, neck, and head, and the right arm), are conveyed into the circulatory system, so that these fluids may be mixed with the blood. It starts from the receptaculum chyli, deep in the upper part of the abdominal cavity ; passes through the aortic opening of the diaphragm, on the right of the aorta ; accompanies this vessel along the thoracic cavity ; passes beneath its arch and the left subclavian artery; then along the left side of the oesophagus ; and, finally, comes forward in the neck from behind the left carotid artery, arching over the subclavian artery, and crossing the phrenic nerve and anterior scalenus muscle, to open usually into the left subclavian vein, near its junction with the in- ternal jugular. It is requisite to remember these facts respecting the course and anatomical rela- tions of the thoracic duct, in order to understand how its chief morbid conditions are produced. The diseases of the thoracic duct resemble those of the absorbent vessels generally ( see Lym- phatic System, Diseases of) ; and it will suffice to indicate here the following practical points : — 1. The passage of fluid along the duct, and its escape into the subclavian vein may be impeded by any condition which interferes seriously with the venous circulation, and distends the veins considerably, such as certain cardiac diseases. 2. Local obstruction of the thoracic duct may arise at any point, from direct pressure upon it, especially by an aortic aneurism, and it may be- come thus permanently occluded ; or from in- trinsic tubercular disease, which is of special importance ( see memoir by Stilling, Virchow’s Archiv, and Lancet, vol. i., 1882). 3. As a result of obstruction, dilatation of the portion of the tube behind this point will probably supervene in various degrees, and it may become consider- ably enlarged and thickened. The other portion tends to become contracted and atrophied. 4. Perforation of the thoracic duct occurs in excep- THREAD-WORM. 1623 tional instances, owing to the destructive effect of an aneurism or other morbid condition, or as the result of injury. It is, as a rule, quite impossible to determine during life that the thoracic duct is diseased. This might bo suspected if, along with some known cause which might lead to obstruction of the tube, the patient became extremely ema- ciated, anaemic, and weak, without other obvious reason to account for these symptoms. No treat- ment directed immediately to the thoracic duct can be practicable under any circumstances. Frederick T. Roberts. THORACIC TUMOUR. — A tumour within the chest. See Bronchial Glands, Diseases of ; Lungs, Malignant Disease of ; Mediastinum. Diseases of; and Thoracic Aneurism. THORAX, Diseases of. See Chest, Dis- eases of; Chest Walls, Diseases of; and De- | formities of Chest. THORAX, Examination of. See Physi- cal Examination. THREAD-WORM. — Synon.: Oxyuris; Fr. Oxyure ; Ger. Spitzschwanzwurm ; Fadenwurm. As stated under the article Oxyuris, thread- worms represent a genus of nematoid worms. They are commonly spoken of as Ascarides, but this is a misnomer. The oxyurides, or thread- worms, are also sometimes termed seat-worms. By whatever name called, they have acquired much clinical importance, since they prove in- jurious not only to young persons, but also to people advanced in life. It may be said, in- deed, that they are more annoying to adults than to children ; the prognosis in cases of the former being more unfavourable than in the latter. It is usually stated in manuals that these parasites reside in the rectum of the human bearer; but this is an error, since their presence in the lower bowel is rather an accident than otherwise. No doubt they are frequently present, both in the rectum and sigmoid flexure of the colon, but their true habitat is higher up, namely, in the caecum. Probably the tendency to migrate is the chief cause of their frequent presence in the lower bowel ; at all events, their passage by the anus at night-time is a constant source of distress to young persons. Their wanderings thence into the vagina, and about the neighbour- ing parts, proves an additional source of serious irritation and discomfort, often leading to the involuntary practice of objectionable habits. It is of the utmost importance to get rid of them, especially at the age of puberty. Before w r e speak, however, of the symptoms and treatment, it may be as well to say a few words respect- ing their modes of introduction into the human body. Until lately nothing had been dono to clear up the mystery of their origin. It was generally supposed — and this view is still held by some unscientific persons — that these entozoa w r ere generated only in individuals af- fected by a peculiar cachexia. The enfeebled condition produced by their presence was pro- nounced to be the cause instead of the effect. Many practitioners cannot shake off their old notion, and some few are impatient of correc- tion in this respect. A healthy person is just a? 1624 THREAD-WORM. I \$ liable to be attacked by nematoid worms as a diseased one, The real question is, How do the germs gain access to the human body ? Various experiments, in which the writer has himself taken part, have been conducted with the view of determining this important point. Everyone is familiar with the size and ap- pearance of the common thread- worm ( Oxyuris vermicularis), at least of the females, which are more numerous than the males. If one of the former, measuring nearly half an inch in length, be submitted to a magnifying power of twenty diameters, the uterine ducts will be seen to con- tain a multitude of eggs. Those ova whose contents are in the most advanced stage of deve- lopment already show a more or less perfectly formed and tad- pole-shaped embryo. These em- bryos, after extrusion of the eggs from the maternal body, soon acquire the ordinary vermiform character. As Yix and Leuckart have shown, ‘ one needs only to expose the eggs to the action of the sun’s rays in a moistened paper envelope, when, at the ex- piration of some five or six hours, the tadpole-shaped embryos will have already become slender elongated worms. At this stage they are not altogether unlike the sexually mature oxyurides in shape, exhibiting rather lively movements under the applica- tion of warmth’ ( Die Mcnsch. Pur.jBd. II. s. 130). Professor Heller has remarked to the wri- ter, that for the artificial rear- ing of the vermiform embryos no plan is better than that of Fid. Ob. Oxyuris simply placing the eggs in a vermicularis, „q asg tube filled with saliva, female. Highly s,, . . , ... magnified. A £- This tube may be conveniently ter Leuckart. carried in the arm-pit, when in a very short space of time the embryonal trans- formations may be followed. In this connection it is a matter of practical importance to know whether or not these and all other embryonal changes which are necessary to the sexual ma- turity of the parasite, can be accomplished with- in the human bowel. On this point Leuckart affirms (loc. cit. s. 329) that 1 elongated embryos are to be found not only in the fteces but also in the mu- cus of the rectum above and around the anus.’ And it appears that Vix, who was the first to discover the filiform stage, has de- tected vermiform embryos, along with eggs of oxyu- rides, in tho large intestine. These statements, taken by themselves, would seem to show that, notwithstanding all that has been said to the contrary, the old view as to the propagation Fig. 93. Eggs of Oxyu- ris vermicularis , in- closing tadpole-shaped embryos; x 450 diam. (original). of thread-worms in the human bearer is correct. All the more recent evidence, however, leads to a contrary conclusion. Thus Leuckart distinctly states that ordinarily the escape of the embryos ‘ takes place under the action of the gastric juice, and 'primarily also under that condition when by some means or other they have gained access to a new bearer’ (loc. cit. s. 329). Speaking also of the subsequent development of oxyuris- embryos, he says : ‘ The development of these em- bryos continues not merely in the free state (when the favourable conditions are thus afforded) but also — at least in the human species — in the intes- tine of the bearer, presupposing of course that the eggs remain there the necessary time.’ What Leuckart conjectured to occur really does take place. According to Heller, who has made experimental observations on this subject, the embryos, after being liberated in tho human stomach, escape into the duodenum and upper bowel. In this situation the vermiform embryos undergo a series of moultings, accompanied by organic changes, and growing with great rapid- ity, soon reach the caecum, where they finally arrive at sexual maturity. As the question at present stands, therefore, we conclude that oui patients ordinarily contract thread-worms by swallowing the eggs of oxyurides. This they may do by ingesting them with uncleaned fruit, and other kinds of food, to which the eggs have become adherent; but, undoubtedly, the most common way in which the disease is prolonged, if not at first contracted, is by swallowing fresh germs conveyed directly to the mouth by the hands of the patient. The writer has had a gentleman under his occasional care, who confessed, that, in his rage with these disgusting parasites, he had taken them alive between his teeth and bitten them. In this exceptional way he must, of course, have liberated thousands of ova at a time, a fact which accounts for the myriads of adult oxyu- rides by which he is infested. Patients frequently handle these parasites, and still more frequently carry the ova under the nails. Children and also grown persons become infected by biting their nails after scratching the anus. The writer lately met with an instance where, from only the vestige of a nail left upon a boy’s thumb, he obtained some ova of oxyurides. Thus, it is obvious that without great cleanliness, persons already har- bouring thread-worms are liable to increase the number of their parasitic guests. Personal cleanliness is thus essential, but it is, we think, going too far to say, with Dr. Ransom, that ‘probably any infected person who adopted the requisite precautions against rein- fection from himself or others would get well in a few weeks without treatment by drugs.’ Symptoms. — The symptoms produced by thread- worms are very variable. Unpleasant sensations show themselves generally in the evening and at night, consisting ordinarily of heat and irritation around the anus. These phenomena often become excessively distressing, especially when they are accompanied by itching within and about the genito-urinary passages. By the wandering of the worms local inflammatory action is set up>. Presently, various sympathetic phenomena are superinduced, such as simple restlessness, gene- ral nervousness and irritability, itchings at the THREAD-WORM. nose, involuntary spasms, chorea, convulsions, and epileptiform seizures. At early puberty the local irritation sometimes induces the sufferer to seek relief by practices which show a per- verted condition of the sexual functions, and in young females these phenomena are occasionally accompanied by leueorrheal discharges, with more or less hysteria. Cases exhibiting varied and anomalous symptoms in connexion with the presence of these and other worms are recorded by different writers, but not many presenting the severer phenomena from thread-worms have appeared in our English journals. In one case, where multitudss of oxyurides were present, a patient of the winter’s suffered from anaemia, deafness, and extreme prostration, the feebleness being so marked that the young lady could not even bear the exhibition of ordinary vermifuges (Worms, 1872, case liii. p. 04). Prognosis. — Speaking generally, the prognoses in cases of thread-worm is favourable or other- wise, according to the age of the sufferer. Treatment. — In young persons small doses of steel, followed by brisk saline purgatives, some- times suffice to expel most, if not all, of the parasites. If the worms return, a repetition of the remedies may be advised, increasing the doses. As a rule, the threadworms will return, and if very numerous they are apt to prove obstinate. In adults the results of treatment are far less satisfactory. The worms are expelled with more difficulty by cathartics, and even copious enemata fail to reach those worms that are lodged high up in the colon and caecum. Many patients object to injections altogether; but if. containing turpentine, they can be em- ployed two or three times weekly, whilst active salines are given by the mouth, there is probably no better mode of obtaining good results. A great variety of drugs have been recommended, such as calomel, scammony, jalap, salt, san- tonin, iron, aloes, and assafcetida ; one or other of these being administered separately or together, followed by medicated enemata containing either lime, tincture of steel, sulphuric ether, tansy, or quassia. It may be said that all of these remedies prove more or less useful, but the writer has of late years relied more upon mode- rate doses of aloes and assafcetida, followed by copious draughts of active mineral waters, such as those of Friedrichshall, Pullna, and Hunyadi- Janos. Many persons who object to drastic cathartics as ordinarily prescribed will not re- fuse to take the Friedrichshall waters by them- selves, or the Hungarian waters in combination with steel or other tonics, to any reasonable amount. In the writer’s experience these waters are of great value in the treatment of certain forms of entozoal disease, especially of thread- worms. Whatever drugs are given, it is espe- cially necessary that attention be paid both to diet and regimen. All green vegetables should be avoided, whether cooked or uncooked. The utmost cleanliness must be enjoined. Daily local washings are, above all things, to be insisted on, especially after the act of defaecation, or nightly at bed-time, whether or not enemata be em- ployed. Simple cold water or olive oil injections ire almost as beneficial as those that are medi- cated. The nails must be kept short and clean, THROAT, DISEASES OF. 1625 and the practice of biting them should be de- nounced. Under any circumstances, and in view of a permanent cure, not only is great perse- verance in the employment of the remedies necessary, but also in the matter of general cleanliness. See Ascarides; Oxyurides; and Seat-worms. T. S. Cobboi/d. THROAT, Diseases of. — Synon. : Fr. Ma- ladies de la Gorge ; Ger. Rachcnkrankheiten. The throat is a comprehensive term, its dis- eases including those of the pharynx, tonsils, palate, and uvula, and in popular language even those of the larynx and trachea. The principal affections of these different structures, with the exception of the palate, are described in their appropriate articles, to which the reader is referred, and here it will only be necessary to offer a few general remarks on throat-diseases, and to refer briefly to the affections of the palate. In many instances all the parts are more or less involved in the morbid conditions pre- sent, but in other cases one structure is mainly or exclusively involved. Moreover, the throat may be interfered with by neighbouring dis- eases, such as retro-pharyngeal abscess, and some affections of the neck. Summary of Diseases.— The affections of the throat may be thus grouped in a general way:— 1. There maybe no actual disease, but the patient merely complains of various sensa- tions referred to the throat, these being of a ner- vous character. 2. The throat is liable to in- jury by substances swallowed. 3. This part is obviously affected in certain general diseases, especially some of the acute specifics. Thus it is particularly involved in scarlatina and diphtheria, and to a less degree in measles, rotheln, influenza, and general catarrh. Syphilis also implicates the throat in its various stages. This region is sometimes attacked by erysipelas, small-pox, herpes, or thrush. 4. Acute congestion, and various forms of acute inflammation, affecting different structures of the throat, are of common occurrence, resulting from causes acting either locally or generally. The cases present much diversity in their severity, depending upon the extent, seat, and terminations of the inflamma- tion. 5. Chronic congestion and inflammation are also not uncommon, of various degrees, and producing different effects in different cases. 6. Ulcerations of the throat are of frequent occur- rence, being usually dependent on some general condition, such as syphilitic, scarlatinal, or diphtheritic ulcers, but sometimes local in their origin. They may become sloughing and gan- grenous, causing much destruction of the tissues, or even opening up vessels, and thus proving fatal by haemorrhage. The after-effects of ulcer- ation may be evident in the way of cicatrices, contraction, adhesions, and permanent loss of parts. 7. Certain structures in the throat are very liable to become relaxed, and thus to produce symptoms, especially the uvula. 8. The throat may be occupied by some enlargement or morbid growth. Here may be mentioned chronic enlargement or so-called hypertrophy of the tonsils, which, however, is usually the result of chronic inflammation, congestion, or albuminoid disease. Cancer and polypi are the forms of 1626 THROAT, DISEASES OF. morbid growth usually met with, and cancer may proceed to ulceration. 9. Malformations are not uncommonly of importance in connection with the throat. The size of the pharyngeal cavity varies much in different persons, but its unusual smallness may be of more or less conse- quence. Deformities of the palate are of much importance, being either congenital or the result of disease. 1 0. Sensory or motor paralysis in- volving the throat is sometimes a serious affec- tion. The condition is especially met with after diphtheria, or in cases of labio-glosso-laryngeal paralysis. Clinical Signs. — The symptoms in throat- affections are very variable, as regards their se- verity, exact nature, and combinations, but they are more or less of the following nature: — 1. Painful or other abnormal sensations are usually complained of. Pain may range from mere ‘ sore- throat ’ to marked suffering, and in some instances it is attended with throbbing, or shoots towards the ear. Tenderness is also very common, when anything passes over the surface, or even when the parts are moved in the act of swallowing, and the painful feeling may be only experienced at this time. Talking or coughing is sometimes painful. Tenderness may also be felt when pressure is made over the tonsils from without. Amongst other sensations often complained of are a sense of dryness, irritation, fulness or tight- ness, heat or burning, and obstruction. 2. Hot only may the act of deglutition be painful, but in throat-disease it is often attended with difficulty in various ways, and may be quite im- practicable ( see Deglutition, Disorders of). 3. Articulation is affected in certain conditions, the voice being characteristically altered, and becoming of a thick, guttural, or Dasal quality. In other cases it is slightly rough or husky, and, of course, is particularly liable to be affected if the larynx is involved in any way. 4. In some forms of throat-disease the breathing is ob- structed, owing to structures filling up more or less the passago of the pharynx. This is espe- cially felt in the recumbent posture ; and patients suffering in this way often breathe with the mouth wide open, and snore loudly. The breath may have an unpleasant or even foetid smell, as the result of morbid states of the throat. 5. Throat-affections frequently excite the acts of hawking or coughing, and various materials are thus expelled in many cases. It may also be mentioned here that some irritation in the pharynx not uncommonly causes reflex vomiting. 6. Morbid conditions in this p>art may give rise to haemorrhage, and this occasionally proves of a serious or even fatal character, as the result of certain destructive lesions. 7. Physical exami- nation of the throat is of essential importance in revealing its morbid conditions. Inspection is usually sufficient, with the aid of a good light, and it is in most cases necessary to depress the tongue by means of the finger, the handle of a spoon, or a tongue-depressor. In some instances it is requisite to feel the parts in the throat with the finger. External examination should also he made beneath the angles of the lower jaw. The objec- tive conditions determined by physical examina- tion will depend on the nature of the disease. Palate, Diseases of. — The palate consists THROMBOSIS. of two parts — namely, the hard, and the soft palate with its arches. This structure takes an important share in the performance of deglu- tition, as well as in articulation. It is liable to be affected by any of the morbid ccnditiona which are met with in the throat, and assists in the production of the symptoms resulting there- from. When the palate is inflamed or ulcerated, marked soreness or pain is likely to be felt when anything passes over its surface in the act of swallowing. As a rule it can be very readily inspected. The points that demand special no- tice with reference to the palate are, that it is not uncommonly the seat of more or less exten- sive congenital deficiencies, as in the different forms of cleft palate ; and that it may be de- stroyed in various degrees during the progress of ulceration, in some instances a perforation remaining, in others the whole soft palate being removed, or even the hard palate involved. Con- sequently the two functions above referred to are often seriously impaired. During the act of deglutition, substances tend to pass back into the nasal cavities through the posterior nares, especially liquids ; while speech is nasal or gut- tural and indistinct, or in some cases almost unintelligible, it being impossible for the patient to articulate the words properly. During the act in some cases the features are more or less distorted. Treatment. — For the treatment of the dif- ferent throat-affections the reader must refer to the articles in which they are respectively dis- cussed. The writer only mentions the subject in order to draw attention to two points, namely: first, the great importance of general treatment in a large proportion of cases of affections of the throat ; secondly, the necessity of usiDg local measures efficiently , when these are required ; while at the same time it is often most desirable that the parts affected should be kept as much at rest as possible. Should the palate be con- genitally deficient, or destroyed by disease, sur- gical operations are often of the greatest ser- vice ; or plates of different kinds may have to be worn. Frederick. T. Roberts. THROMBOSIS (Oplfifros, a clot).— Stxon. : Fr. Thrombose; Ger. Thrombose. Definition. — The coagulation of fibrin in the heart, blood-vessels, or lymphatics during life. Description. — Thrombosis may take place in the heart, the arteries, the capillaries, the veins, and also in the lymphatics. The coagulum con- sists of fibrin, entangling in its meshes a larger or smaller number of blood-globules, which, in rapidly formed thrombi, consist of both red and white varieties, and hence the thrombus is at first dark-coloured. In slowly-formed thrombi, and in those due to projections from the coats of the vessels, the red cells may be absent, and the thrombus is colourless or yellowish-white. In most thrombi the white cells are present in a much larger proportion than in normal blood. When a thrombus occupies the place where coagulation began, it is called ft primitive throm- bus ; when it gradually extends from this point along the vessel, an extension or produced thrombus. This extension usually proceeds along the vessel to its junction with a largv THROMBOSIS. 1827 branch, into which the thrombus may often be teen to project with a rounded extremity, and this, by obstructing the blood-current, may again form the starting point for a fresh extension. Structurally, thrombi maybe distinguished as laminated, and non- laminated or uniform. The former result from a process of continuous, the latter from one of intermitting coagulation. In laminated thrombi there is often a layer of white blood-cells between the laminae, due to the ten- dency which these bodies have to wander out of the clot. Thrombi may further be distinguished into ■parietal, or those which adhere to some part of the wall of the vessel ; and obliterating, or those which complet ely fill the vessel. Parietal thrombi are generally nearly colourless, and are due to some roughness or other change in the lining membrane. Obliterating thrombi, which are at first coloured, are produced by the sudden coagulation of the blood; the thrombus thus formed shrinks, and leaves a space which again fills with blood ; this again coagulates, and so complete obstruction of the vessel is effected. A post-mortem coagulum never completely fills the vessel, as after the shrinking process has taken place, there is no further supply of blood to coagulate. Other points of distinction between post-mortem coagula and thrombi are these — the former are never laminated; they are looser in texture, and moister ; they do not adhere so closely to the wall of the vessel ; and though they may be either coloured or colourless, they never present the appearances due to the subsequent changes which take place in thrombi. Changes in Thrombi. — The first change ob- served after the thrombus has shrunken and become denser is decolorisation. The colouring matter dissolves out of the blood-globules, be- comes diffused, and is transformed. The throm- bus accordingly changes from dark red to tawny, and finally to a yellowish-white ; and at the same time it loses its soft elastic texture, and becomes tougher, denser, or even somewhat friable. The subsequent changes vary. First, a process of shrinking and drying up may occur, by which the thrombus gets converted into a tough leathery substance, which may even become calcified, and in this way are formed the concretions in veins known as phleboliths. Secondly, softening may take place; this may either be due to a process of molecular dis- integration, or more rarely to suppuration. In the former case the thrombus liquefies into a milky fluid, consisting of an oily and granular detritus, the process beginning in the centre. In the heart this change often occurs in the layers of fibrin entangled among the trabeculae, or in the globular masses which sometimes project from them into the cavities, thus giving rise to the formation of cysts. Suppuration is occasionally seen in the thrombi of veins surrounded by, or leading from, inflamed parts ; a multiplication of leuco- cytes takes place in the thrombus, either by pro- liferation or immigration, and the whole softens down into a purulent fluid. In these cases the wall cf the vein itself is always inflamed. These softened and broken-down thrombi are a rommon cause of embolisms. Lastly, the thrombus may become organised. Organisation has been chiefly studied in wounds and ligatures of arteries and veins, and the ap- pearances have been very differently interpreted by different observers. According to one opinion the thrombus itself becomes organised ; the white blood-cells contained in it, or immigrant leuco- cytes from the vasa vasorum, as proved by in- cluding a portion of vein between two ligatures and impregnating the blood with vermilion (Bubnoff), become converted into stellate con- nective-tissue corpuscles, with interlacing pro- cesses ; new vessels permeate the clot along the line of the stellate processes from the unob- structed portion of the artery or vein, and form anastomoses with offshoots from the vasa vaso- rum perforating the tunica intima, which disap- pears; and thus a vascular reticulated connective tissue is formed, in the meshes of which lie the remains of the red blood-globules and fibrin of the clot. The progressive dilatation of the newly formed vessels gradually renders the thrombus cavernous; and finally, by their coalescence, it en- tirely disappears, and the vessel again becomes pervious. Cornil and Ranvier dispute the cor- rectness of these observations, and assert that the appearances are really due to the out- growth, from the tunica intima, of vascular gra- nulations penetrating the thrombus, which gra- dually disappears without taking any part in the formation of the reticulated connective tissue which is found occupying its place. Pathology. — According to the views of coa- gulation now entertained, the formation of fibrin is due to the interaction of two substances pre- sent in the liquor sanguinis : fibrinogen, and fibrinoplastin or paraglobulin, under the influ- ence of a third substance which acts analogously to a ferment. The fibrinoplastin and the fer- ment are contained in the white blood-cells, and are, in all probability, derived from these bodies, for in all spontaneously eoagulable fluids white blood-cells are present, and where they are ab- sent coagulation does not take place. Even in the blood, when coagulation is retarded, as by keeping horse’s blood in a tube formed of the excised jugular vein, it is found that the upper layers, from which the white cells have subsided, coagulate very imperfectly, while a firm clot forms in the lower layers, where the corpuscles are numerous. The white blood-cells also are often seen to form the starting point from which the threads of fibrin form. The nature of the process of coagulation is still very obscure. It does not appear to resemble a chemical precipitate, and it is very doubtful whether the fibrinoplastin actually enters into the formation of the clot ; for in artificial coagu- lation, effected by adding fibrinoplastin to fibrin- ogen, the weight of the clot is always less than that of the fibrinoplastin used. As all the three factors of coagulation, fibrin- ogen, fibrinoplastin, and the ferment, are present in theliquorsanguinis.it is evident that there must be some restraining influence which pre- vents coagulation ; and the cause of thrombosis must be looked for in the removal or weakening of this influence. According to Briicke, contact with the healthy lining membrane of the vessels prevents the bloodfrom coagulating; consequently THROMBOSIS. 1628 any structural change in this membrane is liable to cause thrombosis. The presence of a foreign body produces the same effect, and a thrombus itself acts as a foreign body. Retardation or arrest of the blood-current is also a common cause of thrombosis. Loss of motion in itself tends to retard coagulation, but free circulation is ne- cessary for the maintenance of the nutrition and integrity both of the vessels and the white blood- cells ; hence stagnation tends to cause thrombosis by removing the restraining influence of the healthy vascular wall, and also by setting free fibrinoplastin from the white corpuscles ; more- over, the motion of the blood maintains the contact between each particle and the lining membrane of the vessels, and so prevents coagu- lation. The principal causes, therefore, of thrombosis are alterations in the lining membrane of the vessels, and retardation or arrest of the circula- tion ; to these may be added the presence of foreign bodies, and probably also the microzymes of septic processes. Hyperinosis, or increase in the constituents of the fibrin, and diminished fluidity, as in cho- lera, can only be regarded as predisposing causes requiring retardation of the circulation to take effect. Retardation of the circulation being one of the most important causes of thrombosis, we find, as might be expected, that its most frequent seat is the veins, where the circulation is natu- rally feeble. Varieties.— 1. Venous . — The principal causes of venous thrombosis are two. The first of these is wounds and injuries of veins, where the formation of thrombi is the natural way of arresting haemorrhage. The thrombus may extend along the vein from its primitive seat, and thus cause blocking of venous trunks at a distance from the site of the injury. This is often seen after parturition, when throm- bosis of the uterine sinuses may extend to the iliac and femoral veins. Secondly, inflammation of the coats of the vein, by altering the condition of the lining membrane, may cause thrombosis ; but in many cases of phlebitis the thrombosis is the primary change, and the inflammation of the coats is set up by it. Other causes of venous thrombosis are pressure on the veins, dilatation, and arrest of the circulation in the capillary ter- ritory of the vein, as from embolism or inflam- matory stasis. Hence we occasionally find the veins leading from inflamed organs thrombosed. Lastly, thrombosis of the veins is not unfre- quently due to retardation of the circulation, owing to failure of the propelling power of the heart, in cases of marasmus and exhausting dis- eases. These thrombi are most frequently met with in the veins of the lower extremities and pelvis, next in the sinuses of the dura mater. 2. Arterial . — Apart from wounds and in- juries, thrombosis of the arteries is most fre- quently caused by degeneration of the lining membrane, giving rise to rough surfaces to which the coagula attach themselves, and to aneurisms in which the coagulation is due to stagnation ; aneurysmal thrombi are commonly laminated. Arrest of the circulation from any cause, as embolism, will also cause thrombosis. Thrombosis of the larger arteries, without alteratioh of the lining membrane, is most pro- bably always the result of embolism, the embolus being usually derived in the systemic arteries from thrombi of the heart, the result of asystole. Of this nature are the cases of thrombosis and gangrene of the extremities which sometimes occur in fevers and wasting diseases. Throm- bosis of the pulmonary artery may be produced in a similar manner, or the embolus may be de- rived from a thrombus in the veins. 3. Cardiac . — Thrombosis of the heart may be caused by endocarditis, the thrombi then usually forming caps to the inflammatory outgrowths or vegetations. Large thrombi are most commonly caused by imperfect emptying of the cavities and consequent stagnation, due either to stenosis of the orifices, or to want of tone in the muscular walls. Thrombi may also extend into the right auricle from the venae cavae. 4. Capillary . — Capillary thrombosis may be due to extension from the veins and arteries, or it may be primary. In the Latter case the con- ditions which cause it are imperfectly known ; aggregations of white blood-globules will often block the capillaries and small vessels in the manner of thrombi, but this condition is usually transient, and not attended by true coagulation. The inhibitory influence of the lining membrane of the blood-vessels is so powerful in the capil- laries that, as long as their structure remains intact, coagulation rarely takes place. Thus inflammatory stasis, or obstruction of the afferent artery by embolism, may exist for a considerable time without the blood in the capillaries coagu- lating. 5. Lymphatic . — Thrombosis of the lymphatics has been chiefly observed in the puerperal condi- tion, in the lymphatics of the uterus and their continuations to the lumbar glands, and in rare instances in the thoracic duct. It is probably due to alteration in the constitution of the lymph, normal lymph having very slightly coagulable properties. Symptoms. — The symptoms of thrombosis are those of arrest of the circulation, and they differ according to the vessel affected. In the veins, if a main trunk be obstructed, so that a sufficient collateral circulation cannot be rapidly estab- lished, the effects produced are passive hyper- eemia, venous dilatation, transudation of serum, and sometimes haemorrhage in the territory of the blocked vein, with enlargement of the colla- teral channels. In extreme cases moist gangrene may result. Thus, according to the vein affected, we may have anasarca of an extremity, ascites, or hydrothorax ; haemorrhage from the stomach, intestine, or kidney ; cedema and cyanosis of the face and neck ; and so on. The symptoms of arterial dirombosis are in the main those which have already been described as occurring when the artery is blocked by embolism (see Em- bolism). Coagulation of blood in the arteries of the heart is described in a separate article. See Heart, Thrombosis of. Treatment. — The treatment of thrombosis varies according to the seat of the process. See Aorta, Diseases of ; Braxx, Vessels of, Diseases of; Heart, Tkrombosisof; and Yeixs, Diseasesof. W. Cayley. THRUSH. THRUSH — Synon. : Fr. Aphthe; Ger. Mu n dscJiwa mm . Definition. — The popular name given to aphthae in the mouth, and to morbid states resembling them. It is convenient to confine the term aphtha to cases in which the oidium albi- cans is present ; but the term thrush must be allowed a wider signification, and must be taken to include also many cases of simple stomatitis. See Aphthie ; and Stomatitis. Desceiption. — Thrush is characterised by small white flakes scattered over the tongue and the mucosa of the mouth and lips. Occasionally the disease spreads down the oesophagus. It is frequently met with in infancy, and in adults it occurs in the last stages of wasting complaints. The white flakes are composed chiefly of exuda- tion from a small spot of subjacent mucosa, which is acutely inflamed. Thus it is that they are surrounded by a red areola, and that, if they are picked off, they are speedily reproduced. In the cases which are, strictly speaking, aphthous, the white flakes may readily be transferred from the infant’s mouth to the mother’s nipple. The minute spots of inflammation have a tendency to occur in clusters, and in successive crops, some fading as others appear. They are attended by local heat and tenderness, so that in a severe case the infant can hardly take the breast ; and with this there may be feverishness, drowsiness, and perhaps diarrhoea. The white flakes are sometimes so abundant as to coalesce, and form large patches of fur. When these flakes are shed, or are removed, small ulcers are left be- hind, which are flat and circular or oval, with inflamed bases, and a thin yellowish or greyish slough. Their margins are well-defined, but without thickening or elevation. They are always attended by increased heat and congestion of the mucosa, together with active gastric or intes- tinal disturbance ; and there is fever of a more or less atonic kind. Treatment. — Thrush in infancy is usually due either to improper or insufficient food, giving rise to an acid state of the secretions of the mouth; and the attention of the medical man should, therefore, be directed particularly to this sub- ject. If the infant is being nursed by its mother, inquiry should be made as to her health, for the disease may perhaps arise, or be kept up, by a morbid condition of the milk. If there be no reason to suspect this, the child should be con- fined entirely to the breast, and this should be given only at stated intervals. If the infant is being brought up by hand, the most careful attention should be paid, not merely to the milk or artificial food with which it is supplied, but also to the cleanliness of the vessels in which it is kept, and of the bottles or spoons in which it is given. If, notwithstanding every precaution, artificial feeding does not agree with the child, a wet-nurse must be procured. Attention to these primary rules of health sometimes has an almost magical influence in removing the complaint. At the same time the child’s bowels should be regu- lated by a slight aperient ; while a little of the glycerinum boracis, or a powder composed of borax and sugar, should be laid upon the tongue every hour or two. If ulcers have formed, they should be dusted with powdered alum, or touched THYMUS GLAND, DISEASES OF. 1629 with a strong solution of nitrate of silver or of sulphate of copper, or with the solid caustics. In cases arising from weakness caused by insuffi- cient nourishment, two or three drops of brandy given in the food, four or five times a day, has often a marked effect in checking the disease. When the child begins to amend, a change of air will probably hasten its recovery. When thrush occurs in old people, or as an accompaniment of some wasting disease, it is less easy to destroy the microscopic fungus, and to prevent its reproduction. Still much may be done to regulate the prima via, to support the powers of nature, and to arrest the spread of the aphthous patches. For this purpose, Sir William Jenner recommends a lotion of sulphite of soda (5j to the 5] of water). It should be applied frequently with a camel’s-hair brush, or the mouth should be rinsed with it. A weak solution of carbolic acid may be used in the same way; or a solution of sulphurous acid, in the propor- tion of one part of the acid to six of water. W. Fairlie Clarke. THYMUS GLAND, Diseases of. — S y- non.: Fr. Maladies da Thymus-, Ger. Krank- heiten der Thymusdriise. In consequence of the atrophy of this organ in early life, little notice has been taken of it, either in its healthy state or when affected by disease. According to the researches of Mr. Simon, the thymus gland reaches maturity in the child at the age of two years ; it remains more or less perfect up to eight to twelve years ; then it rapidly decreases in size, the glandular sub- stance becoming converted into fat ; and at the age of twenty years there is no trace of the organ left. At birth its weight is in proportion to the weight of the child. Taking 22 grs. to the lb. to be the usual proportion, 100 to 200 grains will be the weight of the gland at birth. From investigations made on young and hybernating animals, it appears that the greater the ratio of respiratory and muscular activity, the speedier is the decline of the gland. Consequently Mr. Simon thinks ‘ the thymus fulfils its use as a sinking fund of movement in the service of respiration.’ Summary of Diseases. — Instances both of ex- cessive growth, and of prolonged existence of the thymus have been reported. A list of such cases was published by the late Mr. Alexander Bruce. In a healthy boy, aged fourteen, killed by an accident, the gland was found to weigh 620 grains ; in a lunatic, aged twenty-one years, 300 grains; in a woman, aged twenty-nine years, 51 grains ; in another woman, aged forty years, 30 grains. Krause mentions three cases, aged twenty-five, twenty-five, and twenty years, wherein the glands weighed respectively 292, 380, and 356 grains. The actual diseases of the thymus gland which have been recorded are:— (1) Inflammation, fol- lowed by suppuration. In one such instance the abscess burst into the trachea. Syphilis has been stated to be a cause of embryonic inflammation of the gland. (2) Fatty degeneration of the gland. (3) Tubercular deposit in the gland. (4) Malig- nant disease. (5) Enlargement ot the gland in leuc-ccythamia, and in (6) lymphadenoma. ( 7 ) 1630 THYMUS GLAND, DISEASES OF. Calculi hare been found imbedded in the gland- eubstance. Cases have been reported of children dying from suffocation, with no other cause assigned for their death than pressure on the trachea from an enlarged thymus gland. Considering the position of the gland, between the sternum and the windpipe, and the small power of re- sistance possessed by the rings cf the trachea during infantile life, an enlarged thymus may be a possible cause of suffocation. In connection with an enlargement of the gland, a respiratory affection called ‘ thymic asthma’ has been recognised. It is also named after two physicians, ‘ Kopp’s,’ or ‘Millar’s asthma’ ; but the majority of writers on diseases of children deny the existence of such a malady. Pugin Thornton. THYROID GLAND, Diseases of. Synon. : Fr. Maladies de la Glande thyreoide-, Ger. Kranliheiten der Schilddriise. Goitre is the most common affection of the thyroid ; and associated with it, but as a less prevalent disease, is exophthalmic goitre. See Goitre ; and Exophthalmic Goitre. The diseases of the thyroid gland other than goitre are rare. They comprise : — 1. Acute In- flammation or thyroiditis. 2. Hydatid cysts. 3. Calcareous deposit in the gland. 4. Can- cer. 5. Sarcoma. Patty degeneration of the thyroid is of doubtful occurrence. Enlargement of the gland occasionally occurs in leucoeythae- mia, and in lymphadenoma. The gland is some- times absent, or an accessory lobe may be present. It may degenerate in old people. The following affections alone require brief notice. 1. Acute Inflammation. — Synon.: Thyroi- ditis. — This disease occurs in three forms : — (a) idiopathic ; ( b ) metastatic ; and (c) traumatic. (apillse which are TONGUE, DISEASES OF. thiefly affected, and the disease never spreads further back than the line of the circumvallate papillae. Sometimes the papilla;, though enor- mously enlarged, and overloaded with epithe- lium, retain their separate form; at other times they are welded together into smooth, hard, masses. The tylotic coating presents a silvery or snow-white appearance, quite different from any ordinary fur. When the disease has once shown itself, it is very persistent. Its essential nature appears to be that of a chronic inflam- mation. Sometimes the patches are irregular in form and in situation ; at other times they have a remarkably symmetrical arrangement. The disease appears to have a strong tendency to become cancerous, though it may last for twenty or thirty years before it passes into that stage. Treatment. — If the patch be small, it should be excised ; and when the disease has reached the epitheliomatous stage, it must be dealt with as a cancer. But between the early and the late stage the less it is meddled with the better. If any local treatment be used, it should be of a mild and soothing kind. The use of strong caustics, as well as all parings and scrapings, should be forbidden. Mercury, arsenic, or iodide of potassium may be tried, but little dependence can be placed on them. They may produce some amendment, but they cannot effect a cure. Our best hope is to guard the tongue against all sources of irritation, and to regulate and improve the general health. 11. Ulceration. — Ulcers of the tongue, as already said, maybe syphilitic or cancerous, but they may also be of simple origin. Simple ulcer- ation is usually associated with dyspepsia. Dys- peptic ulcers are apt to occur in ill-fed children, and also in adults who habitually eat and drink freely. Such ulcers are generally situated upon the sides or upper surface near the tip ; but not ■•infrequently they are on the frEenum. They are encircled by an inflamed margin ; shallow ; their bases being flat and covered with a greyish slough. They are very sensitive to the touch, and painful when the organ is moved. Some- times there is offensive discharge, with a good deal of swelling of the sublingual and sub- maxillary glands. Simple ulceration is often excited by external causes, acting upon the tongue at a time when its nutrition is impaired by faulty digestion. Thus it may be bitten, or scalded, or wounded with knives or forks, or irritated by the sharp point of a tooth, or by a rough accumulation of tartar. Treatment. — Attention should at once be directed to the digestive organs ; and, after a cholagogue purgative has been given, a course of alterative medicine should be ordered, to be followed by stomachics and tonics. Arsenic sometimes acts like a charm. Whatever dys- peptic symptoms are present must bo met by their appropriate remedies, for example, dilute hydrocyanic acid, bismuth, chlorate cf potash, or bromide of potassium. As a local application, there is nothing better than nitrate of silver. In the case of ulceration following injury, the sore should be touched with caustic, and the patient’s general health regulated and supported. W. Fatbits Ct-abke. TONICS. 1645 TONIC (toros, tension). — A distinctive term used in reference to the nature of spasms, which are usually divided into two classes, namely, tonic spasms and clonic spasms-, the former be- ing those in which the muscles concerned remain in a state of continuous rather than in one of intermittent contraction. See Spasm. TONICS (rivos, tension, tone). — Synon. : Fr. Toniqucs ; Ger. Tonische Mittel. Definition. — Therapeutic agents which im- part permanent strength to the body or its parts. Enumeration. — Amongst the most typical medicinal tonics, which impart a feeling of strength, are iron, nux vomica, quinine, and vegetable hitters. As the strength of the body generally depends on the proper action of its various parts, tonics have been subdivided into those which have an especial action on the blood, circulation, digestion, and nervous system. 1. Blood Tonics. — Cod-liver oil and other fats, and iron and its salts, are the most impor- tant of this group of tonic remedies. Perhaps also phosphate of lime, and salts of potash and soda should be included. Light, fresh air, good food, bathing, and exercise are valuable adjuncts. 2. Vascular Tonics. — The principal vascular tonics are nux vomica and strychnia, digitalis, hellebore, erythrophleum, and squill. The local application of warmth and cold, friction, and massage increase the effect of these medi- cines. 3. Gastric Tonies. — Small doses of sulphuric, nitric, and hydrochloric acids, small doses of arsenic, small doses of alum, aloes, small doses of bismuth, bitter beer, chamomile, cinchona, casparia, cascarilla, small doses of copper, ca- lumba, hops, gentian, orange and lemon peel, quassia, rhubarb, small doses of silver, strychnia, generally vegetable bitters, and small doses of zinc — all impart vigour to the gastric function. Valuable adjuncts are pepsin and hydrochloric acid. 4. Intestinal Tonics. — These are chiefly nux vomica, belladonna, rhubarb, the mineral acids and metallic salts just mentioned, and astrin- gents. 5. Nervine Tonics. — Nux vomica and strych- nia, cinchona and its alkaloids, coca, phospho- rus, arsenic and its compounds, salts of iron, zinc, copper, and silver, are all included under this head. The tonics which act especially on other parts of the system increase also the power of the nervous system, and act indirectly as nervous tonics. Action. — The derivation of the word * tonics ’ indicates the nature of their action. When a person feels limp and weak, and unfit for ex- ertion, like a relaxed bow-string, tonics restore the energy and strength, and render him again fit for work, like, as it were, a re-tightened bow. The exact mode in which tonics act is not yet perfectly ascertained, but in all probability they increase the functions of the different parts of the body by aiding tissue-change, either by in- creased nutrition, increased tissue-metaholism, more rapid removal of waste, or possibly by all three taken together. Uses. — Tonics are employed in conditions of debility, either of the body generally or of it? 1G46 TONICS. different parts, the selection of each depending upon the part of the body affected. In cases ■where the malnutrition of the body appears to be dependent on tte want of the proper constituents of the blood, as in anaemia, struma, or general debility, without any affec- tion of a particular organ, blood tonics, in- cluding iron, cod-liver oil, and phosphates are employed ; and these are also useful where impoverishment of the blood is due to a de- finite constitutional disease, such as phthisis, or Bright’s disease. Where enfeeblement of the stomach appears to be present, as shown by loss of appetite and such signs of imperfect diges- tion as flatulence, weight, and pain after eating, gastric tonics are used. Should its muscular coat be feeble or inactive, as shown by tendency to dilatation, and splashing of the contents on movement, strychnia is especially indicated, and galvanism or systematic kneading may be also employed. Where the stomach is too debilitated to respond sufficiently to this form of treatment, as after long-continued gastric catarrh, or in old age, its work must be partly done for it, and then such substances as hydrochloric acid and pepsin are useful. When the muscular move- ments of the intestine are sluggish, as indicated by constipation, and by a tendency to the dis- tension of the bowel with gas, nux vomica and belladonna may be given ; and when its mucous membrane appears to be relaxed and flabby, and secreting too profusely, the mineral acids, as- tringents, and metallic salts may be of much service. When the pulse is soft and feeble, and there is a tendency to vascular dilatation, either general or local, as shown by local congestion and oedema of dependent parts, or by drowsi- ness in tli9 upright position and sleeplessness in the recumbent posture, vascular ionics are serviceable. Nervine tonics are used where the nervous functions are imperfectly performed, as shown by dulness, loss of memory, incapacity for work, languor, or tendency to spasm, as in chorea, and also in paralysis. As the functions of this system depend very greatly upon the quality of the blood with which the nervous system is supplied, and on the rapidity of the circulation, the other tonics frequently require to he given in addition to nervous tonics. In administering tonics, care should always he taken to ascertain that the case is suitable, for in very many cases of apparent debilily the im- perfect functional activity of the body or of its parts does not depend upon insufficient nutri- tion, but upon imperfect removal of the pro- ducts of waste. The proper treatment iu these cases is not to give tonics, hut to remove the waste products by cholagogues, purgatives, and diuretics. T. Lauder Brtjnton. TONSILS, Diseases of. — Synon. : Fr. Maladies des Amygdales; Ger. KranJcheitcn der Mandeln. These two glands, situated between the ante- rior and posterior pillars of the fauces, are unusually liable to participate in all affections of the throat, both from their peculiar structure and from their position. An evident example of the truth of this statement is to he found in that TONSILS, DISEASES OF. every-day affection, a common cold, in which the tonsils usually exhibit symptoms of the general catarrh. They are also involved in diphtheria, scarlatina, and syphilis ; they may be the seat of ulcers, or even gangrene ; and they may be 'nvolved in malignant disease. The following affections demand special notice, namely, (1) acute inflammation; (2) follicular catarrh.; (3) hypertrophy ; and (4) tonsillar calculus. 1. Acute Inflammation. — Synon. : Tonsil- litis; Cynanclic Tonsillaris-, Amygdalitis', Quinsy. ^Etiology. — This affection is most commonly met with in young persons, in the damp weather of spring and autumn, and one attack seems to predispose to another. Exposure to damp, cold, and wet is generally regarded as sufficient to excite this disorder. Symptoms. — These usually set in with indica- tions of fever. The patient becomes restless, irritable, and hot (the temperature in very acute cases rising to 104° or 105°); complains of head- ache and general weariness ; and may be delirious at night, especially if 3’oimg.' The tongue is covered with a thick, heavy, yellowish coating ; the other symptoms of oral catarrh are present ; the breath is unpleasant ; and salivation is com- plained of. The patient loses the power of opening the mouth to any extent. ; and swallowing is at- tended with much pain and great difficulty, the food not unfrequently returning through the nose. The tone of the voice is altered, becoming thick, guttural, and nasal. The breathing is not, as a rule, impeded, but the patient snores during sleep ; and W’hen he is awake, respiration may be noisy. Occasionally he becomes deaf. The first indica- tion of uneasiness in the throat is a complaint of pricking and dryness in the region of the tonsil, soon passing on to actual soreness, and pain of a dull character, which shoots up towards the ear on the affected side. Externally, behind the angle of the lower jaw, considerable swelling is observed, firm, and exceedingly painful to touch. On examination of the parts internally, one ton- sil, rarely both, will he found to he greatly swol- len, of a bright red colour, perhaps with patches of yellowish secretion adherent to its surface. The soft palate is also greatly swollen, red, cedematous, and falling inwards to the middle of the mouth. The uvula likewise partakes of the general infiltration, and is usually found pushed to the healthy side, and not unfrequently adhe- rent to the tonsil. This state of matters con- tinues for four or five days, increasing in severity, and then it may gradually begin to subside, the inflammation passing off ; and in ten days to a fortnight the patient is able to resume his usual employment. Quite as frequent a termination as resolution is suppuration and formation of abscess in the tonsil. In such a case the symptoms are generally aggravated before the formation of the pus, and more decided pain and throbbing are complained of, extending upwards to the ear. The abscess may burst spontaneously and unex- pectedly. After the evacuation of the pus, which is often fetid, convalescence is speedy. Treatment. — If a case of quinsy is seen at the very outset, an attempt may be made to abort the disease. This, though seldom successful, may be tried by giving an emetic, or by administer- ing tincture of aconite every hour in drop doses ; TONSILS, DISEASES OF. er alum or nitrate of silver may be applied to the inflamed throat. If not seen for two days, or if these abortive measures fail, the patient should be confined to bed ; hot poultices kept constantly round the throat ; steam inhaled as often as practicable ; and gargles of warm milk and water made use of every hour. A brisk saline purga- tive should be given. Ice, if found grateful, may be allowed at discretion. Such diet as the patient can be persuaded to swallow should be ordered, of course in liquid or rather semi-solid form. Stimulants, if called for, must be ad- ministered. Tonics, such as chlorate of potash and iron, or quinine and iron, will be needed when convalescence sets in. If an abscess should form, it must be evacuated by means of a well-protected bistoury ; and astringent gargles should be made use of for some time after con- valescence is established. 2. Follicular Catarrh. — The office of the tonsils is to secrete a lubricating fluid to the bolus of food as it passes into the pharynx, as well as to moisten the fauces. Occasionally we meet with cases where this secretion is altered in character or in quantity. And this may be the result either of a simple catarrh of the ton- sils ; or of thickening of the interstitial tissue of the gland, compressing the follicles, and thus interfering with the free outflow of the secretion. The appearance of the tonsil in such a condition is at times mistaken for a diphtheritic state, in consequence of the whitish patches of secretion deposited upon them. In this catarrhal affection it will be observed that there is no tendency to the formation of a true membrane as in diph- theria, the deposit assuming a pultaceous form, being readily removed, its borders being well- defined, and it is seen to proceed from the fol- licles of the tonsil. As to the treatment of this condition, all that is wanted is a stimulant gargle, probably some general tonic, and the constant use of chlorate of potash — a convenient form of administering which is found in Wyeth's lozenges of the compressed salt. 3. Hypertrophy — This condition of the ton- sils is met with both in the young and in the adult. In the case of the former, there seems to be a hereditary tendency in some families, the tonsils becoming immensely large even as early as the second year. In such there is usually some scrofulous habit of body. In the adult this condition is more frequently the result of repeated angina, which induces a perma- nent thickening of the structures of the tonsils, whereby the secretion,, no longer finding free exit, distends the follicles, thus setting up a low form of inflammation, which results in hyper- trophy of the gland. This condition is free from pain. "When the interstitial tissue becomes much thickened and indurated, there occurs what is sometimes described as ‘ scirrhus ’ of the tonsil. The symptoms indicative of hypertrophy are snoring during sleep ; obstruction to the breath- ing, in consequence of which the mouth is always open night and day; slight impediment to swal- lowing, with a sense of something permanently needing to he swallowed; some degree of deaf- ness ; and thickness of voice or snuffling. These are all greatly aggravated when catarrh is super- added ; and persons having enlarged tonsils are TORSION. 164? specially liable to attacks of angina, and to severe throat-symptoms when any disorder overtakes them, in which the throat is more than ordi- narily the point in which the disease centres itself, for example, scarlatina. Treatment. — The treatment in cases of scro- fulous children consists in the administration of plentiful nourishment, cod-liver oil, iodide of iron, and other drugs of which iodine forms the chief constituent. The bromides of ammonium and potassium also enjoy tbe reputation of re- ducing enlarged tonsils. Locally, they should be treated with iodine dissolved in glycerine, or with the simple tincture, every other day. They should not be removed in children under the age of puberty, as frequently after that period they decrease spontaneously. In adults, if they cause much inconvenience, they should be ex- cised, but not otherwise. 4. Tonsillary Calculus. — When two or three neighbouring follicles of a tonsil, as well as the interstitial tissue, are destroyed, the cavity thereby created pours out a greatly altered se- cretion, the product varying in consistence from a creamy pulp up to a calcareous deposit, of a white or yellow colour. This, on examination, has been found to consist of albumen, phosphate, carbonate, and oxalate of lime, with some animal matter. Some authors regard these calculi as the ‘ resolution of tuberculous deposits in the tonsils, which subsequently give rise to inflam- mation, suppuration, and ejection.’ Claud Muirhead. TOOTHACHE.— Synon. : Fr. Odontalgic; Mai de Dents ; Ger. Zaknwek.- — Pain in connec- tion with the teeth. See Teeth, Diseases of. TOOTH-HASH. See Dentition, Disorders of. TOPHUS ( tophus , sand). — A term for the concretions which are met with in gout, in con- nection with the joints and other structures. It is also sometimes applied to gravel, and to the collection of tartar on the teeth. See Gout. TOPICATi ( vo7ros , a place). See Local. TORMINA (Lat. griping). — This word is applied to severe griping or colicky pains in the abdomen, due to flatus and other causes. See Colic ; and Intestines, Diseases of. TOEPOH (Lat. numbness). — Synon. : Fr. Torpeur ; Ger. 1'orpiditat. — A condition of in activity, bodily and mental, which may be met with in certain brain-diseases or febrile states, more especially in aged persons. The cerebral condition associated with torpor is an unnatural state of consciousness, closely allied to that known as stupor. TORQUAY, in South Devon. — A mild, rather relaxing, and sedative marine climate. Sheltered from W., N., and E. winds. Mean winter temperature 44° Fahr. Sec Climate, Treatment of Disease by. TORSION ( iorquco , I twist).— This word signifies a twisting, and is used in the following associations ; — 1. In relation to certain hollow organs, it in dieates a form of displacement in which an organ 1648 TORSION, is twisted on itself, a condition especially noticed in connection with, the intestines. It gives rise to more or less narrowing of the canal, and may close it completely, so as to cause absolute obstruction. Torsion also interferes with the circulation, thus leading to congestion, inflam- mation, or ultimately even to gangrene. See Intestinal Obstruction. 2. As a method of treatment, torsion is em- ployed in checking arterial haemorrhage, the ends of the bleeding artery being seized by the aid of suitable forceps, and twisted. It is chiefly used in bleeding from small arteries, but may prove efficient even when arteries of some, size are the source of the haemorrhage. Frederick T. Roberts. TORTICOLLIS ( tortum , twisted, and col- lum, the neck). — A synonym for wryneck. See Wryneck. TORTJLA. — Description. — Torula is a form of microscopic fungus, belonging to the order Saccharomycetes, of the class Protophyta , which is the lowest division of Tkallophyta (Sachs). It consists of round or ovoid cells, of an average diameter of about inch, without nuclei, but composed of masses of vacuolated protoplasm, confined within a definite cell-wall. Occasionally they are free, but they are frequently associated into branching chains. See Microscope in Medi- cine. Sources. — Vinous, acetous, and other fermen- tations are due to the presence of low or- ganisms, of which the ‘ yeast plant,’ Mycoderma or Torula ccrivisiee, is the best known. Certain varieties of torula are of constant occurrence in the alimentary canal, and would seem to be nor- mally associated with intestinal digestion. In those cases of vomiting where the ejected matters ferment, torulae are always to be found, together with sarcinm. These bodies are also of frequent occurrence in diabetic urine, if left standing ; but they have also been found in non-saccharine urine. The pathological significance of torula, if any, is not known. W. H. Axechin. TOUCH, Disorders of. — Synon. : Fr. Trou- bles du Tact ; Ger. Stohrungcn des Tastsinncs. — The sense of touch may be considered as a com- pound of four distinct senses, namely, those of contact., pain, temperature, and muscular acti- vity; and it is not necessary that all of these should be affected simultaneously or in an equal degree. Sometimes but one is the seat of dis- order, and occasionally only one escapes. The lesion producing tactile disorder may be in any part of the sensory apparatus — in the peripheral end-organ in the skin which receives impres- sions, in the trunk of the nerve which conveys them, or in the central ganglion, the reaction in which is represented in consciousness as feeling. For the most part disorders of touch must con- sist either in a defective or in an unnaturally heightened reaction to impressions — conditions which are termed respectively ancesthcsia and hyperesthesia. Rut there are besides certain abnormalities of sensation which cannot be re- ferred to either of these categories, as, for example, when a touch causes a sensation of burning, or the electric current is felt as some- TOUCH, DISORDERS OF. thing cold, and in these circumstances the term paresthesia is used. 1. Increased sensibility. — Description. — It is doubtfulwhether the sense of touch proper, the power of tactile discrimination, is ever mor- bidly increased, except possibly in certain cases of hysteria and mental disorder. The term hyper- esthesia would be properly applied to such a con- dition instead of, as it is more commonly used, tc excess of sensibility to painful impressions, which is perhaps better called hyperalgesia. In cuta- neous hyperalgesia even a light touch upon the skin produces more or less exquisite pain. The patient often cannot even wash the skin, which is described as feeling raw or sore to the touch. The symptom frequently occurs in connection with neuralgia (especially of the trigeminal nerve), and in hysteria, as well as in the various forms of local inflammation. It may precede by some days the characteristic pains of neuralgia ; is often associated with excess of sensibility to heat and cold ; and usually with diminution of sensibility of the tactile sense proper. It is seen in its severest form in connection with gunshot injuries of nerves. There may be heightened sensibility to tem- perature, either as regards heat or cold singly, or in respect to both at the same time. This symptom is observed in connection both with peripheral and central disease, as an accom- paniment of neuritis, as well as of degenerative changes in the cord or cerebral ganglia. It is often, but not always, associated with hyper- algesia.. Heightening of the sense of contact is rarely observed, and is of but little practical import- ance. Perhaps the condition known as ‘ fidgets ' is best explained as depending upon a heightened sense of muscular activity. Treatment. — So far as is practicable, the lesion which is the cause of hyperalgesia, whether peripheral or central, must be discovered and become the subject of treatment. But the symptom itself may be mitigated by appropriate means. Such are the local application of moist heat by fomentation or poultice ; of cold, by means of ice; or, of anodynes, such as veratria ointment somewhat diluted, or atropia ointment ; or the hypodermic injection of morphia (gr. to gr. I). Spongiopiline may be sprinkled with a liniment composed of chloroform one part and belladonna liniment three parts ; or equal pans of ether, sal volatile, laudanum, and eau de Cologne may be applied. A piece of lint soaked in chloroform may be laid upon the painful portion of skin and covered with oiled-silk, or the part may be rubbed with camphor-chloral and vase- line, equal parts ; or painted with amyl-colloid. The application of one pole of the continuous current to the hyperalgesic spots, whilst the other is placed on an indifferent part, will often be of service, the power of bearing a gradually increased strength showing the improvement produced. Hysterical hyperalgesia can some- times be successfully treated by the application of a strong induced current, by means of the wire brush, the patient, if necessary, being placed under the infiuence of ether. 2. Defective sensibility. — D escription.— Cutaneous anaesthesia may result from local ab TOUCH, DISORDERS OF. Btrsction of lieat, as from exposure to a very low temperature. In such a case anaemia is pro- duced, from spastic contraction of blood-vessels, followed by hyperaemia from their secondary relaxation. In the anaemic stage, whilst the other tactile sensations are lowered, that of tempera- ture is heightened. Deficient sensibility may be caused by irritating applications, such as soda used by laundresses, and various chemicals em- ployed in the arts. In such cases there is numb- ness iu the hands and forearms, with a sensation of ‘ going to sleep ’ in the fingers. It may occur in connection with herpes zoster , the skin between the groups of vesicles being often partially anaes- thetic. In lepra ancssthetica, in which there are enlargements of the cutaneous nerves, the senses of temperature and pain are often abolished, and severe burns may take place without being re- cognised. Anaesthesia may be produced by pres- sure upon sensory or mixed nerves, by syphilitic and other growths in adjacent tissues. Nar- cotics, as chloroform and ether, may quell the sense of pain, that of contact being, to a certain extent, retained. Wounds and lacerations of the sensory or mixed nerves, followed by inflamma- tory processes, may, by irritating, cause pain to precede the anaesthesia, arising from the inter- ruption of conductivity in the nerve-fibres. Sim- ple mechanical pressure upon a nerve, if long continued, will often, especially if its nutrition be impaired by constitutional causes, excite a low inflammatory condition. In traumatic cases, as also in lepra ansesthetica and in cases of new growths pressing on the nerve, motor and nu- tritive disturbances are apt to accompany the anaesthesia, the nerve-trunks conveying not only sensory, but also motor, vaso-motor. and trophic fibres. Severe trophic disorder is usually asso- ciated with the anaesthesia occasioned by lesion of the fifth nerve ; and to a less extent with that accompanying trigeminal neuralgia. See Trifacial Nerve, Diseases of. Preceding attacks of neuralgia, the skin of the part about to be affected is often found to be •dniesthetic, and during attacks of sciatica and cervico-brachial neuralgia there is often much diminution of tactile sensibility, severally in the foot and lower part of the leg, and in the fin- gers ; .whilst the skin around the eye may be greatly deficient in tactile sensibility during severe supra-orbital neuralgia. It is important to discriminate anaesthesia of the skin caused by disease of the nervous centres, from that which is of peripheral origin. Cutaneous anaesthesia is occasionally an impor- tant symptom of an approaching cerebral hsemor- rhage. A sudden and increasing numbness is experienced in one half of the face, or in the limbs on one side of the body, which maybe fol- lowed shortly by coma and hemiplegia. An apoplectic seizure usually causes unilateral cuta- neous ansesthesia, which is at first widely dif- fused, owing probably to the disturbance of cir- culation in, and consequent disarrangement of the nervous molecules, which extends at first far beyond the site of the effusion. A few hours cr days usually suffice for the clearing off of this anaesthesia, leaving, however, asubjective feeling of numbness, which may endure for a longer or shorter period. 164K The extent of antesthesia bears no necessary relation to the amount of motor paralysis. It usually affects the paralysed side of the body, but in certain cases of haemorrhage into or other lesion of the medulla oblongata and pons varolii, it may occupy the opposite side. Complete hemi-amesthesia of central origin may persist long after the paralysis of motion has disap- peared, and in such a case a lesion is likely to be found in the outside of the optic thalamus, involving the internal capsule. Occasionally, too, hemi-anoesthesia may from the first be un- accompanied by motor paralysis. Much more frequently, however, cutaneous anaesthesia (ex- cept for the first few hours) is of comparatively slight and transitory character, even in cases where there has been extensive disorganisation of the brain from haemorrhage or softening, and where the resulting paralysis of the muscles is complete and permanent. It may be absent altogether from the first, but this is not common, except in eases of cortical lesion of the brain. Recovery is gradual, and proceeds from the ner- vous centre downwards, the fingers sometimes retaining slight anaesthesia long after the rest of the arm has entirely recovered. Cerebral tu- mours may give rise to cutaneous amesthesia by pressure upon the Gasserian ganglion, or upon the trunk or branches of the fifth nerve as they traverse the floor of the skull. lake the motor paresis or paralysis which may be occasioned at the same time, the loss of sensibility is usually, but not always gradual, tending to increase rather than to diminish as time goes on. It is not usually a prominent symptom in cerebral abscess. Lesion of the spinal cord or its membranes may give rise to cutaneous anaesthesia, which is frequently, in the lower extremities, extensive and complete; but it maybe absent, when — as, for example, in very advanced sclerosis of the antero-lateral columns — there is complete para- plegia. A varying amount of cutaneous anaes- thesia, especially affecting the soles of the feet, is apt to occur in progressive locomotor ataxy. Anaesthesia of spinal origin is usually bilateral ; but it affects that lower extremity alone which is opposite to the one paralysed in its motility, when the causative lesion is limited to one half of the cord. Intercurrent complications from disturbances of circulation, the temperature of the limb, the extension or subsidence of inflam- mation, and the effusion of inflammatory pro- ducts about the posterior roots, as well as the spread of sclerotic changes, may cause the extent and completeness of cutaneous anaesthesia to vary considerably in cases dependent upon spinal cord disease. "Where the lesion lies tolerably high up, tickling the soles of the feet, although quite unfelt by the patient, is able to excite the motor nerves, and produce reflex muscular con- tractions, which the loss of muscular sense pre- vents him from recognising. It is extremelv important to remember that cutaneous anaes- thesia of spinal origin is liable to be associated with bed-sores. In certain cases, where pro- bably trophic and vaso-motor nerves have been included in the lesion, this liability is excessive, and may defy all precautions. Loss of tho sense of muscular aciihty may 104 1650 TOUCH, DISORDERS OF. occur in an isolated form, the other modes of tactile sensibility being unaffected ; or it may be associated with impairment of some or all of them. The symptom is especially notable in progressive locomotor ataxy {see Locomotor Ataxy). It may also occur in connection with paresis resulting from coarse disease of the occi- pital lobe of the cerebrum. Loss of muscular sense may accompany hemiplegia, attended with strongly marked and prolonged anaesthesia, from disease of the optic thalamus. It occurs some- times in hysteria. There is a form of anaesthesia occasionally met with in hysteria which it is important to recognise, so as not to confound it with a somewhat similar condition resulting from disease of the neighbourhood of the optic thala- mus. In this the patient may lose the power of perceiving impressions of contact, temperature, and pain throughout the whole of one lateral half of the body, sharply divided from the sound side by a line passing downwards from the ver- tex to the os pubis. Accompanying this hemi- aiuesthesia, as it is called, there is often ambly- opia and colour-blindness of the corresponding eye, loss of taste and smell, together with ten- derness on deep pressure over the region of the ovary on the same side. In some cases, too, the skin is unnaturally pale and cold, and pricks with a pin are said to be not followed by bleed- ing, which readily takes place in corresponding circumstances on the opposite side of the body. Diagnosis. — As regards both hyperaesthesia and anaesthesia the most important considera- tion, after establishing the existence of either, is as to whether the cause be central or peripheral. It is impossible to do more than indicate the general principles upon which this inquiry is to be conducted. The patient’s history, the condi- tion of viscera and circulation, the existence or not of accompanying paralysis or of modifications of the organs of special sense, will lend im- portant aid. As a rule, the anaesthesia of central origin is much more widely diffused, though less complete, than that dependent upon lesion of nerve-trunks, when it is also often accompanied with localised atrophy of muscles or other trophic disturbance. It is very rare that hemi- ansesthesia of central origin is so complete as the hysterical, and it is not accompanied, like the latter, with tenderness on deep pressure over the ovarian region. There is no doubt that hyper- aesthesia has often been mistaken for localised inflammation, and treated accordingly. The ab- sence of febrile movement, and the fact that it is mainly upon light surface-touching that the ex- quisite tenderness occurs, which fails to be felt when deeper pressure is made, coupled with the history, and a study of the concomitant condi- tion, ought to suffice to prevent all mistakes. Treatment. — Anaesthesia is a symptom of a lesion either in the central nervous system or in a peripheral nerve, and its treatment is bound up with that of the disorder which gives rise to it. But there are many cases in which, apparently as a result of disease, the sensory nerves fail to convey impressions for a considerable time after the lesion which interfered witli their function has been healed. In such circumstances very much good can often be done by electrical treat- ment. The skin, carefully dried, should be TRACHEA, DISEASES OF. brushed over for a few minutes every day with the wire brush, connected with an induction machine ; or the well-wetted rheophore connected with the negative pole of a constant current bat- tery may be slid about over the affected surface, well moistened with hot water. In hysterical anaesthesia the application of various metals (gold, silver, copper, tin, lead, iron — one or other of these), has been found very successful in the hands of Drs. Burq and Charcot, of Paris, and a trial of them in appropriate cases should not be omitted. The metal should be closely applied to the affected skin for ten minutes at a time. Static electricity is a valuable means of com- bating anaesthesia of this kind. The patient, seated on an insulating chair, is connected by a conducting chain with a. frictional electrical ma- chine, and sparks aro drawn from the affected surface. 3. Pareesthesia. — Description. — The varie- ties in disorder of the different kinds of tactile sensibility — touch, pain, temperature, muscular activity — are very numerous. Pinches or pricks with a needle may be felt as touch only, whilst a very light touch with the finger is appreciated as touch. Strong faradaic currents (intolerable to the healthy) may be felt as cold. Heat may be felt as cold, but kept still longer applied may be recognised as heat or warmth. A limb plunged into hot or cold water may get the feel- ing, not of heat or cold, but of pain. To such modifications, as well as to feelings of burning or cold, tingling, creeping of ants, or actual numbness, the term paresthesia is often applied A seamstress may be able to pick up and thread her needle, evincing thereby considerable deli- cacy of sense of contact, and yet be scarcely able to feel a prick of a needle in the finger-tip. Or the sense of contact may be in abeyance, as well as that of pain and temperature, and the movements may be then guided by the sense of muscular activity, aided by sight. T. Buzzard. TOX ffIMIA (to£i kbv. a poison, and aTua. blood). — This word literally signifies poisoning of the blood. It is not employed with any very strict or definite meaning, but most commonly implies blood-poisoning due to some pathological condition within the body itself, in contradis- tinction to that which results from the introduc- tion of the ordinary poisons from without. As illustrations of toxaemic states may be men- tioned pyaemia and septicaemia; uraemia: and acetona-mia, upon which, according to some autho- rities, the comatose condition which precedes the fatal issue in some cases of diabetes depends. The accumulation of bile in the blood, in cases of jaundice, is also a form of toxaemia. The mor- bific agents which are supposed to produce the several infectious and malarial fevers are like- wise regarded by many as originating toxaemic conditions ; as are also those which originate such affections as gout and rheumatism. These subjects will be found discussed under their several headings. Frederick T. Roberts TRACHEA, Diseases of. — S yxox. : Fr. Maladies de la Trachcc ; Ger. Krankheiien dm TRACHEA, DISEASES UF. Lh.Jtroh.re . — The trachea is but little prone to disease, except in association with affections of the larynx, bronchi, and neighbouring parts. The diagnosis and treatment of these several diseases is greatly facilitated by the laryngo- scope. With this instrument a skilful manipu- lator can in many cases examine the trachea in its whole length, and an accurate diagnosis being thus attained, remedies may be applied, and in- struments may be introduced for the removal or destruction of growths, or for other purposes, either through the larynx, or by an artificial opening made in the trachea. The principal morbid affections of the trachea will be discussed _n the following order: — 1. Malformations; 2. Inflammation ; 3. Ulceration and Perforation ; 4, Syphilis; 5. Tuberculosis; 6. Tumours ; 7- Stenosis ; and 8. Foreign bodies. 1. Malformations. — Defects in the develop- ment of the trachea occur as rare causes of the death of newly-born infants. The tube may be short and imperforate ; or communication may exist with the oesophagus. These conditions are necessarily fatal. A fistulous opening through the skin occasionally occurs, giving rise to no serious symptoms. Tracheocele , a hernia of the mucous lining of the trachea, is a rare malformation, easily recognised, which may arise from a con- genital defect, but is more frequently acquired. 2. Inflammation. — Tracheitis, simple, spe- cific, or diphtheritic, may result from the exten- sion of inflammation, either from the larynx above, or from the bronchial tubes below; it is rare except in this connection. Some degree of con- gestion is a usual condition of ordinary catarrh ; and chronic tracheitis is a frequent cause of the cough of old people. See Bronchi, Diseases of ; Diphtheria ; and Lartnx, Diseases of. 3. Ulceration and Perforation. — Ulceration and perforation of the walls of the trachea may result from the pressure of an aneurism, which ends by bursting into the air-passages, where it meets with least resistance ; or from an abscess which has taken a similar course. 4. Syphilis. — Syphilis, in its secondary and tertiary stages, may affect the trachea. In the tertiary stage it gives rise to ulcers, which con- tract in healing, and cause a formidable condition of stricture, to be presently considered. Tracheal syphilis, being in its advanced form so grave a matter, calls for active constitutional treatment before this irremediable stage is reached. 5. Tuberculosis. — Tubercle occurs in con- nection with laryngeal and pulmonary phthisis. When the disease has proceeded to ulceration, it may cause the rare complication of general emphysema, the air being forced into the cel- lular tissue by cough and other expiratory efforts, made when the larynx is closed. 1 fi. Tumours. — (a) Cancer. — Cancer of the trachea as a primary disease is almost unknown, but the organ is frequently affected by the ex- tension of the disease from neighbouring organs. The growth first causes the symptoms of stenosis ; and then, as ulceration proceeds, it gives rise to 1 The writer recently examined post mortem, the body of a child (the patient of Dr. W. it. Craig) which had died of acute tuberculosis, and in which this rare pheno- menon had resulted from an ulcer of the right bronchus, situated immediately beyond the bronchial spur. 1651 expectoration and other symptoms. The diag- nosis will not be difficult. The only treatment available for prolonging life is tracheotomy, if the seat of the disease is high enough to admit of it. (6) on-malignant growths. — Polypi are very rare. The symptoms are those of obstructed breathing, modified by the size and seat of the growth. A certain diagnosis can be attained only by tracheoscopy. Without treatment, a polypus is almost certain to cause death by suffocation, its rate of growth depending on its pathological nature. Small growths situated high up may be treated by the galvano-cautery' or by other appli- cations through the larynx ; larger tumours can only be removed through a free opening made into the trachea. A tumour may be so situated that tracheotomy, without extirpation, may en- sure the safety of the patient. 7. Stenosis. — The calibre of the trachea may be lessened (a) by stricture, or by tumours grow- ing within it ; or ( b ) by pressure from without. (a) Stenosis from true stricture, or internal tumour. — Stricture is almost always a result of syphilis ; it may be annular and limited, but it usually involves the tube for some length. Tracheal narrowing, is indicated by obstructed breathing, with hissing inspiratory dyspnoea, un- accompanied by the up-and-down movement of the larynx, and the affection of the voice charac- teristic of laryngeal dyspnoea, and also without the stethoscopic signs of pressure on, or plugging of, a bronchial tube. Under these circumstances, and in the absence of any tumour in the neck or thorax pressing on the trachea, the stenosis must depend on a stricture, or on a tumour within th6 tube. A syphilitic history would lead us to diagnose the former ; and a tracheoscopic exami- nation, if practicable, would make the diagnosis certain. Prognosis. — Stricture being usually cicatri- cial, the prognosis is most unfavourable. Treathent.— T reatment other than operative is seldom available. If the stricture be high up, tracheotomy must be performed below it ; or, an opening being made above the contraction, a long flexible tube maybe introduced and passed through it. Stricture of the trachea is less amenable than laryngeal stenosis to treatment by mechanical dilatation with hollow bougies, but this method must be borne in mind for exceptional cases. (&) Stenosis from compression. — The source of stenosis caused by pressure from without is usually patent, thoracic tumours being diag- nosed by tbeir physical signs and concomitant symptoms. The paroxysmal dyspnoea frequently caused by these tumours is usually laryngeal, depending on pressure on the recurrent nerve ; but in some cases it is a peculiar result of pres- sure on the trachea. It is not relieved by tracheo- tomy, and is akin apparently to the paroxysmal dyspnoea occasionally seen as a result of pres- sure by the tampon-tube used after tracheotomy, for plugging the trachea in certain operations. 8. Foreign bodies. — A foreign body enter- ing the air-passages from the pharynx, may lodge in the larynx, either becoming impacted or lying loose. But, unless prevented by its form or bulk, it usually falls or is drawn through the open glottis into the trachea. Here it may 1652 TRACHEA, DISEASES OF. lodge ; but it more frequently passes on into one of the bronchial tubes — most frequently into the right bronchus, the orifice of which is slightly larger than that of the left, and occupies more of the floor of the trachea. Symptoms. — Occlusion of the larynx by a foreign body, which from its bulk obstructs the passage, may cause instant death ; and the same may be said of the trachea, as when a person vomiting, in a state of unconsciousness from in- toxication, or from the action of an anaesthetic, draws in a quantity of food sufficient to choke up the air-passages. If the body be smaller, it causes dyspnoea, with severe exacerbations from spasm. A very small body, such as a sharp piece of bone or a pin, may be impacted in a position in which it causes only pain and dys- phagia without dyspnoea. Speaking generally, it may be said that when the substance has passed into the trachea, the symptoms to which it gives rise depend on its bulk and weight. Rarely, it lies in the air-passages, giving rise to no symp- toms ; more frequently, varying its position with the rush of air in coughing, &c., it gives rise to paroxysmal dyspnoea, light bodies being forced up to the glottis and exciting spasm. If the substance pass into the bronchus, it may become impacted there, and will give rise to charac- teristic physical signs, usually exciting a chronic circumscribed inflammation, with symptoms akin to pneumonic phthisis. Treatment. — From the larynx a foreign body may be removed by the finger or a suitable forceps, its presence having been determined from the symptoms, aided by digital or laryn- goscopic examination. Although different forms of long forceps are made for passing through the larynx into the trachea, it is seldom practicable to remove per viasnaturales a foreign body which has once passed through the rima. A free open- ing must be made in the trachea, and its edges held well asunder, to give a chance of the body being expelled by cough. If this fail, a forceps must be introduced through the opening, and the body, if possible, extracted. Inversion of the patient, so as to allow a heavy substance to fall back through the glottis into the pharynx, is sometimes successful, but not as a rule without previous tracheotomy. T. J. Walkek. TRANCE ( transilus , a going beyond— of the soul from the body). — S ynon. : Lethargy ; Fr. Lethargic; Maladic du Sommeit; Ger. Schlaf- suckt. Definition. — A sleep-like state, which comes on spontaneously, apart from any gross lesion of the brain or toxic cause, and from which the sleeper cannot be roused. The term ‘ trance,’ in its derivative meaning, aptly expresses the apparent reduction to a vege- tative life, but the popular use of the word re- fers rather to the separate activity of the mind than to the inactivity of the body. Hence many writers prefer the term ‘ lethargy,’ • which also, although etymologically exact, is currently em- ployed in a modified sense. The condition is sometimes included under the generic term ‘ catalepsy,’ according to its etymological mean- ing, ‘a seizing’; but this term is usually re- stricted to those forms which present a peculiar TRANCE rigidity. It may be noted that the terms trance and catalepsy are both due to the theories of a mythical pathology. The ordinary forms of trance will be first described, and afterwards the peculiar variety of ‘ sleeping-sickness’ which is met with on the West Coast of Africa. /Etiology. — The influence of heredity in re- lation to trance is to be traced only in the production of a ‘ neuropathic disposition.’ It occurs chiefly in the female sex, between the ages of twelve and thirty ; very rarely in young men or children. The subjects are seldom in perfect health; they usually present other mani- festations of hysteria, and are often anaemic. The condition is rare, however, even in hysteria. Of a largo number of hysterical patients which have come under the writer’s notice, only two presented spontaneous trance. The condition has been in some cases apparently due to ex- hausting diseases, as typhoid fever, excessive brain-work, insolation, or mechanical obstruction to the supply of blood to the head. The imme- diate exciting cause is usually emotional dis- turbance. In rare cases, in which trance has followed traumatic influences, the mechanism has probably also been psychical. In several cases, trance has succeeded an hysterical convulsion. Rarely no exciting cause may be discoverable. In still more rare instances the state has been voluntarily induced, as in the well-known ease of Colonel Townsend, who could throw himself into a condition of apparent death, lasting several hours. Such voluntary induction is occasionally seen in the East. Lastly, minor degrees of trance may, without difficulty, be artificially produced in most hysterical persons, and less readily, in many others, by the methods described in the article on Hypnotism. The state now designated hypnotism is really induced trance, and trance has been accurately termed ‘ spontaneous hypno- tism.’ Symptoms. — The onset of the state of trance is usually sudden. For instance, in a ease which came under the writer’s notice, a girl went into a room by herself, and was found, shortly after- wards, in a state of trance-sleep, which lasted for thirty-eight hours. In another case (Madden) a young lady went into a room to change her dress, and was presently found on the bed in a state of trance which lasted for a fortnight. As already stated, it may succeed an hysteroid con- vulsion, and in some other cases the onset has been attended with an aura, resembling the glo- bus hystericus or the sensation which precedes hysteroid and epileptic fits, as of a ball rising from the abdomen to the throat. In the cases which succeeded typhoid fever (Madden) the de- lirium of the fever passed gradually into coma- tose sleep, which continued for several weeks. During the state of trance, the countenance is usually extremely pale. The limbs are relaxed, although brief initial rigidity, and sometimes occasional recurrent cataleptic rigidity, or tran- sient convulsive spasms, tonic or clonic, have been noted. In a few instances distinct hystc- roidfits have occurred from time to time during the course of the trance. The eyelids are usually closed, and may resist and quiver on attempts to open them. The eyeballs are directed upwards TRANCE. in most cases ; they often deviate from the middle line, and sometimes diverge slightly. The pupils are usually moderately dilated ; rarely they are moderately contracted. The state of reflex action varies according to the depth of the trance. That from the limbs is sometimes ex- cessive, so that cutaneous stimulation produces tetanic rigidity. Much more frequently reflex action is lost ; snuff blown into the nostrils causes no sneezing, ovarian compression has no effect, and pressure on hysterogenic points, which may have existed before, no longer causes the usual phenomena. Reflex action from the conjunctiva, and even from the cornea, is commonly absent. The pupil may contract to light, but in lessened degree, and sometimes do distinct action can be observed. The mental functions seem, in most cases, to be in complete abeyance. No manifestation of consciousness can be observed, or elicited by the most powerful cutaneous stimulation, aud on recovery no recollection of the state is pre- served. Rut in some cases volition only is lost, and the patient is aware of all that passes, al- though unable to give the slightest evidence of consciousness. The senses may be even preter- naturally acute, as in the analogous phase of induced hypnotism ; or there may be spontaneous mental action, irrelevant to external impressions, and analogous to, probably identical with, the state of ordinary dreaming ; it is manifested by exclamations, and even by movements. Rarely the ‘ obedient automatism ’ seen in induced hyp- notism may be present ; hallucinations occur, and actions are performed, according to sugges- tions made to the patient. The usual condition, however, is that of an entire absence of all evi- dence of mental activity. The pallor of face is the result of a profound depression of the vascular system. The pulse may be less frequent or more frequent than normal, but it is invariably weaker, and it may be imperceptible. The cardiac impulse may dis- appear, although the heart-sounds are still to be heard, sometimes much weakened. Very rarely they have been inaudible. In a case observed by Weir-Mitchell, vascular disturbance preceded the other symptoms. The breathing during tranco may be tranquil, slightly quickened, or slower, or may be so feeble and deliberate that no movement of the thoracic walls can be ob- served, uo respiratory murmur can be heard in the lungs, and a mirror held over the mouth is un- dimmed by moisture. Rarely respiration presents rhythmical variations. Temperature, when ob- served, has been normal in the central parts, lowered at the periphery. The secretions go on ; the urine may be retained in the bladder, or passed into the bed. The catamenia are usually absent, but menstruation has been known to occur with- out modifying the course of the trance-sleep. In the cases in which the depression of the vital functions reaches an extreme degree, the patient appears dead to casual and sometimes to careful observation. This condition has been termed ‘ death-trance ’ ( Scheintod ), and has furnished the theme for many sensational stories, but the most ghastly incidents of fiction have been paralleled by well-authenticated facts. Duration and Course. — The duration of 1653 trance has varied from a few hours or days, to several weeks, months, or even a year. When of short duration, the trance-sleep may he un- broken, but when it lasts for more than a few days, there are usually remissions of a greater or less degree, in which, for instance, the patient will half-wake, take food in an automatic man- ner, and then relapse into stupor. A long trance-sleep may he more profound at first than later. Recovery may be sudden or gradual. Oc- casionally it is attended by some vaso-motor disturbance ; in a well-authenticated case of death-tranee the intense mental excitement pro- duced by the preparations for fastening the coffin-lid occasioned a sweat to break out over the body. In other cases haemorrhages have occurred at the time of recovery, and such ex- travasations in the skin have been regarded as legendary 1 stigmata.’ After the trance is over, nervous prostration, with defective articulation, or mental dulness, may remain for a time. In many cases repeated attacks of trance occur, at intervals of days, months, or years. Most cases of trance-sleep end favourably. The depression of the vital functions enables life to continue with a very small amount of nourishment. Occasion- ally death occurs, as in the case of a deserter from the German army, and in one of the cases after typhoid fever described by Madden. Pathology. — The very few post-mortem ex- aminations which have been made after death in trance, throw no light on its nature. The theo- retical pathology of the subject is involved rn the obscurity which envelopes all the psychical processes in health and disease, the nature of volition, and ordinary sleep. The lowered ac- tion of the brain in sleep, and its lessened blood-supply, have suggested the existence of cerebral anaemia, which the meagre results of anatomical investigation have been supposed to confirm. It is certain that the condition is sometimes associated with defective cerebral nutrition ; but that much more than cerebral anaemia is needed to explain the state of trance, is evident from the facts that, on the one hand, it may occur when there is no preceding sign of defective blood-supply to the brain, while, on the other hand, the occurrence of cerebral anaemia without trance-sleep is a matter of daily observation. The phenomena of hypnotism also afford little support to the theory of the depen- dence of trance-sleep on cerebral anaemia, but, beyond this, they throw no light on its patho- logy. The subject affords abundant scope for theories, which have been freely supplied, but are, for the most part, mere re-statements of the observed phenomena, in the language of psy- chology. Diagnosis. — The diagnosis of trance rests on the impossibility of rousing the sleeper, com- bined with the absence of any evidence of a local cerebral lesion or a toxic cause. Other diagnostic symptoms are the pallor and vascular depression, the occurrence of convulsive phe- nomena of hysteroid type, and the history of other manifestations of hysteria. These symp- toms sufficiently distinguish trance-sleep "from apoplexy, for which, at the onset, it is sometimes mistaken. The distinction from catalepsy rests on the absence of the jlexibilitas ccrea, but cata- 1654 TRANCE. lepsy is merely a variety of trance. The pecu- liar tendency to "brief sleep termed narcolepsy is distinguished from trance by the shortness of the periods of unconsciousness. Thus a man had from youth fallen asleep for a few minutes under various influences, and always did so when a probe was passed down a nasal fistula. It is to be remarked, however, that the term narco- lepsy has been also applied in America to cases of true epilepsy, in which the attacks of petit mal are characterised by sudden somnolence. In cases of ‘ death-trance,’ in which no sign of vitality can he recognised, the presence of life may be ascertained (1) by the absence of any sign of decomposition; (2) by the normal ap- pearance of the fundus oculi as seen with the ophthalmoscope ; (3) by the persistence of the excitability of the muscles by electricity. This excitability disappears in three hours after ac- tual death. In a case observed by Rosenthal, thirty hours after supposed death the muscles were still excitable, and in forty-four hours the patient awoke. See Death, Signs of. Prognosis. — In cases of hysterical lethargy the prognosis is fairly good. The attack usually passes off. In very rare cases death has oc- curred. The slighter the degree of the trance, the shorter is likely to be its duration. The prognosis is grave only when the lethargy has been preceded by a state of great physical de- pression, and is the most serious when the con- dition succeeds an acute disease. Treatment. — The treatment has to be di- rected to two ends : the maintenance of life, and the arrest of the trance. Advantage must bo taken of any intervals of semi-consciousness to give nourishment in a concentrated form. If swallowing is continuously impossible, food must he given by the nasal tube, or by enemata. Warmth should be applied to the extremities, and care taken to prevent bed-sores. In severe eases, every attempt at arrest is often fruitless. Errhines, as snuff, have usually no influence, and it is only in slight cases that this, or stimula- tion of the skin, as by sinapisms, is effective. The most powerful cutaneous excitant is strong faradisation. In a case under the writer’s notice, which had lasted for thirty-six hours, strong faradisation to the arm quickly roused the pa- tient. In another case, which lasted for several mouths, this treatment had, for a long time, no influence ; afterwards the patient could be par- tially roused for a short time by faradisation, and by repeating the application at the same hour every day, a tendency to periodical waking was established, the remissions became longer and more complete, and the attack was ulti- mately brought to an end. Nervine stimulants, such as ether and valerian, may be given by the bowel, or sulphuric ether may be injected subcu- taneously. Alcohol must be given with caution and in small quantities ; enemata of strong coffee are often more useful. A remedy which, from its effect on the vascular system, would cer- tainly deserve trial in trance, is the inhalation of nitrite of amyl. Transfusion of blood has been proposed, and would be justified in cases following exhausting disease. The recurrence of attacks must be prevented by the improve- ment of health, physical and moral. TRANSFUSION OF BLOOD. African Lethargy. — The ‘sleeping sickness of the West Coast of Africa is met with chiefly in the Congo and Sierra Leone regions, and affects exclusively negroes. It occurs in both sexes and at all ages, but is most frequent in males between twelve and twenty. Except that depressing emotions seem to predispose to it, the proximate causes are entirely unknown. Euro- peans, living in the same localities, are exempt. Swelling of the cervical glands sometimes occurs at the onset, and they are excised by the native doctors as a remedial measure ; but the condition is not invariable, and its influence is doubtful. The general health may be perfect. The symp- toms differ considerably from those of hysterical trance. There is a gradually increasing ten- dency to somnolence. The patient will fall asleep at his work or over his meals. At first he can be roused, and if treated by cutaneous stimulation and purging, the symptoms may be removed for a little time ; but they soon recur, and increase in spite of treatment, until at last the patient is always asleep, and refuses food. He gradually emaciates, and dies at the end of three or six months from the onset of the symptoms. Just before death the disposition to sleep often ceases. The disease is extremely fatal. Guerin met with 148 cases, all of which died. The ob- servations of Gore and others place the mor- tality somewhat lower — at about 80 per cent. Post-mortem examination has revealed only hyperaemia of the arachnoid, slight signs of chronic meningitis, but no considerable excess of fluid within the ventricles or outside the brain. The cerebral substance is usually pale. No treatment appears to influence the symptoms. Only one observer (McCarthy) has seen good from excision of the cervical glands. This mys- terious affection clearly needs more systematic investigation than it has yet received. W. R. Gowers. TRANSFUSION OP BLOOD.— Syxox. : Fr. Transfusion du Sang ; Ger. Transfusion des Slides. Definition. — The injection of blood from the human subject or from one of the lower animals, in a pure or defibrinated condition, into the veins of a patient. Description. — This operation was invented in the middle of the 17th century, and is now fully established as a proceeding of great value ; but authorities are still divided as to the best mode of performing it. Transfusion is most frequently undertaken as a means of saving life after a great loss of blood, and most commonly after post-partum haemorrhage. It has also been em- ployed in cases of profound anaemia from other causes, as in leueocythmmia, phthisis, and 1 per- nicious anaemia,’ and its use has been suggested in the so-called blood-diseases, as fevers or pyaemia, but the benefit derived from it in these cases is at most only temporary, and it is probable that the operation will ultimately be limited to cases of anaemia from haemorrhage. Trans- fusion benefits the patient, first, by increasing the quantity of fluid entering the ventricles, and so encouraging their action ; secondly, by in- creasing the number of blood-corpuscles which, as the carriers of oxygen, are essential to life TRANSFUSION OF BLOOD. thirdly, l>y supplying albumen, and so giving nourishment at a time when it is probably im- possible to do so by any other means. For none of these purposes is the fibrin of the blood es- sential, and consequently many operators prefer to defibrinate the blood, by which much trouble in the operation is saved. Experiments on the lower animals, and observations of operations performed on the human subject, seem at present to indicate that defibrinated blood is in every ■way as efficient as pure blood. Yet when all the necessary appliances are at hand, pure blood is undoubtedly the most natural fluid to inject. When human blood has not been available, the blood of a calf, a sheep, or a lamb has been used instead, apparently with equally beneficial re- sults. The difference between the size of the corpuscles in these animals and in man is of no consequence, as those of man are the larger. The corpuscles from these animals probably break up very soon, as hsematin has been found in the urine the day after transfusion with lamb’s blood; but they no doubt serve as carriers of oxygen for a short time, during which the patient may rally. The dangers of transfusion are not very great, but as cases have occurred in which the donor of blood has died in consequence of the operation, it should not be undertaken without a clear prospect of benefiting the recipient. Care must be taken that air is not injected with the blood. The experiments of Ore ( Etudes historiques et pliysiologiques surla Transfusion du Sang, Paris, 1 868) have, however, shown that this danger has been much exaggerated. A bubble of air does no harm ; the quantity to cause death must be considerable. Too great care cannot, how- ever, be taken to exclude air, as fatal cases have occurred from this cause. The injection of clots giving rise to embolism, and perhaps to pyaemia, is always considered one of the dangers of the operation ; but evidence is wanting to show that it has been a frequent cause of death, or that in all the cases in which pyremia or septicaemia fol- lowed the operation it was due to this cause. One case is recorded by Jiirgensen ( Vier Fdlle von Transfusion cles Blutes, Berlin, 1871) in which red maculte formed on the skin after the operation, which subsequently suppurated. These were supposed to be due to minute fragments of fibrin injected with the defibrinated blood. Dr. Madge {Brit. Med. Jour. vol. ii. 1874 ; and Obst. Jour, of Gt. Brit., 1874) has shown, however, that with care no such fragments need be left after whipping and straining. The wounds left after transfusion present nothing special, and are to be treated as ordinary venesection wounds. The difficulties with which the operator has to contend are not great when defibrinated blood is used. When pure blood is used by any but the immediate method of transfusion from artery to artery, or vein to vein, there is some necessary hurry, as the operation must be finished before coagulation sets in. To avoid this. Dr. Braxton Hicks recommends the addition of a solution of phosphate of soda (jj to Oj), in the proportion of one of the solution to three of blood ; and Dr. Richardson a solution of liquor ammonias (n\.xx: and distilled water yj), to be added to a pint of blood. Both these solutions have the power of erresting coagulation. There is often some diffi- 1655 culty in finding the collapsed and empty vein of the patient. An ordinary venesection incision is useless ; the vein must be cut down upon, picked up with forceps, and then opened. Transfusion is either mediate or immediate. In the mediate operation the blood may be either defibrinated or pure. When pure blood is used, the vein of the patient must first be exposed and opened, and a silver cannula introduced. It ia better to use an assistant's fingers rather than s ligature to retain the cannula in its place. It is well to allow a drop or two of the patient's blood to escape from the cannula, if possible, to make sure it contains no air, or it may be filled with warm water or a solution of phosphate of soda. While this is being done the donor is bled into a clean vessel. No precautions need be taken to keep the blood warm. Cold delays coagulation. As soon as sufficient blood has been obtained, it is transferred to a syringe which is provided with an india-rubber tube. Care being taken that the tube and syringe contain no air, they are now connected with the cannula, and the blood slowly injected. Innumerable instruments have been invented for this operation, with the object of saving time, and ensuring against the entrance of air. It is impossible to describe them here. The best known are Hewitt's {Brit. Med. Jour. 1863, vol. ii.), Hicks’s {Guy's Hosp. Reports, 1869), Higginson’s {Liverpool Med. Chir. Jour., 1857). and Mathieu’s {Bull. Acad, dc Med. Paris, 1867). In this last the blood is received directly from the donor into a fun- nel at the top of the syringe, and great ra- pidity of operation is consequently attained. An ingenious instrument, which it is impossible to describe without a drawing, was introduced into London in 1877 by Dr. J. Roussel. When all its parts are in good order it doubtless works extremely well, but it is somewhat complicated and uncertain in its action (Dr. J. Roussel on Transfusiori of Human Blood, with a preface by Sir James Paget. London, 1877). When defi- brinated blood is used, complicated instruments are unnecessary. The blood must bo received into a clean vessel, and whipped with a clean stick or a twisted glass rod, till fibrin ceases to separate. The whipping must be done gently, so as not to injure the blood-corpuscles, or to break off minute fragments of fibrin. After whipping, the blood must be carefully strained two or three times through some clean linen. It may then be injected as above described. The opera- tion of immediate transfusion has been reintro- duced by Dr. Aveling ( Obst. Jour, of Gt. Brit., 1873). In this operation two cannulas are re- quired, one for the vein of the donor, and one for that of the patient. They are connected with each other by an india-rubber tube, with a small ball in the middle and a stop-cock at each end. The cannulas having been inserted are allowed to fill with blood so as to expel the air; or that in the patient’s vein, if no blood will flow into it, is filled with warm water. The india-rubber tube having been previously filled with warm water, is now applied to the cannulae, and the stop-cocks turned on. The small ball is then squeezed, while the tube is pinched on the side of the donor by an assistant. This drives the I fluid in the tube into the vein of the patient 1655 TRANSFUSION OF MILK. The tube is nest pinched on the side of the patient, and the ball allowed to expand and then emptied as before. Each squeeze of the ball drives in three drachms of blood. Immediate transfusion from artery to vein has only been performed when an animal has been the donor. In this operation the carotid artery of a lamb or calf is connected directly with the vein of the patient by means of a simple india-rubber tube, with a cannula at each end. The force of the animal’s circulation is quite sufficient to carry the blood into the patient’s vein. As the result, however, of a series of experiments carried out at the request of the Obstetrical Society of London, Professor Schafer has recommended im- mediate transfusion from artery to artery as the most efficacious method of performing the opera- tion {Trans. Obst. Soc. Lcmd. 1879, vol. xxi.). The quantity injected in any of the foregoing methods of operating varies with the effect pro- duced. Sometimes as much as a pint has been introduced. Half that quantity is usually suf- ficient to produce a marhed effect. Marcus Beck. TRANSFUSION OF MILK.— This ope- ration, or, as it is more correctly termed, Infu- sion or Intravenous Injection of Milk, has been recommended in America by Thomas (Is. Y. Med. Journ. May, 1878), Howe (,V. Y. Med. Hoc. 1878, p. 413), and others, as a substitute for transfusion of blood. In this country it has been practised and recommended chiefly by Ur. Austin Meldon, of Dublin {Med. Press and Cir- cular, Oct. 22, 1879 ; and Lancet, 1880, vol. i. p. 527). The subject has been experimentally studied in F'rance by Bechamp and Baltus, La- borde, Culcer, and others, with the result of showing that a small amount of milk may he injected without any evil consequences ; but if the quantity be too large and too rapidly in- jected, the animal dies asphyxiated after severe dyspnoea. The 'post-mortem examinations showed minute haemorrhages and embolisms, caused by the milk-globules sticking in the capillaries of the lungs, kidneys, brain, and other viscera. The numerous cases in which the operation has been performed on the human subject show that it can be safely undertaken, provided that, in addition to the usual precautions observed in intravenous injections, the following points are attended to. The milk must be freshly di-awn from a cow or goat. A goat may be brought to the bedside of the patient. The milk must be alkaline ; and this is best secured by the addi- tion of a small quantity of carbonate of ammonia. It must be raised to a temperature somewhere near that of the body. Under no circumstances must more than 4i ounces be injected (Meldon). If any dyspnoea is 'observed the operation must he at once arrested. The injection is usually followed by a considerable rise of temperature, and there may be some disturbance of respi- ration, which passes off in a short time. The operation is reported to have been successfully performed in cases of cholera, pernicious anaemia, phthisis, and loss of blood ; and it may perhaps be recommended as a last resource in some of these conditions if no blood can be obtained for transfusion. Injection of milk can only effect TRICHINA. two of the purposes of transfusion. It can in- crease the amount of circulating fluid; and it can, in an imperfect way, supply food at a timo when it could not otherwise be taken; but it can do nothing to increase the oxygen-carrying power of the blood. Its inferiority to immediate trans- fusion is self-evident ; and it is more dangerous and less efficacious than the transfusion of freshly-defibrinated blood, either of man or ani- mals. Marcus Beck. TRANSPOSITION OF VISCERA. See Organs, Displacement of. TRAUMATIC (rpavpa, a wound). — That which is associated or connected with a wound or injury, for example, traumatic fever, traumatic gangrene, and traumatic aneurism. TREATMENT. See Disease, Treatment of ; and Therapeutics. TREMENS, DELIRIUM. See Delirium Tremens ; and Alcoholism. TREMOR (Lat. trembling).- — The most deli- cate form of clonic spasm, consisting of succes- sive movements of very small amplitude. Tre- mors are seen principally in the hands, the head, the tongue, or the facial muscles, as a result of disease or of old age. They are commonly spoken of as ‘ coarse ’ or 1 fine,’ according to the amount of movement which they involve. For some account of the mode in which tremors are related to other disorders of movement see Motility, Disorders of. TRICHIASIS {e P \ l, the hair).— A morbid condition in which the eyelashes are inverted to- wards the eye. See Eye and its Appendages, Diseases of. TRICHINA {rpixivos, made of hair). — Sv- non. : Fr. Trichine', Ger. Trichina. — A genus of nematoid worms, originally established by Pro- fessor Owen for the reception of the minute spiral flesh-worm ( T. spiralis). This entozoon was first discovered in human muscle by Sir James Paget, when a student at St. Bartholomew's Hospital. The history of this and other discoveries in con- nection with trichina, so much misunderstood abroad, is exhaustively discussed in the writer’s work on Entozoa' (Supplement, 1869, p. 1 etseg.); but it must, in justice to continental observers, he here at least permitted us to remark that whilst Herbst was the first to rear capsuled trichinee by experiment, and whilst Virchow was the first to rear and recognise sexually mature intestinal trichinae in a dog, it yet remained ffr Zenker to open up a new epoch in the record of trichinal discovery, by a complete dia- gnosis of the terrible disease which these para- sites are capable of producing in the human frame. With Leuekart rests the honour of com- municating the fullest and most complete details in reference to the structure of the worm, whilst at the same time he solved most of the difficult problems relating to the source and genetic re- lations of the parasite. In this connection the separate labours of Pagenstecher, Davaine, and Heller are also especially noteworthy; the writer's own experimental results at the same time TRICHINA. Corresponding very closely -with, those obtained abroad (Linn. Soc. Proceed., 1865). Description.— The Trichina spiralis may he described as a minute helminth, the sexually mature male measuring the i of an inch, and the female | of an inch in length. The tail of the male is distinguished by / the presence of a bilobed pro- js minence, between the divisions III 4 of which the anal opening is If ff placed, and from which latter a single spieulum can be pro- truded. The female is stouter, and supplied with a bluntly rounded caudal extremity, the reproductive outlet being situ- Fig. 97. Trichina spiralis magnified ; male (a), and female (i). After Leuckart. Fig. 98. Portion of human muscle, enclosing a single capsuled Trichina. Highly magnified. After Leuckart. ated towards the anterior part of the body. The eggs measure only the of an inch in their long diameter, their contained embryos being pro- duced viviparously. As explained by Professor Leuckart, the entire course of development from the period of impregnation up to the time of sexual maturity may, under favourable circum- stances, occupy considerably less than three weeks. The ingestion of trichinous pork is fol- lowed by the maturation of the muscle-larvae in two days, by the birth of embryos_ in six days, and by the arrival of the migrating pro- geny within the muscles of the human or animal bearer in fourteen days. The formation of the lemon-shaped protective capsules around the muscle-worms is a subsequent process, requir- ing several weeks for its accomplishment. In the perfectly formed larva males and females are already recognisable as such. The disorder produced by trichin® is almost entirely due to the injury inflicted on the host by the act of wandering performed by the embryos. The grave symptoms and results thus superin- duced are described in the article Trichinosis. T. S. G'obbold. TRICHINOSIS or TRICHINTASIS.— Svnon. : Pr. Trichinosc ; Ger. TrichinenkranJc- keit. Definition. — The name applied to the vermi- TRICHINOSI3 OR Till CHIN IASIS. 1657 nous disorder called ‘ flesh- worm disease,’ or to that form of helminthiasis which results from the wanderings performed by the larvse of Tri- china spiralis. The discovery of this disease in the living human subjeet is due to Zenker. See Trichina. Historv. — Whilst the literature of this direc- tion is of great extent, the exigencies of clinical instruction can be sufficiently met by a brief record of the principal phenonema of the disease as ordinarily presented by trichinised patients. Whilst the discovery of the worm itself, as a nematoid, rests with Sir James Paget, the earliest recognition of the calcified and lemon-shaped cap- sules (‘gritty particles’) was made by Air. Hilton of Guy’s Hospital. Not only so; Mr. Hilton suggested the parasitic nature of the ‘ specks ’ observed in human muscle, which were, how- ever, regarded by him as ‘ depending upon the formation of very small cysticerci.’ The advo- cates of the prior claims of Tiedemann in this connection, though, in the estimation of a few persons, apparently well-established, do not pre tend to credit that anatomist with the possession of the faintest conception of the parasitic origin of the specks, or ‘ stony concretions,’ as he termed them in Froriep’s Notizen for 1822. In 1828, Mr. Peacock observed similar little bodies. In looking at the subject from a pathological stand- point, we see how large a share our countrymen had in first recognising the trichina capsules in their calcified state. This degenerated condition may be regarded as an invariable sequela of the disease, whenever the latter has run its natural course without proving fatal to the bearer. Mr. Richard Davy discovered a number of lenticular or oval bodies, averaging the fourth of an inch in length, in the muscles of a dissecting-room sub- ject at the "Westminster Hospital. To the naked eye they resembled the early condition of dege- nerating cysticerci; being also firm in texture, white, and of almost uniform size. The writer examined one on the 1st of March, 1876. It consisted of a dense fibrous capsule, containing caseous matter which effervesced on the applica- tion of strong acid. Probably they would have become concretions, similar to those described by Tiedemann. SvjiPTOiis.-The symptoms of tri chinosis, though by no means uniform, are tolerably characteristic. Under ordinary circumstances, the ingestion of badly trichinised meat, insufficiently cooked, is followed after a few hours by symptoms of in- digestion, such as nausea and vertigo, which may be succeeded by actual sickness and marked febrile disturbance. In milder cases the pre- monitory indications are usually insufficient to excite attention ; failure of the appetite, or aver- sion to food, with more or less malaise, being all that is noticeable. If only a very small quantity of diseased meat has been taken, the attack may pass off without particular observation ; but in bad cases diarrhoea sets in, and may continue for several days in succession, the fever becoming more and more marked. The patient is now prostrate. The extremities become stiff and painful ; and thus the first stage of the disorder, usually lasting for about a week, is completed. The second stage of the affection is coincident with, and dependent upon, the active migration TRICHINOSIS OR TRICHINIASIS. 1658 of the progeny resulting from the maturation and propagation of the capsuled trichinae originally ingested by the patient. The ferer increases; there is oedema of the face, which, however, in some cases is limited to the eyelids. Movements of the eyes are accompanied with pain, and there is intolerance of light. Later on, the muscles of the limbs are swollen and rendered extremely pain- ful to the touch, the slightest attempt at move- ment causing excruciating distress. The tongue is red and slightly coated. The pulse is very rapid, rising to 1 10, 120, or more, per minute ; the respiratory movements and temperature like- wise generally increase in rapidity and height. There is usually abundant perspiration, whilst the thirst is by no means excessive. In all cases the pain is apt to render the patient very ix-ritable, his inability to sleep being one of the most distressing symptoms. In grave cases delirium frequently sets in; the limbs become flexed and paralysed; and there is also, generally speaking, excessive and continuous diarrhoea, which rapidly exhausts the patient, and places him in great danger. He lies on his back, in a state of utter helplessness, and frequently can neither move a limb, sneeze, yawn, nor perform the ordinary acts of mastication and swallowing, in consequence of the paralysis of the various muscles concerned in these different functions. Course and Terminations. — In about a month or five weeks from the commencement of the attack the second stage of the disorder is com- pleted ; but the lines of demarcation between these various stages of the malady are necessarily somewhat arbitrary. If death take place, it usu- ally happens before the completion of the second stage, in the third or fourth week ; but when the patient’s strength can support the complete immigration of all the progeny resulting from the original infection, then the marked cessation of the febrile symptoms indicates the commencement of the third stage or common period of recovery. This third stage, however, is not one of invari- able convalescence. As a rule, the diminished frequency of the pulse, the improved state of the respiration, and the diminution of the tempera- ture go on more or less uniformly, until the patient's strength gradually returns with his re- commencing and, at first, very slowly increasing appetite. In bad cases, however, the diarrhoea continues, and there is a general collapse of all the vital powers, resulting from all sorts of sequels that had set in during the progress of the affection. Amongst these, affections of the chest usually play a conspicuous part, such as haemoptysis, pneumonia, and hydrothorax. Dur- ing the period of returning convalescence, the appetite sometimes becomes voracious, the body rapidly gains flesh, and there is always more or less desquamation of the cuticle. The periods both of recovery and death, as the case may be, are exceedingly variable ; in some instances the health not being re-established until two or even three months have elapsed. Diagnosis. — The diagnosis of this disease must be founded on a consideration of the symptoms described, taken in connexion with the discovery of the parasite itself, first, in the suspected arti- cles of food ; secondly, as adult trichinae, in the slvine evacuations during the first six or eight weeks of the disease ; and, thirdly, as specimens obtained from the muscles of the living subject by an instrument called the harpoon, or by simple incision, the part being anaesthetised. Treatment. — The indications as to treatment are obviously few and simple. To support the strength is essential. In our judgment no good can possibly result from the administration of the picronitrate of potash, benzoin, arsenic, or any other drug which is given with the view of destroying the young and migratory trichinae. AVhen once the young parasites have started on their journe}% all hope of arresting their progress is at an end ; when they have become encapsuled, even a strong solution of chloride of zinc (in- jected into the body of the deceased victim for anatomical purposes) will have no effect on them. Far otherwise, however, are the results of treat- ment if the disorder be attacked immediately on the appearance of the premonitory symptoms. If the tricliinous food has not left the stomach, an emetic may prevent all further mischief. If the stomachal contents have passed into the upper bowel, a brisk purgative, repeated for several days in succession, may expel the trichinae before they have arrived at sexual maturity. For this purpose, nothing seems to answer the end so well as calomel, which may be given in five-grain or larger doses, combined with jalap, scammony, or colocynth. According to Rupp- recht (who enjoyed large opportunities for testing the value of different drugs during theHettstadt outbreak), one-scruple doses of calomel can be borne, not only with impunity, but with positive advantage. Castor oil and turpentine, either separately or combined, may be given with benefit; but the employment of the ordinary vermifuges, such as male fern and santonin, is clearly contra-indicated. A good, active cathartic, such as the compound senna mixture, or the simple scammony draught of the British Phar- macopoeia, will probably be fully as efficient as any of the drugs usually administered as ver- mifuges. The measure of success is clearly depen- dent in the main upon prompt catharsis. In cases where the second stage of the disorder has fairly set in, less active purgatives may be given at first, the great obj ect being to lessen the fever, and to support the system by judicious dieting. The disinclination of the patient to take food of any kind must be overcome at all hazards, and soda-water, with meat extract very slightly di- luted, must be administered. AVhen the yolk cf an egg, or milk, or broth can be given in the ordinary way, as a meal, it should be preferred. As remarked before, the strength must be sup- ported, if necessary, by small quantities of wine or brandy. In this way the patient’s life may be upheld during the most critical period, after which, when convalescence is being re-estab- lished, the employment of the ordinary vege- table tonics and steel may be advantageously resorted to. Natural chalybeate waters are also likely to prove serviceable. Prevention. — In regard to the prevention of trichinosis, all that need be remarked in this place has reference to the temperature to which all cooked meat should be raised in order to kill the parasites. According to most authorities, trichinae succumb to a moist heat of 170° Fair. TRICHINOSIS OR TRICIIINIASIS. whilst some assert that 20 degrees less than this, if prolonged, is sufficient for the purpose. Ac- cording to some interesting experiments by Dr. Lewis, the centre of a leg of mutton attains a temperature of 107° Fahr. in about five minutes after the surface of the joint has been exposed to boiling heat (212°). Clearly, with the most ordinary precautions it is easy to avoid infec- tion. Recent experiments show that salting is not fatal to the capsuled trichina. England is singularly free from trichinosis ; but rather from the circumstance that our swine rarely contain trichinae, than that we are unaccustomed to eat underdone meat. Only one small outbreak of trichiniasis has been observed within our borders, the original account of which, by Dr. W. Lindow Dickenson, appeared in the British Medical Jour- nalist the year 1871. Some outbreaks supposed to be those of true trichinosis have turned out to be spurious. The epidemic on board H.M. training ship ‘ Cornwall ' was of this character. An autopsy of one of the boy's revealed the existence of a new species of free nematoid, which the writer called Ehabditis Cornwalli, and which Dr. Bastian named after-wards Pelodera setigera. A large number of parasites have been wrongly described as trichinae, thus causing much error of interpretation (see Pelodera). In Ger- many true trichina epidemics have been noto- riously frequent, and thus for our knowledge of the phenomena of the disorder we have been mainly dependent upon the writings of Rupp- reeht, Zenker, Virchow, Leuckart, Pagenstecker, Heller, and others. The disease is not in- frequent in the United States, where, however, it is for the most part confined to the German in- habitants, who have retained the habit of eating ‘ smoked sausages,’ so common in the Fatherland. (For details, see Dr. Sutton’s excellent Report cm Trichinosis, as observed in Dearborn eo., Indiana, in 1871: Transactions of the Indiana State Medical Society ior 1875 ; and also, espe- cially, Dr. W. C. W. Glazier’s Report on Tri- chinae and Trichinosis, published by order of Congress, "Washington, 1881.) For further par- ticulars on this subject the reader is referred to the writer’s book on Parasites ; to Dr. Althaus’s Essay on Trichinosis ; and to the still more ela- borate and exhaustive memoir by Dr. Thudi- chum, published in the reports of the Privy Council for the year 1864. See Trichina. T. S. ConnoLD. TRICHOCEPHALUS (0f(, a hair, and Ke, I make hard or callous.) Synon. : Callosity. Definition. — Thickenings of the epidermis, occurring on parts of the body that are habitually subjected to pressure or friction. Tylosis is found, for example, on the feet, from the wearing 1078 TYLOSIS, of shoes ; on the hands, from rowing or the constant use of some implement or tool ; and on other parts of the body unduly submitted to pressure. A corn begins by being a callus or laminated corn, and only rightfully acquires the title of corn when it has forced itself at a given point against the derma, and has depressed the latter to a greater or less extent, thereby pro- ducing pain and suffering. Callosities are in- convenient rather than painful; but occasion- ally the inconvenience is so great as to make the resort to treatment necessary. Treatment. — The best remedy tinder the above circumstances, is the removal or avoidance of the cause. Next to this, the hardened cuticle may be softened by soaking in hot water, or by means of a water-dressing, and afterwards scraped. Or it may be painted over with the liniment of iodine daily, until the excess of cuticle exfoliates in laminae and flakes. In either case, the skin must be subsequently protected, in order to pre- vent it from retrograding into its former state. Erasmus Wilson. TYMPANITES ( tympanum , a drum). — Synon. : Fr. Tympanites Ger. Windsucht . — This word is associated "with the distension of the abdomen that results from excessive accu- mulation of gas within its cavity. As a rule, the gas collects in the interior of the alimentary canal, especially the intestines; but in exceptional cases it occupies the peritoneal cavity. ./Etiology. — Tympanites is chiefly met with under the following circumstances : — 1. In con- nection with certain diseases which, from their local effects, tend to paralyse the intestines, especially acute peritonitis, typhoid fever, and dysentery. 2. In cases of intestinal obstruction from any cause, but particularly when this con- dition is acute. 3. In certain low febrile diseases, accompanied with the ‘typhoid state,’ and tend- ing towards a fatal issue, such as typhus fever, small-pox, erysipelas, and typhoid pneumonia. 4. As the result of perforation of the alimentary canal. 5. In certain cases of chronic disease of the spinal cord, of which the writer lias seen a marked example. 6. In connection with hysteria, sometimes. In all these conditions, except where the gas escapes into the peritoneal cavity, the immediate cause of the tympanites is a paralysed state of the walls of the intestines ; but there is often, at the same time, an excessive formation of gas. Symptoms. — The symptoms of tympanites are due to the mechanical effects of the accumulation of air. The patient is usually conscious of the distension of the abdomen, and the sensation may amount to extreme discomfort or actual suf- fering and great distress, there being a feeling as if the abdomen must burst if the condition is not relieved. The mental state of the patient may. however, be such that he is unconscious of, or indifferent to, any unusual sensations. Breath- ing is often interfered with in various degrees, and the act may be very hurried, with a feeling of urgent dyspnoea. The heart is also liable to be affected, and its action more or less dis- turbed. The secretion of urine may be impeded, even almost to actual suppression. Physical Signs.— Those are usually very cha- TYTHOID FEVER. racteristic. 1. The abdomenis uniformly enlarged, often to an extreme degree ; being of a rounded shape ; equal and symmetrical in every part, unless there happen to be a portion of bowel un- duly distended, and without any tendency to pro- jection in dependent parts. The skin is stretched more or less, but there is no protrusion of the umbilicus. 2. The sensations on palpation are those of perfect smoothness and regularity, with tension or a drum-like feel. 3. Percussion gives a general tympanitic sound over the abdomen, and also brings out the drum-like sensation. It' ths distension is extreme, however, the sound becomes more or less muffled and dull. Fre- quently the dulness of the solid organs in the abdomen is partially or entirely obscured, or is displaced upwards. 4. Change of posture pro • duces no alteration in the physical signs. 5. There may he signs of displacement of the tho- racic organs. It must be mentioned that tym- panites may be associated witli some fluid in the peritoneal cavity, or with other conditions, and the physical signs will be modified accordingly. Treatment. — In the first instance, any direct cause of tympanites must be removed, if prac- ticable, such as intestinal obstruction. If the symptom calls for direct treatment, relief may be afforded in some cases by applying heat over the abdomen ; and administering internally such remedies as brandy, aromatic spirits of am- monia, the various ethers, camphor, musk, sum- bul, galbanum, assafoetida or other gum-resins. Should these fail, enemata containing assafoetida or turpentine may sometimes be used with ad- vantage. The passage of a long tube through the anus into the bowel, reaching as high up as possible, such as an cesophagus-tube, is often very serviceable. In extreme cases it is allow- able to puncture the large bowel in several points by me.ans of a very small trochar, and thus af ford an exit for the contained gas. Frederick. T. Roberts. TYMPANITIC {tympanum, a drum). — A peculiar drum-like quality of sound elicited by percussion ( see Physical Examination). The term is also applied to the abdomen, when it is distended with gas. See Tympanites. TYMPANUM, Diseases of. See Ear, Dis- eases of. TYPES OP DISEASE. See Disease, Types and Varieties of. TYPHLITIS (■nepAla', the caecum). — Inflam- mation of the caecum. See C.ecum, Diseases of. TYPHOID FEVER (tO f>_rta, congregated or confluent ; U. subciuanea or deep- seated ; and U. tuberosa, in tuberous masses ; all of which varieties may be simply expressed by the terms ‘ more or less severe,’ or ‘more or less transient or chronic. Urticaria has no constitutional symptoms of its own, but, being itself a symptom, may acci- dentally be associated with general derange- ment of the system, of greater or less severity. This fact is indicated by the term U. febrilis, which ought rather to be named urticaria cum febre ; whilst anothor designation relating to its cause is met with in the term IT. ab ingestis. Somoof its features are found likewise in asso- ciation with other forms of disorder of the skin ; such as its tendency to swell in erythema papu- losum, tuberosum, and tumescens; audits pruritic proclivity in lichen urticatus and prurigo. Diagnosis. — The pathognomonic characters of urticaria are, first, white prominences of the skin, sometimes taking tho form of round tubercles, at other times occurring in stripes or wheals of varying length and figure, which are shown up on a scarlet or bright crimson ground, and are accompanied by a sense of burning and prick- ling, suggestive of the painful sensation caused by the sting of a nettle ; and, secondly, the sudden and complete evanescence of the local signs, as well as of the associated pruritus, without or- ganic lesion of the skin. Prognosis. — Urticaria may be very trouble- some, but is rarely serious. As a symptom of somo other form of derangement, the discovery of the latter must guide our opinion as to the cause and issue of the skin-affection. Treatment. — The evanescent nature of the local affection points to the consideration of a con- stitutional treatment by which we may strengthen digestion, assist the functions of the liver, and maintain a healthy operation of the alimentary canal. A tonic-aperient medicine, combining sul- phate of magnesia with quinine and a bitter in- fusion, will afford immediate relief where the digestive organs are concerned. Bilious and gouty subjects may be assisted by a preliminary blue- pill. The tone of the stomach may be kept up by nitro-hydrochloric acid combined with a bitter ; in other instances, alkalies will be found serviceable. In neurotic constitutions, on the other hand, we must have recourse to quinine in URTICARIA. moderate doses, to the bromides, and occasion- ally to sedatives, to procure rest at night and induce sleep. In very chronic cases the liquor arsenicalis, in doses of three minims three times a day, is of decided advantage. To relieve local suffering the best remedy is a lotion of lime-water inspissated with oxide of zinc, one part of the latter to eight of the former. In more severe eases the hot bath may be found serviceable ; or heat applied by means of flannel or a sponge wrung out of hot water. Erasmus Wilson. UTERUS, Diseases of. See Womb, Dis- eases of. UVULA, Diseases of. — Synon. : Fr. Mala- dies de la Luette ; Ger. Krankheiten des Zapf- chens. — Suspended from the middle of the lower arid free border of the soft palate, is that small conical-shaped prolongation termed the uvula. In structure it is exactly the same as — indeed it is a portion of — the soft palate, which con- sists of a fold of mucous membrane, inclosing muscles, aponeuroses, vessels, nerves, and glands, the latter being very numerous. From its intimate relation with the soft palate, the fauces, the tonsils, and the pharynx, the uvula is likely to become involved when any of these parts is overtaken by disease. This is most evident in cases of catarrhal aDgina. It is extremely rare for the uvula to be primarily and exclusively attacked with inflammation, and yet instances of such an affection are on record. On the other hand, it is by no means uncommon to observe the uvula swollen, cedematous, and elongated, as a consequence of prolonged irritation, relaxa- tion, or often repeated catarrh of the fauces. That form of acute catarrh, of which the uvula partakes when the throat is the subject of this affection, disappears along with the other symp- toms. But the condition known as elongated uvula often proves very intractable to treat- ment for a long time, and all the more so that not very infrequently this condition is entirely over- looked by the nractitionor. It ought to be laid down as a rule, that, in all affections of the throat, the parts should be inspected. In this case, inspection will reveal that the uvula is greatly lengthened, but not of necessity always thickened or cedematous ; so that when the pa- VACCI NATION. 1718 tient reclines, this pendulous body falls back- wards, sometimes even dropping so low as to reach the glottis. The consequence is, that the mucous membrane of the pharynx and la- rynx is kept in a continual state of irritation and general uneasiness. A peculiarly annoying cough is set up by the constant tickling of the parts, so that this condition of the uvula may eveu at times be recognised by the quickly repeated, resultless, brassy cough. It may be described as a quick, ineffectual hack. An inclination to vomit is also induced. An irresistible de- sire to swallow is observed, owing to the sen- sation which the patient perceives in the throat, as if something were lodging there, and which ought to be got rid of by swallowing. If there be much thickening as well as elongation of the uvula, then some slight difficulty may be expe- rienced when deglutition takes place. When the elongation is very pronounced, and the uvula finds its way into the larynx, the patient may ex- perience a sense of suffocation, particularly if he happen to be asleep, when he suddenly wakes up in a state of great alarm and breathlessness. A more temporary condition of elongated uvula is observed in that form of relaxed fauces which public speakers and singers are subject to, and which comes on suddenly, or quickly, after con- tinuous use of the voice for an hour or more. Treatment. — The condition associated with elongated uvula must be treated on general principles (sea Pharynx, Diseases of). Locally, the elongated uvula is best treated by astringent gargles. One of the best of these, which is perhaps as soothing as astringent, is the bro- mide of ammonium gargle, 20 grains to the ounce of water. Glycerine of tannin, tincture of iodine, and other agents which are quite sufficient for the cure of the simply relaxed uvula, may prove insufficient to restore tho elongated uvula, and then a portion of it must be removed, even to the extent of two-thirds. Bifld Uvula is a deformity usually congenital, the treatment of which, if necessary, by the actual or galvano-caustic cautery, or other means, falls within the domain of surgery. Paralysis of the Uvula is met with as a sequela of diphtheria, when other parts of the throat are similarly affected. See Palate, Diseases of; and Paralysis. Diphtheritic. Claud Muirhead. XI T VACCINATION ( vacca, a cow). 1 — Synon.: Fr. Vaccination ; Ger. Kuhpockenimpfung. Definition. — Inoculation with the material of vaccinia or the cow-pox. Its purpose, as ap- plied to the human subject, in which relation alone we have here to consider it, is the protec- tion of the person vaccinated from an attack, 1 This article, which was written hy the late Dr. Beaton, has been revised by Dr. Collie. The passages Inserted by the latter are marked [ ]. and especially from a severe or fatai attack, of small-pox. The cow-pox, which is a natural, though not common, disease in the cow and horse, never occurs spontaneously in man. Nor is it commu- nicable to him hy effluvia, or in any other way than hy the direct inoculation of its own spe- cific virus. Such inoculation before the time of Jenner was never more than a matter of mere accident, and occurred with comparative rarity. VACCINATION. 1720 It was matter of popular tradition, but was left for Jenner to demonstrate, that persons who had thus been accidentally vaccinated enjoyed im- munity subsequently from small-pox ; and it was by his great discovery that the cow-pox, once implanted in the human subject, may be con- tinued by inoculation from individual to indi- vidual indefinitely, that the practice of vaccina- tion became possible. Phenomena of Vaccination. — The phenomena which follow inoculation with the material of cow-pox vary according as the person, in whom the vaccine lymph is inserted, may or may not have been the subject of a previous successful vaccination [a previous inoculation, or a pre- vious small-pox]. The description may be divided into (1) the course of primary vaccination ; and (2) the course of secondary vaccination, or re- vaccination. 1. Course of primary vaccination. — This may be regtilar, irregular, or complicated. (a) Regular course . — When lymph, taken from a vaccine vesicle at that period of its course when the vesiclo is fit for the purpose, is in- serted into the skin by puncture, or is applied to a small abraded surface of the skin of an unpro- tected person, no particular effect is noticeable till about the end of the second day, or early on the third day. By this time, if the vaccina- tion be about to succeed, a slight papular ele- vation becomes perceptible. This, by the fifth or sixth day, has become a distinct vesicle of a bluish-white colour, with raised edge and cen- tral cup-like depression. By the eighth day (the day-week from that on which the lymph was inserted) it has attained its perfect growth ; it is then plump, round, more decidedly pearl- coloured, and distended with clear lymph; its margin is firm, and central depression very marked. On this day, or sometimes even by the end of the seventh day, a ring of inflam- mation, called the areola, begins to form about its base ; and the vesicle and areola together continue to spread for the next two days. The areola is circular, and when fully developed has a diameter of from one to three inches, being then often attended with considerable hardness and swelling of the subjacent connective tissue. After the tenth day the areola begins to fade ; and in two or three days more it has usually dis- appeared, with whatever of hardness or swelling may have existed. With the decline of the areola the vesicle begins to dry in the centre; the lymph remaining in it becomes opaque and gra- dually concretes ; and by the fourteenth or fif- teenth day a hard brown scab is formed, which gradually contracts, dries, and blackens, and from the twentieth to the twenty-fifth day, but usually about the twenty-first day, falls off. There is then left a cicatrix, which is circular, somewhat depressed, foveated, sometimes radi- ated, and, with rare exceptions, permanent in after-life. If the lymph have been inserted by two, three, or more punctures set near together about one spot, or by abrasion over a sufficient surface, two or more vesicles may arise at the spot ; and in the course of their growth, either form a largo vesicle of a compound character, with but sue central depression, or a crop of vesicles, generally coalescing, but eaen retaining its own central depression. These compound vesicles and crops are round, oval, or of irregular outline, according to the manner in which the cutis has been penetrated or exposed ; and the shape of the resulting cicatrices varies accordingly. Vac- cination which has gone through the course above described is held to be protective against small pox. The constitutional symptoms attending these local phenomena are a rise of temperature, sometimes detectable by thermometer as early as the fourth day, more marked, but still often very slight from the fifth to the seventh day ; more obvious feverishness, with restlessness, and frequently derangement of the stomach and bowels, from the eighth to the tenth day, that is, during the stage of areola, subsiding as that sub- sides. The general symptoms are in most cases quite moderate, and often exceedingly slight. Occasionally, when the areola is at its height, swelling of the axillary glands may be intense; and occasionally also at that period in young children of full habit, especially in hot weather, an eruption of roseola ( vaccine roseola) may occur, chiefly on the extremities; or a papular eruption ( vaccine lichen)-, or a vesicular one — the vesicles, however, [differing from] vaccine vesicles, in being entirely free from central de- pression. The duration of any of these forms of eruption, when they do occur, is very transitory, usually not extending beyond a week, and very seldom indeed beyond the falling of the scab. (6) Irregular course . — The exactitude with which vaccination in the immense majority of cases runs the course above described is very remarkable ; but in some cases an irregular course is seen. The irregularity may be merely in point of time] the development of the vesicle being retarded one or two or several days, or being slightly r accelerated, so as to present, for example, by the eighth day, tho appearances usually seen on the ninth. If the phenomena are in all other respects regular, these mere variations in time do not [as far as known] affect the protective power of the vaccination. On the other hand, there may be irregularity of the character and course of the vesicle, constituting spurious vaccination, on which no reliance can be placed for protecting from small-pox. Thus, papules or even vesicles may arise, which, instead of undergoing their proper development, begin by the fifth or sixth day to die away, leaving a mere scale or slight scab by the eighth day. More frequently, there are vesicles beginning early after the in sertion of the lymph, with itching and irritation — symptoms almost invariably absent in a nor mal primary vaccination, assuming as they rise an acuminated or conoidal form, instead of the characteristic flat form with central depression ; containing straw-coloured or opaque fluid, in- stead of clear lymph ; and developing an early and irregularly-shaped areola, which is at its height by the fifth or sixth day, and far on the decline by the day-week. In other cases the vesicles, rising apparently more regularly at first, are found by the eighth day to have burst; and present either an irregular scabby appear- ance, or are in the state of open sores. Tb» VACCINATION. chief causes of these irregularities will be dis- cussed further on. (th does not rapidly follow, infiltration of other and distant, parts, cellulitis, and sloughing. Associated with these local effects are many severe general phenomena, such as depression, fainting, nausea, hurried respiration, vomiting, exhaustion, lethargy, loss of co-ordinating power, paralysis, loss of consciousness, haem rrhagic dis- charges, relaxation of sphincters, coma, and con- vulsions. H' the quantity of poison injected be small or its nature feeble, the earlier symptoms may give way, and recovery take place. Snake-poison acts by paralysing the nerva* 1738 VENOM, EFFECTS OF: centres — sometimes the peripheral distribution of the nerves, and by altering the constitution of the blood. It takes effect through the circula- tion ; and if inserted into a large vessel, such as the jugular, humeral, or axillary veins, it ■will cause almost instant death, the heart’s action stopping in systolic spasm. The respiratory centres, the spinal Corel, the peripheral nerve- distribution, may all be affected ; in ordinary cases death seems to take place by arrest of the respiration, the heart’s action continuing for some time after apparent death. The muscular fibre itself would appear in some cases to have its contractility impaired or destroyed. The poison also acts septieally, producing at a later period sloughing and haemorrhage. There are certain points of difference in the action of viperine and colubrine venom. In the former there is greater tendency to haemorrhage than in the latter. Experiments on animals show that, generally, after death from cobra- poisoning the blood coagulates firmly, whilst after death from viper-poisoning the blood re- mains permanently fluid. In most eases of death in man the blood has been found fluid even after cobra-poisoning. The convulsion or coma that- precedes death is due to the circulation of venous blood in poi- soning by colubrine snakes ; probably to the direct action of the poison on the nerve-centres in poisoning by viperine snakes. Prognosis. — In cases of moderate severity remedies, with careful nursing and tending, may prove successful ; but where the bite has been thoroughly effected by the ophiopkagus, cohra, daboia, eehis, rattle-snake, craspedocephalus, ce- rastes, and others, the prognosis is very un- favourable; in no case, however, should efforts be relaxed until the last. There is often uncertainty as to the kind of snake, its condition, and the extent to which its fangs were used. The great shock or depression which follows a snake-bite may be in a measure due to fright, and will, on reassurance, pass away. The marks of two well-defined punctures attest the insertion of two fangs, and, if the snake has not boen seen, may enable one to form an opinion as to its character. Many of the in- nocuous snakes are fierce, and bite vigorously, but tlleir numerous teeth leave different marks from those of the poison-fangs. There are excep- tions to this rule, however ; a few innocent snakes have the anterior maxillary teeth de- veloped like poison-fangs, but bites from them are not very likely to occur. It may be well to note some of the characters that distinguish the venomous snakes, asthe form and arrangement of the teeth and an examina- tion of the wound will reveal the true character of the bite, and serve to forma correctprognosis. On opening the mouth of a venomous colubrine snake, such as naja or bungarus, two well-de- veloped fangs will be observed, one on either side ; and close behind it there may be seen one or two smaller teeth. There is no row of teeth along the outer side of the mouth, but a double row will be found on the palatine surface. In the viperine and crotaline snakes, a large fang will be found on either side, and a double pala- tine row. There are no small fixed teeth behind VENOMOUS ANIMALS, the fangs as in colubrines, but in a fold ot mucous membrane at the base of the fangs, both in vipers and colubrines, a set of loose reserve fangs will be found. In hydropltidxe the fangs are arranged like those of the cobra, but are very minute, and no reliance can be placed on any mark made by them. The circumstances under which a bite is inflicted will generally help to indicate the kind of snake. Harmless snakes have a double row of equal or nearly equal-sized teeth in the maxillary and palatine bones. But, as before stated, there are certain innocent snakes that have loDg anterior maxillary teeth, which might cause doubt as to the nature of the bite. Treatatent. — There is reason to believe that the numerous agents that have been recom- mended from the earliest times as antidotes of snake-poison are useless, and have no such pro- perties as those ascribed to them. The rational treatment of snake-poisoning is to endeavour to prevent the entry of the virus into the circulation ; to neutralize it in the wound before it is absorbed ; to support the fail- ing nervous force if it have entered; and to favour its elimination. The application of a ligature applied tightly between the bite and the heart, and the im- mediate excision or destruction by cautery or caustic of the bitten spot, are essential; and other local measures subsequently may appear necessary. The injection or the application to the puncture of some decomposing agent, such as liquor potassae or permanganate of potash, has been especially recommended in Australia, in Brazil, and in India. The constitutional treatment requires that the strength should be supported by stimulants, such as alcohol and ammonia. Next, if the respiration be failing, artificial respiration should he resorted to. Elimination should be promoted by stimu- lating diuretics. The patient should be kept warm ; and must not exhaust himself by walk- ing about. Ammonia has always held a high place among remedies in snake-poisoning; and its injection into the veins has been warmly advocated in Australia, and seems to have met with success there which it had not in India. The statement that no lizard is poisonous, is not strictly correct. The heloderm ( heloderma hon'idum), of Mexico, possesses venomous pro- perties, destructive to small animals, and injuri- ous to man himself. 2. Amphibia. — None of the amphibia are known to pcssess a poison-apparatus like that of ophidia ; but toads and salamanders secrete a fluid in glands along the back, connected with the integument, which yields an actively veno- mous principle, capable of causing local irrita- tion, and when injected into the blood, death, preceded by symptoms indicating action on the cerebro- spinal nerve-centres. Dogs seizing the toad, Bufo vulgaris, are known to suffer from swelling of the lips and salivation ; and a ease of death was related in France, in 1S65, of a child in whom an abrasion of the hand came in contact with the secretion of a toad ; death was preceded by vertigo, vomiting, and fainting. V hen this poison is injected into guinea-pigs, small birds, and other animals, violent symptoms and VENOM, EFFECTS OF: death soon follow. It is a viscid, milky fluid, with a slight yellow tint and peculiar odour; it is exuded, and may be pressed, from glands be- hind the orbits. Zalesky has shown that the land and water salamanders, S. maculatus and Triton cristatus, and probably others, have also the power of secreting venom ; and his experi- ments prove that it contains a very active prin- ciple — salamandrine, and that its action on the cerebro-spinal nerve-centres is energetic. It appears that these poisons, like those of ophidia, though effective on others, have no action on their own species. 3. Pisces. — Description. — Several fishes are provided with an apparatus consisting of a cavity at the base of, or a sac and duct leading to, a channelled spine, through which an irritating secretion is ejected. No true poison-gland, how- over, has as yet been certainly made out. This secretion is apparently connected with the secret- ing mucous system; and in certain species it produces marked symptoms of poisoning, though never to the same extent as in the case of the poison of venomous snakes. Fish armed with sharp or serrated opercular or fin spines can inflict severe and painful injuries, liable to cause great pain, and to be followed by the grave symptoms attributable to the lacerated or punc- tured nature of the wounds ; and these may bo aggravated by the irritating nature of the mucHS with which they are contaminated. In several, however, in addition to the spine, there is a dis- tinct receptacle in connection with it, either in the form of a sac or duct such as in the thalas- sophryne, or in a cavity in the spine itself, as in the trachinus or weever. In the case of others, such as the sting-rays, which may produce severe wounds by their pointed and serrated spines, there is no distinct receptacle for the poisons in connection with them. Whilst it is well known that many spiny fish are capable of inflicting wounds that are dangerous from their lacerated and punctured character, it is recognised that others increase the danger by the inoculation of an irritating fluid, as stated above. Effects. — The effect of fish-poison is to pro- duce severe burning pain at and beyond the in- jured part, and fever. The intensity, no doubt, depends upon the quantity of poison injected, and the state of health and constitution of the person at the time. The wound alone, even without the poison, is likely to be painful and severe from its punctured character. Treatment. — Ipecacuanha, alkalies, alum, and ammonia have all been recommended as useful external applications to allay the irritating action of such poisons. Poultices of onions, or warm applications of opium or other 'sedative fomentations, are likely to be useful ; and prompt surgical relief, if suppuration or cellu- litis occurs, is necessary to relieve tension, to evacuate pus, or give exit to sloughs. The constitutional treatment is such as would be indicated by the condition and progress of any other inflamed punctured wound. In case of depression of the heart’s action, alcohol or ammonia would be indicated. Pest, quiet, and due attention to the state of the bowels and of elimination by the skin and kidneys, with careful VENOMOUS ANIMALS. 1730 regulation of the diet, should be observed. See Post-Mortem Wounds. 4. Mollusca. — -Aphysia punctata, the sea- hare, a gasteropod, is said by some to produce an irritating secretion capable of causing urtication and even severe inflammation, and of causing the hair to fall off. 5. Arthropoda; Myriapoda, family Scolo- pendridce. — The centipedes possess mandibles, formed by a pair of dilated feet, joined at their origin, with perforated, hook-like points with an aperture near the apex, through which a poisonous fluid, secreted in a poison-gland, sac, and duct, is ejected when they bite, which they can severely. This, in the case of the larger tropical species, is sometimes very painful, and causes considerable local irritation, and even constitutional disturbance, fever, and delirium. That of the smaller kind generally causes only local and transient irritation. Centipedes are found all over the world nearly, in Europe, Africa, America, the East and West Indies and Islands, aud in the tropics generally. Those of warm climates are the largest and most dangerous. 6. Arachnoidea. — ScorpionidcD or Pedipalps. Description. — Scorpions have a segmented ab- domen, the last six joints of which are na.rrowed into a tail, terminated by a curved perforated spine or hook, with which they strike and wound. At its extremity are two small orifices, through which venom is injected from a gland-receptacle and duct at its base. Scorpions run about quickly, carrying the tail curved over the body. The}' live in holes in the ground, and under stones or logs of w r ood, in dark places. The tail is used as an offensive weapon. They seize small creatures with their palpi, and then pierce them with the sting. The venom is so active that it quickly destroys life. Those of tropical climates are most active and poisonous. They attain to the length of from two to three, four, and six inches. The European genera are smaller aud less active. Scorpions exist in all tropical countries, but extend also into the warmer regions beyond the tropics. They are found in the East and West Indies, Ceylon, and other islands, Australia, Africa, Egypt, South of Europe, and America. There are several genera, and Buthus afer, Androctonus, and Buthus Ccesar, are good ex- amples of the active kinds. Europceus and Occi- tanus are also venomous, but those of Europe are less active than the tropical forms. Effects. — The effects of the sting of the scor- pion and of the bite of the centipede have no doubt been exaggerated ; but they may produce very painful, and in the case of the larger species, severe and serious symptoms, in their character not unlike, or even more severe than, those of the sting of the wasp, namely, pain, swelling, in some cases numbness, vertigo, nausea, vomiting, temporary loss of vision, swelling of the tongue, and fever. Death may occur in deli- cate or sickly subjects. The local and constitu- tional symptoms may be severe in persons of irritable constitution, or otherwise out of health, but generally in the case of bites of ordinary scorpions or centipedes inflicted on healthy sub jects, the suffering is local and soon passes away. Treatment. — A variety of remedies have 1740 VENOM, EFFECTS OF been recommended for scorpion-poisoning. Pro- bably the application of a ligature above the bitten part, or a cupping-glass, or suction of the wound, as in snake-bite, might be useful. Some authorities recommend that the wound should be scarified, volatile ointment rubbed in, and an emollient poultice applied. Suction of the wound, and the application of salt water, vinegar, ammonia, alum, ipecacuanha, spirits of camphor, sau de Cologne, tobacco water, turpentine, tinc- ture of iodine, alcohol, the leaves of cruciferous plants made into poultices, solutions of opium and lead, or other sedatives, all seem to lessen pain and irritation. The use of diffusible stimu- lants, opiates, or other sedatives may be neces- sary, and such surgical interference as suppura- tion or cellulitis may require. 7. Arachnida. — Description. — Some spiders are venomous, and certain of the larger tropical forms are capable of inflicting painful l' : tes. The poison-apparatus of spiders consist of falces or modified mandibles or jaws, the last joint of which is a hard curved fang, with a fissure near the point ; there is an elongated poison-sac and duct in which the venom is elaborated and thence transmitted to the fang, by which it is inocu- lated into the flesh of its prey. Effects. — The venom of spiders is a very active principle, and apparently is capable of rapidly destroying the life of the small crea- tures on which the spider feeds. It also causes symptoms of poisoning in man and the lower animals. Probably all the species have some venomous secretion, but it is only the larger kinds that are obnoxious to man. It may be noted that whilst the fangs of one section of spiders move laterally, those of the Mygalidse move vertically. There are several species. Those reputed venomous are tropical. Lycosa tarantula is reputed to cause extra- ordinary symptoms. It is poisonous, but there is no reason to believe that its effects exceed a cer- tain amount of local irritation. See Tarantism. There are numerous families, genera, and species of spiders, all probably possessing an irri- tating fluid ; but it is only in the larger kinds that they do so to any extent, and there is no very positive proof that even in tropical climates they inflict the grievous injuries ascribed to them, though the venom is very fatal to the creatures on which they prej’. The popular notions that the spider is very poisonous when swallowed, and that its web possesses medicinal properties, are probably ex- aggerated, if not altogether untrue. One species of red spider, however — perhaps a mite— called coya, in Popayan, is very poisonous; the juices of its body when crushed, and coming in contact with the punctured skin, cause tumours, or even it is said death. This is no doubt ail ex- aggeration, but it is probable that the juices are acrid and irritating, and it is therefore better not to crush them when detected on the person, but to brush or blow them away. In India, a streak of almost erysipelatous redness of the skin coming on vapidly, is often attributed to a spider. No one has defined the species; it is possible that it may be analogous to that just referred to. I : VENOMOUS ANIMALS. . Treatment. — The treatment of spider-bites is similar to that of centipedes aDd scorpions. 8. Acarina. — Description and Effects. — Some mites have the power of causing consider- able irritation by a secretion ejected on the sur- face, or injected into the wounds they make in their burrowing operations with claws or mouth. The Tctranychus autumnalh, Leptus aulum- nalis, or Harvest Bug, is brick-red in colour, and very minute. It is bred on plants, but leaves them to fasten on animals, especially man, when it adheres firmly, and causes swelling, great irritation, and severe itching, if in num- bers. The intense irritation causes fever. The symptoms are not unlike the sting of a nettle, erythema or even blistering being caused. The leptus is covered with hairs, and effects entrance into the skin with its claws, and thus gives rise to the great irritation, which is probably aggra- vated by some acrid excretion. These animals are found in Britain, France, and other parts of Europe ; varieties of them in the tropics, for example in Brazil, Honduras, on the Mosquito Coast, and in the IVest Indies. The T. irritans of the Mississippi valleys causes great irritation in the same way. Treatment. — The treatment is to extract the bug with a needle or the point of a knife, and then apply some soothing lotion. Argus per sic us, a gamosid, known also as the Teigne de Miana, venomous bug of Miana, is common in Persia. It is found in the houses, and it is said that its puncture produces serious symptoms, such as convulsions, delirium, and gangrene, or even death. This is an exaggera- tion, though probably it is true that local irri- tation, and perhaps some constitutional distur- bance, may be caused. It is blood-redin colour, spotted with white on the back, the f6et yellow. Argas moubata, a native of Angola, is said to have much the same properties. The Argas talajc of Guatemala produces great irritation. It bites like an ordinary bug, and the punctures are followed by great irritation, swelling, and pain. It lives in holes in the bam- boo walls, or such-like crevices, and issues at night to attack the sleepers. 9. Hemiptera. — Some of the Geocorysts and Hydrocoryscs , or land and water bugs, have irri- tating properties, and also an offensive odour ; they have a suctorial mouth, armed with a grooved instrument or rostrum for piercing the ski n. Cimex lectularius, the bed bug, causes much irritation, and in some persons inflammatory ac- tion in the bitten part. The effects are transient Eotonecta and Nepa, common in pools of water in our islands, are also capable of inflicting a painful puncture. Cimex nemorum causes nearly as much pain by its puncture as the sting of a wasp. The wheel bug, Eeduvius serratus, of the West Indies, gives an electric shock to the per- son it touches. St. Pierre mentions a species of bug in the Mauritius whose bite is as venomous as the sting of a scorpion. The Benchucha, or great black bug, of the pampas of South America, is more obnoxious, it is said, than the common bed bug. 10. Aphaniptera. — Pulicidm or Fleas com- prise several families. Pulcx irritans, the com VENOM, EFFECTS OF: mon flea, is universal. It varies much in size and colour ; some are almost black and very large, and are found on the sandy shores of the Mediterranean. There are many species, such as P, cams, P. musculus, P. vcspertitinus, and others. Pulex penetrans of the West Indies and South America, known also as the jigger or chigoe, penetrates the skin, and beneath the nails, gene- rally of the feet, causing great irritation. It will, if not extracted, deposit its ova, and thus give rise to sevei'e irritation. The effects of the or- dinary flea-bite are well known. Though the irritation of flea-bites is chiefly due to the wound, there is reason to believe that this is aggravated by the presence of some irritating secretion. No special treatment need be described. 11. Diptera. — Description and Effects. — To this order belong the gnats, mosquitoes, pip- sas, sand-flies, and gad-flies, all more or less dreaded for their bites. They have a proboscis composed of a grooved and flexible sheath, through which long, slender, sharp darts are protruded, that pierce the skin and inoculate some venomous secretion, though its nature is not known. They draw blood, raise white lumps or swellings ; some, such as the pipsa of the Oossiah Hills, India, leave a livid spot of effused blood, which gives to the sufferer the appearance of a purpureal rash. They swarm in many countries, generally near water. Tho prin- cipal forms are the Culex pipiens, C. reptans, C. mosquito, C. laniger , and the whame fly, C. tabanus. Some of these are formidable insects, and are insatiable blood-suckers. The tsetze or ti'ib, Glossina morsitans of Africa, is one of the most remarkable. The bite of this poisonous insect is almost certain death to the horse, ox, or dog; though it appears not to trouble man more than by causing slight irritation. The female Simulium, or sand-fly, is irritating to man, the bite often giving rise to painful swellings. The pipsa is probably a simulium. It appears from the great irritation and the swell- ing that follows the puncture of most of these insects, that some acrid secretion is injected into the wound. In young full-blooded persons, es- pecially roceDt arrivals in India or the tropics, the irritation caused by mosquito-bites is often so severe as to give rise to violent inflammatory symptoms, resulting in suppuration or ulcera- tion, and even gangrene. Treatment. — The application of common salt, solution of ammonia, soda, potash, lead, oil, ipe- cacuanha, or alum combined with opium, allays irritation in the first stage. The more violent inflammatory symptoms are amenable to ordinary surgical treatment. Camphor, pulegium, and lime-juice, applied to the skin, are all regarded as preventives. 12. Hymenoptera. — Description and Effects. — A number of species that secrete poison are found among the different families of hymenoptera, including bees, wasps, and ants. See also Sting. They are distinguished by the presence of an ovipositor in the female, which not only is used for depositing the eggs, but as a weapon for in- jecting venom. It consists of two valves as a sheath, and three bristles which form a grooved sting. Through this groove the poison is in- VENOMOUS ANIMALS. 1741 jected into the wound, the ovipositor being con- nected with a poison-gland at its base. Formicidce. — Ants include Formica smaragdina and many others. The sting of the ant causes considerable irritation, especially if many. It has been suggested that formic acid is the irri- tating principle. There are several venomous species of ants, black and red, of various sizes. Some of the larger forms in the tropics are ca- pable of inflicting a very painful injury. Some ants have no sting, hut eject a fluid which irri- tates the skin. Vcspida. — The females and workers of the wasps and hornets are provided with a poison- sac and sting. Vespa ■ vulgaris is a type of the tribe Crabro. It lives in communities. Its sting produces much irritation, pain, and swelling, especially when inflicted on the face, or where the cellular tissue is loose. Apidre. — True bees, and the Bombida or humble bees, have similar properties, their sting pro- ducing very much the same effect as that of the wasp. Some of the parasitic Hymenoptera inject a poison into the wound made by their ovipositor. The best known instance is that of the genus Ophion. The genus Paripla also injects a poison in the same way, and probably others of the Ichneumonidre. Treatment:— Many remedies of a simple na- ture have been recommended to allay the pain and irritatioii caused by the sting of the wasp and bee, such as vinegar, eau de Luce, ammonia, solution of soda or potash, oil, indigo, eau de Co- logne, alum, and all those recommended in scor- pion-stings. In case of venomous stings, where constitutional disturbance is induced, stimulants or sedatives may be necessary ; and as the sting is liable to be left in the wound, it ought to he picked out. In cases of wasp or bee stings in the mouth or throat, which may happen when children bite a peach or other fruit that conceals a wasp, severe consequences may arise from the oedema that supervenes, and extends to the glottis. An emetic is then useful. With the ordinary treatment of oedema, laryngotomy may become necessary. In other cases, should vio- lent symptoms supervene, surgical aid may be required to relieve tension, or give exit to mat- ter. Such untoward results, however, are happily rare. Mutilla coccinea, a native of the warmer parts of North America, is said to produce loss of consciousness within five minutes of the inflic- tion of its sting, life being in danger for sonu daj T s afterwards. 13. Lepidoptera. — The majority of insects furnished with a sting, as a means of defence, belong to the Hymenoptera. It is but recently that a stinging Lepidopterous insect has been found. The species is not mentioned (F. Smith). The bee moth of the Cape of Good Hope is said to defend itself with a sting. Though the ma- jority of the perfect insects of this tribe are harmless, some of the caterpillars appear to be possessed of irritating properties, residing in the fine hairs with which they are cased, and which, being sharp and brittle, break off and remain in the skin, causing irritation mechanically ; hut also probably from the presence of some acrid 1742 VENOMOUS ANIMALS, substance concealed 'within the hairs. In Cey- lon, a greenish hairy caterpillar, longitudinally- striped, probably of the genus Boinbyx, which frequents the leaves of Hibiscus populneus, alight- ing on the skin, causes as much irritation as the sting of a nettle. The larva of Necsra lepida, has similar properties. It is short and broad, cf a pale green, with fleshy spines on the upper surface, each of which is charged with venom that occasions acute suffering. The larvae of Adolia are also armed with venomous hairs. Another, not uncommon in certain trees in the terai of the Himalaya, is a dark-coloured hairy caterpillar, which is apt to fall on people and cause intense irritation. It is known as the Komlah, but the moth that produces it is not known. 14. Coleoptera. — Several beetles have acrid secretions capable of exciting*great irritation and inflammation, raising blisters, and if absorbed causing painful strangury and great urinary irritation. Such are Mylabris Cichorii of India, Cantharis or Lytta, or Meloe vesicatoria, Lytta gigas of Senegal, Lytta vitata of America, and Lytta ruficeps of Chili. 15. Echinodermata. — The long sharp pointed spines of some of the echinids are capable of inflicting painful punetured wounds, but con- vey no true venom. Whether, as in the case of some spiny fishes, there may be an irritating mucous secretion inoculated is uncertain. 16. Coelenterata. — Some of the Medusas or jelly-fish have the pow r er of stinging. The poison-apparatus is placed in certain tubercles on the surface. These contain a collection of granules, amongst which are small vesicles. Within these corpuscles or nematocysts a spiral thread is found, which bursts out on pressure. These corpuscles are found in the mucus exuded by the creature, and to them is attributed the urticating power it possesses. There are several stinging species, some found on our own coasts, others in other seas. It is the larger forms gene- rally that are venomous, the small ones having no effect on man. C'yanea capillata of our seas is a most formidable creature, and the terror of bathers. It has a broad tawny disk, and a long train of ribbon-like streamers floating after it ; it makes its way through the waters ; and what- ever comes in contact with these trailing trains soon writhes in torture, the effect produced being not unlike that of the nettle. Physalea pelagica, the Portuguese man-of-war, has similar properties. It causes severe and stinging pain, extending up the limb, with fever- ishness, which has been knowm to continue for some hours, white wheals forming on the skin, as in urticaria. Several other medusae possess these properties, and honed they have received the name of Acalephae, or sea-nettles. The ap- plication of vinegar or olive oil is said to remove tho unpleasant symptoms. The Actinia , or sea-anemones, and the hydroid polyps, appear to possess a similar power, and are provided also with thread-cells. They cause urtication of the human skin when brought in contact with their tentacles. The Sagartiadce furnish examples of sea-anemones with this pro- perty. The effects, however, of any of them are transient. In some parts of Europe the Acalcphos VENTRICLES OE THE BRAIN. have been used therapeutically as counter-irri- tants, by being brought in contact with the patient immersed in a salt-water bath. In the preceding description the writer has not attempted to treat exhaustively the subject of venomous animals, or to describe all the forms of animal life so endowed. His object has been to point out the principal forms, and to indicate generally the mode of dealing therapeutically witli the effects of the venom. Joseph Fayber. VEtNT 0X7 S HUM. — A peculiar murmur heard on auscultation of the larger veins, espe- cially those of the neck and chest, in ana?mia, and in cases of interference with the flow of the blood through those vessels. See Physical Exa- mination. YENTNOE, in the Isle of Wight.— A mild, dry, bracing climate. Mean winter tem- perature for forty years, 42'43° Fahr. Exposed to S.S.E. and S.W. winds. See Climate, Treat- ment of Disease by. VENTRICLES OF THE BRAIN - , Dis- eases of. — Synon. : Maladies des Vcntricules du Cerveau ; Ger. Krankheiten der Gehirnhohlen . — The chief morbid states of the ventricles of the brain are (]) new growths, degenerations, and inflammatory changes in the lining membrane (ependyma) and velum interpositum ; and (2) accumulations of blood, pus, and serum in the ventricular cavity. 1. Diseases of the lining membrane and velum. — In old age, and in degenerative brain- diseases, such as general paralysis, the ependyma of the ventricles becomes thickened. The surface is uniform, or, in some cases, covered by minute warty granulations. Some of the latter may attain the size of a pea, and constitute small fibrous tumours. Similar changes are sometimes found when the brain has been subjected for a long time to passive congestion. In rare cases the thickened membrane has been found calcified in places. A few morbid growths have been met with in the ependyma, the most common being the granulations of tuberculosis, which have been found both on tho lining membrane and the choroid plexus. The latter and the velum inter- positum frequently present thickening, and un- due adhesion to the ependyma. In rare cases fatty growth has been met with, in this situation. The choroid plexus may present partial fatty degeneration, and frequently contains corpora amylacca. Aggregations of brain-sand are com- mon in the choroid plexus, and occasionally occur in the lining membrane. Cystic degeneration is the most common mor- bid appearance in the choroid plexus, especially iu that part which is within the descending cornu. The cysts are clear, delicate, colourless, transparent, from the size of a pea downwards. They consist of delicate cells pressed together, which are simply normal cellular elements of the part that have undergone a peculiar degene- ration. In some of the larger ones these cells have become destroyed in the centre, so that a true fluid-containing cyst remains. The adhesions sometimes met with may cut VENTRICLES OE THE BRAIN, off the posterior cornu from the rest of the ven- tricle, and it may thus be obliterated. The ventricles may undergo passive congestion in common with, the intracranial organs, or from pressure upon the veins of Galen, -which return the blood from the velum interpositum. In the latter case considerable effusion of fluid may occur. Inflammation involves both the ependyma and the velum interpositum. It is rarely con- fined to the ventricles, still more rarely to one. Commonly it is part of a general meningitis. The ependyma and the velum are thickened and pulp} 7 , being infiltrated -with cells of new forma- tion. The velum is always injected ; the epen- dyma may bo injected or pale. Occasionally a false membrane is found upon its surface. The tissue of the brain beneath the ependyma is softened, and may be injected. The fluid in the ventricles is increased in quantity, and is turbid from pus and exudation-cells, and even debris of nerve-fibres. The inflammation, of which this is part, is usually fatal ; but it may pass away, the ependyma and velum remaining thickened and adherent. See Meninges, Cerebral, Inflamma- tion of, Tubercular. 2. Intraventricular accumulations. — He- morrhage rarely occurs directly into the ven- tricles, except by traumatic rupture of a vein ; but blood may reach them from within the cere- bral substance, or from the subarachnoid space. True pus may be found in the cavities, from the bursting into them of a cerebral abscess ; and a purulent fluid may result from inflammation of the lining membrane. A slight effusion of serum results from inflammation, but is rarely con- siderable, unless the escape of that secreted by the choroid plexus is prevented by the closure of the passage to the fourth ventricle from ex- ternal pressure, or by the obliteration of the foramina in the membrane closing in the fourth ventricle, by which its cavity communicates with the subarachnoid space (Hilton). See Hydro- cephalus. In atrophy of the brain, the fluid within the ventricles (as beneath the arachnoid) undergoes a considerable compensatory increase. Lastly, by violent commotions of the brain the septum lucidum may be ruptured (Wilks and Moxon). Ventricular hemorrhage and hydrocephalus are described in other parts of this work. See Brain, Haemorrhage into ; and Hydrocephalus. The other conditions discussed are marked by no distinctive symptoms, and call for no special treatment. W. R. Gowers. VENTRICLES OP THE HEART, Diseases of. See Heart, Diseases of. VERDIGRIS, Poisoning by. See Copper, Poisoning by. VERMES (Lat. worms).— This is a term of variable import, according to the practical or scientific stand-point from which it happens to be viewed. Thus Gegenbaur includes in this group, not only the helminths or entozoa and their allies, but also a multitude of creatures of widely differing structure, as well as the annu- lated animals properly so-called ( Grundziige dcr Vergleich. Anatomie, 1870, s. 1 ooctseq.'). The late VERRUCA. 1713 Professor Rolleston, in like manner, elevates the term so as to make it of sub-lcingdom value in zoology. Practically, the term ‘Vermes’ is used as the equivalent of Entozoa , which latter term, as we have explained elsewhere, has a wider signification than its simple literal meaning im- plies. See Entozoa; Helminthes; Intest inai Worms; Parasites; and Worms. T. S. Cobbold. VERMICIDES ( vermis , a worm, and ctsdo, I kill).— A group of anthelmintics which kill worms. See Anthelmintics. VERMIFUGES ( vermis , a worm, and fugo, I expel). — A group of anthelmintics which expel worms, but do not necessarilly kill them. See Anthelmintics. VERRUCA (Lat. A wart.) — Synon. : Fr. Vcrrue ; Ger. Warze. Definition. — A wart or papillary growth from the skin. JEtiology. — -The wart, being an aberration of growth of certain of the constituents of the skin, must necessarily result from a want of normal power within the integument ; hence it is mostly found in children and elderly persons, and is less frequently met with in the adult. As children become developed by growth, and their tissues acquire strength, these partial exuberant growths disappear. In young persons of feeble organisa- tion they are sometimes thrown out like an exanthem, and yield to a constitutional treat- ment directed towards the improved innervation and nutrition of the tissues. Their direct rela- tion with the nervous system is often evinced by their sudden disappearance under the influence of mental emotion, a circumstance which has led to the popular use of charms for their cure. In elderly persons they are often met with on the face, where their presence must be ascribed to debility of integument; and they are frequently associated with dirt and neglect. Briefly, warts may he said to he due to aberration of nutri- tive function of the skin, consequent on defective organisation and vitality. Description. — Pathologically a wart is an hypertrophy or excessive growth of a small group of papilla of the skin, with excessive pro- duction of cuticle, forming a hard prominence of the integument. "Warts vary in size, and aro modified according to situation. They some- times cover a considerable extent of surface in patches several inches in diameter, but more com- monly appear as tubercles, either few in number and isolated, or numerous and in clusters. One kind is remarkable for the minimum of promi- nence, resembling a flat, dirty-looking blotch on the skin ; whilst another, as on the hands, may have a prominence of a quarter of an inch, or on the scalp of half an inch. Warts on the hands afford the commonest illustration of verruca, as in this situation, from the greater nutritive energy of the skin and the abundance of epidermis, they are most frequent and most highly developed. When of recent growth they are convex and smooth on the sur- face, hut when of longer standing the apex is flat, from the wearing away of the superficial cuticle, and the anatomy of the wart becomes dia VERRUCA. 1744 closed. Then it is apparent that the wart is composed of a bundle of fibres, held together in a cylindrical form by a boundary of thickened cuticle. Each of these fibres is a vascular papilla of the skin, enclosed in a sheath of cuticle, and the collective mass forms the body of the growth. An old wart 'will frequently split up into several segments — V. lobosa or tabulated wart, and then its construction of fibres — V. fibrosa, is strikingly conspicuous. If a wart be cut through hori- zontally, the vascular papillae will be cut across, and then the structure of a wart of papillae and horny sheaths is still more evident. On the fingers, aDd especially the knuckles of children, the verruca is isolated and large, and not unfre- quently confluent, and on the back of the hands and wrists, as also on the forehead, it is often developed in crops, like an eruption ; but these latter never attain the dimensions of the isolated warts of the fingers. Verrucae are generally sessile — V. scssilis ; but on the scalp they are frequently pedunculate, and, from a peculiarity of structure, have been denominated digitate — V. digitata. The digitate character of the warts of the scalp is due to the lesser quantity of epidermis occurring in .that region ; consequently the hypertrophous papillae are not held together by a ring of thickened cuticle as elsewhere, but being left to themselves shoot out from the centre like fingers ; the papillae likewise grow to a greater length, and their cylin- der is swollen so that the bulk of the mass greatly exceeds that of the base from w'hich thoy spring. .Yevertheless, the digitate verruca must be distin- guished from V. acrocliordon, and the cauliflower- shaped venereal warts, both of which are growths of the integument, and are not restricted to the papillae cutis alone; and thereby fall into the category of molluseum, with which, especially acrochordon, they are closely allied in patholo- gical structure. The normal colour of warts on the hands is a yellowish-grey, but from their roughness they are apt to retain dirt in their crevices, which gives them a brownish appearance. The flat warts of the trunk of the body and face are ac- companied with the production of pigment, and their dirty colour is consequently more striking. A number of warts congregated on the skin sug- gested to the fathers of medicine the idea of ants crawling over the body, and this appear- ance they designated myrmceia ; whilst, another resemblance, which can be frequently verified, brought to the mind the blossom of the thyme, hence the term Thymion employed by Hippo- crates. Diagnosis. — As a simple epidermic growth enclosing hypertrophous papillae, verruca is very distinct from other affections of the skin at- tended with hypertrophous growth of cuticle. The lepra of Willan is accompanied with hvper- trophous papillae and cuticle, but the latter is a morbid product, and is spread out in the form of laminated scales. Ichthyosis likewise is a com- bination of hypertrophous papillae, enclosed in epidermic sheaths, with accumulation of cuticle, but is apt to be associated with filiform and branched processes of the actual integument. True idiopathic warts must bo distinguished from other diseases which sometimes put on a warty appearance, especially carcinoma and - ./- philis. Epithelioma of the skin is occasionally seen as a circumscribed warty growth, but gene- rally with adherent scabs covering superficial ulceration. These signs, together with infiltra- tion of adjacent tissues, implication of neigh- bouring glands, and pain, would arouse sus- picion. It must be remembered, hove ver, that epithelioma frequently attacks a simple wart which has remained quite passive during a life- time; rapid increase of growth with the above- mentioned symptoms would suggest the super- vention of epithelioma. Any chronic inflammatory process of the skin, especially syphilis, is liable to take on a papil- lary character. Without referring to the papil- lary growths of early syphilis (condylomata), which could scarcely lie confounded with simple warts, on account of their position and moisture, mention may be made of the dry warty charac- ter assumed by old syphilitic lesions, especially such as have been preceded by ulceration. The history of the disease (previous ulceration, &c.). together with other concomitant symptoms of syphilis, would assist the diagnosis. As of venereal origin, though never syphilitic. ordinary ‘ venereal warts ’ must also be noted. Other names by which thoy have been described suggest their characters, such as ‘ pointed condy- loma,’ and ‘ cauliflower excrescence.’ They are generally bright red in colour; and the indivi- dual papilla; are pointed. The rapidity of their growth, and the situation where they usually occur (the genitals), serve to distinguish them from verrueie. Moreover they most often accom- pany gonorrhoea, being caused by the irritating discharge. Prognosis. — Verruca is a blemish rather than a disease, and unimportant in its relations to the general health. By an error of diagnosis we sometimes read of malignant warts, and warts have been confounded with those fleshy growths termed ‘ tegumentary naevi.’ Moreover in elderly persons a warty state of the skin is sometimes associated with asthenic ulceration, and occa- sionally with rodent ulcer, for which the de- praved state of the skin, and not the wart, is responsible. Treatment. — The best method of treating verruca; is to touch them with some solvent agent, such as acetic acid. This acid dissolves the epi- dermis, and reaching the vascular papillae, de- stroys the whole structure of the wart down to its root. The pulpy mass then dries up into a scab; and when the scab falls off, the growth rarely reappears. This little operation may either be completed at one sitting, or it may be repeated daily until its purpose is effected. "Where there are numerous verrucas to be dealt with, the process is tedious, and is generally left in the hands of the patient. The writer prefers a saturated solution of potassa fusa, carefully applied by means of a minute pencil of sponge fastened tc the end of a stick. The alkali acts more speodily than the acetic acid, and effects a more thorough cautery of the vascular plexus, from which the hypertrophous papillae derivo their capillary loops. The verrucae digitatae of the scalp are speedily and easily removed by this process. In the exanthematous form the VERRUCA. verrueae are too small and too numerous for the caustic application. These may he treated by frictions of sulphur ointment or tar ointment ; and in this latter form the rerrucae are fre- quently entirely removed by a course of treat- ment with liquor arsenicalis, in three- or four- minim doses, taken immediately after meals, three times a day. Erasmus Wilson. VEBTIGO ( verto , I turn). — Synon. : Giddi- ness ; Dizziness ; Swimming of the head ; Er. J r ertige; Ger. Schwindel. Definition. — The consciousness of disordered equilibration. Physiological Relations. — To understand vertigo normal equilibration must be briefly considered. The equipoise is maintained by a sensori-motor mechanism. The coordinating centre is the cerebellum ; the afferent or sensory apparatus consists of visual, tactile, and labyrinthine impressions ; the efferent or motor apparatus are the muscles, chiefly those of the head, neck, and spine. Derangement of any part of this mechanism may lead to vertigo, by interruption of its power of adjustment. Vertigo is often associated with reeling or stag- gering, and is incorrectly said to cause it. Actually vertigo is the consciousness of dis- turbed locomotor coordination — a rudimentary disorder of coordination of locomotive movements (Hughlings Jackson), whilst reeling is an adap- tive effort to preserve the equilibrium. A fact that supports the assertion that vertigo is a rudimentary disorder of coordination, is that when in a person, who has a sensation as if he were moving or turning in a certain direction, movements actually take place, they are always in the direction in which he previously felt he was turning when no outward movements oc- curred. Experimental researches and observa- tions in disease have established the conclusion that the semicircular canals take an important share in normal equilibration; injury and disease of these parts occasioning locomotive incoordina- tion, temporary when one side only is deranged, permanent when both s'.des are involved. The arrangement of the semicircular canals, and the physical principles involved in their actions, are very complicated, but have been carefullystudied and explained by Flourens, Cyon, Crum-Brown and others ; and it has been demonstrated by Elourens that injury of each canal is followed by definite locomotive disturbance, causing the body to tend to fall, or actually to fall, in a definite and precise direction, forwards, backwards, or to one or other side, according to which of them is injured. The sensory impressions originating in the semicircular canals are caused by varying ten- sion of the endoiymph, communicated to the vesti- bular division of the auditory nerve spread out on the ampullae of the membranous canal. Variations in labyrinthine tension may be produced by alter- ations in the position of the head, by differences in the vascular tension of the labyrinthine blood- vessels, and by the varying pressure in the middle chamber of the ear, induced by obstruc- tion of the Eustachian tube, spasm of the tensor tympani muscle, and other causes; and it may also be due to disease of the labyrinth itself, or communicated to the labyrinth. Visual and 110 VERTIGO. 1745 tactile impressions are liable to be deranged i? many ways, for instance, by unexpected or un- usual movements, as in swinging, being at sea, &c. ; by local disease of the visual and tactile apparatus; and by disease in the nerve-trunk3 and spinal cord, interrupting conduction from the periphery to the centre. By disturbances in visual, tactile, or labyrinthine impressions the equili- brising centre is uninformed or misinformed, and incoordination results, outwardly shown by reeling or falling, and inwardly by the sensation we call vertigo. Loss or perversion of visual or tactile sensations may be compensated for, if tho two remaining sensory processes continue intact, but nothing compensates for entire loss of laby- rinthine impressions (Ferrier). The vestibular nerve which is distributed to the semi-circular canals is a branch of the auditory, the nucleus of which in the medulla is in close relation with that of the vagus ; and thus the fact is ex- plained that disturbances in the large area of distribution of the pneumogastric are found associated with labyrinthine disease, by propa- gation of the irritation from the nucleus of the auditory to that of the adjacent vagus ; and conversely the intimate association of these two nuclei enables us to understand how disease of the jstomneh and other viscera occasions vertigo. It must further be borne in mind that the laby- rinth receives its blood-supply from the vertebral artery, which at its origin from the subclavian is in near propinquity to the inferior cervical ganglion of the sympathetic, from which it re- ceives a rich plexus of nervous filaments. The inferior cervical ganglion also sends communi eating branches to the vagus, and branches to the heart. In this double way, therefore, tho labyrinth has important nervous relations with the stomach, heart, and other organs. Pathology. — Vertigo may be excited by va- riations in the local or general blood-pressure, which cause variations in the labyrinthine ten- sion, as in anaemia, gout, and other affections. Tho symptom is also produced by certain drugs, such as quinine, salicin, and the salicylates, which act probably 7 on the labyrinth through the vascular system. Vertigo may be divided into degrees or stages, namely, (1) a feeling of confusion and instability ; (2) a feeling as if objects are moving; (3) a feeling as if the individual himself is moving ; and (4) actual movements of the body. The important forms of vertigo which occur in practice will be further considered under the following heads: 1. Ocular; 2. Auditory; 3. Gastric; 4. Nervous; 5. Epileptic; 6. Migrainous ; 7. With organic brain-dis- ease ; and 8. Gouty. 1. Ocular Vertigo. — Vertigo is frequently caused by ocular disorders, and is often mistaken for serious cerebral disease. The simplest form is in paralysis of a single muscle, as the external rectus. The vertigo is not occasioned by the diplopia, but by the incorrect notion formed of external objects by the paralysed eye, due to what is known as ‘ erroneous projection.’ The confusion thereby produced gives rise to vertigo, and often to reeling. One of the most import- ant varieties of ocular vertigo is that occasioned by insufficiency of the internal recti muscles — VERTIGO. 1746 muscular asthenopia. This is most commonly met with in myopia. During reading these muscles, which have long been overtaxed by exertions to maintain the convergence of the eyes ren- dered necessary when looking at near objects, suddenly give way under the strain ; they relax, the eyeballs turn out, and the letters on the page become indistinct, run into each other or overlap, and a sense of confusion and giddiness occurs. It is usually accompanied by aching at the backs of the eyes, headache, and sometimes by nausea. Such cases are often misunderstood even by medical men. Muscular asthenopia may occur also with hypermetropia ; and as a sequel to exhausting diseases, such as fevers and diph- theria. For the diagnosis of the particular opti- cal defect and treatment the reader is referred to Vision, Disorders of. 2. Auditory or Aural Vertigo.— Synox. : Vertigo ah aure lesa; Labyrinthine vertigo; Apoplectiform vertigo ; Meniere’s Disease. Auditory vertigo is very generally known by the name of Meniere’s disease, from the excellent description of the malady first given in 1861 by Meniere. Under the term Meniere's disease is grouped a class of cases in which vertigo is caused by perversion or abeyance of the labyrinthine function. The labyrinthine dis- turbance may be caused either (1) directly bj? an affection of the labyrinth, such as (a) hsemor- rhage, (A) congestion and inflammation ; or (2) indirectly, by (a) disease of the middle ear (otitis . media), (A) obstruction of the Eustachian tube, (c) spasm of the tensor tympani, or paralysis of the stapedius, or (d) irritation or obstruction of the external auditory meatus, and pressure on the membrana tympani, as by cerumen, foreign bodies, or by syringing the ears, especially when the membrana tympani is perforated. Thus the labyrinthine affection may be either of an irritative or of a destructive nature, and the effect of the lesion will be exactly the re- verse in the two cases (Ferrier). That is to say, whilst an irritative lesion would cause the tendency to fall in one direction, a destruc- tive lesion of the same canal would cause a ten- dency to fall in the opposite direction. In Meniere’s disease, strictly speaking, there is always coincident affection of the semicircular canals and cochlea, as indicated by the three most important associated symptoms : vertigo, tinnitus, and deafness. Accompanying these car- dinal symptoms there are accessory phenomena, due to secondary visceral disturbance, namely, pallor, faintness, and nausea or vomiting — a con- dition of syncope. The disease makes its appearance, in a person apparently quite well, or the subject only of some chronic auditory disease, with a loud noise in the ear, compared by different persons to the whistle of a steam-engine, the firing of a gun, or the roar of the ocean. When a person, as •not infrequently happens after the first attack, has an habitual noise in the ear, this at the time of the attack is greatly exaggerated. The noise, which is wholly or principally in one ear, is soon followed by the feeling of giddiness. This is generally of a high grade, causing the sensation of surrounding objects moving in some one di- rection, a feeling of translation of the patient's body in the same direction, or actual movement* of the body. The movement, whether apparent or real, is usually from the side on which the ear is affected. In recurring attacks the move- ments, whether of objects or of the individual, are nearly always in the same direction. Usually the sensation of movement is from behind for- ward, or to one or the other side, or the patient has a feeling of rotation in a vertical axis. When in bed, the room, bed, and occupant are felt as if turning round and round, or rising or sinking. Accompanying the vertigo there is reeling, and the patient clings to surrounding objects for support. In some cases the movement is too rapid for the patient to obtain security in this way, and he is thrown to the ground, sometimes with such violence as to occasion serious injuries. When falling takes place, it is usually forwards or to one side. It is, however, to be especially remembered that, except in rare cases, there is no loss of consciousness ; the patient being able immediately after the attack to describe the sensations he experienced, or even to answer questions in the attack itself. Following, in more or less rapid succession, the tinnitus and vertigo, there occur nausea and in most cases vomiting, accompanied by pallor of the face; the skin becomes cold and covered with a clammy sweat. In some cases oscillatory movements of the eyes are observed. It is generally asserted that objects appear to move in a direction opposite to that of the ocular movements. This is not universally true ; and probably, contrary to the statements of most writers, the apparent movements of objects is in the same direction as the observed movements of the eyes. Gradu- ally the attack passes off; the noises in the ear lessen, but deafness is left behind. The body recovers its warmth, and the pallor subsides, but vertigo and vomiting may persist for some hours or even days, both being aggravated or induced by rising from a horizontal position. Slight attacks may only last a few minutes. In cases where there is a direct lesion of the laby- rinth, a certain degree of deafness — a limitation of the field of audition, that is, the loss of certain sounds in the musical scale — and tin- nitus remain. The patient is in all other respects well, except for the dread of a recurrence of the attack. Occasionally, however, a certain degree of vertigo and reeling persist, liable to be aggra- vated by gastric derangement. A patient rarely escapes with one attack. Subsequent attacks are separated by distinct intervals, but in severe cases these may become less and less, until a permanent vertiginous state, of a most distress- ing character, may be reached, liable to paroxys- mal exacerbations. In such very grave cases spontaneous cure may occur on the establishment of complete and permanent deafness, or relief may be obtained by therapeutical measures. When the labyrinthine disturbance is secondary to disease of some othor part of the auditory apparatus, removal of the pirimary disease, as cerumen or tympanic catarrh, will, when prac- ticable, promptly remove the symptoms, and the attacks may not recur. Diagnosis. — Meniere's disease has to be dis tinguished from epilepsy, apoplexy, gastric de- rangement, and other causes of vertigo. From VERTIGO. all of these it is distinguished, by the invariable coexistence of tinnitus, deafness, and vertigo, ■with in addition syncope and nausea, or vomit- ing. The concurrence of the first three symptoms shows that the labyrinth is involved, a point which will be further established by testing audition with a tuning-fork and watch. The vertigo is generally of movement in a certain definite and uniform direction. There is never numbness, tingling, or any sensations analogous to an aura ; but aching of the upper extremities, and discolouration of the hands may occur, from irradiation of the irritation from the inferior cervical ganglion to the brachial plexus (Woakes). As to the diagnosis of the nature of the labyrinth- .ne affection, whether primary or secondary, some rules have been laid down by authorities. If a per- son who has formerly heard well becomes suddenly deaf, or hard of hearing, with the symptoms of an apoplectic attack, and if there is at the same time an uncertain and staggering gait, but no symp- toms of paralysis in the nerve-tracts, and if the examination shows a normal membrana tympani, and perfectly permeable Eustachian tube, we may believe with great probability that there is an affection of the labyrinth (Troltsch). Deafness and tinnitus occurring without vertigo indicate an affection of the middle ear. Vertigo and tinnitus without deafness may be due to an affection of the middle ear. Vertigo, tinnitus, and deafness are certainly due to an affection of the laby- rinth. Careful otoscopic examination should be made, the permeability of the Eustachian tubes tested, and the tuning-fork and watch employed to ascertain the condition of the con- ducting apparatus, before an exact opinion can be formed as to the nature of the labyrinthine affection. Vomiting, following the ingestion of some rich or indigestible food, may be so severe and lasting as to monopolise attention, and the vertigo and tinnitus may not be complained of. In such a case, a mistake may readily occur in a first attack. Peognosis. — Where the labyrinthine affection is due to some remediable defect, the disease will subside on removal of the cause, such as ceru- men, tympanic catarrh, &c. ; hence the great, im- portance of an exact diagnosis as to the nature of the case. When the lesion is primarily of the labyrinth, a certain degree of deafness and tin- nitus is nearly always left, and recurrence of the attack is to be anticipated. Teeatment. — In the attack, and for a short time following it, the recumbent position should be strictly maintained. .Bromide of potassium or ammonium, in ten to twenty grains for a dose, may be administered, and small pieces of ice swallowed. Next, any gastric derangement should be corrected, for in some cases gastric affection excites a paroxysm in a person predis- posed to it by some aural affection, insufficient alone to induce an attack. Alkalies and vege- table bitters, with or without bismuth, will generally be useful for this purpose. Any abnormal local condition must be treated. Sub- sequent to the attack quinine in full doses, 3 to 5 or 10 grains three times a day, perseveringly used, is sometimes attended with the best results (Charcot). Gelsemium and salicylate of soda tsavo been fouud useful (Gowers). Counter- irritants, including the actual cautery, applied to the mastoid region, have proved serviceable in some cases, and may be used in addition to other measures. 3. Gastric Vertigo. — Synon. : Vertigo a sto macho Iceso. Vertigo, occasionally of a high grade, some- times accompanies chronic gastric derangement. It is more common with slight than with grave affections of the stomach, but has been met with in well-marked organic disease of this organ. An explanation of its occurrence has been given in the introductory remarks. It sometimes occurs soon after a meal, but more often when the stomach is empty (Trousseau). Associated with it are usually pain and a feeling of fulness in the stomach, increased by food ; heartburn ; eructations; vomiting; flatulence; andpain in tho left hypocliondrium and chest. The bowels may be torpid, or diarrhoea may be present. The patient, often suddenly experiences a swimming in the head, objects may appear to revolve, the patient's gait becomes tottering, and he may even fall. Often there is constrictive headache, faintness and pallor with nausea, and sometimes trouble- some vomiting, but there is no loss of conscious- ness. Visual hallucinations may be present, and buzzing in the ears experienced, but there is no deafness. The vertiginous symptoms may so predominate that the gastric symptoms may not be complained of, but treatment directed against dyspepsia cures the vertigo. When predisposing gastric disturbance is present, trivial causes, such as looking at objects which lead to con- fused visual impressions, may excite an attack, but this may also arise spontaneously. In many cases relief is obtained by the recumbent posi- tion, but attacks may occur when the patient is lying down. Diagnosis. — This form of vertigo is diagnosed from epilepsy by absence of loss of consciousness ; and from labyrinthine vertigo by the absence of deafness, and the physical signs of aural disease. It cannot be concluded that the vertigo is essen- tially gastric without thorough examination of the ears, for, as already stated, vertigo may be excited by gastric disturbance when there is laby- rinthine affection insufficient alone to determine an attack. It must also be remembered that signs of gastric and intestinal derangement are induced in Meniere's disease, and may be so prominent as to cause the aural affection to be overlooked. 4. Nervous Vertigo. — Synon.: Er. Vertigc nerveuse. Not uncommonly vertigo is one of the most troublesome symptoms of nervous exhaustion and depression. This occurs in persons unduly taxing their nervous powers, by severe in- tellectual strain, especially when combined with anxiety, or by sexual excesses. It occurs also from the depressing effects of the immoderate use of tobacco, alcohol, and tea. The vertigo rarely reaches a high grade, manifesting itself by a sensation of confusion, or of objects re- volving, occasionally only by the feeling of a tendency to fall. It may be associated with a slight reel, but more often the patient feels as if he were walking unsteadily, when there is no perceptible peculiarity of gait. As a rule 1748 VERTIGO. giddiness is only experienced in the upright position, but in some cases it occurs ■when the subject is recumbent, and the patient often com- plains of sudden and violent startings when just in the act of falling asleep. It is often intensified by an elevated position, and in large buildings and assemblies. Hence it is often experienced in church. It is peculiarly distressing, owing to the sufferer’s emotional equilibrium being easily disturbed, and is frequently associated with a dread of impending cerebral disease — epilepsy, apoplexy, insanity, etc. There often coexist gastric derangement and flatulence, with irrita- bility of the heart, palpitation, and sleeplessness, the former no doubt having a share in its pro- duction. There may be slight and temporary buzzing in the ears, but deafness is absent, and no loss of consciousness occurs. In these respects it is readily distinguished from Meniere’s disease and •petit mal. Treatment. — This is to be treated by removal of the cause — over-work, excessive sexual indul- gence, or the abuse of alcohol, tobacco, or tea ; by correction of any dyspeptic symptoms; and by the administi'ation of nervine tonics, such as iron, quinine, or strychnia. Bromides should be avoided if possible. 5. Epileptic Vertigo. — Vertigo may occur in a slight fit of epilepsy, or at the commence- ment of a severe attack. The symptom may replace an epileptic fit, or may coexist with epi- lepsy. It is more common in epileptic vertigo for the patient to imagine that he himself is moving or turning round, than for external objects to appear in motion (Russell-Reynolds). Care must be taken not to accept the patient's mere statement of ‘ giddiness.’ The term is often loosely applied. It is necessary to ascertain his exact sensations, and only to conclude there is vertigo when actual feelings of movement are experienced. If the vertigo is related to change of position of the head, it is probably labyrin- thine. The latter is not usually accompanied by loss of consciousness, and is more apt to be followed by vomiting (Gowers). 6. Migrainous Vertigo. — Vertigo commonly constitutes one of the phenomena of migraine, occurring as a rule after the disorders of sight, touch, and speech, when these form part of the seizure, and either attends or follows the de- velopment of the headache (Liveing). Vertigo sometimes replaces the attacks of migraine. It is apt to occur on change of posture, or on suddenly turning the head. As a rule migrainous vertigo is slight in degree, but it may be quite severe, and accompanied by nausea and vomiting. It is unassociated with noises in the ear, or with deafness. See Megrim. 7. Vertigo in connexion with organic disease of the nervous system.— Vertigo sometimes accompanies disease of the cerebrum, both acute, as apoplexy, and chronic, as tumours. There are reasons for believing that vertigo may be excited by cortical lesions, thus explaining epileptic and migrainous vert igo. Disease of tho cerebellum and of its middle crura are often attended with reeling gait, and sometimes with vertigo. This symptom sometimes accompanies the ataxy of tabes dorsalis ; and is a marked symptom of some cases of insular sclerosis. VIBRATION. 8. Gouty Vertigo. — Vertigo, labyrinthine or other, is occasionally met with in gouty persons. It may disappear after an outburst of gouty arthritis ; or be removed by alkalies, colchieum, and other proper remedies, and attention to diet. Stephen Mackenzie. VESICAL DISEASES. See Bl addeb, Dissases of. VESICANTS ( vesico , I blister). — A class of counter-irritants which produce blisters. Set Counter-Irritants. VESICLE ( vesicula , diminutive of vesica, a bladder). — Synon. : Fr. Vcsicule ; Ger. Bldschcn. Definition. — An elevation of the corny layer of the epidermis, caused by a minute circum- scribed collection of serum or sero-pus, between it and the mucous layer beneath. Description. — Vesicles may he minute or of considerable dimensions ; a vesicle of the size of a millet-seed gives the name to the cutaneous affection miliaria. The vesicles of eczema are minute and frequently confluent ; those of scabies are occasionally acuminated; the vesicles of va- rioloid are not uncommonly umbilicated ; tho30 of herpes iris are developed in rings ; the vesiclea of ordinary herpes attain the bulk of a split pea ; and the vesicles of pemphigus, on account of their large size, are called ‘ bullae.’ The contents of s vesicle are apt to modify its name, since a vesicb. containing a purulent fluid or pus is termed t ‘ pustule.’ The ordinary course of a vesicle is te lose its fluid by evaporation, absorption, or rup- ture of the distended cuticle ; to dry up into a thin scale ; and to terminate by desquamation, without further lesion of the skin. Treatment. — The treatment of vesicles is fully described under the heads of the several diseases of which they are a symptom. See Chicken-pox ; Herpes ; Miliaria ; and Pem- phigus. Erasmus Wilson. VESICULAR EMPHYSEMA.— A form of emphysema of the lungs, in which the alveoli are distended with air. See Lungs, Emphysema of. VIABLE (vie, life). — Synon.: Fr. Viable-, Ger. Lebendig. — An epithet applied to a newly- born child, to indicate its capacity for maintain- ing an independent existence. Viability has chiefly to be determined by the age of the foetus, and by its condition as regards formation, health, and strength ( see Fcetus, Diseases of). It has also been supposed to depend in some measuro upon the season of the year in which a child is born (see Periodicity in Disease). The question of viability has important medico-legal bearings, for which reference must be made to works upon forensic medicine. VIBICES (viler, a wale). — Synon. : Fr. Ver- getures ; Ger. Striemen . — A term applied to patches cf discolourisation on the surface of the body, somewhat resembling the marks of stripes or wales, and due to the presence of altered blood in the part. Vibices may arise either during life, as the result of a variety of causes (see Extravasation) ; or after death, as one form of cadaveric liridity or hypostasis. See Death, Signs of. VIBRATION. — This word is sometimes em- ployed as a synonym for fremitus. See Fremitus VIBRIO. "VIBRIO ( [vibro , I shake). — Synon. : Fr. Vi- brion ; Ger. Zitterthierchen. See Bacteria. VICARIOUS ( vicarius . in place of another). This word signifies substitution, and in physio- logy and pathology implies that some part or organ performs certain functions, or is morbidly affected, instead and in the place of some other part or organ, thus becoming a substitute for it. The notion of vicariousness is chiefly associated •with a discharge of blood, whether physiological or morbid. Thus, it is very common to speak about vicarious menstruation, which is under- stood to mean that the discharge of blood which takes place normally from the uterus at the menstrual period, either does not occur at all, or only imperfectly, and that its place is taken by haemorrhage from some other part, evidenced by epistaxis, haemoptysis, haematemesis, or other forms of bleeding. The same idea is extended to morbid haemorrhages, such as bleeding from piles, when this becomes habitual in an indivi- dual at frequent or regular intervals. It is sup- posed that bleeding may sometimes take place from other parts as a vicarious hsemorrhuge, instead of from the haemorrhoids. Again, discharges, whether normal or morbid, as of secretions, mucus, pus, or other materials, are believed by many to exhibit a vicarious re- lation to each other in some instances, coming from one part while ceasing or diminishing at another, and so on. This may be illustrated by expectoration and diarrhoea in phthisis, which appear to modify each other as to their amount in some cases of this disease. Further, secretions and excretions are regarded as acting vicariously with reference to each other. Thus some of the secretions of the alimentary canal are undoubt- edly capable of acting mutually as substitutes, and. this may be looked upon as an instance of vicarious action ; while such a connection exist- ing between the perspiration and urine is gene- rally recognised. Certain morbid conditions are also considered as having a vicarious relation. For example, con- gestion of or hsemorrhage from one part may take the place of congestion at another; or inflamma- tion in one region may be the substitute for in- flammation in another region. There is probably more or less truth in these notions of vicariousness, as applied in relation to physiology and pathology. In actual practice, however, no case ought to be regarded as belong- ing to this category, without careful and thorough investigation. It has happened that haemor- rhages supposed to be vicarious of menstruation, have been important signs of grave diseases, such as gastric ulcer, or pulmonary phthisis. The principle may be of value in certain conditions as an indication for treatment. Frederick T. Roberts. VICHY, in France. — Thermal alkaline waters. See Mineral Waters. VIGILIA. — Wakefulness; a term formerly applied to conditions of insomnia, but now little used and almost obsolete. See Sleep, Disorders of ; and Coma- Vigil. VILLOUS GROWTH {villus, hair).— Synon. ; Fr. Villen t; Ger. Villos; Zottig. — VISION, DEFECTS OF. 1749 A growth composed of hypertrophied villi. Set Tumours. VIRGINIA SPRINGS, in Virginia, United States. — Sulphur waters. See Mineral Waters. VIRULENT {virus, a poison). — Primarily this word signifies connected with virus or poison. It is generally, however, employed to indicate great intensity or malignancy of disease; for example, virulent inflammation, virulent bubo, and virulent small-pox. VIRUS (Lat.). — Literally this word signifies a poison, but in medical language it is used to designate any kind of contagious material. See Contagion. VISION, Defects of. — S tnon. : Fr. Troubles de la Vision ; Ger. Sehenstohrungen. Sight may be defective as to perception of form, of colour, or of light ; and the whole, or only a part, of the visual field may be affected. Sight is also disordered whenever binocular single vision becomes difficult or impossible {see Strabismus) ; and when visual endurance is im- paired. The terms ‘ vision ’ and ‘ sight,’ as com- monly nsed, indicate acuteness of vision, and refer to the perception of form at the yellow spot. In this article disorders (A) of percep- tion. of light, (B) of perception of colour, and (C) of the visual field, will be shortly alluded to ; hut attention will be chiefly given to (D) disorders of acuteness of vision caused by optical defects in the eyes. A. Disorders of Perception of Light. — Perception of light is equally good in all parts of the retinal area, except the most peripheral zone, which appears to be blind. 1 Impaired perception of light causes disproportionate defect of vision by dull light — ‘ night-blindness ’ {see Nycta- lopia). It may affect the whole field, or only its periphery. It occurs chiefly in diseases of the outer layers of the retina, especially syphilitic retinitis, and retinitis pigmentosa. Lowered light-sense over the whole field occasions the symptoms in the peculiar disease known as func- tional or endemic nyctalopia {torpor retina). The opposite condition, day-blindness {see Hemera- lopia), with true retinal photophobia, is much rarer and more obscure. It is usually congenital, and accompanied by nystagmus, amblyopia, and colour-blindness ; and acuteness of sight, which is defective, is best by dull light. B. Colour-Blindness. — Synon.: Dyschroma- topsia; Achromatopsia. — This, when congenital, is usually not related to any other defects of vision. Congenital colour-blindness occurs with greater intensity and far greater frequency in males than in females (M. 3 to 5 per cent. ; E. "2 per cent, or less). It is shown by more or less want of power to distinguish between certain complementary colours. Red and green are the two commonly confused, the perception of blue and yellow being but rarely affected. Blindness for all colours is very rare except as the result of disease. There are many degrees of colour-blindness. A red- green-blind person sees in the spectrum only two colours, separated by a neutral stripe, which is placed somewhere in the greenish-blue ; all the colours on the side of the red (‘warm’ colours) 1 Landolt, Arch. d'Oplh., i. 203, 18S1. VISION, DEFECTS OF. 1750 are confused together, and all on the side of the violet (‘cold’ colours), but the warm and the told are never confused (Donders). 1 In incom- plete red-green-blindness, green, bluish-green, and often rose are confused with grey of corre- sponding shade, and red is confused with shades of brown and greenish-brown. In a complete case full green and scarlet are confused. The best test for ordinary use is the one due to Holm- gren of Upsala, in which a skein of Berlin wool, of a particular colour and shade (green, rose, or red), is given to the patient, and he is required to match it with all the others which seem to him of the same or a similar colour, amongst a large bundle of skeins of many colours. He is not usually allowed to name the colours, because even the colour-blind often guess the colours of common objects correctly. A very pale, pure green is the first test used, and the colour-blind, even of slight degrees, will match with it not only other green skeins, but also shades of pale grey, buff, and pink. • Slight cases may easily be over- looked, unless the wools are carefully selected, and the examiner practised. Stilling's plates of coloured let! ers, printed on a groundwork of com- plementary colours, are also very valuable. Red and green are not well seen under ordinary circumstances, even by the normal eye, except at the central part of the visual field (i.e. the field for these colours is smaller than for white ; but even at the periphery these colours are re- cognised if very brightly lighted and of large size. 2 Acquired colour-blindness often comes on in degenerative or inflammatory diseases which be- gin in the optic nerve. It is much less common in diseases of the retina, and in glaucoma. Like the congenital form, it usually concerns only, or chiefly, red and green. It may affect the whole visual field of these colours, or only certain parts, a gap, or ‘ scotoma,’ being present, on w'hose area the red and green are not perceived in their true colours. When acquired colour- blindness is well-marked in the whole extent of the field, in cases of disease of the optic nerve, the prognosis for sight is generally very bad; but if it be localised on a central scotoma, even though it there reach a high degree, the prog- nosis is usually good. Progressive atrophy of the optic nerve, however, occasionally reaches a very high degree without any colour-defect. C. Disorders of tire Visual Field. — The visual field is the whole surface visible to one eye singly whilst at rest. It forms a con- cave surface, all the points of which are equi- distant from, and perpendicular to, their corre- sponding points on the retina. In the outward and downward part it reaches to 95° from the centre; jnwards, upwards, and downwards only to about 60°. Projected on a flat surface it thus forms an oval. The centre of the field (‘ fixation point ’) corresponds to the yellow spot, and the ‘blind spot’ is about 15° outwards from this point. In order to measure the field roughly, the patient, placed with his back to the light and covering one eye, looks steadily from a dis- tance of eighteen inches at the nose or eye of the observer, who then moves his hands about in the different parts of the field, and notes any 1 Donders, Brit. Med. Jour., 1880, ii. 767. 3 Landolt, Examination of the Eye, p.213. places whero the hand is invisible or badly seen. This test, carefully applied, will detect any con- siderable loss of the field. Or the patient may gaze at a spot on a black board about one foot off, and a piece of white chalk be moved from different points at the periphery until it just be- comes visible ; a line joining the various points will form the boundary of the field. For accurate measurements, however, a special instrument, the Perimeter, is necessary. D. Disorders of Perception, of Form. — Perception of Form, Synon. : Acuteness of Vision ; Visus ; V . ; Fr. Ac idle visuelle; Ger. Sehschdrfe ; S.— Perception of form is normal only when the image of the object looked at falls on the bacil- lary layer of the retina, at the centre of the yellow spot, is clearly defined, sufficiently bright, and of a certain minimum size. Phixciples. — The size of the image depends (1) upon the size of the ‘visual angle’ enclosed by the two lines drawn from the extremities of the object to the ‘nodal point’ just behind the crystalline lens; and (2) on the distance of the nodal point from the retina, which in the normal eye is 15 mm. The form of any letter or cha- racter is distinguished by a properly formed and healthy eye, with average light, if it subtend a visual angle of five minutes, each of its sepa- rately distinguishable parts subtending an angle of ono minute. If the nodal point be more than fifteen millimetres from the retina, the image will be larger, and acuteness of vision therefore in- creased; this occurs in myopia, and also when a convex glass is held in front of the eye. The reverse is true if the distance be less than fifteen mm., as in hypermetropia, and when a concave glass is held before the eye. Hence convex lenses always increase, and concave lenses always diminish, the size of the retinal images. Vision or ‘ fixation’ is called direct or central when the image of the object looked at falls on the yellow spot; indirect or excentric when, in consequenco of impairment of function at the yellow spot, an image falling on some other part is better seen. The clearness of the image depends (opacities of the media apart) upon the retina being exactly' at the focus of the refracting (dioptric) media of the eye ; it is also influenced somewhat by the size of the pupil, being, cceteris paribus, better when the pupil is small. Normal acuteness of vision is expressed as unity (V. or S. = 1); subnormal vision being expressed as a fraction. Various test-types are in use, composed of letters, words, &c., of such a size that each subtends the minimum angle of five minutes at a certain distance. The test-types of Dr. Snellen are in most general use, and include letters visible under the standard angle at from 60 metres to "5 metre. If No. CO be read at 60 m., then V. = §§ or 1 ; if No. 60 can only be seen at 6 m. V. = ^ ; &c. V. therefore is expressed by a fraction whose nu- merator is the greatest distance at which a given type can be read, and the denominator the dis- tance at which it ought to be seen ; or the frac- tion may be reduced (j^ = ^, &c.). The acuteness is said to become progressively lower after the age of sixty, without disease; so that at eighty it is only about ^ (Donders). 1 1 Anomalies of Accommodation and Refraction, p. 19& VISION, DEFECTS OF. 1. Functional Affections of the Optic Nervous Apparatus. — Amblyopia without ophthalmoscopic changes may be permanent or temporary, and exhibit many differences in the character of tho failure of sight. The positive dis- use (suppression of the retinal image) of one eye, in order to avoid diplopia or the confusion some- times caused by opacity of the cornea or other defect, leads to permanent and great defect of that part of the visual field -which is common to both eyes, ‘amblyopia ex anopsia.’ The defect is psy- chical, and the eye shows no changes. It is most easily acquired early in life, and may be partly remedied by separate use of the eye. In cere- bral hemiansesthesia there may be blindness, or high amblyopia with great contraction of the field and colour-blindness in the eye opposite to the lesion, with a lower degree of the same condition in the other eye. Some rare cases of permanent loss of sight in one eye without changes, in which there is a history of previous paralytic symptoms, probablybelongto this group. In hemiopia (properly hemianopsia ) there is usually loss of the corresponding halves of the visual fields, vision being lost on the side opposite to the lesion ; when the loss of field extends quite up to the fixation-point, affecting central vision, the lesion is probably somewhere between the chiasma and corpora genieulata ; but when an area of several degrees around the fixation-point remains free, it is suggested that the lesion is cerebral. 1 Loss of both temporal halves may indicate disease at the chiasma ; neither this, nor loss of both nasal halves, is frequent. In hemiopia, even of longstanding, the optic discs are seldom altered. In some cases of ‘hemiopia’ only a quarter of each field is lo3t. Disease of the optic nerve at a distance from the rye causes blindness or defective sight, often at first without any ophthalmoscopic changes ; but if the defect remain, signs either of inflammation or atrophy appear in a few weeks. The oph- thalmoscopic changes may, however, be very slight, as is shown in the common cases of central amblyopia usually caused by tobacco-smoking, in which disease of the optic nerves has now been demonstrated; with the exception of this group, casts of retro-ocular disease of the nerve are rare. Temporary fogginess of sight, usually with the appearance of coloured rings around a candle, occurs in the premonitory stage of glaucoma ; these last from half an hour to a day or more ; they do not usually occur in both eyes at once ( see Eye and its Appendages, Diseases of). Attacks of megrim are often ushered in by a peculiar, transient, subjective defect of sight; a small cloud, appearing near the middle of the field, quickly spreads with a quivering movement and zigzag outline over about half the field; its bor- ders are often brilliantly coloured ; it affects both eyes ; is equally visible whether the eyes are open or shut ; lasts about a quarter of an hour ; and is generally followed by the other megrim symptoms to which the patient is subject. But some persons merely complain of a ‘cloudiness’ 1 See Ferrier, ‘ Cerebral Amblyopia and Hemiopia,’ Bruin , January. 1881. The subject, however, is far from exhausted ; see Robin. Troubles Oculaires darts les Mai de V Bnciihale. p. 390, 1S80, Haab, Klin. Mor.atsbl.f. Augen- ‘uilk. Sic., 1881, &c. 1751 or of ‘ spots ’ before their headaches (see Me- grim). Brief attacks of blindness of one eye, coming on quite suddenly, and recurring in the same eye, occasionally take place in the sub- jects of heart-disease. Permanent blindness, with atrophy of disc or the appearances of re. final embolism, has at length supervened in a few of these cardiac and megrim cases. 1 Persons who suffer from severe neuralgic pain in the fifth nerve sometimes describe dimness of the same eye during an attack, but the oppor- tunity of verifying the statement seldom occurs. In connection with severe vertex-headache in hysterical persons, sight is sometimes very bad ; one eye may even appear almost blind. There is photophobia, and there may be symptoms of accommodation-spasm, and the field is, or seems to be, highly contracted. Though it may be exceedingly difficult to say that there is con- scious dissimulation, the groundless nature of the ocular symptoms is sometimes proved by the fact that acuteness of vision, even in the ‘blind' eye, is at once and perfectly restored by the weakest possible lens, or by a piece of flat glass mounted to resemble a trial lens. Intentionally feigned blindness of one eye can nearly always be detected by one device or another ; but pre- tended defect of both eyes is more difficult to expose ; reference must be made to works on ophthalmology for further details. 2. Abnormalities of Refraction. — S ynon. : Ametropia. — These conditions are of importance by preventing the formation of clear retinal images ; in addition they often make the sus- tained use of the eyes difficult or impossible (asthenopia). They include (a) hypennetropia, (b) myopia , and (c) astigmatism. The varieties of asthenopia will receive a short separate ac- count after ‘Disorders of Accommodation.’ As ametropic conditions are remedied by optical aids, it will be convenient first to refer to the subject of spectacles. Spectacles. — Varieties of Construction and Mode of Wearing. — Refracting spectacles are made either of crown-glass or of rock-crystal. The latter is more expensive but harder, less breakable, and rather lighter. Ordinary spec- tacles are biconvex or biconcave spherical lenses. Meniscus lenses are sometimes used, and are called ‘periscopic’ because they give a larger field. In ‘Franklin’ or ‘pantoscopic’ spectacles the upper half is made of a different focal length from the lower ; they are sometimes used by persons who need distance- and reading-glasses of different strengths in the same frame. The various non-refracting protective glasses (goggles, domed glasses, horseshoe- or D-protectors, &c.) are generally included under the term ‘ specta- cles.’ The most important points in the mount- ing of spectacles are that the hinges should be strong, the sides long enough to hold securely without uncomfortable pressure, and that the bridge should fit the nose well. The centres of the lenses should, unless otherwise ordered, be opposite the centres of the pupils when the glasses are in use. All concave glasses and convex dis- tance glasses should sit as close to the eyes as 1 Hutchinson, Oph. Eosp. Reps. viii. 56 ; Lorinfr, Amor. Jour. Med. Bci., Apiil 1874 ; the author, Brit. Med. Jour . June 1879 ; Gakzowski, Gaz. des Hop., Dec. 1881. 1752 VISION, DEFECTS OF. possible; convex reading-glasses may be put further down the nose, and shaped to allow of looking over the top of the frame in distant vision. For ‘simple’ astigmatism the correcting lens is a segment of a cylinder ; for ‘ compound ’ and ‘ mixed ’ cases the effect of a cylindrical and spherical lens is required, and may be obtained either by combining two suitable cylindrical curvatures at right angles to each other, or by grinding the cylinder on the flat side of a plano- convex or -concave lens ; they require of course to be mounted with the curvature of the cylinder exactly in the right direction. When prisms are ordered they are mounted like ordinary spec- tacles, and a lens may be ground upon each sur- face of the prism if necessary; it is not practi- cable to wear prisms of more than about 8°. Spherical lenses can be male to act to a varying degree as prisms, by putting them with their centres nearer to or further from each other than the pupils. Numbering. — Spectacle lenses are at present numbered on two different systems, namely— (1) the inch scale;, and (2) the metrical scale. (1) In the old system the refractive unit is a lens of 1-inch focal length, and the inch may be English, Parisian, or other. The lenses in use being all weaker than the unit are expressed by fractions ; thus the strongest in use in the trial case being a 2-inch Ions is expressed as £( + or—, according as it is convex or con- cave) ; a lens of 10 inches’ focus is -jg ; &c. It is desirable that the series of lenses should rise by equal refraction-intervals, and here the inch scale is inconvenient because it introduces difficult fractions. (2) The inch scale is rapidly giving place to the metrical dioptric scale, in which the measure is international, the refrac- tive unit is a weak instead of a strong lens, and the refractive intervals are equal. The unit is a lens of 1 metre (100 cm.) focal length, and is called one dioptre (1 D.) Stronger lenses are written as whole numbers; thus a lens four times as strong as the unit is 4 D. ; a lens equal to half the unit is -5 D. The disadvantage of the system is that the numbers do not, as on the inch system, express the focal length of the glasses ; but the latter is easily arrived at by dividing 100 by the number of the lens in diop- tres ; thus the focal length of 5 D. = 0 = 20 cm. To convert a lens made by the Paris inch into its equivalent in dioptres, multiply its inch-value by 36 (1 m. = 3G Paris inches nearly); thus, _L x 36 = 1 D. To convert a metrical lens into its equivalent in Paris inches divide its value in D. by 36; thus 4 D. =^j = i. The following are the most important equiva- lent numbers : — Focal length in Dioptres (D.) Paris inches •5 72 (written ,V &c.) •75 50 1- 36 1-25 30 1-5 26 S IS 25 14 a 12 3 5 10 ( nearly) Focal length in Dioptres (D.) Paris inches 4 9 4-5 8 5 7 6 6 7 5* 9 4 11 3V 13 3‘ 15 18 2 Several intermediate numbers found in the trial cases have been omitted. The several abnormalities of refraction and accommodation may now bo discussed in due order. a. Hypermetropia . — In hypermetropia the re- tina lies within, instead of at, the principal focus of the dioptric media. Parallel rays, such as come from very distant objects, therefore meet the retina before being focussed ; and divergent rays, from near objects, meet it still more in ad- vance of their focus. Hence the hypermetropic eye, in repose, sees nothing clearly. Distant objects can be seen clearly if, by exerting accom- modation, the crystalline lens be made more convex; or if the rays, before they enter the eye, be made sufficiently convergent by passing through a suitable convex lens. Common hypermetropia, due to flatness of the posterior segment of the eyeball, called axial hypermetropia, is always congenital ; and a large proportion of children are hypermetropic at birth— according to Ely' 72 percent. In sections the circular fibres of the ciliary muscle are, or appear to be, more abundant than in the normal eye. The cornea is not flatter, but the anterior chamber is rather shallower, and the pupil rather smaller than normal. In high degrees the eye- ball is too small in all directions. The natural remedy for hypermetropia consists in the exercise of accommodation for distant sight; when in the normal or emmetropic eye it is in complete abeyance. A proportionate in- crease of accommodation is required by the hy- permetropic eye for near vision. The absolute quantity, amplitude, or range of accommodation is not greater in hypermetropic than in normal eyes ; hence in hypermetropia it becomes sooner insufficient for the needs ; and the higher the degree of hypermetropia the earlier does this occur. Symptoms. — The symptoms depend on the patient’s age, occupation, and health, and on the degree of hypermetropia. The lower degrees only exceptionally cause symptoms in child hood. The higher degrees in children, and the lower degrees in young adults, cause difficulty in reading, writing, or sewing, especially by artificial light, and towards the end of the day’s or week’s work-accommodative asthenopia.' The difficulty* is expressed in the forms of mistiness of sight, weariness or aching of the eyes, headache, sleepi- ness, watering, chronic congestion and irritation of the palpebral conjunctiva. In the highest degrees the attempt to see clearly is often given up. Such persons often partly compensate for the bad definition of the images by holding the book very close, and so increasing their size, and thus they may seem to be myopic. All the symptoms are worse when the health is low. As accommodation fails with age, a time arrives for every hypermetrope when, unless aided by glasses, no clear vision is possible at any distance ; but spectacles are generally adopted before this occurs. Concomitant convergent squint often arises in hypermetropia (see Strabismus). It isat firsthand may remain, periodic, present only during strong accommodation; but often it becomes constant. 1 E!y, Knapp' t Arch. d. Ophlhalm. ix. p. 4. VISION, DEFECTS OF. 1753 In either case it may alternate or may always affect the same eye. "When constant and fixed the sight of the squinting eye becomes defective, as already described. This occurs most easily in squint acquired early in life. By oft-repeated separate practice of the squinting eye the defect may to a great extent be removed. The squint- ing eye can often be proved to have also had some original defect, as from corneal nebula or a higher degree of ametropia, which led to the other eye being used and this one being allowed to squint. When the crystalline lens is absent (aphakia) the eye is very hypermetropic. Distant vision is restored by means of a convex lens of 10 or 11 D. (3f or 3^ inches) held about half an inch in frontof the cornea ; objects at, say, 25 cm. (10 inches) are clearly seen through a lens of about 15 D. (2j inches). Accommodation is abolished in the aphakic eye ; but if the pupil be round and movable, its contraction aids a little in near vision, by cutting off the peripheral rays of light. From the age of 55 and onwards the normal eye acquires a low degree of hypermetropia, owing to a change in the refraction of the crystal- line lens. Glaucoma is commoner in hypermetropic than in normal or myopic eyes. The habitual use of glasses by hypermetropic persons from early life may aid indirectly in preventing this disease. DiAGNOSis.-The diagnosis is made subjectively by testing with glasses, or objectively by the ophthalmoscope. The former is the more generally useful. Even distant objects are seen indistinctly by the hypermetropic eye with relaxed accom- modation ; but they are made clear if a suitable convex lens be held in front of the cornea. 1. This test is easy to apply when the ciliary muscle is temporarily paralysed by atropia, or abolished by natural senile changes. 2. But when it is active the matter is less simple. The old-stand- ing habit of exerting accommodation whenever clear vision, even at a distance, is needed, in many cases inseparably connects the effort to see, with the action of the ciliary muscle. Such persons cannot relax thU ir accommodation when looking through a convex lens at a distant ob- ject. The effect of the lens is therefore added to, instead of substituted for, that of the accom- modation, and distant vision made worse ; no hypermetropia can be found by trial with glasses, it is entirely ‘ latent ’ ( H.l . ). 3. Between these extremes we find a large number who can par- tially relax their accommodation for distance in favour of a convex lens, but still use a part. They see well, or perfectly, in the distance with- out aid; they see equally well or better with con- vex lenses up to a certain strength. If now the accommodation be suspended by means of atropia we shall often find a higher degree of hyperme- tropia. The part that can be detected when ac- commodation is active is the ‘ manifest’ (H.m.) ; the sum of the ‘ manifest ’ and the ‘ latent’ is the * total ’ (H.). In testing hypermetropia, the patient being not less than ten feet from the test-types, we begin with a very weak convex lens, and if vision is not made worse, try successively higher lenses until we reach the highest which allows the best attain- able vision. _ This lens represents the manifest hypermetropia if accommodation be present, the total if it be absent. A stronger lens causes in- distinctness by bringing the focus in front of the retina. In general the younger the patient the less is the manifest in proportion to the latent hypermetropia, even though troublesome asthen- opia be present. Hypermetropia is diaguosed by the ophthalmo- scope if an erect image of the fundus is easily seen when the observer is at a distance of 18 inches or more from the patient. The image is seen equally well when the observer comes as close as possible to the patient ; and if he pos- sess a. ‘ refraction ’ ophthalmoscope, he can in this position measure the degree of hypermetropia by finding the strongest convex lens through which the details of the fundus still look perfectly clear. In this test the accommodation of both persons must be fully relaxed ; the observer has to learn to do this, but the patient generally re- laxes his ciliary muscle at once in the dark room, even though he could not do so when tried with glasses for the distant types. Another test, Iceratoscopy or retinoscopy, is based on the fact that when light is thrown by the ophthalmoscope into the eye at a distance of three or four feet, slight rotation of the mirror causes a shadow to move across the illuminated field ; in hypermetropia the shadow moves in the opposite direction to the rotation of the mirror. The method is sometimes useful in young or un- ruly children, and in skilled hands affords the means of a tolerably accurate determination. The optic disc in hypermetropia, especially in children, often seems, and sometimes is, hazy, and is sometimes too red ; and the retinal arte- ries are often too tortuous. Treatment. — Treatment is necessary for hypermetropia whenever there is asthenopia, and when strabismus has arisen. Convex spec- tacles are ordered which, according to circum- stances, neutralise a part or all of the hyper- metropia, and are worn constantly, or only for near work. Periodic squint may always be cured by the constant use of fully correcting glasses ; but in most cases where it has become constant, an operation is necessary (see Strabismus). In children with asthenopia it is usually best to order glasses for constant use, which correct almost the whole hypermetropia ; but, if the symptoms are in connection with weak health and the hypermetropia be slight, the temporary use of glasses for near work alone is enough. Young adults using glasses for the first time are often satisfied with those which neutralise only the manifest hypermetropia, using them for all near work ; but after some weeks or months asthenopic symptoms often recur, we find that there is more manifest hypermetropia than be- fore, and are obliged to order stronger glasses. But ophthalmoscopic estimation will, as stated above, generally tell us correctly almost the total even at the first examination ; and when this method makes it clear that the total is much greater than the manifest hypermetropia, glasses of nearly the full strength should be ordered at once. On theoretical grounds it is undoubtedly best for glasses to be worn constantly by hyper- metropes, so that the accommodation may always (754 VISION, DEFECTS OE. be at rest. But a good deal of latitude must be allowed to grown-up patients in regard to wear- ing them for distance, unless there be constant nsthenopia, and this especially with elderly persons. Acuteness of sight is usually normal in cor- rected liypermetropia. In many cases of high degree, where vision is, both with and without glasses, subnormal, some astigmatism is also pre- sent; but cases occur where the defect cannot be thus accounted for, and it is then assumed to be due to defective development of the eye. But probably want of education of the retina in the perception of clear images in a great degree accounts for the phenomenon. b. Myopia . — In myopia the retina lies beyond the principal focus of the dioptric media, gene- rally on account of lengthening of the posterior part of the eye— axial myopia ; it is consequently at the conjugate focus of a point at some definite distance in front of the eye, which indeed is the ‘far point,’ or greatest distance of distinct vision of the eye in question. The greater the elon- gation of the eye, the nearer is the ‘far point,’ the ‘ shorter ’ the sight, or the higher the degree of myopia. By using accommodation objects can be seen at a still shorter distance. IEtiology. — Myopia is comparatively seldom present at birth. The elongation usually comes on between about seven and fifteen years of age ; progresses for a time ; and stops between puberty and adult age. Myopia is often hereditary, and inheritance doubtless accounts entirely for some cases of very severo myopia whero none of the other causes have operated. But habitual use of the eyes upon very close work, especially in a stooping posture, aids very strongly in its pro- duction. Its onset is sometimes determined by a severo illness in childhood. It often comes on after severe keratitis with choroiditis in children. Myopia may also be caused by increased cur- vature of the cornea after keratitis, and is an invariable result of ‘ conical cornea.’ Certain changes in tho lens in the early stages of senile cataract sometimes produce myopia, even of con- siderable degree ; and, as this form of myopia does not, like axial myopia, influence the pro- gnosis, its possibility should always be borne in mind in a case of incipient cataract. Anatomical Characters. — The elongation occurs chiefly in the posterior part of the eye, and especially at the yellow-spot region. The sclerotic and choroid are thinned in proportion to the distension, and the choroid often locally atrophied. The term ‘ posterior staphyloma ’ is given to the bulging region ; in high degrees the eye is enlarged, and its coats are thinned, in all directions. The term ‘ sclerotico-choroiditis posterior’ is also used to indicate the supposed nature of the change. In high degrees, par- ticularly late in life, the vitreous often be- comes fluid and contains opacities ; haemorrhages may occur from the choroid ; and there is a strong predisposition to detachment of the retina and to cataract. In the ciliary muscle of myopic eyes the circular fibres are deficient or wanting. The Bnterior chamber is often deeper, and the pupil larger than usual. Owing to their large size highly myopic eyes aro often prominent and chiefly from the same cause their mobility is somewhat impaired. Symptoms. — A low degree of stationary myopia usually causes no inconvenience. In the higher degrees advice is sought, either because distant sight is bad, cr near work has to be held incon- veniently close ; or on account of eyeache, head- ache, watering, photophobia, or dimness ; or for insufficiency of tho internal recti (muscular asthenopia), or actual divergent squint. In the highest degrees divergent squint is nearly always present at the natural distance of distinct vision, and possibly even for distance ; and in much lower degrees there is often difficulty in keep- ing up convergence, and consequent pain, tension, and weariness. Aching shows that the myopia is increasing; it is alwaj's made worse by use of the eyes, but is often present, even when at rest in bed; it may accompany' the development of a squint, or of detachment of the retina. Myopic eyes, even of low grade, are often in- tolerant of bright light. Acuteness of vision is frequently sub-normal in high degrees, especially in old people ; such defect when not accounted for by visible structural changes, is assigned to irritative congestion of the choroid. Diagnosis. — A myopic person with healthy eyes can read the smallest print fluently at his own ‘far-point ’ (see below), but not further. He gains perfect distant vision by looking through a concave lens, which gives to rays of light from distant objects a divergent direction, as if they came from his natural ‘ far-point.’ Placing him not less than ten feet from the test types wo find experimentally the weakest concave lens that gives the best attainable vision. A stronger lens over-corrects the myopia, producing hyper- metropia, which, in its turn, is corrected by the exercise of accommodation. Myopia is diagnosed objectively as follows : — (1) When by direct ophthalmoscopic examina- tion at a long distance, an image of tho fundus is seen, which, on the observer moving his head from side to side, seems to move in the opposito direction. This image disappears when tho ob- server comes near to the eye examined. (2) When by direct examination close to the patient, a clear image (erect) can be obtained only by placing a concave lens behind the mirror; tho weakest lens which gives a clear image being tho measure of the myopia. (3) When in indirect examination the size of the ophthalmoscopic image increases on withdrawing the objective lens from the patient's eye. (4) By keratoseopy, the shadow moving in the same direction as the rotation of the mirror. The ophthalmoscopic changes depend chiefly on the atrophy of the choroid, which so often takes place on some part of the staphylomatous area. The commonest change is the ‘ myopic crescent,’ a patch of yellowish-white colour (ex- posed sclerotic), due to atrophy of the choroid at the true outer border of the optic disc. It is sometimes seen in eyes not myopic. When more advanced it extends all round the disc (annular staphyloma). There may also be sepa- rate patches of atrophy, or a large area of partial wasting, at the yellow-spot. In high myopia with VISION, DEFECTS OF. ftbrupt bulging of tile tunics, the disc is often tilted and then looks oral, and its outer side often becomes pale. CorasE and Prognosis. — Axial myopia can- not diminish. Though its increase as a rule ceases about the same time as the cessation of the bodily growth, it may continue, or may take a fresh start later in life, especially if the health be bad, or the eyes be excessively used for fine work. But often its course seems to depend upon causes which are not under direct control ; for we see myopia of high degree, leading to disastrous results, or blindness, in persons who have never learnt their alphabet, or straiied their eyes in any way; and, on the other hand, it is common to meet with very myopic people, of studious habits and advanced age, in whom the eyes have not changed since youth. In general the prognosis is worse the higher the degree, the older the patient, and the feebler the health. Teeatment. — Much may doubtless be gradu- ally done to prevent the acquisition and trans- mission of myopia, by improvements in the light- ing of school-rooms, and construction of seats and desks, and by the choice of well-printed books. During the progress of myopia the time given to school-work should, whenever possible, be short- ened ; and if the disorder be quickly increasing, or if there be much aching or irritation, rest of the eye should be insisted upon for several months, or longer. Myopic children should use their eyes only as much as is comfortable, and should be forbidden to read fine print, to read by bad light, or to stoop. If there be severe aching and intolerance of light, or rapid increase of the myopia, especially with diminished acuteness of sight, prolonged rest, subdued light (or smoked glasses), and the use of the artificial leech at intervals of a few days, with derivative treatment, are of service, at least in relieving the symptoms and improving vision fora time. The corrective treatment consists in the use of concave glasses. Myopic children should as a rule wear glasses for distance merely on educa- tional grounds. These glasses may fully correct the defect, but it is better that they should be a little under than over the full strength. If there be muscular asthenopia, the glasses often cannot be continuously worn, unless treatment be also di- rected to the internal recti. Adults may use their own judgment as to wearing distance-glasses. For near work it is seldom safe, except in low degrees, to allow the fully correcting glasses, be- cause their use calls into powerful action the function of accommodation, hitherto but little needed by the myopic eye, and also deranges the relation between this function and convergence of the visual lines. They also cause difficulty by diminishing the retinal images. If their use be persisted in for reading, &c., they may act indirectly in increasing the myopia. “When the natural far-point in myopia is not nearer than 13 inches (33 cm.) reading glasses are seldom re- quired. But for higher degrees it is often neces- sary to order spectacles which partly correct the myopia, that is, make the eyes less myopic, and thus remove the far point further off and allow the patient to read, &c., without stooping. As a general rule, subject to the peculiarities and needs of each case, about half the full correction I 1755 may for this purpose be safely and comfortably used. For music or painting a rather stronger pair of spectacles are sometimes required. When there is muscular asthenopia, shown by the fact that in near vision one eye, if covered, deviates outwards, relief may often be given by combining prisms with their bases inwards, with the reading glasses; the prisms, by allowing the convergence to be lessened, relieve the internal recti. c. Astigmatism. — Astigmatism may be regular or irregular. Regular astigmatism depends upon the refracting surfaces of the eye, chiefly of the cornea, not being spherical, but having different curvatures, that is, focal lengths, in different meridians, the meridians of greatest and least curvatures (‘chief’ or‘principal’ meridians) being always at right angles to each other, and the others having regularly intermediate curvatures. The meridian of greatest curvature of the cornea is generally vertical or nearly so. The astigma- tism of the lens, though less regular than that of the cornea, tends to correct the latter. In ‘ simple’ astigmatism one chief meridian is normal, the other either myopic or hypermetropic ; when ‘compound’ both chief meridians are myopic, or both hypermetropic, but in different degrees ; when ‘mixed,’ the eye is hypermetropic in one chief meridian, and myopic in the other. When the focal difference between the chief meridians, or the degree of astigmatism, is not greater than is represented by a lens of 72 inches’ focus ('5 D.) it may generally be neglected ; and much higher degrees often cause no trouble. Astigmatism is to be suspected in all cases of ametropia where spherical lenses do not raise vision to the normal, no other cause of the defect being found. It is detected subjectively by nu- merous tests, most of which consist essentially of straight lines running in various directions, some of the lines being seen by the astigmatic eye better than others. It can also be detected and measured by the ophthalmoscope. It is corrected by cylindrical lenses which neutralise the differ- ence of refraction of the two chief meridians ; but in the higher degrees acuteness of vision often remains even then subnormal. Irregular astig- matism can seldom be remedied. 3. Anisometropia. — This signifies different refraction in the two eyes, and is a very com- mon condition, the difference sometimes being extreme. When one eye is normal and the other myopic, each may be, and often is, used for.vision at different distances, and each remains perfect ; but if one be astigmatic, or very hypermetropic, it is generally defective from want of use. When slight it may be neutralised by corre- sponding spectacles, but when the inequality is great, fully correcting glasses cause so much difference in the size of the images in the two eyes, that equalisation is seldom possible. But it should be attempted when there is any ten- dency to divergent squint, in order to encourage binocular vision. Effect of blindness of one eye. — Acuteness of sight is always rather better with both eyes than with either alone ; further, both eyes are necessary for the appreciation of solidity and distance. Patients often think that blindness of one eye throws ‘ double work ’ upon the other and ‘ weakens it.’ Nearly always, however. Lb 1756 VISION, DEFECTS OF. inch a case some other cause can he found for at various ages, serves as a useful basis for tl e the asthenopia of the sound eye. selection of spectacles for emmetropic persons : — 4. Disorders of Accommodation. — a. Pres- byopia . — The ‘ amplitude’ or ‘range’ of accom- modation is expressed by the difference between (he greatest distance, ‘far-point,’ (r) and the least distance, ‘near-point,’ ( p ) of distinct vision. Age for age, it is nearly equal in all eyes, ■what- ever their refraction. Its natural failure ■with age causes presbyopia, the onset of which has been arbitrarily fixed to begin, in the emmetropic eye, at the age of 40, when the near point is at nine inches (22 cm.), and the failure generally progresses at a constant rate. Presbyopia is corrected by the convex lens, which enables the patient to read at nine inches; the strength of this lens varies inversely as the amplitude of accommodation, and at the age of 65, the near point being removed to infinity, the correcting lens is one of nine inches’ focus. Symptoms. — Presbyopia is first shown by dif- ficulty in reading or sewing by artificial light, or in the train or carriage ; defective accommo- dation prevents the work being held close enough to compensate for the defective light or for the shaking, and to remedy the former the candle is often placed between the eyes and the book. When more advanced the patient becomes 1 long- sighted,’ and has to put his book at arm’s length unless he wear glasses. If the refraction is nor- mal, distant sight is perfect. In hypermetropia, presbyopia begins at an earlier age, less accom- modation being available for near vision ; and in myopia it sets in later because less accommo- dation is needed for seeing at a given distance. Hence a low degree of myopia is an advantage. AVhen the far point in myopia is at or within nine inches (22 cm.) presbyopia does not occur. Diagnosis. — Presbyopia is to be distinguished from loss of accommodation due to paralysis of the ciliary nerves, and from failure due to feeble health or other causes, both of which may occur at any age. True presbyopia, however, sometimes progresses much more quickly than usual, and especially in eyes which are about to suffer from glaucoma. Treatment. — The treatment of presbyopia consists in ordering convex glasses which enable the patient to read at nine inches or a greater distance. Most people prefer glasses which en- able them to read easily at twelve or fifteen inches, arid with which reading at the standard nine inches is possible only for a very short time, if at all. The smaller the quantity of accommodation remaining, the less is the range of clear vision ; and if accommodation is abol- ished, clear sight is possible only when the object is at the focus of the glasses. Hence the in- crease of strength of the glasses which becomes necessary as age advances should be made gradually, that the patient may grow accustomed to the loss of range, and to the necessity for keeping his book more and more at an unvarying distance. As the book has to be placed nearer by artificial than by day-light, it is generally best to have a rather stronger pair of glasses for evening use than for the daytime. The following table, giving the strength of the glass necessary to bring the near point to nine inches (22 cm.), Age 40 45 50 55 60 <55 70 Lriass required to bnDg y ’ to 9 m. (22 cm.) 0 + /finch 1-6J + 1 dioptre. 2 3 „ 4 „ 4 5 „ 5'5 „ b. Paralysis of Accommodation. — Synon. : Cycloplegia. — Paralysis of the ciliary muscle occurs in paralysis of the whole third nerve. But it may occur without affection of the extrin- sic muscles of the eyeball ; in these cases it is generally combined with paralysis, more or less complete, of the iris ( ophthalmoplegia interna ) ; but it maybe present as an isolated symptom, the pupils being normal, and of this the commonest example is postnliphtheritic cycloplegia. The failure of accommodation in glaucoma mav be accounted for in acute cases by compression of the ciliary nerves, but in old cases is doubtless due to the atrophy of the ciliary muscle which always exists. Cycloplegia, usually with some affection of the iris, is a common result of blows on the eye ; generally recoverable, it is however occasionally permanent. Lowered endurance of sight, pain, and sudden temporary failures of accommodation, are amongst the most important phenomena of sympathetic irritation. c. Spasm of Accommodation. — Temporary spasmodic action of the ciliary muscle, often ex- ceeding the necessary amoimt, frequently occurs in hypermetropia, with every effort to see clearly . it usually ceases at once on going into a dark room. In low myopia with irritative symptoms, the ciliary muscle often acts unnecessarily; and such spasm, when persistent, is probably one cause of further elongation of the eye. Spasm of accommodation also occurs in some functional and hysterical affections of the eyes, with other symptoms of ocular irritation. The function of accommodation is closely associated with that of convergence, although the two can be exerted separately to a limited extent (‘ relative accom- modation ’). The accommodation of one eye cannot be exercised without, and probably not in a different degree from, that of the other; nor is it proved that any part of the ciliary muscle can act independently of the rest. d. Micropsia. — Definition. — Any condition of sight in which objects seem lessened in size, without diminution in the size of the retinal images. This indicates either an extreme effort of accommodation, and maj^ be thus complained of when this function is weakened ; or disease of the retina, especially syphilitic retinitis. 5. Asthenopia. — Asthenopia is any condi- tion in which the eyes cannot be used for long without fatigue, pain, or other symptoms. Muscular asthenopia is caused by difficulty in maintaining the convergence of the visual lines, and is commonest in myopia, though it is often seen with normal refraction, especially in youths and young adults. It causes, besides aching of the eyes, ‘dancing’ or ‘confusion’ of the print, and sometimes double vision. In slight cases, with myopia, partially neutralising glasses, which enable the book to be held at a greater distance. VISION, DEFECTS OF. will often give reliof. In many cases, with or without myopia, spectacles, consisting of prisms with their bases inwards, are of great service, by lessening the convergence necessary for vision at a given distance. In high degrees, tenotomy of the external rectus is called for (see Strabismus). Asthenopia from defective accommodation is also shown by inability to read for long, but there is no ‘ moving ’ or ‘ dancing ’ of the letters, nor any diplopia. The object simply becomes ‘ misty ’ or ‘ the sight goes’ for a time, returning when the eyes are rested for a few minutes ; or the eyes feel tired and hot, and ache. Headache and occasionally even vomiting may follow neglect of such symptoms. It is commonest in hyperme- tropia (asthenopia from excessive demand on accommodation) ; but is also seen in emmetropic, and even in slightly myopic, eyes, if the tone of the ciliary muscle is low (asthenopia from weak- ness of accommodation). Asthenopic symptoms are not common in presbyopia. The above forms of asthenopia often give rise to chronic conges- tion and irritation of the palpebral conjunctiva, with watering and soreness, the symptoms dis- appearing when glasses are worn. On the other hand an irritable and hypersesthetic state of con- junctiva and cornea, and perhaps of the retina, with photophobia, often causes irritable weak- ness of the ciliary muscle, even when there is scarcely any ametropia (asthenopia from hyper- sesthesia) ; these cases are difficult to cure. Retinal Asthenopia. — Functional exhaustion of the retina or optic nerve is sometimes seen in optic neuritis, and other diseases of the optic nerve ; sight being good, but becoming duller after a short period of use. It is not, on the whole, a very important diagnostic symptom. E. Nettleship. VIS MEDICATE. IX ITiTITHAl (Latin). An expression formerly much used to indicate the innate power possessed by Nature of heal- ing or curing disease. See Disease, Treatment of; and Therapeutics. VITILIGO (vitulus, a spotted calf).-SrNox. : Leucopathia ; Leucasmus ; Leucoderma ; ‘ Pie- bald skin’ ; Fr. and Ger. Vitiligo. Description. — This disease occurs as spots, which are white, resulting from absence of pig- ment ( achroma ), of a circular figure, and various in number and dimensions. The pigmentless skin is pale, but otherwise healthy ; and the imme- diately adjacent integument is more deeply co- loured near the margin of the spots than on the rest of th6 surface. At their first appearance the spots are small ; they increase by their cir- cumference ; and, by continuous growth, or by the blending of several spots, they cover a sur- face of greater or less extent. Diagnosis. — Vitiligo is distinguished from other forms of absence of pigment of the skin by the otherwise healthy condition of the integument. Horphoea and scleroma, the two affections for which it might be mistaken, both present mani- fest indications of disorganisation of the derma. Leucoderma has been confounded with the white patches of true leprosy. In this disease, how- ever, the patches are anaesthetic, and there are constitutional symptoms which are never present in leucoderma. VOICE, DISORDERS OF. 1751 Treatment. — Aberration of the pigment-func- tion of the skin, and especially arrest of pigment- formation, imply feebleness of tissue, and suggest, as the indication for treatment, the strengthening of the individual, and througli the individual the strengthening of the faulty organ. "We may expect to derive advantage from tonic remedies, particularly' from arsenic; whilst externally we must have recourse to mild stimulation, either by friction or by some stimulant local application, such as tar or sulphur, which will induce hy- peraemia, a more active circulation of blood, and a more healthy nutrition of the skin. Erasmus "Wilson. VITILIGOIDEA (vitulus, a spotted calf). A term which has been applied by Addison and Sir William Gull to the disease now known as xanthoma and xanthelasma. See Xanthoma. VOCAL FREMITUS.- — The sensation of vibration conveyed to the hand when applied over any part of the respiratory organs during vocalisation both in health and in disease. See Physical Examination. VOCAL RESONANCE. — Thesound heard on auscultation over certain parts of the respi- ratory organs, during vocalization, both in health and in certain forms of disease. See Physical Examination. VOICE, Disorders of. — Synon. : Er. Troubles de la Voix ; Ger. Stdkrungen der Stimme, Introduction. — Voice is the sound produced in the larynx by air driven from the lungs tlirough the rima glottidis, modified in accord- ance with acoustic laws in the upper air-pae- sages. Vocalization is a function needing for its perfect production a healthy condition of the respiratory muscles, of the lungs, trachea, and larynx, of the pharyngeal, oral, and nasal cavi- ties, and of the nerves and nervous centres on which these parts depend for their isolated or co-ordinated muscular movements and their normal sensitiveness. Eor the production of the simplest vocal tone the cords must he free to approximate within a line of one another, while the co-ordinated action of about one hundred muscles is required, to regulate their tension and that of the walls of the air-passages, to modify the form of the latter, and to produce the current of air. Acoustically the organ of the voice must he regarded as a combined reed and pipe ; and for the production of a perfect note, it is necessary that the pipe should be in perfect unison with the reed. This unison depends not only on the shape of the various cavities, but on the relative rigidity or flexibility, and the tension of their walls ; every variation in the number, size, or form of vibrations of the vocal cords, effected by the intrinsic laryngeal muscles, calling for similar modifications of the shape, size, and tension of the consonating cavities. The word ‘ voice,’ when used alone, always implies the presence of a musical tone (periodic vibrations), hut sound sufficient for every pur- pose of speech and articulation may be produced 1758 VOICE. DISORDERS OF. without a musical tone. This is the whispering voice, caused by the rustling of air through the half-open rima and relaxed air-passages. To this condition— absence of musical tone in the voice — the term aphonia is applied, and it must be dis- tinguished from the actual inability to produce sound, which we see after tracheotomy, where in the effort to speak, the organs of articulation and sound are seen to move, but neither noise nor musical sound is heard. Pathological Relations. — The morbid modi- fications of vocalisation are necessarily numerous, in proportion to its complexity and the number of parts concerned in its production ; but it may be generally stated that, in consequence of disease or perverted action in any of these parts, the voice may be altered either (1) in loudness br force (size of sound-waves); (2) in pitch, or relative height of its note (rate of sound- waves) ; or (3) in quality (shape of sound-waves). And even before there is obvious change in any of these respects, the power of passing rapidly and easily from one pitch to another, constitut- ing melody, may be seriously impaired. The morbid alterations of the voice in these several directions will now be discussed ; and brief re- ference will also be made to (4) stammering of the vocal cords ; (5) aphonia, and (6) the vocal signs in the chest. 1. Changesin Force.— The voice is weakened in every disease which lowers the general muscu- lar tone, or depresses the nervous system. The gradual change is well seen in phthisis without laryngeal affection, where at last even the effort to approximate the vocal cords is too much for the patient, and he speaks in only a whispering voice. In the same way painful affections of any of the parts enumerated above, interfering with muscular effort, weaken the voice. Speak- ing generally, mere diminished loudness of the voice depends usually on general rather than on laryngeal disease. 2. Alterations in Pitch. — The note of or- dinary speech may be habitually raised or lowered, and the range of the singing voice may be seriously limited. The note of the voice depends primarily on the rate of vibration of the vocal cords ; and this is the mean result of the tension, the length, the density, and the thick- ness of the cords at the time the tone is produced, and the force of the current of air sent through the rima. Structural changes, therefore, in any one of these respects, will alter the pitch of the voice ; and change in the ordinary vocal note is usually to be referred either to an affection of the tensor muscles of the larynx, to structural change in the mucous membrane covering the cords, or in the cords themselves. Lowering of the pitch of the speaking and the range of the singing voice oc- curs with any condition which relaxes the mucous membrane, weakens the nervous and muscular system, or makes the tense condition of the vocal cords and the eonsonating cavities painful. Paralysis of the intrinsic muscles, which admit of the approach of the vocal cords but interfere with their tension and density, affects the pitch as well as the quality, the voice being rough and deep in the paresis of the tensors (superior laryn- geal nerve) and of the abductors of the larynx (recurrent nerve). The imperceptible transition from the chest to the falsetto voice, in which, whilst tho con- dition of the vocal cords is suddenly altered, the form of tho larynx, trachea, and other conso- nating cavities is simultaneously changed, re- quires a perfect control of the vocal organs, at- tained only by accomplished vocalists. On this change of register occurring involuntarilv, the cracked voice in speaking is the result ; and be- ing referable to imperfect co-ordination, it is common in males about puberty, when the form of the larynx is changing, or may even persist occasionally throughout life. A curious affec- tion of the pitch of the voice, in speaking, when two tones of different pitch are simultaneously produced (diplophonia), appears to depend on the division of the rima into an anterior and posterior opening, either by small morbid growths, strings of mucus, or irregular action of the muscles. 3. Change of Quality. — The quality of the voice is affected by every alteration either in the cords or in the eonsonating cavities, the purity and character of tho tone being liable to nu- merous modifications, until, the musical note disappearing entirely, mere noise (aphonia or whispering) remains. Hoarseness.— Hoarseness and huskiness, a com- bination of whispering and a badly sustained musical note, imply imperfect and irregular approximation of the vocal cords. Over-exertion of the voice, catarrh, &c., produce it temporarily, giving rise to irregular tension of the cords, to shreds of mucus, and to swellings of the mucous lining, which interfere with their regular approxi- mation ; while all changes short of those which absolutely prevent the closure of the cords, maj' cause it as a persistent phenomenon. To the larynx itself we look therefore for the source of persistent hoarseness. Amongst the pathological conditions of which hoarseness is a symptom are chronic swelling of the mucous membrane, general or local, interfering with the closure of the rima ; exudation or ulceration, and therefore inflammation, simple, specific, or diph- theritic ; neoplasms ; old cicatricial contractions ; paralysis of the adductors of one cord, which necessitates the crossing of the normal cord beyond the median line to meet its fellow, as well as other forms of paralysis ; fixing of one vocal cord by anchylosis of the crico-aryttenoid joint. The paralysis may of course depend on disease of the nervous centres, on the nerves themselves, or on pressure by intra-thoracic or other tumours on the nerve-trunks. Hoarse- ness, short of aphonia, is also a symptom ot general exhaustion, as seen in phthisis and cholera. The character of the speaking voice is also altered by any change in the resonating cavities. Thus the voice is said to have a nasal twang when the upper pharyngeal and nasal cavities are not completely shut off in vocalisation ; while, on the other hand, obstruction in the nares, preventing the passage of the air through them and the formation of the nasal consonant sounds, is popularly, though wrongly, called ‘speaking through the nose.’ If the obstruc- tion be situated in front of the nares, the sounds can be produced, but not continued ; if the ob- VOICE, DISORDERS OF, struction be in the upper pharynx, or at the Lack of the nares, they cannot be produced, at all. "When with obstruction in the nares there is swelling of the pharynx and the soft palate, the voice assumes the character so fa mili ar in cases of quinsy. Changes in the walls of the chest and the pectoral cavities also alter the character of the voice, the hollow voice of the emaciated phthisi- cal patient illustrating this. The phonation. on inspiration, of spasmodic croup and of child- crowing or laryngismus stridulus must be re- ferred to as the result of spasm cf the vocal cords, though tills involuntary function hardly comes within the definition of voice, which term should be limited to sound produced in the vocal organs to establish communication between living beings. 4. Stammering of the Vocal Cords. — - Spasm and defective co-ordination are the source of this peculiar affection of the voice, in which there are sudden interruptions of the voice without affection cf the articulation (Prosser James). 5. Aphonia. — The various modifications of voice hitherto considered only occur where the vocal chords are free to meet more or less per- fectly. Aphonia or complete loss of the musical tone, occurs where the cords cannot meet. Amongst the conditions which will prevent the approximation of the cords and cause aphonia are paralyis or paresis of the adductor muscles, on whatever cause it may depend ; fixation of the cords by cicatricial contractions, or by anchylosis of the crico-aryttenoid joints ; their destruction by ulceration ; any painful affection which makes the patient involuntarily rest them; or coating with false membrane. Rut by far the most frequent cause cf this aphonia is the abrogation or perversion of the will, occurring in the morbid mental condition of hysteria or other nervous disease ; perfect power of phona- tion existing, but the patient, for months or years, declining to exercise the power, or to make the necessary effort. The intimate relations of the voice to the higher functions of the brain would lead us to expect that it would be influenced by the emotions. Thus we have a person hoarse with rage, speechless with terror, &e., and the origin of these cases of nervous aphonia is frequently some sudden emotion, causing loss of control over the voice. Yon Ziemssen believes that, even where the vocal cords cannot meet, by a great effort the patient may produce a hoarse, monotonous tone by vicarious vibrations of the ventricular bands. Treatment. — The local treatment of the various diseases of the respiratory organs which give rise to disorders of the voice, is fully dis- cussed in the several articles on these subjects {see Larynx, Diseases of; Stammering; Throat Diseases of; Trachea, Diseases of). The general treatment will depend upon the constitutional btate. See Hysteria ; and Phthisis. 6. Vocal Signs in Chest. — Some consider- ation must be given to the changes in the voice which are audible when the stethoscope is ap- plied to the chest. Normally the vibrations of the vocal cords are conveyed to the ear ap- plied to the chest by propagation along the con- POLITION, DISORDERS OF. 1759 tained air, the rigid portions of the air-chambers, and the thoracic walls, the voice being heard as a feeble, buzzing, musical tone. This sound is weakened when the original tone is weakened by laryngeal disease ; when fluid is interposed be- tween the lung and the chest-wall, pus and less homogeneous fluids forming a more complete obstacle than simple serum; and when the bronchial tubes are obstructed by secretions or other cause, preventing the conveyance of the vibrations. The sound may, on the contrary, be exaggerated, giving rise to the phenomena of bronchophony, amphoric voice, and agophony. Bronchophony is simple increase in the vocal resonance, and is heard under the same con- ditions which give rise to bronchial breath- ing, that is, over lung consolidated by 'exuda- tion or condensed by compression, and over cavities with solid walls. The terra pectoriloquy is commonly applied to excessive bronchophony, but Dr. Bristowe would limit it to the rare in- stances in which not only the laryngeal tone, but the articulate sounds produced in the mouth, are conveyed back to the chest, and thence through the chest-wall to the ear. Amphoric voice ( [amphorophony ) is the term applied where the vocal resonance is not only increased, but acquires a metallic ring, from the addition of a consonant tone acquired in large cavities of the lungs. This is sometimes heard in a marked degree in pneumothorax, though in other cases of the same disease the vocal resonance may be absent or greatly diminished. CEgophony is heard where there is a thin layer of fluid between the ear and the lung, as in small effusions or at the margin of larger effusions. It is a bleating, tremulous tone, supposed by Bris- towe to result from the interposed fluid prevent- ing the fundamental note-vibrations from reach- ing the ear, while it permits the finer and closer vibrations of harmonics to penetrate. See Phtsicai Examination. Thomas J. YTai.ker. VOXiITION, Disorders of. — Srxox. : Fr. Troubles de la Volition; Ger. Sldhrungeti des Wollens. Various lesions of the cortex of the hemi- spheres may arrest or interfere with volition at its source, and that not solely when the lesions occur in the so-called ‘motor regions.’ If we as- sume that these particular regions of the cortex are the parts whence motor incitations pass off on their way to lower centres, it is only necessary to bear in mind, on the one hand, the continuity of molecular actions through definite tracts of the brain-tissue, and, on the other hand, the frequency with which volitions are immediately aroused by some antecedent sensorial processes, to under- stand that damages to certain sensorial centres or intemuncial fibres within the hemispheres aro almost as liable to interfere with certain classes of volition as are those which occur in the so- called motor region itself. After all, volition is only, and must always be, a result of sense and intellect in action. Its manifestations may, there- fore, be impeded either by disease at the sourceE in which it originates, or in one or other portion of tho tracks along which its initial incitations are conducted on their way to motor centres, and 1760 VOLITION, DISORDERS OF. thence to the muscles whose activity is to be a weened. In other cases, with exalted activity of some of the centres in which volitional incitations arise, we may have, especially in acute mania and violent delirium, the birth of impulses which are absolutely ‘ uncontrollable.’ Where these conditions are absent, however, and whether the persons in question have been accustomed or not to exhibit evidences of a weak or defective morale, it is most important not to confound ‘uncontrolled’ with ‘uncontrollable’ impulses. This is the kind of question which becomes all- important in many criminal cases — cases, that is, in which persons are under trial for murder, manslaughter, or theft, and in which ‘ unsound- ness of mind’ is pleaded in extenuation. See Criminal Irresponsibility. On the other hand, a dormant or sluggish volition is met with in some other forms of insanity, as well as in hysteria, the subjects of which cannot or do not rouse themselves to per- form the most ordinary actions. They may from this cause be speechless, or they may experience the most extreme difficulty in arriving at any decision even in reference to the most trivial circumstances. See Insanity, Varieties of. Again, so-called defects of memory and defects of volition are sometimes inextricably involved in many forms of brain-disease ; so that the same disability may, from one point of view, be regarded as an instance of defective memory of a special kind, or from another as a peculiar and limited interference with volition. See Memory, Disorders of. In very many cases of apparent loss of voli- tional power — that is, in multitudes of instances of complete paralysis of a part or of a muscle — where the causal lesion is situated in regions below the cortex cerebri (e.g., in lower motor centres, cerebral or spinal, or in motor nerves), there is not an arrest of volition, but rather an impediment to the actuation of volitions ( see Paralysis, Motor). But whether volition itself is nipped in the bud, or whether, though really existent, it is rendered abortive, the patient is practically reduced to the same condition — since his power of responding to sense or thought through particular muscles may be equally interfered with in either case. See Speech, Disorders of. II. Charlton Bastian. VOLVULUS ( volvo , I roll). — A synonym for intussusception. See Intestinal Obstruc- tion. VOMICA ( vomo , I vomit, I cast up). — Synon. : Fr. Vomique; Ger. Lungenqeschwiir. Definition. — A term applicable to all ulcera- tive spaces in the lung in open communication with bronchi. ./Etiology. — The multifarious agencies leading to excavation may be grouped as follows : — I. Destructive processes: (a) injury, (h) gan- grene. II. Suppurative processes : ( c ) acute pulmonary abscess ; ( d ) suppuration around inhaled foreign bodies ; (e) suppuration around new formations (including hydatids) ; (/) extension of abscesses, G) from the pleural cavity; (2) from the ab- VOMICA. dominal cavity, or from the abdominal organs ; and (3) from the mediastina. III. Degenerative processes : (g) ulceration of cancerous or sarcomatous growths ; ( h ) ulcera- tion of syphilomas ; (i) ulceration of tubercle ; (y) softening of chronic inflammatory consolida- tions (catarrhal pneumonia and caseous pneu- monia) ; (£) softening of intensely congested or cedematous tissues (a condition sometimes due to pressure from aneurisms or tumours) ; ( l ) liquefaction of ancient deposits — caseous, pulta- ceous or haemorrhagic (haemorrhagic nodules — Dr. R. E. Thompson). Phthisis being the cause of the immense majority of pulmonary excavations, the ensuing remarks will be chiefly devoted to phthisical vomicae. Anatomical Characters. — Varieties in size and in shape. — Vomicae may be sub-lobular (then aptly termed cavernules), lobular, lobar, or they may involve the whole of one lung. Tubercular deposits, being usually smaller than catarrhal infiltrations, lead to smaller cavities. Catarrhal inflammation gives rise to the lobular, caseous pneumonia to the lobar excavations, and to the wholesale destruction of a lung. (Edematous forms of catarrhal pneumonia often undergo rapid and extensive softening ; the interlobular septa escaping liquefaction, whilst the paren- chyma is carried away. This dissecting exca vation forms the counterpart of caseous pneu- monia, where the tissues are destroyed en masse, with the sole exception of the larger branches of the pulmonary artery. When strictly confined to a lobule, the excava- tion is roughly spherical. If many lobules should be simultaneously involved, their coalescence may give rise to irregular vomicae ; but the ultimate shape of cavities chiefly depends upon the pecu- liarities of the bronchial distribution to the dis- trict affected. Vomicae are frequently trabeculated. Trabe- culae (clearly to be distinguished from denuded branches of the pulmonary artery) invariably consist of blood-vessels and of collapsed or in- durated alveolar substance. They are the re- mains of intervals of spongy tissue, originally separating distinct cavities. Their ulceration and partial absorption often give rise to a knobbed condition of the internal surface of cavities. During the period of formation and of ex- tension the walls of cavities are rough and ul- cerous. But the completed cavity becomes sur- rounded by a fibro- vascular zone, the outer surface of which is continuous with the pulmonary tis- sue, whilst its innermost stratum constitutes, during the active stages, a pyogenic layer, and subsequently an exfoliating false membrane. Vomicie thus invested are said to be encapsu- lated. Important differences are noticeable in the condition of tissues around cavities. The cap- sule of a vomica may be immediately surrounded by alveolar substance, the expansion of which may exert a favourable amount of pressure upon it ; or it may be continuous with inflamed and thickened tissue, or with tubercular infiltrations. In extreme cases the lung is to such an extent invaded by the fibrous growth from an adherent pleura, that the vomicie present the appearance VOMICA. of haring been formed at the expense of the fibrous tissue itself (‘ fibroid phthisis’). Situations . — No appreciable difference exists between the liability to excavation of the right and that of the left lung. Primary excavation almost invariably attacks the upper part of the upper lobe ; its most common seat is the central part of the subclavicular region, not the apex proper ; it may, however, extend to the very summit of the lung, or involve the greater part of the upper lobe. Phthisical destruction very rarely has its starting-point in the middle or in the lower third of the lung. The base of the lung, on the other hand, is the most common seat of those cavities which are not due to phthisis (for example, abscesses by extension, gangrene, and syphilitic ulceration). The common form of phthisis, originally attack- ing the apex, implicates, almost without excep- tion, the mid-dorsal region secondarily ; this the writer has shown to be due to the transmission of irritating matter along the bronchus supplying that district. Similarly the base becomes affected in the latest stages of excavating disease, if life should be sufficiently prolonged. j Bronchi in relation to vomica . — Cavities not smaller than a lobule inevitably open into a bronchus. The communication may be tem- porarily obliterated, or it may in rare instances become permanently sealed. Most cavities ex- ceeding the size of a single lobule intercept more than one bronchus ; and the air-tubes ulcerate within them at an early period of the softening. Thus two sets of bronchial orifices may be re- cognised in vomicae, the proximal and the distal, forming as many small islands of mucous mem- brane on the internal surface of cavities. Blood-vessels in relation to vomica. — Trabe- culae always contain either patent or obliterated vascular branches. More resistant than all other structures, these vessels may become completely exposed and finally eroded. But aneurism or erosion more commonly has its seat in those branches of the pulmonary artery which ramify in the thickness of the cavity wall, a fact readily explained by the persistence of circulation within these vessels, by their inability to retract, by the uneven support which their coats receive at different points of their circumference, and by their diseased condition. Fatal haemorrhage may occur without any warning from the erosions or from the aneurisms. More habitually premoni- tory bleeding of limited extent recurs at short intervals prior to the fatal rupture. Pulmonary aneurisms sometimes undergo spontaneous cure when their growth is limited by the small size of the cavity which contains them; or the pressure of the extra vasated blood may effect the same result subsequently to their rupture. It is almost the rule for aneurisms to occur simultane- ously at different parts of the same lung. Extension of vomica . — -Cavities increase in size by the gradual necrosis of their inner wall ; by the fusion of adjacent excavations; and by their encroaahment upon fresh bronchial terri- tories, which become the seat of similar ulcera- tion. Retrocession of vomica . — The contraction of cavities is essentially due to the shrinking of their capsule. This force is assisted in some 111 1761 cases by the expansion of theneighbouring spongy tissue, or even of the hypertrophied healthy lung; in other cases by the constricting pressure from a thick zone of fibrous tissue ; indirectly also by the falling-in of the ribs, by the rise - of the diaphragm, and by the abundant growth of new fibrous tissue in the thickness of the pleural adhesions. The retraction towards the root of the lung, which is so commonly observed in chronic vo- micse, is partly due to the inflammatory thicken- ing and shortening of the bronchus; it is often opposed by adhesions of the corresponding pul- monary surface to the chest-wall. In their contracted state vomicae may remain dormant for years. Final obliteration is rarely attained, chiefly owing to their deficient granu- lating power, and to the superficial necrosis of their opposed surfaces, both these conditions being the outcome of imperfect drainage. Consequences of Excavation. — Amongst the general consequences of pulmonary excavation are loss of breathing surface ; exhausting sup- puration, often leading to lardaeeous degenera- tion of the organs ; and tuberculosis. The chief local consequences are secondary deposits (pneu- monic or tubercular) in the healthy portions of the lungs, as a result of the inhalation of the secretion of cavities, and of other products. Lastly, as the result of the contraction of cavi- ties, we meet with local shrinking of the lung and collateral emphysema ; various involutions of the pulmonary surface ; various deformities of the thorax, &c. Among the fatal accidents incidental to ex- cavation rupture of aneurisms has already been referred to. Perforation of the lung, leading to pneumothorax, is a danger special to the more insidious varieties, in which the softening is rapid, whilst the inflammation is of low type and unaccompanied with the usual tissue-reaction. Diagnosis. — The ordinary methods of physical examination, by which the presence of cavities may he detected, are described in other articles (see Phthisis; andPuysicAi, Examination). Afew points only claim specially' to be noticed. Caver- nous sounds are seldom given by cavities smaller than an ordinary filbert, probably owing to the small size of their bronchus. Cavities even of larger size are not infrequently completely masked by the interposition of spongy tissue ; this is more especially the case in the tubercular forms. In the opposite condition of cirrhosis, cavernous sounds may be absent or very feeble, in con- sequence of deficient inspiratory movements. Lastly, the accidental blocking of a bronchus may suspend for a time all auscultatory evidence of excavation. The distance of the vomica from the surface may be roughly estimated from the intensity of the sounds ; its degree of fulness from their liquid character ; the smoothness of its walls from their amphoric nature ; its com- pressibility by surrounding spongy substance, and its elastic resiliency, from the suction-sound sometimes heard during the respiratory pause following cough, aptly termed by Dr. Mitchell Bruce the indiarubber-ball sound. A determination of the extent of the vomica can generally be attained by careful investiga- tion. Sometimes, however, eavernous sounds are 1762 VOMICA. propagated beyond the excavated region by con- solidation. Occasionally they are re-echoed at a symmetrical point in the sound lung, especially at the base. Phantom-caverns of this nature may be suspected whenever absolute identity in the position and in the auscultatory quality of the sounds on either side coincides with great disparity in percussion-resonance and in vocal fremitus. Valuable information is derivable from the sputa. Abundant purulent discharge always in- dicates an active condition ; if mixed with much mucus, it points to a co-existing bronchial ca- tarrh ; if shreddy and foetid, to a cavity of some magnitude, imperfectly drained. The intimate admixture of blood indicates a congested state of the membrane. From the presence of abun- dant, well-preserved, elastic elements it is pos- sible to diagnose the moister forms of necrosis ; caseous lumps argue the existence of caseous pneumonia ; the expectoration of calcareous par- ticles shows that excavation is progressing at the expense of more or less fibrosed tissue resulting from former disease ; and, according to Koch, the presence of bacilli staining deeply with methylene-blue and not decolorised by vesu- vin, is a test for tubercle. Lastly the cessation of all secretion is indicative of a perfect quies- cence of the vomica. Prognosis.— In cavities not due to phthisis, the absence of the constitutional element greatly favours recovery ; and their progress is mainly governed by the nature of their cause, by their size, by their situation, and by other influences enumerated below. Where healing is much delayed in such cases, the eventual development of phthisis is rendered probable. The prognosis of phthisical vomicae is in- timately bound up with the prognosis of phthisis, a subject too wide for discussion here, but fully treated in the article Phthisis, and in Dr. James Pollock's work on The Elements of Prognosis in Consumption. Most unfavourable are the vo- micse due to a breaking up of tuberculo-pneu- monic deposits. Vomic® originating in pure tubercle, although they may contract, seldom heal. Where haemorrhage occurring in a lung previously quite free from disease, subsequently leads to excavation, the closure of the cavity is encouraged by the contraction which charac- terises these cases. But the pneumonic class, which comprises the most rapidly fatal eases of excavation, also supplies the most striking in- stances of recovery. There exists a large clini- cal group in which the affection is limited to a small portion of one lung, and in which the disease is rather local than constitutional. On careful analysis of these favourable cases, the chief elements of their fortunate termination will be found to be the following : — 1st, unila- teral character of the affection ; 2nd, its small extent ; 3rd, comparatively rapid occurrence of softening ; 4th, complete removal of the whole consolidation ; 5th, absence of close adhesions to the thoracic parietes ; and 6th, facilities afforded for collateral expansion. Treatment. — The ideal treatment of cavities would have for its objects: — (1) to restore healthy action to their surface ; (2) to prevent a stagnation of their secretions ; and (3) to en- courage their contraction. VOMIT, EXAMINATION OF. For the fulfilment of these indications various surgical measures have been practised: — 1st, free incision and injections (Barry, 1727); 2nd, paracentesis (Ramadge, 1836); 3rd, free inci- sion and drainage (Hastings and Storks, 1845); 4th, paracentesis and injections (Mosler, 18731; and 5th, needle-injections of medicateii fluids (Pepper, 1874). Much may yet be expected of modern surgery in the treatment of excavating disease. Hitherto, however, there exists but meagre evidence to show that any good has resulted from surgical interference, and the range within which such interference is justifiable is very limited. The ordinary methods of treatment comprise, in addition to the use of constitutional reme- dies : — 1st. Treatment by inhalation of medicated spray, of medicated vapours, of air charged with the natural exhalations from the sea, from pine- forests, &c. See Inhalation ; and Climate, Treatment of Disease by. 2nd. Treatment by posture, sometimes facili- tating, as it does, the drainage of cavities. 3rd. Treatment directed to the enlargement of the thorax and to the expansion of the luDgs, such as passive exercise of the thoracic muscles, inhalation of rarefied air, and especially resid- ence at high altitudes. Wm. Ewart. VOMIT : Examination of Vomited Matters. — Vomited matters may consist either of substances present in the stomach when vomit- ing begins, or of substances entering it during the process. Those present in the stomach when vomiting begins include articles of food and drink, or other ingesta, more or less altered by diges- tion or fermentation; saliva, epithelium, mucus, pus, or blood from the nasal passages, mouth, pharynx, or cesophagus ; fluid or mucus secreted by the 6tomach itself, epithelium-cells, casts of tubules, or even shreds of gastric mucous mem- brane, blood more or less altered proceeding frtim the walls of the stomach, cells or small pieces from morbid growths, and occasionally, as mentioned by Dr. Quain, the whole of a pedunculated morbid growth ; fungi, as torul® and sarcin® ; parasitic worms ; bile ; pancreatic juice ; pus from abscess of the stomach or liver ; f®culent matter from the intestine. During vomiting much saliva may be swallowed ; and bile, pancreatic juice, pus or faces, not originally present in the stomach, may be pressed into it by the straining. Effusion of blood into its cavity may also be caused by the efforts of retching. Method of Examination — In examining the vomited matters it is advisable, first, to separate the larger pieces of undigested food by filtering the vomit through canvas or muslin. The solid residue may be investigated by wash- ing the larger pieces and tearing them up, or making sections of them, so that their nature may be ascertained. Partially digested curd is sometimes not very easy to recognise. When a large quantity of milk has been drunk at one time, the curd which it forms in the stomach may, when vomited, have the appearance of s piece of thick dense grey felt. The filtrate should be put into a conical glass and allowed to settle. The reaction of the fluid VOMIT, EXAMINATION OF. is to be ascertained by litmus paper. The pres- ence of free hydrochloric acid may be tested for, by putting one drop into a watch-glass contain- ing a one per cent, solution of tropeolin, the yellow colour of which is converted into a wine red if hydrochloric acid be present. The total acidity may be estimated by filtering and adding a standard solution of caustic soda or potash to a measured quantity of the filtrate, until it is neutralised. For the methods of examining more particularly the various acids — lactic, acetic, butyric, &c. — and other volatile sub- stances, text books of chemistry must be con- sulted. To ascertain the presence of pepsin in the vomit we add to it its own bulk of dilute hydro- chloric acid (ten minims of dilute hydrochloric acid, B.P., to an ounce of water) and a flock of fibrin or a piece of hard-boiled white of egg ; let it stand for several hours in a warm place ; and then see whether or not the fibrin or albumen is dissolved. To test for trypsin, w r e proceed in the same manner, but use the vomit without the addition of acid ; and if it be already acid, neutralize it with bi-carbonate of soda. To test the vomit for peptone, we must put some of it into a small dialyzer, and let it stand for some hours. We then add to tiie water in which the dialyzer has stood, solution of corro- sive sublimate, which gives a precipitate -with oeptones ; or some liquor potassse and a drop of /ery dilute sulphate of copper solution, which gives a precipitate dissolving on shaking, and forming a red solution, changing to purple when more copper is added. Bile is tested for in the filtered liquid by G-melin’s and Pettenkofer's tests. For blood in the vomit see Hjemateuesis. If the vomited matter bo too thick to allow the sediment to subside, a little of it should be mixed with some distilled water and allowed to settle. A drop of the sediment is then to be examined microscopically ; and the examination is facilitated by adding to one specimen a drop of iodine solution, and to another a drop of aniline red or blue solution. The substances most likely to occur are partially digested fibres of voluntary or involuntary muscle, elastic fibres, connective-tissue bundles from meat in the food, spiral fibres and green chlorophyll granules from vegetables, starch-granules — stained blue by iodine, torulse or sarcinae, blood- corpuscles, leucocytes, scaly epithelium from the mouth, cylindrical epithelium from the sto- mach, and casts of the gastric follicles— some- times fibrinous, sometimes composed of cells and granules, which take up the aniline colour, and are thus rendered more easily visible. Clinical and Pathological Indications. — If the vomited food be unchanged, or but little changed, it indicates either that the vomiting has occurred soon after a meal, or that the secretion of gastric juice is deficient either in quantity or quality. The food is usually com- paratively little changed in nervous vomiting, or in cancer of the cardiac extremity of the stomach. In vomiting from cancer of the pylorus, or duo- denal ulceration, the food is much more digested, as it remains much longer in the stomach. If VOMITING. 1763 undigested food be vomited some hours after a meal, the vomit should be examined in order to ascertain whether pepsin or acid is deficient. Complete absence of hydrochloric acid has been observed in cases of amyloid degeneration of the stomach, and a deficiency of acid has been found experimentally in acute anaemic and febrilo conditions. Abnormal acidity from fermentation of saccharine or farinaceous articles of food, and the consequent production of acetic, lactic, and butyric acids, occurs in chronic catarrhal con- ditions. In some cases of gastric catarrh starch appears to undergo a mucous fermentation, and large quantities of glairy material are formed. When fermentation has gone on to a great extent, the vomit may have a yeasty look, and should then be examined for sareinse and torulae. See Sarcin-s: ; and Stomach, Dilatation of. Sometimes large quantities of a w'atery fluid are vomited. This is occasionally alkaline or neutral, contains potassium sulphocyanide, and digests starch. It consists of saliva, which has been secreted abundantly on account of reflex irritation arising from the stomach, and swal- lowed. At other times it is strongly acid, and appears to be secreted by the stomach. Some- times the vomit appears to be a mixture of both of these fluids. Such vomiting may occur from nervous disturbance of the stomach, but may be symptomatic also of catarrh, ulcer, or cancer. Mucus in the vomit indicates catarrh of the gastric mucous membrane ; and the more acute the inflammation, the more leucocytes occur in the mucus. Bile may he vomited pure, in the form of a tasteless golden-yellow substance like yolk of egg, from the action of poisons, but this rarely happens. Vomiting of bile, more or less green and diluted, or mixed with digestive secretions or food, occurs as a symptom in congestion of the liver ; hut it may take place in all kinds of vomiting, whatever its cause. Large quantities of bile, mixed with the secretions from the mouth and stomach, and forming a grass-green liquid ( vomitus aniginosvs'), may he vomited in peritonitis and cerebral affections. The writer has also observed this character of vomit in opium-eaters. Constant absence of bile when vomiting is persistent, points to pyloric stenosb. Pus may get into vomit from the bursting of an abscess in the mouth or tonsils; it sometimes, though rarely, may arise from au abscess in the wails of the stomach ; but it is more likely to come from abscess of the liver. Blood vomited in large quantity, and of a bright red colour, usually indicates ulceration of the stomach or cirrhosis of the liver. More or less altered, and in smaller quantity, it occurs in the diseases just mentioned, and also in cancer and yellow fever (see Black Vomit; and Yellow Fever). It may also be present in hysterical persons who have swallowed blood, obtained from external sources, or by sucking hollow teeth. Cancer-cells in the vomited matters are diagnostic of the presence of that disease. T. Lauder Brunton. VOMITING (Lat. vomo ). — Synon. : Fr. Vo- missement; Ger. Erbrechen. Definition. — Forcible expulsion of the con- tents of the stomach through the oesophagus. ./Etiology and Pathology.— T he contents -■! VOMITING. 1764 the stomach are expelled from it by the mechanical pressure brought to bear upon it by the diaphragm and abdominal parietes, •which contract simulta- neously. When these muscles contract, if the cardiac orifice of the stomach remains closed, an ineffectual effort at vomiting, or retching, occurs ; but if the cardiac orifice dilate, the gastric contents are expelled. When the dia- phragm and abdominal muscles are paralysed, vomiting is impossible, though the stomach may be in active movement. The stomach is not necessary to vomiting, which will occur when that organ is excised, and a simple bladder tied in its place ; but when the stomach is pre- sent, mere pressure upon it by the diaphragm and abdominal muscles, as in coughing, does not expel its contents. The cardiac orifice is re- laxed by means of the longitudinal fibres, which run along the under end of the oesophagus below the diaphragm, and then radiate completely over the stomach. When they contract they dilate the cardiac orifice, and at the same time aid the evacuation of the stomach by drawing the whole viscus towards the diaphragm. In the act of vomiting, then, the simultaneous contraction of three sets of muscles is required: — (1) of the diaphragm, (2) of the abdominal wall, and (3) of the muscular fibres just mentioned in the stomach itself. The movements of these muscles are co- ordinated by a nervous centre, situated in the floor of the fourth ventricle in the medulla oblongata. This centre is closely associated with, though of course not identical with, the respi- ratory centre. The motor impulses from these centres are sent to the abdominal muscles, dia- phragm, stomach, and oesophagus, by the inter- costal, phrenic, and pneumogastric nerves re- spectively. The reasons for supposing that the nervous centre for vomiting is closely associated with the respiratory centre, are that the move- ments of vomiting are modified respiratory movements, that emetics excite the respiratory centre, and that their action is usually preceded by increased respiratory movement, while de- pression of the activity of the respiratory centre stops vomiting. When the blood is rendered very arterial by excessive respiration, a condition ofapncea,' in which no need of respiration is felt, and no respiratory movements are made, is pro- duced ; but if emetics are then injected into the veins, respiration not only becomes more fre- quent, but apncea can no longer be induced, unless the activity of the respiratory centre be lowered by narcotics. The vomiting centre is usually excited to action by irritation of certain afferent nerves. These may either act directly upon it, or through the medium of the brain. The nerves of special sense act- through the brain. The sight of a disgusting object, a disagreeable stench, or an unpleasant taste, may excite vomiting, and it may also be produced by the simplo thought of such sub- jects. Blows on the head, or inflammation of the brain or its membranes, also excite vomiting. According to Budge, the cerebral centres for the movements of the stomach are in the right corpus striatum, and especially in the right optic thalamus. When these parts are irritated the stomach moves. Irritation of the corresponding •arts on the left side of the brain ' " "• "fleet the stomach. Vomiting occurs in certain cere- bral conditions, either affecting the brain itself or its membranes, such as cancer or tubercle of the brain, apoplexy, cerebellar haemorrhage, softening of the cerebral substance, sometimes en- cephalitis, poisoning by narcotics, melancholia, profuse haemorrhage, or tubercular meningitis. It is also one of the symptoms of Meniere’s disease of the semi-circular canals. It also occurs in various diseases, in which, however, it is -difficult to say whether the vomiting be due to direct affection of the brain itself, or to reflex action upon it from other organs. Such diseases are typhus, plague, yellow fever, cholera, and the cold stage of ague. Very painful im- pressions on sensory nerves throughout the body may excite vomiting. This is seen in cases of loose cartilages in the knee, in dislocation of a joint, or in a painful wound or operation. Here, also, it is uncertain whether the vomiting be produced through a direct connection of sensory nerves with the vomiting centre, or whether the irritation acts indirectly through the cerebrum. Certain afferent nerves appear to have a more direct connection with the vomiting centre than others, and these require special consideration:— (1) Branches of the glosso-pharyngeal nerve to the soft palate, the root of the tongue, and the pharynx. — These parts have a very close connec- tion with the vomiting centre, and tickling them with the finger or with a feather is one of the readiest means of inducing vomiting. We find vomiting occurring in inflammation of the soft palate or tonsils, and also of the pharynx, especially in children. (2) The nerves of the stomach.— The sensory nerves of the stomach are chiefly branches of the vagi, but they belong partly also to the sympa- thetic system. When the vagi are cut vomiting becomes difficult, but efforts at retching occur, and vomiting will even take place from the action of emetics after section of the vagi. It is therefore evident that irritation of the stomach produces vomiting reflexly through other nerves than the vagi. Vomiting may occur from irritant substances in the stomach, whether introduced into the stomach, or formed within it ; from irritation within the stomach, from an inflamed or irritated condition of its walls; or from me- chanical pressure, from without or from within. Thus it may occur from the presence of undi- gested food, from irritating substances produced by imperfect digestion, or from irritant poisons within the stomach. It may be due to catarrh or congestion of the mucous membrane itself, to softening of the mucous membrane, or to cancer in the gastric wall. It may be produced by ex- treme distension of the stomach, by gas, liquids, or solids ; by compression of a part of it within the body, as in hernia of the stomach ; or by the pressure of a tumour upon it. It may be caused by violent compression externally with the hands ; by the pressure of a too tightly laced corset ; by the pressure against the abdominal walls of hard tools or benches in certain trades. It frequently occurs in cough, especially the cough of phthisis ; but here it is probable that the vomiting is due partly to the violent compression between the diaphragm and abdominal walls, aDd partly to the congestion of the vessels which the continued VOMITING. interruption of the circulation during the fit of coughing brings on. (3) The nerves of the liver and gall-ducts . — These consist chiefly of branches of the vagus and sympathetic. From their irritation vomit- ing occurs in hepatitis, or during the passage of a biliary calculus. It is from irritation of these branches, also, that vomiting may occur in pleurisy of the right side, the congestion of the pleura on the upper surface of the diaphragm having led to congestive changes in the liver. (4) Intestinal nerves. — Ligature of the intes- tine in animals produces vomiting, 'which is ar- rested by dividing the nerves passing from the ligatured parts. In man it is the almost in- variable accompaniment of strangulated hernia or intussusception, and it may even occur in ob- struction of the bowel by faecal matters in cases of obstinate constipation. It also takes place in peritonitis from irritation of these nerves. (5) The renal turves.- — From irritation of these nerves vomiting occurs in nephritis, or by calculi in the pelvis of the kidney or passing down the ireter. (6) Vesical nerves. — In cystitis vomiting oc- curs. It may possibly be due, however, not to . rritation of the vesical nerves, but to extension C-f inflammation to neighbouring parts. (7) Uterine nerves. — Irritation of these nerves is one of the commonest causes of reflex vomit- ing. It may be produced in animals on irrita- tion of the uterine plexus, and occurs in the human subject during pregnancy or in metritis. (S) Ovarian nerves. — Vomiting is a symptom of inflammation of the ovaries. (9) The nerves of the testicle. — A blow on this organ tends very readily to produce nausea and vomiting. The cause of vomiting in sea-sic/cncss is uncer- tain, but it appears to the writer to be partly due to the condition of the nerve-centres, and partly to that of the viscera. See Sea-Sickness. Treatment. — The treatment of vomiting is to be directed to two ends (1) to remove the cause if possible ; and (2) to lessen the irritability of the ■vomiting centre. The chief drugs which lessen the irritability of the vomiting centre are opium, morphia, bromide of potassium, chloral, and probably also hydrocyanic acid and belladonna. Strychnia and smalldoses of ipecacuanha are also useful in vomiting, and they probably owe their power to their action on the vomiting centre. Most of these drugs have a local sedative action on the stomach, and therefore it is advantageous to give them by the mouth when possible. Even when the stomach is very irritable, they may be retained by giving them in a concentrated form. When the stomach will not retain them, they must be given by the rectum or by subcutaneous injec- tion. In sea-sickness the effect of the position of the bead is sometimes very marked, and the vomiting may sometimes be arrested completely by removing all pillows and putting the head on a level with, or rather lower than, the body. In cases of disease of the brain or its mem- branes, where it is difficult or impossible to re- move the cause, we must try to lessen the conges- tion by means of leeches and cold applications to the head ; and also to soothe the vomiting centre by hydrocyanic acid, or by bromide of potas- 1765 sium. At the same time, however, considerable benefit is obtained from the use of remedies which act locally on the stomach, these seeming to have some reflex effect upon the vomiting centre. One of the most useful is ice, which may be constantly sucked, and also swallowed in small lumps. Where the vomiting is dependent on the action of poisons circulating in the blood, as in the later stages of contracting kidney, we must endeavour to eliminate these by increasing the action of the kidneys and the skin. In vomiting dependent on inflammation of the mouth and fauces, we lessen the irritability by soothing or astringent gargles, confections, or glycerines. A confection or gly- cerine is often better than a gargle, inasmuch as it remains longer attached to the parts, and thus exercises a more prolonged effect upon them. When vomiting is due to irritant substances in the cavity of the stomach, such as indigestible food, and acrid fluids or poisons, it is best treated by evacuating them. A large draught of luke- warm water, alone or mixed with a teaspoonful of mustard, is one of the best means. Large draughts of warm water alone, even if they are not ejected, may give relief by diluting the acrid substances in the stomach so much as to prevent their irritating the mucous membrane. In this way they sometimes relieve sick-headaches. It is of great importance sometimes, not only to prevent the formation of acrid substances by slow and imperfect digestion, but to prevent the me- chanical irritation of the mucous membrane by undigested food. For example, we not unfre- quently notice that sickness and vomiting will occur in susceptible individuals after meals con- taining such substances as are not only slowly di- gested, but are swallowed in lumps. Examples of these are uncooked apples and cheese, or even potatoes, especially when imperfectly boiled or new. These articles, instead of being crushed to a powder by the teeth, are swallowed in lumps of considerable size, and apparently, instead of pass- ing the pylorus, are retained in the stomach, and, partly by the mechanical irritation, and partly by their giving rise to acrid products, cause sick- ness. Milk, when swallowed in large draughts, or when there is too much acidity in the stomach, instead of falling in fine flakes will coagulate in large lumps, which have a similar effect to the cheese. To relieve this it is advisable to mix the milk with soda-water or lime-water, or to take it, as in the whey cure, by sipping. When vomiting is due to slow or imperfect digestion, which allows decomposition or fermen- tation of food to take place in the stomach, it may be arrested by improving the digestion. Thus five grains of calomel, by acting on the stomach through the liver, may arrest vomiting ; and tincture of walnut (the active principle of which, juglandin, is an hepatic stimulant) has also been recommended. Pepsine also, by facili- tating digestion, may prevent vomiting ; and bitters, such as calumba, may do so also, by pre- venting putrefaction or fermentation. When decomposition or fermentation of food, with formation of acrid or irritating products, has once set in, it may continue a long time, as the organisms which cause it remain con- stantly in the stomach, and renew the process ir, every fresh supply of food. It may bo stopped 1760 VOMITING. by antiseptics. Where the vomited, matters are frothy and yeasty-looking, the sulphurous acid of the Pharmacopoeia, in doses of one fluid drachm, diluted with half a wine-glassful of water, often arrests such vomiting like a charm. Creasote has a similar action, but possibly has some additional action on the nervotis system, as it is useful oven in cases where the vomiting does not appear to be due to decomposition of food. For the treatment of irritant poisoning see Poisoning. When the mucous membrane of the stomach itself is inflamed or irritated, we must try to lessen the irritation. The best drugs for this purpose are ice, hydrocyanic acid, opium, and bismuth. The insoluble salts of bismuth, and especially the sub-nitrate, are to be preferred to the solutions ; and it is advisable to combine them with magnesia, potash, soda, or carbonate of lime, according to the condition of the intestines, pre- ferring the magnesia when the bowels are con- fined, and carbonate of lime when they are too loose. Sometimes the tendency to vomit is in- creased by lying on the right side. This is pro- bably partly due to the drag of the stomach itself upon the cardiac extremity, and partly to the difficulty with which gaseous eructations escape from the stomach in this position. When there is a tendency to vomit, therefore, the patient should lie down on the left side after a meal. In tlie vomiting of hepatitis, in addition to opium and hydrocyanic acid, we may use ice-water, or ice swallowed, and leeches over the liver. In biliary calculus, wo may give, along with opium, a full dose of ether internally, and in addition may employ ether or chloroform by inhalation ; similar treatment maybe adopted in cases of renal calculus. In intussusception or hernia we must remove the cause, if possible. In peritonitis full doses of opium are best. For the vomiting in cystitis and ovarian diseases, we must lessen the sensi- bility of the vomiting centres by the drugs al- ready mentioned, and treat the local conditions. In the vomiting of pregnancy we trust partly to the drugs already mentioned to act on the vomiting centre, and partly to local applica- tions. It is sometimes arrested by the applica- tion of a 10 per cent, solution of nitrate of silver to the os uteri, or by slight detachment of the membranes around the margin of the internal os. Where all other methods fail, the induction of premature labour must be resorted to. See Pregnancy, Diseases and Disorders of. T. Lauder Brunton. VULVA, Diseases of. — Synon. Fr. Maladies de la Vulvc ; Ger. Krankheiten der Schamritze . — The vulva or external genitals of the female com- prise all the structures external to the hymen, having the navicular fossa and perineum behind, the urethral orifice, vestibule, clitoris, and mons Veneris in front, and at the two sides the nymphse and labia majora. These organs may be the seat of many diseases, which will be described in the following order. 1 . Atresia Vulvas. — Closure of the genital fissure is sometimes found as a congenital mal- formation. This is usually of itself of no great im- portance, as it is almost always associated with VULVA, DISEASES OF. other defects in development, as with atrosia ani, hermaphroditisms, extroversion of the bladder, &c. Acquired atresia results from mismanagement of infantile vulvitis, from injuries of the pudenda in childhood, or from cicatrisation following upon some ulcerative process. It may give rise to trouble in micturition if the urethral orifice be involved. In rare cases it is only after puberty that trouble arises, from retention of the menses, or after marriage, from dysparcunia ; or even during labour, from narrowness of the orifice delaying the escape of the infant. In the slighter and more recent cases, where the labia have only been agglutinated, they may be torn apart by pressure with the thumbs ; or by passing a probe or sound behind the line of adhesion, and tearing it up with the handle of a scalpel, or with the nail. Where the union has become organised, the edge of the knife must be employed. In any case the patient should be anaesthetised ; and care must be taken subsequently to prevent the re production of the adhesions. 2 . Inflammation — Synon.: Vulvitis. — In- flammation of the vulva may be (a) general ; or ( b ) localised. (a) General vulvitis. — This variety is found affecting the apposed aspects of the labia, and the whole of the mucous surface they enclose, up to the borders of the hymen. It may be due to gonorrhoeal infection, in which case the catarrhal process is apt to extend to the urethra and the vagina. In infants and young children of stru- mous constitution, it sometimes arises from ex- posure to cold, want of cleanliness, or irritation from ascarides that have passed out of the anus. In the adult it may result from irijurv, or rudo coition ; or from the escape of acrid uterine or vaginal discharges. It shows itself with heat, and tenderness or sometimes itching in the part; a discharge of viscid glairy mucus bathos the surfaces, which sometimes becomes purulent, and glues together the labia. When the labia are separated the seat of the mischief is exposed, and is seen to be rod, aud sometimes resentful of touch. Apart from the constitutional remedies that may be indicated in individual cases, the treatment consists in keeping the parts at rest, an 1 carefully clean ; and in bathing or douching the surface with hot water, followed by an astrin- gent lotion or dusting powder. (A) Localised vulvitis. — The vulvitis may be localised — (a) in the vestibule ; ( 0 ) in the navi- cular fossa ; or (7) in the muciparous follicles anJ glands, and especially in the Bartholinia >1 glands. (a) and (18) occur under the same conditions as the more diffused inflammation, and may be a source of considerable distress in walking or when the part is touched, without being attended by any leucorrhoeal discharge. Such cased re- quire the same treatment as cases of general vulvitis ; only it is important to make the appli- cations directly to the affected spot, and hence it is usually best to apply sulphate of copper, in the form of a solid crystal. (7) Inflammation in the Bartholinian glands is the commonest cause of labial abscess. It may attack females at any age, but is most frequently seen in women from twenty to thirty, whether married or un married. It may arise diu-ing pregnancy, and some women are liable to repeated attacks, ihe VULVA, DISEASES OF. glands becoming swollen and cystic whenever the patient gets a chill. In some cases there is pro- fuse secretion, which escapes freely. Far more frequently the swelling in the lining of the duct leads to occlusion. This occlusion is in some instances transitory, and when the swelling in the duct and around its orifice subsides, the secretion that had accumulated escapes. In other instances the duct becomes permanently closed. These are the cases where the patient acquires a swelling in the labium majus of the affected side, varying in size from a pigeon’s to a hen’s egg. The accumulated fluid may be clear and limpid; but often it is turbid and distinctly purulent. In all the suppurative cases, if the cyst be evacuated through a small opening, the fluid is apt to reaccumulate, and the cyst- walls are now more likely to be the seat of a mischievous inflammation. So that the treat- ment consists first in trying to reduce the in- flammation with hot fomentations or poultices, perhaps aided by sedative lotions containing bella- donna or laudanum, with the view of getting the orifice relaxed ; and where the contents do not escape through the duct, the cyst should be freely opened, and the cavity cauterised. Hu- guier's suggestion, to extirpate the gland, is not ordinarily required, especially if the evacuation be effected with a Paquelin’s thermo-cautery, which first makes a large and safe cut into the cyst, and can then be applied to the interior, so as to destroy the secreting surface. Specific inflammations. — The specific inflam- mations, gonorrhoeal and syphilitic, are treated of in their respective articles. Butit is to be noted that the vulva may be the seat of erysipelas ; and female children have sometimes suffered from a gangrenous vulvitis or noma, of the same nature as the noma of the mouth and cheeks, which may come on after some of the eruptive fevers, such as scarlatina, and require the same kind of treatment, with chlorate of potash and tincture of the muriate of iron and stimulants, from an early stage of the mischief. 3. Eruptions.— Various forms of eruption may be met with in the vulva, sometimes on the nymphpe or internal aspect of the labia majora, sometimes on the external aspect, and extending to tho mons Veneris, or inside of the thighs. The commonest are eczema, erythema, herpes, prurigo, and acne. They are diagnosed and treated in the same way as the same affections in other situa- tions. It is to be remembered, however, that the tendency to chronieity, which is a marked feature of inflammatory processes in the sexual apparatus generally, is apt to show itself in these vulvar eruptions, and that patients, from motives of delicacy, are apt to allow them to remain un- treated for too great a length of time. Further, many of them give rise to itching, which tempts the patient to rub and scratch herself to obtain relief, and may thus cause pruritus. 4. Pruritus. — .Etiology. — Itching of the vulva is a not infrequent symptom of some of the eruptive and inflammatory affections of the part, either when these are healing or have got into a chronic stage, and it may remain as a per- manent trouble after healing has taken place, if the patient have acquired the habit of relieving herself by friction. Sometimes it is reflex, from 1767 oxyuric irritation in the rectum, or when the worms have travelled from the anus to the vulva. Or it may be associated with disease of the va- gina or uterus, as in cases of chronic colpitis or carcinoma of the cervix, in which the itching may either be due to irritation from the nature of the discharge, or be a reflex phenomenon. In some instances it can be traced to circulatory disturbance in the labia, as when the veins are enlarged, and in the congestion of early preg- nancy. In others the renal ^wretion is at fault ; and it is such a common phenomenon in women who are the subjects of diabetes, that in every patient who suffers from pruritus vulvse, tho urine should be tested for sugar. Lastly, there are some cases that can only be described as idiopathic. Symptoms. — The itching may be localised on the internal aspects of the nymph*, or of the labia majora, or around the clitoris or the peri- nseum. In most cases of long standing it be- comes diffused all around to the anus and inside of the thighs. Sometimes it is temporary, as in the pruritus of pregnancy, which passes off under careful management in a few weeks, or in rarer cases during the puerperium ; in other pa- tients it becomes chronic, and constitutes one of the most distressing troubles to which the female is liable. The itching may come on only occa- sionally. For the most part it is likeliest to prove distressing when the patient is warm, as at bedtime, or after exercise; but with some the feeling is never quite in abeyance, and the patieift has the almost constant desire to relieve herself, as for a time she can do, by scratching, or rather, rubbing the parts with her dress or a towel, until the pain overcomes the feeling of itch, or sometimes until the collapse consequent on the onanistic orgasm which she has involuntarily produced, renders her for a time less sensitive to her trouble. The result of such friction, how- ever, is to keep up the local irritation ; so that even in cases where there may not originally have been any local pathological change, but where the. itching and friction have persisted for months or years, the skin and mucous mem- brane become thickened and indurated, and a condition resembling that of a chronic eczema becomes induced. In two cases the writer has seen epitheliomatous nodules develop at the sides of the clitoris and in the vestibule. Treatment. — When diabetes is present it must be combated; and if the patient is gouty, or have her urine too acid or alkaline, these con- ditions must be rectified. Morbid processes that may be present in the vulva or other neighbour- ing structures must be treated according to the requirements of the case. A carefully regulated non-stimulating diet should be enjoined, and a due amount of exercise. The internal remedies that have been found most helpful are bromide of potassium and arsenic. Then, for the relief of the itching, the patient must be warned against tho danger of rubbing the parts, and be taught to soothe it by bathing with very warm or some- times with cold water, and drying the parts with a soft towel or napkin. It can be still better allayed by mopping with a lotion containing infusion of tobacco or belladonna or opium ; or by applying afterwards a piece of lint soaked in 1708 VULVA, DISEASES OF. black lotion, or a lotion of acetate of lead. The most effectual sedatives are ointments containing sulphur, camphor, tor, carbolic acid, thymol, iodide of lead, bichloride of mercury, bismuth, prussic acid, or iodoform (deodorised -with ton- quin bean). o. Tumours. — The following enlargements may be found i n the vulva : — (a) Hypertrophy. — The clitoris has some- times been found of a size sufficient to cause dis- comfort, and warrant its removal. Far more frequently the nymph® are of unusual dimen- sions, their margins projecting beyond the labia, and then they are liable to become the seat of ulcerative processes, and require to be trimmed, which may be done with the knife or scissors, but better with the thermo-cautery. Enlarge- ments of the labia majora, in the form of elephan- tiasis, are mot with among Hindu women. The mass is sometimes of enormous size, and in consequence of the calibre of the nutrient vessels, ablation is apt to be attended with dangerous haemorrhage, so that the application of an elastic ligature is in most cases the best means of effecting its removal. ( b ) Hernia. — Hernial protrusions may occur into the labia, and be found among the swellings of this part. The detection and treatment are to be effected and conducted as in the case of other herni*. (c) Cysts. — Cystic swellings are found in the upper part of the labia, when the canal of Nuck becomes the seat of an accumulation of fluid, which corresponds to hydrocele of the cord in the male ; or lower down, when the duct of a Bartholinian gland has become occluded, and the secretion of the acini accumulates so as to dis- tend the gland without its becoming inflamed. If a complete aspiration in either case is not iollowed by perfect cure, and the fluid re- uccuinulates, as it is apt to do, the second tap- ping should be accompanied with an injection of iodine; and in the case of the Bartholinian cyst, the wall of which is formed of a mucous rather than of a serous membrane, the evacuation may require to be effected through a larger opening, and followed by the application of a more powerful escharotic. ( d ) New growths. — Various neoplasms may WATER CANKER. have their seat in the vulva. At the orifice of the urethra not infrequently small red-flesh growths, the so-called urethral caruncles, make their appearance. They are sometimes unat- tended with any symptom ; more frequently they cause intense suffering during micturition, during coitus, or when the patient takes exercise. The pain is usually referred to the urethral orifice, but it is sometimes reflected to distant parts, as, to the heel. Relief from suffering may be tem- porarily obtained by application of sulphate of copper or nitrate of silver; but cure is only effected by removal of the growth. It is impe- ratively necessary to remove not only the small red body, but the portion of the urethra from which it springs, and the raw surface should be freely cauterised if the ablation have not been effected with a thermo-cautery. Specific swell- ings, warty or gummatous, are, of course, fre- quently to be met with on the vulva. Lipomata sometimes grow under the skin of the labia pudendi. More frequently fibromata occur, which may attain considerable size, and demand re- moval. Lastly, the law that carcinomata have a predilection for surfaces where a transition takes place from one variety of epithelium to another, is illustrated by the frequency with which different forms of cancer affect the vulva. Their development, symptoms, and treatment present no special features. Only it is well to remember that when the mischief is met with in a stage where there is still hope of its eradica- tion, it is best to effect the removal of the neo- plasm by some of the bloodless methods with which modern surgery has become familiar. The tissues in which the growth develops are very vascular ; and whilst in some situations — as at and around the clitoris — it is comparatively easy to control haemorrhage by pressure against the pubic bones, in the parts immediately to the side and back of the vaginal aperture the bleeding from a cut surface is apt to be uncontrollable and dangerous. Hence commencing carcinomata ought to be extirpated with the £eraseur, or better still with Paquelin’s thermo-cautery, which is the most serviceable of all instruments for the removal of tho different varieties of neoplasm that infest the vulva. Alexander Russell Simpson, w WAKEFULNESS. Nee Sleep, D isorders of. WARTS. See Verruc.e. WASTING. — A synonym for atrophy. See Atrophy, General; and Atrophy, Local. WASTING PALSY. — A synonym for progressive muscular atrophy. See Progressive Muscular Atrophy. WATER, JEtiological Relations of. See Disease, Causes of ; and Public Health. WATER. Therapeutics of. See Baths, Hydrotherapeutics ; Mineral Waters ; and Sea Air, Sea Baths, and Sea Voyages. WATER BRASH. — A popular synonym for 1 pyrosis. See Pyrosis. WATER CANKER. — A synonym f"i I cancrum oris. See. Oancrum Oris. WATER ON THE BRAIN. WATER ON THE BRAIN— A popular synonym for hydrocephalus. See Hydrocephalus, Chronic. WATERS, MINERAL. See Mineral Waters. WAXY DISEASE. — One of the synonyms for albuminoid disease. See Albuminoid Dis- ease. WEAL, WALE, or WHEAL.— This is an Old-English word signifying the mark of a stripe, that is, the prominent pale ridge caused by the stroke of a lash upon the skin. The term is applicable especially to the prominent risings of a lengthened figure which are met with in urticaria, in contradistinction to the button-like tubercles or protuberances of that affection. See Urticaria. WEILBACH, in Germany. — Sulphur waters. See Mineral Waters. WEN. — A popular term for a tumour of the integument, without reference to its pathological structure. Wens are commonly fleshy or en- cysted ; in the latter case proceeding from disten- sion of the sac or excretory duct of a cutaneous gland, more especially a sebiparous gland. WET-PACK. See Hydrotherapeutics. WHEEZING. — A peculiar sound, of a dry piping or whistling character, which may be heard in connection with the respiratory organs during the act of breathing, and caused by cer- tain forms of obstruction to the passage of air. See Asthma ; Bronchi, Diseases of ; and Physi- cal Examination. WHIFEING. — A peculiar quality of a mur- mur heard in connection with the heart and vessels. See Heart, Valves of, Diseases of ; and Physical Examination. WHIP-WORM. — This term is not unfre- quently applied to the small human nematode that is better known to the profession as the Trichcccp halos dispar. Several of the older writers, following Biittner, supposed that the whip-like portion of the body formed the tail ; hence the generic term Trichuris under which they described the parasite. Whip-worms not only infest man, but also several of our domesti- cated animals, which latter, however, as in the case of the human host, rarely suffer in conse- quence of the invasion. See Triciiocephalus. T. S. Cobbold. WHISPERING PECTORILOQUY. — A form of pectoriloquy in which the whispered voice is distinctly heard. See Pectoriloquy ; and Physical Examination. WHITE GUM. —A popular name for the white form of strophulus, . I ferment: ferment). — Synon. : Er. Zymotique : Zymase , Ger. Gdhmngsfahig : Gdhrstoff. — The" terms zyme, zyminc, zymotic, and zymosis were intro- duced by Dr. Parr, in a letter to the Registrar- General in 1842, and employed by him to denote, in a general way, the poison (and pathological processes excited by it) of ‘ epidemic, endemic, and contagious diseases.’ In using the word {vfia, he was careful to point out that he did not consider the morbific process to be absolutely identical with the ordinary phenomena of fer- mentation, and that he wished the terms zymosis, zymotic, &c., to be employed in English, ‘ not in 1 In the epidemic of yellow fever in New Orleans dur- ing 1878, when, in a population of 210,000 the deaths numbered 4,056, the writer had an extensive experience of the disease, himself treating 256 cases, of whom 18 died. The plan of treatment was based upon the preceding principles. The alimentary canal was cleared at the outset by an emetic of ipecacuanha, and a powder of 10 to 20 grains each of calomel and quinine, followed by a full dose of castor oil. The action of tlie skin was excited by hot mustard foot-baths and mild diuretics. The function of the kidneys was maintained by the regular use of cold water, by attention to the covering of the patient, and avoiding cold currents of air. Abso- lute rest, in all cases, in a well-ventilated room, for from eight to fourteen days, or even longer, was strictly enforced, supplemented with careful nursing night and day, and the most exact record of the progressive state of the patient. During the period of febrile excitement the patients were confined to barley water. When the initial temperature was high, 2 to 4 drops of tinctnra veratri viridis, or 5 to 10 drops of tinctura gelsemii, were administered every two or four hours, combined with friction with a liniment composed of from 1 to 2 drachms of the sulphate of quinine mixed with 3 fluid ounces each of soap liniment and olive oil. Ten grains of sulpho-carbolate of soda in orange-leaf tea were given every four hours. Where the head was very hot and there was much nervous irritability, cold applications were employed. Gastric irritation was treated by sina- pisms to the epigastrium, with carbonate of lime and creasote internally. Except in eases attended with great nervous excitement, without urinary suppression, opiates and chloral were not given ; but in such cases they were apparently beneficial. Cupping over tbeloins and bromide of potassium were used when the urine was diminished in quantity. After the subsidence of the febrile excite- ment, iced champagne and beef-tea were administered in small quantities, at regular intervals. In cases which assumed the ‘ typhoid state,’ attended with tympanites, ice-cold enemas, containing small quantities of tincture of assafcetida and oil of turpentine, were found to be beneficial, by reducing the temperature, stimulating the bowels to expel the flatus, and promoting the action of the kidneys. When secondary fever ensued, and pre- sented an intermittent or remittent type, the sulphate and bromide of quinine were freely used. And when the stomach would tolerate nourishment and stimulants, beef-tea, chicken tea, beefsteak, and port wine or brandy were administered. When convalescence was prolonged, or life endangered by abscesses or carbuncles, iron and other tonics were given, together with a nutritious diet, and the local application of carbolic acid, tincture of iodine, &c. Relapses were avoided by confining the patient to bed until the heart had regained its u»ta! vigour. 1806 ZYMOTIC: ZYME. the sense which they have in Greek, but as ge- neral designations of the morbid processes and their exciters.’ With this qualification clearly expressed, the use of the root-form ( up . - has be- come general, not only in scientific literature, but also in the public press— almost invariably, however, in the adjectival form zymotic. Fourteen years later (1856), in the Sixteenth Annual Report of the Registrar-General, Dr. Farr described the diseases of the zymotic class as conveniently referable to four groups. These aro : — 1 . The Miasmatic, diffusible through the air or water, attended by fevers of various forms ; the matter by which they are communicated is derived from the human body, as iD small-pox, or from the earth (as in ague). These two dis- eases are types of this class. 2. The Enthetic diseases, which may properly be called contagious, being communicated by contact, puncture, or inoculation. Syphilis and glanders are types of this class. 3. The Dietic diseases, which arise when the blood is supplied with improper or bad food. Scurvy and ergotism are the types of this class. 4. The Parasitic diseases, which at- tack especially dirty populations, and infest the skin, the intestinal canal, and all the structures of the body. This classification is open to serious objections. It is quoted here rather because it continues to be employed in official reports, than on account of its intrinsic importance. Modern pathology will probably soon necessitate its revision. Recently, indeed, the word zymotic has been restricted to the acute specific diseases, included under the first group (miasmatic) in the above classification ; and at the present time it is in this limited sense that it is most commonly used. Another important application of the term must now be referred to. Within the last few years the root-form fun- has been introduced into the terminology of normal physiology by Heidenhain in Germany, to designate the active substance (precursor of trypsin, &c.), contained in gland-cells as zymogen, which develops the ferment by its metamorphosis. Thus, unfor- tunately for the purposes of exact description, the same root-form is employed by pathologists and physiologists to designate two apparently distinct processes. Although the intimate rela- tionship of these two processes was recognised as early as the seventeenth century, by such autho- rities as Sydenham and Morton, they cannot at present be considered identical, notwithstanding the fact that the similarity becomes more strik- ing with every fresh addition to experimental physiology. Corresponding with the adjective zymotic is the substantive zyme. This is a useful namo, by which we refer to the poisonous cause of zymotic diseases. It is simpler than the word zymine, originally proposed by Dr. Farr; and (what is much more important) to speak of the contagious poison as ‘ a zyme,’ does not imply the acceptance of any particular theory of disease, while, on the other hand, the use of the word ‘ germ ’ distinctly conveys the idea of some orga- nised structure, itself the cause of the disease by subsequent growth and multiplication. See Germs of Disease. The necessity for employing the word zymosis does not seem to be felt as yet ; but the same reasons that lead us to speak of the agent as a zyme should also guide us to use zymosis in the place of more usual periphrases. Analogy between Fermentation and Infec- tive Processes. — Such being the derivation of the word zymotic and the terms related to it, it is natural to inquire how far an analogy can be traced between the life-history of the diseases thus designated, and the process of fermenta- tion. This subject, which has an important bear- ing upon the doctrine of contagious diseases, is discussed at length in the article on Contagion (page 290). 1 It is there shown how far the two processes resemble each other, and in what re- spects they appear to be different, at least in some kinds of zymotic disease. It must not be forgotten that fermentation deals with a com- paratively simple substance, for instance dead organic or inorganic compounds, and the dis- ease-process with a more complex one, namely, the living animal organism, although the ele- ments of action (the ferment on the one hand, and the zyme or zymine on the other) seem to have identical characters. By interposing the consideration of putrefaction between that of fermentation and zymosis, it is easy to see, from examining the products of each, how similar must bo the individual agencies ; but, the actual working of the agent in each, or indeed the real nature of each, being unknown, the whole pro- blem remains unsettled. Victor Horsley. 1 Although it is four years since the article Contagion was written by Mr. Simon, he has thought it desirable to leave that article unaltered, preferring that it should be supplemented, in respect of the intervening years, by the present article, and others on related objects. In discuss- ing the subject of the organic constitution of the meta- bolic contagia, Mr. Simon says: — ‘Though it would be at least premature to say of these diseases’ [erysipelas, pyaemia, tuberculosis, enteric fever, cholera, diphtheria, and the smallpox of man and beast], ‘ that they certainly have as their contagia mycrophyles respectively specific to them, it seems at present not too much to say, that pro- bably such will be found the case. How far these anti- cipations have already been realised may be learned by reference to the articles Bacteria ; Bacilli (in Appen- dix) ; Micrococcus ; Pustule, Malignant ; and on the several diseases in which the presence of such organism* has been recognised. See also Antiseptic Treatment.— Ed. (September 1882). APPENDIX ACONITE, Poisoning by. — Synon. : Fr. Empoisonnement par VAconit; Ger. Eisenkut- vergiftung. — The common garden-plant, Aconi- tum napellus, known also as ‘ ■wolfsbane’ or ‘blue- rocket,’ as well as other species of aconitum, are poisonous, and owe their poisonous properties to the presence of an alkaloid, aconitine or aconitia, or perhaps to a mixture of alkaloids passing under this name. A similar alkaloid, pseud- aconitine, has been obtained from the Indian aconite, A. ferox ; and another alkaloid, jap- aconitine, from Japanese aconite roots. All parts of A. napellus are poisonous. The three alka- loids, aconitine, pseudaconitine, and japaconi- tine, are perhaps the most poisonous alkaloids known. All parts of the aconite plant when chewed, and aconitine when placed upon the lips or tongue, produce, after a few minutes, a disagreeable acrid burning sensation, followed by numbness, loss of sensibility of the part, sali- vation, and an after-sensation of searedness. These sensations may last for several hours. The fresh root of aconite has frequently been eaten in mistake for horse-radish, to which it bears a remote resemblance. The root of horse- radish is whitish on the exterior, is long and of fairly uniform diameter, has a pungent odour when scraped, and the scraped surface retains its white appearance ; whereas aconite root is brown and conical, is destitute of pungent odour, and speedily acquires a pink colour when scraped and exposed to the air. Mistakes more frequently occur from liniments containing aco- nite being swallowed in error. In two cases the root has been administered with homicidal in- tent; and in a recent case a young man was killed by the administration of, as it is sup- posed, two grains of English aconitine. Acci- dents have also arisen from the administration cf the potent English aconitine in mistake for the impure inert exotic or German alkaloid, or mixture of alkaloids passing under that name. Anatomical Characters. — After poisoning by aconite there may be gastric congestion or inflammation ; but these may be absent. Symptoms. — When aconite, or any of its pre- parations, is taken by the mouth, the first sensa- tion, transitory and mainly due to the action of the solvent, is followed in about three minutes by an intolerable burning and numbing pain, extending from the place of application to all the surrounding parts of the mucous membrane. There is salivation ; and the burning sensation extends down the gullet to the stomach. Occfe- sionally, when the poison has been rapidly swal- lowed, no marked symptoms may supervene for half an hour. The general symptoms are very varied, but may all be referred to weakening of the heart’s action, disturbances of respiration, and paralysis of sensation on the surface of the body. This last may be described as ‘ numbness ’ or ‘ drawing of the skin,’ or by some equivalent term. There is pain in the epigastrium, violent vomiting, occasionally purging ; the pulse, at first rapid, quickly diminishes in frequency and force till it is imperceptible ; the skin is cold, clammy, and livid ; respiration is laboured. The pupils, at first contracted, afterwards dilate; and this dilatation sometimes occurs suddenly and transitorily, and is accompanied by blind- ness. Convulsions are not common ; but vomit- ing is often due to spasmodic contraction of the diaphragm, causing frothing at the mouth. Con- sciousness is retained till near the end of life. Diagnosis. — The peculiar sensation in the mouth— burning, feeling of searedness, numb- ness, &e.— the great cardiac depression, and the difficulty of respiration, will generally serve to determine the nature of the case. Prognosis. — Death usually occurs within four or five hours. If the patient survive twelve hours, recovery is usually rapid and complete. Fatal dose. — Of the root sixty grains — pro- bably much less might suffice. Of the pharma- copceial tinctura aconiti (1 in S) two or three fluid drachms. Fleming’s tincture is about six times as strong as the officinal tincture, and twenty-five minims have proved fatal. Four grains of alcoholic extract have proved a fatal dose. English aconitine or aconitia (the alka- loid) is terribly potent : l-200(Jth grain will produce a very decided sensation on the tongue, and it is probably as poisonous as the crystal- lised French aconitine-nitrate, one-sixteenth of a grain of which has killed an adult within five hours. Treatment. — In proceeding to treat a case of poisoning by aconite we must, first, wash out the stomach by means of the stomach-pump, and promote vomiting by warm emetics, of which carbonate of ammonia is the best. Stimulants must be freely administered ; also strong black coffee or tea. Brandy and ether may be injected subcutaneously. Digitalis is a counter-poison, and may be administered with effect subcu- taneously, in doses of twenty minims of the 1308 ACONITE, POISONING BY. tincture, repeated in an hour or so if necessary. Inhalations of nitrite of amyl may afford some relief. The patient must be kept strictly in the recumbent position, warmth being applied to the surface ; and, as a last resort, artificial respiration must be used. Thomas Stevenson. AINHUM (Nat., to saw). — This disease was first described by Dr. da Silva Lima of Bahia in 1867. It is peculiar to the African race, being found not only amongst the inhabi- tants of the "West Coast of Africa, but also amongst the Hindoos of African descent, as well as amongst the slave population of South America. At its commencement, a groove or fur- row is seen at the base of the little toe (the part almost invariably attacked), situated on its inner and inferior aspect, and corresponding to the digito-plantar fold. The furrow soon extends to the entire circumference of the toe, and be- coming gradually deeper, the latter is left hang- ing by a slender pedicle, which can only be brought into view by separating the walls of the furrow. The distal portion swells into an ovoid mass, about twice its natural size ; finally some accident snaps the pedicle, and th<3 toe drops off, in from four to ten years from the commencement of the disease. The furrow is caused by a constricting band of hardened and contracted skin — a local sclero- derma — which leads to faulty nutrition and de- generative changes in the parts beyond. Ainhum is not a painful affection in itself, but the extreme mobility of the little toe causes trouble and inconvenience, for which patients often seek relief in amputation. Occasionally the sides and bottom of the furrow ulcerate ; not unfrequently both little toes are attacked by the disease. Males are more subject to it than females. /The micro- scope reveals only atrophic and degenerative changes. The cause of ainhum is entirely ob- scure. It has been cured by the early division of the constricting band. A. Sangster. AMBULANCE ( amhulo , I walk about). — Definition. — A vehicle for the conveyance of invalid or wounded persons. The term is gene- rally applied to such of these vehicles as are drawn by one or more horses. The French use it to designate a field military hospital. The writer has described the requirements of an ambulance carriage as follows: — 1. Ease of entrance and exit ; 2. Freedom from jar during locomotion ; 3. Protection against weather, with facilities for regulating air and light ; 4. Light- ness of structure, consistent with strength ; 5. Facility of turning, and of transferring the vehicle to or from a railway-truck or steam- ship, without disturbing the patient. Military ambulances are adapted for carrying patients both sitting and lying, along with an attendant ; as well as food, water, medicine, and other appliances. In the ambulance designed by the writer, the litter, which is slid noiselessly on india-rubber rollers, rests on a tramway, between which and the body of the vehicle are inter- mediate counterpoise springs, which intercept shock and jar. AUSTRALASIA. _ Every ambulance should be provided with a litter-sheet, which can be used without its stretcher poles, for carrying the patient through places too narrow or tortuous for other modes of conveyance. Benjamin Howard. ANAESTHETICS. — The two following sub- stances have been introduced as anaesthetics since the article on the subject was written, and call for brief description. Bromide of Ethyl (C-.HjBr).— This substance has been recommended and moderately used as an anaesthetic. Its merits are that it exhilarates and produces rapid anaesthesia. Its effects pass off quickly, without any tendency to depress the action of the heart. The objections to the use of bromide of ethyl are that it is liable to decompose, leaves a strong smell and taste of bromine, and sometimes produces headache and sickness. Two deaths from it in America have been reported. Its use has been abandoned in England. Diehloride of Ethidene (C 2 1I.,C1 2 ). — This substance is obtained by distilling aldehyde and pentaehloride of phosphorus. The effects of this agent are intermediate between those of chloroform and ether. Its odour is usually preferred to that of either of the former. The writer has used it very extensively; and in minor cases, in which the operation has lasted only five minutes, the recovery is rarely attended by sickness or excitement. In the more pro- longed cases it was found to cause vomiting, but this ceased much more rapidly than when chloro- form had been given. Its effect upon the heart when given in large doses is depressing, and the pulse should be carefully watched during its administration. This anmsthetic was used by Dr. Snow, but abandoned chiefly on account of its expense. It was reported upon favourably by the Glasgow Anaesthetic Committee of the British Medical Association. They found that the blood-pressure was diminished by it as well as by chloroform, but that it was more regular in its action, and less potent also, so that they found it much easier to keep a dog alive whilst profoundly under its in- fluence than whilst under chloroform. Ether. — The following point is of importance in connexion with the employment of ether as an anaesthetic. Under ether, bleeding is more rapid than usual ; and this may produce syncope when the stimulating effect of the anaesthetic is pass- ing off. To prevent this result, whenever haemor- rhage is likely to be great, temporary ligatures should be applied to the arms and thighs, so as to detain blood in the veins until the chief ves- sels that have been severed have been tied. J. T. Cloves. ARKANSAS SPRINGS, in Arkansas, United States. — Thermal waters. See Mine- ral "Waters. AUSTRALASIA. — The portion of Poly- nesia lying between 10° and 50° S. latitude and 110° E. and 170° W. longitude, which may be said to include Australia, Tasmania, New Zea- land, the Fiji Islands, the New Hebrides, and some less important islands. Australia.— The climate of the T.ast conti- AUSTRALASIA. nent. of Australia, 'which is partly temperate and partly tropical, depends, first, on its latitude, *nd, secondly, on its conformation, the mountain ranges being distributed along the coast lines, especially on the eastern shores. In the interior, which is comparatively flat, and for the most part a sandy desert, there is great heat and little rain. The hot winds from the east are often sufficient in the summer to raise the ther- mometer to 127° Fahr. There are also sea winds from the N. and N. E. The southerly winds, prevailing chiefly from November to February, are winds of great velocity, ending in heavy thunderstorms. In the tropical part the rainfall is from November to April, and in the tempe- rate, which lies to the east and south, it prevails only in the winter season. The following aro among the principal towns or centres to which invalids proceed : — Adelaide, the capital of South Australia, lat. 35' S., long. 135^° E. It suffers from great heat and drought. The mean temperature is 65°, the maximum 115°, and the minimum 34°; the range being 81°, and the mean daily range 20°. The humidity is 60 per cent., and the rainfall 21 inches. The soil is sandy. Brisbane, the chief town of Queensland, lat. 27^° S., long. 153° E. The climate is almost tropical. The mean temperature is 70°, the maximum 108°, the , minimum, 34°; the range 74°, with a mean daily range of 21°. The rain- fall is 51 inches, and the mean humidity 76 per v'-ent. Queensland is for the most part elevated ; and the climate of the Darling Downs is consi- dered very fine. Melbourne, the capital of Victoria, lat. 38° S., long. 145° E. It has the roputation of being a healthy and agreeable residence; the climate being dry and temperate, and far cooler in sum- mer than that of Sydney. Mean temperature 57°, maximum 111°, minimum 27°, showing a range of 84° ; daily range 18°. Mean humidity 72 per cent. Rainfall, 26 inches. Berth, in Western Australia, very healthy, but as yet little suited to the requirements of in- valids. The temperature is 63° (mean), and rainfall 30 inches in 110 days. Sydney, the capital of New South Wales, lat. 24° S. and long. 151° E. The climate of New South Wales is clear and dry, the temperature depending more on the altitude than on the lati- tude. The plains in the interior, swept by hot winds, are very dry, while the coast districts have abundant rain. Mean temperature 62'5°, maximum 107°, minimum 36° ; range 71° ; mean daily range 14°. Humidity 72 per cent., and rainfall 50 inches. Tasmania.— Tasmania lies 150 miles south of Australia, between lat. 40° 40' and 43° 38', and is mountainous, with a deeply indented coast- line. The climate is more temperate and equable than that of the south coast of Australia. In winter the cold is sufficient to produce thin ice in the low lands, and snow showers in the higher ranges. The mean temperature of Hobart Town on the S.E. coast is 54°, the summer mean being 62° and the winter 47°. The rainfall varies greatly, from 100 inches at Macquarie Harbour on the W. coast, to 24 inches at Hobart Town, distributed over 145 days. The prevalent 114 BACILLI. 1809 winds are from the N.E. and S.W. The climate is favourable to infant life, and the country is regarded as a sanatorium for invalids. New Zealand. — New Zealand lies between 34° 50' and 47° 50' S. lat., and consists of a North and a South besides smaller Islands. The Northern Island is for the most part volcanic, and abounds in hot springs, which promise to become extensively useful, and active craters, which impart an important influence to its cli- mate. The Southern Island contains a lofty range of snowclad mountains, whose lower slopes form on the eastern shore a series of terraces known as the Canterbury Plains, and other fer tile regions. The climate is mild and bracing, but deci dcdly of a windy character, and not suited for all invalids : at Auckland in 1876 no calm day was recorded, the prevalent winds being W.S.W. The mean temperature of the North Island is 58°, of the South 54°. The maximum varies from 87° at Christ Church to 75° at Hokitika, and the minimum from 25° to 34° in the Southern Island. Cold is as a rule unknown in the North Island, while in the South there are a few snowy days each year on the coast. The rainfall varies from 32 inches in 135 days at Christ Church, to 131 inches in 186 days at Hokitika. Fiji Islands. — The Fiji Islands, partly of vol- canic and partly of coraline origin, have a tro- pical climate, moderated by the trade winds, so that the mean temperature does not exceed 80'* , the minimum being given as 65°. The rainfall is chiefly from October to April — the hot season, and varies from 124 to 215 inches in 170 days. See Climate, Treatment of Disease by. C. Theodore Williams. BACILLI ( bacillus , a little rod or staff). — Synon. : Ft. Bodies; Ger . Bacillen. Definition. — Rod-shaped vegetable micro- organisms, consisting of single cells, the length of which exceeds twice the breadth. Description. — The bacilli, thus roughly de- fined, form a group of algse which, until lately, wero classified under the general terms of Bac- teria and Schiiomycetce. At present, in accord- ance with the necessities of description, the word bacterium is limited empirically to mean a short rod-shaped organism, whose breadth is not less than half its length ; and, moreover, as the term Schizomyeetse does not fully represent the mode of reproduction in the bacilli, its value as a comprehensive term is thereby lessened. It will, therefore, be well to regard bacilli as a distinct order. From differences in their habitat and nutritive requirements, they may be held to be specifically distinct from one another, al- though this may not be evident morphologically with our present methods of research. In common with the rest of micro-organisms, bacilli consist of a protoplasmic body, surrounded by a sheath, probably of the nature of cellulose. The protoplasm is albuminous, granular, and occasionally shows brightly refracting fat gran- ules within it ; while the sheath or envelope is clear, with a sharp outline, and capable of resist- ing very powerfully the action of reagents 1830 BACILLI. The sides of the rod are parallel straight lines in the adult form, while the extremities may be either rounded or square. Notice has been taken of this fact in attempting to establish diagnostic points of difference among the bacilli; but the shape of the extremities varies in the same kind of bacillus, so as to suggest that the rounded end is but an advance on the square surface left im- mediately after fission of the parent organism. Although the breadth of each bacillus appears to be constant for the same kind, the length, as may be expected, varies considerably, so that measurements in this direction are of but re- lative value. The difference of breadth would afford a means of classification, but at present the bacilli are named after the diseases and other conditions with which they are found to be in relation. Development. — Tho bacilli multiply by two distinct methods, namely, simple transverse fission, and spore-formation. The process of fission, as it occurs in the adult rod, appears to consist, first, in a contraction of the proto- plasm at the centre, followed by an involution of the cellulose envelope, and subsequent sepa- ration of the two halves. The rod may grow to twice its length before dividing ; but when rapid multiplication is occurring, it is common to find rods of half the adult length. The process of spore-formation commences by steady growth of the rod into a long wavy and flexible fila- ment, which, with others, may form a thick felt- work. In the next stage bright points appear in the protoplasm, which increase in size, and, front being first cylindrical in shape, become ovoid, and so form spores imbedded in the fila- ments. The protoplasmic sporo then becomes covered with an envelope similar to that cover- ing the adult rod, and, getting free from the filament, develops into a rod by outgrowth from one end. Adult Life-History. — The vital changes of the bacilli are similar to those of other vegetable miero-organisms, that is, they require a moderate temperature (30° to 10° C.), a nitrogenous pabu- lum, and the admission of free oxygen for their full development. The different kinds of bacilli vary with regard to their pabulum; thus one ( Bacillus subtilis) flourishes best in a hay in- fusion, where another ( Bacillus ant brads') finds it hard to live. Diminution of the supply of oxygen leads to abortive growth. With respect to temperature, they are unaffected (as regards actual vitality) by extreme cold, but probably all varieties enter into heat-rigor at 60° C. Pathological Relations and Classification. The general characters of the bacilli so far have been considered apart from their most important bearing on disease, a preface to which division of the subject will best be afforded by enumer- ating the kinds of bacilli that have ns yet been described. They are as follows : — Bacillus subtilis I not found in living ulna / animal tissues anthracis malari* septienemite (experimental) leprae tuberculosis. Of thsse’kinds of bacilli, the Bacillus anthracis, found constantly in splenic fever, has been very thoroughly investigated (see Pustule, Malig- nant), and maybe accepted as an illustration of the relation borne by the different bacilli to the diseases enumerated in the above list. The con- ditions under which certain symptoms appear synchronously with definite organisms is dis- cussed elsewhere, and it only remains to draw attention to the nature of the classification, as being purely empirical, and of a temporary character. Diagnosis.— If it were possible, it would be desirable to show how a bacillus, found in con- nection with definite symptoms, may be identi- fied as peculiar to a particular pathological pro- cess. Morphologically we may arrange the so-called pathogenetic bacilli in terms of their breadth, commencing with the narrowest, in tho following order — B. septiemmiae, leprie, tuber- culosis, malari®, and anthracis ; whilst, as re- gards length, B. tuberculosis is shortest, arid between this and the remainder we may place B. septic®mi*. But the distinctions here given are only of very general value ; and as the bacilli differ somewhat in their reaction to staining fluids, we have in this another point of diagnostic value. Thus, B. tuberculosis can only be shown in tubercular fluids or tissues after these have been treated with a solution of an aniline salt, also containing pure aniline, anil then washed in moderately strong nitric acid, a process which would be destructive to the oth r forms of bacilli. A complete means of diagnosis would rest on their ph 3 'siologieal properties, but in the present state of knowledge this is impos- sible. 1 Victor Horslf.y. 1 Note ou the mode of demonstrating bacilli. 1. In fluids , such as blood an>l sputum. — An exceed- ingly thin layer of the fluid is first obtained, by placing a drop between two perfectly clean cover glasses, which are then separated by a rapid drawing movement, thus leaving a delicate film on each. The fluid is next eva- porated to dryness, by passing the cover glass a few times through the flame of a Bunsen burner. The coagu- lation of the albumen thus effected is an important step in the success of the staining process. The dry film may now be stained, by pouring on it a concentrated solution of methyl- violet, or by floating it on a solution of fuchsin, to which some pure aniline has teen added. This solution is prepared by dissolving the dye in equal proportions of alcohol and water, 10 which ^th part of aniline is added, thus making the solution alkaline. The preparation is then washed with a 10 per cent, solution of nitric acid, until all the colour has disappeared. Finally, it is washed with a concentrated aqueous solu- tion of aniline, to restore the alkaline reaction ; or the ground substance may be stained with a fluid of the same chemical reaction, namely, vesuvin or chrysoidin; the superfluous reagent is washed off with distilled water ; and the cover-glass mounted (after drying) in Canada balsam, or in a mixture of glycerine, glucose and alcohol, having an index of refraction =1*37. See Bran, Revue M6dicale de la Suisse Romande , August 1SS2. Bacilli can also be shown in albuminous fluids by treating the dried film with a 1 per cent, solution of caustic potash in water. In the case of tubercle, they may be distinguished from the ordinary bacilli of putre- faction by gently re-drying the potash-treated film, ai.d then staining with an aniline dye. Under these circum- stances the tubercle bacilli show up distinctly unstained, whilst the putrefactive organisms are deeply coloured (Baumgarten, Centbt./. d. med . TTiw. S. 257, 1882.) 2. In tissues. — The organs are hardened in alcohol, and very thin sections from these are stained by a similar process to that detailed above. In practice it wiil be found necessary to use a weak solation of acid for the sections ; and although the section appears quite white after its removal from the acid fluid, its colour partly returns on washing with water, again to be nv moved in the subsequent stages of passing the section CANTHARIDES. CAUTHARIDES, Poisoning by. — Synon. : Fr. Empoisonnement par la Cantharide; Ger. Cantharidenvergiftung. — Cantbarides or the Spanish fly owes its poisonous properties to the presence of cantkaridin, a non-alkaloidal body. All the preparations of the drug are highly poisonous. Symptoms. — Soon after taking a poisonous dose of cantbarides, the patient is seized with burning pain in the pharynx, and a sense of constriction in the oesophagus. The pain soon ex- tends to the abdomen, and vomiting ensues ; the .abdominal pain becomes aggravated ; and usually purging sets in. The stools are numerous, often scanty', passed with great pain and straining; they are at first mucous, and finally bloody. .If carefully examined, little iridescent specks — por- tions of the elytra of the beetle — may 7 be ob- served in the faeces and vomited matters. These are of course only observable when the powdered insect has been broken ; and they frequently es- cape observation. Up to this period of the case, should portions of the beetle not have been de- tected, there is nothing to distinguish the case from one of ordinary irritant poisoning; except, perhaps, that salivation and swelling of the sali- vary glands are usually prominent symptoms. The gastro-intestinal inflammation may be so in- tensely and rapidly developed, that death may occur from collapse before strangury, the dia- gnostic symptom, is developed. Generally, how- ever, the course is somewhat different, genito- urinary irritation and inflammation setting in; the symptoms of which are aching pains in the lumbar region, frequent desire to micturate, with violent tenesmus of the bladder, till eventually a few drops of albuminous or bloody urine only can be passed, or none at all. Priapism, erotic excitement, and sw'elling of the genitals are of frequent, though not of constant, occurrence. Delirium, tetanic convulsions, or paraplegia, may be noted in some cases. Eventually the intolerable agony gives way to collapse, stupor, coma, and death. Abortion not infrequently oc- curs in pregnant women, the drug being one in common use as an abortifacient. Diagnosis. — The intense strangury, the swell- ing of the genitals, and the bloody stools, will leave little or no doubt as to the nature of the case ; and the presence of particles of the drug in the ejecta will be conclusive. Fatal dose. — Less than half a drachm of the powder, and an ounce of the tincture, have alike proved fatal. Treatment.— Evacuation of the stomach by the use of the stomach-pump, syphon-tube, or an emetic is the first indication in poisoning by can- tharides. It is best to wash out the stomach well. Mucilaginous drinks, white of egg (not the yolk), and demulcents, may be freely given ; but oil in any form is to be avoided, as tending to dissolve cantharidin. Opium by the mouth or rectum, or the hypodermic injection of one-third of a grain of morphia, is advisable. Leeches to the through alcohol, oh of cloves, and mounting it in balsam. Illumination . — For the complete demonstration of the more difficult bacilli, for instance, B. tuberculosis, it is advisable to employ oil- immersion objectives, and a dis- persive illumination such as that afforded by Abbe’s condenser CHLORAL HYDRATE. 1811 region of the bladder, warm fomentations, and warm sitz-baths may afford relief. Chloral should also be given, or the patient kept cautiously under the influence of chloroform. Collapse may be met by ammonia and other stimulants. The hypodermic injection of a few drops of ether is useful. There is no known antidote for can- tharidin. Thomas Stfvenson. CHLORAL HYDRATE, Poisoning by. — Synon. : Fr. Empoisonnement par V Hydrate de Chloral ; Ger. Ckloralhydratvergiftung. Poisoning by chloral hydrate is a very com- mon occurrence, this medicament being fre- quently taken in fatal quantity by misadven- ture. There is reason to think that it is also largely used for suicidal purposes. The so- called ‘ chloral habit ’ is a growing evil. A s 3’ ru P of chloral hydrate, containing about twenty-two grains of this substance per fluid drachm, is largely sold in this country under a patent-medicine stamp. Anatomical Characters. — There may be an entire absence of any characteristic appearances after death by hydrate of chloral ; and at most these consist in more or less modified signs of asphyxia — especially a dark colour of the blood, and pulmonary and cerebral hypercemia. Symptoms. — The most striking symptom of poisoning by chloral hydrate is the rapid super- vention of quiet sleep, at first simulating natural sleep. In this stage the patient can he easily roused, but he speedily drops off again. The pupils are contracted ; the respirations are full , deep, and regular; the pulse is not. much affected. This condition rapidly deepens into full coma. The respirations slacken ; and the pulse is either weak and slow, or, more commonly, rapid and irregular. The temperature of the body is re- duced ; the muscular system is totally relaxed. The pupils now dilate ; and with feeble thready pulse, the anaesthesia and paralysis gradually end in death, preceded by lividity and collapse. Exceptionally, in fatal cases, burning pain in the mouth, fauces, and throat, and symptoms cl gastritis have been observed. In one case of recovery the patient became idiotic. Diagnosis. — The history of the case, or the finding of a vessel containing the medicine, coupled with the symptoms, will usually set all doubts at rest. Otherwise the case may be mis- taken for poisoning by opium or other narcotic, for carbolic acid poisoning, or for cerebral conges- tion. The pupil is not so contracted as in opium- poisoning ; and, as the coma deepens, it dilates instead of undergoing further contraction. There is an absence of the olive-green or black urine so commonly noticed in carbolic acid poisoning, of the peculiar odour of the breath, and of stains about the mouth and lips. Prognosis. — This will depend upon the state in which the patient is found, and upon the length of time which has elapsed since the in- gestion of the poison. Treatment. — Evacuation of the stomach by the aid of the stomach-pump is the first step in the treatment of a case of poisoning by chloral hydrate. Emetics, unless given early, usually fail to excite vomiting. The patient must he roused, if possible, as in epium-poisoning (se> 1812 CHLORAL HYDRATE. Opium, Poisoning by). The temperature of the body must be kept up by -warm applications. Stimulants may be freely given, and hot coffee injected into the rectum. Strychnia ( 5 b gr.) has been recommended for use as a counter-poi- son, by subcutaneous injection ; also picrotoxine. The former is a dangerous remedy ; the latter also would not perhaps be a safe antidote, if given in full doses. Inhalations of amyl nitrite, and artificial respiration are advisable. Thomas Stevenson. CHOLESTERINE bile, and crrepbs, solid). — Synon. : Fr. Cholesterine ; Ger. Choles- tcrin ; Gallenfett. Chemical and Physical Properties, — Cho- lesterine is a monatomic alcohol, represented by the empirical formula C 26 H J4 0, occurring as a normal constituent of the nervous tissue (519 per cent, of the solids of the white matter and 186 per cent, of the solids of the grey matter of ox-brain) ; and in minute quantities in bile (•25 per cent.) ; and in blood ( - 5 to 2'0 per 1000). When pure it occurs as white glittering scales, which consist of needles, when crystallised cut from ethereal solutions ; and of rhombic plates, often deficient at one corner, when derived from alcoholic solutions {see Microscope in Medicine). It is insoluble in water, alkalies, and dilute acids ; but readily dissolves in ether, boiling alcohol, benzol, chloroform, and solutions of the bile-acids. It melts at 145° Fahr., and its solutions are laevo- rotatory. The crystals, heated with a drop of strong sulphuric acid, give a carmine-red colour. Sources. — The exact physiological significance of cholesterine is not known, but it is generally regarded as a product of the metabolism of the nervous tissues which should be eliminated by tho liver in the hile. Since little or none is found in the faeces, it is believed to undergo a change in the intestine into stercorin (Flint). It is also found in the yolk of egg ; in some vegetables, such as peas and maize ; and in olive and almond oils. Pathological Relations. — The pathological occurrence of cholesterine is varied. It is in- creased in amount in all acute febrile conditions, and especially in those diseases of the liver lead- ing to the retention in the blood of the bile-con- stituents, producing in such cases a condition known as cholcstcrcemia. The fluid of cysts, especially hydatid and ovarian, seems to be more liable to contain it than effusions into serous cavities ; and on this ground it has been referred to in the differential diagnosis of ascites from ovarian dropsy. But it sometimes occurs in con- siderable quantities in hydrocele fluids, and it has been met with in old pleural and peri- toneal effusions. Cholesterine forms the greater bulk of most gall-stones, being formed into coherent masses by inspissated mucus. ' In the caseous degeneration of pus and other inflammatory products, crystals of this substance are to be found. In the urine cholesterine is never found in health, but it occasionally occurs in morbid states, and is especially likely to be met with when there is advanced renal degeneration. W. H. Allchin. conium, Poisoning bi. CONIUM, Poisoning by. — Synon. : Fr Empoisonnement par la Cigue ; Ger. Schierling - vergiftung. — All parts of the hemlock plant {Co- nium maculatum) are poisonous. Both the leaves and fruit are used in medicine. Its toxic pro- perties were known in ancient times ; the plant was used for the destruction of criminals by the ancient Greeks, and there is no doubt that Socrates was poisoned by it. Death from conium in this country has perhaps always been tho result of misadventure or suicide; but on the Continent tho active principle of the plant, conia, an alkaloid, has been administered for the pur- pose of wilful homicide, death resulting from a dose of 10 to 15 drops. Anatomical Characters. — The signs of as- phyxia, engorgement of lungs and of the right heart, and a general venous condition of the blood, appear to be constant after death from co- nium. There is nothing else specially noticeable. Symptoms. — Preparations of conium, as well as the alkaloid, or mixture of alkaloids, known as conia, when taken in toxic doses, produco excessive muscular weakness, beginning in the lower limbs, and extending gradually upwards, with giddiness and disordered vision. These symptoms are in some cases preceded by nausea and vomiting, with dryness or burning pain in the mouth and fauces. There is a desire to re- main quiet, and a peculiar heaviness or drooping of the eyelids, the patient lying with his eyes shut. This, and the impairment of vision, appear to be due to paralysis of the ocular muscles. The pupils may be natural, but later they be- come dilated. The pulse is slow till death is actually impending. Tho paralysis progresses gradually upwards, till eventually heart and re- spiration are affected, more especially the former. Convulsions, and impairment of the mental facul- ties — hitherto intact — now set in ; finally sen- sation is impaired, and death ensues from as- phyxia. Diagnosis.— The paralysis of motion, pro- gressing gradually upwards, with unimpaired sensation, and the peculiar drooping of the eye- lids, are perhaps diagnostic of the nature of the poison. Prognosis. — As no antidote is known which counteracts the effects of conia, the prognosis must always he a guarded one, and will depend en- tirely upon the general condition of the patient. Treatment. — The stomach must be emptied by the stomach-pump or syphon-tube, and well washed out. Emetics may also be used to evacuate the stomach. Tannin and astringents must be freely administered, to precipitate the active alka loid, and prevent its absorption. Castor oil, by the mouth or rectum, may aid the removal o( the alkaloid when it has been rendered insoluble by tannin. Strong coffee, brandy, ammonia, and stimulants generally are serviceable, as may also be the hypodermic injection of ether. Hypo- dermic injections of l-40th grain of sulphate ol atropia are very promising, especially in the later stages ; atropia acting as a respiratory and cardiac stimulant. Artificial respiration, and sti- mulation of the respiratory and cardiac func- tions by the use of electricity, ought not to be neglected when these are affected. Thomas Stevenson. DISTOJAA RINGERL DISTOMA HINGERI. — Under tliis name ibere has lately been described by the writer [Medical Times and Gazette, July 8, 1882), a new species of fluke, the mature form of which inhabits the human lung, where it was first found by Ur. B. S. Binger in Formosa, in 1879. The ova of the parasite have frequently been found by Prof. Baely, of Tokio, and the writer, and by them are associated with a peculiar form of recurrent haemoptysis, to which the term para- sitical hemoptysis has been applied. Symptoms and Pathology. — The symptoms of the disease associated with the presence of the distoma Ringeri are slight cough ; the expecto- ration of a characteristic rusty brown, viscid mucus ; and at times h£emopt}’sis, either to an insignificant or an alarming extent. The haemor- rhage occurs at irregular intervals during many years. The expectoration of rusty bronchial mucus is persistent, and in this the ova are readily discovered with the microscope. These (gi 0 - in. x ^ in.) are pale brown bodies, oval, aouble-outlined, opereulated at the broad end, iud contain protoplasmic globules having very active molecular movements. If the sputum is occasionally shaken up in fresh water, in the course of six weeks to two months an active ciliated embryo is developed in most of the ova, which in time escapes by forcing back the oper- culum. It may be concluded from this that drinking water, or a fresh-water animal acting as intermediary host is the, medium by which the disease passes from one human subject to another. See Distoma. This disease has hitherto been found only in Japan and Formosa, but its distribution is pro- bably much more extended than this. The mature distoma measures if in. x A j n . x A in. The particular tissue of the lung it inhabits has yet to be determined. It certainly communicates with the bronchi, as the bronchial mucus is the medium by which the ova are con- veyed to suitable incubating media ; but whether the animal is free in the bronchi, or is jammed into a branch of the pulmonary artery, has yet to be ascertained. Treatment. — Inhalations of sulphurous acid, and sprays of turpentine, kousso, quassia, and santonine, have been administered with apparent benefit. Patrick Manson. FILARJA SANGUINIS -HOMINIS.— Whilst the article Filaria Sanguinis-Hominis (p. 512) contains a sufficiently full account of the structure of this parasite, recent investigations enable us to furnish a more complete description of the life-history of the mature and embryo worm, and of their pathological relations to chy- luria and elephantiasis. It is now known that the parent worm lives in the lymphatics ; that the embryo while in utcro, by dint of vigorous movements, stretches its oval chorionat envelope, • to form the long tubular sheath in which it lies extended, as we see it in the blood and lymph ; and that, after this stretching of the chorion is complete, the embryo is born into the lymph- stream, which carries it through the glands, along the thoracic duct, and thus into the blood, Under ordinary circumstances of health and habit, FILARIA SANGUINIS-HOMINIS. 1813 the embryo cannot be found in the blood during the day, but at evening it appears there, in num- bers gradually increasing up to midnight (when in some cases as many as 200 may be found in a single drop) and diminishing towards morning. About 8 or 9 a.m. it disappears for the day. This phenomenon (‘ filarial periodicity ’) is appa- rently an adaptation of the habits of the para- site to those of the female of a particular species of mosquito, which preys on the blood at night, and thus imbibes the young filaria, to which it acts as intermediary host. Having entered the stomach of the mosquito, the filaria undergoes a metamorphosis, eventuating in its becoming pos- sessed of an alimentary canal, rudimentary or- gans of generation, increased size, great acti- vity, and a circumoral crown of papillfe. The latter is the boring apparatus, which enables the animal to leave the body of the mosquito, when this insect dies, after depositing her eggs on water; and to traverse the human tissues, to which it gains access, probably by being swal- lowed in drinking water. Pathological Relations. — Chyluria, naevoid elephantiasis or lymph- scrotum, varicose and indurated groin-glands, galactoeele, ascites with milky fluid, craw-cravi , and certain kinds of abscess, lymphangitis, and lymphatic fever, are almost invariably accompanied by the presence of the filaria in the blood or lymph. As tropical elephantiasis is often associated with, or supervenes on, some of these affec- tions, has the same geographical distribution, attacks the same parts, and is a disease of the lymphatics, it is therefore — though the filaria is not usually found in developed elephantiasis — believed to be caused by this parasite. But from the fact that in many countries where the filaria is endemic, quite 10 per cent, of the adult population harbour it, yet only a small proportion of these have any of the diseases enumerated, it is evident that the parasite does not necessarily give rise to disease. Evidence has been adduced which shows that, as long as the parent worm is healthy, it is innocuous, but that if it dies, it acts as a foreign body, causing abscess ; and that the obstruction of the lym- phatics, which eventuates in and causes the diseases above enumerated, is brought about by the premature birth of the embryo, before the chorional envelope has undergone the stretching process alluded to — that is, when ova (seven or eight times the diameter of the outstretched em- bryo) are prematurely launched into the lymph- stream. The ova act as emboli, and being very numerous, effectually plug the glands connected, directly or by anastomosis, with the lymphatic vessel in which the aborting parent lies. The location of the worm, the degree of embolism, and other circumstances, determine the site and exact character of the resulting disease. Treatment. — a. Curative. — No means of kill- ing the filaria have been discovered. The indications for treatment, when disease has de- veloped, are supplied by the pathology. Rest, elevation of the affected parts, elastic ban- daging, and other means to facilitate the flow of lymph through the damaged lymphatics are of great benefit. See Chyluria ; and Elephan. tiakm. IS 14 FILAEIA SANGUINIS-H0MIN1S. h. Preventive. — The fact that the mosquito nets as intermediary host, indicates the di- rection that preventive measures should take. Drinking 'water, in districts where the filaria is endemic, ought to be boiled or filtered ; wells, cisterns, and receptacles for drinking water ought lo le covered by line wire gauze, to prevent the access of the mosquito ; and persons known to harbour the parasite, ought to sleep under pro- perly constructed mosquito-curtains. By any nr all of these means, this parasite in the course of a single generation could be exterminated, and the diseases it produces made things of the past. Patrick Masson. LARYNX, Diseases of. — The chief neu- roses connected with the larynx, and the various forms of paralysis affecting the organ of voice, require more consideration than they have re- ceived in the principal article, Larynx, Diseases of. 1. Sensory Neuroses of the Larynx. — Hyperesthesia, of the laryngeal mucous mem- brane is a usual accompaniment of inflammation, acute and chronic, and is a not unfrequent hys- terical symptom. Anesthesia occurs in cases where the superior laryngeal nerve or its centres are affected, and especially as a sequel of diph- theria. It is usually associated with paralysis of the muscles of deglutition, and of the depressors of the epiglottis, and still further contributes to the dysphagia accompanying the lesion, leading to pulmonary complications, owing to food pass- ing into the larynx deprived of its reflex sensi- bility. If necessary, food must bo administered by the oesophageal tube, while the nervous lesion is suitably treated. 2. Paralysis of the Larynx. — Definition. — Loss of power in the laryngeal muscles, occur- ring in connection with disease or poisoning of the nervous centres, or with pressure upon or disease of the laryngeal nerves or their parent trunks, caused by aneurism, enlarged cervical or bronchial glands, or other tumours ; more rarely of muscular origin. Varieties and Symptoms. — Paralysis of the superior laryngeal nerve, supplying the crieo-thy- riod muscle, in addition to the symptoms men- tioned under ansesthesia, prevents due tension of the vocal cords, and causes dysplionia. Com- plete paralysis of the muscles supplied by both recurrent laryngeals, the motor nerves of the larynx, causes the vocal cords to remain immov- able and semi-closed, as in the dead body; but disease or pressure upon this nerve most com- monly paralyses only certain groups or indivi- dual muscles. The most serious, and perhaps most common, lesion is paralysis of the aoductors (posterior crico-arytrenoids, &c.), causing the vocal cords to approximate in the middle line in a relaxed state. Even in phonation they are not tense ; and during respiration only a narrow chink is left, with relaxed edges, causing very stridulous breathing, and possibly fatal asphyxia. Paralysis of the adductors, when one or both vocal cords are seen at all times relaxed and drawn aside, leading in the latter case to com- plete aphonia, and in the former to aphonia more or less complete, is not necessarily attended LICHEN. with much dyspnoea. "When these conditions are of long standing, the muscles become atrophied ; but many cases have been reported where the paresis of individual muscles has been of true muscular origin. Diagnosis. — The several varieties of paralysis of the larynx must be recognised by the laryn- goscope, the symptoms to which they give rise being common to various diseased conditions. The dyspnoea and stridulous breathing of para- lysis of the abductors is unaccompanied by the pain and other symptoms which attend them in the various inflammatory affections, but may without physical examination be undistinguish- able from thoso caused by neoplasm or by pas- sive oedema. Functional aphonia has been considered in the body of the work (see Larynx, Diseases of). Organic aphonia is not only a frequent symptom of painful inflammation, of ulcerations, neo- plasms, and other affections of the larynx ; but it may be the only symptom, not only of paralysis of the adductors, from disease of the nerves or muscles, but of other conditions closely si mu lating this, such as anchylosis of the crico- arytaenoid joints (Dr. F. Semon), contracted ci catrices, and other mechanical obstacles to tho approximation of the vocal cords. Treatment. — The paralysed condition usually depending on serious disease outside the larynx, local treatment is of little avail. Tracheotomy may be called for to avert asphyxia. Cases where the local use of electricity is supposed to have cured paralysis were probably cases of simulated disease. Sec Larynx, Diseases of; and Pneumogastric Nerve, Diseases of. 1 Thomas J. Walker. LICHEN. — The general pathology of lichen is discussed in the body of this work. Here it is thought desirable to describe the several species of lichen, and to refer to certain other diseases which were formerly associated with each other under this generic name. The somewhat loose definition given by the older writers to the word * papule,’ caused them to include under the head of lichen diseases, or rather conditions of the skin, many of which be- long to other categories. Thus Willan's list in- cluded seven species: — 1, Lichen simplex, 2. L. pilaris, 3. L. circumscriptus, 4. L. agrius, 5. L. Hindus, 6. L. tropicus, and 7. L. urticatus. Lichen simplex is merely a temporary lichen- ous condition — in short, the papular stage pre- ceding the vesicular stage of eczema. L. agruis and L. tropicus may bo disposed of in like manner. Lichen or Pityriasis pilaris is an afiection 1 It seems desirable to refer here to the following points which have not been noticed in the article Larynx, Diseases of. Dilatation of contraction by bougies and plugs has been frequently attempted, and recently successfully practised by Schrotter and others. Perichondritis, and consequent formation of abscess, with consecutive caries and necrosis of the cartilages, have been alluded to as complicating tubercular, syphi- litic, and the worst forms of non-specific laryngitis (typhns, kc.) ; rarely it occurs as a primary affection, giving rise to a limited suppuration. Abscess is so rare a complication of simple laryngitis that its eccurrenee almost invariably indicates perichondritis, with its for midable results— necrosis, caries, Ac. LICHEN. which is differently classed by authors ; it is essentially a chronic condition, characterised by a heaping up of epidermis in horny masses round the hair-follicles, giving the part affected the feel of a rasp. The outer surfaces of the ex- tremities, the backs of the hands and phalanges, are the seats of election; its alliances are with the squamous affections. Lichen circumscriptus or circinatus is a well- defined affection, in which small red papules are seen t.rranged in groups, and especially in segments of circles. The area enclosed by the segments of circles is minutely scaly, andof a buff- pink colour. The seats of election are the sternal region, between the mammse, and the interscapu- lar region ; from these, however, it may spread. The affection is very itchy, and has a strongly marked parasitic appearance, though the existence of fungus is extremely difficult, if not impossible, to demonstrate byordinary methods. Dr. Crocker has, however, described and figured a fungus which he has found associated with L. circum- scriptus. The affection readily yields to a little creasote ointment (m vj-x to the ounce of lard). Lichen lividus is a purpuric condition, in which the purpuric spots appear as papules round hair- follicles. See Purpura. Lichen urticatus is an affection which is now classed as a variety of urticaria. . In accordance with the teaching of Hebra, modern dermatologists are disposed to restrict the term lichen to papular affections in which the papules retain their character as papules, and do not undergo any further evolution. There is another condition imposed, namely, that the papule must be inflammatory. The group Lichen is thus narrowed down to one of Willan’s list, namely, Lichen circumscriptus-, and two newly-described diseases, Lichen ruber and Lichen scrofulosorum. JLichen ruber is a disease first described by Hebra, in Vienna, and in this country by Sir Erasmus Wilson, under the name of Lichen pla- nus. Although denied by some, the essential identity of the two conditions described under these names is generally admitted. The charac- teristic feature of L. planus or ruber is the de- velopment round the hair-follicles of lilac-red, flat-topped, somewhat quadrangular, shining papules; in early stages a central depression or umbilication is recognisable in the centre of each papule. At first the papules remain dis- crete, but they soon tend to group themselves in patches, or run together in lines ; the patches increase in size by the development of fresh papules in the immediate vicinity of the old ones. In this way whole are® may become af- fected, the skin being then much thickened and slightly scaly. The patches itch intensely ; and the clinical alliances of the disease are probably with psoriasis (Hutchinson). In its severest types, where the entire surface is affected, the patient’s life may be threatened ; but in milder forms it is very manageable by the internal ad- ministration of arsenic, combined with the local inunction of a mild tar ointment, such as ft Liquoris Carbonis detergentis 3'j - Adipis 3'- Misce, et fiat unguentum. I/ichen scrofulosorum is another disease, first described by Hebra. It is extremely rare in this NUCLEUS OF CELLS. 1815 country, although itundoubtedly exists, especially amongst the poorer classes. It is characterised by pale papules, approaching the colour of the skin ; these tend to range themselves in circular patches, not circles, generally on the trunk rather than the extremities. Here and there a papule inflames, and becomes acne-like. Thero is little itching. The disease is said to occur in young scrofulous subjects. Cod-liver oil is the remedy internally, and also externally by inunction. Alfred Sangsteb. LUPUS, Local Treatment of. — Volkmann has recently introduced a method of treating lupus locally, namely, by scraping or puncture. 1. Scraping has for its object, first, the re- moval of products of secretion, scabs, and crusts ; and, secondly, the removal of neoplasms formed in or on the skin. Forthis purpose ‘spoons ’ or ‘ scrapers ’ of various sizes are made by the instrument-makers. It is difficult to make any impression on the sound skin with such blunt instruments, and on this fact the simplicity and safety of scraping mainly depend. It is almost impossible to do harm, for all that can be made to break down (using moderate force), under the scraper or spoon, is best removed. 2. Multiple punctiform scarification is the se- cond mechanical method employed by Volkmann. By this the practitioner seeks, first, to destroy newly-formed vessels ; and, secondly, to favour absorption of the neoplasm, by traumatic irrita- tion of the part. It is practised by making hundreds of punctures close together, about two lines in depth. For this purpose a narrow- bladed bistoury may be used ; or the same end is gained in less time by employing an instrument composed of two or more knives set close to- gether. This method of treatment is more appli- cable to non-ulcerated parts, where the cell- infiltration is diffuse, or where the part is swollen and vascular. Such tissue might in some cases be made to break down under the spoon, but less scarring or deformity results if the neo- plasm can be made to disappear by the method of puncture. There is considerable bleeding at first, after either scraping or puncture. This, however, is soon controlled, by the application of sponges squeezed out in iced water. The part may be dressed after operation with some simple dress- ing, for instance, carbolized oil or lead lotion. It is but rational to follow up the scraping by the application of caustics; for in most eases there must exist, deep in the skin, prolongations of lupus-tissue, extending from the mass on the surface along the hair-follicles and other vascular structures. Alfred Sangster. NUCLEUS OF CELLS, The.— Synon. Fr. le Noyau ; Ger. der Kern. Definition. — A minute mass of protoplasm imbedded in the substance of nearly all cells. The nucleus differs from the cell-substance in its optical characters, and in its behaviour to certain chemical reagents; being, for example, more readily stained by various colouring matters, and presenting, as a rule, greater resistance to weak acids and alkalies. Until recently it was 1816 NUCLEUS OF CELLS. believed to form an essential part of all cells. See Cell. Chemical Characters. — Regarding the che- mical characters of nuclei but little is known, beyond the fact that they contain, in all proba- bility, an albuminous body. Microscopical Characters.— The intimate structure of the nucleus is very complex. In many animal cells, more especially gland-, epithelial, and endothelial cells, it is made up of a delicate network of fibres running in all directions, in the meshes of which is a substance of more or less fluid consistence, the whole being surrounded by a membranous envelope from which the fibres spring. Physiological Properties. — It has long been believed that the nucleus plays a predominating role in the process of cell-multiplication ; and this view has recently been materially strength- ened by the discovery of the so-called indirect division of the nuclei of epithelial cells. Indirect division of the nucleus, or, as it is called by Flemming, karyokinesis ( Kapvov , a nucleus, and mVijarir, movement) is the name applied to a complicated series of structural changes accom- panying the division of the nucleus into two halves ; and is employed in contradistinction to the term direct division, in which the nucleus, without any accompanying visible changes of structure, divides into two or more parts, called ‘ daughter-nuclei.’ The changes in karyokinesis consist chiefly in thickening of the intranuclear fibrils above re- ferred to, and in disappearance of the nuclear membrane, accompanied by increase in the size of the nucleus as a whole, this being followed by a complicated series of changes in the form and arrangement of the intra-nuclear fibres, in the course of which they often present the most regular stellate, fan-shaped, or wreath- like figures, ending in their dividing into two bundles of fibrils which draw apart from one another. This is followed by separation into two halves of tho nucleus as a whole, each daughter-nucleus containing a more or less com- plicated bundle of fibres in its interior. The division of the nucleus is followed by that of the cell, while the fibres of the nucleus gradually diminish in thickness, and arrange themselves in the form which they' present in the ‘ resting cell.’ In cell-multiplication by direct division of the nucleus, no change in the intimate structure of the nucleus is to be observed; all that is to be seen is that the nucleus becomes enlarged, and, after assuming a dumb-bell shape, divides into two halves, which may themselves be again divided into two. Pathological Relations. — Karyokinesis is of considerable pathological importance, having been found to take place in the cell-multiplica- tion of certain forms of epithelial cancer. On the other hand, direct division is the mode by which the nuclei of pus-cells multiply. PTOMAINES. The nucleus is, as a rule, more resistant of re- trogressive changes than the rest of the cell, often remaining apparently intact after the whole of the cell-substance and of the cell-wall has dis- appeared. In other cases the destruction of the nucleus goes hand in hand with that of the rest of the cell. Vacuolation of the nucleus is by no means rare, in cases of commencing retrogressive metamorphosis of cells, and also in cases of in- flammation, for instance, of the skin. Charles S. Roy. PTOMAINES (irrwfia, a dead body). — . Synon : Cadaveric Alkaloids; Fr. Ptomaines . — Under this name a class of bodies has been de- scribed, which are stated to ue the basic products of the decay of animal matters, and to which Selmi and others have assigned poisonous pro- perties. It is right, however, to state that although the existence of basic oralkaloidal bodies among the products of decay is highly probable, the definite toxic properties of these substances are by no means generally admitted ; and their preparation, in a stato of even approximate purity, has perhaps not hitherto been achieved. Pauum first showed that by the putrefaction of albuminous matters a soluble ferment is pro- duced, which is poisonous. Fagge and the writer also showed, in 1865, that the alcoholic extracts of many post-mortem liquids taken from the human body are, even after exposure to the tem- perature of the water-bath, poisonous when in- jected beneath the skin of animals. Bergmann, Schwenninger, Sonnenschein, and Zuelzer more or less confirmed these observations, and added to them. Selmi is, nevertheless, the observer who has chiefly worked at the cadaveric alka- loids. According to Selmi ptomaines are alkaloids, generated during decay, and closely resembling tho vegetable alkaloids, not only in their che- mical reactions, but also in their physiological properties. Some ptomaines appear to be poi- sonous ; and others to act as counter-poisons to well-known vegetable alkaloids. The conditions under which they are formed are entirely un- known, except that they may be found in alco- holic anatomical maceration liquids, and that exclusion of air possibly favours their formation. Some ptomaines have no marked physiological activity. Somo are formed even in the living body, during the progress of such diseases as peritonitis. The chief interest attaching to the ptomaines arises from their liability to be confounded with other and well-known natural alkaloids, such as morphia, strychnia, &c. ; and hence to lead to mistakes in medico-legal practice. Brouardel and Boutiny nevertheless have, as they assert, discovered chemical reactions by which the ptomaines as a class may be distinguished from the natural alkaloids. Thomas Stevenson REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE I }m York BQedical Journal, Edited by FRANK P. FOSTER, M. D. T) ECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. J^ECAUSE : It is the exponent of the most advanced scientific medical thought. T) ECAUSE : Its contributors are among the most learned medical men of this country. T) ECAUSE: Its “ Original Articles” are the results of scientific observation and research, and are of infinite practical value to the practitioner. T) ECAUSE : The “ Reports on the Progress of Medicine,” which are published from -*-* time to time, contain the most recent discoveries in the various departments of medicine, and are written by practitioners especially qualified for the purpose. B ECAUSE : The column devoted in each number to ‘-Therapeutical Notes” con- tains a resume of the practical application of the most recent therapeutic novelties. T) ECAUSE : The Society Proceedings, of which each number contains one or more, -L* are the reports of the practical experience of prominent physicians who thus give to the profession the results of certain modes of treatment in given cases. B ECAUSE : The Editorial Columns are controlled only by the desire to promote the welfare, honor, and advancement of the science of medicine, as viewed from a standpoint looking to the best interests of the profession. B ECAUSE : Nothing is admitted to its columns that has not some bearing on medicine, or is not possessed of some practical value. B ECAUSE : It is published solely in the interests of medicine, and for the up- holding of the elevated position occupied by the profession of America. The volumes begin -with January and July of each year. Subscrip- tions must be arranged to expire with the volume. Subscription price, $5.00 per Annum. New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. JOURNAL OF CUTANEOUS AND GENITO-URINARY ITH the number for January, 1889, this Journal enters upon the seventh year of fits publication. The history of the Journal has been one of pro- gression, and, under the present editorial management, there can he no doubt that it will preserve and increase the reputation already established. Devoted to the diseases indicated in its title, the Journal will be contributed to by the most eminent dermatologists and syphilographers in this country. Whenever the subject requires illustration, wood-cuts or chromo-lithographs will be employed. Letters from Europe, one or more of which will appear in each issue of the Journal, will keep the reader informed of the advances in this department of medicine at the great medical centers — Vienna, Berlin, and Paris. 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This treatise is the outcome and represents the experience of a long and active professional life, the greater part of which has been spent in the treatment of the diseases of women. It is especially- adapted to meet the wants of the general practitioner in recognizing this class of diseases as he meets them in every-day practice and in treating them successfully. The arrangement of subjects is such that they are discussed in their natural order, and thus more easily comprehended and remem- bered by the student. Methods of operation have been much simplified by the author in his practice, and it has been his endeavor to so describe the operative procedures adopted by him even to their minutest details, as to make his treatise a practical guide to the gynaecologist. Although all the subjects which are discussed in the various text- books on gynaecology have been treated by the author, it has been a prominent feature in his plan to consider also those which are but incidentally, or not at all, mentioned in the text-books hitherto pub- lished, and yet which are constantly presenting themselves to the prac- titioner for diagnosis and treatment. The illustrations are mostly entirely new, and have been specially made for this work. The drawings are from nature, or from wax and clay models from nature, and have been reproduced by processes best adapted to represent in the most truthful and permanent forms the exact appearances of the diseased organs, methods of operation, or instruments which they are designed to illustrate. Wherever it has been possible to make clearer the author’s methods of treatment by histories of cases which have actually occurred in his practice, this has been done. A simple, typical case, such as is ordi- narily met with, is first described, and then difficult and obscure cases, with the various complications which occur. The history of such cases and the methods of examination and treatment are so minutely detailed as to serve for guides in similar cases. New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. RECENT NEUROLOGICAL WORKS A Treatise on Insanity, in its Medical Relations. By W illiam A. Hammond, M. D., Surgeon-General TJ. S. Army (retired list); Professor of Diseases of the Mind and Nervous System, in the Nevr York Post-Grad- uate Medical School ; President of the American Neurological Association, etc. “With 112 Hlustrations. Eighth edition, revised, corrected, and en- larged by the Addition of a New Section on Certain Obscure Nervons Diseases. 1 voh, 8vo, 945 pages. Cloth, $5.00 ; sheep, $6.00. In this work the author has not only considered the subject of Insanity, hut has prefixed that division of his work with a general view of the mind and the several categories of mental faculties, and a full ac- count of the various causes that exercise an influence over mental derangement, such as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and many other factors. Insanity, it is believed, is in this volume brought before the reader in an original manner, and with a degree of thoroughness which can not but lead to important results in the study of psychological medicine. The Applied Anatomy of the Nervous System. Being a Study of this Portion of the Human Body from a Standpoint of its General Interest and Practical Utility, designed for Use as a Text-book and as a Work of Reference. By Ambrose L. Ranney, A. M., M. D., Ad- junct Professor of Anatomy and late Lecturer on the Diseases of the Genito- urinary Organs and on Minor Surgery in the Medical Department of the University of the City of New York, etc., etc. 1 vol., 8vo. Profusely illus- trated. Cloth, $4.00; sheep, $5.00. “Thia ia a useful book, and one of novel design. It is especially valuable as bringing together facta and inferences which aid greatly in forming correct diagnoses in nervous diseases .’" — Boston Medical and Surgical Journal. “There are many books, to be sure, which contain here and there hints in this field of great value to the physician, but’it is Dr. Eanney’s merit to have collected these scattered items of interest, and to have woven them into an harmonious whole, thereby producing a work of wide scope and of correspond- ingly wide usefulness to the practicing physician .” — Aew York Medical Journal. A Treatise on Nervous Diseases: Their Symptoms and Treatment. A Text-book for Students and Practitioners. By S. G. Web- ber, M. D., Clinical Instructor in Nervous Diseases, Harvard Medical School: Visiting Physician for Diseases of the Nervous System at the Boston City Hospital, etc. 1 vol., 8 vo, 415 pages. 15 Illustrations. Cloth, $3.00. ; *The book before U3 is especially adapted to tbe needs of the .general practitioner •who, though con- scious of his inability to discern and.trace the nervous element in the cases under his care, realizes very fully that this inability is not consonant with the best interests of his patient. Dr. Webber has not writ- ten for tbe specialist, but for the student and general practitioner, who will find in his hook what they most need for the diagnosis and treatment of the diseases as they present themselves in general practice. His style is very readable and lucid, and is well adapted to those who have not specially prepared them- selves to understand the peculiar language of the more advanced neurologist. He covers very completely the field of nervous affections, and his book will prove a very valuable acquisition to the library of the in- telligent physician .’ ‘ — Medical Agz. Paralysis from Brain Disease in its Common Forms. ByH. Charlton Bastian, M. A., M. D., Fellow of the Royal College of Physicians; Professor of Pathological Anatomy in University College, London. With Hlustrations, 1 vol., 12mo, 340 pages. Cloth, $1.75. New York: D. APPLETON & CO., 1, 3, & 5 Bond Street, SCIENCE AND ART OF MIDWIFERY. By WILLIAM THOMPSON LUSK, M. A., M. D., Professor of Obstetrics and Diseases of Women and Children in the Bellevue Hospital Medical College ; Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynaecologist to the Bellevue Hospital. Complete in one volume 8vo, with 226 Illustrations. Cloth, $5.00 ; sheep, $6.00. “ It contains one of the best expositions of the obstetric science and practice of the day with which we are acquainted. Throughout the work the author shows an intimate acquaintance with the literature of obstetrics, and gives evidence of large practical ex- perience, great discrimination, and sound judgment. We heartily recommend the book as a full and clear exposition of obstetric science and safe guide to student and prac- titioner.” — London Lancet. “ Professor Lusk’s book presents the art of midwifery with all that modem science or earlier learning has contributed to it.” — Medical Record , New York. “ This book bears evidence on every page of being the result of patient and laborious research and great personal experience, united and harmonized by the true critical or scientific spirit, and w r e are convinced that the book will raise the general standard of obstetric knowledge both in his own country and in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy practitioner seeking aid in the face of practical difficulties, it is, in our opinion, the best modem work on mid- wifery in the English language.” — Dublin Journal of Medical Science. “ Dr. Lusk’s style is clear, generally concise, and he has succeeded in putting in less than seven hundred pages the best exposition in the English language of obstetric science and art. The book will prove invaluable alike to the student and the practitioner.” — American Practitioner. “ Dr. Lusk’s work is so comprehensive in design and so elaborate in execution that it must be recognized as having a status peculiarly its own among the text-books of mid- wifery in the English language.” — New York Medical Journal. “ The work is, perhaps, better adapted to the wants of the student as a text-book, and to the practitioner as a work of reference, than any other one publication on the subject. It contains about all that is known of the ars obstetrica , and must add greatly to both the fame and fortune of the distinguished author.” — Medical Herald , Louisville. “ Dr. Lusk’s book is eminently viable. It can not fail to live and obtain the honor of a second, a third, and nobody can foretell how many editions. It is the mature product of great industry and acute observation. It is by far the most learned and most com- plete exposition of the science and art of obstetrics written in the English language. It is a book so rich in scientific and practical information that nobody practicing obstetrics ought to deprive himself of the advantage he is sure to gain from a frequent recourse to its pages.” — American Journal of Obstetrics. “ It is a pleasure to read such a book as that which Dr. Lusk has prepared ; every- thing pertaining to the important subject of obstetrics is discussed in a masterly and cap- tivating manner. We recommend the book as an excellent one, and feel confident that those who read it will be amply repaid.” — Obstetric Gazette , Cincinnati. “ To consider the work in detail would be merely to involve us in a reiteration of the high opinion we have already expressed of it. What Spiegelberg has done for Ger- many, Lusk, imitating him but not copying him, has done for English readers, and we feel sure that in this country, as in America, the work will meet with a very extensive approval.” — Edinburgh Medical Journal. “ The whole range of modern obstetrics is gone over in a most systematic manner, without indulging in the discussion of useless theories or controversies. The style is clear, concise, compact, and pleasing. The illustrations are abundant, excellently exe- cuted, remarkably accurate in outline and detail, and, to most of our American readers, entirely fresh.” — Cincinnati Lancet and Clinic. New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. AN ILLUSTRATED Encyclopaedic Medical Dictionary, BEING A DICTIONARY OF THE TECHNICAL TERMS USED BY WRITERS ON MEDICINE AND THE COLLATERAL SCIENCES IN THE LATIN , ENGLISH, FRENCH, AND GERMAN LANGUAGES. By FRANK P. FOSTER, M. D., Editor of "The New York Medical Journal. 11 W. C. AYRES, M. D., E. B. BRONSON, M. D., H. C. COE, M.D., M.R.C. etc. WITH THE COLLABORATION C. S. BULL, M. D., A. F. CURRIER, M. D., I., A. DUANE, M. D., Prof. S. H. GAGE, H. J. GARRIGUES, M. D., C. B. KELSEY, M. D., R. H. NEVINS, M. D., and B. G. WILDER, M. D. The distinctive features of Foster's “Illustrated Encyclopaedic Medical Dic- tionary ” are as follows : It is founded on independent reading, and is not a mere compilation from other medical dictionaries, consequently its definitions are more accurate. Other medical dictionaries have, it is true, been consulted constantly in its preparation, but what has been found in them has not been accepted unless scrutiny showed it to be correct. It states the sources of its information, thus enabling the critical reader to provide himself with evidence by which to judge of its accuracy, and also in many instances guiding him in any further study of the subject that he may wish to make. It is the only work of the kind printed in the English language in which pic- torial illustrations are used. It tells, in regard to every word, what part of speech it is, and does not de- fine nouns as if they were adjectives, and vice versa ; and it does not give French adjectives as the “ analogues ” of English or Latin nouns. It contains more English and Latin major headings than any other medical dictionary printed in English or Latin, more French ones than any printed in French, and more German ones than any printed in German, all arranged in a continuous vocabulary. The sub-headings are usually arranged under the fundamental word, making it much more encyclopedic in character than if the common custom had been followed. GEiPThis work will be completed in Four Volumes, and is sold by Subscription only. THE FIRST VOLUME NOW READY. New York : D. APPLETON & CO., 1 , 3, & 5 Bond Street. A TEXT-BOOK ON SURGERY: GENERAL , OPERATIVE, AND MECHANICAL. By JOHN A. WYETH, M. D., Professor of Surgery in the New York Polyclinic ; Snrgeon to Mount Sinai Hospital, etc. Price, Buckram, uncut edges, $7.00 ; Sheep, $8.00 ; Half Morocco, $8.50. SOLD BY SUBSCRIPTION ONLY. This work, consisting of seven hundred and sixty-nine pages, and containing seven hundred and seventy-one illustrations, of which about fifty are colored, is one of the most beautiful and unique, and at the same time one of the most complete, works on general surgery ever published. It is printed in clear, large type on a superior quality of paper, and the book, large without being bulky, is in a shape to be easily handled. The illustrations are executed with especial reference to the accurate anatomy of the parts represented ; the relations of bones, muscles, nerves, and vessels to adjacent structures ; and lines of incision are indi- cated in operations about the joints and articulations, thus explaining and simplifying their descriptions in the text. The colored illustrations which depict the more important operations, especially with reference to the large arteries, constitute a novel and very im- portant feature of the work. The following brief synopsis will convey an idea of the plan of the work: As a preliminary to the consideration of the various operations the author thoroughly discusses the methods of preparing the different antiseptic surgical dressings, ligatures, sutures, solutions, drains ; the materials for bandaging, with illustrated instructions as to the manner of applying bandages in the various forms employed in different parts of the body ; anaesthesia, both local and general, including the employment of cocaine as a local anaesthetic; the use and method of administering ether and chloroform; instruments and their uses ; haemostasis and the after-treatment of cases. Inflammation, its causes and methods of treatment ; wounds and the manner of closing them; transfusion, poisoned wounds, burns and scalds, gangrene, and the various surgical lesions are thoroughly considered and their appropriate treatment given. Amputations, with full and minute details of the manner of performing them, and the different methods employed, constitute an important chapter in the hook. All the prin- cipal operations are illustrated by colored engravings made from direct tracings of frozen sections on the cadaver. The section devoted to the arteries and the procedures necessary in l'gating them is one of the most important and most beautifully illustrated portions of the work. The woodcuts showing the relation of the parts involved in tying the important arteries arc colored, and their anatomy is depicted in a wonderfully clear and accurate manner. Surgical diseases and surgery of the bones ; surgery of the articulations, regional surgery, including the common operations on the eye, ear, and jaws ; tumors about the neck, thyreotomy, laryngotomy, tracheotomy, and cesophagotomy : the surgery of the thorax and abdomen ; and operations on the rectum and anus are dealt with in the light of the most advanced surgical knowledge. Genito-urinary surgery and specific lesions receive a due share of attention, os do de- formities of the spine and extremities, and malignant tumors and growths. This work, written by an accomplished surgeon of wide experience, and fully abreast of the highest attainments in surgical knowledge and science, presents to the student and practitioner a means of acquainting himself with modern surgery as it is taught and prac- ticed by a master of the art, and will enable him to prepare himself for the intelligent performance of many operations, and to treat many surgical lesions with which he may feel he is not sufficiently familiar. D. APPLETON & CO., Publishers, 1. 3. & 5 BOND ST., NEW YORK.